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The Relationship of Social
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MSU II An Afflmntlvo Action/EM Oppomtnlly IMRt‘Ion

 

THE RELATIONSHIP OF SOCIAL SUPPORT
AND DEPRESSIVE SYMPTOMATOLOGY
DURING PREGNANCY

BY
Ellen F. Heit

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

1996

ABSTRACT

THE RELATIONSHIP OF SOCIAL SUPPORT.AND DEPRESSIVE
SYMPTOMATOLOGY DURING PREGNANCY

BY

Ellen F. Heit

Depression is a major health concern in the U.S.
Depression has been identified with stressful life events,
including pregnancy. The literature suggests that as many
as 30% to 38% of pregnant women experience some degree of
depressive symptomatology. Social support has been
identified as a possible modifier of stressful life events
and the negative responses to such events. Little research
has been done to investigate the relationship of depressive
symptomatology and degree of social support the pregnant
woman perceives.

This study investigated: (1) the extent and severity of
depressive symptomatology and (2) the relationship between
depressive symptomatology during pregnancy and self-reported
social support. Using secondary data analysis, responses
from 124 of the original sample of 172 primarily low income
women who completed the Center for Epidemiologic Studies
Depression Scale and the Norbeck Social Support
Questionnaire were analyzed.

Results of data analysis indicated that, in this

sample, 70% of the women had some measure of depressive

symptomatology; 45% had moderate to severe depressive
symptomatology, with 15% scoring in the severe depressive
symptomatology range. In the areas of total functional
social support and affect the women with the lowest
depressive symptomatology scores had the highest perceived
social support, while those with highest depressive
symptomatology scores perceived the lowest level of social
support. In social support areas of affirmation and aid,
results followed the same trend as that found for total
functional support but were not found to be significant.
The.Advanced Practice Nurse (APN) may be able to use
the results of this study in providing or encouraging social
support for the pregnant client, with the intent of
modifying or reducing depressive symptomatology during

pregnancy.

Dedicated to Dan and Becky Clapp

iv

ACKNOWLEDGEMENTS

Rachael F. Schiffman, PhD, RN, who provided the data
used in this study and chaired the thesis committee;
Kathleen Phelps, MD, who encouraged exploration of the
topic; Cynthia Collier and Carol Navarro, for assistance
in preparation of final product; and Craig R. Weisse, MD,
who encouraged and supported with exceptional patience

and good humor.

Table of Contents

Page
List of Tables..... ..................................... viii
List of Figures ......................................... ix
Introduction ............................................ 1
Background ......................................... 1
Statement of Problem ............................... 4
Conceptual Definitions .................................. 5
Depressive Symptomatology .......................... 5
Social Support.. ....... . ...... . .................... 7
Conceptual Framework/The Roy Adaptation Model ........... 9
Review of the Literature ................................ 13
Depression During Pregnancy ........................ 13
Social Support During Pregnancy .................... 17
Depression and Social Support During Pregnancy ..... 19
Methods ................................................. 27
Design ............................................. 27
Sample ............................................. 27
Instruments ........................................ 29
Operational Definitions ............................ 31
Data Collection .................................... 34
Data Analysis ...................................... 34
Human Subjects Protection .......................... 35
Limitations ............................................. 35
Assumptions ............................................. 36
Results ................................................. 36
Discussion .............................................. 38
Implications for Practice ............................... 44
Implications for Research ............................... 49
Summary ................................................. 51
Appendices .............................................. 53
A: Criteria for Major Depressive Episode ........... 53
B: Representation of CES-D Scale ................... 55

vi

C: Representation of Norbeck Social Support

Questionnaire ...................................... 56
D: UCHRIS Approvals ................................ 58
References .............................................. 61

vii

List of Tables

Page
Table 1: Selected Demographics ..... . ................... 28
Table 2: Frequency and Percent of CES-D Score
Categories .................................... 37

Table 3: Analysis of Variance: Functional
Support on the N850 by CBS-D Symptomatology...39

viii

List of Figures
. Page
Figure 1: Depressive Symptomatology During Pregnancy
Adaptation to Maladaptation .................... 12a

ix

The Relationship Between Social Support and
Depressive Symptomatology During Pregnancy
Introduction
mun—d

Up to one in eight individuals may require treatment
for depression during their lifetimes (U.S. Department of
Health and Human Services, 1993). The U.S. Department of
Health and Human Services (1993) lists several major risk
factors for depression, among them female gender and
stressful life events. It has been suggested that our
present age be called an ”age of melancholy“ (Rabkin &
Klein, 1987,). Given the fact that as many as 10% of
Americans presently suffer from depressive disorders and
that one of every four Americans will suffer from a
significant depressive experience in the course of his or
her lifetime (Rabkin & Klein, 1987), it is clear that this
comment may be an accurate description.

Kizilay (1992) cites epidemiologic studies showing a
prevalence rate of 13-20% of the general population in the
U.S. having depressive symptoms, and noted a consistent
increase in the percentage over the last 20 years.
Depression is the most common psychiatric disorder in women
(Kizilay, 1992). The lifetime risk of depression is 20-26%
for women (Kizilay, 1992). Other studies suggest a range of
10-52% of women who experience depressive symptomatology
(Affonso et al., 1992; Karl, 1991; Yates, 1987; Zuckerman,

Amara, Baucher, & Cabral, 1989). Zuckerman et a1. (1989)

1

found that clinical depression during pregnancy ranged from
4-16%, with depressive symptoms occurring in as many as 30-
38% of pregnant women, while Affonso et al. (1992) found
that 50% of the over 200 pregnant women interviewed admitted
to three or more depressive symptoms during the pregnancy.

Some of the symptoms of depression are very similar to
those normally occurring during pregnancy (e.g. decreased
energy, appetite changes, weight changes, sleep pattern
changes) and are, therefore, often overlooked by healthcare
providers. However, depression or depressive symptoms,
including appetite changes, sleeplessness and loss of energy
and interest, can have important clinical implications for
the pregnant woman's health status. Researchers cite poor
health behaviors secondary to depressive symptomatology,
such as alcohol and drug use, as a factor in negative
pregnancy outcomes (Zuckerman et al., 1989). Steer,
Scholl, Hediger, and Fischer, (1992) suggest that depression
may be related to poor pregnancy outcome by affecting
hormonal levels during pregnancy. O'Hara, Schlewchte,
Lewis, and Varner, (1991) found that depressed women had
lower estradiol levels at 36 weeks gestation than non-
depressed women. Decreased estradiol levels may be
indicative of placenta dysfunction, which may in turn be
associated with intrauterine growth retardation and preterm
delivery.

Depression during pregnancy has also been questioned as

a possible predictor of postpartum depression (Ugarriza,

1989). The severity and/or persistence of the symptoms of
post partum depression can cause debilitating problems for
the mother and are therefore of major concern to healthcare
providers. Karl (1991) identified the behaviors of
depressive symptomatology, including crying or feeling sad,
anxiety or irritability, slowed speech and body movements,
self-absorption, difficulty displaying emotions, sleep
disturbances, headaches, and anorexia, and the episodic and
unpredictable occurrence of these symptoms during the
postpartum period, as “significantly negatively affecting
maternal-infant interaction” (p.386) by decreasing the
mother's availability to meet the infant's needs.

Social support, the support an individual receives from
friends, family and providers of services has been found to
act as a buffer during stressful situations and to have a
positive influence on a woman's sense of well-being during
pregnancy (Aaronson, 1989; Brown, 1986). Social support
effects are not necessarily perceived as dramatically
altering the impact of stressful life events, e.g.
pregnancy, but rather as serving a more protective function
by moderating the impact of stress and facilitating coping
(Aaronson, 1989).

The advanced practice nurse (APN) in primary care is in
an ideal position to both identify the symptoms of
depression in the pregnant client and to provide
intervention through provision of a supportive relationship

and by assisting the client to access other sources of

social support, whether family, friends or prenatal support
group. Early intervention to address the symptoms of
depression and to enhance the support network may positively
impact both the pregnancy experience and the pregnancy
outcome. The APN is educated to approach the client in an
holistic manner, which is essential for the identification
of depressive symptomatology during a period in a woman's
life, when such symptoms have often been viewed by providers
of prenatal care as a normal part of pregnancy.
Statement of Problem

Several studies (Arizmendi & Affonso, 1984; Hock,
Schirtzinger, Lutz, & Widaman, 1995; Laizner & Jeans, 1990;
Steer et al., 1992; Zuckerman et al., 1989) have addressed
the problem of depression or depressive symptomatology
during pregnancy and the links to both poor pregnancy
outcomes and postpartum depression. While the existence of
the problem is becoming well documented, how to address the
problem continues to be an issue for healthcare providers.

