Original Article
Jordanian mothers’ knowledge of infants’ childrearing and developmental milestones R.R. Safadi1 RN, PhD, M. Ahmad3 RN, PhD, O.S. Nassar2 RN, PhD, S.A. Alashhab4 RN, MSN, R. AbdelKader2 RN, PhD & H.M. Amre4
RN, MSN
1 Associate Professor, 2 Assistant Professor, Maternity and Child Health Nursing Department, 3 Professor, Clinical Nursing Department, 4 Lecturer, Community and Mental Health Department, Faculty of Nursing, The University of Jordan, Amman, Jordan
SAFADI R.R., AHMAD M., NASSAR O.S., ALASHHAB S.A., ABDELKADER R. & AMRE H.M. (2016) Jordanian mothers’ knowledge of infants’ childrearing and developmental milestones. International Nursing Review 63, 50–59 Aim: This study explored Jordanian mothers’ knowledge of infants’ childrearing practices and developmental milestones, the socio-demographic variables of relevance to knowledge, and sources of information that guide childrearing practices. Background: Parents’ knowledge is considered the frame of reference for parents’ interpretations of their children’s behaviors and provides the basis for having the appropriate expectation of the child’s developmental stage. Parents’ knowledge of childrearing is essential for children’s physical, cognitive and emotional development. Methods: A cross-sectional design using a modified version of MacPhee’s ‘Knowledge of Infant Development Inventory’ was used to assess 400 mothers’ knowledge of infants’ childrearing and developmental milestones, in Amman, Jordan. Results: Mothers were found to be more knowledgeable in physical and safety skills and less in cognitive, emotional, and parent-infant interaction skills. Parental age, education, parity and planned pregnancy had limited influence on developmental milestones knowledge. Formal and informal sources of information were used conforming to traditional societies. Discussion and conclusion: Results were congruent with findings from other studies in the region and similar traditional societies. Results allude to conclusion that mothers resort to informal sources and traditional practices to replace formally structured programmes when absent. Implications for nursing and health policy: Healthcare professionals, nursing schools and healthcare policy makers are encouraged to develop and institute a holistic approach encompassing physical, cognitive, emotional and parent-infant interaction domains in childrearing educational programmes. Structured parenting programmes for mothers and culturally accepted sources of information for fathers are essential to enhance parenting skills among Jordanian couples.
Correspondence address: Dr Reema R. Safadi, Maternal and Child Health Nursing Department, Faculty of Nursing, University of Jordan, Amman 11942, Jordan; Tel: 009626-5355000; Fax: 00962-65857667; E-mail: [email protected].
Conflict of interest No conflict of interest has been declared by the authors. Funding This research was funded by The University of Jordan, The Deanship of Academic Research, number 1225.
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Keywords: Childrearing Practices, Infant Development, Jordan, Mothers’ Knowledge, Developmental Milestones, Childrearing
Introduction Parental knowledge is defined as parents’ understanding of developmental norms and milestones, processes of child development and familiarity with caregiving skills (Benasich & Brooks-Gunn 1996, p. 1187). This knowledge is conceptualized as a product of personal experience with children and social interactions (Goodnow 1995). Knowledge about childrearing has been of interest to Western researchers for over four decades; however, it is relatively new to the Middle East. Jordan, a small lower middle income country, is among the more developed Arab states in terms of healthcare services and statistical health indicators. Tremendous progress has been achieved in the health care of children and their mothers in the last three decades (Ajluni 2011). Parents’ knowledge of infants’ childrearing practices and development is an important contributing factor as indicated by its role in cognitive stimulation and child maltreatment (Belcher et al. 2007; MacPhee 1981). Knowledge mediates the relation between experience and childrearing practices and, in turn, influences children’s quality of life (Goodnow & Collins 1990; MacPhee 1981). In general, parents’ knowledge is considered the frame of reference for parents’ interpretations of their children’s behaviours and provides the basis for having the appropriate expectation of the child’s developmental stage (Ribas et al. 2003). A review of parenting literature revealed three major foci of research: first, studies concerned with examining the relationship of parental socio-demographic factors with knowledge and childrearing practices (Ertem et al. 2007; Ribas & Bornstein 2005; Williams et al. 2000); second, studies of outcomes of childrearing knowledge and practices, immediate or prospective, on children’s cognitive and emotional development (Benasich & Brooks-Gunn 1996; Halgunseth et al. 2005; Huang et al. 2005); and third, studies that examined cultural and intercultural parenting practice similarities and differences (Bornstein & Cote 2004; Carra et al. 2013; Elliott 2007; Reich 2005; Thomas et al. 2007). Historical Western literature about developmental expectations and mothers’ knowledge of developmental milestones has been pervasive and this is rather not recent. It was the concern of child psychologists during the 1980s and 1990s of the last century revealing information about expectations for children’s behaviour and factors contributing to childrearing abilities and difficulties (Jahromi et al. 2014; Stevens 1984). It was found that
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an unrealistic match between expectations and actual behaviours will result in higher stress levels among parents (Teti & Gelfand 1991). It has also been suggested that mothers with a more accurate estimate of infants’ developmental milestones are more likely to be sensitive to their children’s needs and use more effective parenting strategies to support social and cognitive development (Goodnow 1988; Sigel 1992). In contrast, parents who underestimate their children’s abilities provide little stimulation to evoke their learning potential (Huang et al. 2005). Karraker & Evans (1996) found that adolescent mothers who had lower scores on the Developmental Milestones Survey were more likely to underestimate their infants’ performance. These mothers may fail to encourage their infants’ development and may perceive their infant as less competent than others. On the other hand, parents who overestimated their child’s developmental abilities tended to be impatient and intolerant of their child’s behaviour (Cowen 2001). Studies about childrearing practices in the Arab world are scant and are only in their beginnings in relation to investigating contributing and outcome factors. A study by Al-Ayed (2010) in Saudi Arabia about maternal knowledge of their children’s health problems found that mothers had deficient knowledge and that health professionals had a limited role in providing health education to mothers. They found no relationship between mothers’ knowledge score and level of education, age or number of children. The majority of mothers considered family members as a main source of information and gave little importance to healthcare professional input. A study by Al-Hassan & Lansford (2011) revealed gaps in mothers’ knowledge regarding social, language and play activities for their children, and accordingly a 16-h education programme, the ‘Better Parenting Programme’, was delivered (Al-Hassan & Lansford 2011). The results of this educational programme yielded limited influence on mothers’ knowledge. In Jordan, Jarrah et al. (2012) found that most mothers used traditional practices to manage newborns’ healthcare problems in the first 6 weeks after birth. They found that parity, education and family income had limited influence on mothers’ practices and that mothers used more informal sources of information. In Beijing, grandparents had a dominant role in perpetuating values and practices in childrearing (Binah-Pollak 2014). The purpose of this study is to assess mothers’ knowledge of childrearing practices and developmental milestones of infants, encompassing their basic needs and abilities and factors
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associated with knowledge, namely parental age and education, parity and planned pregnancy. Furthermore, maternal sources of information are identified in an attempt to recognize the value placed by mothers on these sources in gaining knowledge about childrearing. To understand Jordanian mothers’ knowledge of childrearing practices and developmental milestones of their infants, this research aims to answer the following questions: 1 What do Jordanian mothers know about childrearing practices? 2 What is the level of knowledge about infants’ developmental milestones among Jordanian mothers? 3 Are there differences in mothers’ level of knowledge about infants’ developmental milestones in relation to parental age, education, parity and planned pregnancy? 4 What sources of information do mothers use to guide their childrearing knowledge and practices?
have no adverse consequences on healthcare provision. Some mothers refused participation because of family responsibilities or time constraints. All participants were assured of anonymity and confidentiality. Design and procedures
A cross-sectional design was used. Two research assistants were trained to collect data from mothers in the selected MCH centres using face-to-face interviewing methods. Data collection involved the completion of a questionnaire composed of three parts: (a) demographic data (34 questions); (b) knowledge instrument, a purposefully developed tool using items from ‘Knowledge of Infant Development Inventory’ (KIDI; MacPhee 1981) also consisted of two parts (childrearing practices and developmental milestones); and (c) a modified version of the Maternal Sources of Information Questionnaire (Elliott’s 2007 dissertation) (20 questions). Each interview lasted for 30–45 min.
