Cultural Expectations of Motherhood and Maternal Stress

Managing Mixed Messages: Cultural Expectations of Motherhood and Maternal Stress

During Pregnancy

Dissertation

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

in the Graduate School of The Ohio State University

Genevieve Ritchie-Ewing, M.A.

Graduate Program in Anthropology

The Ohio State University

2019

Dissertation Committee

Barbara A. Piperata, Advisor

Douglas Crews

Debra Guatelli-Steinberg

Jennifer Syvertsen

Genevieve Ritchie-Ewing

2019

Abstract

During pregnancy, American women receive competing messages regarding

“proper” behaviors that reflect society’s expectations of “good” mothers. Specifically, the biomedical community and the natural childbirth movement insist pregnant women practice self-discipline to follow “expert” advice according to often opposing recommendations. Research reveals conflicting information about best practices during pregnancy and childbirth frequently cause pregnant women anxiety as they try to decide which “expert” advice to follow, however, no studies have explored how women’s experiences with making these decisions affect self-reported stress or the physiological stress response. In addition, few studies have linked society’s expectations to emotional and physiological stress levels. Connecting cultural beliefs to physiological responses provides a mechanism for explaining the higher preterm birth rates in the U.S. (11.6% in

2012) compared to most European countries, Canada, and Australia (5-9%) even among

“white” women of middle to higher socioeconomic status.

In this dissertation, I investigated the connections between cultural expectations, women’s experiences with decision-making and their emotional and physiological stress levels. My objectives were to 1) determine where pregnant women get information about

“proper” behaviors during pregnancy and childbirth and ascertain if this information conflicts, 2) explore how pregnant women make decisions about which practices to ii integrate into their daily lives and birth plans, 3) investigate links between women’s experiences making decisions about which advice to follow and their self-reported stress levels (particularly pregnancy-specific anxiety or anxiety associated with pregnancy- related concerns), and 4) establish if there are associations between women’s experiences making decisions about “expert” advice and physiological stress levels (i.e., hair cortisol).

I found that women gather information primarily from the individuals in their lives, particularly their female relatives and healthcare providers. They also turned to the internet when the information they needed to supplement information they received from individuals in their lives. Participants also encountered a great deal of conflicting information, which often made them feel anxious and confused. In terms of decision- making, primiparous women and women who reported feeling anxious about conflicting information struggled more with making decisions. Primiparous women had higher levels of pregnancy-specific anxiety in the first trimester only compared to multiparous women.

Women who reported feeling anxious about conflicting information had higher levels of general self-reported stress in the second trimester and higher levels of self-reported anxiety in the first trimester compared to women who did not report anxiety due to conflicting information. Primiparous women had higher hair cortisol levels in the first trimester only compared to multiparous women. Cultural expectations regarding how

“good mothers” should act including gathering information and making decisions about

“appropriate” behaviors affect women’s emotions during pregnancy and, potentially, their physiology, which in turn, could affect birth outcomes.

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Dedication

This dissertation is dedicated to my husband, Chris, for his endless love, support,

encouragement throughout this long and difficult process.

Acknowledgements

Many people helped make this dissertation possible. First and foremost, I want to thank, my advisor, Dr. Barbara Piperata, for her support, encouragement, and tough love through this process. In every way, Barbara has made me the anthropologist I am today.

Her openness to exploring new topics and following her students’ interests is inspiring to me. I only hope I can give my students the same attention and support as I move forward in my career.

I also want to thank the members of my committee, Dr. Douglas Crews, Dr.

Debra Guatelli-Steinberg, and Dr. Jennifer Syvertsen for their advice, feedback, and willingness to challenge me. In addition, I want to thank many other members OSU’s faculty, particularly in the Department of Anthropology, for their willingness to step in and keep this process moving when others had to step out. Each of these faculty members brought new insights that served to make this complicated dissertation better.

For their financial support, I would like to thank the National Science Foundation and OSU’s Department of Anthropology.

I never would have been able to finish this dissertation without the love and support of my family. My parents, Tim and Petra Ritchie, deserve endless thanks for their belief in me throughout my life. They are always willing to bolster my spirits through difficult times and celebrate my accomplishments. To my husband, Christopher Ewing, I v never would have survived this process without you. Your encouragement and support helped me work through the setbacks and keep reaching for this finish line. I also want to thank my friends and colleagues at OSU, especially Addy Carey, Emily Wolfe, and

Taylor Farley. My success depended on my conversations with all of them. They understood when no one else would have.

Finally, I want to thank the women who participated in this study. They generously offered their stories and their hair for research. I appreciate their honesty and candor in describing their feelings about pregnancy and childbirth. I also appreciate their patience as I learned how to collect hair samples and conduct interviews. They always were upbeat and more than willing to work with me. I enjoyed meeting each and every woman in this study. Their strength, independence, compassion, and mothering skills were incredible to witness.

Vita

1999……………………………B.S. Biology, Millersville University of Pennsylvania

2005……………………………M.A. Anthropology, University of Tennessee, Knoxville

2018 to present…………………Adjunct Faculty, Department of Social and Behavioral

Sciences, Central State University

2013 to present…………………Adjunct Faculty, Department of Sociology and

Anthropology, Wright State University

2016 to 2018……………………Graduate Teaching Associate, Center for the Study of

Teaching and Writing, The Ohio State University

2010 to 2016……………………Graduate Teaching Associate, Department of

Anthropology, The Ohio State University

2013 to 2015……………………Graduate Research Associate, Stress and Health in

Pregnancy Research Program, The Ohio State University

2008 to 2010……………………Research Assistant, Lifespan Health Research Center,

Wright State University

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Publications

Ritchie-Ewing GT, Piperata BA. 2019. How conflicting messages during pregnancy

affect U.S. women’s self-reported and biological stress levels. American Journal

of Physical Anthropology 168(s68): 204.

Ritchie-Ewing GT, Mitchell A, Christian L. 2018. Associations of maternal beliefs and

distress in pregnancy and postpartum with breastfeeding initiation and early

cessation. Journal of Human Lactation 35(1): 49-58.

Ritchie-Ewing GT, Piperata BA. 2018. Connections between perceived and biological

measures of stress in early pregnancy in a sample of U.S. women. American

Journal of Human Biology 33(2): e23110.

Piperata BA, Schmeer KK, Hadley C, Ritchie-Ewing GT. 2013. Dietary inequalities of

mother-child pairs in the rural Amazon: evidence of maternal-child buffering?

Social Science & Medicine 96: 183-191.

Ritchie-Ewing GT, Piperata BA. 2012. Household food consumption of Ribeirinhos,

eastern Amazon, Brazil. American Journal of Human Biology 24: 240.

Fields of Study

Major Field: Anthropology

Specialization: Medical Anthropology

Specialization: Human Biology

viii

Table of Contents

Abstract...... ii

Dedication...... iv

Acknowledgements...... v

Vita...... vii

List of Tables...... x

List of Figures...... xiii

Chapter 1: Introduction...... 1

Chapter 2: Theoretical Framework...... 6

Chapter 3: Research Model...... 38

Chapter 4: Research Design and Study Population...... 57

Chapter 5: Preliminary Study...... 77

Chapter 6: Information Gathering and Authoritative Knowledge Decision-Making...... 98

Chapter 7: Authoritative Knowledge Decision-Making and Maternal Stress...... 147

Chapter 8: Discussion and Conclusions...... 194

References...... 235

Appendix A: Messaging Survey...... 255

Appendix B: Interview Script...... 267

List of Tables

Table 3.1. Comparison of the Biomedical and Natural Childbirth Models’ tenets...... 40

Table 4.1. Number of participants and data collection methods for each stage of the study...... 59

Table 4.2. Demographic and descriptive characteristics for n=47 women enrolled in the study...... 68

Table 5.1. Participant occupations for focus groups and key informants...... 79

Table 6.1. Individuals who pregnant women consulted for advice/information...... 112

Table 6.2. Written sources that pregnant women consulted for information...... 112

Table 6.3. Mean number of individuals, written sources, and total sources of information that pregnant women consulted...... 113

Table 6.4. Individuals consulted for advice/information among primiparous and multiparous women...... 120

Table 6.5. Written sources consulted for information among primiparous and multiparous women...... 121

Table 6.6. Mean number of individuals, written sources, and total sources of information consulted among primiparous and multiparous women...... 122

Table 6.7. Individuals consulted for advice/information among women who did not report anxiety due to conflicting information and women who did report anxiety due to conflicting information...... 132

Table 6.8. Written sources consulted for information among women who did not report anxiety due to conflicting information and women who did report anxiety due to conflicting information...... 133

Table 6.9. Mean number of individuals, written sources, and total sources of information consulted among women who did not report anxiety from conflicting information and women who did report anxiety from conflicting information...... 134

Table 7.1. Categorical sociodemographic variables, comparison between primiparous and multiparous participants...... 159

Table 7.2. Continuous sociodemographic variables, comparison between primiparous and multiparous participants...... 160

Table 7.3. Continuous postpartum variables, comparison between primiparous and multiparous participants...... 162

Table 7.4. Categorical postpartum variables, comparison between primiparous and multiparous participants...... 163

Table 7.5. Control variables, comparisons between primiparous and multiparous participants...... 164

Table 7.6. Categorical sociodemographic variables, comparisons between women who reported anxiety and those who did not report anxiety from conflicting information.....167

Table 7.7. Continuous demographic variables, comparisons between participants who reported anxiety and those who did not report anxiety from conflicting information.....168

Table 7.8. Categorical postpartum variables, comparisons between participants who reported anxiety and those who did not report anxiety due to conflicting information...170

Table 7.9. Continuous postpartum variables, comparisons between participants who reported anxiety and those who did not report anxiety from conflicting information.....171

Table 7.10. Control variables, comparisons between participants who reported anxiety and those who did not report anxiety due to conflicting information...... 172

Table 7.11. Self-reported stress variables, comparisons between primiparous and multiparous participants...... 175

Table 7.12. Self-reported stress variables, comparisons between participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information...... 181

Table 7.13. Hair cortisol levels, comparisons between primiparous and multiparous participants...... 188

Table 7.14. Self-reported stress variables, comparisons between participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information...... 188

xii

List of Figures

Figure 2.1. Relative size of maternal pelvic inlet and the size of the neonatal head in different primate species (Rosenberg and Trevathan 1995: 162, adapted from Schultz

1969). Outlined circle represents the maternal pelvic inlet; black circle represents the neonatal head...... 24

Figure 2.2. Levels of influences on personal decision-making about health (adapted from

Baer et al. 1986: 96)...... 28

Figure 3.1. Physiological pathways linking stress, depression, and inflammation

(Christian et al. 2009:1264). Solid lines indicate stimulatory relationships; dashed lines indicate inhibitory relationships. CRH = corticotropin-releasing hormone, ACTH = adrenocorticotropic hormone (or corticotropin)...... 50

Figure 3.2. A conceptualization of the relationships between conflicting information, authoritative knowledge (AK) decision-making, maternal stress, and birth outcomes.....54

Figure 7.1. Self-reported general stress (PSS score; mean ± SE) for primiparous and multiparous participants across pregnancy...... 176

Figure 7.2. Pregnancy-specific anxiety (PSAS score; mean ± SE) for primiparous and multiparous participants across pregnancy...... 177

Figure 7.3. PSAS concerns sub-score (mean ± SE) for primiparous and multiparous participants across pregnancy...... 178 xiii

Figure 7.4. PSAS anxiety sub-score (mean ± SE) for primiparous and multiparous participants across pregnancy...... 179

Figure 7.5. Self-reported general stress (PSS score; mean ± SE) of participants who reported anxiety and those who did not report anxiety from conflicting information across pregnancy...... 182

Figure 7.6. Pregnancy-specific anxiety (PSAS score; mean ± SE) for participants who reported anxiety and those who did not report anxiety from conflicting information across pregnancy...... 183

Figure 7.7. PSAS concerns sub-score (mean ± SE) participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information across pregnancy...... 184

Figure 7.8. PSAS anxiety sub-score (mean ± SE) for participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information across pregnancy...... 185

Figure 7.9. Hair cortisol level (mean ± SE) for primiparous and multiparous participants across pregnancy...... 189

Figure 7.10. Hair cortisol level (mean ± SE) for participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information across pregnancy...... 190

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Chapter 1. Introduction

The Centers for Disease Control and Prevention states that reducing preterm birth in the U.S. is a national priority and has expended extensive resources for research and health promotion to ensure more children are born full term (CDC 2017). These efforts have decreased the preterm birth rate in the U.S. from an all-time high of 10.4% in 2006 to a low of 9.5% in 2014 (Martin et al. 2018). Recently, however, the preterm birth rate has slowly begun to rise again to a current rate of 9.9% in 2017 (Martin et al. 2018). The rate also has remained significantly higher than in most European countries where the preterm birth rate is below 9% with some European countries such as Sweden and

Finland at 5.5% (Martin et al. 2018, MacDorman et al. 2014). Ferré and colleagues

(2016) of the CDC largely contribute the drop in the preterm birth rate between 2007 and

2014 to fewer numbers of births among teenage and young mothers, but the CDC has yet to explain the current upward trend in preterm births (Ferré et al. 2016). As preterm birth is the leading cause of long-term debilitation and mortality among U.S. infants, reducing the preterm birth rate is an important goal for improving infant health (CDC 2017).

The preterm birth rate is highest among women who self-identify as black or

African-American and women with low socioeconomic status (SES). This is largely due to persistent racial discrimination and poverty-related factors including increased

1 likelihood of inadequate nutrition, obesity, and insufficient prenatal care (Averett and

Fletcher 2016, El-Sayed and Galea 2012, Rasmussen et al. 2014, Rosenberg et al. 2002,

Rosenthal and Lobel 2011). In most of the U.S., however, white women in middle to upper socioeconomic categories also experience preterm birth rates above 9% (Conrey

2013, Green et al. 2013, Ward et al. 2010). The preterm birth rate for educated, white, middle- and upper-SES women is not explained fully by traditional behavioral risk factors such as smoking and drug abuse or by risk factors associated with poverty (Green et al. 2013, Ward et al. 2010). Yet, few studies have investigated other potential causes

(Conrey 2013, Green et al. 2013, Ward et al. 2010). The fact that the U.S. preterm birth rate remains high, even among affluent groups, indicates a need to explore other factors influencing birth outcomes. Exploring why a high preterm birth rate persists among white women of middle to upper SES is necessary to improve our understanding of the high preterm birth rate for all U.S. women across the SES spectrum.

One potential explanation for the high preterm birth rate among U.S. women is maternal stress during pregnancy. Maternal self-reported stress and physiological measures of stress during pregnancy are both associated with an increased likelihood of pregnancy and birth complications (Dole et al. 2003, Dunkel Schetter 2011, Lobel et al.

2008). For example, steeper hair cortisol trajectories across pregnancy and higher self- reported stress about pregnancy determined by survey responses are significantly associated with adverse birth and infant health outcomes (Dunkel Schetter 2011, Kalra et al. 2005, Kalra et al. 2007, Kane et al. 2014). While researchers have established a strong connection between maternal stress and complications during pregnancy and childbirth,

2 they have not fully explored potential sources of maternal stress during pregnancy. In particular, few researchers have examined how cultural expectations of pregnant women affect their stress levels, especially in a context where competing cultural models of pregnancy and childbirth exist – such as in the U.S.

In the U.S., there are two potentially conflicting cultural models of pregnancy and childbirth: the biomedical model and the natural childbirth model. I argue that pregnancy- related decision-making in a context of competing messages is a potentially important, yet under-explored, source of stress. In this dissertation, I investigate how societal expectations of motherhood from multiple sources including these two competing cultural models (biomedicine and natural childbirth) affect women’s stress levels during pregnancy by exploring the messages women receive, how women make decisions in the face of competing messages, and how that decision-making affects women’s self- reported and physiological stress during pregnancy.

In Chapter 2, I start with a discussion of the theoretical framework for my dissertation focusing on Foucault’s concept of biopower or the subjugation of human bodies by political-economic forces (Foucault 1979[1976], Foucault 2007). I explain the concept of biopower in detail and describe how it relates to pregnancy and childbirth. The concept of biopower is then intertwined with the neoliberal model of health. In the neoliberal model of health, risk and responsibility for being healthy becomes the domain of private individuals who are influenced by structural forces that exert biopower. These concepts help explain U.S. cultural expectations for mothers. I next discuss the macro, intermediate, and micro-level factors that influence women’s decision-making within the

3 context of these cultural expectations. I conclude Chapter 2 with a discussion of how I interpreted bioculturalism. I then discuss using a biocultural approach to investigate effects of cultural expectations on pregnant women’s self-reported and physiological stress responses. Chapter 3 details my research model beginning with the competing cultural models of pregnancy and childbirth that exist in the U.S. I show how each model exerts biopower and fits with the neoliberal model of health, but, also, how each emphasizes contradictory tenets. I next explore two maternal roles that U.S. society places on pregnant women: the “good mother” role and the “informed patient” role. I connect these roles to the competing U.S. cultural models of pregnancy and childbirth to demonstrate how these roles increase the likelihood women need to navigate conflicting information. Next, I review the ethnographic work that demonstrating connections between conflicting information and maternal stress during pregnancy, and research showing a relationship between maternal stress during pregnancy and adverse birth outcomes. To conclude Chapter 3, I introduce my research questions and discuss why my study site is ideal for exploring my questions.

In Chapter 4, I present my general methodology including study design, sample, and recruitment strategies. My study design includes a preliminary study to investigate the tenets of the biomedical and natural childbirth models. The longitudinal phase of my study included ethnographic work with pregnant women and collection of hair samples for assaying cortisol. I end Chapter 4 with a section about the challenges of my study design and the limitations of my research. I discuss general methodology only in Chapter

4 as I have more detailed methodology sections in Chapters 5, 6, and 7.

I present my preliminary study in Chapter 5. Therein, I explore how women’s health professionals from biomedical and natural childbirth communities view pregnancy and childbirth through focus groups and key informant interviews. In the discussion section, I summarize the two models and connect them to my theoretical framework.

In Chapter 6, I explore my first four research questions using ethnographic data from my longitudinal study. I investigate where women obtain information about pregnancy and childbirth and how they make decisions about their behavior and plans when faced with conflicting information. My analysis of the longitudinal data continues in Chapter 7, focusing on connections between maternal decision-making, self-reported stress, and hair cortisol to test my first and second hypotheses. Therein, I explore how women’s experiences with decision-making affects their self-reported stress, particularly pregnancy-specific anxiety (i.e., stress related to pregnancy-specific concerns such as fetal health, healthcare quality, and childbirth complications). I also examine relationships between maternal decision-making and hair cortisol levels.

In Chapter 8, I discuss common themes and observed trends that integrates my research. Furthermore, using the theoretical framework introduced in Chapter 2, I illustrate the impact of multiple factors on societal expectations, personal experiences, and physiological processes and present my conclusions based on my data. To conclude, I explore future research directions and recommendations for women’s health professionals based on my findings.

Chapter 2: Theoretical Framework

Foucault’s Concept of Biopower

Using a critical medical anthropology framework, this dissertation explores how cultural expectations of motherhood affect women’s information gathering, decision- making, and stress levels during pregnancy. Thereby, it contributes to anthropological theory by advancing discussions of biopolitics around pregnancy and childbirth. For the purpose of this dissertation, I define biopolitics in accordance with Foucault (1979[1976],

2008) as the intersection between biology and politics. In other words, biopolitics is how cultural institutions use political reasoning to exert power (biopower) over human biological processes. Biopower then is the disciplinary power imposed by societal institutions over human biological processes. These two terms (biopower and biopolitics) reflect the way Foucault (1979[1976], 2008) conceptualized how power functions in modern society, as a subtle, but potent force reinforced by all members of society. I explore the biopolitics of pregnancy and childbirth through a critical medical anthropology framework as critical medical anthropology examines the effects of political and economic powers on the human experience of health and illness. This framework allows me to investigate cultural influences on women’s experiences of pregnancy and childbirth as well as how biopolitics affect women’s stress levels during pregnancy. First, I explore how cultural structures use biopower to discipline the

6 individual and regulate the population before discussing the cultural models of pregnancy and childbirth that exert biopower over pregnant women in the U.S.

Freud (1961[1930]), Marx and Engels (2018[1848]), and Nietzsche (1976[1880]) highlight relationships between power and knowledge, but in different ways. Each recognizes knowledge is linked with the exercise of power at various levels including individual, cultural, and global (Freud 1961[1930], Marx and Engels 2018[1848],

Nietzsche 1976[1954], Smart 2002). For Marx, political and economic power is imposed on the powerless through social institutions leading to exploitation and, inevitably, revolt of the powerless (Marx and Engels 2018[1848]). Building on the writings of Freud

(1961[1930]), Neitzsche (1976[1880]), and, particularly, Marx and Engels (2018[1848]),

Foucault acknowledged a strong connection between power and knowledge, but claimed none of these philosophers presented a clear vision of how people gain and maintain power (Foucault 1977, Foucault and Sennett 1982, Smart 2002). In fact, Foucault believed that power, especially in our modern societies, often was not only imposed on the powerless, but rather transmitted by and through everyone within a culture, powerless and powerful alike (Foucault 1977, Foucault and Sennett 1982, Smart 2002). As a result, the control and reproduction of knowledge creates and reinforces cultural concepts that are imposed through a net-like organization of power in which everyone within a culture is caught (Foucault 1977, Foucault and Sennett 1982, Smart 2002). While resistance is possible within Foucault’s notion of power in the form of alternative sources of knowledge, everyone within a culture helps the powerful maintain power by disciplining each other to conform to societal expectations set by the powerful (Foucault 1977,

Foucault and Sennett 1982). As such, Foucault’s work reveals a much more subversive and stable system of societal power than presented by earlier philosophers, but still hinges on knowledge as the cornerstone of power (Foucault 1977, Foucault and Sennett

1982, Foucault 1988, Smart 2002).

Generally, Foucault’s work focused on how discipline of the individual body, as the main technique of power, provides ways to train or coerce people (Foucault 1977,

Foucault and Sennett 1982, Foucault 1988, Foucault 2008). Disciplinary power achieves its hold through three disciplinary mechanisms: widespread observation, examination, and regulating judgement (Foucault 1977, Foucault and Sennett 1982, Foucault 1988,

Smart 2002). These three mechanisms interact to reinforce cultural norms set by the powerful (Foucault 1977, Foucault and Sennett 1982, Foucault 1988). Like Marx and

Engels (2018[1848]), Foucault acknowledges the influence of observation by people in authority in ensuring the powerless follow cultural expectations (Foucault 1977, Foucault and Sennett 1982, Foucault 1988). Foucault, however, emphasizes that people in authority cannot observe everything so their observation is replaced by widespread observation or continuous surveillance of the population by the population (Foucault

1977, Foucault and Sennett 1982, Foucault 1988). Since the population believes cultural expectations are appropriate, everyone watches everyone else to ensure compliance with these expectations or norms. When others observe breaking of cultural norms, examination creates a way to determine what is “normal” and what is not, allowing classification and judgement of individuals (Foucault 1977, Foucault and Sennett 1982,

Foucault 1988). Regulating judgement then provides consequences for those breaking

8 cultural norms. With increases in the size and density of many cultural populations in the

19th century, these disciplinary mechanisms became an important means of ensuring compliance with cultural expectations as surveillance of the whole population by authority figures became even less possible (Foucault 1977, Foucault and Sennett 1982).

Foucault (1977, 1988) termed any society utilizing these disciplinary mechanisms throughout its population as a “disciplinary society.”

While Foucault discussed the relationship between power and knowledge broadly, most of his work focuses on the human body as a key element of power relations in modern societies (Foucault and Sennett 1982, Foucault 1988, Foucault 2008). For my purposes here, his discussions of biopower, or institutional power over life, are important in understanding the institutions that exert power over pregnant women in modern U.S. society (Foucault and Sennett 1982, Foucault 2008). Biopower is exercised by powerful institutions with two main goals: 1) the management and regulation of the population to enhance economic value while safeguarding political compliance and 2) regulation of the population to ensure the population’s health and endurance (Foucault and Sennett 1982,

Foucault 1988, Foucault 2008, Smart 2002). Biopower is maintained using the disciplinary techniques described above to guarantee that the population continues to provide the labor necessary for society to function for many generations to come

(Foucault and Sennett 1982, Foucault 1988, Foucault 2008).

As an example of applying Foucault’s ideas to real-world issues, Schee (2009) proposed health policies in schools were a basis for social evaluation and control. Schee

(2009) illustrated how U.S. society has positioned childhood obesity as a problem that

9 needing intervention; this is verified by a U.S. Department of Health and Human Services

(USDHHS) statement that rates of childhood obesity are alarming. Problematization of obesity is a first step in governing the issue. Since schools are well positioned to influence the diets of children and their families, the USDHHS has encouraged many agencies to partner with schools to implement specific health policies that target children at risk for obesity. Schee’s (2009) analysis of interviews with faculty and staff at a school in northeastern U.S. reveals that faculty and staff create “risk groups” for childhood obesity based on moral assumptions in the wider culture. For example, students living in

“abnormal” families, i.e. families with single parents, young parents, and/or children with guardians were assumed to exhibit poor health. An assumed moral superiority of the classic nuclear family in U.S. culture is clearly influenced the creation of these “risk groups.” In terms Foucauldian, faculty and staff observe, examine, and judge students based on cultural norms unrelated to students’ actual health markers for obesity, thereby reinforcing powerful cultural norms and regulating the student population through a problematized health issue.

Neoliberalism and Cultural Models of Health

The neoliberal model of health emerged around the same time as Foucault’s

(1979[1976]) “disciplinary society.” The neoliberal model of health emphasizes privatized risk and responsibility for being healthy so that individual actions are the main way to maintain health. It began with the development of germ theory in the 19th century and research identifying organisms (e.g. bacteria and viruses) as causes of disease. Germ theory and associated biomedical research triggered a shift from focusing on broad

10 environmental and social causes of diseases such as crowding and poor ventilation, to personal decisions such as immunizations and family planning as the main ways to avoid illness (Brown and Duncan 2002, Goraya and Scambler 1998). As the Industrial

Revolution increased crowding and pollution in cities across the U.S., early public health programs focused on the elimination of crowding, filth, and impure water as the best methods to prevent infectious diseases plaguing the U.S. population (Ansari et al. 2003,

Goraya and Scambler 1998, Kramer 1948, Tomes 1990). For example, in the 1870s and

1880s, the popular American press published abundant warnings about “sewer gas” or impure air escaping from indoor plumbing. These public service announcements maintained that this impure air caused people in the household to contract diseases such as yellow fever and malaria while they slept (Tomes 1990). As a result, they recommended not installing of indoor plumbing in houses as a disease prevention measure (Tomes 1990).

While there was initially widespread public support for sanitation as the answer to most public health problems, this sanitary phase of public health quickly fell into disfavor, as the reforms implemented did not produce expected results (Kramer 1948).

The introduction of germ theory, however, revitalized the sanitary phase as eliminating germs through personal actions including frequent hand washing, boiling water, using chemical disinfectants, and isolating the sick became the primary focus (Goraya and

Scambler 1998, Kramer 1948, Tomes 1990). To continue the example above, proponents of germ theory modeled the spread of yellow fever epidemics during the 1870’s to support a hypothesis that a living organism caused the infection. One physician argued,

“[how else could one account] for the spread of the fever from house to house with the regularity of a postman, at the rate of about 40 feet a day. The infection must be a living organism which could grow and increase outside the body” (Barnard 1873: 75). Despite their convictions about the cause of yellow fever, physicians did not fully understand how to prevent it from spreading (Kramer 1948). As such, their recommendations to households in areas stricken by the disease were to moisten areas before applying ample disinfectants since the germ could not be killed if it was dry or partially dry (Kramer

1948). These recommendations reflect the rising emphasis on household sanitation

(Kramer 1948, Tomes 1990).

In addition, health advocacy from the sanitarians in the 19th century targeted literate, urban middle and upper classes as they had more control over their living conditions. As such, personal and household cleanliness showed individual enlightenment and self-discipline furthering the perceived moral and actual social divides between the lower and upper classes (Tomes 1990). American mothers as the keepers of the household also received increased attention from health advocates who linked rises in disease rates to mothers’ individual failings in their personal and household sanitation

(Tomes 1990).

The neoliberal model of health built on the idea that personal decisions dictate disease risk. As a result, the neoliberal model of health stresses individual self-discipline in making “healthy” decisions as the model for staying “healthy” (Brown and Duncan

2002, Goraya and Scambler 1998). Medical research then focuses on identifying risk factors for disease to inform the public about which decisions are “healthiest.” Rise of the

12 lifestyle-changes approach to health also reflects Foucault’s disciplinary society in highlighting individual discipline as the key to maintaining health (Brown and Duncan

2002, Mansfield 2012). In addition, when appropriate “healthy” behaviors are identified, everyone observes and judges everyone else to assure each makes “healthy” decisions, thereby protecting the population from disease (Brown and Duncan 2002). The neoliberal model of health, therefore, reflects Foucault’s disciplinary mechanisms regulating the population as they believe discipline is key to everyone’s healthy.

Pregnancy and childbirth are necessary for maintaining a population making them important areas of attention by cultural structures exerting biopower and subscribe to the neoliberal model of health (Brown and Duncan 2002, Foucault 2007, Foucault 2008,

Mansfield 2012). As such, women frequently are the focus of surveillance and discipline by population members during their pregnancies, childbirth, and well into motherhood

(Browner and Press 1996, Davis-Floyd 2001, Dumit and Davis-Floyd 1998, Ehrenreich and English 1973, Ginsburg and Rapp 1991, Jenkins and Inhorn 2003, Jordan

1993[1978], Oakley 1984, Scheper-Hughes and Lock 1987). The cultural models exerting biopower have convinced our population to have specific expectations for

“good” mothers. Therefore, population members feel they are entitled to reprimand pregnant women when women violate expectations and are being “bad” mothers

(Browner and Press 1996, Jenkins and Inhorn 2003, Root and Browner 2001). Currently, there are two main cultural models of pregnancy and childbirth exercise biopower over pregnant women in the U.S.: biomedical and natural childbirth. The biomedical and the natural childbirth communities exercise authority over pregnancy and childbirth by

13 placing expectations on women to fulfill societal roles, while emphasizing potential dire consequences of ignoring each community’s recommendations for their children. I explore tenets of these models in the next chapter. Next, I discuss the rise of each model in the U.S. and their connection to modern U.S. cultural ideals.

Biopower in U.S. Cultural Models of Pregnancy and Childbirth

As human health became more medicalized, the biomedical model gained biopower (Brown and Duncan 2002, Davis 2006). Medicalization is a sociopolitical process by which medical professionals expand their jurisdiction by redefining human behaviors, natural life processes, and problems of living as illnesses that requiring medical intervention (Brown and Duncan 2002, Davis 2006). The biopower of the natural childbirth model, on the other hand, is a more recent development. It stems from perceived superiority of “natural” things in U.S. culture (Brown and Duncan 2002, Walsh

2010). In this section, I discuss the development of each model beginning with the medicalization of human health and then moving to the rise of the natural childbirth movement as resistance to biomedicine (Browner and Press 1996, Cosans 2004, Davis-

Floyd and Davis 1996, Walsh 2010). Despite their vastly different origins, both models fit with modern U.S. cultural ideals and societal roles, but they present conflicting messages to pregnant women about how to fulfill those roles (Cosans 2004, Song et al.

2010, Walsh 2010).

Biomedical Model of Pregnancy and Childbirth

In the 17th century, U.S. culture (like many other Western cultures) moved from a belief in Earth as a living organism to a belief in a mechanistic universe with predictable

14 laws (Davis-Floyd 1990, Merchant 1980). These new ideas about how the universe works fit well with the Western cultural belief in the human right to dominate nature and reinforced the idea that humans are outside of the natural world (Davis-Floyd 1990,

Merchant 1980). Humans were not part of the natural world, but rather the natural world was to be explained and overcome by human society (Davis-Floyd 1990, Merchant

1980). As a result, a nature/society divide emerged (Davis-Floyd 1990, Mansfield 2008,

Merchant 1980).

In addition, acceptance of the mechanical model of the universe fragmented the established system of organized religion (Davis-Floyd 1990, Merchant 1980). The belief that the universe has predictable laws ran counter to the unpredictability religion was meant to explain (Davis-Floyd 1990, Merchant 1980). Instead, science became the method of choice for explaining how the world works. Science, as a human creation, sits firmly on the society side of the divide as a way not only to explain nature, but also to bend nature to human will (Davis-Floyd 1990, Merchant 1980). Medicine as a science fit with the new mechanical model of belief and took responsibility for the human body from religion. In medicine, the human body was thought of as a machine consisting of a collection of separate parts rather than an interconnected whole (Davis-Floyd 1990,

Merchant 1980). Medical practitioners, therefore, treat symptoms and/or diseases rather than the body as a whole. Today, these beliefs about how the human body works persist in modern medicine (Crossley 2007, Happel-Parkins and Azim 2015, Kukla 2005, Lee and Kirkman 2008, Malacrida and Boulton 2014). Doctors often focus on a patient’s

15 collection of risk factors for diseases rather than how that patient’s body functions as a whole.

As the new mechanical model was established in a society dominated by Christian religions, this belief system was essentially a patriarchal system (Davis-Floyd 1990,

Ehrenreich and English 1979, Merchant 1980). In medicine, the male body became the prototype of the human body machine (Davis-Floyd 1990, Ehrenreich and English 1979,

Merchant 1980). The female body, on the other hand, was considered abnormal, defective, and dangerously under the influence of nature because men did not understand or know how to control women’s menstrual cycle, pregnancy, or childbirth (Davis-Floyd

1990, Ehrenreich and English 1979, Merchant 1980). Pregnancy and childbirth, as natural processes only females can experience, presented a challenge to the patriarchy, but pregnancy and childbirth are necessary processes to maintain a population (Davis-Floyd

1990, Ehrenreich and English 1979, Merchant 1980). The response to this challenge was to remove pregnancy and childbirth from everyday life, place them in the realm of science, and label them as dangerous because these processes are associated with women who are natural and must be controlled (Davis-Floyd 1990, Ehrenreich and English 1979,

Merchant 1980).

Over time, pregnancy and childbirth became completely medicalized. The place of birth moved from the home to the hospital to better control this “dangerous” process

(Davis-Floyd 1990, Ehrenreich and English 1979, Merchant 1980). In hospitals, women’s movements, clothing, and food intakes are controlled by staff to minimize “risk” (Davis-

Floyd 1990, Ehrenreich and English 1979, Merchant 1980). In addition, birth is expected

16 to proceed in a predictable manner. When it does not progress as anticipated, biomedical practitioners begin often non-negotiable medical interventions to force the natural process into a set schedule (Davis-Floyd 2001, Dumit and Davis-Floyd 1998, Ehrenreich and

English 1973, Ginsburg and Rapp 1991, Jenkins and Inhorn 2003, Jordan 1993[1978],

Oakley 1984, Scheper-Hughes and Lock 1987). These interventions seemingly allow humans to bring order to the “dangerously” unpredictable natural process of birth (Davis-

Floyd 1990, Ehrenreich and English 1979, Merchant 1980). While medical intervention improved pregnancy and childbirth outcomes initially and still prevents deaths when used appropriately, portraying pregnancy and childbirth as risky and dangerous processes creates an atmosphere of anxiety and concern that influences pregnant women, their family and friend, and biomedical professionals. This atmosphere leads to higher intervention rates than frequently are necessary. For example, the 2017 cesarean section

(C-section) rate in the United States is 32.0% (Martin et al. 2018) compared to less than

25% for most European countries (Betrán et al. 2016). Although a C-section can be a life- saving surgery in some cases, biomedical and natural childbirth proponents agree that the high C-section rate in the U.S. is a danger to maternal and fetal health as many of the C- sections performed likely were not necessary (Betrán et al. 2016, Malacrida and Boulton

2014). Betrán and colleagues (2016) propose increasing malpractice pressure influences

C-section rates since doctors proceed with a C-section rather than risk a malpractice suit when adverse birth outcomes emerge after a vaginal birth. In addition to malpractice pressure, Malacrida and Boulton (2014) discuss several different arguments for the rise in

C-sections rates including assumptions that a medically managed birth is more safe than a natural birth.

With the medicalization of pregnancy and childbirth came a separation of these processes from everyday life. As discussed by Jordan (1993), birth systems in all cultures have formal and informal methods of teaching women what they need to know for birth.

For cultures in which pregnancy and childbirth are considered part of normal, everyday life, such as the Mayan of the Yucatan, births occur in family homes where children can see if not the actual birth process at least the actions of attendants and sounds of birth

(Jordan 1993[1978]). As a result, women (and often men as well) have a sense of the length, severity, and progression of labor (Jordan 1993[1978]). While Western societies use informal communication channels to varying degrees, most transfer of knowledge about pregnancy and childbirth comes from formal channels such as doctors, midwives, nurses, and prenatal classes. Jordan (1993) reports that in the U.S., informal channels of communication are used to a very limited extent (Jordan 1993[1978]). While U.S. women talk about birth, they tend to give a romanticized account of their own experience (Jordan

1993[1978]). Consequently, without a sense of what normal labor looks like, U.S. women often believe that when their own birth experience does not match romanticized accounts, they have failed on a personal level (Jordan 1993[1978], Malacrida and Boulton 2014).

Removal of pregnancy and childbirth from everyday life, then, creates a sense of alienation for pregnant women in the U.S. as they have a strong fear of the unknown once they become pregnant (Browner and Press 1996, Hays 1996, Howell-White 1997, Jenkins

18 and Inhorn 2003, Luce et al. 2016, Root and Browner 2001, Scheper-Hughes and Lock

1987).

Several studies have focused on how biomedical power has affected women’s perceptions of pregnancy and childbirth, as well as, the detrimental effects of medical interventions on pregnancy and childbirth complication rates (Browner and Press 1996,

Davis-Floyd 2001, Dumit and Davis-Floyd 1998, Ehrenreich and English 1973, Ginsburg and Rapp 1991, Hays 1996, Howell-White 1997, Jenkins and Inhorn 2003, Jordan

1993[1978], Moore 2011, Oakley 1984, Root and Browner 2001, Scheper-Hughes and

Lock 1987). Root and Browner’s (2001) ethnographic study of how biomedicine shapes women’s decision-making during pregnancy mirrors similar studies in medical anthropology. Root and Browner (2001) reported that pregnant women use multiple strategies to determine authoritative knowledge (AK), or the “knowledge that counts”

(Jordan 1993[1978]: 152) and, therefore, the knowledge they will follow. In making these decision, they often must reconcile AK from biomedical sources with the knowledge women gain from the changes they experience during pregnancy. In fact, pregnant women demonstrate different levels of compliance and resistance in deciding which behaviors they should practice during pregnancy. Some women exhibit absolute compliance with biomedical advice and believe non-medical advice is non-credible, or even dishonest (Root and Browner 2001). Other women exhibit open resistance to biomedical advice often because they do not feel any adverse physical reaction from their behaviors. For example, one interview participant felt her need to have a soda every day was more important than her doctor’s recommendation that she avoid caffeine because

19 she didn’t feel any negative effects from the caffeine (Root and Browner 2001: 216-217).

Root and Browner (2001) note, however, that many more women followed their doctor’s orders rather than showing resistance illustrating how embedded biomedicine is in U.S. women’s ideals about pregnancy and childbirth.

A shift in cultural ideals towards the superiority of “natural” things emerged as a response to the over-medicalization of health (Cosans 2004, Crossley 2007, Walsh 2010).

The natural childbirth movement, specifically, grew in response to the overmedicalization of pregnancy and childbirth as many feminist writers began to dispute the patriarchal control biomedicine had on the feminine processes of pregnancy and childbirth

(Ehrenreich and English 1973, Ginsburg and Rapp 1991, Jenkins and Inhorn 2003,

Jordan 1993[1978], Oakley 1984). These writers instead advocated a return to female- lead childbirth more common in other centuries and in some other parts of the world.

They argue patriarchal control was gained through the demonization of midwives and other female practitioners traditionally associated with pregnancy and childbirth

(Ehrenreich and English 1973, Ginsburg and Rapp 1991, Jenkins and Inhorn 2003,

Jordan 1993[1978], Oakley 1984). Many researchers cite the seminal work, Witches,

Midwives, & Nurses: A history of women healers, by Ehrenreich and English (1973) as the first of many feminist critiques of the medical establishment. In their book,

Ehrenreich and English (1973) illustrate how biomedicine has historic roots in witch hunting and the effect of that history on women’s place in Western societies. According to Ehrenreich and English (1973), as well as other writers, this shift to patriarchal obstetrics not only devalued women in society, but also led to more risks for mother and

20 fetus during childbirth such as increased rates of postpartum fever, vaginal deliveries using instruments such as forceps and suction, and respiratory problems among infants born via C-section (Ehrenreich and English 1973, Ginsburg and Rapp 1991, Jenkins and

Inhorn 2003, Jordan 1993[1978], Lieberman and O’Donoghue 2002, Oakley 1984).

While the natural childbirth movement began in the 1970’s, it has gained momentum in the new millennium as broader U.S. society shows increasing interest in more “natural” practices such as alternative medicine and growing/eating organic foods.

