Научная статья на тему 'Attitudes to motherhood in different cultures'

Attitudes to motherhood in different cultures Текст научной статьи по специальности «СМИ (медиа) и массовые коммуникации»

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Ключевые слова
MOTHERHOOD / IMAGE OF THE CHILD / ATTITUDE TOWARDS MOTHERHOOD

Аннотация научной статьи по СМИ (медиа) и массовым коммуникациям, автор научной работы — Razina Natalya V.

The study of motherhood is a promising and relevant field of psychology. This article represents the results of a study in which a socio-psychological analysis of reproductive attitudes and demographic behaviour was conducted. The study also shows the relationship between attitudes related to motherhood and women’s cultural affiliations. The factors that contribute to the nature of attitudes towards motherhood and the interaction between these factors were studied. According to the results of this study, we distinguished the most significant characteristics of the attitudes to motherhood that influence the nature of the relationship between a mother and her unborn child. The model of the development of attitudes to motherhood proposed by R. V. Ovcharova was detailed. We considered the influence of factors on the nature of attitudes to motherhood as well as the influence of factors on each other. The results of this study allow us to describe the psychological portraits of women with different attitudes to motherhood.

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Текст научной работы на тему «Attitudes to motherhood in different cultures»

Psychology in Russia: State of the Art Volume 7, Issue 2, 2014

Lomonosov Moscow State University

EMPIRICAL RESEARCH OF CONTEMPORARY SOCIAL PRACTICES

Attitudes to motherhood in different cultures

Natalya V. Razina

Russian State University for the Humanities, Moscow, Russia Corresponding author. E-mail: [email protected]

The study of motherhood is a promising and relevant field of psychology. This article represents the results of a study in which a socio-psychological analysis of reproductive attitudes and demographic behaviour was conducted. The study also shows the relationship between attitudes related to motherhood and women's cultural affiliations.

The factors that contribute to the nature of attitudes towards motherhood and the interaction between these factors were studied. According to the results of this study, we distinguished the most significant characteristics of the attitudes to motherhood that influence the nature of the relationship between a mother and her unborn child.

The model of the development of attitudes to motherhood proposed by R. V. Ovcharova was detailed. We considered the influence of factors on the nature of attitudes to motherhood as well as the influence of factors on each other.

The results of this study allow us to describe the psychological portraits of women with different attitudes to motherhood.

Keywords: motherhood, image of the child, attitude towards motherhood Introduction

Historically, attitudes toward motherhood have varied depending on one's particular culture. These, however, have been transformed in the public's perception: not only the aspects related to maternity, but also the image of the child. The current demographic crisis in Russia has reduced its birth rate and increased the average interval of time between pregnancies. However, the opposite is taking place among certain ethnicities within Russia. It is safe to assume that this shift has been caused by different attitudes towards motherhood that prevail among different cultures. It presents up-to-date psychological studies of mothers who belong to different cultures within Russia.

ISSN 2074-6857 (Print) / ISSN 2307-2202 (Online) © Lomonosov Moscow State University, 2014 © Russian Psychological Society, 2014 doi: 10.11621/pir.2014.0209 http://psychologyinrussia.com

In this work, we have applied the detailed approach which was developed by R. V. Ovcharova (2003) that studies motherhood more comprehensively and meticulously: taking into account the influence of individual traits, as well as the influence of the mother's family and social influences on how ideas about motherhood take shape.

R. V. Ovcharova's three-factor model is represented by:

• Macro-level

• Micro-level

• Personal level

Religious affiliation is considered to be an important factor when determining the substance of ideas regarding motherhood. The customs, traditions and rituals (as the basis of religion) of a society or one of its sub-sets, as well as its unique cultural narrative are of interest due to the fact that these form the subjective world-view of an individual within that society. Ideas regarding motherhood constitute part of this subjective worldview.

This work is aimed at identifying the psychological aspects of ideas about motherhood that can be derived from differences in these worldviews.

Methodology

A lot of research on the psychological characteristics of families has been undertaken in the last few years. Many new, more objective diagnostic methods of family life have appeared, as well as new forms of counselling and models of help within a child — parent relationship. At the same time, a distorted relationship often exists between children and parents, and child abandonment is becoming more common. Phenomena such as retracted adoption and child abuse underscore that family research remains essential, and a deeper understanding of the psychological basis of attitudes towards children, their position in the family and their upbringing is needed.

