Stress and Coping in First Pregnancy: Couple-Family Physician Interaction

Penny Williamson, ScD, and Eugenia C. English, MD Seattle, W ashington

First pregnancy and childbirth produce life changes and re­ quire adaptation. This pilot study examined the role of the family physician in caring for nine couples during first preg­ nancy through the postpartum period. Interviews of individu­ als and couples were conducted to evaluate their support, stresses, and coping styles. Concurrently, physicians were in­ terviewed for their knowledge of these dimensions. Interac­ tions between physicians and couples were observed in third trimester and at labor and delivery. Each of the participants perceived predelivery stresses relat­ ing to the pregnancy and to concomitant life changes. Emo­ tional and technical support was high; only two of the nine husbands felt a marked lack of emotional support from any source. All women felt a high level of support. While preg­ nancy related concerns and support were perceived by all physicians, general stresses and sources of emotional support were infrequently known. Significantly more was known about the women than their husbands. Attention to psychosocial is­ sues appeared to depend on physician style of interaction with the couple. When recognized, stresses were reduced by pro­ vision of information, discussion, and reassurance.

First pregnancy is a time of major change, rep­ effects of a stable, supportive husband.8 In con­ resenting a transition from being a couple to being trast, Liebenberg reviewed the range of stresses parents.1 While pregnancy has been described as a reported by expectant fathers.9 The value of social time of unusual well-being,2 it also has been char­ support has been shown by Sussman, who de­ acterized as a “maturational crisis” akin to pu­ scribed the mutual aid provided by family and ex­ berty and menopause with concomitant psycho­ tended networks despite geographic and social logical disturbance3 as well as a time of “person­ mobility.10 The importance of network support for ality crisis.”4 Various observations have linked maintenance of an individual’s psychological well­ environmental stresses and negative attitudes in being in an urban environment was shown by pregnancy with emotional and physical difficulties Kleiner and Parker.11 Other studies have shown during that time.5'7 Cohen described the positive the buffering support of family, kin, and friend networks in mediating stressful situations.1215 In an outcome study of primipara, Nuckolls et al From the Department of Family Medicine, School of Medi­ cine, University of Washington, Seattle, Washington. Re­ showed social support to be a significant protec­ quests for reprints should be addressed to Dr. Penny Wil­ tive factor in the presence of stressful circum- liamson, Department of Family Medicine RF-30, School of Medicine, University of Washington, Seattle, WA 98195. stan ce.16 Since the physician often represents a 0094-3509/81/110629-07$01.75 ® 1981 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5: 629-635, 1981 629 STRESS AND COPING

