Sexual & Reproductive Healthcare 4 (2013) 133–138
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Maternal development experiences of women hospitalized to prevent preterm birth Regina P. Lederman a,⇑, Ellen Boyd b,1, Kathleen Pitts c,2, Cynthia Roberts-Gray d,3, Maria Hutchinson e,4, Sean Blackwell f,5 a University of Texas Medical Branch, School of Nursing and Department of Preventive Medicine and Community Health, Division of Sociomedical Sciences, 301 University Blvd., Galveston, TX 77555-1029, USA b School of Nursing, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-1029, USA c Instructor, Immunology, Allergy & Rheumatology Department, Baylor College of Medicine/Texas Children’s Hospital, 1102 Bates, FC 330, Houston, TX 77030, USA d Third Coast Research & Development Inc, 2728 Ave Q, Galveston, TX 77550, USA e Larry C. Gilstrap MD Center for Perinatal and Women’s Health Research, UT Health Medical School at Houston, 6431 Fannin St., MSB Ste. 3.266, Houston, TX 77030, USA f Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Medical School at Houston, 6431 Fannin St., MSB Ste. 3.286, Houston, TX 77030, USA
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Article history: Received 14 December 2011 Revised 30 September 2013 Accepted 7 October 2013
Keywords: High-risk pregnancy Antepartum bed rest Psychosocial adaptation Maternal development Prenatal or Pregnancy Anxiety
a b s t r a c t Objective: To examine ways that women’s experience of hospitalization with bed rest to prevent preterm birth impacts prenatal maternal development. Method: Interviews based on the Interview Schedules for Dimensions of Maternal Development in Psychosocial Adaptation to Pregnancy were conducted at a hospital in the southwestern United States with a convenience sample of 41 women during confinement to bed rest to prevent preterm birth. The interviews were recorded, and verbatim transcripts were submitted to thematic analysis. Results: Five themes were mapped from the women’s narratives: (1) acceptance of pregnancy, but with fears specific to elevated risks to self and baby; (2) heightened identification with motherhood and fatherhood protector roles; (3) renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy; (4) enhanced couple support and collaboration; and (5) acceptance of responsibility to perform in remaining pregnant and preparing for labor, but willingness to accept help from doctors and nurses. Conclusions: This study of hospitalization to prevent preterm birth showed that women experience hospitalization as a burden to be endured to meet future goals, but that it also can facilitate prenatal maternal development in psychosocial adaptation to high risk pregnancy. Implications for research and practice are discussed. Ó 2013 Elsevier B.V. All rights reserved.
Introduction Preterm birth (PTB) is the leading cause of death of babies in the first four weeks of life and the second leading cause of death in children under five years. Across 184 countries for which data are available, PTB rates range from 5% to 18%: in poorer countries the average is 12% of babies born too soon compared to 9% in ⇑ Corresponding author. Tel.: +1 409 772 6570, +1 713 666 0172; fax: +1 409 772 3770. E-mail addresses: [email protected] (R.P. Lederman), [email protected] (E. Boyd), [email protected] (K. Pitts), [email protected] (C. RobertsGray), [email protected] (M. Hutchinson), [email protected] (S. Blackwell). 1 Tel.: +1 409 772 8261; fax: +1 409 772 3770. 2 Tel.: +1 832 824 1319; fax: +1 832 825 1260. 3 Tel.: +1 409 771 8926. 4 Tel.: +1 713 500 5850; fax: +01 713 500 0510. 5 Tel.: +1 713 500 6415; fax: +1 713 500 7860. 1877-5756/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.srhc.2013.10.004
higher income countries [1]. The United States stands out as a high income country with a PTB rate consistently in excess of 9%, peaking at 12.80% in 2006 and trending down since then to 11.73% in 2011 [2]. A national agenda outlined in 2008 for reducing the PTB rate in the United States called for research to better understand the occurrence of preterm birth and a national education program to help women reduce their chances of giving birth prematurely [3]. Subsequent analyses of rises and reductions of PTB rates in the United States suggest half the change is unexplained, a result that highlights an urgent need for research into the underlying mechanisms of preterm births and development of innovative interventions [4]. PTB has multiple etiologies, among them numerous psychological, social, and behavioral factors [5,6]. Women with pregnancyspecific stresses, severe life events, and high anxiety are more likely to experience adverse maternal and fetal outcomes than pregnant women with low levels of stress and anxiety [7–9]. Be-
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yond reported threats to neurobehavioral development, fetal exposure to maternal stress and anxiety can adversely affect the child’s health and well-being throughout the life course [10–12]. The mainstay of treatment to prevent PTB in the United States is antepartum bed rest (ABR) or activity restriction [13], a treatment which may exacerbate rather than relieve anxiety and stress of the mother-to-be [14–16]. Prescribed for as many as one million women in the United States each year for periods ranging from a few days to months, ABR is defined as confinement to bed and restriction of activity [13]. Pregnant women hospitalized with bed rest report anxiety about financial difficulties, adverse emotional and child care concerns related to children at home, and fear for their own outcomes and that of their baby [17–18]. Primary sources of maternal stress during hospitalization to prevent PTB include separation from and concern for the family at home, negative emotions, self-image, and health status [19]. Although women’s negative experiences of ABR are well documented, less is known about the impact of pregnant women’s experience of complications treated with bed rest [13]. To examine ways in which hospitalization with ABR to prevent PTB impacts maternal development during pregnancy, the current study used an interview approach guided by the Dimensions of Maternal Development model of psychosocial adaptation to pregnancy. This research- and theory-based model of maternal development links prenatal stress and anxiety to complications of pregnancy and childbirth, PTB, and infant birth weight [20]. The first of the seven developmental dimensions explicated in this model is the woman’s acceptance of pregnancy and its assimilation into her way of life. The next two dimensions are complementary: identification with a motherhood role and the renewal or deepening of the mother-daughter relationship. A good motherdaughter relationship helps build a solid foundation for the pregnant daughter’s identification of her own motherhood role and is associated with less fear and anxiety in pregnancy and childbirth. The fourth dimension is that of role adjustments in the relationship with the husband/partner as the couple adapts to the woman’s pregnancy and to the husband’s/partner’s identification with a fatherhood role. The fifth dimension is preparation for labor, learning to cope with mounting anxiety and feelings of uncertainty about the journey by seeking knowledge and working to develop positive anticipation. The culminating dimensions are coping with concerns for well-being of self and baby and acceptance of a degree of personal responsibility for the course of events in labor and delivery as a woman listens to her body and is actively working with it to perform as well as she can on her own, and yet willing to accept help when she needs it. The qualitative and quantitative cross-sectional and longitudinal studies in which the theory-based maternal dimensions model of maternal development is grounded were conducted with populations of pregnant women with no medical or obstetrical complications at the time they entered the studies [21,22]. The current study is a step toward extending the model to better understand the impact of the experience of hospitalization to prevent PTB on women’s maternal development during pregnancy. The interview questions also requested feedback from the women about the maternal dimensions interview as an intervention [20], pp. 299– 302.
Methods This study used a qualitative research interview approach [23,24] to elicit, analyze, and describe the subjective meanings and interpretations of experiences of women with severe complications of pregnancy that resulted in hospitalization to prevent PTB.
