MATERNAL ANXIETY, SOMATIC SYMPTOMS, MARITAL ADJUSTMENT,

AND FAMILY RELATIONSHIPS IN SECOND PREGNANCY

byLucy Newmark Sammons

B.S., Stanford University, l973M.S., University of California, San Francisco, l979

DISSERTATION

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF NURSING SCIENCE

in the

GRADUATE DIVISION

of the

UNIVERSITY OF CALIFORNIA

San Francisco

Approved:º

Committee in Charge

Deposited in the Library, University of California, San Francisco

Date- - -

University Librarian

Degree Conferred: . . . SEP 8, 1965-

(3) Copyright 1985

by

Lucy Newmark Sammons

All Rights Reserved

MATERNAL ANXIETY, SOMATIC SYMPTOMS, MARITAL ADJUSTMENT, AND

FAMILY RELATIONSHIPS IN SECOND PREGNANCY

Lucy Newmark Sammons, R.N., D.N. S.

University of California, San Francisco, 1985

This study described and compared characteristics of maternal health

and perceptions of family relationships throughout the course of second

pregnancy, guided by developmental concepts and propositions from the

psychology of pregnancy literature. Hypotheses predicted that the four

dependent variables of maternal anxiety, somatic symptom levels, marital

adjustment, and maternal concerns about family relationships would be

dynamic over the three antenatal trimesters and the fourth postnatal

trimester; that somatic symptom occurrence would be perceived as more

frequent during second than first pregnancy; and that the dependent

variables would demonstrate intercorrelations.

One hundred and ninety-one obstetrically low risk, partnered women

delivering their second baby through private or prepaid health insurance

plans participated in a passive observational study employing a modified

cross-sectional sequential design. Subjects were recruited into one of

four cross-sectional trimester groups and completed the Spielberger

State—Trait Anxiety Inventory, the Spanier Dyadic Adjustment Scale, an

original Family Relationships Questionnaire, an original Somatic Symptoms

checklist, and a Demographic sheet. The design called for repeated

testing of 135 subjects three months after first testing.

Analysis of variance and two-sample t-test procedures revealed

higher levels of family relationship concerns in the third trimester than

the second trimester, and lower somatic symptom levels in the

midtrimester than in early or late pregnancy. Contrary to study

hypotheses, state anxiety and marital satisfaction were found to be

stable across the four perinatal trimesters. Somatic symptom frequency

was perceived as greater in second pregnancy than previous pregnancy,

with notably greater fatigue. Using correlational statistics, highly

significant associations were demonstrated among all four dependent

variables. Major concerns of secundigravidae antepartally were

anticipated jealousy of the firstborn about the baby, other aspects of

sharing maternal affection and attention between baby and firstborn, and

fear for the expected baby's health after the good fortune of having had

one healthy child. Major postpartal concerns were firstborn misbehavior,

maternal regret at the lack of an exclusive relationship with the new

baby, and firstborn difficulty with sharing maternal affection and

attention.

/– º 29t tº 4 / … / ^ (AX__Lucy Newmark Sammons, Author Ramona T. Mercer, Chair

Acknowledgments

It is my pleasure to take this opportunity to thank the individuals

and agencies who helped with all phases of this project. The essential

relationships I share with the following people are testimony that this

endeavor could not have been undertaken and completed without their

support and assistance.

My Dissertation Chair and Sponsor, Dr. Ramona Mercer, provided

caring, conscientious, and expert assistance throughout my doctoral

education. Dissertation Committee members were Dr. Katharyn May and Dr.

Jacqueline Ventura. Jointly, their guidance and suggestions ably

assisted me in traversing the course from the theoretical underpinings of

this investigation to the realities of research implementation.

Access to subjects was accomplished with the assistance of Ob–Gyn

Nurse Practitioners at Kaiser Permanente Medical Group facilities in

Walnut Creek, Antioch, and Pleasanton. Muriel Giles, Diane Siepel, and

Alicia McAtee made special efforts to provide facility liaison and

maintain recruitment. Susan Gillespie's thorough and energetic

contributions were extraordinary. The participation of Dr. Robert

Marten, Dr. Stephen Weinstein, Dr. Vincent DiMaggio, and Dr. Elwood

Kronick and their staffs is also appreciated. Community-based childbirth

educators Marti Paulson and Rhonda McGrath generously offered their

expertise during the instrument development phase. And to the 191 women

who took time out from their busy lives to participate in this study, I

express my sincere appreciation.

Assistance with data analysis was provided by Dr. Mark Hudes, who

good-naturedly clarified my search for meaning through foot-high piles of

output. Expert guidance and thoughtful counsel regarding all aspects of

iv

computing was graciously provided by Dr. Robert Slaughter.

Colleagues in the UCSF School of Nursing have assisted me both

formally in group seminars and informally through individual contacts

over the years of my doctoral education. The richness and satisfaction

I have derived from these relationships have added immeasurably to the

quality of my doctoral student life. Maternity Seminar members Helen

Dulock, Patricia Mann, Shannon Perry, and Colleen Stainton provided a

forum for discussion and assistance with instrument development. Seminar

members Ellen Olshansky and Brook Randall provided both assistance with

presentation of the research project and findings, as well as humor and

nurturance essential to balancing our lives as novice scholars in and out

of academia.

I am also appreciative of financial support for my doctoral

education and this investigation. I have received support from the

Charles M. Goethe Scholarship Committee; Sierra Pacific Region

Soroptimist International; UCSF Instructional Use of Computing Funds;

UCSF Regents Fellowship; School of Nursing Century Club; UCSF Patent

Funds; National Research Service Award NU–05667–01, DHHS, DN; Stanford

Nurse Alumnae; and California Nurses' Association, Region XI.

I wish to express my gratitude to additional individuals, who,

although they were not formally involved in my dissertation work, have

made significant contribution through their caring. I express

appreciation to my parents, Marion and Milton Maxwell Newmark, who

instilled in me a love of academics and the desire to pursue excellence.

I am grateful to Renee Sheehan and Deanna Bogart, both graduate-prepared

nurses, for helping me keep my family intact and my dissertation on

track, while continuously celebrating the joy of our children. With my

husband, Tim Sammons, I share the relief of this great undertaking now

reaching completion. And to our children, Julie and Andrew, who have

known only a Student–Mom in their young lives, I dedicate this work.

They have enriched my life beyond measure.

San Francisco, California

August, 1985

vi

Table of Contents

Page

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . iv

List of Tables. . . . . . . . . . . . . . . . . . . . . . . . . x

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . xi

Chapter I The Study Problem. . . . . . . . . . . . . . 1

Problem Statement and Study Purpose. . . . . . 2Significance . . . . . . . . . . . . . . . . . . . . . . 3

Chapter II Conceptual Framework and Literature Review. . . . . 6

Introduction . . . . . . . . . . . . . . . . . . . . . . . 6Conceptual Framework . . . . . . . . . . . . . . . . . . . 6

Developmental Psychology of Pregnancy . . . 7Family Development Framework. . . . . . . 9

Maternal Anxiety in Second Pregnancy . . . . . . . . . . . 11

Variables Affecting Anxiety in Second Pregnancy . . . 13

Time . . . . . . . . . . . . . . . . . . . . . . 13Demographic Variables. . . . . . . . . . . . . . 14Experiential and Attitudinal Wariables . . . . . 17

Maternal Concerns during Second Pregnancy . . . . . . 19Maternal Concerns following Second Pregnancy. . . . . 22Conclusions . . . . . . . . . . . . . . . . . . . . . 25

Maternal Perception of Family Relationships in SecondPregnancy . . . . . . . . . . . . . . . . . . . . . . . 26

Marital Relationship . . . . . . . . . . . . . . . . . 29Mother–Baby Relationship. . . . . . . . . . . . . . . 32Father–Baby Relationship . . . . . . . . . . . . . . . 33Mother—Child Relationship . . . . . . . . . . . . . . 34Father—Child Relationship . . . . . . . . . . . . . . 36Child-Baby Relationship . . . . . . . . . . . . . . . 37Variables Affecting Dyadic Family Relationships in

Second Pregnancy . . . . . . . . . . . . . . . . . 38Conclusions . . . . . . . . . . . . . . . . . . . . . 43

Somatic Symptoms in Second Pregnancy . . . . . . . . . . . 45

Introduction. . . . . . . . . . . . . . . . . . . . . 45Prenatal Symptomatology . . . . . . . . . . . . . . . 47Postpartum Symptomatology . . . . . . . . . . . . . . 49Conclusions . . . . . . . . . . . . . . . . . . . . . 50

vii

Interrelationships Between Anxiety, Family Relationships,and Somatic Symptoms in Second Pregnancy. . . . . . . . 51

Anxiety and Family Relationships. . . . . . . . . . . 51Anxiety and Somatic Symptoms. . . . . . . . . . . .Somatic Symptoms and Family Relationships . . . . . . 53Conclusions . . . . . . . . . . . . . . . . . . . . . 54

Definitions and Hypotheses . . . . . . . . . . . . . . . . 55

Definitions . . . . . . . . . . . . . . . . . . . . . 55Hypotheses. . . . . . . . . . . . . . . . . . . . . . 55

Chapter III Methodology. . . . . . . . . . . . . . . . . . . . 56

Introduction . . . . . . . . . . . . . . . . . . . . . . . 56Design . . . . . . . . . . . . . . . . . . . . . . . . . . 56Setting. . . . . . . . . . . . . . . . . . . . . . . . . . 58Sample . . . . . . . . . . . . . . . . . . . . . . . .

-

Data Collection Methods. . . . . . . . . . . . . . . . . . 61

Demographic and Background Data Sheet . . . . . . . . 61Spielberger State-Trait Anxiety Inventory . . . . . . 62Dyadic Adjustment Scale . . . . . . . . . . . . . . . 63Family Relationships Questionnaire. . . . . . . . . . 64Somatic Symptoms Checklist. . . . . . . . . . . . . . 67

Procedure. . . . . . . . . . . . . . . . . . . . . . . . . 69Data Analysis Procedures . . . . . . . . . . . . . . . . . 75Summary. . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter IV Results . . . . . . . . . . . . . . . . . . . . . . 79

Introduction . . . . . . . . . . . . . . . . . . . . . . . 79Demographic and Obstetrical Characteristics of the Sample. 79Dependent Variable Measures. . . . . . . . . . . . . . . . 87

Anxiety . . . . . . . . . . . . . . . . . . . . . . . 87Marital Satisfaction. . . . . . . . . . . . . . . . . 90Family Relationships Questionnaire. . . . . . . . . . 91Somatic Symptoms. . . . . . . . . . . . . . . . . . . 95

Interrelationship of Dependent Variables . . . . . . . . . 100Other Findings . . . . . . . . . . . . . . . . . . . . . . 102Hypothesis Testing . . . . . . . . . . . . . . . . . . . . 104Summary. . . . . . . . . . . . . . . . . . . . . . . . . . 106

Chapter V Discussion . . . . . . . . . . . . . . . . . . . . . 108

Relation of Findings to Research Questions . . . . . . . . 108

Change in Dependent Variables by Trimester. . . . . . 108Anxiety. . . . . . . . . . . . . . . . . . . . . 108Marital Satisfaction . . . . . . . . . . . . . . 111

viii

Family Relationship Concerns . . . . . . . . . . 111Somatic Symptoms . . . . . . . . . . . . . . . . 112

Description of Principal Family Relationship Concerns 112Description of Somatic Symptoms . . . . . . . . . . . 114Associations Among Dependent Variables. . . . . . . . 115

Study Limitations. . . . . . . . . . . . . . . . . . . . . 116Significance and Implications for Health Care. . . . . . . 117Recommendations for Future Research. . . . . . . . . . . . 120Summary. . . . . . . . . . . . . . . . . . . . . . . . . . 121

References. . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Appendices

: Cover Sheet for T-1 Packet. . . . . . . . . . . . . . . 140Consent Form. . . . . . . . . . . . . . . . . . . . . . 141Demographic and Background Information Sheet. . . . . . 142Spielberger STAI-State Self-Evaluation Questionnaire. . 144Spielberger STAI-Trait Self-Evaluation Questionnaire. . 145Spanier Dyadic Adjustment Scale . . . . . . . . . . . . 146Family Relationships Questionnaire—Prenatal . . . . . . 149Family Relationships Questionnaire-Postpartum . . . . . 150Symptoms of Pregnancy Checklist . . . . . . . . . . . . 151

: Postpartum Symptoms Checklist . . . . . . . . . . . . . 152Recruitment Flier . . . . . . . . . . . . . . . . . . . 153Comments for T-1 Packet . . . . . . . . . . . . . . . . 154Cover Sheet for T-2 Packet. . . . . . . . . . . . . . . 155Categorization of Antecedent Variables. . . . . . . . . 156

ix

List of Tables

Table Page

3. 1 Dependent Variable Measures Obtained at T-1 and T-2. . . . 76

4.1 Demographic Characteristics of Total Sample and Groups . . 80

4.2. Obstetric Characteristics of Total Sample and Groups . . . 83

4.3 Dependent Variable Measures for Total Sample and Groups:Analysis of Variance. . . . . . . . . . . . . . . . . 88

4.4 Trimester-Related Antecedent Wariables Affecting DependentVariables . . . . . . . . . . . . . . . . . . . . . . 89

4.5 Highest FRQ Item Scores for Total Sample and TrimesterGroups. . . . . . . . . . . . . . . . . . . . . . . . 93

4.6 Change in FRQ-A Item Means by Trimester: Paired tº Tests. . 94

4.7 Trimester Effects on Symptom Antepartal:—Comparative (SXAC)Levels: Two-Way Analysis of Variance. . . . . . . . . 96

4.8 Trimester Effects on Symptom Antepartal–Current (SXAN)Levels: Paired tº Tests. . . . . . . . . 96

4.9 Frequent Somatic Symptoms for Total Sample and TrimesterGroups. . . . . . . . . . . . . . . . . . . . . . . . 97

4. 10 Change in Somatic Symptoms by Trimester: Paired t Tests. . 99

4. 11 Somatic Symptoms in Second vs. First Pregnancy: One-samplet Tests . . . . . . . . . . . . . . . . . . . . . . . 100

4. 12 Association Between Anxiety, Marital Adjustment, SomaticSymptoms and Family Relationship Concerns . . . . . . 101

4.13 Relations of Selected Variables to Maternal Health . . . . 103

5.1 Weeks of Pregnancy by Trimester Group. . . . . . . . . . . 109

List of Figures

Figure Page

2. 1 Changes in Family Dyads in Second Pregnancy. . . . . . . . 28

3. 1 Sample Distribution in Modified Cross-SectionalSequential Design . . . . . . . . . . . . . . . . . . 57

xi

Chapter I

The Study Problem

Over two million women a year in the United States experience a

second or higher order live birth (Monthly Vital Statistics, 1983), yet

the experiences of these women are seriously neglected by multiple

scholarly disciplines and architects of health policy. First births make

up only 42.8% of all live births in this country, but it is upon this

minority group that psychologists, sociologists, and nurses have

traditionally focused their interests.

Second births make up the largest portion of later births. The

birth rate for second pregnancies had increased annually from 1978 to

1980, then demonstrated a slight (1%) decline consistent with overall

birth rates in 1981, the last year for which full statistics are

available. Second order births actually increased in 1981 for 30–34 year

olds (1%) and 35–39 year olds (7%), supporting the pattern for delayed

childbearing that has emerged since the early 1970's.

The extent to which higher order pregnancies (subsequent

pregnancies, or those occurring after the first birth) have been

neglected is pervasive. A federal government program developed in a

House Committee for consideration by the legislature extends Medicaid

coverage to low-income pregnant women only if they are expecting their

first child (House Committee, 1983). Clinicians as well have left those

experiencing a subsequent pregnancy as an underserved population. A

national survey of 25 veteran childbirth educators across the country

concluded that, "Conspicuous for its absence is a multipara class,

despite the special interests of multiparas——interests which frequently

do not include as much instruction in coping with labor and delivery"

(Shearer & Bunnin, 1983, p. 252).

Several dimensions of the second pregnancy experience emerge as

warranting investigation. Recent reviews have determined it is vital for

expansion of the knowledge base of the psychology of pregnancy to

investigate further the experiences of women and families during second

and later pregnancies (Leifer, 1980; Tilden, 1980; Valentine, 1982). Far

from "knowing the ropes," the woman experiencing a subsequent pregnancy

experiences changes in three arenas——the psychological, social and

physical spheres——which warrant attention during pregnancy (Kirkpatrick,

1978; Mercer, 1979; Westbrook, 1978a). The most critical psychological

and social variables for research about pregnancy have been succinctly

identified by Barnard (1981, p. 286), who stated, "The concepts of anxiety

and of supportive relationships have clearly emerged as unavoidable

independent variables in the study of childbearing and childrearing."

She questions whether health care providers can give responsible care

during the perinatal period without collecting information about these

two variables. The third realm of changes during pregnancy, that of

physical changes, impinges upon the woman's experience as subjectively

defined somatic symptoms. Hence, anxiety, family relationships, and

somatic symptoms are identified as three salient variables affecting the

second pregnancy experience.

Problem Statement and Study Purpose

This study aims to expand knowledge about the second pregnancy

experience. A woman experiencing second pregnancy is referred to as a

"secundigravida." Generally stated, answers are sought for the question,

what are the characteristics of maternal health and concerns about family

relationships throughout the course of second pregnancy? Maternal health

is conceptualized as having two dimensions, the psychological dimension

of anxiety and the physical dimension of somatic symptoms. Family

relationship concerns are considered in terms of dyadic, or two-member

relationships, such as husband—wife, or parent-firstborn.

The purpose of the study is to seek answers to the following

research questions:

1. Do maternal health and perceptions of family relationships

change with time through the course of second pregnancy?

2. What are the principal concerns of the secundigravida regarding

dyadic family relationships?

3. What are the most commonly perceived somatic symptoms of second

pregnancy? Do secundigravidae perceive themselves as having symptoms more

of less often than during their previous pregnancy?

4. Are there correlations among levels of the key dependent

variables: maternal anxiety, family relationship concerns, and frequency

of somatic symptoms?

Significance

This study is useful at both a theoretical and an applied level. At

the theoretical level, the investigation adds to the knowledge base

describing psychological and sociological aspects of pregnancy and early

parenting. By answering the research questions, salient properties and

relationships about second pregnancies will be illuminated, thus filling

the gaps that have existed in this area.

At the applied level, each of the three dependent variables has

demonstrated significance regarding health status and family functioning.

The study of anxiety in pregnancy was encouraged in 1959 (Caplan) in

order to make women more comfortable, to direct psychiatric intervention

towards prevention of the development of disturbed maternal-child

relations, and to investigate the potential for reducing complications of

pregnancy. The association between maternal anxiety and medical

complications of pregnancy is supported by prospective studies (Gorsuch &

Key, 1974; McDonald, 1968; Norbeck & Tilden, 1983). Recent technological

and neurobiochemical advances have allowed quantification and

specification of possible mechanisms for the impact of psychological

factors on perinatal outcomes. Direct evidence of the physiologic

effects of anxiety in pregnant humans is now available. Conflicts and

psychological processes including anxiety in pregnancy have been

correlated with anxiety in labor, uterine contractility, length of labor,

fetal heart rate patterns and newborn Apgar scores (Lederman, Lederman,

Work & McCann, 1978a, 1978b, 1981). High levels of anxiety are related

to complications of labor and newborn depression. Hence, increased

knowledge of the magnitude, sources, and patterns of anxiety throughout

second pregnancy may suggest strategies to improve perinatal health.

Perceptions of family dyadic relationships have evident significance

as an integral part of parenting, childrearing, marital stability and

satisfaction, and family integrity in a social context wherein these

family functions are often challenged. The marital relationship is

acknowledged to have major impact on pregnancy and the puerperium in a

variety of theoretical perspectives. Quality of the pregnant woman's

relationship with her husband has repeatedly been found to be one of the

major determinants of maternal adaptation to pregnancy and parenthood in

empirical investigations (Grossman, Eichler & Winickoff, 1980; Lederman,

Weingarten & Lederman, 1981; Westbrook, 1978b; Shereshefsky & Yarrow,

1973). Increased knowledge of the nature and magnitude of a woman's

concerns about the marital and other dyadic relationships provides

direction for therapeutic intervention to reduce anxiety and discord.

Hence, increased knowledge of family relationships during second

pregnancy will have value for providers and policymakers concerned with

maternity and neonatal care, family health care, adult mental health, and

marriage and family therapy.

Increased knowledge of somatic discomforts during second pregnancy

has relevance for providers and planners of health care and education to

maternity clients. A greater knowledge base about somatic symptoms will

facilitate the provision of more accurate anticipatory guidance to

clients. Specific knowledge of the timing of symptoms through the course

of pregnancy may also suggest a sequential plan for health education

about pregnancy symptoms and their management that may increase

opportunities for client self-care. Data-based guidance provided to

pregnant women may reduce unnecessary use of health care services by

clients who have been adequately prepared for normative symptoms such as

common sensations and minor discomforts.

The study of anxiety, perceptions of family relationships and

somatic symptoms during second pregnancy has been identified as an

important area for further study. In the following chapter, the

conceptual perspective guiding this investigation is presented and

relevant literature is reviewed.

Chapter II

Conceptual Framework and Literature Review

Introduction.

In this chapter, a conceptual framework based on individual

developmental changes during pregnancy and family development is

presented. Thereafter, maternal anxiety and concerns, maternal

perception of dyadic family relationships, and somatic symptoms in

second pregnancy are examined. The purpose of this literature review is

to provide a description of the current state of knowledge about the

phenomena of concern, to identify inconsistencies or limitations of

previous studies which indicate refinements needed in further

investigation, to identify variables known to affect the focal phenomena,

to suggest directional relationships guiding hypothesis formation and

research design, and to place the present inquiry within the broader

realm of received theory and existent literature. The chapter concludes

with statements of the research hypotheses.

Conceptual Framework

A developmental framework is appropriate for investigation of human

patterns as they move through time. A synthesis of family development

and life-course analysis is necessary to understand the movement through

time of an individual family member and the family organization itself

(Elder, 1978). Applying this perspective to the second pregnancy

experience requres consideration of the individual, in this case the

pregnant woman, as well as her family. A dual focus on individual and

family change during childbearing was espoused by Caplan (1959), who

described pregnancy as a state of disequilibrium in both the

intrapersonal forces in the pregnant woman and the interpersonal forces

in her family. An eclectic framework based on psychology of pregnancy

and family development concepts guides this investigation.

Developmental Psychology of Pregnancy

In the classic expositions of the developmental psychology of

pregnancy by Rubin (1975), four critical maternal tasks are described:

ensuring safe passage for the infant, ensuring acceptance of the baby by

the family, binding—in to the new child, and giving of oneself. Progress

in completing each task may be monitored throughout the trimesters of

pregnancy (Rubin, 1975). Increasing centration of maternal focus is

described as the pregnant woman turns her attention increasingly inwards.

Cognitive style is similarly observed to trace a developmental

trajectory, as first trimester concern with the question of being

pregnant gives way to midtrimester focus on the child's condition,

yielding to a third trimester characterized by protectiveness and

vulnerability (Rubin, 1970). A developmental perspective is further

applied to attainment of the maternal role antepartally and postpartally

by classification of the processes of taking—in; concern with self system

categories of the ideal image, the self image, and body image; and the

operations of mimicry, role play, fantasy, introjection-projection

rejection (I-P-R), identity, and grief work (Rubin, 1967). Whereas a

sequential ordering of these processes is suggested, with mimicry

occurring earlier in pregnancy, role play and fantasy predominating from

early to middle pregnancy, and I-P-R observed late in pregnancy, Rubin

conceptualizes the ordering of these processes as more cyclical than

straight-line (1967).

Rubin's work provides support for examining the gravida's

psychological status using the three-month interval of a pregnancy

trimester while seeking developmental patterns. However, applicability

of the tasks and processes described by Rubin to contemporary

secundigravidae are challenged for several reasons. First, major changes

in societal attitudes, women's roles, and health care practices since

Rubin's data collection may have altered psychological processes of

pregnancy, just as Martell and Mitchell (1984) suspect puerperal

attitudes and behaviors have changed since Rubin's early landmark works.

Second, Rubin's data are based on intensive interviews and observations of

small samples willing to tolerate such scrutiny. Testing of her

propositions with larger sample sizes is needed to confirm

generalizability of findings. Third, the concepts and processes

presented in Rubin's works are difficult to operationalize and apply to a

culturally diverse population.

A fourth limitation of developmental conceptual frameworks for

pregnancy has been the failure to adequately address second and later

order pregnancies (Tilden, 1980). Rubin (1967) comments that the

processes of maternal role attainment are somewhat modified for

multigravidae compared to first-time mothers. However, her observations

generally included only minor alterations to the processes described for

first-time mothers. She does acknowledge a unique aspect of second

pregnancy by describing grief work as including detachment from the first

child as well as letting go of the mother's former identity, in later

pregnancies.

Whereas changes in the realm of object relations during pregnancy

have focused on the baby, the mate, and the woman's own mother, (Tilden,

1980) theoretical notions including relationships with the firstborn have

been largely neglected. An important expansion to the conceptual view of

the developmental psychology of subsequent pregnancies is provided by

Walz and Rich (1983), who define the principal tasks of taking-on a

second child as adjusting to the new role, providing continued nurturance

to the older child, and establishing and maintaining family

relationships. Behavioral categories derived from their descriptive,

naturalistic study of the neomaternal period are: promoting acceptance of

the baby, particularly with the first child; grieving the loss of an

exclusive dyadic relationship with the first child; planning tasks;

reformulating the relationship with the first child; identifying the

second child by comparison with the first; and assessing self, including

the capability to nuture two children. Although this elaborated view of

the psychological tasks of mothering two children greatly enriches the

conceptual parameters of the psychology of second pregnancy by

illucidating the dynamics of the mother—firstborn relationship, this

contribution is based solely on interview and observation during the

immediate postpartum period spent in the hospital. The pattern of

progression through these tasks during the course of pregnancy is yet to

be revealed.

Family Development Framework

The family developmental framework is an eclectic merging of

concepts from the disciplines of demography, economy, rural sociology,

developmental psychology, interactionist theory, and role theory (Hill

& Rodgers, 1964). The resulting product is a combination of social

systems, structural functionalism, and a social-psychological approach

which recognizes that dynamic persons are individuals and family members

at the same time (Rowe, 1981). The framework is unique in bringing to

10

family study the developmental concepts of family and social time. The

family changes as reciprocal interaction patterns develop to fulfull the

individual's and family's changing needs and desires. A change in one

part of the family affects change in other parts (Rowe, 1981).

The framework incorporates the concept of developmental task which

had previously been applied to the individual by human developmentalists.