The purpose of this study was to determine the extent
and severity of depressive symptomatology among a group of
low income pregnant women and to determine the relationship
between self-reported social support and depressive
symptomatology among a group of low income pregnant women.
The existing literature, while limited, does point to a
positive relationship between high levels of social support
and low levels of negative emotional states (Moore et al.,

1991; O'Hara, 1986; Vilhjalmsson, 1993). This study focused

solely on the negative emotional state of depressive
symptomatology and sought to provide data that the concept
of social support has a relationship to depressive
symptomatology.

The research questions were: (a) What is the extent of
depressive symptomatology in a sample of low income women;
(b) What is the severity of the depressive symptomatology in
the sample; (c) What is the relationship between self-
reported symptoms of depression and the self—reported
description of social support for a sample of low income

pregnant women?

Conceptual Definitions

Depressive Symptomatology

This study addressed depressive symptomatology rather
than a major depressive episode, also referred to as
clinical depression. The criteria for both are presented to
assist the reader in adequately differentiating between the
concepts. The criteria for a major depressive episode, as
defined by the DSM-IV (American Psychiatric Association,
1994), is a combination of several symptoms, present during
the same two week period and representing a change from
previous functioning. Necessary components for a diagnosis
of a major depressive episode are depressed mood (i.e. sad
or empty feeling or tearfulness) and loss of interest or
pleasure. There may also be weight and appetite changes,

altered sleep patterns, diminished ability to concentrate,

feelings of guilt or worthlessness, observable agitation or
psychomotor retardation, fatigue or loss of energy nearly
everyday during the two week period, and recurrent thoughts
of death or suicidal ideation (see Appendix A for Criteria
for Major Depressive Episode). To meet the criteria for a
diagnosis of a major depressive episode, the individual must
have five or more of the symptoms present during the same
two week period.

Depressive symptomatology was conceptualized as the
presence of some or all of the six major symptom areas
described by the American Psychiatric Association (1994),
the Center for Epidemiologic Studies (Radloff, 1977) and
Beck and Weishaar (1989). These areas include depressed
mood, lack of pleasure in life, feelings of guilt or
worthlessness, helplessness or hopelessness, psychomotor
retardation, loss of appetite and sleep disturbance. To
differentiate from a major depressive episode, the symptoms,
particularly depressed mood or feeling that life is devoid
of pleasure (Beck & Weishaar, 1989), must be present at some
time during the past week by self report. Self-report of
how subjects in the sample may have felt or behaved in the
past week constituted the operational definition of
depressive symptomatology for purposes of this study.
Depressive symptomatology was differentiated from a major
depressive episode primarily by number of symptoms and
duration of symptoms. Depressive symptomatology in this

study was defined similarly by the Center for Epidemiologic

Studies and Beck (Zich, Attkisson, & Greenfield, 1990) as
the presence of any of the symptoms of depression being
present during the past week. The criteria for a major
depressive episode requires that symptoms be present for at
least two weeks. The severity of depressive symptomatology
was determined by the number of symptoms present and the
amount of time during the past week that the subject
experienced any of those symptoms. In contrast, the
criteria for a major depressive episode must include the
presence of specific symptoms and a specific number of
additional symptoms (see Appendix A). The conceptual
definition of depressive symptomatology in this study
involves the affective component of a depressive episode,
either depressed mood, loss of interest or pleasure, or
both.
Social Support

Social Support is defined in the literature as
perceived or received coping assistance (Vilhjalmsson, 1993)
or stress buffering (Aaronson, 1989). Support is seen as
being informational, psychological/emotional or material
(Spencer, Thomas, & Morris, 1989). Social support may come
from a variety of sources within an individual's social
network, including spouse, family, friends, healthcare
providers, clergy, counselors or a peer group of persons
undergoing similar experiences (Norbeck & Anderson, 1989).
For purposes of this study the conceptual definition of

social support was consistent with Norbeck's, which comes

from Kahn, "interpersonal transactions that include one or
more of the following: the expression of positive affect of
one person toward another; the affirmation or endorsement of
another person's behaviors, perceptions, or expressed views;
the giving of symbolic (e.g. information or non-tangible aid
such as problem solving) or material aid to another"
(Cronenwett, 1985; Norbeck, Lindsey, & Carrieri, 1981).

Kahn conceptualized a ”convoy" of social support, in which
each person can be thought of as moving through life
surrounded by a group of other people to whom that person is
related through the exchange of social support (Antonucci &
Akiyama, 1987). Antonucci and Akiyama (1987) present the
convoy model as persons having varying degrees of closeness
to the focal person, with social relationships that help the
focal person maintain well-being and cope with the stresses
of life. The conceptual definition of social support for
this study involved the study subject's perception of
supportive interactions of affect, a demonstration of
positive feelings or caring toward an individual;
affirmation, a demonstration of approval of an individual's
actions, beliefs or feelings; and aid, which may be material
(money, labor, environmental modification), or symbolic
(information, advice, direction, suggestion), provided to
the focal person by a network of relationships. For purposes
of this study only the support perceived by the subject as
being given to or available to the subject from the social

network was considered.

Conceptual Framework

The Roy Adaptation Model

The adaptation model of Callista Roy provided the
framework for understanding the relationship of social
support and the pregnant woman's depressive symptomatology.
Roy's adaptation model is well suited to an examination of
depressed mood in pregnant women. Roy conceptualizes the
person as having four modes of adaptation: physiological
needs, self-concept, role function and interdependence
relations, all of which are involved in the pregnancy
experience. The pregnant woman must adapt to the
physiologic changes of the pregnancy, including hormonal
changes and neurotransmitter alterations. Rapid physical
changes are characteristic of pregnancy. Stressors to the
self-concept mode during pregnancy include adjustment to
energy level changes and altered body image. Role function
is affected by the stress of impending motherhood and the
expectant mother's concern regarding her ability to handle
the new role. Even for multiparous women, adding another
child to the family, whose needs and demands are unknown for
nine months, can be a major stressor. In addition, the
woman's role as a sexual being may be threatened as her body
changes. She may experience fear that her spouse, or the
father of her unborn child, will reject her as her body
changes with the pregnancy. Interdependence needs change as
the woman experiences the emotional roller coaster of

pregnancy associated emotions. Laizner & Jeans (1990)

10

describe pregnancy as a “health and life change event that
challenges the mother's adaptive capacity physically,
psychologically, and socially“ (p.192).

Roy proposes that each person receives and processes
input from the environment, the world within and around each
individual. This input is described by Roy as stimuli, with
adaptation determined by the pooled effect of three classes
of stimuli. The first class is focal, or the internal or
external stimuli immediately confronting the person. In
this study, pregnancy can be considered the focal stimulus.
The second class, contextual stimuli, are all the internal
and external stimuli evident in a given situation. In this
study of primarily low income pregnant women, inadequate
financial resources, poor housing conditions, lack of
transportation, are all possible contextual stimuli.
Residual stimuli, the third class in the Roy model, are
influences the person may not even be aware of, stimuli
which affect behavior but whose effects are not necessarily
validated. In the case of this sample, depressive
symptomatology prior to pregnancy, which may or may not have
been acknowledged or addressed, would be residual stimuli.
The focal, contextual and residual stimuli determine the
range each individual has of coping. Roy terms the
adaptation level as the changing point that represents the
person's ability to respond positively, to adapt, to a given
situation. By balancing the three classes of stimuli

through interaction with the internal and external

11

environment, successful adaptation is achieved (Andrews &
Roy, 1986). In this study, successful adaptation to the
challenges of pregnancy and low income status is determined
to be an absence of, or very low level of, depressive
symptomatology. The severity of depressive symptomatology
on the part of the pregnant woman constitutes the degree of
maladaptive response.

While all four modes are affected by pregnancy, the
emphasis of this study is on the interdependence mode. The
interdependence mode focuses on the interactions related to
the giving and receiving of love, respect and value (Andrews
& Roy, 1986). Through social interaction of the
interdependence mode, a person's need for affectional
adequacy is met. Affectional adequacy, which underlies the
interdependence mode, includes the person's need for
affection, affirmation, approval, care, attention and
belonging (Andrews & Roy, p.152) and is therefore well
suited to this study's conceptual and operational
definitions of social support. The focus of the
interdependence mode is on the individual's relationships
with the support system, including significant others.

