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Maternal-Fetal Attachment, Temporal Orientation and Locus of Control:
Implications for Prenatal Care Behaviors and
HIV Risk Reduction during Pregnancy
A Thesis
Submitted to the Faculty
Of
Drexel University
By
Sara V. Levine Kornfield
in partial fulfillment of the
requirements for the degree
of
Doctor of Philosophy
April 2010
© Copyright 2010
Sara V. Levine Kornfield. All Rights Reserved.
ii
Acknowledgments
The completion of the doctoral dissertation is an event of great personal and
professional significance. This achievement would not have been possible without the
many people who contributed to my education and personal growth during this process.
I wish to thank the members of my dissertation committee, who have been
dedicated to this project since its inception. Each member of my dissertation committee
contributed to this project and my own development into a competent and ethical clinical
researcher in meaningful ways. This project would not have been possible without the
help and guidance of Dr. Sandra Wolf, who not only provided access to her patients but
leant enthusiasm and encouragement every step of the way. I am grateful to Dr.
Jacqueline Kloss and Dr. David DeMatteo for lending their expertise in health
psychology, research design and implication, and statistical consultation. Dr. Ana Nunez
contributed her knowledge of data collection in medical settings which undoubtedly
made this project a success. Lastly, I wish to thank Dr. Pamela Geller for providing
countless hours of guidance, supervision, encouragement, mentorship, and friendship, not
only for the duration of the dissertation research but during my entire graduate career at
Drexel. She sparked my interest in women's health psychology and the perinatal period
and has been instrumental in shaping who I have become as a clinician and a researcher
over the last five years. I aspire to follow her example in my career as a clinical health
psychologist.
Alexa Bonacquisti, Angela Jiang, and Stephanie Stephens dutifully collected and
entered my data and took excellent care in their oversight of this research while I was
completing my internship in New York. They are three of the most professional and
iii
dedicated research assistants that I have had the pleasure of working with. Each of them
went above and beyond what I expected from her, integrating seamlessly with the other
providers and researchers at the Women‟s Care Center. It was only because of their
dedication to this research that we were able to meet and exceed the originally proposed
number of participants included in this study. They will undoubtedly make significant
contributions to the fields of medicine and psychology as researchers in their own rights.
Successfully completing graduate school requires more than just a successful
dissertation defense. For his continuous love and encouragement, I give thanks to my
husband Noah, who never doubted my abilities and supported me unconditionally as I
worked towards this end.
Finally, I wish to thank the women that participated in my study for sharing their
time, experiences, and most of all, their hearts.
iv
Table of Contents
LIST OF TABLES .......................................................................................................... VI
LIST OF FIGURES .......................................................................................................VII
ABSTRACT .................................................................................................................. VIII
1. INTRODUCTION..........................................................................................................1
1.1 HIV Epidemiology .................................................................................................... 1
1.2 Heterosexual Transmission ....................................................................................... 2
1.3 Women as a Vulnerable Population .......................................................................... 4
1.3.1 Minority Women Living in Poverty .................................................................. 4
1.3.2 Women as Partners of IV Drug Users................................................................ 5
1.4 Pregnant Women ....................................................................................................... 6
1.5 Maternal-Fetal Attachment ....................................................................................... 7
1.6 Health Related Locus of Control ............................................................................ 11
1.7 Temporal Orientation (Time Perspective) .............................................................. 14
1.8 Power in Romantic/Sexual Relationships ............................................................... 17
1.9 Female Condom Use ............................................................................................... 20
1.10 Power in Relationships and Partner Refusal to Use Condoms ............................. 21
1.11 HIV/AIDS Risk Perception................................................................................... 23
2. THE CURRENT STUDY ...........................................................................................26
2.1 Rationale ................................................................................................................. 26
2.2 Hypotheses .............................................................................................................. 26
2.2.1 Planned Hypotheses ......................................................................................... 26
2.2.2 Exploratory Hypotheses ................................................................................... 29
3. METHODS AND PARTICIPANTS ..........................................................................31
3.1 Participant Recruitment .......................................................................................... 31
3.2 Inclusion Criteria .................................................................................................... 31
3.3 Exclusion Criteria ................................................................................................... 32
3.4 Recruitment and Assessment .................................................................................. 33
3.5 Informed Consent.................................................................................................... 33
3.6 Training ................................................................................................................... 34
3.7 Ethical Considerations ............................................................................................ 34
3.8 Measures ................................................................................................................. 35
3.9 Statistical Power Analyses ...................................................................................... 40
4. RESULTS .....................................................................................................................41
4.1 Participant Sociodemographics ............................................................................... 41
4.2 Main Variables ........................................................................................................ 44
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4.3 Planned Hypotheses ................................................................................................ 45
4.4 Exploratory Variables ............................................................................................. 52
4.5 Exploratory Hypotheses .......................................................................................... 53
5. DISCUSSION ...............................................................................................................55
5.1 Sociodemographics ................................................................................................. 55
5.2 Planned Hypotheses ................................................................................................ 56
5.3 Implications for Future Research and Clinical Application ................................... 63
5.4 Limitations .............................................................................................................. 66
5.5 Conclusions ............................................................................................................. 68
LIST OF REFERENCES ................................................................................................69
APPENDIX A: MEASURES ..........................................................................................85
VITA................................................................................................................................105
vi
LIST OF TABLES
1. Participant Demographics: Age, Ethnicity &Marital Status……………………….....80
2. Intendedness and Timing of the Pregnancy………………………....………………..81
vii
LIST OF FIGURES
1. Hypothesis 3: The moderating effect of MFA on the relationship between
internal LOC and prenatal health behaviors………………………...…………..….82
2. Hypothesis 4: The moderating effect of MFA on the relationship between
temporal orientation and prenatal health behaviors……….………………………..83
viii
ABSTRACT
Maternal-Fetal Attachment, Temporal Orientation and Locus of Control:
Implications for Prenatal Care Behaviors and
HIV Risk Reduction during Pregnancy
Sara V. Levine Kornfield
Pamela A. Geller, Ph.D.
Pregnancy presents an important time in a woman‟s life for added HIV prevention
behaviors as HIV exposure during pregnancy could lead to delivery of an infected infant.
Unfortunately, pregnancy is generally regarded as a time when HIV preventative
behaviors, specifically condom use, decrease as most women report using condoms
specifically for pregnancy prevention. Maternal fetal attachment (MFA), a characteristic
which describes the relationship between a pregnant woman and her developing fetus has
been shown to be positively related to health promotion behaviors during pregnancy.
Similarly, temporal orientation and health related locus of control (LOC) have also been
shown to increase HIV preventative behaviors, although these have never previously
been tested in pregnant women. One hundred low-income, minority women (81% Non-
Hispanic Black) were recruited from the waiting room of an urban prenatal care clinic in
order to test the hypotheses that higher levels of the aforementioned variables are
associated with better adherence to prenatal care behaviors and HIV prevention behaviors
as measured by condom use during pregnancy. Findings revealed that while MFA had a
significant moderating effect on the relationships between LOC and prenatal health
behaviors and temporal orientation and prenatal health behaviors, respectively, the same
conclusions could not be drawn between these variables and HIV prevention behaviors as
measured by condom use during pregnancy. It should be noted that while the majority of
ix
the women in the study discontinued condom use once pregnancy was confirmed they
reported engaging in other HIV preventative behaviors including decreasing the number
of sexual partners and frequency of sexual contact during pregnancy. Clinical
implications and directions for future research to clarify some of these findings are
discussed.
1
1. INTRODUCTION
Young women of childbearing age are currently the fastest increasing group of
new HIV infections. The majority of these women contract HIV from their male
partners. Pregnancy is an important time for HIV prevention behaviors as many women
discontinue condom use once the contraceptive motivation is gone. What women may
not realize is that in discontinuing condom use they put themselves and their unborn
children at risk for contraction of STDs and HIV if they remain sexually active. There
are many personal attributes that predict adherence to HIV risk reduction behaviors
including temporal orientation and health related locus of control. The current study
investigated whether maternal-fetal attachment, a characteristic specific to pregnancy,
favorably influences pregnant women‟s other personality characteristics such that they
might be more inclined to engage in positive prenatal health behaviors as well as
preventative HIV risk reduction behaviors. It must also be acknowledged that the main
recommended HIV risk reduction behavior, condom use, cannot be performed in
isolation; a woman needs her male partner to cooperate. To that end, a woman‟s level of
power within her relationship was also investigated to examine how this variable interacts
with maternal fetal attachment in the prediction of condom use during pregnancy.
1.1 HIV Epidemiology
The United States‟ Center for Disease Control and Prevention reports that AIDS
and other AIDS related illnesses are currently the leading cause of death among black
women 25-44 years of age and the sixth leading cause of death among adolescents and all
women aged 25–34 years many of whom were likely infected before the age of twenty-
2
five (CDC, 2007). Among men, HIV is the second leading cause of death following
unintentional injury (Selik, Chu, & Buehler, 1993).
During the years 2004 to 2007, the estimated number of HIV/AIDS cases
increased by 15% among the 34 states that have long term name based reporting of new
HIV infections (CDC, 2009). Despite an overall decrease in the national incidence of
HIV/AIDS from 2000 to 2003 (CDC, 2005), the overall HIV infection incidence rose
15% between 2004 and 2007; rates for men infected by risky heterosexual contact
increased by 9% while rates for women rose 14% (CDC, 2009).
Women are especially at risk according to the Centers for Disease Control and
Prevention; in 1998 it was reported that the number of AIDS cases among United States
adolescent and adult females had surpassed 100,000 (CDC, 1998). By 2003, the Center
for Disease Control had estimated close to 300,000 women living with HIV/AIDS in the
United States out of roughly one million infected persons (Glynn & Rhodes, 2005). In
2007, women constituted 28% of HIV/AIDS cases in the United States; approximately
62% of those cases were among non-Hispanic black women, and 16% were among
Latinas (CDC, 2009).
1.2 Heterosexual Transmission
Heterosexual transmission of HIV, the virus that causes AIDS, may occur when a
partner in a heterosexual relationship who is already infected with the virus has
unprotected vaginal, anal, or oral sex with the other uninfected partner of the opposite
sex. HIV is present in seminal fluid as well as vaginal and cervical secretions. During
and following intercourse, viral particles are able to penetrate tiny tears or sores in the
vaginal, rectal, penile, or urethral mucosa. Women are twenty times more likely than
3
men to become infected with HIV through vaginal intercourse, probably because of the
prolonged exposure of the vagina, cervix, and uterus to seminal fluid.
Sexually transmitted infections (STIs) are also likely to increase the risk of
heterosexual transmission of HIV. Microbes such as Treponema pallidum, herpes
simplex, Chlamydia trachomatis, and Neisseria gonorrhoeae are known to cause erosions
in the mucosa and may even increase the concentration of HIV in seminal or vaginal
fluid. Oral sex, however, is much less likely to result in HIV transmission (Gladwin &
Trattler, 2004).
Some of the key risk factors associated with heterosexual transmission of
HIV/AIDS are frequent change of sexual partners, unprotected sexual intercourse,
previous presence of sexually transmitted infections with poor access to treatment, lack
of male circumcision, social vulnerability of women and young people, and political or
economic instability in the community (Lamptey, 2002). It is important to note that
while many of these factors pertain to the individual, others still pertain to societal factors
that are out of the individual‟s control (Lamptey, 2002).
Among women, heterosexual transmission is the most common cause of new HIV
infections. Of the estimated 123,000 women living with AIDS, 71% were determined to
have been heterosexually exposed to the virus as opposed to only 13% of the 332,500
infected adult and adolescent males (CDC, 2005). It has been well documented that the
receptive partner during sexual intercourse is at greater risk for disease infection than the
insertive partner (Anderson, 1999; Gladwin & Trattler, 2004).
4
1.3 Women as a Vulnerable Population
Vulnerability refers to individual and societal factors that increase the risk of HIV
infection. Societal factors include poverty, unemployment, illiteracy, gender inequities,
cultural practices, lack of information and services, and human rights abuses (UNAIDS,
1996). These factors greatly increase the vulnerability of women, young people, and
other minority groups (Lamptey, 2002). Poverty is especially important in assessing the
vulnerability of a population as many studies have noted that low-income women are at
increased risk for HIV/STD infection and unintended pregnancy. Finer and Henshaw
(2006) report that the unintended pregnancy rate is highest among young (18-24 year
old), low-income, minority women. Poverty is often related to unemployment, lack of
education, and little or no access to basic health care. Additionally, women living in
poverty are more often involved in violent relationships with men than their middle or
upper socioeconomic class counterparts (Campbell, 2002). The consequences of living in
poverty, such as having a partner who uses intravenous drugs and being a victim of
intimate partner violence often increase the risk for HIV infection. These problems
associated with poverty are elaborated on below.
1.3.1 Minority Women Living in Poverty
Black and Hispanic women are among those who are most likely to be living in
poverty. Economic inequalities occurring since the 1990s have shaped the distribution of
HIV infection and HIV-risk among women. Zierler and Krieger (1997) reported that in
1994 13.1% of white women, 33.7% of black women, and 33.4% of Hispanic women
were living below the national poverty line, with the degree of poverty experienced by
5
the minority groups being more extreme than that experienced by white populations and
for households headed by women than those headed by a married couple.
Low income minority women have been found to be at highest risk for new HIV
infection. Escalating rates of AIDS cases among minority women are particularly
striking, with rates for blacks and Hispanics being 20 and 7 times greater than rates for
whites, respectively (CDC, 1997; Crosby, Yarber, & Meyerson, 2000).
1.3.2 Women as Partners of IV Drug Users
Hobfoll and colleagues (1994) suggest that minority women and inner-city
women in general are at increased risk for HIV/AIDS infection due to the rate of
exposure among those they are likely to have as sexual partners and because of the higher
than average prevalence of intra-venous drug users in the inner city (CDC, 1991).
Residents of impoverished communities were and continue to be vulnerable to the
temptation to use illegal drugs for relief and stimulation (Zierler & Krieger, 1997). These
neighborhoods tend to have a higher prevalence of drug use which includes drugs such as
crack, cocaine, and heroin which are linked to the risk of HIV infection (Zierler &
Krieger, 1997).
In the United States, 19% of the 332,578 HIV/AIDS cases diagnosed in men as of
2004 are among those whose only risk factor is intravenous drug use (as opposed to men
who have sex with men (MSM), heterosexual contact, and MSM and intravenous drug
use (IDU)) (CDC, 2005). Predominantly men, intravenous drug users occupy a critical
position in the spread of the HIV/AIDS epidemic due to their association among other
groups who would not otherwise be at risk, such as their female sexual partners (Booth,
Koester, Brewster, Weibel, & Fritz, 1991). As of 2004, unprotected heterosexual sex
6
with an injection drug user accounted for 14% (24,568) of all cumulative female AIDS
infections, compared to only 1% (11,048) of all cumulative male AIDS infections (CDC,
2005).