An analysis of the available literature allows one to assume that the root lies with the way motherhood, fatherhood and parenting as a whole are viewed in a society. A general idea of parenting is, to a great extent, determined by the way women view motherhood before they become parents. Before and during pregnancy, parents begin to construct an image of their future child. Depending on how differentiated this image is, a social world of the child is constructed, as are interaction patterns between mother and future child. Consequently, researching these patterns of future mothers' behaviour and attitudes allows one to build a prognosis of how successful a mother will be in general and provides the opportunity to facilitate the establishment of a more concrete relationship between mother and child through pregnancy and after birth.

It is not a secret that family is the first factor that affects a person's development; children perceive culture through their parents. Parents are primary bearers of societal norms and rules (Spivakovskaya, 2000). "Spousal families are in most cases similar to parental families; parental family specifics are unwittingly adapted by children in their own families". The prevailing forms that family relationships

have taken in previous generations may serve as an example for future generations (Chernikov, 2001).

Many psychological approaches such as psychology of personality, child psychology, and pedagogical psychology focus on the study of motherhood.

As V.A. Ramih points out, since very early times human society has actively intervened in the sphere of motherhood, resorting to such regulators as customs, morality and law. This intervention applies to all three periods of maternity: pregnancy, childbirth and the postpartum period. Society always needs labour and a kind of successor. However, such sociocultural factors as concern for future generations, primary socialization, and social experience also play a significant role [5,104].

Due to the numerous cultural and individual approaches to motherhood as well as the complexity of its structure, formation and development, any investigation of motherhood should be integrative.

Currently there is a trend to engage in the complex and interdisciplinary study of motherhood, which results in collective monographs. The most famous of them are: "Different Faces Of Motherhood" (Birns, Hay, 1988), and "The Development of Attachment and Affiliative Systems" (Emde, Harmon, 1982).

Modern, complex research has revealed the necessity of creating an integrative approach to studying motherhood. The relevance of the integrative approach also reflects the following fact: the problems of motherhood and early childhood have not decreased despite the high level of scientific and technical support that exists for mothers and all the modern achievements in the field of medicine, physiology and gynaecology.

In psychological literature (mostly published outside Russia), much attention is paid to the biological basis of motherhood and to the conditions and factors that affect its individual development. In Russian psychology, a number of works have recently appeared that are concerned with the phenomenology, psychophysiology and psychology of motherhood, deviant motherhood, as well as the psychothera-peutic and psycho-pedagogical aspects of pregnancy and early stages of motherhood.

G.G. Filippova (2002) gave the following classification of investigations concerning the phenomenon of motherhood:

1. Motherhood as a providing conditions for child development.

2. Motherhood as part of a woman's personality.

If one assumes that motherhood provides the conditions for child development, we can note the following guidelines:

• The culture-historical aspect of motherhood

• The biological aspect of motherhood (study of physiological aspects of motherhood, comparative-psychological investigations)

• psychological aspects of motherhood

At present, there are three main schools of thought regarding motherhood. The first school reflects complex research that attempts to examine the characteristics of the mother that influence the child's development. Different factors are considered — personal characteristics, life story, level of adjustment to marriage, and

level of satisfaction with the relationship between the future mother and her own mother.

This approach allows for the collation of interesting empirical data regarding the influence of different factors that affect a child's development and his or her relationship with his or her mother. At the same time, data collected using this approach is often contradictory. The same factors that negatively affect a child's relationship in one family turn out to be acceptable in others. This is explained by the lack of a basic theoretical model of family relationships that would emphasise fundamental factors that influence parental attitudes towards children and their relationship.

In some ways this flaw is overcome by the representatives of the second school of thought. It has a definitively dyadic nature. This approach views a mother and child as part of one unified dyadic system. Only upon entering the system do they gain the status of 'mother' and 'child' and develop correspondingly within it.

The results of research have significantly improved our understanding of the unity of mother and child and the need to view them as a whole. However, this approach skims over how this unity is achieved, which is an important factor when reaching said unity.

