The process of preparing for parenthood consists of a series of steps, each of which presents unique challenges and dilemmas. This chapter explores the stages of preparation, beginning with the decision to become a parent, and progressing through choices regarding modes of birth, the impact of new parenthood, and child care issues. Finally, the problems that parenthood presents in several less common circumstances are discussed.

Preparing for parenthood begins with the decision to become pregnant, or the discovery of pregnancy in an unplanned circumstance. Fifty years ago, unreliable or unavailable contraceptive methods resulted in parenthood for couples regardless of readiness. In addition, couples suffering from infertility or repeated miscarriages had few options and generally accepted their inability to become pregnant, ultimately seeking other parenting options, such as adoption. In recent decades, the availability of effective and reliable contraception and sterilization techniques has given many the opportunity to chose the timing of parenthood. Advanced reproductive technologies now enable many couples with infertility problems to achieve a desired pregnancy.

For some couples, the decision to become pregnant is carefully weighed against the impact that pregnancy and birth will have on their careers, lifestyles, financial status, and marital relationship. Others consider the repercussions of pregnancy and parenthood only briefly, or not at all. Despite the availability of effective contraception, the number of unwanted births continues to increase, particularly among less educated, poor, and minority women.¹

Statistical reports of birth and fertility rates reveal interesting childbearing trends. The birth rate for teen-agers has increased at an annual rate of 5% to 7% since 1988.² In contrast, greater numbers of women in their early to mid thirties are childless. Data indicate, however, that nearly two thirds of married childless women plan to have children, which is revealed in the rising first-birth rate among women 35 to 40.³ The pursuit of advanced education, careers and the necessity for two-income families has been largely responsible for the dramatic phenomenon of delayed childbearing. Nearly three fourths of women aged 25 to 44—the age range when most women have small children—are in the work force.⁴ Women who work, be it for personal fulfillment, economic necessity, or higher living standards, are often motivated to have fewer children.⁵ Family size has since decreased significantly, from an average size in 1940 of 3.67 persons, to 2.65 in 1995.^6,7 (Fig. 1.) In the past, this trend had been attributed to declining infant mortality and effective contraceptive methods. However, the current trend toward smaller families is attributable to postponement of childbirth and increasing preferences for no children or very small families. The US Census Bureau projects that the decline in the size of the American family will continue unabated into the next century.⁸

The impact that this delay has had on the family has become increasingly evident in recent years. Several changes in the structure of the American family have emerged: an influx of children into alternative child-care settings, a change in the division of household duties, and an evolution in the roles of parenting for mother and father. Men have become much more involved in the decision-making process in all aspects of family evolution: pregnancy, childbirth and parenting, and child care. Unlike previous generations, prospective parents today are faced with many alternative theories and choices in parenting, beginning with the pregnancy itself.

The choices encountered by women and their partners for their childbirth experience have undergone remarkable changes throughout the twentieth century. Early in this century, midwives conducted most of the births in the United States at home. As the training of physicians began to include obstetrics, use of anesthesia, and other advancing technologies, the place of delivery moved from the home to the hospital. Most births were conducted by physicians rather than midwives by the early 1940s. As medicine became more specialized, obstetricians attended increasing numbers of births, while general practice, family practice physicians and midwife numbers declined. Rising liability costs in the 1970s made obstetric privileges more forbidding. During the past two decades, however, certified nurse-midwives have been attending increasing numbers of births because of rising consumer preferences for natural childbirth alternatives. Today's certified nurse-midwives are registered nurses with advanced obstetric and gynecologic training, typically at the master's degree level, who practice most commonly in a hospital setting in collaboration with a physician. Lay midwives, who learn and attend births through apprenticeship, generally deliver babies in the home. Lay midwives exist throughout the country in rural and urban areas, meeting the needs of women who do not wish to deliver in a hospital or receive its associated interventions. Physicians trained in the specialty of family practice and maternal-child health are emerging as providers of maternity care, having the unique and valuable ability to provide intergenerational continuity of care for mothers, infants, and their families.⁹

Because obstetric care has become more diverse and specialized, women can choose their type of care according to their particular needs and risks. Women can choose an obstetrician, family physician, or nurse-midwife for their prenatal care and delivery. Although they often overlap, the traditional and alternative or “noninterventive” models of health-care delivery emerge as a directive in this choice. The routine or traditional management of the birth process, including the use of technologies such as continuous fetal monitoring, epidural anesthesia, intravenous infusion, and episiotomy, are issues that a woman may consider when choosing her provider. A noninterventive approach that facilitates the natural processes of labor and birth with minimal use of routine interventions or analgesics is preferred by some women. The preparation for pregnancy and parenthood is becoming more consumer-oriented, and women are selecting their provider based on their personal philosophy and desires for their birth experience.

