Prenatal education among low-income groups.

The purpose of this study was to evaluate, describe, and measure the effect of prenatal education among a group of low-income families. One group received preparation for childbirth and parenting (PCP) class and one did not. The classes were offered at a community center with a specifically designed program for high-risk clients. The sample consisted of 58 expectant women, who were at or below the established poverty level for the State of Utah for the year 1978 and $4,500 for a family of four. Data collection continued from May 1, 1978 to January 5, 1979. The Utah Test Appraising Health-IV (UTAH-IV) questionnaire was utilized for the predelivery testing. The 230 questions are arranged in three sets: (1) census data, (2) a set of physical symptoms, (3) common problems confronting normal persons. A consent from was obtained from the participant. During the postpartum period the Utah Tests Appraising Mothers at Home (UTAH-H) was used to score the mother on aspects of mothering and adjustment to becoming a mother. This was done in the mother's home about two weeks after delivery. The scores for the UTAH-IV questionnaire were separated into those related to body systems, to each trimester. In addition, there were two separate sets of questions dealing with the General Adaptation distress and the Cornell Psychiatric Items. These were separated according to the three trimesters of pregnancy and received a numerical score. Also scored were responses to common problems that might have occurred in the previous six to 12 months, and those that had occurred in the previous six months. The scores were also examined according to stress area and each received two scores, for the two different time periods. Illness-proness was assessed by having the women circle symptoms that personally had experienced in the previous 10 years, for a list of 34 possible problems. These answers were given a numerical score. The scores for the various body symptoms and stress areas were compared, untreated to treated, to determine whether a difference was present by means of a T-test and Pearson correlation coefficient tests. Illness-proness was also correlated with the Pearson r test. Income level was submitted to the T-test to determine homogeneity. Outcome variables of delivery not affected by the researcher's possible bias were Apgar, one and five minute scores, weight at birth, gestational age, anesthesia utilized, and type of delivery. Significance at the .05 level was seen with Apgar scores, gestational age, anesthesia, and type of delivery. No significant differences existed for income level, and the mean frequency of education, occupation, parity, and age were very close in numerical values. No significance existed in birth weight between the two groups, however that could have been coding difficulty. The aspects of mother-infant relationship were all significant, except for the psychological aspect; this was a definite problem with the tool utilized as the wording was quite difficult to interpret in the setting of the group of people's homes. The scale for the scoring was limited one to four, and the significance may need to be interpreted as a trend only. These test results suggest that the groups were homogenous in nature, and that differences did occur between the two groups, and the variable of prenatal education should be considered as significant.

PRENATAL EDUCATION AMONG LOW-INCOME GROUPS by Londa Y. Thompson A thesis sumitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah March 1979 THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Londa Yvonne Thompson I have read this thesis and have found it to be of satisfactory quality for a master's degree. Mary anigan Chairman, Supervisory Committee I have read this thesis and have found it to be of satisfactory quality for a master's degree. Beryl P :ers Member. Supervisory Committee I have read this thesis and have found it to be of satisfactory quality for a master's degree. "Il;: \_.\, /\' . ' , t1 ~0R··1~~··~~_V~'~_ _ l~'f~t_~._k_ ._D _·~~v·_~._--_·_-_____________ Jqhn Sullivan ,.Member. Supervisory Committee UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of Landa Yvonne in its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is :ready for submission to the Graduate School. ~/b2 / -Mary Bani gan I Member, Supervisory Committee Appr~ for the Major Department " " ---/-~i"",'ill~4~f:~~ti(~in~[~. /~C Chainnan /Dean . Approved for the Graduate Council u1~ James ~L. Clayton~ Dean of the Graduate School ABSTRACT The purpose of this study was to evaluate, describe, and measure the effect of prenatal education among a group of low-income families. One group received preparation for childbirth and parent­ing (PCP) class and one did not. The classes were offered at a com­munity center with a specifically designed program for high-risk clients. The sample consisted of 58 expectant women, who were at or below the established poverty level for the State of Utah for the year 1978 of $4,500 for a family of four. Data collection continued from May 1, 1978 to January 5,1979. The Utah Test Appraising Health-IV (UTAH-IV) questionnaire was utilized for the predelivery testing. The 230 questions are arranged in three sets: (1) census data, (2) a set of physical symptoms, (3) common problems confronting normal persons. A consent form was obtained from each participant. During the postpartum period the U~ah Tests Appraising Mothers at Home (UTAH-H) was used to score the mother on aspects of mothering and adjustment to becoming a mother. This was done in the mother's home about two weeks after delivery. The scores for the UTAH-IV questionnaire were separated into those related to body systems, to each trimester. In addition, there were two separate sets of questions dealing with the General Adapta­tion Distress and the Cornell Psychiatric Items. These were separated according to the three trimesters of pregnancy and received a numerical score. Also scored were responses to common problems that might have occurred in the previous six to 12 months, and those that had occurred in the previ ow) si x months. The scores were a 1 so examined according to stress areas and each received two scores, for the two different time periods. Illness-proness was assessed by having the women circle symptoms they personally had experienced in the previous 10 years, from a list of 34 possible problems. These answers were given a numerical score. The scores for the various body symtoms and stress areas were compared, untreated to treated, to determine whether a difference was present by means of a T-test and Pearson correlation coefficient tests. Illness-proness was also correlated with the Pearson r test. Income level was submitted to the T-test to determine homo­genei ty. Outcome variables of delivery not affected by the researcher's possible bias were Apgar, one anG five minute scores, weight at birth, gestational age, anesthesia utilized, and type of delivery_ Signifi­cance at the- .05 level was seen with Apgar scores, gestational age, anesthesia, and type of delivery. No significant differences Existed for income level, and the mean frequency of education, occL'pation, parity, and age were very close in numerical values. No significance existed in birth weight between the two groups, however that could have been a coding diffi­culty. v The aspects of mother-infant relationship were all significant, except for the psychological aspect, this was a definite problem with the tool utilized as the wording was quite difficult to interpret in the setting of this group of people's homes. The scale for the scoring was limited one to four, and the significance may need to be interpreted as a trend only_ These test results suggest that the groups were homogenous in nature, and that differences did occur between the two groups, and the variable of prenatal education should be considered as signif­icant. vi CONTENTS ABSTRACT .... LIST OF TABLES. ACKNOWLEDGMENTS CHAPTER I. INTRODUCTION AND L ITERATURE REVIE~J. Significance of the Study .. Statement of the Problem . Literature Review ... Theoretical Framework. Hypotheses . II. METHODOLOGY. Criteria for Subject Selection. Treated. Nontreated . t~easures . I 11. RESUL TS . . . . Description of the Sample .. Operational Definitions of Terms. Hypothesis I . .. . .. . Hypothesis II ...... . Hypothesis III ..... . Ancillary Findings ... . Limitations of the Study. IV. SUMMARY AND RECOMMENDATIONS. APPENDIX .. REFERENCES. VITA ..... Page iv viii ix 3 5 6 19 19 21 22 23 23 23 25 25 29 29 33 33 37 37 39 42 63 71 LIST OF TABLES Table Page 1 . Age and Educational Status of Subjects 26 2. Ma ri ta 1 Status of Subjects 27 3. Income Range for Subjects. 27 4. Parity of Expectant Mothers. 28 5. Experience of Pregnancy. 28 6. Comparison of Mean Scores on UTAM-H between Treated and Untreated Groups . . . . . . 30 7. First Trimester Symptoms .. 31 8. Second Trimester Symptoms .. 31 9. Third Trimester Symptoms. 32 10. Comparison of Group by Stress Indices--Means, t-Va1ues, and Significance. . . . . . . . . . . . . . . . 34 11. Type of Delivery Used--Difference between Groups. .. 35 12. Type of Anesthesia Used--Differences between Groups.. 35 13. Comparison of Group on Apgar Birth Weight and Gestational Age. . . . . . . . . . . . . . 36 14. Type of Actual Feeding--Chi-Square Analysis. . 