Journal of Pediatric Psychology, Vol. 26, No. 8, 2001, pp. 525-538
© 2001 Society of Pediatric Psychology
Review: Psychosocial Well-Being of Parents and Their Children Born After Assisted Reproduction
Johns Hopkins University
All correspondence should be sent to Chun-Shin Hahn, Child and Family Research Section, National Institute of Child Health and Human Development, Suite 8030, 6705 Rockledge Drive, Bethesda, Maryland 20892-7971. E-mail: hahnc{at}mail.nih.gov .
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Abstract |
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Objective: To critically review the empirical literature published from 1980 through June 2000 on the psychosocial well-being of parents and their children born after assisted reproduction.
Methods: A computer-based literature search of PsycINFO and Medline was conducted. Empirical studies were reviewed to document the psychosocial impact of infertility and its treatment on the families involved in terms of quality of parenting, family functioning, and child development.
Results: Several common findings appeared across the studies reviewed. With regard to quality of parenting and family functioning, mothers of children born using assisted reproduction report less parenting stress and more positive mother- and father-child relationships than mothers of naturally conceived children. In most cases, no statistically significant differences in child functioning in terms of emotions, behavior, self-esteem, or perceptions of family relationship have been reported.
Conclusions: The summary findings are positive and reassuring for parents and their children born after assisted reproduction. This critique of the published literature provides interpretative and methodological refinements for future research.
Key words: reproductive technology; parenting; family interaction; child development.
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Introduction |
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TopAbstractIntroductionQuality of ParentingDevelopment of the ChildConclusions and Directions for...AppendixReferences |
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Infertility is defined as the failure to conceive after a year of regular, unprotected sexual intercourse or the inability to carry a pregnancy to live birth (Benson, 1983
).
According to the National Center for Health Statistics, the incidence of
infertility has been increasing. The percentage of childless, infertile
couples increased from 14.4% in 1965 to 18.5% in 1995
(Leiblum, 1997a). Delayed age
childbearing, exposure to environmental toxins, and sexually transmitted
diseases have been cited as factors accounting for the increased prevalence of
infertility (Leiblum,
1997a).
Advances in technological development have grown as a result of great
demands for alternative methods of reproduction
(Sokoloff, 1987). Since the
first in vitro fertilization (IVF)-embryo transfer birth in 1978 in England,
approximately 100,000 children have now been born worldwide as a result of
this technology (Leiblum,
1997a). IVF was successfully used for the first time in 1981 in
the United States, where, since then, more than 45,000 such babies have been
born (American Society for Reproductive
Medicine, 1998).
With the improvement of technology and public awareness of its use, the
number of children born after assisted reproductive technologies has been
increasing annually. Concern has been raised that "the rate of
development of the technology has outpaced the efforts to document the
anticipated and as yet largely unexplored social consequences"
(McMahon, Ungerer, Beaurepaire, Tennant,
& Saunders, 1995, p. 1). Initial research on pregnancy after
assisted reproduction focused on medical, legal, and ethical issues
(Blyth, 1990), but not
recently have the developmental implications for children born by assisted
reproduction been addressed.
This literature provides the backdrop for a review on the psychosocial well-being of parents and their children born by assisted reproduction. The purpose of this review is twofold. First, empirical studies regarding the effects of assisted reproduction, including IVF and donor insemination (DI), on the families involved will be reviewed in three sections: quality of parenting, family issues, and development of the children. Second, the conceptual and methodological limitations of the studies will be discussed, along with recommendations for future research.
Existing studies on family functioning and children's development after
assisted reproduction are mostly motivated by how the psychosocial well-being
of the parents affects their quality of parenting, the parent-child
relationship, and the children's subsequent development. Research over the
past two decades has shown psychosocial distress among random samples of
infertile couples undergoing infertility treatment
(Wright, Allard, Lecours, & Sabourin,
1989), indicating that undergoing IVF treatment may result in
depressive and anxiety symptoms in 10%-50% of women
(Klock & Greenfeld, 2000).
Other psychosocial distress that has been suggested in the literature includes
a diminution of self-esteem, self-concept, and self-efficacy; sexual
dysfunction; poor marital communication and adjustment; and social isolation
(Andrew, Abbey, & Halman,
1991; Berg & Wilson,
1991; Bernstein,
1990; Daniluk,
1988; Kraft et al.,
1980; Seibel & Taymor,
1982).
Clinical observations suggest that women who have become pregnant after
infertility treatments are likely to be anxious about pregnancy and possible
complications. Such anxiety usually derives from years of disappointment and
the fear of miscarriage (Bernstein,
1990; Garner,
1985; Su, Teng, & Yang,
1994; Su, Yang, & Teng,
1997). An important issue related to the study of anxiety during
pregnancy is whether the level of anxiety experienced by previously infertile
women has any immediate effects on the quality of maternal-fetal attachment or
any long-term effects on parenting behavior
(Bernstein, 1990;
Garner, 1985).
One widely researched dimension of parenting behavior is protectiveness.
