Stress and Coping in First Pregnancy: Couple-Family Physician Interaction Penny Williamson, ScD, and Eugenia C. English, MD Seattle, W ashington First pregnancy and childbirth produce life changes and re­ quire adaptation. This pilot study examined the role of the family physician in caring for nine couples during first preg­ nancy through the postpartum period. Interviews of individu­ als and couples were conducted to evaluate their support, stresses, and coping styles. Concurrently, physicians were in­ terviewed for their knowledge of these dimensions. Interac­ tions between physicians and couples were observed in third trimester and at labor and delivery. Each of the participants perceived predelivery stresses relat­ ing to the pregnancy and to concomitant life changes. Emo­ tional and technical support was high; only two of the nine husbands felt a marked lack of emotional support from any source. All women felt a high level of support. While preg­ nancy related concerns and support were perceived by all physicians, general stresses and sources of emotional support were infrequently known. Significantly more was known about the women than their husbands. Attention to psychosocial is­ sues appeared to depend on physician style of interaction with the couple. When recognized, stresses were reduced by pro­ vision of information, discussion, and reassurance. First pregnancy is a time of major change, rep­ effects of a stable, supportive husband.8 In con­ resenting a transition from being a couple to being trast, Liebenberg reviewed the range of stresses parents.1 While pregnancy has been described as a reported by expectant fathers.9 The value of social time of unusual well-being,2 it also has been char­ support has been shown by Sussman, who de­ acterized as a “maturational crisis” akin to pu­ scribed the mutual aid provided by family and ex­ berty and menopause with concomitant psycho­ tended networks despite geographic and social logical disturbance3 as well as a time of “person­ mobility.10 The importance of network support for ality crisis.”4 Various observations have linked maintenance of an individual’s psychological well­ environmental stresses and negative attitudes in being in an urban environment was shown by pregnancy with emotional and physical difficulties Kleiner and Parker.11 Other studies have shown during that time.5'7 Cohen described the positive the buffering support of family, kin, and friend networks in mediating stressful situations.1215 In an outcome study of primipara, Nuckolls et al From the Department of Family Medicine, School of Medi­ cine, University of Washington, Seattle, Washington. Re­ showed social support to be a significant protec­ quests for reprints should be addressed to Dr. Penny Wil­ tive factor in the presence of stressful circum- liamson, Department of Family Medicine RF-30, School of Medicine, University of Washington, Seattle, WA 98195. stan ce.16 Since the physician often represents a 0094-3509/81/110629-07$01.75 ® 1981 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5: 629-635, 1981 629 STRESS AND COPING significant figure in this transition time, it is impor­ to the pregnancy, labor, delivery, and future par­ tant to examine his or her functional role. In an enting, and expected and perceived role of the analysis of physician-patient interaction during family physician. pregnancy, Danziger suggested that ascertaining First Physician Interview. This session explored medical expertise during the interaction process the physician’s knowledge of life stresses and sup­ influenced the outcome.17 ports for both partners and his knowledge of their This pilot study examined the nature of support concerns related to pregnancy as well as his per­ and stresses experienced by nine couples from the ception o f their expectation o f his role in the preg­ third trimester of first pregnancy through the ini­ nancy. tial eight weeks of parenthood. It focused particu­ Couple Interview (near labor and delivery): This larly on the effectiveness of the family physician, interview explored additional stresses, supports, not only in medical “technical” skill, but espe­ and concerns at the later part of pregnancy, cou­ cially for his ability to assess the need for and to ple’s reactions to first interview, couple’s style of provide emotional support, both to the childbearer relating to each other and to the interviewer, and and to her partner in this unique period of life. couple’s reactions to their previous clinic visit and to the pregnancy. Second Physician Interview (near labor and de­ livery): This interview was an exploration of the physician’s knowledge of new concerns, stresses, or any changes in support for either member of the Methods couple as well as changes in his relationship to Nine couple volunteers were recruited for study either husband or wife. from the University of Washington Family Medi­ Observation of Physician with the Couple: This cal Center obstetric population. Twelve couples took place primarily to observe how the physician were approached to obtain the nine