While each family member confronts individual tasks, simultaneously the

family is negotiating tasks which may or may not be supportive of the

individual endeavor. According to Duvall's (1977) classic textbook on

family development, the family performs basic tasks essential for

survival and continuity dealing with maintenance of physical needs,

allocation of resources, determination of home management functions,

socialization, establishment of emotive capacities, reproduction,

negotiation with society, and maintenance of morale and motivation.

Developmental tasks specific to a stage in the family life cycle are in

addition to these basic tasks.

The family life cycle is composed of a sequence of stages as the

family expands, contracts and dissolves. Definition of the stage is

determined by childbearing, progress of the oldest child through school,

departure of the youngest child, employment status and death of a spouse

(Duvall, 1977). Successful achievement of family developmental tasks

leads to present satisfaction, approval, and success with later tasks,

while failure leads to family unhappiness, societal disapproval and

difficulty with later family devlopmental tasks. Although the notions of

family developmental tasks and the family life cycle have not withstood

attempts to establish their empirical validity (Magrabi & Marshall, 1965;

Nock, 1979; Spanier, Sauer, & Larzelere, 1979), their usefulness as

11

conceptual tools, illustrative principles, or didactic techniques has

been supported.

The family development conceptual framework recognizes birth of the

first child as a major developmental step, marking transition of the

family into the childbearing stage (Duvall, 1977). Although the most

pronounced transformations of structure and advancements in a family's

system of meanings usually take place with the first occurrence of a

normative event such as addition of a child, there are exceptions. There

may be special intensity in response to a subsequent birth, or the

subsequent event may have special meaning in the family unit (Terkelsen,

1980).

Hence, the addition of a second child to the family, whether viewed

as a crisis or a less stressful normative transition, stimulates change

within the family. Selection of the family development framework

dictates that an attempt be made to look at some aspect of all family

members, as well as to attempt to capture the dynamic qualities of family

interaction through time.

Maternal Anxiety in Second Pregnancy

Study of the psychosocial experience of pregnancy has evolved from a

legacy of psychoanalytic studies based on pathologic cases (Bibring,

1959; Bibring, Dwyer, Huntington, & Valenstein, 1961; Deutsch, 1945) to

empirically based investigations that include large numbers of generally

healthy women (Colman & Colman, 1971; Entwistle & Doering, 1981;

Grossman, Eichler & Winikoff, 1980; Shereshefsky & Yarrow, 1973).

However, with the exception of the work by Grossman, these investigators

generally have limited themselves to examination of first pregnancy. A

12

discussion of the specific psychosocial variable of interest, that of

anxiety in second pregnancy, must therefore draw on a limited number of

studies in which parity is often only an incidental demographic variable

or parity status is mixed, including both first and later pregnancies.

In this section, variables affecting anxiety in second pregnancy

will be described, following comments on the concept and measurement of

anxiety. Then the sources of maternal concern and the level of anxiety

produced in second pregnancy, often as compared to first pregnancy, will

be examined for the prenatal period and then the postpartum period.

Spielberger (1976) presents a conceptualization of anxiety that is

reflective of current usage in anxiety research. Stress is the

objective, consensually validated stimulus property of a situation which

is characterized by either physical or psychological danger. An anxiety

state is characterized by the intensity of subjective feelings of

tension, apprehension, nervousness and worry experienced by an individual

at a particular moment, and by activity of the autonomic nervous system.

Anxiety also refers to a complex psychobiological process involving a

sequence of cognitive, affective, physiological and behavioral events

initiated by external stimuli or cognitions. Anxiety states vary in

intensity and duration, whereas an individual's trait anxiety is a

relatively more stable disposition towards anxiety.

One of the major methodological advances in the study of maternal

psychological stress is the use of standardized questionnaires for the

measurement of anxiety (Yamamoto & Kinney, 1976). When the focus of

investigation is intrapsychic activity at an unconscious level, then

projective tools such as Rorshach Psychodiagnostic Examination, Selected

Thematic Apperception Test Cards, Rotter Sentence Completion Test, and

13

the Draw A Person Test have been used (Bibring, et al., 1961;

Shereshefsky & Yarrow, 1973).

However, when the subjective, consciously perceived feelings of

tension and apprehension are to be measured, other instruments must be

used. The Institute for Personality and Ability Testing—Anxiety (IPAT)

used by Lubin, Gardener, and Roth (1975); the Taylor Manifest Anxiety

Scale (TMAS) used by Davids and DeVault (1962) and McDonald and

Christakos (1963); and the Spielberger State Trait Anxiety Inventory

(STAI) used by Gorsuch and Key (1974), Grossman, Eichler, and Winickoff

(1980), Norbeck and Tilden (1983), and Tilden (1984); have been found to

have interrcorrelations approaching scale reliabilities (Spielberger,

Gorsuch, Lushene, Wagg, & Jacobs, 1983). These intercorrelations permit

consideration of the various instruments as equivalent measures of trait

anxiety. Of these instruments, only the Spielberger STAI (Spielberger,

et al., 1983) allows assessment of both trait anxiety and state anxiety,

the transitory emotional anxiety condition. The ability to assess change

in a key variable through time has theoretical value for an investigation

guided by developmental concepts. Furthermore, the ability to measure

both state and trait anxiety has proven value in pregnancy research,

illustrated by the finding that prenatal trait anxiety was the only

variable predictive of postpartum state anxiety, accounting for 38% of

the variance in a mixed parity sample examined for relationships between

maternal anxiety, personality, attitudes and obstetric complications

(Beck, Siegel, Davidson, Kormeier, Breitenstein, & Hall, 1980).

Variables Affecting Anxiety in Second Pregnancy

Time. The effect of time on anxiety is of major importance when

examining pregnancy from a developmental perspective. Previous

14

longitudinal study of 64 first-time pregnancies revealed changes in

anxiety by trimester (Shereshefsky & Yarrow, 1973). Anxiety levels

assumed a curvilinear pattern, with high first trimester anxiety

subsiding and then rising again in the eighth and ninth months as labor

and delivery approach. Cohen (1978), however, found the drop in anxiety

occurring slightly earlier, noting that confirmation of pregnancy

decreased fears, with a progressive increase in anxieties through

pregnancy in nine primigravid subjects.

This "V"-shaped pattern appears to apply to multigravidae as well.

Lubin, Gardener, and Roth (1975), who followed 44 secundigravidae with no

previous terminations and 14 secundigravidae with previous spontaneous or

therapeutic abortion in a longitudinal study, found anxiety as measured

by the Anxiety Adjective Checklist (AACL) declined second trimester and

rose again third trimester. A rise in anxiety from second to third

trimester was found as well in a sample of 80 black multigravidae

("Anxiety Worse," 1980). Grossman and others (1980) measured anxiety only

during the first and third trimesters. They found anxiety levels were

not significantly different at these two times, but without an

intermediate measure no conclusions can be drawn regarding constancy or

volatility of anxiety. Although Grimm's (1961) sample of 235 normal

pregnant women of mixed parity drawn in groups of 40 from five intervals

spanning late first trimester to late third trimester demonstrated a

significant rise in psychological tension in the second half of the last

trimester, the general level of psychological tension was constant

through pregnancy to that point. Psychological tension was a composite

variable including anxiety, hostility and depression.

Demographic Wariables. Increasing age appears to be related to

15

lower anxiety in pregnant women of varying parity. Burstein, Kinch, and

Stern (1974) found lower anxiety scores with increasing age among their

sample of 61 women of mixed parity, as did Glazer (1980) in her sample of

100 women. Moss (1981) found the greatest number of concerns in her

sample of multiparae among those under 20 years old, and the least

concerns in mother over 30. On the other hand, Lubin and colleagues

(1975) found a slight but significant postive relationship between age

and anxiety in their sample of wives of medical students and staff of

mixed parity.

Socioeconomic status has been related inversely to anxiety in mixed

parity samples (Doty, 1962; Glazer, 1980). Middle-class women had less

emotional disturbance as measured on a Pregnancy Attitude Scale than

their lower class counterparts (Doty, 1967). Maternal education level

has a significant, inverse relationship with anxiety levels during

pregnancy (Glazer, 1980). Moss (1981) found the least concerns among

multiparae with 12 to 14 years of formal education. Amount of formal

education also significantly affected the type of concerns reported by

202 maternity patients questionned postpartally (Light & Fenster, 1974).

Subjects with more than a high school education had greater concerns

about x-rays and birth defects due to medications, while subjects with

less education were more concerned about childbirth, family, subsequent

pregnancies and finances.

Maternal employment status has received only limited attention in

empirical studies of prenatal anxiety, although family theoreticians have

suggested that level of employment positively influences mothers' level

of anxiety (Rollings & Nye, 1979). Nye (1979) proposes that the working

mother who has more and younger children will encounter greater economic

16

costs of childcare, greater opposition by spouse and children, greater

guilt, and greater sanctions from kin and neighbors, than her counterpart

with fewer or older children. In an exploratory study of 40 new mothers

of second-borns, maternal employment was found to increase postpartum

stress (Lynch, 1982). The distinction between employment in a career,

which requires special training and involves movement through an

hierarchy of prestige, compared to employment in a job as a wage-earner,

warrants attention since maintaining both a committment to a profession

and to a family role with children present creates a strain (Aldous,

1982).

Marital status has been found to affect anxiety in a mixed parity

sample (Tilden, 1984). Single women had higher state anxiety scores than

partnered women, who were either legally married or living with a stable

partner. The non-partnered women revealed additional stressors at mid

trimester, such as dealing with decision-making and disclosure issues

(Tilden, 1983). Length of marriage or relationship is also related to

anxiety levels during pregnancy, with shorter relationships associated

with greater anxiety (Glazer, 1980).

The variable exerting the strongest influence on maternal stress in

Lynch's (1982) postpartum investigation of new mothers of second children

was the age of the firstborn. When the firstborn was under two years

old, the child sought attention and struggled with independence issues.

When the firstborn was over six years old, the child's behavior was not

problematic, but stress was created by the greater change in maternal

demands.

The sex of a later-born infant may affect anxiety levels. Moss

(1981) found greater concerns in multiparae who had delivered males.

17

Sumner and Fritsch (1977) report a higher number of concerns expressed by

mothers breastfeeding males compared to females in their mixed parity

sample.

Experiential and Attitudinal Variables. Several aspects of a

woman's reproductive history influence anxiety during second pregnancy.

Olin (1983) found that a previous fertility problem was related to lower

scores on the Spielberger Self–Evaluation Questionnaire for anxiety in

her sample of 68 primigravidae and 77 multigravidae between the ages of

20 and 39. Lower anxiety scores in the third trimester and postpartum

were also found when the current pregnancy was planned (Olin, 1983).

Similarly, Lynch (1982) found an association between high stress

postpartally and unplanned pregnancy.

Previous and current pregnancy and delivery experiences influence

anxiety in secundigravidae. The diagnosis of "high risk pregnancy" in

itself causes uncertainty, guilt, and anxiety (Galloway, 1976). A

previous problematic or traumatic pregnancy or birth experience would be

expected to kindle heightened anxiety as a situation of similar structure

recurs. Antenatal hospitalization at a high risk pregnancy medical

center heightens fears for mother and infant, while imposing concerns

about other dependent children from whom the mothers are separated

(Merkatz, 1978).

Lipson (1984) describes how the woman who has delivered previously

by Cesarean delivery may be confronted with an overwhelming barrage of

diverse opinions due to newly available options for previous surgical

delivery patients. The response to increased responsibility and choice

varies from delight to increased anxiety. In addition, the experience of

having given birth vaginally prior to a Cesarean birth appears to have a

18

positive effect on the mother's emotional status, since multiparous

Cesarean delivery mothers who had experienced a vaginal delivery rated

higher on the Maternal Attitude to Pregnancy Instrument than those who

had never delivered vaginally (Hart, 1980).

Evolving technologies in prenatal diagnosis (Beeson & Douglas, 1983)

may affect the pattern of anxiety in pregnancy. The process of prenatal

diagnosis itself appears to be changing parents' experience of pregnancy

(Beeson, Douglas, & Lunsford, 1983). Anxiety levels increase before

tests and while awaiting results, perhaps in a suspension of commitment to

the pregnancy. Anxiety may decline after favorable results are reported.

Extent of participation in childbirth education classes may be

correlated with maternal anxiety levels. Although attendance at a series

of childbirth education classes did not change anxiety levels in 26

multigravidae reported in 1984 (Walker & Erdman), an earlier study of the

effect of Lamaze childbirth education on anxiety, maternal attitudes to

pregnancy and biomedical parameters of the delivery, did find differences

in pre- and post-class anxiety levels (Zax, Sameroff, & Farnum, 1975).

Class attendance was associated with lower anxiety, as measured by the

Institute for Personality and Ability Testing (IPAT) scale for

experienced, but not first-time, mothers. Moss (1981) found the least

concerns in multiparae who had gone to one series of prenatal classes,

compared to those who took no classes or those who attended multiple

class series. Hence, the relationship between childbirth education class

attendance and anxiety may be complex. Class characteristics of

information—provision and support may reduce anxiety for some women. For

other women, class attendance may not be causally related to anxiety

level changes, but may instead reflect other correlated psychological

19

dimensions manifested as avoidance or attempts at over-preparation.

Life stress was found to account for 21.4% of the variance in emotional

disequilibrium, a construct composed of weighted values for anxiety

(measured by the Spielberger STAI), depression, and self-esteem, in a

sample of 117 normal prenatal patients of mixed parity (Norbeck & Tilden,

1983). Social support, of the emotional type, explained 6.5% of the

variance in emotional disequilibrium. An interactive effect between life

stress and social support was revealed. Olin (1983) found no significant

relationship between stressful events experienced within the preceding 18

months and anxiety levels during pregnancy, using less complex

statistical analyses and a predominantly middle- to upper-middle class

white sample.

Several experiential variables were reported to have no effect on

anxiety levels in pregnancy. Neither birth defects in the family,

complications during the pregnancy or delivery of the woman's mother, nor

the death of the woman's mother significantly affected anxiety levels of

Olin's (1983) 145 subjects measured late in pregnancy.

Maternal Concerns during Second Pregnancy

A concern is defined as "that which busies or occupies one's

thoughts" (McKechnie, 1975, p. 376), while to be concerned is to be

uneasy or anxious, to experience agitation, uneasiness of mind, or a

disturbed state of feeling. Concern and anxiety may be considered

synonomous, or the concerns may be considered the cognitions which

stimulate anxiety. Maternal concerns and maternal anxiety levels during

pregnancy are often investigated concomitantly. The logical relationship

between anxiety levels and number of issues about which a pregnant woman

has concerns has been empirically validated. Glazer (1980) found a

20

significant correlation between the number of concerns indicated by 100

pregnant women of mixed parity and their anxiety level measured by the

Taylor Manifest Anxiety Scale. The types of concerns of pregnant women

also appear to be a function of gestational age. Glazer (1980) describes

how the major concerns shift from self, childbirth and medical care in

the first trimester, to self, childbirth, effects on the baby, finances,

family and subsequent pregnancy by the third trimester when considering

her total sample of first and later pregnancies.

Concerns and anxiety levels in second pregnancy have often been

investigated in comparison to the first pregnancy experience, with

conflicting results. No significant difference in anxiety level by

parity was found using projective measures throughout pregnancy (Grimm,

1961), using the Health Insurance Plan Pregnancy questionnaire on

emotional adjustment and attitudes administered before 16 weeks to assess

worry about the baby (Grimm & Venet, 1966), nor by using the Manifest

Anxiety Scale (Davids, Holden, & Gray, 1963) or the Spielberger STAI

(Olin, 1983) in the third trimester. Despite what might be a common

expectation for decreased fears and conflicts among experienced mothers,

Lederman and Lederman (1979) stressed the importance of their findings

that there were no differences between multiparae and primiparae on

scales for concerns about well-being for self and baby, acceptance of

pregnancy, identification with the motherhood role, feeling prepared for

labor, or fears pertaining to pain, helplessness and loss of control in

their sample of 119 women.

In contrast to these findings, other investigators have reported

differing levels of anxiety and concerns between first-time and

experienced mothers. The secundigravida has been found to be more fearful

21

for the unborn baby (Larsen, 1966), more fearful for herself (Larsen,

1966) including increased mutilation anxiety (Westbrook, 1978a), and more

fearful regarding what childbirth would be like (Norr, Block, Charles, &

Meyering, 1980). In addition, multiparae were less likely to take Lamaze

classes or to receive aid from their husbands during delivery (Norr,

Block, Charles, Meyering, and Meyers, 1977), and more distressed at the

lack of support in labor from nursing personnel (Larsen, 1966).

On the other hand, contradictory reports describe the emotional

burden of first-time mothers as more distressing. Norr and others (1977)

found fewer worries about birth with increasing parity. Burstein, Kinch

& Stern (1974) found greater anxiety and stress in primigravidae when

measured by an original "Pregnancy Anxiety Scale" of 25 items specific to

pregnancy, however they found no significant parity differences using the

Taylor Manifest Anxiety Scale. Primigravidae also reported more fears

about pregnancy and childbirth (Doty, 1967), greater concern about

childbirth pain (Light & Fenster, 1974), greater fear for themselves and

the baby (Erickson, 1976), and greater fear of physical injury (Grossman,

Eichler & Winickoff, 1980).

While weighing the relative contributions of these reports, it is

important to note that all of the investigations documenting increased

anxiety and concern for multigra vidae are based on data collected in the

postpartum period, whereas much of the data describing greater anxiety in

the primigra vidae were actually collected during pregnancy (except Norr

et al., 1977; Light & Fenster, 1974). The length of time between

pregnancy and data collection was as great as seven months (Westbrook,

1978a). The most accurate measurement of a volatile arousal condition

such as state anxiety and its focal concerns is best made during the

22

experience under scrutiny. Retrospective recall allows intervening

events to influence recollection, hence jeopardizing the validity of

purported pregnancy measures.

Maternal Concerns following Second Pregnancy

Postpartum adaptation and parenting concerns are clearly different

in subsequent pregnancies than in first pregnancies. Although the

literature describing prenatal concerns for the secundigravida is

inconsistent, perhaps because there has been a failure to adequately

assess the unique and central issue of bringing a baby into a family

already occupied by a child, clear and long-standing differentiations in

postpartum concerns by parity have been described. A 1967 report of

interviews with 40 mothers of mixed parity (Henning, Martoglio, Quita,

Rembrecht, & Strickland) found multiparae focused on re-establishing

family relationships and a voiding sibling rivalry, needing help in the

home to allow for recovery, and planning for meals; while primiparae

needed guidance and reassurance in planning self care and care of the

baby at home. These themes have been supported in subsequent

investigations to be discussed in this section.

The new first-time mother has concerns about her infant, herself,

and her marital relationship. Primiparae express significantly greater

concerns and needs for information about infant feeding, gastrointestinal

and skin care (Sumner & Fritsch, 1977); about mothering skills, baby

characteristics and behaviors, and anticipatory guidance (Evans, 1968;

Gruis, 1977); and about caring for baby's physical needs and the

responsibilities of mothering (Light & Fenster, 1974; Norr, et al.,

1980) than multiparae. First-time mothers express more concerns about

their own physical care such as discomforts, breast care, rest, sleep,

23

and diet (Evans, 1968; Light & Fenster, 1974). Primiparae are more

worried about how their husbands feel towards them than multiparae (Norr,

et al., 1980). First-time parents undergo a major disruption in the

marital dyad, which researchers speculate explains why adaptation at two

months postpartum was related strongly to a number of general

psychological measures, pregnancy-related characteristics, and marital

satisfaction in early pregnancy for first pregnancies, but not subsequent

pregnancies (Grossman, Eichler, & Winickoff, 1980).

Recently—delivered multiparae express greater concerns focused on

family relationships, external stresses, and time constraints. Gruis

(1977) captured the shift in concerns for experienced mothers in her

finding that the focus in primiparae is the newborn himself, while in the

multipara the focus of concerns is the strain the new child places on the

rest of the family.

Moss (1981) surveyed 56 multiparae, finding that family subjects

were the most often stated major area of concern on the third postpartum

day. Concern about how the children at home will act towards the baby

was nearly universal. Olin (1983) inter viewed a small subset of her

surveyed sample, also finding that multiparae were most concerned about

the effect the new baby would have on their older child or children.

Evans (1968) found greater psychosocial needs in multiparae, a category

encompassing encouragement, nervousness, concerns about visitors, coping

with critical attitudes of family and friends, household help, and

adjustment of older children to the baby.

External stressors reported to increase with parity include the

stress of too much company and interference from relatives and neighbors

(Larsen, 1966) and financial problems (Olin, 1983). Grossman, Eichler &

24

Winickoff (1980) concur that women having subsequent pregnancies are more

vulnerable to external pressures and factors, since socioeconomic status

and recent life stresses were predictors of anxiety and postpartum

depression for them.

Concern with time limitations is reflected in reports of greater

problems with housework and family routines (Larsen, 1966), concern about

enough time to give to each child (Olin, 1983), and a greater concern

with finding time for oneself (Gruis, 1977). Grubb (1980) studied women

in subsequent pregnancies and found mothers had time for their babies'

needs only by depriving themselves. When they had time for their own

needs, it was usually because someone else had assumed some of their

duties. Lynch (1982) concurs that lack of time for self is a source of

stress for the new mother of two. Comparison of social support perceived

by new mothers revealed that primiparae perceive their network members to

be more able to offer tangible aid than do multiparae (Miller, 1984).

The value of a social time framework for study of transition to

parenthood has been illustrated in a case study of a second pregnancy

(LaRossa, 1983).

In addition to increased concerns about their ability to care for

the family, multiparae had greater concerns about having more children

than they wanted and contraception, in a 1974 report (Light & Fenster).

The current importance of this concern may be mitigated by increased

contraceptive options.

Both first-time and repeat mothers share a concern about their

appearance following birth. Return of the figure to normal was the most

common concern of both multiparae and primipare in Gruis' (1977) survey.

Lynch's (1982) sample of 40 new second-time mothers reported their

25

greatest stressor was self-concern about their body figure, self-image,

and change in abdominal muscle tone. The 56 multiparae in Moss's (1981)

study, asked to select from 21 cards describing potential concerns about

their physical or emotional status in the category that evaluated

concerns about self, most often indicated concern about their weight and

return of their figures to normal. Moss (1981) elaborates that the

postpartum concerns related to the mother's body are not discomforts,

such as sore breasts, but concerns about body alterations. Larsen (1966)

found that concern with weight reduction increased with increasing

parity.

Conclusions

A review of the literature describing maternal anxiety in second

pregnancy suggests the direction for future inquiry. Numerous temporal,

demographic, experiential and attitudinal variables have been found to

affect anxiety in pregnancy. The relative weights or contributions of

these variables to anxiety remains unknown. No single study has examined

anxiety through the course of pregnancy with simultaneous monitoring of the

breadth of variables discussed, thus allowing for control of possible

extraneous variance by design or statistical evaluation. Conflicting

reports of the effect of a particular variable on anxiety may be due to

assessment of anxiety using instruments with poor psychometric

properties. An adequate description of anxiety in second pregnancy also

requires strict control of subject parity status, since most of the

previous investigations have grouped together women with varying numbers

of children.

Review of the prenatal and postnatal concerns of secundigravidae

suggest that anxiety levels do not differ consistently from women bearing

26

a first child, but that the foci of concerns for the woman adding a

second child to her family are different. This conclusion is supported

by giving greater credence to investigations which have used standardized

instruments and have measured anxiety and concerns during the time of

interest rather than relying on retrospective recall. The predominant

practice of reporting pregnancy concerns globally, rather than with

specification of the gestational age at which they are manifested, has

failed to reveal any developmental process which may exist.

The study of concerns during second pregnancy has been limited by

assessment in the areas of traditional inquiry for primigra vidae: fear

for baby, fear for self, and fear of childbirth. When open-ended

questionnaires or interview techniques have been used during pregnancy,

multigravidae have indicated that concerns about family relationships are

prominent. Investigators of the postpartum period, however, have

delineated an emphasis on infant, self, and marital concerns for first

time mothers compared to an emphasis on family relationships, external

stresses, and time constraints, as well as body alterations, among

multiparae. A contrast between an internally-oriented first-time mother

with a focus on her baby within, compared to an externally-oriented

second-time mother renegotiating multiple interpersonal relationships is

suggested. Further research, spanning the course of pregnancy, is

required to illucidate these processes. The following section reviews

dyadic relationships in the family of the secundigravida.

Maternal Perception of Family. Relationships in Second Pregnancy

Both prior and ongoing interpersonal relationships have been

acknowledged to exert an influence on pregnancy and parenting. The

27

relationship of the pregnant woman to her own mother has been identified

as crucial to satisfactory assumption of the role of mother to her new

baby in the psychoanalytic literature (Ballou, 1978; Chodorow, 1978;

Deutsch, 1945). Of the ongoing relationships in the nuclear family, the

marital relationship, particularly in first pregnancies, has been found

to have impact on the childbearing experience (Ballou, 1978; Cohen, 1966;

Grossman, et al., 1980; Westbrook, 1978b). However, there is a need for

studies of relationships in pregnancy affected by the presence and

demands of other children (Richardson, 1982).

Examination of relationships within the family context presents

conceptual and methodologic challenges (Cooper, Grote vant, & Condon,

1982; Gilliss, 1983; Miller, Rollins, & Thomas, 1982). Parke, Power,

Tinsley, and Hymel (1979) stress the need to assess the total set of

relationships among family members in order to understand a single dyad,

as exemplified by work on the father-infant relationship and its effect

on the infant's development. Similarly, Lamb (1979) faults previous

parent-infant research for emphasizing a single dyad. With a component

dyad strategy, all dyads are examined to detect direct and indirect

effects on interaction which may be mediated through another person.

Where direct observation is not feasible, maternal perception of other

family member involvement has demonstrated value in the study of parent

child interaction and child development (Eyres, Barnard, & Gray, 1979).

The law of family interaction (Bossard, 1945) mathematically defines

the number of family interactions (dyads) as a function of the number of

people in the family:

Number of Interpersonal Relationships =

( (Number of persons)” – Number of persons) / 2

28

Mother Father"Tw

>]First Child Baby: Fetus/Newborn

Before second pregnancy

After second pregnancy

Figure 2. 1 Changes in Family Dyads in Second Pregnancy

Hence, a family acquiring a fourth member by birth expands from three to

six dyads (See Figure 2.1), changing from a triad to a quadrate.