Methods Knowledge instrument Population and sample
The recruited participants were Jordanian mothers of normally delivered singleton infants over the first year of infancy. Mothers of various age groups and parity were included. Mothers of infants with abnormalities and complicated births were excluded as these may influence mothers’ knowledge and attitude toward parenting. Participants were recruited from a list of the Ministry of Health, Maternity and Child Health Care Centers (MCH). A random selection of 11 out of 71 centres were selected from Amman regions. Centres that served less than 30 mothers per month were excluded. Sample size was calculated by using G* power 3.0 software (Faul et al. 2007). With an alpha of 0.05, the estimated number needed for an effect size of 0.20 and a power of 0.80 is 392 mothers. A convenience sample of 400 mothers of infants aged between birth and 12 months were interviewed during their visits to MCH centres. We studied this group because what infants experience during the early years sets a critical foundation for their entire life course (Irwin et al. 2007). Ethics
The University of Jordan Research Review Board, Faculty of Nursing Ethics Committee and the Ministry of Health administration gave their approvals, and key persons in the selected MCH centres were approached to facilitate recruitment of mothers. Eligible mothers provided voluntary consent for participation after researchers’ explanation of study purpose, procedures and benefits, and that declining participation would
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A letter of permission to use a number of items from KIDI (MacPhee 1981) was sent to the author (MacPhee 1981). After gaining approval, we selected 24 items that corresponded with Jordanian culture and infants’ age group (birth to 12 months old). Four more questions were suggested by experts to refer to the common parenting problems and known knowledge deficits in this field; one new question was added to knowledge of childrearing practices (part 1); and three questions were added to knowledge of developmental milestones (part 2). KIDI is an inventory for examining knowledge of infant development with 58 questions about babies’ normal behaviour and the age at which an infant can achieve a developmental skill. Test–retest reliability of KIDI 2 weeks apart of a sample of 58 mothers has produced a coefficient of 0.92, indicating good short-term consistency. It was also stable over time: r = 0.65 over 4 months in a sample of college students (MacPhee 1981, p. 14). The MacPhee’s (1981) inventory has reported internal consistency of KIDI based on several studies ranging between 0.80 and 0.86. Originally constructed in English, two bilingual translators with professional skill in English and Arabic translated the newly developed tool into Arabic and then back-translated into English. After translation, two paediatricians, three child health nurses and a statistician checked the tool for meaning preservation, cultural appropriateness and content validity. Different from the original tool (KIDI), questions about developmental milestones were categorized into three domains: physical (eight questions), cognitive (eight questions) and emotional interactions (three questions). Questions had response
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options of agree, younger, older or unsure; if a mother disagreed with the time of achieving a milestone, she was asked to identify whether this developmental skill should happen earlier, later than in the statement of the question or if they were unsure. In the two parts of this questionnaire, correct and incorrect answers were identified and scored as one and zero, respectively. A pilot test was conducted to ensure readability and cultural sensitivity with 40 selected mothers from two different MCH centres. The questionnaire language was modified based on mothers’ responses for simplicity of expressions and cultural relevancy. The Cronbach’s alpha reliability test result for mothers’ knowledge of the developmental milestones was 0.72.
Analysis
Descriptive and inferential statistics were performed using the Statistical Package for Social Science (IBM Corporation 2012). All questions were examined for correct or incorrect practice or knowledge. Negative statements were reversely scored and percentages were calculated. To investigate contributing factors to mothers’ knowledge of developmental milestones, analysis of variance (ANOVA) and t-tests were used to explore whether there were significant differences in mothers’ knowledge of developmental milestones that could be related to parental age, education, parity and planned pregnancy. Descriptive statistics were used to determine the most commonly used sources of information as used frequently (2), little use (1) and not used at all (0).
Results This study addressed mothers’ knowledge of infants’ childrearing practices and developmental milestones during the first year of infants’ lives. It also examined mothers’ knowledge in relation to parental demographics and identified mothers’ commonly used sources of information.
Demographics
Four hundred women completed the study questionnaire. The mean age of mothers was 28.9 [standard deviation (SD) = 6.2], and their spouse mean age was 34.4 (SD = 6.9) years. An equal number of mothers (54.8%) and fathers (54%) had 12 years of education or less. Most of the mothers were unemployed (71%) and (22%) were mothers of only one child. The average age of their children was 6.6 months. Almost two-thirds of the mothers were assisted during the first few weeks after birth. Most assistance was offered by mothers-in-law (31%) and mothers (22%). Their husbands provided the lowest level of assistance (6%) (Table 1).
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Knowledge of childrearing practices
The results of the examination of mothers’ knowledge of infants’ childrearing practices revealed that they were knowledgeable about physical safety issues such as attending an infant in the tub (86.8%), infant’s position in bed (62.5%) and about protecting infants from choking with food particles (58.8%). They also showed good knowledge about managing infants’ diarrhoea (79.8%). Conversely, less than one-fifth of the mothers had correct knowledge for the suitable age (7 months old) for introducing complementary food to infants (15.3%). Fewer mothers had knowledge of parent–infant interactions. Slightly over half (60%) of the mothers recognized that carrying a crying baby does not spoil him or her and less than one-third of the mothers had correctly answered two items related to parent–infant interactions. These items corresponded to mothers’ perception of reasons for the baby’s crying ‘to make trouble’ (29.5%) and getting into the habit of wanting to be always carried (25%) (Table 2).
Knowledge of developmental milestones
Mothers’ knowledge about infants’ developmental milestones is shown in Table 3. Mothers were asked to indicate whether the age indicated in the statement was the correct age for achieving this milestone, should happen later than indicated (underestimating the infant’s abilities), should happen sooner than indicated (overestimating the infant’s abilities) or if they were unsure about the exact age for achieving this skill (uncertain). The results revealed that more than half of the mothers answered 8 out of 19 questions correctly. Mothers displayed correct knowledge about some developmental milestones, including the age of smiling (emotional) (79.3%), babbling (physical) (61%), identifying familiar people from strange people (cognitive) (60%), responding to someone differently according to the person being happy or upset (emotional) (58%), having fear perception of high places (cognitive) (57.3%) and knowing what the word ‘No’ means (cognitive) (55%). There were two major underestimations that were related to physical and cognitive skills (75.3% and 74.5) and one overestimation that was related to a cognitive skill (82.3%) (Table 3). A considerable percentage of mothers were uncertain about the timing of a developmental milestone. Mothers were most uncertain about cognitive domain skills, including infants being afraid of high places by 6 months of age (18%), ability to remember toys being hidden by 12 months (17%) and being afraid of strangers approximately 6 months of age (16.8%). However, mothers displayed less uncertainty in physical/ physiological abilities, which ranged between 12.8% regarding
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Table 1 Mothers’ characteristics/socio-demographics (n = 400) Item
Description
Frequency
(%)
Mean
SD
Mothers’ age
Range (18–45) 18–27 28–35 36–50 >12 years Diploma University Range (20–60) 20–30 31–40 41–60 >12 years Diploma University Working Non-working 1 baby >1 baby Range (1–12) Yes No Yes No Mother-in-law Mother Husband Neighbour Other daughters Others
400 172 167 61 219 81 100 400 134 197 69 216 67 117 116 284 89 311 400 245 155 139 261 43 31 8 18 15 24
(100) (43) (41.8) (15.3) (54.8) (20.3) (25.0) (100) (33.5) (49.3) (17.3) (54) (16.8) (29.2) (29) (71) (22.3) (77.8) (100) (61.3) (38.7) (34.8) (65.2) (30.9) (22.3) (5.8) (12.9) (10.8) (17.3)
28.9
6.2
34.4
6.9
6.59
3.6
Mothers’ education
Husbands’ age
Husbands’ education
Work status Parity Age of the infant in months Planned pregnancy Receive assistance with baby care Source of assistance (139)
SD, standard deviation.
the appropriate age of toilet training and 1.3% regarding the age when babies begin to laugh at things. ANOVA to test mothers’ knowledge of infants’ physical, emotional and cognitive developmental skills showed no significant difference in relation to mothers’ and fathers’ age and education. The result was also not significant for parity with all three domains (t-test). As for planned pregnancy, results showed a significant difference in mothers’ knowledge of cognitive developmental skills, but not in the physical or emotional skills [t = 2.64, degrees of freedom (d.f.) = 398, P = 0.009]. Regarding sources of information, the results revealed that mothers used formal and informal sources. Information provided by nurses and doctors was the highest (M = 1.75, SD = 0.58) followed by one’s mother or sisters (M = 1.68, SD = 0.65), posters and leaflets in the MCH centre (M = 1.66, SD = 0.56) and mothers-in-law (M = 1.52, SD = 0.76). Hus-
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bands ranked as 12th out of the 20 sources (M = 1.05, SD = 0.71) and social workers had the lowest ranking (20th) among all others (M = 0.25, d.f. = 0.58). Other forms such as media (television, 6th; films, 11th; radio, 16th) and modern technology (educational Internet, 15th; search engines, (17th) were less used.