Because these children are born after a long period of investment and waiting,
they are presumably precious, and this leads to parental overprotection
(Golombok, 1992;
McMahon et al., 1995;
van Balen, 1998;
Weaver, Clifford, Gordon, Hay, &
Robinson, 1993). McMahon et al.
(1995) suggested that parental
protectiveness after IVF may parallel the clinical phenomenon of maternal
overprotection described by Levy
(1966), Parker
(1983), and the complementary
"vulnerable child syndrome"
(Green & Solnit,
1964).
Golombok, Cook, Bish, and Murray
(1995) raised concerns about
the parent-child relationship in families with children born by donor
insemination, as the child was unrelated to one or both of his or her social
parents genetically. Snowden
(1988) suggested that using
donor sperm for conception could produce "confusion about
paternity." Most of the infertile men disclosed negative feelings that
they could not "act as real fathers"
(David & Avidan, 1976).
The Warnock reports (1984,
1987) also pointed out the
possibility that the father could feel inadequate and excluded, thus adversely
affecting the parent-child relationship.
This literature search reviewed studies published from 1980 through June
2000 presenting quantitative data on the psychosocial well-being of parents
and their children born by assisted reproduction. A computer-based information
search on the Psyc-INFO and Medline databases used these key words: mother(s),
maternal, father(s), paternal, parent(s), parental, family, interaction,
development, infertility, in vitro fertilization, donor insemination, assisted
reproduction, and reproductive technology. In addition, relevant reviews
(McMahon et al., 1995);
van Balen, 1998) helped to
initiate reference trails to pertinent investigations. To be included in the
review, a study had to meet certain criteria. First, the study focused on
families with children born by either IVF or DI. The population of interest
included previously infertile couples who "bore" their children
through assisted reproductive technologies. Studies on infertile couples
creating families by adoption or surrogates were also important but dealt with
different theoretical issues; therefore, they were not included in this
review. Sample size of at least 20 or more was a second criterion. Third,
dependent variables must have included one or more of the following: quality
of parenting (e.g., parenting stress, emotional involvement with the child,
parenting attitude or styles), family functioning (e.g., marital relationship,
mother- or fatherchild interaction), and child development (e.g., cognitive,
socioemotional development). The Appendix presents a summary of the studies
that examine the psychosocial well-being of parents and their children born
after assisted reproduction.
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Quality of Parenting |
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Overall, mothers of children born using assisted reproduction report less parenting stress and greater parental competence in the parental role than do mothers of naturally conceived children. Van Balen and Trimbos-Kemper (1995
) suggest that the
experiences of infertility may be associated with improved motivation to have
children and a greater awareness of the importance of parenthood. Thus, the
mothers of children born using assisted reproduction report more competence
and happiness with parenting than their counterparts in the control group. On
the other hand, results based on maternal report raise concerns about bias
toward positive self-reporting in a group likely to be sensitive to public
scrutiny and eager to demonstrate that they will be good parents
(McMahon et al., 1995;
McMahon, Ungerer, Beaurepaire, Tennant,
& Saunders, 1997). Results of available studies on parental protectiveness after assisted reproduction are inconclusive, which is partly due to the lack of an adequate measure of "parental protectiveness." The studies, which examined "parental overconcern," "emotional involvement with the children," and "parental protectiveness of the child," were all included.
Reports of research by Golombok and colleagues (Golombok et al.,
1995,
1996) detailed results based
on a total of 227 assisted reproduction families (including 116 IVF and 111
donor insemination families) and 235 control families (including 120 naturally
conceived and 115 adoptive families) with children between the ages of 4 and
8. Families from four countries (the United Kingdom, Spain, Italy, and the
Netherlands) were included; the earlier publication reported results for the
United Kingdom sample separately (Golombok
et al., 1995). Parenting stress and anxiety were measured by
standardized questionnaires. emotional involvement with the child was rated on
a 5-point scale by the interviewer, from little or none (0) to extreme (4),
which took account of "the extent to which the family day was organized
around the child; the extent to which the needs or interests of the child were
placed before those of other family members; the extent to which the mother
was overconcerned, overprotective, or inhibited the child from age-appropriate
independent activities; the extent to which the mother was willing to leave
the child with other caretakers; and the extent to which the mother had
interests or engaged in activities apart from those relating to the
child" (p. 288).
Mothers of children born using assisted reproduction (IVF and DI) reported
lower levels of anxiety and parenting stress than mothers who conceived their
children naturally (Golombok et al.,
1995,
1996). No significant
differences in parenting stress or anxiety were found in fathers
(Golombok et al., 1996).
Mothers of children born using assisted reproduction (IVF and DI) showed
greater emotional involvement with their children than mothers of naturally
conceived children, with no difference between IVF and DI mothers. The level
of emotional involvement shown by mothers of adoptive children was similar to
that of IVF and DI mothers (Golombok et al.,
1995,
1996). Although these
differences were significant, they were not large in absolute terms. All
scores ranged from 1.9 (mothers of naturally conceived children) to 2.4
(mothers of DI children) on a scale from 1 to 5. Finding a mean group
difference on this scale does not imply that the higher group is overly
emotionally involved or overprotective, but simply more concerned and more
protective. Similarly, fathers of assisted reproduction children were found to
interact more with their children and to contribute more to parenting than
fathers with naturally conceived children
(Golombok et al., 1996).