The only investigator to examine maternal perception of all the

family dyadic relationships of multiparae through the course of pregnancy

is Richardson, who interviewed nine multiparae and five primiparae,

predominantly Mexican-Americans drawn from a lower socioeconomic class

clinic population, at two to seven week intervals starting before 14

weeks gestation (1981; 1983a; 1983b). Subjects listed relationships in

order of impact as 1) husband, 2) a child, 3) parental, and 4) peers,

with husband most important (1981). This reflects the total sample,

however, without consideration of separate rankings by those who have a

child. Relationships were found to be more changing than stable through

pregnancy, underscoring the need for specification of gestational age in

dyadic relationship studies of pregnancy. Relationships with one's

husband and own children were most problematic and most intensely

demanded attention (1981). The composite of relationships appears to

determine the character of the pregnancy experience, since a singular

disturbing relationship only becomes problematic if the woman lacks other

positive supportive relationships or if other relationships are troubled

29

as well (Richardson, 1982).

Each of the six nuclear family dyads during second pregnancy will

next be examined. The purpose of this review is to describe the current

level of knowledge and to identify areas in need of further study.

Marital Relationship

A description of the marital relationship throughout second

pregnancy can only be suggested by combining theoretical notions and

empirical data describing segments of the second childbearing year. In

the psychoanalytic realm, Ballou (1978) describes a vital matrix

involving the husband, mother, and child of the pregnant woman, whose

interrelationships are central to emergence of the woman's sense of the

child as a person. Applicability of this matrix to second pregnancy

is untested. Quality of the pregnant woman's relationship with her

husband has repeatedly been found to be one of the major determinants of

maternal adaptation to pregnancy and parenthood for primiparae in

empirical investigations (Lederman, Weingarten, & Lederman, 1981;

Shereshefsky & Yarrow, 1973), but not for multiparae (Grossman, Eichler,

& Winickoff, 1980). An explanation for the apparently diminished impact

of the marital relationship in later pregnancies has not been

established.

There is a dearth of information about the marital relationship

early in second pregnancy. Richardson (1981) has identified the need for

further study of the marital dyad early in pregnancy through to the

postpartum period. Data collected to develop a pregnancy questionnaire

showed primigravidae have greater satisfaction with their husbands, and

with life in general, than multigravidae among a sample of 124 women

tested at their first antepartal visit, before 16 weeks gestation (Grimm

30

& Venet, 1966). Interview data collected from before 14 weeks gestation

to the end of pregnancy from 14 women of mixed parity yielded findings

that husbands were usually described as the most important significant

other in the women's lives and that changes in affective involvement

dominated task performance (Richardson, 1983b). There was a significant

increase in satisfaction with their marital relationships through the

course of pregnancy for the sample as a whole. However, since only five

of the women were pregnant with their second child (five with first, and

four with third or fourth), two of the women of unspecified parity

separated from their husbands in early pregnancy, and three of the

remaining twelve also shared residences with extended family members, the

generalizability of this finding to secundigra vidae must be considered

limited.

Quality of the marital relationship from middle to late portions of

second pregnancy remains unclear. Rankin and Campbell (1983) were

surprised to find 192 white middle-class Lamaze couples of mixed parity

rate their marital relationships as more satisfactory during the third

trimester than they felt they had been three months earlier. Wagaries of

the instrument or sample characteristics were suspected of countering the

expected decline in satisfaction. Improved marital satisfaction from

from 24–36 weeks of pregnancy to 3–21 days postpartum is reported using

the Interpersonal Conflict Scale (Moore, 1983).

The difficulty in assessing a negative change in the marital

relationship towards the end of pregnancy has been acknowledged by a

leading investigator in the field (Lederman, 1984a). Lower scores for

relationship with husband were recorded for multigravidae compared to

primigravidae late in pregnancy during development of the Relationship

31

with Husband scale (Lederman & Lederman, 1979). The lower scores were

felt to reflect the increased stress between parents with children, or

the greater willingness of multigravidae to acknowledge conflict in

marriage.

Other reports similarly find negative effects of subsequent

childbearing on marital adjustment, reported both as parity comparisons

and as a decline from mid- or late-pregnancy to months and years

following subsequent birth. Feldman's (1971) landmark longitudinal study

revealed that further erosion of the marital relationship occurs as

couples experience second pregnancy compared to those with only one

child. Testing in the fifth month of pregnancy, five weeks postpartum,

and five months postpartum revealed lowered satisfaction in the marriage,

perceived negative personality change in both partners, less satisfaction

with home, more instrumental conversation, more child-centered concerns,

and lowering of sexual satisfaction after childbirth for primipare and

multiparae compared to childless couples. Using a standardized marital

satisfaction instrument, the Spanier Dyadic Adjustment Scale (DAS),

Belsky, Spanier, and Rovine (1983) confirmed significantly lower total

scores and subscale scores for satisfaction, cohesion, and affectional

expression in multiparae compared to primipare. Their contemporary

sample of 72 couples were assessed by interview, questionnaire and

observation, revealing a linear decline from third trimester of pregnancy

through three- and nine-months postpartum. These negative effects of an

additional child appear to be long-lasting, as evidenced by a study of

180 married couples with either no children or children five to thirteen

years old showing an inverse relationship between increasing parity

(none, one, or two children) and marital adjustment measured by the

32

Spanier DAS (Rankin, 1981).

Several explanations for the apparent decrease in marital

satisfaction with increasing numbers of children have been presented.

Harriman's (1983) examination of marital change accompanying parenthood

in a mixed parity sample suggests that changes in the sexual relationship

are central to declining marital satisfaction. Forty-eight subjects of

mixed parity drawn from Lamaze classes completed the Fundamental

Interpersonal Relationships Orientation—Behavior instrument (Griffith,

1976). Their responses suggest that discrepancies in the areas of

affection and inclusion account for incompatability during pregnancy.

Whether the decline in affectional and sexual behaviors causes or results

from decreased marital satisfaction, or whether another element of

marital discord is being reflected in less affectional behavior has not

been determined.

Mother—Baby Relationship

Systematic assessment of the mother-baby relationship during

pregnancy is hampered by instrumentation and methodologic limitations.

Contemporary application of reports of increased negativism during

pregnancy towards second babies compared to first (Wallin & Riley, 1955),

positive correlations between negative maternal attitude and increasing

parity (Laukaran & WandenBerg, 1980), and increasing rejection of

pregnancy with increasing parity (Westbrook, 1978a) is limited due to

retrospective designs, inadequately operationalized concepts, and samples

of limited generalizability.

Cranley (1981a, 1981b) devised a 24-item paper-and-pencil

instrument, with items such as "I can hardly wait to hold the baby," to

measure maternal-fetal attachment. Five subscales are designed to assess

33

role-taking, differentiation of self, giving of self, attributing

characteristics to fetus, and interaction with the fetus. She found no

differences by parity following third trimester administration of the

instrument. A developmental sequence throughout the course of pregnancy

was not reported.

Current lay literature describes the mother-second baby relationship

during pregnancy as problematic or somewhat inferior to the first

experience. A mother described her second experience as marked by less

excitement and drama, reporting that she occasionally forgot she was

pregnant (Mattingly, 1983). Brazelton (1981) described a conflicted

mother who did not feel free to attach to her second baby during

pregnancy until given permission by the pediatrician.

Attempts to assess the mother-baby relationship following delivery

have used observational and self-report techniques. Less time was taken

in affectionate interaction with second-borns than with first-borns at

three months of age in a study by Jacobs and Moss (1976). Second-time

mothers had fewer interactions with their newborns on a maternity ward

than first-time mothers (Norr, et al., 1980), which the authors

cautioned may not mean the affectional bond was less strong, but might be

accounted for by less practice needed in baby care or a more easily

established mothering bond.

Father-Baby Relationship

The limitations restricting generalizability of findings about the

mother—baby relationship during second pregnancy pertain as well to the

father's relationship with his expected second child. Prenatally, Weaver

and Cranely (1983) tested a modified version of Cranley's Maternal-Fetal

Attachment instrument with fathers, but they had too few later child

34

pregnancies in their sample of 100 to make parity comparisons.

Postpartally, husbands of first-time mothers are reported to be more

likely to be doing things with the new baby than husbands of second-time

mothers (Norr, et al., 1980). Experienced clinicians describe maternal

doubts that the father will love the new baby like he does the first

(Jimenez & Jones, 1981). Peterson, Mehl, & Leiderman (1979) suggest

that increasing parity is predictive of decreasing father attachment as

assessed by interview and observation up to six months postpartum. Their

measure of attachment is predominantly care-taking activities.

Mother-Child Relationship

The psychological difficulties of preparing to mother more than one

child are graphically presented in a case study report by Jenkins (1976),

who portrays the secundigravida's feelings of betrayal and guilt as she

anticipates her first child's reaction to the newborn and doubts her

ability to love two children equally. Brazelton (1981) has described the

most difficult thing about having a second baby as the necessary

"desertion" of the first. He states that maternal fear that the older

child will suffer and be damaged by rivalry with the new baby is

universal. Another case study (Ulrich, 1982) describes the intense work

involved in gaining acceptance for a second child, illustrating that

maternal bonds with each family member must be loosened and realigned

(Rubin, 1967a). A parents' childcare manual describes different degrees

of love for the firstborn and new baby (Kelly & Parson, 1975). Mothers

are advised not to be ashamed of the overwhelming love they feel for the

first child compared to the prosaic love for the newborn, while being

reassured that they will find a niche for the newborn after months of

daily care.

35

The quality of the mother—child relationship through the course of

second pregnancy is suggested by findings from Richardson's (1983a)

longitudinal study of nine multigravidae. Based solely on maternal

perceptions, the relationship is typically characterized as good or

positive early in pregnancy, becoming problematic later. A progression

of subtle to dramatic and disruptive child behaviors is noted, with the

majority of mothers ranking the overall relationship as more

unsatisfactory than satisfactory. Children sense very early that their

established role position is in jeopardy. A master clinician concurs

that children are aware early of a change regarding their mother

(Brazelton, 1981). He has observed that the mother unconsciously turns

into herself and subtly withdraws from her other children, so that she

is surprised when the children object.

The nature of the dynamics of the mother—child relationship from the

end of pregnancy to the postpartum period is illucidated by several

short-term longitudinal studies. Both mothers and first-born children

exhibited less emotional warmth towards one another at one to two months

after the birth of a newborn than they exhibited shortly prior to birth

(Taylor & Kogan, 1973). Mothers exhibited decreased attention to the

first-born over the same time span (Dunn & Kendrick, 1980; Kendrick &

Dunn, 1980). Longitudinal evaluation comparing firstborn children who do

and do not acquire siblings supports that "dethronement", or the loss of

the firstborn's exclusive relationship with his parents, is marked by

increased dependency behavior to the mother (Feiring, Lewis, & Jaskir,

1983), with males exhibiting more crying and proximity-seeking while

females show more help-seeking behaviors. A sample of 29 mothers who

received private obstetric care, almost all of whom observed regressive

36

behavioral changes in their toddlers on arrival of their newborns, stated

they believed the regression to be a normal developmental or adaptive

phase, with few expressing concern about such change (Kayiatos, Adams, &

Gilman, 1984).

Additional reports describe maternal perceptions of the mother—child

relationship as problematic in the postpartum period. Multiparae

interviewed weekly postpartum often expressed anger and hostility towards

older children by the third week, due to the child's demands and maternal

frustration (Grubb, 1980). Walz and Rich (1983) elaborated the

additional tasks required of the second time mother induced from their

study of 14 middle-class women hospitalized following normal delivery,

which were discussed previously.

Father-Child Relationship

No empirical investigations have examined maternal perceptions of

the course of paternal-firstborn relations during second pregnancy,

although a few small-scale studies have addressed the status of this dyad

following second pregnancy. Kreppner, Paulsen, and Schuetze (1982)

identify the main problem after the birth of the second child as new

structuring of family—home management, in their hermeneutic longitudinal

study of 16 families. They see the doubling of parental involvement in

child-oriented interactions as generating a specific task for the

parents, that of redistributing their attention for children, creating a

new "economy" of parent—child interactions within the family. The

father's role in intrafamilial dynamics is crucial, because he determines

whether the partition of childcare truly relieves the mother from being

forced to "double" her existence. Three patterns of father involvement

were identified. The parents' roles with both children may be

37

interchangeable, the father may increase care for the first child

allowing the mother greater intimacy with the baby, or the father may

perform more household chores while the mother increases care of both

children.

Other observers have commented on occurrence of the second pattern,

that of increased father—firstborn interaction postpartally. Bryant,

Cordaro, Grace, and Meier (1979) and Jimenez and Jones (1981) describe

fathers as finding themselves closer to their older children in the weeks

after birth, in publications for lay audiences. Exploratory field work

using the grounded theory approach suggests that closer father-child

relationships ease the difficulties of affectional and temporal resource

distribution surrounding subsequent childbearing (Sammons, 1983). In

several families studied by LaRossa and LaRossa (1981), the increased

child care demands following second birth were met by increasing the

father's parental role. This was always by increased father care of the

older child, which the investigators attribute to the less demanding

nature of assisting older children.

Child-Baby Relationship

There is a paucity of rigorously obtained information about the

firstborn-baby relationship during pregnancy. As mentioned earlier, an

expert pediatrician has observed that the child senses pregnancy and its

portent of change even before being told (Brazelton, 1981). Maternal

fear of the older child being damaged by sibling rivalry is considered

universal (Brazelton, 1981).

Attempts to reduce the firstborn's expected suffering caused by the

newborn's arrival form the basis of much of the prenatally- and

intrapartally-focused material relevant to the sibling relationship.

38

Prescriptive advice is given in the nursing literature describing how and

when to prepare older children, and how to deal with their behavior after

delivery (Legg, 1974; Malinowski, 1979; Powell, 1981; Vestal, 1979).

Course content for prenatal classes for children and repeat parents is

delineated (Jimenez, Jones, & Jungman, 1979; Sweet, 1979).

The postpartal behavior of the older member of the sibling dyad has

been described by enumeration of common reactions (Legg, 1974). Kreppner

and associates (1982) describe the ambiguous role of first children as

one of trying to emphasize that they are different from the baby, but

also that they have many of the same needs and wants. Dunn, Kendrick,

and MacNamee (1981) have begun to describe normative firstborn behavior

and sibling interaction, correlating factors associated with the

firstborn's reactions prenatally and postpartally using multivariate

analyses.

Variables Affecting Dyadic Family. Relationships in Second Pregnancy

Variables which have an established or suspected effect on the six

family dyads and how they are perceived by the secundigravida will be

presented. The direction of effect will be included in cases where it is

well established.

Factors exerting an influence on marital quality are reviewed in a

monumental work by Lewis and Spanier (1979), who evaluated several

hundred studies representing virtually all empirical and conceptual

propositions related to marital quality and stability. The influences

described relate to marital satisfaction in general, not specifically to

the period of pregnancy. Premarital predispositions including

personality factors, attitudes and values; social factors; circumstantial

factors; marital expectations; and social maturity level affect marital

39

quality. Among social factors, increased marital quality is related to

homogamy of racial, socioeconomic, religious, intelligence, and age

status between partners. Generally, greater social and personal

resources are related to greater satisfaction. Greater marital

satisfaction from parental models and greater support from significant

others also contribute positively to later marital quality. Following

marriage, social and economic factors affect the relationship. Increased

satisfaction is related to higher socioeconomic status, greater community

embeddedness, and decreased density in household composition. The effect

of wives' employment is complex, apparently related to an aspect of

mutual satisfaction with her degree of workforce participation.

Interpersonal and dyadic factors also relate to marital quality, with

greater positive regard, emotional gratification, communication, role fit

and interaction all correlated with increased satisfaction in marriage.

Multiple factors are considered to affect the parent-infant

relationship. Most attention has been given to the mother-baby dyad. A

theoretical consideration of factors impacting on maternal role

attainment relates enhanced role attainment to positive perceptions of

the birth experience, decreased social stress, increased support systems,

positive self-concept, good maternal and infant health, easy infant

temperament, and types of child-rearing attitudes (Mercer, 1981). The

impact of age is complex, suggesting differing processes among teens,

twenties, and thirty-year olds. Conflicting evidence on early maternal

infant separation has been found. A study of adaptation to motherhood in

20 primiparae revealed that previous experience with infants, and

positive perceptions of help from postpartum nurses and husbands were

additional significant variables (Curry, 1983).

40

While the previous two investigators have focused on the mother

infant dyad for first-time mothers, Kirkpatrick (1978) has developed a

structural model for multiparae distinct from primiparae. In the five

tiered model, the first level includes factors of education, present

income, and number of children; the second level includes childbearing

attitudes, wife's income prior to first and last pregnancy, age at first

parenthood, length of marriage prior to parenthood, and number of

children desired; the third level includes attitudes to pregnancy and

preparation for parenthood; the fourth level is composed of marital

adjustment, concept of the infant, income at time of birth, and spacing;

and the final variable is adjustment to parenthood. Importance of age of

the firstborn is well-supported. Children less than two years old when

their siblings are born are more dependent and have less positive social

behavior than their older counterparts (Feiring, Lewis, & Jaskir; 1983).

Discussion to this point has been limited to the mother-baby dyad

after delivery. Cranley (1981b) examined the relationship between

maternal—fetal attachment in the third trimester and other variables.

She found no differences in attachment scores due to antecedent or

demographic variables, including self-esteem and trait anxiety. Two

situational variables measured in her study were significantly correlated

to fetal attachment, with strong social support (most often provided by

husbands) evidencing a positive influence, and high perception of stress

during pregnancy demonstrating a negative influence. Closely spaced

pregnancies appeared to affect fetal attachment, since multigravidae with

a child 18 months or younger at home had lower attachment scores and

higher perceived stress levels. The effect on fetal attachment of

diagnostic technologies which might give a keener sense of the fetus or

41

knowledge of the sex awaits large-scale testing (Beeson, Douglas, &

Lunsford, 1983). The mother's ordinal position within her family of

origin has no established effect upon mother-baby or mother-child

relationships during pregnancy, but speculatively could arouse empathy

for the similarly placed offspring, since women experience a revival of

early childhood conflicts with siblings and parents during pregnancy

(Caplan, 1957).

The mother-firstborn dyad is affected strongly by the age of the

firstborn. More satisfactory mother—child relationships are reported by

women towards the end of subsequent pregnancy when the child at home is

younger than two or between seven and fourteen years of age (Richardson,

1983a). Postpartally, method of infant feeding may affect the mother's

relationship with both children, as some observers have noted the

greatest amount of jealous behavior at nursing (Kelly & Parson, 1975),

while others have identified bottle-feeding as an additional stressor

(Lynch, 1982).

Interactive effects of variables may influence the mother's

relationships with family members. Both breastfeeding and maternal

employment postpartally lead to problems of role overload in response to

multiple demands (Auerbach, 1984). Results of a study of 105 working and

nonworking primiparae five to nine months postpartum suggest work

involvement should be considered an individual difference variable in

research on new motherhood (Pistrang, 1984). Women for whom work before

pregnancy had high importance, but who found themselves not working

postpartally, reported increased irritability, decreased marital

intimacy, increased costs of motherhood, increased depression, and

decreased self-esteem compared to postpartum non-workers with low pre

42

pregnancy work involvement. Among working mothers, previous work

involvement was unrelated to motherhood experiences.

Factors affecting the father-baby and father-child relationships are

less well established. Future inquiry should monitor those variables

already acknowledged as salient for the parallel maternal dyads. In

addition, there appears to be some basis to the claim that fathers prefer

boys (Parke, Power, Tinsley, & Hymel, 1979), exhibiting a stronger

preference for boys than do mothers, to the extent that couples will have

more children than they originally planned to try for a son (Hoffman,

1977).

Factors affecting the child-baby relationship have been detected by

Dunn, Kendrick, and MacNamee's (1981) multivariate analysis of firstborn

reactions to a newborn among their intensely studied longitudinal

subjects. The temperament of the child is correlated with diverse

reaction patterns. Males exhibit more withdrawal than females, and

younger children demonstrate more clinging than older ones. Maternal

state affects the child's response, with increased maternal tiredness or

depression associated with greater child withdrawal. Bottle feeding was

related to increased irritating behaviors by the child to the baby.

Interactive effects of child's temperament, sex, and mother's state were

found to affect child withdrawal and sleep problems. Postpartally, the

nature of mother—firstborn interactions is correlated with types of

sibling interaction. Increased maternal prohibition to the child is

associated with increased firstborn irritating behaviors towards the

newborn (Dunn, Kendrick, & MacNamee, 1981).

Interrelationships among the family dyads in second pregnancy are

suggested. A strong marital relationship appears to aid the

43

establishment of a positive mother-baby relationship (Richardson, 1981;

Richardson, 1983b; Westbrook, 1979b). A strong father-child relationship

has potential to ease the demands of the mother-baby relationship

(Kreppner, Paulsen, & Schuetze, 1982; Sammons, 1983). Mothers' binding

in to the unborn child may be paralleled by a process of coming to see

one's other children as increasingly separate from oneself (Richardson,

1983a). Mothers with problematic mother—firstborn relationships

particularly withdraw from their children during second pregnancy, while

toddlers and preschoolers frequently reveal new preferences for fathers

or other close family members, and older children become more involved

with peer groups (Richardson, 1983a). The role of the father emerges as

central to facilitating role establishment and renegotiation. Yet he may

find himself virtually unsupported, since the mother focuses on the

mother-child dyad nearly to the exclusion of her relationship with her

husband in her efforts to gain acceptance of the new baby (Walz & Rich,

1983). The mother perceives the mother—child relationship as in jeopardy

and demanding attention, while the marital relationship is regarded as

stable and self-sustaining (Walz & Rich, 1983).

Conclusions

A major thrust among the limited previous investigations of family

relationships in second pregnancy has been to compare the satisfaction or

quality in these relationships to families experiencing addition of the

first child. Where parity differences have been found in such studies,

they uniformly present more negative results for subsequent childbearing.

Family interrelationships are consistently portrayed as highly

conflictual and problematic with the addition of a later-born child.

Therefore, it is appropriate to move the focus of investigation beyond

44

simple parity comparisons to a more indepth examination of the processes

and dynamics of these apparently troublesome relationships.

Measurement problems compromising previous study of family

relationships must be addressed. Relationships are multifaceted,

requiring that the particular aspect of the relationship which is of

interest be specified, while attempting to enhance the validity of

measurement instruments.

Literature review has revealed a multitude of demographic,

attitudinal, and experiential factors which affect the six dyadic

relationships in the secundigravida's family. An attempt should be made

to monitor as many sources of potential extraneous variance as possible

in future investigations, to assist in clarifying relationships between

variables. Re-examination of previous findings is called for,

considering the emergence of new variables such as increased maternal

work—force participation and new prenatal diagnostic modalities.

Previous research on family relationships has failed to reflect

experiences of a broad range of families. Sampling from predominantly

Lamaze class registrants or members of a single socioeconomic status

precludes generalizability to a wider segment of the population. Large

scale, contemporary sampling is indicated.

An adequate description of family relationships during second

pregnancy requires data collection commencing early in pregnancy. With

the notable exception of Richardson's sample of nine multigravidae

(1981), there has been a failure to assess dyadic relationships of

secundigravidae which include the firstborn throughout the course of

pregnancy. Others, such as Dunn and Kendrick (1980), have followed their

subjects from third trimester through the second-born's early childhood.

45

An investigation using the same measures on a sample reflective of

pregnancy from the first trimester to the postpartum period would present

a fuller representation of the childbearing experience.

Somatic Symptoms in Second Pregnancy

Introduction

The meaning and origin of symptoms in pregnancy may be viewed from

one of three perspectives. Symptoms are defined as perceptible changes

in the body or its functions indicating disease (McKechnie, 1975, p.

1849) or dysfunction. The first perspective, derived from the

psychoanalytic tradition, considers symptoms as manifestations of

intrapsychic conflicts. Earlier studies would be expected to express

this viewpoint, which would be consistent with the historical prominence

of the psychoanalytic perspective in the early literature on psychology

of pregnancy. For example, Wallin and Riley (1955) considered nausea and

vomiting (heavily weighted), backache, cramps, and fatigue during

pregnancy to be measures of "acceptance or rejection of the coming

child." As an offshoot of the line of inquiry which seeks to determine

the relationship between psychological attributes during pregnancy and

complications of labor and delivery, Heinstein (1967) examined attitudes,

fears, physical symptoms, and perinatal outcomes of 156 low income clinic

patients of mixed parity. Finding an increase in general physical

discomfort for women during pregnancy compared to before pregnancy, he

acknowledged some contribution from physiological changes, but concluded

that anxiety and fear compounded the difficulties which subjects felt

about pregnancy. A psychiatrist found a group of primigravidae used

symptoms and medical concerns to communicate their emotional states

(Colman, 1969). A relationship between symptom ratings and decreased

46

satisfaction with their bodies, more negative or ambivalent feelings

about pregnancy, and greater menstrual stress among 19 primigravidae led

Leifer (1977) to conclude that the range of somatic distress must be

attributed to personality patterns related to previous psychosocial tasks

and body image.

A second perspective is based on the assumptions of family therapy.

This view holds that individual symptomatology and family interaction are

meaningfully related over time. A study of five mother—father—child

families wherein the child was encopretic demonstrated the relationship

between particular family interaction dimensions and symptoms of

involuntary defecation (Straker & Jacobson, 1979). A moderate but

significant correlational relationship was found between family

developmental crises involving addition or loss of a family member and

onset of symptoms in an individual family member (Hadley, Jacob,

Milliones, Caplan & Spitz (1974). In a study of the addition of a family

member by birth, Ventura (1982) found interactive effects between newborn

infant temperament and parental reports of depression, anxiety, and

somatization.

A third perspective guiding reports of symptoms during pregnancy is

derived from a clinical or physiological orientation. The etiology of

discomforts of pregnancy is perceived as physical sources such as changes

in the musculoskeletal, cardiovascular, and gastrointestinal systems

(Horan, 1984). The goal of such reports is expansion of empirically

based data for improved assessment of pregnancy-related discomforts and

improved therapeutic interventions. Exclusive adoption of a single

perspective is not essential. Horan's (1984) report, which is

physiologically oriented, acknowledged the affects of stress and crises,

47

such as difficult family relationships, in increasing discomfort.

Erickson (1967), reporting on instrument development for symptom

assessment in an era dominated by imputation of psychosomatic

attribution, recognized the practical benefits of identifying "high risk"

patients for therapeutic intervention.

Prenatal Symptomatology

A description of the symptoms of second pregnancy is usually made in

comparison to the first pregnancy. Experienced clinicians list increased

backache, fatigue, varicose veins, and hemorrhoids as distinguishing

symptoms of second pregnancy when writing for the general public

(Hillard, 1983; Jimenez & Jones, 1981). Studies of parity differences in

symptom occurrence present discrepant results. No parity differences

were found when assessed before 16 weeks by Grimm and Venet (1966), or

with cross-sectional evaluation throughout pregnancy by Heinstein (1967).