Discussion This study offers salient information for nurses and midwives in parenting practice. It describes mothers’ knowledge of childrearing and developmental milestones of their infants during the first year of their lives. It is one of very few studies about childrearing in the Arab region. This study differs from other studies in a number of ways. First, it is not an exploration of contemporary traditional practices, but its results reflected the common practices and the existent healthcare services
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Table 2 Mothers’ knowledge of childrearing practices Serial number
Item
Correct answers
%
1. 2.
You must stay in the bathroom when your infant is in the tub. When a baby less than 12 months gets diarrhoea, you should stop feeding solid foods and give it mashed potatoes and add more fluids. New foods should be given to the infant one at a time, with 4–5 days between each one. When putting babies in the crib for sleep, place them on their back, not stomach. If a baby (less than a year) wants a snack, give it chips, popcorn, candies or chocolates. * A baby is started on solid foods at the 7th month of age. The more you soothe a crying baby by holding and talking to it, the more you spoil them. Babies do some things just to make trouble for their parents, like crying a long time or pooping in their diapers. Babies should not be held when they cry because this will make them want to be held all the time.
347 319
86.8 79.8
255 250 235 61 238 118 100
63.7 62.5 58.8 15.3 59.5 29.5 25
3. 4. 5. 6. 7. 8. 9.
*Not in Knowledge of Infant Development Inventory (added questions). Q 1–6 = physical safety; Q 7–9 = parent–infant interaction.
Table 3 Mothers’ knowledge of developmental milestones
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Item
Correct
Under-estimating
Over-estimating
Uncertain
Eight month olds act differently with familiar people than with someone not seen before. Infants will avoid high places, like stairs by 6 months of age. Six month olds know what ‘No’ means. One year olds know right from wrong. Infants begin to respond to their name at 10 months. * Babies begin to fear from strangers around the 6th month of age. * Three month olds will recognize their mother’s face when they see her. Infants of 12 months can remember toys they have watched being hidden. Three month olds often will smile when they see an adult’s face. Six month olds will respond to someone differently if the person is happy or upset. Babies begin to laugh at things around 4 months of age. Babies begin to babble around the fifth month of age. Babies usually say their first real word at 6 months. * Babies’ teeth first come in (erupt) around the ninth months of age. Infants are usually walking by about 12 months of age. Most babies can sit on the floor without falling down around the eighth month. Most infants are ready to be toilet trained by one year of age. Babies are about 7 months old before they can reach for and grab things. Four month olds lying on their stomach start to lift their heads.
59.5 57.3 55.3 38.8 38.0 29.8 13.3 8.5 79.3 58.0 42.5 61.0 50.3 50.0 44.0 42.8 38.8 34.3 21.5
16.5 – – – 16.5 34.5 – 74.5 15.5 20.5 21.8 35.0 – 44.0 30.0 13.0 – 60.5 75.3
18.8 24.8 32.0 48.8 40.5 19.0 82.3 – – 9.8 34.5 – 42.3 – 22.8 42.3 48.5 – –
5.3 18.0 12.8 12.5 5.0 16.8 4.5 17.0 5.3 11.8 1.3 4.0 7.5 6.0 3.3 2.0 12.8 5.3 3.3
*Not in Knowledge of Infant Development Inventory (added questions). Q 1–8 = cognitive; Q 9–11 = emotional; Q 12–19 = physical.
available for mothers. Second, as in Tamis-LeMonda et al. (2002) and different from the overall general perspective of development, this study attempted to explore knowledge of physical, cognitive, parent–infant interaction and emotional skills as separate domains.
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The results revealed that the largest number of mothers were knowledgeable about physical care activities but limited in cognitive, emotional and parent–infant interactions skills. Physical information is the main focus and may be the lone information provided by healthcare providers to mothers. In MCH centres,
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physical healthcare services are emphasized and centred on immunizations, physical examination and infants’ growth and development assessments. Immunizations and feeding are frequently addressed in the media and health campaigns for promoting children’s health. In discussing paediatricians’ role in mothers’ parenting practices, Bornstein & Cote (2004) indicated that paediatricians emphasize basic care and health maintenance and do not talk with mothers, and aspects of childrearing education are often ignored. This result was also in agreement with Thomas et al. (2007), who found that Indian urban and rural mothers had inadequate knowledge of psychological development compared with the physical aspects of hygiene, nutrition, safety, sleep and care of illness. In this regard, although there are indications that mothers’ knowledge is limited in specific areas, little efforts have been offered by healthcare providers to address mothers’ need for knowledge in other than physical domains of knowledge. Mothers’ limited knowledge about the timing for introducing complementary food was no surprise in this study. This result was in agreement with three studies about breastfeeding patterns among Jordanian mothers (Abuidhail 2014; Abuidhail et al. 2014; Obeidat et al. 2014). Obeidat et al. (2014) indicated that only 21% of Jordanian mothers continued breast feeding for 6 months and that the average exclusive breastfeeding declined as an infant grew up within the first 6 months after birth (Abuidhail et al. 2014). It was also mentioned by Abuidhail (2014) that a large percentage (68%) of post-partum women gave fluids to their infants as early as the end of the first month of their life. Information about the large number of mothers not being knowledgeable of parent–infant interactions is relevant when we understand that Jordanian mothers have strong held beliefs concerning some aspects of childcare that are transmitted over the generations. One important aspect in parent–infant interactions is concerned with spoiling babies when carried to comfort them. This result is congruent with Silva et al. (2005), who indicated that mothers’ knowledge about parenting was associated with beliefs, strategies and practices of the parents. Mother– child interaction misconceptions and beliefs need to be addressed by educating mothers that the psychological, emotional and social needs of children are as important as physical and safety needs for the normal development of a child. Changing beliefs about interactions and infants’ active roles during interactions can be achieved if healthcare providers place more emphasis on the psychological and social aspects of knowledge and care. For knowledge of developmental milestones, the largest number of mothers (79%) had correct knowledge in areas that reflected their inherent interest in specific infants’ developmen-
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tal abilities. These are the abilities that mothers were excited about and wanted to see soon, such as baby smiling, babbling and responding to them. On the other hand, the timing of the skill that was correctly known by the least number of mothers (8.5%) was related to high-level cognitive skill, remembering toys being hidden, which need to be watched for so that mothers are able to identify its existence. In this study, one can assume that mothers of children less than 12 months old were not knowledgeable of this skill as they had not yet experienced it, confirming the fact that mothers have learned from their own experience and not through formal sources or reading material. Ertem et al. (2007) found that Turkish mothers tended to underestimate their children’s abilities, especially in vocalization, sight, social smiling and overall brain development. In this study, mothers overestimated or were uncertain about two important cognitive skills (recognizing mother’s face and knowing right from wrong) and two physical/neuromotor developmental skills (toilet training and vocalizing). Overestimation and lack of knowledge of a child’s ability are serious matters because this may result in harsh and negligent parenting, subject a child to hazards, especially if it involves a physical safety issue. Tamis-LeMonda et al. (2002) found that lowincome adolescent mothers tended to overestimate the timing of all developmental abilities of their infants, and knowledge about cognitive, language and motor abilities was stronger than knowledge about play and social development abilities. They indicated that parents may become frustrated and worried about future retardation of the baby, which may sometimes result in subsequent abuse or maltreatment of the child. Underestimation of an infant’s abilities is a serious problem. A mother who underestimates a child’s ability may miss developmental retardation and thus delay seeking medical attention, which may be crucial for early intervention and impairment prevention. In this study more than half of the mothers underestimated and were uncertain about four developmental skills (two cognitive and two physical) of their infants. Huang et al. (2005) indicated that mothers who underestimate their infants’ abilities might provide less sensitive stimulation to children’s learning abilities. In this study it is not surprising to find that mothers’ knowledge of physical, emotional and cognitive developmental skills did not differ according to parental age, education and parity. This result is congruent with other studies from this region (Al-Ayed 2010; Jarrah et al. 2012) as there were no relationship between mothers’ knowledge and age, education and parity. One significant finding of this study is the role of planned pregnancy on mothers’ knowledge of infants’ cognitive developmental skills, which to our knowledge has not been reported in the literature. This result is crucial as it brings to attention the