The perception of social support, using the Roy
adaptation model, can be conceptualized as affecting the
four modes of adaptation, but is depicted in the model
developed for this study (see Figure 1 ) as involving the
interdependence mode of adaptation. Interpersonal

interactions of expression of positive affect and

12

affirmation effect adaptation chiefly through the
interdependence mode. Aid in the form of information and
anticipatory guidance also impact all adaptive modes, but in
this study the primary influence is on the interdependence
mode. In the model for this study the four adaptive modes
are presented, with the interdependence mode larger to
demonstrate the focus of the study. Adapting the wheel
model developed by Roy (Andrews & Roy, 1986), the circle
represents the pregnant woman, composed of the four adaptive
modes. The modes overlap within the woman, an holistic view
of the pregnant woman with emphasis on the interdependence
mode in this study. The circle of the woman is shown as a
broken line, demonstrating the capacity for the woman to
receive and be affected by stimuli and to perceive the
support network within the woman’s environment. The
stressor of pregnancy as the focal stimulus, and low income
as the contextual stimulus (Hock et al., 1995; Moore et al.,
1991), with arrows from the stressors to the pregnant woman,
indicate the impact of the stressors on the woman as a
whole. Because these stressors are not inherent in the
woman, they are placed in the model outside the circle
representing the pregnant woman. This study measured the
subject’s perception of social support. This social support
network is placed outside the circle, as part of the
external environment. The continuum of depressive
symptomatology, from no symptomatology (FREE) to severe

symptomatology (SEVERE) and the response to stimuli

12a

Depressive Synptonatology During Pregnancy
. Adaptation to Maladaptation

Focal Stimulus: Pregnancy

¢-———'—\
Social
Support

Interdependence Mode Network

Social

Support,///’
Network
///

     
      
  

Perceived Social Support

Total Functional Support
Affect-Affirmation-Aid

 

   

MILD MODERATE

Self Concept Mode

VL\_..A/

Contextual Stimulus: Low Income

Figure 1

Adapted from Andrews and Roy (1986). Essentials of the Roy
Adaptation Model.

13

(ADAPTATION to MALADAPTATION) are presented in the model
within the interdependence mode (Figure 1).
Review of the Literature

The following is a review of the literature presented by
issue addressed and the instruments used.
W

The research questions of extent and severity of

depressive symptomatology during pregnancy have been
addressed by reseachers utilizing a variety of instruments.
The Beck Depression Inventory (BDI) appears to have been
used most frequently by researchers to measure depressive
symptomatology (Arizmendi & Affonso, 1984). Steer et a1.
(1992) studied adverse health behaviors and negative
pregnancy outcomes in a sample of 712 inner city and
minority adolescents and adults, administering the BDI
during pregnancy. This study used a cut score of 21 to
indicate moderate depressive symptomatology, finding a mean
score for the sample of 8.99, indicating only mild
depressive symptomatology in this sample. Gotlib, Whiffen,
Mount, Milne and Cordy (1989) used the BDI to measure
depressive symptomatology during pregnancy, using a cut
score of 10 to indicate mild to moderate symptoms. This
study found 25.8% of their sample of 360 pregnant women met
their criteria for mild to moderate depressive
symptomatology. Ugarriza (1989), using the BDI and a cut
score of 17 to indicate moderate to severe depressive

symptomatology, found that 6.9% of the sample of 102

14

pregnant women met the criteria for depression. Gotlib,
Whiffen, Wallace, and Mount (1991) used the BDI in a study
of 730 pregnant women, found a mean score of 9.4, with 10.3%
of the sample diagnosed with either a major or minor
depression on further assessment. O'Heron (1991) studied 92
pregnant women for depressive symptomatology, also using the
BDI. Using a cut score of 16 to indicate moderate
depressive symptomatology, 20% of the sample were determined
to be depressed. Huffman, Lamour, Bryan, and Pederson
(1990) studied 62 pregnant women and 36 non-pregnant
controls to test the BDI by cluster of items and the
instruments applicability for evaluation in a pregnant
population. The study found the mean score on the BDI for
the pregnant group to be 7.04, while the control group had a
mean score of 2.69.

The range of cut scores, from 10 to 21, used in these
studies makes drawing conclusions from results very
difficult. These studies each define depression
differently, depressive symptomatology ranging from mild to
severe based on cut score. Steer et al. (1992), Gotlib et
al. (1991), and Huffman et al. (1990) present mean BDI
scores for their samples below the cut score of 10,
indicative of mild depressive symptomatology. Only Steer et
a1. specifically studied low income women.

Several other instruments have been used by researchers
to assess depressive symptomatology during pregnancy. In

their 1992 study of 81 pregnant hispanic women, Zayas and

15

Busch-Rossnagel used the Center for Epidemiological Studies-
Depression Scale (CES-D) to assess for depressive
symptomatology during pregnancy. With 49% of the subjects
scoring higher than the generally accepted cut score of 16
(Radloff, 1977), indicative of moderate to severe depressive
symptomatology, the extent and severity of depressive
symptomatology in this sample points to the seriousness of
this problem.

Kennerley and Gath (1989) and Martin, Brown,
Goldberg, and Brockington (1989) used the Present State
Examination to assess depressive symptomatolgy during
pregnancy. Kennerly and Gath (1989) presented results in
terms of the blues, while Martin et al. (1989) used the same
instrument to provide information regarding diagnosable
depression during pregnancy.

Appleby, Gregoire, Platz, Prince, and Kumar (1994) used
the Edinburgh Postnatal Depression Scale pre— and
postnatally and a screening questionnaire developed by the
researchers for the study as a prenatal screening
instrument. The National Institute of Mental Health .
Standardized Clinical Interview was used as a measure of
clinical depression during pregnancy by Affonso, Lovett,
Paul, and Sheptak (1990).

Each of the studies presented had a focus other than
depressive symptomatology during pregnancy, primarily that
of postpartum depression, although two studies (Appleby et

al., 1994; Huffman et al., 1990) were designed to test

16

screening instruments for depressive symptomatology. The
available literature regarding depressive symptomatology
during pregnancy supports the importance of further study
into the topic by providing data linking prenatal and
postpartum depressive symptomatology (Gotlib et al.,1989,
1991; Huffman et al., 1990; Kennerley & Gath, 1989; Appleby
et al., 1994; Martin et al., 1989; Laizner & Jeans, 1990).
The link between depressive symptomatology during pregnancy
and negative pregnancy outcomes (Steer et al., 1992),
combined with the relationship between prenatal and
postpartum depressive symptomatology strongly supports the
importance of screening for depressive symptomatology during
pregnancy by providers of prenatal care. The instruments to
measure depressive symptomatology and the researchers'
definitions for severity of depressive symptomatology vary
widely, resulting in difficulting in generalizing results.
Gotlib et al. (1989) used a cut score of 10 to indicate mild
depression. Sample sizes are large enough, 62 to 730
pregnant women, to demonstrate reliability of conclusions,
but not all the results are generalizable to a broader
population due to specificity of samples, such as
adolescents, psychiatric inpatients, or specific races. The
studies are particularly problematic as support for the
present study by the use of a variety of instruments and a
range of cut scores to determine severity of depressive
symptomatology, and only Steer et al. (1992) specifically

studied low income pregnant women. There is a need to

17

establish a consistent definition for severity of depressive
symptomatology if we are to better understand the problem of
depressive symptomatology during pregnancy. Cut score to
indicate presence of depressive symptomatology should be
consistent in research, to avoid confusion and potential
misinterpretation of results. These studies all have value
for the current study by providing data to establish the
problem of depression during pregnancy.
Social Support During Pregnancy

The literature regarding the impact of social support
on the pregnant woman is fraught with a confusing array of
conceptual and operational definitions of social support.
While the relevance and significance of social relationships
is the focus of the studies, the issues of definition and
measurement instrument, make it difficult to draw general
conclusions which can be readily validated.

Aaronson (1989) measured perceived social support with
a modified version of the Personal Resources Questionnaire
and received social support with a series of questions
designed for the study regarding specific behaviors of the
pregnant woman's family members. Cronenwett (1985) used the
Social Network Inventory to measure social support, while
Brown used the Support Behaviors Inventory in two separate
1986 studies. Collins, Dunkel-Schetter, Lobel, and
Scrimshaw (1993) developed their own instrument for the
measurement of social support during pregnancy. Spencer et

al. (1989) chose to measure social support during pregnancy

18

by making the support of a lay worker available to the
expectant mother and investigating acceptance of this
support. Norbeck and Anderson, in two separate 1989
studies, used the NSSQ to measure social support during
pregnancy, as did Koniak-Griffin (1988).