1.4 Pregnant Women
It is important to study pregnant women in the context of HIV/STI prevention
because pregnant women are not exempt from participation in high-risk sexual behaviors
and STI infection both during and following pregnancy (e.g., Ickovics, Niccolai, Lewis,
Kershaw, & Ethier, 2003; Meade & Ickovics, 2005). Empirical findings indicate that
most young adults use condoms primarily for pregnancy prevention as opposed to STD
prevention (Cooper, Agocha, & Powers, 1999). Condom use is therefore often
abandoned once a pregnancy is established because the contraceptive motivation no
longer exists (Crosby et al., 2002). In an earlier study by Levine Kornfield & Geller
(manuscript in preparation) the authors confirmed Crosby and colleagues‟ findings. They
found that among a sample of 67 pregnant women, self-reported frequency of condom
use decreased significantly from 59% in the 3 months prior to becoming pregnant to only
23% during pregnancy. Young pregnant women may also be an important and unique
group on which to focus because pregnancy is known to be a stressful transition period
for the mother-to-be as well as her partner. The stressors of pregnancy can strain a
relationship which may influence sexual risk behavior (e.g., Bost, Cox, Burchinal, &
Payne, 2002; Dulude, Belanger, Wright, & Sabourin, 2002). One of these stressors may
be the unplanned nature of the pregnancy itself. Young women, especially those living in
low-income communities are likely to become pregnant with unplanned pregnancies
(Finer & Henshaw, 2006). These authors found that in 2001, the rate of unplanned
7
pregnancy was highest among women aged 18-24, unmarried women, low-income
women, and minority women. Additionally, between 1994-2001 the rates of unplanned
pregnancies increased among poor and less educated women (Finer & Henshaw, 2006).
In a previous study of women recruited from the same population as was recruited in the
current study, Levine Kornfield and Geller (manuscript in preparation) found that 52 of
the 67 women sampled had not planned their pregnancies. Of these women carrying
unplanned pregnancies, 53.8% reported that the pregnancy was mistimed (too soon) and
25% stated that they had not wanted any future pregnancies at the time they became
pregnant (i.e., they did not want any children at all, or had considered their childbearing
complete). This can have implications for the parents as young couples may be still
developing a romantic relationship when they unexpectedly need to focus on pregnancy,
childbearing and childrearing. This transition to parenthood can cause conflict and tax
the partnership (Florsheim et al., 2003).
1.5 Maternal-Fetal Attachment
Maternal-fetal attachment (MFA) is a term used to describe the developing
relationship between a pregnant woman and her fetus (Salisbury, Law, LaGasse, &
Lester, 2003). The term was coined by Cranley (1981) who stated that MFA describes
“the extent to which women engage in behaviors that represent an affiliation and
interaction with their unborn child” (p.282). These prenatal maternal behaviors may
include certain actions used to bond with the unborn child such as assigning pet names,
making reassuring comments, talking affectionately or endearingly towards the baby, and
carrying on imaginary conversations with a partner and the fetus (Leifer, 1977). In a
study by Stainton (1985) the author interviewed pregnant women and found that these
8
women communicated with their fetuses and perceived that their unborn children had
already developed individual personality characteristics and could be interacted with
while in utero. In a later study examining attachment to the fetus, Stainton (1990) found
that expectant mothers believed that their unborn babies also participated in the
attachment process by responding to maternal behaviors by moving towards the mother‟s
touch or becoming calmer when the belly was patted or rubbed. The author‟s
conclusions included the suggestion that MFA is largely an individual process influenced
not only by the mother‟s own personal history but also by her whole experience of the
pregnancy (Stainton, 1990).
There has also been evidence to suggest that MFA increases as the pregnancy
progresses (Grace, 1989). Researchers examined 69 pregnant women monthly during
their pregnancies by having them complete the Maternal-Fetal Attachment Scale (MFAS)
developed by Cranley (1981). Results indicated that MFA increases over the course of
the pregnancy as the MFAS correlation coefficients increased significantly from .55 at
16-28 weeks gestation to .95 at 36-40 weeks gestation (Grace, 1989). MFA also has
significant implications for maternal-infant bonding in the postpartum period. Fuller
(1990) examined 35 pregnant women in a longitudinal study aimed at discovering how
MFA influences postpartum bonding. Pregnant women completed the Maternal Fetal
Attachment Scale between 35-40 weeks gestation. After giving birth these women were
examined again while feeding their infants and mother-infant interactions were measured
with the Nursing Child Assessment Feeding Scale and the Funke Mother Infant
Interaction Assessment. Findings suggest that mothers with higher prenatal levels of
9
MFA were more likely to score higher on the subsequent measures of infant attachment
(Fuller, 1990).
Erickson (1996) reviewed the studies described above and concluded that the
participants who were included in these research studies were mainly white, well-
educated, married women with normal pregnancies. This highlights the point that few
studies have been conducted on how MFA progresses or influences women from a lower
SES, minority ethnicity, or lower educational level.
MFA has also been shown to have a positive relationship with health promotion
behaviors during pregnancy such as smoking cessation, abstaining from alcohol and illicit
drugs, obtaining prenatal care, appropriate weight gain, establishing good rest and sleep
patterns, getting adequate exercise, and learning about pregnancy and childbirth (e.g.,
Lindgren, 2001). Reading, Campbell, Cox, and Sledmere (1982) suggested that MFA
might increase participation in beneficial health practices during pregnancy; however
other researchers (i.e., Lindgren, 2001) propose that conversely, good health practices
may actually lead to stronger MFA. Lindgren (2001) states that women who are more
attached to their fetuses are thought to be more interested and invested in caring for
themselves during pregnancy in an attempt to improve the health outcomes for their
future child.
Lindgren‟s (2001) study showed that high levels of MFA predicted positive health
practices among a group of 252 expectant mothers. Interestingly, her findings revealed
that women with higher education levels and who were married were more likely to
engage in positive health practices. However, the women sampled in this study were
mostly white, married women with a vocational or college degree earning upwards of
10
$50,000 a year. When investigating HIV risk reduction behaviors in the context of MFA,
it is important to consider women who are currently at highest risk of contracting HIV.
The sample described by Lindgren and other abovementioned researchers, does not
adequately capture this group which tends to be predominantly comprised of minority
women (Black or Latina) living in poverty. Lindgren (2003) later conducted another
study of MFA and pregnancy health practices, examining the differences between a
group of inner-city pregnant women (n= 55) and a comparable group of women living in
a small urban area in the Midwest. (n= 197). Her findings indicated that there were no
significant differences in MFA between the two groups, although women living in the
inner-city engaged in significantly fewer health practices during pregnancy.
Interestingly, inner-city women with low MFA scores were found to have lower levels of
health practices than women with higher scores on MFA, but the relationship between
site and health behaviors was moderated by attachment. This indicates that although
inner-city women are less likely to engage in positive prenatal health behaviors overall,
those with higher scores on MFA are more likely to overcome the challenges that inner-
city living presents for this endeavor. This is important as the current study examined
both of these constructs (e.g., MFA and prenatal health behaviors) in a sample of
pregnant women living in inner-city Philadelphia. What Lindgren did not address in her
study was whether the women she surveyed were at risk for HIV infection and how this
may influence prenatal care behaviors. Minority women living in inner city Philadelphia
are at increased risk for HIV due to their minority and gender status coupled with the fact
that Philadelphia is an HIV epicenter (Fife & Mode, 1992). The current study will
examine whether MFA has any effect on whether or not these women engage in HIV risk
11
reduction behaviors during pregnancy in addition to other positive prenatal health
behaviors.
1.6 Health Related Locus of Control
Locus of control was originally studied by Rotter (1954) in connection with his
social learning theory, which states that the likelihood of behavior is a function of two
issues. The first is the extent to which the individual believes the behavior will lead to a
particular reinforcement and the second is the extent to which the reinforcement is valued
by the individual. An extension of this work argued that social learning theory could be
applied on a more general level, dividing individuals into two categories: internal and
external. Rotter (1966) posited that „internals‟ were more likely to attribute
consequences of events to their own actions, while „externals‟ believe that these events
are outside of their own control. Wallston et al., (1978) later applied this directly to
health related events and behaviors and created the Multidimensional Health Locus of
Control Scale to measure health-specific locus of control along three separate
dimensions. These three dimensions were originally proposed by Levenson (1978) and
include the extent to which individuals believe that their health related outcomes are 1) a
result of their own actions, 2) under the control of powerful others, or 3) due to fate or
chance. Norman and colleagues (1998) predicted that individuals with strong internal
health related locus of control beliefs would be more likely to engage in health promoting
activities and behaviors while those with external loci of control related to chance or fate
will be less likely to do so. These authors also state that those with a strong belief in the
„powerful others‟ dimension will be more difficult to predict as they may be influenced
by messages from medical professionals to do something about their health or may
12
believe that medical professionals can cure their illnesses and be less motivated to engage
in positive or preventive health practices. These authors‟ predictions were largely
verified in a sample of 11,632 from a community setting. They found that all three of the
health locus of control dimensions correlated significantly with scores on their self-
developed health behavior index. Individuals who engaged in more health behaviors (not
smoking, using alcohol within recommended limits, exercising more than 20 minutes per
day, 3 times per week, and eating fruit 6-7 days per week) were more likely to score
higher on the internal dimension and lower on the powerful others and chance
dimensions (Norman et al., 1998). Norman and colleagues (1998) also found evidence
suggesting that the value one places on his or her own health may moderate the
relationship between health locus of control and engagement in health behaviors. This
may be relevant to the current study being proposed as pregnant women may place a
higher value on their own health in an attempt to secure the health of their unborn child.
In the current study, value on health will be measured as the extent to which the pregnant
woman values the pregnancy (i.e., attachment and attitude towards the pregnancy). In
terms of family planning behaviors specifically, there has been some interesting findings
which may be challenged in the current study. For example, Fisch (1974) found that in a
sample of “poor black women” there were no significant differences in locus of control
between women who were deemed to be effective versus ineffective family planners.
Overall, Fisch (1974) concluded that these women were highly external. Perhaps this can
be attributed to the communities in which women living in poverty often live where they
may not have very much control over access to health care and therefore may be more
likely to perceive that preserving their own health is out of their own hands.
13
In 1990, when AIDS infection was becoming an epidemic in gay male
communities, Kelly and colleagues conducted a study investigating health locus of
control as related to risky sexual practices in this population. They revised Wallston and
colleagues‟ (1978) original multidimensional health locus of control (MHLOC) scale to
be more relevant to HIV/AIDS as a health risk. Nine items representing the original three
dimensions were tailored to make them pertinent to HIV/AIDS. Their findings indicated
that gay men who did not engage in unprotected anal sex were less likely to attribute
AIDS risk to external factors such as chance, luck, or fate. More recently, Burns and
Dillon (2005) used Kelly and colleagues‟ (1990) AIDS MHLOC scale in a sample of 106
African-American undergraduate students and found that AIDS related locus of control
did not significantly predict condom use. Authors have concluded that perhaps AIDS
health locus of control is too global a construct to predict the specific behavior of condom
use (Burns & Dillon, 2005; Glaser, 1995). Two studies have been conducted looking at
condom use and AIDS health locus of control but neither has captured a sample that is
similar enough to make conclusions about the proposed sample for this study. As
mentioned above, Kelly and colleagues (1990) examined the behavior of gay men, and
Burns and Dillon (2005) investigated the same relationships among black college
undergraduates. Interestingly, these authors found conflicting outcomes which makes
generalizability very difficult. Pregnant women have different issues to deal with in their
lives than either of these two samples, so it is important to continue to investigate these
issues among this unique group of women.
14
1.7 Temporal Orientation (Time Perspective)
Jones (1993) defined temporal orientation as the predominant cognitive, affective,
and behavioral orientation to either the past (“dwelling in the past”), the present (“living
for now”), or the future (“always planning for tomorrow”). The construct of temporal
orientation has been conceptualized in many different ways according to different
researchers who examine it (Burns & Dillon, 2005). Some researchers classify temporal
orientation as a personality characteristic (e.g., Raynor & Entin, 1982; Strathman et al.,
1994) while others conceptualize it as a cognitive schema (Tobacyk & Nagot, 1994).
Regardless of this discrepancy, temporal orientation has been generally accepted to refer
to the time perspective that guides, motivates, and influences an individual‟s actions and
goals (Henson et al., 2006). While all three different time perspectives have been
researched in relation to health behaviors, a temporal orientation to the past has suggested
little explanatory value among the behavior of young adults (the population of interest in
this study) (Henson et al., 2006). As a result the majority of research that has been done
with young adults has focused primarily on a temporal orientation to the present or the
future. To elaborate on the definitions provided above, present time perspective refers to
a primary orientation to the here and now that leads to an inclination to form goals and
perform behaviors that meet immediate desires. Henson and colleagues (2006) report on
two different types of present orientation which are theorized to lead to different
outcomes for the individuals that espouse them. These are hedonistic present time
perspective, which evokes immediate, pleasure-oriented goals, and fatalistic time
perspective, which is typified by general pessimism and self-destructive behavior.
Conversely, individuals with a more future oriented time perspective are more likely to
15
refrain from immediate pleasure in order to focus on long-term rewards (Boyd &
Zimbardo, 2005). Time perspective or temporal orientation has long been studied in
relation to the performance of health behaviors. The overarching finding has been that
present time perspective is closely linked to and predicts risky health behaviors while
future time orientation is linked to the performance of fewer risky behaviors (Henson et
al., 2006). In a study of driving styles, findings indicated that present time orientation
was positively correlated with risky driving behaviors, while future oriented individuals
showed much lower levels of risky driving (Zimbardo et al., 1997). Similarly, in two
different studies of substance abusers, the authors reported that individuals with present
time orientations were significantly more likely to be heavier users of illicit substances,
while those with a future time orientation reported less substance use (Keogh et al., 1999;
Wills et al., 2001). In the same vein, Rothspan and Read (1996) reported associations
between present time orientation and frequent sexual behavior with more sexual partners
and future time orientation and delayed onset of sexual behavior with fewer sexual
partners. Additionally, a temporal orientation to the future has been shown to correlate
positively with condom use (Burns & Dillon, 2005; DiIlorio et al., 1993) and exercise
and healthy eating (e.g., Mahon et al., 1997). Burns and Dillon‟s (2005) study on African
American college students revealed that individuals with greater future time orientations
showed greater probability of condom use. The authors further note that this was seen
especially among the women sampled in their study in that women with stronger future
orientations exhibited more frequent current and past condom use during sexual activity
than male students. While this is one of the first studies to examine this construct among
a group of African American young adults, undergraduate students are likely extremely
16
different from the sample that will be recruited for the current study. A student sample
may be quite different than a community sample even if they have similar racial and
demographic characteristics.
While many studies have investigated temporal orientation as a precursor to
behavior, Padawer and colleagues (2007) questioned why so few studies have examined
the antecedents of future time perspective. Because of the dearth of research in this area,
these researchers conducted a study to investigate the link between time orientation and
demographic variables including age, education level, income, marital status, and sex.
The authors reported that four of these five demographic indicators covaried significantly
with future time orientation. Stronger future orientations were more likely to be found
among individuals who had higher incomes, were older, were male, and were more
highly educated. Marital status did not significantly correlate with future orientation.
Interestingly, results differed by age for men and women. Older men and women both
showed a modest relationship between education level and future time perspective;
however young women differed in that their education level did not significantly relate to
future time orientation. This has significant implications for the current study as the
proposed target population to be sampled is primarily young, female, less educated and
low-income. Padawer and colleagues‟ research shows that the sample intended to be
collected are significantly less likely to be oriented to their own futures. What is
interesting about this study is that pregnant women were not included in this sample and
so while generalizations can be made about young, low-income, less educated non-
pregnant women, the question remains as to whether these same conclusions can be
applied to women who are currently expecting a child. The reasoning here is that women
17
who are pregnant have a specific future date to which they may be oriented as they
anticipate the birth of their child. Therefore, pregnancy may be a time during which
temporal orientation shifts towards the future.