While many people who participated in the counterculture movements of the 1960’s and

1970’s advocated for the more “natural” approaches to healing, widespread interest in these practices didn’t emerge until the 1990’s with the creation of the Office of

Alternative Medicine (OAM) by U.S. Senator Thomas Harkin (Whorton 2002). As

Senator Harkin believed his allergies were cured by bee pollen, he created the OAM to test the efficacy of alternative medicine approaches (Whorton 2002). Public interest continued to increase as the biomedical community began scientifically testing various alternative medicine and natural restorative approaches (Whorton 2002). Since several scientific studies showed the efficacy of some alternative approaches, the biomedical community helped legitimize alternative medicine further establishing natural approaches to health as a viable course of action (Whorton 2002).

In terms of pregnancy and childbirth, women’s rising focus on natural childbirth is visible in the growing number of birth centers, which increased from 170 in 2004 to

248 in 2014, as well as the steadily increasing number of women who elect to give birth outside of a hospital (Hamilton et al. 2015, Hazen 2017). Additionally, more and more

21 women are choosing midwives to attend their births, partly due to women’s own definition of birth as a natural process and their desire to avoid technological interventions (Howell-White 1997, Miller and Shriver 2012). In 1989, the first year for which data are available, 3.0% of births in the U.S. were attended by midwives rising steadily to 8.8% in 2016 (Declercq et al. 2013, Martin et al. 2018). Use of a doula during birth also increased from 3.0% in 2006 to 6.0% in 2012 (Declercq et al. 2007, Declercq et al. 2013). In fact, according to the Childbirth Connection’s Listening to Mothers III survey of 2400 U.S. women, 61% of the sample agreed that childbirth is a natural process and should not be interfered with unless medically necessary (Declercq et al. 2013). The issue, however, as many women discover during childbirth, is that there are power relations at play in deciding when intervention is medically necessary. Particularly in hospital settings, biomedical professionals take control over the birth process by telling women what they can and cannot do (Cole et al. 2019, Happel-Parkins and Azim 2015,

Malacrida and Boulton 2014). In addition, biomedical professionals often present medical interventions as necessary for the survival of the fetus even if the utility of the medical intervention is not well understood (Cole et al. 2019, Happel-Parkins and Azim 2015,

Malacrida and Boulton 2014). For example, after analyzing women’s birth narratives,

Happel-Parkins and Azim (2015) reported that women often were ignored and/or silenced during childbirth. Women in their study also were given false dilemmas, which highlighted the dire consequences of disregarding biomedical advice and limited women’s options during birth. Understanding these power relationships is vital to understanding and potentially reducing women’s stress levels during pregnancy and

22 improving their experiences during childbirth as well as perhaps decreasing rates of adverse birth outcomes.

While many studies analyze and criticize biomedicine’s influence on pregnancy and childbirth, fewer studies have critically examined the model of pregnancy and childbirth presented by the natural childbirth movement as it gains authority in U.S. society (Cosans 2004, Crossley 2007, Mansfield 2008, Walsh 2010). Proponents of the natural childbirth movement have various ideas of what natural childbirth means

(Mansfield 2008, Martin 1987, Moscucci 2003, Thompson 2005, Wertz and Wertz 1989).

Some proponents suggest natural childbirth is simply a return to “human nature,” often citing centuries of childbirth in and around women’s homes as evidence of women’s ability to give birth without assistance (Mansfield 2008, Moscucci 2003, Thompson

2005). Human biological processes and practices including pregnancy and childbirth are distinctly biocultural, drawing elements from the interaction between human biology and human culture (Dressler 2011, Leatherman and Goodman 2011, Mansfield 2008). Still, natural childbirth practitioners frequently place the natural childbirth and biomedical models on opposite sides of the nature-society divide focusing solely on women’s biological reproduction and ignoring the social nature of childbirth (Crossley 2007,

Mansfield 2008, Westfall and Benoit 2004).

The modern human birth mechanism, or the way a human neonate rotates through the birth canal, however, requires both biological and cultural adjustments for the birth process to progress as safely as possible (Fischer and Mitteroecker 2015, Underdown and

Oppenheimer 2016). Known as the obstetric dilemma, childbirth in humans is

23 challenging due to a large neonate head and a relatively small pelvic opening compared to most other primates (Fischer and Mitteroecker 2015, Rosenberg and Trevathan 1995,

Wells et al. 2012) (Figure 2.1). While there is debate about how and when the obstetric dilemma emerged, modern human childbirth remains a difficult process for women

(Fischer and Mitteroecker 2015, Rosenberg and Trevathan 1995, Underdown and

Oppenheimer 2016).

Figure 2.1. Relative size of maternal pelvic inlet and the size of the neonatal head in different primate species (Rosenberg and Trevathan 1995: 162, adapted from Schultz 1969). Outlined circle represents the maternal pelvic inlet; black circle represents the neonatal head.

In addition, human neonates are particularly altricial at birth since their brains are relatively undeveloped compared to other animals (Rosenberg and Trevathan 2000). As a result, women often need assistance during childbirth, a cultural adaptation reflected in the long cross-cultural history of assisted birth practices (Jordan 1993[1978]). In other words, as human ancestors tended to live in social groups and birth became more problematic, assisted birth became the norm and remains the norm across human cultures

(Jordan 1993[1978], Rosenberg and Trevathan 2002).

Other advocates of the natural childbirth model acknowledge that natural childbirth involves a distinctly social component meaning having social support during the birth process is essential to having a natural childbirth (Arney 1982, Mansfield 2008,

Martin 2003). These proponents, however, still tend to place natural childbirth on the nature side and the biomedical model on the society side of a nature/society divide

(Mansfield 2008, Martin 1987, Wertz and Wertz 1989). The natural childbirth model, however, is inherently cultural as it emerged from cultural concepts of pregnancy and childbirth that largely were in opposition to the biomedical model (Cosans 2004,

Mansfield 2008, Merchant 1980, Soper 1995, Wertz and Wertz 1989). As such, the natural childbirth model relies on dialogue with other cultural expectations to define natural childbirth (Annandale and Clark 1996, Crossley 2007, Mansfield 2008, Westfall and Benoit 2004). In addition, advocates of natural childbirth, particularly advocates who interact directly with pregnant women, draw on broader cultural expectations such as cultural ideals of motherhood in explaining why they believe that natural childbirth is important to consider (Annandale and Clark 1996, Mansfield 2008, Mackenzie and

Oliphant 2010, Westfall and Benoit 2004). By emphasizing cultural ideals of motherhood and nature, natural childbirth supporters engrain the natural childbirth model in culture just as proponents of the biomedical model ground it in cultural beliefs about motherhood, science and progress.

With the rise of the natural childbirth movement, women are becoming more familiar with the natural childbirth model as an alternative to the biomedical model

(Miller and Shriver 2012, Walsh 2010, Westfall and Benoit 2004). As both models present strong messages about appropriate behaviors during pregnancy and childbirth, women have to make decisions about which advice to follow. Individual decision- making, however, is influenced by more than cultural expectations.

Individual Decision-Making in a Cultural System with Competing Models

Faced with messages from these two cultural models with biopower, women make decisions about whose advice to trust. In other words, women must determine who has the authoritative knowledge (AK). Making these AK decisions about behaviors during pregnancy and childbirth plans, however, is a personal process that involves consideration of several influences.

Building on the critical medical anthropology framework established by Baer et al. (1986) and Singer (1995), understanding individual decision-making about health requires an investigation of how macro-social, intermediate social, micro-social, and individual factors influence a person’s understanding of appropriate health behaviors

(Figure 2.2). Macro-level factors affect individual decision-making by creating the cultural lens through which people see their health and include cultural institutions of the

26 global political economy such as capitalism as well as pervasive cultural beliefs and national class structure. Intermediate-level factors consisting of popular and folk beliefs influenced by the media and the beliefs of previous generations introduce and reinforce cultural norms about health. Micro-social factors such as interactions with others in the same culture are the main way beliefs about health are transmitted to the person making a decision. Finally, individual factors including personal experience and an individual’s established belief system help determine how a person sees the information they receive.

Cultural expectations about pregnancy and childbirth emerge from macro-level factors including the factors that helped create the two cultural models exerting biopower

(Baer et al. 1986, Singer 1995, Singer and Baer 1995). For example, biomedical definitions of pregnancy and childbirth are based on macro-level factors including a cultural belief in the superiority of science and progress over nature and tradition (Davis-

Floyd 2001, Ehrenreich and English 1973, Scheper-Hughes and Lock 1987, Weber

1946). The biomedical model ignores the cultural context of its recommendations.

Instead, it highlights the superior objectivity of scientific knowledge and creates a view of pregnancy and childbirth as a dangerous medical event. As such, pregnancy and childbirth require technological intervention and maternal self-discipline to follow biomedical advice rather than social support, knowledge passed down through female generations, and embodied knowledge (Jordan 1993[1978], Oakley 1984, Scheper-

Hughes and Lock 1987).

Figure 2.2. Levels of influences on personal decision-making about health (adapted from Baer et al. 1986: 96).

Embodied knowledge is knowledge gained from personal experience. In pregnancy and childbirth, women may have embodied knowledge from direct personal experience if they have children (Davis-Floyd 2001, Lou et al. 2017). First-time mothers, however, also have embodied knowledge about health in general as they have been caring for themselves for several years (Root and Browner 2001, Song et al. 2012).

Biomedical practitioners also focus on fetal health as the most important factor in pregnancy and childbirth sometimes placing only secondary emphasis on maternal health

(Davis-Floyd 2001, Mansfield 2012, Markens et al. 1997, Scheper-Hughes and Lock

1987). In fact, the maternal mortality rate in the U.S. is higher than in any other developed country and is rising, while the rate is decreasing in other developed countries

(CDC 2017). A CDC committee found that over half of maternal deaths in the U.S. were preventable and largely due to hospitals that are insufficiently prepared for maternal emergencies (CDC 2017). Highlighting fetal health over maternal health rather than as two strongly connected parts of a whole is typical of the broader scientific tendency in the U.S. to examine the body as isolated parts instead of an interconnected system

(Mansfield 2012, Markens et al. 1997, Scheper-Hughes and Lock 1987). As such, women making decisions about their behaviors during pregnancy and childbirth are influenced by these beliefs in scientific superiority and the inherent dangers of pregnancy and childbirth.

Additionally, macro-level factors such as capitalist ideals influence the expectations of the biomedical model in several ways. As the U.S. medical system focuses more on profit, medical professionals are pushed to see as many patients as

29 possible leaving less one-on-one time with each patient. Frequently, these pressures on medical professionals results in disjointed relationships between professionals and pregnant women that further alienates pregnancy from “normal” life (Davis-Floyd 2001,

Ehrenreich and English 1973, Miller and Shriver 2012, Scheper-Hughes and Lock 1987,

Weber 1946).

While the natural childbirth model denies the superiority of science and instead advocates for a more “natural” approach to pregnancy and childbirth, its messages also are aligned with established cultural ideals such as the power of nature and the tenets of the neoliberal model of health (Cosans 2004, Mansfield 2008, Merchant 1980, Soper

1995, Wertz and Wertz 1989). As described in the previous section, U.S. society has seen a spike in interest about natural approaches to healthcare that has made room for widespread acceptance of pregnancy and childbirth as natural processes (Miller and

Shriver 2012, Walsh 2010, Whorton 2002). The natural childbirth movement fits with this shift toward a growing cultural belief in the power of nature to maintain health. In addition, the neoliberal model of health stresses a need to take personal responsibility for health and gather information to properly participate in healthcare (Brown and Duncan

2002). Generally, the natural childbirth movement targets women in higher socioeconomic categories through books and websites as these women have more access to the resources needed to gather information about the natural childbirth movement

(Abbyad and Robertson 2011, Song et al. 2012). They also have more choice in their pregnancy and childbirth decisions as they have more healthcare options and the money to pay for additional services such as a doula to help during labor and delivery (Abbyad

30 and Robertson 2011, Lazarus 1994, Song et al. 2012). Women with less privilege, on the other hand, are not expected to have the choices necessary to decide to give birth naturally (Abbyad and Robertson 2011, Lazarus 1994). Although the natural childbirth model contradicts many of the ideas of the biomedical model, use of the recognized cultural ideals surrounding nature and the neoliberal model of health made the natural childbirth model more acceptable to U.S. women and helped establish the natural childbirth model as a second model exerting biopower in the U.S.

With these two powerful models operating in U.S. society, pregnant women now face the decision of whether biomedicine indeed has the authority it claims or if knowledge from the natural childbirth model is more authoritative. For example, in

Westfall and Benoit’s (2004) study of labor induction among women whose pregnancies extended beyond 40 weeks, many women whose labor was induced trusted their doctors to make the decision about when induction was necessary, but they frequently also felt guilty for giving in to biomedical pressure. Women’s guilt about their decision reveals their struggles deciding which model is more authoritative.

Intermediate-level factors including popular beliefs regarding pregnancy and childbirth drawn from the broader cultural ideals described above and reinforced through presentations in the media. Popular beliefs also create Foucault’s disciplinary society by presenting the public with various versions of appropriate behaviors. The public then surveils pregnant women to ensure compliance with whichever behaviors U.S. society deems appropriate (Browner and Press 1996, Miller and Shriver 2012, Song et al. 2012).

As a result, women are further compelled to conform to societal expectations about

31 motherhood (Browner and Press 1996, Root and Browner 2001, Song et al. 2012). The internet, as a main source of information for many pregnant women, may bombard them with conflicting information and unlikely horror stories that create increased pressure and anxiety as women struggle to make decisions regarding their pregnancy and childbirth plans (Song et al. 2012). In addition, media images and stories re-enforce societal expectations by showing how a “normal” pregnancy and childbirth progresses, often stressing the pain and discomfort for comedic effect. Since societal expectations compete, however, popular beliefs can vary greatly creating maternal confusion and stress when they have to decide whose advice to believe (Browner and Press 1996, Song et al. 2012).

Individual decision-making also involves the interaction of the other levels of analysis with micro-social factors including personal interactions with healthcare providers, family, and friends (Baer et al. 1986, Miller and Shriver 2012, Singer 1995,

Singer and Baer 1995). Much of the information on pregnancy and childbirth is transmitted to pregnant women through personal contact, particularly formal meetings with healthcare professionals (Jordan 1993[1978]). These micro-social factors impact women’s decision-making by presenting and reinforcing AK claims through interactions with people women trust in other aspects of their lives (Baer et al. 1986, Miller and

Shriver 2012, Singer 1995, Singer and Baer 1995). For example, many women ask advice from their mothers. The information their mothers provide has authority because many women trust their mothers and are used to relying on their advice. Motherly advice, however, is based on a mother’s own experiences and perceptions of cultural expectations. As such, motherly advice may differ from advice women receive from their

32 friends, other family members, and healthcare providers. Women then must again make decisions about AK to find the “best” pregnancy and childbirth behaviors.

Individuals, however, also make decisions based on their individual experiences and beliefs. In other words, when pregnant women receive advice from all of the sources described, they weigh that advice by determining what is most important according to how they perceive the world around them and what they already know about their health

(Berger and Luckmann 1966, Mannheim 1952, Westfall and Benoit 2004). Women’s socialization process shapes the order in which pregnant women sort through the knowledge they receive. The socialization process is the lifelong practice of learning cultural norms, customs, values and ideologies that provides an individual with the skills and habits necessary for meeting cultural expectations (Berger and Luckmann 1966,

Mannheim 1952). For example, women who grow up in a religious-centered household sometimes reject the biomedical model as they look to religious leaders and sacred teachings to help them make decisions about their health (Klassen 2001, Miller and

Shriver 2012). The religious teachings of their youth promote minimal interference with the body’s natural processes as God determines what happens (Klassen 2001, Miller and

Shriver 2012). These women then prioritize knowledge from religious sources as authoritative since they learned from their family and communities that those are the appropriate authoritative sources (Klassen 2001, Miller and Shriver 2012). As adults, women use the knowledge priorities they establish throughout their lives to decide how to rank the knowledge they receive when messages conflict (Berger and Luckmann 1966,

Mannheim 1952).

Faced with strong competing messages, as is often the case when two models with biopower exist in a single culture, women must negotiate how advice fits into their personal understanding of their culture. Consequently, they must make AK decisions about which information to prioritize often funneling advice through knowledge derived from their own experiences, particularly in subsequent pregnancies (Berger and

Luckmann 1966, Browner and Press 1996, Davis-Floyd and Sargent 1997, Mannheim

1952, Root and Browner 2001, Song et al. 2012). For instance, women pregnant with a second or third child frequently incorporate advice that “promised to resolve physiological problems they experienced in previous pregnancies,” thereby reducing the number of AK decisions they must make during subsequent pregnancies (Browner and

Press 1996: 147). Ethnographic studies also reveal the anxiety about maternal/fetal health and wellbeing (pregnancy-specific anxiety) women feel when forced to sort through conflicting messages (Browner and Press 1996, Root and Browner 2001, Song et al.

2012). For example, in their study of pregnant women, Browner and Press (1996) mention several instances in which their interviewees found available information neither helpful nor reassuring as the information they received included competing messages indicating a need for researchers to examine the messages women receive and the effect of those messages on women’s mental and physical health.

A Biocultural Approach

To investigate how the messages women receive during pregnancy affect their mental and physical health, I used a biocultural approach within the critical medical anthropology framework described earlier in this chapter. Humans are a biocultural

34 species who adapt to their environment in a myriad of cultural ways, but cultural adaptations may affect our biology as well. Examining aspects of health as an interaction between biology and culture, therefore, is essential to understanding many health issues

(Dufour 2006, Leatherman and Goodman 2011, Hicks and Leonard 2014). Currently, however, there is no consensus on what the term biocultural means despite steady usage in anthropological journals over the past 40 years (Hicks and Leonard 2014, Wiley and

Cullin 2016). Wiley and Cullin’s (2016) analysis of articles using the term biocultural in

22 peer-reviewed anthropological journals revealed no consistent definition, methodology, or theoretical framework utilized by anthropologists who identify their work as biocultural. Instead, two trends emerged in biocultural studies: a focus on health and an evaluation of how the cultural environment affects human biology (Hicks and

Leonard 2014, Wiley and Cullin 2016). In addition, many biocultural studies investigate the widespread effects of power differentials and structural violence by applying political economic theories to help explain biological variation (Farmer 2004, Wiley and Cullin

2016). Advocated by Goodman and Leatherman (1998) in their seminal edited volume,

Building a New Biocultural Synthesis: Political Economic Perspectives on Human

Biology, understanding the cultural and historical context of political economic structures is a necessary step to explaining human biological variation as power relations often affect access to resources.

While there is wide variation in the use of the term biocultural, I am following

Dufour (2006: 2) in defining a biocultural approach as a study that explores the “dynamic interactions between humans as biological beings and the social, cultural, and physical

35 environments they inhabit.” In addition, the biocultural approach I use here follows the two trends identified by Wiley and Cullin (2016) in that I focus on how the U.S. sociocultural environment and the cultural and historical context of power relations affect pregnant women’s emotional and physiological responses. As such, the biocultural approach of this project fills an important gap in anthropological literature as no previous studies of which I am aware have investigated the biological consequences of pregnant women’s experiences with cultural expectations of motherhood.

The seminal work of Paul Farmer is a model of a biocultural approach to medical anthropology as his work combines aspects of history, political economy, and health assessment with rich ethnographic methodology (Farmer 1992). Farmer (1992) uses the concept of structural violence to show how local poverty that rose from the political- economic history of Haiti affected Haitians vulnerability to HIV/AIDS. Structural violence describes how social structures such as race and class marginalize some portions of a population. Farmer (1992, 2004) demonstrates how marginalization from structural violence creates Haitian’s biocultural vulnerability to HIV/AIDS through limited access to resources and reduced agency. Examining HIV/AIDS through the intersection of all of these lenses allowed Farmer (1992) to present a more holistic picture of the biological and cultural understandings of this health issue. While I do not focus on how race and class structure limit access to resources, I do consider how race and class privilege affect the messages women receive during pregnancy.

Additionally, I follow Dressler’s biocultural approach (2005, 2007, 2011) in developing specific pictures of the U.S. cultural consensus about what constitutes a good

36 pregnancy and childbirth experience. Using cultural consensus models about pregnancy and childbirth allows me to investigate women’s perceived and biological stress responses when they face conflicting cultural norms and/or fail to conform to cultural norms. Dressler’s (2005, 2007, 2011) work, therefore, provides the methodology I need to show how the cultural environment affects women’s biological stress during pregnancy.

In this dissertation, a biocultural approach provides a way to map how cultural expectations influence women’s perceived and biological stress responses at a moment of major transition. Pregnancy provides a unique opportunity to detect the effects of internalizing cultural expectations, as women must decide how to be a good mother in the midst of competing models exerting biopower that they likely have only previously encountered in passing. As many U.S. women are bombarded with messages about how to be a good mother only after they become pregnant, cultural expectations of motherhood are potentially a new stressor in women’s lives, particularly for first-time mothers. Capturing various types of perceived stress responses and cortisol measures over the course of pregnancy, therefore, helps me see how this potential new stressor affects women’s individual stress responses. Linking cultural beliefs to biological outcomes also provides a possible biocultural mechanism for explaining variation in infant mortality/morbidity and reproductive morbidity adding to an extremely limited body of biocultural research about pregnancy and childbirth.

Chapter 3: Research Model

U.S. society places high and often inconsistent expectations on women regarding pregnancy and motherhood stemming from cultural definitions of how “good mothers” should act (Davis-Floyd 2001, Ehrenreich and English 1973, Hardey 1999, Imber 2008,

Scheper-Hughes and Lock 1987, Song et al. 2012). Differing definitions of “good mother” exist in the U.S., however, reflecting diverse cultural ideals. Many of these

“good mother” definitions emerge from two competing cultural models of pregnancy and childbirth that exert biopower (biomedicine and the natural childbirth movement) operating within the neoliberal model of health, as discussed in Chapter 2 (Foucault

2008, Scheper-Hughes and Lock 1987). While these two major cultural models agree that pregnant women should employ self-discipline in following authoritative advice, they disagree on how and when pregnant women should rely on authoritative knowledge

(AK) and whose knowledge is authoritative (Foucault 2008, Mansfield 2012, Scheper-

Hughes and Lock 1987). Despite the clear disparity between the two models, I am unaware of any research examining women’s experiences negotiating messaging from two competing cultural models at the same time as they make decisions about their behaviors during pregnancy and how they want their childbirth experiences to proceed. I propose that attempting to fulfill these competing societal expectations is an unexplored factor contributing to higher self-reported stress levels and steeper hair cortisol 38 trajectories. Results potentially will contribute to a better understanding of poor birth outcome rates in the U.S.

U.S. Cultural Models of Pregnancy and Childbirth

In the U.S., the biomedical model has created a medicalized model of pregnancy and childbirth that highlights separation of the mind and body and the superiority of scientific knowledge as AK (Davis-Floyd 2001, Davis-Floyd and Davis 1996, Ehrenreich and English 1973, Hardey 1999, Imber 2008, Jordan 1993, Oakley 1984, Scheper-Hughes and Lock 1987). According to biomedical doctrines, pregnancy and childbirth are inherently risky processes that need to be controlled by biomedical professionals for the safety of mother and child (Table 3.1) (Hays, B. 1996, Jordan 1993, Oakley 1984). As such, pregnancy and childbirth require extensive medical management including frequent technological interventions (Davis-Floyd 2001, Davis-Floyd and Davis 1996, Jordan

1993, McCoyd et al. 2010, Oakley 1984, Scheper-Hughes and Lock 1987). Since biomedical professionals have the most knowledge and experience with technological intervention, requiring medical management sets up biomedical professionals as authorities on AK (Davis-Floyd 2001, Ehrenreich and English 1973, Jordan 1993, Oakley

1984).

In addition, technological monitoring by sonogram, electronic fetal monitor, and/or bloodwork allows biomedical professionals to use an objective means of gathering information on fetal health rather than relying on women’s subjective experiences and intuition thereby separating the mother from her fetus (Ehrenreich and English 1973,

Jordan 1987, Jordan 1993, Oakley 1984).

Table 3.1. Comparison of the Biomedical and Natural Childbirth Models’ tenets.

Biomedical Model Natural Childbirth Model

Pregnancy and childbirth are risky Pregnancy and childbirth are natural processes processes Childbirth needs to be controlled by Childbirth needs to be allowed to progress biomedical professionals with on its own without technological technological interventions interference Women need to be informed, but Women need to be informed because biomedical professionals have the biomedical professionals can’t be trusted authoritative knowledge as the single source of authoritative knowledge Fetus as patient Fetus as part of mother Need to collect objective physiological Need to rely on mother’s subjective information on fetus feelings for information on fetus Women should let biomedical Women should be strong in resisting professionals make decisions for them technological intervention

For example, for almost 30 years, most U.S. women have had at least two sonograms during pregnancy to set the due date and check fetal development. In making sonograms routine, biomedical professionals are able to determine how the baby is growing and developing without resorting to women’s impressions of fetal development based on how their bodies feel (Brauer 2016). Sonograms also cement a maternal-fetal separation as the purpose of the sonogram is to detect abnormalities making the fetus an individual patient outside of the mother’s patient status (Brauer 2016). Through reliance on technology to determine both maternal and fetal health, biomedicine creates a cultural model in which authority and responsibility for pregnancy and childbirth primarily lie with biomedical practitioners rather than the mother (Brauer 2016, Davis-Floyd 2001).

As backlash to the over-medicalization of pregnancy and childbirth, the natural childbirth movement and associated model of pregnancy and childbirth emphasizes the superiority of natural things including the “naturalness” of pregnancy and childbirth

(Cosans 2004, Mansfield 2008, Walsh 2010). In contrast to biomedicine, the natural childbirth movement stresses women’s responsibilities in avoiding or even resisting

“unsafe” technological interventions and remaining skeptical of biomedical advice

(McCoyd et al. 2010, Walsh 2010). According to the natural childbirth model, the technological interventions that most women experience during birth are not only unnecessary, but also detrimental as they interrupt natural processes (Hazen 2017,

Mansfield 2008, Walsh 2010). As an example, many natural childbirth proponents use a study by Lent (1999) to demonstrate the risks associated with technological intervention

(Beckett 2005). Lent (1999) shows that widespread use of electronic fetal monitoring leads to a striking overestimation of fetal distress resulting in increased rates of Cesarean section and induction (Beckett 2005). According to natural childbirth proponents, Lent’s

(1999) study demonstrates not only how technological intervention puts mother and child in greater danger, but also the biomedical tendency to separate the fetus from the mother

(Beckett 2005).

In addition, the natural childbirth model warns that the advice women receive from biomedical professionals is tainted by the professionals’ own biases and agendas

(Davis-Floyd 2001, Ginsburg and Rapp 1991, Hays 1996, Sargent and Gulbas 2011). As such, pregnant women have a responsibility to extensively research their options for childbirth. In fact, in her review of books on natural childbirth, Mansfield (2008)

41 mentions that the term “natural” is not well defined among natural childbirth practitioners. Instead, she concludes that “natural” has a distinctive social component which, to make childbirth natural, requires women to explore their options for childbirth, adequately prepare for childbirth by practicing natural childbirth techniques, and find people who support their decision to have a natural childbirth (Cosans 2004, Walsh

2010). Mansfield (2008: 1093) concludes that natural childbirth books require social practice to make natural childbirth successful, but also advocate that women “follow their instincts” and “do what comes naturally.” This seeming contradiction contributes to the mixed messages women receive about “best” practices during pregnancy and childbirth as women must fulfill both the social and instinctive components of natural childbirth to make it natural (Cosans 2004, Jordan 1987, Mansfield 2008, Walsh 2010).

Despite contradictory messages, biomedicine and the natural childbirth movement both argue that not following their advice will harm maternal/fetal health (Foucault 2008,

Mansfield 2012). While many researchers have focused on how the biomedical model has over-medicalized pregnancy and childbirth, fewer studies have examined the tenets of the natural childbirth movement (Beckett 2005, Mansfield 2012, Walsh 2010). A handful of recent studies have examined these two models as they relate to specific birth practices such as views of Cesarean sections and homebirths (Buitendijk 2011, Davis-Floyd and

Davis 1996, Hazen 2017, Klassen 2001, Moore 2011, Walsh 2010, Westfall and Benoit

2004). These studies demonstrate that while a continuum exists between the philosophies of these two models, there are clear differences in how practitioners associated with each model view some aspects of pregnancy and childbirth (Buitendijk 2011, Hazen 2017,

Klassen 2001, Moore 2011, Walsh 2010). To my knowledge, no one has systematically compared these two cultural models as they are understood by women’s health professionals – the very individuals who reinforce the models’ ideals in their work with pregnant women. To address this gap, I began my research with a preliminary ethnographic study of women’s health professionals from biomedical and natural childbirth communities in Columbus, Ohio to further articulate the tenets of these two models. Investigating how these professionals present each models’ ideals is an important step in understanding the potential conflicting information pregnant women must contend with in making decisions about pregnancy and childbirth.

Societal expectations of mothers in the U.S.

Despite their differing messages, both the biomedical and natural childbirth models fit within the neoliberal model of health, which highlights a woman’s responsibility to protect her fetus rather than indulging in behaviors that fulfill her own wants. This emphasis on fetal rights and individual responsibility, within both cultural models, has forced two roles on pregnant women, which they are expected to fulfill

(Hays, S. 1996, Foucault 2008, Mansfield 2012). First, women are expected to become

“informed patients” by researching their options to properly participate in their care

(Song et al. 2012). “Informed patients” must show they are competent and responsible by gathering information and questioning expert opinion. Second, women must show that they are “good mothers” by exerting self-discipline in their choices to ensure the best outcome for their children, as well as, themselves, though maintaining maternal health is considered a less important goal (Foucault 2008, Mansfield 2012, Walsh 2010). “Good

43 mothers” also are expected to devote extensive time and resources to their children even before they give birth (Song et al. 2012). The “informed patient” and “good mother” roles go hand-in-hand as one of women’s responsibilities is to spend time and effort researching “best” behaviors.

Within the biomedical model, women’s “informed patient” role results in a complicated set of expectations. Women must perform extensive research to determine the appropriate behaviors during pregnancy and they should not accept “expert” opinion without question (Barker 2008, Song et al. 2012). Instead, they should work in collaboration with their doctors by discussing information they receive from other sources with biomedical professionals (Song et al. 2012). The opinion of biomedical practitioners, however, is still considered the ultimate authoritative voice regarding the

“best” behaviors for pregnant women (Annandale and Clark 1996, Westfall and Benoit

2004). By expecting women to discuss outside information with their biomedical providers, the “informed patient” role within the biomedical model may actually strengthen the authoritative role of biomedicine rather than undermining it as biomedical professionals have the chance to agree with or refute outside information (Song et al.

2012).

The natural childbirth model also places expectations on women to become

“informed patients,” but the tenets of the natural childbirth model emphasize the dangers of relying on biomedical practitioners as the main source of AK (Annandale and Clark

1996, Cosslett 1994, Westfall and Benoit 2004, Song et al. 2012). Natural childbirth practitioners insist women gather information from multiple sources mostly leaving

44 evaluation of those sources to the women themselves (Annandale and Clark 1996,

Mansfield 2008, Westfall and Benoit 2004). In some ways, then, women have more responsibilities as “informed patients” in the natural childbirth model than they do in the biomedical model. Despite their insistence that women research broadly, proponents of the natural childbirth model recommend books and websites that describe “natural” behaviors such as childbirth methods that focus on ways to give birth without technological intervention, breathing techniques that reduce stress, and herbal medicines for pain relief as important alternatives to biomedical advice (Mansfield 2008, Walsh

2010, Westfall and Benoit 2004).

Both the biomedical and natural childbirth models suggest women need to sacrifice their own wants and needs in favor of choosing the “best” behaviors for their children (Barker 2008, Hardey 1999, Imber 2008, Song et al. 2012). From improving their diets to giving up various foods and substances, women must do what is deemed safest, although as mentioned previously, safe practices are debated not only within the biomedical community, but also between the two biopowers (Browner and Press 1996,

Markens et al. 2010, Song et al. 2012). The two models also emphasize an expectation of maternal sacrifice that indicates “good mothers” should suffer nobly placing great responsibility on women to identify problems (Bessett 2010). Additionally, “good mothers” should spend copious amounts of time researching all aspects of pregnancy and childbirth (Barker 2008, Hardey 1999, Imber 2008, Song et al. 2012). According to the biomedical model, any information received from other sources should be discussed with biomedical professionals to show that a woman is both a “good mother” and an

“informed patient” (Song et al. 2012). The natural childbirth model, on the other hand, emphasizes researching pregnancy and childbirth in order for women to take responsibility for their pregnancies and childbirth experiences and become empowered as a result (Mansfield 2008).

Although all mothers in the U.S. are expected to be “good” mothers, women must possess sufficient economic and cultural resources to participate in their care as required by these two roles meaning women with race and class privilege are better positioned to fulfill societal expectations (Song et al. 2012). In terms of healthcare, women who have little to no healthcare usually have fewer provider and childbirth location choices

(Milligan et al. 2002, Novick 2009, Sword 2003). They may not be able to pick a provider that fits with their ideas of how pregnancy and childbirth should progress

(Milligan et al. 2002, Novick 2009, Sword 2003). They also frequently encounter an unresponsive system with providers who do not listen to their fears and concerns. In fact, studies by Sword (2003) and Milligan et al. (2002) reveal that low-income and/or minority women often feel stereotyped as single, welfare mothers with substance abuse problems who need to be told how to care for themselves and their children. As such, women with race and class privilege encounter messages about how to be a “good” mother more often than other women as white women of middle to upper SES are expected to have greater choice in managing their pregnancy/childbirth and more interest in maternal/fetal health (Abbyad and Robertson 2011, Lazarus et al. 1994, Song et al.

2012). While this has consequences for minority women and those of lower socioeconomic status that I do not discuss here, it also means white women of middle to

46 upper socioeconomic status experience the pressures of the “informed patient” and “good mother” roles more than other women in the U.S. (Roberts 1997, Solinger 2005, Song et al. 2012).

Conflicting information and self-reported stress

While the biomedical model continues to have a prominent position in the U.S., the increasing strength and contradictory nature of the natural childbirth movement creates a potential conflict between these two sources of AK in the messages pregnant women receive about how to fulfill societal expectations (Cosans 2004, Mansfield 2008,

Walsh 2010). If the messages from these two authoritative sources conflict, women will need to make decisions about which authoritative source to trust and follow (Walsh

2010). While no previous research has attempted to measure the stress and anxiety that pregnant women may feel when dealing with conflicting information, several ethnographic research show that conflicting pregnancy-related messages cause stress and anxiety as women navigate how best to fulfill societal expectations of being a “good mother” (Browner and Press 1996, Hays S. 1996, Root and Browner 2001, Song et al.

2012). Browner and Press (1996: 146) reported participants were “met with a vast and often confusing array of information.” In the face of so much information, women often reported feeling confused and stressed as they sorted through prenatal recommendations from multiple sources (Browner and Press 1996). Women interviewed by Root and

Browner (2001) discussed similar emotions as they considered the often contradictory recommendations they received. Women in each of these studies did not mention dealing with messages from the natural childbirth movement, but both studies were conducted

47 before the natural childbirth movement became a significant part of U.S. definitions of pregnancy and childbirth. With the introduction of the natural childbirth movement as a biopower in the U.S., women are likely to encounter even more conflicting information.

Thus, I argue that such AK decision-making about contradictory messages is a significant source of stress and anxiety for pregnant women.

Currently, there is little data on how negotiating potentially conflicting advice from the biomedical community and the natural childbirth movement affects women’s self-reported stress levels (Cosans 2004, Cramer and McDonald 1996, Guardino and

Dunkel Schetter 2014, Song et al. 2012). My hypothesis is women experience higher levels of a specific type of self-reported stress, pregnancy-specific anxiety, if they must make many AK decisions in the midst of contradictory advice. Dunkel Schetter (2011:

534-535) defines pregnancy-specific anxiety as “a negative emotional state tied to worries about the health and well-being of one’s baby, the impending childbirth, of hospital and healthcare experiences… and parenting or maternal role.” Research shows that pregnancy-specific anxiety is a different construct than other types of self-reported stress as pregnancy-specific anxiety is an emotional state rooted in pregnancy-specific concerns (Dunkel Schetter 2011, Guardino and Dunkel Schetter 2014, Huiznik et al.

2004). In addition, pregnancy-specific anxiety is a significant and often more reliable predictor of fetal and birth outcomes than other forms of self-reported stress (Buss et al.

2009, Dunkel Schetter and Glynn 2011, Kramer et al. 2009, Lobel et al. 2008, Roesch et al. 2004). Since pregnancy-specific anxiety measures concerns about fetal and maternal outcomes and experiences, conflicting information from multiple biopowers and other

48 sources may contribute directly to pregnancy-specific anxiety as women worry about choosing the “best” behaviors to ensure fetal health (Guardino and Dunkel Schetter 2014,

Yali and Lobel 1999).

Physiological impact of conflicting information

The normal human response to a stressor, or a factor that alters the body’s existing equilibrium, is controlled by several systems, principally the autonomic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis (Christian et al. 2009, de

Weerth and Buitelaar 2003, Kane et al. 2014). Of interest here is the human response of the HPA axis to psychosocial stressors. In the HPA axis, the hypothalamus releases corticotropin-releasing hormone (CRH) upon encountering a psychosocial stressor such as a high degree of family conflict or lack of social support, which stimulates the anterior pituitary (Figure 3.1) (Christian et al. 2009, de Weerth and Buitelaar 2003, Kane et al.

2014). The pituitary releases adrenocorticotropic hormone (ACTH) to stimulate the adrenal gland, which releases glucocorticoids including cortisol (Christian et al. 2009,

Nepomnaschy et al. 2007, Pike 2005, Ruiz and Fullerton 1999). Cortisol inhibits the anterior pituitary and the hypothalamus in a negative feedback loop ultimately suppressing the production of itself (Christian et al. 2009, de Weerth and Buitelaar 2005,

Kane et al. 2014).

Since pregnancy requires intense energetic investment, women’s bodies must balance maternal survival and reproductive success, including the likelihood of offspring survival, during pregnancy (Baird 2009, Ellis et al. 2006, Pike 2005).

Stress Depression

Hypothalamus

CRH Brain

Anterior pituitary Cytokines

ACTH Cytokine producing cells Adrenal gland

Cortisol

Figure 3.1. Physiological pathways linking stress, depression, and inflammation (Christian et al. 2009:1264). Solid lines indicate stimulatory relationships; dashed lines indicate inhibitory relationships. CRH = corticotropin-releasing hormone, ACTH = adrenocorticotropic hormone (or corticotropin)

If a woman’s body signals the presence of environmental and/or psychosocial stressors, it must “decide” if deferring reproduction by ending a pregnancy will be more beneficial to overall reproductive success than continuing the pregnancy (Ellis et al. 2006, Hobel

2008, Pike 2005). Although mechanisms exist to accelerate fetal development during times of stress, termination of a pregnancy may prevent energetic investment in an infant who has only a modest chance of survival after birth due to stressors in the external environment (Baird 2009, Pike 2005). In particular, stress prompts termination of early pregnancies with little fetal development and limited maternal investment (Sandman et al.

2018, Nepomnaschy et al. 2006, Nepomnaschy et al. 2009, Pike 2005). Thus, the potential exists for stress, including psychosocial stress, to greatly affect pregnancy maintenance and birth outcomes (Arck 2001, Challis et al. 2009, Christian 2012, Copper et al. 1996, Coussons-Read et al. 2005, De Catanzaro 1992, Dole et al. 2003, Hedegaard et al. 1993, Kramer et al. 2009, Nepomnaschy et al. 2007, Nepomnaschy et al. 2009,

Newton et al. 1979, Norbeck and Tilden 1983, O’Hare and Creed 1995, Saito 2000).

If a stressful environment causes an increase in circulating glucocorticoids during pregnancy, additional CRH is released from placental tissues further raising levels of

CRH and eventually glucocorticoids including cortisol (Pike 2005). Higher and higher levels of CRH continue to raise glucocorticoid (cortisol) levels leading to pregnancy termination (Mancuso et al. 2004, Pike 2005). In a study of 282 pregnant women in the

U.S., Mancuso and colleagues (2004) demonstrate links between CRH levels, maternal prenatal anxiety, and delivery timing. They found women with high CRH levels and high maternal prenatal anxiety delivered earlier than women with lower CRH levels and maternal prenatal anxiety (Mancuso et al. 2004).

Cortisol also has an inhibitory effect on cytokine-producing cells increasing pro- inflammatory cytokines, soluble protein involved in immune cell communication, in the

51 blood (Figure 3.1) (Christian et al. 2009). With prolonged cortisol release, the HPA axis and cytokine-producing cells reduce responsiveness leading to discharge of more pro- inflammatory cytokines and fewer anti-inflammatory cytokines (Christian et al. 2009). In non-pregnant individuals, elevated levels of pro-inflammatory cytokines affect immune responses leading to immune dysregulation (Christian et al. 2009). During normal pregnancy, to prevent rejection of the foreign-tissue fetus, inflammatory immune responses are suppressed in favor of humoral (antibody) immune responses.