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importance of planned pregnancy in preparation for better parenting. A possible explanation for this result is that mothers who plan their pregnancy may be more interested in learning about child development and thus recognize the importance of infants’ cognitive developmental skills. In the present study, although mothers have indicated that nurses and doctors are their first source of information, however, this source emphasizes the biologic safety measures and it is not a readily structured service. When formal structured education is absent, informal sources concerning a mother or a mother-in-law predominate, and traditional practices are retained. This result is consistent with Sink (2009), who indicated that mothers used informal sources more often in the post-natal period. Surprisingly and contrary to MacPhee’s (1981) findings, two important sources, husbands and parenting classes, were ranked low in the sources’ list. This finding may be explained in the context of a traditional society where men have very small role in matters concerning parenthood and is congruent with studies from traditional societies (Jarrah et al. 2012; Thomas et al. 2007). In the same vein, and contrary to Sink’s results who found prenatal classes as most helpful, this study found that parenting classes were the second lowest in terms of helpfulness. This is no surprise given that no structured prenatal classes are available to mothers in almost all healthcare sectors in Jordan. One final serious concern is the ranking of social workers as last on sources of information. It is important to know that social workers have a specific job description and are available in every MCH centre. Their role comprises assessment of the social environment and interventions to help mothers with socio-economic problems and is supposedly an integral part of the services. Nevertheless, social workers are mainly called upon to intervene in extreme situations related to poverty and interfamily conflicts. Their role is perceived secondary to healthcare services and scoring lowest on mothers’ sources of information signifies mothers’ emphasis on the physical aspects of health care and the negligence of the holistic nature of care provision.
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systematically assess parents’ needs for health education that include physical as well as cognitive, emotional and parent– infant interaction materials. This assessment and relevant educational material would most likely improve mothers’ knowledge and practice in these domains. Healthcare professionals are key people to effect change in this area because of mothers’ keenness to attend antenatal and post-natal clinics, and thus, formal education is strongly recommended. Structured educational programmes that include mothers and mothers-in-law are crucial because of their important role in shifting parenting processes. In addition, printed materials and media sources should be made accessible to fathers as sources of information to balance cultural barriers for attending classes with their spouses. In nursing education, nursing curricula must recognize the importance of teaching a holistic approach to student nurses that emphasizes comprehensive parenting education to mothers and not limited to physical care. In nursing administration, it is important to design and institute parenting programmes that are integrated into the healthcare system for the purpose of early detection, health promotion and management of parenting problems. Health authorities represented by the Ministry of Health, the largest sector that provides mother–child healthcare services, is responsible for the creation of optimal conditions for parents to learn parenting skills. Therefore, it is important that this sector have early investments in developing parenting skills that improve childhood’s quality of health. This involves providing local healthcare centres, information services, counselling and educational programmes for parents starting during pregnancy and continuing on as their children grow. It is recommended that all appropriate administrative and financial measures are supported to create the best possible conditions for mothers to learn how to raise and nurture their children positively and holistically. Further longitudinal research is needed to assess the influence of mothers’ knowledge on children’s behaviour at different ages. Limitations
Implications for nursing care and health policy
Based on the results revealed by KIDI’s assessment of mother’s knowledge and in reference to the International Classification of Nursing Practice, a nursing diagnosis is indicated: ‘Limited Parenting Knowledge Pertaining to Cognitive, Emotional, and Parent-Infant Interactions’ (Coenen 2003). Given that mothers’ demographics had limited influence on knowledge of childrearing and developmental milestones, and that physical health care was more emphasized by healthcare providers and hence better attained by mothers, we believe that nurses should
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The nature of the cross-sectional design precludes causal statements. Although the centres were selected randomly, a convenience sample of subjects was included in this study. Thus, the sample is not random, and the results may not be generalizable to all mothers in Amman, Jordan. Strengths
This research is only the second study conducted in Jordan that explored mothers’ knowledge of childrearing. A large sample of 400 mothers was included, representing women served by the
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largest healthcare sector, the Ministry of Health, in Jordan. The KIDI, a largely used tool for parenting assessment, is an acknowledged valid and reliable tool in the West that has been partly tested in different cultural contexts and has yielded information that validates other research results indicating that parenting is culturally embedded. Thus, several salient features emerge from this study.
Conclusion Jordanian mothers’ knowledge of childrearing is limited to physical safety measures and embedded with traditional practices. It is possible to indicate that a clinical nursing diagnosis has emerged from these data: ‘Deficient knowledge’ in parenting skills and in specific domains (cognitive, emotional and parent– infant interactions) related to absence of teaching and learning opportunities for parents. This is an expected result as these areas are not emphasized sufficiently in healthcare professional– mother interactions and may be the most important contributor for mothers resorting to traditional beliefs and sources in their practices. As a feasible intervention to this problem, it is suggested here that nurses provide teaching and support to families by offering parenting instruction across all developmental stages of children.
Acknowledgements Many thanks for the reviewers Professor Erika Froelicher and Dr Faris Doghmi who kindly read, edited and gave us valuable comments on this manuscript. Special thanks are extended to the University of Jordan, the Deanship of Academic Research and all mothers who were patient enough to complete the interview questionnaire.
Author contributions Prof Ahmad, Safadi, and Nassar: study design, data analysis, writing up. Dr. Abdelkader, Alashhab and Amre: study design, data collection, review.
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Halgunseth, L.C., Ispa, J.M., Csizmadia, A. & Thornburg, K.R. (2005) Relations among maternal racial identity, maternal parenting behavior, and child outcomes in low-income, urban, black families. Journal of Black Psychology, 31 (4), 418–440. Huang, K.-Y., O’Brien Caughy, M., Genevro, J.L. & Miller, T.L. (2005) Maternal knowledge of child development and quality of parenting among White, African-American and Hispanic mothers. Journal of Applied Developmental Psychology, 26 (2), 149–170. IBM Corporation (2012) IBM SPSS Statistics for Windows, Version 21.0. IBM Corporation, Armonk, NY. Irwin, L.G., Siddiqi, A. & Hertzman, C. (2007) Early child development: a powerful equalizer. Final report to the WHO Commission on Social Determinants of Health, Geneva. Jahromi, L.B., et al. (2014) Family context, Mexican-origin adolescent mothers’ parenting knowledge, and children’s subsequent developmental outcomes. Child Development, 85 (2), 593–609. Jarrah, S., Safadi, R. & Al-Ashhab, S. (2012) Jordanian mothers’ caring practices of infants’ health problems in the postpartum period. Archives des Sciences, 65 (7), 461–483. Karraker, K.H. & Evans, S.L. (1996) Adolescent mothers’ knowledge of child development and expectations for their own infants. Journal of Youth and Adolescence, 25 (5), 651–666. MacPhee, D. (1981) Knowledge of infant development inventory (KIDI). Unpublished manuscript, University of North Carolina, Department of Psychology. Obeidat, M., et al. (2014) Feeding practices in the North of Jordan. Journal of the Royal Medical Services, 21 (1), 11–16. Reich, S. (2005) What do mothers know? Maternal knowledge of child development. Infant Mental Health Journal, 26 (2), 143–156.
