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A R T I C L E

PRENATAL MATERNAL REPRESENTATIONS:


MOTHERS AT PSYCHOSOCIAL RISK

MARJATERTTU PAJULO
ELINA SAVONLAHTI
ANDRE SOURANDER
JORMA PIHA
Child Psychiatry Clinic, University of Turku
HANS HELENIUS
Department of Biostatistics, University of Turku

ABSTRACT: The aim of the study was to explore differences in the content of prenatal mental represen-
tations between a risk group (n ⫽ 84) and a low-risk group (n ⫽ 296) of pregnant women, enrolled from
maternity care centers in southwestern Finland. The method used was semantic differentials of IRMAG
(Interview of Maternal Representations During Pregnancy). The risk group was defined by means of
questionnaire screens that concerned chemical dependency, depression, difficulties in social environment,
and low social support. The ratings on all target subjects, i.e., child, self, partner, self-as-mother and own
mother-as-mother, were significantly more negative in the risk group. The representation profiles of the
groups differed: especially the ratings of partner and own mother-as-mother were more consistently and
strongly negative among the risk mothers.

RESUMEN: El objetivo de este estudio fue el de explorar las diferencias en el contenido de las represen-
taciones mentales antes del nacimiento del infante entre un grupo de riesgo (n⫽84) y un grupo de bajo
riesgo (n⫽296) de mujeres embarazadas, miembros de centros de cuidado de la maternidad en el suroeste
de Finlandia. Se usaron como método las diferenciales semánticas de IRMAG (Entrevista de las repre-
sentaciones maternas durante el embarazo). El grupo de riesgo fue definido por medio de cuestionarios
de selección que incluı́an dependencia quı́mica, depresión, dificultades en el ambiente social y poco apoyo
social. Los puntajes en todos los temas sobre los cuales se les preguntó (sobre el infante, sobre sı́ mismas,
sobre su pareja, ellas como madres y sus propias madres como madres), fueron significativamente más
negativos en el grupo de riesgo. Los perfiles de representación de los grupos difirieron: especialmente
los puntajes con relación a la pareja y a sus propias madres como madres fueron consistente y fuertemente
más negativos entre las madres bajo riesgo.

RÉSUMÉ: Le but de cette étude était d’explorer les différences dans le contexte des représentations mentales
prénatales entre un groupe à risque (n⫽84) et un groupe à faible risque (n⫽296) de femmes enceintes,
inscrites dans des centres de maternité dans le sud-ouest de la Finlande. La méthode utilisée consistait
en différentielles sémantiques de l’IRMAG (abrégé en anglais, soit l’Entretien de Reprentation Mater-
nelles Durant la Grossesse, en français). Le groupe à risque fut défini grâce à des questionnaires de

Direct correspondence to: Marjaterttu Pajulo, Piispankatu 12 B 41, 20500 Turku, Finland; phone: 358-2-2352447;
fax: 358-2-2612412; e-mail: olpaju@utu.fi.

INFANT MENTAL HEALTH JOURNAL, Vol. 22(5), 529– 544 (2001) short
䊚 2001 Michigan Association for Infant Mental Health standard

529 base of drop


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dépistage concernant la dépendance chimique, la dépression, les difficultés dans le milieu social et un base of text
soutien social peu élevé. Les évaluations de tous les sujets cibles, i.e. l’enfant, soi-même, le partenaire,
soi-même en tant que mère, sa propre mère en tant que mère, étaient considérablement plus négatives
dans ce groupe à risque. Les profils de représentation des groupes différaient: les évaluations des parten-
aires et de sa propre mère en tant que mère étaient surtout plus invariablement et plus fortement négatives
chez les mères à risque.

ZUSAMMENFASSUNG: Das Ziel der Studie war es Unterschiede in den vorgeburtlichen Repräsentationen
zwischen einer Risikogruppe (n⫽84) und einer niedrig-Risikogruppe (n⫽296) schwangerer Frauen, die
aus Schwangerenbetreuungszentren in Südwest-Finnland zugewiesen wurden, zu erheben. Als Methode
wurden semantische Unterschiede im IRMAG (Interview der mütterlichen Repräsentationen während der
Schwangerschaft) verwendet. Die Zuordnung zu den Risikogruppen wurde mittels Fragebogen, der nach
Abhängigkeit von Medikamenten oder Drogen, Depression, Schwierigkeiten in der sozialen Umwelt und
geringer Unterstützung in der Gesellschaft fragten, durchgeführt. Die Ergebnisse auf allen Zielvariablen,
wie zum Beispiel Kind, Selbst, Partner, Selbst als Mutter und die eigene Mutter als Mutter, waren in der
Risikogruppe signifikant höher. Die Werte der Gruppe unterschieden sich deutlich. Besonders die Ergeb-
nissen bei den Kategorien Partner und die eigene Mutter als Mutter waren in der Risikogruppe durch-
gehend und stärker negativ geladen.