Van Balen (1996) in the
Netherlands compared parenting stress among 45 IVF parents, 35 other formerly
infertile parents (without IVF) and 35 fertile parents. The children were
between 2 and 4 years of age. Both the IVF and the formerly infertile parents
were couples who had an infertility history of more than 4 years. The Nijmegen
Questionnaire Regarding Child-Rearing Circumstances (NVOS;
Robbroeckx & Wels, 1989),
a Dutch questionnaire for the measurement of family stress, was used to
measure parenting stress. Two aspects of parenting stress were examined in
their study: parental incompetence and parental burden. The results showed
that the IVF mothers and other formerly infertile mothers reported less
parental incompetence than fertile mothers after controlling for the mother's
age and the child's gender. No significant difference was found in parental
burden. No significant difference appeared for fathers.
The Child Rearing Practices Report (CRPR;
Block, 1965), Dutch version,
was used to measure parental concern for their children. The scale
"parental concern" consists of the original CRPR subscales
"protectiveness of child" (e.g., stop child from playing rough
games); "overinvestment in child" (e.g., difficult to punish
child); and "parental worry about child" (e.g., worry about health
of child). No difference was found on parental concern, either in the mothers'
group or the fathers' group.
Colpin, Demyttenaere, and Vandemeulebroecke
(1995) in Belgium compared
parental anxious overconcern in 31 families with 24-30-month-old, single-born
children conceived by IVF, and in 30 control families with naturally conceived
children. No difference was noted as measured by the anxious overconcern
subscale of the Questionnaire for Parental Attitude and Emotions (Engfer &
Schneewind, 1991).
Family Issues
Survey studies consistently report more positive parent-child interaction
in parents and their children born by assisted reproduction. These parents
exhibited significantly higher positive ratings for their feelings about their
children (van Balen, 1996;
Weaver et al., 1993) and were
rated by interviewers as expressing more warmth and greater interaction toward
their children than parents of naturally conceived children (Golombok et al.,
1995,
1996). Other studies utilizing
behavioral observations on mother-child interaction found no significant group
differences in mother-child interactive styles or problem-solving tasks
(Colpin et al., 1995;
Gibson, Ungerer, Leslie, Saunders, &
Tennant, 1999; Raoul-Duval,
Bertrand-Servais, Letur-Konirsch, & Frydman, 1994). Only
Golombok et al.'s studies
(1995,
1996) included DI families in
the evaluation of the parent-child relationship. The literature has broadly
discussed how the exclusion of the father during the process of conception and
the missing genetic link may harm the father-child relationship; this issue
needs to be studied systematically.
McMahon et al. (1995)
reviewed studies that examined quality of marital relationship and concluded
that "the marital relationships were as good or better in IVF as in
comparison groups." On the other hand, Leiblum
(1997b) proposed that the
measures typically used in assessing "general" marital adjustment
were insufficiently sensitive to detect specific effects of infertility on
couples' relationships. A recent study (Hahn & DiPietro, in press), which
examined aspects of marital functioning more specifically, found that the IVF
mothers not only expressed significantly less satisfaction with their families
but also reported poorer marital communication than mothers who conceived
their children naturally. Those results suggest that the impact of infertility
treatment on a couple's relationship needs to be described more specifically
in the assisted reproduction context.
A longitudinal project conducted in Australia was based on 133 families
recruited during pregnancies that were either IVF (n = 70) or
naturally conceived (n = 63;
McMahon, Ungerer, Beaurepaire, et al.,
1997). At 30 weeks gestation, there was no difference between the
two groups in global measures of anxiety (i.e., the Spielberger State-Trait
Anxiety Inventory). However, the IVF mothers felt significantly more stressed
and had more concerns about pregnancy and childbirth (e.g., the normality of
their unborn babies, possible damage to their babies during childbirth, and
separation from their babies after birth) than the control mothers, according
to pregnancy-specific measures developed for the study. Maternal and paternal
fetal attachment was measured using the Antenatal Bonding Questionnaire (ABQ;
Condon, 1993). The ABQ
measures the quality of the parent's affective experiences with the fetus and
the intensity of preoccupation with the fetus. Neither IVF mothers nor IVF
fathers differed from controls on measures of attachment to their babies
during pregnancy. At 4 months and 1 year postpartum, no differences in
maternal anxiety or feelings of attachment were detected
(McMahon, Ungerer, Tennant, &
Saunders, 1997; Gibson et al.,
1999).