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Ribas, R.C. Jr & Bornstein, M. (2005) Parenting knowledge: similarities and differences in Brazilian mothers and fathers. Interamerican Journal of Psychology, 39 (1), 5–12. Ribas, R.D.C. Jr, Moura, M.L.S.D. & Bornstein, M.H. (2003) Socioeconomic status in Brazilian psychological research: II. Socioeconomic status and parenting knowledge. Estudos de psicologia (Natal), 8 (3), 385–392. Sigel, I.E. (1992) The belief-behavior connection: a resolvable dilemma? In Parental Belief Systems: The Psychological Consequences of for Children, 2nd edn (Sigel, I.E., McGillicuddy-Delisi, A.V. & Goodnow, J.J., eds). Erlbaum, Hillsdale, NJ, pp. 443–456. Silva, A.K., Vieira, M.L., de Moura, M.L.S. & Ribas, R.C. Jr (2005) Primiparous mothers’ knowledge about child development: a study in Itajaí, SC. Journal of Human Growth and Development, 15 (3), 1–10. Sink, K.K. (2009) Seeking newborn information as a resource for maternal support. Journal of Perinatal Education, 18 (3), 30–38. Stevens, J.H. Jr (1984) Child development knowledge and parenting skills. Family Relations, 33, 237–244. Tamis-LeMonda, C.S., Shannon, J.S. & Spellmann, M. (2002) Low-income adolescent mothers’ knowledge about domains of child development. Infant Mental Health Journal, 23 (1–2), 88–103. Teti, D.M. & Gelfand, D.M. (1991) Behavioral competence among mothers of infants in the first year: the meditational role of maternal self-efficacy. Child Development, 62 (5), 918–929. Thomas, S., Vijayakumar, C., Siva, R. & Isaac, R. (2007) Parenting children under three years of age in a South Indian setting. Pediatric Nursing, 33 (5), 421–426. Williams, P.D., Jiningsih, S. & Williams, A.R. (2000) Balinese mothers∼ developmental timetables for young children. Western Journal of Nursing Research, 22 (6), 717–735.
Jordanian mothers’ knowledge of infants’ childrearing and developmental milestones R.R. Safadi1 RN, PhD, M. Ahmad3 RN, PhD, O.S. Nassar2 RN, PhD, S.A. Alashhab4 RN, MSN, R. AbdelKader2 RN, PhD & H.M. Amre4
RN, MSN
1 Associate Professor, 2 Assistant Professor, Maternity and Child Health Nursing Department, 3 Professor, Clinical Nursing Department, 4 Lecturer, Community and Mental Health Department, Faculty of Nursing, The University of Jordan, Amman, Jordan
SAFADI R.R., AHMAD M., NASSAR O.S., ALASHHAB S.A., ABDELKADER R. & AMRE H.M. (2016) Jordanian mothers’ knowledge of infants’ childrearing and developmental milestones. International Nursing Review 63, 50–59 Aim: This study explored Jordanian mothers’ knowledge of infants’ childrearing practices and developmental milestones, the socio-demographic variables of relevance to knowledge, and sources of information that guide childrearing practices. Background: Parents’ knowledge is considered the frame of reference for parents’ interpretations of their children’s behaviors and provides the basis for having the appropriate expectation of the child’s developmental stage. Parents’ knowledge of childrearing is essential for children’s physical, cognitive and emotional development. Methods: A cross-sectional design using a modified version of MacPhee’s ‘Knowledge of Infant Development Inventory’ was used to assess 400 mothers’ knowledge of infants’ childrearing and developmental milestones, in Amman, Jordan. Results: Mothers were found to be more knowledgeable in physical and safety skills and less in cognitive, emotional, and parent-infant interaction skills. Parental age, education, parity and planned pregnancy had limited influence on developmental milestones knowledge. Formal and informal sources of information were used conforming to traditional societies. Discussion and conclusion: Results were congruent with findings from other studies in the region and similar traditional societies. Results allude to conclusion that mothers resort to informal sources and traditional practices to replace formally structured programmes when absent. Implications for nursing and health policy: Healthcare professionals, nursing schools and healthcare policy makers are encouraged to develop and institute a holistic approach encompassing physical, cognitive, emotional and parent-infant interaction domains in childrearing educational programmes. Structured parenting programmes for mothers and culturally accepted sources of information for fathers are essential to enhance parenting skills among Jordanian couples.
Correspondence address: Dr Reema R. Safadi, Maternal and Child Health Nursing Department, Faculty of Nursing, University of Jordan, Amman 11942, Jordan; Tel: 009626-5355000; Fax: 00962-65857667; E-mail: [email protected].
Conflict of interest No conflict of interest has been declared by the authors. Funding This research was funded by The University of Jordan, The Deanship of Academic Research, number 1225.
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Keywords: Childrearing Practices, Infant Development, Jordan, Mothers’ Knowledge, Developmental Milestones, Childrearing
Introduction Parental knowledge is defined as parents’ understanding of developmental norms and milestones, processes of child development and familiarity with caregiving skills (Benasich & Brooks-Gunn 1996, p. 1187). This knowledge is conceptualized as a product of personal experience with children and social interactions (Goodnow 1995). Knowledge about childrearing has been of interest to Western researchers for over four decades; however, it is relatively new to the Middle East. Jordan, a small lower middle income country, is among the more developed Arab states in terms of healthcare services and statistical health indicators. Tremendous progress has been achieved in the health care of children and their mothers in the last three decades (Ajluni 2011). Parents’ knowledge of infants’ childrearing practices and development is an important contributing factor as indicated by its role in cognitive stimulation and child maltreatment (Belcher et al. 2007; MacPhee 1981). Knowledge mediates the relation between experience and childrearing practices and, in turn, influences children’s quality of life (Goodnow & Collins 1990; MacPhee 1981). In general, parents’ knowledge is considered the frame of reference for parents’ interpretations of their children’s behaviours and provides the basis for having the appropriate expectation of the child’s developmental stage (Ribas et al. 2003). A review of parenting literature revealed three major foci of research: first, studies concerned with examining the relationship of parental socio-demographic factors with knowledge and childrearing practices (Ertem et al. 2007; Ribas & Bornstein 2005; Williams et al. 2000); second, studies of outcomes of childrearing knowledge and practices, immediate or prospective, on children’s cognitive and emotional development (Benasich & Brooks-Gunn 1996; Halgunseth et al. 2005; Huang et al. 2005); and third, studies that examined cultural and intercultural parenting practice similarities and differences (Bornstein & Cote 2004; Carra et al. 2013; Elliott 2007; Reich 2005; Thomas et al. 2007). Historical Western literature about developmental expectations and mothers’ knowledge of developmental milestones has been pervasive and this is rather not recent. It was the concern of child psychologists during the 1980s and 1990s of the last century revealing information about expectations for children’s behaviour and factors contributing to childrearing abilities and difficulties (Jahromi et al. 2014; Stevens 1984). It was found that
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an unrealistic match between expectations and actual behaviours will result in higher stress levels among parents (Teti & Gelfand 1991). It has also been suggested that mothers with a more accurate estimate of infants’ developmental milestones are more likely to be sensitive to their children’s needs and use more effective parenting strategies to support social and cognitive development (Goodnow 1988; Sigel 1992). In contrast, parents who underestimate their children’s abilities provide little stimulation to evoke their learning potential (Huang et al. 2005). Karraker & Evans (1996) found that adolescent mothers who had lower scores on the Developmental Milestones Survey were more likely to underestimate their infants’ performance. These mothers may fail to encourage their infants’ development and may perceive their infant as less competent than others. On the other hand, parents who overestimated their child’s developmental abilities tended to be impatient and intolerant of their child’s behaviour (Cowen 2001). Studies about childrearing practices in the Arab world are scant and are only in their beginnings in relation to investigating contributing and outcome factors. A study by Al-Ayed (2010) in Saudi Arabia about maternal knowledge of their children’s health problems found that mothers had deficient knowledge and that health professionals had a limited role in providing health education to mothers. They found no relationship between mothers’ knowledge score and level of education, age or number of children. The majority of mothers considered family members as a main source of information and gave little importance to healthcare professional input. A study by Al-Hassan & Lansford (2011) revealed gaps in mothers’ knowledge regarding social, language and play activities for their children, and accordingly a 16-h education programme, the ‘Better Parenting Programme’, was delivered (Al-Hassan & Lansford 2011). The results of this educational programme yielded limited influence on mothers’ knowledge. In Jordan, Jarrah et al. (2012) found that most mothers used traditional practices to manage newborns’ healthcare problems in the first 6 weeks after birth. They found that parity, education and family income had limited influence on mothers’ practices and that mothers used more informal sources of information. In Beijing, grandparents had a dominant role in perpetuating values and practices in childrearing (Binah-Pollak 2014). The purpose of this study is to assess mothers’ knowledge of childrearing practices and developmental milestones of infants, encompassing their basic needs and abilities and factors
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associated with knowledge, namely parental age and education, parity and planned pregnancy. Furthermore, maternal sources of information are identified in an attempt to recognize the value placed by mothers on these sources in gaining knowledge about childrearing. To understand Jordanian mothers’ knowledge of childrearing practices and developmental milestones of their infants, this research aims to answer the following questions: 1 What do Jordanian mothers know about childrearing practices? 2 What is the level of knowledge about infants’ developmental milestones among Jordanian mothers? 3 Are there differences in mothers’ level of knowledge about infants’ developmental milestones in relation to parental age, education, parity and planned pregnancy? 4 What sources of information do mothers use to guide their childrearing knowledge and practices?