Less than 1% of US births occur at home; the majority of women in the United States choose to give birth in a hospital.¹⁰ Free-standing birth centers have recently become available in some locations as an alternative birth site. The safety of out-of-hospital births (free-standing birth centers or home birth) is an ongoing topic of dispute. Many issues surface, including claim to ultimate responsibility and control of the birth, safety, economics, and the right of a woman to choose her place of birth. Studies evaluating the relative safety of home, birth center, and hospital birth are difficult to analyze due to the difficulty in designing well-controlled, prospective, randomized trials. Existing studies report that the overall intrapartum and neonatal mortality rates in birth centers and planned home births are comparable to that of low-risk hospital births,^11,12,13 asserting that they are a safe alternative to hospital birth. The formal position of the American College of Obstetricians and Gynecologists, however, still recommends the hospital as the safest place to give birth.¹⁴

Childbearing women and their partners are almost universally encouraged to participate in childbirth education classes. Although some women choose not to take advantage of these classes, the benefits that can be derived from them warrant careful consideration. Community-based prenatal classes, Lamaze, Bradley, and other methods differ in their philosophy and techniques. Various other classes are also available, including ones that focus on breastfeeding, cesarean birth, prenatal exercise, newborn care, sibling preparation, child care, and more. The main emphasis of most childbirth preparation classes is upon the birth process per se, and unfortunately little attention is given to infant care skills or the impact a new baby will have on the marriage, careers, lifestyle, and financial state of the new parents. This aspect of preparation for parenthood is largely left to personal experience.

Closely associated with the choices of health-care provider, delivery locale, and childbirth education are the decisions involving the birth experience itself. In hospital birth settings, there is a choice of natural childbirth, narcotic analgesia, or epidural anesthesia for pain management. Some women will devise a “birth plan” to facilitate discussion of alternative positions for labor and birth, use of interventions such as amniotomy, intravenous fluids, episiotomy, and labor stimulation. Further preferences must be considered for the postpartum period: breast or bottle feeding, circumcision, return to work plans, child care providers, and so on. The broad spectrum of choices available to childbearing women in the late 20th century is far different from the traditional paradigm employed only a few decades ago.

The heath-care provider is generally in close communication with a woman throughout her pregnancy and immediate postpartum period. Once the event of birth has occurred, however, new parents are left to rely on intuition, past experiences, child-care books, or telephone help lines. Few classes focus exclusively on teaching parenting strategies, skills, and expectations. Advice is proffered from family, friends, health-care professionals, and complete strangers. This advice is often conflicting and confusing. Parenting approaches used by previous generations are considered by some to be outmoded and even harmful, and the “authorities” may offer contradictory advice. Most schools of thought on parenting imply the following:

1. The child's future success and happiness are dependent on the parents' doing the right thing.
   
2. The parents are to blame if something goes wrong.
   
3. Parents can raise superior adults.¹⁵
   

These theories lack scientific support, and do not consider genetic influences or personality traits. The numerous parenting-education strategies employ differing philosophies about what works. Although there are educational books that describe the application of these strategies in detail, few couples prepare for this aspect of parenthood before the birth of their child, and few new parents have time afterward.

When a baby is born, two important developmental changes occur in a family: (1) the marital relationship of the parents is altered; and (2) the child becomes incorporated into the family.¹⁶ The relationship between marriage stability and parenthood has been largely studied. In 1957, LeMasters¹⁷ was among the first to report a decline in marital satisfaction after the birth of a child. Subsequent longitudinal studies have also suggested a decline in marital satisfaction associated with parenthood.^18,19,20,21