Sample and setting Interviews were conducted with a convenience sample of pregnant women confined to bed rest in an academic tertiary medical care center. Located in a large city in the southwestern United States, the medical center averages 4,500 deliveries annually. The Antepartum Care Unit where the women were interviewed had a 20-bed capacity and average daily census of 12 patients with a large proportion transferred to the medical center from outlying hospitals. Interview questions A semi-structured interview guide was comprised of 35 openended questions adapted from two sources. The first source was a review of the research literature [5,16–17,25] focused on women’s concerns about high-risk pregnancy and hospitalization to prevent PTB. The eight questions from this source included such queries as ‘‘Can you tell me what you know about why you were hospitalized at this time?’’ and ‘‘What has this experience of hospitalization been like for you? For your family?’’ The second source was the interview schedules associated with the maternal dimensions model [20], pp. 299–302. The 27 questions adapted from this source included three about acceptance of pregnancy (e.g., ‘‘Can you say to what extent this pregnancy was planned? Initially wanted?’’ and ‘‘How does this compare to your feelings now?’’); three were about identification with a motherhood role (e.g., ‘‘What do you think about most often when you think about the baby or yourself as a mother to the baby?’’); ten asked about the pregnant woman’s relationship with her mother and with her husband/partner (e.g., ‘‘In what ways do you want to be like your mother? In what ways different? Has your relationship to your mother changed since you’ve been pregnant?’’ ‘‘Are there any differences in your relationship to your husband/partner with this pregnancy? If so, how? Do you feel he understands you? Who do you turn to for support?’’); six asked about preparation for labor, fear of pain or helplessness or loss of control in labor, or concern for well-being of self and baby in labor (e.g., ‘‘What are your concerns about pregnancy and childbirth? What will you do if this happens? How would you handle this? How would you feel?’’ and ‘‘Do you feel the doctors and nurses caring for you understand you now...your physical needs and feelings?’’); and five provided broad opportunity for the women to set the direction of the interview (e.g., ‘‘Please feel free to tell me any concerns that are uppermost in your mind–whatever comes to mind.’’). The interview guide was designed as a resource to encourage the women to tell their own story of their experience. There was no expectation that all questions would be asked of all participants. The interview concluded with a request for feedback about the interview itself. Procedures In order to interview sufficient numbers of women to reach data saturation and redundancy [26], research associates made multiple visits to the hospital across a period of nine months. Women were approached no sooner than 24 h after their admission to the Antepartum Care Unit to obtain their signed, informed consent to participate in the interview. When a woman enrolled in the study, the research associate notified the principal investigator (first author, RL) who then made arrangements as soon as possible thereafter to visit the hospital to conduct the interview. With the permission of the woman, each interview was tape recorded and subsequently transcribed verbatim. Interviews lasted 30–90 min and averaged 40–50 min. Written field notes were retained by the interviewer.
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The protocol was approved by the University Hospital Institutional Review Board. Data analysis Three members of the research team participated in thematic analysis of the interview transcripts. The research team analyzed the narratives using Colaizzi’s methods as a guide [27,28]. The steps in this process were: (1) reading and then re-reading each participant’s interview transcript to obtain a general sense of the content; (2) for each transcript, extracting significant statements; (3) formulating meanings from the statements; (4) organizing meanings into themes, theme clusters, and theme categories; (5) integrating the participants’ feelings/perceptions of each theme category, and (6) creating a thematic map to describe maternal development in psychosocial adaptation to high-risk pregnancy. The seventh step in Colaizzi’s method for qualitative analysis is validation of the findings by asking the research participants to compare the researchers’ descriptive results with their experiences. This step was not possible in the current study due to inability to track participants after they were discharged from the hospital. The concluding step in the current study was providing the codebooks and field notes to an expert qualitative researcher whose review was confirmatory of the team’s results. Data collection and analysis were iterative with data collection terminated when agreement was reached within the team regarding data saturation and redundancy. Redundancy was confirmed when the repetition of key statements within the transcripts became evident. Saturation was achieved when no new themes were found in the analyses. Results Participant characteristics A total of 41 pregnant women hospitalized to prevent PTB participated in a single session individual interview during their confinement to hospital bed rest. The women ranged in age from 18 to 43 years (M, SD = 28.17 ± 7.5). Field notes indicated the group had diverse ethnicity with approximately half African American and the remainder closely divided between Caucasian and HispanicAmerican. The majority (n = 26) reported having had some college or having obtained a college degree, but the remaining third had high school education or less. A few (n = 5) of the women were disconnected from the baby’s father (e.g., ‘‘he’s out of the picture’’), but the large majority had a husband (n = 22) or were living with a partner (n = 14). A few (n = 2) of the women’s husbands/partners were in the military and deployed. For approximately one-quarter of the women (n = 10) the pregnancy was their first, but the large majority had one or more other children. Reasons for hospitalization The interviewer’s field notes and the women’s narratives (e.g., ‘‘my water broke’’) indicated a variety of reasons and time frames in which the women were hospitalized and confined to bed rest to prevent PTB. Reasons included preterm rupture of membranes, preterm onset of labor contractions, vaginal bleeding, early onset preeclampsia, cervical insufficiency, diabetes, and gestational hypertension. These circumstances suggested substantial variability in the amount of time confined to bed rest and in the babies’ gestational age at the time their mothers were interviewed. Nearly one-third (n = 13) of the women had experienced a prior PTB. Several of the women reported challenging or traumatic events prior to hospitalization, e.g., having a serious argument or altercation
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with a partner or family member, illness or loss of a close family member, job stress, financial stress, and physical stress such as repeatedly going up and down stairs. Field notes from follow-up with the hospital showed nearly two-thirds (n = 27) of the women subsequently delivered preterm and had low birth weight infants (less than 2500 grams).