significant figure in this transition time, it is impor­ to the pregnancy, labor, delivery, and future par­ tant to examine his or her functional role. In an enting, and expected and perceived role of the analysis of physician-patient interaction during family physician. pregnancy, Danziger suggested that ascertaining First Physician Interview. This session explored medical expertise during the interaction process the physician’s knowledge of life stresses and sup­ influenced the outcome.17 ports for both partners and his knowledge of their This pilot study examined the nature of support concerns related to pregnancy as well as his per­ and stresses experienced by nine couples from the ception o f their expectation o f his role in the preg­ third trimester of first pregnancy through the ini­ nancy. tial eight weeks of parenthood. It focused particu­ Couple Interview (near labor and delivery): This larly on the effectiveness of the family physician, interview explored additional stresses, supports, not only in medical “technical” skill, but espe­ and concerns at the later part of pregnancy, cou­ cially for his ability to assess the need for and to ple’s reactions to first interview, couple’s style of provide emotional support, both to the childbearer relating to each other and to the interviewer, and and to her partner in this unique period of life. couple’s reactions to their previous clinic visit and to the pregnancy. Second Physician Interview (near labor and de­ livery): This interview was an exploration of the physician’s knowledge of new concerns, stresses, or any changes in support for either member of the Methods couple as well as changes in his relationship to Nine couple volunteers were recruited for study either husband or wife. from the University of Washington Family Medi­ Observation of Physician with the Couple: This cal Center obstetric population. Twelve couples took place primarily to observe how the physician were approached to obtain the nine participants. interacted with each member of the couple. The following criteria were satisfied: Observation of Labor and Delivery. This provided 1. Informed consent of both members of the cou­ an opportunity to observe the interactions be­ ple and their physician tween each couple as well as those of the physi­ 2. Couple married or living together cian and other support staff with the wife and the 3. First child for both partners husband. Included were reactions to unexpected 4. Entry into the study in the third trimester of procedures or delays. pregnancy Final Participant Interview (approximately eight Data were collected as follows: weeks postpartum): This interview reviewed the 1. Individual interviews of wife, husband, and labor and delivery process stresses (eg, the influ­ physician upon entry to the study ence of the addition of the baby) and coping of 2. Observation of the couple with their physician each member of the couple. Individual partici­ at a routine prenatal visit using a one-way mirror pants also stated their perception of the meaning 3. Couple interviews immediately after first ob­ of having a child as well as future expectations of servation their physicians. 4. Physician interview immediately after first ob­ Final Physician Interview (eight weeks postpar­ servation tum): Similar issues were explored from the phy­ 5. Observation of labor and delivery sician’s point of view to ascertain congruence of 6. Individual interviews of husband, wife, and expectations and the physician’s knowledge of physician after an eight-week postpartum visit. stresses and coping in the couple. First Participant Interview (third trimester): This Semistructured interview formats included five- interview included demographic data on the family point scaling as well as open ended questions.* of origin (including parenting styles, affection, and The same investigator interviewed the same discipline), birth order of participants, recent and member of the couple in each of the individual anticipated life changes and stresses, availability and means of emotional and practical support, background information and concerns pertaining *AII forms available from the authors upon request.

630 THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 S T R E S S AND COPING

interviews, and each investigator interviewed an 1. Types, degree, and timing of stresses approximately equal number of men and women to 2. The perceived need for support distribute any error that might be due to the inter­ 3. The couple’s preparation for coping with this viewer. Charts were reviewed at the outset of each life change couple’s involvement, and they provided informa­ 4. The physician’s management of labor, delivery, tion on medical risks and special wishes of the and the puerperium in conjunction with his knowl­ couple regarding birth plans. edge of the psychosocial dimensions of pregnancy Because this was a small study and because the for each couple authors participate as regular members of the Fam­ 5. Estimation of unmet emotional or medical ily Medical Center, their involvement was close. needs For example, one of the authors is a family physi­ 6. Observed changes in the relationship of the cian (ECE) and when present as an observer of couple to their physician throughout the study. labor and delivery, she also supervised the resi­ dent physician. While this precluded maximal ob­ jectivity, it permitted the investigators increased rapport with couples and freer exchange of infor­ mation, which in itself served as an intervention Results (see Discussion). For the couples in this study, pregnancy was All interviews were tape recorded. Typed tran­ but one of a cluster of general life changes, some scripts were made of the first participant inter­ of which were perceived as stressful by husband views. Abbreviated transcripts of the remaining and/or wife. Issues which surfaced included health taped interviews were made using the interview concerns (other than pregnancy), financial con­ forms as guides to code answers to each question. cerns, recent geographic moves, job changes, per­ The tape recorded notes made during observations ceptions of isolation from spouse, concerns relat­ of the physician and couple interviews, and during ing to new roles, cultural issues, and difficulties labor and delivery, were transcribed. with parents. Pregnancy itself raised predictable Content analysis was conducted by compiling questions and concerns for both husbands and information from all transcripts according to major wives, including stress if the pregnancy was un­ categories for each participant and physician. planned, the normalcy of the fetus (ongoing con­ These categories included the following areas: cerns regarding diet and drugs), fear of pain during 1. Major stresses and life changes perceived by labor and delivery, apprehension about complica­ each individual tions during labor and delivery, a desire to be ac­ 2. Major perceived sources of support tively involved in all facets of management, and 3. Pertinent background information and relation­ pregnancy related sexual concerns. ship of childhood experiences to anticipated par­ Available support varied for individuals and enting style and noted apprehensions was obtained from a variety of sources. Usual 4. Major concerns regarding pregnancy, labor and sources of emotional support included spouse, delivery, and parenting friends, parents, family physician, and church. 5. Physician knowledge of concerns, stresses, and Technical support in preparation for and during supports for both members of the couple labor and delivery came from spouse, physician, 6. Perceived role of the physician by couple and Childbirth Education Association classes. The 7. Actual role of the physician usual source of financial help in this sample was 8. Outcome of pregnancy parents. Table 1 summarizes the self-ratings of 9. Other notes of interest, eg, role of investiga- stresses and supports reported by husbands and tor(s), meaning of pregnancy to participant, self- w ives in this study. ratings by participants The physicians in this sample were well aware Evaluation of the content was necessarily sub­ of pregnancy related concerns and also of the jective and included self-ratings by participants, pregnancy related supports for husbands and recorded perceptions of individuals and couples, wives in their population. However, physician and consensus of the investigators. For each par­ awareness of general stresses and emotional or fi­ ticipant the following assessments were made: nancial supports was less consistent and seemed

THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 631 STRESS AND COPING

Table 1. Patients' Self-Ratings of Stresses and Supports

Husbands (n=9) Wives (n=9) Number X Level* Number X Level*

Stress G e n e r a l H e a l t h 1 5 . 0 1 5 . 0 M o n e y 5 3 . 2 3 2 . 7 Geographic m ove 4 2 . 8 2 3 . 5 J o b 8 3 . 1 3 3 . 0 Isolation from spouse 3 3 . 7 3 4 . 0 N e w r o l e 8 2 . 8 2 3 . 5 C u l t u r a l 1 4 . 0 1 1 . 0 P a r e n t s 2 4 . 0 1 4 . 0 Pregnancy related U n p l a n n e d 1 2 . 0 ______N o r m a l c y 3 2 . 3 4 2 . 8 Pain: Labor and delivery 2 1 . 0 4 3 . 0 Com plications 3 1 . 7 4 3 . 0 M anagem ent: Labor and delivery 4 3 . 5 4 3 . 8 Sexual concerns — — 2 3 . 0 S upport E m o t i o n a l S p o u s e 8 4 . 4 9 5 . 0 F r i e n d s 8 3 . 6 9 4 , 0 P a r e n t s 8 4 . 0 9 4 . 0 Physician/Staff 9 4 . 2 8 4 . 8 C h u r c h 3 4 . 0 4 4 . 5 T e c h n i c a l H u s b a n d —— 9 5 . 0 Physician/Staff —— 9 5 . 0 CEA classes** 9 5 . 0 9 5 . 0 F i n a n c i a l P a r e n t s 6 4 . 4 6 3 . 7

*M ean levels of stress or support reported. Scale 1-5; 5=m axim al stress or support **Childbirth Education Association

to depend on physician style. In general, more was and especially the prospective fathers were un­ known consistently about wives than about their clear about their physician’s interest in concerns husbands in all areas (Figure 1). other than biomedical pregnancy related issues. In the course of the interviews, several unresolved psychosocial or biomedical issues surfaced for one Discussion or both members of the couple. These initial dis­ cussions often led to further ventilation by the The Study as an Intervention couple alone, with the interviewers, or with their The close involvement of the authors in this family physician. pilot study served at times as an intervention and In one case, following a first interview which provided useful additional insights. As examples, included self-ratings of perception of support by the investigators learned that five of the couples the husband as well as the wife, the husband real-