The quality of the marital relationship before parenthood has been demonstrated to have a major influence on attitudes and sensitivity during pregnancy and early parenthood. A longitudinal study by Belsky and colleagues¹⁹ of 72 volunteer couples reported that those who scored high on various measures of marital adjustment and functioning before the birth of the child continued to score high throughout the extended postpartum period. A recent longitudinal study of family development conducted by Lewis¹⁶ attempted to clarify the factors crucial to the psychological growth of couples as they became parents. Thirty-eight couples were interviewed before and after the birth of the first child to evaluate the impact of the birth on psychological health, marital quality, and the transition to parenthood. Couples with higher levels of marital competence or strength prenatally adapted better to the stress of the transition to parenthood. Although the transition to parenthood is recognized as stressful to most if not all couples, certain marital relationships were found by this study to be vulnerable to regression or dysfunction after the birth of a child. For example, relationships that lacked intimacy and commitment were shown to be at risk for greater dissatisfaction and conflict. Parents in dysfunctional marriages were also more apt to show less investment, sensitivity, and warmth in interacting with their child than were parents from competent and stable marriages. Infant gender was also cited as having an influence on parental attitudes. Mothers of boys were warmer and more invested in parenting than mothers of girls. Fathers were also significantly warmer to boys than to girls.

The changes in marital satisfaction and period of adjustment caused by the birth of a child should be of great concern to health-care providers. Generally, it is the ongoing prenatal and postpartum relationship between the patient and the physician, midwife, and/or pediatrician that will reveal marital conflict or family dysfunction precipitated by pregnancy or childbirth. Social support services or family counseling may be necessary in cases of unresolved conflict or crisis in the young family.

The parent-child relationship is central to a child's moral development, social behavior, and ultimate attainment of adult independence. The fact that the mother and father are the most important people in the growing child's life prompts particular concern for the growing number of children in child care outside the family. The care of young children was once considered the responsibility of the family and extended family. In the 19th and early 20th centuries, grandparents played an instrumental role in religious training, education, and child care. However, the migration of families from rural to urban settings and economic changes characterized by an expanding white collar work force resulted in a shift to functional support systems outside the family and a diminished role for grandparents.²²

Most discussions about parenting and child care are intimately linked with the mother. Traditionally, the mother was considered the childrearer and the father the breadwinner. The women's movement, however, brought about a social change in the family roles of men and women, resulting in more shared childrearing. This change has not been without conflict, as women feel pressure both to stay at home to care for their children and to return to work. Employed mothers feel guilt and doubt about their child-care competence, whereas women who stay at home report a loss of social or professional standing.²³ Women have become divided over employment status, choosing sides for what is viewed as best for the children. In response to this societal change, the demand for quality child care has become a major issue in government policy, the women's rights movement, and employee benefit negotiations. The increasing number of dual-provider households has generated a flurry of research designed to evaluate the expected negative impact of supplementary day care on a child's development. Research indicates, however, that day care has little effect on a child's intellectual development, emotional attachment, or social relationships.^24,25,26 It appears that children who are enrolled in day care are similar developmentally to those reared by their parents at home. Compromise is sought by some women; those who work part-time seem to experience the least role conflict and guilt. There is no easy solution: major attitudinal change by those who determine government and employee policy is needed in order to support the children of working mothers.

The involvement of fathers in parenting has changed dramatically in recent years. Part of this is due to an increase in the number of working mothers, necessitating a more active and shared role in parenting responsibilities by the father. The removal of obstacles to paternal participation in pregnancy, birth, and parenting has also contributed to increased involvement. Fathers are attending childbirth classes, providing support during labor and birth, and learning basic infant-care skills to prepare for their new role. This is not without its drawbacks, however. Father participation has become expected rather than optional, an attitude nearly exclusive to the American middle class.²⁷ Two problems arise:

1. Fathers who choose not to participate are sometimes regarded with suspicion or malice by health-care providers.
   
2. Participation may not be appropriate for all fathers.
   

In fact, there is no strong research evidence to suggest that paternal participation improves father-infant bonding, the marital relationship, or confidence in infant-care skills.²⁷ There is perhaps an association between father participation and these factors; however, self-perception, motivation, and expectations are important confounding variables.

Today's fathers are much more involved in the care and nurturing of their children. This new role has contributed to the stress of the transition to parenthood, as the father is viewed as financier, stabilizer, companion, and caretaker. Attending parenting classes has not been shown to assist this adjustment substantially.^28,29 Learning how to be an effective parent is a challenging task discovered mostly through trial and error. Health-care providers must acknowledge the pressure that is placed on today's fathers to perform efficiently in various roles. Further, this recognition must be coupled with understanding, compassion, and support for their transition into parenthood.