36 ACKNOWLEDGMENTS I would like to acknowledge those individuals who made contri­butions toward the completion of this thesis. Appreciation is extended to the members of my supervisory committee, Mary Banigan, Chairman; Beryl Peters; and John Sullivan, for their interest, guidance, and suggestions during the preparation of this study. Dr. Peters particularly for her assistance in editing the final draft, and Mary Banigan for her unfailing support of this endeavor. Thanks to Greg Stoddard for his help with the statistical interpretation of the data and for helping me write a computer program to test the hypotheses. Warm gratitude is expressed to each of the families who parti­cipated in this study, without their cooperation, the entire project would have failed. I would like to thank also Joyce Cameron who prepared me to teach the series of classes that were the basis for the study. Sincere recognition is offered to my parents, for without their financial support I would have been unable to continue, in particular my mother who has enabled the actual thesis to be typed and published; my darling children, whose patience, love and under­standing enabled me to finish the project; my eldest daughter, Tamara, who baby sat with her younger brother and sister with un­failing love so I could work on the project. To the staff of 5E at the University of Utah Medical Center, pdr icularly the 11 :00 to 7:00 shift, whose friendship, support, and patience has been so helpful--my warm gratitude is expressed. To the Central City Community Center Staff who graciously has let us use their rooms free of charge. To the March of Dimes for initially funding the project and a special thanks to Ruth Ann Heady and Alice Compel, who have volunteered to keep the classes going. Without them this study would not have been possible. x CHAPTER I INTRODUCTION AND LITERATURE REVIEW This study was begun after three years of working with a high­risk pregnant population, and recognition that lack of childbirth education or preparation for parenting was a constant factor in the myriad of problems facing this population. It had been observed that the most highly-stressed individuals were also of low-income or poor. The disadvantaged client is at greater risk than her financially stable sister, due to stress factors arising from the inability to obtain the necessary nutrition and prenatal care. The disadvantaged mother usually enters pregnancy in poorer general health. The vital statistics for the State of Utah for 1970 showed that 9.1% of the state population was considered to be living on an income less than $4,000/year for a family of four. Of the total population of Salt Lake County, 8.1% fell below the poverty level. In 1978 the level of poverty was determined to be less than $4,500/ year (Utah Health Profile, Department of Social Services, State of U ta h, 1 971 ) . Utah's fertility rate in 1974 was 117.0/1,000 for women between the ages of 15-44. This is 71% higher than the national fertility rate of 68.4/1,000 (Utah Vital Statistics, 1974). There were 29,946 live births to Utah residents in 1974~ an increase of 7.0% over 1974; this increase was felt likely to continue. One thousand fifty-two infants born in Salt Lake County had one or more complications, 2 birth injurifs, or cogenital anamo1ies. In the state there were 1,591 low-birth weight infants (2,500 grams or less) or 5.3% of the total births. This compared favorably to a national rate of 7.4%. The infant and fetal death rate for the Greater Salt Lake area was 13.0/1,000 (fetal) and 15.0/1,000 (infant), for 1970 (Utah Health Profile, 1971). Neither report included income levels and associated birth problems, or death, and no low-income or borderline income figures were reported. However, the median income for Salt Lake County for 1970 was $9,771 for a family of four (Utah Health Profile, 1971). Women delivering at the high-risk center of the University of Utah r~edical Center consistently stated that the main reason for not obtaining information about childbirth was that they could not afford prenatal classes or felt that they would feel awkward because they were not married. Lack of transportation, availability of baby sitters, and money to pay for these services were also frequently mentioned. Another problem identified in these families was a jeopardized mother-infant relationship. A mother who has had a difficult, tiring pregnancy, frightening labor, and little or no help or support during the postpartum period cannot meet her baby's needs as well as her counterpart in better circumstances. The disadvantaged mother may have been raised in poverty, never had much, is frequently alone, and not aware of the resources for learning and special help. She may receive welfare aid, but may refuse as sis tance due to flri de. Thi s mother va in ly tri es to cope 3 with the added pressures dnd frequently does not succeed; she suffers, as does the baby_ The quality of life is a large issue at present in the world. When one intervenes with a pregnant woman and helps her better to control her life, impart some knowledge and learn from her, people are affected, others as well as she and her baby . . ~nJ}i cance of the Study' The relevance of this investigation to the health and well-being of mothers and infants is discussed in relation to high-risk pregnancy. A high-risk pregndncy is one in which the fetus has a significantly increased chance of death, either before or after birth, or increased risk of later disability. Some fetuses may be damaged early, late, or born prematurely, or may be small for gestational age. long. A few will he too large or will have remained in utero too Each situation has its special hazards. The normal development of the fetus is threatened by a myriad of factors, both singly and in combination. Maternal complications play a role, but of greater importance are the environmental factors, social conditions~ nutritional deficits, which can influence or create maternal complications. An interaction between many of these factors occurs and adversely affects the quality of survivors. Such factors have resulted in the identification of high-risk pregnancies and high-risk infants (Rudolph, 1973). The mother infant relationship, "bonding," is of prime impor­tance for the infant to survive physically and emotionally. The infant's quality of life, is affected by the maternal-infant rela­tionship. The infant's potential as a contributing member of the human race is at risk, and the mother's emotional health will either facilitate or hinder realization of potential. Socioeconomic factors, such as social class, income, education, and marital status, which dictate life style and influence partici­pation in social institutions, are interdependent. They determine where an individual will live, access to a variety of services, as well as family values and attitudes. The first published study to sUbstantiate the relationship between socioeconomic conditions and pregnancy outcome was the 1925 Children's Bureau Survey "Causal Factors in Infant Mortality." 4 The findings showed that (1) color and nationality exerted a IIpowerful" influence over infant mortality, (2) mortality among infants in congested living conditions was two and a half times as high as among infants living in noncongested homes, and (3) there was a marked- correlation between a father with low earning and high infant mortality--this relationship being independent of nationality and largely independent of h0using congestion (Willis, 1977). The concept "poor" is ancient, dating to Biblical times. liThe poor always ye have them with you .... " (John 12:8). There will always be poor people and as the population increases so do the numbers of disadvantaged peo~le. The need to be aware of their needs and of ways to reach them is increasing in importance as their numbers grow. The lower-income person experiences a crisis-life style; con-stantly trying to make do with string where rope is needed (Fitzpatrick, 1971). Since crisis involves stress, the person's life is constantly affected. The childbearing process, probably more than any other time period in a woman's life is a time of numerous changes in a rela-tively short span of time. It can be the breeding ground of mal- 5 adjustments that can affect the marriage or relationship, the family, the potential baby, and the mother. Bearing a child can and should be a beautiful time in a woman's life, but for the poor, no matter how much the baby may be wanted, the stress is increased many times over that which her advantaged counterpart may experience. It has been observed that some women adapt better than others; many advantaged women have extremely stressful pregnancies. Therefore, it cannot be assumed that income alone is the only stress factor which contributes to high-risk pregnancy. The potential for trouble is greater for a woman who hus few resources, and is currently burdened with numerous problems. Statement of the Problem The purpose of this study was to evaluate, describe, and measure the mo-ther-infant relationship and delivery outcome variables 'in two groups of low income families. One group received ctlildbirth educa­tion classes specifically designed for low-income high-risk people, and offered free of charge by the investigator at a community center. 6 The other group received no formal instruction of any kind and qua 1 i fi ed fc,r the study by income 1 eve 1 _ The interrelated effects of stress, poverty, and pregnancy; and lack of knowledge regarding pregnancy, labor and delivery and parent-ing were felt to be of some significance, as the lower socio-economic groups contribute in overwhelming numbers to the parinatal mortality and morbidity rate in this country_ Literature Review The review of literature revealed a variety of studies focused on stress, ~overty, pregnancy, and the effect of childbirth educa-tion. No studies interrelated all variables, some combined two or more, and many mentioned the mother-infant relationship. Delivery outcomes were most frequently examined as perinatal mortality and morbidity, however Apgar and birth weight and gestational age were measured in only a few studies. Each variable will be reviewed as separately as possible. Stress The effects of stress on the fetus during pregnancy has been examined in some fashion for at least two centuries. In 1867, Whitehead stated: Severe physical shocks such as falling from a height may leave the fetus unperturbed and unharmed. But it seems otherwise when the mental system of the mother becomes un­balanced by violent and sudden shocks of anguish or by pro­longed and severe anxiety. . .. (Clark, 1976, p. 252) A number of investigators have compared the relationship of stress to illness and others have studied the events in the lives of patients which were antecedent to illness (Caplan, 1959; Rahe, 1972; Selye, 1956). Wu (1973) examined the relationship between behavior and illness. Holmes and Rahe utilized a technique in which a list of events regarded as capable of affecting an individual's psychological equilibrium was drafted. The events were compared in terms of the relative amount of adjustment required by an individual experiencing them. The results were mathematically interpreted, and each life event was assigned a numerical value; life change units (LCU). A number of investigators have determined that a LCU score of 200 or more within a single year significantly increases an individuals probability of becoming more vulnerable to illness (Blair & Salerno, 1976) . A project conducted for three years at the University of Utah and supported by a Maternal and Child Health grant was examined, Pregnancy, Illness-Proness and Stress (PIPAS). The objectives were to determine the relations of measures of symptom-proness, symptom­resistance, and stress to standard symptoms of women throughout the pregnancy cycle, labor and delivery, and postpartum-hospitalization. The general theory was that stress activates symptom-proness tendencies if they are present. A hypothesis emerging from this theory is that highly stressed symptom-resistant patients have a low probability of becoming ill, although they may increase their activity levels, become neurotic or have psychotic breakdowns. By contrast, a symptom-prone individual under low stress will activate symptoms (Sullivan, 1977). 