P4817 —-—— BEIQRNING MATERIAL§§ Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. A__— .- MIT FEB 1 5 7.087 @3220? PERCEIVED CHILDBEARING, CHILDREARING AND MARITAL CONCERNS OF PARENTS EXPECTING THEIR SECOND CHILD BY Nancy L. Maudlin A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1988 ABSTRACT PERCEIVED CHILDBEARING, CHILDREARING AND MARITAL CONCERNS OF PARENTS EXPECTING THEIR SECOND CHILD BY Nancy L. Maudlin A descriptive study of 36 middle-class Caucasian couples expecting their second child was executed to determine the perceived childbearing, childrearing and marital concerns of parents during the third trimester of their second pregnancy. Self-administered questionnaires developed for the study provided data on the convenience sample. The seven sub-scales of concern related to self, spouse, marital relationship, firstborn, expected baby, childbirth, household and finances were not found to be acceptable as initially constructed. Mothers and fathers did not report high levels of concern on the retained study sub-scales, run: the sub-scale measuring marital concerns had the highest reported level of concern by both mothers and fathers. Mothers reported significantly higher levels of concern than fathers on all study sub-scales. Based on findings from the study, the implications for nursing education, practice and research are addressed. DEDICATION This project is dedicated to my parents, Charles and Jeanne Fliss, who have lovingly encouraged and supported me through each stage of my life, and to my children, Jared and Jessica, who fill each day with love and joy, and to my wonderful husband Dan. ii ACKNOWLEDGEMENTS Further acknowledgments are given to the followimg individuals, who never failed to offer their support and encouragement: Kathy Abolins Judith Daniels Cynda Greenman Kathie Fliss Martell Shirley Maudlin Judy Smith Manfred Stommel Marge and Dick Tuinstra Special recognition is given to the following members of my thesis committee for their professional guidance: Barbara Given Sandra Hayes Patricia Peek Jacqueline Wright TABLE OF CONTENTS LI ST OF TABLES O O O O O O O O O O O O O O O O O I O O O O O O O O O O O O 0 O O O O O O 0 Vi 1 LIST OF FIGURES O. O O O O O O O O O O O O O O O O O O O O O O O O I O O I I O O O O O I Viii CHAPTER I. THE PROBLEM Introduction .............................. 1 Background ................................ 2 Purpose of Study .......................... 4 Definitions of Concepts ................... 5 Research Questions ........................ 9 Assumptions ............................... 10 Limitations ............................... 11 II. THE CONCEPTUAL FRAMEWORK Introduction .............................. 13 Definitions of Parental Concerns .......... 16 Parental Concerns in the Literature ....... 17 Conceptual Framework ...................... 36 III. REVIEW OF THE LITERATURE Introduction .............................. 51 Concerns Related to Self .................. 51 Concerns Related to Spouse ................ 82 Concerns Related to the Marital Relationship ............................ 84 Concerns Related to the Firstborn ......... 93 Concerns Related to the Baby .............. 104 Concerns Related to the Childbirth Experience .............................. 109 Concerns Related to the Household and Finances ................................ 120 CHAPTER IV. METHODOLOGY Overview .................................. 127 Research Questions ........................ 127 Operationalization of Concepts ............ 128 Criteria for Inclusion in Study ........... 131 iv CHAPTER IV. V. VI. TABLE OF CONTENTS (continued) METHODOLOGY (continued) sample OOOOOCOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Data Collection Procedure ................. Instrument Parental Concerns Questionnaire ........... Extraneous Variables ...................... Operational Definitions of Variables ...... Extraneous Variable ....................... Data Analysis Procedures .................. Summary ................................... DATA PRESENTATION AND ANALYSIS Overview .................................. Results of Pilot Study .................... Description of the Study Sample ........... Extraneous Variables ...................... Reliability of the Study Instrument ....... Analysis Pertinent to Study Questions ..... Significant Findings Among the Extraneous Variables and Study Sub-scales .......... Summary ................................... SUMMARY AND CONCLUSIONS Overview .................................. Data on Sample and Significant Inferential Statistics .................. Sociodemographic Data of the Sample ....... Modifying Variables of the Sample ......... Action Variables of the Sample ............ Interpretation of Major Research Question.. Implications of Questions I, II, and III to King's Framework .................... Implications of Question I, II, and III to Nursing Practice ..................... Implications of Question I, II, and III for Nursing Education .................. Recommendations for Future Research ....... Conclusion 132 132 135 135 137 138 142 150 153 154 154 155 155 165 167 180 187 188 188 189 195 203 211 218 222 229 230 235 TABLE OF CONTENTS (continued) APPENDICES A. Mother's Questionnaire ....................... B. Father's Questionnaire ....................... C. Letter of Agreement to Assist With Study ..... D. Letter of Introduction to Parents ............ E. Telephone Screening Tool ..................... F. Consent Form G. General Directions 0.0.0.0....0.00.00.00.00... H. Verification of Research Approval ............ I. Retained Study Sub-scales .................... LIST OF REFERENCES vi 238 247 256 257 259 261 262 263 264 268 10. 11. 12. LIST OF TABLES Sociodemographics on the Study Sample .......... Percent of Mother‘s and Father's Utilization of Sources for Childbearing and Childrearing Information 0.0...OOOOOOOOOOOOOOOOOOOOO0....O... Alpha Coefficients on Retained Sub-scales of Parental Concerns Questionnaire ................ Pearson Correlation Coefficients Among sub-Scales OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO. Mean Results and Standard Deviations of Mothers and Fathers on Five Sub-scales of Concern ...... Intercorrelations of Mothers' Five Sub-scale Concern scores 0.00.0.0...OOOOOOOOOOOOOOOOOOOOOO Individual Items of Concern Ranked by Mean Response and Frequency for Mothers and Fathers 00.0.0.0...OOOOOOOOOOOOOOOOOO0...... Intercorrelations of Fathers Five Sub-scale concern scores .0.0.0.0.0.0...OOOOOOOOOOOOOO0.0. Means of Pairwise Difference Scores Between HUSbands and Wives 0..OOOOOOOIOCOOOOO0.0.0.0.... Analysis of Variance for Relation of Mothers' Extraneous Variables to Sub-scales ............. Correlations Between Sub-scales and Extraneous Variables for Mothers Correlations Between Sub-scales and Extraneous Variables for Fathers vii 158 163 166 167 169 169 172 176 178 182 185 185 LIST OF FIGURES A Process for Human Interaction ................ 39 Application of King's Theory to the Study concepts 0.00.00.00.00...OOOOOOOOOOOOOIIOO0.0... 44 Proposed Adaptation of King's Model to the Process of Interaction Between Nurse and Parents Expecting Their Second Child ................... 47 Revised Adaptation of King's Model to the Process of Interaction Between Nurs and Parents Expecting Their Second Child ................... 219 viii CHAPTER I THE PROBLEM Introduction Pregnancy and the period of transition into parenthood is generally accepted to be a stressful time for expectant parents. Previous roles must be redefined as couples prepare to enter into the new role of parent. Couples who are unable to meet the challenges and demands of parenthood are susceptible to crisis. In fact, some researchers refer to this period as a crisis point in the lives of parents (Dyer, 1963; LeMasters, 1957). Whether researchers argue that the childbearing period is a transition period accompanied by difficulty (Hobbs, 1976) or a crisis experience (Dyer, 1963; LeMasters, 1957), they must recognize that it "is a time when preventive intervention can do much to influence the attitudes and functioning of prospective parents" (Miller & Brooten, 1977, p. 90). If nurses are to assist expectant parents in their adaptation to the childbearing period, then they must first be aware of parents' perceived concerns during this period of their lives. What about couples expecting their second child? Do they also have concerns regarding the second pregnancy and the demands it will place on them; or, are they more immune to these stressors because of their past experience? The literature abounds with concerns of 2 first-time parents as though to maintain that multiparous mothers and fathers have less concerns (or less important concerns?) anui, therefore, need less support from nurses and other health care providers. With the assumption that there are differences the "second-time around", the purpose of this study was to explore expectant parents' perceived concerns during the third trimester of their second pregnancy. Background Over the past two decades there has been a trend to increase the involvement of expectant parents and their families in all areas of the childbearing process. Mothers have become more active in their childbearing experiences by participating in childbirth education classes, requesthu; rooming-in after delivery and choosing to breastfeed their infants (Lipkin, 1978). Fathers have joined their wives in becoming more involved in the birth of their child by also attending childbirth preparation classes, coaching their wives through labor and delivery, and being not passive, but active participants in both vaginal and cesarean births (Lipkin, 1978; Miller & Brooten, 1977). Parents are demanding and acquiring greater involvement in the childbearing process, not only by fathers but also by siblings (Marecki, et a1, 1985). Siblings are now able to visit their mother and the new baby on many postpartum units and sometimes are present for 3 the birth itself (Mullaly & Kervin, 1978; Sweet, 1979). Of course, greater involvement of the entire family in the childbearing process was also made possible because it was promoted more by health care providers caring for expectant parents. Nurses caring for expectant parents have also become more sensitive to the couple's changing needs and have attempted to learn more about the unique concerns that parents and their femalies might have during the childbearing period (Hiser, 1987; Kintz, 1987). As one might expect, the majority of the literature and research is directed to the concerns of primiparas, and first-time fathers, and to a lesser extent to multiparas and siblings. This author has found very few studies which include second-time fathers. So, unfortunately, less is known about time concerns of both mothers and fathers expecting their second child. And yet, in 1980 there were 29.5 first-born live births and 21.8 second-born live births per 1,000 women in the 15-44 year old age range in the United States (U.S. Department of Health and Human Services, 1984). If we look at women in the 25-44 year old age range, during that same period, second-born live births surpass the number of first-born live births. But statistics are only as meaningful as the attention that is given to them, and those parents expecting their second child have received less attention by researchers in the health care system. As Jiminez, Jones and Jungman (1979) 4 conclude from their work with parents in repeat prenatal classes, "the health care system cannot in good conscience continue to overlook the needs of the family just because this is not their first time around in the childbearing cycle" (p. 308). As Mermin (1982) found in his study of both first-time auui second-time parents, veteran parents may 1x3 more reactive to the birth of their second child, thus requiring greater adjustments in marital and child care role arrangements. Purpose of Study There are numerous potential concerns perceived by parents expecting their second child, but second-time parents have been given little attention by investigators and, therefore, their specific concerns remain poorly studied. Without knowledge of these parents' concerns, nurses and other health care professionals cannot offer complete care to parents who are expecting a second child. Therefore, the purpose of this study was to explore expectant parents' perceived concerns during the third trimester of their second pregnancy. From the information gained by this study, nurses will be able to more fully understand the differences and similarities between fathers and mothers expecting their second child which will impact on their nursing interactions, assessments, and inter- ventions with this population. Also, an expectation of the study was 13) uncover information which may assist nurses 5 and other health care professionals in the future development of research studies which will compare the concerns and needs of second-time parents to first-thme parents thus promoting a broader base of knowledge for the profession of nursing. Specific questions to be answered by this study were: 1. What are the perceived childbearing, Childrearing, and marital concerns of mothers during the third trimester of their second pregnancy? 2. What are the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of the second pregnancy? 3. Are there differences in the perceived childbear— ing, Childrearing, and marital concerns of mothers when compared to the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of a second pregnancy? Definitions of Concepts Perception In order to meet the needs of parents expecting their second child, nurses must first validate the concerns perceived by the parents. Perceptions by nurses of the meaning of the second pregnancy to the pregnant couple are only valid when tested against the perceptions of the parents themselves. When the perceptions of both the expectant parent and the nurse are in synchrony, mutual 6 goal setting can occur. In this study, perception was understood to mean the father's or mother's "image of reality" which gives meaning to their pregnancy and childbirth experience and influences their behavior. This process of organizing, interpreting, and transforming informatitni from their sensory data and memories was demonstrated by their responses on the concerns questionnaire during the third trimester of pregnancy (King, 1981, p. 24). Concerns Concerns of expectant parents identified in the literature have been categorized in a multitude of ways. Rubin's (1976) well-known framework of four maternal tasks of pregnancy (safe passage, acceptance by significant others, binding-in, and giving of self) was incorporated by Stark and Carrico (1983) in their study of primiparas and multiparas. (Blazer (1980) utilized the Taylor Manifest Anxiety Scale along with a 62-item concerns questionnaire in her study of expectant mothers and subsequently grouped her results according to those major concerns related to baby, self, medical care, childbirth, finances, and subsequent pregnancies. In their study of both primiparas and multiparas, Light and Fenster (1974) investigated ten categories of concern related to the baby, childbirth, subsequent pregnancies, self, finances, medical care, family, doctor, medication and birth defects. 7 Based on a review of the literature, and with the consideration that this study was exploring the concerns of both mothers and fathers expecting their second child, concerns were investigated as they related to self (mother or father answering questionnaire), spouse, the marital relationship, first-born child, expected baby, the childbirth process, and the household and finances. Concerns were defined as those issues of interest viewed as important by the expectant parent or those issues seen as occupying his/her thoughts (Bull, 1981; Glazer, 1980). Expectant parent The term expectant parent potentially encompasses the time frame from the very moment of conception to the birth of the baby. Parent can further be described by the method of conception (biologic or artificial insemination), or assumption (adoptive or through re-marriage). Furthermore, being married is not a pre-requisite for parenthood. In order to limit the scope of the term, expectant parent, the more traditional description was used. Expectant parents were both mothers and fathers who were pregnant with their own second child, were married and living together at the time of the study and had one child of their own and no children from previous marriages. Mother The term mother potentially refers to any female who has a child. For the purpose of this study, mother 8 referred to the female spouse who had biologically conceived one normal child with her present husband and who was presently in her third trimester of pregnancy with her second child by the same father. eager In this study, father was defined as "the male who shared the (second) pregnancy with the female in the psychosocial as well as the biologic sense" (Jensen, Benson & Bobak, 1981, p. 221). The relationship was one that was legally sanctioned and the father did not have children from a previous marriage. Third Trimester It is possible that both fathers and mothers experience certain concerns during each trimester of their pregnancy. In her study of both primiparas and multiparas, Glazer (1980) found the greatest number of concerns expressed during the third trimester. Taking into consideration Glazer's findings, regarding the third trimester as a critical time period for uncovering parental concerns, then, expectant parents in this study were asked to complete the concerns questionnaire during the third trimester of their second pregnancy. Third trimester was defined as the last three, full, calendar months of the pregnancy or an estimated gestation of 27 weeks or more as calculated by the expected date of confinement (Clark & Affonsa, 1976). 9 Second Pregnancy It is possible that the birth of a second child is not the result of a second pmegnancy since abortions or miscarriages may have been experienced by the parents. To eliminate these variables and for the purpose of this study, second pregnancy denoted that the mother was a gravida 2: para 1 (Ruder, Mastroianni & Martin, 1980) who was experiencing a normal pregnancy or one that was not at high-risk. High-risk pregnancy was defined as "one in which the life or health of the mother or offspring is jeepardized by a disorder coincidental with or unique to pregnancy" (Jensen, Benson & Bobak, 1981, p. 315). Also, the mother and father had one child of their own who was alive and without abnormalities and there were no children from previous marriages. Research Questions In this study the following research questions were investigated. Based on expectant parents' perceived concerns as gathered by means of the study questionnaire during the third trimester of their second pregnancy: 1. What are the perceived childbearing, Childrearing, and marital concerns of mothers during the third trimester of their second pregnancy? 10 2. What are the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of the second pregnancy? 3. Are there differences in the perceived childbear- ying, Childrearing, and marital concerns of mothers when compared 11) the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of a second pregnancy? Assumptions The following assumptions were accepted to allow for progression of the study. 1. Perceptions gathered from previous life experiences (a first pregnancy, labor, and birth) influence parents' perceptions of subsequent life experiences, such as a second pregnancy, labor, and birth experience. 2. Since the childbearing period is a stressful time, parents will have concerns during the second pregnancy. 3. Perceptions by parents of their concerns during the second pregnancy will influence their actions, interactions, and transactions. 4. Concerns perceived by expectant parents during a second pregnancy vdll cause stress which could interfere with their growth during the childbearing and Childrearing stage of the life cycle. 11 5. Incongruent perceptions between nurses and expectant parents will interfere with their ability to successfully communicate toward mutually defined goals. 6. Nurses must be able to help expectant parents recognize and deal with their concerns so as to maintain the maximum potential level of health of the family unit. 7. Both mothers euul fathers expecting their second child would be willing to relate their concerns. Limitations l. The size of the study sample was limited by the number of both mothers and fathers who agreed to respond to the concerns questionnaire. 2. Furthermore, the convenience sample drawn from private practices in one midwestern area also limited the population to which this study's results can be generalized. 3. Focusing on only the third trimester of pregnancy excluded parental concerns pertinent to the first two trimesters and to pregnancy as a whole. 4. Excluding couples who were expecting their first child and those couples expecting their third or more did not alltnv for comparisons, based on the variables on the concerns questionnaire, between these groups and the couples in this study. 5. The concerns questionnaire for this study was not {previously used or tested on a large population. Reliability for this study needed to be established. 12 6. There were no controls set for the age of the first born child of parents in the study. 7. There were no controls set for the maximum age of the parents in the study. 8. The study results reflect a one-time measure of concerns of expectant parents since the study was not longitudinal in design. 9. Variables which may have influenced the study results, such as marital satisfaction, satisfaction within the family triad, history of infertility, or previous interventions to decrease concerns, were not addressed. Even with consideration of the above limitations for this study, the perceived concerns of both mothers and fathers who were expecting their second child merited further investigation. Contained in Chapter two is a discussion of the relationship between variables in the study to King's (1981) conceptual framework. A review of the literature related to the study's variables and the profession of nursing will be expanded upon in Chapter three. In Chapter four the methodology of the study, including descriptions of the sample population, definitions of the variables and explanations regarding the concerns questionnaire and scoring measures used, will be described. Analysis of the data and their relationship to the research questions will be described in Chapter five. Included in Chapter six will be a summary of the study and its implications for advanced nursing practice and primary care. CHAPTER II THE CONCEPTUAL FRAMEWORK Introduction In chapter two, the concepts of the study as they relate to findings in the current literature, will be further described. The relationship of the various areas of parental cnncerns to each other and to the conceptual framework of King, upon which the study is based, and subsequent implications for the profession of nursing will be discussed. Not only are the needs of repeat parents overlooked by the health care system, but the system is designed to give more support to those pregnant mothers who are at high-risk and less support to those who are "normal“. In her study of adaptation of "normal" primiparous women to motherhood, Curry' £1983) found that 25% had difficulty adapting and, therefore, summarized that "all pregnant women and new mothers, not just those at high-risk, may potentially need additional support" (p. 120). Concerns of multiparous mothers, especially those that are ”normal", have not been fully addressed by health care professionals. Even less is known about the concerns of fathers expecting a second child. Because the concerns of (parents expecting a second child have been less fully :researched, health care providers caring for this group of Iparents may be basing their care on incomplete or 13 14 inaccurate assumptions. The increased complexity of interrelationships that occur within the family unit with the addition of aa second child should alert health care professionals that second-time parents may need at least as much, if not more, support as parents expecting their first child. "Whereas the primipara, upon the birth of her infant, moves from one interrelationship or dyad in her nuclear family to three, the secundigravida encounters six dyadic relationships. If this is her third child, she goes home to face ten dyadic relationships" (Mercer, 1979, p. 301). Concerns of parents expecting their second child must be acknowledged so that they can be fully addressed. Parental concerns previously identified by investigators have been drawn from samples of first-time mothers (n: fathers and, to a lesser extent, from second- time mothers. Concerns of second-time fathers are mentioned even less frequently in the literature. Since the rate of second births when compared to first births is substantial, it would seem appropriate that health care professionals caring for parents during their childbearing years be aware of the concerns of parents expecting their second child. Awareness of parental concerns is necessary in order to pmomote and maintain the total health of the family. With the advent of family-centered maternity care, it is accepted that the goal of each pregnancy is not only to have a healthy mother and baby, but also a healthy :Eamily unit as well (Lipkin, 1978). 15 Just as first-time parents may be concerned about their'rufiv role of mother or father (Dyer, 1963; Obrzut, 1976), second-time parents may also have concerns about their new role as a mother of two children or father of two children (Moore, 1978). The family is a social system. Like all systems, the family is affected by the addition of new members and certain changes are expected (Bash & Gold, 1981; Kreppner, Paulsen & Schuetze, 1982). As Brazelton (1981) states, "there are important adjustments that are distinct to each new addition to a family" (p. 39). Although parenting one child may be helpful in preparing for a second, personal experience in parenting the second child will be necessary for role acquisition to be finalized. Since the final step necessary for role acquisition is the personal experience of that role (Thornttni & Nardi, 1975), it is very likely that parents expecting their second child may have concerns about being a mother or father of two children, even though they have already experienced being a parent of one child. As expectant parents prepare to take on this new role as parents of two children, they may experience concerns regarding the effect this may have on themselves, their spouse, their marital relationship, their first-born child, the expected baby, the second upcoming childbirth experience and their household and finances. The purpose of this study then was to investigate the perceived concerns of parents, both mothers and fathers, 16 during the third trimester of their second pregnancy and to explore the relationships between those concerns perceived by mothers as compared to those concerns perceived by fathers. Knowledge of repeat parents' concerns will assist the nurse in promoting the health of the family, since the closer the nurse's perceptions are to those of the parents, the more meaningful her interventions will be (King, 1981). Definitions of Parental Concerns In this study, the concerns of expectant parents were investigated as they related to self, spouse, the marital relationship, first-born child, expected baby, the childbirth process and the family's household and finances. These seven categories provided a method for assigning the concerns identified by parents into significant subscales for analysis. The following section includes brief definitions of these areas of concern. Self Concerns related to self were those specific to the individual needs and lifestyle of the parent, mother or father, responding to the questionnaire. Spouse Concerns related to the spouse were those identified by the mother or father as affecting the daily life, health and general well-being of their husband or wife. Marital relationship Both the physical and emotional components of communication, affection and time between spouses were 17 reflected in questions focusing on concerns relevant to the marital relationship. First-born child Concerns related to the first-born child were those relating to the general physical and mental well-being and care of the couple's first-born child. Expected baby Concerns related to the expected baby were those specific to the physical and mental health, love, care and acceptance of the second child. Childbirth experience Concerns relating to the forthcoming labor, delivery and immediate postpartum period, with the birth of the second child, along with the physical and emotional care by doctors and nurses during this time, were reflected in the area called childbirth experience. Household and finances Concerns related to the household and finances were those specific 11) the physical environment of the home, daily routines, income and expenditures of the family. Now that the above areas of parental concerns have been defined, the literature relevant to the development of the study concepts will be presented. Parental Concerns in the Literature Concerns of mothers and fathers during pregnancy have laeen identified in the literature. Most of these concerns were gathered from first-time mothers and fathers, less 18 often fixnn second-time mothers, and even less frequently from second-time fathers. The following concerns already identified in the literature helped to focus the direction of this study. Concerns for self Both mothers and fathers may wonder how a first or second child may alter their daily lives. Concern for the effect of a first child on the parent's self-identity, personal interests, freedom and social life have been well documented in the literature (Hobbs, 1965; Dyer, 1963: Le Masters, 1957). Mothers, especially, may be concerned about the effect of a new baby on their job or career goals (Le Masters, 1957). Simply having quiet time or time alone for oneself may be a concern to new mothers (Barber & Skaggs, 1975). In their study of maternal concerns during pregnancy, Light and Fenster (1974) found that one of the most frequent concerns expressed by multiparas was the ability to care for their families. Mothers may worry about adequately fulfilling their new role as a mother of two children, or wonder if they will have the time, energy and patience required to nurture the emotional and physical needs of their spouse and children. It is feasible that second-time fathers, as well as mothers, may also feel challenged by the demand to balance the needs of self, aspouse, first-born child and new baby (Duvall, 1977). This newly reawakened feeling of responsibility for 19 another family member can cause both mothers and fathers to have more thoughts about their own health or possible death (Friederich, 1977; Kleinman, 1977). The second time around, each spouse may realize that any threat to their health could affect not just the other spouse, but also the remaining first-born child and possibly the new baby. These feelings are definitely not unique to mothers, for as Hott (1976) found, fathers may also harbor ”fears and fantasies about their own deaths" (p. 1438). Feelings regarding the pregnancy's affect on the woman's figure and weight, body image, and feelings of physical attractiveness have been well documented in the literature as being a concern of pregnant and newly delivered mothers (Mueller, 1985: Strang & Sullivan, 1985). In her study of both primiparous and multiparous women during the postpartum period, Gruis (1977) found that the most frequent concern expressed by these women was the return of their figures to normal. Parents may feel they receive less support and attention from relatives and friends during their second pregnancy and after the birth of the second baby. Whereas the announcement of being pregnant with the first child might have been met with celebration, the announcement of being pregnant with the second child is more often met with less enthusiasm by relatives and friends (Jiminez, Jones & Jungman, 1979; Mercer, 1979). 20 Mothers, especially, may wonder if they will get the help and support from their husbands that they need in order to manage the demands of another child (Glazer, 1980; Leifer, 1977).. Oftentimes, fathers may spend less time assisting their wives with infant care activities than the fathers themselves projected on doing prenatally (Hangsleben, 1983). By their use of a postpartum self- evaluation questionnaire, Lederman, Wiengarten and Lederman (1981) found that multiparas reported significantly less husband involvement in infant care than did pmimiparas. Many mothers may'kxa trying to balance these new responsibilities, in addition to being employed outside the home, while receiving less help and support from their husbands, family and friends. To summarize then, both mothers and fathers expecting a child may have concerns related to their own self during pregnancy. Realizing the demands that one child has made on their time may cause parents to wonder if the addition of a second child will further reduce their personal free- dom and ability to pursue both career and social interests. Mothers may be especially concerned about their figure and weight. Pregnancy is a time when both mothers and fathers may spend more time thinking about their own death or possible illness as they ponder whether they will be able 'to meet the needs of their growing family. And all these <:oncerns may be occurring at a time when parents expecting a second child feel they are receiving less support from 21 family and friends than when they were pregnant with their first child! Concern for spouse Expectant parents may have more thoughts regarding their (Hui health, tun: they may also find themselves thinking more about the health or possible death of their spouse (Friederich, 1977; Lipkin, 1978). Since the wife is physically experiencing the pregnancy, labor and delivery, husbands may find themselves particularly concerned about their wives' health (Marquart, 1976). The women are not the only ones concerned about the return of their figures once the baby is born. Evidently, concern with the expectant mother's weight gain and body changes can also be felt by the father (Moore, 1978). And, as Friederich (1977) acknowledges, "the support of the husband can be crucial to the woman's accepting her body change" (9. 30). Both mothers and fathers may have concerns related to their spouse during pregnancy. Fathers may be especially concerned with their wives' health since the mother physically experiences the pregnancy and childbirth and may find themselves thinking more about their wives' possible death. Fathers may also wonder whether their wives will regain their prepregnant figure. Information specific to concerns regarding one's spouse during pregnancy is limited. There is an obvious need for more research to be done in this area. 22 Concern for the marital relationship Concern that a couple may have regarding the effect of a child on their marital relationship has been repeatedly documented.iJi the literature (Clark & Affonso, 1976; Duvall,'j1977: Kleinman, 1977: Valentine, 1982). Concern for the marital redationship can be experienced by both first-time mothers (Leifer, 1977) and first-time fathers (Obrzut, 1976), and particularly by the multiparous couple (Jiminez, Jones & Jungman, 1979). Mothers may concern themselves with trying to be a "good" wife and, therefore, not neglecting their husbands after time baby's birth (Dyer, 1963; Gruis, 1977; Lipkin, 1978). First-time fathers may feel semi-isolated or think that their wives are less interested in them, and possibly feel jealousy toward the baby (Bash & Gold, 1981; Hangsleben, 1983). Mothers may feel that their husbands are not paying enough attention to them after their first child is born (Ryder, 1973). This may explain why Rollins and Feldman (1970) found that the dependent children stages of the family life cycle were associated with negative evaluations of the marriage by the wife. In his study of couples expecting their first child, Fein (1976) found that men's preparations for postnatal stresses in their relationships with their wives took several forms. Some men began taking time off from work while others began paying increased attention to their wives and spent more time talking about their relationship 23 and their future with the baby. Wandersman (1980) studied forty-seven first-time fathers and found that although fathers felt more comfortable as parents as their babies become older, they reported a slight decrease in marital satisfaction. Some parents find that their marital relationship has improved or at least stayed the same since their baby's birth (Russell, 1974). Both mothers and fathers may have concerns related to changes in their sexual relationship during pregnancy and after the baby's arrival (Clark & Affonso, 1976; Gruis, 1977; Marquart, 1976). Dyspareunia, differing sexual drives, anui impotency may be problems experienced by pregnant couples which can cause frustration and embarrassment (Jensen, Benson & Bobak, 1981). In her study of both primiparas and multiparas, Larsen (1966) found.1fluit decreased libido concerned mothers prenatally and during the postpartum period. Nquuart (1976) found that sexuality was not a source of over- whelming problems for the fifteen expectant fathers she interviewed, but that these men did ask many questions about sexuality when given the opportunity. Hobbs (1965) found that decreased sexual responsiveness of self was the second most discriminating item chosen by first-time mothers and that decreased responsiveness of spouse was the tenth most discriminating item chosen by first-time fathers. Feelings regarding sexuality may vary between 24 expectant mothers and fathers during pregnancy. Some pregnant females may find their bodies fat and unattrac- tive, or may feel more womanly and pleasing. Some men may find their pregnant wives more beautiful than ever, or lose sexual interest in their wives (Mueller, 1985). And, if sexual interest decreased and the frequency of sexual intercourse decreased after birth of their first child, parents expecting their second child may wonder if this pattern of decreased interest or frequency will worsen. Considering contraceptive techniques to either prevent or postpone further pregnancies can be a concern to parents (Glazer, 1980). Parents may be weighing the decision of contraception versus sterilization after the second child's birth. Ihi their study of women in the postpartum period, Light and Fenster (1974) found that multiparous women expressed.aa higher incidence of concern than primiparous women regarding either having more children than desired or the choice of contraceptive technique to use after the baby's birth. In summary then, parents may be concerned about how their marital relationship will be altered by the birth of a child. Parents may wonder if they will have time for companionship as well as sexual intimacy. First-time fathers may feel somewhat isolated when their child is born. Choices to be made regarding contraception or sterilization after the baby's birth may concern parents. 