Inflammation from stress, however, as a largely cell-mediated immune response, may shift the immune system of a pregnant woman back toward cell-mediated immunity

(Arck 2001, Challis et al. 2009, Coussons-Read et al. 2005, Makhseed et al. 1999, Saito

2000). In fact, Makhseed et al. (1999) and others demonstrate more cell-mediated immune responses in women with recurrent spontaneous abortions (Arck 2001,

Coussons-Read et al. 2005, Makhseed et al. 2000, Marzi et al. 1996, Saito 2000).

Overall, higher levels of cortisol in the blood, saliva, or hair generally indicate prolonged exposure to physical and/or psychosocial stressors (Buss et al. 2009, Christian et al. 2009, D’Anna-Hernandez et al. 2011). Cortisol naturally increases two to four-fold during the course of pregnancy and is released by the placenta increasingly as delivery approaches (Buss et al. 2009). Steeper increases in cortisol trajectories (change over time) indicate dysregulated stress response during pregnancy secondary to higher maternal stress levels (Buss et al. 2009, D’Anna-Hernandez et al. 2011).

While studies show pregnancy-specific anxiety has an impact on maternal stress responses including cortisol levels, studies have not addressed why women experience

52 this anxiety including the potential role of conflicting information (Dole et al. 2003, Pike

2005, Roesch et al. 2004). Research demonstrates that higher self-reported maternal stress levels, including pregnancy-specific anxiety, correlate with steeper cortisol trajectories during pregnancy (Kalra et al. 2007, Kane et al. 2014). In addition, higher pregnancy-specific anxiety and steeper cortisol trajectories correlate with poorer birth outcomes (Dole et al. 2003, Dunkel Schetter 2011, Kalra et al. 2005, Kalra et al. 2007,

Kane et al. 2014, Karakash et al. 2014, Lobel et al. 2008). While birth outcomes are not the focus here, establishing connections between AK negotiations and subjective and objective stress levels may help explain poor birth outcomes not only among “white”

U.S. women of middle to upper SES, but also all women across racial/ethnic and SES spectrums. Figure 3.2 represents a model of how I propose cultural expectations affect maternal self-reported and physiological stress levels and, potentially, birth outcomes.

Figure 3.2. A conceptualization of the relationships between conflicting information, authoritative knowledge (AK) decision-making, maternal stress, and birth outcomes.

Research Questions

Drawing on the research model presented in Figure 3.2, I sought to address six research questions in a longitudinal, multi-stage study of women’s health professionals and pregnant women.

• RQ1: Where do pregnant women get information regarding best practices during

pregnancy and childbirth?

• RQ2: Which sources do women rely on most heavily for information about best

practices during pregnancy and childbirth?

• RQ3: In what ways does this information conflict?

o RQ3a: What effect does conflicting information have on pregnant

women’s emotions and decision-making?

• RQ4: How do pregnant women make authoritative knowledge decisions about

which practices to integrate into their daily lives and birth plans?

o RQ4a: What information do women prioritize in making decisions about

their behaviors during pregnancy and their childbirth plans?

o RQ4b: Why do women prioritize some information over other information

in their decision-making process?

• RQ5: How are women’s experiences with authoritative knowledge decision-

making related to self-reported stress, particularly pregnancy-specific anxiety?

o H1: Women who struggle more with authoritative knowledge decisions

will have higher levels of self-reported stress, particularly pregnancy-

specific anxiety.

• RQ6: How are women’s experiences with authoritative knowledge decision-

making related to hair cortisol levels and trajectories over the course of

pregnancy?

o H2: Women who struggle more with authoritative knowledge decisions

will have higher hair cortisol levels at each timepoint and steeper hair

cortisol trajectories across pregnancy.

Childbirth in Ohio

Columbus, Ohio is an ideal site to investigate these research questions for two primary reasons. First, the 2018 preterm birthrate in Ohio (10.4%) was higher than the national rate of 9.8% placing Ohio 40th in the nation (MOD 2018). In response, the Ohio

Department of Health has focused on developing interventions to decrease the preterm birth rate, with a particular emphasis on increasing the uptake of prenatal care among women living in poverty (Conrey et al. 2013). State-level data, however, indicate that the preterm birth rate among women of middle to upper SES of 10.9% to 11.9% also exceeds the national average of 9.9% (Conrey et al. 2013, Martin et al. 2018). Ohio officials have made few attempts to explain this finding (Conrey et al. 2013). Second, Ohio has moderately restrictive laws regarding midwifery, homebirth, and freestanding birth centers. While the state licenses nurse midwives, there is no regulation of midwives without biomedical training. In Columbus, most nurse midwives practice only in hospital settings. Freestanding birth centers also are state regulated, but no freestanding birth centers exist in Columbus. Coupled with the lack of regulation for direct entry midwives, the absence of Columbus birth centers indicates that women can only decide between a homebirth or a hospital birth. This dichotomous choice may force women’s health professionals in Columbus to associate more strongly with either the biomedical or natural childbirth model creating more disparate opinions. Pregnant women in Ohio, therefore, may face stronger competing messages as they encounter professionals, friends, and family members who more fiercely align with one cultural model or the other.

Chapter 4: Research Design and Study Population

Study goals, research questions, and hypotheses

This chapter gives an overview of the research design and sample for my study including how the chosen research design helps answer my research questions. The overall goal of this study was to explore how cultural expectations about how mothers should act during pregnancy and childbirth affect pregnant women’s stress levels in the

U.S. In particular, my goals were to: (1) investigate how women make authoritative knowledge (AK) decisions about their behaviors, especially when faced with conflicting from varied cultural expectations; and, (2) to connect women’s experiences with AK decision-making with their self-reported and physiological stress levels. As such, this study investigated the following research questions and associated hypotheses, where applicable:

• RQ1: Where do pregnant women get information regarding best practices during

pregnancy and childbirth?

• RQ2: Which sources do women rely on most heavily for information about best

practices during pregnancy and childbirth?

• RQ3: In what ways does this information conflict?

o RQ3a: What effect does conflicting information have on pregnant

women’s emotions and decision-making?

• RQ4: How do pregnant women make authoritative knowledge decisions about

which practices to integrate into their daily lives and birth plans?

o RQ4a: What information do women prioritize in making decisions about

their behaviors during pregnancy and their childbirth plans?

o RQ4b: Why do women prioritize some information over other information

in their decision-making process?

• RQ5: How are women’s experiences with authoritative knowledge decision-

making related to self-reported stress, particularly pregnancy-specific anxiety?

o H1: Women who struggle more with authoritative knowledge decisions

will have higher levels of self-reported stress, particularly pregnancy-

specific anxiety.

• RQ6: How are women’s experiences with authoritative knowledge decision-

making related to hair cortisol levels and trajectories over the course of

pregnancy?

o H2: Women who struggle more with authoritative knowledge decisions

will have higher cortisol levels at each timepoint and steeper hair cortisol

trajectories across pregnancy.

I explored these research questions and tested these hypotheses using a multi- staged and longitudinal research design (Table 4.1).

Table 4.1. Number of participants and data collection methods for each stage of the study.

Stage 1: Preliminary Study Participants Women’s health professionals (n=24) Purposes To document the two main U.S. cultural models of pregnancy and childbirth as potential source of conflicting information To generate a Messaging Survey for use in Stage 2 Data Collection Focus Groups Interviews Methods Key Informant Interviews

Stage 2: Longitudinal Study Participants Pregnant women (n=47) Subset of full sample (n=28) Purposes To address research questions and test hypotheses Data Collection Methods RQ1 Messaging survey (generated from literature and Stage 1 data) with full sample (n=47) Interviews with subset of full sample (n=28) RQ2 Messaging survey (generated from literature and Stage 1 data) with full sample (n=47) Interviews with subset of full sample (n=28) RQ3 and RQ3a Messaging survey (generated from literature and Stage 1 data) with full sample (n=47) Interviews with subset of full sample (n=28) RQ4, RQ4a, and Messaging survey (generated from literature and Stage 1 RQ4b data) with full sample (n=47) Interviews with subset of full sample (n=28) RQ5 (H1) Pregnancy-specific anxiety survey with full sample (n=47) General self-reported stress survey with full sample (n=47) Messaging survey (generated from literature and Stage 1 data) with full sample (n=47) Survey instrument with five control variable scales with full sample (n=47) RQ6 (H2) Cortisol levels from hair samples with full sample (n=47) Messaging survey (generated from literature and Stage 1 data) with full sample (n=47)

I dedicated the first stage of the study to documenting cultural models of pregnancy present among women’s health professionals who aligned with the either the biomedical or the natural childbirth. I accomplished this task though key informant interviews and focus groups. In addition, I used the data collected in Stage 1 to create a survey about authoritative messages regarding best practices that I administered to a sample of pregnant women in Stage 2.

In Stage 2, I explored pregnant women’s experiences with conflicting information, decision-making, and stress (self-reported and physiological measures).

Stage 2 was longitudinal since pregnancy is a longitudinal process.

As women experience emotional and physiological changes over the course of their pregnancy, this longitudinal design was necessary to explore how information gathering, decision-making, and stress vary over time. During study visits with the full, longitudinal sample (n=47), I administered a survey instrument that included the Messaging survey I designed as well as two self-reported stress scales. I also collected a hair sample at each study visit. In addition, I conducted personal, semi-structured interviews with a subset of the full sample (n=28) to collect more in-depth ethnographic data on information gathering and decision-making.

This study was approved by the Institutional Review Board (IRB) at The Ohio

State University (Protocol # 2015B0142).

Sample

Stage 1: Preliminary study

Recruitment. I recruited women’s health professionals using a range of methods and at various locations on The Ohio State University (OSU) campus and in the city of

Columbus, Ohio from September 2015 through April 2016. I began by creating a

Facebook page for potential participants to learn more about the study. I also posted information about the study on two Facebook pages maintained by central Ohio doula organizations. I then conducted online searches to find women’s health professionals in the Columbus area. I emailed these women’s health professionals to ask if they would be willing to participate in a focus group or key informant interview. In addition, I posted flyers on notice boards in academic and medical buildings across the OSU campus. I also visited OSU medical offices to ask if I could leave brochures for their staff to review. I repeatedly advertised in two online newsletters (OSU’s OnCampus Today and OSU

Medical Center’s ThisWeek) throughout the recruitment period and solicited help of an

OSU service called StudySearch. StudySearch is an OSU service that acts as a clearinghouse that links OSU-related research projects needing volunteers with individuals seeking such opportunities. Finally, I visited every obstetrician and midwife office I found in my online searches. I spoke with staff in each location to explain my study goals and request permission to leave brochures with my contact information for the staff, doctors, and midwives to peruse.

Enrollment criteria. When recruiting participants for Stage 1, I broadly defined the phrase “women’s health professional” as a person who interacted with pregnant

61 women in a professional capacity. As I intended to document cultural models of pregnancy and childbirth from biomedical and natural childbirth perspectives, I needed a broad definition of “women’s health professional” to avoid excluding non-biomedical health professionals in my recruitment efforts. I, therefore, purposely recruited women’s health professionals from a variety of backgrounds including doulas, obstetricians, midwives, and childbirth educators. I only included professionals currently practicing in their chosen profession rather than students still learning their professions. I felt practicing professionals would have more defined ideas about pregnancy and childbirth.

Participants. I recruited 24 women’s health professionals. Fourteen participants worked within the biomedical system and 10 identified as part of the natural childbirth community. Chapter 5 provides detailed information on the Stage 1 participants.

Stage 2: Longitudinal Study

Recruitment. I recruited participants for the second stage of my study with a similar range of methods and at various locations on The Ohio State University campus and in the city Columbus, Ohio from April 2016 through May 2017. I updated the

Facebook page I created for Stage 1 of the study to reflect the goals and recruitment focus of Stage 2. I also updated the posts about the study on the central Ohio doula Facebook pages. I then emailed the Stage 1 participants to ask their assistance in recruiting their pregnant clients in effort to reach as many pregnant women in the Columbus area as possible. I next placed new flyers on the OSU notice boards in academic and medical buildings across campus requesting interested pregnant volunteers and revisited OSU medical offices that specialize in pregnancy and childbirth to ask if I could leave

62 brochures for their patients. I replaced the advertisements in OSU’s OnCampus Today and OSU Medical Center’s ThisWeek to reflect my new recruitment focus. I advertised in each of these newsletters repeatedly throughout the recruitment period. I again used

OSU’s StudySearch to reach potential volunteers.

In addition to the above-mentioned strategies, I employed new recruitment strategies on OSU’s campus to recruit women for Stage 2. I signed up with a second OSU service called ResearchMatch. ResearchMatch maintains a database of volunteers interested in participating in research. With ResearchMatch, I was able to contact all volunteers in the database that fit my basic inclusion criteria. I also sent emails to each department at OSU requesting that they forward my recruitment announcement to their faculty and graduate student lists. I had advertisements made for OSU’s Campus Area

Bus System (CABS). The advertisements were posted on the interior of CABS buses for six weeks at a time. I posted CABS advertisements four times during the recruitment period for Stage 2.

To expand beyond the OSU campus, I revisited every obstetrician and midwife office from Stage 1. I spoke with staff in each location to explain the progress of my study and request permission to leave brochures for their interested patients. I also hung flyers on community notice boards in Columbus area libraries, cafés, churches and yoga studios offering prenatal yoga. Finally, I used snowball sampling with three of the pregnant women who enrolled in Stage 2. Each referred one additional women to my study.

Despite these efforts, recruitment remained slow. Therefore, I decided to expanded into the Dayton, Ohio area. I posted flyers on notice boards in academic buildings on three Dayton area university campuses: Miami University, University of

Dayton, and Wright State University. I also posted advertisements in newspapers that service the Dayton area generally and Wright Patterson Air Force Base specifically.

Finally, I visited Dayton area obstetricians and midwives. I explained my research and asked permission to leave brochures at their offices for any interested patients. None of the volunteers who responded to any of my recruitment efforts in the Dayton area fit the enrollment criteria, however.

Enrollment criteria. During recruitment, I screened participants using an online survey covering the following enrollment criteria. I originally only enrolled women between 7 and 12 weeks pregnant. However, due difficulties recruiting women in their first trimester (<12 weeks), I decided to raise the maximum gestational age for enrollment to 25 weeks. My difficulty in recruiting women in their first trimester may be related to the fact that many women refrain from telling others about their pregnancies until late in the first trimester due to the high risk of miscarriage during this early stage of pregnancy

(Nepomnaschy et al. 2006). Challenges enrolling women also led me to increase the maximum maternal age to 40 years. I initially intended to recruit women between the ages of 25 and 35 years as according to the biomedical community, the risk for pregnancy/birth complications rises after 35 years (Ales et al. 1990, Catanzarite et al.

1995, Lehmann and Chism 1985, O’Reilly and Cohen 1993). However, recent research shows risks for adverse pregnancy/birth outcomes increases after 40 years of age rather

64 than 35 years (Kenny et al. 2013). My final inclusion criteria were that women identified as “white” or “Caucasian” and of middle to upper socioeconomic status (SES). I chose these two enrollment criteria for two main reasons. First, current literature suggests racial discrimination affects women’s stress levels during pregnancy in underexplored ways

(Rosenberg et al. 2002; Rosenthal and Lobel 2011, Williams 2002). By controlling for the potential impact of racial discrimination on participants’ stress levels; I increased the likelihood of identifying the effects of competing cultural expectations. Second, ethnographic research indicates that “white” women of middle- to higher-SES deal with conflicting information more often than women of lower-SES. This is because higher-

SES women are the targets of societal expectations that require “good mothers” to seek out and observe the “best” advice (Kingfisher and Millard 1998, Lazarus 1994, Song et al. 2010). They are also more likely to be under surveillance because society expects them to know the “proper” behaviors for pregnant women (Browner and Press 1996).

In addition to the inclusion criteria reviewed above, I excluded women who had previous pregnancy complications (i.e., preterm birth, preeclampsia, and miscarriage), major physical or mental health issues (i.e., diabetes, depression, and anxiety disorders), or experience with fertility treatments. Prior pregnancy complications and major health issues change women’s information-seeking behaviors and increase pregnancy-specific anxiety as women worry more about pregnancy outcomes and fetal health (Dole et al.

2003, Lagan et al. 2010, Lobel 1994, Song et al. 2012, Woods-Giscombé et al. 2010).

Experience with fertility treatments is likely to impact results because women who become pregnant through fertility treatments already rely heavily on biomedical advice

65 and are closely monitored during pregnancy (MacDougall et al. 2012). Wang and colleagues (2002) found a significant relationship between use of fertility treatments and preterm birth rates. I also excluded women who reported drug/alcohol abuse or smoking.

These factors affect fetal development and the probability of preterm birth, which is likely to increase women’s pregnancy-specific anxiety, as they are concerned about the effects of substance use on fetal health (Dunkel Schetter et al. 2000, Pinto et al. 2010). I limited the sample to couples who live together to partially control for the moderating effect of partner social support as women who have a partner experience less stress and anxiety than single pregnant women (Campos et al. 2008, Feldman et al. 2000,).

Participants. I recruited 25 participants in early pregnancy (7-12 weeks) and an additional 22 women in their second trimester (18-25 weeks), for a total sample of 47 women. Once recruited, I followed all participants through the remaining trimesters of their pregnancies and into the postpartum period. I conducted all postpartum visits within the first 4 weeks after participants gave birth. All participants were between 24 and 38 years old at the first study visit and all self-identified as “white” or “Caucasian,” although five participants selected more than one race/ethnicity. All participants also self- identified as of middle- to high-SES. One participant had an Associate’s or technical degree. The remaining participants has at least a Bachelor’s degree. Twenty-seven participants were pregnant with their first child and 20 participants were pregnant with a second or third child. I made the decision to include primiparous and multiparous women for comparison purposes.

Primiparous women were expected to have less embodied knowledge, struggle more with decisions about authoritative knowledge (AK) and, therefore, experience more pregnancy-specific anxiety than multiparous women (Browner and Press 1996). Table 4.2 summarizes the characteristics of the study participants. For three of the 47 women, I was unable to obtain data on their postpartum variables from medical records. This was due to a variety of reasons including moving out of the area and failure to respond to multiple contact attempts.

I offered all participants the opportunity to be part of additional visits involving semi-structured, personal interviews (Bernard 2011, Guest et al. 2006). A subsample

(n=28) of the full, longitudinal sample (n=47) chose to participate in these interviews, which included nineteen first-time mothers and nine mothers pregnant with a second or third child.

Data Collection

Stage 1: Preliminary Study

Study visits. I met with all participants on a single occasion either as part of a focus group or key informant interview. To get potentially more variation in responses, no women’s health professional participated in both a focus group and key informant interview. I conducted all focus groups at the Ohio State University. For key informant interviews, I allowed the participants to choose the location to make them feel more comfortable meeting with me. As a result, I met with participants in their places of work, cafes, and homes.

Table 4.2. Demographic and descriptive characteristics for n=47 women enrolled in the study

Variable Age at first visit, years (mean, (sd)) 30.1 (3.5) Pre-pregnancy bmi (kg/m2) (mean (sd)) 24.7 (3.5) Gestational age at first visit (weeks) (mean (sd)) 8.7 (2.2) Parity (n (%))

Primiparous 27 (57.4) Multiparous (1) 18 (38.3) Multiparous (2) 2 (4.3) Race/ethnicity (n (%)) White/caucasian 42 (89.4) Multi-racial 5 (10.6) Relationship status (n (%)) Married 44 (93.6) Unmarried, but cohabitating with a significant 3 (6.4) other Time in relationship (months) (mean (sd)) 98.8 (101.0) Education [n (%)] Associate’s or technical degree 1 (2.1)

Bachelor’s degree 12 (25.5) Some graduate school 6 (12.8) Graduate degree 28 (59.6) Socioeconomic status (n (%)) Middle 37 (78.7) Middle to upper 8 (17.0) Upper 2 (4.3) Student (n (%)) Yes 13 (27.7) No 34 (72.3) Employed outside home (n (%)) Full-time (38-40 hrs./wk.) 34 (72.3) Part-time (<38 hrs./wk.) 9 (19.1)

No 4 (8.5) Attend spiritual/religious services (n (%)) Never 17 (36.2) Less than once per month 11 (23.4) Once per month 3 (6.4) Two to three times per month 6 (12.8) Nearly every week 10 (21.3)

Methods. I conducted focus group and key informant interviews with participants who identified with either the biomedical (n=16) or natural childbirth model (n=10). The goal of the focus groups and key informant interviews was to document the two main

U.S. cultural models of pregnancy and childbirth as potential source of conflicting information. Therefore, I asked women’s health professionals in each community to define the important characteristics of a “healthy” pregnancy and “good” childbirth experience. Chapter 5 has detailed information about how I conducted the focus groups and key informant interviews.

Stage 2: Longitudinal Study

Study visits. I visited each of the 47 women on three or four occasions depending on whether they were recruited in their first or second trimester. If a participant agreed to be interviewed, I set up a second visit within one to two weeks of the regular study visit for the interview. Since the initial study visit lasted 1-1.5 hours, participants often did not have time to be interviewed during the regular study visit. I visited this subset of participants (n=28), therefore, twice each trimester and twice postpartum to collect more detailed data on information gathering and decision-making. I recorded and transcribed all interviews. I conducted all study visits and interviews at locations chosen by the women, which included their homes, cafés, and libraries. I allowed participants to choose the study visit location to make them more comfortable speaking with me and to minimize inconvenience to the participant.

Methods. Using the methods described below, I gathered data on conflicting information, authoritative knowledge (AK) decisions, and stress to address my research questions.

1. I administered a survey instrument to all 47 women at each visit. The survey

instrument included sociodemographic questions and a Messaging survey that

included questions about information sources, lifestyle changes, and women’s

experiences with conflicting information, which I developed from the data

collected in the focus group and key informant interviews. The Messaging

survey was used in addressing all research questions and testing both

hypotheses. The survey instrument also contained two stress scales and five

control variable scales to address RQ5. All eight scales were validated for use

with pregnant women previously.

2. I conducted serial semi-structured interviews with a subset of 28 women to

address RQ1, RQ2, RQ3, RQ3a, RQ4, RQ4a, and RQ4b.

3. I collected hair samples for cortisol analysis from all 47 women, three to four

times per woman to address RQ6.

I also reviewed medical records of mothers (n=44) and infants (n=44) to gather data on any health complications and pregnancy/birth outcomes after each woman gave birth.

I collected and managed survey data using REDCap (Research Electronic Data

Capture), a tool administered through the Ohio State University’s Wexner Medical

Center. REDCap is a secure, web-based application designed to support data collection for research studies. It provides 1) an intuitive interface for validated data entry; 2) audit

70 trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources (Harris et al. 2009). I administered all surveys on a password-protected laptop using a secure wireless connection.

To address RQ1, RQ2, RQ3, RQ3a, RQ4, RQ4a, and RQ4b, I collected data using two main methods. First, I developed a messaging survey from previous literature and the focus group and key informant interview data. The purpose of the messaging survey was to gather data on where women get information about pregnancy and childbirth and the types of messages women receive. As such, I asked questions about the people women rely on for advice and where they access print information. I also questioned participants about the messages they received including whether or not the messages conflicted and how conflicting information made them feel. As another way to uncover messages, I added questions about lifestyle changes the women made and the reasons for those changes. The lifestyle change questions also helped me uncover information about participants’ decision-making behaviors (RQ2).

Second, I conducted interviews with a subset of 28 women in which I inquired about how women made decisions regarding their behaviors during pregnancy and their childbirth plans. We also discussed their ideal pregnancy and birth experiences during the first visit and again in the postpartum, which allowed us to explore the extent to which their plan matched their actual experience.

To address RQ5, I collected data using the messaging survey on conflicting information described above as well as the following two stress scales and five control variable scales.

1. To gather data on pregnancy-specific anxiety, I used the validated Pregnancy-

specific Anxiety Scale (PSA) (Guardino and Dunkel Schetter 2014). Guardino and

Dunkel Schetter (2014) argue that this recently created survey better predicts

physiological responses to stress than previously used pregnancy-specific anxiety

scales. The PSA scale includes questions about women’s concerns regarding

pregnancy, childbirth, and maternal/fetal health. The scale, however, does not

explore why women are concerned about their pregnancies or why they make

lifestyle changes.

2. To gather data on other sources of stress, I included the Perceived Stress Scale

(PSS). The PSS is a self-reported stress measure focusing on a person’s ability to

deal with their responsibilities (Cohen et al. 1983). It helps capture stress in

everyday life. I used the PSS because I predicted that this study sample would have

high stress from the many tasks they must accomplish each day. Most of the

women in this study are balancing careers and home life. They are busy attempting

to fulfill many demands on their time. I predicted this lifestyle would impact their

general self-reported stress levels.

3. The first control variable was prenatal health behaviors. I used the Prenatal Health

Behaviors Scale (PHBS) to collect data on this variable (Lobel 1994, Lobel et al.

2008). The PHBS includes questions about diet (fruit and vegetable consumption,

vitamin use, and fish consumption), exercise frequency and substance abuse.

Research connects “unhealthy behaviors” such as poor nutrition, lack of exercise,

and substance abuse to worse birth outcomes, partly because women under stress

are more likely to engage in these unhealthful behaviors (Barnet et al. 1995, Lobel

et al. 2008, McCormick et al. 1990). Many women also worry about the impact of

their “unhealthy” behaviors on their pregnancies. Controlling for prenatal health

behaviors is necessary when studying stress, therefore, because “unhealthy”

behaviors may have a significant impact on self-reported stress and, potentially,

birth outcomes (Dunkel Schetter et al. 2000).

4. The second control variable was sleep quality. I used the Pittsburgh Sleep Quality

Index (PSQI) to collect data on this variable. The PSQI evaluates sleep quality and

efficiency during pregnancy (Buysse et al. 1989). Poor sleep quality is a common

problem during pregnancy, however, stress and anxiety increase sleep disruption

(Baratte-Beebe and Lee 1999, Lee 2006). Literature also suggests possible

connections between poor sleep quality and preterm birth, duration of labor, infant

birth weight, and infant Apgar scores (Okun et al. 2011, Zafarghandi et al. 2012).

5. The third control variable was social support. I used the Multidimensional Scale of

Perceived Social Support (MSPSS) to assess women’s perceptions of their social

support including from family, friends and a significant other (Zimet et al. 1988).

Social support moderates the effects of stress, but study results are inconsistent

(Barnet et al. 1995, Campos et al. 2008, Feldman et al. 2000). Social support

during pregnancy is particularly important as women have more emotional and

physical needs as their bodies change. Lack of social support can be a stressor

(Cramer and McDonald 1996, Davis-Floyd and Sargent 1997, Duman and Kocak

2013, Jordan 1993).

6. The fourth control variable was stressful life event. To collect data on this variable,

I included the Life Experiences Survey (LES), which asks about the occurrence of

stressful life events since the start of pregnancy (Sarason et al. 1978). The LES

covers 39 life events such as the death of a close relative and experiencing a house

fire with additional space to add events not otherwise mentioned. Stressful life

events not only affect the physiological stress response directly, but also affect

how well a person deals with other stressors (Sarason et al. 1978).

7. The fifth control variable was women’s locus of control or their perceptions of

who/what has control over their pregnancy/childbirth outcomes. I used the

Pregnancy Attitude Index (PAI) to collect data on this variable. PAI is a locus of

control survey based on Levenson’s (1972) work and is designed for use with

pregnant women (O’Connell 1983). The PAI determines if women believe the

outcome of their pregnancy is the result of their own behavior, the behavior of

their physician and/or hospital, or by luck/fate. Degree of pregnancy-specific

anxiety is determined, in part, by how much control women think they have over

the outcome of their pregnancy (Tinsley et al. 1993).

To address RQ6, I again utilized data from the messaging survey on conflicting information as well as the cortisol levels from women’s hair samples. A detailed

74 discussion of the methodology used to collect and analyze the hair samples is included in

Chapter 7.

Data Analysis

Here I give an overview of the data analysis procedures I utilized in analyzing the data for Chapters 6 and 7. A more detailed discussion of data analysis is included in the individual chapters. For the qualitative data, I read through the interview transcripts and qualitative survey responses. I made notes of key themes and developed a codebook to help me organize the data from my multiple qualitative sources (Bernard 2011). I coded the qualitative data with the codebook and then analyzed the data using MaxQDA 11 software to assess patterns and themes over time to address RQ1, RQ2, RQ3, RQ3a,

RQ4, RQ4a, and RQ4b (Bernard 2006, Coffey and Atkinson 1996, Ryan and Bernard

2003). I also compared the frequency of themes between primiparous and multiparous mothers to determine if the two groups gathered information and/or dealt with AK decisions differently to address RQ1, RQ2, RQ4, RQ4a, and RQ4b. I then used the qualitative data to determine if women’s experiences with conflicting information affected their AK decision-making and emotions to address RQ3 and RQ3a. I then used these comparison groups to examine patterns of self-reported stress (measured with the established scales). In other words, I wanted to ascertain if women who had less experience with pregnancy (i.e., primiparous women) and/or women who felt more anxious and confused about the conflicting information they received had higher rates of self-reported stress to address RQ5. I explain the reasoning for these divisions in Chapter

6 and 7. I incorporated information from the control variable surveys into my

75 examination of self-reported stress patterns and hair cortisol levels with group comparison t-tests. Finally, I analyzed cortisol trajectories with repeated measures

ANOVAs (Buss et al. 2009, Kane et al. 2014) to investigate relationships between women’s struggles with AK decision-making and hair cortisol levels and trajectories to address RQ6. I used the patterns in the qualitative data (as described above) to determine if steeper cortisol trajectories connect to experience and/or anxiety and confusion associated with AK decision-making.

Chapter 5: Preliminary Study

Introduction

“A mother’s preferences are very important – they should be respected and discussed. They should not trump what research has shown is safest for mom and baby, though.” [Julie, a nurse, March 2016]

“If the woman is confident and relaxed, then she is not frightened by her own body and not resisting [her body] because she is anxious about what is happening or about being a mom. If she is anxious about being a mom, she isn’t ready to be a mom.” [Carrie, a doula, October 2015]

In this chapter, I present the results of Stage 1 of my research study. Stage 1 is a preliminary study with two main purposes. First, I conducted the preliminary study to document the two main U.S. cultural models of pregnancy and childbirth. I explored areas of concordance between the two models as well as areas of discordance. The areas of discordance are potential sources of conflicting information for pregnant women.

Documenting the information from these two models, therefore, is a necessary first step in understanding how conflicting information affects pregnant women’s self-reported and physiological stress levels. Second, I utilized the data collected from the preliminary study in generating a Messaging survey used in Stage 2. I administered the Messaging survey to pregnant women as part of my longitudinal study to investigate the information

77 they receive and how they make decisions about which information/advice to incorporate into their daily lives and childbirth plans.

Methods

Sample

The sample includes 24 women’s health professionals, 14 working within the biomedical system and 10 who identified as part of the natural childbirth community. I used purposive sampling in order to create sample variation by recruiting professionals in each community from a variety of backgrounds (Table 5.1). I recruited participants through emails to doulas, childbirth educators, and midwives identified during online searches, posted advertisements on the Ohio State University campus, and visits to obstetrician and midwife offices. All of the participants were women as only women responded to my recruitment efforts. The lack of male participants reflects the overwhelming number of women working as women’s health professionals throughout the U.S. including in Columbus. In fact, although 41.3% of obstetricians are men nationally, only 12% of nurses are men and few male nurses work in obstetrics (NASEM

2011, Rayburn 2017). Additionally, only 2% of nurse-midwives are men and no men are registered with the Ohio Midwives Alliance (ACNM 2016, OMA 2017). Finally, while statistics are not available on gender for doulas and childbirth educators in the U.S., my online searches revealed no advertisements for male doulas or childbirth educators practicing in Columbus.

Table 5.1. Participant occupations for focus groups and key informants.

Occupation Natural Biomedical Nurse 0 6 Midwife 2 0 Doctor 0 2 Doula 4 0 Childbirth educator 2 0 La Leche League leader 2 0 Other medical professionals 0 6

Study Design and Data Collection

I conducted a multi-phased study that began with focus groups. I followed these up with individual key informant interviews. I conducted the focus groups and key informant interviews with women’s health professionals who identified with either the biomedical or natural childbirth model. I asked professionals in each community to define the important characteristics of a “healthy” pregnancy and a “good” childbirth experience. I used their responses to construct cultural models of pregnancy and childbirth. These data were collected as the initial step in a larger research project that explores how pregnant U.S. women make pregnancy-related decisions based on the messaging they receive and how that decision-making affects their health.

Focus groups. I collected data from 3 biomedical focus groups with a total of 10 participants and 1 natural childbirth focus group with 3 participants. Focus groups were limited to 3-4 individuals to encourage participant interaction. The difference in the number of biomedical and natural childbirth focus groups is related to scheduling difficulties. Biomedical professionals were relatively easy to schedule for focus groups as

79 many worked regular office hours on or off the Ohio State University medical campus. In contrast, many of the natural childbirth professionals had limited availability as doulas and natural childbirth educators often visit clients according to client convenience.

Following Dressler et al. (2005) and Bindon (2007), I first asked all focus group participants to free list characteristics that they associate with a healthy and an unhealthy pregnancy as well as a good and a bad childbirth experience. They wrote single characteristics for each of the four categories on notecards. I consolidated the free lists into common themes and then asked focus group participants to rank the themes in order of importance. After ranking, I discussed emergent themes with participants in effort to clarify meaning and explore potential areas of discordance.

Key informant interviews. In order to further address my research question, I conducted key informant interviews with professionals from each community who did not participant in the focus groups. I continued recruiting key informants until I reached saturation in each theme. Four biomedical professionals and seven natural childbirth professionals participated in the key informant interviews. Similar to the focus groups, I asked participants to free list and rank characteristics that they associated with a healthy and an unhealthy pregnancy, as well as, a good and a bad childbirth experience. I also conducted semi-structured interviews with the key informants focusing on questions about areas of discordance that emerged during focus group discussions including the importance of women gathering information about pregnancy and childbirth, the significance of women’s emotions and preferences, and women’s responsibilities regarding pregnancy and childbirth.

Data Analysis

I recorded and transcribed the focus groups and interviews. I also wrote interviewer notes during and after each focus group and key informant interview. After developing a coding system from my initial read-through, I performed a content analysis focusing on my key domains of interest in the notes and transcripts in order to construct cultural models of pregnancy and childbirth from each set of participants (Bernard 2011,

Dressler et al. 2005). For the free lists of ranked characteristics, I averaged the rankings for each theme and then listed the themes based on their average rankings. I also calculated standard deviations and proportions for each theme to examine variation between participants working within the biomedical and natural childbirth models.

Results

Participants from both communities focused on the same seven general themes when asked to characterize a healthy pregnancy and a good childbirth experience:

1. Women’s Emotions 2. Ability to Make Own Decisions 3. Relationship with Provider 4. Women’s Responsibilities 5. Pregnancy and Childbirth Complications 6. Social Support 7. Fetal/Newborn Health

There were clear areas of consensus and discordance, though, in how participants from each community discussed each theme as I explore in detail below. In addition, two minor themes emerged: Bonding Time with Infant and Pain during Childbirth. Bonding time with the infant was mentioned by one natural childbirth and two biomedical participants, but these participants mainly discussed bonding as it related to Theme 1:

Women’s Emotions. The second minor theme, pain during childbirth, was mentioned by two natural childbirth participants. They agreed that intense pain during childbirth does not correlate with a bad childbirth experience. Biomedical participants did not mention pain during childbirth as part of a good or bad childbirth experience.

Theme 1: Women’s Emotions

Participants from the biomedical and natural childbirth communities both discussed the importance of women’s emotions regarding pregnancy and childbirth.

Biomedical and natural childbirth participants agreed that women who experience positive emotions about their pregnancies are more likely to have a healthy pregnancy and a good childbirth experience. In addition, both groups acknowledged that women need to feel heard throughout their pregnancy and childbirth. Jenny, a nurse, discusses the importance of women’s emotions in this way:

“Women’s emotions are vital to the delivery process. They need to be acknowledged and validated…acknowledge that childbirth is scary – she needs to understand the changes that are happening in her body. She needs to feel supported.”

Similarly, natural childbirth participants felt recognizing women’s emotions was important, but they also discussed the long-term effects of positive maternal emotions as well. Tracy, a doula, remarks:

“Women’s emotions are important. A balanced emotional mom throughout pregnancy and childbirth leads hopefully to a more balanced emotional postpartum period and better bonding with baby.”

Alice, a childbirth educator in the natural childbirth method, also mentions the potential impacts of a negative emotional environment, “[Judgmental advice] can negatively affect a mother’s confidence that she can carry the baby in her womb, give birth, and be

82 mother.” Overall, women’s emotions about pregnancy and childbirth were mentioned almost twice as often by natural childbirth compared to biomedical participants further demonstrating how important natural childbirth participants considered women’s emotional states.

Theme 2: Ability to Make Own Decisions

Like women’s emotions, women’s ability to make their own decisions during pregnancy and childbirth was discussed twice as often by natural childbirth participants compared to biomedical participants. Generally, the two groups did not agree on who should make decisions and how that decision-making process connects to women’s emotions and future parenting skills. Natural childbirth participants felt that women should make their own decisions, while biomedical participants wanted to give women some choice, but ultimately felt decisions were best left to the “experts” (i.e., doctors and nurses).

Natural childbirth participants emphasized the importance of allowing women to make their own decisions so that women would have better pregnancy and childbirth experiences and more confidence in their parenting skills, again highlighting the belief that women’s experiences in this process have long-term effects. As such, natural childbirth participants strongly encouraged women to gather information so that they would be prepared to make decisions if complications arose. Heather, a doula, connected childbirth experience to decision-making by saying, “a woman has a less than positive experience when she doesn’t understand that she can call the shots, not medical professionals.” She further lamented her clients’ perceptions about making decisions

83 during childbirth, “the biggest challenge in labor and delivery is getting clients to understand that they are in charge. You are paying for it.” Anne, a midwife, also mentions women’s responsibility to make their voices heard, “in childbirth, women need to be prepared to speak up or have someone speak up if she has specific things she does or doesn’t want.” Some of the natural childbirth participants, such as Martha, a La Leche

League leader, placed blame on biomedical professionals for women’s lack of agency in childbirth:

“The biggest challenge to a good childbirth experience is time, desire, and direction from healthcare providers who fail to educate women adequately on natural birthing and what is happening to their bodies.”

Carrie, a doula, and other natural childbirth participants connected women’s lack of agency to their ability to parent, “if the woman is brushed aside, then she will have less confidence as a mother.”

Additionally, natural childbirth participants discussed a need to create empowerment by trusting women’s understanding of their own bodies. Ester, a midwife, voiced her frustration about how biomedical professionals interact with women:

“Often answers are presented as do this or your baby will die. We need more trust in women to make decisions. A pregnant woman has more information about her body and her baby than any professional. We need to listen to that.”

The emphasis from natural childbirth participants on empowerment and confidence leaves little room for maternal uncertainty, however, as Carrie, a doula, discussed:

Similar to natural childbirth participants, biomedical participants mentioned that a woman’s preferences about her pregnancy and childbirth experience should be respected.

Biomedical participants, however, emphasized that a woman should only be allowed to make decisions if her choices did not endanger maternal/fetal health. When pressed about who determines when child and mother are in danger, three-quarters of the biomedical professionals said the doctor, as the expert, knows when intervention is necessary, although they thought that women still ultimately decide. Taylor, a physician assistant, comments, “the doctor decides when intervention is necessary by providing facts and stats; ultimately it’s the woman’s choice what she does and whose advice she follows.”

The remaining quarter of biomedical participants like Jenny, a nurse, thought there could be legitimate disagreement, but still believed biomedical professionals should decide what jeopardizes fetal health,

“Unless the preferences affect the successful completion of the pregnancy (affects maternal/baby outcomes) then [preferences] should be respected. There can be a valid disagreement between care provider and mother.”

Biomedical participants also emphasized finding a provider to trust so that women would feel comfortable allowing the provider to make decisions. For example, Mary, a nurse, commented, “if women feel more comfortable and more trusting toward their provider, then they are able to give up some control.” Beth, a nurse, even acknowledged the tendency of biomedical professionals to undermine women’s decision-making ability saying, “women are labeled if they assert themselves.” Unlike most biomedical participants, Beth felt that fear of how women will be perceived and pressure from biomedical professionals might limit women’s ability to make choices. Beth did not

85 discuss her own role, as a biomedical professional, in creating and reiterating biomedical advice as authoritative knowledge nor her own effect on women’s childbirth experiences, though. Julie, a nurse, summarizes some of these overriding themes by saying, “a mother’s preferences are very important – they should be respected and discussed. They should not trump what research has shown is safest for mom and baby, though.”

Theme 3: Relationship with Provider Participants from the biomedical and natural childbirth communities felt strongly that women needed to have a “good” relationship with their healthcare providers. They disagreed, though, about the definition of a “good” provider relationship. As mentioned in my discussion above, biomedical participants emphasized that women should find a provider they trust and listen to their provider’s advice. Like other biomedical professionals, Julie, a nurse, revealed her belief in physician advice as authoritative knowledge:

“Women should take time to listen and respect what their physician says. It is her responsibility to follow what the physician says. If she is uncomfortable, they should have a discussion and come to a mutual understanding.”