1.8 Power in Romantic/Sexual Relationships
The balance of power in romantic and sexual relationships has been found to have
consequences for individuals engaged in these types of relationships (Felmlee, 1994).
Some examples of these types of consequences include general psychological well-being,
relationship satisfaction, and level of conflict within the relationship. A study by Horwitz
(1982) found that men and women who occupied more powerful roles in their
relationships experienced lower levels of psychological distress than did those who
reported less power than their romantic partner. A number of similar studies find that a
more equal balance of power is associated with higher levels of relationship satisfaction
(Gray-Little & Burks, 1983). Additionally, other research suggests that power
imbalances are more highly related to increases in conflict in a partnered dyad. In a study
of lesbian couples, Caldwell and Peplau (1984) found that those women who perceived
an inequitable balance of power anticipated a greater number of problems or difficulties
than those with more equitable relationships.
Despite these findings indicating that unequal power distribution can cause
problems for the relationship, our society is still one in which males most often dominate
in relationships and otherwise. Gender-based power is derived from the social norms that
accompany the biological differences between men and women and refers to the societal
expectations about appropriate gendered behavior (Blanc, 2001; Gupta, 2000). Blanc
18
(2001) states that gender-based power in sexual relationships is frequently unbalanced
and that women usually have less power than men.
Power in romantic and sexual relationships has been defined in a variety of ways
(Blanc, 2001). According to past feminist literature, gender affects both the “power
over” and “power to” (Riley, 1997). According to Riley (1997) “power to” refers to the
ability to act, while “power over” refers to the ability to assert wishes or goals even in the
face of opposition from a significant other. Pulerwitz and colleagues (2000) state that for
the purposes of studying the role of power in sexual relationships, the “power over”
construct refers to one partner‟s ability to act independently of the other, dominate the
decision-making, engage in behavior against the other‟s wishes, or to control a partner‟s
behavior or actions. Blanc (2001) notes that it is not the absolute power of one member
of the dyad that is important, rather it is the “comparative influence of each partner
relative to the other.”
In the Boston Dating Couples study conducted by Peplau (1979; 1984; Peplau &
Campbell, 1989) the author found that less than half of both male and female respondents
reported that their relationships were equally balanced in terms of power. Among the
participants who reported a discrepant power balance, the majority perceived the man to
hold more power in the relationship. Another more recent study confirmed these findings
by Peplau and colleagues. Felmlee (1994) enrolled 413 heterosexual dating individuals
in her study of power dynamics in romantic and sexual relationships. Her findings
indicated that less than half of the dyads reported an equitable balance of power. In
couples where there was a recognized imbalance of power, the author found that the man
in the couple was more likely to be viewed as the dominant partner (Felmlee, 1994).
19
These findings have significant implications for women in imbalanced
partnerships especially in the current age of the HIV/AIDS epidemic. In cases where
women have less power than their male partners, those women in communities where
HIV/AIDS is prevalent are at higher risk for contracting these infections. A woman‟s
ability to negotiate safer sex practices with her partner is a critical component of
HIV/STD prevention strategies (Pulerwitz, Amaro, DeJong, Gortmaker, & Rudd, 2002)
and is influenced by both her and her partner‟s level of power in the relationship.
Researchers examining condom use have proposed that these types of gender-based
imbalances of power can restrict a woman‟s capacity to negotiate safer sex through
condom use (e.g. Amaro, 1995; Bowleg et al., 2000; De Bruyn, 1992; Ehrhardt et al.,
1991; England, 1997; Felmlee, 1994; Gage, 1997; Gomez, et al., 1996; Heise et al., 1995;
Monahan et al., 1997; Pulerwitz et al., 2002; Wingood, et al., 1998). Amaro &
Gornemann‟s 1992 study examined 69 focus groups comprised of Latinas living in the
United States and found that the issues of power and condom use created a major
obstacle to HIV risk reduction behaviors in three fourths of the groups. This is important
and troublesome as women must rely on cooperation from their male partner in order to
successfully use a male condom during sexual contact (Campbell, 1995). Pulerwitz and
colleagues (2002) acknowledge that not much research has been done in the area of
relationship power and its relationship with condom use. Due to the dearth of knowledge
on that topic and the use of unvalidated measures in the few previous studies that had
been conducted, the authors created and validated the Sexual Relationship Power Scale
(Pulerwitz et al., 2000). They then used this scale to test the hypothesis that relationship
power constitutes a key factor in condom use negotiation. Their findings indicated that
20
women with high and medium levels of power in their romantic and sexual relationships
were significantly more likely to report consistent condom use than women with low
levels of power. In fact, women with high, medium and low power in their relationships
reported declining rates of condom use. Women with high power reported that they were
5.96 times more likely to use condoms and women with medium power were 3.66 times
more likely to use condoms (Pulerwitz, et al., 2002).
1.9 Female Condom Use
The female condom was approved for use by the Food and Drug Administration
in 1993 as a female-controlled method to prevent unintended pregnancies and HIV and
other STDs (Gollub, 2000). In a 1994 study to determine the contraceptive efficacy of
the female condom among 328 participants over 6 months, the accidental pregnancy rate
was in the same range as other recommended barrier methods. In addition, the female
condom has the added benefit of preventing STIs including HIV (Farr, Gabelnick,
Sturgen, & Dorflinger, 1994). Due to these and other favorable study results, many
policy-makers, public health agencies, community based groups and individual
practitioners both in the United States and internationally have advocated the use of the
female condom for its intended purposes (Gollub, 2000). Research trials with the female
condom have suggested that there is a high level of interest in this method and that its use
is feasible in high-risk populations. Some of the most liked features of the female
condom include the fact that women can place it autonomously and trust that it is not torn
or otherwise sabotaged by a partner, the high level of protection it affords when used
correctly, and its soft and lifelike feel. The features of the female condom that are most
unappealing to women in high-risk populations are the need to practice insertion before
21
use, the fact that it can be seen by the partner (because it hangs outside of the body), and
for some, the discomfort of the inner ring (Gollub, 2000).
The availability of the female condom can be empowering for some women.
Before its inception, a woman‟s only option for protecting herself from unintended
pregnancy and STDs in case of her partner‟s refusal to use a male condom was to refuse
sex altogether. This was often problematic however in the context of a relationship;
refusal can be perceived as antagonistic, and there may have been the possibility or threat
of violence. The female condom can be used as a tool by a woman in the non-threatening
negotiation between partners (Gollub, 2000).
1.10 Power in Relationships and Partner Refusal to Use Condoms
Partner refusal is an especially important deterrent to actual condom use among
those women who have high condom use intentions because of financial dependence on
their male partner, social norms that discourage an active role, and even fear of physical
violence. Because impoverished women often live in communities where HIV and STD
prevalence is high, barriers to consistent condom use can put them at especially high risk
of infection (Santelli et al., 1996). Heterosexual relationships are often characterized by
adherence to traditional gender roles and power inequalities that create an environment in
which men have greater or absolute power in the safer sex decision-making arena. This
is especially true in high-risk heterosexual communities (Exner, Gardos, Seal, &
Ehrhardt, 1999). In a study of 362 primarily African American women living in Miami,
Florida, 56% of the participants had a main partner resist her condom use attempt.
Fourteen percent of that group of women had a partner ignore her, 22% had a partner
argue with her, 28% had a partner who thought the woman was accusing him of having a
22
disease, 24% had a partner who thought the woman was having sex with others, and 45%
had a partner who thought the woman was accusing him of having sex with others
(Perrino, Fernandez, Bowen & Arheart, 2005). Levine Kornfield & Geller (manuscript in
preparation) found that pregnant women who had experienced a partner‟s refusal to use
condoms were significantly less likely to actually use condoms. The authors posit that
this could be due to a woman‟s partner indicating he would not allow condom use or to
the woman herself learning from past experience that it upsets her partner to even ask.
Interestingly, other studies show that women are more likely than men to actively
initiate condom use and initiative on the part of the female partner regarding condom use
is extremely important in actually achieving condom use (Troth & Peterson, 2000).
Women report that requesting condom use within an established relationship often
creates conflict stemming from accusations about fidelity and STIs, or complaints about
loss of sexual pleasure (Neighbors, O‟Leary & Labouvie, 1999).
Some feminists posit that asking women to initiate and insist upon condom use by
their male partners causes men to view the condom as an interruption of the “normal” and
“natural” practice of unsafe heterosexual sex (Vitellone, 2002). Women‟s responsibility
for condom use is understood to challenge the spontaneity that often characterizes sex
between a man and a woman and can be seen as feminizing the true masculinity of
heterosexual sex (Vitellone, 2002). Other literature cites more straight-forward reasons
that men do not like to use condoms such as discomfort, loss of sexual pleasure, and
interruption of the spontaneity of the sexual act leading to a loss of erection.
23
1.11 HIV/AIDS Risk Perception
Many minority women feel that they are not personally at risk for HIV infection.
According to a study conducted by Kalichman, Hunter, and Kelly (1992), minority
women reported less concern about contracting the virus that causes AIDS and they
estimated their personal risk to be lower than did nonminority women. Similar to gay
men at risk for HIV infection, women in this study showed an optimistic bias, defined as
perceiving their own risk to be less than that of others, which may help explain why
women (especially those who are labeled high-risk) are unlikely to use condoms
(Helweg-Larsen & Shepperd, 2001; Kalichman, Hunter, & Kelly, 1992). More recently,
investigators Takahashi, Johnson, and Bradley (2005) found that in a study of 2,911
sexually active adults who completed the Sexual Behavior Module of the 2000
Behavioral Risk Factor Surveillance System nationwide survey, among the 51% of the
sexually active adults (between the ages of 18 and 49 years) in their study who were at
any increased risk of HIV infection (defined as having two or more partners in the past
year, having used intravenous drugs, having been diagnosed with a sexually transmitted
disease or having anal sex without a condom in the last year), 84% considered their own
personal risk to be “low” or “none at all.” Similarly, Stringer and colleagues (2004)
reported that 52% of the 245 women in Lusaka, Zambia who reported that they were at
“low” or “no risk” for HIV infection (before being informed of their actual serostatus)
were actually already infected with the virus. An additional finding of this study was that
women with higher levels of HIV/AIDS-related knowledge appeared more likely to
engage in more risky behaviors (Stringer et al., 2004).
24
Perceived risk is frequently cited as a necessary component of behavioral change,
and has been listed as a central construct in many major health behavior models
(Kaemingk & Bootzin, 1990). Perceived risk maintains a position of central importance
in each the health belief model, the common sense model of illness danger, the theory of
reasoned action, the PRECEDE model, the Information, Motivation, and Behavioral
Skills (IBM) model, and the AIDS Risk Reduction Model (ARRM) (Kowalewski,
Henson, & Longshore, 1997). The general idea behind the inclusion of perceived risk
with a position of importance in each of these well known models is that individuals who
recognize that their behavior places them at increased risk of HIV infection are more
likely to engage in less risky behaviors than those who do not. But as stated above,
individuals tend to underestimate their own risk as the phenomenon of unrealistic
optimism tends to skew their assessments of their own risk. What complicates matters
further is the fact that risk perception is likely influenced by one‟s social identity or group
membership; values, attitudes, beliefs, and behaviors are all developed in relation to
one‟s reference group. Additionally, the moral stigma associated with HIV and AIDS
and the tendency to deny risks associated with stigmatized behaviors may lead members
of one high-risk group to underestimate their risks relative to those of another at-risk
stigmatized group (Kowalewski et al., 1997).
Existing literature on health behavior research has seen perceived risk used as
both an outcome variable as well as a predictor variable (Catania, Kegeles, & Coates,
1990). Kowalewski and colleagues (1997) reviewed relevant literature and reported that
a variety of factors have been found to predict perceived risk of HIV infection. Among
these factors are ethnicity, gender, partner characteristics, personal history of injection
25
drug use, having had multiple sex partners, social proximity to persons with AIDS, fear
of AIDS, or health concerns (see Kowalewski et al., 1997). Conversely, findings
regarding perceived risk as a predictor variable in the adoption of health behaviors has
been mixed and inconclusive. Several studies found that heightened risk perceptions are
significantly related to reductions in risky behaviors or intentions to engage in HIV
preventative behaviors (e.g., Allard, 1989; Cochran & Peplau, 1991; Moatti, Bajos,
Durbec, Menard, & Serrand, 1991). Cochran and Peplau (1991) and Schilling, El-Bassel,
Gilbert, and Glassman (1993), for instance, both found indirect relationships between
perceived risk and high-risk sexual behaviors. Still, other researchers found no
relationship between perceived risk of HIV infection and the adoption of protective
health behaviors or intentions to adopt these behaviors (e.g., James, Gillies, & Bignell,
1992; O‟Leary, Goodhart, Jemmott, & Boccher-Latimore, 1992). These inconsistencies,
however, do not indicate that perceived risk is an unimportant or irrelevant construct in
regards to HIV/AIDS prevention efforts, rather they highlight the increased need for
further exploration within different populations.
26
2. THE CURRENT STUDY
2.1 Rationale
An internal locus of control, a future orientation, increased power in relationships,
and high perceived risk of HIV infection are all more likely to increase intended and
actual condom use among women (Burns & Dillon, 2005; Kelly et al., 1990; Pulerwitz et
al., 2000; Schilling, El-Bassel, Gilbert, and Glassman, 1993). However, in general,
pregnant women are less likely than their non-pregnant peers to use condoms as the
contraceptive motivation is lacking (i.e., the thought that “the damage is already done”)
(Crosby et al., 2002). What they may not realize is that this increases their chances of
STD or HIV infection during pregnancy. Pregnant women are often motivated by
maternal feelings to improve their health for the sake of their developing child (Hobfoll et
al., 1993); perhaps pregnancy itself and the maternal attachment that accompanies it may
increase a woman‟s perceived power in the relationship, future orientation, internal locus
of control, and perceived risk now that she is acting on behalf of her unborn child as well
as herself.
2.2 Hypotheses
2.2.1 Planned Hypotheses
Hypothesis 1: Pregnant women with higher levels of maternal fetal attachment (or
positive attitudes towards the pregnancy and the baby) are more likely to have a future
oriented temporal perspective than women with lower levels of maternal fetal attachment.
Rationale for Hypothesis 1: MFA is significantly associated with engagement in positive
health promotion behaviors during pregnancy (Lindgren, 2001). Future time orientation
27
is linked to refraining from immediate pleasure in order to focus on long-term rewards.
Among pregnant women, the health of the unborn child can be seen as a long-term
investment, however the level of MFA may influence whether the mother-to-be
experiences a more future or present time orientation during her pregnancy. This is
especially important because little research (e.g., Burns & Dillon, 2005) has examined
these variables in a low-income, minority group, and no studies have been done on the
temporal orientation of pregnant women.
Hypothesis 2: Pregnant women with higher levels of maternal fetal attachment (or
positive attitudes towards the pregnancy and the baby) are more likely to have an
internal AIDS health related locus of control compared to women with lower levels of
maternal fetal attachment who may be more likely to have an external LOC.
