Maternal Compliance Research Articles

Effect of counseling on maternal reporting of adverse effects in nursing infants exposed to antibiotics through breast milk

In a recent trial, we found that nursing women reported diarrhea in their nursing infants after maternal use of antibiotics. However, because they were told that this could occur during a medication counseling session, the observed effect could have been due to a reporting bias. The objectives of this study were to determine if counseling nursing women about side effects of antibiotic they used could (a) influence the adverse event reporting rate or (b) influence maternal nursing and medication compliance behavior. In a randomized, controlled trial, nursing women calling a teratogen information service for advice about selected antibiotics received one of two possible counseling formats (A and B). Both groups were informed that the antibiotics were safe to use. Mothers in group B were also informed about a theoretical risk of diarrhea in the infant. Mothers later reported clinical events they noted in the infants and judged whether they were due to the antibiotic. Eighty-seven percent ( 54 62 ) of group A subjects compared to 68% ( 52 76 ) of group B subjects reported clinical events in their infants during their antibiotic therapy ( P = 0.017). The incidence of reported diarrhea was 26% in group A compared to 17% in group B ( P = 0.3); 34% of subjects in both groups attributed clinical events to antibiotic therapy ( P = 1.0). Diarrhea was attributed to antibiotic therapy in 13% of group A and 12% of group B subjects ( P = 1.0). No differences were observed between groups in breastfeeding pattern and antibiotic compliance. Breastfeeding women counseled about adverse effects were not more likely to report side effects in their infants or to change nursing behavior and medication compliance.

Maternal compliance to court-ordered assessment in cases of child maltreatment

Parental compliance to court-ordered assessment was examined in 82 mothers whose children had been removed from the home due to child maltreatment. Compliant ( n = 52) and Noncompliant ( n = 30) mothers were compared on parental and psychosocial risk factors previously documented in child maltreatment research. The results indicate that noncompliant mothers tend to be younger, lead more transient lifestyles, show a greater degree of antisocial behavior, and experience more violence in their spousal relationships. The implications of these data for clinical and legal involvement with these families is discussed.

PRENATAL TREATMENT OF CONGENITAL ADRENAL HYPERPLASIA (CAH) DUE TO 21-HYDROXYLASE DEFICIENCY: EUROPEAN EXPERIENCE IN 223 PREGNANCIES AT RISK

In the aim to prevent the in utero virilization of CAH affected females a prenatal treatment (Rx) has first been attempted by David and Forest in 1979; later these authors reported their first results and proposed a therapeutic protocol (J. Pediatr. 1984; 104: 799-803). Except for the experience of the French multicentric study in 42 pregnancies at risk (Endocr. Res.1989;15:277-301), prenatal Rx of CAH using therapeutic protocols quite similar to the above, and subsequently reported in the literature were concerned with a limited number of cases. Indeed, prenatal Rx of CAH is not frequently instituted. Nevertheless, a number of experiences have not been reported. This is why, we decided to collect a maximum of data from European Pediatricians. A questionnaire was constructed to enquire about the effects of prenatal Rx on the fetus on one hand (therapeutic protocols, prenatal diagnosis (Dg), results on the external genitalia of CAH female fetuses, effects if any on the development of the fetus or child) and on the mother on the other hand (follow-up, compliance and tolerance of Rx, course of pregnancy, short and long term effects or side-effects in the mothers). Informations were obtained in a total of 223 treated pregnancies: 75 cases from the French multicentric study (M.G. Forest, M.David), 58 German cases (collected by H.G. Dorr and W.G. Sippell in cooperation with the APE), and 27 Scandinavian cases coordinated by E.M. Ritzen. The questionnaire was also sent to the other European ESPE Members and to date data were collected on 63 additional cases. There was no prenatal Dg in 20 cases (not available or refused). Prenatal Dg was first made on HLA typing and/or steroid measurement in the amniotic fluid. An earlier prenatal Dg was subsequently made by HLA typing on chorion villus sampling (CVS). On the whole, steroid measurement was safe (if Rx interrupted) except in 2 cases and HLA serological typing helpful, but at least 8 false prenatal Dg were recorded. For the last 2-4 years, DNA studies are performed on CVS (HLA RFLP, C4-CYP21 genes) with increasing safety. Prenatal Rx was with dexamethasone (Dex) or Dex acetate (France in particular), usually at a dose of 0.5 mg, 2 to 3 times a day. The Dex dose was more rarely adapted to maternal body weight (20 μg/kg, as advocated by Forest et al (above ref). Among the 38 CAH treated females, 37 were born, with normal (9) or slightly virilized genitalia (17); none of them would need surgery. Prenatal Rx was not successful (stage III/IV) for apparently logical reasons (late start of Rx, insufficient Dex dose, early interruption, lack of compliance) in 9 CAH females but not explained in 2 others. There was a remarkable lack of side-effects in fetuses or children, except for a severe hydrocephalus in a male fetus (treated for 7 wks) and 2 deaths in utero near term while Rx was stopped for several months (both not attributed to Dex Rx by specialists), and an unexplained failure to thrive in a CAH girl treated until term. Maternal acceptance of Rx was said to be good to excellent. Maternal compliance was usually good (as judged by low maternal levels of cortisol, DHAS or estriol). Maternal side-effects were reported in some but not all mothers. In the mothers where Rx was stopped in mid-pregnancy (unaffected cases) there was often no complaint or that of an excessive weight gain (reasonably controlled by salt and caloric restriction in the French study), observed more often in the mothers given 1.5 mg of Dex, and always resuming after delivery. When treatment was continued until term (n = 53), more serious side-effects were observed in some mothers : marked weight gain (n=15), edema (n =3), increased blood pressure (n= 5). In addition, Rx tolerance was poor in 7 mothers (weight gain, edema, fatigue, feeling of exhaution, or hypertension, or gestational diabetes mellitus) leading twice to interrupting Rx despite prenatal Dg of a CAH female fetus. This is why a more detailed follow-up of the maternal well-being is undertaken. In conclusion, prenatal Rx of CAH appears effective, providing a good rationale in the Rx protocol. Observations made in a large number of pregnancies show that short term Rx (started at 4-7 wks, and stopped after a prenatal Dg based on DNA studies on CVS, at about 12 wks) is usually well tolerated. Tolerance of long term Rx seems to be a problem in some mothers. These findings lead us to propose that Dex Rx should be adapted to maternal size in all mothers (20 μg/kg), then Dex dose should or could eventually be decreased by 50% from mid-pregnancy to term in those mothers who bear a CAH female fetus.