Kaij, Jacobson, and Nilsson (1967) found multiparae were more often

healthy until delivery and showed lower frequency of onset of slight

psychiatric symptoms during pregnancy, as measured by questionnaires

listing numerous minor physical symptoms mailed postpartally. On the

other hand, multiparae were found less likely to feel very good and more

likely to report greater fatigue during second pregnancy when questioned

postpartally (Norr, et. al., 1980); multiparae scored significantly

higher on irritability and tension, on depression and withdrawal, and on

a Lack of Health During Pregnancy scale administered during all stages of

pregnancy (Erickson, 1976); and to rate higher on a standardized

depression scale in the third trimester (Jarrahi–Zadeh, Kane,

Wandecastle, Lachenbruch, & Ewing, 1969).

Temporal, experiential, and demographic variables have been found to

48

affect symptom occurrence in second pregnancy. Somatic symptoms varied

by trimester as a function of previous pregnancy history in a

longitudinal study by Lubin, Gardener, and Roth (1975). They found

somatic symptoms described a "W" shaped curve for secundigravidae with no

previous abortion (spontaneous or therapeutic), and an inverted “V”

shaped curve in secundigravidae with previous pregnancy termination,

compared to consistent decrease over trimesters for primigravidae. They

attribute the high second trimester score to fear of repeated pregnancy

loss, in a sample where most abortions were spontaneous.

Erickson (1967) devised a checklist assessing the frequency of 31

symptoms which nine primigravidae and 11 multigravidae were to complete

nightly throughout pregnancy. No statistical analyses were attempted on

the small sample, but trends were observed. Symptomatology was not

highly related to trimesters, but groups of symptoms demonstrated trends

through time. Fatigue, depression, irritability, and anxiety were

reported most frequently in the first half and last month of pregnancy.

Backache, increased appetite, tension, and increased sexual desire were

relatively constant through pregnancy. Nausea, vomiting, headache,

decreased sexual desire, and euphoria were generally limited to the first

trimester. Insomnia was problematic throughout pregnancy, increasing the

last month. Swollen limbs, shortness of breath and groin pain were only

problematic the last month.

Increasing socioeconomic status has been found to correlate with

increased physical symptoms (Doty, 1967), while subjects with less than a

high school education recorded significantly more psychosomatic anxiety

than better educated counterparts in another study (Heinstein, 1967).

Incidence of gastrointestinal symptoms of nausea, vomiting or upset

49

stomach was not affected by age, race, education or parity in that study

(Heinstein, 1967). The linkage between somatic symptoms and emotional

status, referred to above, will be discussed further in a later section.

Postpartum Symptomatology

The salience of somatically-oriented topics revealed in studies of

postpartum concerns has been addressed previously in this paper.

Multiparae are concerned with their weight (Larsen, 1966; Lynch, 1982),

body alterations (Moss, 1981), and returning their figures to normal

(Gruis, 1977).

Investigations examining the effect of parity on postpartum

symptomatology reveal slightly more discomforts for multiparae. Fatigue

was the fourth most common concern of the multiparae in Gruis' (1977)

study, reported by 83% of repeat mothers, but was not among the most

highly rated concerns of primipare. On the third postpartum day,

multiparae scored higher on depression, mood change, and fogginess than

primipare (Jarrahi-Zadeh, et al., 1969). While total sample parity

comparisons of 861 Swedish mothers showed no differences in neurotic

symptoms measured by the subjects' own recall of mild somatic symptoms, a

subsample analysis did differentiate by parity (Kaij, Jacobson, &

Nilsson, 1967). Among three-fifths of the sample, increasing occurrence

of "psychiatric symptoms" such as irritability, feeling dyspnea, and

globus was related to increasing number of full-term pregnancies. No

confirmation of the subjects' physical or mental health status

independent of self-administered questionnaire responses is reported.

Analysis of postpartum symptomatology requires consideration of

other factors potentially affecting the woman's discomfort level.

Breastfeeding may produce discomforts and fatigue not experienced by

50

bottle-feeding mothers. The delivery experience may affect postpartum

symptom levels, for example the increased pain resulting from a Cesarean

delivery compared to a vaginal delivery (Frink & Chally, 1984).

Conclusions

Further study is needed to verify and amplify the secundigravida's

experience of somatic symptoms. Synthesis of previous findings is

difficult due to a failure to adopt standardized techniques of

measurement and reporting.

Several aspects of symptom occurrence require clarification. Parity

comarison studies may be misleading if they report no difference between

groups when relying on comparison of simple summation scores. The types

of discomforts experienced may have varied by groups, but such data would

be lost by comparing only number of symptoms. Global reports of symptom

occurrence have less value than reports of particular symptom patterns

(e.g. Erickson, 1967) for clinical applications seeking information for

anticipatory guidance and preventive education. Analysis by comparison

of group means also loses information about individual differences. A

longitudinal study through two pregnancies, examination of meticulous

records maintained through subsequent pregnancies, or measurement of a

gravida's perception of somatic symptoms in comparison to previous

pregnancy would enable evaluation of an individual's comparative

experience of symptoms during pregnancies. Also, a distinction must

be made between whether particular symptoms are scored equally regardless

of the frequency and severity of occurrence, or if symptoms are weighted

according to these parameters. Erickson (1967), for example, proposed a

four-point rating scale based on frequency of occurrence. Criteria for

symptom item inclusion also requires explication.

51

Large sample studies of secundigravidae collecting data

prospectively throughout the course of pregnancy are required. Just as

Heinstein found in 1967, there are still no such studies which provide a

basis for determining what are the normal expectations for physical

complaints during pregnancy.

Interrelationships Between Anxiety, Family Relationships, and Somatic

Symptoms in Second Pregnancy

A review of the interrelationships between the three variables of

interest in second pregnancy leads to consideration of three sets of

paired variables, anxiety and family relationships, anxiety and somatic

symptoms, and somatic symptoms and family relationships.

Anxiety and Family Relationships

Families are units composed of interacting personalities, wherein a

change in one part of the family affects change in other parts (Rowe,

1981). Hence, changes in the anxiety level and behavior of one member

would be expected to influence dyadic family relationships. While no

investigation has systematically assessed such influences on multiple

dyads in second pregnancy, the effect of maternal anxiety on particular

dyads is suggested. The appropriateness of examining the relationship

of individual personality traits or characteristics and the marriage

relationship is supported by Filsinger and Wilson (1983), who found

social anxiety to be negatively correlated with marital adjustment of the

subject, but not the spouse, in a sample of married couples. Davids,

Holden, and Gray (1963) found high maternal anxiety, as measured by the

Taylor MAS in third trimester, related to increased marital conflict and

greater irritability towards the husband. Brown (1984) reported anxiety

52

in a sample of 313 primigravidae to be positively related to satisfaction

with partner support.

While Cranley (1981b) did not find maternal—fetal attachment scores

significantly affected by trait anxiety, she did find a significant

correlation with high perception of stress during pregnancy and lower

scores. Perhaps a measure of maternal transitory state anxiety would

better capture this dynamic. The relationship between anxiety levels and

maternal-baby attachment is complex, as illustrated by Leifer's (1977)

findings based on firsttime mothers. She reported that the focus of

anxiety during pregnancy must be specified, since high anxiety about the

fetus reflected attachment, but high self-concern occurred in women with

minimal attachment to the unborn baby.

The effects of prenatal maternal anxiety on the mother-baby

relationship postpartally are identified by Davids, Raymond, and Gray

(1963), who found high prenatal anxiety scores related to greater

dissatisfaction with the role of being a mother and greater irritability

with children. Whether increased maternal anxiety would cause similar

disaffection between the father and baby, via modeling, or whether the

father would adopt compensatory affectional behaviors is not determined.

Increased maternal anxiety would be expected to strain the mother

firstborn relationship, particularly postpartally, when the mother is

susceptible to external stressors (Grossman, Eichler, & Winickoff, 1980),

the mother—firstborn dyad is problematic (Richardson, 1983a), and

pressure is exhibited as anger and hostility towards the child (Grubb,

1980). Again, response to maternal anxiety in the father—child dyad is

not know. Dunn, Kendrick, and MacNamee (1981) established the

relationship between the mother's depression and negative mood and the

53

firstborn's response to the newborn, but they did not measure maternal

anxiety.

Anxiety and Somatic Symptoms

A positive relationship appears to exist between maternal anxiety

and somatic symptom levels in subsequent pregnancy. Previously discussed

studies found positive correlations between anxiety and fears and

reported symptoms in first and later pregnancies (Colman, 1969;

Heinstein, 1967). Entwistle and Doering (1981) also found that their

primiparous subjects with the most symptoms reported the most anxiety.

Doty (1967) found a correlation between anxiety measured by the Taylor

MAS and physical symptom levels in a third trimester sample of mixed

parity. Lubin, Gardener, and Roth (1975) found a positive significant

correlation between anxiety, measured by both the IPAT and AACL, and

somatic symptoms over the three trimesters of pregnancy, in their sample

of mixed parity. Heinstein (1967) found that women of mixed parity who

were more fearful for themselves or the baby experienced greater

depression, psychosomatic anxiety, and sleep disturbance in a cross

sectional sample from each trimester.

Somatic Symptoms and Family Relationships

Tentative relationships between somatic symptom levels and selected

family dyads are suggested. Positive correlations were found between an

aspect of marital quality, women's satisfaction with partner support, and

levels of emotional and physical symptoms in Brown's (1984) primiparous

sample. Correlation between maternal symptoms and the mother-baby

relationship is suggested by Heinstein's (1967) findings that pregnant

women who expressed positive attitudes and feelings about pregnancy also

reported fewer physical complaints, in a mixed parity sample of 156 women

54

drawn from each trimester. Attitudes towards the condition of pregnancy

cannot be equated with feelings towards the new baby, however. The

mother—firstborn dyad may also be influenced by maternal physical

symptoms, as the mother's fatigue and discomfort add to a relationship

already described as problematic towards the end of pregnancy and into

the postpartum period (Richardson, 1983a; Dunn & Kendrick, 1980).

Conclusions

In conclusion, it appears that the three variables of anxiety,

family relationships, and somatic symptoms during second pregnancy are

interrelated. Statements describing causal linkages between correlated

variables cannot be made.

Anxiety levels are related to family relationships in two regards.

On the one hand, maintenance and renegotiation of each family dyadic

relationship may be a focus of anxiety and a source of concern to the

secundigravida. On the other hand, maternal anxiety levels may affect

the dynamics of the three dyads of which she is a member, and the three

dyads upon which she exerts an indirect influence.

Maternal anxiety levels during pregnancy and levels of somatic

symptoms also appear to be related. Whether this correlation exists in a

sample of women all experiencing second pregnancy and evaluated

throughout pregnancy has not been determined.

The degree of somatic symptoms experienced by the secundigravida is

logically related to the character of the three family dyads of which she

is a member. Whether somatic symptoms are construed as reflective of

emotional and psychological processes or simply as physiologically based

alterations affecting one's feeling of well-being, they can be expected

to influence some aspect of the pregnant woman's interactions and

55

emotional involvement with her mate, her firstborn, and her new baby.

The relationships between these variables have not yet been

systematically investigated in second pregnancy.

Definitions and Hypotheses

Definitions

Second pregnancy is defined as pregnancy in anticipation or

delivered of a second live birth, acknowledging that additional

pregnancies may have terminated in spontaneous or therapeutic abortion

prior to 20 weeks gestation. Fourth trimester and the postpartum period

are used interchangeably to designate the first three months following

delivery. Anxiety is the subjective, consciously perceived feeling of

tension and apprehension composed of both state and trait dimensions

(Spielberger, 1976). Concerns are the cognitions which stimulate anxiety.

Hypotheses

The following hypotheses related to study research questions were

tested among women experiencing second pregnancy:

Hypothesis 1: Second trimester maternal state anxiety and somatic

symptom frequency will be lower than first or third trimester reports.

Hypothesis 2: The number of family relationship concerns of the

mother in third trimester will be greater than first or second trimester.

Hypothesis 3: Marital satisfaction will decline from second

trimester to fourth trimester.

Hypothesis 4: Somatic symptom occurrence will be perceived as higher

during second pregnancy than during first pregnancy.

Hypothesis 5: Maternal anxiety, somatic symptom frequency, and

level of family relationship concerns will be positively related to each

other and inversely related to marital satisfaction.

56

Chapter III

Methodology

Introduction

This chapter describes the research design, research settings,

sample size and selection criteria employed in this investigation. Data

collection instruments and procedures which were chosen for investigating

the research questions and testing the hypotheses are also discussed.

Design

The investigation took the form of a passive observational study

(Cook & Campbell, 1979), since there was no true manipulation of an

independent variable in order to observe causal effects on dependent

variables. In a developmental study such as this one, age is considered

to be an "index variable" (Baltes, Reese, & Nesselroade, 1977) that

provides a clear ordering of events.

A modified cross-sectional sequential design was conducted to

examine the levels and inter-relationships of maternal anxiety, somatic

symptoms, marital satisfaction, and family relationship concerns through

the course of second pregnancy. Sequential designs arise from the three

dimensional analyses of development conceptualized by Schaie (1965),

wherein time, age, and generation are components of development which may

be confounded in any combination. Goldstein (1979) has subsequently

argued that the design is adequately conceptualized by two dimensions,

age and time. In this study, the age dimension is represented by

increasing gestational age, or progression through the three trimesters

of pregnancy and the postpartum period (Ages A-1, A-2, A-3, and A-4). The

time dimension is represented by the interval of three months between the

57

Fourth Trimester (A-1) S-4 (n=35) S—3 (n=46)

Third Trimester (A-2) S–3 (n=47) S–2 (n=41)Age 2

Second Trimester (A-3) S–2º S-1 (n=48)First Trimester (A-4) S-1 (n=65)

T–1 T–2

Time

Figure 3.1, Sample distribution in modified cross-sectional sequential

design.

Cell designations: S-X = Subjects subgroup; () = Number of subjects.

two test periods (Times T-1 and T-2).

A cross-sectional sequential design (see Figure 3.1) requires the

traditional observations of a cross-sectional design, which are

observations of members of various cohorts made at a single point in

time, embellished by additional observations of members of each cohort

(except perhaps the oldest cohort) at a specified time later (Schaie,

1965). As Hill and Rodgers (1964) have admonished, a synthetic pattern of

development from cross-sectional data can only suggest developmental

patterns. While cross-sectional methodology per se does not get at

intra-individual change, cross-sectional age differences can be

interpreted as average, intraindividual changes if it can be argued that

the different age groups come from the same population and differ only in

age (Baltes, Reese, & Nesselroad e, 1977).

58

A cross-sectional sequential design provides advantages over either

a simple cross-sectional or simple longitudinal design. The repeated

testing of the same subjects constitutes a "segmented longitudinal study"

(Hill & Rodgers, 1964), or a "one-group pretest-posttest segment"

(Campbell & Stanley, 1963). By also testing different aged groups at

each interval, which can be classified as a "static group comparison"

(Campbell & Stanley, 1963), potential problems of strictly longitudinal

studies from the effects of history and test-retest effects are

diminished. Hence, advantages of longitudinal study allowing measurement

of individual change, and advantages of cross-sectional design, allowing

between—cohort observation, are both achieved in a short period of time.

Usage of the label "cross-sectional sequential" design differs

slightly from that specified by Baltes (1968), who intended to designate

independent observations at all cohort and age levels. Independent

longitudinal observations, as would be created by testing only a randomly

selected half of the sample at each of the two observation periods, would

require twice the sample size, hence doubling recruitment costs.

Therefore, the longitudinal observations were repeated testings of the

same subjects, which is compatible with Schaie's (1965) original

conceptualization.

Setting

Subjects were recruited principally from the obstetric clientele

of a large prepaid Health Maintenance Organization (HMO) in the San

Francisco Bay Area. Although random sampling for representativeness was

clearly not feasible, the selected HMO provided an impressionistic modal

setting (Cook & Campbell, 1979, p. 77) for such an investigation.

59

Services at the selected HMO are available to members and their eligible

dependents who participate through employer—sponsored group health plans

offered to a broad occupational range, as well as to independent

subscribers who may be self-employed or retired. Hence, this HMO

clientele is more broadly reflective of the naturally occurring

heterogeneity in socioeconomic status, age, race, and level of obstetric

complications than would be found by sampling solely at alternative sites

such as the county health care facility, a tertiary medical center

facility, or private health care offices.

This HMO serves 30–50% of the population of Northern California,

where it has achieved a high degree of acceptability (Marymee, 1984).

Obstetric clients delivering at the selected site (200–240 deliveries per

month) receive their ambulatory care at either the main medical complex

or one of two satellite clinics. The majority (86.4%) of the 191 study

subjects were recruited from the HMO clientele, with 35.1% receiving care

at the main medical center (Site 1), 35.6% at one satellite clinic (Site

2), and 15.7% from the second satellite clinic (Site 3). In addition, in

order to hasten the timely accrual of an adequate sample, subjects

constituting 13.6% of the study population were recruited from a private

group obstetrical practice (Site 4), which performs deliveries (20–40 per

month) at the private community hospital in the same city.

Sample

One hundred and ninety-one women who met study inclusion criteria

were inducted into one of four subject groups (S-1 to S-4) during a

prenatal or postpartum clinic visit for their second live birth

pregnancy. The inclusion criteria were: 1) pregnant or delivered within

the previous 3 to 12 weeks, 2) history of only one previous pregnancy

60

carried to term with that first child living at home, 3) present

pregnancy medically uncomplicated (i.e., not labelled "high risk" at the

HMO setting, which excluded maternal diabetes, cardiac disease,

hypertension, collagen disease, malignant tumor, multiple gestation, or

onset of labor before 36 weeks gestation), 4) the firstborn, and newborn

if delivered during the subject accrual period, were free of severe acute

or chronic illness, 5) the woman was married to or living with the

father of both children, 6) she read and spoke English, and 7) she

planned to stay in the geographic area for four months if a second

observation of her cohort was required.

The inclusion criteria dictated certain restrictions in family

structure and health status in order to limit sources of extraneous

variance potentially affecting the dependent variables of anxiety, family

relationship concerns, and somatic symptoms. Limitations on the women's

verbal skills and plans for travel from the area were enforced in order to

facilitate completion of research instruments at two time intervals.

The number of subjects (see Figure 3. 1) recruited initially (T-1)

into each group was: S-1 (initially in their first trimester) = 65,

S–2 (initially second trimester) = 44, S-3 (originally in the third

trimester) = 47, and S-4 (in the fourth trimester) = 35. The cross

sectional sequential design (Baltes, 1968) involved a repeated testing of

all cohorts except the inital post-delivery group at the second

observation period three months later (T-2). Having determined through

power analyses, as discussed subsequently, that measurement scores from

30 subjects in each of groups S-1, S-2, and S-3 must be obtained

at T-2, overrecruitment for these groups was undertaken to allow for

occasional incomplete measures and attrition over the ensuing three

61

months. Attrition was minimal. At T-2, 48 subjects from group S-1, 41

subjects from S-2, and 46 subjects from S-3 participated (see Figure 3.1)

The number of T-2 participants from group S-1 is not reflective of

subject mortality rates. When an adequate number of T-2 measures for

that group were obtained, no further subjects were retested. Reasons for

subject loss are described with study procedures.

Power analyses demonstrate the achieved sample size is sufficient to

reveal at least large effects sizes for all planned analyses when o' = .05

and power = .80, performing two-tailed tests. Independent sample measure

comparisons (n=30) detect standardized difference means of d-.75

(Cohen, 1977). Related sample measure comparisons (n=30) detect

standardized difference means of .53 (Cohen, 1977). Correlational

analyses (n=60) detect magnitudes of association corresponding to effect

size nearing a medium range of .30 appropriate for much psychological

investigation (Cohen & Cohen, 1975).

Data Collection Methods

Data were collected through the use of self-administered paper-and

pencil instruments completed by the subjects. A packet, introduced by

instructions and consent forms (Appendices A & B), containing the

instruments described below was delivered to participants.

Demographic and Background Data Sheet

The Demographic and Background Data Sheet (Appendix C) is an

original questionnaire covering personal and family demographic,

experiential and attitudinal variables which have been identified by

literature review and clinical experience as having potential influence

on maternal health and family relationships during second pregnancy.

62

Information was solicited about maternal and paternal age, occupation,

education, race, and religion; about firstborn characteristics,

obstetrical history and attitudes, and perceived health status; and about

delivery and newborn characteristics for women who had already delivered

their second child. Evolution of the form to maximize clarity and

relevance, while minimizing difficulty or bothersome characteristics,

included pilot testing by women meeting study inclusion cirteria,

revision, additional critiquing by secundigra vidae, and further refining.

Additional input from three faculty experts in maternity and family

health was incorporated into the third and final version.

Spielberger State-Trait Anxiety Inventory

The State-Trait Anxiety Inventory Self-Evaluation Questionnaire

(STAI) (Form Y) (Speilberger, et. al., 1983) is a tool with well

established validity and reliability for measurement of anxiety in

research and clinical practice. The S–Anxiety scale, measuring state

anxiety (see Appendix D), is composed of twenty statements reflecting the

respondent's anxiety "right now". This sensitive indicator for

measurement of transitory anxiety is suitable for repeated administration

(Spielberger, 1976). The T-Anxiety scale, measuring trait anxiety (see

Appendix E), uses twenty statements to evaluate the respondent's anxiety

in general. Each statement is rated on a score of 1 to 4 indicating

intensity of tension, apprehension and nervousness.

This recently modified (Form Y) version of the test was revised as a

purer measure of anxiety, discriminating more precisely between anxiety

and depression. Internal consistencies for state and trait scales are

high as measured by alpha coeeficients (.92 and .90 overall median scores

for normative samples) and item—remainder correlations (Spielberger, et

63

al., 1983). In the present study, alpha coefficients for S-Anxiety were

.93 at T-1 (180 cases) and .94 at T-2 (134 cases). Cronbach alpha

reliability for T–Anxiety at T-1 based on 188 cases was .93. In

addition, concurrent, convergent, divergent, and construct validity of

the STAI scales have been established. Although test scores were

normalized on working adults, college students, high school students and

military recruits, the STAI has well-established use in the subpopulation

of pregnant women (see, for example, Lederman et al., 1981a; Norbeck &

Tilden, 1983).

Dyadic Adjustment Scale

To aide in selection of the optimal instrument for assessment of the

marital relationship during second pregnancy, four multiparae were

administered both the DAS (Dyadic Ajustment Scale) (Spanier, 1976), and

another commonly used instrument, the Locke-Wallace Short MaritalAdjustment Scale (Locke & Wallace, 1959). All respondents preferred the

DAS in terms of ease, emotional comfort, validity, and appropriateness for

a contemporary sample. In addition, the parity status of the married

sample on which the DAS was normalized (mean number of children is two)

supports its suitability for use in study of second pregnancy.

The Dyadic Adjustment Scale (DAS), a widely used paper-and-pencil

measure of marital adjustment, was therefore chosen to assess maternal

perception of the marital relationship. The test has 32 items (Appendix

F) reflecting couple agreement, communication, affection, and commitment.

Content, criterion-related, and construct validity have been documented

(Spanier, 1976). Factor analysis has identified four interrelated

components. These four subscales, labelled consensus, satisfaction,

cohesion, and affectional expression, demonstrate adequate factor

64

stability (Spanier & Thompson, 1982).

Total scale reliability has been reported at a level of .96 for both

Cronbach's Alpha and Spearman–Brown formulas for internal consistency.

(Spanier, 1976). Reported subscale Cronbach alpha values range from .73

to .94. The alpha reliabilities for 173 cases at T-1 and 123 cases at T

2 in this study were: total .93, .89; consensus .82, .80; cohesion .78,

.73; affection .62, .63; and satisfaction .89, . 83.

Family. Relationships Questionnaire

An original instrument for assessment of maternal concerns about

dyadic relationships in a family experiencing second pregnancy was

developed. Because a suitable standardized instrument was available only

for evaluation of the marital relationship, the new instrument was

designed to evaluate maternal perception of the five remaining dyads in a

family adding a second child.

The instrument, the Family Relationships Questionnaire (FRO), was

constructed using an inductive approach. Protection of the rights of

human subjects during instrument development was supervised by the

Committee on Human Research, Univerity of California, San Francisco,

under approval #933416–01.

Statements reflecting maternal perception of concerns about the

mother-baby, father-baby, mother—firstborn, father—firstborn, and

firstborn-baby dyads were collected via an open-ended questionnaire

survey distributed to a convenience sample of 20 women pregnant with or

recently delivered of their second child. This approach for item

generation was selected to provide empirical grounding to material

gathered from literature review and the investigator's clinical

experience and previous field study (Sammons, 1981). The sample of 20

65

was recruited from prenatal "refresher" multigravid Lamaze class

registrants, women known to the investigator socially and their

acquaintances, and patients of the private obstetric practice where the

investigator was affiliated as a Nurse Practitioner.

The questionnaire, composed of questions focusing on each dyad

during the present pregnancy and the previous pregnancy, plus two global

questions requesting comparison between the woman's first and second

pregnancies, was personally distributed or mailed to 29 women. A sample

question asked, "What do you think about most these days regarding your

husband's relationship to your older child?" Twenty questionnaires (69%)

were returned, with seven from first trimester subjects, five from women

in the second trimester, four from those in the third trimester, and four

from women who were six to eight weeks postpartum. Time required to

complete the questionnaire ranged from 10 to 90 minutes.

Questionnaire responses were collated by dyad. For each of the

dyads, the following number of statements were recorded: Mother-baby

41, Father—baby 36, Mother—firstborn 38, Father—firstborn 34, and

Firstborn-baby 47. From the raw responses, three to eight statements were

constructed for each dyad and assembled as Preliminary FRO's. Parallel

versions were created to reflect prenatal and postpartum concerns.

Statements were intended to reflect concerns that were common and which

would be sensitive to and discriminating of varying levels of concern.

Theoretical considerations also guided item selection. An earlier field

study by the investigator suggested that critical dimensions in family

response to arrival of a newborn were affectional, temporal, spatial, and

informational resources (Sammons, 1983). An attempt was made to include

statements for each dyad reflecting these dimensions.

66

The instrument was constructed so that respondents indicated their

level of agreement (1=Strongly agree to 5=strongly disagree) on a five

point Likert-type scale to statements such as, "I want my husband to give

more attention to our older child now." Structural soundness of dyadic

items was reviewed by a doctorally prepared faculty member with expertise

in behavioral science instrument construction.

The Preliminary FRO's were administered to five women, pregnant with

or recently delivered of their second child. Critiques on instrument

clarity, pertinence, awkwardness, redundancy, and comprehensiveness were

considered when making revisions to final versions of the FR0–Prenatal

(see Appendix G) and FRQ-Postpartum (see Appendix H).