Answers to these questions can be found within the culture-historical (cultural narrative) approach where a child is seen as a representative of the human race (L. S. Vigotskiy, N. N. Avdeeva, T. I. Baranovskaya, M. I. Lisina, S. Y. Mescheryakova, E. I. Isenina, E. V. Popcova, E. O. Smirnova), and the child's relationship with adults is a separate research object. A mother's behaviour is seen as the source of her child's development. Hence, the child's evolution as a subject of cognitive activity, interaction and apperception mandates that the mother possess certain characteristics. These characteristics allow her to create the necessary conditions for the child's development. Among these characteristics, the most important roles are given to the attitude towards the child as an independent entity, the encouragement of cognitive activities, and the support of interaction initiatives and so on. These and many other characteristics are derived from the woman's idea of motherhood.

R. V. Ovcharova's model of determining attitudes towards motherhood is the most suitable. It is closely linked to the culture-historical approach and views motherhood as a unified phenomenon. It takes into account the personal qualities of the mother, her own family's influence, and the influence society exerts on ideas about parenting. According to Ovcharova, the following must be noted when examining women's attitudes towards motherhood:

1. The macro-level, representing the general level of society's development, which determines the influence of societal factors on what constitutes an ideal parent;

2. The micro-level, representing the level of a family's development, which determines the influence of familial factors on what motherhood is;

3. The personal level, representing individual factors that determine attitudes towards motherhood (Ovcharova, 2003).

Below we shall consider in more detail each of the determined levels, the degree of their influence on the formation of ideas regarding motherhood and the reciprocal influence of the factors:

Macro-level. A. I. Antonov (1973) considered the influence of social impact on the reproductive behaviour of an individual not only as the social regulation of the birth rate but also as social management — "a system of targeted influence by state authorities on the reproductive motives of a family, an economical and moral incentive to increase the birth rate as a feature of demographical policy" (Antonov, 1973, p. 75).

However, as it was pointed out at the beginning of this work, the motivational factor employed by the state only results in quantitative changes (for instance, a birth rate increase) rather than substantive changes (value of the child, educational settings, value of maternity).

But in society there is also an informal influence, reflected in the system of values and environment of an individual. Such influences include the religious beliefs of a majority of the population in the community, mass media, and works of art and culture. It is this informal influence which is reflected on the substantive side of perceptions of parenthood in general and motherhood in particular.

V. V. Boiko points out that the influence of society on motivating the need for children provides for the orientation of an individual with respect to the feelings and pedagogical settings of the new generation.

A. I. Antonov (1973) mentions the context for reproduction that is imposed by society. The pressure of this social context can be quite intense because it can be very important (within the system of criteria) for the mother's subjective happiness and social prestige. The instructive and evaluative aspects of the society's reproductive standards, accompanied by the relevant emotional tone, represent the "appropriate behavioural model of millions of individuals and families" (Antonov, 1973, p. 80). According to the author, these reproductive standards are not realized by an individual more often than other standards.

The works of E. I. Isenina and Y. I. Baranovskaya (1999), aimed at studies of the influence of socio-economic characteristics on the mother's qualities, should also be mentioned. These studies revealed the high significance of effect of the social functionality of the family on the mother's qualities, with the husband's social functionality being the most significant. The authors came to the conclusion that the social circumstances influence the development of the mother's psychological characteristics, as they result from social conditions at present and in the past.

Society gives individuals an example of motherhood, which gives rise to the development of a sense of motherhood in each individual case; this is affected by a woman's personality, her value and motivation system, and the experience she received living with her own parents in a family setting.

Micro-level. The nuclear family is the primary social environment of an individual, the environment of socialization.

A child's family environment, relations with his or her family, system of values and parental setting are the first factors to affect the development of the child's personality.

Children adopt the norms of community life in a society and perceive culture thorough their parents. It is within the family that an individual gets his or her first social experience and adopts rules and norms of behaviour. The nuclear family is the most readily available context where the establishment of role models is observed. Parents, as a rule, are significant people for an individual; for this reason

they partly consciously and partly unconsciously internalize parenting methods and subsequently copy them when raising their own family: "...what parents we have become to a significant extent depends on what we saw, experienced and perceived in the behaviour of our own parents" (Spivakovskaya, 2000)

"A direct correlation can be observed between the structures of one's parents' family and the family one creates with his spouse — 'spousal' families are in a vast majority of cases similar to 'parental' ones, the characteristics of one's parental family are unconsciously perceived by the children in their families" (T. I. Dymnova, 1998, p.47).