7 Medical research of illness proness was summarized by Hinkle (1959). An extract of the summary follows: 8 1. There is a positive relation between: the number of illness episodes and the variety of illnesses; the number of illness episodes and illness involving many systems; the number of illness episodes and greatest number of causes reported; and the number of minor illnesses and the number of major illnesses. 2. The illnesses of an individual cluster about a mean, but fluctuate with life situations. According to Engel and Schmale (1965): 3. Illness occurs not at times of great physical or environ­mental stress but when the individual feels he is not able to cope with his environment. Nuckolls, Cassel and Kaplan (1972) classified 170 women into two dichotomous groups as having "normalll or IIcomplicated" preg­nancies. They found that the group which had IIhigh adaptive poten­tial for pregnancy" and who scored high on the Schedule of Recent Experience, had only one-third the pregnancy complications of those who scored high on the schedule but low on "adaptive potential for pregnancy. II The statistical results were not presented, so the study is only an indication that there might be some interaction between stress and pregnancy complications. Important determinants of all behavior are the individual's system of beliefs, values, needs, and motives. Subjective reality is how events appear to the individual as opposed to objective reality which is how they really are. Determinants of health behavior are involved in the factors that motivate a person to decide to take action and the factors that determine in what direc­tion the action will be taken. Since behavior is determined by sub­jective reality, what the individual believes to be good or right for himself determines whether or not he will engage in a given activity. The recommended action will probably be taken as long as the individual beliefs are congruent with objective reality (Hochbaum, 1956; Rosenstock, 1961). 9 Individuals vary widely in beliefs about personal susceptibility to a given illness. They also vary in interpretation of the conse­quences of following or not following recommended action. St,!ess Related_to Pre~nan~l_ David et al., (1961) administered a comprehensive battery of psychological tests after delivery, The test results were examined for indices that differentiated between mothers who had a difficult time in the delivery room, or gave birth to children with a physical abnormality. The mothers in this group were found to have increased anxiety. In a follow-up study, David (1962) found that women experienc­ing difficult deliveries were markedly more anxious. David reported that women who are alienated are in a state of personal and social maladjustment, and consequently are habitually in a state of greater emotional stress. Heymans (1972) demonstrated a precise biochemical state which correlates with emotional state throughout pregnancy. Neurohormal variations were identified in accordance with the hypotheses that the normal woman experiences conflicts which are greatest in the early months of pregnancy and decrease as the woman adjusts to the pregnancy (Caplan, 1957; 1959), and then rise again as labor approaches. The level of 17-hydroxycorticosteriods, which reflect the level of conflict physiologically was found to correlate with a pattern of conflict in the normal woman (Roberts, 1972). Emotional states such as stress and tension are accompanied by the release of hormones and chemical substances, primarily cortisone compounds and adrenal in, an excess of which act upon the body and 10 elicit physical manifestations. These hormones also effect the fetus and the initial newborn period. Affected infants exhibit increased restlessness, poor feeding, excessive crying, irritability, vomiting and loose stools on occasion (Clark, 1976; Wimer, 1948). Several researchers suggested a relationship between stress and hyperirritability of the uterus, causing it to abort or pre­maturely deliver its contents (Clark, 1976; Fitzpatrick, 1971; Zucherman, 1963). Studies have demonstrated a relationship between stress and the incidence of congenital malformations, in particular, cleft palate (Klein, 1950). They stated, It is possible and perhaps probable that two factors operate in the production of this congenital abnormality--geneic activity and stress. One operation without the other may be unable to produce cleft plata ... severe emotional stress, particularly when associated with hyperemesis, appears to have been the most important single factor. (p. 122) Caplan (1959) asserted that it is as important to evaluate the woman1s psycholgoical state in pregnancy as the pregnancy progresses 11 as it is to follow her physical state. Soichet (1972) stated that the emotional conflicts of the pregnant patient present a great chal­lenge to the obstetrician. He held discussions with expectant parents about the personality of unborn babies and found it a useful avenue for the women to ventilate feelings regarding themselves. Pregnancy as a Developmental Task The tasks of pregnancy as described by Rubin (1976) are divided into four broad interdependent areas. They are: (1) seeking safe passage for herself and her child through pregnancy, labor and delivery; (2) ensuring the acceptance of the child she bears by sig­nificant person in her family; (3) binding-in to her unknown child; and (4) learning to give of herself. Not specifically mentioned above are fear and anxiety. These factors have been noted by many investigators as being important to the outcome of the pregnancy and the woman's attitude toward child­birth and her child (Doering & Entwisle, 1975; Klein, 1950; Klusman, 1975; Perdue, 1977; Roberts, 1976; Rubin, 1976; Seiden, 1976; Soep, 1976; Zuckerman, 1963). Pregnancy represents a clear turning point in a woman's life. Women have both positive and negative attitudes toward pregnancy and this is affected by their own mothering experiences as children and their relationships with their mothers greatly influences their responses to being mothers (Clark, 1976; Nuckolls, 1972; Purdue, 1977) . Many factors of psychosocial nature influence the acceptance 12 and adaptation of the woman to the pregnant state. Social, cultural and personality factors, shape a woman's reactions and behaviors. Whatever relationship, marital or other, in which she is engaged will either support her or create discordance and increased anxiety (Clark, 1976; Kosa, 1969). Physiologic perspectives of normal pregnancy involve change and adaptation by the body as a whole to sustaining the pregnancy. Unless the mother has an underlying medical condition that prevents or alters this, adaptation will then proceed normally unless a medical condition develops, or psycho-social problems alter the woman's coping mechanisms (Blair & Salerno, 1976; Clark, 1976, Fitzpatrick, 1971). Follow-up studies of Soichet (1972) revealed that emotional preparation for parenthood channeled the patient's preoccupation from fears of pregnan(:y and labor into a healthy awareness of the roles of motherhood. This awareness was felt to fortify self-esteem. Pdeparation for Childhirth E ucation Before" societies were as complex as they are today the females of the family or tribi~ learned about childbirth by observing birth. Birth and death were natural processes, unhidden and not feared. Taboos certainly existed regarding them, but on the whole they were viewed as a natural process. As societies increased in size and complexity, disease ald poorly trained birth attendants increased the death rate of lab)ring mothers to the point that fear of life was valid. As medicine inproved~ also did the chances of surviving labor. 13 However, with the increase in physicians and hospitals the birth experience was removed from the home. Common knowledge of what birth was like decreased. In the United States, formal prenatal education began in 1919, when classes were provided by the Maternity Center Association, to teach women how to prepare for and care for newborn babies. This work was directed toward tenament sections of the city and did have a large impact. From a very simple explanation of labor cleanliness, and baby care, prenatal classes have progressed to the modern myriad of methods; Lamaze, Read, Bradley, Harris, naturopathic, etc. Modifications in prenatal education has progressed as changes have occurred in maternity care in this country. In the 1920's and 1930 l s the hospital as the place to give birth was entrenched as an American tradition (Jackson, 1955). In the late 1930's parents protested the impersonal, and inconsiderate management of mothers, infants, and tathers (Lawrence, 1945; Witmer, 1948). As the hospital stay for maternity care has decreased from nine days in the 1930's to two or three days currently, adequate prepara­tion of parents is not possible (Jackson, 1955). The trend towards more family centered maternity care has helped broaden the scope of prenatal education and to change their focus from mothers' classes to couples' classes. Fathers have gradu­ally become involved, may be present during labor and in most delivery rooms now, if they wish. Rooming in--the unified care of mother and infant -was begun in the 1960's and has now progressed to the birth­ing room, where the entire family is together, and discharge after 12 hours is possible. These changes have occurred because the con­sumers of maternity care have assumed a more assertive role, and become a powerful force behind many of the changes (Banta & Marinoff, 1975-1976; Keane, 1952; Wiedenbach, 1949). Dick-Read in 1933 pioneered the idea of psycho-physical pre­paration as a means of controlling pain associated with labor and delivery. His method was based on the assumption that the fear of pain created and intensified true pain through a pathological ten­sion (Fear- Tension -Pain Syndrome). When his method was used, most mothers were able to deliver without the risks of analgesics or anesthetics. In 1947 the Dick-Read methods were brought to the United States and have spread rapidly (Wiedenbach, 1949; Thoms, 1950; Tupper, 1956). The Psychoprophylactic Method was initiated in Russia and introduced to the western world by Lamaze of Paris in 1952. Karmel (1959) was instrumental in popularizing Lamaze techniques. The method consists of three parts based on Pavlov1s theory of con­ditioned responses which (1) involve education of the mother to develop conditioned reflexes of controlled relaxation so that defensive reflexes can be overcome and pain eliminated; (2) remove erroneous ideas regarding childbirth, and (3) replace them with positive attitudes (Chabon, 1966). The International Childbirth Education Association now 14 espouses the "childbearing year ll perspective which includes five classes during early pregnancy, four during late pregnancy, and four parenting classes after the baby is delivered. 