The relationship between maternal characteristics, maternal vulnerability beliefs, and immunization compliance.

The purpose of this descriptive study was to determine the relationship of demographic variables and mothers' perceived vulnerability to eight communicable diseases with immunization compliance. A random sample consisting of 40 mothers with preschool-age children 4-24 months of age was interviewed by means of the Communicable Disease Perceived Vulnerability Scale and the investigator-developed Demographic Data Collection Instrument. Data were analyzed with descriptive statistics and chi-square (p < or = .05). The average mother in the sample was White, had a 10th- to 12th-grade education, was 24-31 years old, and had a yearly income of $10,000-$45,000. Statistically there were no significant relationships between maternal characteristics or between maternal vulnerability beliefs and immunization compliance. However, it is clinically significant that the overall compliance rate of 70% in this rural area is much higher than the national average of 50%. Findings suggest that using health education materials at the time of newborn discharge, mailing reminder cards, and accessing a statewide computer recall system may increase immunization compliance. In addition, mothers who perceived a vulnerability to the diseases had a 60.6% compliance rate, suggesting that perception of vulnerability may be a useful predictor of immunization compliance.

Maternal Autonomy Granting: Predictors of Normal and Depressed Mothers' Compliance and Noncompliance with the Requests of Five-Year-Olds

Maternal compliance and noncompliance to child requests, thought to represent an autonomy-granting aspect of socialization, were studied in 24 well mothers and 26 mothers with a history of depression and their 5-year-old children. Mothers continued to retain substantially more power than children in the control process. There were no differences between normal and depressed mothers in the extent to which they granted or denied their children's requests, but the determinants of maternal autonomy granting differed in the 2 groups. Depressed, but not well, mothers' responses to child requests could be predicted from their self-reported mood prior to the interaction and from the concurrent child's behavior. Depressed mothers who reported negative mood and whose children were uncooperative most often denied their requests. Depressed mothers' noncompliance to their children's requests was determined by the quantity rather than quality of their children's behavior: they did not discriminate between skillful and unskillful forms of the children's autonomy expressions.