Single-parent families are becoming more commonplace. The number of babies born to unmarried women rose 46% between 1980 and 1991.³⁰ The factors responsible for this increase cannot be precisely determined, although it is known that a growing number of unmarried women of childbearing age are postponing marriage, and an increasing number of marriages are ending in divorce. It is estimated that one of every five families with children less than 18 years of age are headed by a single parent. Mothers continue to be the children's primary caretaker, with more than 80% of single-parent families maintained by the mother.³¹ These families are characterized by a high rate of poverty and minority representation, low educational levels, and high mobility. The economic and social needs of this group are enormous. Single-parent families can be divided into three types: (1) single parenting as a result of divorce or death; (2) unplanned single parenting; and (3) “elective” single parenting.

Divorce

The country's divorce rate has quadrupled since 1970. It is estimated that nearly half of all American children will experience the breakup of their parents' marriage before the age of 18 years, and nearly one third of children will live in a single-parent home (Fig. 2).³¹ For divorcing families, there has been little change in custody arrangements over the past 15 years, despite expert predictions to the contrary. The effect of divorce on parents and children will vary for different members of the family and generally involves an extended adjustment period. Many of the parenting responsibilities previously shared as a couple will fall upon the custodial parent. The stresses and difficulties in coping that are experienced by families in which the parents are divorced can lead to disturbances in personal and social adjustment.³² This fact is countered, however, by the knowledge that divorce may be a positive solution to destructive family functioning. Effective social support systems must be identified and developed that will help the family adjust to the parental changes associated with divorce.

Unplanned Parenting

The number of unplanned pregnancies continues to escalate despite the availability of effective contraceptive methods. Reasons for this phenomenon have been proposed by various theories, including the intrapsychic conflict theory, which postulates unconscious desires to manifest fertility; and theories of complex contraceptive risk-taking behavior. Adolescent pregnancy is a matter of great public concern, as there has been a sizable increase in birth rate among young teen-agers in recent years. Parenthood at an early age not only affects the educational and social prospects for the adolescent mother, but the child may be more likely to have developmental and health problems.³³ Research results have found that adolescent parents have high levels of stress, inadequate social support, poor knowledge of child development, and inappropriate child-rearing attitudes.³⁴ Most teen-age mothers live at home with a parent or parents, the majority keeping their babies. The ability of an adolescent to parent in a manner that promotes optimal child development is controversial. Research on adolescent pregnancy is conflicting; however, there is evidence suggesting that the parental behavior of adolescents differs from that of older mothers in maternal competency,³⁵ physical and verbal interaction, and sensitivity.³⁴

Elective Single Parenting

Elective single parenting has become more acceptable and popular in the past decade. Women who choose to become a parent without the involvement of a partner typically come from two groups: those who have become discouraged with or jaded toward men in general; and those whose advancing age necessitates their becoming pregnant while they are still biologically able. For some physicians this represents an ethical dilemma: their personal attitudes regarding the upholding of a traditional family structure interfere with their willingness to make modern reproductive options, such as artificial insemination, available to these women. Some physicians are concerned about the financial stability of elective single mothers and the lack of male role models for their children, believing that these factors may stunt the child's social and cognitive development. Many centers of reproductive medicine require a psychological profile to evaluate factors underlying the desire for elective single parenting. During the psychological interview, emotional readiness and financial status is explored. It is known that sex roles are learned from many sources, and fatherless children generally do not suffer gender identity confusion. In addition, recent studies indicate that children raised by their mothers alone show cognitive abilities similar to children of two-parent families.³⁶ Despite this information, some physicians will deny artificial insemination to single women. Whether they have a legal or ethical right to do so remains to be determined.

Changes in attitudes among lesbian women and gay men during the past few decades have allowed many to consider the possibility of parenthood. Although some consider adoption, there is an increasing number of lesbian women seeking artificial insemination and gay men seeking women to carry their child. Several concerns have been addressed regarding adoption and artificial insemination, respectively:

1. The biased view of lesbian women and gay men that focuses on their sexuality instead of their personal capabilities may falsely lead some to believe that homosexual persons cannot be good parents, or that their children will not have appropriate sexual role models.³⁷ Research indicates, however, that the sexual orientation of the parent seems to have no effect on the child's sexual preferences.^37,38 In addition, gay and lesbian parents have been shown to provide effective parenting for their children with no more frequent gender confusion or psychiatric problems than children of heterosexual parents.³⁹ These new, nontraditional family forms are resisted by those concerned about the ongoing erosion of the family.
   