The FRO-Prenatal consists of 25 statements. Five statements reflect

maternal perception of the mother-baby relationships (items

#2R, 7R, 11R, 13R,23R); five items reflect perception of the father-baby dyad

(5, 16R, 18R,22R,25R); eight relate to the mother—firstborn dyad

(1,4R,6,10R, 14R, 17R, 19R,20); four pertain to the father—firstborn dyad

(3,8R,21,24); and three address the firstborn-baby dyad (9,12R, 15). The

FRO-Postpartum is composed of 22 statements. Five items reflect maternal

perception of the mother-baby relationship (#2R,6R,10R, 15,19); four are

about the father-baby dyad (4R, 8, 12R, 17); six about mother—firstborn

relations (1,9R, 14R, 16R, 20R, 22R); four about the father-firstborn dyad

(3,7,22, 21R); and three about perceptions of the firstborn-baby dyad

(5R, 13, 18R). Scoring is accomplished by summing the points indicated

from one to five for a total score. Since statements are presented in

either a concern—present or concern—absent manner, some statements

require point reversal before summing. These items are indicated in the

preceeding listing by the letter "R". The resultant possible range of

67

scores is 25 to 125 on the prenatal version and 22 to 110 on the

postpartum version.

For these newly developed instruments, content validity of the items

was determined through expert review and critique by five

maternity/family health care nurse scholars and clinicians. Internal

reliability was determined by computing Cronbach's alha values.

Coefficient alpha for the FRO–Prenatal was .76 with 148 T-1 cases and .78

with 87 T-2 cases. FRO-Postpartum Cronbach alpha values were .75 with 34

T-1 cases and .78 with 45 cases at T-2. These values approach the .80

level of acceptability suggested by Carmines and Zeller (1979). While it

would have been desireable to find high reliability values for each of

the dyad subscales, only the mother-child subscale, with coefficient

alphas .63 to .75, and the postpartum child-baby subscale, with

coefficient al phas of .62 and .63, tended toward internal reliability at

both test periods.

Somatic Symptoms Checklist

The instrument for reporting symptomatology during pregnancy devised

for longitudinal study by Erickson (1967) was modified for use in this

investigation. The original instrument consisted of a list of 31

symptoms, to which the subject responded how frequently the symptom or

feeling was experienced daily on a four point scale ranging from often to

never. For this investigation, several items were deleted, such as

"chills," which did not, in isolation, seem to be common symptoms of

pregnancy or the postpartum period. Other new items, such as "varicose

veins," were added. Preliminary instruments were tested by three

subjects. After revisions for clarity of format and instructions, the

instruments were piloted on an additional six subjects and further

68

refined. The revised instruments contained 29 items on the prenatal form

(Appendix I) and 23 items on the postpartum form (Appendix J).

The tool was modified additionally to assess how the magnitude of

discomfort for a particular complaint relates to the woman's recollected

experience at the same trimester in her previous pregnancy on a three

point scale from less to more frequently experienced presently. This is

in essence comparison by means of retrospective estimates (Schaie, 1973).

While the proposed design offers no group of women pregnant for the first

time for a statistical comparison, the perceived differences are

qualitatively valuable in themselves.

Scoring was accomplished by summing the frequency of symptoms,

providing a range of 0–87 (prenatal) and 0–69 (postpartum). Direct

comparability on this scale between pregnancy and post-delivery is not

expected, since the nature of post-delivery discomfort is often related

to delivery procedures, involutional processes, and lactation. Ranges

for comparative symptom scores are the same as the respective current

symptom version ranges.

Content validity was determined by expert review by three nurse

scholars with extensive clinical and research experience in maternity

health care. Further support for face validity is provided by the

similarity between these instruments and the prenatal symptom list used

by Entwistle and Doering (1981), which was sufficiently sensitive to

detect variations in somatic complaints by trimester in a group of 120

Maryland primigra vidae, and the postpartum feelings and health status

reported most frequently by 264 primiparae investigated by Mercer,

Hackley, and Bostrom (1982). Assessment of internal reliability is

inappropriate, since the instrument measures frequencies of the

69

occurrence of diverse symptoms, which lack theoretical relatedness.

Procedure

All 191 subjects were recruited and inducted into the study from

October 15, 1984, to January 8, 1985. The 135 subjects involved in

repeated testing completed their second questionnaire packets between

January 16 and March 27, 1985. Human Subjects protective assurances were

observed under approval of the Committee on Human Research, University of

California, San Francisco (#933921–01).

Nursing and medical staff involvement in and orientation to the

study project took place in the year proceeding actual data collection.

Site liaison activities, facilitated by the senior Nurse Practitioners

(NPs) at each site, consisted of assistance with: obtaining approval from

nursing, medical, and administrative departments; formulation of

recruitment strategies consistent with local patient flow, logistics, and

time constraints; and fostering staff acceptance.

Recruitment procedures varied by site, dependent upon facilities and

staff commitment to the project. Although later analyses indicated that

there were no differences in the occurrence of the dependent variables

based on site of subject induction, recruitment techniques are discussed

in relation to the four sites to provide an indication of the magnitude

of subjects recruited with minimal bias compared to those subjects who

were more self-selected.

At the site contributing the most (68) subjects, Site 2, prenatal

records of all clinic registrants were reviewed by staff nursing

personnel, due to the high level of commitement of the sole clinic NP.

Potential subjects were then informed of the study on their next prenatal

visit or by telephone. All potential subjects at this site then

70

completed the response card (see "Second Baby Pregnancy" card, Appendix

K) indicating interest in the study. This comprehensive approach

introduced no bias into subject selection.

At Site 1, the clinic held at the HMO medical center itself, 68

subjects were recruited. Here, all new obstetric registrants receiving their

initial obstetric packet information and laboratory forms, at either the

prenatal orientation class or individually, were given the study flier

with detachable response card (Appendix K) from either the investigator

attending the prenatal class or from staff nursing personnel. Once this

system was established, dissemination of recruitment materials to new

registrants, largely in their first trimester, proceeded without any

observable bias. Again, all potential subjects from this source did

return response cards indicating interest in the study.

Recruitment at Site 1 by other methods was less comprehensive.

Collectively, the five NP's at this site see approximately 75% of all

obstetric patients, which excludes high risk obstetric patients, staff

wives, and patients preferring to see only physicians. An attempt was

made to have fliers handed out to all potential subjects seen by the

NP's. However, NP cooperation varied from placement of fliers on all

pertinent obstetric charts seen by all NP's and MD's using a common

nursing station, to lack of involvement in recruitment.

Recruitment at Site 3, where 30 subjects were inducted, was hampered

by difficulties in coordinating with three part-time NP's. After weeks

of poor recruitment, the investigator gained permission to review all

prenatal records for obstetric inclusion criteria. This resulted in the

placement of 100 fliers in eligible charts towards the end of the

71

recruitment period. Since prenatal recruitment ended shortly thereafter,

staff later pulled the unneeded fliers from charts.

At the private obstetric office, Site 4, nursing assistants

introduced the study flier. Twenty-six subjects were recruited from this

site. It appeared that staff here selected subjects who were past the

early months of pregnancy, when staff felt they were still vulnerable to

early pregnancy loss.

An additional method used at all four sites was the prominent

placement of fliers at the obstetric check-in area, where the drop box

for response cards was also located. This technique would tend to favor

inclusion of subjects more highly motivated to actively seek out

involvement in a study, who may be either more comfortable with

themselves or more adamantly concerned about their situation than those

who would not respond to such a general solicitation.

Recruitment for second and third trimester subjects ended November

12, 1984. Since recruitment procedures were integrated into the prenatal

clinic routines, and not the postpartum visit routines, recruitment for

fourth trimester subjects continued on, as well as recruitment for the

additional first trimester subjects required by the design and higher

potential subject mortality of that group.

The recruitment flier briefly described the study goals and

participant requirements. Women were encouraged to deposit a detachable

card in a conveniently located drop-box on the premises, indicating

whether they wished to be contacted for further details. The investigator

collected response cards from each site at least semi-weekly. Potential

subjects were contacted by telephone, informed of the nature of the

study, and given an opportunity to ask questions.

72

Although a minority of subjects had met the investigator at the

clinics or had known the investigator from her prior affiliation with the

private obstetric office, for most subjects this telephone conversation

constituted the only personal contact. The cooperation, commitment, and

candor subsequently demonstrated by participants is remarkable in light

of this minimal relationship. Contributing factors may be the

investigator's identification of herself as a Nurse Practitioner, an

established supportive role for most subjects; an attempt to convey an

accommodating, warm, and respectful attitude; characteristics of the

psychology of pregnancy conducive to sharing the emotional experience;

payment of $5 for each instrument packet completed; and the apparent need

for further information about second pregnancies which these women had

confronted and wished to remedy for others in the future.

Of all response cards received by the investigator, only four

indicated they were not interested in completing questionnaires. One

indicated as a reason the temporariness of her stay in the area; the

other three gave no reason. Additional information about these anonymous

respondants is not available. Women who had completed response cards

were contacted by telephone by the investigator until sufficient numbers

for each trimester group were obtained. During this telephone contact,

additional screening for eligibility was performed. Twenty interested

women were not inducted into the study at this point for the following

reasons: one had a spontaneous abortion since completing the card; two

were medically high-risk patients; eight had firstborn children by a

partner other than the father of the second child; two were separated

from the children's father; one had a second born older than 13 weeks of

age; and six had stepchildren of their husbands' living in or frequently

73

visiting the home. This last group was excluded due to the focus of the

study on introduction of the second child into the family system.

Following explanation of the study by telephone, remarkably, all

women agreed to participate. A packet of questionnaires (see Appendices

A through J, L) was then mailed for the woman to complete at her

convenience at home within the following week. The initial packet

contained a cover letter of instructions, a copy of the consent form to

be retained and one to be returned, the Demographic and Background Data

Sheet, both the state and trait forms of the Spielberger Self-Evaluation

Questionnaire, either the prenatal or postpartum Symptom Checklist

followed by the appropriate version of the Family Relationship

Questionnaire, the Spanier Dyadic Adjustment Scale, and a sheet for

additional comments. Return of the packet was requested in an addressed,

postage-paid envelope which was included.

Three potential subjects had changes before completing the packets

that caused them to no longer fall within the inclusion criteria: one

spontaneous abortion, one marital separation, and one medical high risk

condition. Additional subjects were recruited to fill their places.

Ninety-two percent of the completed packets were returned within three

weeks of being mailed out. Follow-up of delinquent packets consisted of

no more than three telephone or mail contacts. Thirteen of the 15 late

respondents did return packets after the follow-up contacts. Only two

(1%) of the 191 eligible participants were lost to the study for failure

to complete the instruments, one who decided not to participate for

unspecified reasons and one who continually found her schedule too hectic

to find time to fill out the forms. These two were replaced, providing

191 participants at T-1. An additional 59 women who had deposited cards

74

in the drop-boxes were notified that no additional participants were

required.

Three months after completing the first packet, subjects in all but

the initial postpartum group were mailed T-2 packets. The T-2

packets contained a cover sheet (see Appendix M) with questions to update

experiential data that may have changed since T-1 (e.g. route of delivery

if previous packet completed in the third trimester), the appropriate

Symptoms Checklist and FRQ, the Dyadic Adjustment Scale, the state

anxiety version only of the Spielberger Self—Evaluation Questionnaire,

and a return mail envelope. Subjects were compensated $5 for

each packet completed. Payment for initial packet completion was

included in the second packet. Payment for the final packet was

mailed separately within four weeks.

More subjects required follow-up contacts for delinquent return of

packets at T-2 than at T-1. Whereas only 8% of the subjects needed

to be called during the first test administration period, 24% of the

those who eventually did return completed T-2 packets required follow-up

contact for late materials.

Subject loss from T-1 to T-2 was minimal (see Figure 3.1). Of the

47 members of group S-3, who went from third to fourth trimester, only

one subject did not complete her second packet. She gave reasons of

English as a second language making reading difficult, as well as illness

among family members. Of the 44 members of group S-2, who went from

second to third trimester, three subjects did not return their second

packets. One declined participation due to much stress after the-

premature delivery of an infant with hydrocephalus, and two women who

could not be contacted later by telephone failed to respond to written

75

follow-up, after initially indicating continued interest at the second

test period. In order to collect 48 responses from the S-1 group at T-2,

it was not necessary to contact all the original 65 women. Only three

contacted subjects withdrew, two because of spontaneous abortions and one

who reported her husband said the information was too personal. They

were replaced with the next consecutive subjects based on when completed

T-1 packets had been returned. Fourteen members of the original first

trimester group were informed they would not be retested.

In sum, only 7 of the 142 subjects receiving T-2 packets did not

participate, producing an attrition rate of 5% over the three month

period. The 135 participants at T-2 exceeded the sample size demands of

the proposed design and analyses. Due to cases where attrition was known

to result from medical complications, the study sample is reflective of

women experiencing medically uncomplicated pregnancies, which is

consistent with the original intent.

Data Analysis Procedures

Pursuit of answers to the research questions required employment of

descriptive, comparative, and correlational statistics. Data were

analyzed using SPSS-X, version 2.0 (SPSS Inc., 1983).

To determine whether the four dependent variables of maternal

anxiety, marital satisfaction, level of family relationship concerns, and

somatic symptomatology change with time for secundigra vidae, comparisons

were made between measurements taken from subjects in the first, second,

third, and fourth trimesters. Preliminary analyses were performed

to identify potentially confounding variables by examining the

relationships of antecedent variables (demographic and background

76

Table 3. 1

Dependent. Variable Measures. Obtained at T-1 and T-2

Test Period Trimester Measure

T–1 All Spielberger STAI-Y T(rait)–ANXietyT-1, T-2 All S(tate)—ANXietyT-1, T-2 All Spanier DAS (Dyadic Adjustment Scale)-Total

Subscale—CONCConsensus)Subscale-COH(Cohesion)Subscale-AFF (Affection)Subscale—SAT(Satisfaction)

T-1, T-2 1,2,3 FROA(Family Relationship Questionnaire)-PrenatalSubscale—MCA (Mother—Child Dyad, Antepartum)

T-1, T-2 4 FROP-PostpartumSubscale—MCP (Mother—Child Dyad, Postpartum)Subscale—CBP (Child-Baby Dyad, Postpartum)

T-1, T-2 1, 2, 3 SXAN (Symptoms Antepartum, Now—this pregnancy)T-1, T-2 1,2,3 SXAC (Symptoms Antepartum, Compared-to last

pregnancy)T-1, T-2 4 SXPN (Symptoms Postpartum, Now—this pregnancy)T-1, T-2 4 SXPC (Symptoms Postpartum, Compared—to last

pregnancy)

variables) with trimester groups, and antecedent variables with dependent

variables. All dependent variable scale scores were considered to yield

interval data (see Table 3.1). Antecedent variables were classified as

nominal or interval (see Appendix N). For nominal data, group

differences were examined using chi-square tests. For interval data,

group differences were examined with one-way analysis of variance

procedures, with pairwise a posteriori contrasts computed using the Tukey

Honestly Significant Difference (HSD) test (Nie, Hull, Jenkins,

Steinbrenner, & Bent, 1975). The HSD holds experimentwise error rate to

alpha, which was set at .05, and is approximate for unequal group sizes.

The assumption of homogeneity of variances, which is required for valid

analysis of variance procedures, was tested by computation of the

77

Barlett-Box F statistic, selecting a significance level of p = .05 as

acceptable. The assumption of the absence of covariate-by-factor

interaction in analysis of variance was accepted without testing. In the

search for possible significant relationships between dependent variables

and antecedent variables, the Pearson product moment correlation

coeeficient was computed for antecedent variables. Dichotomous nominal

antecedent variables were examined in relation to dependent variables

using independent t tests, with selection of the Student's t or the

approximation to t as the test statistic based on, respectively, the

presence or absence of equal variances (Nie, et al., 1975.) Nominal

variables with more than two categories were examined in relation to

dependent variables using one-way analysis of variance as described above.

The effect of trimester group membership on the dependent variables

was then examined by two approaches. The effect of trimester on

independent (cross-sectional) samples was determined by performance of

one-way analysis of variance, with control for potential confounding

variables as indicated. The effect of trimester on dependent variables

in related (longitudinal) samples was tested by performing the paired t

test. Computation of correlated t followed assurance that the

correlation between the paired measures was positive (Nie, et al.,

1975). The matched sample comparisons proved to be superior for

detecting change between trimester groups due to removal of the subject

to-subject variability.

Dependent variable scale reliabilities were computed using the

Cronbach alpha measure of internal reliability. To test

interrelationships among dependent variables, the Pearson product moment

correlation coefficient was computed.

78

Analysis of individual item characteristics of FRO and Somatic

Symptom measures was obtained by manual ordering and examination of

descriptive statistics generated for each instrument item and by

performance of one-way analysis of variance procedures. For assessment of

somatic symptoms regarding comparison to the previous pregnancy, one

sample t tests were performed between obtained scores and an assigned

value of "2", which would indicate no difference between perception of

present and previous symptom occurrence on the original instrument scale

employed in this study.

Summary

This chapter explained the modified cross-sectional sequential

design employed to examine the research questions. One hundred and

ninety-one secundigravidae were administered paper-and-pencil

questionnaires assessing their perceptions of anxiety, somatic symptoms,

family relationship concerns, and marital satisfaction. Three months

later, a subsample of 135 subjects underwent repeated testing of the same

measures. Subject recruitment settings and procedures, sample inclusion

criteria, measurement instrument characteristics, and data collection and

analytic procedures were described.

79

Chapter IV

Results

Introduction

Study findings are presented in this chapter. Sample

characteristics of the total sample and comparison groups are first

presented. In the next section, statistical characteristics of the four

dependent variable measures are described. Then, data relevant to the

interrelationships of the four dependent variables are examined.

Finally, statistical analyses in relation to hypothesis testing are

addressed.

Demographic and Obstetrical Characteristics of the Sample

Demographic and obstetrical characteristics of the sample were

examined for the total study sample, as well as analyzed for differences

in occurrence between trimester groups. Among demographic variables, no

significant differences between trimester groups were found for the

variables of maternal or paternal age, race, years of school, or

occupational rank; nor for family religion, marital status, socioeconomic

level, or age of the firstborn (See Table 4.1).

With the exceptions of one 16-year-old and one 17-year-old, the age

range of women participating in the study was 19 to 38 years, with a mean

age of 27.44 and a modal age of 27. Fathers were slightly older, with an

average age of 30.21 years. Most of the study subjects were white, not

of Hispanic origin (86.4% of the participants and 84.8% of their

partners). Fifteen women (7.9%) were Hispanic, seven were Asian/Pacific

Islanders, two were Black, one was an American Indian, and one

categorized herself as belonging to another unspecified group.

80

Table 4.1

Demographic Characteristics of Total Sample and Groups

Variable Trimester Trimester Trimester Trimester Total Test (df)1 2 3 4 Walue

n=65 n=44 n=47 n=35 n=191 p.

Maternal AgeMean 28.08 26.84 27.34 27.15 27.44 F(3,185)SD 4.25 4.28 3. 89 4.42 4.20 .86Range 20–37 16–38 19–37 17–37 16–38 .46

Paternal AgeMean 30.46 29. 67 30.28 30.29 30.21 F(3, 186)SD 5.24 4. 78 4.71 5.58 5.05 T22Range 20–41 22–41 22–42 18–45 18–45 .88

Maternal Race – categories combined for analysisWhite, not Hispanic

59 38 40 28 165 X*(3)Hispanic) 4 5 3 3 15 2.34Other ) 2 1 4 4 11 . 50

Paternal Race – categories combined for analysisWhite, not Hispanic

60 37 37 28 162 X’ (3)Hispanic) 3 7 6 3 19 4.84Other ) 2 O 4 4 10 . 18

Religion – missing values=3Protestant

19 17 12 11 59 X” (9)Catholic 19 15 16 8 58 9.81None 11 2 8 10 31 . 37Other 15 9 10 6 40

Maternal Years of EducationMean 13.86 13. 72 14.24 14. 14 13.97 F(3,185)SD 2. 10 1.94 2.01 1.88 2.00 .64Range 10–19 11–19 12–18 11–18 10–19 .59

Socioeconomic Level – Hollingshead Four-Factor ScaleMean 45.36 42.38 44.23 41.77 43.74 F(3,185)SD 12. 27 9.78 12.25 10.96 11.50 1.00Range 21–66 22–63 27–66 21.5–66 21–66 .39

Age of firstborn (months)Mean 31.26 28.59 32.87 34. 28 31.60 F(3,187)SD 17. 52 14. 55 21.95 14.74 17. 63 .. 79Range 4–84 7–67 12–117 14–74 4–117 .50

81

The two most commonly identified religious affiliations were

Protestant (30.9%) and Roman Catholic (30.4%). A large segment (16.2%)

indicated no preference regarding religion. Other religions indicated

were Church of Later Day Saints (5.2%) and Jewish (2.6%). Twenty-five

additional women wrote in a specific affiliation, such as Christian or

Baptist, which they felt did not fit into the other categories.

All subjects were partnered, as this was requisite for inclusion in

the study. All women were married except four: one in the second

trimester group, two inducted into the third trimester, and one in the

fourth trimester group.

Socioeconomic status (SES) was calculated using the Hollingshead

(1975) Four Factor Index of Social Status. Weighted values are given to

occupation and years of schooling of both partners, if they are involved

in the work force, to obtain a family score between 8 and 66. The

occupations of both employed mothers and fathers in the study sample were

codified according to rankings from one (farm laborers/menial service

workers) to nine (higher executives, proprietors of large businesses, and

major professionals). Women in the sample were almost evenly divided

between those who considered themselves housewives (49.2%) and those who

worked outside the home. Among the 95 women who were employed, the modal

category (27 women) was six (technicians, semiprofessionals, and small

business owners), followed by category five (clerical and sales workers,

small farm and business owners). Women were involved in the entire range

of nine categories. The range of occupations filled by fathers also

spanned the nine categories. Their modal value (59 fathers) was category

four (smaller business owners, skilled manual workers, craftsmen, and

tenant farmers); their mean value was 5.65.

82

Education of the employed partners is also considered in social

status determination. Fathers' schooling ranged from nine to twenty

years, with a sample mean of 14.43 years. This approximated mothers'

education, which spanned ten to nineteen years, with a mean of 13.97

years. Computation of the Hollinghead SES score produced a range of 21

to 66, with a mean of 43.74. This places the average study family in the

lower end of the social stratum labelled "medium business, minor

professional, technical", just above "skilled craftsmen, clerical, sales

workers."

All study families had one healthy child living at home, as this

also was a criterion for study inclusion. The range of ages of

firstborns was 4 to 117 months, with a sample mean of 31.6 months.

Calculations were performed to create a variable called Spacing,

indicative of the age of the firstborn at time of birth of the second

child. The range of spacing was 11 to 118 months, with a mean value of

35.0 months.

Obstetric characteristics of the study sample were examined

to obtain a description of the total sample and to determine if

differences between comparison groups existed (see Table 4.2). No

differences were found between trimester groups regarding the number of

previous spontaneous or therapeutic abortions. The total sample range

was from zero to three miscarriages or abortions, with about one in five

women having experienced miscarriage and about one in three having

experienced an induced abortion.

Women's global recollection of their previous pregnancy and delivery

experience ranged from very easy and comfortable to extremely difficult

and uncomfortable. When examining for between group differences using

83

Table 4.2

Obstetric Characteristics of Total Sample and Groups

Variable Trimester Trimester Trimester Trimester Total Test (df)1 2 3 4 Value

P.

MiscarriagesMean .24 . 12 . 14 .40 .21 F(3,164)SD . 58 . 51 .41 . 72 .56 T. 79Range 0–2 0–3 0–2 0–3 0–3 . 15

Abortions

Mean . 37 .24 .40 .47 . 37 F(3,165)SD . 65 . 58 . 72 . 73 . 67 -

Range 0–2 0–2 0–3 0–2 0–3 .53

Base & Comfort in First Pregnancy/DeliveryVery Easy 10 8 16 8 42 X” (9)Mod Easy 24 17 14 8 63 17.43Somewhat .04Difficult 13 13 3 8 37

Very Diff 14 4 9 10 37

Previous DeliveryWaginal 49 43 40 32 164 X” (3)C/Section 16 1 7 3 27 11.9

.01

Intendedness of Pregnancy- missing values = 3No/Not now 10 18 18 10 56 X? (3)Yes 54 26 29 23 132 10. 37

.02Months Attempting Conception

Mean 3.08 1.86 2.08 2.42 2.43 F(3,180)SD 2.09 2.14 2.14 2.23 2.18 3.36Range 0–8 0–8 0–8 0–8 0–8 .02

Had Prenatal Diagnostic Test – missing values = 2Yes 10 20 19 23 72 X” (3)No 55 24 28 10 117 29.31

.00

Future Prenatal Diagnostic Test Planned – missing values = 16Yes 50 36 43 25 154 X’ (3)No 12 6 1 2 21 7.87

.05

Attend Childbearing Class – missing values = 4Yes 26 19 10 13 68 X*(3)No 39 25 37 18 119 6.29

84

the chi square statistic, it was necessary to collapse categories to

limit the occurrence of cells with expected frequencies less than five.

The forced choice questionnaire format had not allowed expression of a

childbirth experience in which the pregnancy was easy, but the delivery

was difficult. Eleven women had written in such a description, and their

responses were lost in the collapsed cell group comparison. Intergroup

differences were found (X” (9)= 17.43, p = .04; Cramer's V=. 03). In the

third trimester group, more women recalled their previous experience as

being very easy and less recalled it as somewhat difficult, than would be

expected statistically. In the second trimester, more women described

their first experience as somewhat difficult, while fewer women described

it as very difficult, than would be expected. Followup comparison

between just second and third trimester groups revealed second trimester

members had more uncomfortable/moderately difficult experiences than the

third trimester group (X’ (3) = 11.13, p = .01; Cramer's W = . 132).

Most of the study participants (86%) experienced vaginal delivery

with their first pregnancy. Of the 24 women who had had operative

deliveries previously, equal numbers planned repeat Cesareans and vaginal

birth after Cesarean this time. Examination for group differences

revealed more Cesarean births than expected in the first trimester, and

fewer than expected in the second trimester group (X*(3)=11.90, p = .01).

The intendedness of the current pregnancy was assessed by asking

women to respond if the pregnancy was planned: no; yes, but not now; or

yes, now. In this sample of women, the vast majority of whom had access

to prepaid health care, an impressive 29% had not intended to get

pregnant at this time. Testing for group differences after combining

the two categories of respondents not intending to get pregnant at

85

present revealed fewer women in first trimester had unintended

pregnancies than would be expected, while there were more unintended

pregnancies second trimester than expected (X’(3) = 10.37, p = .02).

Comparison groups also differed with the same pattern regarding a

related variable, the number of months women were attempting to conceive

(F(3,180) = 3.36, p = .02). Followup with the Tukey-HSD procedurerevealed that the first trimester group mean score (3.08) was

significatly higher than the second trimester group (M = 1.86) score.