Again, several biomedical participants thought that providers need to listen to women’s preferences, although biomedical professionals ultimately should decide what is best for the fetus. Biomedical participants also stressed discussion between a woman and her provider about the mother’s preferences prior to childbirth as a way of avoiding conflict and disappointment during the birthing process. They, however, believed that a birth plan was counterproductive to a good childbirth experience as it limited the flexibility needed during childbirth. They discussed the possibility that childbirth may not progress as

86 planned and that a rigid birth plan could lead to conflict between biomedical professionals and parents. Julie, a nurse, reveals not just a need for flexibility, but the futility of planning childbirth and the biomedical emphasis on the fetus in the birthing process:

“The baby ultimately picks the birth experience not the mother. Mom can plan all day long and the baby will pick what it wants…In the end, the baby is going to do what the baby wants.”

Finally, biomedical participants discussed the importance of timely prenatal care as a way of cementing biomedical experts’ authority over pregnancy and childbirth. Jenny, a nurse, emphasized: “Good prenatal care is timely care. In other words, a woman is ready to have kids and calls the doctor from the moment she becomes pregnant.”

Conversely, natural childbirth participants stressed that providers should listen to women, as women have more information about their own bodies than the providers.

Anne, a midwife, says “interaction with the care provider includes the mother and/or partner knowing options and what’s going on with her body and the baby as well as given a chance to ask questions.” While natural childbirth participants agreed that childbirth is unpredictable, they believed developing an initial birth plan was essential for proper communication between healthcare provider and mother. Ester, a midwife, mentions the importance of discussing women’s preferences prior to childbirth and the possibility of complications,

“It is very important that women’s preferences are explored and discussed as to why she has certain preferences. She needs to be realistic going into childbirth. It is important that her preferences are acknowledged. We want birth to happen as much like she wants as possible, but the provider needs to explain that it may not.”

Theme 4: Women’s Responsibilities

Women’s Responsibilities contained several subthemes including taking care of one’s self, compliance with medical advice, and information gathering. Participants from both communities agreed that woman have several responsibilities during pregnancy, but there was discordance in terms of how women should fulfill those responsibilities. First, biomedical and natural childbirth participants felt women should take care of themselves during pregnancy by taking vitamins, eating well, exercising, and avoiding hazardous substances such as illegal drugs. Biomedical participants, however, focused on the need for women to develop healthy habits in order to protect the fetus. Women’s own health was mentioned only in the context of how women’s health might affect fetal health.

Alyssa, a physician, explains why planning the pregnancy is necessary in order to properly take care of one’s self:

“It’s best if a pregnancy is planned to avoid bad behaviors during early pregnancy when you don’t know you’re pregnant. Early bad behaviors could have a huge impact…could ruin the baby.” (emphasis added)

Natural childbirth participants seldom mentioned fetal health, but instead concentrated on women’s responsibilities to develop healthy habits and take time to consider their postpartum lives. Carrie, a doula, declares, “most importantly, women need to take time for themselves so that they are okay with the fact that they will give birth and be a mother.” The few natural childbirth participants who discussed fetal health believed that as long as a woman was taking care of herself then the baby should be fine. They also acknowledged that women should not feel guilty if complications arise as many issues are not within women’s control.

A second responsibility heavily emphasized by biomedical participants is the need for women to comply with medical advice. Biomedical participants believed following medical advice would help ensure fetal health. Sydney, a nurse, stated, “[A woman’s responsibilities] are to remain healthy, keep prenatal appointments, be compliant, and don’t do things harmful to her and the baby.” Natural childbirth participants, by contrast, focused on women listening to their bodies and making their own decisions. According to

Grace, a natural childbirth educator,

“Mothers need to be able to come to decisions and conclusions without misinformation and judgment from peers, social media, even some caregivers can be judgmental. She needs a safe place to voice her opinion.”

Finally, participants from both communities believed women should gather information about pregnancy and childbirth to become “informed patients,” but they disagreed about the best sources of information. Biomedical participants thought healthcare providers are the best source of information When women receive information from other sources, they should discuss it with their healthcare providers further cementing the authoritative position of biomedical professionals. Taylor, a physician assistant, highlights this belief, “the best place to get information is the healthcare provider, particularly an obstetrician or gynecologist. Other mothers and internet sites may be okay too.” Natural childbirth participants emphasized gathering information from multiple sources as healthcare providers may not offer the most useful or relevant information available. Alice, a natural childbirth educator, thought “women should gather information on their own” and the “best way to gather information is multiple sources – doctor/midwife, hospital, other women (peers and older). Also, research from books,

89 nutritionists.” The natural childbirth practitioners also stressed that women should continue to gather information throughout pregnancy in order to make confident and informed decisions.

Themes 5: Pregnancy and Childbirth Complications

Participants from both communities mentioned that a lack of pregnancy/birth complications is important for a healthy pregnancy and good childbirth experience, although natural childbirth participants concentrated on women’s limited ability to avoid many major complications. Rosie, a La Leche League leader, remarks:

“[a woman] should keep herself and her child healthy as best she can. I don’t want to overemphasize her ability to do this. [Birth] is a natural process so when the burden [for having a healthy child] is placed on women, it can be difficult.”

Biomedical participants, on the other hand, simply mentioned that a healthy pregnancy does not include pregnancy/birth complications. Emily, a physician, explained,

“Medically, [a healthy pregnancy is] the pregnancy going well with no major complications for mother or baby.”

Theme 6: Social Support

Participants from both communities agreed that social support was important to ensure a healthy pregnancy and good childbirth experience. Jenny, a nurse, simply stated,

“[the mother] needs to feel supported.” Some of the natural childbirth participants, however, believed finding impartial social support that met women’s personal preferences was difficult in the U.S. cultural context. Alice, a natural childbirth educator, sees finding appropriate support as a major obstacle to a healthy pregnancy and good childbirth experience as many people might be judgmental:

“the biggest challenge [to a healthy pregnancy] would be finding unbiased support. What I mean by that is that mothers are often bombarded with unsolicited advice and comments that can be wrong or unintentionally judgmental.”

As such, natural childbirth participants revealed their belief that many women have support systems that are not truly supportive as they challenge women’s decisions.

Both groups of participants also mentioned the importance of communication between professionals, women, and family/friend support. Laura, a nurse’s aide, discussed a connection between maternal stress and communication between all parties:

“The level of stress can change hormone composition and a woman’s ability to have a vaginal birth versus a C-section. Good communication is necessary between the provider, mom, and her support network throughout, especially in emergency situations in order to reduce mom’s stress.”

Natural childbirth participants, however, emphasized not just communication, but the need for women to feel heard by their support network, including health professionals present at the birth, further highlighting their belief that the quality of the support network matters. Ester, a midwife, described why:

“It’s important that women feel listened to and have a good support network. Her feelings need to be validated. The baby is soaking in her emotional state so it’s important for her and her baby.”

Theme 7: Fetal/Newborn Health

Biomedical participants believed that having a healthy newborn was the single most important factor for a good childbirth experience. All of the biomedical focus groups and key informants ranked newborn health highest in the pile sorts. In addition, newborn health was discussed eight times as often in biomedical vs. natural childbirth focus groups and key informant interviews. Laura, a nurses’ aid, explains in this way,

“A woman can have a horrible labor or emergency C-section, but fetal issues trump all else…Even if you have a good homebirth, but the baby is rushed to the hospital, it makes a bad experience – it’s all about the baby.”

Natural childbirth participants seldom mentioned fetal/newborn health, instead focusing on the woman’s childbirth experience in terms of her emotions and decision-making ability.

Discussion

Overall, there was general consensus between the biomedical and natural childbirth participant groups on several points including the importance of positive maternal emotions, the need for social support during pregnancy and childbirth, and lack of pregnancy/birth complications as part of a healthy pregnancy and good childbirth experience. The areas of discordance in the general themes, however, show that the two groups have different foci resulting in very dissimilar messages. Biomedical participants emphasized the central role of biomedical professionals in pregnancy and childbirth as the main source of information and authoritative advice. As such, it appears that the biomedical community, through education and discussion about women’s preferences, are giving women the illusion of choice and control, but ultimately biomedical professionals, as experts, feel women should be compliant with biomedical advice. If women choose to discard “expert” advice, then biomedical professionals must step in to make the “right” decisions.

On the other side, natural childbirth participants emphasized women making their own choices during pregnancy and childbirth, gathering independent information, and finding unbiased support networks. In addition, they stressed the long-term effects of

92 women’s experiences during pregnancy and childbirth on women’s emotional states and parenting skills. They regularly discussed maternal empowerment and confidence, but in doing so left little room for maternal uncertainty, apathy, and anxiety. They insisted women gather information and make decisions placing pressure on women to fulfill these responsibilities.

While the biomedical model continues to dominate views of pregnancy and childbirth in the U.S., the rise of the natural childbirth model means women have two competing cultural models from which they must choose in order to make decisions about their behaviors during pregnancy and childbirth plans (Hays, B. 1996, Jordan 1993,

Sargent and Gulbas 2011, Walsh 2010). Ethnographic research indicates that white women of middle to upper SES deal with this conflicting information more often than other women because they are the targets of cultural expectations requiring “good mothers” to seek out and observe the “best” advice (Kingfisher and Millard 1998,

Lazarus 1994, Song et al. 2010). Their higher social position gives them more access to resources, education, and options in their healthcare resulting in increased cultural pressure to become “good” mothers.

The biomedical model exerts biopower over these and other women by insisting women follow biomedical recommendations to protect maternal and fetal health

(Foucault 2008, Jordan 1993, Scheper-Hughes and Lock 1987). According to biomedical tenets, therefore, women’s self-discipline is the basis for women’s health during pregnancy and childbirth (Foucault 2008, Jordan 1993, Scheper-Hughes and Lock 1987).

In addition, as pregnant women are part of the U.S. population, everyone, including

93 biomedical professionals, has a responsibility to surveil pregnant women to ensure their compliance with biomedical messaging and advice to maintain the health of the population as a whole (Davis-Floyd 2001, Jordan 1993, Scheper-Hughes and Lock 1987).

The natural childbirth movement is emerging as a new cultural model that exerts biopower with similar expectations for pregnant women in terms of using self-discipline to guard the human species’ future (Cosans 2004, Mansfield 2008, Walsh 2010).

Proponents of the natural childbirth movement demand that women use self-discipline to resist biomedicine, citing women’s ability to decide on natural childbirth and, thereby, avoid injury to their children due to unnecessary biomedical intervention (Cosans 2004,

Mansfield 2008, Walsh 2010).

Although ethnographic research shows that women frequently exhibit a combination of compliance and resistance with biomedical advice, the presence of a second powerful cultural model, the natural childbirth model, increases the likelihood that women will experience confusion about the “best” way to ensure a good outcome for themselves and their children (Hardey 1999, Root and Browner 2001, Walsh 2010). As such, both communities place pressure on women to follow their recommendations by often stating that their children’s health and future will be compromised if they do not.

Conflicting information leads to confusion and anxiety as women are forced to make authoritative knowledge decisions about pregnancy and childbirth that they are told by both communities have significant consequences for their child’s wellbeing (Browner and

Press 1996, Lazarus 1994, Song et al. 2012)

Generally, biomedical participants emphasized the authoritative knowledge inherent in their recommendations by concentrating on the essential role of the healthcare provider. Women are expected to follow their provider’s advice and let the provider take control in the event of complications. Biomedical participants also focused on the need to protect the fetus as, in most cases, women’s physical and emotional well-being was only discussed as it related to the health of the fetus. This emphasis on the fetus highlights the role of the woman as incubator rather than person as part of the maternal-fetal conflict

(Markens et al. 1997, Oakley 1984, Terry 1989, Weir 2006). The maternal-fetal conflict arises as the fetus is credited with the full rights of a person necessitating protection from the mother through policing of pregnant women (Terry 1989, Weir 2006).

Even though natural childbirth participants’ messages focus more on the woman than the fetus, they still suggested that women exert self-discipline in making the “right” decisions for a healthier pregnancy and a better childbirth experience. Women are expected to gather as much information as possible as the healthcare provider’s advice might be tainted by the provider’s preferences. Women also need to make their own decisions and gather support to help them stick to their decisions. Women should stay strong in their convictions in order to generate feelings of empowerment that translate to confident parenting. This emphasis on information gathering, decision-making, and empowerment may make women who do not want these responsibilities feel inadequate in their preparation for motherhood, although to date there is little research on how women handle these messages (Walsh 2010).

Ethnographic work with pregnant women highlights the layers of “internal and external constraints and considerations” that women sort through when deciding if they should follow advice (Browner and Press 1996: 152). Pregnant women use their embodied knowledge to help them decide if the advice they receive is authoritative knowledge, but they also are influenced by broader societal expectations including “good mother” definitions (Browner and Press 1996, Lazarus 1994, Root and Browner 2001).

The natural childbirth movement’s insistence that pregnant women gain and maintain control is in contrast to the biomedical model’s expectation of compliance (Lazarus 1994,

Walsh 2010). Pregnant women, then, not only have to decide if they will resist biomedical recommendations, but they also must make decisions about natural childbirth authoritative knowledge including maintaining control over their bodies to generate empowerment (Root and Browner 2001, Walsh 2010). Making decisions about authoritative knowledge creates anxiety for pregnant women as they worry about choosing the “wrong” behaviors since both models suggest that not following recommendations can have dire consequences for the infant (Browner and Press 1996,

Lazarus 1994, Root and Browner 2001).

Extensive research reveals that stress during pregnancy can lead to an increased risk for complications in pregnancy and childbirth. These complications include higher intervention rates including increased rates of C-section and induction, as well as, poor birth outcomes such as higher rates of preterm birth and lower birth weights (Dole et al.

2003, Dunkel Schetter 2011, Glynn et al. 2008, Lobel 1994, Lobel et al. 2008).

Bombarding women with conflicting information, therefore, may impact their

96 maternal/fetal health, particularly as there are many other potential sources of conflicting information including family, friends, and internet stories. Understanding how women navigate not just the biomedical messages they receive, but also the other messages they encounter, therefore, could improve overall outcomes. In addition, drawing attention to the adverse effects of strong competing messages can encourage women’s health professionals to examine their messages and as Walsh (2010: 496) suggests “limit their essentialist tendencies,” thereby fostering more compassionate and trusting relationships between professionals and pregnant women.

As my sample size was relatively small, I do not suggest that my findings reflect the beliefs of all women’s health professionals working within biomedical or natural childbirth contexts. In addition, as Columbus, Ohio lacks a birth center and licensing for non-nurse midwives, my choice of study site may have resulted in more dichotomous results than I would have obtained from another area of the country. There likely is a continuum of beliefs among practitioners that I did not fully explore as my goal was to create cultural models of pregnancy and childbirth from these two perspectives. In addition, my difficulties scheduling focus groups with natural childbirth professionals may have impacted my results as I may have missed the unique insights that often emerge from participant interaction. Nonetheless, the clear areas of discordance between my two participant groups support the idea that pregnant women face conflicting information potentially affecting maternal/fetal health, which argues for a better understanding of how societal expectations impact pregnant women.

Chapter 6: Information Gathering and Authoritative Knowledge Decision-Making

Introduction

In the U.S., women receive a large amount of novel information as they begin to navigate the new experiences of pregnancy and childbirth. As this information can come from a variety of sources, the information pregnant women receive potentially compete or even outright conflict. In the presence of competing information, women must make decisions about which information to believe and follow. In this chapter, I explore the information women receive and how they make authoritative knowledge (AK) decisions about that information throughout their pregnancies and during the birth of their children.

To explore this topic, I collected qualitative data using two methods (1) a survey instrument administered to 47 women and (2) open-ended, individual interviews with 28 women to address the following questions:

• RQ1: Where do pregnant women get information regarding best practices during

pregnancy and childbirth?

• RQ2: Which sources do women rely on most heavily for information about best

practices during pregnancy and childbirth?

• RQ3: In what ways does this information conflict?

o RQ3a: What effect does conflicting information have on pregnant

women’s emotions and decision-making?

• RQ4: How do pregnant women make authoritative knowledge decisions about

which practices to integrate into their daily lives and birth plans?

o RQ4a: What information do women prioritize in making decisions about

their behaviors during pregnancy and their childbirth plans?

o RQ4b: Why do women prioritize some information over other information

in their decision-making process?

Methods

Messaging Survey (see Appendix A)

I developed a Messaging Survey to address all of my research questions using two methods. First, I assembled interview and survey questions from the literature that addresses pregnant women’s decision making (Root and Browner 2001). Second, I utilized data collected from the focus groups and key informant interviews I conducted in

Stage 1 of my research study. I only administered the Messaging Survey during the study visits that occurred when women were pregnant as I wanted to explore information gathering and decision making during pregnancy rather than in the postpartum.

I divided the Messaging Survey into four sections. Below I describe the contents of each section, details on how I created each section and the relationship between each section and the specific research questions.

Section 1. The first section covered where women get information or advice about pregnancy and childbirth as well as how which sources they rely on most heavily to

99 explore RQ1 and RQ2. I also asked if women received conflicting information and how any conflicting information they received made them feel to address RQ3 and RQ3a.

Drawing on the academic literature, I created a list of individuals and written sources that pregnant women were likely to utilize when seeking out information (Root and Browner

2001, Song et al. 2012). Based on my literature review, the list of individuals included friends, spouse/partner, mother, grandmother, other female relatives, father, other male relatives, obstetrician, midwife, and other medical professionals. I also used the academic literature to generate the list of written sources, which included books, internet sites, blogs, message boards, pamphlets, magazines, and written information provided by medical professionals. I gave participants the opportunity to write in additional sources that were not included on the two lists as well. I allowed participants to indicate that they used multiple sources from each list when needed. For subsequent visits, I specified that participants should only mark sources that they had consulted since the previous visit.

The last two questions in this section of the Messaging survey focused on conflicting information by asking women if information from these sources agreed or disagreed, in what ways sources conflicted, and how conflicting information made them feel to address

RQ3 and RQ3a.

Section 2. In the second section of the Messaging survey, I asked women about any lifestyle changes they made and the reasons behind those changes. I also inquired about women’s expectations regarding their pregnancies and childbirth experiences. This section helped answer RQ1 and RQ2 by revealing additional information sources women utilized and prioritized that caused them to make lifestyle changes and influenced their

100 expectations. These questions also helped me explore the AK decision-making process women underwent as they explained why they made lifestyle changes and why they had certain expectations to address RQ4, RQ4a, and RQ4b. For the second section, I started with questions from Root and Browner’s (2001) study of how the culture of biomedicine affects women’s perceptions of appropriate behaviors. With slight modifications, I used the following questions from Root and Browner (2001):

• Has your diet changed since you became pregnant? If yes, why did you make

these changes?

• Has your physical activity changed since you became pregnant? If yes, why did

you make these changes?

• Have you changed your use of any substances (i.e., alcohol, caffeine, nicotine,

drugs, sugar, chocolate, and beauty products or treatments) since you became

pregnant? If yes, why did you make these changes?

In addition, I added similar questions about changes in women’s sleeping habits, sexual habits, and work/personal relationships. The questions I utilized from Root and Browner

(2001) as well as the questions I added to the Messaging Survey were included to elicit more data about the information women received by exploring why they made lifestyle changes. Similar to Root and Browner (2001), I found these questions revealed data about the information women received that did not emerge when I asked women about information gathering directly. For example, if a participant indicated that she changed her diet on the Messaging Survey, the next question she answered asked why she changed her diet. The participant may then mention information sources such as her

101 pregnant sister’s advice about diet that she did not think to mention in questions that directly asked about information sources she utilized.

Section 3. The third section of the Messaging Survey contained questions about women’s concerns regarding the health of their babies, the labor and delivery process and how worrying might affect the baby. Women’s concerns often result from information/ advice they receive, particularly if women receive conflicting information/advice (RQ1,

RQ2, and RQ3). In addition, women frequently make AK decisions based on their concerns (RQ4, RQ4a, and RQ4b). I began this section by asking if women were worried about the health of their babies, their prenatal care, and/or what will happen during labor and delivery. I designed these questions to reflect the concerns listed in the established

Pregnancy-specific Anxiety Scale described in Chapter 4. If participants answered yes to any of these questions, I asked them to explain why they were worried. I then added another question from Root and Browner (2001): do you think your worrying is having an effect on the baby?

Section 4. The final section (Section 4) of the Messaging Survey used a Likert scale and asked women to agree or disagree with thirty different statements that emphasized the points of discordance between the two U.S. models of pregnancy and childbirth: biomedical and natural childbirth. This section of the survey helped identify conflicting information that women received (RQ3). This section also identified instances where a woman agreed with conflicting tenets. In these instances, she would decide which information to prioritize (RQ2). I derived the thirty statements I included in this section of the Messaging Survey from the focus group and key informant interview data I

102 collected in Stage 1. I created the agree/disagree statements to emphasize the areas of discordance between the biomedical and natural childbirth models I discussed in Chapter

5. For example, one area of discordance between these two models is where women should get information about pregnancy and childbirth. According to the biomedical model, the healthcare provider is the best (and sometimes the only appropriate) source of information for pregnant women. The natural childbirth model, on the other hand, posits that women should gather information from many sources as healthcare providers are often viewed as presenting biased information. I used these results to create the following series of agree/disagree statements that were included in the thirty Likert scale statements:

• Women should seek information about labor and delivery options from multiple

sources other than their healthcare provider.

• The healthcare provider frequently is not a woman’s best source of information on

pregnancy and childbirth.

• Women should independently gather information about how to maintain a healthy

pregnancy from multiple sources other than their healthcare providers.

• Following the healthcare provider’s advice is the most important responsibility a

woman has during pregnancy.

• A woman’s intuition is more important than the healthcare provider’s advice

during pregnancy.

I purposely created provocative statements to elicit strong agreement or disagreement from participants. I wanted to determine if participants were clearly aligned with one

103 model over the other and, therefore, less likely to be confused by conflicting information they encountered.

Interviews (see Appendix B for interview script with additional probes)

To gather more detailed data on where women get information and how women make decisions about their behaviors during pregnancy and their childbirth plans (RQ1,

RQ4, RQ4a, and RQ4b), I conducted in-depth, semi-structured, personal interviews

(Bernard 2011) with n=28 of the women in my longitudinal study. I offered every participant the opportunity to take part in the interviews during their regular study visit.

Each woman who gave her consent was interviewed three or four times during pregnancy depending on her child’s gestational age at the first study visit. In other words, women who joined the study in their first trimester were interviewed once during each trimester and once postpartum for a total of four interviews. Women who joined the study in their second trimester were interviewed once in the second and once in the third trimesters as well as once postpartum for a total of three interviews. I conducted interviews within one to two weeks of the regular study visit in which participants completed the survey instrument and I collected hair samples (for cortisol analysis). As such, I visited women who participated in interviews twice as often as other participants. Interviews lasted between 15 and 42 minutes depending on how much the participant wanted to share about her experiences with information gathering and decision making. I recorded all interviews with a Phillips Voice Tracer digital recorder. Following the interview, I downloaded the digital file to a laptop and marked it with the participant’s number, date of the interview, and visit number.

104

I also wrote interviewer notes about the location, the interviewee’s demeanor, and other insights I had during and after the interview. These notes allowed me to place the interview in context. In addition, I reflected on the interview process including my own reactions to the interviews as a personal check on my assumptions about the topic. I also used these notes to examine my relationships with the participants and how those relationship dynamics might have affected responses to the interview questions.

During interviews, I began with the following two questions from Root and

Browner (2001):

• How have you been feeling these days?

• Are there ways that being pregnant has changed your daily life?

I found these two questions helped put participants at ease and elicited information that I could revisit during the interview. For example, many women mentioned how experiencing excessive tiredness during their pregnancies made them feel lazy. Given this information, I then inquired about what information contributed to their feelings of laziness. In addition to the questions from Root and Browner (2001), I asked the following series of questions about decision making during pregnancy to address RQ4,

RQ4a, and RQ4b:

• How comfortable are you making decisions about your pregnancy and childbirth

plans? What types of decisions are you more comfortable making? Why are you

more comfortable making these types of decisions?

• How do you make decisions regarding your behavior during pregnancy and

childbirth?

105

• What decisions have you made and then later changed? Why did you make these

changes?

If participants expressed confusion about these questions or did not provide detailed responses, I asked them about a specific decision they recently made regarding their pregnancy or childbirth experience. I then questioned them about the process they went through in making that decision.

I also inquired about sources of information and conflicting information with the following set of questions to address RQ1, RQ2, RQ3, and RQ3a:

• Who do you go to with questions or concerns about your pregnancy and childbirth

plans?

• Where else do you search for information?

• About what kinds of things do you seek information? Why do you want

information on these things? What do you think of the information you have

found on these subjects?

• How often do you seek out information from these sources? Does the information

from these sources agree?

• Does anyone give you advice you have not requested? [If yes] who are these

people? What do you think of the advice each person gives you?

• Do you discuss information you obtained from other sources with your nurse,

doctor, or midwife? Why or why not?

In several instances, participants spoke about sources of information when they discussed their decision-making process as well. These questions, however, helped identify other

106 sources of information as women did not always consult the same sources of information for all types of decisions. For example, a woman might rely heavily on information from her doctor for medical decisions such as whether or not to do genetic testing, but for decisions about who to have in the delivery room during childbirth, she may prioritize advice from her friends and relatives.

Finally, I used the following questions to inquire about women’s expectations and concerns. With these questions, I wanted to explore the information women encounter further, particularly from the biomedical and natural childbirth models, a potential source of conflicting information (RQ3 and RQ3a).

• What expectations do you have for your pregnancy and childbirth experience?

From where do you think your expectations for your pregnancy and childbirth

experience come? Why do you have these expectations?

• Which things about your pregnancy and your child’s birth are most important to

you? Why are those things important?

• What things worry you about pregnancy and childbirth? Why are these things of

concern to you?

As I built rapport with women, I changed the interview script periodically to gather more detailed data on the women’s information gathering and decision-making behaviors (Appendix B). I continued to ask the questions in the original script, but I added probes when women did not understand a question or did not give much information. For example, I found that when asked about decisions, women would discuss decisions they already had made with few details about their decision-making

107 process. When I asked if they currently were struggling with any decisions, however, women would describe how they were working through a current decision with much more detail about the decision-making process.

Data Analysis

To determine where women get information and which sources they rely on most heavily (RQ1 and RQ2), I tallied the total number of participants stating they utilized each source. I then calculated percentage of all participants in the sample utilizing the source for each source at each study visit. I also calculated the mean number of individuals and written sources consulted for information separately as well as total sources consulted for each study visit. I then calculated percent change over time for the most used sources using the percentage of participants using each source in the first and third trimesters to determine if women used some sources more heavily than others in at different points in pregnancy. I also compared source use at the first and second visits and the second and third visits for the number of individuals consulted, the number of written sources consulted, and the total number of sources consulted with paired sample t-tests.

I then divided the participants into first-time mothers or primiparous women

(n=27) and mothers pregnant for the second or third time or multiparous women (n=20).

Previous ethnographic work shows that primiparous women struggle more with AK decisions than multiparous women (Browner and Press 1997, Crossley 2007, Root and

Browner 2001, Song et al. 2012). As primiparous women have little experience with pregnancy and childbirth, they must sort through a great deal of new information about pregnancy and childbirth, which frequently makes them more confused about which

108 information to prioritize (Cole et al. 2019, Coxon et al. 2014, Davis-Floyd 2001, Jordan

1993, Malacrida 2015, Sargent and Gulbas 2011). Multiparous women, on the other hand, usually follow the same pregnancy behaviors and childbirth plans from their previous pregnancies (Browner and Press 1997, Crossley 2007, Root and Browner 2001,

Song et al. 2012). As a result, primiparous women may use sources differently and prioritize different sources than multiparous women (RQ1 and RQ1a). Primiparous women also may have a different decision-making process compared to multiparous women. In an effort to better understand how women make AK decisions (RQ4, RQ4a, and RQ4b) and choose to prioritize some information over others (RQ2), therefore, I compared source use and decision making between these two groups. I repeated the process described above after splitting the sample into primiparous and multiparous women. I tested for differences between these two groups in source use using Chi-square tests, Fisher’s exact test, and t-tests as needed. I also used repeated measures ANOVAs to compare patterns of change in consultation of individuals, written sources, and total sources between primiparous and multiparous women.

To address RQ3 and RQ3a, I tallied how many women reported encountering conflicting information. I also tallied how many women reported anxiety, confusion, and/or frustration due to conflicting information. I then divided the sample into women who reported anxiety due to conflicting information (n=25) and those who did not report anxiety due to conflicting information (n=22) according to women’s answers to the questions in Section 1 of the Messaging Survey. My intention with this division of the sample was to explore how conflicting information affects women’s prioritization of

109 sources and decision-making process (RQ3a). I compared women’s source use between these two groups using Chi-square analyses, Fisher’s exact test, and t-tests as needed. For the agree/disagree statements in section 4 of the Messaging Survey, I calculated a composite conflict score for each woman within each model to see if women were receiving conflicting information from these models (RQ3). I gave women negative values if they disagreed with a statement and positive values if they agreed with a statement. I then added these scores separately for the biomedical model statements and the natural childbirth model statements. If a woman disagreed with most of the biomedical statements, she had a negative biomedical composite score. If she also agreed with most of the natural childbirth statements, she had a positive natural childbirth composite score. If a woman’s score was close to zero for both composite scores, I categorized her as not aligning strongly with either model. Lastly, in the Messaging

Survey data, I coded the qualitative data to identify themes in each section including how women prioritized information, feelings about conflicting information, and women’s concerns about pregnancy and childbirth to add depth to the above analyses and further explore RQ4, RQ4a, and RQ4b.

Using the digital audio file for each interview, I transcribed each interview as a rich text file. I then loaded the transcript into MaxQDA v11 qualitative software (Udo

Kuckartz Berlin 1995-2018). I read the transcripts concentrating on sources of information, discussions of conflicting information, and the decision-making process.

From this initial read-through, I developed a coding system for each research question and performed content analysis separately for each research question (Bernard 2011). To

110 address RQ1 and RQ2, I coded for information sources to determine where women got information and which sources were used most heavily. To address RQ3 and RQ3a, I focused on discussions of conflicting information and coded for different reasons the information conflicted and the effects of conflicting information on women’s prioritization of sources and decision-making process. To address RQ4, RQ4a, and RQ4b,

I focused on discussions of decision-making and coded for how and why women chose to prioritize some information sources over others (Dressler et al. 2005, Bernard 2011).

Finally, when using quotations from participants, I changed all names to pseudonyms to protect confidentiality.

Results

RQ1: Where do pregnant women get information regarding best practices during pregnancy and childbirth?

RQ2: Which sources do women rely on most heavily for information about best practices during pregnancy and childbirth?

Participants reported gathering information from a variety of individuals and written sources (Tables 6.1, 6.2, and Table 6.3). Generally, while women consulting more written sources of information, the ethnographic data showed that they trusted information from individuals more than information from written sources. Additionally, there were preferred individuals from whom women sought advice, which I discuss in more detail below. For written sources, women relied most heavily on the internet for information despite their admission that information on the internet often is suspect. I also found a trend in the timeline of information seeking.

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Table 6.1. Individuals who pregnant women consulted for advice/information.

Visit 1 (n=25) Visit 2 (n=47) Visit 3 (n=47) % of % of % of Individual n sample n sample n sample Friends 19 76.0 35 74.5 30 63.8 Family Father 2 8.0 2 4.3 1 2.1 Grandfather 1 4.0 0 0.0 0 0.0

Grandmother 2 8.0 4 8.5 3 6.4 Mother 17 68.0 30 63.8 22 46.8 Other female relatives 11 44.0 20 42.6 12 25.5 Other male relatives 2 8.0 0 0.0 0 0.0 Spouse/Partner 13 52.0 19 40.4 20 42.6 Health professionals Doula 1 4.0 5 10.6 7 14.9 Midwife 5 20.0 12 25.5 12 25.5 Obstetrician 17 68.0 31 66.0 26 55.3 Other childbirth professionals 0 0.0 4 8.5 4 8.5 Other medical professionals 3 12.0 7 14.9 4 8.5 Other person not listed 0 0.0 2 4.3 4 8.5

Table 6.2. Written sources that pregnant women consulted for information.

Visit 1 (n=25) Visit 2 (n=47) Visit 3 (n=47) % of % of % of Written source n sample n sample n sample Books 16 64.0 24 51.1 22 46.8 Internet sites 24 96.0 42 89.4 36 76.6 Blogs 8 32.0 11 23.4 12 25.5 Message boards 6 24.0 12 25.5 9 19.1 Pamphlets 0 0.0 3 6.4 3 6.4 Magazines 4 16.0 6 12.8 5 10.6 Written info from medical professional 15 60.0 22 46.8 12 25.5 Other source not listed 1 4.0 4 8.5 3 6.4

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Table 6.3. Mean number of individuals, written sources, and total sources of information that pregnant women consulted.

Sources consulted Mean SD Visit 1 # of individuals consulted 3.7 2.1 # of written sources consulted 3.0 1.1 Total # of sources consulted 6.7 2.7 Visit 2 # of individuals consulted 3.8 1.6 # of written sources consulted 2.8 1.4 Total # of sources consulted 6.6 2.4 Visit 3 # of individuals consulted 3.6 1.7 # of written sources consulted 2.3 1.2 Total # of sources consulted 6.0 2.3

Women generally reduced their information seeking over the course of pregnancy.

Finally, primiparous women sought out more information than multiparous women and showed a different trends for information seeking in second and third trimester visits. I explore all of these trends in detail in the following sections.

Individuals. In interviews, women mentioned gathering information from individuals three times more often than from written sources. They also mentioned being able to trust the individuals in their lives as sources of advice over the information they found in books or on the internet. Within this group of individuals, women relied most on their friends for advice. Other important sources of advice included women’s mothers, spouse/partners, other female relatives, and healthcare providers (obstetrician or midwife)

(Table 6.1).When women reported a person causing negative emotions, they generally

113 mentioned one of two individuals: their friends or their mothers/mothers-in-law. Nine participants (19%) said their friends evoked these emotions most commonly, while seven participants (15%) mentioned that advice from their mothers or mothers-in-law caused the most negative emotions. In terms of positive emotions such as reassurance, safety, and confidence, women more frequently mentioned their obstetrician or midwife as the person who evoked positive emotions more than any other person (n=18, 38%).After their healthcare provider, women stated that friends and mothers caused the most positive emotions. Fourteen participants (28%) named friends as their main source of positive emotions and nine women (19%) named their mothers as their main source of positive emotions. Only five participants (11%) chose their spouse or partner as the person who gave them the most positive emotions.

In interviews, women explained why they chose some individuals over others for advice. Most often, women mentioned generational differences in the information given as the reason they avoided asking their parents or grandparents for advice. As Ashley explains,

“My parents give advice about that stuff too, like what I can’t eat. I think [that advice] has changed a lot since when my mom was having us. There are a lot of things that are different. I think the lunchmeat thing didn’t exist before. The whole Listeria fear [a bacterium that can enter the body from eating lunchmeat and affect the fetus] wasn’t really a thing back then either.”

Other participants said the unsolicited advice they received from their parents or their partner’s parents did not agree with what women had already decided was best or with their doctor’s advice. Lorraine expressed her frustration with the advice she received from her mother and mother-in-law,

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“My mom said she never had an ultrasound at all and that I’m very healthy. My mother-in-law said that as well. So, then I’m like, I don’t know. But I don’t listen to their advice, a lot of their advice, like don’t move, stay in bed all the time, stop jogging. I still do some minor exercises nowadays and then I eat the food that they ask me not to. Like [they say] not to eat spicy foods, but I like spicy foods, especially sour, spicy, heavy tastes. So, I feel like, not listening to them.”

In addition, while women often expressed their tendency to discuss information they receive with their spouses or partners, they preferred to ask their mothers and other female relatives for advice despite generational differences. Sophia laughed about her preference for discussing certain topics with her female relatives,

“And frankly, there are some things I will discuss with [my husband] and there are other things that he probably isn’t the first. And whether or not that’s right or wrong, whatever. Partly because, not that I don’t value his opinion, but as a man who’s never given birth and will never give birth, you know, I would value my mother’s opinion in certain circumstances over his. I would never say that to him, of course. But in terms of information seeking, [I would] definitely go to my mom. I also have an aunt, my mom’s youngest sister, who’s always been kind of a big sister to me. She’s a great source of advice. I like to go to her if I’m truly feeling stuck.”

Again, women tended to use multiple sources of information to help answer their questions (v1: mean 5.80; v2: mean 1.98; v3: mean 5.06). Just as they often checked information they received from individuals against written sources, they frequently discussed information they received from written sources with their trusted advisors. In her first trimester visit, Erin stated her intention to confer with her midwife about information she received from other sources,

Interviewer: If you do get information from other sources, do you usually discuss that information with your midwife or doula?

Erin: Well, I’ve only seen them once so no, I haven’t really discussed anything with them.

Interviewer: Do you think you will discuss information from other sources?

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Erin: Oh yeah, definitely with my midwife. I mean she’s a professional so definitely.

Interviewer: So, you feel like you can trust what she says?

Erin: Trust what she has to say? Oh yeah, definitely. I definitely trust what she has to say.

While women prioritized advice from biomedical professionals, they often expressed that they felt checking multiple sources of information would allow them to make better decisions. I discuss how they make those decisions later in this chapter.

Written sources. Overwhelmingly, women went to the internet for information over other written sources (Table 6.2). Mostly, women relied on internet sites, but they also visited blogs and message boards for information. In the Messaging Survey, women indicated that they consulted books, but, in the individual interviews, women rarely mentioned books. Instead, most women discussed internet sites they visited and the difficulties they faced in determining if the information was valid. Sophia expressed how blogs affected her,

“I’ve reduced time on social media because I feel it’s a time suck anyway, but I do read a couple of blogs and, you know, I’m very susceptible to reading something somebody’s written and thinking, oh, I need to do that. You know, because there’s always that comparison piece so if I were to hear about someone who is pregnant doing certain things that might also make me feel like I’m not doing enough because it sounds like that person is doing more than me.”

Many women also mentioned how the abundance of “horror” stories on blogs and message boards caused them to worry. Monica, for example, details her concerns about the information she found on the internet and its effect when a complication arose.

“I feel like I sought out a lot of information on the internet, although I feel it’s really not that reliable. But I usually go to the internet if I run into an issue. I had

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some bleeding issues actually several times in the beginning [of my pregnancy] and even in the beginning of my second trimester. So, that’s really scary. And, of course, the internet didn’t give me comfort at all on that issue. Because there were people who said, ‘oh, it happens a lot’ and other people would say, ‘this is how I lost my baby’. Yeah, and then I read some really sad stories that made me sad. I also looked up some test and stuff, like where people did some of the testing and the results were not good. I mean I started looking for information about those [bleeding] issues and then it usually would go into a different direction. And then it would become people telling how sad they are. It’s not really that comforting.”

For medical decisions such as whether or not to do genetic testing, women usually read written information given to them by their obstetrician or midwife (Table 6.2). In some cases, however, women felt they needed to supplement the written information they received with information from other sources. Olivia received information about which medicines were safe to take, but sought out more information about taking medicine when she caught a cold.

“[My doctor], just this time around, gave me a list of all the medicines I can take and the doses she considered safe, if you have a cold or if you have constipation, whatever you can think of. And then when I looked those same medicines up online, some of them would say absolutely don’t take that and that’s horrible. And then I got a cold. My husband went to get Sudafed because the sheet said take Sudafed. That was an okay thing to take so he went to the pharmacy and got it. And the pharmacist was even saying, ‘don’t give that to her, absolutely do not give that to her, I would never take that’.”

This tendency to consult multiple sources of information was common. Again, the internet was the main written source of information either before or after receiving information from other sources (Table 6.2).

Source Use Across Pregnancy. Generally, women sought out less information over time, particularly in the second trimester. For many sources, there was little change between the first trimester and the second trimester, but for some sources, use decreased dramatically in the third trimester. For written sources, use of books reduced by 26.9%

117 and use of internet sites reduced by 20.2% between the first and third trimesters. Use of written information provided by medical professionals also decreased from the first to the third trimester by 57.5%. Other written sources showed little change in use over time. For people, use of friends as a source of advice decreased by 16.0% from the first to the third trimester. Use of spouse as a source of advice decreased by 18.1% and use of mother as a source of advice reduced by 31.2% from the first to the third trimester. Women even decreased their use of their obstetrician as a source of information by 18.7%.

This downward trend also was visible in comparing the mean number of sources for each trimester visit (Table 6.3). In comparing mean number of individuals consulted for information, no significant differences emerged between the first and second trimester visits, the second and third trimester visits, or the first and third trimester visits (v1 vs. v2: t(23)=0.23, p=0.82; v2 vs. v3: t(45)=0.80, p=0.43; v1 vs. v3: t(23)=0.76, p=0.50).

Comparisons between the mean number of written sources consulted at each trimester visit (Table 6.3), however, revealed significant differences between the second and third trimester visits (t(45)=2.11, p=0.04) and the first and third trimester visits (t(23)=2.10, p=0.05), but the first and second trimester visits were not significantly different

(t(23)=1.73, p=0.10). In addition, for the mean total number of sources (Table 6.3), the second and third trimester visits were significantly different (t(45)=2.18, p=0.04), but the first and second trimester visits (t(23)=1.22, p=0.24) and the first and third trimester visits (t(23)=1.70, p=0.10) were not significantly different. These trends were different, however, when comparing primiparous and multiparous women as discussed in the next section.