Psychosocial adaptation to high-risk pregnancy Five themes were identified across the women’s narratives. Exemplars of significant statements from the narratives are presented in Table 1 organized as a thematic map of maternal development in psychosocial adaptation to high-risk pregnancy. Theme one was acceptance of pregnancy, but with fears specific to elevated risks for self and baby. Women indicated they wanted the pregnancy and the newborn infant and wanted ‘‘to be a good mother.’’ However, they also expressed fears about ‘‘losing the baby or something really being wrong,’’; wondering ‘‘is he going to be sick. . .is he going to be okay?’’; not wanting ‘‘nothing to go wrong anymore [because]. . .I would miss my baby...miss him a lot’’; and feeling ‘‘sad thinking [about maybe] having to see my baby with all those tubes in her. . .’cause I know she’s going to be real tiny.’’ They also reported fears about elevated risks to their own health, including ‘‘if I have a C-section I can have a hemorrhage’’ and concerns about being discharged but uncertain about symptoms for which to be alert. And they grieved for the loss of a normal pregnancy saying ‘‘it’s just not the way [pregnancy] is supposed to be’’; and ‘‘I was expecting to come and have my baby and leave in 2–3 days, not so many days in bed’’; ‘‘I just want it to be like how it used to be’’; and ‘‘it’s been normal up until this point...I was just thrown for a loop when my water broke.’’ Theme two was heightened identification with motherhood/ fatherhood protector roles. The women indicated they were ‘‘willing to cope with everything the doctors want me to do for the health of my baby,’’ would ‘‘do anything as long as my baby is healthy,’’ and understood that ‘‘bed rest is just what happens for the baby’s sake.’’ They indicated they were ‘‘trying to keep the baby in as long as possible’’; ‘‘I want [the baby] to be more protected. . .’cause he is a premie’’; and we’re working to make it ‘‘to a point where [the baby] can eat and feed, breathe, and go home with me.’’ Women reported their husbands/partners were exhibiting protective behaviors, ‘‘trying to get all the ducks in a row for our daughter,’’ working increased hours on the job to help ease the family financial burden, and ‘‘doing more around the house’’ including laundry, cleaning, and caring for other children at home. There was acknowledgement that ‘‘his adjustment I would guess is as hard as mine.’’ Theme three was renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy. The women’s narratives about their own mothers showed ‘‘the experience of me being in the hospital has actually helped me get a little bit closer to my mom’’; and the desire ‘‘to be as strong as my mom emotionally...especially now [with] the bed resting’’; and that being hospitalized has allowed the pregnant woman ‘‘to be the daughter again and [the mom] is also now kind of my friend as mom.’’ They said that ‘‘since I’ve been in the hospital [my mother] has stepped up to the plate. . .helping us out a lot’’; and that ‘‘[my mom] treats me more like an adult now instead of her little baby girl.’’ Some of the mothers of the expectant women had traveled considerable distances, even across continents, to support their daughters. A few of the women indicated they were estranged from their own mother or that ‘‘she stresses me out,’’ but even these women would sometimes add ‘‘she tries to help the best way she can’’ or that closeness has developed with another family member including ‘‘my granny [who] is one loving lady [and] will do everything for
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Theme 1. Acceptance of pregnancy, but with fears specific to elevated risks to self and baby ‘‘I am afraid of losing the baby or something really being wrong. . .It’s just not the way [pregnancy] is supposed to be.’’ ‘‘Since [I’m] in the hospital I just worry about is he going to be sick? ...is he going to be okay?. . . how am i going to deliver?. . . like all those kind of ‘in the moment’ questions as opposed to big grand plans.’’ ‘‘...if I have a C-section I can have a hemorrhage. . .they might have to take my uterus.. . .So it’s kind of hard to just have that in your mind.’’ Theme 2. Heightened identification of motherhood/fatherhood protector roles ‘‘I am willing to cope with everything that the doctors want me to do for the health of my baby.’’ ‘‘I want [my baby] to be more protected. . .’cause he is a premie.’’ ‘‘[My husband] is trying to get all the ducks in a row for our daughter, making sure his work,. . .his wife, are all taken care of. . .his adjustment I would guess is as hard as mine.’’ Theme 3. Renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy ‘‘I think the experience of me being in the hospital has actually helped me get a little bit closer to my mom. She’s been there for me. . .In the past it was not the case.’’ ‘‘I want to be as strong as my mom emotionally. . .we share her experiences about when she [was] pregnant. Especially now, the bed resting, she came here thousands of miles away to look after me and I do appreciate that.’’ ‘‘I guess we bonded on a womanly mother’s level as opposed to just mother–daughter. . ..She took care of me. . .I guess I’ve gotten to be the daughter again and she is also now kind of my friend as mom.’’ Theme 4. Heightened couple support and collaboration in staying pregnant and preparing for labor ‘‘When he found out that I was in the hospital. . .it took him nine hours to get here. He said. . .It’s okay, it’s okay. [He went home] and the doctors came and momma told him I was flustered. . . .He turned around and came right back.’’ ‘‘[His concerns] are the same as mine...that the baby is healthy and safe, and my well being,. . .and financial [concerns].’’ ‘‘No intercourse. . .we’ve come to an understanding. . .not trying to do anything to jeopardize the baby or my health. . .make sure we’re still loving and affection is there, hold hands, hugging. . .We understand.’’ Theme 5. Acceptance of responsibility to perform, yet willing to accept help from doctors and nurses ‘‘I try not to get up too much. . .I want to do whatever I can.’’ ‘‘The doctors give me information that I can understand, and it helps me feel better to know what is going on, for me and my baby.’’ ‘‘[They] explained everything. . .and why they’re doing it, and what to expect and what to look forward to. . .so I am not in the dark about anything.’’
Table 1 Thematic map of psychosocial adaptation to high-risk pregnancy and hospitalization
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me,’’ or ‘‘[my husband’s/partner’s] mom is up here . . .every other day. . .always doing stuff for me.’’ Theme four was heightened couple support and collaboration in remaining pregnant and preparing for labor. The women said they felt ‘‘closer’’ to their husbands/partners and that ‘‘the pregnancy brought us together more,’’ and showed a side of him ‘‘I hadn’t seen before.’’ ‘‘When he found out that I was in the hospital he traveled for nine hours to get here.’’ The women reported their husbands’/partners’ concerns were ‘‘the same as mine,’’ and even those few whose husbands were in the military and deployed elsewhere in the world said they could be counted on ‘‘emotionally and mentally.’’ Most of the women indicated they wanted their husbands/partners in the delivery room with them and believed their presence would help the laboring woman achieve and maintain composure. They said, ‘‘he calms me down’’ and ‘‘he brings me back to reality’’ and ‘‘he’ll help in labor. . .with breathing and keeping me calm, just being here, supportive by being here.’’ Support and collaboration was reported by the women in their couple relationships in statements such as ‘‘no intercourse. . .we’ve come to an understanding...not trying to do anything to jeopardize the baby or my health. . .[but] make sure we’re still loving and affection is there.’’ Theme five was acceptance of responsibility to perform, but with willingness to accept help from doctors and nurses. The women reported their ABR experience as ‘‘miserable and tiring’’ and boring, lonely and frustrating, but they also said ‘‘I try not to get up too much. . .I want to do whatever I can’’ and ‘‘whatever they tell me to do, I do.’’ They described the medical team attending them during their hospitalization as ‘‘understanding’’ and ‘‘knowledgeable.’’ They indicated the help provided would assist them in performing well in retaining the pregnancy and in labor and delivery, saying ‘‘the doctors give me information that I can understand, and it helps me feel better to know what is going on for me and my baby,’’ and ‘‘[they] explained everything . . .and why they’re doing it, and what to expect and what to look forward to. . .so I am not in the dark about anything.’’ They noted that without such information and assistance, they might be less able to perform, e.g., ‘‘my husband is scared of delivery because we didn’t get to go to class.’’ Women’s feedback about the interview as an intervention The women indicated they had enjoyed participating in the interview, and several recommended participation for all mothers. They said participating in the interview was ‘‘helpful, ‘cause you don’t have to keep everything just bottled up inside,’’ and that it was good to ‘‘have someone to share feelings with and get the big picture of what is going on, that it ‘‘helped me...say some things. . .that. . .maybe I needed to talk about. . .like. . .how close me and my husband are and my mom, and how I feel about pregnancy.’’ Discussion Results of this study reinforce other researchers’ descriptions of ABR as a negative experience for women that may exacerbate rather than alleviate pregnancy related stress and anxieties, but the results also showed some ways in which the experience of hospitalization and confinement to bed rest to prevent PTB can facilitate maternal development in psychosocial adaptation to high-risk pregnancy. Consistent with other researchers’ descriptions of pregnant women’s experience of ABR as a burden to be endured to meet future goals [13,15,17], the women in the current study experienced hospitalization as a miserable, tiring, and frustrating effort for the health of the baby. Despite fears specific to elevated risks to self and baby, e.g., being afraid of los-