25 Concern for the first-born child In addititui to the above concerns, both parents may worry about the effect of the second child's arrival on their first—born child. Parents may be concerned that their fire”: child will feel threatened (Barber & Skaggs, 1975: Jiminez, Jones & Jungman, 197:) or possibly exhibit regression (Lipkin, 1978). Parents may worry about how they will manage the care of their first-born child while they are at the hospital delivering and getting acquainted with their new baby (Larsen, 1966). The potential for sibling rivalry and how expectant parents will deal with it may cause parents concern as they try to anticipate their first-born's reactions and adjustment to the new baby (Clark & Affonso, 1976; Moore, 1978, Moss, 1981). Will the first-born child possibly regress to the use of the bottle or pacifier again, or will gains made toward toilet training be lost? Maybe the parents fear that the older sibling will behave aggressively toward the new baby or behave negatively towards them. Parents' concerns regarding aggression and regression become even more valid if the two children are closely spaced since "the closer in age the two siblings are, the more likely the older one is to behave in a hostile manner toward the younger child" (Hymovich & Chamberlin, 1980, p. 271). Whereas an older child may at times compete with parents for the baby's attention, a younger child may be competing with the baby for their 26 parents' attention (Costello, 1985). Mothers nun! feel guilty because they feel too tired during their second pregnancy to participate in the special activities that they formerly shared with their first-born child (Grubbs, 1980; Stark & Carrico, 1983). Both mother and father may fear the loss of the exclusive and unique relationship that they have developed with their first-born child (Jenkins, 1976; Moore, 1978). As Kendrick and Dunn (1980) found in their investigation of 40 families, there was a marked increase in confrontation between mother and first-born and a decrease in maternal attentive playfulness after the birth of the second child. The addition of the second child to the family system will necessitate that some changes be made. The effect of change on any system can be positive or negative. Anticipation of the perceived negative aspects of change on the family may concern both the expectant mother and father. To summarize, parents may have many concerns related to their first-born child. Parents may wonder how they will manage the care of their first-born while the mother is hospitalized and also after the baby comes home. Parents may wonder if or how they will deal with their first-born child's developmental regression or possible aggression towards the baby. Parents may feel that their time vfiJfli their first-born child and the special :relationship that they have with that child will be tflireatened by the addition of the new baby to the family. 27 Concern for the expected baby Along with concerns related to the first-born child, the expectant parents are likely to have concerns regarding the expected baby. It is not unusual for both mothers and fathers to feel somewhat ambivalent upon learning that they are expecting a child (Barber & Skaggs, 1975; Hrobsky, 11977: Mayn .1976). This ambivalence usually decreases as the pregnancy progresses (Lipkin, 1978; Moore, 1978). But for the mother or father expecting a second child, sensing this ambivalence toward the arrival of the baby may promote feelings of failure, fear or guilt (Gulbas, 1981; Jenkins, 1976). It is interesting to note, though, that these feelings of ambivalence do not seem to lessen a parent's concern for the health and welfare of the baby (Hott, 1976; Rubin, 1976). Both Larsen (1966) and Stark and Carrico (1983) found that concern for the baby's health and normalcy may be greater among multiparas when compared to primiparas“ IRarents may feel that since they have been fortunate enough to have had one normal child, that their luck might run out the second time around. Mothers and fathers who have become accustomed to caring for the increasingly independent toddler or preschooler may again feel overwhelmed by the care required to meet the needs of a newborn baby. In their investigation of postnatal parental concerns, Sumner and Fritsch (1977) were surprised to find that 25% of the Inultiparous mothers eligible to call in for advice did so. 28 Also, altjunufli primiparous mothers made more phone calls seeking help with their new baby, multiparous mothers asked more questions per phone cell. Concerns of fathers and mothers may not be limited to those related to the baby's physical care but may also include the aspect of promoting the baby's total growth and development (Giefer & Nelson, 1981). Greater concern for the baby's overall growth and development may be especially true for parents expecting their second child (Gruis, 1977; Moss, 1981). With all this thought given to meeting the needs of the new baby, parents may feel concerned, and possibly guilty, that they will not be able to give their second child the individual time and attention that they gave their first-born child (Barber & Skaggs, 1975; Stark & Carrico, 1983). In addition, depending on whether or not parents delivered a child of the desired sex the first time, delivering a child of the desired sex may potentially become a greater concern the second time around (Bernstein, 1984). Amidst feelings of ambivalence and lack of support from significant others, parents find themselves confronted by their emotions regarding an additional family member. Both mothers and fathers have developed a unique relationship with their first-born and with each other as a family unit or triad. A very frightening question that many expectant parents ask themselves is "can I love another child as much as the first?" Concern with their 29 (Hui ability to love another child can haunt both mothers and fathers (Gulbas, 1981; Light & Fenster, 1974; Jiminez, Jones & Jungman, 1978; Mercer, 1979). This doubting of one's ability to love is expressed by the secundigravida in .Jenkins' (1976) case study when she states, 'I think one difference between having your first baby and having your second baby is that when you're having the first, you love .it almost from the time of conception. But, when you're having the second, you don't feel that way' (p. 120). This wondering about one's ability to love the second child, especially if this was not a concern while expecting the first child, may be cause for concern by the parents. Not only may each parent question their own ability to love a second child, but mothers and fathers may be concerned that their spouse will be able to love a second child (Jiminez, Jones & Jungman, 1978). In summary, parents may be concerned with their ambivalent feelings towards a second child, yet multiparas may be particularly concerned for the second baby's health and normalcy. The sex of the second child may become a greater issue tflua second time around if this is the couple's last pregnancy or if their first child was not the sex they had wanted. And parents may be concerned that they will be unable to offer the second baby the undivided time and attention that they offered their first child. Finally, parents may wonder if they and their spouse will be able to love their second child as much as their first. 3O Concern regarding the childbirth process With anticipation of the new baby's arrival may come concerns regarding the childbirth process, or actual labor and delivery, and postpartum hospitalization. Both mothers (Glazerqiil980; Rubin, 1976) and fathers (Hott, 1976; Marquart, 1976) may worry about possible injury to the mother during childbirth. In fact, Westbrook (1978) found that there tended to be greater mutilation anxiety with increasing parity. The couple's experience during their first labor and delivery can either increase or decrease their fears of the second birth process. As Norr, Block, Charles and Meyering (1980) discovered in their study on parity and birth experiences, multiparas tended to worry more about what childbirth would be like than did primiparas. As these authors concluded, "multiparas, with at least one birth experience behind them, cannot so easily ignore any fears they have" (p. 31). Regarding an upcoming childbirth, mothers may wonder if they will be able to stay in control (Lipkin, 1978). Fathers may also be concerned with maintaining control during labor if this has been a mutual goal the couple has set for their labor and delivery experience. Parents may also be concerned about the controls put on them by the hospital environment. In their study of primiparas and multiparas, Pridham and Schutz (1983) found that mothers wanted greater involvement of both fathers and older ssiblings during the delivery and postpartum hospitalization 31 period than was made available to them. Besides the expectations for themselves that parents may share, they are also likely to have certain expect- ations for the doctors and nurses caring for them. Parents may'kxe concerned that they will receive quality physical care and sensitive emotional support from their doctors and nurses (Glazer, 1980; Larsen, 1966). Support by the father is especially important to the laboring mother (Larsen, 1966; Valentine, 1982). In their study on the affect of support of the husband and obstetrician in pain perception and control in childbirth, Block and Block (1975) found that practical help by the husband increases the mother's ability to utilize tools effectively and control pain. And yet, Norr, Block, Charles and Meyering (1980) found that even though multiparas worried more about the birth process, they prepared for it less and received less support from their spouses during labor. In summary, both mothers and fathers may worry about the safe process of the mother through the childbirth process. Multiparas may actually have greater concerns than primiparas regarding the delivery and yet multiparas may be receiving less support from their husbands. In addition, parents may wonder about the quality of care they will receive from their doctors and nurses while liospitalized. 32 Concern regarding finances/household In addition to the above concerns are those related to the economic reality of adding another member to the family. The family's financial situation is likely to be challenged by the addition of another household member (Dyer, 1963; Moore, 1978; Obrzut, 1976). Career changes may be made to accommodate the addition of a second child (Dyer, 1963; Le Master, 1957). Mothers may choose to quit their jobs or decrease their work hours. Mothers who continue to work full time or part time after their pregnancy leave expires will be faced with the task of .arranging and paying for child care for two children instead of one. All these career and financial changes may be occurring at a time when family expenses are increasing due to added health care costs and the need for more clothes, food, and furniture (Clark & Affonso, 1976; Light & Fenster, 1974; Lipkin, 1978). With these potential changes in mind, it is no wonder that parents may be concerned that they will be able to buy what each of them wants and needs and also what their children will want and need (Glazer, 1980). Along vfiAfli additional financial pressures will come additional demands for physical space. Living quarters or sleeping arrangements may need to be changed in order to .accommodate the fourth family member (Jiminez, Jones & (Jungman, 1979; Lipkin, 1978; Moore, 1978). The house that 33 seemed to adapt easily with the addition of the first child may suddenly seem cramped when a fourth family member moved in to share the finite space available. Managing the daily upkeep (ME the household along with additional child care demands may be a concern for both parents, but especially for the expectant mother (Glazer, 1980; Leifer, 1977). The economy of the United States has undergone a variety of changes over the past decades. For the previous generation, it was the mother's job and duty to bear children euui stay home to raise them. Fathers were the main breadwinners. 'Poday's prospective parents have to consider balancing career and maternity leaves with day care, or the professional and financial drawbacks of having children in the first place. Working parents living in New York City can expect to spend as high as twenty-seven thousand dollars for their child during the first year (Lee & Siegel, 1986). With this in mind, the potential economic implications of having a second child on the family's household and budget cannot be overlooked. In summary, the added cost of having and raising a second child, along with the added demand for space, may be a concern to both parents, although general upkeep of the household and family may be a greater concern for mothers. A family's financial income and household space do not necessarily expand proportionately as the family grows. From these areas of concerns related to self, spouse, 'the marital relationship, first-born child, expected baby, 34 childbirth, and household/finances, it appears that not only first-time parents, but also those experiencing a second pregnancy, may perceive many concerns related to their upcoming developmental stage of parenthood. As indicated in previous studies, multiparas may have more or different concerns than primiparas (Glazer, 1980; Gruis, 1977; Larsen, 1966; Light & Fenster, 1974; Moss, 1981; Stark.£i Carrico, 1983; Westbrook, 1978). A previous experience with pregnancy, labor and delivery or a demanding newborn can actually increase the nmltipara's anxiety regarding the upcoming birth process (Brown, 1979; Tolchin & Egan, 1978; Winokur & Werboff, 1956). Therefore: multiparas could potentially experience more emotional problems and feel more vulnerable during their pregnancies and postpartum adjustment periods than primiparas (Cohen, 1966; Grubbs, 1980; Jarrahi-Zadeh, Kane, Van DeCastle, Lochenbruch & Ewing, 1969; Knox & Wilson, 1978). Although more has been learned about the concerns of multiparous women, little attention has been given to the study of fathers expecting their second child. Considering the paucity of information in the literature on the concerns of second-time fathers, it appears that the attitude that just because it's their second time around, "they know the ropes” may exist for second-time fathers as well as mothers. Rubin (1970) states that "pregnancy is a period of preparation for giving up rights and privileges in the 35 prevailing sets or relationships to accommodate another new set of relationships in the realignment of the family group" (p. 506). As seen by this description of pregnancy, a second pregnancy may actually require more, or at least different, preparation and accommodation on the part of the family group as they move from triad to tetrad. Since the family is a system with numerous roles and functions, any change in the structure (addition of a second child) will require change in other aspects of the system (mother, father, first-born child) as the system (family) attempts to regain balance (Kandzari & Howard with Rock, 1981). "The integration of the second child can thus be seen.aus a long chain of intrafamilial interaction sequences in which shifts and changes between and among all family members occur" (Kreppner, Paulsen & Schuetze, 1982, p. 376). The attention and support a couple receives during the prenatal period can influence their ability to adapt to their new life situation (Benson, 1978). If it is accepted that the addition of a new child to the family is a stressful period in their lives, then it is also a time when preventive interventions of the part of all health care professionals, particularly nurses, are likely to be accepted (Donner, 1972). ”Promoting parental bonding begins prenatally“ (Jenkins & Westhus, 1981, p, 115). In order to promote parental bonding, the perceived concerns of parents must be understood. Knowing that reactions 36 during pregnancy may be indicative of future parenting behavior (Leifer, 1977) and warn of the risk of postpartum depression (Petrick, 1984), the prenatal period is a likely starting pmflxn: for anticipatory guidance and therapeutic interventions. Conceptual Framework The conceptual framework of Imogene King can guide the interactions of nurses providing health care for parents expecting their second child and was chosen to give direction to this study. King is a nursing theorist, educator, practitioner and author who has organized a conceptual framework for nursing practice based on the concepts of man, social systems, perceptions, interpersonal relationships, and health (George, 1980). From her studies, King has also developed a model to represent the interpersonal redations that occur between the nurse and her clients (King, 1981). The following section will further describe King's framework and model and their significance to the interactions between nurses and second- time expectant parents. Nursing is defined by King as "a process of action, reaction and interaction whereby nurse and client share information about their perceptions in the nursing situation" (1981, p. 2). Therefore, nursing is understood to be a process of human interaction leading to goal attainment with a client. King's framework is based on the 37 five concepts of man, social systems, perceptions, interpersonal relationships and health, with man being the central focus of the framework (George, 1980). Kimm; (1981) defines health as "dynamic life experi- ences of a human being which implies continuous adjustment to stressors in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living" (p. 5). As the largest group of healifli professionals in the United States, nurses can assist individuals and communities in coping with changes in their health and also play a part in discovering new knowledge about human transactions with the environment which can help maintain healthy individuals and commun- ities. The goal of nursing is to help individuals and groups attain, maintain, and restore health. King's frame- work indicates that human beings are the focus for nursing. Perception is defined by King (1981) as "a process of organizing, interpreting and transforming information from sense data and memory ... a process of human transactions with environment" (p. 24). Perception is one's image of reality which gives meaning to life experiences and in- fluences an individual's behavior. Therefore, nurses must have a knowledge of perception in order ”to assess, inter- pret and plan for a client's identification and achievement of goals that maintain health" (King, 1981, p. 24). Human beings are understood to be reacting beings. "An individual's perceptions of self, of body image, of 38 time and space, influence the way he or she responds to persons, objects and events in his or her life" (King, 1981, p. 19). Therefore, man actively processes information from the environment, constantly relating past experiences to present events. Man is viewed by King as a social, time-oriented being. Through human interactions, man reacts to persons, events and objects through his/her own set of expectations, needs and perceptions. Man's prediction for the future is based on past experiences along with an awareness of the present. How a man perceives, judges, acts and reacts to a situation will determine the transactions he makes in that situation. Therefore, as King (1981) summarizes, "if behavior is an outcome of perceptions, then human perceptions become the basic data of human interactions and the facts that nurses must gather and analyze if they are to deliver effective nursing care" (p. 47). Through her model for a process of human interaction (Figure 1), King demonstrates how the perceptions and judgments of individuals are involved in every type of interaction. ZEach person involved in human interactions with another brings to that situation his/her perceptions derived from previous life experiences. Based on these perceptions, judgments are formed of the present situation. .A value is pflaced on the situation. Action then follows iwhich ”may be verbal or nonverbal and will involve a sequence of behaviors related to recognition of and efforts 39 to control conditions and events" (George, 1980, p. 190). Reaction involves each person then indicating their perceptions and actions to the other. In King's model for human interaction, the steps of perception, judgment, action and reaction are behaviors that cannot be directly observed but rather only references can be made-about them. Feedback Perception Client Judgment ( . I Action \ Reaction -—-u¥ Interaction —>- Transaction Action Y Nurse Judgment Perception 1 Feedback Figure 1. A process for human interaction (King, 1981). Interaction which follows the step of reaction can be directly observed. At the step of interaction, goals are mutually identified by the two parties in the process. As these individuals develop the means to achieve their mutual goals, they move closer to the step of transaction, where 40 mutually defined goals are actively attained. Feedback of the process tfluui occurs back to each individual, adding further to their pool of perception. The above process of human interaction is utilized by nurses as they work within various personal, interpersonal and social systems. King defines social system as "an organized boundary system of social roles, behaviors and practices developed to maintain values and the mechanisms t1) regulate the practices and rules" (1981, p. 115). Nurses must be able to interact with individuals in a variety of systems such as family systems and health care systems. the be able to interact effectively in these systems, King states that nurses must possess knowledge about the concepts of organization, authority, power, status and decision making. King's framework and model for human interaction can be very helpful to nurses caring for expectant parents. In King's framework, man is understood to be a reacting, time- oriented social being. Based on King's theory, expectant parents can be viewed as reacting beings who are aware of the second pregnancy and how this event relates to the people around them, particularly their spouse and first- born child. This awareness, in turn, leads to certain perceptions, expectations and needs. As time-oriented beings, the expectant parents may recall past events (birth of first-born child) to influence present circumstances (second pregnancy and expected birth of second child) to 41 plan frur future goals (the acceptance and integration of the second child into the family unit). As social beings, the expectant parents will be exchanging with persons in their environment (spouse, first-born child, health care providers) and can interact with others and thus communi- cate their thoughts, feelings and perceptions (King, 1981). A family unit can also be viewed as a small group or social system. There are values and norms that guide members of a family unit. Each member has a certain role (father, mother, spouse, child, sibling). Each role is accompanied by the status and authority awarded it, or the behavior expected of it, which affects the interpersonal relationships or interactions within the family unit (King, 1981). Each member of the family unit has certain perceptions of the pregnancy and how the addition of the second child may affect them or other members of the family unit. Each family member's perceptions are their interpretations of what goes on in their environment. The nurse working with the family also has certain perceptions of the family and the effects of a second child on that family unit. Optimally, the nurse will base her actions on perceptions which are similar to those of the family. At the very least, the perceptions of the nurse should not be in direct conflict with those of the family (George, 1980). The nurse who misinterprets the perceptions of the family will not be able to address concerns or help to develop goals 42 which are mutually satisfying for that family. King describes health as being a dynamic process. To maintain health, one must respond to stressors in the environment and utilize resources to adapt successfully so that one's maximum potential for living can be met. Since pregnancy and the childbearing period is a time of stress for the expectant parents and their first-born child, the nurse must be able to help the family to adapt to this challenging period in order to maintain the maximum potential level of health of the family unit (King, 1981). King's concept of human interaction or interpersonal relationships is based on the six phases of perception, judgment, action, reaction, interaction and transaction (King, 1981). When a family member interacts with another member of the family unit or with the nurse, each brings certain perception to that interaction on which judgments are made. Either verbal or nonverbal actions follow. The nurse cn: family member then reacts to indicate their perception and action to the other. The interaction that follows includes not just the exchange of ideas and feelings lmxt also one person doing something for another (George, 1980). Transaction then occurs when family members, or a family member, and the nurse are actively working at attaining their common goal. When the nurse is working with expectant parents, her efforts may be directed by utilizing King's process of action-reaction-interaction- transaction to promote the health of the family as it 43 adapts to the birth of the second child. Figure 2 is a diagram of how King's framework and model relate to this study. By means of a self- administered questionnaire developed for this study, the investigator studied the perceived childbearing, Childrearing, and marital concerns of fathers and mothers expecting their second child. Concerns studied were based (Hi the investigator's personal clinical experiences and also cui.a review of past and current literature. Childbeaidiuy, Childrearing and marital concerns were investigated as they related to the seven sub-concept areas of self, spouse, marital relationship, firstborn child, expected baby, childbirth experience, and househohd and finances. Extraneous variables (sociodemographic, modifying, and action), implicated in the literature as possibly influencing concerns perceived by expectant parents, are represented in the model. Sociodemographic variables (age, education, income, ethic background, religion, employment) along with various modifying variables (age and sex of firstborn child, previous pregnancy, labor and birth experiences) have been implicated in the literature as factors which could effect the concerns perceived by expectant parents. Therefore, information on these socio- demographic and modifying variables was also collected. In Figure 2, the influence of these sociodemographic and. modifying variables, relating to previous life experiences Mother Sociodemographic Variables - Age 0 Ethnicity - Income Education Employment Religion Modifying Variables - Age of Firstborn - Sex of Firstborn - Planning of Pregnancies - Feelings regarding First childbirth experience - Complications with First childbirth Father Sociodemographic Variables ° Age ' Ethnicity - Income - Education ° Employment - Religion Modifying Variables - Age of Firstborn ' Sex of Firstborn - Planning of Pregnancies - Feelings regarding First childbirth experience Complications with First childbirth Figure 2. 44 Perception Concerns related to childbearing, childrearing and marriage during second pregnancy - Self - Firstborn - Spouse - Baby - Marital relationship - Childbirth - Household/Finances Judgments Evaluation of present Options based on i perceptions of life experience Action Variables related to controlling conditions - Attendance at childbirth preparation classes - Amount of preparation during second pregnancy as compared to First ‘° Spouse attendance at labor and birth ° Support resources for discussion of concerns ° Feeding methods chosen ° Employment intentions I> Reaction l Action Variables related to controlling conditions ' Attendance at childbirth preparation classes ° Amount of preparation during second pregnancy as compared to First ° Spouse attendance at labor and birth - Support resources for discussion of concerns ° Feeding methods chosen - Employment intentions Judgments Evaluations of present Options based on t perceptions of life experiences —-> I Perception Concerns related to childbearing, childrearing and marriage during second pregnancy - Self ' Firstborn - Spouse . Baby - Marital relationship - Childbirth - Household/Finances Application of King's Theory to the Study Concepts () ’f’ 'f) I Ir, (‘1 (I) In ‘a 45 on the parents' perceptions of current life events is demonstrated. Concerns relating to self, Spouse, marital relationship, firstborn, expected baby, childbirth and household and finances during the second pregnancy are naturally influenced by sociodemographic and modifying variables from previous life experiences. Evaluative processes occuring during the judgment phase were not specifically addressed in this study. But judgments made by expectant parents are influenced by their perceptions of the second pregnancy and will, in turn, influence their mental and physical actions. These actions taken by expectant parents to control their present situation were also investigated. These actions included such areas as preparation for chihflflxth, plans for attendance of father at the labor and delivery, choice of feeding for the new baby, use of support resources, and intentions for employment after the baby's birth. Following King's framework, actions of the expectant Eaarents would then influence their reactions, regarding the Second pregnancy, to their spouse. Since it was not the lilatent of the investigator, nor the purpose of this study, 1=<> study the reactions, interactions and transactions which Occur between mothers and fathers expecting their second (leild, the model for this study (Figure 2) stops after the aCtion phase. A more complete demonstration of how King's framework and model for interaction would relate more fully t1) nurses involved with fathers and mothers expecting their 46 second child is contained in Figure 3. A brief overview of King's nuxhel, as adapted for nurses caring for expectant parents, will be described below. A fuller description of King's model will follow in Chapter six. Based on previous life experiences, fathers and mothers expecting their second child perceive various concerns during a second pregnancy. Based on their previous clinical experiences, nurses caring for expectant parents also perceive various concerns which these parents may experience during a second pregnancy. Based on their perceptions, the expectant parents and their nurse will have certain judgments or evaluations of the meaning of these concerns as related to the second pregnancy. Certain physical or mental actions may be taken by the expectant parents or their nurse to control certain events related to that second pregnancy. In the clinical setting, the nurse will be able to react to the perceptions of the expectant parents and they in turn will be able to react to her perceptions. Communication will optimally lead to an interactive process where nurse, father, and mother will be able to identify mutual goals during a second pregnancy and also the interventions needed to achieve these goals. During transaction, mutually identified goals are attained. A feedback system is present in the model indicating that even after transaction, new perceptions may evolve based on further life experiences promoting continuing communication to mutually modify goals as needed. 0! h% .Afimmq .mc_xv u_rgu ucoumm L_m;u m=_uomaxm mucmgma ecu omen: cmozuwn cowuuucmucw co mmmuoga as“ ou .muoe m.mcmx co cc_uauaau< vomoqoga .m mg=m_u xuanuumm aucmcmuta new m=_g=u “Foam co acmec_auu< =o_uuamcmth m:o_uamuumg co woman housemate ucw mo covuua—o>u . moucacwuxvpozmmaoz. £2525. 3:39:29. .322. anon. acogaa mo museums cronamtpu. gauges acuuumaxm. mucosa; acuuuoqxo so «cguucou pauvgoa ecu u=_googv—_=u .mc—gooau—vgu aucucmmga vcm mcwcan m_oom mo acoEm>oacum so» m:o_u Aucocmota new a ucm>gmuc— ecu m_oom mo mco_uaougoa nu 23330.3; lull 3.52 2233er .3 33.. 3:83.:— u=~ mo gazes—gm ‘ $ «cosouvaa aucocmuga new m=.g:v mucosa ~ouucou cu mgoa>usoa pauvmaga can —ou=u: copuu .1! 8:553 5253. rtfio 05 8 All covuomgmucn :owuummz xucacmmga ecu m:_t=u muco>o —otucou cu atov>ogmn pau_m>ga can _~u=o= co.uu< o. ucoamuaa moucacvmxvposomsoz. .3322? 35.5322 .32»... .xaam. «macaw. CLODHmmeo h—OWu metmucou .aupgos can m=_guogv—.=u .m=.guoavp_=u mcoquougmu n.5usuou . xuanvomu aucucmoga new a:_g=u «new,» pogucou o» «Lov>u:oa pau_mnza can Fauna: ‘ . v .333 I‘ll 33309.2. .3 325 3:33.... EN .3 332.36 .. .A-zl. : input. mummmmmm moucucvmxupozomaoz. 5.22:8. 358328 .322... i Anna. . omaoam. . 4 cgoaumtvu. upon. . «caoocou pou.cus ecu m=.gaogu_—nu .a=_g~onu.¢=u mucosa; ‘ul l' 232082 «.553. A! 23896 L 48 In utilizing King's theory when working with expectant pareunns during a second pregnancy, the nurse will be challenged to identify concerns of both the mother and the father which are similar, or not, to each other's and to her (Nfll. The nurse will be reacting to the perceptions, judgments and actions of each parent as an individual, but also to both parents as a couple. With King's framework as guide, the nurse should be able to maintain a relationship with expectant parents which allows for reactions and interactions to occur leading to the attainment of individual and family goals which are able to be modified as needed based on feedback. The closer the perceptions of the nurse to those of parents expecting their second child, the more likely that mutual goals will be identified and attained. If the nurse's perceptions are in conflict with those of the parents, then mutual goals will not be identified or met. For example, if the expectant mother only wants to gain 18 pounds during her second pregnancy, the father feels 40 pounds will assure a healthy baby and the nurse perceives 25-30 pounds as a safe weight gain, then this nurse will have difficulty in attaining a mutually set goal with this family unless perceptions of the mother, father and nurse are modified. Through King's process of feedback and further action, reaction and transaction, the nurse and expectant parents may be able to identify a goal for weight gain which is mutually satisfying. 