Each study presented different conceptual and
operational definitions of social support and each used a
different instrument to measure social support. Collins et
a1. (1993) and Spencer et al. (1989) developed their own
measurement indices for social support, adding to the
difficulty in both replicating the studies or drawing any
comparisons from the existing literature. With different
instruments used in each study, comparisons of results and
generalizability is impractical. However, with the
exception of Spencer et al. (1989), each of the studies
cited found that social support, especially from the baby’s
father or from the expectant mother's family members, had a
positive relationship to the pregnant woman's health
behaviors or to positive pregnancy outcomes. Of the nine
studies cited addressing social support during pregnancy,
low income women made up the sample in only three studies
(Collins et al., 1993; Norbeck & Anderson, 1989a, 1989b).
Low income pregnant women are the focus of the current
study, a group which received little attention in the
literature presented. The apparent importance for the
pregnant woman of social support found in the literature

does support further research.

19

Dppreppion 3nd Social Support
Zuckerman et al.(1989) used the CES-D and NSSQ to study

a total of 1014 primarily poor, pregnant women. The study
findings indicated that the higher the depressive
symptomatology score on the CES-D, the lower the perceived
social support score on the NSSQ. The mean CES-D score for
the sample was 18.6, above the generally accepted cut score
of 16 for moderate to severe depressive symptomatology.
This hallmark study presented the extent and severity of
depressive symptomatology during pregnancy and a
relationship between depressive symptomatology and perceived
social support in a very large sample of primarily low
income pregnant women. A strength of this study is that it
is easily replicable for other sample populations of
pregnant women.

Collins et al. (1993) assessed social support during
pregnancy with an instrument developed for their study.
Depressive symptomatology postpartum was assessed with the
CES-D. Social support was found to be positively related to
better birth outcomes and lower CES-D scores postpartum.
Since multiple interviews were conducted prepartum to assess
social support, the study would have been strengthened by an
assessment of prepartum depressive symptomatology. This
study lacks the replicability of Zuckerman et al. (1989) by
the researchers’ decision to utilize interviews to assess
social support rather than an instument with tested

reliability and validity.

20

Sacco and Macleod (1990) used the Procidano and Heller
Perceived Social Support from Family Scale to assess social
support in a sample of 61 pregnant adolescents. The CES-D
was utilized to measure depressive symptomatology during
pregnancy. The findings include evidence that depression
level is related to more negative interpersonal reactions,
supporting the interpersonal process view of depression,
which suggests that others react to depressed persons with
conflicting affective, attitudinal and behavioral responses.
While strenthened by the use of standardized instruments,
the conclusions of the study are weakened by the small
sample size.

Mercer and Ferketich (1988), using the CES-D and
Barrera’s Inventory of Socially Supportive Behaviors, with
some additions to the social support instrument from an
instrument developed by McMillan, studied a sample of 153
high risk pregnant women, 75 of their mates, 128 low risk
pregnant women and 147 of their mates. The findings of the
study were that the lack of perceived support by pregnant
women was a significant predictor of depression during
pregnancy. There was also a correlation between network
size and perceived support, suggesting that larger networks
contribute to the woman's perception of greater available
support. The findings of this study, that perception of a
high level of social support was related to lower depressive
symptomatology scores, were similar to those of Zuckerman et

al. (1989).

21

Turner, Grindstaff, and Phillips (1990) also used the
CES-D to measure depressive symptomatology in a sample of
268 pregnant teenagers. Social support was assessed using
the Provisions of Social Relations Scale to measure support
from family and friends, with five new items developed to
assess support from the father of the baby. The results
indicated that subjects living with parents had
significantly lower CES-D scores than those living in other
situations. "Family support was by far the most powerful
predictor of depression among adolescent mothers" (p.51).
These findings, from an adequately large sample, are an
extension of the findings of Zuckerman et al. (1989), more
specifically defining the part of the social network
correlated with depressive symptomatology.

The BDI was used by Cutrona (1989) to measure
depressive symptomatology in a sample of 115 pregnant
adolescents. Perceived social support was measured by the
Social Provisions Scale, completed by both the pregnant
adolescent and a person close to the adolescent. Results
were similar to those of Zuckerman et a1. (1989), with lower
depressive symptomatology scores being correlated with
higher scores on the measure of social support. In
addition, results suggested that even when social support is
evaluated by an external source, this correlation between
social support and depressive symptomatology remains.

In a study of factors involved in the onset of and

recovery from postpartum depression, Gotlib et al. (1991)

22

used the BDI to measure depression during pregnancy in a
sample of 730 women. The Dyadic Adjustment Scale was used
to measure social support from the marital relationship, the
only part of social support network examined in this study.
Of the women who were depressed postpartum, the mean score
on the BDI prepartum was 3.4 points higher than that of
their non-depressed counterparts, while the mean score
prepartum on the measure of social support from the marital
relationship was 8.7 points lower. The women diagnosed as
depressed postpartum reported higher levels of depressive
symptomatology during pregnancy, reported lower marital
satisfaction. More negative perceptions of caring from
their own parents, were found in the depressed group on
postpartum interview. The correlation between higher
depressive symptomatology scores and lower social support
scores agreed with the findings of Zuckerman et al. (1989).
However, only social support from the marital relationship
was measured prenatally in this study, providing less
information regarding the relationship of social support and
depressive symptomatology and social support than the
Zuckerman study. Findings have no generalizability to
single mothers, a group to which the Zuckerman study can be
related.

O'Hara (1986) measured depression, rather than
depressive symptomatology, with the Schedule for Affective
Disorders and Schizophrenia. Social support was assessed

with the Social Support Interview. O'Hara reported that, of

23

the 99 pregnant women in the sample, 9% experienced a major
or minor depression during pregnancy. The depressed women
reported a perception of insufficient emotional and
instrumental support from their spouses. It is difficult to
determine whether this insufficient support was the result
of living with a depressed woman or if the depression
resulted from insufficient support. Zuckerman et al. (1989)
did not attempt to arrive at a causal relationship between
social support and depressive symptomatology. Likewise,
O’Hara did not propose causality. However, other support
from the network is not evaluated by O'Hara. It is also
important to note the distinction between depressive
symptomatology as measured by a self-report instrument and
major or minor clinical depression diagnosed in the O'Hara
study. The Zuckerman study is more readily generalizable to
a broader population than the O'Hara study.

Degen, Myers, Williams-Peterson, Knisley and Schnoll
(1993) studied a sample of 25 pregnant drug abusers and 55
pregnant nonusers, using the Pregnancy Research
Questionnaire to measure both anxiety and depression and the
Interpersonal Support Evaluation List to measure social
support. The premise of the study was that social support
is protective throughout the life span as people face the
stress of life transitions. Results of the study were that
those women with higher depressive symptomatology perceived
less social support availability than their counterparts

with lower levels of depressive symptomatology. The

24

researchers interpreted their findings as upholding the
protective aspect of social support. The sample was
probably too small to draw either conclusions or
generalizability.

Norbeck and Tilden (1983) and Tilden (1984) used the
Lubin Depression Adjective Checklist to assess depression
and the Cohen and Lazarus Social Support Questionnaire with
samples of 117 pregnant women and 141 pregnant women
respectively. .Norbeck and Tilden concluded that low social
support was significantly related to high emotional
disequilibrium, that is, depression and anxiety. Emotional
support was significantly related to emotional
disequilibrium, while tangible support was not. Tilden
(1984) compared single and partnered pregnant women in the
areas of depression and social support among other areas.
Findings indicated that single women had lower social
support, but that depression between the two groups did not
differ significantly. Tilden proposed that there was no
compelling reason to study depression during pregnancy in
normal samples. The Norbeck and Tilden study combines
depression and anxiety with the term emotional
disequilibrium, which lacks clarity in terms of other
studies.

Thorpe, Dragonas and Golding (1992) attempted a cross-
cultural study of pregnant Greek and British women, using
the Crown-Crisp Experiential Index to measure depression and

an instrument designed for the study to measure social

25

support. Results were inconclusive in all areas with the
Greek sample due to instrument insensitivity to cultural
differences. For the British sample, social support was one
of the best predictors of maternal emotional well-being
during pregnancy. This study points up clearly the
importance of careful selection of instruments in research.

Vilhjalmsson (1993), in an analysis of the literature
addressing life stress, social support, and clinical
depression, lists twelve studies, ten of which used the
Present State Examination to assess clinical depression
during pregnancy. The remaining two studies used the
Schedule for Affective Disorders and Schizophrenia and the c
Clinical Interview for Depression. Consistent for all these
studies was the primary support relationship as that with
the husband or boyfriend. Vilhjalmsson emphasizes that
clinical depression, not self-reported depressive
symptomatology, is measured. This may account for the
consistency of the measurement instrument used.