Concerning mother-child interaction, at 4 months postpartum the IVF mothers
rated their children as more difficult and IVF infants displayed more negative
behaviors in response to interactive stress (mother was instructed to be
unresponsive and to keep her face still for two minutes) during the structured
observation of mother-child interaction
(McMahon, Ungerer, Tennant, et al.,
1997). At 1 year postpartum, mother-child interaction was assessed
in a free play context using the Emotional Availability Scales
(Biringen, Robinson, & Emde,
1993). There was no significant group difference on maternal
(sensitivity, structuring, hostility) or child (responsive, involving)
dimensions of interaction during play
(Gibson et al., 1999).
Raoul-Duval et al. (1994)
in France conducted a longitudinal study exploring mothers' attitudes toward
their babies from birth to the third year. Each IVF mother-infant pair was
paired with two control groups according to parity, socioeconomic status
(SES), mother's age, and number of children. Control groups were composed of
mothers with a history of sterility (conceived after ovarian induction) and
mothers who conceived naturally. These mother-infant pairs were seen in the
hospital after delivery, then at home after 9 months, 18 months, and 3 years.
Observation of the mother-infant relationship was evaluated based on the
manner in which the mother held, addressed, and looked at her child, as well
as her intention to breastfeed the baby. No significant between-group
difference was found across the 3 years.
Colpin et al. (1995) in
Belgium assessed parentchild relationships in families with 24-30-month-old,
single-born children conceived by IVF and in control families with naturally
conceived children. The behavioral assessment included observations of
mother-child interactions in a series of four problem-solving tasks. During
the problem-solving tasks, the children were rated on seven scales:
enthusiasm, persistence in the task, reliance on mother for help, compliance
by mother, avoidance of the mother, hostility, and the expression of positive
feelings toward the mother. The mother's behavior was assessed on 7-point
scales for four dimensions: supportive presence, respect for the child's
autonomy, structure and limit setting, and hostility toward the child. No
significant group differences were found for the parent-child interaction, as
indexed by the Rating Scales for Structured Tasks
(Erickson, Sroufe, & Egeland,
1985).
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Development of the Child |
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The biological risk associated with assisted reproduction is the likelihood of multiple births due to the use of ovulation-stimulating drugs and the transfer of multiple embryos (Leiblum, 1997a
). With respect to IVF, transferring only two embryos at one
time can considerably reduce this risk, with minimal effect on overall
pregnancy rate. In contrast, selective reduction remains the only option for
reducing the risk of multiple births after induction of ovulation alone
(Gleicher, Oleske, Tur-Kaspa, Vidali,
& Karande, 2000;
Templeton, & Morris,
1998). It is now well established that children born using
assisted reproduction have a higher incidence of preterm birth and low birth
weight (Gibson, Ungerer, Leslie, Saunders,
& Tennant, 1998; van
Balen, 1998), while the incidence of birth defects is the same as
that for children who are conceived naturally
(American Society for Reproductive
Medicine, 1998). Given the financial, psychological, and medical
risks associated with multiple pregnancies and the uncertainties surrounding
effective monitoring of overian stimulation, Bhattacharya and Allan (2000)
recently supported the use of IVF with the transfer of no more than one or two
embryos at one time rather than other fertility protocols.
The earliest study of cognitive development of children born after assisted
reproductive technology can be dated to 1968. Hzuka, Sawada, Nishina, and Ohi
(1968) examined the physical
and mental development of 54 children born after DI in Japan. The intelligence
quotient (IQ) and development quotient (DQ) of these children tended to
distribute over a higher range than the established Japanese norm. The authors
attributed this difference to the higher education background of the parents
who sought DI treatment at that time and the more optimal child-rearing
environment for these families.
Recent studies using different measures, including Bayley Scales of Infant
Development and Griffith's Developmental Scale for Children from 12 to 30
months, excluding those of preterm births, did not find group differences
between assisted reproduction and naturally conceived children
(Brandes et al., 1992;
Gibson et al., 1998; Morin et
al., 1988; Spensley, Mushin, &
Barreda-Hanson 1986; Yovich,
Parry, French, & Grauang, 1986).
Results of the socioemotional development of preschool and early-school-age
children conceived by assisted reproduction suggested no statistically
significant difference when compared to either naturally conceived or adoptive
children. Kovacs, Mushin, Kane, and Baker
(1993) in Australia used the
Child Behavior Checklist (Achenbach,
1991a) to compare children who were conceived by DI to adoptees
and naturally conceived children. The children were between 6 and 8 years of
age. No significant differences were found for children conceived by DI on the
CBCL when compared to controls. Utilizing the same questionnaire, Chan, Raboy,
and Patterson (1998) in the
United States studied a group of 7-year-old children conceived by DI. Results
showed that these children were functioning well according to parents' and
teachers' reports: all scores approximated the normed average (Achenbach,
1991a,
1991b). However, reliance on
comparisons to normative data and not a control group of naturally conceived
children limits its usefulness for generalization.
Golombok et al. (1995,
1996) reported no significant
difference between the assisted reproduction (IVF and DI) and the control
(adoptive and naturally conceived) children ages 4 to 8 years in emotional and
behavioral measures encompassing separation anxiety, family relationship,
perceived competence, and social acceptance either by experimenter assessment
or maternal/teacher's report. Levy-Shiff et al.