49 Application For Nursing Since iflua perceived concerns of both the mother and father who are expecting their second child have not been ginmnu adequate attention by the health care system, this study proposed to identify these concerns. Since knowledge of time client's perceptions is necessary for mutual goal setting (King, 1981) and appropriate interventions by nurses, then this study should expand the knowledge base of the nursing profession and assist nurses in their care of parents expecting a second child. As Kunst—Wilson and Cronenwett (1981) suggest, "interventions aimed at establishing healthy early family relationships can be the unique contribution of nursing as distinguished from the focus of medicine [i.e., the delivery of a physically healthy mother and infant]" (p. 208). Therefore, expanding the nurse's knowledge regarding tine concerns of parents expecting their second child can increase the effectiveness of the nurse's anticipatory guidance with these parents and establish the nursing profession's unique contribution to this aspect of the health care of families. Nurses and other health care professionals caring for families during their childbearing years can be a tremendous resource and can assist families in identifying and utilizing further internal and external resources. A starting point in promoting the health of parents expecting their second child is to identify and acknowledge their SO perceived concerns. King's (1981) process of human interaction demonstrates how individuals mutually identify goals and the means to achieve them. The culmination of positive interactions will be the attainment of goals or what King refers to as transaction. The process of transaction can only be achieved after the perceptions, judgments and actions of each person have been clearly exchanged through the pmocesses of reaction and interaction. Therefore, health care professionals interacting with parents expecting their second child must first understand the concerns perceived by these parents in order in) effectively work with them in promoting and maintaining their family's health. King's conceptual framework for nursing interaction can supply the framework needed to direct the care of nurses interacting with parents during their childbearing years. Included in chapter three will be a review of the literature pertaining to concerns identified by parents during the childbearing period. CHAPTER III REVIEW OF THE LITERATURE Introduction In this chapter a discussion of research studies relevant to concerns of expectant parents will be discussed. The literature review will be presented in reference t1) the seven sub-concept areas of concerns related to self, spouse, the marital relationship, the first-born child, the expected baby, the upcoming childbirth experience, and the household and finances. Major research findings relative to the concepts under investigation will be presented as well as strengths and weaknesses of the studies examined. Although the time focus for this study is the prenatal period, literature pertaining to both the prenatal and postnatal periods will be reviewed to insure a complete overview of all possible parental concerns since some concerns may be present in both periods. Since there has been less research done on parents expecting their second child, particularly fathers, literature relevant.ix>'both primiparous and multiparous mothers and fathers will be presented. Concerns Related to Self LeMaster (1957) was the first researcher to conclude that the addition of the first child constituted a crisis event. His conclusion was based on a retrospective, 51 52 exploratory study (ME 46 couples who had delivered their first child within five years of the date interviewed. LeMaster utilized Hill's (1949) definition for crisis, *which is "any sharp or decisive change for which old patterns are inadequate" (p. 51). The couples were all middle-class, married and between the ages of 25 and 35. In addition, the wife was not employed outside the home after the first child's birth and the husband was a college graduate. Both husband and wife were interviewed together by LeMasterq ‘A five-point Idkert scale was utilized in coding the interview data. Crisis scores were arrived at by agreement between LeMaster and the couple interviewed. The hypotheses tested were that, (a) the addition of a new member to a family system would force a reorganization, and that (b) if the previous hypothesis is true, that the arrival of the first child could be construed as a crisis or critical event. LeMaster concluded that the hypotheses were supported since 38 of the 46 couples (83 percent) reported extensive or severe crisis in adjusting to their first child and the remaining eight couples (17 percent) reported relatively mild crisis. Thirty-four of the 38 couples in the crisis group (89 percent) rated their marriages as good or better, and 35 of the 38 pregnancies in the crisis group were planned. This data supported the belief that crisis patterns occur even when the pregnancy was planned or the marriage was good. The majority of the concerns and feelings reported by mothers centered on self: 53 such as: exhaustion; curtailment of social contacts; satisfaction and income of outside employment; additional housework; being a better mother; time required in caring for an infant; decline in housekeeping standards; and worry over their appearance. Fathers' concerns echoed those of their wives but also included: decline in sexual response of wife; decreased income and economic pressures; interference with social life; worry about a second pregnancy; and disenchantment with the paternal role. LeMaster's study has several limitations. The sample of couples was non-random limiting the generalizability of the findings. Joint interviewing of couples may have altered their honest reporting of perceived changes. Frequency distribution by children's ages for crisis scores were not reported. LeMaster does not provide any information about the scale item construction utilized in interpreting the interviews. Since this was a retrospective study, the accuracy of the parents' recall of the crisis is questionable. The children's ages and developmental levels may have had an effect on the parents' recall of the extent of the crisis experienced. One very positive outcome of LeMaster's research is the question it raised that, can even the most "normal" of changes in the family be perceived as stressful. In summary, LeMaster concluded that the addition of the first child constituted a crisis event forcing reorganization of the family system. LeMaster's study has important 54 implications for the pmesent study, since the assumption that the addition of a child to a family causes reorganization can also be applied to families expecting a second child. In 1963, Dyer closely replicated LeMaster's (1937) study on the effects of the arrival of the first child upon family roles and relationships. A convenience sample of 32 couples was chosen and was very similar to LeMaster's sample except that Dyer limited the timing of the interview 'Uo within two years of the couples' first child's birth. Dyer utilized a Idkert-type crisis scale to determine the level of crisis for each couple. The reliability of the scale (r = 0.84) was tested by the split-half method, which, when corrected by the Spearman-Brown formula, gave a reliability coefficient of (r = 0.94). Face validity of the scale was supported by a jury of six young married couples having one or more small children. Dyer found that the state of the marriage and family organization prior to the first child's arrival was average or above average for a majority of the couples in his sample. The distribution of families as to crisis scores were: (a) no crisis - none: (b) slight crisis - 9 percent; (c) moderate crisis - 38 percent; (d) extensive crisis - 28 percent; and (e) severe crisis - 25 percent. By comparison, LeMaster found only 17 percent of his families in the first three categories, and the remaining 83 percent in the extensive and severe crisis categories. 55 Dyer concluded that, for his sample, the addition of the first (flmild did constitute a considerable crisis for the couple. For new nethers, the most frequent areas of concern were: (a) tiredness and exhaustion (87 percent); (b) loss of sleep (87 percent); (c) feelings of neglecting husband (67 percent); and (d) feelings of inadequacy in fulfilling the mother role (58 percent). The most frequently reported problem areas for new fathers included: (a) loss of sleep (50 percent); Ow adjusting to new responsibilities and routines (50 percent); and (c) upset daily routines (37 percent). The most severe problems reported by 87 percent of the wives were: (a) adjusting to being tied down; (b) getting accustomed to being up at all hours; (c) inability to keep up with housework; and (d) feeling of anti-climax, or letdown, after baby's birth. Eighty percent of the fathers admitted to the fellowing severe problems: (a) adjusting to one income; (b) adjusting to new demands of parenthood; (c) getting used to new routines; and (d) sharing with grandparents and other relatives. Testing by Chi-square revealed significant negative relationships (P < 0.05) between the degree of crisis and the following variables: (a) marital adjustment ratings after tflua baby's birth; (b) preparation for marriage courses taken in school; (c) length of marriage greater than three years; (d) college education of husband; (e) a planned pregnancy; and (e) first child being older than six 56 months of age. The generalizability of Dyer's study is somewhat limited by the smaller sample size being solely urban middle-class 5J1 nature. ADyer did improve on LeMaster's study by utilizing a questionnaire based on LeMaster's findings which was answered separately by both husband and wife. (Doing so, Dyer was able to collect individual perceptions of the husband and wife which were less likely to be influenced by either the interviewer or the presence of the spouse. In summary, Dyer's findings were similar to those of LeMaster's supporting the hypothesis that the addition of the first child does create changes which can be interpreted as a crisis experience. Dyer's findings have implications for the present study, since it may be assumed that the addition of a second child to the family may also create changes which may be interpreted as being stressful. Hobbs (1965) carried out a retrospective study of first-time parents in an attempt to learn if earlier findings by LeMaster (1957) and Dyer (1963) with middle- class subjects would generalize to a probability sample of first-time parents' adjustment to perenthood. A random sample of 53 white, urban, first-time parents was drawn from public birth records. A 23 item checklist was administered to the couples whose first child had been born within the previous 3 to 18 weeks. Crisis scores of fathers and mothers were separately analyzed. Over 90 57 percent of the subjects of both mothers and fathers rated their marriages as being happy and satisfying prior to their first child's birth. By examining the percentage of fathers who indicated that a given item bothered them either "somewhat" or "very much", Hobbs found that 75 percent of fathers were bothered by interruption of routine habits such as sleeping and going places, and 60 percent of the fathers were bothered by increased money problems. In comparison, 74 percent of mothers were bothered by interruption of routine habits, 68 percent were bothered by fatigue, 66 percent were bothered by increased money problems, and 60 percent were bothered by feeling emotionally upset. Discrimination index values for items ranged from 0.20 to 1.00, with a mean value of 0.48 for fathers and 0.55 for mothers. A split-half reliability coefficient of r'== 0.62 was obtained for each sex. The ten most discriminating items for fathers were: increased money problems; feeling emotionally upset; additional amount of work; physical fatigue; having to change plans made before baby's birth; interruption of routine habits; housekeeping not as neat as it should be; decreased contact with friends; and decreased sexual responsiveness of wife. In contrast, the ten most discriminating items for mothers were: interference from in-laws; decreased sexual responsiveness of self; physical fatigue; feeling emotionally upset; decreased contact with 58 persons an:‘work; worry about loss of figure; worry about personal appearance in general; interruption of routine habits; housekeeping not as neat as it should be; and doubting one's worth as a parent. Review of tine percentage distribution of couples by crisis category reveals that 86.8 percent of the sample in Hobbs' study reported only "slight" crisis, whereas in comparison, LeMaster (1957) reported 83 percent and Dyer (1963) reported 53 percent in the "extensive" and "severe" categories. Fifteen variables were investigated to search for those that could be predictive of crisis. Only four of the variables departed from chance distribution to a statistically significant degree at the P < 0.05 level. Hobbs reported the following findings for first-time parents: (a) for fathers, family income and crisis scores were negatively correlated (P < 0.01); (b) for father, infant's age and crisis scores were positively correlated (P < 0.01); (c) none of the correlation coefficients for mothers was significant. The design of Hobbs' study improved on LeMaster's (1957) and Dyer's (1963) studies through utilization of a random sample of parents and limitation of their first child's age to a period within 3 to 18 weeks. Findings of Hobbs' study diverged sharply from those of LeMaster and Dyer, both in the distribution of couples according to the degree of difficulty reported and with regard to variables 59 differentiating couples who have little difficulty with the first child from those who have greater difficulty. Furthermore, Hobbs questioned the wisdom of combining husband and wife crisis scores to get crisis scores for couples since time fathers and mothers in his sample differed significantly on the crisis variable, their crisis scores were not correlated and they differed on individual items. Hobbs study is limited by the small sample size and failure to address the reliability of the instrument used. In summary, Hobbs found adaptation to parenthood to be only slightly to moderately difficult for new parents, and also that concern over income to be the only variable which might be used to predict difficulty with the first child. Hobbs study is relevant to the present study, since the variable of concern over income may have even greater implications for the expanding family who is expecting the second child. By studies such as Hobbs', this researcher was directed to investigate extraneous variables, such as income, which might correlate with concerns of expectant parents. One decade later, Hobbs (1976) replicated his study on 65 couples randomly chosen from the same city as in his 1965 study. bebs' sample had similar characteristics to the 53 couples studied in 1965 except that the mean age of their infant was 25.9 weeks rather than 9.8 weeks as in his initial study. The 23 item checklist was identical to the one utilized in 1965. The mean difficulty scores were 5.9 60 for fathers anui 9.7 for mothers, a difference which was significant at the P < 0.001 level. The differences between the means for fathers and mothers in 1965 as compared to 1976 were not statistically significant. As in the 1965 study, variables were sought which differentiated between parents on the amount of difficulty they reported in adjusting to the first child. Chi-square scores were computed for 14 selected variables. None of the variables studied were ihnuui to be statistically reliable for mothers. Four of the chi-square values were statistically reliable for fathers at the P < 0.05 level: health of baby; pre-birth and post-birth ratings of marriage; and the number of additional children desired. Computation of a Pearson product moment correlation coefficient between difficulty score and five variables yielded two significant results. The father's age and difficulty score correlation was r = 0.41, significant at the P < 0.01 level. The parents' income and difficulty score correlation was r = 0.27, significant at the P < 0.05 level. In the 1965 study, fathers's difficulty scores were significantly correlated with babies' ages (r = 0.59) and income (r = -0.37); none of the correlation coefficients for mothers were significant. Five of the ten most discriminating items of difficulty found for men were identical to the 1965 study. Seven out of ten items were the same for women in the two studies. The rank order of the items varied considerably 61 for the same sex samples in the two studies and between the sexes in both studies. The top three discriminating items for fathers were: increased money problems, decreased sexual responsiveness of wife, and decreased contact with friends. The top three discriminating items for mothers were: feeling emotionally upset, increased money problems, and housekeeping not as neat as it should be. The main weakness in Hobbs' restudy is the utilization of a checklist which, by the researcher's own admission, contains items which lack discriminatory power in measuring the difficulty experienced by new parents. In addition, the sample size was small and the mean age of the infants the time of the study (25.9 weeks) was greater than the mean age of the infants (9.8 weeks) at the time of Hobbs' 1965 study. Positive aspects of Hobbs' study included studying parents within a defined time span from their first child's birth and obtaining separate difficulty scores for fathers and mothers. In summary, findings of Hobbs' (1976) study confirmed his earlier research from 1965. Hobbs again found only slight to moderate levels of difficulty experienced by new parents with mothers experiencing slightly more difficulty than fathers. Again, Hobbs concluded that the period following the birth of the first child is one of transition, not crisis as previously felt by LeMaster (1957) and Dyer (1963). Hobbs finding that mothers may experience slightly more difficulty than fathers after the 62 birttl.a random sample of new parents in a large metropolitan area yielded 296 returned questionnaires from mothers and 272 returned questionnaires from fathers. The ages of the babies ranged from 6 to 56 weeks at the time of the study, the mean age being 29 weeks. Marital adjustment was measured by the Locke-Wallace short form, degree of crisis was measured by Hobbs' (1965) checklist, and positive aspects of parenting were measured by means of a gratificatixnm checklist devised by Russell and fashioned after Hobbs' crisis checklist. The 12-item checklist was limited to face validity since more highly-educated respondents tended to check fewer gratification items. The reliability of the gratification checklist as computed by the split-half method was 0.93. The mothers' mean score was 1.45 and the fathers' mean score was 1.27. The difference was found to be significant at the P < 0.001 level using a two-tailed t-test. There was also a difference in the items most frequently checked as problem areas by sex. Mothers tended to check items which clustered around the emotional and physical self, such as: worry. about personal appearance, fatigue, 63 interrupted sleep, loss of figure, and feeling emotionally upset. Fathers checked items more external to their physical or emotional self, such as: interrupted sleep and rest, suggestions from in-laws, baby increased money problems, baby's birth caused change in plans, and the additional amount of work required by baby. Although parents indicated the above items to be bothersome, evaluation of crisis scores indicated that the majority of both mothers (96.6 percent) and fathers (91.9 percent) fell in the slight to moderate level of crisis category. Of the 28 independent variables tested, eight were found to be significantly related to crisis scores for mothers, and nine variables were found to be significantly related to father's crisis scores. Chi-square was used as the test of independence with P < 0.05 as the minimum acceptable significance level. Level of crisis experienced was inversely and significantly related to the following variables for mothers: months married, planned pregnancy, conception after marriage, marital adjustment, health, ease of pregnancy, ease of delivery, and having a "quiet" baby. For fathers, level of crisis experienced was inversely and significantly related to the following variables: planned pregnancy, conception after marriage, marital adjustment, wanting more children, wife's ease of delivery, age, prestige, saliency of father role, and having a "quiet" baby. Russell's findings are hampered by the use of a new 64 gratification checklist which lacked validity since it appeared to measure sophistication more than gratification. At the same time, Russell should be commended for initiating the construction of an instrument to measure the positive aspects of parenting, not simply the negative. With further use and testing, the gratification checklist may become a valid tool for measuring new parents' positive experiences. In summary, Russell's findings are similar to Hobbs' (1965) indicating that new parents perceive the first year of parenthood as only moderately stressful and one that is also supplied with rewards. Again, mothers were found to have more difficulty than fathers after the first child's birth. Russell's findings are useful to the present study. Since Russell, like Hobbs (1965), found that mothers perceived more difficulty after the birth of a child than fathers, iJ:Jbecomes necessary to investigate and compare concerns of mothers and fathers to gather a realistic perception of parental concerns. In 1983, Curry carried out a descriptive study of normal primiparous women in order to examine which variables are related to adaptation to motherhood. A convenience sample of 20 middle—class women, drawn from the obstetrical clinic of a large university teaching hospital, was recruited. Data were collected at three intervals. During the third trimester of the pregnancy, demographic data was obtained and the Tennessee Self-Concept (TSCS) was 65 administered. {Hue TSCS has content, criterion, and construct validity along with sub—scale test-retest reliabilities ranging from 0.60 to 0.92. The second data collection occurred approximately 36 hours after delivery. While the mother was breast feeding, Curry twilized an observational checklist developed by de Chauteau to record mother and infant behaviors and maternal attachment behaviors. The final data collection took pnace three months after delivery in the mothers' homes. The de Chauteau observational checklist was used again, the mothers were interviewed and the TSCS was readministered. Content analysis of the audio taped three-month interviews was used to identify mothers who reported either easy or difficult adaptations to motherhood. The mothers self- concept scores, income and educational background were analyzed by t-test, the remainder of the selected variables were analyzed by descriptive data. Additional variables that might have influenced adaptation, such as length of labor, were analyzed by t-test and chi-square to determine if there were any significant differences between the two groups (easy or difficult adapter). Fifteen mothers were found to be easy adapters and five mothers were having difficulty adapting after their first child's birth. There were no significant differences between the two groups in age, income, educational back- ground, length of labor or in the planning of the pregnancy. Nine of the fifteen easy adapters raised their 66 total positive scores on the TSCS between the prenatal testing and post-testing (average increase of 25.44 points). Six of the easy adapters scored lower postnatally (average decrease of 12.33 points). All but one of the mothers experiencing difficulty had a decrease in her total positive score on the TSCS between the two testing periods (average decrease of 23.5 points). Of the five women who were having difficulty adjusting to parenthood, three had negative comments about the help they received from nurses in the postpartum period, and four perceived their husbands as busier and less helpful than the easy adapters. The small convenience sample and narrow generaliz- ability of the findings are obvious limitations of Curry's study. Validity and reliability of the de Chauteau checklist is not addressed. A positive aspect of Curry's study is the comparison of both prenatal and pestnatal self-concept scores by use of the TSCS. In summary, Curry found that 25 percent of the healthy, normal, primiparous women in her study experienced difficult adaptation to parenthood, which supports previous findings by LeMaster (1957) and Dyer (1963). Support from postpartum nurses and husbands along with postpartum self- concept were found to be related to adaptation in her sample. Curry's findings are relevant to the present study and reinforce the need to study concerns of, not only women experiencing a high risk pregnancy but also, those women experiencing a normal pregnancy. 67 In 1976, Fein conducted an exploratory study of 30 couples Vduo were expecting their first child in order to understand men's perinatal experiences. The middle-income couples were recruited from childbirth preparation classes :hn the Boston area. Husbands and wives were interviewed together approximately four weeks before and six weeks after the birth of their first child. Both before and after the birth, study participants completed the Rotter Incomplete Sentences Blank (projective story task designed for time study), a modification of the Truax Relationship Questionnaire, a household tasks sharing form, three self- report "feeling" forms, a sharing of feelings form, and (after the birth) a parent-infant interaction question- naire. The men and women were interviewed together but separate copies of the instruments were completed. Validity and reliability of the instruments was not addressed by Fein. Statistical analysis of the data was not described. Major findings of the study were that: ha) men decreased significantly in their level of wishes for emotional support, general anxiety and infant-related anxiety from before to after the births, but not in their concerns about emotional support; and (b) men who reported doing more infant care together with their wives and greater willingness to share infant care decreased significantly more in infant-related anxiety than other men. Fein interpreted that effective postpartum concerns 68 mentioned by fathers in pre-birth interviews included those related to: labor and delivery, parenting, the emotional support they would be able to give and receive in the weeks after tflua birth, and possible long-term changes in their marriage. Lifestyle adjustment in men was related to the development of some kind of coherent role rather than any particular role. Most of the nineteen men who appeared to adjust to postpartum life with relatively little difficulty were seen as adopting one of two roles: bread-winner or non-traditional father. The other eleven men in the study seen as having relatively more difficulty adjusting to life with their wives and babies seemed generally unsure of how much they wanted to be involved with their infants as non- traditional fathers or how much they wanted to adopt breadwinner roles. Fein's study complements the findings of Curry (1983) in one dimensitnn. Both researchers indentified the relationship between perceived emotional support of spouse and expectations of parental role by spouse as they affect adaptation after the first child's birth. Since Fein's sample was relatively homogeneous and chosen non-randomly, generalizability of the findings is limited. Failure to address the validity and reliability of the instruments used along with absence of the statis- tical analysis of the data leaves the reader unable to fully appreciate the study results. Fein's study does highlight the concerns and experiences of fathers expecting 69 their first child and generates questions for further research. In summary, Fein concluded that developing some kind of a coherent role was more important to men's adjustment to being a father than was developing any particular role. Prenatal concerns of fathers focused on the ability to give and receive emotional support, the ability to parent, and the childbirth process. Fein's research supports the inclusion of fathers in the study sample. Fishbein (1984) also studied couples expecting their first child focusing on the relationship between stress in prospective fathers auul congruence of attitudes between husbands and wives regarding the projected role of the fathers vdJfli their newborns. A nonprobability sample of 103 couples was recruited between their sixth and eighth prenatal months from parents attending hospital tours in preparation for childbirth classes. The anticipated male parenting behavior by expectant couples was measured by independent variable of Alter's Projected Paternal Behavior Scaleu, The Spielberger State Anxiety Inventory measured the dependent variable of anxiety in the father. In addition, a demographic questionnaire was administered in order to identify other variables that could affect those variables under the study. Analysis of the data supported Fishbein's major prediction at I"< 0.01: parental agreement regarding the projected paternal role was associated with lower anxiety 70 in the father. In addition, further analysis of the Projecteml Paternal Behavior Scale revealed that both increased age and combined family income were related to more agreement with one's spouse. Validity and reliability of the instruments used were not addressed by Fishbein. The non-probability sample drawn from parents enrolled in childbirth classes limits the generalizability of the findings. Fishbein further supports the findings of Fein and expands on them by adding the dimension of mothers' expectations in fathers adapting to their paternal role. In summary, Fishbein concluded that: (a) assumption of the paternal role can cause significant anxiety in the new father; and (b) similarity and consistency of attitudes and expectations between mother and father appears to be important in facilitating the socialization of the man for the new role of father. By Fishbein's study, the usefulness of studying similarities and differences in attitudes of fathers and mothers, as in the present study, is supported. Hangsleben (1983) also found the early days of fathering to be stressful and disruptive for new fathers. Hangsleben's exploratory study focused on transition to fatherhood for 50 first-time fathers. The subjects were given a series of questionnaires to complete within three weeks of their baby's expected birth and within three to five weeks after their baby's birth. Inventories 71 administered prenatally measured marital adjustment, depression, activities with own father, and activities with own child. Minus tine marital adjustment inventory, the above inventories were repeated postnatally along with the lifestyle changes inventory. Pearson correlation coefficients were computed on all variables against all other variables. In general, Hangsleben found the correlations to be low but statistically significant at E"< 0.001. Postnatally, fathers with more signs of depression also tended to report greater lifestyle changes (r = .35), a sex preference for a baby boy (r = -.41), and an unplanned pregnancy (r = .24). Fathers who reported more lifestyle changes and greater involvement in baby care also reported more signs of depression, sunfii as irritability, fatigability and sleep disturbance, although new fathers reported doing fewer baby care activities than they had projected prenatally. Considerixm; 52.8 percent of the subjects gave their religious affiliation as Church of Jesus Christ of Latter- Day Saints, generalizability of the findings from the non- random sample is further impaired. Reliability for the multiple inventories used was not established. Hangsleben's study is valuable in that it focuses on the transition of men into their new paternal role by studying them during both the prenatal and postnatal periods. With further testing, the instruments employed by Hangsleben may be reliable measurement tools for future researCh. In 72 summary, Hangsleben found that transition to fatherhood is complex with many variables such as nerital adjustment, baby care activities, and depression impacting on the experience. Glazer (1980) and Stark and Carrico (1983) studied the concerns of primigravidas and multiparas during the prenatal 1meriod. These authors found no significant difference in the amount of concerns expressed by primigravidas as compared to multiparas. Glazer (1980) randomly selected 100 pregnant women from private physicians' offices and the outpatient prenatal clinic of a private university-affiliated hospital. The sample subjects ranged from one to nine months pregnant. Along with completion of a demographic informatitnl sheet, the subjects completed the Taylor Manifest Anxiety Scale (test-retest reliability > .80) and a 62-item concerns questionnaire adapted for the study. The number of expressed concerns showed a statistically significant correlation with anxiety level (r = 0.5678; P < .001), with clinic patients having significantly higher anxiety levels than private patients. The greatest number of concerns were expressed by women 1J1 their third trimester of pregnancy. Major con- cerns expressed were those related to the baby, childbirth, and self. Personal appearance was a major concern for 91 percent of the women. Glazer did not compare the primigravidas in her sample 73 to the multiparas as to differences or similarities in the types of concerns expressed. Reliability for the 62-item concerns questionnaire was not indicated. Glazer was one of the first investigators to study the level of anxiety in relation in) concerns expressed by both primigravidas and multiparas during pregnancy. In summary, Glazer found the greatest number of concerns expressed in the third trimester of pregnancy and a positive correlation between number of expressed concerns and anxiety level. Glazer's finding that the third trimester of pregnancy may be the most critical time period for cmwaining concerns of expectant mothers is useful in directing the time frame for collection of data in the present study. Stark and Carrico (1983) utilized a convenience sample of 40 rm11tiparas and 28 primigravidas in their third trimester of pregnancy and enrolled in childbirth preparation classes in two cities. Multiparas completed an instrument developed by Humenick and Bugen to measure a woman's perception of control during labor and delivery. Inter-item reliabilities for the sub-scales resulted in Cronbach's Alpha's :> 0.83. Both primigravidas and multiparas completed a questionnaire to obtain demographic data. Primigravidas also completed a 40-item concerns questionnaire while multiparas completed a 50-item concerns questionnaire. Items on the two questionnaires were matched excluding the ten additional items on the multiparas' questionnaire related to siblings and past 74 childbirth experiences not applicable to prhmunavidas. Test-retest reliability for the sub-scales on the concerns questionnaire was > 0.83. Items on the concerns questionnaire were ranked by the percentage of women who indicated they more frequently had that concern. Regaining their pre-pregnancy weight was a frequent concern for 45 percent of the multiparas and 53.6 percent of the primigravidas. While primigravidas indicated more frequent concerns about adjustments in lifestyle and complications in childbirth, multiparas were more frequently concerned with the adjustment and preparatjtni of their children. Analysis of total scores for time Humenick and Bugen labor and delivery scales indicated that multiparas whose previous labors were less than eight hours had a significantly greater sense of control when remembering their previous labor and were more likely in) positively anticipate their upcoming labor and delivery experience. Since a significant difference was found in the income levels of time subjects taken from the two different locales, and since all subjects were enrolled in child- birth classes, the convenience sample has obvious biases. Nonetheless, Stark and Carrico concluded that, although primigravidas and multiparas may differ in the types of concerns experienced during pregnancy, concerns of multiparas are not significantly less than those of primigravidas during the third trimester of pregnancy. The 75 findings of Stark and Carrico support the need for further investigation of concerns of multiparous women during pregnancy. Larsen (1966) explored stresses experienced by primi- gravidas and multiparas during the childbearing years. The retrospective study included 33 women with one child and 40 women with two children who had all attended childbirth preparation classes. Participants responded to open-ended questions directed at problems experienced as stressful during pregnancyy labor and delivery, and the postpartum period. Fatigue was stressful to 32 percent of the women pregnant with their second