2. Although artificial insemination can minimize legal custody battles that must be fought by adoptive lesbian parents, the difficulty of finding a known donor or using a sperm bank must be resolved.⁴⁰
   

Many institutions require psychological screening prior to acceptance into a donor insemination program. Gay men must find a woman willing to be inseminated and carry the pregnancy for them. There are further legal, ethical, and health issues, all of which must be considered carefully by lesbian women and gay men who wish to become parents. Health-care professionals must have an understanding of these issues and be attentive to their personal attitudes about this type of nontraditional parenting.

It is a common misconception that women who are disabled cannot adequately care for children. The stereotypes of helplessness, passivity, and lack of intelligence that are often encountered by the physically challenged has lessened slightly with a recent increase in public awareness.⁴¹ Efforts have been made to provide public access for those who are blind or confined to a wheelchair, and technological advances have provided the opportunity for many women to function independently at work and at home. Women who are disabled must consider the same financial and emotional factors of parenthood as nondisabled women that will impact their lives. Furthermore, they must find health-care providers who will support their desire to become a parent. In order for parenthood to be a realistic option for these women, adjustments in living arrangements may be necessary depending on the limitations of their disability, and a greater range of supportive services is often required. Thus, the financial cost of parenthood may be greater, the preparatory effort more involved, and the physical requirements more challenging among these women than among women without disabilities. Once these issues are considered, the option of parenthood for women with physical challenges will become even more feasible.

Many societal changes have had an impact on parenthood in the United States. Women are postponing childbearing and having fewer children. Subsequently, an increasing proportion of couples will have impaired fertility as a result of advancing age. Conditions affecting a woman's ability to conceive and bear children may be more difficult to treat as she becomes older.

More mothers than ever are in the work force, and consequently more children are in alternative child-care settings. This is not likely to change, as two incomes are becoming increasingly necessary to meet household costs of living. The impact of increasing numbers of working mothers is far-reaching. Alternative child-care settings will increase in number, thus increasing the concern over their quality, size, and accessibility. Government representatives and employers must recognize the need for major changes in policy to assist working mothers and their children. There is a wide spectrum of choices available to women preparing for childbirth: birth attendant, birth setting, childbirth education classes, and various procedures and medications proffered during the birth itself. The trend for consumer involvement and control is likely to continue as women become more knowledgeable about their own health care. To meet the needs of childbearing women, prudent health-care providers and hospitals will keep abreast of consumer requests for birthing alternatives.

Single-parent families are more commonplace today because of high divorce rates, unplanned parenting, and elective single parenting. Nontraditional parenting arrangements chosen by single professional women and homosexual couples are occurring more frequently, challenging societal norms and changing definitions of parenthood and family.

1. Mosher WD, Bachrach CA: Understanding U.S. fertility: Continuity and change in the National Survey of Family Growth, 1988-1995. Fam Plann Perspect 28: 4, 1996

2. Ventura SJ, Martin JA, Taffel SM: Advance report of final birth and fertility statistics, 1992. Monthly vital statistics report 43(5). Hyattsville, MD, National Center for Health Statistics, 1994

3. US Bureau of the Census: Fertility of American women: June 1990. Current population reports, series P-20, no. 454. Washington, US Department of Commerce, 1991

4. Women in the labor force: Statistical bulletin. Metropolitan Insurance Companies 75:3, 1994

5. Changing profile of birth in the United States: Statistical bulletin. Metropolitan Insurance Companies 67:20, 1986

6. US Bureau of the Census: Historical Statistics of the United States, Colonial Times to 1970, Bicentennial ed. Millwood, NY, Kraus, 1989

7. US Bureau of the Census: Statistical Abstract of the United States: 1996, 116th ed. Washington, DC, US Bureau of the Census, 1996

8. US Bureau of the Census: Projections of the number of households and families: 1986 to 2000. Current Population Reports Series 986:25, 1986

9. Larimore WL: Family centered birthing: A style of obstetrics for family physicians. Am Fam Phys 48: 725, 1993

10. US Bureau of the Census: Statistical Abstract of the United States: 1996, 116th ed. Washington, DC, US Bureau of the Census, 1996

11. Rooks JP, Weatherby NL, Ernst EK et al: Outcomes of care in birth centers: The national birth center study. N Engl J Med 3211: 1804, 1989

12. Anderson RE, Murphy PA: Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery 40: 483, 1995

13. Declercq ER: Where babies are born and who attends their births: Findings from the revised 1989 United States Standard Certificate of Live Birth. Obstet Gynecol 81: 997, 1993

14. American College of Obstetrics and Gynecology and the American Academy of Pediatrics: Guidelines for Perinatal Care, 4th ed., 1997