While some attention has been directed toward the
problem of depression during pregnancy in recent years and
the possible relationship of social support to depressive
symptomatology, the literature suffers from the same
difficulties as have been previously described. Numerous
instruments have been used to measure both social support
and depressive symptomatology. The majority of the studies
have focused on postpartum depression or outcomes of

pregnancy, but have provided useful information regarding

26

the problem of depressive symptomatology during pregnancy.
The problems with interpretation and generalizing of the
studies are confounded by the range of conceptual
definitions of social support. Certain symptoms of
depression, including changes in sleep pattern, energy level
and appetite, are also symptoms of pregnancy, making
assessment of depressive symptomatology during pregnancy
more complex.

While multiple measurement instruments have been used
to assess depressive symptomatology during pregnancy and an
even greater variety of social support measures have been
utilized, with only one exception (Tilden, 1984), there is
support for a relationship between depressive symptomatology
and social support. The research has investigated sample
sizes ranging from 61 (Sacco & Macleod, 1990) to 1014
(Zuckerman et al., 1989) pregnant females, from adolescents
(Cutrona, 1989; Sacco & Macleod, 1990; Turner et al., 1990)
to adults (Collins et al., 1993; Gotlib et al., 1991; Mercer
& Ferketich, 1988; Norbeck & Tilden, 1983; O'Hara, 1986;
Tilden, 1984; Zuckerman et al., 1989), all income levels,
and ethnic groups from hispanic (Zayas & Busch-Rossnagel,
1992) to British (Thorpe et al., 1992). Researchers have
also addressed the relationship of social support and
depressive symptomatology during pregnancy in black and
caucasian samples. The diversity of subject samples and the
generally adequate sample sizes of the existing research,

while primarily focused on birth outcomes or postpartum

27

depression, has provided a basis for further investigation
of the relationship of social support and depressive
symptomatology during pregnancy.
Methods

929133

This study was a descriptive, correlational secondary
analysis of data collected as part of an evaluation project
at a comprehensive private, not for profit center serving
primarily low income women for prenatal care (Schiffman &
Omar, 1994). The evaluation consisted of survey
administration including the Center for Epidemiologic
Studies Depression Scale (CES-D), the Norbeck Social Support
Questionnaire (NSSQ), and a chart review which included
demographic data (see Appendix E).
Sppple

The sample used in this secondary data analysis was
comprised of those women from the original study who
completed both the CES-D and the NSSQ. The original
convenience sample of 172 subjects consisted of primarily
low income, single, caucasian women ranging in age from 15
to 38 years, with an average age of 22.7 years (Schiffman &
Omar, 1994). Of this original sample, 124 women completed
both the CES-D and NSSQ. Low income women were defined as
those women in the sample who had Medicaid, had Medicaid
applications pending, or had no insurance to cover the cost
of prenatal care and delivery. The majority of the sample

were single and caucasian, with few having education beyond

28

high school. Of the original sample, only 17% were either
married or living with someone, a percentage assumed to
apply to the sample in the present study. The original
sample was obtained from two sources for prenatal care in
Jackson County, Michigan, the Center for Healthy Beginnings
(n=137) and the Jackson County Health Department Maternal
Support Services Program (n=35) (Schiffman & Omar, 1994).
Table 1 provides selected demographic data for the original
sample.

Table 1

Selected Demographics (N=172)

 

p %
Age
519 Years 51 29.7
20-29 Years 100 58.1
130 Years 21 12.2
Marital Status
Single 108 62.8
Married/Cohabiting 47 27.3
Separated/Divorced 17 9.9
Race
Caucasian 140 81.4
African American 29 16.9
Hispanic 2 1.2
Other 1 .6
Education Level
(High School 3 1.7
Some High School 52 30.2
High School Diploma/GED 82 47.7
Some College 25 14.5
Associate Degree 4 1.7
Insurance Status
Medicaid 120 69.8
Blue Cross 2 1.2
Other Insurance 2 1.2
Cash 7 4.1
Medicaid & Other Ins. 1 .6
Medicaid Pending 40 23.3

29

M

The Center for Epidemiologic Studies Depression Scale
(CES-D) is a 20 item questionnaire for the self-reporting of
symptoms of depression developed for research in the general
(nonpsychiatric) population (Radloff, 1977) (See Appendix B
for sample CES-D). Of the total of sixteen items which
assess depressive symptomatology in the CES-D five items
assess depressed mood, three assess feelings of guilt and
worthlessness, three assess feelings of helplessness and
hopelessness, two assess psychomotor retardation, one
assesses loss of appetite and one assesses sleep
disturbance. Four items assess positive affect and help to
minimize bias towards response sets. Each item is scored
from 0 (rarely or none of the time: less than one day) to
3 (mpgt or all of the time: 5 to 7 days) (See Appendix B).

The scale was designed to indicate a current state
measure of depression and to respond to changes in state by
assessing the frequency of symptoms occurring in the past
week. Items in the CES-D are suggestive of symptoms that
are less severe than those measured by other depressive
inventories and include fewer somatic symptoms than the Beck
Depression Inventory, also designed for use in the general
population (Hock et al., 1995,). The CES-D is believed to
produce fewer false positives in women during pregnancy and

postpartum (Hock et al., 1995).

30

Internal consistency reliability coefficients have been
reported to be .85 or above (Radloff, 1977) across varying
age, sex and racial groups. Cronbach's alpha for the
original study was .87 at the prenatal administration of the
scale (Schiffman & Omar, 1994). Test-retest reliability
correlation was .67 at a four month interval (Radloff,
1977).

Validity of the CES-D has been tested with known groups
and has been found to differentiate between diagnosed
depressed and non-depressed subgroups (Rabkin & Klein,
1987). Rabkin and Klein (1987) recommend use of the CES-D
to measure depressive symptomatology but not for diagnosis
of clinical depression.

Schiffman and Omar (1994) report that the three items
in the CES-D which might be influenced by physiological
changes of pregnancy rather than depression (poor appetite,
effort and restless sleep) did not demonstrate a pattern of
response different from other items.

The Norbeck Social Support Questionnaire (NSSQ) is a
self-administered questionnaire developed by Norbeck et al.
(1981) to measure multiple dimensions of social support (See
Appendix C for representation of instrument). Three main
variables are included in the instrument: total functional
support, total network and total loss. Each variable is
then divided into subscales. The functional support
variable is divided into the components of affect (the

expression of positive attitude of one person toward

31

another), affirmation (approval of another's deeds, beliefs
or perceptions), and aid (the giving of symbolic or material
assistance to another). The network variable is measured by
the number of people in the network, duration of the
relationships, and frequency of contact with network
members. The loss component measures recent losses of
network members and subsequent loss of support. In this
study, only the functional support variable was measured.
Scoring is on a 5-point Likert Scale, from 1 (not at all) to
5 (a gpeat deal).

Initial test-retest correlations were reported to be
between .85 and .92 within a one week interval, and the
internal consistency coefficient was .88 (Norbeck et al.,
1981). In later testing (Norbeck, Lindsey & Carrieri,
1983), a moderately high level of test-retest reliability
was found over a seven month interval (ranging from .58 to
.78). Construct validity was demonstrated between the NSSQ
and two similar interpersonal constructs (need for inclusion
and affection), and through lack of correlation between the
NSSQ and an unrelated construct (need for control) (Norbeck
et al., 1983).

Qppretiopal pefinitions

The purpose of this study was to determine the
existence of a relationship between depressive
symptomatology during pregnancy and social support. For
that reason, there are no designated dependent and

independent variables, but rather the categorical variable

32

of depressive symptomatology and the continuous variable
social support.