* * *
The assessment of interactional behavior alone has not been found as fruitful as was once
thought (Vizziello, Antonioli, Cocci, & Invernizzi, 1993; Zeanah & Barton, 1989), and the
prognostic implications of the inability to organize representations of the child and parenthood
in mother – infant relationship disturbances has aroused increasing interest. The importance of
childhood relationships for later close relationships is already central to Freud’s theory, while
intergenerational continuity of parental behavior is also emphasized in attachment theory
(Bowlby, 1977).
According to Joan Raphael-Leff (1991, 1993), the maturational phases of pregnancy are
defined by the woman’s subjective experience of being pregnant. The first phase lasts until the
movements of the baby are felt, and the second phase ends with the belief that this baby would
survive if born now. In the first phase, the mother is mainly preoccupied by changes in her
body image, but she also experiences the reactivation of old conflicts, particularly in relation
to her own mother. In the second phase, her attention shifts from the pregnancy more to the
baby. The process of both identification and differentiation with the baby and her own mother
modifies the characteristics and capacities of maternity. In the third place, the mother is in- short
creasingly preparing herself, both consciously and unconsciously for the birth and the infant. standard
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In her mind, the imaginary baby is gradually giving way to the more real one. According to base of text
Dinora Pines (1972), although it is a phase of reactivation of old conflicts, pregnancy is also
seen as a phase of possibilities to resolve old ambivalent identifications.
The mental representations of generalized interactions are regarded as building blocks from
which the “working models” of interaction are constructed (Main & Kaplan, 1985; Stern, 1989,
1995; Zeanah & Barton, 1989). The mental representations of maternity and being a child are
thought to become strongly activated during pregnancy, and are considered useful criteria for
studying motherhood. Especially from the fourth to seventh month of gestation the represen-
tations grow and enlarge regarding both the infant and self-as-mother (Ammaniti et al.,1992;
Stern, 1995; Stern & Bruschweiler-Stern, 1998). The representation of self-as-mother is thought
to be based on the representations of self-as-woman and own mother-as-mother. From about
the eighth month of gestation onwards, the representations become less active; perhaps to
protect the mother from potential discordance. After birth, the mother rebuilds her represen-
tations, now based more on the real child. Towards the term of pregnancy the mother increas-
ingly begins to see herself as the major contributor to the baby’s characteristics and life, and
the baby more strongly as her own. Near the birth some women have trouble including even
their husbands in the imaginary circle (Stern & Bruschweiler-Stern, 1998). According to Stern
(1995), the importance of maternal representations for early mother-infant-interaction is con-
sidered to lie in the fact that the most active representations are played out in interactive
behavior. The maternal representations can influence the baby only through the mother’s overt
interactive behavior, and in a form that is potentially meaningful to the infant. For instance, a
mother who represents herself as being rejected by her own mother, tends to reject her baby
first, to protect herself; for example, this can take the form of breaking mutual eye contact with
the child.
The nature of the mother’s attachment to her child during pregnancy is considered to be
related to her motivation for becoming pregnant, room for this baby in the family, and the
mother’s own position in her family of origin. Other factors are thought to include the physical
health of the mother, the emotional support she receives, the number of other children, psy-
chosocial stress, work, and other demands (Raphael-Leff, 1991). The intensity of the deficit in
establishing attachment relationships is considered to determine the ability to form bonding
ties with her new-born child (Daghestani, 1988). Mothers who have difficult experiences of
relationships with their own mothers are found by clinicians to experience a reactivation of
emotional conflicts when becoming mothers themselves (Lier, Gammeltoft, & Knudsen, 1995).
Childhood experiences of insufficient physical and emotional care are crucial for the internal
working models or representations of being cared for and being a mother. In psychosocial risk
situations, the mothers are considered to have more difficulties in building up the mental
representations of herself-as-mother and her infant, which may lead to interactional failures
(Lyons-Ruth & Block, 1996). Traumatic experiences in childhood are usually associated with
early attachment figures, and the behavior of her own child may be particularly threatening to
the mother, leading to unresponsive maternal behavior as a protective mechanism. According
to O’Connor (1996), the psychological unavailability of the mother creates the expectation in
the infant that he/she is not worth being cared for. The link between the way in which a mother
recalls her own childhood experiences and the quality of the relationship between her and her
child has also been increasingly shown in empirical research (Crowell & Feldman, 1989;
Fonagy, Steele, & Steele, 1991). In the study by Steele and colleagues, the Adult Attachment
Interview was shown to be capable of identifying prenatally 75% of infants whose attachment
to the mother was insecure as opposed to secure. The mother’s current experience of her own
mother as being rejecting has been shown to be related to her rejection of her own infant. In short
addition, idealization of her parents, difficulties in remembering her own childhood and inco- standard
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herency in her narration of attachment have been found to be related to the mother’s rejection base of text
of her own infant (Main & Goldwyn, 1984). Mothers with secure attachment representations
are seen to be more aware of their own internal experiencing, which enables them to provide
more sensitive care for their children. Mothers with insecure attachment representations are
seen to be limited in this respect on the basis of the representational models. However, no
differences have been found in parenting style between secure mothers from loving back-
grounds, and those from adverse backgrounds who have later managed to break the cycle of
dysfunctional parenting (“earned secure”) (Pearson, Cohn, Cowan, & Cowan, 1994; Crandell,
Fitzgerald, & Whipple, 1997); many of these mothers having experienced physical, emotional,
or sexual abuse or abandonment, parental substance abuse, or parental depression.
Alcohol- and drug-dependent mothers, especially, have often experienced pathological
interactive and communicative patterns within their family of origin, even physical and sexual
abuse (Bauman & Dougherty, 1983; Bays, 1990; D’Agnone & Basyk, 1989; Davis, 1990;
Stanton, 1979). In an Italian study (Mazzoni, 1992) using the same method as we have used
in our study, substance-dependent mothers were found to view themselves as persons partic-
ularly negatively during pregnancy. The view of the child’s father, however, was as positive
as in nonaddicted mothers, perhaps due to the fact that the mothers were in many ways de-
pendent on their partners. The view of the child was idealized during pregnancy, but after birth
characteristics such as the weakness and dependence of the child became particularly strength-
ened. The period after birth is suggested to be especially critical for mother – baby couples
from a high-risk psychosocial background; the mothers having difficulties in adapting to the
real situation (Mazzoni, 1992). The negative view of own mother-as-mother has been suggested
to be of special importance. According to a study by Conte and colleagues, a subgroup of high-
risk mothers was found within the group of substance-dependent mothers. These mothers who
had been separated from their babies within 2 years due to infant neglect, viewed the maternal
characteristics of their own mother as significantly worse than the other substance-dependent
mothers (Conte, Mazzoni, Serretti, Fundaro, & Tempesta, 1994).
The mothers who have been able to break the intergenerational cycle of dysfunctional
parenting, abuse, and neglect have been found to have received a lot of support from other
relationships during life, or through an especially meaningful single relationship, such as in
the therapeutic situation (Egeland, Jacobvitz, & Sroufe, 1988; Main & Goldwyn, 1984; Ricks
1985). Although the mother may consciously strive not to treat her child as she was treated, it
is difficult for her to act on this wish unless her underlying representational models of self and
others have changed (Fraiberg, Adelson, & Shapiro, 1975).
The purpose of this study was to gain epidemiologic data about the contents of prenatal
maternal representations among two groups of mothers: mothers at psychosocial risk and moth-
ers without this risk, i.e., low-risk mothers. The hypothesis of the study was that the mothers
at psychosocial risk differ from low-risk mothers in terms of their mental representations of
themselves, the child, their partner, and their own mother. On the basis of the definition of the
risk group, the ratings of self, partner, and own mother-as-mother were hypothesized to be
significantly more negative in the risk group.