Rationale for Hypothesis 2: MFA is significantly associated with engagement in positive
health promotion behaviors during pregnancy (Lindgren, 2001). Internal AIDS health
locus of control is also more closely linked to positive HIV/AIDS preventative behaviors
among gay men, but not among black undergraduate students (Kelly et al., 1990; Burns
& Dillon, 2005). Earlier research found that “poor black women” (Fisch, 1974) were
highly external; however this research was conducted on non-pregnant women. To date,
no research has been conducted on how MFA influences health related locus of control in
a sample of minority women living in poverty.
28
Hypothesis 3: It is expected that maternal-fetal attachment moderates the relationship
between health related locus of control and engagement in positive prenatal health
behaviors/risk reduction behaviors.
Rationale for Hypothesis 3: Following from the findings of Norman and colleagues
(1998) who found evidence to suggest that the value one places on his or her own health
moderates the relationship between health locus of control and engagement in health
behaviors, it is expected that MFA will act in the same way as the value one places on his
or her own health. As pregnant women may place a higher value on their own health in
an attempt to secure the health of their unborn child, in the current study, the extent to
which the pregnant woman values the pregnancy (i.e., attachment and attitude towards
the pregnancy) will be a proxy for value on health.
Hypothesis 4: It is expected that maternal-fetal attachment moderates the relationship
between temporal orientation (future vs. present) and engagement in positive prenatal
health behaviors/risk reduction behaviors.
Rationale for Hypothesis 4: It is known that individuals with a future oriented time
perspective are more likely to engage in positive health promotion behaviors and fewer
risky behaviors, and that pregnant women with higher levels of MFA do the same. It is
expected in this study that the level of MFA will influence the strength of the relationship
between temporal orientation and health promotion/risk reduction behaviors such that
women with higher levels of MFA and a future temporal orientation will be most likely
to engage in positive prenatal health behaviors and HIV risk reduction behaviors, while
29
women with subsequent combinations of high/low MFA and future/present temporal
orientations will show decreasing probability to engage in such behaviors.
2.2.2 Exploratory Hypotheses
Hypothesis 5: Among pregnant women, higher levels of maternal-fetal attachment will be
associated with a higher level of perceived relationship power.
Rationale for Hypothesis 5: MFA has been associated with many positive health
practices during pregnancy. Other research has shown that women with higher levels of
power within their romantic relationships are more likely to use condoms, which is also
considered a positive health practice regardless of pregnancy status. Because MFA
predicts positive health behaviors, as does level of relationship power, it is therefore
hypothesized that the more attached a woman is to the unborn child, the more empowered
she may feel in her relationship with her partner to insist on methods to protect the fetus.
Hypothesis 6: It is expected that level of maternal-fetal attachment will moderate the
relationship between relationship power and condom use in a sample of pregnant
women.
Rationale for Hypothesis 6: Research on perceived power in relationships suggests that
women with higher levels of power in their romantic partnerships are more likely to have
their partners agree to use male condoms and to actually follow through on intentions to
use condoms. Similarly, pregnant women with higher levels of MFA are also more likely
to engage in health promotion and risk reduction behaviors during pregnancy. It is
hypothesized that MFA and relationship power will interact significantly in the prediction
of condom use/risk reduction behaviors during pregnancy.
30
Hypothesis 7: Among pregnant women, higher levels of maternal fetal attachment are
significantly associated with higher levels of HIV risk perception.
Rationale for Hypothesis 7: Literature on risk perception indicates that it has been
explored as both a predictor variable as well as an outcome variable. In studies
examining risk perception for HIV infection as a predictor variable, it has been shown
that increased risk often leads to engagement in less risky behaviors (e.g., Schilling et al.,
1993). It is hypothesized here that the MFA that develops during pregnancy may
influence a woman‟s perceived risk for HIV infection such that women with higher levels
of MFA will show higher levels of risk perception.
31
3. METHODS AND PARTICIPANTS
3.1 Participant Recruitment
Pregnant participants for the current study were recruited from the waiting room
of the Women‟s Care Center located at 1427 Vine Street, Philadelphia, Pennsylvania.
This clinic is an affiliate of the Drexel University College of Medicine and Hahnemann
Hospital Tenet Health Care System. The director of the Women‟s Care Center, Dr.
Sandra Wolf, gave her permission for recruitment and assessment protocols for this study
to take place at the clinic. The clinic‟s patients consist mainly of low-income, Black
women living in the city of Philadelphia. About one third of the women who present for
care are pregnant with their first child, while the remaining two thirds of the women
present with a subsequent pregnancy.
3.2 Inclusion Criteria
Pregnant women who were over age 18 years and fluent English speakers (at a 6th
grade reading level), were included in the study. In order to have had time to confirm
their pregnancy status and possibly been sexually active while knowing that they were
pregnant, participants were required to be at least 20 weeks pregnant. Participants must
have had penile-vaginal intercourse at least once since learning they were pregnant as
well as have used a condom at least once during vaginal sexual intercourse with a male
partner in the year prior to becoming pregnant. Participants were also required to be
HIV-negative at last HIV test. HIV tests are routinely administered to pregnant women
at their first prenatal visit so every pregnant woman was aware of her HIV status.
32
The inclusion criteria listed above specify that in order to be eligible for the study,
women must have used condoms during penile-vaginal intercourse at least some of the
times during the previous year in order to capture a sample of women who are amenable
to using condoms at all.
Although previous research (Zimerman & Doan, 2005) has shown differences in
attachment scores as measured on Condon‟s Maternal Antenatal Attachment Scale (1993)
such that first time mothers score higher on prenatal attachment than do mothers pregnant
with a subsequent child, this study will not restrict enrollment to first time mothers.
Authors Zimerman and Doan (2005) have suggested that perhaps pregnant women
expecting a subsequent child are busy with their already existing children, which leaves
them less time to think about the developing fetus. Alternatively they also posit that
perhaps these results were found due to the fact that these women have already
experienced pregnancy before, these mothers feel less preoccupied with the fetus and
pregnancy as it is more routine. Regardless of the reasons why first time mothers report
higher levels of attachment than mothers pregnant with subsequent pregnancies, these
differences were accounted for by statistical control as opposed to research design
control.
3.3 Exclusion Criteria
Pregnant women over the age of 35 were excluded from the current study as
women of advanced maternal age may be at higher risk for complications during
pregnancy and may therefore be otherwise motivated to preserve the health of the fetus
for other reasons. Additionally, men were excluded from the study.
33
3.4 Recruitment and Assessment
All female patients attending the Women‟s Care Center who were between 18-35
years old and at least 20 weeks pregnant were approached by study personnel following
referral from medical clinic staff. The patients were approached by the study researcher
or research assistant in the waiting room of the clinic, after they had undergone the initial
triage and were waiting for a room assignment in order to be seen by the doctor or nurse
practitioner.
The study research assistant asked the woman if she would be interested in
answering a few questions while she waited for the doctor. If she agreed, the consent
form and the screening questionnaire were then administered in a secluded area of the
waiting room. If the woman was eligible to participate she was then invited to continue
with a longer set of questions and self-report measures. An example of the script that
was used is as follows:
“If you agree to participate, I‟ll ask you a series of questions about various
topics related to your pregnancy. I‟ll be asking you about your behaviors,
attitudes and beliefs regarding your pregnancy, your baby, and your sex
life before and since you‟ve become pregnant. I‟ll also ask you to fill out
some questionnaires. Does this sound okay to you? Would you be
interested in participating while you wait for the doctor?”
3.5 Informed Consent
The purpose of the study was explained to the women as research which intends
to investigate sexual and health related behaviors, attitudes, and relationship issues
among sexually active pregnant women in order to better protect the health of women and
34
their children. The participants were told that there are no real benefits to participation in
the study other than that they may learn something new about themselves. Risks were
explained by acknowledging that that certain questions may cause mild distress. The
participants were told that all identifying information would be kept confidential, no
records with a name would ever be shown to a woman‟s doctor or partner, and that after
the study enrollment, all documents would be identified with a research ID number.
Finally, each participant was informed that she would receive $5 in cash to thank her for
her time in participating.
3.6 Training
Each research assistant associated with this project was trained to ensure that she
was able deliver the assessment in a sensitive and competent way. Research Assistants
were three female graduate students in the fields of psychology or post-baccalaureate pre-
medicine. The training they received consisted of a sexual desensitization workshop
where they learned to feel comfortable with the terminology they would be using during
the protocol. There was also a sensitivity training regarding multicultural issues in light
of the fact that the majority of the participants are expected to be low-income minority
women. This ensured that the research assistants who collected the data behaved in a
way that is consistent with the non-judgmental and sensitive attitudes that generally make
it easier for the research participants to respond truthfully.
3.7 Ethical Considerations
It was determined that if, during the study, any participant became distressed by
the subject matter, the proper referral to a mental health practitioner or hotline would be
35
made. A list of phone numbers of mental health practitioners in the area and Philadelphia
mental health hotlines was provided to all participants at the start of the study.
Additionally, Dr. Sandra Wolf the primary care obstetrician and the Women‟s Care
Center‟s staff social worker were to be informed by the study personnel of any adverse
reactions the participants may have to the study protocol. There was only one such case
where a referral was warranted and the appropriate steps were taken to ensure that this
woman was seen in a timely manner by the social worker on duty at the time.
3.8 Measures
Maternal Antenatal Attachment Scale (MAAS; Condon, 1993)
The MAAS was developed and validated by Condon, an Australian researcher
who critiqued the existing instruments by noting that they inadequately differentiated the
attitude towards the baby from the attitude towards the pregnancy and impending role of
motherhood. Condon‟s measure focuses on the thoughts and feelings about the baby and
ignores attitudes about the physical state of pregnancy or the maternal role. The measure
consists of two factors, quality and intensity. Quality describes the affective experiences
the mothers reported including closeness/distance, tenderness/irritation, positive/negative,
joyful/unpleasant anticipation, and a vivid/vague internalized representation of the fetus
as a real person. Intensity refers to the amount of time the mother spends thinking about,
talking to, dreaming about, or tactilely interacting with the fetus. This instrument
contains 19 items and a high internal consistency with alpha equal to .82.
Maternal Attitudes and Maternal Attachment (MAMA; Kumar, Robson, & Smith, 1984)
The MAMA questionnaire was developed and validated by Kumar, Robson, and
Smith in 1984. The questionnaire consists of five subscales measuring body-image,
36
somatic symptoms, marital relationship, attitudes towards sex, and attitudes to pregnancy
and the baby. For the purposes of the current study, only the subscale measuring
attitudes to pregnancy and the baby will be used. This subscale includes 12 items rated
on a 4-point Likert type scale ranging from “never” to “very often.” The questionnaire
was tested on a group of 218 pregnant women who either volunteered to help validate the
measure (n=99) or were already taking part in a prospective study of mental health
(n=119). Responses were recorded at the 12th week of pregnancy. Test-retest reliability
(n=38) revealed an alpha of .81, while split-half reliability (n=119) showed an alpha of
.74. The Attitude Toward Pregnancy and the Baby subscale was significantly correlated
with responses on both the Neonatal Perception Inventory and a systematic interview
administered by the researchers that had previously been shown to have satisfactory inter-
rater reliability (kappa = .90). The 60-item questionnaire was completed by the majority
of participants without difficulty in about 10 minutes. Because only one subscale (12
questions) of the questionnaire will be used, it is anticipated that the measure will take as
little as 2-3 minutes to complete.
Of the measures describing MFA, the MFAS and the MAAS are the two most
commonly used measures (Laxton-Kane & Slade, 2002).
Health Practices in Pregnancy Questionnaire-II (34-item) (HPQ-II; Lindgren, 2005)
The original HPQ (Lindgren, 2001) is an 18-item self-report questionnaire
designed to assess health practices during pregnancy that have been shown to be related
to pregnancy outcomes: diet, substance abuse, adequacy of prenatal care, rest and
exercise, use of seatbelts, and education about childbearing. Despite good internal
reliability and validity, the author felt there were shortcomings and revised the
37
Questionnaire to improve some awkward items and some items that may not be clear to
minority populations, resulting in the HPQ-II. The HPQ-II is a 34-item scale that
addresses adequacy of health practices in the following areas: balance of rest and
exercise, safety measures, nutrition, avoiding use of harmful substances, obtaining health
care, and obtaining information. Each item is rated on a 5-point Likert scale ranging
from 1 (never) to 5 (always, daily, or frequently). Higher scores indicate a higher quality
of health practices important to pregnancy outcomes. The potential scale range is 34-170
and the measure takes approximately 10 minutes to complete. The HPQ-II has an alpha
coefficient of .81 and was significantly correlated with both The Health Promoting
Lifestyle Profile (r = .54) and the Attitudes Toward Pregnancy and the Baby subscale of
the MAMA (r = .30).
Sexual Relationship Power Scale (Pulerwitz et al., 2000)
The Sexual Relationship Power Scale was developed by Pulerwitz and colleagues
(2000) to assess power in intimate relationships. The SRPS is a 23-item scale that is
comprised of two subscales measuring issues related to Relationship Control and
Decision-Making Dominance within the relationship. The subscales are sufficiently
reliable to use independently or in conjunction with one another. The internal
consistency reliability of the overall scale is .84. The Relationship Control subscale
consists of 15 items and has a reliability coefficient of .86, while the Decision Making
Dominance subscale includes 7 items and a reliability coefficient of .62. The measure
was validated on a population of African American and Latina women, which makes it
useful for the current study which aims to capture a sample of similar women. The SRPS
contains four items which are related to condom use (e.g., “If I asked my partner to use a
38
condom he would get angry”). These items were removed and the Scale reanalyzed in
order to ensure that the SRPS‟s association with consistent condom use was not solely
related to these four items. The modified version of the scale (SRPS-M) still showed a
significant relationship with the outcome of consistent condom use. The SPRS-M also
shows good internal reliability (alpha = .85) as does each of the subscales (alpha,
Relationship Control = .84; alpha, Decision Making Dominance = .60).
Perceived Risk Scale (Lollis et al., 2000)
The Perceived Risk Scale consists of five face valid questions designed to assess
worry or concern about AIDS and feelings regarding one‟s likelihood of contracting the
virus. Three items on the scale were adapted from a scale used by Adame and colleagues
(1991) which measured students‟ perceived susceptibility, knowledge, and attitudes
regarding AIDS. Lollis and colleagues (2000) also retained two additional items that had
been added to the scale by Johnson and colleagues (1992). Items are presented on a five
point Likert scale from Strongly Disagree (1) to Strongly Agree (5) and a composite
score is obtained by adding the numbers each participant endorses. Higher scores on this
measure indicate increased perceptions of AIDS vulnerability. The alpha coefficient for
this scale is good at .73.