have no adverse consequences on healthcare provision. Some mothers refused participation because of family responsibilities or time constraints. All participants were assured of anonymity and confidentiality. Design and procedures
A cross-sectional design was used. Two research assistants were trained to collect data from mothers in the selected MCH centres using face-to-face interviewing methods. Data collection involved the completion of a questionnaire composed of three parts: (a) demographic data (34 questions); (b) knowledge instrument, a purposefully developed tool using items from ‘Knowledge of Infant Development Inventory’ (KIDI; MacPhee 1981) also consisted of two parts (childrearing practices and developmental milestones); and (c) a modified version of the Maternal Sources of Information Questionnaire (Elliott’s 2007 dissertation) (20 questions). Each interview lasted for 30–45 min.
Methods Knowledge instrument Population and sample
The recruited participants were Jordanian mothers of normally delivered singleton infants over the first year of infancy. Mothers of various age groups and parity were included. Mothers of infants with abnormalities and complicated births were excluded as these may influence mothers’ knowledge and attitude toward parenting. Participants were recruited from a list of the Ministry of Health, Maternity and Child Health Care Centers (MCH). A random selection of 11 out of 71 centres were selected from Amman regions. Centres that served less than 30 mothers per month were excluded. Sample size was calculated by using G* power 3.0 software (Faul et al. 2007). With an alpha of 0.05, the estimated number needed for an effect size of 0.20 and a power of 0.80 is 392 mothers. A convenience sample of 400 mothers of infants aged between birth and 12 months were interviewed during their visits to MCH centres. We studied this group because what infants experience during the early years sets a critical foundation for their entire life course (Irwin et al. 2007). Ethics
The University of Jordan Research Review Board, Faculty of Nursing Ethics Committee and the Ministry of Health administration gave their approvals, and key persons in the selected MCH centres were approached to facilitate recruitment of mothers. Eligible mothers provided voluntary consent for participation after researchers’ explanation of study purpose, procedures and benefits, and that declining participation would
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A letter of permission to use a number of items from KIDI (MacPhee 1981) was sent to the author (MacPhee 1981). After gaining approval, we selected 24 items that corresponded with Jordanian culture and infants’ age group (birth to 12 months old). Four more questions were suggested by experts to refer to the common parenting problems and known knowledge deficits in this field; one new question was added to knowledge of childrearing practices (part 1); and three questions were added to knowledge of developmental milestones (part 2). KIDI is an inventory for examining knowledge of infant development with 58 questions about babies’ normal behaviour and the age at which an infant can achieve a developmental skill. Test–retest reliability of KIDI 2 weeks apart of a sample of 58 mothers has produced a coefficient of 0.92, indicating good short-term consistency. It was also stable over time: r = 0.65 over 4 months in a sample of college students (MacPhee 1981, p. 14). The MacPhee’s (1981) inventory has reported internal consistency of KIDI based on several studies ranging between 0.80 and 0.86. Originally constructed in English, two bilingual translators with professional skill in English and Arabic translated the newly developed tool into Arabic and then back-translated into English. After translation, two paediatricians, three child health nurses and a statistician checked the tool for meaning preservation, cultural appropriateness and content validity. Different from the original tool (KIDI), questions about developmental milestones were categorized into three domains: physical (eight questions), cognitive (eight questions) and emotional interactions (three questions). Questions had response
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options of agree, younger, older or unsure; if a mother disagreed with the time of achieving a milestone, she was asked to identify whether this developmental skill should happen earlier, later than in the statement of the question or if they were unsure. In the two parts of this questionnaire, correct and incorrect answers were identified and scored as one and zero, respectively. A pilot test was conducted to ensure readability and cultural sensitivity with 40 selected mothers from two different MCH centres. The questionnaire language was modified based on mothers’ responses for simplicity of expressions and cultural relevancy. The Cronbach’s alpha reliability test result for mothers’ knowledge of the developmental milestones was 0.72.
Analysis
Descriptive and inferential statistics were performed using the Statistical Package for Social Science (IBM Corporation 2012). All questions were examined for correct or incorrect practice or knowledge. Negative statements were reversely scored and percentages were calculated. To investigate contributing factors to mothers’ knowledge of developmental milestones, analysis of variance (ANOVA) and t-tests were used to explore whether there were significant differences in mothers’ knowledge of developmental milestones that could be related to parental age, education, parity and planned pregnancy. Descriptive statistics were used to determine the most commonly used sources of information as used frequently (2), little use (1) and not used at all (0).
Results This study addressed mothers’ knowledge of infants’ childrearing practices and developmental milestones during the first year of infants’ lives. It also examined mothers’ knowledge in relation to parental demographics and identified mothers’ commonly used sources of information.
Demographics
Four hundred women completed the study questionnaire. The mean age of mothers was 28.9 [standard deviation (SD) = 6.2], and their spouse mean age was 34.4 (SD = 6.9) years. An equal number of mothers (54.8%) and fathers (54%) had 12 years of education or less. Most of the mothers were unemployed (71%) and (22%) were mothers of only one child. The average age of their children was 6.6 months. Almost two-thirds of the mothers were assisted during the first few weeks after birth. Most assistance was offered by mothers-in-law (31%) and mothers (22%). Their husbands provided the lowest level of assistance (6%) (Table 1).
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Knowledge of childrearing practices
The results of the examination of mothers’ knowledge of infants’ childrearing practices revealed that they were knowledgeable about physical safety issues such as attending an infant in the tub (86.8%), infant’s position in bed (62.5%) and about protecting infants from choking with food particles (58.8%). They also showed good knowledge about managing infants’ diarrhoea (79.8%). Conversely, less than one-fifth of the mothers had correct knowledge for the suitable age (7 months old) for introducing complementary food to infants (15.3%). Fewer mothers had knowledge of parent–infant interactions. Slightly over half (60%) of the mothers recognized that carrying a crying baby does not spoil him or her and less than one-third of the mothers had correctly answered two items related to parent–infant interactions. These items corresponded to mothers’ perception of reasons for the baby’s crying ‘to make trouble’ (29.5%) and getting into the habit of wanting to be always carried (25%) (Table 2).