METHOD

Sample
In Finland, the situation of prenatal care is exceptionally good: it takes place in free-of-charge short
maternity care centers, and is attended by 99.9% of all pregnant women. The data for this standard
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cross-sectional study were collected using questionnaires between 1 May 1998 and 15 January base of text
1999, from 14 maternity care centers in four cities of South-Western Finland. The midwives
of these maternity care centers were guided both personally and in writing on how to carry out
the data collection. The inclusion criteria for the participants included being at least 3 months
and not more than 8 months pregnant, expecting only one child, speaking and understanding
Finnish fluently, and participating in this study only once. The midwives were especially ad-
vised not to otherwise select the mothers, but to offer the questionnaires to every mother fitting
these criteria. The mothers participated in the study voluntarily and anonymously, being in-
formed about the nature and aims of the study. The questionnaires were returned by the par-
ticipants to the researcher in an enclosed, addressed envelope. There were 680 potential mothers
who fulfilled the inclusion criteria during the collection. Mainly due to the workload of mid-
wives at maternity care centers, only 575 mothers (85 %) received the questionnaires. During
the study period, 391 mothers returned the questionnaires, i.e., 68% of all recipients. Of these
391 mothers, eleven were excluded because of insufficient data.
The definition of the risk group (n ⫽ 84) was made by using four questionnaire screens
in the maternity care center sample. The criteria of the definition included having one or more
of the following: depression (screening positive in EPDS, n ⫽ 30), substance dependency
(screening positive in SASSI, n ⫽ 24), experiencing many difficulties in social environment
(the highest 10% in SSQ1, n ⫽ 36), and experiencing lack of social support (the lowest 10%
in SSQ2, n ⫽ 29). Within this risk group, there was considerable overlap concerning the risk
factors in that 35% of the mothers screened as substance-dependent were also screened as
depressive, compared to 30% of the mothers screened as depressive who were also screened
as substance dependent. Within both of these groups (depressive and substance-dependent
mothers), 64% experienced low social support or many social environment difficulties. The
rest of the maternity unit sample is from now on referred to as the low-risk group (n ⫽ 296).
The background characteristics and statistically significant differences of the groups are
presented in Table 1. The groups did not differ significantly by age (means 27.5 and 28.6
years), or by duration of gestation (mean 23 weeks). The mothers in the risk group were
significantly more often single, unemployed, had more economic difficulties, previous miscar-
riages or abortions, and unplanned pregnancies.

Measures
Interview of Maternal Representations During Pregnancy (IRMAG): Semantic differentials.
The IRMAG semantic differentials (Ammaniti et al., 1992; Ammaniti, Candelori, Pola, &
Tambelli, 1995; Ammaniti, Tambelli, & Perucchini, 1998) are adjective lists given along with
the IRMAG interview to the mothers, concerning maternal representations of the baby, self-
as-woman, partner (child’s father), self-as-mother, and own-mother-as-mother (target views).
Only the questionnaire part of the method was used in this particular study. Each adjective list
contains 17 pairs of opposite adjectives placed at one or the other end of a horizontal line. The
subjects are asked to mark the point from 1 to 7 that best indicates their rating; a higher score
means a more positive view. Subjects complete three similar adjective lists for perceived in-
dividual characteristics of the unborn infant, the mother herself and the infant’s father, and two
other lists for perceived characteristics of oneself-as-mother and own-mother-as-mother. On
the basis of the factorial structure of the method (Ammaniti et al., 1998), the adjectives are
divided into four representation areas. The adjectives of each area, the sumscore ranges of each
area (scores of the adjective pairs counted together) and an example of one adjective pair are
shown in Table 2. The method is an adaptation of Osgood’s semantic differential (Osgood & short
Suci, 1952) developed for pregnant women through the collaboration of an international re- standard
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TABLE 1. Background Characteristics of the Risk Group (n ⫽ 84) and the Low-Risk Group (n ⫽ base of text
296), and the Significance of Differences Between the Groups