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Source Use Among Primiparous and Multiparous Women. Generally, more primiparous women consulted information sources than multiparous women, although differences were not significant for all information sources or at all time points (Tables

6.4, 6.5, and 6.6). No significant differences in source use emerged between these two groups in the first trimester. I had fewer participants who completed a first trimester visit

(n=25), however, which makes finding significant differences between groups more difficult. In the second trimester, significantly more primiparous women reported gathering information from books (Χ2=9.644, p<0.01), message boards (p=0.05, Fisher’s exact test), and written sources provided by medical professionals (Χ2=6.706, p=0.01) than multiparous women. In addition, significantly more primiparous women consulted friends for advice than multiparous women (Χ2=4.067, p=0.04). Midwives also were a more widely used source among primiparous women than multiparous women (p=0.05,

Fisher’s exact test). Number of individuals consulted, written sources consulted, and total sources consulted also differed significantly between these two groups in the second trimester (Table 6.6). In the third trimester, more primiparous women relied on books

(Χ2=4.639, p=0.03) and written sources provided by medical professionals (p=0.04,

Fisher’s exact test) than multiparous women. Number of individuals consulted, written sources consulted, and total sources consulted differed significantly for primiparous and multiparous women in the third trimester as well (Table 6.6).

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Table 6.4. Individuals consulted for advice/information among primiparous and multiparous women.

Primiparous Multiparous Visit 1 Visit 2 Visit 3 Visit 1 Visit 2 Visit 3 (n=12) (n=27) (n=27) (n=13) (n=20) (n=20) % of % of % of % of % of % of Individual n sample n sample n sample n sample n sample n sample Friends* 9 75.0 23 85.2 19 70.4 10 76.9 12 60.0 11 55.0 Family Father 2 16.7 2 7.4 1 3.7 0 0.0 0 0.0 0 0.0 Grandfather 1 8.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Grandmother 2 16.7 4 14.8 2 7.4 0 0.0 0 0.0 1 5.0 Mother 9 75.0 19 70.4 14 51.9 8 61.5 11 55.0 8 40.0

120 Other female relatives 6 50.0 14 51.9 8 29.6 5 38.5 6 30.0 4 20.0

Other male relatives 2 16.7 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Spouse/Partner 7 58.3 12 44.4 14 51.9 6 46.2 7 35.0 6 30.0 Health professionals Doula 1 8.3 3 11.1 5 18.5 0 0.0 2 10.0 2 10.0 Midwife*+ 4 33.3 10 37.0 10 37.0 1 7.7 2 10.0 2 10.0 Obstetrician 7 58.3 16 59.3 13 48.1 10 76.9 15 75.0 13 65.0 Other childbirth professionals 0 0.0 3 11.1 4 14.8 0 0.0 1 5.0 0 0.0 Other medical professionals 2 16.7 4 14.8 2 7.4 1 7.7 3 15.0 2 10.0 Other person not listed 0 0.0 2 7.4 4 14.8 0 0.0 0 0.0 0 0.0 * Significantly different in the second trimester + Significantly different in the third trimester

Table 6.5. Written sources consulted for information among primiparous and multiparous women.

Primiparous Multiparous Visit 1 Visit 2 Visit 3 Visit 1 Visit 2 Visit 3 (n=12) (n=27) (n=27) (n=13) (n=20) (n=20) % of % of % of % of % of % of Written sources n sample n sample n sample n sample n sample n sample *+ Books 8 66.7 19 70.4 16 59.3 8 61.5 5 25.0 6 30.0 Internet sites 12 100.0 25 92.6 22 81.5 12 92.3 17 85.0 14 70.0 Blogs 2 16.7 6 22.2 6 22.2 6 46.2 5 25.0 6 30.0 Message boards* 4 33.3 10 37.0 7 25.9 2 15.4 2 10.0 2 10.0 Pamphlets 0 0.0 3 11.1 2 7.4 0 0.0 0 0.0 1 5.0

121 Magazines 1 8.3 4 14.8 3 11.1 3 23.1 2 10.0 2 10.0

Written info from

*+ medical professional 6 50.0 17 63.0 10 37.0 9 69.2 5 25.0 2 10.0 Other source not listed 1 8.3 3 11.1 3 11.1 0 0.0 1 5.0 0 0.0 * Significantly different in the second trimester + Significantly different in the third trimester

Table 6.6. Mean number of individuals, written sources, and total sources of information consulted among primiparous and multiparous women.

Primiparous Multiparous Mean SD Mean SD t-test results Visit 1 # of individuals consulted 4.3 2.5 3.2 1.5 t(23)=1.46, p=0.16 # of written sources consulted 2.8 1.2 3.1 1.0 t(23)=-0.55, p=0.60 Total # of sources consulted 7. 2 3.3 6.2 2.1 t(23)=0.87, p=0.40 Visit 2 # of individuals consulted 4.2 1.4 3.0 1.5 t(45)=2.70, p=0.01 # of written sources consulted 3.2 1.4 1.9 0.8 t(45)=3.90, p<0.01 Total # of sources consulted 7.4 2.2 4.8 1.7 t(45)=4.23, p<0.01 Visit 3 # of individuals consulted 3.6 1.3 2.5 1.7 t(45)=2.77, p<0.01

122 # of written sources consulted 2.3 1.0 1.6 1.2 t(45)=2.55, p=0.02 Total # of sources consulted 5.9 2.0 4.0 2.2 t(45)=3.30, p<0.01

While there were significant differences between number of sources used at the second the third trimester visits, primiparous and multiparous women did not show a significantly different pattern of source use over time (individuals: F(1,23)=0.03, p=0.86; written sources: F(1,23)=1.83, p=0.20; total sources: F(1,23)=0.81, p=0.38).

Interviews with women showed a similar trend in that multiparous women frequently mentioned that they did not feel the need to ask as many questions or seek out as much information in their second or third pregnancy compared to their first pregnancy.

Pregnant with her second child, Kelly seemed surprised at her lack information gathering,

“You know, it’s funny, I had my OB (obstetric) check-up last Monday. And with my first pregnancy, I came in with a list of like fifteen questions to every appointment. And with this one, we had just gotten back from vacation and I was really just interested in hearing the baby’s heartbeat and that was it.”

Stephanie, another multiparous women, expressed a similar sentiment,

“I generally feel much more calm about things [with this pregnancy]. I feel like nothing is unexpected at this point. I have a better barometer for what’s normal and how wide the range of normal actually is. And I’m less hyper-responsive for every little new symptom…I did a lot more information gathering with the first pregnancy.”

When asked about giving birth to her second child, Melanie expressed her thoughts as simply, “Since I’ve done [childbirth] once before, it’s not as scary as it was the first time around.” Other participants mentioned how similar feelings about pregnancy and childbirth reduced their need to gather information. Sophia discussed why she felt more confident and how that affected her need to gather information, “I feel better equipped this time around. Even if there are complications, I have a tool set that exists now that didn’t exist before. I have a proven supportive husband and a proven supportive family.

So, I don’t need to worry as much or ask as many questions.”

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Summary for RQ1 and RQ2. Overall, women relied on written sources more than individuals for information, but they tended to trust information from individuals more than information from written sources. In particular, women consulted their friends, spouse/partner, obstetrician, mother, and other female relatives for advice more frequently than other individuals in their lives. For written sources, considerably more women sought out information from the internet than any other written source. In addition, women reduced information seeking as the pregnancy progressed, particularly between the second and third trimesters. Finally, primiparous women sought out information from more sources than multiparous women indicating a need to see multiple options before making an AK decision about which behaviors are most “appropriate.”

Primiparous women also continued gathering information from more sources longer into their pregnancies than multiparous women.

RQ3: In what ways does this information conflict?

For every visit during pregnancy, the majority of participants reported encountering conflicting information in the sources they consulted for information and advice. In the first trimester visits (n=25), 68% of women (n=17) reported encountering conflicting information. In the second trimester visits (n=47), 70% of women (n=33) reported finding conflicting information. In third trimester visits (n=47), 57% of women

(n=27) reported encountering conflicting information in the sources they utilized. Of the women who reported conflicting information, 52% (n=17) discussed finding this information on the internet, while 22% (n=7) mentioned dealing with conflicting information from individuals in their lives including their friends, coworkers, family, and

124 healthcare providers. A small number of participants (n=3; 9%) discussed a mismatch between the information they found online and information they received from individuals. For example, in her second trimester, Sarah expressed her frustration with information on the internet, particularly in blogs, as well as the role her mother and mother-in-law have in controlling her fears,

“There is a lot of inconsistencies in the information online. There also are many 'horror stories' on the forums that seem to suggest to me that any little negative sign can mean catastrophe. At the same time, my mother/mother-in-law tend to tell me those signs are normal.”

Other participants, such as Ariel, stated similar thoughts about information on blogs and message boards, but had less concern about which advice to follow, “Most advice regarding pregnancy seems to be opinion – not fact. The opinions vary from person to person.”

Ashley discussed not only conflicting information she received about how best to prepare for birth, but also her desire to place her trust in biomedical professionals.

“[My] mother-in-law [gave] not necessarily bad advice, but just her idea of what it is that we should do during the pregnancy. [We] started having conversations about, you know, ‘when you do the Lamaze class…’ And I think, you know, my husband and I talked about it, we’re like, we don’t really need to do those classes and my doctor didn’t say we had to do those classes. We’ll just kind of figure it out when it comes. If there’s something I’m not doing that I need to be doing, I’m sure the doctor or nurse will tell me. But, other than that…like, again, I don’t want to go through the class and have them tell you all of the things that can go wrong and then just make me worried. I’d rather just avoid that and say that, the things I really need to know, they’ll tell me. So, but, yeah, so things like that. So she’s mentioned the Lamaze class and, you know, we kind of had the discussion with her, like, is that really necessary? And her response was, well, yeah, and like Mike (he’s my husband) needs to know what to expect.”

Many women, like Ashley, prioritized information from biomedical professionals. Some participants also acknowledged how information they found tied to websites dedicated to

125 the natural childbirth model conflicted with information given to them by their doctors.

Anna, for example, found differences in views of pregnancy/childbirth as a source of conflicting information, “People give different advice on exercising, how to prep for natural childbirth, some sites are way more 'crunchy' than others.” When asked what she meant by “crunchy,” Anna explained that some websites focus more on natural remedies for symptoms and childbirth techniques that do not involve drugs.

As another example of conflicting information in which women prioritized biomedical advice, Monica relates her experiences attempting to decide on how much caffeine to consume given conflicting information from multiple sources.

Monica: So, it’s like…well, it was on one of the lists the doctor gave me. I think it was recommended not to do this, that, that. Most of the stuff they were against, I don’t usually eat anyway. But they were like maybe having more than that much caffeine involves some risk for low birth weight. I was a little scared in that moment because everyone kept…not everyone, but I had this impression that everyone kept telling me it was kind of dangerous for the first three months and everything. So, I felt like it was better to be safe so I stopped drinking coffee for like almost three months. It was really hard. And honestly, I feel like if I have another baby, I might not do that again. I don’t even feel it matters that much. I mean it’s probably some sort of low correlation. I don’t think it’s that…it’s not like…I mean, actually, I feel like smoking or drinking alcohol is not good, but I don’t think coffee really matters that much. I don’t know. Maybe a person who really likes to drink [alcohol] would say the same thing. You know, people who really like to drink, they have babies. It’s weird because my colleague was talking about how she started to eat all of the [forbidden] food when she was pregnant. She already had a son. Like, she started to eat everything bad that her doctor recommended against. And she said, oh, women in this part of the world are still eating that. Like, women in France are still eating those cheeses even though, you know, you’re not supposed to eat that. Those people are still eating deli meat so I can eat that too. She basically started doing all of those things that her doctor recommended against. And I’m sure those things are related to like risk factors and stuff, but she ended

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up fine. I guess she is not the unlucky one on the trend line or whatever.

Interviewer: So, you feel like it was a little too…the risk might have been less than what they’re saying or…?

Monica: Yeah.

Interviewer: It wasn’t as big a deal as they were saying?

Monica: Yeah, I guess related to coffee. Also, my mother-in-law, she is a big coffee drinker. And she kind of gave me a good excuse for drinking coffee. She’s like…she has three kids and she said, oh, if you completely go cold turkey, it’s actually not good. So, I was like, yeah, she said that. I don’t know. I shouldn’t distrust…I feel like I shouldn’t distrust research, but I just feel that I wouldn’t really have had…I don’t think the coffee is that evil. Yeah.

Similarly, Matilda, pregnant with her second child, discusses how she felt in her previous pregnancy when she was faced with information about caffeine consumption that conflicted with what her doctor had told her.

“I drink coffee. Again, because my doctors tells me I can, but I do know for a fact that coffee, up to 300 mg per day, is safe to drink during pregnancy. I’ve seen that in research over and over again. Although, I think they err on the side of 200, actually. And, I wrote something on my Facebook page about drinking coffee during pregnancy and it probably came out really awful. I said something like, wow, I can’t imagine how fast your heartbeat is after I drink my cup of coffee in the morning. And I’m realizing now that that sounds so bad, but it’s true because her heartbeat, you know, is always so fast. And then, one of my “friends” on Facebook said something like, that was an awful thing to say, first of all, you shouldn’t be drinking any coffee during pregnancy, it’s so bad for the baby. And I’m like, yeah, well, yeah, it looked like…it sounded really awful. I shouldn’t have worded it like that.”

Matilda’s experience also shows that conflicting information sometimes comes from unsolicited advice, an issue dealt with by most women in the study.

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RQ3a: What effect does conflicting information have on pregnant women’s emotions and decision-making?

Although a majority of participants reported conflicting information in all three trimesters, not all of these women were adversely affected by conflicting information as shown in the examples above. In fact, 29% (n=5) of women in their first trimester visit,

24% (n=8) in their second trimester visit, and 33% (n=9) of women in their third trimester visit who reported encountering conflicting information said this information did not cause them any confusion, concern, or anxiety. Cindy was one participant who was not bothered by the conflicting information she found online, “In most cases, I already have an opinion. For example, drinking – I know that this is something I won't do, so the information doesn't concern me too much. In regards to the weight gain and other things, I seek advice from my [obstetrician].” Emily similarly had little trouble dealing with conflicting information online as she was able to get information she trusted from one of her friends.

Emily: [I] mostly get information…for example, if I have a certain pain. I check, like, I don’t know, pain in the stomach and pregnancy. So I get…I Google that and I get a lot of different answers. So, I try to go to the most serious sites, not just blogs. And usually everything I’ve looked for, it says it’s absolutely normal to feel this. Or, for example, with some drugs…is it okay to take this drug during pregnancy? Yes, super fine. I look mostly for that kind of thing.

Interviewer: Do you talk about that information with anyone?

Emily: Mostly with my husband, yes. And if it’s something that I…after looking at the internet, I’m still not clear about it then I ask my friend, my obstetrician friend.

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The other participants who reported conflicting information, however, discussed the worry and anxiety they felt when faced with the need to sort through this information

(visit 1: 71%; visit 2: 76%; visit 3: 67%). When asked how conflicting information made her feel, Emma discussed her feelings this way, “[Conflicting information] makes me feel worried. Add in the hormones and I become hysterical.” Andrea expressed similar emotions when she had to deal with conflicting information, “I feel anxious, concerned, confused, and often afraid.” Violet, pregnant with her first child, mentions her confusion when dealing with conflicting information, but also her reluctance to bring her questions to the individuals in her life.

“Well, I don’t ask people a lot of stuff, only very occasionally. So, I read the doctor’s lists or whatever, their documents. And then I borrowed a pregnancy book. I haven’t finished the whole book. I didn’t actually…I probably read like half of the book overall. So, most of the information is the same, but some isn’t, which is confusing.”

When asked why she did not want to consult her friends, family, and/or obstetrician for advice, Violet answered,

“Well, I wouldn’t…it’s weird because my mother…it would be some sort of. I wouldn’t say it’s advice. She gives me very, very vague suggestions. Like, oh, you take care. It’s like whatever she would usually tell me even if I wasn’t pregnant. And she would say, oh, be very careful in the first three months. She doesn’t really…my mother and I really don’t talk about…like, I don’t know what’s it’s like between mother and daughter in other people’s families, but my mother usually is not very straightforward in talking with me about certain things anyway. Like, yeah. So, she never goes into detail or anything. So, I just don’t really ask for that much advice.”

She went on to discuss why she avoids asking her doctor to answer her questions,

“I also don’t talk too much with my doctor unless I have burning questions. First, I feel like the doctor is very busy. I mean she’s a doctor. She’s just like so busy. Every time I go see her, she is usually arrives a half hour after my appointment time. Because I think she’s one of the best doctors in that location. I mean she’s

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really good and everything, but I feel like she’s so busy. I feel like I don’t want to kind of bother her with too much, especially if I feel like I don’t have any issues. So, I just usually ask her if I run into anything. I don’t usually ask about anything that I looked up. I’m certainly not going to tell her I saw a sad story; do you think that might happen to me? That’s just stupid. Yeah, so, I feel like it’s more just strictly medical consulting.”

Without individuals to consult for advice, Violet had to rely on written information sources, particularly the internet, which 83% of interview participants agree frequently has conflicting information.

Tracy, another first-time mom, even discussed how conflicting information affected her ability to make a decision, “When I see [conflicting information], I get confused and overwhelmed. I worry that I will make the wrong decision.” Sadie echoed this connection between anxiety due to conflicting information and decision making, “I feel anxious about what is to come during childbirth, what to expect, and how to prepare.” Melanie, pregnant with her second child, was unhappy with her first childbirth experience. She chose to have her second child at home attended by a midwife in response to her first experience. She made her decision partly based on the frustration she felt about how the information she received from the obstetrician she used in her first pregnancy conflicting with information from her midwife.

“I felt less empowered with my first. I had a birth plan. I went to the Bradley method class for, you know, husband-coached birthing and all that. And I learned in that class about having a birth plan, making sure it’s okay with your [obstetrician] and all that kind of stuff. So, I took that to [my obstetrician] before and she was okay with it. And I really did not want to go with Pitocin to be induced. My mom had told me horror stories about how she was with her fourth; how terrible the labor pain was with, you know, inducing. But I ended up having to get induced, which I hated. [My obstetrician] forced it at 41 and a half weeks. Which speaking to the midwives just recently, my cycle is, the normal days is like 28 days, mine’s on average 37 so it could be that I just take longer to grow a baby. And so the midwives said based on that number, I would’ve been around 37

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weeks when I delivered my first, but it said like 41 and a half on the normal scale.”

I will explore the relationship between conflicting information and decision making in more detail in the next section.

Anxiety due to conflicting information also affected women’s use of sources

(Tables 6.7, 6.8, and 6.9). Although differences in source use were not always significant between women who did not report anxiety due to conflicting information and those who did report anxiety due to conflicting information, women who reported anxiety frequently used individuals and written sources more often than women who did not report anxiety

(Table 6.9). This tendency for women who reported anxiety due to conflicting information to use sources more often than women who did not report anxiety due to conflicting information reveals that women feel a need to seek out more information in order to make an AK decision when they must deal with conflicting information.

No significant differences emerged between those women who experienced anxiety and those who did not in terms of the individuals or information sources they consulted for advice in the first trimester. In the second trimester, however, more women who reported anxiety due to conflicting information used books (Χ2=4.018, p=0.05) and internet sites (Χ2=4.022, p=0.04) than women who did not report anxiety due to conflicting information. More women who reported anxiety due to conflicting information also utilized written sources provided by medical professionals compared to women who did not report anxiety due to conflicting information (p=0.02, Fisher’s exact test).

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Table 6.7. Individuals consulted for advice/information among women who did not report anxiety due to conflicting information and women who did report anxiety due to conflicting information.

No anxiety due to conflicting information Anxiety due to conflicting information Visit 1 Visit 2 Visit 3 Visit 1 Visit 2 Visit 3 (n=10) (n=22) (n=22) (n=15) (n=25) (n=25) % of % of % of % of % of % of Individual n sample n sample n sample n sample n sample n sample Friends 6 60.0 13 59.1 12 54.5 13 86.7 22 88.0 18 72.0 Family Father 1 10.0 2 9.1 1 4.5 1 6.7 0 0.0 0 0.0 Grandfather 0 0.0 0 0.0 0 0.0 1 6.7 0 0.0 0 0.0

13 Grandmother 1 10.0 3 13.6 2 9.1 1 6.7 1 4.0 1 4.0

Mother 6 60.0 12 54.5 11 50.0 11 73.3 18 72.0 11 44.0 Other female relatives 3 30.0 8 36.4 4 18.2 8 53.3 12 48.0 8 32.0 Other male relatives 1 10.0 0 0.0 0 0.0 1 6.7 0 0.0 0 0.0 Spouse/Partner 3 30.0 8 36.4 10 45.5 10 66.7 11 44.0 10 40.0 Health professionals Doula 1 10.0 4 18.2 4 18.2 0 0.0 1 4.0 3 12.0 Midwife 3 30.0 8 36.4 9 40.9 2 13.3 4 16.0 3 12.0 Obstetrician 6 60.0 12 54.5 10 45.5 11 73.3 19 76.0 16 64.0 Other childbirth 0 0.0 3 13.6 2 9.1 0 0.0 1 4.0 2 8.0 professionals Other medical 0 0.0 2 9.1 2 9.1 3 20.0 5 20.0 2 8.0 professionals Other person not listed 0 0.0 1 4.5 2 9.1 0 0.0 1 4.0 2 8.0

Table 6.8. Written sources consulted for information among women who did not report anxiety due to conflicting information and women who did report anxiety due to conflicting information.

No anxiety due to conflicting Anxiety due to conflicting information information

Visit 1 Visit 2 Visit 3 Visit 1 Visit 2 Visit 3

(n=10) (n=22) (n=22) (n=15) (n=25) (n=25)

% of % of % of % of % of % of

Written sources n sample n sample n sample n sample n sample n sample

* Books 4 40.0 10 45.5 10 45.5 12 80.0 14 56.0 12 48.0 * Internet sites 10 100.0 18 81.8 16 72.7 14 93.3 24 96.0 20 80.0 Blogs 1 10.0 4 18.2 6 27.3 7 46.7 7 28.0 6 24.0 Message boards 3 30.0 3 13.6 6 27.3 3 20.0 9 36.0 3 12.0 Pamphlets 0 0.0 2 9.1 2 9.1 0 0.0 1 4.0 1 4.0 Magazines 0 0.0 2 9.1 3 13.6 4 26.7 4 16.0 2 8.0

13 Written info from 5 50.0 12 54.5 3 13.6 10 66.7 10 40.0 12 48.0

3 + medical professional Other source not listed 1 10.0 2 9.1 2 9.1 0 0.0 2 8.0 1 4.0

* Significantly different in the second trimester + Significantly different in the third trimester

No anxiety from Anxiety from conflicting conflicting information information Mean SD Mean SD t-test results Visit 1 # of individuals consulted 3.1 2.1 4.1 2.0 t(23)=-1.23, p=0.23 # of written sources consulted 2.4 1.1 3.3 1.0 t(23)=-2.25, p=0.03 Total # of sources consulted 5.5 2.9 7.5 2.3 t(23)=-1.89, p=0.07 Visit 2 # of individuals consulted 3.8 2.0 3.8 1.2 t(45)=0.00, p=1.00 # of written sources consulted 2.9 1.3 2.7 1.4 t(45)=0.41, p=0.68 Total # of sources consulted 6.7 2.9 6.5 2.0 t(45)=0.23, p=0.82

13 Visit 3

4 # of individuals consulted 3.8 2.0 3.5 1.2 t(45)=0.75, p=0.46 # of written sources consulted 2.4 1.3 2.2 1.1 t(45)=0.59, p=0.56 Total # of sources consulted 5.7 2.8 6.3 1.9 t(45)=0.81, p=0.42

Women who reported anxiety from conflicting information and women who did not report anxiety from conflicting information also did not have significant different patterns of source use over time (individuals: F(1,23)=1.92, p=0.18; written sources:

F(1,23)=2.60, p=0.12; total sources: F(1,23)=3.62, p=0.07).

Summary for RQ3 and RQ3a. Most women in this study reported encountering conflicting information as they sought information and advice about their behaviors during pregnancy and childbirth. The majority of women who encountered conflicting information reported feeling confused, anxious, or frustrated by the conflicting information they found. Women who reported anxiety due to conflicting information had more trouble making decisions about “appropriate” pregnancy behaviors and childbirth plans. Their difficulties with decision making also are reflected in their tendency to consult more sources for information than women who did not report anxiety due to messaging.

RQ4: How do pregnant women make authoritative knowledge decisions about which practices to integrate into their daily lives and birth plans?

RQ4a: What information do women prioritize in making decisions about their behaviors during pregnancy and their childbirth plans?

RQ4b: Why do women prioritize some information over other information in their decision-making process?

Generally, women fell into three main categories when making a decision: gathering information first, following previous personal experience, or going with convenient options. If women chose to research their options before making a decision,

135 they usually turned to trusted advisors and/or the internet as discussed in the previous sections. Lorraine describes how she was working through a major decision about her pregnancy with the help of the individuals in her life,

Lorraine: I just made a big decision about my pregnancy, which is not to do any genetic screening tests.

Interviewer: So, tell me a bit about how you came to that decision.

Lorraine: I actually wanted to do it, but then I talked it over with my mom and dad and my mother-in-law and my husband. Everyone said I shouldn’t do it because of my family history and my age. They said the test was only 19% correct and that my chances of having the diseases is like 1 out of 10,000. Then I talked with my [obstetrician] and he didn’t recommend the tests either because he said I’m in such a low-risk group.

Interviewer: Okay. So, it sounds like you wanted to do the test originally and then you got some more information.

Lorraine: I still want to do it. It’s good to know, isn’t it? I’m still struggling at this point. I just canceled [my appointment to have genetic testing] this morning. They asked me if I wanted to reschedule or cancel it and I told them to cancel it. I don’t think I’m going to [have the genetic tests].

When asked about decisions she made regarding childbirth, Kim discussed using a combination of strategies to make her decisions,

Kim: I was working through whether or not to write a birth plan and the delayed cord clamping and the donation of the cord blood. So, I talked to my doctor about that stuff at our last appointment. She said they pretty much always do delayed cord clamping and if I wanted to donate the cord blood, it would cost me a lot of money. They didn’t have a way to do that without costing me so that ruled that out. And she said not to even write a birth plan.

Interviewer: How did you work through [the decision not to write a birth plan] before you got to the doctor?

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Kim: I kind of weighed it back and forth in my mind. Like, you read all of these stories about women having babies and it never goes according to plan. So, I thought, okay, if the chances are good that things are not going to happen the way that I want them to, why stress myself out and worry about trying to come up with something. I’m just going to roll with it.

If they followed their personal experience, their experience did not need to be directly related to the decision they were trying to make. In other words, women relied on their previous experiences in health-related situations if they did not have direct experience with pregnancy and childbirth. Julie discussed her health philosophy to help explain her decision to have a natural childbirth,

Interviewer: How did you come to the decision to have a natural childbirth?

Julie: I’m an herbalist and I don’t really use too much medicine. I don’t have to go to the doctor very much because I’m pretty healthy because I take a lot of herbs to maintain my health. I don’t like using chemicals generally. [Natural childbirth] just made a lot of sense…So, yeah, just definitely who I am. Yeah, and I don’t like how [using pain medications during childbirth] could potentially affect the baby. And I found a lot in meditating and yoga that has totally changed my life. So, I really believe that stuff can really help me during childbirth.

Many women also mentioned how convenience influenced their decisions including how changes in their bodies forced them to make more convenient decisions. Phoebe revealed how cravings and aversions affected her decisions about what to eat,

Interviewer: What things about your pregnancy and your child’s birth are most important to you?

Phoebe: I would say trying to be healthy, trying to make sure that I eat okay. I was on a really healthy diet right before I got pregnant. That’s probably why I got pregnant. So, I have been a bit concerned because I haven’t been able to eat the same things that I was eating before like lots of salad, kale, chickpeas, lentils, just super healthy foods. And now I had to swap out a lot of the

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vegetables I was eating with fruit because I just really don’t want vegetables. Most of the time, I just really don’t want them.

Interviewer: So, you are just following what your body is telling you?

Phoebe: Yeah. I wanted macaroni and cheese only for like two weeks straight. And I was just thinking, this is so bad for me. So, we got some organic mac and cheese. I don’t know if that’s any better. Yeah, I’ve really been trying to keep it balanced even though there are cravings and some days it’s like I literally don’t want anything except for this.

Although Phoebe had strong opinions about what she should be eating, she chose to follow her body’s signals about what to eat that did not match her opinions about diet.

While she felt bad about what she ate, convenience and body signals trumped the information she had gathered and her previous experiences with food.

Many women used each of these strategies for different types of decisions. For example, a woman might use the internet or speak with her healthcare provider to research medical decisions such as genetic testing, but trust her personal experiences and intuition when making decisions about her diet. For example, Stephanie’s relied heavily on information she gathered to make her decision about genetic testing,

Stephanie: The only real decision so far has been regarding genetic testing. We decided not to do it because any outcome will not affect our decision [to have the baby]. So, with the risks involved and the false positive rate, I’m not interested in pursuing those.

Interviewer: So, that was a fairly easy decision for you to come to?

Stephanie: Yes.

Interviewer: How did you come to that decision?

Stephanie: I talked to my doctor and then I did some independent research on the statistics.

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Interviewer: Did you discuss that information between you and your spouse after that?

Stephanie: Yeah, we discussed it. And we were both coming in with the instinct of not wanting [genetic tests] unless there was something in our family history that indicated it was normal or expected and neither of us have any of those risk factors that we’re aware of.

When asked about her decisions regarding her childbirth plans, however, Stephanie relied on her previous birth experience,

Interviewer: What kind of expectations do you have for your childbirth experience?

Stephanie: …I plan to have a traditional, hospital-based birth like I had with [my first child] so I expect that to go through. I’m not committed to a natural birth or an epidural-free [birth]. If a C-section happens, it’s not the end of my world. It wouldn’t be my top choice, but I’m fairly open to medical interventions if they are deemed necessary.

Interviewer: Okay, where do you think these expectations come from?

Stephanie: A lot of previous experience. I feel like I went in blind with [my first child] in some ways. I didn’t take any classes. I was very much cautioned to avoid the “What to Expect When You’re Expecting” book because it has a tendency to go to the worst-case scenario, which is not great for my level of anxiety. So, I kind of trusted that the doctors would know what to do and my body would figure it out. That worked pretty well for me…And so now I have that experience and I feel like I’m just more prepared. My decisions about childbirth are already made.

Despite this tendency to utilize both strategies in making decisions, women commonly relied more heavily on one than the other in the majority of their decisions, although which strategy they preferred differed from woman to woman.

Parity and decision making. Multiparous women relied on personal experience more often compared to primiparous women as multiparous women had direct experience with pregnancy and childbirth. In fact, in interviews, 93% of multiparous participants

139 reported relying on personal experience, while 52% of primiparous women reported relying on personal experience. Olivia described how her thoughts regarding childbirth changed once she experienced it,

“The first time around, I really, really wanted a C-section because I wanted control. I’m a control person. I wanted to know [when the baby would come]. I wanted [the doctor] to say here’s the date, here’s the time, here’s when you’re coming. We can schedule it. Then I could figure it out at work and everything would be great. My doctor said, no, it doesn’t work like that. And now that I didn’t end up needing a C-section [with my first child], I realized [childbirth] wasn’t so bad. I mean, now, I wouldn’t want a C-section. Now, I’m more fearful of a C-section because I’ve been there and I know what to expect with a vaginal birth.”

Similarly, Rachel discussed how she planned to rely on a decision she already made if she faces the same situation in her current pregnancy.

“I remember one decision that we really did a lot of research on and really talked about was circumcision since we knew it was going to be a boy. And we elected not to circumcise based on the research we did. And so, I feel like if it’s a boy again then we’ve already gone through the process and we don’t have to think about it. We’ve already come to terms with it.”

Like many women, Rachel felt that she made most of her decisions in her previous pregnancy and she, therefore, did not need to make them again. Instead, multiparous women, particularly those pregnant with their second child, concentrated their information gathering on how to handle two children at once and how to introduce a new sibling into the family.

One example of a choice that demonstrated the difference between decision making among primiparous and multiparous women was the choice of healthcare provider. All, but one multiparous participant chose to stay with the healthcare provider from her first pregnancy. They mentioned their trust in their provider as the main reason

140 they stayed. The one participant, Melanie, who switched her healthcare provider was very unhappy with her first childbirth experience in a hospital setting. As such, she chose to find a midwife who would support her decision to have her second child at home.

Finally, multiparous women frequently mentioned their tendency to choose more convenient options with their current pregnancy than they did in their previous pregnancy. When I asked Melanie, pregnant with her second child, about any topics on which she was currently gathering information, she discussed her decision to buy something to help the baby sleep after birth,

Melanie: [I’ve been gathering information] on things that will work for keeping baby quiet or helping baby go to sleep because my first was not a sleeper at all. So, I’m seriously considering investing in a Mom-A-Roo this time even though the first time I was like that is ridiculously expensive. This time around I might actually do it. Do you know what that is, the Mom-A-Roo?

Interviewer: No.

Melanie: It’s like a mom-simulated machine. They’re like four or five hundred dollars. It’s self-standing and can kind of sway the baby or whatever the baby need to put her to sleep. Yeah, naps were terrible [with my first child]. They’re still bad and she’s almost three. For the first three nights, she didn’t really sleep. I mean we didn’t sleep. We can’t do that again, especially with another kid in the house…So, yeah, I’m thinking about investing in something that might actually help [the new baby sleep].

Although this was a decision about Melanie’s life after her current pregnancy, her reasoning mirrored the decision making process of other multiparous women.

Conflicting information and decision-making. When faced with conflicting information, women prioritized their healthcare provider’s advice unless women felt their

141 provider’s advice was insufficient as shown in quotes below. Jennifer described her method for dealing with conflicting information in general.

“I think I, to some extent, if I seek out multiple sources of information that if there seems to be an outlier from the general advice that I’m probably more likely to disregard that. I think I’m far more likely to trust things that are coming from a doctor or a reputable medical source compared to, you know, mommy blogs. I take [information from the mommy blogs] with a grain of salt.”

Jennifer then went on to describe a specific instance of conflicting information that frustrated her,

“I do some weight lifting and wanted to make sure that that was safe. I got in touch with my doctor to ask her what the recommendations were. She was pretty wishy washy about it because I don’t think there are a lot of good recommendations. So, then I read several peer-reviewed articles about weight lifting during pregnancy to help inform that (which like I said I think is probably because I’m a professor-type and have access to all of that). So, I think [information on weight lifting] was actually hard to find because there wasn’t much online. The guidelines that my doctor had for me weren’t really useful. She said there really aren’t a lot of guidelines for recreational weight lifting. It really depends on what type of shape you’re in. You know, they gave guidelines for occupational lifting, but it was like don’t life more than 25 pounds. And I’m going to be honest, I’ve been regularly lifting a 100 pounds or more. And I’m like, this is stupid. If you are not going to let me pick up more than 25 pounds, I’m not following that [advice].”

While Jennifer started by asking her doctor for advice, she found the information from her doctor to be insufficient for making a decision. After doing her own research, Jennifer still felt like she did not have enough information. Only then did she decide to trust her body,

“I felt like [only lifting up to 25 pounds] was a little overly conservative so I did a little more looking around and concluded in concert with my doctor to use common sense and generally reduce weight somewhat – higher reps, lower weight. And if anything starts to feel weird, don’t do it.”

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Other participants went against their doctor’s advice if they felt the decision was more cautious. When discussing using medications for common ailments such as colds and heartburn during pregnancy, Michelle preferred not take any medication even if her doctor said it was okay,

Michelle: Yeah, there’s lots of conflicting [information] on what meds are safe and not safe.

Interviewer: How do you decide if you want to take a medication?

Michelle: If there is a lot of information telling me not to take a medication even if the doctor say it’s okay, I don’t take it.

When their healthcare providers gave very little advice, women usually relied on the internet for information and/or chose the most convenient options. For example, while healthcare providers often gave women a list of foods they should not eat, providers seldom offered information on what they thought women should eat. This lack of advice led women to seek out information on the internet, even if they eventually decided not to follow the information they found. Lilly discussed her dietary decisions in this way,

Lilly: My diet makes me feel like a terrible mother because I let myself have what I want. I didn’t change my diet overall to be this like healthy, vegetarian, you know, eating grains and fruit and vegetables all the time. I just…you know, I eat a frozen meal for lunch every day. And I do eat potato chips. And I do let myself have chocolate. And I feel terrible about it.

Interviewer: So, where do you think the ideas about what your diet should be come from?

Lilly: The internet.

Despite the messaging she received from the internet sites she visited, Lilly made decisions about her diet based on what was convenient for her lifestyle and what her body

143 told her to eat. This mismatch between the messaging Lilly encountered and her own behavior caused her distress as she believed her behavior made her a “terrible mother.”

Summary for RQ4, RQ4a, and RQ4b. Women made decisions by gathering information first, following their previous personal health experience, or choosing the most convenient options. Multiparous women relied on their previous personal health experience more often than primiparous women as multiparous women had experiences more specific to pregnancy. When faced with conflicting information, many women prioritized their healthcare provider’s advice unless that advice was insufficient or deemed too liberal. If women chose to disregard their healthcare provider’s advice, they sought out more information from other sources before making an AK decision about which behaviors were “appropriate.”

Summary

RQ1: Where do pregnant women get information regarding best practices during pregnancy and childbirth?

RQ2: Which sources do women rely on most heavily for information about best practices during pregnancy and childbirth?

Women relied most heavily on friends, spouse/partner, obstetrician, mother, and other female relatives for advice. They tended to trust individuals in their lives to give them information more than written sources. If they sought out information from written sources, almost every participant turned to the internet first. Despite this tendency to rely heavily on the internet for information, many women acknowledged the need to be

144 careful with the online information they found as the internet includes facts and opinion.

Women also reduced source use over time during their pregnancies.

Primiparous and multiparous women exhibited different source use patterns.

Primiparous women relied on sources more heavily than multiparous women as they had little advanced information about pregnancy and childbirth. Primiparous women also continued this pattern on consulting many sources further into their pregnancies than multiparous women. As pregnancy and childbirth generally are removed from everyday life in the U.S., primiparous women needed to consult more sources overall to make their

AK decisions, while multiparous women could rely on their personal pregnancy/childbirth experiences.

RQ3: In what ways does this information conflict?

RQ3a: What effect does conflicting information have on pregnant women’s emotions and decision-making?

Women frequently reported encountering conflicting information in the sources they consulted. When they found conflicting information, most women reported feeling confused, anxious, or frustrated, which tended to make them seek out information from more sources before making a decision about what to do. Women who were not concerned about conflicting information, however, often had trusted sources they could rely on to provide information about “appropriate” behaviors and childbirth plans. In addition, women who reported anxiety due to conflicting information had difficulties making decisions about their behaviors and childbirth plans due to the presence of conflicting information and their desire to follow the “best” advice.

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RQ4: How do pregnant women make authoritative knowledge decisions about which practices to integrate into their daily lives and birth plans?

RQ4a: What information do women prioritize in making decisions about their behaviors during pregnancy and their childbirth plans?

RQ4b: Why do women prioritize some information over other information in their decision-making process?

Women employed three main strategies for making decisions about their behaviors during pregnancy and childbirth: gathering information first, following their previous personal health experience, or choosing the most convenient options. If they chose to gather information first, women prioritized their healthcare provider’s advice unless women felt that advice was inadequate or did not fit with their previously held beliefs. If women were unsure about whether or not to follow their healthcare provider’s advice, they sought out more information from other sources before making an AK decision. Multiparous women relied on their previous personal health experience more frequently than primiparous women as multiparous women had specific health experiences related to pregnancy and childbirth. Primiparous women, however, also sometimes followed their previous personal health experience if they had strong opinions about health-related behaviors such as avoiding pharmaceutical drugs. Multiparous women also were more likely to choose more convenient options both because they had to care for one or more other children and because they were less concerned about choosing the “best” pregnancy/childbirth behaviors.

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Chapter 7: Authoritative Knowledge Decision-Making and Maternal Stress

Introduction

As discussed in detail in Chapter 2, U.S. women generally do not participate in or discuss pregnancy and childbirth in detail until they become pregnant. This separation of pregnancy and childbirth from everyday life means pregnant women encounter a great deal of new information when they become pregnant. In addition, pregnant women frequently feel isolated as U.S. culture portrays childbirth as a risky medical event rather than a commonplace occurrence leaving women few outlets for discussing the information they receive. As a result, pregnant women must make authoritative knowledge (AK) decisions about which information to believe and incorporate into their daily lives and childbirth plans often on their own.

