Aspects of the normal psychology of pregnancy: The midtrimester ROSALYN

L.

MEL

L.

Detmit,

Michigan

PH.D.

BARCLAY,

BARCLAY,

M.D.

In this study nonpegnant women were compared with pregnant women. A set of feelings and attitudes along with questions relevant to the anatomy and physiology of parturition were the measures of comparison. The pregnant women and the nonpregnant women had almost identical feelings and attitudes. There were, however, three exceptions to this general concordance. They were : (1) the nonpregnant women’s regard of pregnancy as a depressive and withdrawing experience, (2) a greater fear for tb fetus among the nonpregnant women, and (3) higher scores on a pregnancy information inventory among the pregnant women.

PREPARTIJM education has recently become a major focus of interest in both public and private patient care settings. Most of these educational efforts have had a twofold purpose. On one hand, they provide factual information; on the other, they enable pregnant women to share common anxieties, fears, and experiences. These educational programs generally proceed on the assumption that (1) pregnancy and the anticipation of childbirth produce a high level of psychological stress in the mother and that (2) misinformation potentiates this stress. A number of papers have appeared in the medical and psychological literature describing the psychological stresses of pregnancy.‘, 2 A major difficulty in interpreting such studies, however, is that the assessment of psychological disturbance is made in isolation, without reference to normative data. The purpose of this study was to examine, in a normative way, the attitudes, anxieties, and factual knowledge of primigravid women and to compare these measures with those of nulligravid women. Additionally, the relationship between standard measures of anxiety and level of factual knowledge was assessed. From the Department of Obstetrics and Gynecology, Hos;bital of Detroit and Wayne State University. Recrived

for publication

Revised

May

Accepted May Reprint

Nov.

Sinai

5, 1974.

9, 1975. 28, 1975.

requests: Mel L. Barclay, M.D., Department Obstetrics and Gynecology, Wayne County General Hospital, Eloise, Michigan 48132.

of

Materials and methods Subjects. The study group consisted of 44 primigravidas between 22 and 28 weeks’ gestation and 28 nulligravid college students. The pregnant women were respondents to advertisements placed in local obstetricians’ offices, the local University newspaper, and the Red Cross meeting room at Sinai Hospital, Michigan. Second-trimester women were Detroit, selected for the study because of their availability and certainty of pregnancy. These patients had some prenatal medical attention but participated in the current study prior to formal prenatal education as required by the study design. The nulligravid women were students in an introductory-level psychology course at Wayne State University, Detroit, Michigan, and participated in this study as part of their course requirement. Both groups had nearly identical mean levels of education, 14.0 years for the pregnant group and 14.8 years for the nonpregnant group. This difference was not statistically significant (t = 1.97, 0.05 < p < 0.10). The mean ages of the primigravidas and students were 24.63 and 20.43 years, respectively. This difference was statistically significant at the 0.0 1 level of probability. All pregnant women were married. Only two of the nulligravid women were married. Measures. Two questionnaires were administered in this study. The first was a 25 item Pregnancy Information Inventory developed by the authors covering general information relevant to pregnancy anatomy and physiology, and testing adherence to obstetric tales.

208

Barclay

Table

and Barclay

I. Content

summary Content

Anatomy

and

and data

tabulation

for pregnancy

item summary

information

Per cent wror

inventory

items

(pregnant)

alld physiology:

Site of conception is uterus Pelvic bones separate in labor Cervix is same as vagina “Breech” means head first Placenta is means of nourishment Labor discomfort due to cervix dilation Braxton-Hicks contractions are preparatory Maternal-fetal anesthesia effects Maternal-fetal anesthesia interaction Fetus’ role is active in labor Nature of uterine contractions Membrane rupture is necessary to begin labor

48.8 47.7 14.0 11.4 9. I 54.5 30.2 48.8 39.5 62.8 35.7 20.9

57.1 47.2 “I.4 42.9 25.0 55.6 14.8 82.1 29.6 75.0 28.6 78.6

0.0

14.3 74.1 32.1 71.5 46.4

Information:

Effects of coitus on pregnancy Protracted labor is common Deliveries are frequently uncomplicated Average duration of labor Rh (-) is dangerous in first pregnancy Danger

58.1 38.6

47.8 29.6

sips:

Bleeding is certain danger in pregnancy Rapid weight gain signals danger Obstetrical

tales

34.1

25.9 44.4

9.1 I

Falls are extremely dangerous to fetus Breast feeding causes maternal weight gain Tight clothing suffocates fetus Induction is more painful labor “Dry” labor is more painful Milk quantity related to breast size

The second questionnaire was composed of several parts and was designed to assess attitudes toward pregnancy, number of physical symptoms, and level of anxiety. The Pregnancy Research Questionnaire (PRQ) was developed by Schaefer and Manheimer3 to measure attitudes toward the pregnancy experience. This instrument has been used by previous investigators.4-R The first 68 items of the PRQ are divided into seven scales: fears for self (e.g., Any pregnant woman dreads delivery), lack of desire for pregnancy (I sometimes wish I were not going to have this baby), dependency (I would like to have my mother or some older woman help me take care of my baby), fears for baby (I have been worried that the baby may be born dead), irritability/tension (I have been hard to get along with since pregnancy), lack of maternal feeling (I would like rooming-in), and depression/withdrawal (I have lost interest in things during pregnancy). The women answered each question on a scale graded from “strongly agree” to “strongly disagree.” High scores reflect more negative attitudes. Forty additional items questioned women about the frequency of certain physical complaints. Responses LO these items are labelled Psychosomatic Anxiety Symptoms.