Risk Group Low-Risk Group

Mean (SD) Range Mean (SD) Range p*

Age (years) 27.5 (5.7) 17–40 28.6 (4.6) 17–43 NS


Weeks of Gestation 23.3 (4.5) 14–34 23.1 (5.2) 13–37 NS

N % N % p**

In partnership 73 87 286 97 ⬍.01


Social class NS
Upper 14 17 85 29
Middle 62 74 195 66
Lower 8 10 17 6
Unemployed 28 33 41 14 ⬍.001
Housewife 18 21 46 16 NS
Economic difficulties ⬍.001
Considerable/moderate 27 32 21 7
Minor 22 26 72 24
None 35 42 203 69
Primiparty 42 50 141 48 NS
Previous miscarriage/abortion 32 38 73 25 .02
Pregnancy problems 16 19 37 13 NS
Planned pregnancy 67 80 271 92 .01

* t-test for independent samples; ** Fisher’s exact test.

search group, including Charles Zeanah, Daniel Stern, and Graziella Fava Vizziello, and further
adapted by Massimo Ammaniti and colleagues. The questionnaire part has been included in
the IRMAG method especially for research purposes.
The Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987) is
a 10-item self-report scale that covers the common symptoms of depression during the previous
week. It has been developed as a postnatal screen for major and minor depression, but has
been validated for use also during pregnancy. Each of the ten items is scored on a four-point
scale (0 to 3), with a total score ranging from 0 to 30. The EPDS takes about five minutes to
complete and has been found to be acceptable to women (Murray & Cox, 1990). The cutoff
point of 12/13 has been recommended, and was used in this study. In a Finnish study using
this cutoff point the sensitivity was 64% and the specificity 96% (Tamminen, 1990).
The Substance Abuse Subtle Screening Inventory (SASSI-2) (Horrigan, Piazza, & Wein-
stein, 1996; Miller, 1985,1994) is a psychological screen for alcohol and other drug abuse
problems, and is the most widely used empirically derived substance abuse screen in the United
States. It consists of two parts: one logically derived with two subscales (26 face valid items,
scored 0 to 3), the other empirically derived with six subscales (62 true/false items), where
some items belong to two subscales. The method is especially developed to identify both
alcohol and other drug dependency even when the person is in denial or trying to conceal the
problem. Its discriminative validity has been investigated in Finland (Pajulo, Savonlahti, Grön-
roos, Piazza, & Piha, 2001a), and it has been found to reliably differentiate persons with short
chemical dependency from a control group. standard
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TABLE 2. Adjectives Belonging to Each base of text
Representational Area of the IRMAG Method
(Semantic Differentials)

Individual characteristics
1. Personal functioning (6– 42)
● passive/active
● timid/enterprising

● difficult/easy
● intellectual/emotional*

● untidy/tidy

● weak/strong

2. Interpersonal style (3– 21)


● rejecting/accepting

● closed/sociable

● dependent/independent

3. Emotional tendencies (5– 35)


● excitable/calm

● sad/cheerful

● detached/affectionate

● timorous/confident

● unlively/lively

4. Contents of oral, anal, and phallic impulses (3– 21)


● unwilling/voracious

● messy/clean

● submissive/determined

Maternal characteristics
1. Emotional tendencies (3– 21)
● not affectionate/affectionate
● anxious/calm

● sad/cheerful

2. Personal role (6– 42)


● passive/active

● authoritarian/permissive

● serious/playful

● insecure/secure

● inflexible/flexible
● impatient/patient

3. Maternal role (2– 14)


● unsatisfied/satisfied in the role

● finds the role burdensome/easy

4. Sensitivity and maternal interaction (6– 42)


● distracted/amenable

● detached/overprotective
● not accepting/accepting

● likes to control/gives free reign

● ungiving/generous

● not possessive/possessive

Theoretical range of each area sumscore in parentheses


* In original version: unintelligent/intelligent.
Example:
1 2 3 4 5 6 7
Not accepting Accepting
— — — — — — —

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The Social Support Questionnaires 1 and 2 (SSQ 1 and 2) are self-report questionnaires base of text
focusing on experienced difficulties in social relationships and life circumstances and on ex-
perienced amount of support. The SSQ 1 (Murray, 1994, personal communication) contains
seven items that explore difficulties the mother has experienced during the previous 2weeks in
her intimate and network relationships, housing, and economic situation. Each of the seven
items is scored on a four-point scale: no, some, moderate or considerable difficulty. The range
of the sumscore in this study is, thus, from 7 to 28. The SSQ 2 is derived from the Significant
Others Scale (SOS) (Power, Champion, & Aris, 1988), and it consists of 15 items divided into
five different areas of interest: the amount of support experienced by the mother from her
partner, her mother, father, mother-in-law, and best friend. Each area includes two items on
emotional support and one item on practical support. Each item is scored on a three-point scale:
never, sometimes, always supportive. Thus, the range of the sumscore in this study is from 15
to 45.

Statistical Analysis
The data are summarized with frequencies, percentages, mean values, and standard deviations.
The background characteristics of the groups were compared using t-test for independent sam-
ples and Fisher’s exact test. The evaluations concerning the five subjects (self, child, child’s
father, self-as-mother, own mother-as-mother) were given by the same mother, and thus the
ratings were not independent observations. The comparison of the sumscores between groups
and target subjects was conducted with analysis of variance of repeated measurements, with
one grouping factor (groups) and one within factor (targets) (Arnold, 1981; Crowder & Hand,
1990). With this statistical analysis it was possible, in addition to group differences, to explore
the differences in evaluations of different targets and their dependence on grouping. For this
reason it was preferred to multivariate analysis of variance. Bonferroni-correction was made
to the p-values for the post hoc comparisons. The similarity of each mother’s scoring on the
five subjects was measured in both groups using Pearson’s correlation coefficient. The statistical
computation was performed with SAS System for Windows release 6.12/1996.