Maternal Responsiveness and Child Compliance: The Role of Mood as a Mediator

Parpal and Maccoby demonstrated that responsive maternal play increases children's compliance. They suggested that positive mood induction might be one mechanism mediating this effect. Study 1 tested the hypothesis that a responsive maternal play procedure would indeed induce a positive mood. 32 4-year-olds and their mothers participated. Half of the mothers were trained in a responsive play technique prior to a laboratory play session; half of them were not trained. Postplay self-reports of mood indicated that responsive play increased positive mood but did not affect arousal levels. Study 2 tested the hypothesis that experimentally induced positive mood increases compliance in the types of tasks reported in the Parpal and Maccoby's research. 24 4-year-olds were randomly assigned to either a positive or negative mood induction and then tested for response to maternal compliance demands. Children induced into positive moods complied more and complied with shorter latencies than children induced into negative moods. The fact that maternal responsiveness induces a positive mood points to a mechanism that may be significant in both attachment and socialization beyond infancy.

Immunization of newborns of HBsag- positive mothers: A successful first step in control of hepatitis B virus in Taiwan

To combat hepatitis B virus (HBV) infection in Taiwan, a mass immunoprophylaxis program was launched on July 1, 1984, aiming first at prevention of chronic HBV carriage from perinatal mother-to-infant infection. In the first 15-month period, 352721 (78%) of 450585 pregnant women were screened for hepatitis B surface antigen (HBsAg); HBsAg was present in 62359 (18%), with 50% of them categorized as highly infectious. Infants born to HBsAg-positive women were given 5 μg of a plasma-derived hepatitis B vaccine at ages 1, 5, and 9 weeks, with a booster at age 12 months. Infants of highly infectious carrier mothers recived an additional 0.5 mL of hepatitis B immune globulin within 24 hours after birth. The coverage rate of the hepatitis B immune globulin was 77% in 27375 infants born to highly infectious mothers, and that of the first, second, third, and the fourth doses of vaccine was 88%, 86%, 84%, and 71%, respectively, in infants of 55620 carrier mothers. The reported untoward reactions to immunization were negligible. We conclude that a mass hepatitis B vaccination program is feasible in hyperendemic areas such as Taiwan; this should be a significant step toward the effective control of HBV infection in these areas. To evaluate the efficacy of the mass hepatitis B vaccination program in Taiwan in interrupting perinatal hepatitis B virus transmission, 3464 randomly selected 18-month-old infant vaccinees born to hepatitis B surface antigen-carrier mothers were recruited from 9697 eligible infants during a six-month period of the program. They were divided into ten groups according to maternal in-fectivity and compliance with the vaccination schedule. Serum samples were tested for hepatitis B surface antigen, antibody to hepatitis B surface antigen, and antibody to hepatitis B core antigen. In 786 infants who had highly infectious mothers and who received hepatitis B immune globulin and vaccine on schedule, the protective efficacy was about 85%. The efficacy seemed to be slightly lower in those immunized off schedule. Overall, 11% of infants still carried hepatitis B surface antigen, and 81% of the infants had antibody to hepatitis B surface antigen that exceeded 10 mlU/ mL in more than 90% of them. The geometric mean titers of antibody to hepatitis B surface antigen were more than 200 mlU/mL in every group of infants. We conclude that the mass vaccination program is efficacious in preventing perinatal hepatitis B virus transmission and the chronic carrier state; most infant vaccinees have adequate levels of protective antibody at 18 months of age. This program is extremely significant in the control of hepatitis B virus infection in Taiwan.

Compliance with antibiotic regimens in hispanic mothers

Sixty-six young Hispanic mothers were evaluated for compliance with prescribed antibiotic regimen for their children suffering from acute otitis media. The study utilized a two-group experimental design and was conducted in a free medical clinic setting. Findings did not support the hypothesis that maternal compliance would be significantly greater when written/pictorial instructions in the primary language of the client were added to the verbal instructions given to the control group. Findings imply that future research needs to focus on poor, frequently undocumented Hispanics with limited access to quality health care to discover the variables which influence compliance among this growing client population.

Efficacy of a Mass Hepatitis B Vaccination Program in Taiwan

To evaluate the efficacy of the mass hepatitis B vaccination program in Taiwan in interrupting perinatal hepatitis B virus transmission, 3464 randomly selected 18-month-old infant vaccinees born to hepatitis B surface antigen-carrier mothers were recruited from 9697 eligible infants during a six-month period of the program. They were divided into ten groups according to maternal infectivity and compliance with the vaccination schedule. Serum samples were tested for hepatitis B surface antigen, antibody to hepatitis B surface antigen, and antibody to hepatitis B core antigen. In 786 infants who had highly infectious mothers and who received hepatitis B immune globulin and vaccine on schedule, the protective efficacy was about 85%. The efficacy seemed to be slightly lower in those immunized off schedule. Overall, 11% of infants still carried hepatitis B surface antigen, and 81% of the infants had antibody to hepatitis B surface antigen that exceeded 10 mIU/mL in more than 90% of them. The geometric mean titers of antibody to hepatitis B surface antigen were more than 200 mIU/mL in every group of infants. We conclude that the mass vaccination program is efficacious in preventing perinatal hepatitis B virus transmission and the chronic carrier state; most infant vaccinees have adequate levels of protective antibody at 18 months of age. This program is extremely significant in the control of hepatitis B virus infection in Taiwan.