AIDS Multidimensional Health Locus of Control Scale (AIDS MHLOC; Kelly et al.,
1990)
The AIDS MHLOC Scale is used to assess AIDS related health locus of control
and is an adaptation by Kelly and colleagues (1990) of the original Health Locus of
Control (HLOC) Scale (Wallston, Wallston, & DeVellis, 1978). Kelly and colleagues
(1990) modified nine items to make the scale pertinent to HIV/AIDS. These items
39
reflected the original measures‟ three dimensions: Internal Control, Chance/Luck
External Control, and Powerful-Others External Control. All items are arranged on a six
point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). While Kelly
and colleagues (1990) did not report on psychometric properties of the revised items
within the scale, Glaser (1995) did. Glaser (1995) reported an internal consistency of
alpha = .77 and a test-retest reliability at two weeks apart of .86. This author also
reported on the reliability for the individual subscales; alpha = .75, .57, and .55 on the
Internal Control, Chance/Luck External Control, and Powerful-Others External Control
subscales respectively. Due to the low reliability among the External subscales of the
AIDS MHLOC Scale, these items were reserve scored and summed with the internal
items to create a total score. Higher scores reflect higher levels of an internal locus of
control. The reliability for this summated scale was determined to be fair (alpha = .69)
(Burns & Dillon, 2005; Glaser, 1995).
Zimbardo Time Perspective Inventory (Zimbardo & Boyd, 1999; also referred to as the
Stanford Time Perspective Inventory) (37 items)
Zimbardo and Boyd (1999) developed and validated the Zimbardo Time
Perspective Inventory thus improving the theoretical basis of time perspective/temporal
orientation by reconceptualizing the construct as an overarching, non-conscious
psychological process which includes social, personality, affective, and cognitive
influences which shape a person‟s perceptions, actions, and goals. There are three
subscales which each use a 5-point Likert response scale ranging from “very
uncharacteristic” to “very characteristic.” The future scale includes 13 items, the
hedonistic scale, 15 items, and the fatalistic scale, 9 items. Reliability for the scales is
40
good with average inter-item correlation for the future, hedonistic, and fatalistic scales
reported at .24, .22, and .25 respectively. The average corrected item total correlations
were reported at .44, .41, and .42 for the future, hedonistic, and fatalistic scales,
respectively. And, lastly the alpha reliability coefficient was .81, .80, and .74
respectively for the three scales. For the purposes of this study, only the future and the
hedonistic scales will be given. Personal communication with the first author has
confirmed that this is an acceptable use of the instrument (P.G. Zimbardo, personal
communication, July 31, 2008).
3.9 Statistical Power Analyses
Based on the program g-power in combination with Cohen‟s power tables (1992),
it was determined that in order to see a power of .80 with a medium effect size (.30) and
alpha equal to .05, 84 participants will be necessary to detect an effect if it really exists
for those hypotheses (1, 2, 5, & 7) that will utilize a linear regression analysis. Sixty-
eight participants are necessary for those hypotheses (3, 4, & 6) which will utilize a
multivariate regression moderator analysis, assuming that the minimum accepted power
of .80 will be used along with a medium effect size (.15) and alpha equal to .05.
41
4. RESULTS
All data were analyzed using the Statistical Package for the Social Sciences (SPSS)
version 16. Initial descriptive analyses were conducted to provide sociodemographic
information about the women who participated in the study, as well as more detailed
information about other variables of interest.
4.1 Participant Sociodemographics
Over the course of one year (January-December 2009), a total of 269 women were
approached in the waiting room of an urban prenatal clinic after having been identified by
clinic staff as eligible according to maternal and gestational age. Of this number, a total
of 101 women enrolled in the study. A total of 168 women did not participate; 39 were
interested but self-reported they were ineligible once the study criteria were explained,
and 129 declined to participate. No demographic data were collected from the women
who did not participate as the Drexel University Institutional Review Board did not grant
approval for this. Of the 39 women who were interested but did not enroll, 35.8% (n=14)
self-reported that they were not eligible due to their age (less than 18 or over 35), 23%
(n=9) self-reported that they were not eligible due to being less than 20 weeks gestation,
15.4% (n=6) self-reported that they were not eligible due to lack of condom use, 12.8%
(n=5) women were ineligible due to lack of English language fluency, 10.25% (n=4) self-
reported that they were not eligible due to lack of sexual activity during pregnancy, and
5.1% (n=2) declined to answer why they were ineligible. Of the 129 women who
declined to participate, 58.1% (n=75) stated they were not interested while the remaining
41.9% (n=54) women stated that they did not have time. Roughly 50% of the women
who reported that they did not have time reported that this was the case because they
42
were scheduled to have an ultrasound directly following the scheduled prenatal
appointment.
One hundred and one eligible pregnant women were enrolled in the study. Of
these, 100 women completed the study by answering all of the interview questionnaires.
The one woman who did not complete the study was unable to do so as clinic staff
recommended she go directly to the labor and delivery unit shortly after beginning the
interview. Data from this participant were excluded from the analyses. As expected,
non-Hispanic Black women comprised the majority of the sample, representing 81%
(n=81) of the participants. Non-Hispanic white women made up 5% of the sample,
Hispanic Black, Hispanic „other‟, and non-Hispanic biracial women each comprised 4%,
and Hispanic biracial women represented 2%. The mean age of the participants was
23.56 years old with a standard deviation of 5.098 and a range of 18-35.
Of the 100 participants in the study, 48% reported themselves as never married,
43% reported themselves as single and living with their partner, and 9% were married.
On average, the women presented for enrollment in the study at 30.46 weeks gestation
with a standard deviation of 6.3 weeks, and a range from 20-40 weeks. For 41% of the
women, the current pregnancy would result in their first living child; 33% percent of
women already had one child, 14% had two, and 12% had three or more children.
Twenty-nine women reported that the current pregnancy was their first. Of the 71
women who reported having had a prior pregnancy, 49.3% (n=35) reported having had at
least one elective abortion and 31% (n=22) reported having had at least one spontaneous
pregnancy loss.
43
Eighty-two women (82%) reported that the current pregnancy was unplanned.
Only 18 women (18%) reported having planned to become pregnant with the current
pregnancy. Of the 82 women who did not plan their pregnancies, 17.1% (n=14) reported
not having wanted the current pregnancy or any future pregnancies in their lifetime. Of
the remaining 68 women who had desired a future pregnancy at some point in their
lifetime 70.5% (n=48) reported that the pregnancy had occurred too soon, 17.6% (n=12)
reported that it had occurred at the right time, 2.9% (n=2) reported the pregnancy had
occurred too late, and 8.82% (n=6) did not have a preference regarding the timing of the
pregnancy. See Table 2.
Sexual activity was examined to determine whether this sample reported numbers
consistent with other published research on number of sexual partners and condom use in
a low-income, primarily African American population (i.e., Cochran & Peplau, 1991;
Rothspan & Read, 1996). These, as well as other studies have shown that, in general,
minority women living in low-income communities tend to initiate sexual experience
earlier, have more lifetime sexual partners, and use condoms or other safer sex practices
less often. In the current sample, 16% of the women had had more than 1 sexual partner
in the six months prior to confirming their pregnancy; actual numbers of sexual partners
ranged from two to eight sexual partners in the previous six month period. Only 3% of
the participants reported more than 1 sexual partner during pregnancy, and each of these
three women had had two sexual partners during their pregnancies. Means for number of
sexual partners in the six months prior to pregnancy and during pregnancy were 1.25 and
1.03 with standard deviations of .821 and .171, respectively. A paired-samples t-test
44
revealed that there was a significant decrease in number of sexual partners after
pregnancy was confirmed (t(99)=2.712, p=.008).
Amount of sexual activity and rate of condom use was also explored. Overall, the
sample was highly sexually active both prior to and during pregnancy. The mean number
of sex occasions in the six months prior to confirming the pregnancy was 119.03 with a
standard deviation of 67.87 and a range from 2-504. The number of sex occasions during
pregnancy was significantly lower (t(99)=2.350,p=.021) with a mean of 47.16, a standard
deviation of 64.6 and a range from 1-400. Condom use also significantly decreased from
the six months prior to becoming pregnant to the prenatal period (t(99)=-3.171, p=.002).
Condom use prior to pregnancy was at a mean rate of 24.6% of all sexual contact
(sd=29.3), while condom use during pregnancy declined to 13.3% of all sexual contact
(sd=29.47). Interestingly, prior to pregnancy, only 31% (n=31) of the participants
reported „never‟ using condoms; after pregnancy was confirmed that number jumped to
74% of the women.
4.2 Main Variables
The mean score for the current sample on maternal fetal attachment (MFA) as
measured by the Maternal Antenatal Attachment Scale (MAAS) is 81.95 with a standard
deviation of 8.12 and a range of 62-95. Skewness is determined to be -.799 with a
standard error of .241 indicating a significantly negatively skewed distribution of scores
on this measure. A negatively skewed distribution indicates that there are more high
scores on this measure than might be seen in a normally distributed sample, suggesting
that the women who participated in this study generally have high levels of MFA.
45
The mean score on the AIDS Multidimensional Health Locus of Control Scale
(AMHLOCS), which measures internal versus external locus of control (LOC), is 26.54
with a standard deviation of 4.07 and a range of 17-39. Higher scores on this measure
indicate a more internal LOC for AIDS/HIV acquisition. A skewness statistic of .411
with a standard error of .241 shows that this sample‟s responses to this questionnaire are
normally distributed.
Future and present temporal orientation measured by the Zimbardo Time
Perspective Inventory (ZTPI) provided mean scores of 3.7 and 3.11, with ranges of 2.3-
4.9 and 2.07-4.33 respectively. Compared to the mean provided by this measure‟s
author, the current sample scored relatively higher on future orientation and lower on
present orientation than the normed sample. Skewness statistics for scores on the future
subscale (skewness = -.019) and present/hedonistic subscale (skewness = -.074) show
that each of these variables is normally distributed (SE of skewness = .241).
Lindgren‟s (2005) Health Practices Questionnaire-II (HPQ-II) revealed a mean of
138.9 for the current sample, with a standard deviation of 12.7 and a range of 93-167. A
skewness of -.666 with a standard error of .241 indicates that this sample reported a
negatively skewed distribution of health practices during pregnancy. This indicates,
similar to the findings for the distribution of MFA, that this sample generally reported
high levels of engagement in healthy prenatal behaviors.
4.3 Planned Hypotheses
Hypotheses 1 predicted that pregnant women with higher levels of MFA are more
likely to have a future oriented temporal orientation as opposed to women with lower
46
levels of MFA, who are likely to have a more present oriented temporal focus. Personal
communication with the first author of the Zimbardo Time Perspective Inventory (ZTPI)
indicated that the preferred method of data collection for this measure was to give at least
two subscales. At Zimbardo‟s suggestion, both the future and present/hedonistic
subscales were used (P.G. Zimbardo, personal communication, July 31, 2008). In order
to confirm that each of these subscales measured what it proposed to measure, correlation
analyses were undertaken with data from the future and present/hedonistic subscales of
the ZTPI. These two subscales were found to be significantly negatively correlated (r(98)
= -.227, p<.05) indicating that they measure opposite constructs (i.e., those who have a
high future orientation also have a low present/hedonistic orientation). Based on this
information, and with confirmation that this was an appropriate use of the data by the
measure's author, only data from the future subscale were used (P.G. Zimbardo, personal
communication, February 8, 2010).
In order to test the hypothesis that MFA is significantly associate with higher
future temporal orientation, variables representing total scores from the maternal
antenatal attachment scale (MAAS) and the ZPTI future subscale were entered into a
bivariate linear regression in SPSS as the independent and dependent variables
respectively. Results indicate that hypothesis 1 was confirmed; MFA is associated with a
more future oriented time perspective in the mother-to-be (R2=.163, F(1,98)=20.229,
p<.01; β=.414, t(98)=4.498, p<.01) and explains a significant amount of the variance in
ZPTI future scores.
Hypothesis 2 posited that pregnant women with higher levels of MFA are more
likely to have an internal AIDS health multidimensional LOC compared with women
47
with lower levels of MFA who may be more likely to have an external LOC. This
hypothesis was examined using a bivariate linear regression that aimed to fit these two
variables into a best fit line. Variables representing total scores from the MAAS and the
AMHLOC were entered into the data analysis program as the dependent and independent
variables respectively. The regression, which confirms hypothesis 2, indicated that as
MFA increases so does the score on the AMHLOC (R2=.057, F(1,98) =6.9, p=.010; β=-
.258, t(98)=-2.646, p=.010). MFA also explains a significant portion of the variance in
LOC scores. As stated above, higher scores on the AMHLOC indicate a more internal
LOC.
Hypothesis 3 examines the moderating effect of MFA on the relationship between
health related LOC and engagement in positive prenatal health behaviors/risk reduction
behaviors. Parity was controlled for as a covariate as correlation analyses revealed a
significant relationships between parity and the dependent variable (r(98)=-.273, p<.01).
In order to appropriately analyze the data to show a moderating effect of MFA, a series of
multiple regressions were used to first analyze main effects and then the interaction
effects. Both MFA and health related LOC were entered as independent variables and
run in separate bivariate regressions against the dependent variable, prenatal health
behaviors. An interaction variable was created by multiplying the centered data from
each of the two independent variables entered into a regression against the dependent
variable, prenatal health behaviors. Data were centered in order to increase the ease of
interpretation and to avoid problems with multicollinearity (Aiken & West, 1991; Judd &
McClelland, 1993). As expected, there was a significant main effect of the relationship
between MFA and positive prenatal health behaviors (R2=.369, F(1,98)=20.324, p <.01;
48
β=.603, t(98)= 7.068, p<.01) indicating that as MFA increases so does engagement in
positive prenatal health behaviors. There was no significant main effect of the
relationship between AIDS related LOC and positive prenatal behaviors (R2=.187,
F(1,98)=3.272, p=.074; β=-.180, t(98)=-1.809, p=.074) although the p-value appeared to
be approaching significance. According to Baron and Kenny (1986), it is still possible to
find a significant effect of the interaction variable even if main effects are not significant.
The analysis of the interaction variable confirmed hypothesis 3; there exists a significant
moderating effect of MFA on the relationship between health related LOC and
engagement in positive prenatal health behaviors as seen in Figure 1 (R2=.043,
F(3,96)=5.421, p<.05; β=.229, t=2.32, p=.02). This indicates that higher levels of MFA
combined with a more internal LOC contributes to higher levels of engagement in
positive prenatal health behaviors, while subsequent combinations of lower levels of each
of these variables are associated with lower adherence to positive health behaviors during
the prenatal period. Despite the fact that the moderating effect of MFA is significant, it
should be interpreted carefully as the effect size (f2 = .045) indicates that the interaction
only accounts for a small amount of the variance in the relationship. Conversely, the
effect size of the main effect of MFA (f2 = .585) suggests that this is the driving variable
in the regression. The effect size of the interaction as a whole only accounts for 4.5% of
the variance while MFA alone accounts for 58.5% of the variance of the regression.
Because the relationship between health related LOC and prenatal health
behaviors was significantly moderated by MFA, an analysis of the simple slopes was
undertaken as a post-hoc probe to determine whether each of the variables was significant
at a conditional value of the moderator (Holmbeck, 2002). To conduct an analysis of
49
simple slopes, both high and low values of the moderator were calculated at + 1 standard
deviation (+8.08642) of the mean of the moderator. Then these new conditional
moderator values were used to create interaction terms by multiplying each of them by
the independent variable, health-related LOC. Two independent regressions were then
run; the + 1 standard deviation value of the moderator was entered into a regression in
SPSS along with the independent variable, health-related LOC as well as the new
interaction term and run against the dependent variable, engagement in positive prenatal
health behaviors. The same procedure was undertaken with the –1 standard deviation
value of the moderator. This resulted in a simple slope (b=.077, p=.835) for those with
high MFA and a simple slope (b=-.19, p=.558) for those with low MFA. Although the
simple slope analyses were non-significant, this does not change the outcome of the
original interaction. These non-significant simple slopes indicate that neither simple
slope accounts for a significant amount of the variance of the equation alone, however,
the difference between them is still significant as indicated by the significant overall
interaction effect. This appears to confirm the fact that this regression has a relatively
small effect size.