The study of the influence of the micro-level (the level of the mother's family) on the formation of maternal behaviour (mainly, deviant behaviour) was performed by V. I. Brutman, A. Y. Varga, and I. U. Hamitova (2000). Their works are devoted to the study of the malfunctioning of mechanisms for the creation of maternal behavior that can be connected with the dynamics of the family of the future expectant mother (i.e. her relationship with her parents). The results of clinical observations have revealed that the reasons for deviant maternity stem from the dramatic relationship between a woman exhibiting deviant behaviour and her mother. According to the authors, the existing malfunctioning is the consequence of the impossibility of her identifying with the role of the mother (due to maternal deprivation) at the level of psychological gender as well as at the level of her developing her maternal role. Therefore, it's concluded that identifying with one's mother and further emotional separation (on that basis) are two prerequisites for developing normal maternal behaviour.

The study of mother-daughter relations is further considered as a separate direction from the point of view of their influence on the success of the daughter as a mother. Works dedicated to this topic emphasize the influence of a substantive part of the mother-daughter emotional relationship on the daughter's own maternal role. Among the important factors are: the mother's support at the stage of early ontogenesis, continuity of attention of the mother to the daughter's emotional problems in adolescence, responding adequately to the daughter's psychological problems relating to her pregnancy and subsequent role as mother, as well as the dynamics of unconscious complexes in mother-daughter relations.

All of the diversified studies that have been presented on the influence of a woman's parents and family on the maturity of her conception of motherhood are brought together in the works of I. S. Kon (2000). He sets out his opinion of the influence of the micro-level on motherhood in the following manner: "The continuity of generations is always selective: some knowledge, standards and values are adopted and transferred to subsequent generations, while others which are not consistent with the circumstances that have changed are denied or transformed. The continuity is not similar in different fields of activity. In the field of consumer orientation and certain other settings, the difference between the senior and junior member as a rule is greater than in relation to principal social values..." (Kon, 2000).

Personal level. As mentioned above, society and the nuclear family only provide a specific model of parenthood, which is influenced by beliefs, opinions and individual characteristics.

It is important to note that while all the factors emphasized by Ovcharova are significant, they are not equal. In this vein, familial ideas about ideal parenting, etc., and the similar individual propensities the mother has are directly linked to societal factors. Like L. S. Vigotskiy, we are tempted to view the macro-level more as the influence of culture, rather than societal factors, onto communal, familial and individual ideas on motherhood.

Knowledge about the factors influencing the content of attitudes will allow us to distinguish risk groups, carry out diagnostics and appropriate correction, and to apply preventive measures to those women who are in at-risk groups. The latter is extremely important in modern society because of the relevance of the problems of women who end up having abortions or abandoning or abusing their children and the problems connected with the distortions of child-parent relationships. These problems cause emotional trouble and deviations from the optimal development of the child.

We attempted to prove that culture plays a primary role in forming attitudes towards motherhood by examining these attitudes in women with different religious affiliations. We postulated that belonging to a certain religion is tantamount to belonging to a certain culture. Sixty women aged 18 to 22 took part in the research. They were divided into three sample groups — Christians, Muslims, and Buddhists.

The Muslim group was composed of women who were born and reside in Kazan, Tatarstan, who identify as Muslims and belong to the KulShareef Mosque congregation. The Buddhist group was composed of women residing in Elista, Kalmi-kiya who identified themselves as Buddhists. The Christian group was composed of women residing in Podmoskovie who belong to the All Saints Church of Beloo-zerskoe and identify themselves as Christians.

Based on the results obtained through different methods of research, we attempted to identify the three levels Ovcharova discovered.

The macro-level (societal level) was researched with the help of questionnaires (socio-demographic characteristics). The micro-level (family level) was researched with the help of the "Prologue" technique (Borovikova, 1998). The individual level (personality level) was researched with the help of a free association technique, where women were instructed to complete the sentence "Motherhood is.. ". To examine the degree to which favourable/unfavourable ideas affected motherhood, a drawing test, "Me and my future child" (Filippova, 2002), and a composition on the topic of "Ideal motherhood" were used.

The free association method was used to study the substance of the ideas of motherhood, and we also considered acceptance/denial of the public level (macro-level) at the individual level.