This variable is subject to interpretation in two ways. The value "O"

represented not trying to conceive. Increasing numbers were codes for

incremental numbers of months trying to conceive, with the value "8"

indicating 24 months or more. Hence, one interpretation is that high

values indicate greater difficulty in becoming pregnant, although only

18% reported trying longer than six months. The other interpretation is

that low values indicate less wantedness or intendedness of pregnancy.

Since this question was not evaluated at the second test period, it

cannot be determined whether recollections of intent to conceive vary

through pregnancy, or if this represents a chance mal distribution of the

variable among subjects.

Trimester groups also lacked homogeneity regarding completion of

prental diagnostic tests. Fewer women in their first trimester and more

women in their fourth trimester had undergone diagnostic tests than would

have been randomly expected. This is a reasonable finding, considering

that most of the 62 tests experienced were sonograms, which were

performed largely throughout the second and third trimesters. Consistent

with these findings were group differences in the numbers of women

expecting prenatal tests in the future (X*(3)=7.87, p = .05). More women

86

in the first trimester, and fewer women in the third trimester, planned

future diagnostic tests than expected statistically.

Postpartum characteristics of the sample are summarized for

descriptive purposes. The following figures represent both the 35

women in the fourth trimester at T-1 and the 46 women in the fourth

trimester at T-2. More male (58%) than female infants were born. Most

mothers (72%) selected breastfeeding as the predominant feeding method.

Fathers attended the delivery in all but five (6%) of the cases.

Additional obstetric experiential and attitudinal variables were

monitored. No differences by trimester group were found for number of

children desired by mother, number of children desired by father,

discrepancy between parents in the number of children wanted, maternal or

infant illness, or planned attendance at childbearing classes. Variables

related to family background were also examined. No differences between

comparison groups were found for length of marriage/relationship, sex of

the firstborn, number of sibling in the mother's family of origin, nor

the mother's own birth order.

Trimester groups were also found to be comparable regarding maternal

employment variables. There were no group differences in the mothers'

classifications of selves as housewife or employed person, or hours spent

apart from the firstborn. Among the employed, no group differences were

found between job vs. career classification, or hours spent at work.

In summary, the sample can be characterized as predominantly white,

married women, in their twenties and early thirties, with access to

private or prepaid health care. The women, who typically had two

years of post-high school education, were equally divided between

housewives and those employed outside the home. The average family fell

87

into the social stratum composed of medium business, minor professional,

and technical categories. The typical firstborn child was two and a half

years old.

In addition to demographic variables, a variety of obstetrical,

family, and maternal characteristics were monitored. Group differences

among the comparison trimester groups were found only for the variables

of comfort in first childbearing (COMFORT1), delivery mode for first

birth (DELIVER1), intendedness of second pregnancy (INTEND2), months

trying to conceive (CONCEPTN), and prenatal diagnostic tests experienced

(TEST) or expected (TSTFUTR). Where interactive effects of these

variables with the dependent variables might introduce bias, statistical

controls were instituted.

Dependent Wariable Measures

In this section, the four dependent variables of maternal anxiety,

marital satisfaction, perception of family relationship concerns, and

somatic symptoms will be discussed. For each variable, both descriptive

information about the total sample and comparative information about

trimester groups will be provided.

Anxiety

Both trait and state anxiety measures were obtained (see Table 4.3).

Subject scores for trait anxiety (T-ANX) covered virtually the entire

instrument range. The total sample mean score for T–ANX of 35.01 fell

between published norms of female working adults (34.79) and female

college students (40.40) (Spielberger, et al., 1983). State anxiety (S-

ANX) scores evidenced a slightly more restricted range, with absence of

extremely high anxiety scores noted for the second test administration.

The means for S-ANX scores at both test periods (33.18 and 33.57) were

88

Table 4.3

Dependent Wariable Measures for Total Sample and Groups:Analysis of Variance

Variable Trimester Trimester Trimester Trimester Total Test(df)1 2 3 4 Value

P.

Trait-Anxiet T–1

Mean 34.70 36.49 33.75 35.43 35.01 F(3,187)SD 9.96 11.56 8.23 9.87 9.92 .62Range 20–78 22–68 20–55 24–61 20–78 . 60

State–Anxiety (T-1Mean 32.62 35. 35 31.83 33.31 33.18 F(3,187)SD 10.62 11.93 9.73 10. 20 10.65 . 92Range 20–76 20–64 20–66 20–60 20–76 .43

State-Anxiety (T-2Mean DNA 35. 22 34.68 30.87 33.57 F(2,132)SD DNA 10.42 11.09 8. 74 10.21 2.53Range DNA 20–59 20–62 20–56 20–62 .08

Marital Satisfaction: DAS

Mean 111.67 110.84 117.06 113.62 113.14 F(3, 186)SD 15. 72 15. 29 15. 37 15. 66 15.59 1.51Range 51–144 50–131 56–144 67–139 50–144 .21

Family Relationships Questionnaire - Antepartum (FRQA)Mean 55.91 57.20 54.72 DNA 55.92 F(2,153)SD 10.30 11.41 11. 49 DNA 10.95 . 57Range 35–86 41–90 33–88 DN 33–90 .57

Symptoms, Antepartum – Now (SXAN)Mean 25.38 24. 18 24.89 DNA 24.90 F(2,153)SD 7. 74 11. 32 9.07 DNA 9.22 .22Range 11-48 5–57 7–41 DNA 5–57 .80

Symptoms, Antepartum - Comparative (SXAC).Mean 59.91 58.46 61.17 DNA 59.89 F(2,147)SD 5.41 5.25 5.30 DNA 5.40 2.76Range 47–73 40–70 47–70 DNA 40–73 .07

below reported means

students (38.76).

for female working adults (35.20) and college

One-sample t tests were performed to compare study

sample anxiety scores with the norms for working adult women, revealing

no differences in T-ANX scores (t(190)=.31, p = .76). However, study

89

Table 4.4

Trimester-Related Antecedent Variables Affecting Dependent Variables

Dependent Wariable Antecedent Wariable Test value (df or n), p

State Anxiety COMFORT1 F(3,175)=4.20, p = .0067INTEND2 t(76.01)=4.05, p = .000CONCEPTN r(n=184)=–. 18, p = .014

Marital DAS COMFORT1 F(3,174)=2.55, p = . O575INTEND2 t(73.18)=-3. 37, p = .008

FRQ-Antepartal COMFORT1 F(3,141)=.70, p = . 5548CONCEPTN r(n-153)=–.22, p = .007INTEND2 t(68.08)=2.81, p = .007

Symptoms Antepartal—Now COMFORT1 F(3,141)=4.58, p = .0043

Symptoms Antepartal–ComparativeCOMFORT1 F(3,136)=3.32, p = .0218

sample S–ANX scores were significantly lower than normative data

(t(190) = -2.62, p = .01).

The effect of pregnancy trimester on state anxiety was evaluated by

cross-sectional and longitudinal examinations of S-ANX scores. In the

one-way analysis of variance, no differences were found between the four

trimester group scores at T-1 or T-2 (see Table 4.3). Three of the six

antecedent variables previously identified which were not evenly

distributed across trimester groups demonstrated relationships with

S–ANX. These variables (see Table 4.4) indicated higher anxiety among

women who recalled a difficult, rather than easy, previous pregnancy; who

were not intending this pregnancy; and who were trying fewer months to

conceive. The three variables were were entered into a three-way

analysis of covariance, in which trimester of first test administration

(TRIM1), COMFORT1, and INTEND2 served as non-metric factors, and CONCEPTN

was the covariate with S-ANX. No trimester main effects with S-ANX were

90

found (F(3,140) = .22, p = .88).

Longitudinal evaluation of patterns of state anxiety throughout

pregnancy was made through repeated measures tests in related samples.

Paired t-test scores of the 135 subjects tested at T-2 (see Figure 3.1)

were examined by trimester group. No differences in S-ANX scores between

the two administrations were found for Subjects group S-1, t{47) = -1.68,

p = . 10; group S-2, tC40) = .21, p = .84; or group S-3, t(45) = .25,

p = .81.

Marital Satisfaction

Marital satisfaction was measured with the Spanier Dyadic Adjustment

Scale (DAS) (see Table 4.3). Obtained scores ranged from 50 to 144, on a

scale with a theoretical range of 0 to 151 (Spanier, 1976). Although

high and low score cut-off points are not provided in the literature, the

mean scores for married (114.8) and divorced (70.7) couples used in

instrument development (Spanier, 1976) are available for comparison. The

study mean of 113.1 approximates the married sample score from that

report. However, the total and trimester group scores are considerably

higher than the 97.2 mean reported in another study for contemporary

multiparous couples tested in the third trimester, and three and nine

months postpartum (Belsky, Spanier, & Rovine, 1983). Examination of the

component subscale scores reveals that it is the subscale for

Satisfaction which is considerably higher (39.63 vs. 28.2) in the current

study than in the 1983 report.

No differences by trimester group membership were demonstrated

through one-way analysis of variance procedures (F(3, 186) = 1.51,

p = .21). Two-way analysis of covariance was then performed to control

for potentially confounding variables COMFORT1 and INTEND2. Marital

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satisfaction scores had been found to be higher in women reporting an

easy/comfortable previous childbearing and positive intendedness of

current pregnancy (see Table 4.4). No main effects for trimester were

found (F(3,144) = 1.56, p = .20).

Marital satisfaction was reported as stable, rather than dynamic,

through related sample measures as well. Paired t tests failed to

demonstrate differences from T-1 to T-2 for Subject group S-1,

t(47) = −.88, p = .38; S-2, tC40) = −.62, p = .54; or S-3, t(45) = 1.00,

p = .32.

Family Relationships Questionnaire

The Family Relationships Questionnaire (FRO) will be discussed first

in terms of the total scale, and second in terms of individual items.

The FRO-A was administered to subjects in the first three trimesters,

while the FRO-P was administered only to subjects in the fourth

trimester. Scores on the FRO—A ranged from 33 to 99, with a mean of

55.92, out of a theoretical range of 25 to 125. Higher scores represent

a higher cummulative level of maternal concern about family

relationships. FRO-P scores varied from 29 to 73, with a theoretical

range of 22 to 110. Because this investigation represents the first use

of the FRO's, there are no normative data for comparative analyses.

Cross-sectional analyses involving the three prenatal trimesters

in one-way analyses of variance failed to reveal trimester group

differences in the level of maternal concerns about family relationships,

where F(2,153) = .57, p = .57 (see Table 4.3). The only dyadic prena tal

subscale demonstrating internal consistency, as reported earlier, was the

mother—child antepartum (MCA) subscale. No cross-sectional group

differences were detected with this subscale either, with F(2,153) = .56,

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p = .57.

Two trimester-related antecedent variables were related to FRO-A

scores at either T-1 or T-2 (see Table 4.4). Levels of family

relationship concerns were negatively correlated with number of months

trying to conceive (r. = −.22, p = .007). Also, women not intending to

become pregnant reported higher levels of concern. Because COMFORT1 had

demonstrated a strong relationship with many maternal health variables,

it was included in the followup analysis as well. Therefore, a three-way

analysis of covariance including TRIM1, COMFORT1, INTEND2, and CONCEPTN

was performed. No main effects for TRIM1 were found, with F(2,118) =

1.075, p = .345).

The dependent sample longitudinal comparisons revealed no

differences in FRQ-A or MCA scores between first and second trimester

measures. However, Subjects group S-2, which was in the second trimester

at T-1 and the third trimester at T-2, demonstrated significant increases

in both scores. Mean FRQ-A scores increased from 56.58 to 61.36, t|40) =

–2.98, p = .005. Mean MCA scores increased from 17.70 in the second

trimester to 19.44 in the third trimester, tC40) = -2.51, p = .016.

Individual items on the FRO instruments were also examined. The

range of response for an individual item was from one to five. Following

reversal of concern—present item scores, high scores represent greater

maternal concern. The descriptive information which follows is based on

the T-1 administration. On the antepartum version, all 25 items elicited

the full range of responses, except four items (#9, 14, 15, 24) which

produced ranges of one to four. On the postpartum version, the range of

responses was not used as fully, with 15 items spanning 1–5, 6 items

ranging from 1–4, and one item (#7) eliciting only responses 1-2.

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Table 4.5

Highest FRQ Item Scores for Total Sample and Trimester Groups

AntepartumItem Trimester 1 Trimester 2 Trimester 3 Total—Antepartum

#12.My older child may be jealous of the baby.Mean 3. 88 3.93 3. 89 3.90SD . 89 1.11 .96 .97

#4. My first child may misbehave to get attention.Mean 3. 69 3.50 3.53 3.59

SD .93 1. 17 1.16 1.07

#23.I think about the chances of this baby not being as healthy as myfirst child.

Mean 3.51 3.39 3.13 3.36SD 1. 19 1.45 1. 31 1. 30

#19. It will be difficult for my first child to share me with the baby.Mean 3.03 3. 36 3.02 3. 12SD 1. 17 1. 38 1.28 1.27

Postpartum Item Trimester 4

#22.My older child misbehaves to get my attention.Mean 3.46SD 1. 38

#10.I'm sad the new baby does not get all my attention in the exclusiveway the first child did.

Mean 3.29SD 1.53

#9. It is difficult for my first child to share me with the baby.Mean 3.06SD 1. 53

Item response means were examined to determine the greatest concerns

for the total antepartum sample (n=156) and each trimester group (see

Table 4.5). For the antepartum version of the FRO, four items had mean

scores greater than three, indicating the presence of concern, for all

antenatal trimesters and the total prenatal sample. Their relative rank

94

Table 4.6

Change in FRQ-A Item Means by Trimester: Paired T-tests

Item Mean (1) Mean (2) (df)t, p.

Subject Group S-1, Trimester 1 vs Trimester 2

#21 1. 792 2. 188 (47) –2.22, .031

Subject Group S-2, Trimester 2 vs Trimester 3

#2 2. 317 2.756 (40) –2.37, .022#4 3.415 3. 878 (40) -2.60, .013#7 1. 717 2. 122 (40) –2.59, .013#8 2.951 3.537 (40) —2.76, .009#17 2. 175 2. 750 (39) –2.89, .006#18 2.415 3. 195 (40) —4.61, .000

remained constant throughout trimesters. Three items dealt with

distribution of affection and attention within the mother—firstborn-baby

triad. The fourth dealt with maternal health concerns for the new baby.

Average scores of three items from the postpartum FRO were greater than

three. These items reflected themes of responses by the firstborn or the

mother to the finite resources of affection and attention.

Potential patterns of individual maternal concerns through pregnancy

were examined from both cross-sectional and longitudinal perspectives.

Oneway analyses of variance of the 25 FRO-A items through the three

prenatal trimesters revealed change by trimester in only one item,

F(2,153) = 4.40, p = .014. A posteriori contrasts revealed that women in

the second trimester were more concerned about their husbands spending

enough time with the firstborn (#21, mean = 2.43) than were women in the

third trimester (mean = 1.77).

Data from longitudinal measurements demonstrated changes in the

levels of several maternal concerns by trimester (see Table 4.6). From

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first to second trimester, the mean of only one item changed, in an upward

direction. From second trimester to third trimester, six item means

changed, all in the direction indicating greater maternal concerns in

third trimester. The nature of the increasing concerns address paternal

(#18) and maternal (#2) preference about the baby's sex; decreased

maternal pleasure with the pregnancy due to the firstborn (#17);

increased desire for the husband to attend to the firstborn (#8);

increasing concern about ability to love the newborn as the firstborn

(#7); and greater concerns about firstborn misbehavior (#4).

Somatic Symptoms

The levels of somatic symptoms experienced by secundigravidae were

assessed with antenatal and postpartal instruments for both the current

pregnancy (SXAN and SXPN), and as compared to the same trimester of the

previous pregnancy (SXAC and SXPC). Higher scores indicate greater

frequency of symptoms now. The obtained range of current antepartum

symptom scores spanned from 5 to 57, while comparative antepartum scores

varied from 47 to 73, both out of a theoretical range of 0 to 87 (see

Table 4.3). Current postpartum scores occupied the lower end of the

possible range, varying from 2 to 38, while comparative postpartum scores

went from 44 to 60, out of a possible range of 0 to 69.

One-way analysis of variance failed to reveal trimester effects on

either current or comparative somatic symptom levels (see Table 4.3).

However, comfort of first childbearing was related to both trimester and

symptomatology (see Table 4.4). Followup a posteriori contrasts

demonstrated that women who recollected their previous childbearing as

very easy had current symptom level mean scores (20.93) significantly

lower than either women with somewhat difficult (mean = 27.61) or very

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Table 4.7

Trimester Effects on Symptom Antepartal-Comparative (SXAC) Levels:Two-Way Analysis of Variance

Main Effects SS df F. P.

TRIM1 174.001 2, 128 3.220 .043COMFORT1 291. 320 3, 128 3.595 .016

difficult (mean = 28.54) previous pregnancies. Women who rated the

previous pregnancy as very comfortable rated the second pregnancy as

comparatively more symptomatic (mean = 61.49) than women who remembered a

very uncomfortable first experience (SXAC mean = 57.12). Two-way

analyses of variance were then performed, designating both TRIM1 and

COMFORT1 as factors. No main effects for trimester were found for

current symptom levels. But trimester effects were found for comparative

symptom levels (see Table 4.7). The adjusted mean comparative symptom

levels for the first three trimesters were 59.95, 58.11, and 61.14, with

significant differences between second and third trimester scores.

Table 4.8

Trimester Effects on Symptom Antepartal Current (SXAN). Levels:Paired T Tests

Group Trimester–Mean Trimester–Mean (df) t P

S-1 1 – 25.79 2 — 23.21 (47) 2.74 .009S–2 2 – 23. 37 3 – 25.58 (40) —2.41 .021

The pattern of current somatic symptom levels was better described

by analysis of related samples. Paired t tests performed on SXAN means

obtained from subject groups measured at both T-1 and T-2 showed

significant decline in somatic symptom levels from first to second

trimester, and an increase in symptom levels from second to third

trimester (see Table 4.8).

Table 4.9

Frequent Somatic Symptoms for Total Sample and Trimester Groups

AntepartalSymptom Total—Antepartum Trimester 1 Trimester 2 Trimester 3

TirednessMean 2.03 2.25 1.77 1.96SD .80 . 75 .94 .63

Frequent UrinatingMean 1.99 1.94 2.00 2.04SD .84 . 85 . 75 .91

IrritabilityMean 1.26 1.29 1.27 1.22SD . 85 . 74 .95 . 92

Trouble SleepingMean 1.21 1. 11 .95 1.57

SD 1.02 .99 .96 1.04

NauseaMean 1. 20 1.83 . 89 .62SD 1. O7 .98 .95 .82

Postpartum Symptom Trimester 4

TirednessMean 2.06SD . 87

OverweightMean 1.87SD 1.13

Breast discomfortMean 1. 31

SD 1.02

IrritabilityMean 1.26SD .85

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Data about individual symptoms were also examined. To determine

which symptoms occurred with greatest frequency, mean scores for each

symptom were rank ordered by magnitude within total antepartal sample and

trimester groups. Respondents ranked frequency of symptom occurrence

from 0 = rare/none, to 3 = constant, so scores greater than 1.5 are above

the scale midpoint. Although the most frequent symptoms for the total

antepartum period, in descending order, were tiredness, frequent

urinating, irritability, trouble sleeping, and nausea, this order did not

persist by trimester grouping (Table 4.9). Most frequent postpartum

somatic symptoms were tiredness, overweight, breast discomfort, and

irritability, followed by backache and constipation.

As would be expected due to the differential rank ordering of

symptoms by antepartal trimester, multiple symptoms demonstrated

significant differences in frequency by trimester group. Repeated

measures from subjects obtained at T-1 and T-2 revealed that frequency of

12 of the 29 symptoms evaluated differed between first and second

trimesters (see Table 4.10). Decreases occurred in frequency of

dizziness, appetite loss, nausea, tiredness, vomiting, weakness, cold

hands/feet, and breast discomfort; while increases in backache, shortness

of breath, swollen legs/hands, and groin/pelvic pain/pressure were

detected. The subjects who moved from second to third trimester

experienced decreases in nausea, increased appetite, headache, and breast

discomfort; as well as increased frequency of backache, trouble sleeping,

painful intercourse, shortness of breath, and groin/pelvic pain/pressure.

Data allowing comparison between somatic symptom frequency during

the present and previous pregnancy (SXAC and SXPC) took the form of

ratings on a three-point scale evaluating the current symptom frequency

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Table 4.10

Change in Somatic Symptoms by Trimester: Paired T-test

Symptom Mean (1) Mean (2) (df) to p

Subject Group S-1, Trimester 1 vs. Trimester 2

5. Dizziness . 625 .333 (47) 3. 10, .00310. Appetite loss . 979 . 417 (47) 5.07, .00011. Nausea 2.000 .521 (47) 11.40, .00015. Tiredness 2. 271 1. 646 (47) 4.23, .00016. Vomiting . 833 . 229 (47) 4.82, .00017. Weakness . 936 . 638 (46) 3.72, .00120. Cold hands/feet . 936 . 596 (46) 2.07, .04428. Breast discomfort 1.333 . 771 (47) 3.71, .001

1. Backache . 872 1. 319 (46) –3.48, .00113. Shortness of breath . 521 . 896 (47) –2.65, .01114. Swollen legs/hands . 146 .521 (47) –3.54, .00129. Groin/pelvic pain . 750 1. 250 (47) —3.23, .002

Subject Group S-2, Trimester 2 vs. Trimester 3

11. Nausea . 829 .463 (40) 2.49, .01723. Increased appetite 1. 171 . 829 (40) 3.00, .00527. Headache 1.146 . 658 (40) 3.48, .00129. Breast discomfort 1. 131 . 610 (40) 4.11, .000

1. Backache 1.073 1.415 (40) –2.65, .0117. Trouble sleeping . 902 1. 780 (40) -5.60, .00012. Painful intercourse .564 . 769 (38) —2.08, .04413. Shortness of breath . 658 1. 146 (40) -3.86, .00029. Groin/pelvic pain . 878 1.658 (40) —4. 19, .000

as 1=now less, 2=now the same, or 3=now more, than the same trimester of

the previous pregnancy. One-sample t-test comparisons of SXAC and SXPC

item means to a value of "2" allowed determination of which symptoms were

perceived as having different frequency in second pregnancy. Fourteen

symptoms were experienced differently for secundigravidae (see Table

4.11), with seven symptom comparisons producing p < .001. Three symptoms

were perceived as occurring less often in second pregnancy, while 11

symptoms were experienced more often for secundigravidae. Postpartal

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Table 4.11

Somatic Symptoms in Second vs. First Pregnancy: One-sample t Test

Antepartal Symptom Mean T-test comparison to 2.00: (df)t, p

Backache 2. 18 (154) 3.46, .001Trouble sleeping 2.25 (152) 5.67, .000Depression 2. 12 (150) 2.65, .009Shortness of breath 2.14 (153) 3.20, .002Tiredness 2.40 (154) 7.65, .000Weakness 2.19 (150) 5.03, .000Frequent urinating 2. 15 (154) 3.77, .000Irritability 2.21 (153) 4.37, .000Heartpounding 2.13 (146) 3.22, .002Headache 2. 12 (151) 2.61, .010Groin/pelvic pain 2.19 (150) 3.81, .000

Swollen legs/hands 1.76 (152) —5.69, .000Rapid weight gain 1. 87 (155) –2.57, .011Increased appetite 1.90 (153) —2.04, .043

comparative symptom measures produced no significant differences from the

first pregnancy, based on only 30 – 35 values per symptom. Postpartal

comparative symptom means which varied the most from 2.00 were tiredness

(M = 2.23, tC34) = 1.85, p = .07) and trouble sleeping (M = 2. 18,

t(33) = 1.79, p = .08).

Interrelationship of Dependent Variables

Association among the dependent variables was examined by

computation of Pearson product-moment correlation coeeficients (r). The

strength and direction of the identified associations for dependent

variable measures for the total sample at T-1 are presented in Table

4.12. The resultant matrix presents as a highly enmeshed set of

variables describing maternal health. All the prenatal dependent

measures demonstrated highly significant correlations in the expected

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Table 4. 12

Association Between Anxiety, Marital AdjustmentSomatic Symptoms, and Family Relationship Concerns

Variables S–ANX

Pearson's r (n), P

T—ANX DAS SXAN SXPN FRO—A FRO–P

State Anxiety(S–ANX)

Trait Anxiety .832(T-ANX) (191)

.000%

Marital -.559(DAS) (190)

.000%

Symptoms . 537Ante-Now (156)(SXAN) .0003%

Symptoms —. 023Post–Now ( 35)(SXPN) . 897

Family Concern .477Ante (156)(FRO–A) .000+

Family Concern .406Post ( 35)(FRO–P) .016

*p < .001

—. 601(190). OOO%

.473 – .334(156) (155).000+ .000+

. 148 .048 DNA( 35) ( 35). 395 . 785

.492 – .433 .261 DNA(156) (155) (156).0003% . 000+ .001

. 492 –. 366 DNA .089 DNA( 35) ( 35) ( 35).044 .031 . 610

directions, with high anxiety, low marital satisfaction, high levels of

somatic symptoms, and high levels of family relationship concerns

significantly related (p & .001). The two postpartum measures

were dependent upon a more limited sample size of 35. Postpartum level

of maternal family relationship concerns nonetheless evidenced

102

significant associations with anxiety and marital satisfaction. Only

postpartum symptom levels failed to demonstrate association with other

dependent variables at T-1.

The association among measures obtained at T-2 was examined in a

similar manner. All measures except T-ANX were obtained at the second

test period. S-ANX and FRQ—A continued to demonstrate strong

associations with antenatal variables. Postpartum variables demonstrated

stronger association to other measures, with postpartum group size of 46

at T-2. FRQ-P was related to S-ANX, r =.473, p = .001; to DAS, r=-.489,

p = .001; and approached a significant relationship to SXPN, ra.196,

p = .053. SXPN demonstrated a strong relationship to S-ANX, ra.459, p =

.001. The absence of association between postpartum symptom levels and

marital satisfaction persisted, and the association between antepartum

symptoms and marital satisfaction was not significant at T-2.

Other Findings

Incidental to analyses undertaken to answer the study research

questions, relationships between a variety of antecedent variables and

the dependent variables of maternal health were observed. Those

demographic and background variables related to more than one dependent

variable are summarized in Table 4.13. All relationships refer to data

obtained at T-1 unless otherwise specified.

Maternal age was negatively correlated with state and trait anxiety,

and current somatic symptom levels both before and after delivery.

Socioeconomic status was related to those same four variables, as well as

being positively correlated with marital adjustment. The number of

miscarriages experienced was positively related to state anxiety, but not

to trait anxiety. This suggests that women who have had a miscarriage

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Table 4.13

Relation of Selected Variables to Maternal Health

Variable Dependent Wariable Test value(df or n), p.