RESULTS

Individual Characteristics
Compared to the low-risk group, the general level of ratings of child, self, partner (child’s
father) was significantly more negative in the risk group in all four representational areas
(Table 3).
The three ratings of individual characteristics (child, self, partner) differed significantly
for emotional tendencies and content of impulses. For emotional tendencies, the difference was
greatest between self and child, and for content of impulses, between self and partner. De-
pending on the group, the relative distances between the ratings of self and child, child and
partner, were significantly different for personal functioning and for emotional tendencies
(Table 3). It was characteristic of the profile of the risk group that the ratings of the partner
were the most negative ones in all representational areas. The ratings of the child tended to be
the most positive ones, and closest to those of the low-risk group. short
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TABLE 3. Representations of Individual Characteristics

Target Comparison of the


Comparison of the Target Groups in Target View
Child Self Partner Comparison of the Groups Views Distances

Area (Mean, SD) (Mean, SD) (Mean, SD) F df p F df p F df p

Personal functioning
Low-risk group 31.4 (3.8) 31.9 (3.9) 31.8 (4.1)
Risk group 29.8 (3.8) 29.3 (4.1) 28.8 (4.5) 37.22 1,371 ⬍.001 0.66 2,742 NS 4.27 2,742 .01a
Interpersonal style
Low-risk group 15.6 (2.1) 15.8 (2.5) 16.0 (2.6)
Risk group 15.0 (2.1) 14.7 (2.7) 14.5 (3.0) 16.98 1,370 ⬍.001 0.05 2,740 NS 2.88 2,740 NS
Emotional tendencies
Low-risk group 28.9 (3.4) 27.6 (3.6) 27.8 (3.9)
Risk group 27.7 (3.4) 25.5 (4.0) 24.9 (4.9) 29.19 1,370 ⬍.001 44.56 2,740 ⬍0.001b 6.04 2,740 ⬍.01c
Content of impulses

RIGHT INTERACTIVE
Low-risk group 16.9 (2.4) 17.1 (2.3) 16.4 (2.6)
Risk group 15.9 (2.4) 16.0 (2.7) 14.7 (3.4) 29.95 1,370 ⬍.001 16.26 2,740 ⬍.001d 2.46 2,740 NS

Means and standard deviations of area sumscores. The risk group (n ⫽ 84) compared to the low-risk group (n ⫽ 296). Tests were done using analysis of variance of repeated measurements.
Difference was significant in post hoc comparisons between:
a Child and partner (p ⫽ .02), child and self (p ⫽ .04); b child and partner (p ⬍ .001), child and self (p ⬍ .001); c child and partner (p ⬍ .01), child and self (p ⫽ .02); d child and partner (p ⬍ .001), self and partner

(p ⬍ .001) (p-values are Bonferroni-corrected).

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Maternal Characteristics base of text
Compared to the low-risk group, the general level of the ratings of self-as-mother and own
mother-as-mother was significantly more negative in the risk group in all four representational
areas (Table 4).
The two ratings (self-as-mother, own mother-as-mother) differed significantly for all four
representational areas. Depending on the group, the relative distances between the ratings of
self-as-mother and own mother-as-mother were significantly different in three out of four rep-
resentational areas (Table 4). It was characteristic of the profile of the risk group that the rating
of own mother-as-mother was more strongly negative compared to the rating of self-as-mother,
than it was in the low-risk group.
The correlations between the ratings of the target subjects were calculated within both
groups, and presented in more detail in Table 5: between the ratings of self and child, child
and partner (father), self and partner, self and own mother. The ratings tended to have the
strongest association between self and child, and the least association between self and partner
(child’s father), within both groups. The correlations were in general at a somewhat lower level
in the risk group than in the low-risk group. In particular, there tended to be more similarity
between the ratings of self and partner in the low-risk group than in the risk group. In addition,
especially the correlation between ratings of self-as-mother and own mother-as-mother in sen-
sitivity and maternal interaction differed depending on the group (r ⫽ .17 in the risk group, r
⫽ .39 in the low risk group).

DISCUSSION
The purpose of this study was to compare the contents of prenatal maternal representations in
a group of mothers defined as being at psychosocial risk to those of mothers without such a
risk factor. This is the first epidemiologic type of study on the subject: the risk group was
derived from a general population sample from maternity care centers, where the mothers were
screened with questionnaires.
The risk group had significantly more negative representations of the child, self-as-woman,
partner, self-as-mother, and own mother-as-mother than the low-risk group. The risk group
also differed significantly from the low-risk group concerning background variables; living
more often single, being more often unemployed, having more economic difficulties, having
more often unplanned pregnancies and previous miscarriages/abortions. On the basis of the
definition of the risk group and the difference in background characteristics between the groups,
the group difference in prenatal representations was to be expected. The fact that the ratings
of the partner were the most negative ones in all areas in the risk group is consistent with our
knowledge of low social support and a high degree of experienced difficulties in social rela-
tionships among these risk mothers, especially involving the partner. The more negative view
of self-as-woman and self-as-mother is consistent with the knowledge that many of these
mothers were screened as depressive. The tendency to rate the child most positively was
stronger within the risk group, but this tendency has also been previously described to prevail
among low-risk mothers (Ammaniti et al., 1995; Mazzoni, 1992). In this study, however, the
risk group mothers’ positive view of their child was not supported by a positive view of their
partner. The tendency to rate own mother-as-mother more negatively than self-as-mother was
stronger in the risk group in all representational areas, which also was hypothesized and sup-
ports previous views (Conte et al., 1994; Mazzoni, 1992). Among risk mothers, the difference
between the ratings of self-as-mother and own mother-as-mother was greatest in the area “sen- short
sitivity and maternal interaction.” The low-risk mothers’ representations of child and self-as- standard
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TABLE 4. Representations of Maternal Characteristics