The most obvious difference between the public understanding of motherhood and the personal understanding of it was detected in the "Christianity" sample (a large number of poorly-differentiated definitions with a wide range of ranks), these differences are less pronounced in the "Buddhism" and "Islam" samples: individual perceptions had a greater frequency of coincidence with public perception.

Thus, we can speak about the acceptance or denial of a society at the individual level.

A high level of acceptance of once's perception of society regarding positive and negative motherhood was obtained from the "Islam" and "Buddhism" samples. In the sample "Christianity", social norms are accepted to a lesser extent.

Additional results we perceived allowed us to detect qualifying differences among the sample groups on the subjects of the image of the child, the image of mother and the parent-child relationship. Moreover, sample groups differed in their attitudes towards future motherhood.

Favourable and unfavourable ideas of motherhood were analysed through content analysis work. We have emphasised substantial items of analysis, by which we mean the group members' perceptions of motherhood were estimated. To these items we assigned: image of mother (absence of perception, negative attitude, neutral attitude, positive attitude), image of child (absence of perception, negative attitude, neutral attitude, positive attitude), the interaction between mother and child, the expansion of the situation by objects and subjects, and the centration of the spousal relationship.

In the micro-level study, and attitude to the unborn child (as a component of ideas of motherhood), emphasis was placed on the following scales: "attitude to the future of child", "attitude to parental family", and "childhood" (the "Prologue" technique). The specifics of the general state of girls were also analysed: well-being, self-doubt, anxiety, signs of proneness to conflict and hostility, etc.)

Results

Our results allowed the detection of the distinguishing characteristics of attitudes towards motherhood in women from different cultures.

• Sample group "Muslims"

As a whole, based on three techniques (the "Ideal motherhood" composition, the "Me and my future child" drawing and "Prologue"), the image of the child is more favourable among the women from the sample group "Muslims". The child is mentioned more often in the composition (as opposed to women from the sample group "Christians") and the mentions are of a positive emotional nature.

"Interaction with child" yielded higher scores as well (joint mother-child activities were researched). The results of the drawing test tend to be more favourable as well. On the individual level, women from this group were more likely to accept the societal level (according to the results of the free association technique "Motherhood is..."). Motives for terminating a pregnancy were vastly different from the other two sample groups. Most women answered that abortion is not acceptable under any circumstances, while a few answered that a threat to the mother's life was the only reason to abort. For the women of this sample group, the value of the life of the future child is very high. These women don't think that "children will stop them from life. Children will be a burden and to have children means to have extra problems. It's far better to live for my own pleasure". The number of children they desired was 2.6, which is higher than in the other sample groups. The ideal age for getting married and having one's first child is slightly lower than in other sample groups.

• Sample group "Christians"

Based on the results of the composition "Ideal motherhood", the image of the mother is mentioned much more often, and has a more positive nature than the image of the child. Often the image of the child is missing, or has a neutral emotional nature (in some cases a negative emotional nature). The same goes for interaction with the child. The drawing test revealed states of anxiety and self-doubt. On an individual level, the societal level is not accepted. This is evidenced by a large number of answers during the first stage of the free association technique and discrepancies during the results ranging stage. Based on questionnaire answers, reasons for terminating a pregnancy are as follows: financial situation (housing problem, low income, etc.), marital status (unmarried, husband doesn't want to have children, etc.), personal interests (haven't lived myself yet, don't want to settle down). The number of children desired averaged 1.27. The ideal marriage age and preferred age for giving birth to one's first child are higher than in the other sample groups.

• Sample group "Buddhists"

The sample group "Buddhists" is similar to the sample group "Christians" in terms of its composition. The only difference is that Buddhist women more often expand motherhood to include other people (husband, parents, other relatives, etc). The drawing test revealed a low level of anxiety. On an individual level, the groups social norms are accepted. Based on the answers to the questionnaire, pregnancy may be terminated for a variety of reasons: marital situation (poor relationship with the husband, unmarried, divorced, illegitimate child, etc.), due to the child having a disability, and issues related to woman's health. Most of the women questioned do not view abortion as murder unless it is a late term abortion. The average number of children these women wanted to have averaged 2.16. The group's ideal age for marrying and having one's first child are marginally higher than in the sample group "Muslims".

Thus, based on the results of our research, we can conclusively say that culture determines the specifics of attitudes towards motherhood and that the majorly influences state and family attitudes.