632 THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 S T R E S S AND COPING

ized his extreme feelings of isolation and subse­ to the infant after delivery, but also to provide quently invited his father to visit at the time of general care for the husband. The style of this birth. In another, the couple was able to verbalize couple replicated each of their backgrounds inso­ their appreciation of their physician’s attentive­ far as both the husband and his father were some­ ness to their financial and medical concerns, what isolated, although main providers for their which subsequently allowed them to form a more families. Picking up on the sense of isolation per­ comfortable bond with their physician after an ini­ ceived by the husband could have provided a tial “ adversary” relationship. unique opportunity for the physician to facilitate a The view often expressed was that physicians more evenly balanced relationship between hus­ were interested only in the medical well-being of band and wife. This husband’s psychosocial needs mother and child. Explicit interest (by the authors were particularly great, since he felt cut off from of the anticipated role shifts, financial concerns, easy support from his peers and since his wife had perception of support, and physical health of the her own special developing interests during preg­ husband, for example) served to initiate relevant nancy and her preoccupation with the new infant. discussions and to educate the couple in this re­ In this case the husband’s needs seemed intensi­ gard. Similarly, after being interviewed as part of fied by the number of major life changes the cou­ the study, several physicians asked questions ple had made on short notice. Sensitivity to the about stresses and supports and specifically in­ husband’s concern regarding his ability to provide volved husbands as a focus in subsequent patient for the new family might also have facilitated in­ encounters. clusion of the husband in the health care of the family by the family physician. Awareness of this couple’s style of coping with life changes could The Physician as Doctor for the Family prove useful to the family physician in predicting One couple illustrated that the family physician similar patterns during future changes: the hus­ often must clarify and assert that his role is not band did not easily ask for support but nonetheless only to give medical care to the pregnant wife and readily talked about his own needs when drawn

THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 633 STRESS AND COPING

Table 2. Guidelines for Prenatal Discussion (mark V1 if discussed with patient)

First Trimester Acceptance of pregnancy: Yes Ambivalent No Life Style: Yes Quantity No P a t i e n t _ _ C i g a r e t t e s Expectant father _ _ _ A l c o h o l C o f f e e D r u g s — — — M edications: _ Normal changes: _ Danger signals: bleeding _ abdom inal pain _ _ f e v e r _ Nutrition/vitam ins: _ Breastfeeding: Y e s _ N o __ General stresses: (m ove, job, health, cultural, o th er) _ Financial considerations: billing office: Yes No social worker: Yes No Pregnancy education materials: Y e s _ N o __ Second Trimester Knowledge of normalcy: Yes _ N o _ Offer tim e for expectant father/any others sharing responsibilities _ Anticipation of em otional changes _ s e x i s s u e s __ Discussion of role shifts and tim e com m itm ents _ Childbirth education classes: Y e s _ N o __ Patient Expectant Father Social support _ _ Coping style _ _ Other health _ _ c o n c e r n s Prem ature labor _ Other concerns _ Third Trimester Tour of labor/delivery facilities: Y e s _ N o __ Emotional changes associated with: Patient Expectant Father/Others provider role _ _ sex issues _ _ anticipation of labor _ _ anticipation of delivery _ _ indications/cesarean section _ _ new baby/sleep lack _ _ p a r e n t i n g _ _ Signs of onset of labor _ How to contact physician _ Circum cision _ Breastfeeding _ Infant care arrangements _ (working m others) Postpartum contraception: _ Parenting education m aterials: Y e s _ N o __

out by a sympathetic listener. The wife was more the process, educating each to anticipate likely outgoing and seemed more forthcoming with feel­ changes, and developing the needed rapport with ings and concerns, but both awaited cues of inter­ understanding of the couple to ensure his optimal est regarding personal matters from their physi­ and continuing effectiveness as their family phy­ cian and did not spontaneously offer information sician. It is instructive to note that it took no more or concerns. than the usual amount of time at each prenatal visit Another couple did not present major concerns to achieve these prototypical family physician (either medical or psychological) for their physi­ goals. Further, this physician’s view of his role cian, and yet he played a critical role in the clearly helped to educate this couple to expand pregnancy—that of monitoring the normalcy of their expectations of him in their future care.