Knowledge of developmental milestones
Mothers’ knowledge about infants’ developmental milestones is shown in Table 3. Mothers were asked to indicate whether the age indicated in the statement was the correct age for achieving this milestone, should happen later than indicated (underestimating the infant’s abilities), should happen sooner than indicated (overestimating the infant’s abilities) or if they were unsure about the exact age for achieving this skill (uncertain). The results revealed that more than half of the mothers answered 8 out of 19 questions correctly. Mothers displayed correct knowledge about some developmental milestones, including the age of smiling (emotional) (79.3%), babbling (physical) (61%), identifying familiar people from strange people (cognitive) (60%), responding to someone differently according to the person being happy or upset (emotional) (58%), having fear perception of high places (cognitive) (57.3%) and knowing what the word ‘No’ means (cognitive) (55%). There were two major underestimations that were related to physical and cognitive skills (75.3% and 74.5) and one overestimation that was related to a cognitive skill (82.3%) (Table 3). A considerable percentage of mothers were uncertain about the timing of a developmental milestone. Mothers were most uncertain about cognitive domain skills, including infants being afraid of high places by 6 months of age (18%), ability to remember toys being hidden by 12 months (17%) and being afraid of strangers approximately 6 months of age (16.8%). However, mothers displayed less uncertainty in physical/ physiological abilities, which ranged between 12.8% regarding
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Table 1 Mothers’ characteristics/socio-demographics (n = 400) Item
Description
Frequency
(%)
Mean
SD
Mothers’ age
Range (18–45) 18–27 28–35 36–50 >12 years Diploma University Range (20–60) 20–30 31–40 41–60 >12 years Diploma University Working Non-working 1 baby >1 baby Range (1–12) Yes No Yes No Mother-in-law Mother Husband Neighbour Other daughters Others
400 172 167 61 219 81 100 400 134 197 69 216 67 117 116 284 89 311 400 245 155 139 261 43 31 8 18 15 24
(100) (43) (41.8) (15.3) (54.8) (20.3) (25.0) (100) (33.5) (49.3) (17.3) (54) (16.8) (29.2) (29) (71) (22.3) (77.8) (100) (61.3) (38.7) (34.8) (65.2) (30.9) (22.3) (5.8) (12.9) (10.8) (17.3)
28.9
6.2
34.4
6.9
6.59
3.6
Mothers’ education
Husbands’ age
Husbands’ education
Work status Parity Age of the infant in months Planned pregnancy Receive assistance with baby care Source of assistance (139)
SD, standard deviation.
the appropriate age of toilet training and 1.3% regarding the age when babies begin to laugh at things. ANOVA to test mothers’ knowledge of infants’ physical, emotional and cognitive developmental skills showed no significant difference in relation to mothers’ and fathers’ age and education. The result was also not significant for parity with all three domains (t-test). As for planned pregnancy, results showed a significant difference in mothers’ knowledge of cognitive developmental skills, but not in the physical or emotional skills [t = 2.64, degrees of freedom (d.f.) = 398, P = 0.009]. Regarding sources of information, the results revealed that mothers used formal and informal sources. Information provided by nurses and doctors was the highest (M = 1.75, SD = 0.58) followed by one’s mother or sisters (M = 1.68, SD = 0.65), posters and leaflets in the MCH centre (M = 1.66, SD = 0.56) and mothers-in-law (M = 1.52, SD = 0.76). Hus-
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bands ranked as 12th out of the 20 sources (M = 1.05, SD = 0.71) and social workers had the lowest ranking (20th) among all others (M = 0.25, d.f. = 0.58). Other forms such as media (television, 6th; films, 11th; radio, 16th) and modern technology (educational Internet, 15th; search engines, (17th) were less used.
Discussion This study offers salient information for nurses and midwives in parenting practice. It describes mothers’ knowledge of childrearing and developmental milestones of their infants during the first year of their lives. It is one of very few studies about childrearing in the Arab region. This study differs from other studies in a number of ways. First, it is not an exploration of contemporary traditional practices, but its results reflected the common practices and the existent healthcare services
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Table 2 Mothers’ knowledge of childrearing practices Serial number
Item
Correct answers
%
1. 2.
You must stay in the bathroom when your infant is in the tub. When a baby less than 12 months gets diarrhoea, you should stop feeding solid foods and give it mashed potatoes and add more fluids. New foods should be given to the infant one at a time, with 4–5 days between each one. When putting babies in the crib for sleep, place them on their back, not stomach. If a baby (less than a year) wants a snack, give it chips, popcorn, candies or chocolates. * A baby is started on solid foods at the 7th month of age. The more you soothe a crying baby by holding and talking to it, the more you spoil them. Babies do some things just to make trouble for their parents, like crying a long time or pooping in their diapers. Babies should not be held when they cry because this will make them want to be held all the time.
347 319
86.8 79.8
255 250 235 61 238 118 100
63.7 62.5 58.8 15.3 59.5 29.5 25
3. 4. 5. 6. 7. 8. 9.
*Not in Knowledge of Infant Development Inventory (added questions). Q 1–6 = physical safety; Q 7–9 = parent–infant interaction.
Table 3 Mothers’ knowledge of developmental milestones
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Item
Correct
Under-estimating
Over-estimating
Uncertain
Eight month olds act differently with familiar people than with someone not seen before. Infants will avoid high places, like stairs by 6 months of age. Six month olds know what ‘No’ means. One year olds know right from wrong. Infants begin to respond to their name at 10 months. * Babies begin to fear from strangers around the 6th month of age. * Three month olds will recognize their mother’s face when they see her. Infants of 12 months can remember toys they have watched being hidden. Three month olds often will smile when they see an adult’s face. Six month olds will respond to someone differently if the person is happy or upset. Babies begin to laugh at things around 4 months of age. Babies begin to babble around the fifth month of age. Babies usually say their first real word at 6 months. * Babies’ teeth first come in (erupt) around the ninth months of age. Infants are usually walking by about 12 months of age. Most babies can sit on the floor without falling down around the eighth month. Most infants are ready to be toilet trained by one year of age. Babies are about 7 months old before they can reach for and grab things. Four month olds lying on their stomach start to lift their heads.
59.5 57.3 55.3 38.8 38.0 29.8 13.3 8.5 79.3 58.0 42.5 61.0 50.3 50.0 44.0 42.8 38.8 34.3 21.5
16.5 – – – 16.5 34.5 – 74.5 15.5 20.5 21.8 35.0 – 44.0 30.0 13.0 – 60.5 75.3
18.8 24.8 32.0 48.8 40.5 19.0 82.3 – – 9.8 34.5 – 42.3 – 22.8 42.3 48.5 – –
5.3 18.0 12.8 12.5 5.0 16.8 4.5 17.0 5.3 11.8 1.3 4.0 7.5 6.0 3.3 2.0 12.8 5.3 3.3
*Not in Knowledge of Infant Development Inventory (added questions). Q 1–8 = cognitive; Q 9–11 = emotional; Q 12–19 = physical.
available for mothers. Second, as in Tamis-LeMonda et al. (2002) and different from the overall general perspective of development, this study attempted to explore knowledge of physical, cognitive, parent–infant interaction and emotional skills as separate domains.