(1998) in Israel assessed the
long-term effect of IVF on the children. Fifty-one 9-10-year-old children
conceived by IVF were compared with 51 naturally conceived children matched
for age, gender, birth order, and family SES. These were by far the oldest
children studied in the literature. No significant difference was found in IQ
or cognitive performance, but IVF children were rated lower by teachers in
socioemotional adjustment and reported themselves to be more anxious,
depressed, and more aggressive than peers. This is the only report of poorer
emotional adjustment of the IVF children. Almost all existing data on the
psychosocial well-being of parents and their children born after assisted
reproduction come from studies in Europe, Australia, and the United States.
The utility of the Israeli study is compromised by lack of data on the
parenting attitude or styles to allow evaluation of whether cultural factors
may have influenced parenting differently than reported in other samples.
Cultural factors may significantly mediate the impact of infertility and
assisted reproduction on parenting, family functioning, and subsequent child
development and may help explain discrepancies in results among studies.
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Conclusions and Directions for Future Research |
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Infertility problems affect more than 4 million American women and their partners, and 2% of all women of reproductive age (1.3 million) and their partners who received medical advice or treatment for infertility (Collins, 1994
). Because of
the high cost associated with assisted reproductive techniques, IVF is not a
standard benefit in the majority of health insurance programs
(Collins, Bustillo, Visscher, &
Lawrence, 1995). Neumann, Gharib, and Weinstein
(1994) investigated the cost
of a successful delivery with IVF based on the 1992 listings of charges from
published brochures obtained from six IVF facilities across the country and
concluded that IVF services cost approximately $67,000 (for the first cycle)
to $114,000 (by the sixth cycle). For older couples with more difficult
problems of infertility, the cost is approximately $800,000 per delivery
(Neumann et al., 1994). These
figures were certainly high compared with $9,845 total hospital charges for a
mother of a singleton neonate and her child
(Callahan et al., 1994).
Collins, Bustillo, Visscher, and Lawrence
(1995) argue that the focus
solely on the cost of IVF, however, ignores the potential benefits of IVF
services. A potential benefit of IVF not captured in cost analyses is the
contribution of life satisfaction and well-being for couples who may otherwise
be adversely affected by unsuccessful attempts at having children
(Neumann et al., 1994).
Further understanding of psychosocial adjustment of families may help inform
related policy questions. Overall, the existing literature is reassuring for infertile couples who are contemplating assisted reproductive techniques, as well as for parents and health professionals: the psychosocial functioning of parents and their children born by assisted reproduction is more similar than dissimilar to that of the control families. In most cases, no statistically significant differences in child functioning in terms of emotions, behavior, self-esteem, or perceptions of family relationship have been found. Parents of children born using assisted reproduction tend to report less parenting stress and more positive parent-child relationships than the control parents. The use of donor sperm appears to have no impact on the father-child relationship based on maternal reports. There are two caveats regarding conclusions based on parental self-report in the IVF/DI context. First, parents of children born using assisted reproduction may feel that they do not have the luxury of expressing distress about something they have wanted so long. Second, parents of children born using assisted reproduction may feel and report more positive feelings about parenthood but do not behave in ways that are different from the controls. No evidence of actual differences in maternal behavior between assisted reproduction and control mothers has been reported in observational studies.
This critique of the existing literature provides several directions for future research. First, inclusion of control groups of families matched on SES, gender, birth order of the target child, and family structure is likely to contribute important data in the study of these complex issues. Data from multiple sources and observational methodologies may also help increase the rigor and generalizability of research in this field.
Second, the unique impact of infertility and its treatment on a couple's
relationship and adjustment to the parenthood process calls for more specific
measures designed for the IVF/DI context
(McMahon, Ungerer, Beaurepaire, et al.,
1997). Global or general adjustment measures may fail to capture
the unique impact of infertility and assisted reproduction on the psychosocial
adjustment of pregnant women with successful IVF/DI treatment and the
relationships of these couples (e.g., Hahn & DiPietro, in press).
Third, the design of most existing studies cannot exclusively determine whether group differences are a function of assisted reproduction or of the experience of infertility in general. To discern the effect specific to assisted reproduction, research may include in control groups those parents with a history of infertility who never receive infertility treatment.
Fourth, the couples who conceived their children by assisted reproduction
are a heterogeneous group, who vary in pregnancy histories and experiences of
treatment failure (McMahon, Ungerer,
Beaurepaire, et al., 1997). Exploration of the association between
psychosocial adjustment as well as quality of parenting with
infertility-related variables (e.g., number of failed treatments, duration of
treatments) will help clarify the relationship between experiences of assisted
reproduction and the couples' psychosocial adjustment. For example, an
important dimension, which may mediate the characteristics of parents with
successful treatment and their quality of parenting, is coping abilities and
parents' motivation to have children. Future research will benefit from a more
systematic look at differences in personalities, coping abilities, and social
support systems between parents who have children by assisted reproduction
versus those who do not, and how these personal characteristics and contextual
variables relate to their quality of parenting and family functioning.