The variable in this study of depressive symptomatology
was measured by the score on the CES-D. On a 4-point scale,
respondents indicate the frequency and duration of each item
experienced during the past week. Responses range from
0 (rarely or none of the time: less than one day), to
3 (mpgt or all of the timp: five to seven days), with
reverse scoring for the four positive affect items. Scores
range from 0 to 60, with higher scores reflecting greater
depressive symptomatology. For this study the CES-D data
will be divided into four subsets: those with scores of 10
or less (free of depressive symptomatology), scores of 11 to
15 (minimal to mild depressive symptomatology), scores of 16
to 26 (moderate depressive symptomatology) and scores of 27
to 60 (significant or severe depressive symptomatology). A
score of 16 or higher has generally been determined to
indicate depressive symptomatology warranting further
clinical assessment in the general population (Weissman,
Sholomskas, Pottenger, Prusoff & Locke, 1977). Zich et a1.
(1990) suggest a more stringent cut-off of 27 for increased
accuracy of diagnosis of depression in those persons
receiving medical treatment in primary care, a group in
which pregnant women could be included. While it was not
the purpose of this study to diagnose depression or
designate any group as having a major depressive episode as

opposed to depressive symptomatology, this group of scores

33

of 27 or higher was of interest in determining severity of
depressive symptomatology in this sample of pregnant women.
The other variable for this study was social support,
as measured by score on the NSSQ. For purposes of this
study, social support is operationalized as the self-report
of the subjects sampled regarding the perceived approval,
positive feelings or aid in any form from a member or
members of the subject's network In completing the NSSQ,
the respondents were asked to list each significant person
in their life who provides support or is important to them
now, and to specify their relationship to each person,
choosing from a list of nine categories (spouse or partner,
friend, family or relative, neighbor, healthcare provider,
counselor or therapist, clergyman, work or school
associate). Questions are asked regarding each relationship
and respondents rate each member of their network on a 5-
point Likert scale, ranging from 1 (not at all), to 5 (p
great deal). Scoring is done from the respondents ratings
for each person in their network in the functional component
subscales and the network subscales, providing data for both
quantity and quality of the network. Total score and mean
score on the NSSQ functional support component was used to
determine the variable of social support, with a further
breakdown of functional support scores into categories of
affect, affirmation, and aid (see Appendix C) expressed as
mean score for each subset. Responses to other questions

regarding duration of relationship, frequency of contact,

34

and loss were not analyzed in the current study, because the
study is limited to perceived functional support.
Wig;

Data for this secondary analysis study was collected
for the original study from a sample of 172 subjects
enrolled between May, 1992 and May, 1993. Subjects were
obtained from two sources, the Center for Healthy Beginnings
(p=137) and the Jackson County Health Department Maternal
Support Services Program (Schiffman & Omar, 1994). Data was
provided for the present study by the original researchers'
code book and computerized data, recorded and analyzed
initially using the SPSS statistical package.

Data Analysis

The SPSS statistical package was used to analyze data.
Frequency distributions for maternal sociodemographic data
were calculated using frequency and percents. To address
the research question regarding the degree or severity of
depressive symptomatology in this sample, total scores on
the CES-D were calculated for each member of the sample.
Utilizing the cut points previously described, four groups
were established. The number and percent of women in the
sample who fell within each group determined the extent and
severity of depressive symptomatology. To answer the
question of the existence of a relationship between
depressive symptomatology during pregnancy and social
support, a one-way ANOVA was performed using total

functional support score on the NSSQ for each group of CES—D

35

scores. A one-way ANOVA was then carried out for each
subset of NSSQ scores in the functional category: affect,
affirmation and aid.

Human Subjects Protection

The original project was approved by the Michigan State
University UCHRIS committee (see Appendix G). Approval of
the Michigan State University UCHRIS committee was obtained
for this secondary data analysis (see Appendix G). Only the
previously coded data were used, with no identification of
subjects except the numbers assigned by the original
researchers.

My

In performing secondary data analysis the researcher is
limited by the sample selected for the original study. It
is believed that the size of the original sample (N=172) is
adequate for this study and that the subjects in the
original sample who completed both the CES-D and NSSQ
(N=124) was an adequate sample for the present study.

When conducting secondary data analysis of previous
research one is also limited by original subject selection
criteria, potentially limiting the generalizability of the
results of data analysis to a broader population than the
primarily low income pregnant female population sampled in
the original study. For purposes of this study, the
original sample of 172 primarily low income pregnant women
in Jackson, Michigan was considered adequate, as were the

instruments used, the CES-D and the NSSQ. Any omitted

36

questions or responses by the subjects were not assumed to
significantly effect the outcome of the data analysis of
this study. The nature of the data available for this study
does not provide information regarding the subjects'
depression status prior to pregnancy, or whether any of the
subjects had previously received treatment for depression.
This limits this study's ability to attribute CES—D scores
available solely to the stressful life event of pregnancy.
Mpg—09;

It was assumed that all respondents were able to read
the questionnaires, were given identical instructions for
the completion of the questionnaires, provided accurate and
honest responses and were not influenced by transient
feelings of distress or a desire to provide what they viewed
as socially appropriate responses. It was further assumed
that data was entered for analysis accurately into the SPSS
program.

Results

Of the original sample of 172 pregnant, primarily low
income women, 124 completed the CES-D. Total score on the
CES-D ranged from 0 to 46. In reference to the question of
severity and extent of depressive symptomatology in this
sample, mean score for the sample was 16.33, with 16 being
the accepted score for symptomatology warranting further
evaluation for depression. As can be seen in Table 2, 37 of
the 124 subjects who completed the CES-D (30%) had scores in

the range considered free of depressive symptomatology. The

37

remaining 87 subjects (70%) had some degree of depressive
symptomatology. Just over 45% of the sample scored in the
moderate to severe range of depressive symptomatology, with

15% of the sample scoring in the severe range (Table 2).

Table 2

Freguency and Percent of CES-D Score Categories (N=124).

 

 

Depressive Symptoms p %
on CBS-D

FREE

(0-10) 37 29.8

MILD

(11-15) 30 24.2

MODERATE

(16-26) 38 30.6

SEVERE

(27+) 19 15.3

 

 

To address the research question of the existence of a
relationship between depressive symptomatology during
pregnancy and perceived social support, a one-way ANOVA for
analysis of variance was completed from NSSQ results for
total functional support related to each of the four CES-D
categories and for each subset of functional support:
affect, affirmation and aid, related to each of the four
CES-D categories (Table 3). Results supported the
hypothesis that there is a relationship between social
support and depressive symptomatology in the areas of total
functional support and the affect support component. Those
subjects in the group free of depression perceived a
statistically higher level of total functional support than

the group with severe symptoms of depression (Table 3).

38

The same pattern was observed in the affect component
of functional support within the group free of depressive
symptomatology and having significantly higher social
support scores than found in the severe symptomatology
group. The ANOVA for both the aid and affirmation
components did not show sigificant differences for any of
the CES-D groups, although the aid component showed a trend
in the same direction. The lowest scores in all categories
of social support analyzed were in the severe symptomatology
group, falling well below both the free of symptomatology
and mild symptomatology group scores.

Discussion

Question 1, what is the extent and severity of
depressive symptomatology in this sample, is answered as
expected, based upon the review of the literature. Of the
124 valid responses, 45.9% scored 16 or higher on the CES—D,
indicative of depressive symptomatology warranting clinical
evaluation (see Table 2). This percentage is markedly
higher than the extent of depressive symptomatology found in
the literature when a similar cut score was used. O'Heron
(1991), using a cut score of 16 with the BDI, found 20% to
meet the criteria for depressive symptomatology, while
Gotlib et al. (1989) found 25.8% of their sample of 360
women to meet the criteria, using a cut score of 10 on the
BDI. Zuckerman et al. (1989) report a mean score of 16 and
median of 18.9 on the CES-D for their sample of 1014

primarily low income women, compared with a mean score of

39

16.33 for the current sample of 124 primarily low income

women .

Table 3

Analysis of Variance: Functional Support on the NSSQ by CES-
D Symptomatology (N=107)

Group n M SD Range 3 _p
Total FS a 2.75 .05
FREE b 29 193 117.90 49-478

MILD 28 159 72.31 55-338

MODERATE 35 164 84.62 38-380

SEVERE b 15 113 48.97 37-199
Affect FS 3.08 .03
FREE b 30 72 47.48 20-180

MILD 28 56 25.10 20-114

MODERATE 35 59 32.13 12-144

SEVERE b 17 41 16.69 10-69
Affirmation FS 2.20 .09
FREE 29 64 42.21 16-183

MILD 28 53 23.31 16-104

MODERATE 35 54 28.24 12—131

SEVERE 16 40 17.87 14-68
Aid FS 2.53 .06
FREE 30 58 32.71 13-144

MILD 28 50 25.40 18-120

MODERATE 35 50 25.87 12-120

SEVERE 17 35 15.14 13-70

 

Note. 107 of the sample of 124 completed both the CES-D and

 

NSSQ, therefore 107 responses were included in the analysis.
a FS=Functional Support. b These two groups are
significantly different at the .05 level by Scheffe post hoc
analysis.

The sample in the current study differs from that of
Zuckerman et al. (1989) in being primarily caucasian
compared to the 1989 sample of primarily African American

women. The samples are similar in other categories. The

40

current sample differs from the O'Heron (1991) sample, which
consisted of middle income women with a mean education level
of 13.3 years. The majority in the O'Heron sample were
married and receiving prenatal care from private
practitioners. Like the current sample, O'Heron's subjects
were primarily caucasian. Findings in each study were
similar, despite differences in sample characteristics.

The subjects for the current study were recruited and
interviewed during their first, second and third prenatal
visits, presumably during their first trimester. O'Heron's
1991 sample was recruited during the second and third
trimesters. It is unclear at what point during pregnancy
Zuckerman et al. (1989) recruited their sample. Given
similar findings in each study, the trimester during which
women are interviewed may not effect extent or severity of
depressive symptomatology.

