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The Effects of Prematurity on Development: Outline and Introduction

By Michelle Bell

Outline

Introduction
Outcome Studies
Process Studies
Premature Birth
Attachment Literature
Object Relations Theory
Summary of Research Literature Findings
Discussion
Implications and Conclusion
References

Introduction

Advances in neonatal intensive care have significantly improved the survival rate of premature infants in the past two decades. Modern medical technology has continued to push back the limits of mortality, resulting in more aggressive interventions so that infants as young as 23 weeks gestation with weights as low as 500 grams may now survive (Szatmari, Saigal, Rosenbaum & Campbell, 1994). Data that documents the outcome of these infants also imply that many more infants that are premature remain in hospitals for longer periods than ever before. Prolonged hospital care intrudes upon maternal interactions, and mother-infant bonding, where interactions take place in a newborn intensive care unit, often separating mothers and their infants for long periods of time, resulting in limited opportunities for mothers to feed or nurture their premature infant (Eckerman & Oehler, 1992).

Given these significant delays in early maternal bonding, it is reasonable to suggest that maternal attachment may pose a significant challenge for mothers of premature infants, which may also impact on a mother's emotional state following the discharge of her premature infant. Indeed a large body of research has documented that parents of premature infants continue to show limited maternal responsiveness towards their infant following discharge, and clinicians have long searched for explanations for such caretaking practices (Field, 1977; Minde, 2000). Yet, little attention has been given to the unique experience in the emotional life of the mother in forming a selective and enduring bond with her premature infant.
From a psychoanalytical perspective, Winnicott's (1956) seminal paper concerning a mother's mental life during the immediate post-birth period asserts that following the birth of an infant, the mother's mental life changes from a normal mental state to a heightened state of caring anxiety that he termed 'primary maternal preoccupations'. This condition refers to the mother's obsessive-like involvement with thoughts and concerns for her newborn that is not only typical, but is also crucial to the formation of maternal attachment and subsequent bonding. Moreover, a mother's inability to become totally preoccupied with her infant is considered a risk signal that is likely to result in diminished maternal responsiveness characteristic of maternal depression (Feldman, Weller, Leckman, Kuint & Eidelman, 1999). Accordingly, the first aim of the current study was to explore the consequences the prolonged separation of mothers from their premature infant had on mother's emotional life following the discharge of her premature infant.

In addition, this thesis seeks to understand the potential costs involved in the prolonged separation of infants from their nursing mother on the psychological development of prematurely born children independently of their mothers emotional state. Given that premature infants initial development takes place in a highly technical space, in the face of intrusive and often stressful medical and nursing procedures (Eckerman & Oehler, 1992; Minde, 2000; Goldberg & DiVitto, 2002), it seems likely that prematurity may predispose an infant to significant delays in psychological development. Indeed, premature infants have been described as being less responsive, less attentive, less likely to show positive affect and more likely to be irritable when compared to full-term infants (Field, 1979; Minde, 2000). Because prolonged hospital care has been widely documented, and that premature infant's beginnings are substantially different when compared to full-term infants, it seems useful to consider a developmental explanation for this pattern of results.

In particular, object relations theory (ORT) which outlines a developmental sequence operative during infancy and progressing through various phases to early childhood, may serve as a useful research tool in the investigation of the psychosocial development of prematurely born children. Briefly, this theory contends that the quality of early parenting in addition to the infant's biological and social capacities modifies the formation of the internal object representation, which governs later relational behaviours (Mahler, Pine & Bergman, 1975). Given the early aberrations in dyadic interactions between mothers and premature infants, it is the assertion of this thesis that ORT may provide a more complete understanding of the complex psychosocial development of prematurely born children than is currently available. Examining these principles in relation to premature children's later personality and in particular behavioural functioning is the main aim of the present study.

This thesis begins with an overview of the empirical literature derived from medical research, commonly labelled the outcome approach, and summarises the data according to how it relates to the psychosocial functioning of prematurely born children. Following this, is an overview of the process literature, which delineates the difficulties faced by mothers following the birth of a premature infant and finally the attachment literature which documents the difficulties prematurely born infants have in the development of secure attachment. Rather than refute these approaches this thesis attempts to deepen the understanding of prematurely born children and their caregiver with complementary psychodynamic perspectives derived from Object Relations theories.

Despite objective criteria defining this condition, prematurity is associated with many factors and is therefore multifaceted. While current research subdivides the population of premature children according to birthweight categories (low birth weight = <2500 g; very low birth weight = <1500 g; extremely low birth weight <1000 g), this thesis draws on an inclusive interpretation of prematurity. That is, prematurity is defined as those children who are born less than 36 weeks gestational age, and spent more than 4 weeks in hospital following birth.

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