Per cent reject (pregrtant)

Per crnt

reject (nonpregnant)

81.4

32.1

86.1 75.0

78.6 64.3 75.0

80.9 59.1 95.5

59.3 78.6

Also incorporated into the questionnaire used in this study were three scales assessing attitudes toward the maternal role,* a short form of the Taylor Manifest Anxiety Scale (MA), and the 15 item Lie Scale of the Minnesota Multiphasic Personality Inventory (MMPI). The Taylor Manifest Anxiety Scale assesses general anxiety level. The Lie Scale items were included as a measure of the validity of the responses to the total questionnaire. Several of the attitude items were altered slightly to make them meaningful to the nonpregnant women. Item content remained the same.

Results Analysis of responses to the Pregnancy Information Inventory indicated that pregnant women made fewel errors (5.86, S.E.M. = 2 0.43) than the nulligravid women (8.89, S.E.M. & 0.47). This difference was statistically significant (t = 4.53, p < 0.001). Question content and per cent incorrect responses for each group are presented in Table I. *These scales were developed by Schaefer and Bell’ for the Parental Attitudes Research Inventory (PARI) assessing: Irritability with Children, Marital Conflict and Rejection of the Homemaking Role.

Volume Number

125 2

Table

II. Mean

Aspects of normal psychology of pregnancy

scores on pregnancy

research

questionnaire

and pregnancy

information

Pregnant Scale

Fear for self Lack of desire for pregnancy Dependency Fear for baby Irritability/tension Lack of maternal feeling Depression/withdrawal PAR1 irritability Marital conflict Rejection of homemaking role Psychosomatic anxiety Lie Manifest anxiety Information errors Rejection obstetric tales

Mean

score

22.45140 12.73132 26.89140 22.57140 23.07140 23.34141 19.59/40 12.61/20 14.64/20 13.14/20 74.021145 3.77115 6.30120 5.86/19 4.7316

The largest number of errors related to the anatomy and physiology of reproduction. Nearly 50 per cent of pregnant women believed that fertilization occurred in the uterus and that during labor the pelvic bones separated. Sixty-eight per cent believed that the fetus plays an active role in the process of labor. Pregnant women rejected more of the obstetric tales than nonpregnant women (see Table I). This difference was statistically significant at the p < 0.01 level (t = 2.79). Table II presents mean scores on the second major inventory according to attitude measured. Fig. 1 demonstrates these data in profile. Mean scores on the Lie Scale were 3.77 and 3.57 for pregnant and nonpregnant groups, respectively. These scores are middle-range scores for this test, indicating that the women responded without undue defensiveness.s The expressed attitudes of pregnant and nonpregnant women were strikingly similar. Significant differences between the two groups occur on only two of the 13 attitude scales: fears for baby and depression/ withdrawal. The nulligravidas expressed greater fear for the unborn fetus and anticipated greater depression when pregnant than was actually experienced by the pregnant sample. The women generally desired pregnancy but did express negative feelings about required changes in life roles (e.g., elevation in rejection of the homemaking role). They expressed concerns about themselves in labor but reported greater fear for the unborn fetus. Physical complaints generally regarded as psychosomatic in origin were virtually identical in both groups. Nulligravid women expressed a somewhat greater general manifest anxiety level (MA); however, the difference between the two groups was not statistically

209

inventory Nonpregnant

% 56.13 39.78 67.23 56.43 57.68 56.93 48.98 63.05 73.02 65.70 51.05 25.13 31.50 30.84 78.83

Mean

score

21.39140 10.68132 26.04140 25.21/40 23.75140 22.21141 22.07140 11.82/20 14.96120 12.54120 73.18/145 3.57115 8.07120 8.89119 3.8616

% 53.48 33.38 65.10 63.03 59.38 54.17 55.18 59.10 74.80 62.70 50.4; 23.80 40.35 46.78 64.28

p < 0.05

p < 0.01

P < 0.001 P < 0.01

significant at the p < 0.05 level (0.05 < p < 0.10). The correlations between anxiety measures, MA PA, and the Information Inventory score were and 0.05, respectively. These levels of correlation not statistically significant, and therefore suggest random levels of association.