Because this study initially proposed to examine HIV risk reduction behaviors in
addition to health promotion behaviors, hypothesis 3 was rerun (referred to herein as
hypothesis 3a) using rate of condom use during pregnancy as the dependent variable in
order to compare relative differences in the effect of the independent variables of interest
on HIV risk reduction. The covariate, parity, was not used in these analyses as
correlations revealed no significant relationship to the dependent variable. The variables
MFA, LOC, and the interaction variable MFA*LOC were entered into the regression
50
analysis against the dependent variable, rate of condom use during pregnancy, using
SPSS. Contrary to expectations, there were no significant main or interaction effects.
Neither MFA, nor AIDS related health LOC were associated with condom use during
pregnancy (R2=-.030, F(3,96)=.044, p=.988; (LOC)β=-.032, t(97)=-.303, p=.763; (MFA)
β=.013, t(97)=.120, p=.905). Although there were no significant main effects of the
predictor variables, according to Baron and Kenny (1986) it is still an acceptable use of
the data to test the interaction effect. This analysis, however, also yielded non-significant
results indicating that there is no moderating effect of MFA on the relationship between
AIDS related health LOC and condom use during pregnancy (R2=-.030, F(3,96)=.044;
β=-.002, t(97)=-.020, p=.984). Hypothesis 3a was not confirmed.
Hypothesis 4 predicted a moderating effect of MFA on the relationship between
temporal orientation and engagement in healthy prenatal behaviors and HIV risk
reduction behaviors. Similarly to Hypothesis 3, parity was used as a covariate due to the
significant correlation with the dependent variable, and a series of multiple regression
analyses were used to examine the main and interaction effects. Data for the two
independent variables were centered and used to create an interaction term by multiplying
the two data sets and creating a new variable. All three variables (X1, X2, and X1*2)
were then entered into the regression in SPSS. As above, there was a significant main
effect of the relationship between MFA and positive prenatal health behaviors (R2=.378
F(1,98)=61.084, p <.01; β=.620, t(98)= 7.816, p<.01). Results revealed a significant
main effect of future orientation on healthy prenatal behaviors (R2=.095, F(1,98)=11.33,
p<.01; t(98)=3.367, β=.322, p<.01) indicating that as future orientation increases (and
present orientation/hedonism decreases) so too does engagement in healthy prenatal
51
behaviors increase. Lastly, the interaction variable was entered into the regression and
results revealed no significant moderating effect of MFA on the relationship between
temporal orientation and engagement in prenatal health behaviors (R2=.001,
F(3,96)=1.121, p=.292; β=-.106, t(98)=-1.059, p=.292). Consultation with the measure's
author and his colleague revealed that using a median split to differentiate “caseness” of
future orientation (i.e., having a score below the median on the future orientation subscale
indicates a present orientation) is sometimes recommended (N. Fieulaine, personal
communication, February 8, 2010). When data for the future subscale of the ZTPI were
transformed into categorical data using a median split (future vs. present), results showed
that there was a significant moderating effect of MFA on the relationship between time
perspective and prenatal health behaviors (see Figure 2) (R2=.242, F(3,96)=32.653,
p<.01; β=.500, t(98)=5.714, p<.01). With the median split data, there continued to be a
significant main effect of future vs. present orientation on prenatal health behaviors
((R2=.048 F(1,98)=6.045, p=.016; β=..241, t(98)=2.459, p=.016). An effect size of
f2 =.607 suggests that MFA accounts for more of the variance in the regression than the
interaction (f2 = .319) and so although the interaction is statistically significant, it should
be interpreted with caution.
Because the moderating effect of MFA was significant as above in Hypothesis 3,
the same procedure to run an analysis of the simple slopes was undertaken. High and low
values of the moderator were calculated using + 1 standard deviation of the value of the
moderator. These new conditional moderator values were used to create two new
interaction terms with the independent variable, temporal orientation. Then regressions
were run in SPSS for each conditional value of the moderator (high and low). This
52
resulted in simple slopes of (b=2.7, p=.484) for those with high MFA and (b=-.035,
p=.990) for those with low MFA. As above, the non-significant simple slopes analyses
suggest that neither simple slope accounts for a significant portion of the regression on its
own. The overall interaction described above indicates however that these simple slopes
are significantly different from each other even if they are not significantly different from
zero.
For hypothesis 4a, the same procedure was undertaken to rerun the data against
the dependent variable of condom use; the variables representing MFA, temporal
orientation and their interaction variable were regressed on the dependent variable,
condom use during pregnancy. Similar to hypothesis 3a, results of this analysis were not
significant, showing no significant effect of either independent variable or their
interaction on rates of condom use during pregnancy (R2=-.017, F(3,96)=.445; (MFA)β=-
.037, t(97)=-.325, p=.746; (ZTPIfuture) β=.081, t(97)=.728, p=.468; (MFA*ZTPIfuture)
β=-.090, t(97)=-.848, p=.399). Hypothesis 4a was not confirmed.
4.4 Exploratory Variables
Sexual relationship power was measured by the Sexual Relationship Power Scale
which yielded a mean score of 49.8 with a standard deviation of 7.07 and a range of 34-
60. The skewness statistic is equal to -.162 with a standard error of skewness of .241.
The current sample‟s scores on this measure are there normally distributed as the
skewness statistic is less than two times the standard error of skewness.
Perceived HIV risk, which was measured by the Perceived Risk Scale, resulted in
a mean score of 17.23 with a standard deviation of 3.472 and a range of 10-27. The
53
sample is normally distributed as skewness equals .105 with a standard error of skewness
of .241.
4.5 Exploratory Hypotheses
Hypothesis 5 predicted a linear relationship between MFA, as measured by the
MAAS, and relationship power, as measured by the Sexual Relationship Power Scale
(SRPS). This hypothesis assumed that higher levels of MFA would influence a woman
to act on behalf of her unborn child‟s health and increase her perceived power in the
relationship with her sexual partner. This hypothesis was analyzed using a bivariate
linear regression. Results were significant, suggesting that higher levels of MFA are
significantly associated with a higher level of perceived power in the sexual/romantic
relationship (R2=.086, F(1,98)=10.288;β=.268, t(99)=3.207, p=.002).
Hypothesis 6 predicted a moderating effect of MFA on the linear relationship
between perceived power in the relationship and condom use during pregnancy. As
above, for analyses on hypotheses 3 and 4, each of the independent variables were
centered and then an interaction variable was created by multiplying the centered data.
All three variables were then entered into a series of multiple regression analyses in
SPSS. Results yielded non-significant findings for each of the two main effects as well
as the moderator effect(R2=-.007, F(3,96)=.770;(MFA)β=-.017; t(99)=-.148, p=.883;
(SRP)β=-.056, t(99)=-.529, p=.598; (MFA*SRP) β=-.152; t(99)=-1.405, p=.163).
Hypothesis 7 predicted a linear relationship between MFA and HIV risk
perception such that higher levels of MFA are associated with higher levels of HIV risk
perception. The hypothesized relationship was examined with a bivariate linear
regression and determined to be non-significant suggesting that among the 100
54
participants in this study, MFA is not significantly associated with an increased HIV risk
perception (R2=-.005, F(1,98)=.548;β=.075; t(99)=.740, p=.461).
55
5. DISCUSSION
5.1 Sociodemographics
A sample of women generally determined to be at high risk for HIV acquisition
was targeted for this study by recruiting participants from the waiting room of an urban
Philadelphia prenatal clinic which serves predominantly young, low-income, minority
women carrying unplanned pregnancies. Collectively, they are representative of the
young, low-income, minority women who currently comprise the fastest growing group
of individuals being diagnosed with new cases of HIV in the United States. Despite the
high prevalence of unplanned and even unwanted pregnancies in this sample, these
women scored higher than the normed samples on measures examining their levels of
maternal fetal attachment. While this could be due to a social desirability effect as the
questionnaire was administered in an interview format, it has been noted in other
literature that once the initial shock of an unexpected pregnancy wears off, future mothers
are generally satisfied with their pregnant status (Levine Kornfield & Geller, unpublished
manuscript). Similarly, participants tended to have scores on the ZTPI future scale
indicating higher levels of future orientation than what was evident in the normed sample,
which contradicts the expectations set up by Padawer and colleagues (2007). According
to Padawer et al., those who are more likely to be oriented to their own futures are male,
more highly educated, older, and earning higher incomes. The characteristics of the
participants enrolled in this study are largely opposite of those posited by Padawer and
colleagues to have higher levels of a future orientation in that they are female, less
educated, young, and earning low, if any, incomes. It would have been interesting in the
current study to have had a comparison group of non-pregnant women in order to
56
determine whether future temporal perspective was a direct outcome of pregnancy as
mothers-to-be focus on a specific future date as they await the birth of their child.
5.2 Planned Hypotheses
Hypothesis 1, which was confirmed, found that MFA is significantly associated
with future temporal orientation indicating that pregnant mothers with stronger
attachment to the developing fetus are more likely to be cognizant of how their current
actions and goals affect later outcomes. Because previous research (i.e., Padawer et al.,
2007) found that those with future perspectives tend to be older, male, more highly
educated, and earning higher incomes the findings detailed herein are a departure from
the published literature in that the participants in this study differ markedly from those
who generally are more future oriented. Once pregnancy is confirmed and the mother‟s
attachment to her unborn child grows, it seems as though the mother begins to develop a
heightened awareness that her actions may affect outcomes that will only be seen later in
the life of her child. It is a general assumption that most pregnant women are motivated
to ensure the wellbeing of the fetus. The finding of hypothesis 1 confirms this
supposition by noting that pregnant women with more attachment to the fetus are more
willing to put immediate desires and pleasures aside as they plan for the future of their
child. Sadly, the alternate of this is also true; pregnant women with less attachment to the
fetus are less likely to put aside immediate gratification for the investment in future
outcomes.
Similar to hypothesis 1, hypothesis 2 found that MFA is significantly associated
with an internal AIDS-related LOC. This finding suggests that as the mother‟s
attachment to the fetus increases she feels more strongly that her own actions can control
57
her health related outcomes. Because MFA is a construct that is solely relevant during
the unique prenatal period in a woman‟s life, it is possible that as the reality of the
pregnancy becomes apparent, a woman begins to understand the connections between her
own behaviors and their consequences (i.e., that her unprotected sexual activity prior to
pregnancy resulted in becoming pregnant) and this leads to a greater understanding that
her own actions can lead to different outcomes. As attachment to the fetus grows, so too
does the belief that the pregnant woman‟s own behaviors will have an effect on her
ability to remain free of HIV/AIDS, also known as an internal locus of control.
These results add to the findings published by Fisch (1974) which found that
“poor black women” were highly external, meaning that they did not believe that their
own actions necessarily contributed to their health outcomes. The current study, largely
comprised of a sample similar to Fisch‟s, however, finds that pregnancy and the resultant
attachment that develops in the mother for her unborn child may influence a woman to
realize that her own actions can have an impact on what happens to her health. This shift
from external to internal LOC may be due to the fact that the pregnant women in this
study were receiving regular prenatal care and may have been influenced towards this
mode of thinking by their prenatal care medical providers. Evidence against this is that
women with lower levels of MFA also tended to show a more external bias in HIV/AIDS
related LOC suggesting that it was not solely the intervention of the medical provider, but
rather some quality unique to pregnancy or MFA that results in a general change from
external to internal LOC. In other words, if a medical provider was able to influence
pregnant women to have a more internal locus of control then this might be evident
among all women regardless of their level of attachment to the fetus. Because the level
58
of internal LOC varies by level of MFA, it appears likely that level of attachment, which
is a unique quality of pregnancy, is more responsible for the change in cognitive style
than an educational intervention by the prenatal care provider.
As predicted, hypothesis 3 found a moderating effect of MFA on the relationship
between LOC and healthy prenatal behaviors. In examining the main effects of this
hypothesis, the current study confirms Lindgren's (2001) findings that MFA significantly
predicts adherence to positive prenatal health behaviors as measured by her Health
Practices in Pregnancy Questionnaire-II. Just as Norman and colleagues (1998) found
evidence to suggest that the value one places on one's health moderates the relationship
between LOC and living a healthy lifestyle, the current study finds that among pregnant
women, the level of attachment to the fetus acts as a proxy for the value one places on
one's own health. Interestingly, with no main effect of LOC on healthy prenatal
behaviors, it can be concluded that an internal LOC alone does not necessarily prompt an
individual into action for health related behavior change. However, when combined with
the attachment towards the developing child, those with an internal LOC are most likely
to engage in more frequent adherence to healthy behaviors during the prenatal period.
This finding could be due to the fact that many individuals are not motivated to maintain
their own health even though they know what to do and how to do it. This is common
among medical patients diagnosed with diabetes (i.e., Glasgow, Toobert, & Gillette,
2001) as well as other chronic conditions including HIV/AIDS (i.e., Kalichman et al.,
2001). It is often easy to justify not taking proper care of oneself as there is a perception
that it is the individual alone who will suffer as a result. In the case of pregnancy, an
expectant mother no longer has the "luxury" of neglecting her own health and assuming
59
that she alone will bear the consequences. Simply because a woman has the knowledge
that her own actions can control her health outcomes (i.e., internal LOC) does not mean
that she will take part in proper self-care. However, understanding and caring that her
actions may adversely affect her future child may initiate the motivation needed to
engage in positive prenatal health behaviors.
The results of this moderator analysis also shed light on an unexpected finding.
Among women with a low MFA, a high internal LOC is less likely to be associated with
engagement in prenatal health care behaviors than a low internal (i.e., external) LOC.
Because the HPQ-II was not designed to measure constructs other than overall prenatal
health behaviors, it was not possible to look at different types of prenatal health behaviors
in order to draw conclusions about whether women with a high vs. low MFA may be
more likely to engage in certain types of prenatal care behaviors. Had a measure been
chosen that differentiated between self-oriented and fetus-oriented prenatal health
behaviors it may have been possible to do some additional statistical analyses to
investigate this curious finding. It is possible that among women with a low level of
MFA those who have a low internal (i.e., external) LOC engage in more health behaviors
because they may be more compliant with instructions from a medical provider. Women
with an external LOC are more inclined to believe that their health outcomes are related
to chance or fate. Because the medical provider is a force separate from the woman
herself, pregnant women with external LOC may be more inclined to comply with his or
her directions even without the understanding or belief that her own actions will have a
positive impact on the fetus if adhered to correctly. Alternatively it is possible that
women with a low MFA and a high internal LOC may be those who are depressed or
60
distressed over their pregnancy status because they recognize the extent to which their
own actions are responsible for their present situation. In these cases, the neglect of
prenatal health care behaviors could reflect the low level of attachment that has
developed between the mother and child. The above information is solely speculation.