Maternal sensitivity and patterns of infant-mother attachment.

48 12-month-old infants and their mothers were videotaped in the Ainsworth Strange Situation. Each infant-mother dyad was also filmed for 3 min while the mother completed a questionnaire and the infant was left to explore the room devoid of toys, a situation in which maternal compliance with the request to complete the questionnaire was expected to compete with attentional demands made on her by the infant. Infant-mother attachment was classified as secure, anxious-avoidant, or anxious-resistant on the basis of behavior in the Strange Situation. Assessment of maternal sensitivity during the questionnaire situation included behaviors classified as reflecting appropriate, insufficient, and intrusive responses to infant cues. 3 summary measures of maternal sensitivity, each of which distinguished between mothers of securely and anxiously attached infants in 1-way analysis of variance tests, were entered into a discriminant function analysis. Using the discriminant function coefficients for combining the maternal sensitivity scores, 94% of the infants were correctly classified as securely or anxiously attached on the basis of their mothers' behavior in the questionnaire situation.

Maternal Sensitivity and Patterns of Infant-Mother Attachment

48 12-month-old infants and their mothers were videotaped in the Ainsworth Strange Situation. Each infant-mother dyad was also filmed for 3 min while the mother completed a questionnaire and the infant was left to explore the room devoid of toys, a situation in which maternal compliance with the request to complete the questionnaire was expected to compete with attentional demands made on her by the infant. Infant-mother attachment was classified as secure, anxious-avoidant, or anxious-resistant on the basis of behavior in the Strange Situation. Assessment of maternal sensitivity during the questionnaire situation included behaviors classified as reflecting appropriate, insufficient, and intrusive responses to infant cues. 3 summary measures of maternal sensitivity, each of which distinguished between mothers of securely and anxiously attached infants in 1-way analysis of variance tests, were entered into a discriminant function analysis. Using the discriminant function coefficients for combining the maternal sensitivity scores, 94% of the infants were correctly classified as securely or anxiously attached on the basis of their mothers' behavior in the questionnaire situation.

Predictors of Maternal Satisfaction Regarding Clinic-Referred Children: Methodological Considerations

We examined predictors of maternal satisfaction in clinic-referred children and added several methodological improvements to previous studies. These included a more comprehensive coding system used with the entire family, measures of mothers' satisfaction with both the child's positive and negative behavior, and an older participant sample. Thirty-three families with one clinic-referred child between 6 and 11 years of age served as participants. Five different criterion measures of maternal satisfaction were used (including both positively and negatively valued ones). Predictors included maternal depression and direct observation of the content and affect of all family members. Results indicated that different predictors accounted for each of two negatively valued satisfaction measures only: Mothers' level of depression and neutral affect predicted one measure, whereas maternal depression and child compliance predicted the other. Further methodological improvements for future research are recommended.

Pediatricians' Opinions of Mothers

The purpose of this study was to determine factors that influence pediatricians' opinions of mothers. The degree to which mother-physician interactions, mother-child interactions, and maternal demographic variables influence pediatricians' opinions of mothers was assessed with a 54-item questionnaire. Questionnaires were mailed to 470 Chicago-based American Academy of Pediatrics Fellows; 268 (57%) of the questionnaires were returned and, of these, 230 were suitable for analysis. A majority of pediatricians reported that their opinions were "greatly" positively influenced by mothers who communicate clearly (60%), understand recommendations (56%), follow recommendations (68%), and keep appointments (58%). In comparison, significantly fewer pediatricians' opinions were "greatly" influenced by mothers who are friendly to them (38%) or who like them (34%) (chi 2, P less than .001). Pediatricians were also "greatly" influenced by mothers who seem safety conscious (67%), use car restraints (57%), and keep immunizations updated (61%). Female pediatricians, in contrast to men, were significantly more influenced by mothers who "respond to their crying infants" and who "try to calm an anxious child" (chi 2, P less than .05). Pediatricians' opinions of mothers appear to be greatly influenced by maternal compliance, communications skills, and cognitive abilities, as well as by mothers who promote health and safety. Affective variables such as friendliness seem less important. Female pediatricians appear more influenced by mothers who actively console their children.