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ing the baby or worrying the baby is going to be sick or feeling concerned about possible side effects if C-section becomes necessary, they accepted responsibility to do ‘‘whatever I can’’ to remain pregnant and to protect the baby. Heightened identification of a motherhood protector role during hospitalization to prevent PTB was accompanied in the current study by the pregnant women’s reports that hospitalization helped them to get closer to their own mother or, in the absence of their mother, closer to their grandmother or their mother-in-law. The pregnant woman’s relationship with her mother has been shown in other research to be correlated with identification with a motherhood role [20,29]. Consistent with research indicating heightened motherhood and fatherhood roles that are protective of their unborn infants in couples experiencing high risk pregnancies [14], pregnant women in the current study acknowledged the work their husbands/partners were doing to protect the baby. The extent of husbands’/partners’ role and responsibility adjustment described by the women in the current study was appreciably greater than was described in research on maternal development conducted in populations of pregnant women with no medical or obstetrical complications at the time they entered the studies [20], Women in the current study indicated high-risk pregnancy had brought the couple together more. They reported they had reached mutual understanding of the importance of showing love and affection but not doing anything to jeopardize the baby, and provided other indications of heightened couple support and collaboration in retaining the pregnancy and preparing for labor, as well as identifying with motherhood and fatherhood protector roles. These findings are notable because a woman’s dissatisfaction with the relationship with her husband/partner is a strong predictor of maternal prenatal emotional distress [30]. The increased closeness with their husbands/partners reported by the women in the current study may have assisted them in reframing their roles and responsibilities in coping with high risk pregnancy [17]. There are indications in the current results that hospitalization and confinement to bed rest may have positive influences upon maternal development in psychosocial adaptation to high risk pregnancy. This does not, however, constitute an endorsement of ABR as an effective treatment to prevent PTB. For two-thirds of the women who participated in this study’s interviews, the pregnancy outcome was preterm birth and delivery of a low-birth-weight baby. Results of the current study do suggest options, however, for responding to the admonition that investigators and care providers must pay strict attention to the prevention and treatment of adverse side effects of ABR [13]. Women’s voices in the current study were endorsing of conclusions reached by others that a specialized medical team ready to listen to patients and inform them about how to improve their high-risk status may play a crucial role in how parents adjust to high-risk pregnancy [14] and that women hospitalized to prevent PTB want to know that nurses support their efforts to carry their babies to full term [25]. The women in the current study indicated information provided by the medical team caring for them during their hospitalization to prevent PTB would assist them in performing well in remaining pregnant and in labor and delivery. They also said that participating in an interview grounded in the maternal dimensions model of psychosocial adaptation to pregnancy [20] was helpful, giving them the opportunity to talk about their feelings, their closeness with their husband/ partner and with their mother and/or mother-in-law, and getting ‘‘the big picture of what is going on.’’
Conclusions and implications This study showed the usefulness of extending the maternal dimensions model to better understand the impact of women’s
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experience of hospitalization for pregnancy complications on their maternal development. The women’s narratives indicated ABR is experienced as miserable, tiring, and a frustrating effort for the health of the baby. Among the ways hospitalization with ABR was indicated to have had a positive influence upon maternal development were: heightened identification with motherhood protector role; intensification of renewal or deepening of the pregnant woman’s relationship with her own mother or a mother substitute; and enhanced couple support and collaboration in retaining the pregnancy and preparing for labor. The results also reinforced conclusions reached by others that ABR is associated with stress and anxiety specific to elevated risks to self and baby. Implications for practice and for future research include focusing attention on preventing and treating adverse side effects of ABR. Care for high-risk antepartum women should include assisting the expectant mother to maintain family function. The allowance of liberal visitation hours should be considered for husbands/partners, other children, mothers and mothers-in-law and other family members. Incorporating a ‘‘child-friendly’’ family visitation room on the antepartum unit can facilitate interaction of the expectant mother with her significant others. The doctors’ and nurses’ provision of information to the women about what to look forward to so they are ‘‘not in the dark about anything’’ can help women accept responsibility to perform well in remaining pregnant and in labor and delivery. Additional research is needed to investigate the women’s assertion that participating in an interview grounded in the maternal dimensions model of maternal development was helpful, allowing them to talk about their motherhood role and their closeness with husbands/partners and their own mothers. These recommendations should be explored in future research projects to determine their consequences for maternal adaptation to high risk pregnancy, differences in maternal-fetal health outcomes, and mother and infant postpartum adaptation. Acknowledgment This research project was supported in part, by the Larry C. Gilstrap MD Center for Perinatal and Women’s Health Research. References [1] World Health Organization, Preterm birth, Fact sheet No363, [internet]; 2012 November. Available from: http://www.who.int/mediacentre/factssheets/ fs363/en/ [retrieved 8/22/13]. [2] Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Matthews TJ, Births: Final data for 2011. National Vital Statistics Reports, 62(1) US Department of Health and Human Services Jun. 28; 2013. [3] Surgeon General’s Conference Outlines Agenda to Prevent Preterm Birth [internet], 2008 June 19. Available from: [retrieved 8/23/13]. [4] Chang HH, Larson J, Blencowe H, Spong CY, Howson CP, Cairns-Smith S, et al. Preventing preterm birth: analysis of trends and potential reductions with interventions in 39 countries with very high human development index. Lancet 2013;381(9862):223–34. [5] Behrman RE, Butler AS, editors. Preterm birth: causes, consequences, and prevention. Washington, DC: National Academies Press; 2007. [6] Office of the Surgeon General. The Surgeon General’s Conference on the Prevention of Preterm Birth [webcast on the internet]. June 16–17; 2008. Available from: http://videocast.nih.gov/summary.asp?Live=6770 and http:// videocast.nih.gov/summary.asp?Live=6771. [7] Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008;371(9608):261–9. [8] Brown SJ, Yelland JS, Sutherland GA, Baghurst PA, Robinson JS. Stressful life events, social health issues and low birthweight in an Australian populationbased birth cohort: challenges and opportunities in antenatal care. BMC Public Health 2011;11(196):1–12. [9] Class QA, Lichtenstein P, Langstrom N, D’Onofrio BM. Timing of prenatal maternal exposure to severe life events and adverse pregnancy outcomes: a population study of 2.6 million pregnancies. Psychosom Med 2011;73(3):234–41. [10] DiPietro JA, Hilton SC, Hawkins M, Costigan KA, Pressman EK. Maternal stress and affect influence fetal neurobehavioral development. Dev Psychol 2002;38(5):659–68.
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[21] Lederman R. Psychosocial adaptation to pregnancy: seven dimensions of maternal development. 2nd ed. New York: Springer; 1996. [22] Weis K. Maternal identity formation in a military sample: a longitudinal perspective. Unpublished Dissertation, University of North Carolina, Chapel Hill, NC; 2006. [23] Seidman I. Interviewing as qualitative research: a guide for researchers in education and the social sciences. 2nd ed. New York: Teacher’s College Press; 1998. [24] Pope C, Mays N. Qualitative research in health care. 3rd ed. Malden, MA: Blackwell Publishing Ltd.; 2006. [25] Thornburg P. Waiting as experienced by women hospitalized during the antepartum period. MCN Am J Matern Child Nurs 2002;27(4):245–8. [26] Steinar K. Interviews: an introduction to qualitative research interviewing. Thousand Oaks, CA: Sage; 1996. [27] Colaizzi PF. Psychological research as the phenomenologist views it. In: Valle RS, King M, editors. Existential phenomenological alternatives for psychology. New York: Oxford Press; 1978. p. 48–71. [28] Sanders C. Application of Colaizzi’s method: interpretation of an auditable decision trail by a novice researcher. Contemp Nurse 2003;14(3):292–302. [29] Deutsch FM, Ruble DN, Fleming A, Brooks-Gunn J, Stangor C. Informationseeking and maternal self-definition during the transition to motherhood. J Pers Soc Psychol 1988;55(3):420–31. [30] Rosand GB, Slinning K, Eberhard-Gran M, Roysamb E, Tambs K. Partner relationship satisfaction and maternal emotional distress in early pregnancy. BMC Public Health 2011;161(11):1–12.