15 Definitive research into prenatal education has been limited in nature and not well documented. Most studies have examined outcome variables such as length of labor, anesthesia required, maternal and/ or fetal complications. Whitney (1972) reported that labors were shorter in prepared patients, but the use of medication and infant outcome was unchanged. As the use of medication decreases and shorter labors become more common, there is less obstetrical assis­tance with delivery (use of instruments and medication) (Bradley, 1965; Dick-Read, 1944, 1953; Goodrich, 1949; Charles, 1970; Thoms, 1950; Van Auken and Tomlinson, 1955; and Yahia and Ulin, 1965). Tupper (1956) reported that mothers prepared for natural child­birth had more satisfactory deliveries and produced infants who were less irritable, more content, and did better initially. Studies of prepared childbirth demonstrate conflicting results. Stevens (1977) studied the psychophysical strategies used in pre­pared childbirth and concluded that the techniques may adequately substitute for chemical analgesics. However, other investigators (Davis & Morrone, 1962; Reid, Ryan & Benirschke, 1972; Thordarson & Costanzo, 1976) were unable to duplicate these results. They reported that prenatal preparation did not alter the length of labor nor the amount of analgesia and/or anesthesia needed. Conflicting findings may be due to the difficulty encountered in accounting for all the possible variables. In addition, outcome measures are difficult to ascribe to attendance or nonattendance of prenatal classes because of exogenous variables. Motivation pro­vides a useful example as Leonard (1973), Graham-Cummings (1967), and David and Morrone (1962) noted. Mothers who participate in an education program are more interested, aware and assume greater responsibility for their prenatal preparation. 16 In 1917, 90 of 1,000 live births in the U.S. resulted in infant death. Among non-whites that rate rose to 150.7/1,000. Maternal mortality for whites was 63.3/1,000 and 117.7/1,000 for non-whites. This has changed in 1970 to 1.4/1,(100 for \'Jhites and 5.6/1,000 for non-whites (Bicentennial Statistics, 1976). When the poorer areas are examined the joint perinatal postneonatal mortality rate may rise to 65.8/1,000 (Kosa, 1969). The studies cOfllpleted in the carly sixties, which pointed out che difference "in prenatal care and delivery outcomes for certain areas of the countr~ were the basis for the maternal and infant programs which now function in every state of the union. It has been shown that intensive inpatient and outpatient prenatal care applied to high risk cases pays good dividends (Rudolphi, 1973). From the excell ~nt start with the poorer women in New York City in 1919, prenatal classes are now almost exclusively a middle­to- upper-rniddle class advantage. nann et al., (1961) examined the type of people who attended prenatal classes. Subjects ranged from professionals to those with 1 ittle or no educational back­ground. Results indicated that professional people and highly educated people who had read extensively on the subject of child­bearjng attended classes. Those with least educational preparation 17 were not represented on the class rosters. Nutritional state and general health are greatly influenced by the level of indigency, educational background, and ethnic eat­ing habits. There are no conclusive reports on the effect of chronic malnutrition in the mother as a single factor on the fetus, but is known that malnutrition in the fetus does have an effect on tissue replication and growth, especially brain tissue (Rudolph, 1972). There are characteristics of lower-income persons which influence the ability to deal with the medical organization and obtain high­quality results. Poor women tend to visit hospitals, and clinics. These are often large, complex, and impersonal. They are character­ized not only by a great deal of s~ecialization of function and specialized clinics but by a degree of impersonality which is felt even by middle-class patients (Brinton, 1972; David et al., 1977; Horowitz, 1977; Kosa, 1969; Lowe, 1973; Milio, 1967; Podell, 1972; Pratt, 1971). Low-income people are less skilled at obtaining needed information and tend to be less aggressive in demanding explanations. A number of investigators have observed that middle-class patients are preferred by most professionals for treatment. They are seen as more treatable. Most professional health workers have a middle-class bias. They tend to stereotype poorer people as shift­less, irresponsible, dirty, etc. The people toward whom these biases are directed perceive them and act accordingly (Kosa, 1969; Lowe, 1973; Milio, 1967; Osofsky. 1974; Pratt, 1971; and Fitzpatrick et al.,1971). Disadvantaged people do not conform to the expectations of how "jood" and "consideratell patients should behave. Their behavior is often frustrating and annoying to medical personnel. Disadvantaged people like anyone tend to seek personal rather than professional relationships, as a result there is considerable anxiety caused when this relationship does not exit and the person has to deal with the system unaided (Fitzpatrick, et al., 1971). But our clinic patients just are not interested in learn­ing .... Of course they are not receptive, and do not use the techniques taught, if what they are being offered is identical with what the middle class mother responds to. Teaching is only seen as appropriated by the women herself when it is related to her own expectations of birth and parenthood. (Kitzinger, 1972, p. 24) During the childbearing process, the poorer person, just as any other is confronted with numerous changes in a relatively short span of tilne. ~'Jhen the woman is provided with necessary informa-tion regarding expected changes, she is able to make decisions regarding her health status and life style. Education for childbirth can provide for the underpriveleged woman not only the ability to give birth with understanding, but something even more significant; a healthy baby, the possibility of choice, self-decision and action; dignity. Preparation for birth can mean a contribution not only to health education but to better corrrnunity relations (Kitzinger, 1972). Doering and Entwisle (1974) noted that they found the more prepared women are for labor and delivery, the higher the level of cwareness was at delivery. These women did want to be awake and experience labor. They wanted to be totally aware of what was 18 occurring. Awareness, in turn, is strongly associated with positive reactions to the infant. Women who have more positive first reactions toward their newborns, continue to have closer mother­child relationships subsequently. Theoretical Framework The theory of stress and its affect on illness as discussed by Rahe, Sullivan, and co-workers was the basis for this study. 19 The interrelatedness of stress on illness, combined with low income status has heen discussed above. When dealing with a less motivated population r renata1 classes need to be geared to the stress and learning neE~ds of the population, rather than the more traditional approaches. This does not mean that important information regard­ing nutrition, fetal growth, etc., is not required, but the person must have tIle ahi 1 i ty to understand the importance as well as having the resources to provide the necessary food, prenatal care, baby items, and/or know where to obtain them. !1Eotheses_ 1. Prenatal education of the lower-socio-economic mother will not improve the mother-infant relationship as measured by the UTAM-H instrument over her counterpart who has not received ~renatal education from any source. 2. The number of reported health and stress symptoms reported ()n the UTAH- IV wi 11 not di ffer between the treated and untreated group. 3. Prenatal education will not effect the type of delivery, anesthesia used, Apgar scores at one and five minutes, birth anesthesia used, Apgar scores at one and five minutes, birth weight nor gestational age of the infant. 20 CH,l\PTER I I METHODOLOGY The purpose of this investigation was to describe, evaluate, and measure the mother-infant relationship in two groups of low income families. Other parameters examined were the immediate delivery outcomes indices, type of delivery, anethesia used, Apgar scoring, birth weight, and gestational age. The two groups were also compared for differences in health and stress symptoms reported on the (juestionnaire util-ized for this study. These para­meters were explored utilizing the static group comparison design. The static group comparison i' one in which one group has experienced and is compared with olle which has not. Major draw­backs of this type of study are (1, lack of formal means of certi­fying that the groups would have b,len equivalent had it not been for X; (2) selection of the groups (in personal bias, different sub­ject motivation); and (3) experimental mortality. In dealing with two groups if they differ, the difference may have come about through the differential recruitment of person selecting the groups. The groups may have differed without the occurrence of X. This is particularly true when the lIe"~p~rif1lental group" has sought exposure to X (Campbell & Stanley, 1966, p. 12), These critisms speak to the irlternal validity of this design. Internal validity is the basic minimum without which any experiment 22 is uninterpretable: Did in fact the experimental treatments make a difference in this specific experimental instance? External val­idity asks the question of generalizability: To what populations, settings, treatment variables, and measurement variables can this effect be generalized? Internal validity is a requirement, external validity is never completely answerable (Campbell & Stanley, 1963). The groups were compared on fQ~'!n values on income, occupation, parity, age and educational level, and were well-matched as a whole. The selection of the groups was