What can be definitively said is that it appears that MFA is the driving variable in the
interaction and that the low level of MFA is likely more responsible for low levels of
engagement in prenatal care behaviors than the internal locus of control among women
with those combination of traits.
Hypothesis 4 found a significant moderating effect of MFA on the relationship
between a pregnant woman's time perspective and her tendency to engage in positive
prenatal health behaviors. As above, the main effect of MFA on health behaviors
confirmed the findings of Lindgren (2001). A significant main effect of future time
perspective on positive prenatal health behaviors among the pregnant women in this
study also seems to logically follow the findings of previous researchers whose work
indicated that those with a future orientation are more likely to drive safely (Zimbardo et
al., 1997), use condoms more frequently (Burns & Dillon, 2005), and eat healthier and
exercise more (e.g., Mahon et al., 1997)and less likely to engage in substance abuse
(Keogh et al., 1999; Wills et al., 2001) than those with a present/hedonistic time
perspective. As predicted, MFA moderates the relationship between temporal orientation
and healthy prenatal behaviors such that women with high levels of attachment to the
fetus combined with a future orientation are more likely to be committed to prenatal
healthcare behaviors while those with subsequent combinations of lower levels of each of
these variables engage in fewer prenatal health practices.
61
When hypotheses 3 and 4 were rerun using the dependent variable of condom use
during pregnancy there were no significant relationships between any of the predicted
variables or their interaction variables. This is true for hypothesis 6 as well, which also
utilized condom use as the dependent variable. These findings are surprising because
other researchers have written about condom use as a health promotion/disease
prevention behavior. Given that the participants in this study were generally motivated to
engage in healthy prenatal behaviors depending on their levels of MFA, LOC, and
temporal orientation, it would have seemed likely that condom use may have been a
logical addition to prenatal care behaviors such as smoking cessation and healthy eating.
While past research has shown that knowledge does not necessarily translate to behavior
(Bachanas et al., 2002; Kirby & DiClemente, 1994) it appears likely that among this
sample the women may not have even considered condom use as a prenatal care behavior
that was pertinent to maintaining fetal health. This becomes concerning due to the fact
that the majority of the women in the study reported that they were not in committed
relationships with the father of the child and either had been or were currently engaging
in sexual activity with other partners. This can increase the risk of HIV or other STD
infection and subsequent transmission to the fetus. Despite this, it appears that women
were not motivated to use condoms as a means of ensuring their unborn child‟s health. It
is possible, however that the women in this study were aware of how their sexual
behaviors may influence the health of the pregnancy and subsequent baby. Whereas
relatively few women reported increased condom use during pregnancy, and in fact
overall rates of condom use decreased during pregnancy, the majority of the participants
actually decreased the number of sexual partners with whom they had contact after
62
confirming the pregnancy. For the purpose of this study, condom use was used as a
measure of HIV and other STD prevention behavior. However, it appears that even if
women in this study discontinued condom use once they became aware of the pregnancy,
they were still aware of and engaging in specific behaviors designed to limit their HIV
and STD exposure. This conclusion is consistent with the findings from hypothesis 7;
although it was expected that MFA would be significantly associated with an increased
HIV-risk perception, this was not the case. As women in this study were actively
engaging in alternative (i.e., non-condom) HIV/STD risk reduction behaviors once
pregnancy was confirmed, it is likely that they possessed an accurate perception of their
HIV risk which was not influenced by the pregnancy status and resultant development of
maternal fetal attachment.
What MFA does influence, however, is the level of a woman‟s perceived power
in her relationship with her main partner, which can have a significant impact on her
ability to engage in risk reduction behaviors such as condom use or less frequent sexual
contact. Similar to conclusions made above regarding the willingness to engage in
prenatal health promotion behaviors for the sake of the child, it stands to reason that
pregnant women are more likely to feel empowered to assert themselves in their
relationship on behalf of the unborn child. As pregnant women with high MFA are more
motivated to maintain their health for the sake of having a healthy child, so too are they
more empowered in their relationships with male partners to assert their own needs for
the sake of the child. It is possible that prior to pregnancy and development of MFA
women are more permissive or accepting of their partner‟s controlling, jealous, or other
negative behavior. Similar to conclusions made above, by remaining powerless in the
63
relationship, a woman may believe she is only harming herself by allowing her partner to
treat her poorly or in a controlling manner. The confirmation of the pregnancy and the
development of a strong attachment to the child therefore may elicit a sense of motherly
protection that may give the woman a sense of permission to assert herself for the sake of
the new life she is bringing into the world. While this construct was studied solely in
pregnant women for the purposes of this study, it would be interesting to investigate
whether this is true only during pregnancy or whether mothers in general have a greater
sense of empowerment in their relationships when their children are in their care.
5.3 Implications for Future Research and Clinical Application
Women who already possess an internal health related locus of control and a
future oriented temporal perspective prior to pregnancy or for those in whom it develops
during pregnancy may be at an advantage in that the intrinsic motivation to maintain their
health already exists. The results of this study show that an internal LOC and a future
orientation are positively influenced by MFA in the service of engagement in prenatal
health care behaviors; however, there still exists a subset of the population of pregnant
women who lack the fundamental traits that appear to spontaneously motivate healthy
behaviors. While it may not be possible to instill these specific traits in the pregnant
women who lack them, it is possible to bring their attention to the primary goal of most
expectant mothers, which is to deliver a healthy infant.
Prenatal care providers are in the unique position of having regular access to their
pregnant patients who may not be intrinsically motivated to engage in behaviors which
would ensure a healthy birth outcome. However, for those in whom MFA does not
positively affect an external LOC or a present focused temporal orientation, yet who
64
presumably still want a healthy birth outcome, "preaching" the benefits of healthy
behaviors may simply not be enough. In these cases, Motivational Interviewing
strategies may be a useful addition to the prenatal care these women receive in order to
promote healthy prenatal behaviors. More than simply using scare tactics, motivational
interviewing (Miller & Rollnick, 2002) aims to create some discrepancy between an
individual‟s current actions and their desired outcome in order to elicit the desire to
change from within the patient. The goal is for the healthcare provider to facilitate
change with the impetus for change being elicited directly from the patient herself.
Because Miller and Rollnick (2002) describe motivational interviewing as a "directive,
client-centered counseling style for eliciting behavior change by helping clients to
explore and resolve ambivalence," this strategy could be useful even for those women
who are ambivalent about the pregnancy as evidenced by a low MFA score. It is viewed
as being particularly useful for clients who are reluctant to change or who are ambivalent
about changing their behavior. The strategies of motivational interviewing are generally
seen as more persuasive than coercive, more supportive than argumentative, and the
overall goal is to use the principles of individual responsibility, internal attribution, and
cognitive dissonance to increase the patient's intrinsic motivation so that change arises
from within rather than being imposed from without (Rubak & Sandbaek, 2005).
Motivational interviewing is effective in achieving the desired results in health
behavior change; in a meta-analysis of 72 randomized controlled trials with motivational
interviewing as the intervention, psychologists and physicians obtained a significant
effect in approximately 80% of the studies, while other healthcare providers obtained an
effect in 46% of the studies. When using motivational interviewing in brief encounters of
65
only 15 minutes, 64% of the studies showed an effect. More than one encounter with the
patient ensures the effectiveness of motivational interviewing (Rubak & Sandbaek,
2005). This strategy has been used successfully in smoking cessation (Lai et al., 2010),
alcohol dependence recovery (Miller, 1983), weight loss (West et al., 2007), and
HIV/AIDS medication adherence (DiIorio et al., 2003). Motivational interviewing has
not been tested thoroughly in pregnant patients, although there is preliminary research
which suggests it may be effective in smoking cessation interventions during pregnancy
(Ondersma, Chase, Svikis, & Schuster, 2005) as well as alcohol reduction during
pregnancy (Handmaker, Miller, & Manicke, 1999). Motivational interviewing has also
been shown to be effective in promoting HIV risk reduction behaviors in non-pregnant
young adults (Baker & Dixon, 1991).
While the current study did not find evidence to support the predictions that MFA,
temporal orientation, and LOC have a significant effect on condom use behavior during
pregnancy, it should be noted by prenatal healthcare providers that women may still be
actively engaging in some HIV/STD risk reduction behaviors such as reducing their
number of sexual partners. Many prenatal healthcare providers may assume that
pregnant women are in monogamous relationships and are therefore not at risk for HIV or
other STD infection. Providers should be encouraged to question women about their
sexual behavior during pregnancy and to promote condom use or other methods of
HIV/STD risk reduction through motivational interviewing.
Future research directions may elaborate on the current study by providing a
motivational interviewing session at the first prenatal visit for a random selection of
participants and investigating whether the internal traits of MFA, LOC, and temporal
66
orientation are receptive to this type of counseling approach. Additionally, for the
purpose of this study, it has been assumed that MFA alone has increased the sense of
internal LOC and future temporal orientation among those women who were committed
to healthy prenatal behaviors. One way to elucidate this connection would be the
inclusion of a non-pregnant comparison sample. It is difficult to know if the findings
described above are unique to this sample because of their pregnant state or for some
other reason. The inclusion of a non-pregnant comparison group may help further clarify
some of the conclusions.
The dependent variable of condom use proved to be a non-significant dependent
variable most likely due to low rates of condom use in this sample. However, simply
because women in this study did not use condoms does not mean they were not aware of
their HIV/STD risk and actively trying to reduce this risk. Using alternate dependent
variables such as number of sexual partners or number of sexual contact occasions may
be useful ways to continue to explore the general variable of HIV risk reduction without
solely relying on condom use.
5.4 Limitations
This study is limited in its scope of generalizability because, although women
were recruited from a clinic that primarily serves low-income minority women at high
risk of HIV infection, the women who enrolled in the study seemed to possess good
knowledge and implementation of HIV risk reduction behaviors, even though rates of
condom use were relatively low. While the study aimed to draw conclusions about
condom use as a health promotion/disease prevention strategy during pregnancy, the
67
majority of women did not use condoms on a consistent basis during pregnancy and
instead relied on other methods of health promotion/disease prevention. Previous
research has made conclusions about women with similar demographic characteristics
(i.e., minority, inner-city, low income) that highlighted a lack of awareness of risk
behaviors and subsequent high level of engagement in risk behaviors. Perhaps because
the current sample was pregnant at the time of the study or because they were only
representative of those receiving regular prenatal care, the women enrolled in this study
seemed to possess higher levels of awareness of and engagement in healthy behaviors
than what might be expected. This unexpected and positive finding may be attributed to
successful community based HIV/STD prevention educational efforts in the greater
Philadelphia area or perhaps to the dedicated efforts of the healthcare providers who
work at the Women's Care Center, where the participants in this study were receiving
their prenatal care.
Similarly, the women in this study generally scored high on measures of MFA
and engagement in healthy prenatal care behaviors. It is possible that if recruitment had
included alternate strategies, such as community recruitment through flyers or
advertisements, a different type of sample would have been enrolled in the study. By
recruiting from a prenatal care clinic, this study ensured that participants were all
receiving excellent and consistent prenatal care and were most likely invested in the
health of the child due to the clinic's commitment to have patients attend all scheduled
appointments.
68
5.5 Conclusions
This study found a significant moderating effect of MFA on both the relationship
between LOC and prenatal care behaviors as well as the relationship between temporal
orientation and prenatal care behaviors. It appears that MFA significantly positively
influences those women who possess a heightened sense of each health-related locus of
control and a future orientation, to engage in healthy prenatal behaviors. For those
women with lower levels of these variables, MFA does not consistently positively
influence engagement in prenatal care behaviors. For these women, a motivational
interviewing approach taken by a medical provider may help orient them to the expected
desired outcome- a healthy birth. Surprisingly, hypotheses predicting a moderating effect
of MFA on the relationship between each LOC and temporal orientation and HIV risk
reduction through condom use were not significant. Despite this finding, it is incorrect to
conclude that pregnant women in non-monogamous relationships living in an HIV
epicenter are not motivated to reduce their HIV risk behaviors. Although condom use
rates decreased after pregnancy was confirmed, alternate methods of HIV risk reduction
increased, including reducing the number of sexual partners during pregnancy and the
frequency of sexual contact. This should be taken into consideration by medical
providers who treat prenatal patients as not all pregnant women are in monogamous
relationships. Among those who are sexually active during pregnancy other HIV risk
reduction behavior changes may be useful to promote through motivational interviewing.
69
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Table 1. Participant Demographics: Age, Ethnicity & Marital Status
Age
Mean
Ethnicity
%
Marital
Status
%
Maternal age
23.56
Non-Hispanic
Black
81
Never
Married
48
Gestational age
30.46
Non-Hispanic
White
5
Living with
partner
43
Hispanic Black
4
Married
9
Hispanic Other
4
Divorced
0
Non-Hispanic
Biracial
4
Widowed
0
Hispanic
Biracial
2
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Table 2. Intendedness and Timing of the Pregnancy
Pregnancy Intendedness
N
%
Planned
18
18
Unplanned
82
82
Unwanted
14
17.1
Timing
N
%
Too Soon
48
70.5
Right Time
12
17.6
No preference
6
8.82
Too Late
2
2.9
83
137.5
138
138.5
139
139.5
140
140.5
Low Internal LOC High Internal LOC
Prenatal Health Behaviors
Low MFA
High MFA
p = .02
Figure 1. Hypothesis 3: The moderating effect of MFA on the relationship between
internal LOC and prenatal health behaviors.
84
p=.016
Figure 2. Hypothesis 4: The moderating effect of MFA on the relationship between
temporal orientation and prenatal health behaviors.
120
125
130
135
140
145
150
155
Low Future Orientation
High Future Orientation
Prenatal Health Behaviors
Low MFA
High MFA
85
APPENDIX A: Measures
Pregnancy Demographic Form
A1. How old are you? ___________
A2. What is your ethnicity?
Hispanic
Not Hispanic
A2a. What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Biracial
Prefer not to report
A3. Were you born in this country?
Yes
No
A3a. [If No, ask:] Where were you born? ____________________
A3b. How old were you when you came to this country? ______ years old.
A4. What language do you speak at home? _______________________
A5. What is your current marital status?
Never Married
Married
Divorced
Widowed
Living with Partner
A6. How many children do you have?
________
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A7. What‟s the highest year of school that you have completed, including the GED?
________
A8. What is your family‟s income? (Remember all of this information is completely
private)
Less than $10,000
$10,000-$25,000
$25,000-$40,000
More than $40,000
A9. When did you learn that you were pregnant? ___________________
A10. How many weeks pregnant were you at that time? _________________
A11. Did you plan to become pregnant?
Yes [If Yes, skip to next section]
No
A12. Right before you became pregnant (this time), did you, yourself, want to have
a(nother) baby at any time in the future?
Yes
No
Not sure, don‟t know
Didn‟t care
A13. So would you say you became pregnant too soon, at about the right time, or later
than you wanted?
Too soon
Right time
Later
Didn‟t care
A14. What, if anything, were you doing to prevent pregnancy?
Nothing
Using male condoms
Using female condoms
Using a hormonal method: pill, patch, ring, depo provera or Norplant.
Using the sponge
Using spermicidal foam or lubricant (like N-9)
Using the withdrawal method
Using the rhythm method
Douching after sex
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Practicing Oral Sex
Practicing Anal Sex
Other: __________________
88
Now I am going to ask you some questions about certain sexual behaviors you may
have engaged in before or since you learned that you were pregnant.