participants. interacted with each member of the couple. The following criteria were satisfied: Observation of Labor and Delivery. This provided 1. Informed consent of both members of the cou­ an opportunity to observe the interactions be­ ple and their physician tween each couple as well as those of the physi­ 2. Couple married or living together cian and other support staff with the wife and the 3. First child for both partners husband. Included were reactions to unexpected 4. Entry into the study in the third trimester of procedures or delays. pregnancy Final Participant Interview (approximately eight Data were collected as follows: weeks postpartum): This interview reviewed the 1. Individual interviews of wife, husband, and labor and delivery process stresses (eg, the influ­ physician upon entry to the study ence of the addition of the baby) and coping of 2. Observation of the couple with their physician each member of the couple. Individual partici­ at a routine prenatal visit using a one-way mirror pants also stated their perception of the meaning 3. Couple interviews immediately after first ob­ of having a child as well as future expectations of servation their physicians. 4. Physician interview immediately after first ob­ Final Physician Interview (eight weeks postpar­ servation tum): Similar issues were explored from the phy­ 5. Observation of labor and delivery sician’s point of view to ascertain congruence of 6. Individual interviews of husband, wife, and expectations and the physician’s knowledge of physician after an eight-week postpartum visit. stresses and coping in the couple. First Participant Interview (third trimester): This Semistructured interview formats included five- interview included demographic data on the family point scaling as well as open ended questions.* of origin (including parenting styles, affection, and The same investigator interviewed the same discipline), birth order of participants, recent and member of the couple in each of the individual anticipated life changes and stresses, availability and means of emotional and practical support, background information and concerns pertaining *AII forms available from the authors upon request. 630 THE JOURNAL OF FAMILY PRACTICE, VOL. 13, NO. 5, 1981 S T R E S S AND COPING interviews, and each investigator interviewed an 1. Types, degree, and timing of stresses approximately equal number of men and women to 2. The perceived need for support distribute any error that might be due to the inter­ 3. The couple’s preparation for coping with this viewer. Charts were reviewed at the outset of each life change couple’s involvement, and they provided informa­ 4. The physician’s management of labor, delivery, tion on medical risks and special wishes of the and the puerperium in conjunction with his knowl­ couple regarding birth plans. edge of the psychosocial dimensions of pregnancy Because this was a small study and because the for each couple authors participate as regular members of the Fam­ 5. Estimation of unmet emotional or medical ily Medical Center, their involvement was close. needs For example, one of the authors is a family physi­ 6. Observed changes in the relationship of the cian (ECE) and when present as an observer of couple to their physician throughout the study. labor and delivery, she also supervised the resi­ dent physician. While this precluded maximal ob­ jectivity, it permitted the investigators increased rapport with couples and freer exchange of infor­ mation, which in itself served as an intervention Results (see Discussion). For the couples in this study, pregnancy was All interviews were tape recorded. Typed tran­ but one of a cluster of general life changes, some scripts were made of the first participant inter­ of which were perceived as stressful by husband views. Abbreviated transcripts of the remaining and/or wife. Issues which surfaced included health taped interviews were made using the interview concerns (other than pregnancy), financial con­ forms as guides to code answers to each question. cerns, recent geographic moves, job changes, per­ The tape recorded notes made during observations ceptions of isolation from spouse, concerns relat­ of the physician and couple interviews, and during ing to new roles, cultural issues, and difficulties labor and delivery, were transcribed. with parents. Pregnancy itself raised predictable Content analysis was conducted by compiling questions and concerns for both husbands and information from all transcripts according to major wives, including stress if the pregnancy was un­ categories for each participant and physician. planned, the normalcy of the fetus (ongoing con­ These categories included the following areas: cerns regarding diet and drugs), fear of pain during 1. Major stresses and life changes perceived by labor and delivery, apprehension about complica­ each individual tions during labor and delivery, a desire to be ac­ 2. Major perceived sources of support tively involved in all facets of management, and 3. Pertinent background information and relation­ pregnancy related sexual concerns.