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Maternal development experiences of women hospitalized to prevent preterm birth Regina P. Lederman a,⇑, Ellen Boyd b,1, Kathleen Pitts c,2, Cynthia Roberts-Gray d,3, Maria Hutchinson e,4, Sean Blackwell f,5 a University of Texas Medical Branch, School of Nursing and Department of Preventive Medicine and Community Health, Division of Sociomedical Sciences, 301 University Blvd., Galveston, TX 77555-1029, USA b School of Nursing, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-1029, USA c Instructor, Immunology, Allergy & Rheumatology Department, Baylor College of Medicine/Texas Children’s Hospital, 1102 Bates, FC 330, Houston, TX 77030, USA d Third Coast Research & Development Inc, 2728 Ave Q, Galveston, TX 77550, USA e Larry C. Gilstrap MD Center for Perinatal and Women’s Health Research, UT Health Medical School at Houston, 6431 Fannin St., MSB Ste. 3.266, Houston, TX 77030, USA f Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Medical School at Houston, 6431 Fannin St., MSB Ste. 3.286, Houston, TX 77030, USA
a r t i c l e
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Article history: Received 14 December 2011 Revised 30 September 2013 Accepted 7 October 2013
Keywords: High-risk pregnancy Antepartum bed rest Psychosocial adaptation Maternal development Prenatal or Pregnancy Anxiety
a b s t r a c t Objective: To examine ways that women’s experience of hospitalization with bed rest to prevent preterm birth impacts prenatal maternal development. Method: Interviews based on the Interview Schedules for Dimensions of Maternal Development in Psychosocial Adaptation to Pregnancy were conducted at a hospital in the southwestern United States with a convenience sample of 41 women during confinement to bed rest to prevent preterm birth. The interviews were recorded, and verbatim transcripts were submitted to thematic analysis. Results: Five themes were mapped from the women’s narratives: (1) acceptance of pregnancy, but with fears specific to elevated risks to self and baby; (2) heightened identification with motherhood and fatherhood protector roles; (3) renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy; (4) enhanced couple support and collaboration; and (5) acceptance of responsibility to perform in remaining pregnant and preparing for labor, but willingness to accept help from doctors and nurses. Conclusions: This study of hospitalization to prevent preterm birth showed that women experience hospitalization as a burden to be endured to meet future goals, but that it also can facilitate prenatal maternal development in psychosocial adaptation to high risk pregnancy. Implications for research and practice are discussed. Ó 2013 Elsevier B.V. All rights reserved.
Introduction Preterm birth (PTB) is the leading cause of death of babies in the first four weeks of life and the second leading cause of death in children under five years. Across 184 countries for which data are available, PTB rates range from 5% to 18%: in poorer countries the average is 12% of babies born too soon compared to 9% in ⇑ Corresponding author. Tel.: +1 409 772 6570, +1 713 666 0172; fax: +1 409 772 3770. E-mail addresses: [email protected] (R.P. Lederman), [email protected] (E. Boyd), [email protected] (K. Pitts), [email protected] (C. RobertsGray), [email protected] (M. Hutchinson), [email protected] (S. Blackwell). 1 Tel.: +1 409 772 8261; fax: +1 409 772 3770. 2 Tel.: +1 832 824 1319; fax: +1 832 825 1260. 3 Tel.: +1 409 771 8926. 4 Tel.: +1 713 500 5850; fax: +01 713 500 0510. 5 Tel.: +1 713 500 6415; fax: +1 713 500 7860. 1877-5756/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.srhc.2013.10.004
higher income countries [1]. The United States stands out as a high income country with a PTB rate consistently in excess of 9%, peaking at 12.80% in 2006 and trending down since then to 11.73% in 2011 [2]. A national agenda outlined in 2008 for reducing the PTB rate in the United States called for research to better understand the occurrence of preterm birth and a national education program to help women reduce their chances of giving birth prematurely [3]. Subsequent analyses of rises and reductions of PTB rates in the United States suggest half the change is unexplained, a result that highlights an urgent need for research into the underlying mechanisms of preterm births and development of innovative interventions [4]. PTB has multiple etiologies, among them numerous psychological, social, and behavioral factors [5,6]. Women with pregnancyspecific stresses, severe life events, and high anxiety are more likely to experience adverse maternal and fetal outcomes than pregnant women with low levels of stress and anxiety [7–9]. Be-
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yond reported threats to neurobehavioral development, fetal exposure to maternal stress and anxiety can adversely affect the child’s health and well-being throughout the life course [10–12]. The mainstay of treatment to prevent PTB in the United States is antepartum bed rest (ABR) or activity restriction [13], a treatment which may exacerbate rather than relieve anxiety and stress of the mother-to-be [14–16]. Prescribed for as many as one million women in the United States each year for periods ranging from a few days to months, ABR is defined as confinement to bed and restriction of activity [13]. Pregnant women hospitalized with bed rest report anxiety about financial difficulties, adverse emotional and child care concerns related to children at home, and fear for their own outcomes and that of their baby [17–18]. Primary sources of maternal stress during hospitalization to prevent PTB include separation from and concern for the family at home, negative emotions, self-image, and health status [19]. Although women’s negative experiences of ABR are well documented, less is known about the impact of pregnant women’s experience of complications treated with bed rest [13]. To examine ways in which hospitalization with ABR to prevent PTB impacts maternal development during pregnancy, the current study used an interview approach guided by the Dimensions of Maternal Development model of psychosocial adaptation to pregnancy. This research- and theory-based model of maternal development links prenatal stress and anxiety to complications of pregnancy and childbirth, PTB, and infant birth weight [20]. The first of the seven developmental dimensions explicated in this model is the woman’s acceptance of pregnancy and its assimilation into her way of life. The next two dimensions are complementary: identification with a motherhood role and the renewal or deepening of the mother-daughter relationship. A good motherdaughter relationship helps build a solid foundation for the pregnant daughter’s identification of her own motherhood role and is associated with less fear and anxiety in pregnancy and childbirth. The fourth dimension is that of role adjustments in the relationship with the husband/partner as the couple adapts to the woman’s pregnancy and to the husband’s/partner’s identification with a fatherhood role. The fifth dimension is preparation for labor, learning to cope with mounting anxiety and feelings of uncertainty about the journey by seeking knowledge and working to develop positive anticipation. The culminating dimensions are coping with concerns for well-being of self and baby and acceptance of a degree of personal responsibility for the course of events in labor and delivery as a woman listens to her body and is actively working with it to perform as well as she can on her own, and yet willing to accept help when she needs it. The qualitative and quantitative cross-sectional and longitudinal studies in which the theory-based maternal dimensions model of maternal development is grounded were conducted with populations of pregnant women with no medical or obstetrical complications at the time they entered the studies [21,22]. The current study is a step toward extending the model to better understand the impact of the experience of hospitalization to prevent PTB on women’s maternal development during pregnancy. The interview questions also requested feedback from the women about the maternal dimensions interview as an intervention [20], pp. 299– 302.