Target
Comparison of the Target Comparison of the Groups
Self-as-mother Own mother-as-mother Comparison of the Groups Views in Target View Distances

Area (Mean, SD) (Mean, SD) F df p F df p F df p

Emotional tendencies
Low-risk group 18.3 (1.9) 16.8 (3.3)
Risk group 16.9 (2.7) 14.4 (3.8) 38.51 1,370 ⬍.001 114.32 1,370 ⬍.001 6.75 1,370 ⬍.01
Personal role
Low-risk group 32.0 (3.9) 30.0 (6.4)
Risk group 29.6 (5.1) 26.8 (6.7) 27.24 1,370 ⬍.001 33.69 1,370 ⬍.001 0.59 1,370 NS
Maternal role
Low-risk group 11.8 (1.6) 11.0 (2.5)
Risk group 10.9 (2.2) 9.3 (3.4) 28.82 1,347 ⬍.001 53.06 1,347 ⬍.001 8.93 1,347 ⬍.01
Sensitivity/maternal

RIGHT INTERACTIVE
Interaction
Low-risk group 29.3 (3.1) 28.7 (5.4)
Risk group 29.3 (3.4) 26.3 (5.8) 6.58 1,369 .011 24.77 1,369 ⬍.001 10.39 1,369 .001

Means and standard deviations of area sumscores. The risk group (n ⫽ 84) compared to the low-risk group (n ⫽ 296). Tests were done using analysis of variance of repeated measurements.

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TABLE 5. Pearson’s Correlation Coefficients (r) Between the base of text
Ratings of Target Subjects

Low-Risk
Risk Group Group

r p r p

Child/self
Personal functioning .58 ⬍.001 .53 ⬍.001
Interpersonal style .34 ⬍.01 .47 ⬍.001
Emotional tendencies .47 ⬍.001 .60 ⬍.001
Content of impulses .58 ⬍.001 .54 ⬍.001
Child/father
Personal functioning .32 ⬍.01 .50 ⬍.001
Interpersonal style .40 ⬍.001 .39 ⬍.001
Emotional tendencies .19 .08 .53 ⬍.001
Content of impulses .41 ⬍.001 .38 ⬍.001
Self/partner
Personal functioning .37 ⬍.001 .45 ⬍.001
Interpersonal style .04 .69 .36 ⬍.001
Emotional tendencies .12 .27 .54 ⬍.001
Content of impulses .13 .24 .30 ⬍.001
Self/own mother
Emotional tendencies .50 ⬍.001 .49 ⬍.001
Personal role .24 .03 .39 ⬍.001
Maternal role .48 ⬍.001 .39 ⬍.001
Sensitivity/maternal .17 .12 .39 ⬍.001
interaction

Correlations were calculated for four representation areas of five target subjects, in
the risk and low-risk group.

mother have, according to previous views, been described as changing during the postnatal
period, being influenced by the real interaction with the baby, while the view regarding own
mother-as-mother has been described as remaining fairly unchanged. Well-adapted mothers
tend to see themselves as more similar to their own mother after birth than during pregnancy.
Less well-adapted mothers see themselves less favorably postnatally than during pregnancy,
and also tend to see themselves as even less similar to their own mothers postnatally than
during pregnancy (Ammaniti et al., 1998; Mazzoni, 1992). According to this study, the prenatal
representations of maternal characteristics seem to be of special importance: the ratings of self-
as-mother were more negative in the risk group than in the low-risk group, the ratings of own
mother’s maternal characteristics were more negative in comparison to those of self in both
groups, and more strongly so among the risk mothers. According to preliminary results of a
pilot study among high-risk mothers, using the same method for exploring representations
(Pajulo, Savonlahti, Sourander, Helenius, & Piha, 2001d, submitted), it was found that the
change towards negativity in view of own mother’s sensitivity and maternal interaction tended
to be associated with more problems in mother’s own interactive behavior at 6 months post-
partum. We, therefore, suggest that there may be a special difficulty in finding support from
identification with own mother in this representational area.
According to the correlation matrix, the ratings tended to be most strongly associated short
between self and child in both groups, which is consistent with the current theoretical view standard
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(Stern & Bruschweiler-Stern, 1998). However, even the highest correlations were only mod- base of text
erate, indicating that the mothers were able to create separate views of all target subjects. The
ratings of the child tended to be the most positive ones in the risk group, suggesting that the
view of the child is least affected by past experiences, most open to positivity and hope, but
perhaps also to idealization.