child as compared to 18 percent of the primigravidas. Primigravidas (67 percent) experienced greater stress from physical discomforts during pregnancy than women expecting their second child (33 percent). Multiparas recalled being more irritable, fatigued, and depressed than primiparas. The non-probability sample limits generalizability of the findings. The sample was also biased since only mothers sun) had attended prenatal classes were included. Larsen's findings are reflected by Glazer (1980) and Stark and Carritx> (1983): Concerns of multiparas are not significantly less than primiparas, but may be different. In summary, Larsen found that concerns related to the mother herself apparently increase math each successive pregnancy. Light and Fenster (1974) found the opposite to be true 76 and concluded that primiparas have more concerns than multiparas. Light and Fenster's 60-item concerns question- naire was administered to 202 randomly selected women while hospitalized during the postpartum period. The 93 primi- paras auui 109 multiparas responded yes (did worry) or no (did not worry) to items related to the ten categories of concern chosen for investigation. Nine items of concerns were significantly higher for primiparas than multiparas. Concerns of multiparas differed. The two concerns of multiparas with the highest statistical differences ( P < 0.001; x2 = 41.591; df=1) were: (a) the multipara being able to care for her family, and (b) the type of contra- ceptive the multipara would use after the baby was born. The title "Maternal concerns during pregnancy" used by Light and Fenster for their article is somewhat deceptive since time women in their study complete the concerns questionnaire during the postpartum period and not while pregnant” The validity and reliability of the study and questionnaire used are not addressed by the authors. The large sample size and inclusion of both pmindparas and multiparas does result in findings that incite further research in the area of maternal concerns. In summary, Light and Fenster found primiparas to have more concerns than multiparas during the postpartum period, specifically in the areas concerning childbirth and caring for a new baby. The findings of Light and Fenster are useful in directing further investigation of multiparous women's concerns 0 77 Both Gruis (1977) and Strang and Sullivan (1985) found concerns regarding return of the recently pregnant figure to normal important to both primiparas and multiparas. Strang and Sullivan questioned whether "concern with return of figure to normal" meant the same as "poor body image". Gruis (1977) sent a questionnaire to a non-random sample of women one month after their delivery. Forty mothers (17 primiparas and 23 multiparas) returned the questionnaire. Return of their figures to normal was a major concern for 95 percent of the women. This was followed closely by regulating demands of husband, housework and children, emotional tension, and fatigue. The primiparas' concerns focused on the newborn (infant behavior and feeding), while the multiparas' concerns focused on the strain felt by the entire family. Regulat- ing family demands and finding time for self shared second place as concerns expressed by 21 of the 23 multiparas. The small sample size of primiparas and multiparas in Gruis' study reduce generalizability of the findings. Bias is introduced since all participants were under the care of obstetricians in private practice and were also recruited non-randomly. By her study, however, Gruis does help support the need for more research into the concerns of both primiparas and multiparas during pregnancy and the postpartum period. In summary, Gruis found return of their figure to normal to be a major concern for both primiparas and multiparas in the postpartum period. The inclusion of 78 the concern regarding return of figure to normal was relevant to the present study. Strang and Sullivan (1985) studied body image attitudes during pregnancy and the early postpartum period from a non-random sample of 30 primiparas and 33 multi- paras. A repeated time measure design was used, with data collected at two and six weeks postpartum. Pregnant and pre-pregnant attitudes were collected retrospectively. The ten-item Attitude to Body Image Scale was adopted from Jourard's Body Cathexis Scale and content validity and reliability (Spearman r = 0.71 and 0.89) were determined. Participants indicated their attitude toward their bodies by rating each of the ten body parts on seven point Likert- type scale. The majority of subjects (71.4 percent) in the study had a slightly positive attitude toward their bodies in the postpartum period. A significant difference (P < 0.03) was found in attitude toward body image between primiparas and multiparas with multiparas indicating a more positive attitude toward their body image then did primiparas. The non-probability sample limits generalizability of the findings. One has to question the method of obtaining pre-pregnant and pregnant body image attitude scores retrospectively during the postpartum period. Strang and Sullivan successfully question Gruis' (1977) interpretation that "concern for return of figure to normal” be equated Vfilfll a negative body image attitude. In summary, Strang 79 and Sullivan found women felt were positive about their postpartum body image than their pregnant body image with multiparas feeling more positive about their postpartmm body image tflmui primiparas. By their study, Strang and Sullivan encourage this researcher to include concerns related to body image in the present study. Studies done by Knox and Wilson (1978) and Moss (1981) focus on changes and concerns perceived by multiparas after their second child was born. The authors of both studies indicate that having two children brings its own set of unique concerns and problems. Knox and Wilson (1978) utilized a 49-item question- naire in) measure the motivation for and complications of having a second child. The questionnaire was given to a non-random sample of 144 mothers who had two children, the second child being less than five years old. Although the mothers reported their first child had a greater personal effect on them than the second; 76.6 percent of the mothers reported having less time for themselves after the second child was born. In addition, 75.7 percent of the mothers reported an increase in noise and fewer than 4 percent reported that "two are as easy as one". Even in light of the above, most of the mothers (93.1 percent) said that they never wished that they could return to a one-child family. Both validity and reliability of the questionnaire used in the study were not addressed by the authors. The 80 non-probability sample comprised of mostly white (96.6 percent), Protestant (72.0 percent), and highly educated, middle-class (72.7 percent) subjects restricts the ability to generalize the study results. Knox and Wilson reinforce the need ix) further investigate the unique problems and concerns of families with more than one child. In summary, Knox and Wilson found that although the impact of the first child was greater than the second, the latter involved less time for self, more work, and more noise for the mother. Moss (1981) found multiparas in her study to be not so concerned about themselves or their infants as about family relationships. Moss utilized a 61-item card-sort instru- ment to elicit the concerns (interests and worries) of 56 multiparas on their third postpartum day. The mothers sorted the 61 index cards into three stacks labeled ”interests", "worries”, and "not of concern". Use of the Spearman-Brown Prophesy Formula on three pairs of similar items yielded split-half reliabilities of .84, .86 and .89. Results indicated multiparas were not as preoccupied with themselves or their newborns as with relationships within the family. Concern with "weight" and "return of figure to normal" were ranked third and sixth highest respectively by multiparas, whereas "how children at home will act toward baby" and “meeting the needs of everyone at home” were the top two highest ranking concerns among new multiparas. In addition, the most numerous interests and worries were exhibited by three groups of mothers: those 81 having (nus other cflmild at home; those under 20 years of age; and those delivering male infants. Ceneralizability of the findings is limited by use of the non-probability sample. Moss' study is particularly enlightening since mothers were able to classify concerns as to those that were of interest and those that caused them to worry. Moss' finding that mothers who delivered male infants were one of the groups that exhibited the most concerns is very interesting, yet she does not attempt to discuss this, particularly in relationship to the first child's sex. In summary, Moss found multiparas to be more concerned with family relationships and less concerned about themselves or their newborn. In summarizing the research related to concerns about self, iJ: is evident that both primiparas and multiparas, and mothers and fathers, may experience a variety of concerns related to self while expecting, or after delivering their child. Some authors feel the childbearing period is stressful (Hobb, 1976), others have called it a period of crisis (LeMaster, 1957; Dyer, 1963). Through their research, the above authors have indicated that, whether greater or less, concerns related to self are felt by mothers and fathers expecting a first child, and by mothers expecting their second child. The lack of research specific to fathers expecting their second child indicates the need for further research in this area. In addition, it is evident that the perceptions of the researchers vary 82 among each other and also their perceptions vary from those of the parents. Whereas some researchers found the concerns of primiparas to be greater (Light & Fenster, 1974), others (Glazer, 1980; Stark & Carrica, 1983) found the concerns of multiparas to be just as snnuficant as those of primiparas. Concerns Related to Spouse Leifer (1977) carried out a descriptive, exploratory study of nineteen primigravidas during pregnancy and the postpartum period to examine the psychological changes accompanying pregnancy and motherhood. Twelve different instruments along with interviews were utilized to collect data durdxu; each trimester of pregnancy, the third post- partum day, at two months postpartum, and at seven months postpartum. To obtain reliability, interviews were evaluated independently by two raters until the percentage of agreement was at least 80 percent. Analysis of the characteristics shown in early pregnancy, throughout the pregnancy, and in the postpartum period indicated that the degree of personality integration achieved by early preg- nancy was predictive of the extent to which psychological growth was experienced throughout pregnancy and early parenthood. One very interesting finding of Leifer was that in the last trimester of pregnancy, fear of loss of the husband (either to another woman or by accidental death) was 83 commonly expressed. Therefore, the primigravidas' increased anxiety during the third trimester was reflected, not only by fear for self and the developing fetus, but also by increased fears for their spouse. Because of the small non-probability sample, general- izability of the findings is limited. In addition, although multiple instruments were utilized, their validity and reliability are not addressed by the author. Leifer's study is helpful in revealing some of the psychological changes that may occur over time during pregnancy and which warrant further research. In summary, Leifer found that the degree of personality integration in early pregnancy was predictive of the extent of psychological growth experienced by primigravidas throughout pregnancy and early parenthood. Concern for the health and safety of one's spouse was a common concern of primigravidas during the third trimester. Light and Fenster (1974), whose study was discussed previously, also found that the primiparas and multiparas in their study had concerns related to their spouses. Multiparas reported a higher incidence of concerns related to family than did primiparas. Both primiparas and multi- paras (31.44 percent) expressed concern about: (a) their husband's reaction to their pregnancy, and (b) whether or not their husband would accept and love the baby. In summary, primigravidas may be concerned with the health and welfare of their husbands during their pregnancy 84 and both primiparas and multiparas may be concerned about their husband's reaction to the pregnancy and his ability to love tine new babyu .Again, more research of fathers' concerns related to spouse is needed as evidenced by the few studies cited and the obvious lack of research in this area generated by nurses and social scientists. Concerns Related to the Marital Relationship Both mothers and fathers, first-time parents or second-time parents, may have concerns related to their Imarital relationship during pregnancy. As described earlier, LeMaster (1957) found that decline in the sexual response of their wives was worrisome to first-thma fathers. Since 89 percent of the couples in the crisis group rated their marriages as good or better than average, LeMaster concluded that the addition of children to the family stresses the marital dyad. LeMaster's study is limited by the use of a non-random sample, information obtained retrospectively, and lack of control set on the age of the children of parents included in the study. Rollins and Feldman (1970) studied general and Specific aspects of marital satisfaction over the family life cycle» ‘A questionnaire was utilized to survey 799 couples who were then classified as belonging to one of eight stages of the family life cycle. Data on marital satisfaction was taken from four questions on the question- naire. Chi square was computed from the cross tabulation 85 frequencies on the response categories for each of the four questions. Rollins and Feldman found a steady decline in "general marital satisfaction" for wives from the "beginning" in) the "school-age" stage (x2 = 55.8). For husbands, there was a slight decrease in marital satis- faction over the first five stages with a continuous increase in the "empty nest" and "retirement" stages (x2 = 32.5). In addition, 47 percent of the wives recognized the more frequent occurrence of specific aspects of marital dissatisfaction, such as: feelings of resentment, feelings of not being needed and feelings of being misunderstood. Only 37 percent of the husbands had such feelings. Rollins and Feldman concluded that the presence of dependent children ("infant" through "school-age" stages) in the home appears to be related to a high level of negative feelings in the wife from her interaction with her husband. Since Rollins and Feldman's sample was drawn from predominantly Caucasian, well-educated, middle and upper- class persons in their first marriage with the wife not *working outside the home, their findings can only be generalized to this population. Classification of couples into the eight stages of the family life cycle does not allow for comparisons of couples with one, two or more children. Positive aspects of their study were the collection of data from both husbands and wives, and analysis drawn over eight stages of the family life cycle. In summary, Rollins and Feldman found that the dependent 86 stages cm? the family life cycle were associated with negative evaluations of the marriage by the wife. Burr (1970) also studied various aspects of marriage over the life cycle. Utilizing a lengthy questionnaire and interview conducted in the home, Burr randomly sampled 116 couples who were in one of seven stages of the family life cycle. Because the number of couples in several categories was small, the childbearing and preschool stages were collapsed and labeled the young children stage. The degree of satisfaction was Operationalized by having subjects respond.ix> three questions in regard to each of the six areas of marital interaction: 1) handling of finances, 2) social activities, 3) task performance, 4) companionship, 5) sex, and 6) relationship with children. Unlike Rollins and Feldman (1970), Burr did not find any type of gradual trend in satisfaction. Rather, Burr found the most abrupt overall change to be from the preschool stage to the school-age stage. The lowest satisfaction scores for both husbands and wives occured during the school-age stage and were related to finances, task performance, companionship, sex and relationships with children. In analyzing Burr's findings, it is unfortunate that he made no attempt to assess the statistical significance of the inter-stage variations found. The findings relied solely on the reporting of raw scores. The generalizability of his findings is further limited to well-educated, Mid- western, middle-class population. 87 Burr's findings somewhat reinforce those of Rollins and Feldman (1970) by indicating a general decline in marital satisfaction after the arrival of children. In summary, Burr found tine lowest level of nerital satisfaction for both husbands and wives to be the school-age stage, but the findings are severely limited by failure to present the statistical analysis (M5 the raw data. However limited, this information prompted the author of the present study to set no limitations on the age of the firstborn child of parents in this study. Studies by Ryder (1973), Glenn and Weaver (1978), and Belsky, Spanier and Rovine (1983) echo the findings of both Rollins auui Feldman (1970) and Burr (1970). There is a general decrease in marital satisfaction after the arrival of children. Ryder (1973) utilized the Marriage Dissatisfacthmi Scale and tine Lovesickness Scale to initially test three groups of couples in various stages of marriage and to retest them one to two years later. The 112 couples included 1J1 the research were divided into three categories: 1) childless, 2) child couples, who were not knowingly pregnant at pretest but had their first child by the post-test, and 3) pregnant cases, in which the wife was knowingly pregnant at the pretest. Pre-post change scores were computed for each spouse and t-tests were used to com- pare the groups. The only significant correlate (p < .05) of having a child was that wives became more likely to 88 report that their husbands were not paying enough attention to them. Ryder's (1973) findings are limited by a non- probability sample of young couples, in their first year of marriage, who were essentially white and middle-class. Reliability and validity of the instruments used were not addressed. In summary, Ryder found that women who have a child are more likely to report that their husbands are not paying enough attention to them. Glenn and Weaver (1978) used data gathered over three years ifixnn U. 8. national surveys to estimate the direct effect of each of ten independent variables on the reported marital happiness of white males and females ages 18 through 59. Face to face interviews were conducted with modified probability samples of over 400 civilians during each of the three years. The method of analysis used was linear correlation and multiple regression. The only statistically significant (p < .001) relationship was for women and for a child or children under age six, for which the mean (-.113) was the second highest of all the partial coefficients reported. Glenn and Weaver (1978) do not address the reliability (n: validity of the instrument used, nor do they describe how their modified probability sample was obtained. Their findings do support those of Rollins and Feldman (1970) and Ryder (1973) and indicate decreased marital happiness in wives with young children. The age of the firstborn child 89 of parents in the present study was not controlled in order to investigate possible correlations with concerns identified by fathers and mothers in the study. Belsky, Spanier and Rovine (1983) studied 41 primiparas and 31 multiparous couples from their last trimester of pregnancy through their infant's first year. Joint couple interviews, individual spousal questionnaires and in-home behavioral observations were utilized to assess marital adjustment, marital functioning, and changes in marital interaction. Analysis of mean scores indicated a significant change in marital adjustment, functioning, and interaction after the baby's birth. In addition, wives reported significantly more marital adjustment than husbands (p < 0.05), and primiparous couples reported significantly more marital adjustment than multiparous couples (p < 0.01). The generalizability of Belsky, Spanier and Rovine's (1983) findings are limited by use of a non-probability sample. Their study contributes further to research on childbearing families since they utilized a longitudinal design that included both primiparous and multiparous couples allowing for comparisons of these groups over time. In summary, Belsky, Spanier and Rovine (1983) found that marital quality declines following the transition to parenthood and this decline continues as additional children are added to the family. Although the present study was not longitudinal in design, concerns related to 90 the marital relationship were investigated to further expand on information obtained from previous research described above. Mermin (1982) also found a greater decrease in marital satisfaction and satisfaction with home life in multi- partnus couples. Mermin longitudinally studied 18 primi- parous couples and 14 multiparous couples during their third trimester of pregnancy through 18 weeks postpartum. Through the use of an adjective checklist, four variables were studied.ix> assess the degree of negative impact of adjustment to the new baby: anxiety, marital satisfaction, satisfaction with rmmme life in general, and discrepancy between global self-description and description of one's aspired parental identity. In addition, two variables on the adjective checklist measured personality change: nurturance and aspired nurturance. Alpha coefficients of internal consistency for the adjective checklist scales ranged from 0.56 to 0.95 for males (Median = .76), and from 0.53 to 0.94 for females (Median = .75). Multivariate analysis of variance revealed a main effect of parity such that multiparous couples experienced more disequilibrium or strain after their baby's birth than primiparous couples. This difference was principally due to multiparous couples' greater dissatisfaction with both marriage and home life which was stable over all three testing periods. The generalizability of Mermin's findings is limited 91 by the use of a small, non-probability sample which was totally Caucasian and middle to tmmer-middle class. By longitudinally investigating both primiparous and multi- parous couples, Mermin allows for comparisons of these groups over time. Like Belsky, Spanier and Rovine (1983), Mermin found a greater decrease in marital satisfaction among multiparous couples and questions the need for further research regarding the adjustments required by parents expecting a second child. Studies such as Mermin's were influential in directing the focus of the present study to include multiparous mothers and fathers. Broom (1984) studied 22 couples expecting their first child to investigate consensus about the marital relation- ship during transition to parenthood. The couples were randomly assigned to the prenatal or postpartum test groups. Husbands and “fives individually rank-ordered 35 concerns from Most Important to Least Important and then estimated how their spouses would rank the same concerns. Estimates of reliability for procedure ranged from 0.78 to 0.94. Husbands and wives were also asked to indicate the three concerns they discussed the most and the three concerns they discussed the least. In order of rank importance, prenatal concerns of husbands were: 1) less time for shared leisure activity with spouse; 2) balancing demands of spouse, job, and child; 3) time and energy required to care for baby; 4) less time in) be alone with spouse; and 5) little 92 time/energy to devote to giving special attention to spouse. Prenatal concerns of wives in order of rank importance were: 1) amount of time/energy required to care for babyv :2) balancing demands of spouse, housework/job, and child; 23) feeling too busy; 4) less time for shared leisure activity with spouse; and 5) emotional tension. For both the prenatal and postpartum groups, husbands were significantly more accurate then their wives in their estimation of their wives' views on the importance of concerns (P < 0.05). In addition, both prenatal husbands and wives perceived significantly more agreement on the importance of concerns than actually existed (P < 0.01). Generalizability of Broom's findings is limited since the small sample was chosen non-randomly, and consisted of very well-educated couples attending childbirth education classes. The relatively high level of estimated reliabil- ity of Broom's instrument warrants consideration of its use in future research endeavors. By studying couples in both the prenatal and postpartum periods, Broom allows for comparisons between these groups. Expanding the study to include multiparous couples would be a positive addition for future research. Broom found that agreement between husbands and wives about the importance of concerns is not high. Furthermore, with the exception of postpartum wives, individuals perceived greater agreement than actually existed. Based on the above findings, Broom challenges health care providers to direct more effort to working with 93 couples in order to facilitate commnfitation within the dyad. Ir1 summary, multiple researchers have indicated that marital satisfaction decreases after the addition of children (Belsky, Spanier & Rovine, 1983; Burr, 1970; Glenn & Weaver, 1978; Mermin, 1982). The stage of dependent children may cause the greatest disruption in the marital relationship, particularly for the mothers. In addition, couples with more than one child may experience greater changes in their marital relationship than couples with only one child. To complicate matters even further, although parents individually recognize concerns during pregnancy, they perceive greater agreement with their spouses about the importance of these concerns than actually exists. Although couples may have concerns about their marital relationship during pmegnancy and the postpartum period, they may be communicating less with their spouses about these concerns since they incorrectly perceive agreement that does not exist. These findings indicate the need for further research regarding concerns of both primigravida and multigravida couples during both the prenatal and postpartum periods. Concerns Related to the Firstborn Child Kendrick and Dunn (1980) observed and interviewed 40 families one to three months before and two to three weeks 94 after the birth of the second child. The direct effects of the mother's attention to the second child on her inter- action with the first child were studied by comparing three situations: mother 1) feeding the second child, 2) holding/care-giving the second child, and 3) not involved with the second child. The age range of the firstborn children was from 18 to 43 months at the birth of the sibling. Assessment of inter-observer reliability based on the range of ratio of agreement to agreement plus disagree- ment resulted in a mean of 0.84. Agreement on the coding of the transcribed conversational episodes for eight cases ranged from 0.85 to 1.00, with a mean of 0.91. Results from the Wilcoxon matched pair tests indicated a significant decrease from the presib-birth to the post- sib birth observations in the amount of time mother and child spent in joint attention and joint play (P < 0.05). Additional comparisons showed that measures of positive interaction between nmwher and firstborn child increased during times when the mother was feeding the baby. There were, however, also more negative interactions between the mother and the firstborn in the feed context than in the not-with-baby context. Based on results from the Wilcoxon matched pairs test, comparisons of the pme-sib birth to post-sib birth observations showed that there was a significant increase in the number of incidents of deliberate naughtiness (z = 3.29, P < 0.001) after the birth of the sibling. There was a nonsignificant trend for 95 the firstborn boys to be deliberately naughty more frequently than the girls (2 = 1.5, P < 0.12), and to show a greater increase in the frequency of incidents of deliberate naughtiness from the pre-Sib birth to post-sib birth observations (2 = 1.8, P < 0.07). There were also more incidents of deliberate naughtiness during bottle than during breast feeding (Mann-Whitney U test, Mdn number of incidents per 100 10-sec units on breast feedings = 0.44, bottle feedings = 3.40; z = 2.74, P < 0.02). In addition, in all three contexts, 1) mother feeding, 2) holding, and 3) not with baby), the younger firstborn children were more likely to Spend more time being held (r = -.52, P < 0.001) and staying close to their mother (r = -.51, P < 0.001) than the older firstborn children. Through their study, Kendrick and Dunn (1980) revealed findings regarding changes in family interactions after the addition of the child which are valuable to all profess- ionals working with families in the childbearing years. Findings based on comparisons of younger to older firstborn children are confusing since the authors do not indicate the age criteria used to separate these groups. Although their study is limited by the use of a non-probability sample, Kendrick and Dunn inspire more research into the area of family adaptation to the birth of a second child. In summary, Kendrick and Dunn found both an increase in confrontation and positive involvement between the mother and firstborn child when the mother was occupied 96 with the second child. The decrease in maternal attention after the sibling birth occurred in contexts in which the mother was not occupied with the baby. With younger firstborns, the above effects were particularly marked. Confrontation between mother and firstborn child was higher in bottle-feeding than in breast feeding situations. Based on the findings of Kendrick and Dunn, this researcher investigated concerns related to both the firstborn child and the expected baby in the present study. Grubbs' (1980) descriptive study of mothers' perceptitnus of time in relation to themselves and others during the postpartum period supports the findings of Kendrick and Dunn (1980). Four unstructured and non- directive interviews were conducted weekly with eight multiparous women. Written accounts of the interviews were content analyzed for the theme of time revealing two dimensions; time was either a commodity or it was a criterion. Analysis of the written protocols revealed postpartal mothers referred to time in relation to themselves, their babies and older children, their husbands, persons who were not members of the nuclear family, and their household responsibilities. The data was classified with the dimensions of time as the dependent variable and the referents as the independent variable. The Analysis of Variance was used to examine the relative effects of change over the four weeks on the frequencies of data. The chi square test for significance of differences 97 between sample proportions was used to test for the effects of the intervening variables of method of infant feeding, the number of children, and the health or illness of the infant. The mothers' statements indicating they felt pressured for enough time (as a commodity) to adequately meet their older children's needs accounted for over two-tenths of their references to their decreased amount of time (242/1151). No significant differences were found between bottle and breast feeding mothers in relation to time as a commonodity. The mothers expressed concern that they would not have enough time to meet their older child's needs in a manner to which the child and mother had been accustomed. Mothers related not having enough time to give their older children their undivided attention and believed they were depriving them of adequate mothering. By the third week, mothers expressed being distressed by their older children engaging in acting-out behavior. When viewing time as a criterion, the four breast feeding mothers made significantly more statements than did the four bottle feeding mothers (2 = 287:233, x2 = 8,03, df = l, P < 0.01). During the first postpartal week, mothers made slightly more statements using time to orient to their older children than to their babies. Breast feed- ing mothers made considerably more statements in which they used time in) orient to information about their offspring than did bottle feeding mothers (2 = 149:79, x2 = 21.49, 98 P < 0.01).. Women who had given birth to their third or fourth babies made more statements using time to orient to their children than did mothers who had given birth to their second babies (2 = 158:106, x2 = 10.24, p < 0.01). The mothers' second greatest use of time to orient themselves was in relation to their older children (332/1268, by week; 95, 67, 111, 59). Mothers related using time to adapt themselves to the new role of the older child who was no longer the baby of the family. The mothers' third most frequent use of time to compare characteristics and capabilities concerned their older children (105/457, by week: 28, 17, 41, 19). Mothers used time ix) compare alterations in their expectations of the role and behavior of the older children and also changes in the older children's role within the family. Considering the extremely small sample which was chosen runrarandomly, the generalizability of Grubb's findings is limited. Bias may have been introduced into the study since the author gave direct nursing care to the subjects in the clinical setting. In addition, the ages of the older children was not controlled and had a large range from 17 months to 14 years of age. Grubb's findings offered direction t1) this researcher to investigate parental perceptions of possible concerns with their relationships to both their firstborn child and the expected baby. In addition, the study instrument included items which addressed the concept of time for self and 99 family members. In summary, Grubbs found that women's perceptions of time during the first postpartal month may be used as an indicator of the personal and family stress and disorgan- ization they experience. Multiparous women have concerns related to their older child/children as these mothers attempt to rework their relationship with these children in light of their new position in the family. Kendrick and Dunn (1980) found that mothers give less time and attention to their firstborn child after the baby is born. Fishbein (1981) and Kreppner, Paulsen and Schuetze (1982) have studied changes in the family system after the addition of a second or third child. Their findings add credence ix) the concerns expressed by parents in the studies previously discussed. Fishbein (1981) studied two and three-child families to determine whether family dysfunction is affected by the sex and birth order of the children. Subjects were selected from tflua entire pool of approximately 3100 families seeking treatment at the Philadelphia Child Guidance Clinic. After application of the selection criteria, 209 single parent families and 279 two-parent families were included in the study. For each child admitted to the child guidance clinic, two factors were noted: 1) the number of natural parents the child was currently living with, and 2) the sex and birth order of the sibling set of which the child was a member. Chi 100 square analyses were carried out using the frequency of occurrence of the various possible sibling set compositions as the target of the analyses. Chi square analyses indicated that the likelihood of a family seeking treatment for one of their children was lowest for all girl sibling sets in both two—child and three-child families. The Sibling sets associated with the highest degree of family dysfunction in both two-child and three-child families were those in which at least one boy precedes one girl. Intermediate levels of family dysfunction were found associated with Sibling sets in which girls precede boys or boys precede boys. The above patterns were found to be stronger for two-parent than single-parent families. Fishbein (1981) does not indicate the demographic data for the subjects in his study nor does he consider the possible relationships of education, income, or other variables to family dysfunction when discussing his findings. Although his sample size is large, subjects were chosen non-randomly from only one clinic in one geographic area. Duplication of Fishbein's study in a variety of geographic areas would add further to the knowledge base on family functioning after the addition of children. To summarize, Fishbein (1981) found that the likelihood