According to published literature and the ethnographic data I discussed in Chapter

6, pregnant women often need to make these AK decisions when they encounter conflicting information (Beckett 2005, Sargent and Gulbas 2011, Walsh 2010). For example, a pregnant woman may hear from her mother who had a natural childbirth that using pain-relieving drugs during childbirth will be harmful to the woman’s baby. Her doctor, on the other hand, may tell her that pain-relieving drugs have very few side effects for a woman’s fetus. The pregnant woman then must decide whose advice is more authoritative or whose advice is more believable to her. While conflicting information 147

creates a situation in which women must make AK decisions, the information women receive does not have to directly conflict to produce a need for AK decision-making. For example, a pregnant woman may hear that walking is an excellent exercise during pregnancy from her sister. She may find on the internet that prenatal yoga is an excellent exercise during pregnancy. If she does not have enough time to both walk and attend prenatal yoga classes, she must decide which behavior to follow (if any). As such, her decision may hinge on which source of information is more authoritative. As ethnographic work with pregnant women reveals a great deal of anxiety and confusion associated with making AK decisions, this decision-making process has the potential to increase self-reported and measured cortisol stress levels.

In this chapter, I explore the connections between authoritative knowledge decision-making, self-reported stress, and hair cortisol levels in order to address the following research questions and test the associated hypotheses:

• RQ5: How are women’s experiences with authoritative knowledge decision-

making related to self-reported stress, particularly pregnancy-specific anxiety?

o H1: Women who struggle more with authoritative knowledge decisions

will have higher levels of self-reported stress, particularly pregnancy-

specific anxiety.

• RQ6: How are women’s experiences with authoritative knowledge decision-

making related to hair cortisol levels and trajectories over the course of

pregnancy?

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o H2: Women who struggle more with authoritative knowledge decisions

will have higher cortisol levels at each timepoint and steeper hair cortisol

trajectories across pregnancy.

Methods

Sociodemographic and Control Variables

I collected data from all participants (n=47) using the survey instrument discussed in Chapter 4. The survey instrument included sociodemographic questions, a messaging survey developed by me, two stress scales, and six control variable scales.

Sociodemographic questions collected data on socioeconomic status, relationship status, race/ethnicity, education, employment status, parity, age, pre-pregnancy weight, and height at the first study visit, which occurred either in the first or second trimester. I calculated pre-pregnancy body mass index (BMI) from self-reported pre-pregnancy weight and height. I also asked participants about their due date at each study visit as some participants had not seen a healthcare professional prior to the first study visit.

Additionally, due dates often are adjusted after ultrasounds or some fetal development has occurred making continued checking necessary. I used the due date from a participant’s initial ultrasound to calculate gestational age at each study visit. Following childbirth, I collected data on pregnancy/birth complications, delivery route, location of birth, pain medication use, infant sex, infant weight, infant length, duration of labor, total pregnancy weight gain, and Group B streptococcus (GBS) rate. GBS is a bacterial infection found in pregnant women’s vagina or rectum, which usually requires the administration of antibiotics prior to childbirth to prevent transmission of the bacteria to

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infants at birth. When possible, I pulled postpartum data from women’s medical records, although some data were missing from these reports. When data were missing, I asked participants to provide additional information. I collected self-reported data on control variables including prenatal health behaviors, sleep, social support, stressful life experiences, and locus of control attitudes. The methods I used to collect these data are described in detail in Chapter 4.

Self-reported General Stress and Pregnancy-specific Anxiety For self-reported stress, I administered one self-reported general stress scale and one pregnancy-specific anxiety scale to each of the 47 women. The Perceived Stress

Scale (PSS) measures self-reported general stress in the last week. Self-reported stress is the degree to which a person finds general life problems and situations stressful such as approaching deadlines or family conflicts. The PSS includes questions such as: 1) In the last week, how often have you been upset because of something that happened unexpectedly and 2) In the last week, how often have you felt that you were unable to control the important things in your life.

Pregnancy-specific anxiety scales include questions about concerns women have regarding pregnancy and childbirth. As a result, pregnancy-specific anxiety scales reflect concerns related to the information women receive about pregnancy and childbirth.

Higher pregnancy-specific anxiety measured with these scales correspond to adverse pregnancy and childbirth outcomes. The Pregnancy-specific Anxiety Scale (PSAS) I used was developed by Guardino and Dunkel Schetter (2014). Guardino and Dunkel Schetter

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(2014) argue that their PSAS predicts pregnancy and childbirth outcomes better than other pregnancy-specific anxiety scales.

The PSAS scale is divided into two sections: anxiety and concerns. The anxiety section asks women how often in the past week they felt certain emotions about their pregnancy. The list of emotions includes four adjectives related to anxiety: anxious, concerned, afraid, and panicky. These adjectives are embedded in a list with nine other adjectives such as confident, excited, and happy. The anxiety section produces a PSAS anxiety sub-score. This sub-score is a reliable measure of pregnancy-specific anxiety on its own and predicts length of gestation (Guardino and Dunkel Schetter 2014, Roesch et al. 2004). While the PSAS anxiety section provides information about how women are feeling about their pregnancies, it does not provide insight into the concerns women have about their pregnancies.

The concerns section of the PSAS, on the other hand, focuses on which concerns are most relevant to women during their pregnancies (Guardino and Dunkel Schetter

2014). The PSAS concerns section asks women how often they agree with a set of statements about their pregnancies such as: 1) I am confident of having a normal childbirth, 2) I am fearful regarding the health of my baby, and 3) I am afraid that I will be harmed during delivery. The PSAS concerns section produces a sub-score that has predicted timing of delivery (Rini et al. 1999).

The PSAS anxiety and concerns sub-scores as well as the overall PSAS score give a fuller picture of women’s emotions and concerns regarding pregnancy and childbirth

(Guardino and Dunkel Schetter 2014). The PSAS, like other pregnancy-specific anxiety

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scales, however, does not fully explore why women are concerned about their pregnancies or why they make lifestyle changes. Therefore, I complemented the scale with additional focus-group derived questions and semi-structured interviews described in Chapter 6.

Hair sample collection for cortisol analysis

I collected a hair sample from each woman (n=47) at every study visit to help me answer H2. The hair samples were analyzed for cortisol level to give me a mean cortisol level in the previous 3-month period for each sample as well as information about how cortisol levels changed over the course of pregnancy for each participant. I collected all hair samples from the posterior vertex of the skull as cortisol levels vary less in hair collected from this region of the scalp (Sauvé et al. 2007). I collected hair samples using the methods outlined by Hoffman, Karban, Benitez, Goodteacher, and Laudenslager

(2014). While wearing gloves, I used a fine-tooth comb to lift the hair from the back of the head. I then gathered a thin layer of hair from the section lifted by the comb, approximately 100-300 hair shafts depending on the thickness of the hair. I pushed the covering hair aside and combed the hair held between the index and middle finger away from the scalp to align the hair shaft. I next cut the hair as close to the scalp as possible with a clean pair of scissors. Once cut, I held the hair tightly between my two fingers to ensure no hair was lost and that the root end of the hair was maintained. I placed the cut hair onto a labeled foil packet and immediately taped the hair sample onto the foil approximately 4 cm from the root end (Wennig 2000). I secured the hair shafts by supplying pressure to the tape to ensure all shafts were secured to the foil. Finally, I

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marked the root end of the sample before folding the foil to create a packet with the hair sample in the center. I delivered the foil packets to the College of Nursing Center for

Nursing Research and Health Analytics (CNCRHA). Hair samples were stored frozen at -

20oC in the CNCRHA lab until I submitted enough samples to warrant the running the 1-

3002-Cortisol Salivary Immunoassay by Salimetrics.

Once I submitted enough samples, the CNCRHA staff prepared the sample for analysis (D’Anna-Hernandez et al. 2011, Hoffman et al. 2014). They only analyzed the first 3 cm of hair in each sample for cortisol, which gives the mean cortisol level deposited into the hair over the previous 3-month period. Any hair more than 3 cm from the scalp was discarded prior to pulverization and analysis. Once the hair was cut to a 3 cm length, the sample was placed into a 7-15 ml screw-cap polypropylene conical tube.

Next, 5 ml of high performance liquid chromatography (HPLC)-grade isopropanol was added to the tube. This was followed by repeated inversion for 5 min using a shaking table. The isopropanol then was decanted into a waste container. The washing and decanting was repeated once more before the hair was allowed to dry overnight to ensure complete isopropanol evaporation prior to pulverization.

Once dry, 25-75 mg of hair was placed into a pre-weighed 1.5 ml round end microcentrifuge tube manufactured with reinforced plastic for high-speed metallic ball bearing milling. The vial was reweighed to obtain the sample weight. Using fine tipped scissors cleaned with propanol to remove any previous contaminants, the sample was cut repeatedly into 2-4 mm lengths inside the microcentrifuge tube. Next, two 5 mm chrome steel balls were added to the tube and the sample was grinded for 5 to 15 minutes in a

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Retsch 400 Mill. If visual inspection revealed that the sample was insufficiently pulverized, grinding was continued for an additional 5 minutes. Without removing the chrome steel balls, 1.1 mL of HPLC-grade methanol was added to the tube containing the pulverized sample. The tube then was capped and the sample was incubated for 18 to 24 hours at room temperature with constant agitation using a shaking table. The microcentrifuge tube was placed in a rack and incubated on its side to ensure continuous mixing of the hair-methanol suspension during the extraction phase.

Following incubation, the tube was centrifuged at 5000g for 5 minutes at room temperature to pellet the powdered hair. The entire amount of supernatant (<1.0 mL) then was transferred to a clean microcentrifuge tube, taking care not to disturb the pellet of powdered hair in the bottom of the tube. The centrifuge and transfer steps were repeated to remove any additional powered hair that may have been accidently transferred to the clean microcentrifuge tube.

Next, the methanol was removed from the sample in the microcentrifuge tube by evaporation using a stream of air or nitrogen gas for 6 to 8 hours at room temperature.

Following removal of the methanol, the cortisol extract was reconstituted in 100ul of

Salimetric immunoassay cortisol analysis diluent buffer according to the manufacturer’s directions (Salimetrics LLC, State College, PA, USA). The reconstituted sample was either assayed immediately using a radioimmunoassay (1-3002-Cortisol Salivary

Immunoassay by Salimetrics) or frozen at -20 °C for later analysis. When analyzed, each sample was assayed twice to help ensure reliability and validity of the results.

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As cortisol ELISA kits such as the 1-3002-Cortisol Salivary Immunoassay by

Salimetrics used in my study are designed to measure cortisol values in liquid samples such as saliva or plasma, the output of the microplate reader software must be converted to amount of cortisol per unit weight of powdered hair. The following formula converts assay output in μg/dl to pg cortisol per mg hair:

(A/B) * (C/D) * E * 10,000 = F where A = μg/dl from assay output; B = weight (in mg) of hair subjected to extraction; C

= volume (in mL) of methanol added to the powdered hair; D = volume (in mL) of methanol recovered from the extract and subsequently dried down; E = volume (in mL) of assay buffer used to reconstitute the dried extract; and F = final value of hair cortisol concentration in pg/mg.

Data analysis

Both of the hypotheses I test in this chapter (H1 and H2) explore the relationship between authoritative knowledge (AK) decision-making and stress variables (self- reported (H1) and physiological (H2)). To determine whether stress increased when women struggled more with AK decisions, I divided the sample in two ways: 1) primiparous vs. multiparous women and 2) women who reported anxiety due to conflicting information vs. those did not report anxiety due to conflicting information.

My decision to divide the sample in these two ways is supported by the ethnographic data

I collected as part of this study, as well as by the published literature on this topic. These two sets of comparison groups allowed me to explore my research questions in multiple ways to account for individual variability in participant’s decision-making.

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I first divided the participants into first-time mothers or primiparous women

(n=27) and mothers pregnant for the second or third time or multiparous women (n=20).

The ethnographic data discussed in Chapter 6 as well as previous ethnographic work suggests primiparous women struggle more with AK decisions than multiparous women as primiparous women are encountering most of the information they receive about pregnancy and childbirth for the first time (Browner and Press 1997, Crossley 2007, Root and Browner 2001, Song et al. 2012). Multiparous women, on the other hand, frequently are consistent in their behaviors and plans from their previous pregnancies unless they had a bad experience in their prior pregnancies or childbirths (Browner and Press 1997,

Crossley 2007, Root and Browner 2001, Song et al. 2012).

I then divided the participants into those who reported anxiety about conflicting information (n=25) and those who either did not encounter conflicting information or for whom conflicting information did not cause anxiety (n=22). The ethnographic results I discuss in Chapter 6 show that women who report anxiety as a result of encountering conflicting information struggle more with AK decisions as they have more confusion about which information to prioritize. In addition, my ethnographic results reveal that women who do not report anxiety from encountering conflicting information or who do not encounter conflicting information have an easier time making AK decisions. While more primiparous women reported anxiety about conflicting information, some multiparous women also reported anxiety when they encountered conflicting information.

Before beginning my data analysis, I tested each continuous variable for normality using a one-sample Kolmogorov-Smirnov test including time in relationship,

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pre-pregnancy BMI, maternal age at first visit, gestational age at each study visit, infant birth weight, infant birth length, pregnancy weight gain, duration of labor, control scale scores, stress scale scores and sub-scores, and cortisol levels. Several of the continuous variables were not normally distributed. To explore differences between each set of groups, I used a combination of parametric and nonparametric tests on the continuous variables depending on whether or not each variable was normally distributed.

I tested for differences in the control variables between each set of groups using t- tests, Mann-Whitney U tests, Chi-square tests, and Fisher’s exact test as required. I then compared self-reported stress levels in each trimester and in the postpartum (when applicable), including pregnancy-specific anxiety levels and general self-reported stress

(H1) as well as hair cortisol levels (H2) at each time point between each set of groups with Mann-Whitney U test or t-tests as needed. I examined self-reported stress (H1) and hair cortisol levels (H2) for longitudinal differences using Friedman’s test as each variable was not normally distributed at all time points. I ran repeated Friedman’s test with and without the data from Visit 1 to investigate differences in the full sample as only

25 participants completed the first trimester visit. If significant differences emerged in the

Friedman’s test, I conducted Wicoxon Signed Ranks tests to determine which sets of groups showed significant differences. I also used Wilcoxon Signed Ranks tests to investigate differences between time points for pregnancy-specific anxiety (total score and sub-scores) without the first trimester visit data as removing the first trimester data left only two pregnancy-specific anxiety data points.

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Results

Demographic characteristics, postpartum variables, and additional control variables.

As discussed in Chapter 4, I controlled for several key variables important for testing both H1 and H2 using my inclusion criteria. As such, the sample was relatively homogenous in terms of several variables including race/ethnicity, socioeconomic status

(SES), and relationship status (Table 7.1). I also collected data on a range of other control variables known to be associated with stress during pregnancy. I describe how and why I collected this data in Chapter 4. I compared the control variables between each set of groups: 1) primiparous vs. multiparous and 2) women who reported anxiety due to conflicting information and women who did not report anxiety due to conflicting information. My intention was to make sure each set of groups do not differ significantly for any of the control variables prior to testing my research hypotheses.

Primiparous vs. Multiparous women. I found no significant differences between primiparous and multiparous women for these variables. In addition, no significant differences emerged between the two groups of women for time in relationship, attendance at spiritual/religious services categories, education, student status, employment status, pre-pregnancy body mass index (BMI), or gestational age at any timepoint (Tables 7.1 and 7.2). Primiparous women were significantly younger than multiparous women were at the first study visit, however (Table 7.2).

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Table 7.1. Categorical sociodemographic variables, comparison between primiparous and multiparous participants. Primiparous Multiparous (n=27) (n=20) Variable n % n % Χ2 results Attend spiritual/religious services X2(4)=5.77, p=0.22 Never 10 37.0 7 35.0 Less than once per month 5 18.5 6 30.0 Once per month 3 11.1 0 0.0 Two to three times per month 5 18.5 1 5.0 Nearly every week 4 14.8 6 30.0 Relationship X2(1)=2.37, p=0.12 Married 24 88.9 20 100.0 Unmarried, in a relationship 3 11.1 0 0.0 Single 0 0.0 0 0.0 SES X2(3)=0.45, p=0.93 Low 0 0.0 0 0.0 Low to middle 0 0.0 0 0.0 Middle 22 81.5 15 75.0 Middle to upper 4 14.8 4 20.0 Upper 1 3.7 1 5.0 Race/Ethnicity X2(3)=2.20, p=0.53 White/Caucasian 24 88.9 18 90.0 Black/African-American 0 0.0 0 0.0 Asian 0 0.0 0 0.0 Multi-racial 3 11.1 2 10.0 Education X2(3)=1.22, p=0.75 Not a high school graduate 0 0.0 0 0.0 High school graduate 0 0.0 0 0.0 Some college 0 0.0 0 0.0 Associates or technical degree 1 3.7 0 0.0 Bachelor’s degree 6 22.2 6 30.0 Some graduate school 4 14.8 2 10.0 Graduate degree 16 59.3 12 60.0 Student X2(1)=1.02, p=0.31 Yes 9 33.3 4 20.0 No 18 66.7 16 80.0 Employed outside home X2(2)=1.01, p=0.61 Full-time (38-40 hrs/wk) 21 77.8 13 65.0 Part-time (<38 hrs/wk) 5 18.5 4 20.0 No 1 3.7 3 15.0

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Table 7.2. Continuous sociodemographic variables, comparison between primiparous and multiparous participants

Primiparous (n=27) Multiparous (n=20) Variable Range Mean SD Range Mean SD Test results Time in relationship (months) 12-720 97.6 128.8 34-189 100.5 44.4 U(45)=183.5, Z=-1.86, p=0.06 Pre-pregnancy BMI (kg/m2) 18.9-31.4 24.0 2.9 20.7-35.0 25.8 4.1 t(45)=-1.80, p=0.08 Age @ 1st visit (years) 24-37 29.2 3.4 25-38 31.4 3.2 t(45)=-2.21, p=0.03 Gestational age @ 1st prenatal visit (weeks) 4-12 8.7 2.1 4-13 8.6 2.3 U(45)=247.0, Z=-0.51, p=0.61 Gestational age @ 1st trimester visit (weeks)+ 7-14 10.4 2.8 8-14 11.7 1.8 U(23)=58.0, Z=-1.10, p=0.27 Gestational age @ 2nd trimester visit (weeks) 21-26 23.4 1.4 21-27 23.7 2.2 U(45)=235.5, Z=-0.55, p=0.58 Gestational age @ 3rd trimester visit (weeks) 31-38 34.9 1.8 33-38 35.2 1.8 t(45)=-0.63, p=0.53

160 +For first trimester visit, n=25 with 12 primiparous participants and 13 multiparous participants

The two groups did not differ in their infants’ sex, birth length (cm), birth weight (g), duration of labor, or total pregnancy weight gain (Table 7.3). The two groups also did not differ in their rates of preterm labor, preterm delivery, gestational diabetes, gestational hypertension or preeclampsia, or any other complications during labor and delivery for which data were collected (Table 7.4). Most of the participants (n=34) had a vaginal delivery, although half of those participants were given medications to induce or increase the pace of labor (n=19). The two groups did not differ, however, in delivery route.

Almost all of the participants (n=43) gave birth in a hospital setting, with only one participant giving birth at home. Columbus has no birth centers so no participants were given the opportunity to give birth in this setting. Most participants (n=37) used pain medication, with epidural as the most popular choice (n=31). The two groups did not differ significantly in their use of pain medications. However, primiparous women were diagnosed with group B streptococcus (GBS) significantly more often than multiparous women in this sample.

For additional control variables, I found no significant differences between primiparous and multiparous women in sleep quality (Pittsburgh Sleep Quality Index

(PSQI) score), self-reported social support levels (Multidimensional Scale of Perceived

Social Support (MSPSS) score), or stressful life events (Life Experiences Survey (LES) score) at any time point (Table 7.5). In addition, primiparous and multiparous women did not differ significantly in their locus of control (LOC) perceptions (Multidimensional

Health Locus of Control Scale Form C score). At each time point, the two groups had no significant differences for internal LOC, powerful others LOC, or chance LOC.

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Table 7.3. Continuous postpartum variables, comparison between primiparous and multiparous participants

Primiparous (n=24) Multiparous (n=20) Variable Range Mean SD Range Mean SD Test results Infant birth weight (g) 2460-4224 3532 418 2892-4423 3568 411 t(42)=-0.58, p=0.57 Infant birth length (cm) 45.7-57.2 52.1 2.5 43.2-55.9 51.8 3.5 U(42)=118.5, Z=-0.19, p=0.85 Duration of labor (hours) 1.0-33.0 14.6 8.7 0.5-36.0 10.3 10.3 t(42)=1.37, p=0.18 Total pregnancy weight gain (kg) 11.3-27.2 16.4 4.0 6.4-22.7 14.5 4.7 t(42)=1.34, p=0.19

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Table 7.4. Categorical postpartum variables, comparison between primiparous and multiparous participants.

Primiparous Multiparous (n=24) (n=20) 2 Variable n % n % Χ results Preterm labor X2(1)=0.05, p=0.83 Yes 1 4.2 1 5.0 No 23 95.8 19 95.0 Preterm delivery X2(1)=0.67, p=0.41 Yes 4 16.7 3 15.0 No 20 83.3 17 85.0 Gestational X2(1)=3.29, p=0.07 hypertension/preeclampsia Yes 3 12.5 1 5.0 No 21 87.5 19 95.0 Gestational diabetes X2(1)=1.39, p=0.24 Yes 0 0.0 1 5.0 No 24 100.0 19 95.0 Other complications during delivery X2(1)=0.11, p=0.74 Yes 2 8.3 1 5.0 No 22 91.7 19 95.0 Delivery route X2(4)=4.34, p=0.36 Spontaneous vaginal delivery 8 33.3 8 40.0 Spontaneous vaginal delivery w/ 6 25.0 3 15.0 induction Induced vaginal delivery 5 20.8 5 25.0 Planned Cesarean section 1 4.2 1 5.0 Unplanned/emergency Cesarean 4 16.7 3 15.0 section Location of birth X2(1)=1.39, p=0.24 Home 0 0.0 1 5.0 Birthing Center 0 0.0 0 0.0 Hospital 24 100.0 19 95.0 Other 0 0.0 0 0.0 Pain medications used X2(3)=6.53, p=0.09 None 2 8.3 5 25.0 Epidural 19 79.7 12 60.0 Epidural and other 2 8.3 0 0.0 Other only 1 4.2 3 15.0 Group B Streptococcus (GBS) X2(1)=4.93, p=0.03 Positive 6 25.0 0 0.0 Negative 18 75.0 20 100.0 Infant Sex X2(1)=2.56, p=0.11 Male 14 58.3 9 45.0 Female 10 41.7 11 55.0

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Table 7.5. Control variables, comparisons between primiparous and multiparous participants.

Primiparous (n=27) Multiparous (n=20) Variable Range Mean SD Range Mean SD t-test results Sleep quality (PSQI score) @ 1st trimester 1-14 4.6 3.3 2-12 5.8 2.5 U(23)=46.0, Z=-1.77, p=0.08 visit+ Sleep quality (PSQI score) @ 2nd trimester 1-15 5.0 3.2 2-11 5.7 2.4 U(45)=192.5, Z=-1.51, p=0.13 visit Sleep quality (PSQI score) @ 3rd trimester 1-13 6.5 3.2 2-14 6.8 3.4 U(45)=217.0, Z=-0.20, p=0.84 visit Sleep quality (PSQI score) @ postpartum 2-14 7.7 2.4 4-13 8.4 2.3 t(42)=-0.94, p=0.36 visit# Locus of control - internal @ 1st trimester 15-30 23.1 4.2 19-31 23.4 4.5 t(23)=-0.16, p=0.88 visit+ Locus of control - powerful others @ 1st 18-34 26.5 4.3 19-31 26.4 4.1 t(23)=0.07, p=0.95 trimester visit+ Locus of control - chance @ 1st trimester 11-41 23.4 8.8 10-33 22.5 6.3 t(23)=0.31, p=0.76 + 164 visit Locus of control - internal @ 2nd trimester 10-33 24.0 4.5 14-39 23.2 5.1 U(45)=218.0, Z=-0.94, p=0.35 visit Locus of control - powerful others @ 2nd 16-30 25.1 4.3 17-36 27.2 5.0 U(45)=203.0, Z=-1.27, p=0.21 trimester visit Locus of control - chance @ 2nd trimester visit 11-35 24.0 6.8 13-34 24.0 5.8 t(45)=0.00, p=1.00 Locus of control - internal @ 3rd trimester 12-33 23.3 4.7 17-36 23.8 4.7 t(45)=-0.35, p=0.73 visit Locus of control - powerful others @ 3rd 17-32 26.2 3.7 13-35 27.1 5.3 U(45)=194.0, Z-0.77, p=0.44 trimester visit Locus of control - chance @ 3rd trimester visit 13-36 23.4 5.8 6-32 24.5 5.6 t(45)=-0.65, p=0.52 Stressful life experiences (PLES score) 0-12 3.4 3.1 0-6 3.1 1.9 U(45)=204.5, Z=-0.51, p=0.61 Continued

Table 7.5 Continued

Primiparous (n=27) Multiparous (n=20) Variable Range Mean SD Range Mean SD t-test results Unhealthy eating (PHBS sub-score) @ 1st 5-10 7.4 1.8 2-11 6.6 2.7 t(23)=0.86, p=0.40 trimester visit+ Physical strain (PHBS sub-score) @ 1st 6-12 8.8 1.8 5-10 7.3 1.4 U(23)=41.5, Z=-2.03, p=0.04 trimester visit+ Overall (PHBS score) @ 1st trimester visit+ 14-23 19.9 2.6 13-22 18.1 2.7 t(23)=1.67, p=0.11 Unhealthy eating (PHBS sub-score @ 2nd 4-11 8.1 2.0 1-10 7.4 2.3 U(45)=213.0, Z=-1.06, p=0.29 trimester visit Physical strain (PHBS sub-score) @ 2nd 5-12 9.7 1.9 5-12 7.6 1.9 U(45)=108.5, Z=-3.39, p<0.01 trimester visit Overall (PHBS score) @ 2nd trimester visit 15-24 20.1 2.5 13-24 18.1 2.6 t(45)=2.70, p=0.01 Unhealthy eating (PHBS sub-score) @ 3rd 5-11 8.2 1.7 1-9 6.4 2.7 U(45)=136.0, Z=-2.22, p=0.03 trimester visit Physical strain (PHBS sub-score) @ 3rd 5-12 9.3 1.9 4-12 7.5 2.1 U(45)=115.0, Z=-2.75, p<0.01 16 trimester visit

5 rd

Overall (PHBS score) @ 3 trimester visit 16-25 19.6 2.5 13-21 17.4 2.3 t(45)=3.00, p<0.01 Social support (MSPSS score) @ 1st 55-84 72.6 8.7 65-84 77.2 7.1 t(23)=-1.47, p=0.16 trimester visit+ Social support (MSPSS score) @ 2nd 56-84 74.2 5.9 63-84 76.3 6.5 t(45)=-1.15, p=0.26 trimester visit Social support (MSPSS score) @ 3rd 66-83 74.7 4.3 62-84 75.2 7.1 t(45)=-0.26, p=0.80 trimester visit Social support (MSPSS score) @ 66-84 75.5 5.6 64-84 75.1 1.6 t(42)=0.18, p=0.86 postpartum visit# +For first trimester visit, n=25 with 12 primiparous participants and 13 multiparous participants #For postpartum visit, n=44 with 24 primiparous participants and 20 multiparous participants

In other words, neither group indicated a strong perception that participants themselves, powerful others, or chance had the most control over their pregnancy and childbirth outcomes. There were significant differences, however, in health behaviors between the two groups (Table 7.5). At the first and second trimester visits, primiparous women had higher total scores on the Prenatal Health Behaviors Scale (PHBS) than multiparous women indicating that primiparous women engaged in “healthy” behaviors more frequently. Despite the higher overall score, primiparous women reported significantly higher levels of physical strain such as standing for long periods compared to multiparous women at the first, second, and third trimester visits. Primiparous women also reported significantly higher frequency of eating “unhealthy” foods such as fatty foods at the third trimester visit only. There were no significant differences in the other PHBS sub-scores including healthy eating, exercise, cigarette use, or caffeine use.

Women who reported anxiety due to conflicting information vs. those who did not.

Again, likely due to the homogeneity of the sample in terms of race/ethnicity, socioeconomic and relationship status, I found no significant differences between women who reported anxiety due to conflicting information and those who did not for these variables (Table 7.6). In addition, no significant differences emerged between these two groups of women for time in relationship, attendance at spiritual/ religious services, education, employment status, pre-pregnancy body mass index (BMI), maternal age at first visit, or gestational age at any timepoint (Tables 7.6 and 7.7). Women who reported anxiety due to conflicting information were more likely to be a student than women who did not report anxiety due to conflicting information.

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Table 7.6. Categorical sociodemographic variables, comparisons between women who reported anxiety and those who did not report anxiety from conflicting information. Anxiety from No anxiety from conflicting conflicting information information (n=25) (n=22) Variable n % n % Χ2 results Attend spiritual/religious X2(4)=5.61, p=0.23 services Never 10 45.5 7 28.0 Less than once per month 2 9.1 9 36.0 Once per month 2 9.1 1 4.0 Two to three times per month 4 18.2 2 8.0 Nearly every week 4 18.2 6 24.0 Relationship X2(1)=3.82, p=0.05 Married 19 86.4 25 100.0 Unmarried, in a relationship 3 13.6 0 0.0 Single 0 0.0 0 0.0 SES X2(3)=0.52, p=0.92 Low 0 0.0 0 0.0 Low to middle 1 4.5 2 8.0 Middle 16 72.7 17 68.0 Middle to upper 4 18.2 5 20.0 Upper 1 4.5 1 4.0 Race/Ethnicity X2(3)=3.21, p=0.36 White/Caucasian 19 86.4 24 96.0 Black/African-American 0 0.0 0 0.0 Asian 0 0.0 0 0.0 Multi-racial 3 13.6 1 4.0 Education X2(3)=2.04, p=0.57 Not a high school graduate 0 0.0 0 0.0 High school graduate 0 0.0 0 0.0 Some college 0 0.0 0 0.0 Associates or technical degree 1 4.5 0 0.0 Bachelor’s degree 4 18.2 8 32.0 Some graduate school 3 13.6 3 12.0 Graduate degree 14 63.6 14 56.0 Student X2(1)=4.06, p=0.04 Yes 9 40.9 4 16.0 No 13 59.1 21 84.0 Employed outside home X2(2)=1.47, p=0.48 Full-time (38-40 hrs/wk) 15 68.2 19 76.0 Part-time (<38 hrs/wk) 3 13.6 4 16.0 No 4 18.2 2 8.0 Parity Primiparous 17 77.3 10 40.0 X2(1)=6.08, p=0.01 Multiparous 5 22.7 15 60.0

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Table 7.7. Continuous demographic variables, comparisons between participants who reported anxiety and those who did not report anxiety from conflicting information

No anxiety from Anxiety from conflicting conflicting information information (n=25) (n=22) Variable Range Mean SD Range Mean SD Test results Time in relationship (months) 12-720 101.2 145.9 34-189 98.0 42.1 U(45)=193.5, Z=-1.74, p=0.08 Pre-pregnancy BMI (kg/m2) 18.9-31.6 24.8 3.5 20.7-35.0 24.7 3.7 t(45)=-0.07, p=0.95 Age @ 1st visit (years) 24-37 29.2 3.8 25-38 30.9 3.1 t(45)=-1.71, p=0.10 Gestational age @ 1st prenatal visit 4-13 9.0 2.4 4-12 8.4 2.0 U(45)=232.5, Z=-0.93, p=0.35 (weeks)+ Gestational age @ 1st trimester visit 7-13 10.2 2.3 8-14 11.7 2.1 U(23)=47.5, Z=-1.55, p=0.12 (weeks) Gestational age @ 2nd trimester visit 21-27 23.1 1.7 19-26 23.8 1.8 U(45)=191.0, Z=-1.61, p=0.11 (weeks) 168 Gestational age @ 3rd trimester visit 31-38 34.5 1.8 33-38 35.4 1.5 t(45)=--2.00, p=0.06

(weeks)

+For first trimester visit, n=25 with 10 participants reporting no anxiety and 15 participants reporting anxiety due to conflicting information

There also were no significant differences in almost all of the postpartum variables. More women who reported anxiety from conflicting information tested positive for GBS infections (Tables 7.8 and 7.9).

In terms of additional control variables, I found no significant differences between women who reported anxiety due to conflicting information and those who did not in sleep quality (PSQI), self-reported social support (MSPSS), or stressful life events (LES) at any time point (Table 7.10). Additionally, these two groups did not differ significantly in their locus of control perceptions (Multidimensional Health Locus of Control Scale

Form C) at any time point. Overall, neither group indicated a strong perception that participants themselves, powerful others, or chance had the most control over pregnancy and childbirth outcomes (Table 7.10). Similar to primiparous and multiparous women, there were significant differences in health behaviors between women who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information (Table 7.10). At the second and third trimester visits, women who did not report anxiety due to conflicting information had higher total scores on the PHBS.

This finding indicates that women who did not report anxiety due to conflicting information engaged in “healthy” behaviors more frequently. There were no significant differences in the PHBS sub-scores, however.

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Table 7.8. Categorical postpartum variables, comparisons between participants who reported anxiety and those who did not report anxiety due to conflicting information. Anxiety from No anxiety from conflicting conflicting information information (n=21) (n=23) 2 Variable n % n % X results Preterm labor X2(1)=0.88, p=0.35 Yes 0 0.0 1 4.3 No 21 100.0 22 95.7 Preterm delivery X2(1)=0.47, p=0.49 Yes 2 9.5 4 17.4 No 19 90.5 19 82.6 Gestational X2(1)=1.49, p=0.22 hypertension/preeclampsia Yes 3 14.3 1 4.3 No 18 85.7 22 95.7 Gestational diabetes X2(1)=0.47, p=0.49 Yes 0 0.0 1 4.3 No 21 100.0 22 95.7 Other complications during delivery X2(1)=0.22, p=0.64 Yes 1 5.0 2 8.7 No 20 95.0 21 91.3 Delivery route X2(4)=6.96, p=0.14 Spontaneous vaginal delivery 6 28.6 11 47.8 Spontaneous vaginal delivery with 5 23.8 2 8.7 induction meds Induced vaginal delivery 5 23.8 6 26.1 Planned Cesarean section 0 0.0 2 8.7 Unplanned/emergency Cesarean 5 23.8 2 8.7 section Location of birth X2(1)=0.88, p=0.35 Home 0 0.0 1 4.3 Birthing Center 0 0.0 0 0.0 Hospital 21 100.0 22 95.7 Other 0 0.0 0 0.0 Pain medications used X2(3)=1.85, p=0.60 None 4 19.0 3 13.0 Epidural 14 66.7 18 78.3 Epidural and other 1 4.8 0 0.0 Other only 2 9.5 2 8.7 Group B Streptococcus (GBS) X2(1)=8.80, p<0.01 Positive 8 38.1 0 0.0 Negative 13 61.9 23 100.0 Infant Sex X2(1)=0.02, p=0.88 Male 10 47.6 12 52.2 Female 11 52.4 11 47.8 170

Table 7.9. Continuous postpartum variables, comparisons between participants who reported anxiety and those who did not report anxiety from conflicting information.

Anxiety from conflicting No anxiety from conflicting information (n=23) information (n=21) Variable Range Mean SD Range Mean SD Test results Total pregnancy weight 11.3-27.2 16.2 4.2 6.4-22.7 14.9 4.5 t(42)=0.90, p=0.38 gain (kg) Infant birth weight (g) 2460-4224 3466 461 2892-4423 3563 414 t(42)=-0.69, p=0.50 Infant birth length (cm) 45.7-57.2 51.8 3.0 43.2-55.9 52.1 3.1 U(42)=108.0, Z=-0.60, p=0.55 Duration of labor (hours) 1.0-33.0 14.5 10.3 1.0-36.0 11.5 9.2 t(42)=0.95, p=0.35

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Table 7.10. Control variables, comparisons between participants who reported anxiety and those who did not report anxiety due to conflicting information.

Anxiety from No anxiety from conflicting conflicting information (n=22) information (n=25) Variable Range Mean SD Range Mean SD t-test results Sleep quality (PSQI score) @ 1st trimester 1-6 3.9 1.6 2-14 6.1 3.3 U(23)=43.5, Z=-1.77, p=0.08 visit+ Sleep quality (PSQI score) @ 2nd trimester 1-15 4.8 3.1 2-11 5.7 2.6 U(45)=201.0, Z=-1.37, p=0.17 visit Sleep quality (PSQI score) @ 3rd trimester 1-13 6.2 3.2 2-14 7.0 3.3 U(45)=196.5, Z=-0.82, p=0.41 visit Sleep quality (PSQI score) @ postpartum 2-14 7.7 2.6 5-11 8.2 1.9 t(42)=-0.66, p=0.52 visit# Locus of control - internal @ 1st trimester 15-30 23.3 5.4 19-31 23.2 4.3 t(23)=-0.05, p=0.96 visit+ Locus of control - powerful others @ 1st 18-31 25.8 3.8 19-34 26.9 4.4 t(23)=-0.63, p=0.54 172 trimester visit+ st Locus of control - chance @ 1 trimester 11-41 26.2 8.6 10-33 20.7 6.0 t(23)=1.89, p=0.07 visit+ Locus of control - internal @ 2nd trimester 10-33 22.8 5.0 18-39 24.3 4.5 U(45)=232.5, Z=-0.67, p=0.51 visit Locus of control - powerful others @ 2nd 16-34 24.9 4.6 17-36 27.0 4.6 U(45)=189.5, Z=-1.62, p=0.11 trimester visit Locus of control - chance @ 2nd trimester visit 11-35 23.4 7.2 13-34 24.5 5.6 t(45)=-0.60, p=0.55 Locus of control - internal @ 3rd trimester 12-33 23.6 4.9 16-36 23.4 4.4 t(45)=-0.08, p=0.94 visit Locus of control - powerful others @ 3rd 13-34 25.9 4.7 17-35 27.2 4.1 U(45)=191.5, Z=-0.94, p=0.35 trimester visit Locus of control - chance @ 3rd trimester visit 6-36 23.4 7.3 15-32 24.3 3.9 t(45)=-0.52, p=0.61 Continued

Table 7.10 Continued Anxiety from No anxiety from conflicting information conflicting information (n=25) (n=22) Variable Range Mean SD Range Mean SD t-test results Stressful life experiences (PLES score) 0-10 3.3 2.7 0-12 3.2 2.7 U(45)=224.0, Z=-0.15, p=0.88 Unhealthy eating (PHBS sub-score) @ 1st 5-11 7.8 2.3 2-10 6.5 2.3 t(23)=0.36, p=0.72 trimester visit+ Physical strain (PHBS sub-score) @ 1st 6-12 8.2 1.8 5-11 7.9 1.8 U(23)=72.0, Z=-0.17, p=0.87 trimester visit+ Overall (PHBS score) @ 1st trimester visit+ 14-23 19.5 3.1 13-22 18.5 2.5 t(23)=0.88, p=0.39 Unhealthy eating (PHBS sub-score @ 2nd 4-11 8.2 2.0 1-10 7.5 2.2 U(45)=223.0, Z=-0.89, p=0.38 trimester visit Physical strain (PHBS sub-score) @ 2nd 5-12 9.2 2.1 5-12 8.4 2.1 U(45)=195.5, Z=-1.49, p=0.14 trimester visit Overall (PHBS score) @ 2nd trimester visit 15-24 20.3 2.8 13-22 18.3 2.3 t(45)=2.70, p=0.01 rd

17 Unhealthy eating (PHBS sub-score) @ 3 5-10 8.1 1.6 1-11 6.9 2.7 U(45)=170.0, Z=-1.48, p=0.14

3 trimester visit Physical strain (PHBS sub-score) @ 3rd 4-12 8.8 2.3 6-12 8.4 2.0 U(45)=198.5, Z=-0.78, p=0.44 trimester visit Overall (PHBS score) @ 3rd trimester visit 16-25 19.9 2.6 13-22 17.7 2.3 t(45)=2.88, p<0.01 Social support (MSPSS score) @ 1st 55-84 71.2 9.3 65-84 77.5 6.3 t(23)=-2.03, p=0.06 trimester visit+ Social support (MSPSS score) @ 2nd 56-84 75.1 6.5 63-84 75.1 6.0 t(45)=0.03, p=0.97 trimester visit Social support (MSPSS score) @ 3rd 62-84 74.6 5.1 64-84 75.2 6.1 t(45)=-0.34, p=0.74 trimester visit Social support (MSPSS score) @ 63-84 74.1 5.5 66-84 76.4 6.3 t(42)=1.26, p=0.21 postpartum visit# +For first trimester visit, n=25 with 10 participants reporting no anxiety and 15 participants reporting anxiety from conflicting information #For postpartum visit, n=44 with 21 participants reporting no anxiety and 23 participant reporting anxiety from conflicting information

H1: Women who struggle more with authoritative knowledge decisions will have higher levels of self-reported stress, particularly pregnancy-specific anxiety.

To determine if AK decision making affected self-reported stress levels, I divided the sample in two ways: primiparous vs. multiparous women and women who reported anxiety due to conflicting information vs. those who did not report anxiety due to conflicting information. Within each set of groups, one group made more AK decisions than the other allowing me to connect differences in self-reported stress levels to AK decision making.