Maternal Age S–ANX r (189)=–.215, p = .003T—ANX r(189)=–.273, p = .000SXAN r (155)=–.286, p = .000SXPN r( 34)=–.370, p = .031

SES S–ANX r (189)=–. 198, p = .006T–ANX r(189)=–.219, p = .002SXAN r(154)=–. 190, p = .018SXPN r( 35)=–.427, p = .010DAS r(188)= .226, p = .002

Miscarriage S–ANX r(168)= .260, p = .001T-ANX r(168)= . 116, p = . 133SXAN r(138)= . 188, p = .027

# Children S–ANX r (185)= . 183, p = .013Desired, Father T–ANX r(185)= . 166, p = .024

FROP (T-2) r( 45)= .390, p = .008DAS–SAT subscale (T-2) r(131)=–.237, p = .006

Spacing FROP (T-2) r( 46)=–.309, p = .036SXPN (T-2) r( 45)=-.512, p = .000

Interview S–ANX t(35.28)=–2.98, p = .005T—ANX t(35.11)=–2.95, p = .006FROA |t( 130)=–2.08, p = .040SXAN t( 130)=–4.49, p = .000

previously are more apprehensive about another loss during pregnancy, but

do not have an increased underlying predisposition towards higher anxiety

than women who have not had miscarriages.

Women who reported that their partners desired high numbers of

children recorded higher state and trait anxiety scores, higher levels of

family relationship concerns at time T-2, and lower satisfaction

subscale scores on the DAS at T-2. This may be indicative of maternal

dissatisfaction with a partner perceived as focused on children to the

104

detriment of the marital dyad. Alternatively, since some male partners

had children by previous marriages not living in their current home, the

relationship between subjects' emotional discomfort and higher numbers of

children desired by their partner may, speculatively, reflect stresses of

remarriage with stepchildren in some cases.

The number of months of spacing between first and second children

was negatively correlated postpartally with both levels of family

relationship concerns and current symptoms, as measured at T-2. These

selected variables contribute to a profile of the secundigravida at risk

for poor health. High anxiety, high symptom levels, high levels of

postpartum concerns, and lower marital adjustment scores were associated

with low age, low SES, a history of spontaneous abortions, a partner's

high fertility desires, and closely spaced children.

A methodologic finding is also noteworthy. Initially interviews

were planned, although they were not conducted due to the adequacy of the

quantitative data. At the time written consent was obtained from

subjects, women were asked to indicate whether they would agree to being

interviewed later for one hour, at a time and 1 ocation of their choice.

The consent further stated that if respondents said "yes" now, they may

change their mind later. About 1 in 12 study participants would be

involved. The 29 subjects who declined potential interviews were more

anxious, had higher levels of antepartal family relationship concerns,

and had more antepartal somatic symptoms than the 130 women who agreed

they could be contacted for interview.

Hypothesis Testing

The first hypothesis, that midtrimester state anxiety and somatic

symptom frequency would be lower than first or third trimester levels,

105

was partially supported. No differences between trimester groups in

anxiety levels were found. Lower somatic symptom levels for second

trimester were found in comparison to first and third trimester scores in

repeated testing of longitudinal subjects.

The second hypothesis, that the level of maternal family

relationship concerns would be higher in third trimester than first or

second trimester was also partially supported. Dependent sample testing

demonstrated higher scores for both the total family relationship scale

and the maternal-child subscale in the third trimester compared to the

second trimester. The cross-sectional independent sample testing showed

no differences between the three trimester groups. The design did not

permit comparison of first and third trimester groups between dependent

samples.

The third hypothesis, that marital satisfaction will decline from

second trimester to fourth trimester, was not accepted. No group

differences were found through either cross-sectional or longitudinal

analyses.

The fourth hypothesis, that perceived frequency of somatic symptom

occurrence will be higher in second pregnancy than in first pregnancy,

was accepted. Of fourteen symptoms perceived differentially between the

two pregnancies, eleven were experienced more frequently the second time.

The fifth hypothesis, predicting the interrelationships between

maternal anxiety, somatic symptom frequency, level of family relationship

concerns, and marital satisfaction, was accepted. The matrix created by

the interrelationships of the dependent variables, including their

alternate versions, includes 17 cells. Of these, 13 demonstrated

significant associations based on the first test administration. Those

106

cells were reexamined with data from the second test period, which

altered trimester group distribution. Of four variable relationships not

significantly associated at T-1, one involving trait anxiety was not

examined; one demonstrated highly significant association; one

association approached significance; and one, postpartum symptom levels

and marital satisfaction, remained unrelated. A11 associations were in

the predicted direction.

Summary

Data analytic procedures and study findings were presented in this

chapter. Sample characteristics of the total sample and comparison

groups were described. The sample can be characterized as obstetrically

low risk, white, married women in their twenties and early thirties,

delivering their second baby through private or prepaid health insurance

plans. Differences betwen trimester comparison groups were found only

for comfort and delivery mode of previous childbearing, intendedness of

and months trying to conceive the current pregnancy, and prenatal

diagnostic tests experienced or expected.

Statistical analyses required to answer the research questions were

performed with the four study dependent variables. Testing of hypotheses

related to the effect of trimester on maternal health variables revealed

higher levels of family relationship concerns in the third trimester than

the second trimester, and lower somatic symptom levels in the

midtrimester than in early or late pregnancy. Contrary to study

hypotheses, both state anxiety and marital satisfaction were found to be

stable across the four trimesters of pregnancy and the postpartum period.

Somatic symptom frequency was found to be greater during second pregnancy

107

compared to recollections of the previous pregnancy, as predicted. The

hypothesis regarding interrelationships between maternal anxiety, somatic

symptom frequency, level of family relationship concerns, and marital

satisfaction was supported. In addition, information describing

frequency and trimester distribution of specific family relationship

concerns and somatic symptoms was provided.

108

Chapter V

Discussion

In this chapter, the meaning of study findings are discussed in

relation to the research questions. Limitations of this investigation

are presented. The significance of the study and implications for

nursing and health care are discussed. The chapter concludes by

addressing directions for future research suggested by outcomes of this

investigation.

Relation of Findings to Research Questions

Change in Dependent Variables by Trimester

The first research question sought the answer to whether maternal

health and perceptions of family relationships change with time through

the course of second pregnancy. Study findings will be discussed in

relation to each dependent variable.

Anxiety. Study findings failed to support the hypothesis that

midtrimester anxiety would be lower than anxiety in the first or third

trimesters. Several factors may account for why the current study

results differ from those of Lubin, Gardener, and Roth (1975), who

identified the "W" shaped pattern of anxiety among primiparae and

multiparae. Differences in demographic characteristics between Lubin's

work and this study do not appear to account for discrepant results,

since samples appear comparable regarding race, age, education, and SES.

However, the status of Lubin's subjects regarding other factors with an

identified effect on anxiety in secundigravidae, such as comfort of

previous childbearing and intentedness of pregnancy, are not known.

109

Table 5.1

Weeks of Pregnancy by Trimester Group

Trimester 1 Trimester 2 Trimester 3 Trimester 4 Total

Range 6 – 14 15 – 27 28 – 39 43 – 50 6 – 50Mode 11 22 35 43/44 11Mean 10.74 20.09 33. 74 46.00 25.02SD 2.01 3.41 3.68 2.40 13.55

The construct of anxiety was measured with different instruments.

Lubin and others used the Anxiety Adjective Check List (AACL). The

instrument used for anxiety measurement in this study was the Spielberger

STAI. Although Spielberger and others (1983) did not address inter

instrument correlations for state anxiety tools, he reported having found

high correlations between his instrument and several other measures of

trait anxiety. He found only moderate correlations with the AACL,

suggesting that that scale is apparently less adequate as a measure of

trait anxiety.

Failure of this study to detect higher levels of anxiety in the

first trimester may be due to failure to take measurements at intervals

adequately representing the trimester distinctions. While administration

of first trimester test packets varied from 6 to 14 weeks, the modal test

time was 11 weeks and the mean was 10.74 weeks (see Table 5.1). Lubin (1975)

reports that his first test administration was at two months. It may be

that subjects in this study had already passed the weeks of ambivalence

and fear of miscarriage that accounted for high anxiety in other reports.

Consideration of sample anxiety scores in relation to established

norms is also valuable in interpreting study findings. Anxiety trait

scores were consistent with norms for working adult women, indicating

1 10

study subjects were within population parameters for the underlying

predisposition towards apprehension and tension. However, scores for the

transitory feelings of state anxiety were lower for study subjects than

for the normative group. Grossman and others (1980) similarly found

scores on the Spielberger STAI-State to be below normative levels, with

values of 33.1 first trimester and 33.68 in the third trimester

(comparable to values in this study of 32.6 and 33.18). Since Grossman

did not obtain a midtrimester measure, no conclusions from that study can

be made about a pattern of state anxiety across all three trimesters.

But among women with initially low state anxiety scores, it may be that

further reduction of anxiety would not occur. Further research is needed

to determine if a midtrimester decline in anxiety would occur among women

with high trait anxiety, or among women with high state anxiety during

pregnancy. Women in this study, perhaps in concert with their relatively

stable lifestyle, the financial provider's employment status, and

assurance of adequate health care, which were all indirectly inclusion

criteria, reacted to second pregnancy with less anxiety than their

normative, non-pregnant counterparts were experiencing.

The methodologic rigor employed in studying anxiety in pregnancy

meets the standards recently explicated by Lederman (1984a). In a

thoughtful review of the measurement of anxiety in pregnancy, she calls

for consideration of age, education, parity, gravidity, socioeconomic

status, previous obstetrical experience, health and health history,

marital status and relationship, trimester of pregnancy, gravida's coping

experiences, social desirability, design, instrumentation, and state and

trait anxiety. The current study succeeded in attending to the majority

of these elements.

111

Marital Satisfaction. Marital satisfaction was also found to be

stable across the four trimesters of pregnancy. Hence, incongruencies in

the literature between reports of increasing satisfaction in late

pregnancy (Rankin & Campbell, 1983; Richardson, 1983b) and into the

postpartum period (Moore, 1983), compared to reports of declining

satisfaction (Belsky, Spanier, & Rovine, 1983; Feldman, 1971) are not

resolved.

The failure to find differences between third and fourth trimester

reports of marital satisfaction was inconsistent with the findings of

Belsky and others (1983), who found declining satisfaction using the same

instrument on a contemporary sample of comparable race, education, and

SES. This discrepancy may be clarified by consideration of data

collection times. Data collection points for paper-and-pencil measures

in the Belsky study were the last trimester of pregnancy and three months

postpartum. Combined with data from the Miller and Sollie (1980) report,

which identified a "baby honeymoon" interval postpartally followed by

stressful effects of the newborn, the boundaries of the honeymoon period

can be defined as extending through the first month and ending by the

third postpartal month. The average time of postpartum data collection

in this study was six weeks (see Table 5.1), too early to detect marital

dissatisfaction that may follow. It is difficult to interpret why

average DAS scores among the study subjects were considerably higher than

the scores obtained by participants in the Belsky study, who were self

selected volunteers recruited individually and through public

solicitations.

Family. Relationship Concerns. As hypothesized, the level of family

relationship concerns increased in the third trimester. Both FRQ total

112

and FRQ Mother–Child Antepartal scores increased. These findings are

consistent with Richardson's (1983a) observations of the increasingly

problematic nature of the mother-child relationship through subsequent

pregnancy.

Somatic Symptoms. Change in somatic symptom levels across the three

antepartal trimesters assumed the hypothesized pattern of lower frequency

midtrimester than in first or third trimester. This is consistent with

the pattern for secundigravidae found by Lubin and others (1975), and

with widely held conceptions of the midtrimester as the comfortable,

benign portion of pregnancy marked by feelings of well-being (Rubin,

1984).

Description of Principal Family. Relationship Concerns

The second research question was exploratory in nature, asking for

descriptors of the most common family relationship concerns of

secundigravidae. The same four items were ranked the highest by all

antenatal trimester groups, underscoring their prominence to the

secundigravidae. The most salient concern throughout pregnancy involves

jealousy of the firstborn about the baby. Two of the other most common

concerns also deal with sharing affection and attention among the

firstborn and the baby. Rubin (1984) speaks to the uniquely human

problem of simultaneously managing two or more ongoing maternal-child

relationships. Mothers are bound in by a history of mutual and

reciprocal experiences with older children. Rubin observes that the

secundigravida in particular, influenced by guilt in bringing another

child into the time and space previously occupied by the firstborn alone,

attempts to maintain ties to the firstborn with time, companionship, and

interest.

113

Of 25 items on the prenatal FRO, the statement indicative of the

third highest level of concern through each trimester and the total

antepartal sample was, "I think about the chances of this baby not being

as healthy as my first child." The predominance of this issue throughout

pregnancy appears to indicate more than the task of ensuring safe

passage, which Rubin (1984) describes as evolving towards the end of

second trimester. Clinical experience and data collected during FR0

instrument development support that multigravidae have a keen sense of

limited fortune. Study participants all had one healthy child living at

home. By virtue of having already experienced the good fortune of the

firstborn's good health, there is a sense of fear of having used up part

of one's quota from the finite pool of healthy babies.

Three items from the postpartal FRO indicated high levels of

concerns by mothers. These items dealt with responses by the firstborn

or the mother to distribution of affection and attention. The concerns

of women in the study, who had been home from three to ten weeks, vary

somewhat from the observations of hospitalized women which led to Walz

and Rich's (1983) identification of tasks of taking on a second child.

The highest rated item, "My older child misbehaves to get my attention,"

reveals a recognition of negative behavior by of the firstborn. Based on

their hospitalized sample, Walz and Rich discussed the task of Promoting

Acceptance, but observed that mothers failed to report firstborn's

negative responses, either due to refusal to accept them or denial of

their existence. Data from this study demonstrate that such thorough

denial of firstborn misbehavior is no longer operable after several weeks

at home postpartally.

114

The second rated FRQ-P item, "I'm sad the new baby does not get all

my attention in the exclusive way the first child did," indicates

grieving over the absence of a "first time" experience with the second

born. Walz and Rich did not identify this task among newly delivered

mothers. The task of Grieving which they identified pertained solely to

the loss of a pre-existing exclusive relationship with the firstborn.

The third rated FRQ-P item fits into Walz and Rich's task of

Reformulating a Relationship, referring to the maternal—firstborn dyad.

Hence, a shift can be discerned between previously reported

descriptions of maternal concerns about family relationships of the

secundigravida in the first three days following birth and the concerns

after several weeks at home. An initial "honeymoon" period with the

firstborn during hospitalization appears to have passed by three to six

weeks postpartum. During later weeks, feelings towards the firstborn are

less benign, and the interests of the newborn are more prominent.

Description of Somatic Symptoms

The third research question had both descriptive and comparative

aspects, inquiring about the description of common somatic symptoms

during second pregnancy, and about their occurrence compared to the first

pregnancy. The symptoms identified as occurring most frequently during

the three trimesters of second pregnancy are similar to those described

by Erickson (1967), who studied 9 primigravidae and 11 multigravidae

longitudinally. It appears that the symptoms women experience in each

trimester of second pregnancy are the same ones which would be expected

during first pregnancy, with fatigue, frequent urination, and nausea most

frequent first trimester; frequent urination and fatigue predominating in

115

the mid trimester; and the two lead symptoms followed by trouble sleeping,

and groin/pelvic pressure in the third trimester.

However, approximately half of the 29 symptoms evaluated were

perceived as being experienced differently during the second pregnancy

than during first childbearing. Only three symptoms were perceived as

occurring less often in the second pregnancy; while eleven symptoms were

reported more frequently (see Table 4.11, p.100). Of the three symptoms

with reports of lower frequency in second pregnancy, one may be

attributable to measurement techniques. Seasonal effects may have

influenced the reported reduction in swelling, since data were collected

in Fall and Winter, when summer heat would not be a factor in increased

swelling. Therefore, a distinction which may clarify reported

discrepancies discussed earlier between symptoms among primigravidae vs.

multigravidae may be based on what is being assessed. The types of

symptoms which are felt appear to be common to women of varying parity.

The frequency with which these symptoms are felt differs markedly, with

the greater frequency preponderantly occurring during the second

pregnancy.

Associations Among Dependent Variables

The fourth research question asked if correlations existed between

the dependent variables. Highly significant associations were found

between maternal anxiety, family relationships concerns, marital

adjustment, and somatic symptom frequency levels. Although pairs of

study dependent variables had been linked in reports discussed earlier,

this study demonstrated a robust relationship among this cluster of

variables elaborating maternal health in second pregnancy.

116

Study Limitations

Recruitment of the majority of study participants appeared to take

place without systematic bias. However, the health care settings

selected as research sites and the homogeneous communities from which

subjects were drawn produced a sample which is limited to women with

Private or prepaid health insurance and limited in racial diversity.

Data collection was limited to a mono method approach.

Complementing paper-and-pencil self-report instruments with other methods

such as interview or observation may have provided validity checks to

data obtained. However, that may be accomplished at the cost of

decreased external validity, based on the data collected which

demonstrated that women willing to participate in more personal or

invasive methods such as interviews represent a sample which is

significantly skewed toward less anxious, less concerned, more

comfortable subjects.

Assessment of phenomena within families is problematic and

challenging (Gilliss, 1983). Assessment of family relationships from a

sole respondent in this study is legitimized by a focus on maternal

health, and the growing body of literature linking maternal perceptions

and concerns to perinatal outcomes and maternal well-being. However,

the boundaries of knowledge related to young family formation, parenting

roles, and sibling relations could be expanded by obtaining data from

multiple respondents.

Lacking tools with established psychometrics for the assessment of

maternal perception of family relationship concerns, it was necessary to

develop an original instrument. Refinement of the FRO and exploration of

its psychometric properties would enhance its value in later analyses of

11 7

the present data set, as well as in future applications. Similarly, the

somatic symptom checklist, particularly the postpartum version, would

benefit from refinement including deletion of underutilized items.

Seasonal effects referred to previously warrant consideration.

Significance and Implications for Health Care

Findings from the study yield both theoretical and practicalcontributions. At the theoretical level, a matrix associating aspects of

maternal physical health, maternal emotional health, marital dyadic

adjustment, and perceptions of family relationship concerns at the time

of addition of the secondborn child has been identified. Further

exploration of the interrelationship of these variables is required to

attempt predictive modeling. Knowledge of the occurrence of this cluster

of variables is also of practical value to maternity and family service

practitioners. The different factors vary in the degree to which they

may be easily, rapidly, or accurately assessed. The variables also

differ in their amenability to therapeutic intervention. Knowledge of

the strong association of the variables prepares the practitioner to be

alert for other co-occurring factors once one has been identified, and to

support the pregnanct woman and her family in the multiple dimensions

suggested by this variable matrix.

The knowledge that contemporary women, many involved in multiple

roles during subsequent childbearing, experience less state anxiety

during pregnancy than their non-pregnant normative counterparts, despite

normative trait anxiety levels, bodes well for perinatal health.

Multigravidae were found to experience lower perinatal complications than

primigravidae, in a study examining psychological and social factors in

complications of pregnancy (Norbeck & Tilden, 1983). Further knowledge

118

of the mechanism which mediates the accommodation in multigravidae,

whether it be social, psychological, or hormonal, would be of value in

extending the benefits of reduced perinatal anxiety to high risk groups.

Although trimester of pregnancy was found to be an important factor

only in the incidence of symptomatology and family relationship concerns,

additional variables related to multiple maternal health variables were

identified. Many of these, such as maternal age, SES, number of

miscarriages, spacing of children, comfort of previous childbearing, and

intendedness of current pregnancy, are easily assessable. Preventive

services to support physical, emotional, and family health can be

directed to target populations with identifiable high-risk

characteristics.

Information obtained about two easily assessable maternal background

variables in particular suggests directions for emphasis in providing

health care to childbearing women. The relationship between low

intendedness of second pregnancy and poor maternal health scores

indicates a need for assistance with contraceptive vigilance from women's

health care providers. This need is particularly impressive in light of

unintended pregnancies among almost one-third of this adult study

population with access to largely prepaid health care. The salience of

perceptions of the comfort of first childbearing highlights the need for

maternity care providers to facilitate resolution of feelings regarding

prior childbirth.

Increased knowledge of the nature and dynamics of somatic symptom

occurrence and family relationship concerns throughout the course of

pregnancy provides nurses with important information for planning and

providing maternal and family services. The timing of informational and

119

support services can be guided by knowledge of when symptoms are most

frequent or when family relationships are most conflictual. The content

of material for anticipatory guidance is dictated by a systematically

obtained data base. For example, secundigravidae should be informed of

the comparative increase in fatigue they are likely to experience, and

encouraged to set realistic goals and make adequate preparations.

Of methodologic interest is the consistent superiority of

longitudinally obtained data over cross-sectional data in detecting

differences in dependent variables, despite meticulous monitoring of a

breadth of confounding variables. Longitudinal investigations, despite

their costs and complexities, provide accuracy in assessment not

otherwise possible in perinatal health research, where confounding

variables may be unquantifiable or as yet unidentified, due to the

decrease in subject-to-subject variability in dependent samples.

The strengths of this investigation include population sampling,

design characteristics, and analytic procedures. Recruitment strategies

were effective in obtaining a study sample that is more diversified than

the upper-middle class subjects with more advanced education who

frequently constitute samples in childbearing and family formation

studies. Mothers' education varied from 10 to 19 years, with the average

schooling being two years of post-high school education. Fathers,

similarly, averaged two years of trade or post-secondary education.

The carefully conceived design is another strength of the

investigation. The prospective, short-term panel longitudinal design

lends itself effectively to assessment of developmental phenomena in

individuals and families. The cross-sectional sequential design in

particular demonstrated value in detecting developmental patterns with

120

great efficiency and economy of investigator and participant resources.

Observations pertaining to the entire childbearing year were obtained

without encountering problems of prolonged subject retention, biased

subject mortality, extensive retesting, or commitment of investigator

resources to a more extended data collection schedule. Data analysis

procedures were also carefully conceived and appropriately implemented.

Intervening variables were carefully monitored and controlled for through

statistical procedures. Further research using this type of design is

warranted.

Recommendations for Future Research

One direction for future research based on the findings of this

study involves refinement of the original measurement instrument, the

Family Relationships Questionnaire. Factor analytic studies would reveal

an underlying factor structure, which could be used in secondary analysis

of the existing data and in subsequent studies to explicate maternal

concerns and psychological processes through pregnancy and the addition

of a second child into the family.

Further data analytic procedures applied to the cluster of dependent

variables which were found to be strongly interrelated would provide

valuable knowledge of maternal health and family relationships. Causal

modeling would permit predictive statements elucidating the relationships

such as that between marital dissatisfaction and high maternal anxiety.

Following development of patient education materials based on the

descriptive information about somatic symptoms and common family

relationship concerns, effects of the information on both the perinatal

client and the health care system could be evaluated. Maternal health,

1.21

comfort, and satisfaction variables could be monitored. Utilization of

health care facilities could be assessed as well, to determine if

preventive educational strategies affected consumption of health care

services.

Nursing intervention research could be directed to assess the

effects of preventive and supportive services provided to women

identified through demographic and obstetrical background factors as

being at high risk for maternal health and troublesome family

relationships when pregnant with a second child. A team approach would

make available the abilities of a clinically expert women's health

clinical specialist and a family care specialist, versed in family

dynamics and therapeutics.

Summary

This concluding chapter addressed the meaning of study findings in

relation to research questions and congruent and incongruent reports in

the literature. Anxiety and marital relationship scores were found to be

stable across the four pregnancy trimesters. In the case of anxiety,

this stability may be accounted for as 1) an accurate assessment with the

instrument used, or 2) a valid representation of anxiety in a low

anxiety population, or 3) a distortion due to failure to adequately

represent trimester groups by date of test administration. The stability

in marital relationship measures also appears to be due to the early

portion of the postpartum period assessed. Family relationship concerns

and somatic symptom levels both rose from second to third trimester. All

four dependent variables demonstrated strong associations.

Descriptive data derived from the FRO revealed themes of concern

over the baby's health based on fear of limited good fortune, and greater

122

negative attribution to the firstborn at home postpartally than is

reflected in data obtained in the hospital postpartally. Comparable

symptoms appear to occur with second and earlier pregnancy, although many

symptoms are experienced with different frequency from one pregnancy to

the other. The majority of symptoms perceived with differing frequency

are experienced more frequently in the subsequent childbearing.

Perception of increased tiredness was a prominent finding. Study

limitations, significance and implications for nursing care, and

directions for future research were also discussed.

123

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Appendix A

Cover Sheet for T–l Packet

ºSECOND BABY PREGNANCY STUDY

PACKET #1

1. Please read and sign the top "Consent" form and place it in thereturn en velope. (You retain the Consent form labelle d "This is foryour records.")

2. Complete this packet of questionnaires within one week, if possible.Make sure you have checked both front and back sides of each page |Please d is regard extra lines and numbers in the far columns used foranalyzing results.

3. Return the packet, with one consent form, in the prepaid envelope.

4. You will receive a check for $5.00 with you r next packet in a bout 3months (or with in 4 weeks if you have a 1 ready del i v ere d or if you werein the group that only fills out only one set of forms.)

5. Question n aire s of ten don't let you t e l l the who le story, so pleasefeel free to make a d di ti on a 1 comments a long the way or a t the end thatclarify the way you feel. A page at the end is provided for thispurpose.

6. If you would like a copy of the results of the study when a vailable(around mid 1985) complete the form on the back page.

7. If you no longer wish to participate in this project, please checkhe re and return this sheet to me in the prepaid en v e l'ope. Pleasein dicate why you wish to withdraw:

Otherwise, I will be looking forward to your responses within a week orSO .

Thank you again for your most valuable help with this project

Lorrie Sammons, RN, NPDoctoral Candidate,University of California, San Franciscoc/o 2608 Campeche CourtSan Ramon, CA 94.583

Appendix B 141

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

BERKELEY - DAVIS • IRVINE • LOS ANCELES • RIVERSIDE • SAN DIECO - SAN FRANCISCO SANTA BARBARA • SANTA CRUZ

SCHOOL OF NURSING SAN FRANCISCO, CA LIFOR NIA 941 4 3

Department of Family Health Care NursingStudy No. 9334 21–01

CONSENT TO BE A RESEARCH SUBJECT

A) Lorrie Sammons, RN, NP, a nurse in the UCSF Graduate Nursing program, isstudying women during and after pregnancy with a second baby. I have beeninvited to be in this study.