In this sample, at least 97.8% are low income, as
evidenced by eligibility for Medicaid as at least one
defining characteristic for low income status. The
literature indicates that studies which have drawn samples
from low income populations have shown the highest
percentage of women scoring in the higher range of the
depression inventories used (Zuckerman et al., 1989; Zayas &
Busch-Rossnagel, 1992). Regardless of the reasons for this
high level of depressive symptomatology, it is indicative
of a serious problem which has been largely overlooked by

providers of prenatal care.

41

Results of the data analysis which supported the
hypothesis and the expected outcome are the mean total
functional support scores and mean affect component scores,
which is supported in the literature (Collins et al., 1993;
Degen et al., 1993; Norbeck & Tilden, 1983; Thorpe et al.,
1992; Turner et al., 1990; Zuckerman et al., 1989) Women
with the highest social support scores on other indices have
shown that the acceptance and love of spouse, partner and
family are most important for the woman to feel supported.
This is also a category of support which people with limited
economic resources can provide. The literature also
suggests that women with severe depressive symptomatology
are less able to access the support of others or to reach
out due in part to feelings of worthlessness and diminished
interest in activiities. The NSSQ asks two questions
regarding aid, one of which involves material help in the
way of money or transportation, the other involving extended
help if confined to bed for several weeks. In a sample of
low income women, it would be expected that this area might
receive low scores, since many low income people do not have
persons in their network who have money to lend or cars with
which to provide transportation. Few low income women have
members in their support network who could freely devote
assistance over a period of several weeks. It is an
assumption of this researcher that people have in their
networks primarily others who are in like circumstances.

Low income women would tend to have friends and family from

42

similar economic circumstances, which would account for
lower scores in the aid category. Despite the low scores in
the area of aid functional support, ANOVA results showed a
trend toward the significant results in the total functional
support and affect components.

The affirmation component of functional support showed
the least significance in the ANOVA. It would appear likely
that affect and affirmation would follow similar patterns,
which is noted in Table 3, with differences in the
relationship and probability items. It could be assumed
that the failure of the affirmation component to show
stronger relationship to depressive symptomatology is
because depressed women are unable to confide in members of
their support network or that depressed women have
difficulty feeling support and affirmation from others in
the presence of feelings of worthlessness.

It is important to note that because this sample
consisted of primarily low income pregnant women enlisted
during their first prenatal visit, with questionnaires
completed during the second and third prenatal visits, it
cannot necessarily be generalized to a broader population of
other income levels or in the later stages of pregnancy.
However, the results support the evidence in the existing
literature that pregnant women who perceive a higher degree
of functional social support tend to have lower depressive
symptomatology scores. While the results of this study do

not indicate a cause and effect relationship between social

43

support and depressive symptomatology, the results do
support the hypothesis that there is a relationship between
perceived social support and self-reported symptoms of
depression.

Any interpretation of results of this study is limited
by lack of information regarding the subjects' depressive
symptomatology prior to pregnancy and their perceptions of
social support throughout the pregnancy. Subjects completed
questionnaires on only one occasion during pregnancy,
generally during the first trimester. This limits
interpretation of the results to relationship of the
variables at a point in time and does not extend
interpretation to a cause and effect relationship.

Interpretation of results of data analysis is limited
by missing data. Of the 172 original subjects, 124
completed the CES-D, while only 107 subjects completed both
the CES-D and NSSQ. A sample of this size is adequate and
the missing data was not considered to be problematic for
data analysis.

The model for this study, adapted from the wheel model
developed by Roy, shows the adaptive response as free of
depressive symptomatology and the presence of severe
depressive symptomatology as a maladaptive response to
pregnancy (Figure 1). The model presents a continuum of
response from adaptation to maladaptation as evidenced by
the absence of (FREE) to presence of depressive

symptomatology (MILD, MODERATE, SEVERE). Low income status

44

is presented as the contextual stimulus influencing the
pregnant woman's response. The pregnant woman's response
could perhaps be mediated by her perception of social
support from her support network, but does not imply cause
and effect. The model is therefore well suited to the study
and is supported by the findings. The findings indicate
that an adaptive response in terms of no depressive
symptomatology or mild symtomatology for the subjects of the
study is related to perceived total functional support and
the affective component of functional support. The model
presents the possibility of a relationship of the variables
without assuming more that the study results present. The
results of the study do not imply cause and effect, only the
existence of a relationship between variables. The model is
not fully supported by the study results in the components
of affirmation and aid, which are presented as an integral
aspect of functional support from the support network.
Implications for Practice

Implications for the APN, based upon the data in this
study, are that the extent and severity of depressive
symptomatology during pregnancy appears to be much greater,
at least among low income women, than has previously been
acknowledged. The study also offers support for a
relationship between depressive symptomatology during
pregnancy and total functional support, particularly the

affect component of social support.

45

With support in the literature for the possibility of
negative health behaviors and poor birth outcomes as a
result of depression (Collins et al., 1993; Degen et al.,
1993; Zuckerman et al., 1989) it is important that prenatal
care include an assessment for depressive symptomatology,
with further evaluation for clinical depression as indicated
by assessment results. Score on a standardized assessment
tool for depressive symptomatology can assist the APN in
selecting an appropriate role with the pregnant woman. The
APN functions in a variety of roles with the pregnant woman.
The assessor role can identify both history of depressive
symptomatology and present depressive symptomatolgy, while
the roles of coordinator of primary care and collaborator
with other health care professionals can facilitate referral
of the client for necessary counseling for moderate to
severe depressive symptomatology. For clients with minimal
or mild depressive symptomatology the APN can serve as
counselor and educator regarding the physical and emotional
changes of pregnancy.

The current study shows a statistically significant
relationship between total functional social support and the
affect component to depressive symptomatology during
pregnancy for the group free of symptomatology and those
with severe symptomatology. This relationship, supported in
the literature, should serve to guide the role of the APN as
a provider of not only healthcare, but social support.

Encouraging the pregnant woman to bring a family member,

46

friend, or significant other to prenatal appointments may
facilitate an avenue of support for the client from her own
network. Discussing with the client who in her network
could be a source of support is an important role for the
APN. Utilizing the NSSQ can facilitate this discussion.
The APN, as clinician, can provide anticipatory guidance at
prenatal visits, to aid the client in dealing with the
physical and emotional changes that commonly occur during
pregnancy. Based upon the findings of this study, focus on
the affective component of social support by the APN, by
listening and evidencing respect and concern for the
patient's questions, thoughts and emotions, can guide
practice in the support role.

The APN should pay attention to the characteristics of
the low income women who present for care. The pregnant
women in the current sample were primarily under the age of
thirty and single. Based on study results, attention should
be paid to facilitating interaction with the social support
network of women who fit this profile, particularly those
women who score in the moderate to severe range on a self-
report depression scale. Visits may be necessary for these
women on a schedule differing in frequency from the
traditional monthly visits early in the pregnancy. The APN
can reach out to these and other women in the community
through the establishment and facilitation of support groups
to address prenatal and depressive symptomatology issues.

Working in conjunction with such community resources as

47

Community Mental Health and the local health department, the
APN can provide information for the professional community
regarding the extent and severity of depressive
symptomatology in this population of pregnant women and
utilize the expertise of other professionals as speakers or
co-facilitators for support groups. The resources of the
community can assist in enhancing available social support
for the pregnant women. While not all components of
functional support showed significant relationship to
depressive symptomatology in data analysis, there were
significant results for the groups free of symptoms and with
severe symptoms in the total functional support category.
This would indicate that support in any component area would
be included in total functional support and would possibly
enhance the social support system of group members.

Women who are experiencing moderate to severe
depressive symptomatology present a challenge to the APN in
that this group has difficulty both reaching out for and
accepting support due to symptoms including feelings of
worthlessness and loss of energy or interest in
relationships or activities. These women should be strongly
encouraged to participate in a support group. Efforts
should be made by the prenatal care provider to encouage
participation. These women may also require particular
efforts from the provider to include a member or members of
the woman's support network to be involved in prenatal

visits. With the client's consent, a Community Mental

48

Health outreach therapist can attend a prenatal visit to
meet the client in a non-threatening setting and offer
individual therapy if necessary. Office visits for prenatal
care should be scheduled frequently in order to provide
close observation of depressive symptomatology. In
addition, prenatal visits for clients with moderate and
severe depressive symptomatology should be allowed adequate
time on the schedule for counseling and ongoing mental
health assessment. Individual therapy at Community Mental
Health and evaluation for medication by the CMH psychiatrist
can be facilitated by the APN during prenatal visits.