Methods This study used a qualitative research interview approach [23,24] to elicit, analyze, and describe the subjective meanings and interpretations of experiences of women with severe complications of pregnancy that resulted in hospitalization to prevent PTB.
Sample and setting Interviews were conducted with a convenience sample of pregnant women confined to bed rest in an academic tertiary medical care center. Located in a large city in the southwestern United States, the medical center averages 4,500 deliveries annually. The Antepartum Care Unit where the women were interviewed had a 20-bed capacity and average daily census of 12 patients with a large proportion transferred to the medical center from outlying hospitals. Interview questions A semi-structured interview guide was comprised of 35 openended questions adapted from two sources. The first source was a review of the research literature [5,16–17,25] focused on women’s concerns about high-risk pregnancy and hospitalization to prevent PTB. The eight questions from this source included such queries as ‘‘Can you tell me what you know about why you were hospitalized at this time?’’ and ‘‘What has this experience of hospitalization been like for you? For your family?’’ The second source was the interview schedules associated with the maternal dimensions model [20], pp. 299–302. The 27 questions adapted from this source included three about acceptance of pregnancy (e.g., ‘‘Can you say to what extent this pregnancy was planned? Initially wanted?’’ and ‘‘How does this compare to your feelings now?’’); three were about identification with a motherhood role (e.g., ‘‘What do you think about most often when you think about the baby or yourself as a mother to the baby?’’); ten asked about the pregnant woman’s relationship with her mother and with her husband/partner (e.g., ‘‘In what ways do you want to be like your mother? In what ways different? Has your relationship to your mother changed since you’ve been pregnant?’’ ‘‘Are there any differences in your relationship to your husband/partner with this pregnancy? If so, how? Do you feel he understands you? Who do you turn to for support?’’); six asked about preparation for labor, fear of pain or helplessness or loss of control in labor, or concern for well-being of self and baby in labor (e.g., ‘‘What are your concerns about pregnancy and childbirth? What will you do if this happens? How would you handle this? How would you feel?’’ and ‘‘Do you feel the doctors and nurses caring for you understand you now...your physical needs and feelings?’’); and five provided broad opportunity for the women to set the direction of the interview (e.g., ‘‘Please feel free to tell me any concerns that are uppermost in your mind–whatever comes to mind.’’). The interview guide was designed as a resource to encourage the women to tell their own story of their experience. There was no expectation that all questions would be asked of all participants. The interview concluded with a request for feedback about the interview itself. Procedures In order to interview sufficient numbers of women to reach data saturation and redundancy [26], research associates made multiple visits to the hospital across a period of nine months. Women were approached no sooner than 24 h after their admission to the Antepartum Care Unit to obtain their signed, informed consent to participate in the interview. When a woman enrolled in the study, the research associate notified the principal investigator (first author, RL) who then made arrangements as soon as possible thereafter to visit the hospital to conduct the interview. With the permission of the woman, each interview was tape recorded and subsequently transcribed verbatim. Interviews lasted 30–90 min and averaged 40–50 min. Written field notes were retained by the interviewer.
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The protocol was approved by the University Hospital Institutional Review Board. Data analysis Three members of the research team participated in thematic analysis of the interview transcripts. The research team analyzed the narratives using Colaizzi’s methods as a guide [27,28]. The steps in this process were: (1) reading and then re-reading each participant’s interview transcript to obtain a general sense of the content; (2) for each transcript, extracting significant statements; (3) formulating meanings from the statements; (4) organizing meanings into themes, theme clusters, and theme categories; (5) integrating the participants’ feelings/perceptions of each theme category, and (6) creating a thematic map to describe maternal development in psychosocial adaptation to high-risk pregnancy. The seventh step in Colaizzi’s method for qualitative analysis is validation of the findings by asking the research participants to compare the researchers’ descriptive results with their experiences. This step was not possible in the current study due to inability to track participants after they were discharged from the hospital. The concluding step in the current study was providing the codebooks and field notes to an expert qualitative researcher whose review was confirmatory of the team’s results. Data collection and analysis were iterative with data collection terminated when agreement was reached within the team regarding data saturation and redundancy. Redundancy was confirmed when the repetition of key statements within the transcripts became evident. Saturation was achieved when no new themes were found in the analyses. Results Participant characteristics A total of 41 pregnant women hospitalized to prevent PTB participated in a single session individual interview during their confinement to hospital bed rest. The women ranged in age from 18 to 43 years (M, SD = 28.17 ± 7.5). Field notes indicated the group had diverse ethnicity with approximately half African American and the remainder closely divided between Caucasian and HispanicAmerican. The majority (n = 26) reported having had some college or having obtained a college degree, but the remaining third had high school education or less. A few (n = 5) of the women were disconnected from the baby’s father (e.g., ‘‘he’s out of the picture’’), but the large majority had a husband (n = 22) or were living with a partner (n = 14). A few (n = 2) of the women’s husbands/partners were in the military and deployed. For approximately one-quarter of the women (n = 10) the pregnancy was their first, but the large majority had one or more other children. Reasons for hospitalization The interviewer’s field notes and the women’s narratives (e.g., ‘‘my water broke’’) indicated a variety of reasons and time frames in which the women were hospitalized and confined to bed rest to prevent PTB. Reasons included preterm rupture of membranes, preterm onset of labor contractions, vaginal bleeding, early onset preeclampsia, cervical insufficiency, diabetes, and gestational hypertension. These circumstances suggested substantial variability in the amount of time confined to bed rest and in the babies’ gestational age at the time their mothers were interviewed. Nearly one-third (n = 13) of the women had experienced a prior PTB. Several of the women reported challenging or traumatic events prior to hospitalization, e.g., having a serious argument or altercation
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with a partner or family member, illness or loss of a close family member, job stress, financial stress, and physical stress such as repeatedly going up and down stairs. Field notes from follow-up with the hospital showed nearly two-thirds (n = 27) of the women subsequently delivered preterm and had low birth weight infants (less than 2500 grams).