Splinting for CDH--initial impressions of a 'user-friendly' alternative.

A lightweight, washable, and easily adjusted splint for the congenitally dislocated hip, designed to improve maternal compliance, is described. Observations are currently scientifically uncontrolled, though initial impressions are favourable.

Maternal Compliance in Immunization of Preschoolers as Related to Health Locus of Control, Health Value, and Perceived Vulnerability

The health attitudes and behaviors of 94 mothers of preschool children were investigated by personal interview in this descriptive correlational study. Mothers were divided into two groups, depending on their compliance or noncompliance, with recommended immunizations for their children. Subjects were assessed for health locus of control, perceived vulnerability to six communicable diseases, and health as a value. Demographic variables of age, education, religion, ethnicity, income, and recall of earlier poliomyelitis epidemics were studied. Analysis of variance, chi-square and descriptive statistics were used in the data analysis. Results revealed no significant differences between compliant and noncompliant mothers to health locus of control measure, perceived vulnerability to six diseases under study, or recollection of earlier poliomyelitis epidemics. The majority of mothers were Hispanic, Catholic, in their late twenties, of low income and with a 12th grade education or less. Health as a value was selected first or second by the subjects in most cases, regardless of immunization compliance behavior. Compared with a normative sample, mothers in this study were predominantly more external than internal in their locus of control orientation.

Maternal Compliance and Children??s Self-Concept in Cystic Fibrosis

To examine the hypothesis that the degree of maternal compliance with physical therapy regimens for cystic fibrosis (CF) is correlated with the child's psychological adjustment, compliance was classified by independent raters as "moderate" (intermediate) or "unmoderated" (rigid adherence or clear noncompliance). Compliance data were obtained in a structured self-report interview. The Piers-Harris Children's Self-Concept Scale was administered to the children (23 boys, aged 7-15 years) to measure this dimension of psychological adjustment. Children of mothers with unmoderated compliance scored significantly lower on total self-concept scores and on subtests measuring popularity and physical appearance and attributes than those with mothers whose compliance was rated as moderated. These findings, if confirmed in studies with larger samples that include girls with CF, have implications for practitioners who treat children with this disorder.

Maternal placental vascular compliance in rabbits.

We studied compliance on the maternal side of the placenta of 20 New Zealand white rabbits, using 51Cr and 125I labels to determine erythrocyte, plasma, and whole-blood volumes per gram of placental tissue under varying maternal pressure conditions. At normal maternal arterial (Pa) and venous (Pv) pressures of 71.8 and 5.5 mmHg, placental blood volume (mean +/- SE) was 0.447 +/- 0.051 ml/g placental tissue. When venous pressure was raised (Pa = 45.5, Pv = 12.2) by occluding the inferior vena cava, blood volume increased to 0.729 +/- 0.068 ml/g, a significant 63% rise. However, when arterial pressure was lowered by occluding the aorta in two steps, dropping to Pa = 33.8, Pv = 7.0, and Pa = 13.5, Pv = 5.4, volume did not decrease significantly. We estimated intervillous space pressure (Pivs) from arterial and venous pressures assuming a ratio of venous to total resistance of 0.02. Compliance calculated from the slope of Pivs vs. volume was 0.0471 ml/mmHg per g. Maternal placental hematocrit averaged 27%, appreciably less than the circulating hematocrit of 38%. Overall, the results suggest that placental volume would be maintained during hypotension and would increase when venous pressure is elevated.

Dr. Hoekelman Replies

The issues raised by Dr. Stein and Dr. Weinberger are quite important and, in fact, prompted the determination of correlation coefficients for the actual number of well-baby visits made and the maternal competence, satisfaction, and compliance scores between and within settings by provider groups and, overall, between settings. These were all less than .25 as reported in the text of the article. It must be remembered that the visit figures presented in Table XIV to which both writers refer are means for the entire sample.

Parental Assimilation by Children with and without Behavioral Problems

Summary A correlational study of parental assimilation patterns revealed greater paternal compliance and greater maternal compliance and internalization in a sample of teacher-judged adjusted boys than in a comparison sample of unadjusted boys. Adjusted boys were more similar to their fathers in terms of their personal orientations toward child behavior. The generalized expectations of these boys were also more similar to their mothers' expectations. Data on intrafamilial perceptions were reported to illustrate the greater parental assimilation by the adjusted boys. These results lend additional support to the theorized importance of parental identification in the early development of behavior disorders.