of a family seeking treatment for one of their children was lowest with all girl sibling sets and highest with sibling sets in which at least one boy was older than one girl. These patterns were found to be strongest in lOl two-parent families. In the present study, information on the variable of the firstborn child's sex along with concern for a desired sex in the expected baby was obtained ix) be able ix) investigate possible correlations with concerns perceived by expectant parents. Kreppner, Paulsen, and Schuetze (1982) carried out a longitudinal-observational study in the homes of 16 families who were followed during pregnancy with the second child through that child's first two years of age. The purpose of their research was to study the family system as it changed with the arrival and development of a second child. In addition to observations made in the home, parental interviews dealing with biographical and child- rearing information were conducted. Data analysis involved the use of hermeneutic techniques with an emphasis on data fit and holistic interpretation. The families were balanced according to social class and sex of the first child, but these aspects were not considered in the analysis. The age of the firstborn children at the birth of the second child was four years or less. Through their study, Kreppner, Paulsen and Schuetze (1982) discovered a three-phase process through which families progress as they change from a triadic to a tetradic system. The phases were viewed by the authors as resulting from the interaction of structural features within the family and developmental changes in the second child. The major task in Phase 1 (0-8 months) was learning 102 to care fin: a second child while not neglecting the first one at the same time. During Phase 1, firstborn children responded to the birth of their sibling by either requiring greater interaction with their parents or by turning to their own activities, leaving their parents and the second child alone. Fathers were seen as playing a crucial role in this phase by helping relieve the mothers of certain child care and household responsibilities. In Phase 2 (9- 16 months), as the second child becomes more active, he begins to be perceived as a rival by the firstborn child. During iflmis phase, firstborn children were often seen as behaving disruptively in order to regain parental attention being shown to the younger sibling. At the beginning of Phase 3 Cb7-24 months), the authors found that positions between siblings began to be settled. Although rivalries between siblings still occurred, they were less fierce and more symbolic in nature. Two subsystems, "parents" and "children", were seen by the authors as arising in Phase 3. Parents IK) longer experienced interacting with an "older child" or ”younger infant", but rather parents had the experience of interacting with "children" which changed their perception of themselves as being "parents". The small non-probability sample limits the generalizability of the findings. Analyses are based solely on case studies of individual families and comparison of patterns across families. The formative analysis is helpful in generating data for further research 103 1J1 the area (ME changes 1J1 family interactions after the addition of a second child. In summary, Kreppner, Paulsen and Schuetze (1982) concluded that, with the addition of the second child, the family is constantly finding a balance between the integration of the new nember and the change of old interaction patterns of problem-solving strategies. A three-phase model was developed by the authors to describe the turning point: affecting family interaction as the second child develops. Learning to care for the new baby 'while not ignoring the firstborn child, and managing sibling rivalry were tasks confronting the parents. In the present study, data on the variables of sex and age of the firstborn cfluLhi was obtained to investigate possible correlations with concerns identified by expectant parents, thereby adding in) previous information obtained in this area by authors such as Kreppner, Paulsen and Schuetze (1982). In summary of the above studies, not only do parents have concerns regarding their firstborn child, but researchers have found stresses on/changes in family function with the addition of a second or third child (Fishbein, 1981; Kreppner, Paulsen & Schuetze, 1982). Whereas parents may wonder how they will give their firstborn child the necessary attention after the second child is born, researchers have found the mothers do, in fact, give their firstborn child less attention after the 104 second child is born. Parents may worry about their firstborn child regressing or acting aggressively after the second child is born. Researchers have found that increased negative demands for parental attention and sibling rivalry are oftentimes present after the birth of a second child» More research needs to be done which includes fathers' concerns regarding the firstborn child while expecting, or after the birth of the second child. Concerns Related to the Baby Jacobs and Moss (1976) compared mother-infant inter- actions on 32 first and second-born siblings when each was three months old. The sample consisted of four equal-size subgroups of same and opposite sex sibling pairs. Data were collected during two six-hour observations on noncon- secutive days for each mother-infant pair and then coded by a modified time-sampling technique. Each of the groups were observed when the infants were above 90 days old, with the firstborn children ranging between 17 and 35 months of age. Variables observed included both maternal, infant and older sibling behaviors. The mean inter-observation reliability based on computation of product-moment correlation coefficients was 0.77 for the firstborn study and 0.79 for the second-born study. For the main analysis, t-tests for correlated means were performed on the 41 home observation variables comparing firstborns and second borns. The trtests were computed for the total sample as 105 well as the four sibling-sex subgroups. Through their investigation of nether-infant inter- actions, Jacobs and Moss (1976) found that mothers spent less time in social (t = 7.28, P < 0.001), affectionate (t = 3.70, P < 0.001), and caretaking (t = 4.36, p < 0.001) activities with their second borns than they had with their first-horns” Comparisons of sex to birth order revealed that the decrease in maternal interactions with second borns was greatest for females with older sisters and next greatest for females with older brothers. Maternal behavior toward second-born boys decreased less than that toward second-born girls. Boys with older brothers received less maternal attention than their firstborn siblings, but this decrease was smaller than in the comparisons involving the female second-born subgroups. No decrease occurred in neternal attention for males who had firstborn sisters. No significant effect on the study results was found based on maternal age. There was, however, ea strong correlation between demands of the firstborn for attention and the mother's behavior. Demands of the firstborn were associated with the mother being in close physical contact with the younger sibling, particularly when the firstborn was a male (mother attending baby, t = .76, P < 0.001). The relatively small, stratified non-probability sample limits the generalizability of the study findings. In addition, mothers in the study were all white, welL— 106 educated women living in the same metropolitan area. The authors did not indicate whether any of the mothers in their study were working outside the home. By repeating. the same study on second borns, Jacobs and Moss (1976) were able to uncover some very interesting data on differences in maternal interaction with firstborns as compared to second borns. Replication of studies such as this is needed for fathers and remains a challenge for future researchers. In summary, Jacobs and Moss (1976) found that interactions between mothers and their babies varied depending on the birth order and gender of the infant. Mothers Spent significantly less time in social, affectionate, and caretaking activities (except for feeding activities) with their second borns than they had with their firstborns; this difference was greatest when the second born was female. The findings of Jacobs and Moss directed this researcher in the present study to gather concerns of mothers and fathers in relationship to the sex and age of their firstborn child while expecting their second child. Findings by Jacobs and Moss (1976) related to mother- infant interaction, and echoed in the concerns of mothers :hn Grubbs' (1980) study, were previously discussed. The mothers' statements about their lack of time to meet all of the needs of the new baby accounted for 28 percent of their statements about not enough time, making new babies the 107 mothers' second greatest concern about not having enough time. Mothers expressed concern that they could not offer their new baby the time they had with their older children when those older children were babies. IxIea poll taken by Parents Magazine, Yarrow (1983), over 14,000 fathers spoke out on their feelings about fatherhood. As in Jacobs and Moss' (1976) study, the response of the fathers varied with the sex of their children. Although validity and reliability of the questionnaire utilized in the poll were not addressed in the article and the sample taken from subscribers/readers is biased, the results are very interesting. Although 45 percent of the fathers said they had no preference for a boy or girl as their first child, an almost equal proportion (42 percent) said they had wanted a boy. Only 13 percent of the fathers polled wanted a girl. The article did not address the fathers' preference for a boy or gird.imith their second child. This information would have been interesting, particularly for fathers whose firstborn child was not the sex they had preferred. When fathers did not get their choice, the majority (75 percent) said it did not affect their relationship with their child. In addition, 60 percent of the fathers said that if they could change any part of their role, it would be to spend more time with their children. This concept of needing more time is congruent with findings by Grubbs (1980) which indicated that mothers of two children felt they lacked the 108 necessary time for both their new babies and their firstborn children. Sumner and Fritsch (1977) investigated concerns of mothers in the first six weeks after the teby's birth. Their descriptive survey was carried out to document the Spontaneous requests by new parents for inflnmetion and support as evidenced by their telephone calls to the health care facility. calls were recorded by nurses in various area health care facilities and coded as to the number of calls auui the types of questions asked. Reliability and validity of the study were not addressed in the article. (if the 270 calls received, 62 percent were made by primiparas and 38 percent were made by multiparas. Twenty- five percent of the multiparous women eligible to call did so, while 88 percent of the primiparous women eligible to call did. Although primiparous women called more often than multiparous women, the multiparous women asked more questions per call. Regardless of parity, mothers of male infants asked more questions about "feeding" than did mothers of females. Although the authors describe the percent of mothers in the study who made telephone calls seeking help, the authors did not clearly indicate how their sample was obtained nor the total number of mothers who were considered eligible to call. Although Sumner and Fritsch (1977) found that mothers of firstborn or male infants have a higher rate of questions, the authors stated surprise 109 that 25 percent of the multiparas called and had more questions per phone call than primiparas. In summary, parents may have many concerns related to their second child. Parents may be concerned about having enough time to spend with their second born. This concern appears to be valid since researchers have found that mothers do interact less with their second borns than they did udJfli their firstborns, and mother-infant interactions may differ based on the sex of the child (Jacobs & Moss, 1976). In addition, some parents have a preference for a particular sex for their child. Although multiparas may have less questions than primiparas regarding caring for their new babies, these "experienced" mothers may still need the support of nurses in adjusting to caring for their second borns. Since the majority of the above studies involved mothers during the postpartal period, more research needs to be done to investigate concerns of .fathers regarding their first and second borns, particularly during the prenatal period. Concerns Related to the Childbirth Experience Research done over the past four decades, in relation to parental perceptions of the childbearing experience, has revealed many interesting findings. Winokur and Werboff (1956) and Larsen (1966) investigated maternal attitudes in relation to the labor and delivery experience. 110 Utilizing EH1 eight-item questionnaire developed for their exploratory study, Winokur and Werboff (1956) surveyed attitudes of 69 primigravidas and 55 multigravidas during their third trimester of pregnancy. All of the women were wives of United States Air Force personnel and were receiving their prenatal care in the military clinic. Reliability and validity of the instrument were not addressed by the authors. Analysis (n5 variance and correlational studies were performed on the collected data. Winokur and Werboff (1956) found that the more children a woman had, the less likely it was that she wanted her present baby at the time of conception (r=.4461, P < CLOl). In addition, a greater percentage of primigravidas wanted their babies at the time of conceptitnl than multigravidas (primigravidas 83%, multigravidas 62%). Also, primigravidas tended to be less apprehensive about their upcoming childbirth experience than multigravidas (primigravidas = 17% apprehensive, multigravidas = 29% apprehensive). The methodology utilized in Winokur and Werboff's (1956) study is lacking in many areas. The nonprobability sample was drawn from an isolated population of military wives. The authors did not indicate that the women in their study gave their consent to participate nor fully understood that they were partaking in the research. No attempts were made to pilot-test the very brief question- naire and obtain a reliability index. But, Winokur and 111 ‘Werboff were two of the first researchers to compare attitudes (ME both primigravidas and multigravidas during pregnancy and their study does promote further interest in this area. In summary, Winokur and Werboff concluded that multigravidas are less likely to want their children at the time (ME conception as compared to primigravidas, and multigravidas are more apprehensive about pregnancy and delivery than primigravidas. Larsen (1966), described previously, also studied maternal attitudes of primigravidas and multigravidas during the childbearing period. Larsen surmised that with each successive pregnancy, fears for the unborn baby and fears for the mother herself appeared to increase. In addition, Larsen also found that nuflrigravidas perceive more distress than primigravidas over the lack of support from the nursing personnel during successive labor experiences. ‘Therefore, both Winokur and Werboff (1956) and Larsen (1966) found that multigravidas experience more stress and apprehension about their childbirth experience than primigravidas. These findings were useful in directing this researcher to include questions related to childbearing concerns in the present study. Studies focusing on parental expectations regarding the childbirth experience were done by May (1982) and Pridham and Schutz (1983). Although Pridham and Schutz collected data from mothers after the child's birth and May collected data from fathers prenatally, through their 112 studies these authors reveal new information regarding parental expectation about the birth experience. May (1982) studied men's experiences of first—thma expectant parenthood by carrying out intensive interviews with 20 expectant couples. Short field interviews were also done with 80 additional fathers at various stages of their partners' pregnancies. Data were analyzed using comparative analytic techniques for qualitative data. May identified three phases in the development of father involvement in pregnancy among first-time expectant fathers: 1) announcement, 2) moratorium, and 3) focusing. The third phase, focusing, occurs in approximation with the third trimester. DMring the focusing phase, a recurrent theme identified by May was the men's fear of the upcoming birth experience. May found that this fear might be intensified among men who have prepared to support their spouses during labor and birth, and who feel responsible for a successful birth. The small, nonprobability sample limits the generalizability of May's findings. Since comparative analyses were made of the qualitative data, no attempts were made to statistically analyze the findings. Reliability and validity of the study were not addressed. The method used for collection of data was not consistently employed across the sample. Further research is needed, with a more diverse group of fathers, to determine the validity and usefulness of May's findings. In summary, May 113 proposed that there are three phases of father involvement in pregnancy and birth. During the third phase, focusing, fathers may feel isolated or fearful as they anticipate the childbirth experience and begin to redefine themselves in terms of their new role of father. Pridham emu} Schutz (1983) carried out a descriptive study utilizing a.neiled questionnaire to survey the accomplishment of childbirth goals by 91 families (53% primiparas, 47% multiparas) after their child's birth. Content validity for time 158-item questionnaire was obtained. The majority of items were either in a checklist or a Idkert-type scale. ‘An intercoder agreement of 89.6% was obtained for responses to open-ended items on the questionnaire. Analysis of data relevant to accomplishment of plans for the labor and delivery experience indicated that 13% of the parents had planned on the father holding the baby in the recovery room but were unable to meet this goal. The following parental goals for the peetpartum period were ‘planned by the parents, but not accomplished: 1) 47% of the parents had wanted the sibling to visit the mother in the hospital room, 2) 30% of the parents had planned on the sibling holding the infant in the hospital, and 3) 26% of the parents had planned on the sibling seeing the infant in the nurseryu Medical complications were most frequently cited by parents as interfering with achievement of their goals. Pridham and Schutz did find that almost one third 114 of the reasons given for not fulfilling a desired goal involved hospital practices assumed to be policy by the parents. Since the study sample was nonrandomly obtained from family practice residency program clinics at a midwestern university hospital, the generalizability of the findings is limited. Although the authors repeatedly refer to parental goals, they indicate that the questionnaires were mailed only to mothers. It is unclear whether only mothers responded to the questionnaire or whether both mothers and fathers jointly completed the questionnaire. In addition, parents were asked to recall their experiences up to thirteen months after their child's birth. What Pridham and Schutz ch) reveal is the need for nurses to identify parental expectations for their childbirth experience since these parental goals might not always be fulfilled. Both May (1982) and Pridham and Schutz (1983) identified the importance of considering parental goals for their birth experience. May found that fathers who feel responsible for assisting their wives through a successful childbirth experience might feel fear about the birth, particularly during the third trimester. Pridham and Schutz surmised that certain parental goals for the child- birth experience might not be met, therefore, nurses must be aware of the parents' goals to be able to promote their goals, or assist the parents in dealing with their possible disappointment if their goals were not accomplished. The 115 above findings proved useful to this researcher Since, in the present study, information on variables such as the father's plans tx>kxe with his wife during labor and birth was obtained. Butani and Hodnett (1980) described fifty mothers' perceptions of their labor experiences based on interviews obtained within 48 hours of the mothers' delivery. Interviews vdifli the 29 primiparas and 21 multiparas consisted of both structured and open-ended questions. Findings were grouped according to four areas: 1) pre- paratitni, control, and attitudes about self in labor; 2) expectations of labor; 3) perceptions of specific aspects of labor; and 4) overall subjective evaluation of the labor experience. No correlation was found between attendance at prenatal classes and a positive attitude about the labor experience. Both primiparas (38%) and multiparas (24%) expressed regrets about their behavior during labor. Loss of control was the reason given by all of them. Degree of difficulty of labor and amount of pain experienced were reasons given by primiparas (72%) and multiparas (52%) for feeling that their labor expectations were not met. Fetal monitoring and oxytocin inductions produced negative re- actions in some subjects (47% of those induced). Responses of mothers indicated that they felt the nurses needed to give more attention to them as a person instead of to the machines! When asked what measures helped them to 116 cope vfldfli pain, time most frequently occurring responses were: .breathing techniques (24), epidural (15), and encouragement from husband (10). When asked what they like most about their childbirth experience, 21 of the mothers listed tine care and concern of others (husbands, nurses, students, doctors) as being very gratifying to them. The nonprobability sample utilized in this study limits the generalazibility of the findings. Reliability and validity of the study were not addressed by the authors. Neither tine interview schedule nor the statistical findings were clearly presented in the article. Butani and Hodnett do raise questions for further research. In summary, they found that over two-thirds of both primiparas and multiparas expressed regret over their behavior during labor and felt that their expectations were not met. Like May (1982) and Pridham and Schutz (1983), Butani and Hodnett (1980) challenged nurses to identify and promote parental goals for their childbirth experience. Both Westbrook (1978) and Norr et al. (1980) investigated childbirth experiences of primiparas and multiparas during the postpartum period. These authors found that multiparas worried more about their labor than primiparas. Westbrook (1978) carried out a descriptive, retro- spective study on 200 women within two to seven months following the birth of their child. Ninety-two of the women in the sample had their first child, 58 their second, 117 32 their third, and 18 a fourth or later child. Their reactions to childbearing were measured by their responses ‘Uo 18 attitude items, and the application of 12 content analysis affect scales to their recollections which were activated by a pictorial stimulus. An intercoder agreement of 96 percent was obtained for assessment of the maternal recollections. Six cm? the thirty experiential variables studied showed significant effects (P < 0.05) due to parity of the birth. They were: mutilation anxiety, negative attitudes regarding rejection, physical problems, baby care problems, feelings of well-being, and wider family satisfactions. Westbrook found that women having their first child suffered significantly (P< 0.05) less mutilation anxiety than those having second or fourth babies. Westbrook recognized that although later births are considered easier from an obstetric point of view, the multiparous women in her study were more anxious concerning physical injury with childbirth tfluni the primiparas. Although multiparas indicated greater mutilation anxiety, no relationship was found between parity of the birth and proportion of mothers expressing maternal warmth in their recollections (x2 = 0.3, df = 3, p < .05). The nonprobability sample drawn from a large metropolitan (Sydney, Australia) area may limit the generalizability of the findings. In addition, information recalled by mothers up to seven months after the childbirth 118 experience may have been.dfistorted by time. The strong reliability indexes obtained for scales utilized in the study support the argument for future replication of this study. By including both primiparas and multiparas in their study, Westbrook (1978) adds important information to the knowledge base regarding maternal perceptions of child- birth. Westbrook surmised that there tended to be greater mutilation anxiety, a more negative and less positive attitude with increasing parity but similar affective arousal (anxiety, hostility, and positive feelings). Westbrook concludes that disproportionate emphasis has been given to the problems of primiparous women. Norr et al., (1980) also investigated birth exper- iences of primiparas (n = 118) and multiparas (n = 131) and found information similar to that of Westbrook's (1978). The 249 women, randomly chosen from maternity floors in a large teaching hospital, were interviewed and also completed a self-administered questionnaire within one to three days postpartum. Data were compiled to examine the effects of parity on three areas: the pregnancy experience; the birth itself; and interaction with the baby during the immediate postpartum period. Half of the multiparas, but more than two-thirds of the primiparas, reported some serious worries during pregnancy. Primiparas were more likely to worry about baby care, husband's feelings, continuing social activities, and gaining weight. Out of eleven concerns indicated on the 119 questionnaire, the one checked more often by multiparas was worrying about what childbirth would be like. Multiparas were found to have more physical discomfort (P < 0.01), but fewer worries during pregnancy than primiparas. In addition, multiparas worried about labor more (P < 0.01) but prepared for childbirth less (P < 0.05) than primiparas. Since the sample was drawn from maternity patients in one hospital, and.tuui a higher than average social status and educational background, the sample is not represent- ative of a cross-section of women delivering babies. In addition, reliability and validity of the instruments used were run: addressed by the authors and the instrument and scorirm; system were not made available. Considering the large sample size and the study findings, replication of the study with subjects drawn from a more diverse population seems warranted. In summary, Norr's et al. (1980) findings are supportive of those of Westbrook (1978) indicating that multiparas may experience greater anxiety about their childbirth experience than primiparas. These findings were useful to this researcher when developing a study instrument that addressed childbearing concerns of mothers and fathers. From the above research it is evident that both first time mothers and fathers, and multiparas may have certain expectations for their childbirth experience. Since oftentimes these goals or expectations might not be met, 120 nurses must first identify parental childbirth goals so that they can either better assist parents in meeting these goals when possible, or help perents deal with possible feelings of disappointment when goals are not met. In addition, some researchers have found that multiparas may have greater mutilation anxiety and worry more about their childbirth experiences than primiparas. The lack of information relevant to the childbirth concerns of fathers expecting their second or more children warrants focusing future research endeavors towards this area. Concerns Related to the Household and Finances Many of time authors, whose studies' were previously reviewed, have found that both first-time parents and parents expecting their second, or more, child have concerns related.ix> the areas of household and finances during their pregnancy and the postpartum period (LeMaster, 1957; Hobbs, 1965; Grubbs, 1980). In their studies on transition.tx> parenthood, Dyer (1963), Hobbs (1965), Russell (1974), and Hobbs (1976) found financial worries to be a concern of first-time mothers and particularly of first-time fathers. In addition, many of the first-time mothers were bothered by concerns related to the management of the household. Dyer (1963) found "financial worries" to be the fifth most frequently mentioned concern among the 32 new fathers in his study, and the concern identified as "severe" by 121 more than 80 percent of the fathers. Fathers related concerns in adjusting from two incomes before the child's birth to (nus income after the child's birth. Sixty-two percent of the wives in Dyer's study had been employed before time child's birth. In comparison, the fifth most frequently mentioned concern of the wives in Dyers study was their inability to keep up with the housework. Eighty- seven percent of the wives identified this to be a "severe" problenn Concern regarding finances was not included in the top six most frequently mentioned concerns of the wives. Ind summary, Dyer found financial concerns to be more prevalent among the first-time fathers, whereas, concerns related to the household were identified more frequently by the first-time mothers. In 1965, and then again in 1976 in a replication of his first study, Hobbs found concerns related to finances and the household to be present in both first-time fathers and mothers in his studies. In his study of fifty-three couples in 1965, Hobbs found 60 percent of the fathers bothered "somewhat" or "very much" buy increased money problems. When concerns were listed in rank order by the fathers, "increased money problems" was the first most discriminating item identified by fathers, "housekeeping not as neat" was the seventh most discriminating item admitted to by new fathers. In comparison, sixty-six percent of new mothers were "somewhat" or "very much" bothered by increased money problems. Financial concerns 122 were not ranked as one of the top ten most discriminating items by new mothers. "Housekeeping not as neat as it could be" was ranked ninth by the mothers. Hobbs (1976) replicated his study a decade later with (EB couples. The main difference between the two studies was the mean age of the children at the time the parents responded to the questionnaires. In Hobbs study in 1965 the children averaged 9.8 weeks of age compared to 25.9 weeks of age in 1976. Rank order of possible items for concern revealed that "increased money problems" was ranked first by fathers and second by mothers. "Housekeeping not as neat" was ranked third by mothers and did not fall in the top ten most discriminating items ranked by fathers. One-half of the ten most discriminating items for men were the same in Hobb's (1965, 1976) two studies. A similar pattern was found for the females. Rank order of items varied considerably for the same sex samples in the two studies and between the sexes in both studies. Hobbs (1976) does ruyt discuss possible reasons for the differences found. Historical considerations, such as the oil embargo and economic recession in the early 1970's and more women joining the work force, could have been addressed by the author. In summary, Hobbs found concerns related to finances and household to be identified by both first-time fathers and mothers in his studies done in 1965 and 1976. "Increased money problems" was ranked highest by fathers in 123 both studies; whereas, its ranking by mothers changed, from not being included in the top ten, to the second highest most discriminating item. "Housekeeping not as neat as it should be" was ranked Sixth by fathers in the 1965 study and was not ranked in the top ten in the 1976 study. "Housekeeping not as neat as it should be" changed from the ninth highest item ranked by mothers in the 1965 study to the third highest item ranked by mothers in the 1976 study. Russell's (1974) findings are somewhat similar to those of Dyer (1963) and Hobbs (1965, 1976) for first-time parents. The third highest item most frequently identified by fathers (47 percent somewhat, 6 percent very much) as being "bothersome” was that the arrival of the baby increased money problems. The mothers in Russell's study more frequently identified items that were interpreted by the author as clustering around the emotional and physical self. Concerns related to the household or finances were not admitted to by the mothers in this study. In summary, Russell found financial problems to be a concern for fathers but not for mothers. Concerns related to the household were not found to be significant for fathers or mothers. In her study of women's perception of time with eight primiparas and eight multiparas Grubbs (1980) found that the women's fourth greatest concern about time was in relation to household maintenance (184/1296 responses). These new mothers expressed frustration that they were not 124 able ix) keep up Vanni the minimal housekeeping, laundry, grocery shopping, and preparation of meals. Unlike concerns related to self, children, or baby, concerns related to time household increased during the third and fourth weeks. In summary, Grubbs found that concern about time, in relation to household maintenance, was the fourth greatest concern of primiparas and multiparas in her study. In addition, concern about time in relation to the household increased with time. From review of the above studies, it is apparent that concerns related to finances can be experienced by first- time mothers and fathers. First-time fathers are more likely ix) be concerned with finances than first-time mothers. In contrast, first-time mothers are more likely ix: be concerned with household management than first-time fathers. Both primipara and multipara may be concerned about the time needed to maintain their households as they would like. Further research is needed to identify concerns related to finances and the household of parents during tflua prenatal period, and particularly concerns of fathers expecting their second, or more, children. The above research findings were helpful to this researcher since concerns related to both income and househohd management were included in the study instrument. In conclusion, the above review of the literature related to parenthood indicates that both mothers and fathers may experience concerns related to self, spouse, 125 their marital relationship, their firstborn child, the baby, their childbirth experience and the househohd and finances. These concerns may be present in both the prenatal and postpartum period. Further research, utiliz- ing data collected longitudinally from the prenatal through time first years postpartum, needs to be done to identify how parental concerns remain the same or change with time. In addition, further research needs to be done to be able to compare and contrast the concern of mothers to fathers, and those of first-time parents to parents expecting their second, third, or more child. The authors mentioned above have drawn conclusions, sometimes contrasting, based on their perceptions of their studies' findings. Some authors found that first-time parents had a more difficult time adjusting to parenthood, others found that parents of two or more children had similar concerns which were equally significant to those of first-time parents, or possibly had different concerns from first-time parents. Considering the above variety of findings, nurses must continue to investigate the concerns of all parents related to their transition to parenthood. So as to base their nursing care on a strong knowledge base, concerns of both mothers auui fathers, or first-time (and greater) parents must be investigated. Nursing interventions should not be based on the issue of "who has the most or the greatest concerns?” As seen by the variety of findings described in the review of literature, all expectant parents and new 126 parents deserve attention to their concerns. In order to be able to deliver the most comprehensive nursing care to expectant couples and families, their perceptions must be known. This will be possible through further reseanfii which focuses, not only on the concerns of mothers or first-time parents, but on all parents in the childbearing years. Included in Chapter four is an overview of the methodology of the study. Study variables will be operationally defined followed by a description of the sample, instrumentation and scoring, data collection procedures and data analysis. CHAPTER IV METHODOLOGY Overview This was a descriptive study designed to examine the perceived concerns of expectant parents during the third trimester of their pregnancy with their second child. A questionnaire developed especially for this study was used to measure expectant parents' perceptions of their concerns during the third trimester of pregnancy with their second child. In addition to questions about their concerns, sociodemographic information about the subjects was collected to characterize the study sample. The exact research questions to be studied will be described in Chapter SUI along with operational definitions of the concepts. Next, the sample selection will be described. Finally, instrumentation and scoring, human rights protection procedures, reliability and validity of the instrument, and data collection and analysis procedures to be used will be described. Research Questions The following research questions were addressed in this study: 1. What are the perceived childbearing, Childrearing, and marital concerns of mothers during the third trimester of their second pregnancy? 