Psychosocial adaptation to high-risk pregnancy Five themes were identified across the women’s narratives. Exemplars of significant statements from the narratives are presented in Table 1 organized as a thematic map of maternal development in psychosocial adaptation to high-risk pregnancy. Theme one was acceptance of pregnancy, but with fears specific to elevated risks for self and baby. Women indicated they wanted the pregnancy and the newborn infant and wanted ‘‘to be a good mother.’’ However, they also expressed fears about ‘‘losing the baby or something really being wrong,’’; wondering ‘‘is he going to be sick. . .is he going to be okay?’’; not wanting ‘‘nothing to go wrong anymore [because]. . .I would miss my baby...miss him a lot’’; and feeling ‘‘sad thinking [about maybe] having to see my baby with all those tubes in her. . .’cause I know she’s going to be real tiny.’’ They also reported fears about elevated risks to their own health, including ‘‘if I have a C-section I can have a hemorrhage’’ and concerns about being discharged but uncertain about symptoms for which to be alert. And they grieved for the loss of a normal pregnancy saying ‘‘it’s just not the way [pregnancy] is supposed to be’’; and ‘‘I was expecting to come and have my baby and leave in 2–3 days, not so many days in bed’’; ‘‘I just want it to be like how it used to be’’; and ‘‘it’s been normal up until this point...I was just thrown for a loop when my water broke.’’ Theme two was heightened identification with motherhood/ fatherhood protector roles. The women indicated they were ‘‘willing to cope with everything the doctors want me to do for the health of my baby,’’ would ‘‘do anything as long as my baby is healthy,’’ and understood that ‘‘bed rest is just what happens for the baby’s sake.’’ They indicated they were ‘‘trying to keep the baby in as long as possible’’; ‘‘I want [the baby] to be more protected. . .’cause he is a premie’’; and we’re working to make it ‘‘to a point where [the baby] can eat and feed, breathe, and go home with me.’’ Women reported their husbands/partners were exhibiting protective behaviors, ‘‘trying to get all the ducks in a row for our daughter,’’ working increased hours on the job to help ease the family financial burden, and ‘‘doing more around the house’’ including laundry, cleaning, and caring for other children at home. There was acknowledgement that ‘‘his adjustment I would guess is as hard as mine.’’ Theme three was renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy. The women’s narratives about their own mothers showed ‘‘the experience of me being in the hospital has actually helped me get a little bit closer to my mom’’; and the desire ‘‘to be as strong as my mom emotionally...especially now [with] the bed resting’’; and that being hospitalized has allowed the pregnant woman ‘‘to be the daughter again and [the mom] is also now kind of my friend as mom.’’ They said that ‘‘since I’ve been in the hospital [my mother] has stepped up to the plate. . .helping us out a lot’’; and that ‘‘[my mom] treats me more like an adult now instead of her little baby girl.’’ Some of the mothers of the expectant women had traveled considerable distances, even across continents, to support their daughters. A few of the women indicated they were estranged from their own mother or that ‘‘she stresses me out,’’ but even these women would sometimes add ‘‘she tries to help the best way she can’’ or that closeness has developed with another family member including ‘‘my granny [who] is one loving lady [and] will do everything for
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Theme 1. Acceptance of pregnancy, but with fears specific to elevated risks to self and baby ‘‘I am afraid of losing the baby or something really being wrong. . .It’s just not the way [pregnancy] is supposed to be.’’ ‘‘Since [I’m] in the hospital I just worry about is he going to be sick? ...is he going to be okay?. . . how am i going to deliver?. . . like all those kind of ‘in the moment’ questions as opposed to big grand plans.’’ ‘‘...if I have a C-section I can have a hemorrhage. . .they might have to take my uterus.. . .So it’s kind of hard to just have that in your mind.’’ Theme 2. Heightened identification of motherhood/fatherhood protector roles ‘‘I am willing to cope with everything that the doctors want me to do for the health of my baby.’’ ‘‘I want [my baby] to be more protected. . .’cause he is a premie.’’ ‘‘[My husband] is trying to get all the ducks in a row for our daughter, making sure his work,. . .his wife, are all taken care of. . .his adjustment I would guess is as hard as mine.’’ Theme 3. Renewal or deepening of mother-daughter closeness intensified by high-risk pregnancy ‘‘I think the experience of me being in the hospital has actually helped me get a little bit closer to my mom. She’s been there for me. . .In the past it was not the case.’’ ‘‘I want to be as strong as my mom emotionally. . .we share her experiences about when she [was] pregnant. Especially now, the bed resting, she came here thousands of miles away to look after me and I do appreciate that.’’ ‘‘I guess we bonded on a womanly mother’s level as opposed to just mother–daughter. . ..She took care of me. . .I guess I’ve gotten to be the daughter again and she is also now kind of my friend as mom.’’ Theme 4. Heightened couple support and collaboration in staying pregnant and preparing for labor ‘‘When he found out that I was in the hospital. . .it took him nine hours to get here. He said. . .It’s okay, it’s okay. [He went home] and the doctors came and momma told him I was flustered. . . .He turned around and came right back.’’ ‘‘[His concerns] are the same as mine...that the baby is healthy and safe, and my well being,. . .and financial [concerns].’’ ‘‘No intercourse. . .we’ve come to an understanding. . .not trying to do anything to jeopardize the baby or my health. . .make sure we’re still loving and affection is there, hold hands, hugging. . .We understand.’’ Theme 5. Acceptance of responsibility to perform, yet willing to accept help from doctors and nurses ‘‘I try not to get up too much. . .I want to do whatever I can.’’ ‘‘The doctors give me information that I can understand, and it helps me feel better to know what is going on, for me and my baby.’’ ‘‘[They] explained everything. . .and why they’re doing it, and what to expect and what to look forward to. . .so I am not in the dark about anything.’’
Table 1 Thematic map of psychosocial adaptation to high-risk pregnancy and hospitalization
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me,’’ or ‘‘[my husband’s/partner’s] mom is up here . . .every other day. . .always doing stuff for me.’’ Theme four was heightened couple support and collaboration in remaining pregnant and preparing for labor. The women said they felt ‘‘closer’’ to their husbands/partners and that ‘‘the pregnancy brought us together more,’’ and showed a side of him ‘‘I hadn’t seen before.’’ ‘‘When he found out that I was in the hospital he traveled for nine hours to get here.’’ The women reported their husbands’/partners’ concerns were ‘‘the same as mine,’’ and even those few whose husbands were in the military and deployed elsewhere in the world said they could be counted on ‘‘emotionally and mentally.’’ Most of the women indicated they wanted their husbands/partners in the delivery room with them and believed their presence would help the laboring woman achieve and maintain composure. They said, ‘‘he calms me down’’ and ‘‘he brings me back to reality’’ and ‘‘he’ll help in labor. . .with breathing and keeping me calm, just being here, supportive by being here.’’ Support and collaboration was reported by the women in their couple relationships in statements such as ‘‘no intercourse. . .we’ve come to an understanding...not trying to do anything to jeopardize the baby or my health. . .[but] make sure we’re still loving and affection is there.’’ Theme five was acceptance of responsibility to perform, but with willingness to accept help from doctors and nurses. The women reported their ABR experience as ‘‘miserable and tiring’’ and boring, lonely and frustrating, but they also said ‘‘I try not to get up too much. . .I want to do whatever I can’’ and ‘‘whatever they tell me to do, I do.’’ They described the medical team attending them during their hospitalization as ‘‘understanding’’ and ‘‘knowledgeable.’’ They indicated the help provided would assist them in performing well in retaining the pregnancy and in labor and delivery, saying ‘‘the doctors give me information that I can understand, and it helps me feel better to know what is going on for me and my baby,’’ and ‘‘[they] explained everything . . .and why they’re doing it, and what to expect and what to look forward to. . .so I am not in the dark about anything.’’ They noted that without such information and assistance, they might be less able to perform, e.g., ‘‘my husband is scared of delivery because we didn’t get to go to class.’’ Women’s feedback about the interview as an intervention The women indicated they had enjoyed participating in the interview, and several recommended participation for all mothers. They said participating in the interview was ‘‘helpful, ‘cause you don’t have to keep everything just bottled up inside,’’ and that it was good to ‘‘have someone to share feelings with and get the big picture of what is going on, that it ‘‘helped me...say some things. . .that. . .maybe I needed to talk about. . .like. . .how close me and my husband are and my mom, and how I feel about pregnancy.’’ Discussion Results of this study reinforce other researchers’ descriptions of ABR as a negative experience for women that may exacerbate rather than alleviate pregnancy related stress and anxieties, but the results also showed some ways in which the experience of hospitalization and confinement to bed rest to prevent PTB can facilitate maternal development in psychosocial adaptation to high-risk pregnancy. Consistent with other researchers’ descriptions of pregnant women’s experience of ABR as a burden to be endured to meet future goals [13,15,17], the women in the current study experienced hospitalization as a miserable, tiring, and frustrating effort for the health of the baby. Despite fears specific to elevated risks to self and baby, e.g., being afraid of los-