Fifth, most of the studies reported are cross-sectional and examine functioning in families mostly with preschool children. It would be premature to draw a general conclusion about the future well-being of the children and their parents based on assessments conducted exclusively on children younger than 8. Moreover, none of the studies has examined children of multiple births, which is a common outcome of infertility treatment, and parental adjustment. Separating the IVF/DI from the preterm/ill issues that contribute to parenting would be a very challenging study to design. Notwithstanding this challenge, the physical and psychological health of such children and their relationships with parents are a current source of public attention and could be a direction for future research.
Finally, most of the studies focus on "traditional" two-parent middle-class families. Demographically, the samples reviewed are biased relative to the broader range of family structures seen in our society (e.g., low-income families, single parents, remarried families, gay and lesbian families, ethnic minority families). Future research on the psychosocial adjustment of the parents and children born by assisted reproduction that includes or addresses these issues will likely enhance the generalizability of these findings.
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Appendix |
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Studies Examining the Psychosocial Well-Being of Parents and Their Children Born After Assisted Reproduction
Chan, Raboy, & Patterson (1998
) in the US.Sample. 37 boys and 18 girls conceived by DI, and their lesbian parents. 17 boys and 8 girls conceived by DI, and their heterosexual parents. Children averaged 7 years of age.
Research Questions. To examine the relations among family structure, family process, and the psychological adjustment of children who had been conceived by DI.
Study Design. Cross-sectional; parental self-report and independent ratings of child development obtained.
Variables.1
Child development: Child Behavior Checklist
(Achenbach, 1991a). The Teacher
Report Form (Achenbach,
1991b).
Results. Children in all family types were functioning well compared to norms.
Comments. Children's developmental outcomes were compared to established norms.
Colpin, Demytte-naere, & Vandemeulebroecke
(1995) in Belgium.
Sample. 31 IVF and 31 control parents at 24-30-month
postpartum.
Research Questions. To examine parent-child relationships in families created by IVF.
Study Design. Cross-sectional; parental self-report and independent ratings of mother-child interaction obtained.
Variables. Quality of parenting: Questionnaire for Parental
Attitudes and Emotions (Engfer & Schneewind, 1991). Family issues: The
Maudsley Marital Questionnaire (Arrindell,
Boelens, & Lembert, 1983). Observation of mother-child
interaction: The Rating Scale for Structure Tasks
(Erickson, Sroufe, & Egeland,
1985).
Results. No difference was found on parent-child relationship or for the parent's psychosocial functioning.
Comments. Significant differences in parental age and education level were controlled by statistical analyses. Did not control for other demographic variables (e.g., child sex, family SES, etc.). Coders of the mother-child interactions were not blind to the IVF status of the families.
Golombok et al.
(1996) in the UK, Spain,
Italy, and the Netherlands.
Sample. 116 IVF families, 111 DI families, 115 adoptive families,
and 120 families with naturally conceived children. All children were between
4-8 years of age.
Research Questions. To "examine culturally determined attitude toward assisted reproduction and the influences of attitudes on the functioning of the family and the development of the children."
Study Design. Cross-sectional; parental self-report and independent ratings of child development obtained.
Variables. Quality of parenting: The Parenting Stress Index-Short
Form (Abidin, 1990). Family
issues: Golombok Rust Inventory of Marital State
(Rust, Bennun, Crowe, & Golombok,
1988; Rust, Bennun &
Golombok, 1990). Structured interview to obtain information on
father-, mother-child interaction, warmth, and emotional involvement with the
children. Child development: The Rutter Scale
(Rutter, Cox, Tupling, Berger, & Yule,
1975). The Separation Anxiety Test
(Klagsbrun & Bowlby,
1976). The Family Relations Test
(Bene & Anthony, 1985). The
Pictorial Scale of Perceived Competence and Social Acceptance for Young
Children (Harter & Pike,
1984).
Results. Quality of parenting in IVF and DI families is superior to that shown in families with a naturally conceived child. No group differences were found for any of the children's measures. Common findings regarding the quality of parenting and the socioemotional development of the children were found across the four countries studied.
Comments. Low response rate (47%) from the DI families. Only 68% of the children's teachers completed the questionnaires. There were significant differences in child age, maternal age, number of children in the family, and family social class. They were entered into analyses of variances as covariates.
Golombok, Cook, Bish, & Murray
(1995) in the UK.
Sample. 41 IVF, 45 DI, 43 naturally conceived, and 55 adopted
children and their parents. All children were between 4 and 8 years of
age.
Research Questions. To "examine the role of genetic ties in family functioning and child development."
Study Design. Cross-sectional, parental self-report and independent ratings of child development obtained.
Variables. Same as Golombok et al.
(1996).
Results. Quality of parenting in IVF and DI families is superior to that shown in families with a naturally conceived child. No group differences were found for any of the children's measures.
Comments. There were significant differences in age of the child and mother and family social class. Because these three demographic variables were not significantly correlated with the measures of quality of parenting, they were not entered in the analyses of covariance. There was a trend toward fewer children in the assisted reproduction families, and significantly more first-born children in the DI families. Forty percent of the children conceived by IVF/DI were only child, while only 20% of the naturally conceived children were only child.