127 128 2. What are the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of their wife's second pregnancy? 3. Are there differences in the perceived child- bearing, childrearing and marital concerns of mothers when compared.ix> the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of their second pregnancy? Operationalization of Concepts Perception In this study, perception was understood to mean the father's or mother's "image of reality" which gives meaning to their pregnancy and childbirth experience and influences their behavior. This process of organizing, interpret- ing, and transforming information from their sensory data anui memories was demonstrated by their responses on the concerns questionnaire during the third trimester of pregnancy (King, 1981, p. 24). Concerns Concerns were defined as those issues of interest viewed as important by the expectant parent or those issues seen as occupying his/her thoughts (Bull, 1981; Glazer, 1980). Forty-eight items on the concerns questionnaire. were designed to uncover concerns of parents related to self, spouse, the marital relationship, the firstborn child, tflua expected baby, the childbirth experience, and 129 the household and finances. Concerns were measured by the parents' response to each of the 48 Likert-Scale items on the concerns questionnaire. The parents were asked to indicate whether they strongly agreed, agreed, disagreed or strongly disagreed to each of the statements. Expectant Parent The term expectant parent potentially encompasses the time frame from the very moment of conception to the birth of the baby. Parent can further be described by the method of conception (biologic or artificial inseminathmn, cu' assumption (adoptive or through re-marriage). Furthermore, being married is not a pee-requisite for parenthood. In order to limit the scope of the term expectant parent, the more traditional description was used. Parents were married auui experiencing the third trimester of a normal pregnancy with their second child. Expectant parents were referred to as mothers and fathers when the mother was pregnant with their second child. Mother The term mother potentially refers to any female who has conceived a child. For the purpose of this study, mother referred to the female Spouse who had biologically conceived one normal child with her present husband and who was presently in her third trimester of pregnancy with their second child by the same father. Father In this study, father was defined as "the male who shared tflua (second) pregnancy with the female in the 130 psychosocial as well as the biologic sense" and was also the biologic father of the firstborn child. (Jensen, Benson & Bobak, 1981, p. 221). Third Trimester It is possible that both fathers and mothers experience certain concerns during each trimester of their pregnancy. In her study of both primiparas and multiparas, Glazer (1980) found the greatest number of concerns expressed during the third trimester. Taking into consid- eration Glazer's findings, that the third trimester is the most critical time period, then, expectant parents in this study were asked to complete the concerns questionnaire during the third trimester of their second pregnancy. Third trimester was defined as the last three, full calendar months of the pregnancy or an estimated gestation of 27 weeks or more as calculated by the expected date of confinement (Clark & Affonsa, 1976). Second Pregnancy It is possible that the birth of a second child is not the result of a second pregnancy since abortions or mis- carriages may have been experienced by the parents. To limit these variables and for the purpose of this study, second pregnancy, denoted that the mother was a gravida 2; para 1 (Ruder, Mastroianni & Martin, 1980) who was exper- iencing a normal pregnancy or one that was not at high- risk. High-risk pregnancy was defined as "one in which the life or health of the mother or offspring was jeopardized 131 by a disorder coincidental with or unique to pregnamqf' (Jensen, Benson & Bobak, 1981, p. 315). Criteria for Inclusion in Study Mother To be eligible for inclusion in the study, mothers had to meet the following criteria: 1) adult female 21 years of age or older; 2) expecting her second child or gravida II para 1, and in her third trimester of pregnancy; 3) married to the expected baby's father; 4) living leii household with father which included one other child by the same father; 5) experiencing a normal pregnancy without high-risk complications. Father To be eligible for inclusion in the study, fathers had to meet the following criteria: 1) an adult male 21 years of age or older; 2) the father of the firstborn child and the expected baby; 3) married to the expected baby's mother; 4) without children from a previous marriage; 5) living with expected baby's mother. Firstborn In addition, the firstborn child of the mother and father had to be: 132 1) essentially healthy without severe or life- threatening congenital defects or acquired diseases. Sample The study participants were taken from fathers and mothers expecting their second child. Participants for the study were obtained from a mixed urban/rural community in a midwestern area with a population of approximately 200,000. Private doctors' offices, a certified nurse midwife's office and area childbirth and sibling preparation classes were utilized to locate the sample. Because the sample was chosen by convenience and was not random, the results of the study cannot be generalized beyond the sample. Data Collection Procedure Personal contact was made by telephone with area physicians and a certified nurse midwife in private practice, and childbirth and sibling preparation educators :hn order to explain the purpose of the study and receive permission to approach their clients for inclusion in the study. Following the physicians', certified nurse midwife's or childbirth and sibling preparation educators' stated permission to allow their clients to be approached to participate in the study, a letter documenting their agreement was sent (See Appendix C). An appointment was then scheduled at the convenience of the office staff to explain the purpose of the study and the criteria for the 133 sample. Letters to parents explaining the purpose of the study, potential health risks/benefits, and assurance of confidentiality were left at each office/clinic (See Appendix D). The office staff or childbirth educator then distributed tine letter to parents expecting their second child and in their third trimester of pregnancy. The second page of the letter included a section for parents to leave their name, address, and phone number at the facility if they were interested in participating in the study. The second page was then torn off and left with the office staff or childbirth educator so that the parents could keep the ix“) section of the letter for their own information. Sample participants were recruited over a four month period in 1987. Upon collection by the investigator of the names, addresses, and pflunua numbers of interested parents from each facility each couple was contacted by the investigator by telephone. A standard format (See Telephone Screening Tool in Appendix E) was used for each telephone contact which included the following information: an introduction of the investigator by name and title, the purpose of the study, perceived willingness to take part in study and general criteria for inclusion in the study. Based on the parents' answers, second-time parents were asked to participate in the study if they qualified according to the criteria outlined above. Parents were informed that participation in the study would require approximately twenty minutes of their time to complete the questionnaire. 134 Parents were assured that all information would remain confidential. An opportunity was provided for parents to ask any questions they might have had. Parents were assured that they could withdraw from the study at anytime without penalty; .Any parent.vflu> seemed hesitant or wanted more time to discuss their involvement in the study with their spouse was recontacted within 3-5 days to obtain their response. If refusal to participate in the study occured during the initial or follow-up phone contacts, the parents were thanked for their time and communication with them was terminated. When second-time parents agreed to participate in the study the following process was implemented. A cover letter uddfli general directions, (See Appendix G) the consent forms (See Appendix F) and questionnaires for each parent (See Appendices A and B), and a self-addressed stamped envelope was mailed to the participants within three days. Participants were requested to complete their questionnaire alone and to return both questionnaires within one week. Once the questionnaires were returned, the participants' code numbers were assigned and the questionnaires were prepared for data analysis. Human Rights Protection Specific procedures were followed to assure that the rights of the study participants were not violated. These procedures were required and approved by the Michigan State 135 University Committee on Research Involving Human Subjects (UCRIHS) (see Appendix H). Participation in the study was voluntary and participants could withdraw from the study at any time without penalty. Return of the completed questionnaire was accepted as consent by the participant to partake in time study (see Consent Form, Appendix F). A code number was assigned to each returned questionnaire since the participant's name was never on the questionnaire. The introductory letter and general directions explaining the purpose of the research study, the approximate tinwazrequired to complete the questionnaire, and promise of anonymity were given to each participant (see Appendices D and G). Some of the information about the study contained in the introductory letter was restated in the general directions enclosed with each questionnaire (see Appendices A, B, and G). Instrument In time following section, operational definitions of time study variables will be discussed. In addition, the development of the instrument to be utilized for this study will be described. Since the study instrument had not been previously utilized, reliability analyses for the seven sub-scales proposed by the investigator will be addressed. Parental Concerns Questionnaire The instruments utilized in the study were self- 136 administered questionnaires for mothers and fathers developed by the author (see Appendices A and B). The questionnaires answered by mothers and fathers in the study were very similar in content, but the format was changed so as to be appropriately worded for the parent answering the questionnaire. The development of the instruments was based (M) a review of the literature (Bull, 1981; Glazer, 1980; Gruis, 1977; Stark & Carrico, 1983), interviews with family child health nurses and nursing educators, and from personal experiences of the author while a pmofessional nurse caring for expectant couples. The instruments were set up into two parts. The first part of each instrument was designed to collect sociodemographic data on the sample and also to elicit information about modifying and action variables that might influence the expectant parents' perceptions of concerns during the pregnancy (see Appendices A and B, 1 through 26). The second part of each questionnaire included 48 items which proposed to address Specific concerns expectant parents may have (see Appendices A and B, 27 through 74). The last 48 items on the questionnaire were designed to describe childbearing, Childrearing and marital concerns as measured by the seven sub-concepts previously identified and itemized: concerns related to self, spouse, the marital relationship, the firstborn child, the expected baby, the childbirth experience, and the household and finances (see Appendices A and B, 27 through 74). 137 A four-point Likert scale was utilized to record responses to the 48 items (27 through 74). The 48 items of concern (27 through 74) were very similar for both the mother's questionnaire and father's questionnaire, but their sequence was randomized separately and some items were reworded so as to be appropriate for the parent (mother (n: father) answering the questionnaire. Answers were recorded (Nl«a four-point Likert scale which ranged from strongly agree to strongly disagree, with a category titled not-applicable available. For the purpose of analysis, responses were recorded in such a way that endorsement of positively worded statements, and non- endorsement of negatively-worded statements were assigned a higher number (Strongly Agree = 4, Agree = 3, Disagree = 2, Strongly Disagree = 1). The last question (#75) on the questionnaires was an 'open-ended question which allowed parents to write in any additional concerns they had which were not addressed in items 27 through 74. The additional concerns were then categorized into the seven subscale areas of self, spouse, marital, :firstborn, expected baby, childbirth experience, and household and finances. Extraneous Variables A review of the literature indicated that various extraneous variables may influence concerns perceived by expectant parents during a pregnancy. Data were collected on these sociodemographic, modifying, and action variables 138 through questions 1 through 26 on the concerns question- naires. Operational definitions of these variables follow. Sociodemographic variables There were six items which requested information concerning time age of the respondent, ethnic background, religitnus affiliation, education, family income, and present employment status. Modifying variables There were eleven items which requested information regarding previous labor and birth experiences, age and sex of firstborn, and planning of pregnancies. Action variables There were eight items which requested informathmi regarding mental or physical actions decided upon during this pregnancy in order to control situations. These included plans for the father's attendance at the labor and birth, method of feeding baby, attendance at childbirth preparation classes, preparation for childbirth, and sources for discussion of concerns. Operational Definitions of Variables The seven subscales described under the broader categories (ME childbearing, Childrearing and marital concerns will not be combined for analyses, rather, these seven subscales will be treated individually in the data analysis. 139 Concerns Related to Self These were operationalized by seven items for the mothers and Efljt items for the fathers which proposed to address concerns during pregnancy related to themselves. Items covered such areas as time for self (Appendix A, 61; Appendix B, 35), thoughts about own health (Appendix A, 44; Appendix B, 55), happiness about pregnancy (Appendix A, 49; Appendix B, 61), meeting the needs of the family (Appendix A, 67; Appendix B, 59), career goals (Appendix A, 33; Appendix B, 51), and support of family and friends (Appendix A, 66; Appendix B, 56). The additional question :fler mothers focused on their concern about their figures (Appendix A, 27). Concerns Related to Spouse These were operationalized by six items for mothers and seven items for fathers which proposed to address their concerns related to their spouse. Items included such areas as career goals of spouse, (Appendix A, 40; Appendix B, 53), spouse's health, (Appendix A, 37; Appendix B, 34), spouse's happiness about the pregnancy (Appendix A, 51; Appendix B, 31), spouse's ability to pursue own interests (Appendix A, 50; Appendix B, 49), support of spouse (Appendix A, 28; Appendix B, 64), and spouse feeling stifled after second child's tflrth (Appendix A, 71; Appendix B, 73). The additional question for fathers focused on the concern that their wife's figure would not return to normal after the second child's birth (Appendix B' 43). I40 Concern Related to the Marital Relationship These were operationalized by eight items for both mothers auui father proposed to address concerns they had related to their marital relationship. The focus of these items was (Ml shared leisure activity (Appendix A, 65; Appendix B, 66), the sexual relationship (Appendix A, 42; Appendix:13, 41), attention from spouse (Appendix A, 54; Appendix B, 32), contraception (Appendix A, 39; Appendix B, 63), sexual attractiveness (Appendix A, 59; Appendix B, 69), changes in own sex drive (Appendix A, 35; Appendix B, 52), changes in spouse's sex drive (Appendix A, 31; Appendix B, 65), and possible consideration of sterilization (Appendix A, 36; Appendix B, 47). Concerns Related to the Firstborn Child These were operationalized by seven items for both mothers and fathers which proposed to focus on concerns they had related to their firstborn child during their pregnancy. Items concentrated on such areas as their firstborn child loving the new baby (Appendix A, 46; Appendix B, 30), possible aggression towards the new baby (Appendix A, 64; Appendix B, 48), loss of their special relationship with their firstborn after the baby's birth (Appendix A, 34; Appendix B, 74), care of firstborn while mother is hospitalized (Appendix A, 38; Appendix B, 72), attention for firstborn after baby is born (Appendix A, 68; Appendix B, 46), regression of skills (Appendix A, 72; Appendix B, 27), and lack of energy for firstborn during 141 pregnancy (Appendix A, 29; Appendix B, 42). Concerns Related to the Expected Baby These were operationalized by six items for both mothers and fathers which proposed to address concerns they had related to the expected second child. Items in this area focused (M1 the health of the baby (Appendix A, 52; Appendix B, 40), ability to love the second child as much as time firstborn child (Appendix A, 47; Appendix B, 67), desired sex of the beby (Appendix A, 63; Appendix B, 36), time anui attention for second child (Appendix A, 62; Appendix B, 38), ability to care for a baby (Appendix A, 41; Appendix B, 33), and ability of spouse to love second child as much as first (Appendix A, 45; Appendix B, 29). Concerns Related to the Childbirth Experience These were operationalized by eight items for both mothers and fathers which proposed to focus on concerns they had related.tx3 the upcoming labor and delivery experience. Such items as difficulty of labor (Appendix A, 30; Appendix B, 50), control during labor (Appendix A, 73; Appendix B, 71), preparation for labor and delivery (Appendix A, 58; Appendix B, 70), physical care received from doctors and nurses (Appendix A, 70; Appendix B, 39), safety of mother during labor and delivery (Appendix A, 43; Appendix B, 54), emotional support of doctors and nurses (Appendix A, 48; Appendix B, 60), support by father during labor and delivery (Appendix A, 57; Appendix B, 58) and flexibility of visitation while hospitalized (Appendix A, 142 55; Appendix B, 28) were included in this area. Concerns Related to the Household and Finances These were operationalized by six items for both mothers auui fathers vflflrfii proposed to focus on concerns they ruui related to the family household and finances as they awaited the arrival of a second child. Items in this area included health care costs (Appendix A, 74; Appendix B, 68), possible career changes decreasing income (Appendix A, 69; Appendix B, 57), general upkeep of the house as desired (Appendix A, 32; Appendix B, 37), being able to afford to raise a second child (Appendix A, 60; Appendix B, 44), available space in house (Appendix A, 56; Appendix B, 62), and having enough money to meet the needs of the family (Appendix A, 53; Appendix B, 45). Extraneous Variables The instruments were designed to elicit information about variables (sociodemographic, modifying, action) that could influence the concerns perceived by parents expecting their second child (see Appendices A and B, 1 through 26). The decision to include the following items in the questionnaires was made after review of previous research indicated that these variables may influence concerns perceived by parents during pregnancy. Sociodemographic AGE OF THE PARENT: The respondent's age in years at the time of the study (Appendices A and B, 3). 143 RACE/ETHNICITY: Response categories for racial background were White, Black, American Indian, Mexican American, Oriental, or Other (Appendices A and B, 4). RELIGION: Response categories for religious preference were Catholic, Jewish, Protestant, None, or Other (Appendices A and B, 5). LEVEL OF EDUCATION: Response categories for highest level of education attained ranged from grade school to beyond four years of college (Appendices A and B, 6). ANNUAL FAMILY INCOME: Respondents were asked to indicate their annual family income. Response categories ranged from $9,999 and under to above $50,000 (Appendices A and B, 7). PRESENT EMPLOYMENT STATUS: Respondents were asked to indicate their current employment status, which included the option of homemaker. Response categories were Employed Full Time (40 hours/week), Employed Part Time (less than 40 hours/week), Homemaker, or Unemployed (Appendices A and B, 8). Modifying Variables GESTATION: Elicited by two questions which asked the respondent to record today's date (#1) and the baby's expected due date (#2). For the purpose of calculation, the difference between the two dates represented the number of weeks remaining to reach 40 weeks of gestation. Therefore, 40 minus the difference was the number of weeks of gestation at the time the questionnaire was completed. 144 FEELINGS REGARDING FIRST LABOR AND BIRTH EXPERIENCE: Response categories were Positive, Neutral, or Negative regarding respondent's first labor and birth experience. (See question #17.) PLANNING OF PREGNANCIES: Response categories were Yes or No regarding planning of present and previous pregnancy. (See questions #10 and #18.) COMPLICATIONS IN LABOR/BIRTH: Elicited by two questions asking if there were major complications during the first labor and birth experience. Responses were Yes and No. Space was provided for the respondent to describe the complication experienced. (See questions #11 and #14.) AGE OF FIRSTBORN CHILD: This question asked the age of respondent's firstborn child at the time the questionnaire was completed in years and months. (See question #16.) SEX OF FIRSTBORN CHILD: Responses were Male or Female regardirm; sex of respondent's firstborn child. (See question #15.) Action Variables PLANS FOR HUSBAND TO ATTEND LABOR AND BIRTH: Response categories were Yes or No regarding plans for father to be present during the mother's labor and birth with the second child. (See questions #19 and #20.) ATTENDANCE AT CHILDBIRTH PREPARATION CLASSES: Response categories were Yes, No or Undecided regarding attendance at childbirth preparation classes during second 145 pregnancy. (See question #22.) METHOD OF FEEDING: Response categories for method of feeding time new baby were Breast, Bottle, Breast and Bottle, or Undecided. (See question #21.) COMPARISON OF CURRENT PREPARATION FOR CHILDBIRTH TO FIRST PREGNANCY: Response categories regarding the amount of childbirth preparation taken during the present pregnancy as compared to the first pregnancy were About the Same, More with this Pregnancy, or Less with this Pregnancy. (See question #23.) SOURCES FOR INFORMATION: Response categories for sources of information regarding childbirth and children were: Books, Magazines, Newspaper Articles, Pamphlets from Doctors' offices, Television Programs, Personal Experience, Family and Friends, Doctors, Certified Nurse Midwife, Nurses, Instructor in Childbirth Preparation Classes. (See question #24.) DISCUSSION OF CONCERNS: Response categories were Yes or bk>.as to discussion of concerns regarding current pregnancy with others. (See question #25.) SOURCES FOR DISCUSSION OF CONCERNS: Response categories for sources utilized for discussion of concerns during pmesent pregnancy were Spouse, Relatives, Friends, Doctors, Certified Nurse Midwife, Nurses, Instructor or Parents in Childbirth Preparation Classes, and Other. (See question #26.) FUTURE EMPLOYMENT INTENTIONS: Response categories for intentions for employment after baby's birth were Full-time 146 Employment (40 hours/week), Part-time Employment (less than 40 hours/week), and No Plans to Work Outside the Home. (See question #9.) Pre—Test of the Instrument Three couples expecting their second child who were not participants in the study were asked to criticize the instrument for ease of readability, suitability of the questions, ability to comprehend the directions, and the amount of time needed to complete each section of the questionnaire. The researcher was available by telephone to answer any questions or concerns about the instrument that couples in the pilot study had. Upon completion of the questionnaires, the researcher met with each couple to review their suggestions for the questionnaires. Based on input by the couples, the addition of the choice "Certified Nurse Midwife" was made in questions #24 and #26. Reliability and Validity of the Instrument The first part of each questionnaire surveys socio- demographic, modifying and action variables that may influence concerns experienced by expectant parents. The second part of each questionnaire, items 26 through 74, addresses 48 specific concerns that expectant parents may experience. These items were developed by the investigator based on a review of the literature. The 48 items of concern resulted from expanding the seven broad sub-concept categories of self, spouse, the marital relationship, firstborn child, expected baby, childbirth experience, and 147 household and finances. The study participants were asked to identify on a four-point scale their level of agreement that each item was or was not a concern experienced by them during their present pregnancy. Reliability auui validity for the concerns question- naires rmui not been established prior to this study. Establishment of these qualities was crucial for inter- pretation of the data because the researcher needed to find out whether the dimensions of concerns actually exhibited by respondents did correspond to the classification proposed tn] the researcher. The following will describe techniques utilized in this study to establish reliability and validity of the concerns questionnaire. "Reliability is the degree of consistency or depend- ability with which an instrument measures the attribute it is designed to measure" (Polit & Hungler, 1987, p. 316). The reliability of an instrument can be assessed by utilizing a measure of internal consistency. An instrument is understood ix) be internally consistent to the extent that all. .56) found between the expected baby, firstborn and childbirth sub-scales warrant further attention in regards to the independence of each sub-scale. The sub-scales were retained for this preliminary study and no further analysis of the sub-scales was made. However, before future study replications are executed, the high intercorrelations of the expected baby, firstborn and childbirth sub-scales would need to be re-evaluated. Table 4 Pearson Correlation Coefficients Among Subscales Expected Childbirth Marital Firstchild Baby Finances Childbirth 1.0000 .3774* .6927* .5614* .4824* Marital 1.0000 .4498* .4980* .4048* Firstchild 1.0000 .6826* .3713* Expected Baby 1.0000 .3941* Finances 1.0000 *P I .001 Analysis Pertinent to Study Questions Data which answers the study questions will be presented in the following section. Each question will be analyzed as outlined in Chapter IV. 168 Question I. What are the perceived childbearing, Childrearing, and marital concerns of mothers during the third trimester of their second pregnancy? 1%”; mean scores of mothers on the five retained sub- scales are shown in Table EL. The mothers mean scores for all five sub-scales were below 2.5 indicating that the five sub-scales did not represent areas of concern for the majority of mothers in the study. The percent of mothers who did indicate levels of concern greater than 2.5 on each of time sub-scales follows: childbirth 25% (n=9); marital 47% (n=16); firstborn 39% (n=14); expected baby 33% (n=12); and, finances 29% (n=10). The greatest number of concerns reported by mothers were related to the marital relationship followed by concerns related to their firstborn child, then the expected baby and finances, and finally the area of childbirth. The Pearson r was computed on the five sub-scales to investigate the degree of relationship between the sub- scales for mothers. The correlations of the sub-scales for mothers are shown in Table 6. 169 Table 5 Mean Results and Stdandard Deviations of Mothers and Fathers on Five Sub-Scales of Concern Mean Scores Mothers Fathers Mean SD Mean SD Retained Sub-scales N=36 N=36 Childbirth 2.15 .36 1.88 .35 N=36 N=36 Marital 2.44 .48 2.14 .60 N=36 N=36 Firstborn 2.30 .45 1.95 .43 N=36 N=36 Expected Baby 2.24 .53 1.98 .55 N=35 N=36 Finances 2.24 .52 1.92 .53 Table 6 Intercorrelations of Mothers' Five Sub-scale Concern Scores Child- Expected Sub-scale birth Marital Firstborn Baby Finances .17 .60 .55 .37 Childbirth P=.16 P=.000 P=.000 P=.01 .17 .29 .29 .30 Marital P=.16 P=.05 P=.04 P=.04 .60 .29 .67 .22 Firstborn P=.000 P=.05 P=.000 P=.11 Expected .55 .29 .67 .31 Baby P=.000 P=.04 P=.000 P=.04 .37 .30 .22 .31 Finances P=.01 P=.04 P=.11 P=.04 170 As seen in Table 6, correlations between all sub- scales for mothers were positive. Strongest relationships were found between time firstborn and expected baby sub- scales (r=.67, P<.001), between the firstborn and child- birth sub-scales (r=.60, P<.001), and between childbirth and expected baby sub-scales (r=.55, P<.001). Moderate correlations were found between the marital sub-scale and firstborn (r=.29, P<.05), expected baby (r=.29, P<.04), and finances (r=.30, PK.04). The weakest relationships were found between the marital and childbirth (r=.17, p=.16) sub-scales, and between the firstborn and finances (r=.22, p=.11) sub-scales. Although the five sub-scales did not represent areas of concern for the majority of mothers in the study, those mothers who reported more concerns related to their'2firstborn child also reported more concerns related to their expected baby and the upcoming childbirth experience. The higher correlations (r = .55, p g_.001) found for mothers between the firstborn, expected baby and childbirth sub-scales warrant further attention before future study replications are attempted. Higher intercorrelations for these three scales could indicate a relationship requiring consideration of the fusion of the childbirth, firstborn and expected baby sub-scales into one scale for measuring childbearing and Childrearing concerns in general. In addition to the above analysis, the individual 48 items of concern were ranked according to values of mean 171 responses greater than 2.5, and also by the frequency of items assigned tine highest Likert scores. This data is presented in Table 7 along with comparable data from the fathers. Items not included in the five retained sub- scales are indicated. In Table 7 the number of items with nmmui scores > 2.5 and those most frequently assigned the higher Likert score is greater for mothers as compared to fathers. Furthermore, about half of the items receiving higher or more frequent concern scores by mothers were not included in the five study sub-scales due to low inter-item correlations with other items on the assigned scale. Therefore many of the individual items of concern initially prOposed by the investigator, and found to individually indicate areas of concern for mothers, were not included in the final, retained study sub-scales. The Significance of these individual items of concern was not tapped by the present study but indicate areas for further research. It could be that the individual items were poorly constructed in relation to the initially proposed sub-scales, or it could be that the individual items which had higher concern scores represented a dimension of concern not tapped by the initially proposed sub-scales. In addition, these individual items of concern, not retained in a sub-scale, may have been so common among mothers that the varying degrees of concern regarding the item could not be discriminated by the study instrument. 1722 Table 7 Individual Items of Concern Ranked by Mean Response and Frequency for Mothers and Father: Mothers N - 36 Mean Fathers N - 36 Mean Maintaining Control in Labor 3.15 'Time for Spouse to Pursue Her 2.72 Personal Interests *Time for Personal Interests 3.00 Time for Shared Leisure Activities 2.64 with Spouse 'Maintaining Household 3.00 'Oesire Child of Opposite Sex than 2.57 Firstborn Time for Second Child 2.92 *lime for Personal Interests 2.53 Time for Shared Leisure Activities 2.92 with Spouse *Having a Healthy Baby 2.71 *Balancing Needs of Family with 2.69 Other Commitments Loss of Special Relationship with 2.67 Firstborn Difficulty of Labor and Birth 2.66 *Receiving Enough Attention From 2.58 Spouse Children Interfering with Sexual 2.54 Relationship 'Thoughts About Spouse's Health or 2.53 Death Mothers M I 36 Frequency Fathers M - 36 Frequency *Time for personal interests 31 *lime for Spouse to Pursue Her 26 Personal Interests Maintaining Control in Labor 29 Time for Shared Leisure Activities 20 with Spouse Time for Second Child 28 *Time for Personal Interests 19 *Maintaining Household 27 *Considering Sterilization 18 Time for Shared Leisure Activities 27 *Thoughts About Own Health or Death 18 with Spouse *Having a Healthy Baby 24 *Balancing Needs of Family with 22 Other Commitments Loss of Special Relationship with 22 Firstborn Difficulty of Labor and Birth 22 *Receiving Enough Attention From 22 Spouse Children Interfering with Sexual 20 Relationship Having Enough Money to Meet Needs 19 of Family * Indicates items not included in five retained study sub-scales. 