not planned, it was offered to all who fit the criteria. Experimental mortality was not a problem as the study was of short duration. The study was completed for each individual subject two to three weeks after delivery, and most questionnaires were completed within two to three months of delivery. Internal validity was controlled. Criteria for SUbject Selection Subjects were selected on the basis of pregnancy, low income, and willingness to complete the questionnaire. Data were collected from May 1, 1978 to January 5, 1979 in order to avoid seasonal pressures, illnesses, or birth booms. Seventy women were tested and visited at home. Those excluded from the study were: those whose babies died before the home visit or before delivery, and those unwilling to allow the visit. Six subjects were excluded, four because the questionnaires were not completed, and two because husbands objected. Two cases were dropped from statistical analysis because 23 they were twin births; and four additional ones due to illicit drug use. Informed consent was obtained from each subject and anonymity of participants preserved. The questionnaire was benign and com-pleted privately. It was returned to a person other than the investigator to decrease any pressure. It was impossible to control subjects· awareness that a study was in progress and that a home visit was included. Treated Women in the treated group attended four of five classes offered by the investigator at the community center. The classes were free of charge, centrally located, with babysitting available. treated This group received no prenatal instruction from any source, but the subjects all answered affirmatively when asked if they would have attended classes had they known that free classes were available. The free classes were a new program and not well known, so the chan~es were excellent that the woman would have not heard about them. This was an attempt to control for motivation. Measures Two instruments were utilized for data collection--the Utah Test Appraising Health-IV and the Utah Test Appraising Mothers at Home. The UTAH-IV had been previously been administered to 2400 women. The UTAM-H was an adaptation of the Utah Test Appraising Mothers (UTAM). The Utah-IV is a questionnaire that can be numerically scored and consists of 230 questions divided into three sets: (1) census data (2) physical symptoms and (3) questions about common problems confronting normal persons. The census data includes obstetrical history, feeding method used with the previous baby and plans for feeding the expected baby. The physical symptoms relate to the gastrointestinal tract, general adaptational stress, the reproduc­tive system, neuromuscular system, skin, and cardiovascular/ respiratory systems. It also includes 19 questions taken from the Cornell Psychiatric Inventory. The third set is a stress scale. These questions are divided into categories of social stress, work stress, family stress, financial stress, life style stress, and personal habits changes stress. 24 The UTAM-H was revised for this study to include four addi­tional aspects for scoring mother-infant relationship: (1) physical care of baby; (2) psychological adjustment; (3) expectancy regarding the baby; and (4) constriction or expansion of desired activities 'since the birth of the taby. The instrument was administered by the investigator during a two-week postpartum home visit. The major limitation of the tool was the inability to score the home environment. CHAPTER III RESULTS Qescription of the Sample The total sample consisted of 58 expectant women, 30 in the group that received prenatal education (the treated group) and 28 who received no formal type of childbirth education (the untreated group). The mean age of the sample was 23 years old; the treated group's mean was 23.3 and the untreated group 24.3 years. Table 1 reflects the age and educational levels of the subjects. Marital status of the subjects was as follows: 24% single, 45% married, divorced, separated, and 16% living with a bcy-friend. Table 2 shows the marital status of the subjects in each group. Income level was reported by income range. Data reflectin~ family size was not available. Table 3 represents income data. Included are statistical results of the Mann-Whitney nonparametric test which was applied to the data. The Mann-Whitney utilizes rank ordering and was considered more appropriate than the Chi­square statistic for these data. No statistical difference was found between treated and untreated groups. Three percent had less than $l,OOO/year income, 17% were in the $1 ,OOO-2,999/year range, 29% in the $3,000/4,999 range, 10% in the $5,000/6,999 range, 2f% Table 1 Age and Educational Status of Subjects 15-19 20-24 25-29 30-34 Over 35 0-6 grades Junior High School Some High School Graduate High School One Year College Gradua te Co 11 ege Postgraduate Treated Group N = 30 Mean 23.3 Range = 15-34 20.0% 46.7% 13.3% 23.3% Age Untreated Group N = 28 Mean = 24.3 Range = 17-40 17.9% 35.7% 25.0% 10.7% 3.6% Too-:Cf% ---------- ----------.~-- Educational Level of Female 6.7% 3.6l.. 10.OX, 14.3)G 23.3% 30. o~~ 36.7% 35. 7~~ 1 3. 3~~ 10. 7~~ 6.7% 3. 6j~ 3.3% 26 27 Table 2 Marital Status of Subjects --------"~ -----~,---'----------------~- Married Single Separated Divorced Boy Friend Under $1 ,000 $1,000-2,99~ $3,000-4,999 $5,000-6,999 $7,000-8,999 $9,000-10,999 $11 ,000-12,999 Treated N = 30 20.0% 63.3% 6.7% 3.3% 6.7% foo.O% -----------, Table 3 Income Range for Subjects Treated N = 30 3. 3/~ 16.7% 30.0% 10.0% 23.3% 10.0% 6. 7~~ Untreated N = 28 28.6% 25.0% 7 . 1 % 14.3% 25.0% 100.0% Untreated N = 28 3.6% 17.9% 28.6% 1 0.7% 28.6% 7.1% 3.6% Note: The Mann-Whitney between groups on income significance = .4023 (one-tail). Not significant. Table 4 Parity of Expectant Mothers ------------------->-------- Pari ty o 2 3 4 5 6 7 8 Treated N = 30 Mean = 1.7 Range = 0-8 46.7?{, 33.3% 20. OX, 3. 3~~ 6. 7~:, 3. 3~{' 3.3'X Table 5 Experience of Pregnancy --~----------------------- Easier Than Expected As Expected More Difficult Treated N = 30 36.7X) 33.3~ 30.0% Untreated N :::; 28 Mean:::; 2.0 Range = 0-8 32.1% 14.3% 17.9% 17.9% 7.1% 3. 6~~ 3.6% 3.6% Untreated N = 28 32. 1 ~~ 25. O~~ 28 in the $7,000/8,999 range, 9% in the $9,000/10,999 range, and 5% in the $11,000/12,999 range. Seventy-eight percent of the sample had no previous children. 29 The mean number of children for the sample was 2.1. These date are presented in Table 4. On response to the question: Was the pregnancy (1) easier than expected; (2) what was expected; or (3) more difficult than expected --35% of the group stated it was easier, 30% said it was as expected, and 35% stated it was more difficult. Table 5 shows these data. Operational Definitions of Terms Stress: A mentally or emotionally disruptive or disquieting influence; distress, as perceived by the individual. For the pur­pose of this study, the higher the score on the stress scale of the UTAH-IV, the more "stressed" a subject was considered. Low income: An income below or within the range of $3,000- $6,999 per years. Pregnancy: The condition of having a developing embryo or fetus in the body_ Mother-infant relationship: The affectional bonds between infant and mother, as observed by the investigator on a home visit. Wellness: Good health, physical and psychological, adaptation to pregnancy. !i.Yl)Q thes is I Prenatal education of the lower socioeconomic mother will not improve the mother-infant relationship as measured by UTAM-H over 30 Table 6 Comparison of Mean Scores on UTAM-H between Treated and Untreated Groups Treated Untreated Group I Group II Category N = 30 N = 28 t-Test Sig.* -,~<~------- Aspect of Feeding 3.40 2.41 5.27 < .001 Interaction with Infant 3.30 2.21 6.45 < .001 Behavior toward Self 2.60 1 .96 3.68 .001 Reaction toward Others 2.93 1.93 4.79 < .001 Degree of Discomfot 3.00 2.18 3.89 < .001 Physical Activity 2.77 2.11 3.22 .002 Eating Behavior 2.80 1 .93 3.56 .001 Response to Family/Friends 3.23 2.25 4.20 < .001 Staff/Family/Friend Support 3.00 2.04 4.20 < .001 Physical Care of Baby 3.10 2.54 2.5 .005 ,Psychological 3.03 3.04 - .01 n. s . Expectancy for Baby 3.27 2.61 2.34 . 023 Desired Activities Outside of Home 3.37 2.78 2.26 .028 --~----- *t value 31 Table 7 First Trimester Symptoms Treated Untreated t-Value Sig. N = 30 N = 28 --_._._- Gastro-Intestinal Symptom 3.18 2. 16 - .79 n.s. General Adaption Distress 1 .96 3.86 1 .54 n. s. Reproduction 1 . 18 1 .50 .77 n.s. Neuromuscular .78 .43 .66 n. s. Skin .43 .53 .42 n.s. Cardiovascular/Respiratory .50 1 .27 1 .65 n. s. Cornell Psychiatric Index 1 .50 1 .76 .34 n.s. -.~--------.--,-~--~ Table 8 Second Trimester Symptoms Treated Untreated t-Value Sig. N 30 N = 28 Gastro-Intestinal Sympton 3.18 3.10 - .02 n. s. Genera 1 Adaption Distress 2.93 3.20 .38 n. s. Reproduction 2.85 3.70 1 .37 n. s . Neuromuscular 1 .39 1 .67 . 57 n.s . Skin 1 .61 1.63 . 06 n.s. Cardiovascular/Respiratory 1 .60 2.40 1 .41 n.s . Cornell Psychiatric Index 2.36 2.63 . 35 n.s. -.---~--< .. ---.. --.. -- . 32 Table 9 Third Trimester Symptoms -~ --... _-._--_._-......... _--_._--- Treated Untreated t-Value Sig. N = 30 N ::: 28 Gastro-Intestinal Symptom 3.52 3.90 .57 n.s. General Adaption Distress 4.70 4.90 .27 n.s. Reproduction 4.90 5.36 . 71 n.s. Neuromuscular 3.37 3.46 . 15 n. s. Skin 2.63 2.36 - .56 n. s. Cardiovascular/Respiratory d.C39 3.67 - .31 n. s. Corne 11 Psychiatric Index 4.48 3.46 - .96 n. s. 33 over her like counterpart who had not recieved prenatal education. The hypothesis was tested by comparing the treated and untreated groups. Mean scores obtained from the UTAM-H were compared between the groups by using the t-test. The hypothesis was rejected sug­gesting that prenatal education does improve the mother-child rela­tionship as measured by the UTAM-H. Table 6 presents the means for each group, the t-test value and levels of significance. The psychological aspect of how the mother felt about the baby WdS the only one that did not show significant difference. ~pothesis II The nunilier of health and stress symptoms reported on the UTAH­IV will not differ between the treated and untreated groups. The hypothesis was tested by comparing the treated and untreated groups. Mean scores obtained from the UTAH-IV were compared between groups by using the t-test. No comparison revealed a value approaching significance and the hypothesis was accepted. Health and stress symptoms were similar for the two groups. Tables 7, 8 and 9 present the mean health and stress symptom scores for each group in terms of the trimester of pregnancy for which they were reported. Hypothesis III Prenatal education will not affect the type of delivery, anesthesia used, Apgar scores, birth weight of the infant or gestational age. Table 10 Comparison of Group by Stress Indices--Means, t-Values, and Signficance Untreated Treated t-Value Significance N = 28 N = 30 Social Stress ious 6-12 months 1.50 1 .82 .61 n. s. Previous 0-6 months 1 .26 2.28 -2.17 .035 Work Stress 6-12 1 .43 1 .53 - .14 n. s. 0-6 2.00 1 .57 .57 n. s. Family Stress 6-12 1 .83 2. 