Kovacs, Mushin, Kane, & Baker
(1993) in Australia.
Sample. 22 children conceived by DI, 20 naturally conceived
children, and 10 adopted children. All children were between 6-8 years of
age.
Research Questions. To examine the psychosocial development of children conceived by DI.
Study Design. Cross-sectional; parental self-report.
Variables. The Child Behavior Checklist (Achenbach).
Results. No significant between-group difference was found.
Comments. Children's outcome measures were based on maternal reports only. Controls were matched for child age and gender. No information on the degree of matching. No information on differences in family SES.
Levy-Shiff et al.
(1998) in Israel.
Sample. 51 IVF/ET children and 51 naturally conceived children.
All children were between 9 and 10 years old.
Research Questions. To assess long-term effects of assisted reproduction on children's adjustment.
Study Design. Cross-sectional; parental and children's self report, and independent ratings of child development obtained.
Variables. Child development: Medical assessment by pediatricians.
Wechsler Intelligence Scale for Children—Revised
(Wechsler, 1976). Visual Motor
Gestalt (Bender, 1946). Visual
Retention Test (Benton, 1963).
Reading Comprehension Test (Orthar &
Ben Shahar, 1976). The Rating Scale for School Adjustment
(Smilansky & Shephatia,
1976). Conners Symptoms Questionnaire
(Conners, 1973). State-Trait
Anxiety Inventory for Children (Spielberger) Children's Depression Inventory
(Kovacs, 1978;
Kovacs & Beck, 1977)
Children's Aggression Inventory (Feshbach,
1966). Children's Behavior Inventory
(Shepherd, Oppenheim, & Mitchell,
1971).
Results. IVF/ET children did not differ from the controls in physical, neurological status, or cognitive measure of IQ. The IVF/ET children were scored lower by teachers on measures of socioemotional adjustment in school and reported themselves to be more anxious, aggressive, and more depressed.
Comments. The IVF children and controls were matched for age, gender, birth order, and family SES, and were comparable in this regard. The data were collected from multiple sources. The pediatrician and psychologists were blind to the IVF status of the children. Lack of data on the parents.
McMahon, Ungerer, Beaurepaire, Tennant, & Saunders
(1997) in Australia.
Sample. 70 IVF couples and 63 matched controls at about 30 wks of
gestation.
Research Questions. To "compare couples who had conceived by IVF with matched controls for the prevalence of anxiety and quality of attachment to the fetus during pregnancy."
Study Design. Prospective in design, but report only cross-sectional data; parental self-report and interview.
Variables. Family issues:
Spielberger State-Trait Anxiety Inventory
(Spielberger, Gorusch, Lushene,
1970). A self-constructed pregnancy-specific anxiety measure. Baby
Schema (Gloger-Tippelt, 1991).
Antenatal Bonding Questionnaire (Condon,
1993).
Results. No group differences were found when utilizing global measures of anxiety. Pregnancy-specific measures revealed significantly higher levels of anxiety in IVF mothers. No group differences were found on maternal or paternal attachment to the fetus.
Comments. Significant differences in parental age and educational level were controlled for by analyses of covariance. The IVF mothers scored significantly higher than the control mothers on the Courtauld Emotional Control Scale, which may suggest a tendency toward positive reporting in the IVF mothers. However, this variable was not used as a covariate when making between-group comparisons.
McMahon, Ungerer, Tennant, Saunders
(1997) in Australia.
Sample. 65 primiparous IVF-ET mothers and 62 mothers with no
history of infertility at 4-month postpartum.
Research Questions. To "examine psychological adjustment to early mother-hood at 4 months postpartum in mothers who conceived by IVF-ET."
Study design. Prospective in design, but report only cross-sectional data; maternal self-report, independent ratings of quality of mother-child interaction obtained.
Variables. Psychological adjustment and quality of parenting: The
Spielberger State-Trait Anxiety Inventory
(Spielberger et al., 1970).
The Edinburgh Postnatal Depression Scale (Cox, Holden, Sagovsky, 1987). The
Dyadic Adjustment Scale (Spanier,
1976). Modified version of the Self-Esteem as a Woman
(Rosenberg, 1965). The Being a
Parent Questionnaire. The Maternal Self-Efficacy Scale
(Teti & Gelfand, 1991).
The Neonatal Perception Inventory
(Broussard, 1979). Family
issues: The Maternal Postnatal Attachment Questionnaire. The Maternal
Separation Anxiety Scale (Hock, DeMeis,
& McBride, 1988). The Short Temperament Scale for Infants
(Oberklaid, Sanson, & Prior,
1986).
Results. No group differences were found on measures of anxiety, postnatal depression, marital satisfaction, or use of support services. The IVF-ET mothers reported lower self-esteem, and lower maternal self-efficacy, and rated their infants as more difficult. Behavior observation revealed no group difference in maternal behavior. The IVF-ET infants displayed more negative behaviors in response to interactive stress.
