Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)




Background: Maternal-fetal attachment (MFA) is the bond between a mother and her unborn child during pregnancy. Pregnant women with diabetes are considered high-risk and their numbers are expected to increase as levels of obesity rise and women wait longer to have children. This researcher has observed health care providers instructing pregnant women with diabetes about diabetes self-management (DSM) activities such as “dietary management” and encouraging the women to make those changes for their baby. However, some women remained unable to successfully engage in DSM behaviors despite having exhibited signs of MFA, e.g., expressing “thoughts of the fetus” to health care providers. The inability to make DSM changes during pregnancy can increase the risk of poorer maternal and fetal outcomes and quality of life (QOL). Whether MFA impacts the DSM and QOL of pregnant women with diabetes is unknown. This study described the relationships among these variables and others guided by the revised Wilson & Cleary’s Health-Related Quality of Life model. Purpose: The purpose of this study was to investigate the relationship between MFA and other factors such as glycemic management, mood, e.g., anxiety and depression, DSM, e.g., dietary management, and physical and mental health perceptions that may impact QOL in pregnant women with diabetes. The primary aim was to describe relationships between MFA, glycemic management, mood, DSM, and QOL after controlling for potential confounders such as social support. The proposed hypothesis was higher MFA would be associated with better glycemic management, less mood disturbance, and better DSM, perceived health, and QOL. An exploratory aim of this study was to determine if MFA mediated the relationships between mood or DSM and QOL. Method: A descriptive, cross-sectional study of 103 pregnant women was conducted between 28 – 40 weeks gestation (M = 33 weeks + 5 days). The convenience sample included pregnant women with type 1 diabetes (T1DM) and pregnant for the first time or diagnosed with gestational diabetes mellitus (GDM) or newly discovered type 2 diabetes (T2DM) for the first time with the current pregnancy. Data analyses included descriptive statistics, Chi-square tests, independent sample t-tests, and ANOVA. Hierarchical multiple linear regression was used to assess for significant predictors of QOL. Hayes conditional process analyses were used to assess the indirect effect of MFA between mood, then DSM and QOL. Sample Description: Most women were college educated or greater (59.2%), married (81.6%), living with a partner (96.1%), and diagnosed with GDM (87.0%). Many participants met the American College of Obstetrics and Gynecology (ACOG) recommended average fasting blood sugar (FBS) of < 95 mg/dL (71.8%). Some participants managed their blood sugars with only diet and exercise (38.8%), with the remaining women requiring some type of insulin (61.2%). Participants identified mostly as White (53.4%), whose ages ranged from 19 – 41 years (M = 31.3) and were employed outside the home (71.9%). A few women (6.8%) had a normal BMI, while others were overweight (26.2%), and most were obese (67.0%) using ACOG BMI classifications. The participants had higher rates of infertility (14.6%) when compared to the U.S. reported rate of 10.9 % of all women ages 15 – 44 with impaired fecundity in 2019. Many reported a family history of first degree relatives diagnosed with some type of diabetes (75.0%) and 50.0% had first degree relatives with hypertensive disorders. Results: The participants reported an average total MFA (79.5 ± 5.9) using the Maternal Antenatal Attachment Scale, with a potential range of 19 – 95. Likewise, when compared with other literature reviewed involving high-risk pregnancies the participants reported higher MAAS subscale levels of MFA: quality of attachment/preoccupation (46.3 ± 2.9) and time in attachment mode/intensity (28.3 ± 3.9). It was difficult to know if these findings represent all pregnant women with diabetes as this was a novel aspect of the current study. However, this may have suggested that regardless of DSM demands, participants maintained a bond with their unborn child, which might ensure better maternal and neonatal outcomes. The women in this sample reported lower levels of anxiety and depression symptomatology over the prior two weeks. The total Diabetes Self-Management Questionnaire (DSMQ) scores could range from 0 – 10 and the current sample average suggested good DSM (8.6 ± 1.0), which is consistent with the high percentage of women meeting ACOG (2018) FBS guidelines in this sample. The DSM sub-scale scores ranged from 0 – 10 and were highest for maintaining physician contact (9.3 ± 1.2) and lowest for dietary control/management (7.9 ± 1.9), followed by physical activity (8.1 ± 1.7) suggesting these were the best and more difficult areas of DSM for most participants, respectively. Overall, participants reported high QOL satisfaction, especially the happiness of their families, children, and partners, respectively. Likewise, participants reported above average social support which might have helped improve sample QOL scores. Maternal-fetal attachment was significantly related to DSM (r = .20, p = .039), perceived mental health (r = .26, p = .007), and satisfaction with QOL (r = .24, p = .013). However, MFA was not significantly correlated with FBS or mood. The significant predictors of a higher QOL score included social support (? = .48, t (99) = 5.14, p < .001), DSM (? = .37, t (99) = 5.17, p < .001), physical health (? = .20, t (99) = 2.93, p = .004), and mental health perceptions (? = .46, t (99) = 5.54, p < .001). MFA was trending as a predictor of QOL (? = .14, t (99) = 1.95, p = .054) until physical and mental health perceptions were included in the model. Finally, MFA was not a significant mediator between mood or DSM and QOL. Conclusions: This study confirmed that better perceived social support was a strong predictor of QOL in pregnant women with diabetes, even when controlled for as a covariate. This finding may suggest social support is an area that should be assessed before, during, and after pregnancies complicated with diabetes and may be an area for intervention development to help with examining ways to improve social support and improve a woman’s QOL. A positive perceived mental health, better DSM, and perceived physical health were significant predictors of QOL in this sample of women diagnosed with predominantly GDM. MFA was trending towards being a predictor of QOL, but more research will be needed with larger samples and equal groups of the several types of diabetes. Maternal-fetal attachment did not function as a mediator between mood or DSM and QOL. However, higher levels of MFA were related to better DSM. Maternal-fetal attachment may function more as a characteristic of the individual and could act as a moderator instead of or in addition to being a mediator. Additional moderated mediation analyses are warranted to determine how the variables of interest especially MFA interact to affect QOL in pregnant women with diabetes. Implications for Nursing Practice: In pregnant women with diabetes, higher MFA was associated with better DSM specifically, maintaining physician contact, and QOL. The lowest scores for DSM were regarding dietary control and physical activity suggesting these may be areas for nurses to focus on when caring for pregnant women with diabetes. Likewise, knowing a woman’s obstetrical history, e.g., infertility/loss, social support, DSM, and that general health are predictors of QOL may help inform nursing practice and encourage nurses to find and make ways to increase MFA in vulnerable women. Simple inexpensive interventions such as recommending the patient have someone accompany them to appointments, spending time with patients to assess how their family is doing, asking what types of and who supports them, going over the results of findings after the clinic visit, and then creating an individualized plan of care with patient input could help improve MFA, DSM, and QOL. Future research should also include different study designs, e.g., longitudinal which could examine MFA then maternal child attachment (MCA) levels after pregnancies complicated by conditions such as diabetes or equal sample sizes among the types of diabetes. Not only could this improve maternal, fetal, and child outcomes but may further substantiate the importance of MFA during, and MCA after, a pregnancy complicated with diabetes as a detail of interest for nurses. Likewise, additional conditional process analyses may reveal how MFA functions in this vulnerable population. Finally, studies with more diverse populations including the LGBTQIA community, urban areas, and single parents must be completed to obtain a more holistic view of how MFA, DSM, and QOL are related during pregnancies complicated by diabetes.

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Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

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