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The results revealed that the largest number of mothers were knowledgeable about physical care activities but limited in cognitive, emotional and parent–infant interactions skills. Physical information is the main focus and may be the lone information provided by healthcare providers to mothers. In MCH centres,
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physical healthcare services are emphasized and centred on immunizations, physical examination and infants’ growth and development assessments. Immunizations and feeding are frequently addressed in the media and health campaigns for promoting children’s health. In discussing paediatricians’ role in mothers’ parenting practices, Bornstein & Cote (2004) indicated that paediatricians emphasize basic care and health maintenance and do not talk with mothers, and aspects of childrearing education are often ignored. This result was also in agreement with Thomas et al. (2007), who found that Indian urban and rural mothers had inadequate knowledge of psychological development compared with the physical aspects of hygiene, nutrition, safety, sleep and care of illness. In this regard, although there are indications that mothers’ knowledge is limited in specific areas, little efforts have been offered by healthcare providers to address mothers’ need for knowledge in other than physical domains of knowledge. Mothers’ limited knowledge about the timing for introducing complementary food was no surprise in this study. This result was in agreement with three studies about breastfeeding patterns among Jordanian mothers (Abuidhail 2014; Abuidhail et al. 2014; Obeidat et al. 2014). Obeidat et al. (2014) indicated that only 21% of Jordanian mothers continued breast feeding for 6 months and that the average exclusive breastfeeding declined as an infant grew up within the first 6 months after birth (Abuidhail et al. 2014). It was also mentioned by Abuidhail (2014) that a large percentage (68%) of post-partum women gave fluids to their infants as early as the end of the first month of their life. Information about the large number of mothers not being knowledgeable of parent–infant interactions is relevant when we understand that Jordanian mothers have strong held beliefs concerning some aspects of childcare that are transmitted over the generations. One important aspect in parent–infant interactions is concerned with spoiling babies when carried to comfort them. This result is congruent with Silva et al. (2005), who indicated that mothers’ knowledge about parenting was associated with beliefs, strategies and practices of the parents. Mother– child interaction misconceptions and beliefs need to be addressed by educating mothers that the psychological, emotional and social needs of children are as important as physical and safety needs for the normal development of a child. Changing beliefs about interactions and infants’ active roles during interactions can be achieved if healthcare providers place more emphasis on the psychological and social aspects of knowledge and care. For knowledge of developmental milestones, the largest number of mothers (79%) had correct knowledge in areas that reflected their inherent interest in specific infants’ developmen-
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tal abilities. These are the abilities that mothers were excited about and wanted to see soon, such as baby smiling, babbling and responding to them. On the other hand, the timing of the skill that was correctly known by the least number of mothers (8.5%) was related to high-level cognitive skill, remembering toys being hidden, which need to be watched for so that mothers are able to identify its existence. In this study, one can assume that mothers of children less than 12 months old were not knowledgeable of this skill as they had not yet experienced it, confirming the fact that mothers have learned from their own experience and not through formal sources or reading material. Ertem et al. (2007) found that Turkish mothers tended to underestimate their children’s abilities, especially in vocalization, sight, social smiling and overall brain development. In this study, mothers overestimated or were uncertain about two important cognitive skills (recognizing mother’s face and knowing right from wrong) and two physical/neuromotor developmental skills (toilet training and vocalizing). Overestimation and lack of knowledge of a child’s ability are serious matters because this may result in harsh and negligent parenting, subject a child to hazards, especially if it involves a physical safety issue. Tamis-LeMonda et al. (2002) found that lowincome adolescent mothers tended to overestimate the timing of all developmental abilities of their infants, and knowledge about cognitive, language and motor abilities was stronger than knowledge about play and social development abilities. They indicated that parents may become frustrated and worried about future retardation of the baby, which may sometimes result in subsequent abuse or maltreatment of the child. Underestimation of an infant’s abilities is a serious problem. A mother who underestimates a child’s ability may miss developmental retardation and thus delay seeking medical attention, which may be crucial for early intervention and impairment prevention. In this study more than half of the mothers underestimated and were uncertain about four developmental skills (two cognitive and two physical) of their infants. Huang et al. (2005) indicated that mothers who underestimate their infants’ abilities might provide less sensitive stimulation to children’s learning abilities. In this study it is not surprising to find that mothers’ knowledge of physical, emotional and cognitive developmental skills did not differ according to parental age, education and parity. This result is congruent with other studies from this region (Al-Ayed 2010; Jarrah et al. 2012) as there were no relationship between mothers’ knowledge and age, education and parity. One significant finding of this study is the role of planned pregnancy on mothers’ knowledge of infants’ cognitive developmental skills, which to our knowledge has not been reported in the literature. This result is crucial as it brings to attention the
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importance of planned pregnancy in preparation for better parenting. A possible explanation for this result is that mothers who plan their pregnancy may be more interested in learning about child development and thus recognize the importance of infants’ cognitive developmental skills. In the present study, although mothers have indicated that nurses and doctors are their first source of information, however, this source emphasizes the biologic safety measures and it is not a readily structured service. When formal structured education is absent, informal sources concerning a mother or a mother-in-law predominate, and traditional practices are retained. This result is consistent with Sink (2009), who indicated that mothers used informal sources more often in the post-natal period. Surprisingly and contrary to MacPhee’s (1981) findings, two important sources, husbands and parenting classes, were ranked low in the sources’ list. This finding may be explained in the context of a traditional society where men have very small role in matters concerning parenthood and is congruent with studies from traditional societies (Jarrah et al. 2012; Thomas et al. 2007). In the same vein, and contrary to Sink’s results who found prenatal classes as most helpful, this study found that parenting classes were the second lowest in terms of helpfulness. This is no surprise given that no structured prenatal classes are available to mothers in almost all healthcare sectors in Jordan. One final serious concern is the ranking of social workers as last on sources of information. It is important to know that social workers have a specific job description and are available in every MCH centre. Their role comprises assessment of the social environment and interventions to help mothers with socio-economic problems and is supposedly an integral part of the services. Nevertheless, social workers are mainly called upon to intervene in extreme situations related to poverty and interfamily conflicts. Their role is perceived secondary to healthcare services and scoring lowest on mothers’ sources of information signifies mothers’ emphasis on the physical aspects of health care and the negligence of the holistic nature of care provision.
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systematically assess parents’ needs for health education that include physical as well as cognitive, emotional and parent– infant interaction materials. This assessment and relevant educational material would most likely improve mothers’ knowledge and practice in these domains. Healthcare professionals are key people to effect change in this area because of mothers’ keenness to attend antenatal and post-natal clinics, and thus, formal education is strongly recommended. Structured educational programmes that include mothers and mothers-in-law are crucial because of their important role in shifting parenting processes. In addition, printed materials and media sources should be made accessible to fathers as sources of information to balance cultural barriers for attending classes with their spouses. In nursing education, nursing curricula must recognize the importance of teaching a holistic approach to student nurses that emphasizes comprehensive parenting education to mothers and not limited to physical care. In nursing administration, it is important to design and institute parenting programmes that are integrated into the healthcare system for the purpose of early detection, health promotion and management of parenting problems. Health authorities represented by the Ministry of Health, the largest sector that provides mother–child healthcare services, is responsible for the creation of optimal conditions for parents to learn parenting skills. Therefore, it is important that this sector have early investments in developing parenting skills that improve childhood’s quality of health. This involves providing local healthcare centres, information services, counselling and educational programmes for parents starting during pregnancy and continuing on as their children grow. It is recommended that all appropriate administrative and financial measures are supported to create the best possible conditions for mothers to learn how to raise and nurture their children positively and holistically. Further longitudinal research is needed to assess the influence of mothers’ knowledge on children’s behaviour at different ages. Limitations
Implications for nursing care and health policy
Based on the results revealed by KIDI’s assessment of mother’s knowledge and in reference to the International Classification of Nursing Practice, a nursing diagnosis is indicated: ‘Limited Parenting Knowledge Pertaining to Cognitive, Emotional, and Parent-Infant Interactions’ (Coenen 2003). Given that mothers’ demographics had limited influence on knowledge of childrearing and developmental milestones, and that physical health care was more emphasized by healthcare providers and hence better attained by mothers, we believe that nurses should
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The nature of the cross-sectional design precludes causal statements. Although the centres were selected randomly, a convenience sample of subjects was included in this study. Thus, the sample is not random, and the results may not be generalizable to all mothers in Amman, Jordan. Strengths
This research is only the second study conducted in Jordan that explored mothers’ knowledge of childrearing. A large sample of 400 mothers was included, representing women served by the
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largest healthcare sector, the Ministry of Health, in Jordan. The KIDI, a largely used tool for parenting assessment, is an acknowledged valid and reliable tool in the West that has been partly tested in different cultural contexts and has yielded information that validates other research results indicating that parenting is culturally embedded. Thus, several salient features emerge from this study.
Conclusion Jordanian mothers’ knowledge of childrearing is limited to physical safety measures and embedded with traditional practices. It is possible to indicate that a clinical nursing diagnosis has emerged from these data: ‘Deficient knowledge’ in parenting skills and in specific domains (cognitive, emotional and parent– infant interactions) related to absence of teaching and learning opportunities for parents. This is an expected result as these areas are not emphasized sufficiently in healthcare professional– mother interactions and may be the most important contributor for mothers resorting to traditional beliefs and sources in their practices. As a feasible intervention to this problem, it is suggested here that nurses provide teaching and support to families by offering parenting instruction across all developmental stages of children.
Acknowledgements Many thanks for the reviewers Professor Erika Froelicher and Dr Faris Doghmi who kindly read, edited and gave us valuable comments on this manuscript. Special thanks are extended to the University of Jordan, the Deanship of Academic Research and all mothers who were patient enough to complete the interview questionnaire.
Author contributions Prof Ahmad, Safadi, and Nassar: study design, data analysis, writing up. Dr. Abdelkader, Alashhab and Amre: study design, data collection, review.
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