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ing the baby or worrying the baby is going to be sick or feeling concerned about possible side effects if C-section becomes necessary, they accepted responsibility to do ‘‘whatever I can’’ to remain pregnant and to protect the baby. Heightened identification of a motherhood protector role during hospitalization to prevent PTB was accompanied in the current study by the pregnant women’s reports that hospitalization helped them to get closer to their own mother or, in the absence of their mother, closer to their grandmother or their mother-in-law. The pregnant woman’s relationship with her mother has been shown in other research to be correlated with identification with a motherhood role [20,29]. Consistent with research indicating heightened motherhood and fatherhood roles that are protective of their unborn infants in couples experiencing high risk pregnancies [14], pregnant women in the current study acknowledged the work their husbands/partners were doing to protect the baby. The extent of husbands’/partners’ role and responsibility adjustment described by the women in the current study was appreciably greater than was described in research on maternal development conducted in populations of pregnant women with no medical or obstetrical complications at the time they entered the studies [20], Women in the current study indicated high-risk pregnancy had brought the couple together more. They reported they had reached mutual understanding of the importance of showing love and affection but not doing anything to jeopardize the baby, and provided other indications of heightened couple support and collaboration in retaining the pregnancy and preparing for labor, as well as identifying with motherhood and fatherhood protector roles. These findings are notable because a woman’s dissatisfaction with the relationship with her husband/partner is a strong predictor of maternal prenatal emotional distress [30]. The increased closeness with their husbands/partners reported by the women in the current study may have assisted them in reframing their roles and responsibilities in coping with high risk pregnancy [17]. There are indications in the current results that hospitalization and confinement to bed rest may have positive influences upon maternal development in psychosocial adaptation to high risk pregnancy. This does not, however, constitute an endorsement of ABR as an effective treatment to prevent PTB. For two-thirds of the women who participated in this study’s interviews, the pregnancy outcome was preterm birth and delivery of a low-birth-weight baby. Results of the current study do suggest options, however, for responding to the admonition that investigators and care providers must pay strict attention to the prevention and treatment of adverse side effects of ABR [13]. Women’s voices in the current study were endorsing of conclusions reached by others that a specialized medical team ready to listen to patients and inform them about how to improve their high-risk status may play a crucial role in how parents adjust to high-risk pregnancy [14] and that women hospitalized to prevent PTB want to know that nurses support their efforts to carry their babies to full term [25]. The women in the current study indicated information provided by the medical team caring for them during their hospitalization to prevent PTB would assist them in performing well in remaining pregnant and in labor and delivery. They also said that participating in an interview grounded in the maternal dimensions model of psychosocial adaptation to pregnancy [20] was helpful, giving them the opportunity to talk about their feelings, their closeness with their husband/ partner and with their mother and/or mother-in-law, and getting ‘‘the big picture of what is going on.’’
Conclusions and implications This study showed the usefulness of extending the maternal dimensions model to better understand the impact of women’s
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experience of hospitalization for pregnancy complications on their maternal development. The women’s narratives indicated ABR is experienced as miserable, tiring, and a frustrating effort for the health of the baby. Among the ways hospitalization with ABR was indicated to have had a positive influence upon maternal development were: heightened identification with motherhood protector role; intensification of renewal or deepening of the pregnant woman’s relationship with her own mother or a mother substitute; and enhanced couple support and collaboration in retaining the pregnancy and preparing for labor. The results also reinforced conclusions reached by others that ABR is associated with stress and anxiety specific to elevated risks to self and baby. Implications for practice and for future research include focusing attention on preventing and treating adverse side effects of ABR. Care for high-risk antepartum women should include assisting the expectant mother to maintain family function. The allowance of liberal visitation hours should be considered for husbands/partners, other children, mothers and mothers-in-law and other family members. Incorporating a ‘‘child-friendly’’ family visitation room on the antepartum unit can facilitate interaction of the expectant mother with her significant others. The doctors’ and nurses’ provision of information to the women about what to look forward to so they are ‘‘not in the dark about anything’’ can help women accept responsibility to perform well in remaining pregnant and in labor and delivery. Additional research is needed to investigate the women’s assertion that participating in an interview grounded in the maternal dimensions model of maternal development was helpful, allowing them to talk about their motherhood role and their closeness with husbands/partners and their own mothers. These recommendations should be explored in future research projects to determine their consequences for maternal adaptation to high risk pregnancy, differences in maternal-fetal health outcomes, and mother and infant postpartum adaptation. Acknowledgment This research project was supported in part, by the Larry C. Gilstrap MD Center for Perinatal and Women’s Health Research. References [1] World Health Organization, Preterm birth, Fact sheet No363, [internet]; 2012 November. Available from: http://www.who.int/mediacentre/factssheets/ fs363/en/ [retrieved 8/22/13]. [2] Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Matthews TJ, Births: Final data for 2011. National Vital Statistics Reports, 62(1) US Department of Health and Human Services Jun. 28; 2013. [3] Surgeon General’s Conference Outlines Agenda to Prevent Preterm Birth [internet], 2008 June 19. Available from: [retrieved 8/23/13]. [4] Chang HH, Larson J, Blencowe H, Spong CY, Howson CP, Cairns-Smith S, et al. Preventing preterm birth: analysis of trends and potential reductions with interventions in 39 countries with very high human development index. Lancet 2013;381(9862):223–34. [5] Behrman RE, Butler AS, editors. Preterm birth: causes, consequences, and prevention. Washington, DC: National Academies Press; 2007. [6] Office of the Surgeon General. The Surgeon General’s Conference on the Prevention of Preterm Birth [webcast on the internet]. June 16–17; 2008. Available from: http://videocast.nih.gov/summary.asp?Live=6770 and http:// videocast.nih.gov/summary.asp?Live=6771. [7] Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008;371(9608):261–9. [8] Brown SJ, Yelland JS, Sutherland GA, Baghurst PA, Robinson JS. Stressful life events, social health issues and low birthweight in an Australian populationbased birth cohort: challenges and opportunities in antenatal care. BMC Public Health 2011;11(196):1–12. [9] Class QA, Lichtenstein P, Langstrom N, D’Onofrio BM. Timing of prenatal maternal exposure to severe life events and adverse pregnancy outcomes: a population study of 2.6 million pregnancies. Psychosom Med 2011;73(3):234–41. [10] DiPietro JA, Hilton SC, Hawkins M, Costigan KA, Pressman EK. Maternal stress and affect influence fetal neurobehavioral development. Dev Psychol 2002;38(5):659–68.
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