15. Heins M, Seiden AM: Parenting and the pediatrician. Am J Dis Child 141: 1188, 1987

16. Lewis JM: The Birth of the Family: An Empirical Inquiry. New York, Brunner/Mazel, 1989

17. LeMasters EE: Parenthood as a crisis. Marriage Fam Liv 19: 352, 1957

18. Grossman FK, Eichler LS, Winickoff SA et al: Pregnancy, Birth, and Parenthood. San Francisco, Jossey-Bass, 1980

19. Belsky J, Spainer GB, Rovine M: Stability and change in marriage across the transition to parenthood. J Marriage Fam 45: 567, 1983

20. Cowan CP, Cowan PA, Heming G et al: Transitions to parenthood: His, hers, and theirs. J Fam Iss 6: 451, 1985

21. Feldman SS, Nash SC: The transition from expectancy to parenthood: Impact of the firstborn on men and women. Sex Roles 11: 84, 1984

22. Campbell V, Bubolz M: Parenting by related adults. In Kostelnik MJ, Rabin AI, Phenice LA, Soderman AK (eds): Child Nurturance, Vol 2, Patterns of Supplementary Parenting. New York, Plenum Press, 1982

23. McCartney K, Phillips D: Motherhood and child care. In Birns B, Hay DF (eds): The Different Faces of Motherhood. New York, Plenum Press, 1988

24. Peters DL, Belsky J: Day care: Past, present, and future. In Kostelnik MJ, Rabin AI, Phenice LA, Soderman AK (eds): Child Nurturance, Vol 2, Patterns of Supplementary Parenting. New York, Plenum Press, 1982

25. Belsky J, Steinberg LD, Walker A: The ecology of day care. In Lamb ME (ed): Nontraditional Families: Parenting and Child Development. Hillsdale, NJ, Erlbaum, 1982

26. Gottfried AE, Gottfried AW: Maternal Employment and Children's Development: Longitudinal Research. New York, Plenum Press, 1988

27. May KA: Father participation in birth: Fact and fiction. J Calif Perinat Assoc 2: 41, 1982

28. Wandersman LP: The adjustment of fathers to their first baby: The roles of parenting groups and marital relationship. Birth Fam J 7: 155, 1980

29. MacLaughlin SM, Taubenheim AM: A comparison of prepared and unprepared first-time fathers' needs during the childbirth experience. J Nurse Midwifery 28: 9, 1983

30. Ventura SJ: Births to unmarried mothers: United States, 1980-92. In Vital and Health Statistics: Data on Natality, Marriage and Divorce, Series 21, Vol 53, p 1, 1995

31. US Bureau of the Census: Statistical abstract of the United States: 1996, 116th ed. Washington, DC, US Bureau of the Census, 1996

32. Heatherington EM, Cox M, Cox R: Effects of divorce on parents and children. In Lamb ME (ed): Nontraditional Families: Parenting and Child Development. Hillsdale, NJ, Erlbaum, 1982

33. Jemail JA, Nathanson M: Adolescent single parent families. In Hansen JC (ed): Clinical Issues in Single-Parent Households. Rockville, MD, Aspen Publications, 1987

34. Elster AB, McAnarney ER, Lamb ME: Parental behavior of adolescent mothers. Pediatrics 71: 494, 1983

35. Mercer RT, Hackley KC, Bostrom A: Adolescent motherhood: Comparison of outcome with older mothers. J Adolesc Health Care 5: 7, 1984

36. Cashion BG: Female-headed families: Effects on children and clinical implications. J Marital Fam Ther 8: 77, 1982

37. Tasker F, Golombok S: Adults raised as children in lesbian families. Am J Orthopsychiatry 65: 203, 1995

38. Gold MA, Perrin EC, Futterman D, Friedman SB: Children of gay or lesbian parents. Pediatr Rev 15: 354, 1994

39. McCandlish BM: Against all odds: Lesbian mother family dynamics. In Bozett FW (ed): Gay and Lesbian Parents. New York, Plenum Press, 1988

40. Leiblum SR, Palmer MG, Spector IP: Non-traditional mothers: Single heterosexual/lesbian women and lesbian couples electing motherhood via donor insemination. J Psychosom Obstet Gynecol 16: 11, 1995

41. Baskin BH, Riggs EP: Mothers who are disabled. In Birns B, Hay DF (eds): The Different Faces of Motherhood. New York, Plenum Press, 1988