173 Question #75 (n1 the study instrument allowed for mothers to write in additional comments regarding their concerns during pregnancy. Additional concerns related to the initially proposed sub-scales follow: 1) self: managing visiting relatives, time away from career, patience needed to deal with two young children, emotional drain of caring for two young children, 2) marital: wanting more children when husband doesn't, time left over for husband after being drained by two children, 3) firstborn: having to leave firstborn with neighbors while in hospital since no family live near, firstborn suffering from lack of attenticnn, 4) expected baby: fear of delivering a handi- capped child, managing breastfeeding baby when returning to work, decreased positive response by family and friends if baby is the same sex as the firstborn child, 5) childbirth: hoping to gain better control during second labor, requir- ing a cesarean section (first baby born vaginally with forceps), problems breastfeeding, developing preeclampsia again, recovering from a repeat cesarean section, and 6) finances and household: financially caring for family, childcare arrangements for returning to work, working to support decreased family income since husband is in graduate school. In summary, although the five sub-scales did not represent areas of concern for the majority of mothers in the study, the marital relationship sub-scale had the highest mean score and stronger relationships were found 174 between the firstborn sub-scale and the expected baby and childbiriji sub-scales. In addition, many items deleted from the study sub-scales were individually ranked by mothers as being frequent areas of concern. Question II. What are the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of their wife's second pregnancy? The mean scores of fathers on the five retained sub- scales are shown in Table 5 along with those of mothers. The fathers' mean scores for all five sub-scales were well below 2.5 indicating that the five sub-scales did not represent areas of concern for the majority of fathers in the study. The percent of fathers who did indicate levels of concern greater than 2.5 on each of the sub-scales follows: childbirth 3% (n=1); marital 28% (n=10); firstborn 6% (n=2); expected baby 8% (n=3); and finances 11% (n=4). As seen in Table 5, the overall mean scores of fathers on the five sub-scales was lower than mothers indicating even lower levels of concerns related to these areas. As with mothers, thOugh, the sub-scale with the highest mean score for fathers was that of concerns related to the marital relationship. The remaining sub-scale areas of concern for fathers in descending order by mean score were: expected baby, firstborn, finances, and childbirth. In comparison, after marital concerns the remaining sub-scale areas of concern for mothers in descending order by mean score were: 175 firstborn, expected baby and finances (both i = 2.24), and childbirth. As seen above, the order of the sub-scales by mean response were similar for mothers and fathers but there was a difference in the mean level of concern between mothers and fathers on each sub-scale. The Pearson r was also computed on the five sub—scales to investigate the degree of relationship between the sub- scales for fathers. The correlations of the sub-scales for fathers are shown in Table 8. As seen in Table 8, correlations between all sub- scales were positive for the fathers in this study. Strongest relationship were found between the firstborn and childbirth sub-scales (r=.69, P<.00), firstborn and expected baby sub-scales (r=.59, P<.00), and marital and expected baby sub-scales (r=.56, P<.00). Correlations between the childbirth and firstborn sub-scales were higher for fathers (r = .69, Pg.000) than mothers (r = .60, Pi.000), whereas correlations between the firstborn and expected baby sub-scales were higher for mothers (r = .67, Pi.00) than fathers (1 == .59, Pg.000). Childbirth and expected baby sub-scale correlations were also higher for mothers 0: = .55, Pg.00) than fathers (r = .44, P5300). Although all correlations between sub-scales were positive, indicating a similar direction of concern on the sub- scales, the level of correlation between sub-scales differed for mothers and fathers. Higher correlations between the firstborn and expected baby sub-scales for 176 mothers indicates less distinction by mothers between concerns for their children in general. Moderate correlatitnu5‘were found between the remaining sub-scales all at significant levels of .03 or less. As with mothers, the higher correlations found for fathers between the firstborn snfly-scale and the expected baby and childbirth sub-scales (r Z_.59, P S_.OO) should be addressed before further study replication. These higher intercorrelations may, in fact, indicate the three scales (firstborn, expected baby, childbirth) actually represent one scale for concerns . Table 8 Intercorrelations of Fathers' Five Sub-scale Concern Scores Child- Expected Sub-scale birth Marital Firstborn Baby Finances .44 .69 .44 .48 Childbirth P=.OO P=.000 =.00 P=.00 .44 .48 .56 .41 Marital P=.00 P=.OO P=.OOO P=.01 .69 .48 .59 .37 Firstborn P=.OOO P=.00 P=.000 P=.01 Expected .44 .56 .59 .33 Baby P=.00 P=.OOO P=.OOO P=.03 .48 .41 .37 .33 Finances P=.OO P=.01 P=.Ol P=.03 In additicni to the above analysis, the individual 48 items of concern were also ranked by mean response and frequency of highest Likert score for fathers. This data is presented in Table 7 along with comparable data from 177 mothers. Items not included in the five retained sub- scales are indicated. As seen in Table 7, the number of items with mean scores > 2.5 and those most frequently assigned tine highest Likert score was less for fathers as compared t1) mothers. In addition, the majority of items receiving higher or more frequent concern scores by fathers were not. included in the five study sub-scales due to low inter-item correlations with other items on the assigned scale. Questirni #75 (Hi the study instrument allowed for fathers to write in additional comments regarding their concerns during their wives pregnancy. These additional concerns were: 1) spouse: coping with mood swings of wife during pregnancy, wife feeling tied down with two children, and 2) marital: dealing with emotional stress between husband and wife when baby is unplanned, and spouses not having enough time for each other. In summary, although the five sub-scales did not represent areas of concern for the majority of fathers in the study, the area of concerns related to the marital relationship had the highest mean score for fathers which is similar to mothers. In addition, items not retained in the final sub-scales represented the majority of items individ- ually ranked by fathers as being frequent areas of concern. As with mothers, the reasons that individual items of higher concern were not retained in the initially proposed sub- scales could be due to poor item construction, poor sub- 178 scale construction which possibly ignored different dimensions of concern, or the homogeneous sample which resulted in difficulty discriminating among the varying degrees of concern on the item. Question III Are there differences in the perceived childbearing, Childrearing and marital concerns of mothers when compared to the perceived childbearing, Childrearing, and marital concerns of fathers during the third trimester of their second pregnancy? A pair-wise comparison of couples for all sub-scales was done computing a difference-score for each couple in order to examine the degree of relationship between the concerns perceived by mothers and fathers. The difference score was based on the subtraction of the father's scores from tjua mother's scores. Positive scores indicated greater concerns by mothers and negative scores indicated greater concerns by fathers. In Table 9 is shown the sub- scale means obtained by computing the difference scores. Table 9 Means of Pairwise Difference Scores Between Husbands & Wives g' g §Q T-Value g Childbirth 36 .27 .42 3.86 .000 Marital 36 .30 .61 2.90 .010 Firstborn 36 .36 .37 5.73 .000 Expected Baby 36 .46 .68 4.03 .000 Finances 35 .31 .49 3.70 .001 179 As seen in Table 9, the means for all five sub-scales are positive indicating that mothers had greater concerns than fathers. The percent and number of mothers indicating greater concerns than their husbands on each of the sub- scales follows: childbirth 72% (n=26); marital 67% (n=24); firstborn 89% (n=32); expected baby 86% (n=31); and finances 86% (n=30). The t-statistic for pairs was also computed for each couple on the five sub-scales. The difference in means for all couples was significant for the five sub-scales at P 5 .01 or better. Data on the paired t-tests is shown in Table 9. The differences in the level of concerns between husbands and wives was statistically significant on all five sub-scales. The probability that the differences found between the amount of concern expressed by each mother and her spouse was a result of chance factors was less than 0.01. The coefficient of variation was computed to compare the variability between spouses on each sub-scale. Variation measures >>Il are considered meaningful and were found for all five sub-scales as follows: nerital V = 2.03, finances V = 1.58, childbirth V = 1.55, expected baby V = 1.48, and firstborn V = 1.03. Therefore, the highest variation in difference scores between spouses was on the marital sub-scale, and the lowest variance between spouses was on the firstborn sub-scale. 180 In summary then, nmmhers indicated having a greater level of concern on all five sub-scales than fathers. Computation of the difference score for pairs on all five sub-scales was positive, indicating that mothers also reported greater levels of concern on all five sub-scales than their spouses. Furthermore, the differences in means found between spouses was significant at 0.01 or better and the greatest variance between spouses was on the marital sub-scale. Significant Findings Among the Extraneous Variables and Study Sub-Scales Included in time final section of this chapter is a presentation of findings relating the extraneous variables (sociodemographic, modifying, action) to the study sub- scales. Emta relevant to mothers and fathers as a group will be discussed. Analysis of Variance (ANOVA) was computed for all nominal-level extraneous variables in order to examine the mean differences between mothers and fathers on the five sub-scales. The nominal-level extraneous variables examined pertained to the three areas of sociodemographics, modifying and action. Sociodemographic nominal-level variables included: 1) ethnic background, 2) religion, and 3) present employment status. Modifying nominal-level variables included: 1) planning first pregnancy, 2) complications with first pregnancy or birth, 3) type of delivery with first child, 4) firstborn child's sex, and 5) 181 feelings regarding first labor and birth experience. Action nominal-level variables were: 1) planning of present pregnancy, 2) plans for attendance of Spouse during labor or birth, 3) planned feeding method for expected baby, 4) attendance at or plans to attend childbirth preparation classes, 5) amount of preparation during second pregnancy as compared to first, and 6) discussion of concerns during second pregnancy with others. Data was examined for previous childbirth experiences which may have modified concerns during the second pregnancy. Mothers vflu: reported feeling negative about their first labor and birth experience (n=7, x = 2.41) had the highest level of childbirth concerns, followed by mothers who reported feeling neutral (n=5, x = 2.26) and mothers who reported feeling positive (n=24, x = 2.05). The difference in the means was significant at the 0.05 level. Action variables data was also collected on actions or decisicnus taken during the present pregnancy which could relate ix) the concerns reported on the study sub-scales. Mothers who were undecided as to whether they would attend childbirth preparation classes (n=2, x = 2.67) reported the highest level of financial concerns, followed by mothers who were planning on attending childbirth classes (n=31, x = 2.30) and mothers who were not planning on attending childbirth classes (n=2, x = 1.17). The difference in the means was significant at the 0.003 level. Differences in the mean level of concerns expressed by mothers on the five 182 sub-scales was significant for the emiraneous variables shown in Table 10. No significant differences were found for fathers. Table 10 Analysis of Variance for Relation of Mothers Extraneous Variables to Sub-scales Modifying ' Action Attending Preparation Planned Discussion Feelings Regarding Childbirth for Feeding of First Labor 8 Birth Classes Childbirth Method Concerns x - 2.15 h' ' - - - - C ildbirth P : .05 - x = 2.44 Marital - - - P 2 .04 - . X = 2.30 Firstborn - - P t .006 - - Expected _ _ X a 2.24 _ X = 2.24 Baby P = .05 P = .02 Financ X a 2'24 es 9 = .003 Mothers who reported preparing less for their second childbearing experience had the highest level of concerns regarding their firstborn child (n=30, x = 2.36) and concerns regarding the expected baby (n=30, x = 2.29). Mothers who reported preparing about the same for their second child caring experience as they did for their first experience had the next highest level of concern for their firstborn child and the expected baby (n=5, x = 2.2). The mother who reported preparing more for her second childbeardJm; experience reported the lowest level of concern on both the firstborn and expected baby sub-scales (n=1, x = 1.00). The significance levels for the 183 difference in means (Ml the relation of childbearing preparation to the firstborn and expected baby sub-scales were 0.006 and 0.05, respectively. Mothers who planned on bottle feeding their second child reported the highest level of marital concerns (n=5, )< = 2.74). Mothers nun) planned on combining breast and bottle feeding their second child reported the next highest level of marital concerns (n=14, x = 2.61). Less marital concerns were reported by mothers who planned or only breast feeding their second child (n=16, x = 2.22). The lowest level of marital concerns were reported by the mother who was undecided as to the feeding method she would use :or run: second child (n=1, 2.0). The difference in means was significant at the 0.04 level. The highest level of concerns regarding the expected baby were reported by mothers who reported they did discuss their concerns during pregnancy with others (n=35, x = 2.28). A lower level of concern regarding the expected baby (n=1, ){ = 1.00) was reported by the one mother who reported she did not discuss her concerns during pregnancy with others. The difference in means was significant at the 0.02 level. In summary, the highest level of childbirth concerns was iknnui with mothers who reported feeling negative regarding their first childbirth experience. Mothers who were undecided about whether or not they would attend childbirth preparation classes reported the highest level 184 of financial concerns. The highest level of concerns regarding the expected baby was reported by mothers who prepared less for their second childbearing experience than for their first, and also by mothers who reported discussing their concerns during pmegnancy with others. Mothers inn) reported preparing less for their second childbearing experience also had the highest level of concerns regarding their firstborn child. The highest level of marital concerns was reported by mothers who planned on bottle feeding their second child. Computation of ANOVA on all nominal-level extraneous variables in search of relations to the study sub-scales resulted in no significant findings for the fathers in the study. In the case of all interval-level extraneous variables the Pearson product-moment correlation coefficient was computed to analyze the relationship to the study sub— scales. Interval-level variables on sociodemographic data included age of parent, education and family income. Interval-level variables on modifying variables included the age of the firstborn child and the length of the first labor. Significant correlations for mothers are shown in Table 11, those for fathers are shown in Table 12. 185 Table 11 Correlations Between Sub-scales and for Mothers Sociodemographic Age of Family Parent Income Childbirth - - Marital - - Firstborn - - Expected Baby - - Finances -.35 -.53 P=.02 P=.001 Table 12 Correlations Between Sub-scales and Fathers Sociodemographic Age of Family Parent Income Childbirth - - Marital - - Firstborn - - Expected Baby - - Finances -.32 -.52 P=.02 P=.001 Extraneous Variables Modifying Length of First Labor .39 P=.Ol Extraneous Variables for Modifying Age of Education Firstborn - -040 p=.01 -032 '- p=.03 186 Sociodemographic Variables The age of the parent was found to be negatively correlated with financial concerns for both mothers (r = -.35, p g .02) and fathers (r = - .32, p _<_ .03). The younger the mother or father, the greater the financLal concerns. Likewise, the family income was found to be negatively correlated with financial concerns for both mothers (r = -.53, p g .001) and fathers (r = -.52, i .001). The lower the family income, the greater the financial concerns for both mothers and fathers. Education was negatively correlated with financial concerns for fathers (r = -.32, p g .03), but these were not found to be significantly correlated for mothers. Modifying Variables For fathers, concerns related to the firstborn child were negatively correlated with the age of the firstborn child (r = -.40, p g .01). The younger the firstborn child the greater the concerns related to the firstborn child by fathers. For mothers, the length of their first labor and birth experience was positively correlated with marital concerns (r = .39, p g .01). The longer the first labor and birth experience the greater the marital concerns reported by mothers. In summary, both mothers and fathers who were younger or had lower family incomes reported greater financial concerns. Fathers with less education also reported 187 greater financial concerns. The younger the firstborn child the greater the level of concerns regarding the firstborn child reported by fathers. For mothers, having a longer first labor and birth experience related to greater marital concerns. Summary Included in Chapter V was a descriptive analysis of the study sample, a review of the reliability indices for the study sub-scales, and answers relevant to the research questions. In addition, findings relevant to the extraneous variables were presented. The data described in Chapter V will be summarized and interpreted in Chapter VI. Based on the study findings, auui with consideration of the conceptual framework, implications for nursing practice and future research will be discussed. CHAPTER VI SUMMARY AND CONCLUSIONS Overview In Chapter VI the research findings of the descriptive study of parental concerns during a second pregnancy will tma breastfeed their baby and these women commented more frequently on the dimension of time when discussing adjustment to the new baby. The lack of consensus between Spouses on the feeding method chosen and the greater marital concerns expressed by mothers in the present study who chose to bottle-feed warrants further research. Possibly, the lack of consensus between spouses on the feeding method chosen is reflected in increased marital concerns by mothers who chose to bottle-feed. Maybe mothers who chose to bottle-feed would rather breastfeed but their husbands are not in agreement, or, maybe mothers who chose to bottle-feed have husbands that would prefer they breastfeed. Either of these situations just given could impact on the marital concerns expressed by bottle-feeding mothers and possibly be reflected in feelings of guilt or marital discord requiring interventions by the clinical nurse specialist in primary care. 205 Attendance at Childbirth Classes The majority of nmfihers (86.1%) and fathers (83.3%) reported taking or planning on taking childbirth preparat- ion classes during the second pregnancy. Attending child- birth classes was found to significantly (p=.003) relate to financial concerns for mothers. Mothers who were undecided as to whether they would attend childbirth classes reported more financial concerns (i=2.67). Possibly the decision of whether or not to attend classes is partially cost related. For some parents, the cost of the class fee along with the cost;u¢ .e oeamwu sunbeam» - .mcouuom oveqacmoEmuovuom mo eovaaeou.meou vea woe—.3em meeeauau—_eu gap: mooeopcuaxo «man an vupu.uaa mueoeaa ueouuuaxo 5o mecuueoo pouecue vea ae_eaocv._eu .aeeeounu—veu meoeumaoeue omen: meowuquocon eo comma aoeuemoca uew no eowuuapa>u _. neueomvaa a o m .‘ Aueaeooeq oeeemmea new newest nae > .oeueou o» meow>eeoe Puu_mxea veg payee: uew newest m—eoo ma eovuu< Aueaemmta vew Hensosmweuu to» meow» Aueeemmea uew a _ 9:26 38m -5235 new 33m mo 20.5383 ,‘l to 28532 3:253 2:33. rafio 2: B A“ eowuoemeeee eo_uoeeuue_ eoeuuaom aueuemoeq new ueFLSe muem>o aueuemocn uew aeeeav mueo>o _ocueou o» meo_>aeme .auwmxee uee peace: Foeueou ou meoe>aeoa poupmxea eee payee: eo.5u< All . |'. e032 meowuamueoa eo emmae aueeemmca new we eowueapa>w _¢ meo_uauueoa eo wanna Aueoemuca uew mo eo_aa=—e>u ¢ uewavaa ‘H 7 ”v uegmga weapon» oweaucmoEmuovuOm uemmmca acouuu» oveaacaoamuo_uom «eumoea nee mmuemwcmaxo ne'eemae_eeu amen an vm_e_uoa uea mouem_cuaxo oeveameup_eu amen an.uovmvvom mecmoeoo Feuwens eea aevcaoee_weu .meeeemev_reu metmueoo —au_cee veg neveeoeu_.eu .ueweaunv—peu mueoeaa meozafima ”.358 A“ «ll 23833.. «Loewe: ueeuumexm . » xuunummu 220 King's (1981) :framework is particularly applicable to interactions occurring between nurses and parents during their childbearing and childrearing years. Nursing is viewed by Harm; as a process of human interactions leading to goal attainment. Nurses must be able to use their knowledge and skills to help individuals and groups cope with present situations while also learning how to adjust to changes in their lives. And finally, nurses must be able to help persons maintain their health so that they can function in their roles. Utilizing King's (1981) concepts it is quite clear that nurses interacting with expectant parents hope to achieve certain goals. Nurses interacting dynamically with parents twill foster achievement of mutually developed childbearing goals. Nurses will need to draw on their knowledge and skills in) help expectant parents cope with the present childbearing experience while also helping expectant parents learn how to adjust to changes in their lives caused by the addition of a new family member. And finally, nurses must be prepared ix) help these parents maintain their physical and emotional health so that they can function in their new roles as parents of two children while also maintaining previous roles. King (1981) views human beings as being social, perceiving, reacting and purposeful beings who are also action and time-oriented. As seen in Figure 4, both the expectant parents and the nurse are human beings who enter the interaction process with certain perceptions about the 221 life event. In the present study, perceptions of nurses were not investigated. Concerns perceived by parents during the second pregnancy were found to relate to various past childbearing experiences or present sociodemographic factors. Younger mothers and fathers and those with lower family incomes were fcmnd to have greater financial concerns. Mothers Mun) reported feeling more negative regarding their first childbirth experience also reported more childbirth concerns during their second pregnancy. In the present study then, it was found that previous life experiences and sociodemographic factors did influence perceptions of mothers and fathers regarding a current life event. In addition, there was a significant difference found in the level of concern reported by mothers and fathers. It was not the intent of time investigator to study the next phase of the model which recognizes judgments made based on evaluation of perceptions. Following King's theory, judgments would then lead to certain mental or physical actions. The action phase of the model was addressed by investigating actions taken by expectant parents to control events during the second jpregnancy. In the present study it was found that mothers who were undecided about attending childbirth preparation classes had the greatest financial concerns. Mothers who prepared less during their second pregnancy than during their first had greater concerns regarding both their firstborn and the expected baby. And mothers who discussed their concerns 222 during pregnancy with others also had more concern regarding the expected baby. The investigator for the present study did not attempt to explore concepts in King's (1981) model occurring beyond the action pmase. But as seen in Figure 4, it is at this next phase, the reaction phase, that all the previous factors influencing perceptions of mother, father, and nurse begin to unfold an; individuals i1) the interacting process begin to react to the other's perceptions of the present event. It was not the intent of the investigator to study the reaction, interaction, or transaction phases of King's model as they apply to expectant parents. What is evident from the study is that, at the point of reaction in the interaction process with the nurse, expectant parents join in the process with perceptions which must be explored by the nurse if mutual goals are to be identified. In the present study it was found that mothers and fathers differed significantly in the amount of concern reported on all five sub-scales. Without knowledge of perceptions of each parent the nurse will be at a disadvantage to compare her perceptions with those of the parents, evaluate areas which are similar or different, and proceed with interactions which are productive and lead to interventions which meet the parents' needs. Implications of Questions I, II, and III to Nursing Practice Based on the above application of King's theory to the present study, implications for nurses in practice can be 223 addressed. First, nurses in advanced practice must identify their (fifll perceptions regarding expectant parents. In the case of second-time parents, nurses must acknowledge the individual perceptions of each parent. Even though both parents experienced the same previous life event (first childbirth), each parent's first childbirth experience was probably not perceived as being identical to the other parent's and so the individuality of perceptions must be assessed. A meaningful finding of this study was that mothers and fathers reported significantly different levels of concern on the study sub-scales. The clinical nurse specialist in advanced practice should have the interviewing skills needed to obtain data on each parent's perceptions during the second pregnancy. The clinical nurse specialist in advanced practice will need to implement strategies to access expectant parents, particularly fathers. Parenting classes, conducted by clinical nurse specialists through community hospitals and organizations, may offer parents a bridge of support to deal with childrearing concerns before and following the birth of a child. Parenting classes should be offered at various times and settings (evening and morning hours, places of employment) so that both mothers and fathers from a variety of socioeconomic backgrounds can be reached. The family clinical nurse specialist should involve herself in continuing education offerings for nurses working with expectant parents to educate her colleagues to the changing 224 needs and perceptions of mothers and fathers adapting to additional family members. Nurses rmast be able ix) assess similarities and differences between their own perceptions and those of each parent” In order for mutual goal setting to occur, nurses should assist parents in recognizing the simihnfitjes and differences (n5 their perceptions within the marital dyad. Utilizing role modeling in various settings, such as prenatal clinics, childbirth classes, labor and delivery or postpartum units, where nurses interact with both mothers and fathers, nurses in advanced practice will be able to demonstrate communication techniques which promote the feedback of each parent regarding their perceptions. By role modeling acceptance of individual perceptions and sound communication techniques, the clinical nurse specialist can promote better awareness of perceptions within the dyad and also between each parent and their health care providers. Attendance by fathers at their wives' prenatal and postpartum clinical appointments and their childrens' well-child examinations should be initiated and encouraged by nurses in advanced practice caring for families. By dynamically encouraging involvement of fathers and siblings, the clinical nurse specialist will be able to better assess family interactions and offer anticipatory guidance regarding family adaptation, communication, or development. In addition, the clinical nurse specialist working with families in the primary care setting will be promoting health care which is truly comprehensive and continuous. 225 Part CHE recognizing one's own perceptions about a particular life event is comparing one's own perceptions to those (n3 others. Current literature incorporating new findings from nursing research and other social science disciplines should be utilized fully by nurses to reevaluate their own perceptions. Continuing education through reading professional nursing journals to attending conferences, seminars and workshops can be stimulating methods for keeping abreast of new knowledge within the nursing profession. Nurses with generic education in nursing may particularly benefdi: from continuing education activities. Through workshops on family assessment or on interviewing skills needed in caring for childbearing families, nurses can expand their knowledge and gain from undergraduate nursing education. Clinical nurse specialists in advanced practice should be leaders for other nurses caring for expectant parents by involving themselves as consultants or speakers at continuing education offerings. Nurses in advanced practice must be able to assess the individual perceptions, needs, and goals of parents during different childbearing and childrearing stages. Nurses practicing true family-centered nursing must redirect their attention from focusing solely on the acute care of the pregnant or laboring mother to promoting the health of all family members as they adapt to life changes during the childbearing and childrearing years. Nurses in advanced practice must take the initiative to share knowledge of family concepts through research and education with nurses 226 caring for expectant parents so that the health of the entire family is promoted. ‘Variablens influencing perceptions of parents expecting their second child must be identified by nurses in advanced practice caring for this group. In the present study, mothers who reported feeling negative regarding their first childbirth reported more childbirth concerns during the second pregnancy. Increased childbirth concerns of multi- paras have been identified by previous researchers (Larsen, 1966; Norr, et al., 1980; Westbrook, 1978; Winokur & Werboff, 1956). In the present study, mothers who were undecided as to whether (Mr not they would attend childbirth preparation classes during their second pregnancy also reported increased financial concerns. Ln organizing childbirth preparation classes for repeat parents, nurses in primary care must consider and evaluate financial deterrents for parents attending. Possibly offering tuition reimbursement for lower income families or offering concurrent child care for the older sibling may encourage more parents to attend repeat childbirth classes. Once again, perceptions of the parents need to be assessed before realistic goals which are mutually identified can be met. Ln the present study, fathers with younger firstborn children reported greater concern regarding their firstborn child. Mermin (1982) found that fathers of one child were least satisfied as they approached a second childbirth. Possibly satisfaction with a second childbirth is somehow related to the age of the firstborn child and increased 227 concern by fathers for younger children. Again, perceptions of both fathers and mothers, along with variables influencing their perceptions must be identified by nurses caring for this group. Through further research and evaluation of nursing interventions, nurses in advanced practice will gain a better understanding of the perceptions of expectant mothers and fathers. Knowledge of parental perceptions will lead to the development of nursing interventions which can be evaluated as to their ability to best meet the needs of childbearing mothers and fathers. Nurses vfliji knowledge of family concepts will want to assist parents in identification of their own perceptions of the meaning of the addition of a new family member. Based on this knowledge of the family, nurses in primary care will want to offer parents the anticipatory guidance needed to be prepared to adapt to these life changes. One finding from the present study was that books and childbirth class instructors are highly utilized by parents as sources of information during pregnancy. Interventions as simple as suggesting good books to assist parents in dealing with issues of importance to them should not be overlooked. Since childbirth preparation instructors are usually nurses who meet with both mothers and fathers over several class periods, they are in a wonderful position to augment repeat childbirth classes with dynamic approaches to parenting. In addition to offering information on managing labor and birth, why not offer an additional class or classes directed by the clinical nurse specialist on family 228 adaptation and managing changes brought on by an additional family member? Anticipatory guidance regarding adjustment of the firstborn child, maintaining a good marital relationship with children, or time management with a growing family may prove beneficial in preventing adaptive problems within the family and should be incorporated by nurses in advanced practice. In addition, clinical nurse specialists in advanced practice must evaluate the role of all nurses workimg in primary care settings. The promotion of the nurse's time for family-centered assessment, education and counseling of expectant parents, along with the performance of physical assessments and technical tasks, is an area which requires the support and involvement of nurses in advanced practice. Nurses in both education and advanced practice must risk involvement in research, the testing of theories, and the evaluation of interventions based on these theories and research. Although all nurses may not be in a position to initiate research, nurses in education and advanced practice may be able to assist their colleagues as clinical experts in the development of the study instrument. Nurses in advanced practice can involve all nurses in assisting with data collection and with the testing of nursing interventions in the clinical setting. Ideas for research, related to issues Specific to families during the childbearing and childrearing years, should be generated by nurses in advanced practice and brought in) the attention of research committees of .institutions which do have the resources available for 229 nursing research. Clinical nurse specialists on these research committees can focus efforts towards identifying perceptions of families during the childbearing and childrearing years 5M) as to develop nursing interventions which allow for the families' needs to be met through mutual goal setting. In summary, several suggestions have been made regarding the implications for nursing education and advanced practice. Nurses must be able to assess and reevaluate their own perceptions regarding parents during the childbearing years. Nursing education and practice cannot focus solely on the acute needs of parents during childbirth periods. Nursing interventions which are family-centered should promote health of the entire family. Specific interventions like anticipatory guidance or role modeling of communication techniques may be effective in promoting healthy adaptation in childrearing families. Continuing education, which expands (”1 family concepts introduced at the undergraduate level, should be encouraged for all nurses. Involvement in nursing research by clinical nurse specialists in primary care will promote expansion of the knowledge base of nursing in regards to both parental and nurse perceptions during the childbearing and childrearing years. Implications of Questions I, II, and III for Nursing Education In reassessing their own perceptions of the child- kNearing family, nurses in education must also evaluate their 230 judgments and actions generated from their perceptions. Does the nurse educator prefer to assign primiparas rather than multiparas to her undergraduate nursing students because of the assumption that primiparas need more care and therefore primiparas offer a better learning experience to the student? If so, many students may not be given the opportunities during their undergraduate nursing education to acquaint themselves with perceptions of multiparas during the child- bearing period which are unique to multiparas or similar to primiparas. In) nurse educators focus the curriculum mainly on the challenges and problems confronting first-time parents in adapting ix) their firstborn child? If so, nursing students may never learn to appreciate the complexity of forces interacting within the family when a second or third child is added. The period of undergraduate nursing education is important in the development of perceptions in students which are likely'ix> influence them once they are practitioners. Therefore, nurse educators must promote diverse learning situations which acknowledge the unique needs of each individual. The introduction of family concepts at the undergraduate level, and further integration of family concepts at the graduate level, will promote a broader base of knowledge for nursing students and practitioners. Recommendations for Future Research Recommendations for future nursing research based on filuiings from the study are presented in the following Section. 