11 - .41 n. s. 0-6 3.60 3.67 - . 11 n. s. nancial Stress 6-12 2.63 1 .93 1 .06 n.s . 0-6 3.93 3.43 . 75 n.s. Life Style Stress 6-12 2.45 2.94 .80 n. s. 0-6 5.30 3.93 1 .61 n. s. Personal Stress 6-12 2.53 2.18 .42 n.s. w 0-6 6.66 5.93 .73 n.s. +::- Table 11 Type of Delivery Used--Difference between Groups Normal Vertex Type of Delivery Spontaneous Delivery Breech Low Forcep Mid Forceps Casarean Section Untreated N = 28 42.9% 3.6% 32.1% 21.4% Treated N = 30 70.0% 13.3% 3.3% 13.3% Note: Comparison of groups with increased obstetrical assistance/difficulty seen in untreated groups. Mann-Whitney statistic 304, significance .0551 (one-tail). Table 12 Type of Anesthesia Used--Differences between Groups Type of Untreated Treated Anesthesia N = 28 N = 30 None 10. 7~: 30.0% Local Only 3. 6~{) 20.0% Peridermal 7.14% 26.7% Epidermal 60.7% 23.3% Combination of 2 or More 7.14% Note: (one-tail). Mann-Whitnej Test statistic 206, significance .0008 Untreated group will use anesthesia more frequently. 35 36 Table 13 Comparison of Group on Apgar Birth Weight and Gestational Age Untreated Treated t-Value Sig. N = 28 N = 30 Apgar (1 minute) 6.78 7.73 3.08 .003 (5 minutes) Birth Weight 2974 3222 1 .62 n.s. Gestational Age 38 40 2.37 .021 Table 14 Type of Actual Feeding--Chi-Square Analysis -------~ --~----~"----------------.------------.-~---- Untreated o Treated Breast 7 in Group 25.0 22.6 12. 1 24 in Group 80.0 77.4 41 .4 31 53. 4/~ 2 21 6 Bottle in Group 75.0 77.8 36.2 in Group 20.0 22.2 10.3 46. 6~~ Total 28 48% 30 51% 58 100.0% Note: Corrected Chi-square 15.46675, t + df., significance .0001, that woman who has taken the class will breast feed her baby. The hypothesis was tested by comparing the treated with the untreated groups. The t-test was used to compare Apgar scores, birth weights and gestational ages of the infants. Apgar scores and gestational ages were found to be significantly different. Infants of treated women had higher Apgar scores and increased gestational ages. Birth weight was not significantly different between the groups. 37 The type of delivery necessary and the anesthesia used was com­pared by the Mann-Whitney Test. Significantly less obstetrical intervention was necessary with the treated group. Therefore, the hypothesis was rejected, suggesting that pre­natal education does positively affect the labor and delivery experienced. Tables 10, 11, 12, and 13 show these data. Ancillary findings Infant feeding was not considered in a formal hypothesis. A difference in feeding pattern was noted between groups. The advantages of breast feeding for mother, baby and their relation­ship is well documented. The treated group did choose breast feed­ing significantly more than the untreated group. A Chi-square analysis of the two groups revealed a significance level of .001. Table 14 shows the infant feeding choices of the subjects. Limitations of the.Study Several limitations of the study were noted. The personal bias of the investigator, who collected all data, cannot be ignored. The 38 wording of questions related to the psychological affect of areas was not applicable to the groups under study. There was no instru­ment to evaluate the home environment. Family size in relation to income level was not determined. CHAPTER IV SUMMARY AND RECOMMENDATIONS The rejection of hypothesis I,which states that prenatal edu­cation of the lower socioeconomic mother will not improve the mother-infant relationship as measured by UTA~~-H over her 1 ike counterpart who has not received prenatal education, does appear to suggest strongly that education can make a difference in this cru­cial relationship. A larger sample with comparison to groups of higher income mothers would be more conclusive. Educational levels could be better determined, along with occupation. The acceptance of hypothesis II--the number of health and stress symptoms reported on the UTAH-IV will not differ bet\veen the treated and untreated group--supports the premise that the groups were similar. The rejection of hypothesis III that prenatal education will not affect the type of delivery, anesthesia used, Apgar scores, birth weight of the infant or gestational age suggests the pre­sence of strong trends. Decreased use of anesthesia might lead to less obstetrical interference, and possibly affect the Apgar scores. The finding needs to be duplicated with a larger sample. The rationale for this and future studies is the improvement of 1 i fe for low income fami 1 i es. Knowl edge is the best weapon against ignorance and fear. 40 In conclusion: The low income group of people cannot be ignored, without the rest of the population suffering financially, or through social problems engendered by a large population that is maladjusted. As inflation increases, social programs receive decreased funding, and the number of low-income or borderline income people increases. Information is being shared with patients regarding health care and options for that care by the medical establishment. In no area is this truer than in dealing with childbirth. Disadvantaged groups are just beginning to be involved. They know about classes, feel they would probably help, but lack funds, transportation, and also fear being poorly accepted because they are different. Understanding is urgently needed. An old Plains Indian saying expresses the problem, IIUntil you have walked in my shoes, do not tell me which path to follow. 1I Pregnancy is a time of adjustment greater than any other period of life. Whether the adjustment is successful depends on many multi-faceted factors. Early prenatal education can help the most in this area, when the pregnant woman is not aware that others feel as she does. Relief of stress, and strengthening coping mechanisms will improve the total pregnancy and outcome. A pre and posttest of the people taking classes would be most helpful to the development of future classes and what knowledge was actually obtained. Large-scale outcome evaluation of labor and delivery and various complications would give added validity to sustaining and supporting prenatal education. Such evaluation would identify prenatal education variables which help promote positive and healthy childbearing experiences. 41 Long-term follow-up of the mother-infant relationship would be invaluable in determining what is the most helpful for the mother to know. When that type of data can be shown to have validity, then legislators will fund prenatal education programs. APPENDIX UNIVERSITY OF UTAH COLLEGE OF NURSING Utah Test Appraising Health-IV (UTAH-IV) The tollowing survey was compiled by the research section of the University of Utah College of Nursing. If you are willing to cooperate in this research, please read carefully and sign the following statement. ---------------------------------------, Informati on This questionnaire consists of 230 questions arranged in three sets: ( 1) cens us da ta, (2) a set of phys i ca 1 symptoms, (3) common problems c0nfronting normal persons. The goal of this research is to explore the various means by which pregnant women maintain health throughout the pregnancy cycle. About 20-30 minutes are required to complete the form. Your coopera­tion in filling out this survey will help us to advance our under­standing of the processes involved in health of pregnant women and of their babies. Consent I have read the foregoing and "~ questions have been answered. I desire to participate in this study and give permission to the scientists of the College of Nursing to examine my medical records on labor and delivery for research purposes and reporting to the appropriate scientific bodies. Signature of Patient Date of Birth This project is supported by Public Health Service grant MC-R- 490355-02. The contents of this survey are not the responsibility of the awarding agency. CENSUS D/l.TA 1. What is your age? ------ 2. What is your marital status? Single Married Widow Divorced Separated 3. What is your height? What is your husband's height? What is his weight? ----- 4. What was your weight at the beginning of this pregnancy? ----- 5. How many miscarriages or terminated pregnancies have you had (under 5 months pregnant)? 6. How many children have you had born alive? ----- (PLEASE NOTE: If this is your first pregnancy please skip to question No. 14.) 7. How many children have you had born dead after the fifth month of pregnancy? ----- 8. How many babies have you had whose weight was under five and one half pounds? ----- 9. How many caesarean operations have you had? ----- 10. During your previous pregnancy did you have any of the following? (please check) a. Breast abscess e. Severe swelling ----- b. Severe hemorrhage f. Diabetes ----- c. Blood transfusion --- d. High blood pressu g. Infection immediately after delivery ---- ----- 11. If you have had any children who suddenly died without having an accident or previous illness, what were their ages? ----- 12. What is the date of your last delivery? ______________ _ 13. What are the birth weights of your previous babies? ---------- 14. In what hospital do you plan to have your baby? ------------------------- 15. How many months pregnant are you now? _____ _ ..j:::l. ..j:::l. 16. Are you now regularly taking any of the following medications? (please circle) Cortisone Digitalis Hormones Laxatives Dilantin Shots Vitalilins Sleeping pills Thyroid medi:::ine Tranquilizers Blood thinning pills Water pills Antibiotics Barbiturates Aspirin, Bufferin, Anacin Blood pressure pills Insulin or diabetic pills Iron or poor blood medications No medications regularly Other drugs not li INSTRUCTIONS: The following questions are to be answered by circling the appropriate response on this booklet. If the item is not applicable, do not respond at all. If the item is applicable, please respond by circling the appropriate response. Example: Please Circle the Illnesses or Symptoms You Have Had Within the Past Ten Years l. 2. 3. 4. 5. 6. This means you have had stomach cramps, hemorrhoids (piles) and trouble with your teeth/gums within the past ten years, but have not had gas, gallbladder trouble or crampy pain in your abdomen. Remember: (1) The responses are to be circled on this booklet and (2) if the item is not applicable, you make no mark on the booklet. Please Circle the Illnesses or Symptoms You Have Had Within the Past Ten Years 1. Gas 4. Hemorrhoids (piles) 2. Stomach cramps 5. Crampy pain in abdomen 3. Gallbladder trouble 6. Trouble with teeth/gums .