Coincidentally, some similarities were observed in all three sample groups. The image of the mother in all three groups yielded level numbers (composition "Ideal motherhood": Christians — average of 2 points, Muslims — average of 2.1 points, Buddhists — average of 1.8 points).

All three sample groups showed a correlation between the attitude towards the parental family and the attitude towards one's future child (as seen in the "Prologue" technique). There are differences between the attitude towards the parental family and the attitude towards the future child in the sample groups, but the scale of influence at the familial level on the attitude towards motherhood is similar. This correlation may point to the interdependence of the societal and familial levels: in different cultures, the micro-level (familial level) is be different. In this respect, Ovcharova's three-tiered model is more complex: there is an inter-determination between the components.

An analysis of similarities and differences between the sample groups allows us to examine the components of attitudes towards motherhood that affect major

influences on the future relationship between mother and child. The creation of the image of the child is a more important component in terms of its differentiation and emotional value. Comparable results were reached by other researchers (O. A. Kopil, O. V. Bazhenova, 1994). They examined the personal characteristics of the mother and discovered the importance of the image of the child for a future relationship with the mother.

Our research allows us to pinpoint the important characteristics of attitudes towards motherhood: the image of child, the mother and the parent-child relationship: their existence and emotional attitudes towards them as well as the types of attitudes to future maternity that can majorly influence the mother-child relationship. The most important role is allotted to the macro-level that deals with the culture in which a woman lives. An important factor is her personal acceptance of cultural and familial ideals.

Ovcharova's levels of attitudes towards motherhood do exist. However, they do not exist in a vacuum but instead determine each other. As was stated above, the most significant level is the macro-level. At the same time it can be accepted or not accepted by a woman. In other words, the individual level can either be a complete derivative of the macro- or micro-level, or there can be a conflict. These interdependence peculiarities of different levels greatly influence the attitude towards motherhood. If there is a conflict between the individual and macro-level, a negative view of motherhood appears; if the mother accepts the macro-level at the individual level, a more favourable view of motherhood appears.

This statement allows us to look at this contradictory situation in science, which is connected with the problem of determination of female reproductive behaviour in a different way: it's important to take into account not only the individual activity of the woman but also the influence society has on the formation of attitudes toward motherhood.

Conclusion

The results of the research made it possible to identify women who are more and less likely to have a favourable future relationship with a child.

Women with a favourable attitude towards motherhood tend to have a full-fledged and differentiated image of the mother, her child, and their mother-child relationship. They are all of a positive emotional nature. The image of the child is central. Women construct the image of present and future, and motherhood occupies a leading position in their system of values. There is no conflict between the individual and societal levels. These women imagine themselves as "surrounded by children and giving them love". The number of children desired is two or more. They are prepared to adopt or foster-parent and/or volunteer for children's charities. Their physical, emotional and psychological capabilities allow them to do it. They have a negative view of abortion and see no reason for it or would only endorse it if the mother's safety and health were in danger.

Women with a fair attitude towards motherhood tend to include images of mother and child, but they are of a neutral or faintly positive emotional nature. There is no negative emotional connotation in this group. The mother-child relationship is missing or not differentiated. As well as in the previous group, in this

group there is no conflict between individual and societal levels. They desire two children. Women from this group point out that they have limitations in the sphere of motherhood. Abortion is not embraced, but the circle of acceptable reasons is larger. Reasons such as one's marital situation, a malformed or disabled fetus, and woman's heath occupy the leading positions in their hierarchy of reasons.

For women with an unfavourable attitude towards motherhood, the image of the child tends to have a negative emotional connotation (connected with difficulties, resentment) or not exist at all. Women do not want to include the child in joint activities, which they find it burdensome and/or unnecessary. Their relationship with a child is not presented. The image of the mother is central. In contrast to other groups of women, there may be a conflict between the individual and societal levels. These women only desire one child. Their motives for abortion are widespread and include physical, economic and psychological aspects. They may abort due to an unsatisfactory financial situation, their marital status, or due to personal interests.

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The highlighted characteristics of women with different attitudes towards motherhood open up possibilities for testing and correcting attitudes that are of a less than favourable nature. This would help pre-emptively improve the relationship between the mother and her future child.

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Original manuscript received January 15, 2013 Revised manuscript accepted June 1, 2014 First published online June 30, 2014

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