B) If I agree to be in the study,1) I will fill out 1 or 2 sets of forms about my background, my feelings, andmy family relationships. These forms take less than an hour to complete athome. If I forget to complete them, I will receive a phone call and/or aletter as a reminder.2) A few (about 1 in 12) of the women completing questionnaires will be askedby telephone if they would agree to being interviewed for one hour, at a timeand location of their choice. The inter view is about the feelings, symptoms,and family relationships during second pregnancy. If I am asked, I agree tobe inter viewed (Please check) Yes; No. If I say "yes" now, I may changemy mind later.3) Mrs. Sammons may also review my medical records.

C) There should be no risk to me unless some of the items in the questionnaires make me feel upset or concerned about emotional or family changes. IfI feel upset, I can a) contact my regular Obstetrical doctor or nurse, or b)contact Mrs. Sammons (666–4695) to discuss these feelings. I may choose not toanswer any questions I do not want to answer.

My privacy will be protected by separating names from responses. Confidentiality will be protected as far as possible under the law.

D) There will be no direct benefit to me from participating in this study. Itis hoped this study will improve understanding of the emotional, physical andfamily changes of second pregnancy so that clinicians can be more helpful tofamilies in the future.

E) I will receive $5 for each packet of questionnaires or interview.

F) I have talked with Lorrie Sammons, RN, about this study, who has offered toanswer any questions I may have at 666–4695. In addition, I may contact theCommittee on Human Research, which is concerned with the protection of volunteers in research projects between 8 and 5, Monday–Friday at (415) 666–1814.

G) I have received a copy of this form to keep. My participation is voluntaryand I have the right to decline to participate or withdraw at any pointwithout jeopardy to my health care.

Signature of participant Date

This copy is to be returned with completed questionnaires.

142Appendix C

BACKGROUND INFORMATION In O :

T- z- 3- tº- 5- 6

Today's date: Baby due date /delivery date: —■-

— —9.9Your age 10, 11

Check your occupation category (do not count the 3 months before& after delivery if different from your usual activity).

A. House wife: O I.B. Work outside home (either full or part-time) _12

If "B": do you consider employment to be "Job" or "Career" ? - 13Nature of work: T T14, 15Number of hours spent at employment-related work, preparation &commute in typical recent week: 16, 17If you usually have outside employment, do you plan to return towork 2 No . Yes , when 2 . Completely undecided . 18

19Your number of years of schooling (High school = 12): — —20, 21

Circle which comes closest to describing your race or ethnicgroup : 0. Hispanic 1. American Indian or Alaskan Native

2. Black 3. Asian or Pacific Islander4. White, not of Hispanic origin5. Other. Please describe —22

Circle your religious preference: 0. Roman Catholic 1. Jewish2. Pro testant 3. LDS 4. Jehovah's Witness 5. No preference6. Other: Please describe _23

Number of brothers & sisters in your own family besides yourself: _24If oldest child = #1, what is the number of your birth order?_ —25

Number of previous pregnancies: _ 26, 27Misc arriages: Abortions: 28, 29

Age of your child living at home : Years +Months _ _30, 31

Sex of your older child : Male Female —32

Number of hours first born away from mother in typical week (includeall separations, e.g. child's school, child's activities,child visiting relatives, child care, etc.): _33

Relationship with children's father : Married Not married _34

Length of marriage/relationship in years:-

_35, 36

Total number of children desired by you :_ — 37by your husband : I38

I39Number of people living in household besides you, spouse, first born l!0. ly(and newborn , if arrived): Describe relationship :

- -0, 141

Husband's age:-

_42,43

Husband's racial/ethnic group0. Hispanic 1. American Indian or Alaskan Native

1143

BACKGROUND INFORMATION n O : -

+ -■ - -3 + -■ - 6

2. Black 3. Asian or Pacific Island er4. White, not of Hispanic origin5. Other. Please describe _ !!!,

Husband's years of school ing: _45,46

Husband's occupation : — — 47,48

Overall, I would rate my first pregnancy and delivery as (circle) :0. Very easy/comfor table 1. Moderately easy/comfortable2. Somewhat difficult/un comfortable3. Very difficult /uncomfortable4. Extremely difficult/uncomfor table — 49

What *WP: of delivery do you plan? (for women before delivery only : )a . Vaginal b. Cesarea n, repeatc. Cesar ean , first d. Vaginal after Cesare an — 50

Was this second pregnancy planne d ? No-

Yes, but not now . Yes, now-

— 51

Number of months at tempting conception this time: — 52

Have you at tended any classes for families a da ing a new baby this time?(e.g., parent "re freshers," children preparation classes, etc.)Yes. Not yet, but plan to . No plans to . 53If taken or planned, please list classes:

Do children at tend ? Yes No _54

Regarding prenatal diagnostic tests, such as amniocentesis or sonograms,have you had any special pre natal tests 2 Yes No _55

If yes, you have had a test, do you know the results 2 Yes No 3%If yes, what test and what are the results 2 57

If no , what test and when will you find out results 7 58Do you know of any special test you will have in the future?

No Yes . If yes, what and when 2 _59

Are you ( or baby) having any serious medical problems ? Please comment: 60

For after-second-delivery mothers only:

Sex of new born : Male Female –;Main method of infant feeding : Bottle Breast T 63

Type of delivery: Vaginal (repeat)_ Waginal (after Cesarean)Planned Cesare an Emergency Cesare an T 64

Husband present at birth 2 Yes No 65

Appendix D

SELF-EVALUATION QUESTIONNAIRE

DIRECTIONS: A number of statements which people have used todescribe themselves are given below. Read each statement and then '', /.

blacken in the appropriate circle to the right of the Statement to indi- 12. K. °, ^*,cate how you feel right now, that is, at this moment. There are no right * . , 72, '',or wrong answers. Do not spend too much time on any one statement ”, °, %, ^2,but give the answer which seems to describe your present feelings best. 2 *, *, *.

!. I feel calm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j\ } @ 3

2. I feel secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T 3, 3, 3

3. I am tense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3) @ 3) 3,

4. I feel strained . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 : 3 7

5. I feel at case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 3 5, 2

6. I feel upset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . © 3, § 3

7. I am presently worrying over possible misfortunes . . . . . . . . . . . . . . () (? 3) 3

8. I feel satisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . © $ 3, 3.

9. I feel frightened . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3) 3 3, 3

10. I feel comfortable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T. G. 3, 7.

ll. I feel self-confident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 (?) 3, 2

12. I feel nervous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . @ 3, 3) (3)

13. I am jittery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o a 3 &14. I feel indecisive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3) (? 3) (3)

15. I am relaxed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G) @ 3) (3)

16. I feel content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G.) (3) 3) (3)

17. I am worried . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G) (?) G) (3)

18. I feel confused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q) @ G) 3)

19. I feel steady . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q) @ 3) (3)

20. I feel pleasant . . . . . . . . . . . . . . . . . . . . . . . . . . * . . . . . . . . . . . . . . . . . . . . . () () (3) (3)

@ Consulting Psychologists Press577 College Avenue, Palo Alto, California 94306

Reproduced by special permission of the Publisher, ConsultingPsychologists Press, Inc., Palo Alto, CA 94.306 from the STAI-yby Charles Spielberger and Associates Copyright 1983. Furtherreproduction is prohibited without the Publisher's consent.

11:5Appendix E

SELF-EVALUATION QUESTIONNAIRESTAI Form Y-2

DIRECTIONS: A number of statements which people have used to

describe themselves are given below. Read each statement and then º, º,blacken in the appropriate circle to the right of the statement to in- º, W. %,dicate how you generally feel. There are no right or wrong answers. Do 5. 1. %. f_ ‘.not spend too much time on any one statement but give the answer *1, %. *z, ”,which seems to describe how you generally feel. 4 *■ , *. 1. 'j.

21. I feel pleasant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (i) (? (3, 3.

22. I feel nervous and restless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Ö (2, 3, 2

23. I feel satisfied with myself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (i) (? 3, 2.

24. I wish I could be as happy as others seem to be . . . . . . . . . . . . . . . . . 1 *, 3, 2

25. I feel like a failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 : 2 3 (3.

26. I feel rested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2 3, 2

27. I am “calm, Cool, and collected” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (i) 2. 3. 2.

28. I feel that difficulties are piling up so that I cannot overcome them (i) 3, 3 (3)

29. I worry too much over something that really doesn't matter . . . . . . © 3, 3. 2.

30. I am happy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . © (? 3 3

31. I have disturbing thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . () (? 3, 3)

32. I lack self-confidence . . . . . . . . . . . . . . . . . . . . . .- - - - - - - - - - - - - - - - -

@ 3, 3, 2)

33. I feel secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (i) @ 3 (3)

34. I make decisions casily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . © (?) 3 (3)

35. I feel inadequate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3) 3, 3) (3)

36. I am content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 (?) 3 (3)

37. Some unimportant thought runs through my mind and bothers me 3) (?) 3 (3)

38. I take disappointments so keenly that I can't put them out of my

mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . @ 3 3, 3)

39. I am a steady person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * - - - - - - - - - - - - 3) 3 3) (3)

40. I get in a state of tension or turmoil as I think over my recent concerns

and interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G) @ (3, 3)

Reproduced by special permission of the Publisher, ConsultingPsychologists Press, Inc., Palo Alto, CA 94.306 from the STAI-Yby Charles spielberger and Associates Copyright 1983. Furtherreproduction is prohibited without the Publisher's consent.

146

Appendix F

Spanier Dyadic Adjustment Scale

Respond as you feel about your marriage/partner relationship at this time. 1 l;7

Most persons have disagreements in their relationships. Please indicate below theapproximate extent of agreement or disagreement between you and your partner foreach item on the following list.

Almost Occa— Fre— Almost

Always Always sionally quently Always AlwaysAgree Agree Disagree Disagree Disagree Disagree

1. Handling family finances (8)

2. Matters of recreation (9)

3. Religious matters (10)

4. Demonstrations of affection (11)

5. Friends (12)

6. Sex relations (13)

7. Conventionality (corrector proper behavior) (14)

8. Philosophy of life (15)

9. Ways of dealing withparents or in-laws (16)

10. Aims, goals, and thingsbelieved important (17)

11. Amount of time spenttogether (18)

12. Making major decisions (19)

13. Household tasks (20)

14. Leisure time interestsand activities (21)

15. Career decisions (22)

All Most of More often 0ccathe time the time than not sidnally Rarely Never

16. How often do you discussor have considered divorce,separation, or terminatingyour relationship? (23)

17. How often do you or yourmate leave the house

after a fight? (24)

18. In general, how oftendo you think that thingsbetween you and your partnerare going well? (25)

19. Do you confide in your mate? (26)

20. Do you ever regret that youmarried? (or lived together) (27)

All Most of More often Occathe time the time than not sionally Rarely Never

21. How often do you and your 1 l;8partner quarrel? (28)

22. How often do you and your mate"get on each other's nerves?" (29)

Every Almost OccaDay Every Day sionally Rarely Never

23. Do you kiss your mate? (30)

All of Most of Some of Very few None ofthem them them of them them

24. Do you and your mate engage inoutside interests together? (31)

How often would you say the following events occur between you and your mate?Less than Once or Once or

once a twice a twice a Once a MoreNever month month week day often

25. Have a stimulatingexchange of ideas (32)

26. Laugh together (33)

27. Calmly discuss something (34)

28. Work together on a project (35)

These are some things about which couples sometimes agree and sometime disagree.Indicate if either item below caused differences of opinions or were problems inyour relationship during the past few weeks. (Check yes or no)

Yes. No.29. Being too tired for sex. (36)

30. Not showing love. (37)

31. The dots on the following line represent different degrees of happiness in yourrelationship. The middle point, "happy," represents the degree of happiness ofmost relationships. Please circle the dot which best describes the degree ofhappiness, all things considered, of your relationship.

1 2 3 4 5 6O O O o o o ©

Extremely Fairly A Little Happy Very Extremely PerfectUnhappy Unhappy Unhappy Happy Happy (38)

32. Which of the following statements best describes how you feel about the futureof your relationship?

I want desperately for my relationship to succeed and would go to almost anylength to see that it does.

that it does.- - - -

I want very much for my relationship to succeed, and will do my fair share tosee that it does.

It would be nice if my relationship succeeded, but I can't do much more thanI am doing now to help it succeed.It would be nice if it succeeded, but I refuse to do any more than I am doingnow to keep the relationship going.My relationship can never succeed, and there is no more than I can do to keepthe relationship going. (39)

21.

22.

23.

Appendix G

Family RELATIONSHIPS QUESTIONNAIRE-PRENATAL no: ***

The following statements have been made by some women having a second baby.

disagree, 5=strongly disagree)

Circle

the response that best reflects how much you agree with each statement now.(1=Strongly agree,2=somewhat agree, 3= either mildly agree or disagree, 4=somewhat

AGREE

I spend as much time with my first child as I'd like to. 1 2

I have a strong preference about the sex of the baby. 1 2

My husband and our first child will get closer with the new baby coming. 1 2

My first child may misbehave to get attention. 1 2

My husband will be relaxed enough with a new baby this time. 1 2

I give my first child enough attention. 1 2

It will take a while until I will love the new baby as much as my olderchild. 1 2

1 2I want my husband to give more attention to our older child now.

DISAGREE3 4

3 4

3 4

3 4

3 4

5

It will be a good experience for our child to have a new brother or sister.1 2 3 4 5

I'm afraid my first child won't feel as close to me after the baby comes.

I think about whether other family and friends will love this baby asmuch as our first.

My older child may be jealous of the baby.

I go for long periods without thinking about the new baby.

I wonder if I'll love my first child less after the new baby comes.

The two children will enjoy each other very much.

My husband doesn't have time to be interested in the new baby.

Because of my older child, I don't get a chance to enjoy this pregnancy.

My husband has a strong preference about the sex of the baby.

It will be difficult for my first child to share me with the baby.

I don't feel as close to my older child now that I'm pregnant.

My husband spends enough time with our first child.

My husband worries about the costs and responsibilities of the new baby.

I think about the chances of this baby not being as healthy as my firstchild.

24. My husband has a loving relationship with our first child.

25. I wish my husband were more excited about the new baby.

1 2 3 4 5

1 2 3 4 5

1 2

1 2

3 4

3 4

3 4

Appendix H 150

FAMILY RELATIONSHIPS QUESTIONNAIRE-POSTPARTUM In O

The following statements have been made by some women who have had a second baby.Circle the response that best reflects how much you agree with each statement now.(1=Strongly agree,2=somewhat agree, 3=either mildly agree or disagree, 4=somewhatdisagree, 5=strongly disagree)

AGREE DISAGREE

! . I spend as much time with my first child as I would like to. 1 2 3 4 5

2. I think about whether other family and friends love this baby asmuch as our first. 1 2 3 4 5

3. My husband and our first child are getting closer now that the newbaby is here. 1 2 3 4 5

4. My husband doesn't seem to have time to spend with the new baby. 1 2 3 4 5

5. My older child is jealous of the baby. 1 2 3 4 5

5. It will take more time until I love the new baby as much as myolder child. 1 2 3 4 5

7. My husband has a loving relationship with our first child. 1 2 3 4 5

3. My husband is very excited about the new baby. 1 2 3 4 5

9. It is difficult for my first child to share me with the baby. 1 2 3 4 5

10. I'm sad the new baby does not get all my attention in the exclusiveway the first child did. 1 2 3 4 5

11. My husband spends enough time with our first child. 1 2 3 4 5

12. My husband worries about the costs and responsibilities of the newbaby. 1 2 3 4 5

13. Our older child acts in a very caring way towards the baby.-

1 2 3 4 5

1". My older child doesn't let me enjoy the baby. 1 2 3 4 5

15. I can handle the time demands of my new baby. 1 2 3 4 5

16. I don't feel as close to my older child now that the new baby is here. 1 2 3 4 5

17. My husband pays a lot of attention to the new baby. 1 2 3 4 5

18. My older child is enjoying being a big brother/sister. 1 2 3 4 5

19. I don't get enough time with the new baby. 1 2 3 4 5

20. My older child acts as though I don't love her/him as much as I usedto. 1 2 3 4 5

21. I want my husband to give more attention to our older child now. 1 2 3 4 5

22. My older child misbehaves to get my attention. 1 2 3 4 5

3) L. N. Sammors, 1984

Appendix I

SYMPTOM'S OF PREGNANCY CHECKLIST no ; – — — — — —

The following are sensations or discomforts of pregnancy sometimes described bywomen. Indicate how often you have experienced each item recently by circling thenumber that best reflects your experience: 0=rarely or not at all; 1=occasionally;2=fairly often; 3= very often to constantly. Use a ruler if needed.

Then, compare to last time. Indicate if you are experiencing the item more orless often than you did at the same month of your previous pregnancy, to the best ofyour memory: A=less than before; B– the same; C=more than before.

THIS PREGNANCY NOW COMPARED TO LAST PREGNANCYRARE/NONE CONSTANT NOW LESS SAME NOW MORE

backache O 1 2 3 A B C — — 9, 10

varicose veins 0 l 2 3 A B C — — 11 - 12

constipation O 1 2 3 A B C — — 13.1%diarrhea 0 1 2 3 A B C — — 15, 16dizziness O l 2 3 A B C — — 17, 18heartburn O l 2 3 A B C — — 19, 20

trouble sleeping 0 l 2 3 A B C- -

21, 22

bleeding O 1 2 3 A B C — — 23, 24depression O 1 2 3 A B C — — 25, 26appetite loss O 1 2 3 A B C _ _ 27, 28I■ lau Sea O l 2 3 A B C _ _ 29, 30painful intercourse 0 1 2 3 A B C

- -31, 32

shortness of breath 0 1 2 3 A B C - -33, 34

swollen legs/hands 0 l 2 3 A B C- -

35, 36tiredness O l 2 3 A B C _ _ 37, 38vomiting 0 1 2 3 A B C _ _ 39,40weakness O l 2 3 A B C — — 41,42

flushed feeling 0 1 2 3 A B C _ _ 43,44frequent urinating 0 l 2 3 A B C

- -l; 5, 196

cold hands/feet 0 1 2 3 A B C __ 47,48irritability 0 1 2 3 A B C _ _ 49, 50rapid weight gain 0 , 1 2 3 A B C _ _ 51, 52increased appetite 0 l 2 3 A B C - -

53,514heartpounding O 1 2 3 A B C - -

55, 56hemorrhoids O 1 2 3 A B C _ _ 57, 58anxiety 0 1 2 3 A B C __ 59,60headache 0 1 2 3 A B C __ 61.62breast discomfort 0 l 2 3 A B C - -

63,614groin/pelvic pain 0 1 2 3 A B C - -

65,66or pressure

If you are feelido vo: reve any i

ng symptoms differently than at this month of your last pregnanºdeas as to why? Please comment below or on the inside back cover.

152

11.

13.

19.

20.

21.

22.

23.

If you are feeling symptoms differently n2g than at this time after your Previous

Appendix J

POSTPARTUM SYMPTOM'S CHECKLIST In O :

The following are sensations or discomforts sometimes described by women afterdelivery. Indicate how of ten you have experienced each item after delivery bycircling the number that best reflects your experience: 0= rarely or not at all ;1=occasionally; 2-fairly often; 3=very often to constantly. Use a ruler if needed.

º tº: to last time. Indicate if you are experiencing the item more ori lessen than you did after birth of your first child, to the best of your memory:A=less than before; B– the same; C=more than before.

NOW: FOLLOWING BIRTH OF SECOND CHILD COMPARED TO LAST POSTPARTUMRARE/NONE CONSTANT NOW LESS SAME NOW MORE

backache 0 1 2 3 A B C _ _ (9,10)varicose veins O l 2 3 A B C — — (11.12)

constipation O 1 2 3 A B C __ (13.1%)diarrhea 0 1 2 3 A B C __ (15,16)dizziness O l 2 3 A B C _ _ (17, 18)trouble sleeping O l 2 3 A B C _ _ (19.20)depression O 1 2 3 A B C __ (21, 22)appetite loss O l 2 3 A B C __ (23.2%)Ilau Sea O l 2 3 A B C __ (25,26)painful intercourse 0 l 2 3 A B C __ (27, 28)swollen legs/hands 0 l 2 3 A B C _ _ (29, 30)tiredness O 1 2 3 A B C — — (31 - 32)weakness O l 2 3 A B C — — (33.3%)

overweight O l 2 3 A B c __ (35, 36)cold/flu symptoms 0 l 2 3 A B C — — (37,38)irritability O l 2 3 A B C _ _ (39, 40)increased appetite 0 l 2 3 A B C _ _ (41,42)excessive bleeding 0 l 2 3 A B C __(43,44)hemorrhoids 0 1 2 3 A B C __(45,46)anxiety 0 1 2 3 A B C __(47,48)headache 0 1 2 3 A B C __(49.50)breast discomfort 0 1 2 3 A B C __(51, 52)groin/pelvic pain 0 1 2 3 A B C

-—' 53, 54)

or pressure

pregnancy, do you have any ideas as to why? Please comment below or on back cover:

(3) L. N. Sammons, 1983

Appendix K153

Recruitment Flier

HAVING ASECOND BABY? JUST DELIVERED YOUR SECOND?

You are invited to take part in a study of the emotions, symptoms andrelationships during second pregnancy.

What to do:

Complete a set of questionnaires in about 45 minutes at your convenience at homenow and again in 3 months. (All responses are treated anonymously and confidentially.)

What you will receive:1. $5.00 per set of questionnaires, in appreciation of the accommodation to your

your schedule.2. A summary of the results, if desired.

How to get more information:Complete the “Second Baby” card (attached, or available on drop-box at appt. desk)and place it in the yellow drop-box by the OB appointment desk or phone-in area.You will be contacted within a week.

If you are interested, DROP OFF THE CARD TODAY. Women in each month of pregnancy and first3 months after delivery are needed NOW.

Study conducted by Lorrie Sammons, RN, NP, Doctoral candidate, School of Nursing, University ofCalifornia, San Francisco (666-4695). Correspondence address: 2608 Campeche Court, San Ramon,California 94583.

T-“SECOND BABY PREGNANCY” card–,

ALL women who are pregnant with thier second baby or who delivered within 3 months are asked to respond. PLEASE COMPLETE

Would you be interested in completing a set of- -questionnaires about

the second pregnancy experience? THIS CARD

- - IDNO, because (please indicate why; you will NOT be contacted). . . TODAY!

DYES, My name:Baby due date/date delivered:Phone number(s) where I can be reached:Best times to call:

- t!

Address:

Q(GºDROPIN YELLOW Box by OB appointment desk or by phone-inarea TODAY or mail to Lorrie Sammons, RN, NP, 2608 CampecheCt., San Ramon CA 94583.

Appendix L- - - - -

Comments for T–l Packet

Is the re any thing you would like to comment on a bout emotions,physical sensations, or family relationships when having a secondb a by ?

Is there anything that you felt might be having a particularinfluence on you and your family during/after this pregnancy?

Are there any reactions to this set of question n aires you wouldlike to share 2

Please feel free to use the following space for any comments:

Thank you.

Complete the following only if you would like a copy of theresults of this study around mid 1985.

Name:Address:

155

Appendix M

Cover Sheet for T-2 Packet()

SECOND BABY PREGN ANC Y STUDY

PACKET #2

Thank you for completing the first packet of questionnaires. I am happy to be ableto enclose $5 in appreciation for your assistance.

Please complete this questionnaire this week and return it to me in the envelopeprovided. You should receive another $5 within four weeks. Please indicate if youhave a new address:

1. Today's date: Baby due date/delivery date: _(7)— (8.9)

2. Have their been any major changes in your lives in the last 3 months that mightaffect your emotions, symptoms, and family relationships other than pregnancy/delivery itself? If yes, please comment (use reverse if needed): (10)

3. Has there been any serious illness or complication for you or the baby? Ifyes, please comment here or on the reverse side: (11)

4. Did you attend any pregnancy related classes since completing the last packet?Yes No . (12)

If yes, did your first child attend? Yes No_. T(13)

5. Regarding prenatal diagnostic tests (e.g. amniocentesis, sonogram), did you haveany tests since completing the last packet? Yes No_. If yes, what kind? (14)

6. Did you get the results of any prenatal tests since completing the last packet?Yes_ No_. If yes, what kind of test and what were the results? _(15)

If you have delivered since completing packet #1, please indicate:

7. Sex of newborn : Male Female _(16)

8. Main method of infant feeding: Bottle Breast_ _(17)

9. Delivery type: Vaginal (repeat)_ Waginal (after Cesarean)_Planned Cesarean_ Emergency Cesarean_ (18)

10. Husband present at birth? Yes_ No_ _(19)

andIf you no longer wish to participate in this project, please check herereturn this sheet to me in the prepaid envelope. Please indicate why you wish towithdraw:

Lorrie Sam mons, RN, NP; 2608 Campeche Ct. , San Ramon, CA 94.583

156

Appendix N

Categorization of Antecedent Variables

Variable Name Level of Data

DemographicAgeM(aternal) IntervalAgeP(aternal)

-Interval

RaceM(aternal) Nominal *RaceP(aternal) Nominal”Religion NominalMarital (Status) Nominal”SchoolM(aternal) IntervalSchool P(aternal) IntervalOccup(ation)M(aternal, ranking) IntervalOccup(ation)P(aternal, ranking) IntervalSocioeconomic Status (SES) Interval

Obstetric Experience & AttitudesMiscarry (# Spontaneous Abortions) IntervalAbortion (# Therapeutic Abortions) IntervalComfortl (Comfort in 1st Pregnancy/Delivery) NominalDeliver 1 (Route of first Delivery) NominalIntend 2 (Was 2nd Child Planned Now) NominalConceptn (Months Trying to Conceive) IntervalChilBesM (# Children Desired by Mother) IntervalChilDesR (# Children Desired by Father) IntervalChilBif (Difference & Direction, # Children

Desired, Mother vs Father) NominalIll (Maternal/Baby Medical Problems) Nominal—dichotomousTest (Had prenatal diagnostic test) Nominal—dichotomousTstfutr (Test planned for future) Nominal—dichotomousClass (Plan/attend childbearing class/es) Nominal

PostpartumSex B(aby) Nominal-dichotomousFeedB(aby-Breast vs Bottle) Nominal—dichotomousF(ather)Present (at birth) Nominal—dichotomous”

Family BackgroundLeng (th of )Mar(riage/Relationship) IntervalAge first (Firstborn Age) IntervalSpacing (1st born Age at Birth of 2nd-computed) IntervalSex-child (Firstborn) Nominal—dichotomousSibnum (# Siblings in Mother's Family) IntervalBirthord (Mother's Ordinal Birth Order) Interval

Maternal Employment CharacteristicsEmployM(aternal-classify yes/no) Nominal—dichotomousJob (vs)Career (Maternal) NominalHours (spent at) w(or)k IntervalHour(s a) part (mother & firstborn, per week) Interval

*Descriptive purposes only; insufficient dispersion for comparisons

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