+::> U1 7. Loss of appetite for more than a day 21. High or low blood pressure 8. Burning sensation in stomach 22. Anemia 9. Sensitive to particular foods 23. Bleeding tendency 10. Ea raches 27. Feeling of general weakness 11. Trouble with eyes 28. Gain or loss of weight (more than 10 lbs.) 12. Prolonged stuffy nose 29. Severe menstrual cramps 13. Severe headaches 30. Stiff or sore joints 14. Hay fever 31. Specific muscle weakness 15. Tonsillitis 32. Many skin infections 16. Pneumonia 33. Cuts or wounds which healed slowly 17. Persistent cold in chest 34. Bruise easily INSTRUCTIONS: The following questions are to be answered by circling the appropriate response on this booklet. If the item is not applicable, do not respond at all. If the item ;s applicable, please respond by circling the appropriate response. Example: Please Circle the Trimester(s) During THIS Pregnancy in Which You OFTEN Have Had or Are Having Any of the Following Symptoms 35. Loss of appetite for some time 36. Frequent dry mouth--bad breath 37. Persistently bleeding gums When 1-3 Months Pregnant tYe0 ~ Yes When 4-6 Months Pregnant Yes Yes ® When 7-9 Months Pregnant Q;;) Yes Yes ..j::::. 0'1 This means you had loss of appetite for some time during the first and third trimesters but not during the second trimester; you did not experience frequent dry mouth--bad breath during any of the trimesters; and you had persistently bleeding gums during the second trimester bu+ not during the first and third trimesters. Remember: (1) The responses are to be circled on this booklet; (2) if the item is not applicable, you make no mark on the book1et; and (3) you may circle more than one response for each symptom. Please Circle the Trimester(s) During THIS Pregnancy in Which You OFTEN Have Had or Are Having Any of the Following Symptoms When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant 35. Loss of appetite for some time Yes Yes Yes 36. Frequent dry mouth--bad breath Yes Yes Yes 37. Persistently bleeding gums Yes Yes Yes 38. Frequent constipation Yes Yes Yes 39. Certain foods bother you Yes Yes Yes 40. Troubled by nausea or morning sickness Yes Yes Yes 4l. Troubled with vomiting (other than No. 40) Yes Yes Yes 42. Bothered by diarrhea if not taking lIiron pillsll Yes Yes Yes 43. Heartburn Yes Yes Yes 44. Gas Yes Yes Yes 45. Stomach cramps Yes Yes Yes 46. Crave certain foods Yes Yes Yes 47. Frequent frightening dreams Yes Yes Yes 48. III health frequently affecting your work Yes Yes Yes .:::. ""'-I 49. Felt persistently tired 50. Not much energy 51. Frequently need more sleep than usual 52. Gained more weight than you wanted to 53. Increase in nervous irritability 54. More sensitlve to light, sounds, smell 55. Trouble getting to sleep 56. Trouble staying asleep 57. Tired when you get up in the morning 58. Headaches 59. Persistent increase in vaginal discharge without itching or burning 60. Discharge of fluid from breasts (colostrum) 61. Painful breasts 62. Tingling in breasts 63. Vaginal bleeding (more than spotting) 64. Vaginal bleeding (spotting) 65. Increased breast size 66. Contraction of uterus, sometimes associated with discomfort, pain 67. Excess i ve movement of baby When 1-3 Months Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes When 4-6 Months Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes When 7-9 Months Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes ..r:::. co When 1-3 When 4-6 When 7-9 r~onths Months Months Pregnant Pregnant Pregnant 68. Sharp pains in lower abdomen on either side when you suddenly change positions Yes Yes Yes 69. Baby too big or too small for your dates Yes Yes Yes 70. Do you feel stretched out of shape? Yes Yes Yes 71 . Need to pass urine (water) frequently Yes Yes Yes 72. Pain or burning feeling during/following urination (passing water) Yes Yes Yes 73. Muscle cramps especially at night Yes Yes Yes 74. Low backache Yes Yes Yes 75. Stiff or sore joints Yes Yes Yes 76. Joints of body feel loose Yes Yes Yes 77. Aching in arms/legs Yes Yes Yes 78. Numbness in arms/legs Yes Yes Yes 79. Weakness in arms/legs Yes Yes Yes 80. Have a tendency to drop things Yes Yes Yes 8l. Pains in rib cage Yes Yes Yes 82. Have difficulty walking Yes Yes Yes 83. Hands often sweaty Yes Yes Yes 84. Defi ni te rashes Yes Yes Yes 85. Itchy skin Yes Yes Yes 86. Perspire a great deal Yes Yes Yes ..t::o >...J When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant 87. Skin blotches Yes Yes Yes 88. Marked changes in hair Yes Yes Yes 89. Skin infections Yes Yes Yes 90. Bruise easily Yes Yes Yes 91 . Stretch marks on breasts, abdomen, hips Yes Yes Yes 92. Frequently feel heart pounding Yes Yes Yes 93. Have problems with varicose veins Yes Yes Yes 94. Have problems with hemorrhoids Yes Yes Yes 95. Frequently feel short of breath Yes Yes Yes 96. Need to sleep on two or more pillows Yes Yes Yes 97. Get Itcolds lt frequently Yes Yes Yes 98. Troubled by stuffy nose Yes Yes Yes 99. Frequent cough day or night Yes Yes Yes 100. Frequent dizzy spells Yes Yes Yes 10l. Often felt like fainting Yes Yes Yes 102. Swelling in ankles and legs Yes Yes Yes 103. Swelling of hands/face late in the day Yes Yes Yes 104. Frequently feel hot and flushed Yes Yes Yes 105. Did/do you get nervous and shaky when approached by someone you consider to be important? Yes Yes Yes 106. Did/do you usually feel unhappy and depressed? Yes Yes Yes ()"1 a .. .......,.~-. When 1-3 Months Pregnant 107. Did/does life look entirely hopeless? Yes 108. Did/do you suffer from severe nervous exhaustion? Yes 109. Did/does every little thing get on your nerves lately and wear you out? Yes 110. Did/do you often become suddenly scared for no good reason? Yes 111. Did/do you often with you were dead and away it all? Yes 112. Did/does your thinking get completely mixed up when you have to do things quickly? Yes 113. Were/are you constantly keyed up and jittery? Yes 114. Did/do frightening thoughts keep coming back in your mind? Yes 115. Did/do you often get spells of complete exhaustion or fatigue? Yes 116. Were/are you often bothered by thumping of the heart? Yes 117. Did/do you wear yourself out worrying about your health? Yes 118. Did/does your heart often race like ? 119. Did/does pressure or pain in the head often make life miserable for you? 120. Did/do you wish you always had someone at your side to advise you? Yes Yes Yes When 4-6 Months Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes When 7-9 Months Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes O'l When 1-3 '''lonUI5 Pregnant 121. Did/do you go to pieces if you don't constantly control yourself? Yes 122. Did/do you often shake or tremble? Yes 123. Did/does worrying continually get you down? Yes 124. Were/are you considered to be a nervous person? Yes When 4-6 !''IOnth s Pregnant Yes Yes Yes Yes When 7-9 ~10nths Pregnant Yes Yes Yes Yes Please Answer IIYes" to the Following Questions if They Apply to YOU During One or Both of the Two Periods in the Last Year 125. 126. 127. 128. 129. 130. 13l. 132. 133. 134. 135. Have you been in an automobile accident in which the major fault was yours? Have you changed to a different line of work? Have you had a change in your role as wife or mother? Do you have a mortgage over $10,000? Have you had a change in living conditions? Have you changed some of your personal habits? Have you been arrested for a minor violation? Have you had a change in responsibilities at work? Have you experienced a marital reconciliation Do you have a mortgage under $10,000? Have you had a change in residence? 136. Have you changed some of your eating habits? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes U'1 N 137. Have you had a fight with a close friend? 138. Have you had trouble with your boss? 139. Have you had a change in the number of family get-togethers? 140. Do have monthly car payments? 141. Have you begun or finished school? 142. Have you changed some of your sleeping habits? 143. Have you been either drunk or disorderly? 144. Have you had a change in attitude towards your job? 145. Have you gotten married? 146. Do you have a bank loan (other than education, house, or car loan)? 147. Have you had a change in your usual social activities? 148. Have you changed some of your exercise habits? 149. Have you left home for a period of hours or longer because of a dispute? 150. Have you had a change in your boss? 151. Have you had trouble with your in-laws? 152. Do you have any outstanding medical bills? 153. Have you had a change in your usual church activities? 154. 155. 156. Have you changed your recreational activities? Have you changed marital partners? Have you had a change in your co-workers? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 'y't::::::> Yes Yes Yes Yes Yes U1 W 157. 158. 159. 160. 161 . 162. 163. 164. 165. 166. 167. 168. 169. 170. 171 . 172. 173. 174. 175. Have you had more or fewer arguments with your spouse? Have you had a reduction in family income? Have you started or stopped any social activities? Have you been a vegetarian? Have you been abandoned by your family? Have you had a change in your physical conditions at work? Have you had difficulties in your sexual relationship? Have you had an increase in family income? Have you had a difficult time budgeting for household expenses? Have you gone on or off a reducing diet? Have you run away from home? Have you had a change in your work due to seasonal changes? Have you discussed a possible separation from your spouse? Have you had a change in your financial state? Have you had a change in your hobby? Have you changed the time you wake up or go to bed? Have you had a close friend who has been arrested or jailed? Have you had a temporary change in the kind of work you do? Have you had an increase or decrease in the number of people in your household? 176. Has recent inflation forced you to shop more carefully? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (J'1 ~ 177. Have you had a change in your mode of transportation? Have you had a change in the quality of your dreams? 179. Have you been planning'any legal action against someone? 180. Have you had a change in work which strains your competencies? 181. Have you had religious conflicts within your household? 182. Have you recently made a major purchase (house, furniture, car, etc.)? 183. Have you had a change in the time (more or less) you spend by yourself? 184. Have you changed the amount of time you spend doing housework? 