Testing H1 via parity. As I did not have a full sample at the first trimester visit

(n=25), analyses involved comparing smaller primiparous (n=12) and multiparous (n=13) groups. Primiparous and multiparous participants did not differ significantly in self- reported general stress (Perceived Stress Scale (PSS) score) at any time point (Table

7.11). However, at the first trimester visit (n=25), primiparous women reported significantly higher levels of pregnancy-specific anxiety (Pregnancy-specific Anxiety

Scale (PSAS) score) than multiparous women. This significant difference did not emerge, however, when I divided the PSAS into anxiety and concerns sub-scores as described in the methods section of this chapter (Table 7.11). The two groups did not differ significantly in total PSAS score or sub-scores at any other time point.

In examining these measures of stress longitudinally, self-reported general stress showed no significant pattern of change over time when analyzed with the first trimester visit for the primiparous women (X2(3)=0.78, p=0.86) or the multiparous women

(X2(3)=6.75, p=0.08 (Figure 7.1).

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Table 7.11. Self-reported stress variables, comparisons between primiparous and multiparous participants.

Primiparous (n=27) Multiparous (n=20) Variable Range Mean SD Range Mean SD Results General stress (PSS score) @ 1st trimester visit+ 13-24 18.3 3.8 14-23 18.2 2.4 t(23)=1.23, p=0.12 General stress (PSS score) @ 2nd trimester visit 11-25 17.7 3.3 11-30 18.5 4.6 U(45)=252.5, Z=-0.17, p=0.87 General stress (PSS score) @ 3rd trimester visit 12-28 18.1 4.6 12-33 18.4 5.1 U(45)=214.5, Z=-0.26, p=0.80 General stress (PSS score) @ postpartum visit# 11-25 17.3 3.8 11-32 17.4 4.7 U(42)=198.0, Z=-0.16, p=0.87 Pregnancy-specific anxiety (PSAS score) @ 1st 20-43 28.5 7.2 17-34 25.3 4.7 U(23)=43.8, Z=-2.13, p=0.05 trimester visit+ PSAS concerns sub-score @ 1st trimester visit+ 13-30 18.6 4.8 11-24 16.5 3.5 t(23)=1.22, p=0.24

st +

17 PSAS anxiety sub-score @ 1 trimester visit 5-16 9.9 3.3 6-15 8.8 2.7 t(23)=0.96, p=0.35

Overall pregnancy-specific anxiety (PSAS 17-46 28.7 7.2 19-35 27.0 5.3 t(45)=0.92, p=0.36 score) @ 2nd trimester visit PSAS concerns sub-score @ 2nd trimester visit 13-30 19.9 4.6 13-25 18.0 3.5 U(45)=197.5, Z=-1.39, p=0.16 PSAS anxiety sub-score @ 2nd trimester visit 4-16 8.9 2.9 4-16 9.0 3.0 U(45)=242.0, Z=-0.40, p=0.69 Overall pregnancy-specific anxiety (PSAS 18-41 28.4 6.8 4-40 26.0 8.2 t(45)=1.07, p=0.29 score) @ 3rd trimester visit PSAS anxiety sub-score @ 3rd trimester visit 4-14 9.6 2.9 6-13 9.3 2.3 t(45)=0.34, p=0.73 PSAS concerns sub-score @ 3rd trimester visit 13-30 18.9 4.5 11-27 17.8 4.1 t(45)=0.78, p=0.44 +For first trimester visit, n=25 with 12 primiparous participants and 13 multiparous participants #For postpartum visit, n=44 with 24 primiparous participants and 20 multiparous participants

reported General General Score reported Stress 12

- Self 10 Trimester 1 Trimester 2 Trimester 3 Postpartum Primiparous Multiparous

Figure 7.1. Self-reported general stress (PSS score; mean ± SE) for primiparous and multiparous participants across pregnancy.

There also was no significant pattern of change over time when I analyzed self-reported general stress without the first trimester visit data for primiparous women (X2(2)=0.59, p=0.75) or multiparous women (X2(2)=1.60, p=0.45).

In terms of pregnancy-specific anxiety, when including the first trimester data, I found no significant pattern of change over time for primiparous women (X2(2)=1.95, p=0.28) or multiparous women (X2(2)=0.19, p=0.91) (Figure 7.2). Additionally, no significant pattern of change emerged for the PSAS concerns sub-score when the first trimester visit data were included for primiparous women (X2(2)=0.84, p=0.66) or multiparous women (X2(2)=1.23, p=0.54) (Figure 7.3).

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32 30 28 26 24 22

specific Anxiety Score Anxiety specific - 18 16

Pregnancy 14 12 Trimester 1 Trimester 2 Trimester 3 Primiparous Multiparous

Figure 7.2. Pregnancy-specific anxiety (PSAS score; mean ± SE) for primiparous and multiparous participants across pregnancy.

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score - 15

5 PSAS Concerns Concerns SubPSAS

0 Trimester 1 Trimester 2 Trimester 3 Primparous Multiparous

Figure 7.3. PSAS concerns sub-score (mean ± SE) for primiparous and multiparous participants across pregnancy.

The PSAS anxiety sub-score with the first trimester visit data, however, showed a significant pattern of change over time for primiparous women (X2(2)=8.21, p=0.02), but there was no significant pattern of change for multiparous women (X2(2)=2.40, p=0.30)

(Figure 7.4). Analysis of individual time point differences revealed PSAS anxiety differed significantly between the second and third trimesters only (Z=-1.94, p=0.05).

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10 score - 8

PSAS Anxiety Sub Anxiety PSAS 2

0 Trimester 1 Trimester 2 Trimester 3 Primiparous Multiparous

Figure 7.4. PSAS anxiety sub-score (mean ± SE) for primiparous and multiparous participants across pregnancy.

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Testing H1 via anxiety due to conflicting information. Women who reported anxiety due to conflicting information had significantly higher levels of self-reported general stress (Perceived Stress Scale (PSS) score) at the second trimester time point, but there were no significant differences between these groups at the other time points (Table

7.12; Figure 7.5). The two groups did not differ significantly in their levels of pregnancy- specific anxiety (Pregnancy-specific Anxiety Scale (PSAS) score) at any time point

(Table 7.12; Figure 7.6). The two groups also did not differ significantly in the PSAS concerns sub-score at any timepoint (Table 7.12; Figure 7.7). Women who reported anxiety due to conflicting information, however, did have higher levels of the PSAS anxiety sub-score but only at the first trimester visit (Table 7.12; Figure 7.8).

In examining these measures of stress longitudinally, self-reported general stress showed no significant pattern of change across time for women who reported anxiety due to conflicting information (X2(3)=5.40, p=0.15) or for those who did not report anxiety due to conflicting information (X2(3)=6.86, p=0.08) when the first trimester visit data were included (Figure 7.5). Additionally, no significant pattern of change emerged for either group when the first trimester data were not included (X2(2)=4.51, p=0.11;

X2(2)=0.46, p=0.80; Figure 7.5). There was no significant pattern of change across time in pregnancy-specific anxiety for women who reported anxiety due to conflicting information (X2(2)=0.16, p=0.93) or for those who did not report anxiety due to conflicting information (X2(2)=1.27, p=0.53) when the first trimester visit data were included (Figure 7.6).

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Table 7.12. Self-reported stress variables, comparisons between participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information.

No anxiety from Anxiety from conflicting conflicting information (n=22) information (n=25) Variable Range Mean SD Range Mean SD Results General stress (PSS score) @ 1st trimester visit+ 13-24 18.4 4.3 15-23 18.1 2.2 t(23)=0.256, p=0.800 General stress (PSS score) @ 2nd trimester visit 11-25 16.6 3.5 14-30 19.2 3.9 U(45)=156.5, Z=-2.35, p=0.02 General stress (PSS score) @ 3rd trimester visit 12-33 17.7 5.2 13-28 18.7 4.4 U(45)=184.0, Z=-1.13, p=0.26 General stress (PSS score) @ postpartum visit# 11-32 17.2 5.3 12-25 17.4 2.9 U(42)=173.5, Z=-0.94, p=0.35 Pregnancy-specific anxiety (PSAS score) @ 1st 22-43 25.1 7.4 17-34 29.5 4.5 U(23)=49.0, Z=-1.45, p=0.15 trimester visit+ PSAS concerns sub-score @ 1st trimester visit+ 13-30 18.4 5.4 11-24 16.9 3.3 t(23)=0.841, p=0.409 st + 181 PSAS anxiety sub-score @ 1 trimester visit 7-16 8.1 2.8 5-15 11.1 2.6 t(23)=2.733, p=0.012

Overall pregnancy-specific anxiety (PSAS 17-46 27.6 6.8 19-46 28.2 6.3 t(45)=-0.321, p=0.750 score) @ 2nd trimester visit PSAS concerns sub-score @ 2nd trimester visit 13-30 18.9 4.8 14-30 19.2 3.8 U(45)=247.0, Z=-0.35, p=0.73 PSAS anxiety sub-score @ 2nd trimester visit 4-16 8.8 2.6 4-16 9.1 3.2 U(45)=244.5, Z=-0.40, p=0.69 Overall pregnancy-specific anxiety (PSAS 18-41 28.3 7.8 4-40 26.7 7.1 t(42)=0.725, p=0.473 score) @ 3rd trimester visit PSAS concerns sub-score @ 3rd trimester visit 11-30 18.7 5.3 13-27 18.2 3.5 t(42)=0.360, p=0.721 PSAS anxiety sub-score @ 3rd trimester visit 4-14 9.6 3.2 6-13 9.3 2.1 t(42)=0.363, p=0.719

+For first trimester visit, n=25 with 10 participants reporting no anxiety and 15 participants reporting anxiety from conflicting information #For postpartum visit, n=44 with 21 participants reporting no anxiety and 23 participant reporting anxiety from conflicting information

20 19 18 17 16 15 14

13 reported General General Score reported Stress

- 12

Self 11 10 Trimester 1 Trimester 2 Trimester 3 Postpartum No messaging anxiety Messaging anxiety

Figure 7.5. Self-reported general stress (PSS score; mean ± SE) of participants who reported anxiety and those who did not report anxiety from conflicting information across pregnancy.

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32 30 28 26 24 22

20 specific Anxiety Score Anxiety specific - 18 16

14 Pregnancy 12 Trimester 1 Trimester 2 Trimester 3 No messaging anxiety Messaging anxiety

Figure 7.6. Pregnancy-specific anxiety (PSAS score; mean ± SE) for participants who reported anxiety and those who did not report anxiety from conflicting information across pregnancy.

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score -

5 PSAS Concerns Concerns SubPSAS

0 Trimester 1 Trimester 2 Trimester 3 No messaging anxiety Messaging anxiety

Figure 7.7. PSAS concerns sub-score (mean ± SE) participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information across pregnancy.

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score -

4 PSAS Anxiety Sub Anxiety PSAS 2

0 Trimester 1 Trimester 2 Trimester 3 No messaging anxiety Messaging anxiety

For the PSAS anxiety sub-score, there was a significant pattern of change over time when the first trimester visit data were included for both women who reported anxiety due to conflicting information (X2(2)=7.04, p=0.03) and those who did not report anxiety due to conflicting information (X2(2)=6.47, p=0.04; Figure 7.8).

Summary for H1. Although results were mixed, if a significant difference emerged between the comparison groups (primiparous vs. multiparous and women who reported anxiety due to conflicting information vs. those who did not report anxiety due

185

to conflicting information), the group who struggled more AK decisions always had higher stress levels. The significant results for H1 are listed below.

• Primiparous women had significantly higher levels of pregnancy-specific anxiety

than multiparous women in the first trimester only.

• Primiparous women, but not multiparous women, had a significant pattern of

change in PSAS anxiety sub-scores across pregnancy.

• Women who reported anxiety due to conflicting information had significantly

higher levels of self-reported general stress than women who did not report

anxiety due to conflicting information in the second trimester only.

• Women who reported anxiety due to conflicting information had significantly

higher PSAS anxiety sub-scores than women who did not report anxiety due to

conflicting information in the first trimester only.

H2: Women who struggle more with authoritative knowledge decisions will have higher hair cortisol levels at each timepoint and steeper hair cortisol trajectories across pregnancy.

To determine if AK decision making affected hair cortisol levels, I used the same sample divisions utilized in testing H1: primiparous vs. multiparous women and women who reported anxiety due to conflicting information vs. those who did not report anxiety due to conflicting information. Again, within each set of groups, one group made more

AK decisions than the other, which allowed me to explore the relationship between hair cortisol levels based and AK decision making.

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Overall, hair cortisol levels were low and ranged from 1.5 mg/pg to 15.7 mg/pg across all four study visits except for a single outlier of 43.7 pg/mg in one second trimester visit. As normal hair cortisol levels range from 1.0 to 100.0 pg/mg, none of the participants had abnormally high hair cortisol levels.

Testing H2 via parity. Similar to pregnancy-specific anxiety, however, primiparous women had significantly higher hair cortisol levels at the first trimester visit compared to multiparous women (U(23)=42.6, Z=-2.11, p=0.05) (Table 7.13; Figure 7.9).

Hair cortisol levels did not differ significantly at the other time points. In analyzing the hair cortisol levels across time, no significant pattern of change emerged for primiparous women (X2(2)=0.12, p=0.99; Figure 7.9) or multiparous women (X2(2)=2.46, p=0.48;

Figure 7.9) when the first trimester data were included. This also was true for both primiparous women (X2(2)=3.25, p=0.20) and multiparous women (X2(2)=2.47, p=0.29) when the first trimester visit data were not included (Figure 7.9).

Testing H2 via anxiety due to conflicting information. No significant differences emerged for hair cortisol levels between the two groups at any time point (Table 7.14;

Figure 7.10). There also were no significant pattern of change across time for hair cortisol level in women who reported anxiety due to conflicting information (X2(3)=0.23, p=0.97) or women who did not report anxiety due to conflicting information (X2(2)=3.30, p=0.35) when the first trimester visit data were included (Figure 7.10).

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Table 7.13. Hair cortisol levels, comparisons between primiparous and multiparous participants.

Primiparous (n=27) Multiparous (n=20) Variable Range Mean SD Range Mean SD t-test results Hair cortisol @ 1st trimester visit (pg/mg)+ 1.6-15.7 7.1 4.8 2.0-8.6 4.7 2.1 U(23)=42.6, Z=-2.11, p=0.05 Hair cortisol @ 2nd trimester visit (pg/mg) 2.2-43.7 6.0 8.0 1.5-9.7 5.2 2.4 t(45)=1.27, p=0.21 Hair cortisol @ 3rd trimester visit (pg/mg) 1.5-10.9 4.4 2.2 1.7-16.5 5.9 3.6 t(45)=-1.76, p=0.09 Hair cortisol @ postpartum visit (pg/mg)# 1.8-10.6 4.1 1.9 2.2-15.0 5.5 3.9 t(42)=-1.58, p=0.12

+For first trimester visit, n=25 with 12 primiparous participants and 13 multiparous participants #For postpartum visit, n=44 with 24 primiparous participants and 20 multiparous participants

Table 7.14. Self-reported stress variables, comparisons between participants who reported anxiety due to conflicting information and those who did not report anxiety due to conflicting information.

8 No anxiety from conflicting information Anxiety from conflicting (n=22) information (n=25) Variable Range Mean SD Range Mean SD Results Hair cortisol @ 1st trimester visit (pg/mg)+ 1.6-15.7 6.5 5.2 2.0-8.6 5.0 2.0 U(23)=73.0, Z=-0.11, p=0.91 Hair cortisol @ 2nd trimester visit (pg/mg) 2.2-9.1 4.8 2.2 1.5-43.7 7.1 8.2 t(45)=-1.23, p=0.23 Hair cortisol @ 3rd trimester visit (pg/mg) 1.8-16.5 5.5 3.4 1.5-10.9 4.6 2.5 t(45)=-1.04, p=0.31 Hair cortisol @ postpartum visit (pg/mg)# 1.8-15.0 4.5 2.9 2.2-14.9 4.8 3.0 t(42)=-0.29, p=0.77

10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0

2.0 Cortisol Level Level (pg/mg) Cortisol 1.0 0.0 Trimester 1 Trimester 2 Trimester 3 Postpartum Primiparous Multiparous

Figure 7.9. Hair cortisol level (mean ± SE) for primiparous and multiparous participants across pregnancy.

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10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0

Cortisol Level Level (pg/mg) Cortisol 2.0 1.0 0.0 Trimester 1 Trimester 2 Trimester 3 Postpartum No messaging anxiety Messaging anxiety

There also was no significant pattern of change across time in women who reported anxiety due to conflicting information (X2(2)=0.09, p=0.96) or those who did not report anxiety due to conflicting information (X2(2)=3.90, p=0.14) when the first trimester visit data were excluded (Figure 7.10).

Summary for H2. One significant difference emerged between hair cortisol levels in the comparison groups. Specifically, primiparous women had significantly higher hair cortisol levels than multiparous women in the first trimester only.

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Summary

I divided the sample into two sets of comparison groups: primiparous vs. multiparous women and women who reported anxiety due to conflicting information vs. those who did not report anxiety due to conflicting information. Within each set of comparison groups, one group struggled more with AK decisions than the other, according to published literature and the ethnographic data I presented in Chapter 6.

Between primiparous and multiparous women, primiparous women struggle more with

AK decisions as they have less personal experience with pregnancy and childbirth.

Primiparous women also often are encountering information about pregnancy and childbirth for the first time. As such, they struggle more with AK decisions about the

“best” behaviors during pregnancy and the “best” childbirth plans. Between women who report anxiety due to conflicting information and those who do not report anxiety due to conflicting information, women who report anxiety struggle more with AK decisions as they grapple with which pregnancy and childbirth behaviors are the “best” when they encounter conflicting information. These comparison groups allowed me to test if struggle more with AK decisions affected women’s self-reported stress levels and hair cortisol levels.

H1: Women who struggle more with authoritative knowledge decisions will have higher levels of self-reported stress, particularly pregnancy-specific anxiety.

Self-reported stress levels were not always significantly different between the comparison groups. Several significant differences emerged, however. In each case, the group who struggled more with AK decisions had higher self-reported stress levels. For

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primiparous vs. multiparous women, primiparous women had significantly higher levels of pregnancy-specific anxiety than multiparous women in the first trimester only.

Primiparous women also have a significant pattern of change in PSAS anxiety sub-scores across pregnancy largely due to higher PSAS anxiety sub-scores for primiparous women in the first trimester. For women who reported anxiety due to conflicting information vs. those who did not report anxiety due to conflicting information, women who reported anxiety had significantly higher levels of self-reported general stress than women who did not report anxiety due to conflicting information in the second trimester only. Women who reported anxiety due to conflicting information also had significantly higher PSAS anxiety sub-scores than women who did not report anxiety due to conflicting information in the first trimester only.

H2: Women who struggle more with authoritative knowledge decisions will have higher hair cortisol levels at each time point and steeper cortisol trajectories across pregnancy.

Few significant differences emerged between the comparison groups for hair cortisol levels. Primiparous women as the group who struggles more with AK decisions did have higher cortisol levels than multiparous women in the first trimester only.

Other important results for future research

The results revealed a few avenues that require further investigation in future research studies as well.

• Current literature posits that saliva, blood, and hair cortisol levels show a 2- to 4-

fold increase over the course of pregnancy (Kalra et al. 2007, Kirschbaum 2008,

Mastorakos and Ilias 2003). Contrary to this literature, however, I found no

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significant pattern of change in hair cortisol levels over the course of pregnancy in

this relatively high SES sample.

• Little research exists examining factors that lead to Group B streptococcus (GBS)

colonization during pregnancy (Colicchia et al. 2015). In addition, Page-Ramsey

and colleagues (2013) found that among women who did not have GBS

colonization in previous pregnancies, primiparous and multiparous women had

similar rates of GBS colonization in their current pregnancies. In this study,

however, primiparous women had significantly higher rates of GBS than

multiparous women. In addition, connections between GBS colonization and

stress have not been explored.

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Chapter 8: Discussion and Conclusions

Introduction

My goal in this dissertation was to explore how cultural expectations of motherhood affect women’s self-reported and physiological stress levels during pregnancy. Unlike many other cultures in the world, most U.S. women who have never given birth do not discuss pregnancy and childbirth in detail or attend a childbirth

(Browner and Press 1997, Crossley 2007, Jordan 1993[1978], Root and Browner 2001,

Sayakhot and Carolan-Olah 2016, Song et al. 2012). As such, U.S. women have limited knowledge about pregnancy and childbirth before they experience these processes themselves (Malacrida and Boulton 2014, Song et al. 2012). When women receive information from many different sources during pregnancy, therefore, they must sort through this new information to make decisions about their behaviors during pregnancy and childbirth (Malacrida and Boulton 2014, Song et al. 2012). These information sources also reflect cultural expectations of U.S. mothers, but they frequently demonstrate competing expectations (Cole et al. 2019, Lazarus 1994, Malacrida and

Boulton 2014, Root and Browner 2001, Walsh 2010). This competing information, therefore, has the potential to overwhelm pregnant women in the U.S., particularly during their first pregnancies, causing anxiety and stress (Browner and Press 1996, Root and

Browner 2001). With this study, I intended to explore how the competing and possibly 194

conflicting information pregnant women receive affected their decision-making process and their self-reported and physiological stress levels. Linking cultural beliefs to these measures of stress shows the consequences of women’s experiences with cultural expectations. In addition, the published literature makes clear that connections exist between both self-reported and physiological stress levels and adverse birth outcomes

(Buss et al. 2009, Dunkel Schetter and Glynn 2011, Kramer et al. 2009, Lobel et al. 2008,

Roesch et al. 2004). Competing cultural expectations, therefore, may help explain variation in infant mortality / morbidity and reproductive morbidity.

Preliminary study

The first step in my study was to examine the two dominant models of pregnancy and childbirth present in the U.S. (biomedical and natural childbirth) as potential sources of conflicting information. Since these two models have competing tenets, I wanted to explore how the cultural expectations inherent in each were expressed by their respective proponents. Although other researchers have explored the differences between these two models, no other study has systematically compared these two models as they are viewed by women’s health professionals – the very individuals who reinforce the models’ ideals in their work with pregnant women (Cole et al. 2019, Hays 1996, Sargent and Gulbas

2011, Walsh 2010). While I found that proponents of both communities focused on the same seven general themes, there were important areas of consensus and discordance in how proponents of each model discussed the different themes. In focus groups and key informant interviews, proponents of the biomedical model portrayed pregnancy and childbirth as risky processes that require extensive medical monitoring and intervention

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(Brauer 2016, Cole et al. 2019, Hayter 2005, Johnson 2008). While medical intervention initially improved pregnancy and childbirth outcomes, the biomedical portrayal of pregnancy and childbirth further removes these processes from everyday life and makes medical intervention seem necessary to produce a healthy child (Cole et al. 2019, Coxon et al. 2014, Davis-Floyd 2001, Jordan 1993[1978], Malacrida 2015, Sargent and Gulbas

2011). As a result, several researchers show how the biomedical view of pregnancy and childbirth sometimes create medical situations that put women and their children in danger (Beckett 2005, Hazen 2017, Lent 1999, Mansfield 2008). Proponents of the natural childbirth model, on the other hand, focus on pregnancy and childbirth as natural processes and stress women’s responsibilities in gathering extensive information to make informed decisions that resist biomedical doctrine (Cosans 2004, Happel-Parkins and

Azim 2015, Mansfield 2008, Walsh 2010). As discussed in detail in Chapter 5, my results show that both of these models, despite their conflicting messages, place a great deal of responsibility on women to choose the “correct” behaviors during pregnancy and childbirth. Which behaviors are “correct,” however, can be difficult to determine if women receive conflicting information from these models (Cole et al. 2019, Lazarus

1994, Malacrida and Boulton 2014, Root and Browner 2001, Walsh 2010). In fact, biomedical professionals emphasized women’s responsibility to adhere to biomedical advice, while natural childbirth proponents stressed women’s responsibility to gather extensive information before making decisions. Natural childbirth proponents, however, also highlighted women’s responsibility in resisting biomedical doctrine. Both models suggest that not following their recommendations will have disastrous consequences for

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maternal and fetal health. These models, therefore, exert biopower over women or attempt to control women’s bodies through insistence that a successful pregnancy and childbirth hinges on women’s individual responsibility. Malacrida and Boulton (2014) found a similar tendency of biomedical and natural discourses to discipline women’s bodies by proposing ideal, but opposing ways to give birth. The women in Malacrida and

Boulton’s (2014) study also blamed themselves if they did not meet the standards of one or both models illustrating the models’ biopower. In addition to providing data to create the Messaging survey, my preliminary study adds to the published literature in detailing the tenets of both models as discussed by their proponents who present these tenets to pregnant women. This preliminary study also illustrates how biopower is exerted by these models through the individuals pregnant women encounter during their pregnancies and childbirths.

Research Questions and Hypotheses

Given the potential for conflicting information to exist, the next step in my study was to collect survey responses, interviews, and hair samples from pregnant women in a longitudinal study to explore the following research questions:

• RQ1: Where do pregnant women get information regarding best practices during

pregnancy and childbirth?

• RQ2: Which sources do women rely on most heavily for information about best

practices during pregnancy and childbirth?

• RQ3: In what ways does this information conflict?

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o RQ3a: What effect does conflicting information have on pregnant

women’s emotions and decision-making?

• RQ4: How do pregnant women make authoritative knowledge decisions about

which practices to integrate into their daily lives and birth plans?

o RQ4a: What information do women prioritize in making decisions about

their behaviors during pregnancy and their childbirth plans?

o RQ4b: Why do women prioritize some information over other information

in their decision-making process?

• RQ5: How are women’s experiences with authoritative knowledge decision

making related to self-reported stress, particularly pregnancy-specific anxiety?

• RQ6: How are women’s experiences with authoritative knowledge decision

making related to cortisol levels and trajectories over the course of pregnancy?

To address RQ1, RQ2, RQ3, RQ3a, RQ4, RQ4a, and RQ4b, I utilized ethnographic data collected through survey responses and interviews with study participants during two, and in some cases, three visits during pregnancy.

To address RQ5 and RQ6, I utilized quantitative data collected from survey responses and hair cortisol analysis as well as qualitative data collected in two to three study visits during pregnancy and one postpartum visit. My intention was to test the following hypotheses:

• H1: Women who struggle more with authoritative knowledge decisions will have

higher levels of self-reported stress, particularly pregnancy-specific anxiety.

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• H2: Women who struggle more with authoritative knowledge decisions will have

higher cortisol levels at each timepoint and steeper cortisol trajectories across

pregnancy.

Discussion of results

RQ1: Where do pregnant women get information regarding best practices during pregnancy and childbirth?

RQ2: Which sources do women rely on most heavily for information about best practices during pregnancy and childbirth?

Women in this study sought out information principally from the people in their lives including the healthcare professionals they visited throughout their pregnancies.

They particularly relied on their friends, spouse/partner, healthcare provider, mother, and other female relatives. Recent studies of women’s information gathering during pregnancy in the U.S. have focused on information from written sources such as the internet and/or written information provided by medical professionals (Cole et al. 2019,

Lagan et al. 2010, Sanders and Crozier 2018, Song et al. 2012). For example, Song and colleagues (2012) focused on the role of the internet as a resource for pregnant women in managing their pregnancies and the doctor-patient relationship. Song and colleagues

(2012) suggest that the internet often replaces women’s family and community as a main source of information and advice. My findings, however, reveal the importance women place on information from their social circles over written information. While women also consulted written sources for information, they expressed a preference for obtaining information from conversations with individuals with whom they had personal

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relationships. More research, therefore, should concentrate on the impact pregnant women’s social networks have on their decision-making process, even in this era of modern technology.

Women in this study also felt their female friends and family had more to offer in terms of advice than their male friends and family. They reported that their female friends and family, especially those who previously were pregnant and gave birth, had similar relevant experiences and, therefore, provided advice that was more reliable. This tendency to trust women’s insights into pregnancy and children over men’s reflects a historical and cross-cultural trend of women-centered support explored by several researchers (Davis-Floyd 2001, Jordan 1993[1978], Oakley 1984, Sanders and Crozier

2018, Sargent and Gulbas 2011, Scheper-Hughes and Lock 1987). In her classic cross- cultural study of birthing systems, Jordan (1993[1978]) showed that while men often are included in the birthing process in other cultures, women make-up the main support system during birth. For example, in the Mayan culture of the Yucatan, women frequently have their husbands present, but women attendants give instructions during birth (Jordan 1993[1978]). Similarly, in Holland, where almost 30% of all births occur at home, a midwife, a midwife’s assistant, and a women’s chosen support person attend most births (Jordan 1993[1978], Wiegers and Hukkelhoven 2010). While male midwives exist in Holland, just as they do in the United States, midwifery is dominated by women

(ACNM 2016, OMA 2017). Oakley (1984) discussed a similar trend in the U.S. prior to

20th century in which women often gave birth at home with female relatives as attendants.

Discussion of pregnancy and childbirth was relegated to the realm of women and seldom

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broached by men as well (Oakley 1984). Women also reported preferring to consult friends and family closer to their own age citing generational differences in ideas about

“appropriate” behaviors. In my study, generational differences contributed to conflicting information women received, which is explored in more detail in the next section. My results show that U.S. women, like their historical counterparts and women in many other cultures, seek out women’s advice over men’s advice, although the (male or female) healthcare provider’s advice, as a particularly authoritative source in the U.S., often still trumps advice from other women.

Women frequently sought out information from their healthcare providers; particularly for medical decisions such as drug safety pregnancy. Analogous to findings from existing literature, women tended to prioritize information from their healthcare providers over information they received from other sources demonstrating the prominence the biomedical model still holds in the U.S. (Cole et al. 2019, Coxon et al.

2014, Happel-Parkins and Azim 2015, Malacrida and Boulton 2014, Miller and Shriver

2012). In their interviews with pregnant women, Malacrida and Boulton (2014) found that women’s choices about their childbirth experiences were constrained by structural forces. In particular, they showed that despite women’s expressed preferences for a natural childbirth, they prioritized information from healthcare provider’s in the moment of birth. For instance, participants in their study who desired a birth free of medical intervention seldom achieved this ideal since their doctors presented intervention as medically necessary for maternal and fetal health (Malacrida and Boulton 2014). Since their participants accepted the biomedical definition of pregnancy and childbirth as risky

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events, they prioritized information from biomedical professionals over the information they had gathered about natural childbirth (Malacrida and Boulton 2014). Happel-Parkins and Azim (2015) found a similar tendency for women to accept biomedical advice that contradicted their previous beliefs during the process of childbirth. Most of the published literature, however, focuses on decision-making during the birth process. The importance of my results is two-fold. First, women prioritize information from biomedical professionals throughout their pregnancies, not just during the birth process. Second, as information from individuals proved more important to women overall than written information, all biomedical information was not necessarily prioritized, but rather the information from a biomedical professional with whom the women had a personal relationship was considered more worthy of attention. Again, women preferred to take advice from individuals they trusted, which included their healthcare professional. These results highlight the prominence of a women’s healthcare provider as a source of information, a position of authority that healthcare providers need to use carefully to make sure women’s voices are heard and wishes are followed.

While women relied most heavily on individuals for information, they also turned to written sources of information, especially the internet, to supplement the advice they received from individuals (Lagan et al. 2010, Sanders and Crozier 2018, Song et al.

2012). In particular, similar to the findings of Sanders and Crozier (2018), women sought out information from the internet when they felt the information they received from people was insufficient or did not match their previous ideas about health. Despite this

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tendency to rely heavily on the internet for information, many women acknowledged the need to be careful with online information as the internet includes both facts and opinion.

Women’s inclination to seek out multiple sources of information reflects the pressure they are under to find as much information as possible before making decisions about their pregnancies and childbirth plans (Brauer 2016, Coxon et al. 2014, Happel-

Parkins and Azim 2015, Hays, B. 1996, Malacrida and Boulton 2014, Sanders and

Crozier 2018, Song et al. 2012). As U.S. culture suggests that “good mothers” are informed patients who follow the “best” practices to protect themselves and, particularly, their children, seeking out information from multiple sources constitutes “good mother” behavior (Brauer 2016, Happel-Parkins and Azim 2015, Hays, B. 1996, Miller and

Shriver 2012, Sanders and Crozier 2018, Song et al. 2012). Malacrida and Boulton

(2014) similarly found that women collected copious amounts of information about childbirth before making decisions. Malacrida and Boulton (2014: 45) discuss cultural expectations for women to be “endlessly responsible” and one of their responsibilities is to be “informed medical consumers” as the driving forces behind women’s information gathering behaviors. Brauer (2016) also examined the expectation that pregnant women gather a great deal of information. Brauer (2016) again connects this behavior to cultural ideas of maternal responsibility, but also emphasizes the cultural view of women as nurturers. One way of nurturing the unborn fetus according to Brauer (2016), therefore, is to gather information to make informed and “appropriate” decisions. My results mirror the information gathering behaviors of pregnant women shown in other ethnographic studies. I will explore more of my ethnographic results in future sections to connect

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information gathering from multiple sources to cultural expectations and decision- making.

Participants consulted the most sources in the first and second trimesters, but reduced their source use in the third trimester. Interview data revealed that most women had made their AK decisions regarding pregnancy behaviors and childbirth plans by the third trimester reducing their need to consult sources. This tendency to reduce source use once AK decisions were made was also visible in the differences in source use between primiparous and multiparous women. Few other studies have examined this connection between source use and decision making (Lagan et al., Regan et al. 2013). The few studies that do connect source use and decision-making again focus primarily on decisions about childbirth. For example, Regan and colleagues (2013) studied how source use affected women’s decisions about mode of birth. Regan and colleagues (2013) found that nearly 45% of the women in their study knew which type of birth they wanted before they became pregnant. These women tended to consult only a few sources to further refine, but not change their decision. In fact, these women seldom consulted sources that did not support the decision they had already made. Regan and colleagues’ study (2013) shows similar results to my study in that women who had made an AK decision reduced their information gathering behaviors. The longitudinal nature of my data, however, allows for not only a broader understanding of information gathering and decision- making throughout pregnancy, but also provides a clearer picture of how information gathering relates to different types of decisions during pregnancy.

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Generally, primiparous women in this study relied on sources more heavily than multiparous women. This finding is in agreement with several ethnographic studies in which multiparous women mentioned that that they did not need to consult as many sources after their first successful pregnancy (Browner and Press 1996, Root and

Browner 2001, Sayakhot and Carolan-Olah 2016, Song et al. 2012). In contrast to multiparous women, primiparous women continued consulting many sources throughout their pregnancies. Most U.S. women pregnant with their first child have little experience with pregnancy and childbirth since these processes are removed from everyday life in the U.S. (Browner and Press 1997, Crossley 2007, Jordan 1993[1978], Root and Browner

2001, Sayakhot and Carolan-Olah 2016, Song et al. 2012). To revisit Jordan’s

(1993[1978]) work with the Maya of the Yucatan, pregnancy and childbirth are considered a normal part of everyday life since births occur in family homes. Both male and female children see the actions of birth attendants and hear the sounds of birth long before they are involved in an actual birth. In addition, Jordan (1993[1978]) reports that in cultures that treat birth as a normal part of life, children pretend to have babies in very realistic ways. As almost all U.S. births occur in hospitals with few family members or friends attending the actual birth, U.S. women do not have this same level of first-hand knowledge about childbirth (Cole et al. 2019, Happel-Parkins and Azim 2015, Jordan

1993 [1978], Malacrida and Boulton 2014). As a result, Western women often have a romanticized account of childbirth (Cole et al. 2019, Happel-Parkins and Azim 2015,

Jordan 1993 [1978], Malacrida and Boulton 2014). In Malacrida and Boulton’s (2014) study of the use of birth plans, women frequently had little idea about how childbirth

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actually progresses, particularly in a hospital environment. Their participants often wanted a natural childbirth without medical intervention, but instead experienced multiple medical interventions during birth. Cole and colleagues’ (2019) analysis of online birth narratives discovered similar results in which women described medical interventions as unwanted, but found those interventions impossible to avoid. Clearly, the biomedical model affects U.S. women’s experiences with childbirth as women accept medical interventions because interventions are not offered as options. Crossley (2007), however, also partially blames women’s unrealistic expectations about birth on natural childbirth discourse. The natural childbirth model insists that women take responsibility and make their own choices. U.S. women, however, often do not feel they have control over the birth process as medical interventions are presented as necessary to protect maternal and fetal health (Cole et al. 2019, Crossley 2007, Happel-Parkins and Azim

2015, Jordan 1993 [1978], Malacrida and Boulton 2014). In addition, primiparous women may not feel confident enough about the childbirth process to resist medical interventions even if avoiding those interventions is their desire (Cole et al. 2019,

Crossley 2007, Happel-Parkins and Azim 2015, Jordan 1993 [1978], Malacrida and

Boulton 2014).

This lack of direct knowledge about pregnancy and childbirth leads to a greater need for primiparous women to consult sources for information about what to do and what not to do during pregnancy and childbirth before making decisions about their behaviors compared to multiparous women. (Browner and Press 1996, Root and Browner

2001, Sanders and Crozier 2018, Sayakhot and Carolan-Olah 2016, Song et al. 2012). In

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Root and Browner’s (2001) ethnographic study of U.S. pregnant women, multiparous participants regularly relied on their own bodies in determining what to do, while primiparous women sought out diverse sources of information regarding pregnancy before making a decision. In their review of seven publications, Sayakhot and Carolan-

Olah (2016) similarly found that multiparous women were less likely to seek online health information than primiparous women were. These studies mirror my results in showing that primiparous women sought out information from more sources than multiparous women. Little research, however, has been done to determine if there is a difference in the pattern of information gathering over time between primiparous and multiparous women. My study, therefore, adds to the literature by showing that not only do primiparous women gather information from more sources than multiparous women, but that this pattern extends further into pregnancy for primiparous women.

RQ3: In what ways does this information conflict?

The information participants received from all of these sources, however, competed and often conflicted (Cole et al. 2019, Johnson 2008, Lock 2001, Walsh 2010).

The majority of participants reported encountering conflicting information in the sources they consulted. Conflicting information mainly emerged from: 1) generational differences in ideas about the “best” behaviors during pregnancy and childbirth and 2) differing ideas from biomedical and natural childbirth models of pregnancy and childbirth. Cultural ideas about pregnancy and childbirth have shifted over time from women-supported homebirths to biomedical hospital events largely attended by male doctors until relatively recently as discussed above (Beckett 2005, Cosans 2004, Crossley 2007, Johnson 2008,

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Sargent and Gulbas 2011, Walsh 2010). Beckett (2005) reports that since the 1970’s, hospital birth became the norm across all U.S. demographic groups with approximately

90% of births occurring in hospitals. This is in contrast to most U.S. women giving birth at home attended by a midwife throughout the 19th century. With this shift towards defining pregnancy as a medical event, medical interventions became more common and cast as necessary (Beckett 2005). As an example, the Cesarean section (C-section) rate rose from 5% in 1970 to 32% in 2017 as C-sections are now often considered a safer alternative to vaginal birth (Martin et al. 2018, Molina et al. 2015). When C-sections became more commonplace, some U.S. women who desired control over the timing of birth offered by a C-section began requesting to schedule a C-section (Beckett 2005,

Molina et al. 2015). Several researchers, including biomedical professionals, have raised concerns about the current high C-section rate (Molina et al. 2015). As a result, biomedical recommendations now do not support elective C-sections and urge doctors to carefully consider other alternatives to a C-section delivery. These shifts in thinking about safety and risk regarding childbirth potentially result is variation in views about how pregnancy and childbirth should progress across generations (Beckett 2005, Sargent and Gulbas 2011). No studies of which I am aware, however, have ethnographically examined how changes in cultural ideas across generations have influenced the advice women receive about pregnancy and childbirth. My results fill this gap by showing that women frequently deal with conflicting information from women of different generations. Women in this study mentioned receiving conflicting information from their friends, mothers, and grandmothers due to these generational differences in cultural ideas

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of pregnancy and childbirth. They also often discussed the pressure they received from their mothers and grandmothers to follow behaviors that the women themselves felt were outdated.

Women in this study encountered conflicting information due to the competing cultural models of pregnancy and childbirth in the U.S. as well. Participants agreed that pregnancy and childbirth are natural processes that should not require medical intervention demonstrating the biopower exerted by the natural childbirth model (Cole et al. 2019, Coxon et al. 2014, Malacrida and Boulton 2014). In an examination of online birth narratives, Cole and colleagues (2019) also found that women preferred to avoid medical interventions citing that childbirth is a natural process. Cole and colleagues

(2019) attributed the belief in the naturalness of pregnancy and childbirth to a broader cultural idealization of natural childbirth originating with the natural childbirth movement in various Western cultures including the U.S. Drawing on Foucault’s disciplinary society, Malacrida and Boulton (2014) also discuss the disciplining qualities of the natural childbirth model after analyzing interviews with 22 women about their birth experiences. Most of the women in their study described “natural” birth as the ideal birth

(Malacrida and Boulton 2014). Throughout their interviews, Malacrida and Boulton’s

(2014) participants adhered to natural birth ideology by describing birth experiences without medical interventions and giving birth in an atmosphere that was conducive to natural labor. Despite similar beliefs among women in this study, however, all participants except one gave birth in a hospital and most used pain medications during the

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birth process mirroring national trends (Cole et al. 2019, Coxon et al. 2014, Malacrida and Boulton 2014).