Limitations
Due to the anonymous collection procedure, it was not possible to identify the individuals at
risk for further evaluation. Nor was it possible to explore the change in the content of repre-
sentations from pregnancy to postnatal period. However, the study design was chosen to make
participation easier even for those mothers who felt they might have problems in the areas
concerned. The study can be criticized, especially for combining several risk factors together
to define a risk group; information about the characteristic profiles of each subgroup of the
different risk factors was not studied separately. This decision was based on the fact that all
the risk factors included in the definition were shown to be strongly interrelated in this same
sample, and purely separate groups would have been very small (Pajulo, Savonlahti, Sourander,
Helenius, & Piha, 2001b, 2001c). The coexistance of these risk factors has also been described
also in previous studies (Burns, Melamed, Burns, Chasnoff, & Hatcher, 1985; Dimitrovsky,
Perez-Hirshberg, & Itskovitz, 1987). Although the authors’ original interest specifically con-
cerned substance-dependent mothers, the findings made it more relevant to widen the definition
of risk group in this sample.
The questionnaires used in the study to measure the content of representations have not
been widely used as a separate instrument. The change and/or stability from pregnancy to the
postnatal period and the factorial structure have been investigated with Italian mothers (Am-
maniti et al., 1999; Vizziello et al., 1993), and this is still ongoing with the Finnish sample.
Changing the original continuous 0 – 100 millimetres scale of the questionnaires to a seven-
point scale was done with the permission of the developer of the method, to make the filling
in simpler for the mothers. Although the authors do not suspect that this would have influenced
the results, it should be taken into account in any comparison with results of other studies. In
addition, this part of the IRMAG method is only a measure of the content of representations;
it does not give a picture of the formal features of the mothers’ narratives.

CONCLUSIONS
On the basis of the current theory, the importance of maternal representations lies especially
in their influence on the mother’s interactive behavior with the baby. According to this study,
the mothers at psychosocial risk have a more negative prenatal view of the child, being a parent
and being cared for. However, the view of the child is the most positive one among risk mothers,
and to a lesser extent related to the view of the partner than previously reported. The mothers
at psychosocial risk have a more complicated starting point for their parenthood in many ways,
also in terms of their mental representations. Although the continuity of the group difference
in the content of representations from pregnancy to the postnatal period was not investigated
in this study, the time after birth is known to be especially critical for mothers with psychosocial
problems, when they are faced with the real situation and the dependency of the child. The
role of the representations being enacted becomes essential at this point. Enhancing the iden-
tification of mothers at psychosocial risk is of great importance, and the maternal representa-
tions should be taken into account more in clinical work with pregnant women and new moth- short
ers. The midwives should be encouraged to pay more attention to mothers’ prenatal and standard
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postnatal views of the baby and maternity, to be able to help the mothers in their adaptation base of text
to the actual situation. The topic of this study has important clinical implications, and the
results make further investigation a matter of great interest.

REFERENCES
Ammaniti, M., Baumgartner, E., Candelori, C., Perucchini, P., Pola, M., Tambelli, R., & Zampino, F.
(1992). Representations and narratives during pregnancy. Infant Mental Health Journal, 2, 167–182.
Ammaniti, M., Candelori, C., Pola, M., & Tambelli, R. (1995). Maternita e gravidanza. Studio delle
rappresentazioni materne. Milano: Raffaello Cortina Editore.
Ammaniti, M., Tambelli, R., & Perucchini, P. (1998). From pregnancy to the postnatal period: Stability
and change of the factorial structure of maternal representations. Unpublished manuscript.
Arnold, S.F. (1981). The theory of linear models and multivariate analysis. New York: John Wiley &
Sons.
Bauman, P., & Dougherty, F. (1983). Drug-addicted mothers’ parenting and their children’s development.
The International Journal of Addictions, 18, 291–302.
Bays, J. (1990). Substance abuse and child abuse: Impact of addiction on the child. Pediatric Clinics of
North America, 4, 881– 901.
Bowlby, J. (1977). The making and breaking of affectional bonds. British Journal of Psychiatry, 130,
421–443.
Burns, K., Melamed, J. Burns, W., Chasnoff, I., & Hatcher, R. (1985). Chemical dependency and clinical
depression in pregnancy. Journal of Clinical Psychology, 41, 851–854.
Conte, G.L., Mazzoni, S., Serretti, A., Fundaro, C., & Tempesta, E. (1994). ”Separation” of the mother–
child couple: Pregnancy and maternity of drug-dependent women. Acta Paediatrica, Supplement
404, 47– 53.
Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the
10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786.
Crandell, L.E., Fitzgerald, H.E., & Whipple, E.E. (1997). Dyadic synchrony in parent–child interactions:
A link with maternal representations of attachment relationships. Infant Mental Health Journal, 3,
247–264.
Crowder, M.J., & Hand, D.J. (1990). Analysis of repeated measures. London: Chapman and Hall.
Crowell, J.A., & Feldman, S.S. (1989). Assessment of mothers’ working models of relationships: Some
clinical implications. Infant Mental Health Journal, 10, 173–184.
Daghestani, A.N. (1988). Psychosocial characteristics of pregnant women addicts in treatment. In I.J.
Chasnoff (Ed.), Drugs, alcohol, pregnancy and parenting (pp. 7–16). London: Kluwer Academic
Publishers.
D’Agnone, O., & Basyk, L. (1989). Some familial dynamic aspects in drug abusers. Medicine and Law,
8, 431–432.
Davis, S. (1990). Chemical dependency in women: A descriptive of its effects and outcome in adequate
parenting. Journal of Substance Abuse Treatment, 7, 225–232.
Dimitrovsky, L., Perez-Hirshberg, M., & Itskovitz, R. (1987). Depression during and following preg-
nancy: Quality of family relationships. Journal of Psychology, 12, 213–218.
Egeland, B., Jacobvitz, D., & Sroufe, L.A. (1988). Breaking the cycle of abuse. Child Development, 59,
1080–1088.
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy
predict the organization of infant– mother attachment at one year of age. Child Development, 62,
891–905. short
standard
IMHJ (Wiley) RIGHT INTERACTIVE