and 0.27 are only

Comment In this study, attitudes and psychosomatically related symptoms of midtrimester gravidas were neither negatively nor positively conditioned by the physiologic state of pregnancy. The pregnant women did express fears, concerns, and somatic symptoms, but these were also regularly experienced by the nulligravid sample. The three exceptions to this general pattern of concurrence were: (1) nonpregnant women expressed greater fear for the unborn child, (2) nonpregnant women perceived pregnancy as more depressing than was actually experienced by the pregnant sample, and (3) the primigravidas knew more about pregnancy and rejected more obstetric tales than the nulligravid women prior to formal prenatal education. The similarity of measures in these two groups of women may raise questions as to whether the items used are relevant to the pregnancy experience. The psychiatric literature, g-n however, seems to uniformly identify the attitudes assessed here as central during this period. Other attitudes not measured by this study may also prove important. The educational similarity of the women supports the validity of intergroup comparisons. The disparity of mean ages, however, may introduce bias which was uncontrolled in this study. The generally congruent measures in pregnant and control groups further question the assumption upon

210

Barclay

and Barclay

FS

LDl%

Dep

FB

In Tn

LMFg

DW

PA irr

MC

RHR

PA

Lie

MA

Inf Err

RJDB TJkS

Fig. 1. Per cent scores on individual test scales for pregnant and nonpregnant women. KS, Fear for seff; LD Pg, lack of desire for pregnancy; FB, fear for baby; Irr Tn, irritability/tension; LM Fg, lack of maternal feeling; DW, depression/withdrawal; PA irr, irritability; MC, maternal conflict; RHR, rejection of homemaking role; PA, psychosomatic anxiety; MA, manifest anxiety: Inf Err, information errors; RjOB T&s, rejection of obstetric tales.

which many prenatal education programs are based, that is, that pregnancy and the anticipation of childbirth produce high levels of psychological stress. Rather it would seem that a modal constellation of attitudes and concerns exists prior to pregnancy and is not significantly altered by that state when assessed in the second trimester. Goldzieher and associatesr2 have clearly demonstrated the importance of control data in the identification of normal patterns of behavior. The concept of a normative baseline is pointedly illustrated in this study by the responses to one item from the Psychosomatic Anxiety Symptom scale. This item asked women whether they felt that they were going to have a nervous breakdown. Twenty-four per cent of this pregnant sample gave positive responses. Heinstein? using the same questionnaire, reported that 32 per cent of his gravid sample expressed this fear. These proportions seem alarming until one notes that 57 per cent of the nonpregnant sample in the current study expressed the identical concern. The data reported here also question whether a lack

REFERENCES 1. Bibring, processes 1959.

G.: Some considerations in pregnancy, Psychoanal.

of the psychological Study Child. 14: 113,

of information about pregnancy contributes to the gravida’s anxiety. No significant correlation was found between amount of information and level of general anxiety. This may mean that prenatal anxiety is unrelated to knowledge about the physiology and anatomy of reproduction or may reflect on the validity of the measures used. The Manifest Anxiety Scale, however, is a widely used instrument and has been well standardized as a measure of general anxiety. The Information Inventory has not been used previously and did not include questions specific to the experiential events of labor and delivery. These parts of the birth experience may be an important source of prenatal concern, and may require further investigation. Perhaps the use of instruments similar to those used here, on a larger scale and in other periods of gestation, will provide those involved in prenatal care with better, more systematic insights into the needs of primigravidas and the normative aspects of the prenatal experience.

2. Wilson, A. R.: An investigation into the psychological aspects of pregnancy and the puerperium, J. Psychosom. Res. 12: 73, 1968. 3. Schaefer. E. S., and Manheimer, H.: Paper read at

Volume Number

125 2

Eastern Psychological Association, New York, April 1, 1960. Clifford, E.: Expressed attitudes in pregnancy of unwed women and married primigravida and multigravida, Child Dev. 33: 945, 1962. Heinstein, M.: Expressed attitudes and feelings of pregnant women and their relations to physical complications of pregnancy, Merrill-Palmer Q. 13: 2 17, 1967. Doty, B.: Relationships among attitudes in pregnancy and other maternal characteristics, J. Genet. Psychol. 111: 203, 1967. Schaefer, E. S., and Bell, R. Q.: Development of a parental attitude research instrument, Child Dev. 29: 339. 1958.

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8. Dahlstrom, W. G., Welsh, G. S., and Dahlstrom, L. E.: An MMPI Handbook, Minneapolis, 1972, University of Minnesota Press. 9. Klein, H. R., and Dyk, R. B.: Anxiety in pregnancy and childbirth, New York, 1950, Hoeber. 10. McDonald, R.: The role of emotional factors in obstetric complications: A review, Psychosom. Med. 30: 222, 1968. 11. Davids, A., DeVault, S., and Talmadge, M.: Psychological study of emotional factors in pregnancy: a preliminary report, Psychosom. Med. 23: 93, 1961. 12. Goldzieher, J. W., Moses, L., Averkin, E., et al.: A placebo-controlled double-blind crossover investigation of the side effects attributed to oral contraceptives, Fertil. Steril. 22: 609, 1971.

Aspects of the normal psychology of pregnancy: the midtrimester.

In this study of nonpregnant women were compared with pregnant women. A set of feelings and attitudes along with questions relevant to the anatomy and...
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