A15. How many male partners have you had vaginal, anal, or oral sex with in the 6
months before learning that you were pregnant?
______
How many of these male partners…..
Main Other
A16a….have been in jail in the last 10 years? _______ ______
A16b….have had sex with other women in the last year? _______ ______
A16c….have had sex with other men in the last year? _______ ______
A16d….have used intravenous (injected) drugs in the last 10 years?_______ ______
A16e….have been diagnosed with a sexually transmitted disease
such as (list here) in the last year? _______ ______
A16f….have been diagnosed with HIV in the last year? _______ ______
A17. In the 6 months prior to becoming pregnant how many times have you engaged
in vaginal, anal or oral sex with a male partner? This may be easier to think about
in terms of per day, per week, or per month. [PROBE: Did you have sex during
the week of your period?]
______times
A18. Of the _____ times you had sex, how many times have you used male or female
condoms in the 6 months prior to becoming pregnant?
# of times_______
A18a. If Never, Why not? (check all that apply)
I was trying to get pregnant
Partner just doesn‟t want to
It ruins the moment for me
It ruins the moment for my partner
It is uncomfortable for me
It is uncomfortable for my partner
I‟m in a monogamous relationship
I felt my partner(s) was/were safe
Other: ___________________________________
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Now I am going to ask you some questions about your sexual behaviors since
learning that you were pregnant.
B1. How many male partners have you had vaginal, anal, or oral sex with since learning
that you were pregnant?
______
B2. [If more than one partner] Is one of these a main partner, like a husband or
boyfriend?
Yes
No
How many of these male partners…..
Main Other
B3a….have been in jail in the last 10 years? _______ ______
B3b….have had sex with other women in the last year? _______ ______
B3c….have had sex with other men in the last year? _______ ______
B3d….have used intravenous (injected) drugs in the last 10 years? _______ ______
B3e….have been diagnosed with a sexually transmitted disease
such as (list here) in the last year? _______ ______
B3f….have been diagnosed with HIV in the last year? _______ ______
B4. Has this partner ever refused to use a male condom during vaginal or anal sex?
Yes
No
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B5. Since you found out that you were pregnant how many times have you engaged in
vaginal, anal or oral sex with a male partner? This may be easier to think about in
terms of per day, per week, or per month.
______times
B6. Of the ______ times that you had sex, how often have you used male or female
condoms since you learned that you were pregnant?
# of times_________
B6a. [If Never] Why not? (check all that apply)
I‟m already pregnant
I‟m in a monogamous relationship
I felt my partner(s) was/were safe
I had never used condoms before I became pregnant
Other: ___________________________________
B7. In the past, when you have used condoms, what was your main reason for using
them?
Pregnancy prevention
STD/HIV prevention
Both pregnancy and STD/HIV prevention
Partner insisted
Other: _____________________________________
B8. Since you learned you were pregnant, have you changed your behavior at all to
reduce your risk for HIV exposure?
Yes
No [Skip to next section]
B8a. If yes, what have you done?
Started using male condoms more often
Started using female condoms more often
Stopped having sex with partners other than my main partner
I asked my partner to get tested
Started using the withdrawal method
Started douching after sex
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Now I am going to ask you some questions about your pregnancy history.
C1. You already, told me that you have _____ children. How many times have you been
pregnant whether you‟ve had a baby or not?
#_______
C2. [If # of children and # of pregnancies are inconsistent, ask:] How many abortions or
miscarriages have you had?
#_______ abortions #_______ miscarriages
92
MATERNAL ANTENATAL ATTACHMENT SCALE
These questions are about your thoughts and feelings about the developing baby. Please
tick one box only in answer to each question.
1) Over the past two weeks I have thought about, or been preoccupied with the baby
inside me:
Almost all the time
Very frequently
Frequently
Occasionally
Not at all
2) Over the past two weeks when I have spoken about, or thought about the baby
inside me I got emotional feelings which were:
Very weak or non-existent
Fairly weak
In between strong and weak
Fairly strong
Very strong
3) Over the past two weeks my feelings about the baby inside me have been:
Very positive
Mainly positive
Mixed positive and negative
Mainly negative
Very negative
93
4) Over the past two weeks I have had the desire to read about or get information
about the developing baby. This desire is:
Very weak or non-existent
Fairly weak
Neither strong nor weak
Moderately strong
Very strong
5) Over the past two weeks I have been trying to picture in my mind what the
developing baby actually looks like in my womb:
Almost all the time
Very frequently
Frequently
Occasionally
Not at all
6) Over the past two weeks I think of the developing baby mostly as:
A real little person with special characteristics
A baby like any other baby
A human being
A living thing
A thing not yet really alive
7. Over the past two weeks I have felt that the baby inside me is dependent on me for its
well-being:
Totally
A great deal
94
Moderately
Slightly
Not at all
8) Over the past two weeks I have found myself talking to my baby when I am alone
Not at all
Occasionally
Frequently
Very frequently
Almost all the time I am alone
9. Over the past two weeks when I think about (or talk to) my baby inside me, my
thoughts:
Are always tender and loving
Are mostly tender and loving
Are a mixture of both tenderness and irritation
Contain a fair bit of irritation
Contain a lot of irritation
10. The picture in my mind of what the baby at this stage actually looks like inside the
womb is:
Very clear
Fairly clear
Fairly vague
Very vague
I have no idea at all
95
11. Over the past two weeks when I think about the baby inside me I get feelings which
are:
Very sad
Moderately sad
A mixture of happiness and sadness
Moderately happy
Very happy
12. Some pregnant women sometimes get so irritated by the baby inside them that they
feel like they want to hurt it or punish it:
I couldn‟t imagine I would ever feel like this
I could imagine I might sometimes feel like this, but I never
actually have
I have felt like this once or twice myself
I have occasionally felt like this myself
I have often felt like this myself
13. Over the past two weeks I have felt:
Very emotionally distant from my baby
Moderately emotionally distant from my baby
Not particularly emotionally close to my baby
Moderately close emotionally to my baby
Very close emotionally to my baby
14. Over the past two weeks I have taken care with what I eat to make sure the baby
gets a good diet:
Not at all
Once or twice when I ate
96
Occasionally when I ate
Quite often when I ate
Every time I ate
15. When I first see my baby after the birth I expect I will feel:
Intense affection
Mostly affection
Dislike about one or two aspects of the baby
Dislike about quite a few aspects of the baby
Mostly dislike
16. When my baby is born I would like to hold the baby:
Immediately
After it has been wrapped in a blanket
After it has been washed
After a few hours for things to settle down
The next day
17. Over the past two weeks I have had dreams about the pregnancy or baby:
Not at all
Occasionally
Frequently
Very frequently
Almost every night
97
18. Over the past two weeks I have found myself feeling, or rubbing with my hand, the
outside of my stomach where the baby is:
A lot of times each day
At least once per day
Occasionally
Once only
Not at all
19. If the pregnancy was lost at this time (due to miscarriage or other accidental event)
without any pain or injury to myself, I expect I would feel:
Very pleased
Moderately pleased
Neutral (i.e. neither sad nor pleased; or mixed feelings)
Moderately sad
Very sad
98
Maternal Attitudes and Maternal Adjustment Scale
Please complete each question by putting a circle around the answer which most
closely applies to you. Work quickly and please remember to answer each question.
We want to know how you have been feeling during the past month. If you have not
considered some of the questions during the past month, answer them based on your
present feelings.
1. Have you been worrying that you might not be a good mother? Not at all A little A lot Very much
2. Having you been worrying about hurting your baby inside you? Not at all A little A lot Very much
3. Has it worried you that you may not have any time to yourself
once your baby is born? Not at all A little A lot Very much
4. Have you regretted being pregnant? Never Rarely Often Very Often
5. Has the thought of wearing maternity clothes appealed to you? Very much A lot A little Not at all
6. Have you been feeling happy that you are pregnant? Not at all A little A lot Very much
7. Has the thought of having more children appealed to you? Not at all A little A lot Very much
8. Have you felt that pregnancy was unpleasant? Very much A lot A little Not at all
9. Have you been looking forward to caring for your baby‟s
needs? Not at all A little A lot Very much
10. Have you been wondering whether your baby will be healthy
and normal? Not at all A little A lot Very much
11. Have you felt that life will be more difficult after the baby is
born? Not at all A little A lot Very much
12. Has the thought of breastfeeding your baby appealed to you? Not at all A little A lot Very much
99
AIDS Multidimensional Health Locus of Control Scale
This set of statements involves opinions about the AIDS/HIV virus. Please indicate
how much you agree with each statement from 1= strongly disagree to 5= strongly
agree. Please don’t skip any questions.
Strongly
Disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
Agree
5
I am in control of whether I get the AIDS virus
If I get the AIDS virus, it‟s a matter of fate
Other people play a big role in whether I get the
AIDS virus
If I take the right steps, I can avoid the AIDS
virus
If it‟s meant to be, I will get the AIDS virus
More than anything else, chance determines
whether I get the AIDS virus
Whether or not I get the AIDS virus depends on
what my sexual partner wants to do
My own behavior determines whether I get the
AIDS virus
Whether I get the AIDS virus is determined by
other people
100
Perceived Risk Scale
Please indicate how strongly you agree with each of the following statements from
1= strongly disagree to 5= strongly agree. Please don’t skip any questions.
Strongly
Disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
Agree
5
I am afraid of getting AIDS
I am not worried about getting AIDS
I am less likely than most people to get AIDS
I am not the kind of person who is likely to get
AIDS
I would rather get any other disease than AIDS
I consider myself a member of an AIDS high
risk group
101
The Sexual Relationship Power Scale
The following questions pertain to your relationship with your main partner. This
person may be your husband, boyfriend, or lover. If you do not have a main
partner, answer these questions for the partner with whom you have sex most
frequently.
Please indicate how much you agree with each statement from 1= strongly agree to
4= strongly disagree. Please don’t skip any questions.
Strongly
Agree
1
Agree
2
Disagree
3
Strongly
Disagree
4
1. If I asked my partner to use s condom, he would get
violent.
2. If I asked my partner to use a condom, he would get
angry.
3. Most of the time, we do what my partner wants to do.
4. My partner won‟t let me wear certain things.
5. When my partner and I are together, I am pretty quiet.
6. My partner has more say than I do about important
decisions that affect us.
7. My partner tells me who I can spend time with.
8. If I asked my partner to use a condom, he would think I
am having sex with other people.
9. I feel trapped or stuck in our relationship.
10. My partner does what he wants, even if I do not want
him to.
11. I am more committed to our relationship than my
partner is.
12. When my partner and I disagree, he gets his way most
of the time.
13. My partner gets more out of our relationship than I
do.
14. My partner always wants to know where I am.
15. My partner might be having sex with someone else.
102
Zimbardo Time Perspective Inventory
Read each item and, as honestly as you can, answer the question: “How characteristic or true
is this of you?” Check the appropriate box using the scale.
Very Untrue Neutral Very True
1
2
3
4
5
1. I believe that getting together with friends to party is one of life‟s important pleasures.
6. I believe that a person‟s day should be planned ahead each morning.
8. I do things impulsively.
9. If things don‟t get done on time, I don‟t worry about it.
10. When I want to achieve something, I set goals and consider specific means for
reaching those goals.
12. When listening to my favorite music, I often lose all track of time.
13. Meeting tomorrow‟s deadlines and doing other necessary work comes before tonight‟s
play.
17. I try to live my life as fully as possible, one day at a time.
18. It upsets me to be late for appointments.
19. Ideally, I would live each day as if it were my last.
21. I meet my obligations to friends and authorities on time.
23. I make decisions on the spur of the moment.
26. It is important to put excitement in my life.
28. I feel that it‟s more important to enjoy what you‟re doing than to get work done on time.
30. Before making a decision, I weigh the costs against the benefits.
31. Taking risks keeps my life from becoming boring.
32. It is more important for me to enjoy life‟s journey than to focus only on the destination.
40. I complete projects on time by making steady progress.
42. I take risks to put excitement into my life.
43. I make lists of things to do.
44. I often follow my heart more than my head.
45. I am able to resist temptations when I know that there is work to be done.
46. I find myself getting swept up in the excitement of the moment.
48. I prefer friends who are spontaneous rather than predictable.
51. I keep working at difficult, uninteresting tasks if they will help me get ahead.
55. I like my close relationships to be passionate.
56. There will always be time to catch up on my work.
103
As you are pregnant or have recently had a baby, we would like to know how you
are feeling. Please check the answer that comes closest to how you have felt IN THE
PAST 7 DAYS, not just how you feel today.
1. I have been able to laugh and see the funny side of things
____ As much as I always could
____Not quite so much now
____Definitely not so much now
____Not at all
2. I have looked forward with enjoyment to things
____As much as I ever did
____Rather less than I used to
____Definitely less than I used to
____Hardly at all
*3. I have blamed myself unnecessarily when things went wrong
____Yes, most of the time
____Yes, some of the time
____Not very often
____No, never
4. I have been anxious or worried for no good reason
____No, not at all
____Hardly ever
____Yes, sometimes
____Yes, very often
*5 I have felt scared or panicky for no very good reason
____Yes, quite a lot
____Yes, sometimes
____No, not much
____No, not at all
104
*6. Things have been getting on top of me
____Yes, most of the time I haven‟t been able to cope at all
____Yes, sometimes I haven‟t been coping as well as usual
____No, most of the time I have coped quite well
____No, I have been coping as well as ever
*7. I have been so unhappy that I have had difficulty sleeping
____Yes, most of the time
____Yes, sometimes
____Not very often
____No, not at all
*8. I have felt sad or miserable
____Yes, most of the time
____Yes, quite often
____Not very often
*9. I have been so unhappy that I have been crying
____Yes, most of the time
____Yes, quite often
____Only occasionally
*10. The thought of harming myself has occurred to me
____Yes, quite often
____Sometimes
____Hardly ever
____Never
105
VITA
Dr. Levine Kornfield was born in Baltimore, Maryland. She received her B.A. (2003) in
Psychology from Barnard College, Columbia University in New York City, where she
was the recipient of the April Benson '63 Psychology Award in 2002. Dr. Kornfield went
on to receive her M.S. (2008) and Ph.D. (2010) in Clinical Psychology from Drexel
University in Philadelphia. While at Drexel, she taught undergraduate classes, held
positions at clinical practica, and was the recipient of several academic awards for her
research at local and national conferences. She completed her predoctoral internship at
the Veteran's Affairs Medical Center in Northport, NY and will commence a post-
doctoral fellowship at the Veteran's Affairs Medical Center in Philadelphia. See below
for a selection of published works:
Levine Kornfield, S.V., Geller, P.A. (2010) Mental health outcomes of abortion
and its alternatives: Implications for future policy. Women’s Health
Issues, 20(2), 92-95.
Geller, P.A., Psaros, C., Levine Kornfield, S.V. (2010). Satisfaction with
pregnancy loss aftercare: Are women getting what they want? Archives
of Women’s Mental Health, 13(2), 111-124.
Maret, A. Ding, C., Levine Kornfield, S., Levine, M.A. (2008). Analysis of the
GCM2 Gene in Isolated Hypoparathyroidism. The Journal of Clinical
Endocrinology and Metabolism, 93(4), 1426-1432.