634 THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 STRESS AND COPING

In the case of three couples with special con­ to examine a larger population at other practice cerns, optimal joining of forces between them­ settings. All the couples in this study were married selves and their physicians was observed. This and attended childbirth education classes to­ was attributed to the physicians’ readiness to offer gether. Moreover, they obtained health care at the time for discussion early in prenatal visits, and to University Family Medicine Residency site. Fur­ address possible areas of stress or conflict during ther research could involve both single and mar­ pregnancy, labor, delivery, and in the puerperium. ried patients in obstetric clinics, in both urban and The needs of still another couple, relevant to rural communities, cared for by a spectrum of the physician, were predominantly medical. These caregivers. Such studies might provide an ex­ two people were extremely supportive of each panded definition of the role of the family physi­ other and had close friends and family who met cian in first pregnancy. support needs. The physician ascertained the area of need and appropriately restricted specific in­ volvement. This emphasizes that all couples do Acknowledgement not demand a high level of psychosocial or sup­ This study was supported in part by the Zlinkoff Foun­ portive involvement from their physician. dation. In a couple in which the husband was not forth­ coming with his own problems, it became strik­ ingly clear that the family physician often had to References be quite direct regarding his role. The authors hy­ 1. Rossi AS: Transition to parenthood. J Marr Fam 30: pothesize that it is necessary for the physician to 26, 1968 2. Hooke JF, Mraks PA: MMPI characteristics of preg­ direct explicit questions regarding role changes, nancy. J Clin Psychol 18:316, 1962 stress, and support perceived by both the wife and 3. Bibring GL (ed): Psychoanalytic Study of the Child, ed 14. New York, International Universities Press, 1959 the husband to help educate them to the appropri­ 4. Caplan G: Emotional implications of pregnancy and ateness of the physician’s role in the care of the influences on family relationships. In Stuart HC, Prugh DG (eds): The Healthy Child. Cambridge, Mass, Harvard Uni­ family as a unit. First pregnancy presents an op­ versity Press, 1960, p 72 portunity uniquely suited to this education and to 5. McDonald RL: The role of emotional factors in ob­ stetric complications: A review. Psychosom Med 30:222, negotiation of the appropriate role of the family 1968 physician with the family members. 6. Hanford JM: Pregnancy as a state of conflict. Psy­ chol Rep 22:1313, 1968 In summary, different kinds of couples in dif­ 7. Grimm E: Women's attitudes and reactions to ferent life circumstances need different things childbirth. In Goldman GD, Milman DS (eds): Modern Woman. Springfield, III, CC Thomas, 1969, p 129 from their family physician, who, in turn, needs 8. Cohen MD: Personal identity and sexual identity. In the flexibility to see these differences and respond Miller JB (ed): Psychoanalysis and Women. Harmonds- worth, England, Penguin, 1973, p 88 accordingly. This study raises several interesting 9. Liebenberg B: Expectant fathers. In Shereshefsky hypotheses: (1) careful interviewing of the pro­ PM, Yarrow LJ (eds): Psychological Aspects of a First Preg­ nancy and Early Postnatal Adaptation. New York, Raven spective father and mother by the physician can Press, 1973, p 103 assure assessment of each of their needs, (2) care­ 10. Sussman MB: Relationships of adult children with their parents in the United States. In Shanas E, Streib GF ful interviewing can also lead to a better percep­ (eds): Social Structure and the Family: Generational Rela­ tion of the physician’s role by the couple, and (3) tions. New Brunswick, NJ, Prentice-Hall, 1965, p 91 11. Kleiner RJ, Parker S: Network participation and psy­ including assessment during first pregnancy of the chological impairment in an urban environment. In Mead­ psychosocial concerns of husband and wife (eg, ows P, Mizruchi EH (eds): Urbanism, Urbanization and Change. Reading, Mass, Addison-Wesley, 1976, p 322 allowing ventilation, promoting communication 12. Walker KN, MacBride A, Vachon MLS: Social sup­ between husband and wife, linking couple with port network and the crisis of bereavement. Soc Sci Med 11:35, 1977 additional support should that be needed), rather 13. Horwitz A: Family, kin and friend networks in psy­ than singular attention to medical concerns, allows chiatric help-seeking. Soc Sci Med 12:297, 1978 14. Finlayson A: Social networks as coping resources. the physician to give optimal care. Soc Sci Med 10:97, 1976 Table 2 provides guidelines to the physician for 15. Pilisuk M: Cognitive balance, primary groups and the patient-therapy relationship. Behav Sci 8:137, 1963 assessing the range of potential needs and issues 16. Nuckolls KB, Cassel J, Kaplan BH: Psychological as­ with husband and wife during the course of first sets, life crisis and the prognosis of pregnancy. Am J Epi­ demiol 95:431, 1972 pregnancy. In order to generalize from the infer­ 17. Danziger SD: The uses of expertise in doctor-patient ences of this small pilot study, it will be necessary encounters during pregnancy. Soc Sci Med 12:359, 1978

THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 635