231 Instrument Revision and Study Replication lJ Replication of this research study is recommended gnly after revision of the instrument. The instrument struc- ture originally proposed did not prove to be highly reliable in the present study. Reevaluation is necessary to determine if the childbirth, firstborn and eXpected baby sub-scales are independent sub-scales or if they do continue to lack multi- dimensionality as in the present study. If after revision and replication, the reliability measures remain the same or lower and intercorrelations of the childbirth, firstborn and expected baby sub-scales remain high, then there is additional evidence that the proposed instrument structure should run: be retained. High intercorrelation between the firstborn and expected baby sub-scales, along with conceptual legitimacy, warrant consideration of fusing these scales into (NH? scale measuring concerns regarding children. This new scale would then need to be tested with samples of parents expecting their second child. The remaining sub-scales would then need to have other items formulated to naintain the internal consistency of each scale. Additional factor analysis of the study items, not limited to seven clusters, might delineate the conceptual make-up for different sets of measures than the seven proposed by the investigator for the present study. These newly clustered measures might prove to be more reliable in future studies. 2. Replication involving lower socioeconomic subjects in order to obtain a more culturally and socioeconomically diverse sample. 232 3. Replication with the same group of parents during each trimester would add to the findings. Concerns identified by parents during each trimester of the prenatal period could 1x3 compared to their concerns during the postpartum period. 4. Replication is suggested using samples which include mothers and fathers expecting their first, second, third, or fourth child so that comparisons between these groups can be made. Expanded Research 1. 'The perceptions of nurses caring for childbearing couples in conjunction with those of the mother or father need to be explored. Nursing interventions should be made with time clear knowledge that their perceptions can effect goal attainment by the mother or father. Nurses need more knowledge about perceptions of parents, but nurses also need an awareness of their own perceptions when interacting with these parents. 2. Extraneous variables investigated in the present study offer direction for future research. Research efforts should focus on identifying those variables which consis- tently relate to increased concerns by parents so that constructive nursing interventions can be developed. 3. Concern regarding the marital relationship was reported by both mothers and fathers to be the scale with the highest level of concern but the greatest variance between spouses. A study which evaluates marital satisfaction (using 233 standardized marital satisfaction scales) during the childbearing and childrearing years in relation to parental concerns could 1x3 conducted. Lt would be interesting to compare changes in marital satisfaction of spouses over time in relation to various areas of concern. 4. Individual items reported by mothers and fathers to have greater levels of concern, but that failed to correlate VUJfll other items on a sub-scale, could offer direction for future research. Different dimensions than those tapped by the study sub-scales, such as time demands or changes expected anfli the addition of another child, could provide focus to future research endeavors. 5. Multi-site studies would allow for random sampling of parents ihxnn a variety of socioeconomic levels allowing for further interpretation of the effects of extraneous variables (n1 parental concerns during various childrearing stages. A large-scale study of this type would probably require funding by national health or nursing organizations or government agencies. Experimental Research From significant findings of descriptive studies nursing interventitnus need to be developed and their effectiveness researched. A study could be designed to evaluate adaptation and gratification of parents fellowing the birth of their child who were exposed to additional classes on childrearing or family adaptation along with the more traditional core childbirifli preparation classes during the prenatal period. 234 Various strategies should be evaluated, such as combining or separating mothers and fathers during critical discussnm1 periods and having a male direct the fathers' discussions and a female direct the mothers' discussions, or possibly having couples who delivered their second child in the last year return to moderate the class discussions. More research needs to be implemented in order to evaluate the effective- ness of nursing behaviors and interventions. Studies designed to evaluate the effectiveness of nursing intervent- ions in promoting healthy adaptation to life changes during the childbearing and childrearing years would be valuable and should be generated by the clinical nurse specialist in advanced practice. Marital Stressors ResultingAFrom Couples' Differing Concerns After identification of Cfiffering perceptions between spouses are identified through further research, the effect of these differences on reactions, interactions and trans- actions between spouses needs to be investigated. Marital stress caused by differing areas or levels of concern between spouses may hinder the healthy adaptation of families during the childrearing years. Interventions With Siblings The clinical nurse specialist in advanced practice need to study auui evaluate those nursing interventions with siblings which promote healthy adaptation of the entire family to its new member. Prior to intervening, more des- criptive studies are needed to establish current practices 235 regarding preparation of siblings during the childbearing period. Studies sflumahd consider the age of siblings when examining current practices and interventions which are found to be most effective. Conclusion There is a need for continued research into the concerns of parents and children during each stage of the family life cycle. The interrelationship of research to theory develop- ment, practice, and education is an ongoing process which must be maintained by nurses in advanced practice in order to promote dynamic nursing interventions with families. This study, which proposed to investigate the concerns of mothers and fathers expecting a second child, attempted to test nursing theory as it relates to individuals experiencing a very normal life event. There are major methodological weaknesses within the study. The small sample of subjects was non-randomly obtained from two main sites, private physician's practices and childbirth or sibling preparation classes. The non- probability sample limits the generalizability of the study findings beyond tflue study sample. limitations of a small sample were found in relationship to various extraneous variables thereby making potentially meaningful comparisons irrelevant. These limitations may have been reduced by utilizing a broader choice of sites for subject selection. Including study participants obtained from public prenatal 236 clinics, and subjects obtained randomly, would have strengthened the study sample. (Nu? other major limitations of the study were a very homogeneous sample and the use of an instrument which was not previously tested. Two of the seven initially proposed sub- scales were not retained, reliability indices on the remain- ing five sub-scales were low, and intercorrelations on three sub-scales were too high and therefore determined to be unacceptable for replication. Further testing of the instru- ment is necessary. Reliability of the imerument may be improved by adding relevant items to each sub-scale which expand on the concept, or by increasing the heteroginicty of future study samples through random selection from a variety of sites (Polit & Hungler, 1983). Longitudinal studies must be developed which compare changes over time in families during the childbearing and childrearing years. Descriptive studies will provide the base needed for further investigative studies of the effectiveness of nursing interventions. Ideally studies would be geared to assess the adjustments of couples and families during each stage and with each family addition. Longitudinal studies are generally more costly, time consuming, and threatened by attrition. Although the difficulties common to longitudinal studies can not be easily ignored, the effectiveness of the longitudinal design in studying families may well be worth the effort of nurses in advanced practice. 237 With an awareness of the study limitations, several significant relationships were found which merit further investigation. The conceptual framework of King's (1981) nursing theory was found to provide the structure needed in interpretiju; the study questions. Although reactions, interactions and transactions of expectant parents were not measured, the significant differences found between spouses in their level of concern would be cause for suspicion regarding the effectiveness of previous interactions. Healthy adaptations of family members to life changes would be promoted by interactions which develop from an awareness of perceptions which eventually lead to effective trans— actions. King's (1981) concept of perceptions can offer direction to nurses in advanced practice and primary care as they interact with families to promote their health during the childbearing and childrearing years. In Chapter VI the research findings were presented. Included were a description and analysis of the study sample as compared to other studies. The implications and recommendations for nursing practice, education and research were discussed. APPENDI CES APPENDIX A MOTHER'S QUESTIONNAIRE 247 FATHER'S QUESTIONNAIRE Please answer each question to the best of your knowledge. 1. What is today's date? , 1987 (month) (day) 2. When is your baby's expected due date? , (month) (day) 1987 3. What is your age? 4. What is your ethnic background? (Please circle one). a. White b. Black c. American Indian d. Mexican America e. Oriental f. Other (Specify) 5. What is your religious affiliation? (Please circle one). a. Catholic b. Jewish c. Protestant d. None e. Other (Specify) 6. What is the hi best level of education you completed? (Please circle one). a. Grade school d. Some college courses b. Some high school e. College graduate c. High school graduate f. Beyond 4 years of college 7. What is your family's annual income? (Please circle one). a. $9,999 and under d. $30,000 to $39,999 b. $10,000 to $19,999 e. $40,000 to $49,999 c. $20,000 to $29,999 f. Above $50,000 r 10. ll. 12. 13. 239 What is your present employment status? (Please circle one). a. Employed full time (40 hours/week) b. Employed part time (Less than 40 hours/week) c. Homemaker d. Unemployed What are your intentions for employment after your second child is born? (Please circle one). a. Full—time employment (40 hours/week) Part-time employment (Less than 40 hours/week) c. No plans to work outside the home Was your first child planned? (Please circle one). a. Yes b. No Did you have any major complications when you were pregnant with your first child (e.g. high blood pressure, diabetes, etc.)? (Please circle one). a. Yes b. No If yes, please briefly describe the complications you had: How long were you in active labor with your first child? (Please circle one). a. 5 hours or less d. 16-20 hours b. 6-10 hours e. 21-24 hours c. ll-lS hours f. more than 24 hours What type of birth did you experience with your first child? (Please circle one). a. Vaginal b. Vaginal with forceps c. Cesarean 14. 15. l6. 17. 18. 19. 20. 240 Did you experience any major cxmmflications during your first child's birth? (Please circle one). a. Yes b. No If yes, please explain the complications you had: What is the sex of your first child? (Please circle one). a. Male b. Female What is the age of your first child? (Indicate number of years and months). years months How would you describe your feelings regarding your first labor and birth experience? (Please circle one). a. Positive b. Neutral c. Negative Was your current pregnancy planned? (Please circle one). a. Yes b. No Do you and your spouse plan on being together during labor with your second child? (Please circle one). a. Yes b. No c. Undecided Do you and your spouse plan on being together during your second child's birth? (Please circle one). a. Yes b. No c. Undecided 21. 22. 23. 24. 25. 241 What method have you decided upon for feeding your second child? (Please circle one). a. Breast b. Bottle c. Breast and bottle d. Undecided Do you plan on attending or have you attended childbirth preparation classes during this pregnancy? (Please circle one). a. Yes b. No c. Undecided How much preparation (reading, television viewing, classes, discussions) related to childbirth and children have you done during this pregnancy compared to the amount (If preparation you did during your first pregnancy? (Please circle one). a. About the same amount b. More with this pregnancy c. Less with this pregnancy What is your source for information concerning childbirth and children. (May circle more than one). a. Books f. Personal experience b. Magazine articles 9. Family and friends c. Newspaper articles h. Doctor (8) d. Pamphlets from doctor's office i. Nurse Midwife e. Television programs j. Nurse (8) k. Instructor in childbirth preparation classes. Do you discuss your pregnancy or childbirth concerns with others? (Please circle one). a. Yes (Go on to question #26). b. No (Go on to question #27). 26. 242 If yes, \uith whom Ch) you discuss your pregnancy or childbirth concerns. (May circle more than one). a. Spouse Relatives Friends d. Doctor (5) e. Nurse Midwife f. Nurse (5) g. Instructor or other parents in childbirth preparation class h. Other (Specify) Please turn the page and complete the remainder of the questionnaire. Thanks! 243 Directions The following are a variety of concerns that parents may have during a second pregnancy. Please check the appropriate box to the :right of each statement indicating to what extent you agree or disagree that each statement expresses a concern that you might have during this pregnancy. A concern should be thought of as something ‘that occupies your thoughts, attracts your interest, or is possibly disturbing to you. Please respond to all the statements by checking the apprOpriate box indicating if you: strongly agree(SA), agree(A), disagree(D), strongly disagree(SD), or feel the statement is not applicable(NA). SA A D SD NA 27. I am afraid that my figure will not return to normal after the baby is born. [J [J [J [J [J 28. I feel confident that my husband will think I give him the help and support he needs after the baby is born. [J [J [J [J [J 29. I feel I have lacked the energy needed to give my first-born child the attention he/she needs during this pregnancy. [J [J [J [J [J 30. I worry if my second labor and delivery experience will be more difficult than my first. [J [J [J [J [J 31. I am concerned by changes in my husbands sex drive during this pregnancy. [J [J [J [J [J 32. It should not be difficult to keep up our house as I would like after our second child is born. [J [J [J [J [J 33. I am confident that the addition of a second child will not hamper my career goals. [J [J [J [J [J 34. I worry that I will have to give up the special relationship I have with my first- born child after the baby is born. [J [J [J [J [J 35. I am not concerned by any changes in my sex drive during this pregnancy. [J [J [J [J [J 36. My husband and I are considering the possibility of sterilization (vasectomy or tubal ligation) after the baby is born. [J [J [J [J [J 37. I find myself thinking more often about my husband's health or possible death. [J [J [J [J [J 38. 39. 4C. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 244 I feel comfortable with our plans for the care of our first-born child while I am in the hcsyital. I am certain of the method of contraception my husband ard I will tse after the baby is born. I feel having a second child will not hamper my husband's career goals. I am confident in my ability to care for a new baby again. I am concerned that the addition of a second child will interfere with my husband's and my sexual relationship. I am confident that nothing bad will happen to me during my labor and delivery. I find myself thinking more about my own healil (I lcssille death. I am certain that my hustand will be able to love our second child as much as he loves our first. I feel confident that our first-born child will love the new baby. I wonder if I will be able to love my second child as much as I love my first-born child. I am confident that my doctor, nurse midwife and nurses will be supportive of my emotional needs during my hospitalization. I am happy about this pregnancy. I am sure that my husband will have enough time to pursue his personal interests after our second child is born. I am concerned that my husband does not seem to be happy about this pregnancy. I worry that something will be wrong with this baby. I worry about having enough money to buy what my family wants and needs. [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J (7 [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J INA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 245 I wonder if my husband will be able to give me the attention I need after the baby is born. I feel comfortable that my husband and our first-born child will be allowed to visit me and the new baby as much as I would like while I am in the hospital. I feel the Space available in our house can easily accommodate a second child. I worry that I will not get the support I need from my husband during my labor and delivery. I feel prepared for my second labor and delivery. I think my husband finds me sexually unattractive during this pregnancy. I feel confident that we can afford to raise a second child. I am concerned that caring for two children will leave me little time for myself and my own interests. I worry that I will not be able to give my second child the time and attention I gave my first-born child. I hope our second child is the Opposite sex from our first-born child. I am afraid that our first-born child might act aggressively toward the new baby. I am confident that my husband and I will have enough time for shared leisure activities after we have our second child. I feel I have gotten the support I need from my family and friends during this second pregnancy. I worry about being able to balance the needs of my family with my other commitments and responsibilities. SA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J SD [J [J [J [J [J [J [J [J [J [J [J [J [J [J NA [J [J [J [J [J [J [J [J [J [J [J [J [J [J 68. 69. 70. 71. 72. 73. 74. 75. 246 I feel confident that I will be able to give my first-born child the attention he/she needs after the baby is born. Career changes made after the birth of our second child will decrease our family income. I feel that I will receive quality physical care from my doctor, nurse midwife and nurses while I am in the hospital. I worry about my husband feeling stifled after our second child is born. I am concerned that my f “at-born child may regress in the skills ne/she has learned after the baby is born. I wonder if I will be able to stay in control during my labor and delivery. I am concerned about the health care costs for having our second child. SA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J SD [J [J [J [J [J [J [J Please describe any concerns you may have during this second pregnancy which were not addressed by the statements above. NA [J [J [J [J [J [J [J THANK YOU 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 253 I worry that I will not be able to give my second child the time and attention I gave my first-born child. I feel that my wife will receive quality physical care from her doctor, nurse midwife, and nurses while she is in the hospital. I worry that something will be wrong with this baby. I am concerned that the addition of a second child will interfere with my wife's and my sexual relationship. I feel I have lacked the energy needed to give my first-born child the attention he/she needs during this pregnancy. I am afraid that my wife's figure will not return to normal after the baby is born. I feel confident that we can afford to raise a second child. I worry about having enough money to buy what my family wants and needs. I feel confident that I will be able to give my first-born child the attention he/she needs after the baby is born. My wife and I are considering the possibility of sterilization (vasectomy or tubal ligation) after the baby is born. I am afraid that our first-born child might act aggressively toward the new baby. I am sure that my wife will have enough time to pursue her personal interests after our second child is born. I worry if my wife's second labor andN delivery experience will be more difficult than her first. I am confidert that the addition of a second child will not hamper my career goals. I am not concerned by any changes in my sex drive during this pregnancy. SA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J NA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 254 I feel having a second child will not hamper my wife's career goals. I am confident that nothing bad will happen to my wife during her labor and delivery. I find myself thinking more about my own health or possible death. I feel I have gotten the support I need from my family and friends during this second pregnancy. Career changes made after the birth of our second child will decrease our family income. I worry that I will not be able to give my wife the support she needs during her labor and delivery. I worry about being able to balance the needs of my family with my other commitments and responsibilities. I am confident that my wife's doctors, nurse midwife, and nurses will be supportive of her emotional needs during her hOSpitalization. I am happy about this pregnancy. I feel the space available in our house can easily accommodate a second child. I am certain of the method of contraception my wife and I will use after the baby is born. I feel confident that my wife will think I give her the help and support she needs after the baby is born. I am concerned by changes in my wife's sex drive during this pregnancy. I am confident that my wife and I will have enough time for shared leisure activities after we have our second child. I wonder if I will be able to love my second child as much as I love my first-born child. I am concerned about the health care costs for having our second child. SA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J SD [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J NA [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J [J fhv 69. 70. 71. 72. 73. 74. 75. 255 I find my wife sexually unattractive during this pregnancy. I feel prepared for my wife's second labor and delivery experience. I wonder if my wife will be able to stay in control during her labor and delivery. I feel comfortable with our plans for the care of our first-born child while my wife is in the hospital. I worry about my wife feeling stifled after our second child is born. I worry that I will have to give up the special relationship I have with my first- born child after the baby is born. SA [J [J [J [J [J [J A [J [J [J [J [J [J D [J [J [J [J [J [J SD [J [J [J [J [J [J Please describe any concerns you may have during this second pregnancy which were not addressed by the statements above. THANK YOU NA [J [J [J [J [J [J APPENDIX C LETTER OF AGREEMENT TO ASSIST WITH STUDY 256 xxxxxxxxx XXXXXXXXX XXXXXXXXX XXXXXXXXX Dear xxxxx: Thank you for agreeing to approach your clients who are expecting their second child for inclusion in my study. As we discussed the purpose of the study is to investigate the concerns perceived by parents (both mothers and fathers) during the third trimester of their second pregnancy, while expecting their second child. By helping me to contact parents expecting their second child, you will be supporting my efforts to complete requirements for a Master's degree in Nursing from Michigan State University. Again, let me assure you that assisting with the study will take very little of your time and approximately only 20 minutes of your cflient's time. All the participants' responses on the study questionnaire will remain strictly confidential. As we discussed, all study participants should be 21 years of age, experiencing the third trimester of a normal pregnancy, have one normal child who is alive and well (gravida 2: para 1), and be married to their child's and the expected baby's biologic father. Although no beneficial claims will be made to participants in the study, it is hOped that those of your clients who agree to answer the study questionnaire will find it an interesting and worthwhile experience. Enclosed is a copy of the study questionnaire for your information. If you have any questions regarding the question- naire please feel free to contact me at the number given below. I will make arrangements to deliver the introductory letters for potential study participants to your office within two weeks so that you or your office staff can begin to share them with receptive clients as soon as possible. Thank you again for helping to support my research and educational efforts! I hOpe you find that the feedback from your clients who choose to participate in the study is positive! Sincerely, Nancy L. Maudlin, R.N., C., M.A., MSN Candidate Michigan State University College of Nursing, Graduate Program Family Clinical Nurse Specialist Program Phone: (616) 375-8850 APPENDIX D LETTER OF INTRODUCTION TO PARENTS 257 Dear Expectant Mother and Father: The purpose of this letter is to request your participation in a study of parents (both mothers and fathers) who are expecting their second child. JI am a certified family nurse practitioner and a graduate student presently completimg requirements for a Master's Degree in Nursing at Michigan State University. In order to provide the best nursing care possible to parents who are expecting their second child, it is important that nurses better understand those concerns which are unique to parents during their second pregnancy. The purpose or the study is to gain information regarding concerns specific to those parents who are expecting their second child. By completing the questionnaire developed for this study, you and your spouse will have the opportunity to share the thoughts, feelings and concerns you may have during this pregnancy as you anticipate the arrival of your second child. Participation in this study is voluntary. All participants should.1xa at least 21 years of age and at least 27 weeks into their second pregnancy. The completion time is approximately 20 minutes and all responses will remain confidential. You are free to withdraw from the study at any time. Participation in the study or withdrawal from the study will in no way effect the health care your family is now receiving. Thank 3mm: for considering to share your time and thoughts with me for the benefit of other parents who are expecting their second child. My best wishes to you both for an enjoyable birth. Sincerely, Nancy L. Maudlin, R.N., C., M.A., MSN Candidate Michigan State University College of Nursing, Graduate Program Family Clinical Nurse Specialist Program Phone: (616) 375-8850 If you think that you and your spouse might be interested in participating in the study, please fill out the attached form and leave it with the receptionist or class instructor. Please feel free to take this letter home with you for your information. If you indicate interest in participating in the study by completing the attached form, you can expect to be contacted by me within two weeks. 258 Yes, my spouse and I are interested in participating in your study on concerns of parents expecting their second child. Jame: -- -------’.'-Qmu.-- Mailing Address Zip Code Home Phone: Work Phone: Best time to call: [J Check this box if you would like a summary of the Study. APPENDIX E TELEPHONE SCREENING TOOL 259 u—oeomao: memem new uo_ccez mmepeeez meow>oea emcep_eu mpeweea bemopo_m mmwueeemmea mo geese: peace . eeoaemeeu eeo_~a= sueaemoca peacezu pesto: Hw A om< memo . * ouou beea_o_ugea eeeop_eu eoFmspueH .oo» me_emmcom 260 .emumoecoc me_p oboe e_ boaueou oeoeampoe a:-3oppou me .mueaawo_eeea m>_uumamoca ep_z pumpeou meoeao—m» peweweH HHH so» xeaee emeozme< meopumoao eo_umaeo_ueea eo eme_umee= muaa_u_peea o» —mmzemm ouma_uwueea o» mocm< sense ea zo_>ae eopuoaoocaen open * meow nemaFuPucea mob pomueou meoeampme APPENDIX F CONSENT FORM 261 CONSENT FORM Being at least 21 years of age, I consent to participate in one study requiring the completion of one research questionnaire of approximately 20 minutes. It has been explained to me and I understand that: l. The purpose of the research is to gather information on the concerns of expectant parents during the third trimester of their second pregnancy: 2. Participation in the Study or withdrawal from the Study, will in no way effect the health care my family receives. 3. The questionnaire is not intended to be therapeutic or educational and no claims of beneficial therapeutic or educational effects have been made: 4. Reading and answering questions related to concerns experienced during a second pregnancy may cause emotional discomfort. The possibility of emotional discomfort is the only potential Study risk identified: 5. I may discontinue my participation at any time: 6. All information obtained will be treated with strict confidentiality and the identity of participants will remain strictly anonymous: 7. I have been given an Opportunity to ask questions about the Study» If I have any further questions, I may contact Nancy L. Maudlin, R.N., at (616) 375-8850. 8. Results will be made available to me upon request. My consent to participate is freely given, without coercion by anyone. My return of the completed questionnaire constitutes my informed, voluntary consent to participate in the Study. APPENDIX G GENERAL DIRECTIONS 262 General Directions Thank you for agreeing to take the time necessary to take part in this study. The purpose of this study is to explore the concerns of mothers euul fathers expecting their second child. The information that you and your spouse and other couples provide will help other nurses and myself in planning the health care of parents who are expecting their second child. Mothers, please complete the pink questhnumire; and fathers, please complete the blue questionnaire. Please read the directions before beginning to answer your questionnaire and answer all questions as honestly and accurately as you can. To insure confidentiality, do not put your name anywhere on the questionnaire. As you answer the questionnaire, please remember that it is not a test. There are no wrong or right answers to any of the questions. Therefore, your honest responses are appreciated. If you do not understand any part of the question- naire, please do not hesitate to call me at the number below for help. After you both have completed the questionnaires, please feel free to discuss your answers with your spouse, but do 223 change your answers. Then, please place the questionnaires in the stamped envelope provided and return them to me within one week. I will be pleased to send you a summary of the results of this study following its completion if you so desire. Again, thank you for your time and help in my study. Nancy L. Maudlin, R.N., C., M.A., MSN Candidate Michigan State University College of Nursing, Graduate Program Family Clinical Nurse Specialist Program Phone: (616) 375-8850 APPENDIX H VERIFICATION OF RESEARCH APPROVAL 263 MICHIGAN STATE UNIVERSITY UNIVERSITY COMMITTEE ON RESEARCH INVOLVING EAST LANSING 0 MICHIGAN 0 (8824-1046 HUMAN SUBJECTS (UCRIHS) 238 ADMINISTRATION BUILDING (517) 395-2186 August 4, 1987 Ms. Nancy L. Maudlin 5405 Swallow Kalamazoo, Michigan 49002 ”F Dear Ms. Maudlin: z-m s ... - .. ' Subject: Proposal Entitled, "Parents' Perceived Concerns While Expecting Their Second Child" UCRIHS' review of the above referenced project has now been completed. I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and the Committee, therefore, approved this project at its meeting on August 3, 1987. You are reminded that UCRIHS approval is valid for one calendar year. If you plan to continue this project beyond one year, please make provisions for obtaining appropriate UCRIHS approval prior to August 3, 1988. Any changes in procedures involving human subjects must be reviewed by the UCRIHS prior to initiation of the change. UCRIHS must also be notified promptly of any problems (unexpected side effects, complaints, etc.) involving human subjects during the course of the work. Thank you for bringing this project to our attention. If we can be of any future help, please do not hesitate to let us know. Sincerely, WWL Henry E. Bredeck, Ph.D. Chairman , UCRIHS HEB/jms cc: Dr. Barbara Given MEI/0's am Affirmative Adiom/qual Oppnrfwmify Institution APPENDIX I RETAINED STUDY SUB-SCALES 264 PrOposed and *Retained Sub—scale Items of Concern Self I am concerned that caring for two children will leave me little time for myself and my own interests. I am confident that the addition of a second child will not negatively change my career goals. I feel I have gotten the support I need from family and friends during this second pregnancy. I am happy about this pregnancy. I worry about being able to balance the needs of my family with my other commitments and responsibilities. I am afraid that my figure will not return to normal after the baby is born (Item only on mother's questionnaire). Spouse I find myself thinking more often about my spouse's health or possible death. I am sure that my spouse will have enough time to pursue his/her personal interests after our second child is born. Having a second child should not effect my spouse's career goals. I worry about my spouse feeling stifled after our second child is born. I feel confident that my husband will be able to give me the help and support I need after the baby is born. I am concerned that my spouse does not seem to be happy about this pregnancy. I am afraid that my wife's figure will not return to normal after the baby is born (Item only on father's questionnaire). 265 Marital Relationship ‘*I am concerned that the addition of a second child will interfere with my spouse's and my sexual relationship. I wonder if I will be able to give my spouse the attention he/she needs after the baby is born. *I think my husband finds nme CI find my wife) sexually unattractive during this pregnancy. *I am not concerned by any changes in my sex drive during this pregnancy. I am certain of the method of contraception my spouse and I will use after the baby is born. My spouse anui I are considering the possibility of sterilization (vasectomy or tubal ligation) after the baby is born. *I am confident that my spouse and I will have enough time for shared leisure activities after we have our second child. *I am concerned about changes in my spouse's sex drive during this pregnancy. *Indicates retained Sub-scale item. Firstborn *I feel confident that our firstborn child will love the new baby. *I feel comfortable with our plans for the care of our firstborn child while I am in the hospital. *I am afraid that our firstborn child might act aggressively toward the new baby. *I feel confident that I will be able to give my firstborn child the attention he/she needs after the baby is born. ‘*I worry that I will have to give up the special relationship I have with my firstborn child after the baby is born. *I am concerned that my firstborn child may regress in the skills he/she has learned after the baby is born. During this pregnancy I feel I have lacked the energy needed to give my firstborn child the attention he/she needs. *Indicates retained sub-scale item. 1: 266 Expected Baby *I worry that I will not be able to give my second child the time and attention I gave my firstborn child. I am confident in my ability to care for a new baby again. I hope our second child is the opposite sex from our firstborn child. I worry that something will be wrong with this baby. *I wonder if I will be able to love my second child as much as I love my firstborn child. *I am certain that my spouse will be able to love our second child as much as he loves our first. *Indicates retained sub-scale item. Childbirth Process *I am confident that nothing bad will happen to me/my wife during my/her labor and delivery. *I worry if my/my wife's second labor and delivery experience will be more difficult than my/her first. *I am confident that my/my wife's doctors and nurses will be supportive of my/her emotional needs during my/her hospitalization. *I wonder if I/my wife will be able to stay in control during my/her labor and delivery. *I feel prepared for my/my wife's second labor and delivery. *I worry that I will not get/I will not be able to give the support I/my wife needs from my husband/me during my/her labor and delivery. *I feel comfortable that my husband/I and our firstborn child will be allowed to visit me/my wife and the new baby as much as I would like while I/she is in the hospital. *I feel that I/my wife will receive quality physical care from my/her doctors and nurses while I/she is in the hospital. *Indicates retained sub-scale item. 267 Household/Finances *I feel confident that we can afford to raise a second child. 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