Comments. Significant differences in parental age and educational level were controlled for by analyses of covariance.
Gibson, Ungerer, Leslie, Saunders, & Tennant
(1999) in Australia.
Sample. 65 primiparous women and their singleton infants conceived
by IVF and 61 mothers with their naturally conceived children.
Research Questions. To "examine the nature of mother-child relationship at 12 months postpartum following IVF through evaluating the security of infant attachment and the quality of dyadic interaction."
Study Design. Prospective in design, but report only cross-sectional data; independent ratings of quality of mother-child interaction obtained.
Variables. Infant attachment and mother-child interaction: The
Strange Situation (Ainsworth, Blehar,
Waters, & Wall, 1978). The Emotional Availability Scales
(Biringen, Robinson, & Emde,
1993).
Results. No group differences were found in the proportion of children classified in any of the secure or insecure attachment groups. Behavioral observation revealed no significant group differences on maternal (sensitivity, structuring, hostility) or child (responsivity, involving) dimensions of interaction.
Comments. Significant group differences in the perinatal variables (birth weight and days spent in neonatal nursery care) and the sociodemographic variables (e.g., maternal age and education) were included as covariates when examining differences on maternal and child dimensions of interaction.
Raoul-Duval, Bertrand-Servais, Letur-Konirsch, & Frydman
(1994) in France.
Sample. 33 IVF mother-infant pairs, 33 mother-infant pairs of
mothers with a history of sterility (without IVF); 33 naturally conceived
mother-infant pairs were observed at birth, at 9 months, 18 months, and at 36
months.
Research Questions. To examine psychosocial development of the IVF children.
Study Design. Prospective; maternal self-report, and independent ratings of mother-infant interaction obtained.
Variables. Mother-child relationship: interview and observation.
Child psychomotor development: Brunet-Lézine
Test (Brunet &
Lézine, 1952).
Results. No significant between-group differences were found on the psychomotor development of the IVF children when compared to the control children across 3 years. The mother-child relationship was reported to be "excellent" in all groups.
Comments. The mother-child pairs were matched for family SES, maternal ages, and number of children. No report on the degrees of matching. All data reported were based on interview and observations. No standardized questionnaire was used. It's not clear whether the coders were blind to the IVF status of the families or not.
van Balen (1996) in
the Netherlands.
Sample. 45 IVF children and their parents, 35 children of formerly
infertile parents, and 35 naturally conceived children and their parents.
Research Questions. To "compare child rearing among IVF parents, other formerly infertile parents, and fertile parents."
Study Design. Cross-sectional; parental self-reports.
Variables. Quality of parenting: The Child Rearing Practice report
(Block, 1965). The NVOS, a
Dutch questionnaire for the measurement of family stress
(Robbroeckx & Wels, 1989).
Child development: Child Behavior Scale (a self-constructed questionnaire by
the author).
Results. The IVF mothers and other formerly infertile mothers reported less parental incompetence compared to the fertile mothers. The IVF children were rated by their mothers as being more social than the controls. No significant differences were found among the fathers.
Comments. There was no between-group difference in education level, religious denomination, child age, gender, or the number of children (only child). Only maternal reports were used. No information was given as to whether other kinds of infertility treatment (e.g., ovarian stimulation) had been used to aid conception in the formerly infertile without IVF group.
Weaver, Clifford, Gordon, Hay, & Robinson
(1993) in the UK.
Sample. 20 IVF/GIFT couples and 20 controls between 15 and 27
months postdelivery.
Research Questions. To examine social-emotional well-being and parental functioning of IVF/GIFT couples.
Study Design. Cross-sectional; parental self report.
Variables. Quality of parenting: The Mother-Child Relationship
Evaluation (Roth, 1980).
Family issues: The Crown-Crisp Experiential Index
(Crown & Crisp, 1979). The
Dyadic Adjustment (Spanier,
1976). Quality of Life
(Campbell, Converse, & Rodgers,
1976). The Parent's Feelings Scale
(Reading, Cox, Sledmere, & Campbell,
1984).
Results. No differences in emotional health or marital adjustment were found. IVF parents gave higher positive ratings for feelings about babies and feelings of freedom. The IVF parents reported themselves to be more protective.
Comments. The IVF group included 4 twins. There were no twins in
the control group. No information on the between-group difference in family
SES. Only parental self-reports were used. The MCRE (for parental
overprotection) was too outdated to provide valid normative information for
use with present families (Doll,
1995).
|
Acknowledgments |
|---|
This review is based on my doctoral dissertation submitted to the Johns Hopkins University, in partial fulfillment of the requirements for the ScD degree and supported in part by the Training Program in Maternal and Child Health, MCJ-000106. I thank Janet A. DiPietro for her valuable feedback on earlier versions of this article.
|
Notes |
|---|
1 Only variables covered in this review are listed in the appendix.
Received April 27, 1999; revision received November 1, 1999; revision received July 12, 2000; revision received October 3, 2000; accepted December 2, 2000
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References |
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