top of rh
Prenatal Maternal Representations ● 543 base of rh

cap height
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery. Journal of the American Academy base of text
of Child Psychiatry, 14, 387– 421.
Horrigan, T., Piazza, N.J., & Weinstein, L. (1996). SASSI is more cost effective and has better selectivity
than urine toxicology for the detection of substance abuse in pregnancy. Journal of Perinatology,
16, 326– 330.
Lier, L., Gammeltoft, M., & Knudsen, I.J. (1995). Early mother–child relationship. The Copenhagen
model of early preventive intervention towards mother–infant relationship disturbances. Arctic Med-
ical Research, 54, 15– 23.
Lyons-Ruth, K., & Block, D. (1996). The disturbed care-giving system: Relations among childhood
trauma, maternal caregiving and infant affect, and attachment. Infant Mental Health Journal, 17,
257– 275.
Main, M., & Goldwyn, R. (1984). Predicting rejection of her infant from mother’s representation of her
own experience: Implications for the abused-abusing intergenerational cycle. Child Abuse and Ne-
glect, 8, 203– 217.
Main, M., Kaplan, N. & Cassidy, J. (1985). Security in infancy, childhood and adulthood: A move to the
level of representation. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory
and research (pp. 66– 104) (Monographs of the Society for Research in Child Development, 50).
Mazzoni, S. (1992). Tossicomania e gravidanza. In M. Ammaniti (Ed.), La gravidanza tra fantasia e realta
(pp. 217– 235). Roma: Il Pensiero Scientifico.
Miller, G.A. (1985, 1994). The Substance Abuse Subtle Screening Inventory. Manual and supplement
for SASSI-2. Bloomington, IN: Addiction Research and Consultation.
Murray, D., & Cox, J.L. (1990). Screening for depression during pregnancy with the Edinburgh Postnatal
Depression Scale (EPDS). Journal of Reproductive and Infant Psychology, 8, 99–107.
O’Connor, M.J. (1996). Attachment in children exposed to alcohol prenatally. In H.-L. Spohr & H.L.
Steinhausen (Eds.), Alcohol, pregnancy and the developing child (pp. 183–206). Cambridge, UK:
Cambridge University Press.
Osgood, C.E., & Suci, G.J. (1952). A measure of relation determined by both mean difference and profile
information. Psychological Bulletin, 49, 251–262.
Pajulo, M., Savonlahti, E., Grönroos, M., Piazza, N.J., & Piha, J. (2001a). Assessing the Substance Abuse
Subtle Screening Inventory (SASSI) in Finland. Manuscript submitted for publication.
Pajulo, M., Savonlahti, E., Sourander, A., Helenius, H., & Piha, J. (2001b). Antenatal depression, sub-
stance dependency and social support. Journal of Affective Disorders, 65, 9–17.
Pajulo, M., Savonlahti, E., Sourander, A., Helenius, H., & Piha, J. (2001c). Motherhood at risk— detecting
substance dependency among pregnant women. Unpublished manuscript.
Pajulo, M., Savonlahti, E., Sourander, A., Helenius, H., & Piha, J. (2001d). Substance-addiction, mental
representations and maternal interactive capacity in the postnatal period. A pilot study. Manuscript
submitted for publication.
Pearson, J.L., Cohn, D.A., Cowan, P.A., & Cowan, C.P. (1994). Earned- and continuous-security in adult
attachment: Relation to depressive symptomatology and parenting style. Development and Psycho-
pathology, 6, 359– 373.
Pines, D. (1972). Pregnancy and motherhood: Interaction between fantasy and reality. British Journal of
Medical Psychology, 45, 333– 343.
Power, J., Champion, L.A., & Aris, S.J. (1988). The development of a measure of social support: The
Significant Others (SOS) Scale. British Journal of Clinical Psychology, 27, 349–358.
Raphael-Leff, J. (1991). Psychological processes of childbearing. London: Chapman and Hall.
Raphael-Leff, J. (1993). Pregnancy. The inside story. London: Sheldon Press. short
standard
IMHJ (Wiley) LEFT INTERACTIVE

top of rh
544 ● M. Pajulo et al. base of rh

cap height
Ricks, M.H. (1985). The social transmission of parental behavior. Attachment across generations. In I. base of text
Bretherton & E. Waters (Eds.), Growing points of attachment theory and research (pp. 211–227)
(Monographs of the Society for Research in Child Development, 50).
Stanton, M. (1979). Family treatment approaches to drug abuse problems: A review. Family Process, 18,
251–280.
Stern, D.N. (1989). The representation of relational patterns: developmental considerations. In A.J. Sa-
meroff & R.N. Emde (Eds.), Relationship disturbances in early childhood: A developmental ap-
proach (pp. 52– 69). New York: Basic Books.
Stern, D.N. (1995). The motherhood constellation. A unified view of parent–infant psychotherapy. New
York: Basic Books.
Stern, D.N., & Bruschweiler-Stern, N. (1998). The birth of a mother. How the motherhood experience
changes you forever. New York: Basic Books.
Tamminen, T. (1990). Postnatal depression, breastfeeding and mother–infant interaction (Äidin masen-
nus, imetys ja varhainen vuorovaikutus). Unpublished doctoral thesis, University of Tampere, Tam-
pere, Finland.
Vizziello, G.F., Antonioli, M.E., Cocci, V., & Invernizzi, R. (1993). From pregnancy to motherhood:
The structure of representative and narrative change. Infant Mental Health Journal, 1, 4–16.
Zeanah, C.H., & Barton, M.L. (1989). Introduction: Internal representations and parent–infant relation-
ships. Infant Mental Health Journal, 3, 135–141.

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standard