185. Have you occasionally used social drugs (marijuana, alcohol)? 186. Have you had a changein work which now does not make good use of your capabilities? 187. Have you had political or religious conflicts in your family? 188. Because of inflation, have you changed your eating habits? 189. Have you felt that you never have enough time for yourself? 190. Have you increased or decreased activities in church? 191. Have you thought of suicide? 192. Have you changed the location of your work? 193. Have yOU experienced the death of a close family member? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes c.n c.n 194. 195. I~ you have a checking account, have you overdrawn it? Have you been spending less time in outdoor activities? i :j 0 • h d v E:: Y 0 U I II C I e as e a 0 r Q e ere a Sed S () CI ale 0 n t act -' . 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208. 209. 210. 211 . Have you been a victim of a swindle or fraud? Have you felt that your work has become more of a strain for you because of your pregnancy? Have you experienced a change of attitude toward your family? Have you had to borrow money from your family or friends? Have you watched television or read more than before your pregnancy? Have you seemed to feel more optimistic? Have you been a victim of a serious crime? Have you changed your work hours or work conditions? Have you had conflicts over who performs various tasks in your household? Have you put money away each month in a savings account? Have y~u ch~~ged ~ro~ thin~in~ of yourself as a oregnant woman to being the mother of an unborn baby? Have you experienced considerable mood changes? Have you become fearful of being alone while at home? Have you strongly disliked your work? Have you had arguments about family finances? Six to Twelve Months Ago Yes Yes le~ Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes ~es Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (.Tl ~ 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222. 223. 224. 225. 226. 227. Have you bought major purchases on credit? Have you become close to or lost some friends? Have you had any personal injury or illness? Have you gotten divorced? Have your co-workers generally been satisfied with their work? Have you had some outstanding personal achievement? Has there been a change in your financial state? Have you changed your style of dressing? Have you had a change in your sex life? Have you exceeded the speed limit by more than 10 miles per hour? Have you wanted to quit your present job (if you could afford not to work)? Have you had a pregnancy? Have you had to change your vacation plans because of financial reasons? Have you changed your shopping habits? Have you had a change in your daily activities? Do you tend to feel physically and emotionally exhausted at the end of your working day? 228. Has your family changed in any important way? 229. Have you changed your hair style or cosmetic makeup? 230. Have you had a change in health? Six to Twelve During the Past Months Ago Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (J"l ......, 1. Who is the chief earner of income in your family? (please check one) Husband Wife Other 2. What is the yearly income for your family from all sources? (please check one) --- None $13,000-14,999 -- $ 1,000-2,999 --$15,000-16,999 -- S 3,000-4,999 --$17,000-18,999 -- $ 5,000-6,999 -- $19,000-20,999 -- $ 7,000-8,999 --$21 ,000-22,999 -- ~ 9,UUO-10,9~~ $23,000 or I!lore --$11 ,000-12,999 3. What is the highest level of education achieved by: (please check one) --- Female Head Household Male Head Household 0-6 grades, ungraded 7-9 grades, Junior High School 10-11 grades, some High School Graduate, High School At least one year College Graduate, four years College (J"J co 4. What is the occupation of the head of the household? (please check one) Student in High School, Trade School --- Craftsman Laborer, farm laborer --- Salesman Other service worker --- Clerical Domestic worker --- aPgroripcruielttuorre, manager, business or Operator --- Professional, including college student 5. Was this pregnancy planned? (please check one) -- Yes --- No 6. Do you plan to breast feed? (please check one) --- Yes --- No 7. Has this pregnancy so far been: ease circle one) a. easier than you expected? b. what you expected? c. harder than you expected? U'1 \.0 PREGNANCY, ILLNESS-PRONENESS AND STRESS PROJECT UTAH TESTS APPRAISING MOTHERS Please Note: This form is to be filled out on the mother on the second day postpartum. Mother: Mother's Age ___ Hospi Subject No. ______ _ Delivery: Date/Time Date/Time Delivered Date This Newborn: Sex Weight Gest. Age (Wks.) Apgar-l Min. 5 Min. Parity-T __ P __ A __ L __ Name of Nurse 1lh~:ll>r!lIll>r ________________ _ Aspect Not level A level B level C level 0 I Obsd. (lower 15%) (35%) (35%) (Upper l5~) COlTITlents Welcomes the Somewhat Helpless, All OK, Enjoys Opportunity To Clearly in the Interested and Feedi ng Baby, Nourish Her Baby, Upper 15% in Feeding Concerned for Feels Worthwhile Psychologically Nourishing Her Baby's Nutrition As Well As Baby 0 a 0 0 o o Nutritionally a 0 0 I Mildly Interested Accepting, Warm, But Cool, Only Cuddles Baby, Establishes Close Clearly in the Interaction Regard for Basic Regard for Baby's Phys i ca 1 Bond Wi th Upper 15% in ~lith Infant Sustenance & Comfort & Wel1- Baby, Promotes General Care of Maintenance, Being, Seeks Interaction Infant Holds Baby Away Others I Opinions With Baby From Own Body Of Baby D 0 o D 0 0 0 0 0 Sa d, Some Rema rk s Generally Eager To Have Rarely About Inadequacy, Positive, Share Joy With Seen Anyone Behavior Pccasiona1 Crying, Cheerful, Others, l&D Seen With As High Towards Self Inappropriate Outward- As A "Peak" Self Morale As Overenthusiasm looking Experience" This Mother 0 a D 0 0 0 0 0 Restrained But Talkative, Nor- Open, Seeks Social ~esponsive, Dozes ma lly Responsive Contacts, If Not Really Beaut i fu 1 Reactions But Does Hot Enjoys Talkingto Vi s Hors Then Relations With Towards Others Resent Being People But Does Telephone, Books, Others, Upper Awakened Not Require It TV, etc. 15% of Women 0 _ D _______ D 0 0 alb 0 ~--- - -L-. 0"1 o Aspect Repcrtec Discom­fort Physical Activity Eating Behavior Response to Family/Friend Support Staff !Family! Friend Support Not Obsd. o o o o o PREGNANCY, ILLNESS PRilllENESS AND STRESS PROJECT UTAH TESTS APPRAISING MOTHERS Level A (Lower 15%) Level B (35%) leve I C (35%) level 0 (Upper 15%) Cons1derable. but tolerable suffer; n9. fre­quently asks for pain medication Some discomfort. no real problems No complaints, "feels fine" Really superb physical recovery o 010 Exhausted, weak, voluntary move­ment, needs con­stant encourage­ment to get UP. eats 1 ittle Recovering strength, gets up on own, good appitite DID DID May need to be held down, energetic, active self-helping Upper 15% of women ; n terms of physical act i vity 01(1 o 010 010 010 010 Very selective or over-eats Normal intake Cleans plate. looks forward to next meal, snacks Unusually good recovery of eating behavior upper 15% o Depressed and unresponsive, complains about lack. of medical attention DID CIO 010 Expresses wishes for more concern from others. initiates calls to others, i n­vi tes vi s i tors Very pleased about interest shown in herself and baby Ideal relations with family/ friends whi ch is rare 010 o aID CID DID 010 Few calls or Frequent calls & Many calls, cards Upper 15% in visits from c10s visits from many flowers, family response to family, indif- different people, often, warmly staff/family/ ferent towards appreciative of appreciative of friend support staff care, self staff care, fol- staff care sufficient, lows carefully Comments [J o o o wound up in self staff suggestions o 00 DID O[ DID 0 Q) Aspect Not Obsd. Physical care of baby 0 Psychological 0 Expectancy for the baby I I 0 Desired Activi-ties (constric-tion or expan-sion of) outside the home -- 0 PREGNANCY, ILLNESS-PRONENESS AND STPESS PROJECT UTAH TESTS APPRAISING MOTHERS Level A Level B leve I C (lower 15%) 05%) 05%) Takes almost all Most of her time She can leave the her time. She is spent caring baby if she wants can't leave for for the baby, but to. short time. not all. level D (Upper 15%) The baby takes time, but she still has lots of free time for herself . 0 o 0 o 0 o 0 t1 She worries She worries about Is able to leave She doesn't about the baby the baby a lot, baby some of the worry about the all the time. but not all the time with family, baby, but has time. friends, or other interests. sitters. 0 U 0 0 10 0 0 0 Considerably The baby is a Easier than she She thinks that more diffi cul t 1 i ttle more thought it would her baby is very to care for baby difficult than be. easy to care for. than she expec- was expected. ted. 1 (1 0 0 o 0 o 0 c 0 o 0 She has given She has had to She has changed She enjoys acti-up all usual restrict former and given up vities with the outside acti- outside acti- some unimportant baby/family and vities. vities somewhat. activities. doesn't feel con-stricted by the respons ; b il ity for the care of 0 o 0 o 0 o 0 the baby. o 0 Comments 0 0 0 0 I 'N" REFERENCES 64 Auerbach, A. B. Parents learn through d_iscussion. New York: Wiley, 1968. Banta, D., & Marinoff, S. C. Effective consumer participation in obstetric care. Birth and the Family Journal, 1975-1976, £ (4),15-18. Benedek, T. The psychobiology of pregnancy. In J. Anthony & T. Benedek (Eds.), Parenthood--its psychology and psychopathology. Boston: Little, Brown and Company, 1970. Bibring, G. L. Recognition of psychological stress often neglected in obstetric care. Ho~~~lTopics, 1966, 42, 100-103. Bibring, G. L., Huntington, D. S., & Valenstein, A. F. A study of the psychological processes in pregnancy and of the earliest mother-child relationship. Jhe Psychoanalytic Study of the Chi !Q, 1961, }~, 9-24. Blair, C., & Salerno, E. The eXPdndi~~ Childbearing. Boston: Little, Brown and Company, 1976. Bradley, R. Husband coached childbirth. New York: Harper & Row, 1965. Bruce, S., & Chand, M. A. Methods of teaching & counseling. In J. P. Cl au sen (Ed.), Ma~!~!:.QjJLnurs ~. __ today. 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Journal of Con­su1t~ sycho_~, 1963, ?:1.' 324-329. 70 Name Birthddte Birthplace High School 1 ~j65 College 1971-1975 Professional Position VITA Londa Yvonne Thompson September 17, 1946 Glendale, California Littleton High School Littleton, Colorado B.S. University of Utah Salt Lake City, Utah Magna Cum Laude Staff Nurse High-Risk OB Unit University of Utah Medical Center, 1975-1976 July 1976 to present UCLA--Newborn Intensive Care Unit, January 1976 to to June 1976. Prenatal Instructor, 1976 to present