In addition, in explaining why they chose to have their children in a hospital, participants in this study cited concerns about the health and safety of their children indicating that the hospital is the safer choice (Beckett 2005, Cole et al. 2019, Coxon et al. 2014, Happel-Parkins and Azim 2015, Malacrida and Boulton 2014). Again, analogous to my results, Cole and colleagues (2019) showed that despite their desire to avoid unwanted medical interventions, most women felt that those interventions were unavoidable during childbirth as their doctors told them the interventions were necessary.

Malacrida and Boulton (2014) similarly found the lived experiences of birth often involved extensive medical intervention contrary to their participants’ desires for a natural childbirth. Both of these studies as well as others reveal the biopower wielded by the biomedical model (Cole et al. 2019, Coxon et al. 2014, Happel-Parkins and Azim

2015, Malacrida and Boulton 2014). Having these competing models, therefore, increased the conflicting information women received as shown in other studies (Beckett

2005, Cole et al. 2019, Coxon et al. 2014, Happel-Parkins and Axim 2015, Malacrida and

Boulton 2014). Again, few studies examine how conflicting information women receive affects decisions about their behaviors during pregnancy (Browner and Press 1996, Root and Browner 2001, Song et al. 2012). Instead, studies about information gathering focus on decisions surrounding childbirth as most of the debate between the biomedical and natural childbirth models surround the process of childbirth (Beckett 2005, Cole et al.

2019, Coxon et al. 2014, Happel-Parkins and Axim 2015, Malacrida 2015). This study

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adds to the existing literature, therefore, by providing a more complete understanding of how conflicting information affects women’s decision-making throughout pregnancy and then into childbirth.

RQ3a: What effect does conflicting information have on pregnant women’s emotions and decision-making?

When they found conflicting information, most women reported feeling confused, anxious, or frustrated. Other women were not affected by conflicting information they encountered or reported that they did not encounter conflicting information. In interviews, participants who encountered conflicting information expressed a need to explore the topic further before making AK decisions. As such, they tended to seek out information from more sources before making a decision about their behaviors and childbirth plans compared to women who were not concerned about conflicting information. Women who were not affected by conflicting information frequently trusted sources they felt gave them the information they needed. In addition, women who reported anxiety due to conflicting information had difficulties making decisions about their behaviors and childbirth plans. Their confusion and anxiety made identifying the

“best” behaviors a more difficult proposition (Brauer 2016, Browner and Press 1996,

Happel-Parkins and Azim 2015, Miller and Shriver 2012, Sanders and Crozier 2018,

Song et al. 2012).

Song and colleagues (2012) contend that for pregnant women to be “good mothers” they must gather the expertise and knowledge to make the best choices for their children. When the participants in their study encountered conflicting information,

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particularly information that conflicted with their previously held beliefs, women sought out more information and had more issues making a decision. In their study of women considering a vaginal breech birth, Petrovska and colleagues (2017) found that conflicting information caused their participants a great deal of anxiety. In discussions with women, doctors highlighted the difficulties women experienced when they went against doctor’s recommendations even if women presented information that contradicted medical advice (Petrovska et al. 2017). In addition, a recent meta-synthesis of qualitative studies on how informal information sources influence pregnant women’s decision- making by Sanders and Crozier (2018) suggests conflicting information frequently has a detrimental effect on women’s emotional and mental states. Their study found that much of the disconnect between women’s lived experiences of birth and their expectations is due to the conflicting information they receive about birth (Sanders and Crozier 2018).

When women did not experience the childbirth they expected, they internalized blame causing stress and anxiety (Sanders and Crozier 2018). This study adds to the published literature by showing that women encounter conflicting information throughout their pregnancies about a variety of topics other than childbirth. As this conflicting information affects pregnant women’s emotions, understanding the scope of this issue is important for improving women’s pregnancy and childbirth experiences.

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RQ4: How do pregnant women make authoritative knowledge decisions about which practices to integrate into their daily lives and birth plans?

RQ4a: What information do women prioritize in making decisions about their behaviors during pregnancy and their childbirth plans?

RQ4b: Why do women prioritize some information over other information in their decision-making process?

In making AK decisions about behaviors during pregnancy and childbirth, women utilized one of three main strategies: gathering information first, following their previous personal health experience, or choosing the most convenient options. Women who gathered information first prioritized their healthcare provider’s advice over other sources of information, particularly for decisions deemed “medical” decisions such as which drugs to consume during pregnancy. Where to give birth was also treated as a “medical” decision. All except one participant gave birth in a hospital. In addition, only one of the participants who gave birth in a hospital considered a homebirth. The others never considered anything but a hospital birth revealing the prominence of the biomedical model. While the biomedical model dominated, women expressed openness or even a desire to have a “natural” childbirth with minimal to no medical intervention within the hospital setting (Cole et al. 2019, Happel-Parkins and Azim 2015, Johnson 2008).

Despite this desire, 85% of the participants used pain medications during childbirth.

When asked about their childbirth experiences, participants in this study generally felt the interventions they experienced were necessary at the time as their doctors and nurses had deemed them necessary. Much like Happel-Parkins and Azim’s (2015) findings, women

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found it difficult to have a “natural” childbirth even if they were interested as they tended to accept the biomedical definitions of pregnancy and childbirth presented by their doctors in making decisions about their pregnancy behaviors and childbirth plans (Cole et al. 2019, Coxon et al. 2014, Malacrida and Boulton 2014).

If participants felt that advice they received was inadequate or did not fit with their previously held health beliefs, women sought out more information from other sources before making an AK decision. Similar to other studies, while women prioritized biomedical advice, they did not accept it unilaterally (Lagan et al. 2010, Lazarus 1994).

In their study of internet use among pregnant women, Lagan and colleagues (2010) reported that 48.6% of their participants turned to the internet when they were dissatisfied with the information provided by their healthcare professionals. Their participants saw the internet as an easy way to get a second opinion about a topic (Lagan et al. 2010). The middle-class participants in Lazarus’ (1994) study also questioned biomedical advice.

One of participant described conspiring against her attending physician:

The attending physician wanted me to move to the delivery room [informant wanted to deliver in the labor room]. We had to conspire against her [the attending physician] – so we decided to tell the attending [physician] the birth happened too quickly [to move to the delivery room]. (Lazarus 1994: 38)

Lazarus (1994) concludes that middle-class women have a need to maintain control in pregnancy and childbirth, which sometimes leads them to disregard or even circumvent instructions from biomedical professionals. Lazarus (1994) emphasizes, though, that despite the women’s desire for control, they frequently willingly gave over control to their physicians, as the choice of physician was their main source of control. Again, as discussed above, the tendency of women in this study to seek out multiple sources before 214

making an AK decision shows the responsibility and pressure they feel to make the

“right” decisions (Brauer 2016, Happel-Parkins and Azim 2015, Hays, B. 1996, Miller and Shriver 2012, Sanders and Crozier 2018, Song et al. 2012).

This study also focuses on the experiences of women who self-identified as

“white” or “Caucasian.” I chose to limit the sample in this to this population because I wanted to minimize stress associated with racial discrimination. In addition, “white” women often have more choices in their pregnancy and childbirth behaviors, but they often are the focus of the cultural expectations generated by the biomedical and natural childbirth models. Recent research with women who identified as “black” or “African-

American,” on the other hand, reveals that biomedical professionals often make decisions for pregnant women of color as the professionals assume drug use or poor parenting skills

(Rosenthal and Lobel 2016, Rosenthal and Lobel 2011, Williams 2002). As such, pregnant women of other ethnicities/races may not be given the ability to make as many decisions during pregnancy and childbirth (Rosenthal and Lobel 2011, Williams 2002).

In addition, Rosenthal and Lobel (2011) concluded that abuses of black American women by the medical system due to unfavorable stereotypes about their sexuality and ability to mother was a source of stress for black American women. These additional factors in the decision-making process and their possible effect on pregnant women’s stress levels shows the variation in pregnant women’s experiences in the U.S.

Participants in this study who relied on their previous health experience often expressed less of a need to gather information from multiple sources. Instead, they relied on embodied knowledge about how their bodies worked and trusted in practices that

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protected their health in the past. While multiparous women relied on their previous personal health experience more frequently than primiparous women, some primiparous women, particularly those with confidence in “natural” alternatives to modern medicine, chose to follow their previous health practices.

As Sanders and Crozier (2018: 1) propose, “women do not enter pregnancy as empty vessels devoid of a conceptual framework.” Instead, many women in this study, even those pregnant with their first child, come into pregnancy with ideas about the best practices to protect their health. Since pregnancy and childbirth are new experiences for primiparous women, however, my results show that compared to multiparous women, primiparous women more often sought out information and struggled with AK decisions even if they relied on their embodied knowledge to focus their information seeking.

Multiparous women’s previous pregnancy and childbirth health experiences, however, reduced the need for them to make extensive AK decisions in their subsequent pregnancies as they had embodied knowledge that related directly to their current pregnancies (Browner and Press 1996, Root and Browner 2001). Coxon and colleagues

(2014) found a similar connection between previously held health beliefs and childbirth experiences. Although they did not separate their participants by parity, women in their study who chose to give birth outside of the hospital emphasized not only that birth was a natural process, but also the success of natural remedies they had used in the past (Coxon et al. 2014). In this study as in others, primiparous women’s inclination to choose

“natural” health behaviors during pregnancy that mirrored their beliefs in other areas of health shows the growing acceptance of “natural” medical solutions and the potential

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impact of the natural childbirth model (Cole et al. 2019, Coxon et al. 2014, Happel-

Parkins and Azim 2015, Malacrida and Boulton 2014). As more women see childbirth as natural, their desire for alternative birth settings increased (Cole et al. 2019, Coxon et al.

2014, Happel-Parkins and Azim 2015, Malacrida and Boulton 2014). Coxon and colleagues (2014) concluded, however, that the dominant biomedical model constrained women’s decisions about birth setting as even women who described birth as a natural process emphasized the riskiness of the childbirth process. In this study, women relied on their embodied knowledge about pregnancy to resist biomedical advice, but their decisions about childbirth still were constrained by biomedical doctrine.

Multiparous women in this study also were more likely to choose more convenient options partly because they were less concerned about choosing the “best” pregnancy/childbirth behaviors. Okah and Cai (2014) found that multiparous women were more likely to choose health-compromising behaviors in their large study of pregnant women. They suggest that women pregnant with a second child perceive a lack of consequences for their behaviors if they engaged in similar behaviors in their first pregnancies without adverse pregnancy and childbirth outcomes. Okah and Cai (2014), however, concentrate on behaviors such as alcohol consumption and smoking that potentially cause devastating consequences for the fetus. The authors report little ethnographic evidence to support their explanations. Results from this study expand on

Okah and Cai’s (2014) study by showing that multiparous women consult fewer sources and make fewer AK decisions overall, not just in health-compromising behaviors. In addition, drawing on ethnographic data, this study adds to Okah and Cai’s (2014)

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explanation for why women continue engaging in behaviors in their subsequent pregnancies that worked in their first pregnancies. Women in this study did not report engaging in behaviors that could severely compromise maternal and fetal health such as smoking or excessive drinking, but their reasoning for continuing behaviors from their previous pregnancies were similar to those found by Okah and Cai (2014). This study, therefore, expands on the findings of Okah and Cai (2014) by showing that multiparous women continue a wide variety of behaviors from their previous pregnancies, not just health-compromising behaviors. Women in this study also mentioned the success and/or lack of consequences from their behaviors in previous pregnancies as the main reason they did not feel a need to change their behaviors. As such, my results show the significant impact of previous pregnancy and childbirth-related experiences on women’s information gathering and AK decision-making. Understanding what factors influence women’s decision-making during pregnancy is essential to creating a strong relationship between women and their healthcare providers.

H1: Women who struggle more with authoritative knowledge decisions will have higher levels of self-reported stress, particularly pregnancy-specific anxiety.

In examining relationships between AK decision-making and self-reported stress,

I found several important differences between the groups I analyzed. In particular, when significant differences emerged between the comparison groups (primiparous vs. multiparous and women who reported anxiety due to conflicting information vs. those who did not report anxiety due to conflicting information), the group who made more AK decisions always had higher self-reported stress levels. These findings reveal a possible

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connection between AK decision-making and self-reported stress levels hinted at in other studies (Browner and Press 1996, Root and Browner 2001, Sanders and Crozier 2018,

Song et al. 2012) as well as supported by my ethnographic data as described above.

H1 via parity. As discussed earlier in this chapter, primiparous women have less personal experience with pregnancy and childbirth compared to multiparous women

(Davis-Floyd 2001, Jordan 1993[1978], Sayakhot and Carolan-Olah 2016, Song et al.

2012). In fact, primiparous women in the U.S. often have little advanced detailed knowledge about pregnancy prior to getting pregnancy as pregnancy and childbirth are not commonly discussed or witnessed by women who have not been pregnant (Davis-

Floyd 1990, Jordan 1993[1978], Luce et al. 2016, Sayakhot and Carolan-Olah 2016,

Song et al. 2012). As a result, primiparous women struggle more with AK decisions than multiparous women, particularly in the face of competing information (Browner and

Press 1996, Hays, B. 1996, Sanders and Crozier 2018, Song et al. 2012). Struggling more with AK decisions affects primiparous women’s choice of behaviors and how they feel about their behavioral choices (Browner and Press 1996, Hays, B. 1996, Sanders and

Crozier 2018, Song et al. 2012).

My findings that primiparous women practice more “healthy” behaviors than multiparous women illustrate how the decision-making process of primiparous women differs from multiparous women. These findings mirror previous studies, although little research exists to explain this result (Blankson et al. 1993, Browner and Press 1996, Ning et al. 2003, Okah and Cai 2014). For example, as discussed above, Okah and Cai (2014) found that multiparous women in health-compromising behaviors such as excessive

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drinking and smoking more often than primiparous women. Similarly, Ning and colleagues (2003) reported that multiparous women are less likely to participate in recreational physical activity during pregnancy compared to primiparous women. While

Okah and Cai (2014) mention that women becoming less concerned about their behaviors following a live birth, they can only speculate about the cause of this trend as their study, like similar studies, does not include ethnographic data (Blankson et al. 1993, Ning et al.

2003).

Browner and Press’ (1996) study, on the other hand, includes interview data from

158 pregnant women. They also found that multiparous women were less concerned about their behavior during subsequent pregnancies, but as their study focused on incorporation of biomedical advice; they did not explore this trend in detail. My interviews with primiparous and multiparous women help fill this gap. In my study, multiparous women also were less concerned with practicing “healthy” behaviors. In fact, many multiparous participants expressed that they were too concerned about choosing the

“right” behaviors in their first pregnancies. Multiparous women frequently mentioned that as their first pregnancies went well, they did not feel the need to adhere to strict

“health” behaviors in subsequent pregnancies. For example, multiparous participants felt more relaxed about eating what they wanted and exercising less because they did not believe that watching their diets closely and exercising more would have changed the birth outcomes in their first pregnancies.

In terms of stress, my results show that women who have less personal experience with pregnancy/childbirth, i.e. primiparous women, had higher levels of pregnancy-

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specific anxiety, but not higher levels of self-reported general stress in the first trimester only. As discussed in Chapter 6, women in this study began gathering information in the first trimester in preparation for the AK decisions they would have to make about their behaviors throughout their pregnancies and childbirths. Overall, primiparous women consulted more sources than multiparous women and were more adversely affected by conflicting information. In addition, similar to findings by other researchers, primiparous participants often felt overwhelmed and anxious about their pregnancies in their first trimester as they adjusted to the changes in their bodies, unpleasant pregnancy symptoms, and becoming a mother (Browner and Press 1996, Root and Browner 2001). One participant from Browner and Press’ (1996: 144) study described her experiences as a first-time mother in this way:

“Because...[in] your first couple of months you don’t know what’s going on...getting your blood labs [to see] if you are diabetic [and] to check all the diseases that baby could carry. And well, there’s so much information and pamphlets that they’re willing to give [you]...[And also] if I’m feeling weird, like I get a kick and it feels really warm after the kick, but only in one spot...to me, it’s like is that normal?”

Primiparous women in this study expressed similar feelings about their pregnancies. The higher levels of pregnancy-specific anxiety, therefore, may reflect these feelings and again show the impact of removing pregnancy/childbirth from everyday life (Davis-Floyd

1990, Jordan 1993[1978], Luce et al. 2016, Sayakhot and Carolan-Olah 2016, Song et al.

2012).

In the second trimester, primiparous women expressed more positive feelings about the changes that accompany pregnancy compared to the first trimester. As a result, they reported less pregnancy-specific anxiety and self-reported general stress. According 221

to my interview data, these positive feelings resulted from three main sources: a reduction in uncomfortable pregnancy symptoms, a growing acceptance of their new role as mother, and less concern about “right” behaviors. Self-reported general stress and pregnancy-specific anxiety, therefore, may have dropped due to primiparous women’s adjustment to pregnancy. As they have experience with pregnancy, multiparous women knew what to expect from pregnancy and motherhood was not a new role for them

(Browner and Press 1996, Hays 1996, Sanders and Crozier 2018, Song et al. 2012). They, therefore, were better able to keep their general self-reported stress levels steady between trimesters. My longitudinal analysis of stress levels further supports my conclusion that experience affects maternal stress level during pregnancy as primiparous and multiparous women showed significantly different patterns of change in PSAS anxiety sub-scores.

These finding indicate that dealing with uncertainty surrounding pregnancy and childbirth due to less personal experience (i.e. primiparous women) impacts women’s self-reported stress levels, particularly early in pregnancy. While primiparous women report feeling anxious, stressed, and uncertain about their pregnancies more often than multiparous women in the published literature, no other studies of which I am aware attempted to connect those reports with an established scale of self-reported stress

(Browner and Press 1996, Root and Browner 2001, Song et al. 2012). Browner and Press

(1996), for example, describe how their participants felt that the information they received during pregnancy was confusing, particularly for primiparous women. Their participants also discuss instances in which conflicting information caused them anxiety and confusion about how to proceed. While Browner and Press (1996) note that

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multiparous women were less concerned about the conflicting information they received, they did not administer a self-reported stress scale to test perceived stress levels. As such, though their ethnographic results and the results of similar studies (Root and Browner

2001, Song et al. 2012) support my conclusions, the addition of self-reported stress scales in this study allowed me to show primiparous women have more pregnancy-specific anxiety, at least in the first trimester. Not only does this addition to the literature make future comparisons between studies easier, it also connects women’s experiences with measures of self-reported stress that have been used in studies of self-reported stress and adverse birth outcomes (Buss et al. 2009, Dunkel Schetter and Glynn 2011, Kramer et al.

2009, Lobel et al. 2008, Roesch et al. 2004).

In addition, these results again suggest that cultural ideas and practices in the U.S. surrounding pregnancy may influence pregnant women’s stress levels as they try to navigate a new experience in their lives (Browner and Press 1996, Hays, B. 1996,

Sanders and Crozier 2018, Song et al. 2012). Song and colleagues (2012) discussion of the “informed patient” and “good mother” ideals demonstrate the connection between women’s experienced stress levels and cultural expectations. According to Song and colleagues (2012), pregnant women must become consumer-oriented “informed patients” by gathering a great deal of information about the “best” behaviors to protect themselves and their children before making decisions. Becoming “informed patients” is one of the main ways women in the U.S. first establish themselves as “good mothers” (Song et al.

2012). “Good mothers” spend abundant time, energy, and resources on their children

(Song et al. 2012). Women begin the process of being “good mothers” before they give

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birth by gathering information and making AK decisions about the “best” behaviors

(Malacrida and Boulton 2014, Hays, B. 1996, Song et al. 2012). Since primiparous women have little experience with pregnancy and childbirth, they may not have dealt with these two intertwining ideals on a personal level previously (Malacrida and Boulton

2014, Song et al. 2012). As such, they gather more information and struggle more with

AK decisions than multiparous women as discussed in Chapter 6 and earlier in this chapter. While my results regarding connections between AK decision-making and self- reported stress measured via established surveys were mixed, my ethnographic results clearly show that women report anxiety, frustration, and confusion when faced with conflicting information because this information makes decision-making more difficult.

My ethnographic data, therefore, support the hypothesis that women who struggle more with AK decisions have higher self-reported stress levels even if established surveys do not always show the same results.

H1 via anxiety due to conflicting information. Women who reported anxiety due to conflicting information had significantly higher levels of pregnancy-specific anxiety in the first trimester only and significantly higher levels of self-reported general stress in the second trimester only compared to women who did not report anxiety due to conflicting information. Overall, more primiparous women reported anxiety from conflicting information than multiparous women. This shows women are more likely to feel anxiety when faced with conflicting information if they lack experience with pregnancy/ childbirth, which expands on findings discussed earlier. Having more primiparous women in the group who reported anxiety from conflicting information could have

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contributed to the higher self-reported stress levels for women who reported anxiety from conflicting information. The significant differences that emerged in this set of comparison groups, however, were different from the significant differences that emerged when comparing primiparous and multiparous women. In addition, as I am exploring the relationships between struggling with AK decision-making and self-reported stress levels in this section, the overlap between the two sets of comparison groups is less important as both primiparous women and women who reported anxiety from conflicting information struggle more with AK decision-making.

Women who reported anxiety due to conflicting information had higher PSAS anxiety sub-scores. Interviews suggest women feel anxious in the face of conflicting information, as they are more uncertain about which behaviors are the “right” behaviors for themselves and their children. As discussed above, women who are less concerned about conflicting information generally struggle less with AK decision-making (Blankson et al. 1993, Ning et al. 2003, Okah and Cai 2014). The lack of significant difference between the two groups in PSAS concerns sub-scores also suggests that women generally are anxious about doing the “right” thing to remain healthy rather than directly concerned about pregnancy or childbirth complications.

As discussed in Chapter 6 and earlier in this chapter, pregnant women equate making the “right” decisions with being “good” mothers (Brauer 2016, Happel-Parkins and Azim 2015, Hays, B. 1996, Miller and Shriver 2012, Sanders and Crozier 2018, Song et al. 2012). Their anxiety, therefore, potentially stems from their inability to fulfill cultural definitions of what it means to be a “good” mother (Happel-Parkins and Azim

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2015, Miller and Shriver 2012, Sanders and Crozier 2018). Again, while examining relationships between AK decision-making and self-reported stress measured via established surveys showed mixed results, my ethnographic data supports H1. The established stress surveys, therefore, may not always capture women’s anxiety about pregnancy and childbirth, particularly the anxiety they feel surrounding their decision- making processes.

H2: Women who struggle more with authoritative knowledge decisions will have higher cortisol levels at each timepoint and steeper cortisol trajectories across pregnancy.

Hair cortisol levels showed too few significant results to fully support my second hypothesis that more AK decision making is related to higher hair cortisol levels and steeper trajectories. The one significant result, namely that primiparous women had higher hair cortisol levels in the first trimester than multiparous women, supports the findings I described above in self-reported stress levels. In other words, both in survey responses and interviews, primiparous women consistently reported more anxiety and stress than multiparous women demonstrating the greater impact cultural expectations have on primiparous women due to their lack of experience with pregnancy and childbirth (Browner and Press 1996, Root and Browner 2001, Song et al. 2012).

While few significant results emerged for hair cortisol levels, my sample had low overall levels with little change over time. Contrary to previous research results, there was no significant increase in hair cortisol levels across pregnancy (Glynn et al. 2007,

Kane et al. 2014, Mastorakos and Ilias 2003, Meulenberg and Hofman 1990). Research using blood cortisol levels typically report a 4-fold increase in cortisol levels across

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pregnancy, while research using salivary cortisol levels report a 2-fold increase in cortisol levels across pregnancy (Buss et al. 2009, Glynn et al. 2007, Kane et al. 2014,

Mastorakos and Ilias 2003, Meulenberg and Hofman 1990). Published literature generally attributes the rise in cortisol over the course of pregnancy on cortisol released from the placenta in preparation for birth. Samples in most of the studies that utilized measures of cortisol, however, are disproportionately from lower income women. While some studies such as the one performed by Buss and colleagues (2009) have a sample of mixed SES individuals, the majority of the sample still comes from lower SES categories. There are no studies of which I am aware that measure cortisol (blood, saliva, or hair) in a sample of middle to upper-SES women exclusively. In addition, Buss and colleagues (2009) discuss possible methodological concerns with salivary cortisol studies, as there is variation in salivary cortisol concentrations throughout the day, which is not always controlled for in studies of salivary cortisol in pregnancy.

I chose hair cortisol as a physiological measure of stress partly to avoid the methodological difficulties associated with salivary cortisol. I also wanted to capture cortisol level over the course of pregnancy. As hair cortisol gives a mean cortisol level for the previous three months, I felt hair cortisol would give a more complete picture of cortisol level throughout pregnancy. Few studies, however, have examined longitudinal patterns of hair cortisol levels (Kirschbaum et al. 2008). A study by Kirschbaum and colleagues (2008) of mothers with neonates, mothers with toddlers, and control women showed significantly higher hair cortisol levels among mother with neonates. These

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increased levels are attributed to increases in cortisol levels during pregnancy as early postpartum hair cortisol analysis captures cortisol levels in the third trimester.

My results contradict the idea that a significant increase in cortisol happens in every human pregnancy. Instead, perhaps because my sample had low overall chronic stress levels, my results reveal little change in hair cortisol levels over time. As my sample consisted of women in middle to upper-SES categories, they did not have poverty-related stressors. This study, therefore, adds to the existing literature by emphasizing the need to examine multiple, varied groups before making generalizations about how cortisol functions in human pregnancy. Since hair cortisol gives a mean cortisol level over a three-month period, small increases over time, particularly if the increase lasted a short period, may be difficult to perceive. Further research is necessary, therefore, to determine if a significant rise in blood and saliva cortisol levels occur in other low-chronic-stress populations.

Pushing anthropological theory forward

This study contributes to anthropological theory in two ways. First, it explores negotiations of authoritative knowledge (AK) from two cultural models of pregnancy and childbirth, biomedical and natural childbirth. Drawing from Foucault’s concept of biopower, I explore how these two models attempt to control and regulate women’s bodies by insisting that women take full responsibility for their health and the health of their children (Foucault 2008, Mansfield 2012). While these two models demand different ways of taking responsibility, they both exert biopower through their insistence that taking responsibility is the only way to ensure their health and the health of their

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children (Walsh 2010). As such, women come to regulate their own bodies in accordance with these powerful cultural models (Foucault 2008, Mansfield 2012, Walsh 2010).

This emphasis on responsibility also reflects cultural ideals championed in the neoliberal model of health. The neoliberal model of health posits that people should exercise their self-discipline in making decisions that protect their health for the good of the population as a whole (Foucault 2008, Mansfield 2012). The neoliberal model of health highlights importance of authoritative knowledge as well since exercising self- discipline requires an understanding what authorities consider “appropriate” behaviors

(Foucault 2008, Mansfield 2012, Song et al. 2012, Walsh 2010).

With this study, I help to establish the cultural expectations surrounding pregnancy and childbirth. Traditional discussions of the biopower in models of pregnancy and childbirth concentrate on governance through the AK of the biomedical community.

This study extends that literature to establish the biopower exerted by the natural childbirth model. Since the natural childbirth model emerged as resistance to the over- medicalization of pregnancy and childbirth, most research has focused on how the natural childbirth can improve pregnancy and childbirth outcomes and experiences (Beckett

2005, Davis-Floyd 2001, Hazen 2017, Jordan 1993[1978], Lent 1999, Mansfield 2008).

Little research, however, has examined the potential adverse impact of the natural childbirth model (Happel-Parkins and Azim 2015, Malacrida and Boulton 2014, Walsh

2010). Further, no research of which I am aware has explored how the natural childbirth model exerts biopower over women, just as the biomedical model does. Having two models exerting biopower over women within the same society increases the likelihood

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that women will be affected by conflicting information from these models. In addition, my interviews with pregnant women show the influence of the neoliberal model of health in the individual responsibility women feel to be “informed patients” and their need to practice self-discipline to be “good mothers.” (Foucault 2008, Mansfield 2012, Scheper-

Hughes and Lock 1987, Song et al. 2012).

I also show how cultural expectations are internalized by women during this process by exploring the interaction between macro-, intermediate, and micro-level social factors. Most studies of health ignore the potential impact of cultural expectations on health-related processes (Baer 1995, Buss et al. 2009, Glynn et al. 2008, Kalra et al.

2007, Kane et al. 2014, Nepomnaschy et al. 2007, Pike 2005, Roesch et al. 2004. Singer

1996, Singer and Baer 1995). In investigating how pregnant women make AK decisions about which information to prioritize in the midst of conflicting information from these two models and other sources, this study advances discussions of how societal expectations become internalized by linking AK decision making and women’s self- reported stress levels.

Second, this project uses a biocultural approach to show that there may be physiological effects of internalizing societal expectations. This highlights the role of culture in human biology (Dufour 2006, Goodman and Leatherman 1998, Wiley and

Cullin 2016). Studies on the physiological consequences of maternal stress during pregnancy frequently ignore the influence of societal expectations on the maternal stress response, while research investigating the influence of societal expectations on women’s experiences seldom considers the physiological outcome for maternal and fetal health

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(Buss et al. 2009, Dole et al. 2003, Kramer et al. 2009, Lobel et al. 2008, Nepomnaschy et al. 2007, Pike 2005, Roesch et al. 2004). This study helps fill an important gap in the anthropological literature by demonstrating a connection between cultural beliefs and stress responses creating a more holistic picture of human reactions during pregnancy.

Practical implications

While pregnancy and childbirth are biological processes, pregnancy and childbirth experiences are culturally constructed. In the U.S., the two main models of pregnancy and childbirth (biomedical and natural childbirth) both maintain that their tenets will help women achieve the safest pregnancy and birth experiences. These discourses combined with generational differences in ideas about pregnancy and childbirth produce conflicting information for pregnant women in the U.S. to consider. The polarizing nature of these two models place women in the uncomfortable and anxiety-producing position of attempting to fulfill competing cultural expectations.

To improve women’s pregnancy and childbirth experiences, however, proponents of both models need to emphasize women’s choices in a way that does not suggest that ignoring their advice will be catastrophic for women and their children. In other words, proponents of both models need to be more aware of the way choices are presented. In fact, all of the individuals in women’s lives should be more careful about how advice is offered. Overall, women need more support for the wide range of decisions they can make about pregnancy and childbirth behaviors. Acknowledging that there are many ways to be pregnant and to give birth, just as there are many ways to parent, will help women feel less guilt and more peace about the decisions they make. Additionally,

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reducing women’s anxiety about their decisions during pregnancy and childbirth likely will decrease women’s pregnancy-specific anxiety and possibly physiological stress, both documented risk factors for preterm birth and other adverse birth outcomes.

Limitations

As I recruited participants from a single geographic location and limited my sample by several factors, my results are not necessarily representative of women’s decision-making and stress responses in the national population (Rosenthal and Lobel

2016, Rosenthal and Lobel 2011, Williams 2002). Specifically, my sample was restricted to women who identified as “white” or “Caucasian” and of middle to upper socioeconomic status to control for other potential stressors. This sample, however, may not have the same experiences in decision-making and stress as women of other ethnicities/races and/or other socioeconomic statuses (Rosenthal and Lobel 2016,

Rosenthal and Lobel 2011, Williams 2002), which limits my ability to generalize my results. My results, however, show the potential impact of cultural expectations on women’s emotions and physiology, which can be expanded to other groups with careful consideration of the cultural expectations that apply to each group.

I also had difficulties with recruitment resulting in a smaller sample size (n=47) than originally planned (n=60). Despite the extensive and varied recruitment strategies described above, I had problems finding women willing to participate who fit my inclusion criteria. I expanded my inclusion criteria in an attempt to find more participants, but my final sample size of 47 participants was below the 60 participants I needed for all of my statistical analyses. In particular, finding significant differences

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between my comparison groups was more difficult with a smaller sample size. In addition, the limited sample size for first trimester data (n=25) compared to the other trimesters (n=47) made longitudinal comparisons more problematic.

Additionally, Columbus, Ohio lacks birth centers, a facility that offers a more home-like setting for birth and frequently gives women more freedom in choosing their own strategies to handle the pain of childbirth. Ohio also has no regulation and licensing procedures for non-nurse midwives. Women in my study site, therefore, had fewer options for birth location and fewer licensed options for birth attendant. As such, women in Columbus may be less likely to choose to give birth outside of the standard hospital setting because they are uncomfortable with the choices available. On the other hand, the

OSU Wexner Medical Center regularly has nurse-midwives attending births, which makes choosing a midwife over an obstetrician more acceptable. The midwives available, however, were nurses before they were midwives and generally adhered to biomedical tenets.

Finally, while some correlational relationships emerged between my quantitative variables, I was not able to determine causal relationships with statistical analyses. My ethnographic methods, however, provided a rich qualitative dataset. With this dataset, I was able to show clear relationships between self-reported stress, conflicting information, and AK decision-making. Exploring women’s experiences with qualitative methods, therefore, allowed me to demonstrate causality even when these connections were not definitively established with existing self-reported stress surveys.

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Conclusion

The goal of this study was to understand how cultural expectations of motherhood affect women’s information gathering, decision-making, and self-reported and physiological stress levels during pregnancy. This study showed that cultural expectations from many sources influence women’s information gathering and decision- making behaviors, particularly for women with less pregnancy-specific experience and/or women who encounter more conflicting information. In addition, cultural expectations also increase women’s anxiety and stress surrounding their pregnancies as they worry about making the “right” decisions for themselves and their children. While this study could not show that these concerns influence women’s physiological stress levels, I did find overall low hair cortisol levels with little change over time. The published literature indicates cortisol levels increase significantly during pregnancy. This contradiction highlights the importance of examining human variation before making generalizations about physiological processes. This study also shows the importance of using a biocultural approach to understand a culturally constructed biological process such as pregnancy and childbirth. Using an anthropological perspective, therefore, enhances our ability to understand both the cultural and physiological aspects of these processes by examining their interaction.

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Appendix A: Messaging Survey

Participant ID: Date: Visit #: 1. To whom do you look for information or advice about pregnancy and childbirth? Mark all that apply. ○ Friends ○ Spouse/Partner ○ Mother ○ Grandmother ○ Other female relatives ○ Father ○ Other male relatives ○ Obstetrician ○ Midwife ○ Other medical professionals ○ I rely on someone who does not fit into these categories 2. If you rely on someone who does not fit the above categories, what is your relationship with this person?

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3. How does the information you receive from these people make you feel? Mark all that apply. ○ Reassured ○ Anxious ○ Concerned ○ Lucky ○ Excited ○ Upset ○ Afraid ○ Pleased ○ Confident ○ Confused 4. Whose advice gives you the most negative feelings? 5. Please describe the negative feelings you get from this person’s advice. 6. Whose advice gives you the most positive feelings? 7. Please describe the positive feelings you get from this person’s advice. 8. Aside from people, where else do you look for information regarding pregnancy and childbirth? Mark all that apply. ○ Books ○ Internet sites for organizations ○ Blogs ○ Message boards ○ Pamphlets ○ Magazines ○ Written information given to you by medical professionals

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○ I look for information in another source that does not fit into these categories 9. If you use a source that does not fit the above categories, what is this information source? 10. How does the information you receive from these sources make you feel? Mark all that apply. ○ Reassured ○ Anxious ○ Concerned ○ Lucky ○ Excited ○ Upset ○ Afraid ○ Pleased ○ Confident ○ Confused 11. Does the information you received about pregnancy and childbirth from all of these sources agree? Please explain. 12. If the information does not agree, how does the conflicting information you receive make you feel? 13. Have you changed your diet since you became pregnant? ○ Yes ○ No 14. [If yes] Why did you make these changes? 15. Have you changed your physical activities since you became pregnant? ○ Yes ○ No 16. [If yes] Why did you make these changes? 17. Have you changed your use of any substances since you became pregnant (probes: alcohol, drugs [prescription, other-the-counter, illegal], caffeine, sugar, sugar substitutes, chocolate, nicotine, beauty products and treatments)? ○ Yes ○ No 257

18. [If yes] Why did you make these changes? 19. Have you purposefully changed your sleeping habits since you became pregnant? ○ Yes ○ No 20. [If yes] Why did you make these changes? 21. Have you changed your sexual habits since you became pregnant? ○ Yes ○ No 22. [If yes] Why did you make these changes? 23. Have your work and personal relationships changed since you became pregnant? ○ Yes ○ No 24. [If yes] Why have these changes occurred? 25. Are you worried about the health of your baby? ○ Yes ○ No 26. If yes, why are you worried about your baby’s health? 27. Are you worried about what will happen during labor and delivery? ○ Yes ○ No 28. If yes, why are you worried about what will happen during labor and delivery? 29. Do you think your worrying is having an effect on the baby? ○ Yes ○ No 30. Why or why not do you think your worrying is having an effect on the baby? 31. What are the most important characteristics you looked for when choosing your healthcare provider for this pregnancy? 32. Can prenatal care ever cause problems for pregnant women and/or their babies? ○ Yes ○ No 33. [If yes] How? 34. What kinds of expectations do you have for your pregnancy? 35. Describe your ideal childbirth experience.

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36. Indicate if you agree or disagree with the following statements about pregnancy and childbirth. a. Healthcare providers always should consider women’s preferences during labor and delivery. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

b. The woman’s preferences are more important than the healthcare provider’s preferences during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

c. Childbirth should make women feel empowered. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

d. Women should seek information about labor and delivery options from multiple sources other than their healthcare provider. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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e. The healthcare provider frequently is not a woman’s best source of information on pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree f. Women should independently gather information about how to maintain a healthy pregnancy from multiple sources other than their healthcare provider. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree g. An unplanned pregnancy is more likely to result in pregnancy and labor complications. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree h. A good healthcare provider is always responsive to a woman’s preferences during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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i. A woman’s physical health is more important than her mental health during pregnancy. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree j. Having a healthy baby is always the most important factor for a good childbirth experience. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree k. Pregnancy and childbirth are natural processes. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree l. Giving birth in a hospital creates problems for many women. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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m. Most women can give birth safely at home. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree n. Medical intervention during childbirth such as induction of labor and artificial rupture of women’s membranes frequently put mother and infant at higher risk of injury. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree o. Women need to learn how to give birth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree p. Pregnancy and childbirth require frequent medical supervision such as doctor’s visits, ultrasounds, and blood tests. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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q. Feeling ignored and/or powerless always leads to a bad childbirth experience for the mother. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree r. Immediate bonding with baby is an essential component of a good childbirth experience. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree s. Long, painful labor always creates a bad childbirth experience. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree t. A good childbirth experience leads to a more confident mother. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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u. Most women should give birth in a hospital or birth center.

○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree v. Women should trust their healthcare providers. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree w. A woman’s emotions have a major impact on her physical health during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree x. Healthcare providers frequently have to decide what is best for women during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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y. Following the healthcare provider’s advice is the most important responsibility a woman has during pregnancy. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree z. Labor and delivery are risky for mother and baby. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree aa. A pregnant woman should not be in pain during her labor. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree bb. The healthcare provider should worry more about the baby than the mother. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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cc. A woman’s intuition is more important than the healthcare provider’s advice during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree dd. The healthcare provider should trust the mother during pregnancy and childbirth. ○ Very Strongly Disagree ○ Strongly Disagree ○ Mildly Disagree ○ Neutral ○ Mildly Agree ○ Strongly Agree ○ Very Strongly Agree

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Appendix B: Interview Script

1. How have you been feeling these days?

a. Additional probe: Have you changed anything to make yourself feel

better?

2. Are there ways that being pregnant has changed your daily life?

a. Additional probe: Why have those things changed?

3. How comfortable are you making decisions about your pregnancy and childbirth

plans?

a. Additional probe: Are you struggling with any decisions right now?

b. Additional probe: How do you work through a decision when you are

struggling?

4. What types of decisions are you more comfortable making?

a. Why are you more comfortable making these types of decisions?

5. How do you make decisions regarding your behavior during pregnancy and

childbirth?

a. Additional probe: Tell me about making a decision regarding your

pregnancy or childbirth plans.

6. What decisions have you made and then later changed?

a. Why did you change this decision? 267

7. Who do you go to with questions or concerns about your pregnancy and childbirth

plans?

a. Additional probe: Why do you go to those individuals with your

questions?

8. Where else do you search for information?

9. About what kinds of things do you seek information?

a. Why do you want information on these things?

b. What do you think of the information you have found on these subjects?

10. How often do you seek out information from these sources?

11. Does the information from these sources agree?

12. Does anyone give you advice you have not requested?

a. [If yes] who are these people?

b. What do you think of the advice each person gives you?

13. Do you discuss information you obtained from other sources with your nurse,

doctor, or midwife? Why or why not?

14. What expectations do you have for your pregnancy and childbirth experience?

a. From where do you think your expectations for your pregnancy and

childbirth experience come?

b. Why do you have these expectations?

15. Which things about your pregnancy and your child’s birth are most important to

you?

a. Why are those things important?

268

16. What things worry you about pregnancy and childbirth?

a. Why are these things of concern to you?

269