The APN has a responsibility to share the findings of
this and other studies with the professional community
providing prenatal care. Beyond the APN's individual
practice, development of a practice protocol for prenatal
care including initial assessment of the patient's or her
family's history of depression and completion of a self-
report depression scale on the second prenatal visit.
Utilizing a standardized scale such as the CES-D which has
efficacy in this population as documented in the literature,
will help to avoid subjective evaluation of symptomatology
on the part of other providers in a practice. The ongoing
assessment of depressive symptomatology, once during each
trimester, would provide improved understanding of the
problem of depression during pregnancy.

As a professional in the community the APN can reach

out to prenatal care providers in the area to share

49

information regarding the relationship of depressive
symptomatology and social support based on the results of
this study and available literature.
Implications for Research

The implications for further research based on the
findings of this study involve the need for further research
into the extent and severity of depressive symptomatology
during pregnancy for other income groups. Previous research
has primarily addressed depressive symptoms during pregnancy
as they relate to postpartum depression or to pregnancy
outcomes. While these are important issues, the affective
state of the pregnant woman is also important. A depressed
state can affect healthcare decisions the woman makes and
can result in energy changes limiting activity and social
interaction. Pregnancy is a time when the generally
accepted treatment for depression, medication, is not a
desirable option. Nurse researchers have a responsibility
to better understand the problem of depressive
symptomatology during pregnancy and to seek to develop
interventions which might decrease the extent and severity
of the problem. While the current study does not offer
information regarding cause and effect, it does offer
support for further research into the relationship between
depressive symptomatology during pregnancy and perceived
social support. Reseachers need to study both depressive
symptomatology and perceptions of social support throughout

the pregnancy for enrolled subjects. Specifically,

50

measurement of depressive symptomatology and network support
once during each trimester would provide information
regarding changes in perception of social support and
symptomatology which would have further implications for
practice. Information is needed through research regarding
the impact of support groups on self-report depressive
symptomatology and perceived social support through an I
intervention study. The role of low economic status in
depressive symptomatology during pregnancy warrants further

investigation to add to the existing body of research.

 

Economic groups from low to high could be compared in a
study of perceived social support and depressive
symptomatology. It is only by building a large enough body
of research that professionals from areas other than nursing
will begin the develop altered practice patterns. Research
with samples drawn from various income groups would provide
information regarding the role of economic status on the
extent and severity of depressive symptomatology during
pregnancy. The subjects in the current study were primarily
single, with 41% primigravidas and 88% under the age of
thirty. Further research is needed regarding the impact of
marital status, parity and maternal age on both depressive
symptomatology during pregnancy and perception of social
support. Does marital status impact perceived social
support? Does parity effect severity of depressive
symptomatology? Does maternal age effect severity of

depressive symptomatology and perception of social support?

51

It is also important, based upon a review of the
literature, for nurse researchers and other researchers into
human relationships to establish a more unified conceptual
definition of social support with agreement regarding
measurement instruments. For the practitioners to
effectively utilize research, some consistency in the
measurement of social support is needed. Current research
and the myriad of both instruments and terminology result in
confusion and difficulty in interpreting the research and
extending it to new subjects. Multiple studies utilizing a
single instrument to assess social support, such as the
NSSQ, will aid in making the instrument more widely
accepted.

Summary

This study is a secondary analysis of data collected
from 124 primarily low income women. The extent and
severity of depressive symptomatolgy for this group of women
and the possible relationship of depressive symptomatology
and the each woman’s perception of available social support
were analyzed statistically. While the results were not
clear cut and conclusive in all areas, the problem of
depressive symptomatology during pregnancy for this
particular group was defined and a relationship between

depressive symptomatology and perceived functional social

52

support was found. This study lends support to the existing
literature and opens the door for further research. Further
study is needed to better understand the role of social

support in depressive symptomatology among pregnant women.

Appendices

53

Appendix A
: il l E H l I . E . I

A: Five (or more) of the following symptoms have been
present during the same 2-week period and represent a change
from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or
pleasure.

Note: Do not include symptoms that are clearly due to a
general medical condition, or mood-incongruent delusions or
hallucinations.

(1) depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g. feels sad or
empty) or observation made by others (e.g. appears tearful).
Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day (as
indicated by either subjective account or observation made
by others).

(3) significant weight loss when not dieting or weight
gain (e.g. a change of more than 5% of body weight in a
month), or decrease or increase in appetite nearly every
day. Note: In children, consider failure to make expected
weight gains.

(4) insomnia or hypersomnia nearly every day.

(5) Psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective feelings of
restlessness or being slowed down).

(6) fatigue or loss of energy nearly every day.

(7) feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly every
day (not merely self-reproach or guilt about being sick).

(8) diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).

54

(9) recurrent thoughts of death (not just fear of
dying). recurrent suicidal ideation without a specific plan,
or a suicide attempt or specific plan for committing
suicide.

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.

D. The symptoms are not due to the direct physiological
effects of a substance (e.g. a drug of abuse, a medication)
or a general medical condition (e.g. hypothyroidism).

E. The symptoms are not better accounted for by bereavement,
i.e., after the loss of a loved one, the symptoms persist
for longer than 2 months or are characterized by marked
functional impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation.

American Psychiatric Association (1994)
Diagnostic Criteria from DSM-IV

55 Appendix B
Win

INSTRUCTIONS FOR QUESTIONS: Below is a list of the ways you
might have felt or behaved. Please tell me how often you
have felt this way during the past week.

Rarely or None of the Time (Less than 1 Day)

Some or a Little of the Time (1-2 Days)

Occasionally or a Moderate Amount of Time (3-4 Days)

Most or All of the Time (5-7 Days)

was bothered by things that usually don't bother me.
did not feel like eating; my appetite was poor.
felt that I could not shake off the blues even with
from my family or friends.
felt that I was just as good as other peOple.
had trouble keeping my mind on what I was doing.
felt depressed.
felt that everything I did was an effort.
felt hopeful about the future.
. thought my life had been a failure.
10. I felt fearful.
11. My sleep was restless.
12. I was happy.
13. I talked less than usual.
14. I felt lonely.
15. People were unfriendly.
16. I enjoyed life.

m o o
I-‘

\qummbb‘wmw
HHHHHH'UHHH

17. I had crying spells.

18. I felt sad.

19. I felt that people dislike me.
20. I could not get "going".

The CES-D scale: A self-report depression scale
for research in the general population.

56
Appendix C

For each person you listed, please answer the following
questions by writing in the number that applies:

1=not at all

2=a little

3=moderately

4=quite a bit

5=a great deal

Personal Network

First name or initials Relationship

 

 

 

 

 

 

 

 

(flcwaH

 

 

(total of 20 spaces provided)

 

Questions

*1. How much does this person make you feel liked or loved?
(affect)

*2. How much does this person make you feel respected or
admired? (affect)
*3. How much can you confide in this person? (affirmation)
*4. How much does this person agree with or support your
actions or thoughts? (affirmation)
*5. If you need to borrow $10, a ride to the doctor or some
other immediate help, how much could this person usually
help? (aid--short term)
*6. If you were confined to bed for several weeks, how much
could this person help you? (aid--long term)
*7. How long have you known this person? (duration of

relationship)

*8. How frequently do you usually have contact with this
person? (phone calls, visits, or letters) (frequency of
contact)

9. During the past year, have you lost any important
relationship due to moving, a job change, divorce or
separation, death, or some other reason? (recent 1055)

9a If YES, check the category(s) of persons who are no
longer available to you. (9 categories listed)

9b How much support did this person (or persons)
provide for you during the past six months?

 

Ratings are based on a 5-point rating scale specified
for each question. Question 1 to 6 and 9b: 1=not at all to
5= a great deal. Question 7: 1=less than 6 months to 5=more
than 5 years. Question 8: 1=once a year or less to 5=daily.

57

NQLeI*QueStions used for analysis of social support in the
present study.

 

OFFICE OF
RESEARCH
AND
GRADUAJE
STUDIES

University Committee on
Research lnvolvln
Human Sable
(UCRIHS)

Michigan State University
232 Administration Building
East Lansing, Michigan
48824-1046

517L355:2180
FAX: 517/432-1171

The Michigan State University
IDEA is Institutional Diversity,
Excellence in Action.

MSU is an allmnative-action.
equal-opportunity institution

Appendix D

MICHIGAN STATE
u N l v E R s l T Y

August 10, 1995

TO: ' Rachel F. Schiffman
A112 Life Sciences

RE: IRBI: 95-423
TITLE: THE RELATIONSHIP OF SOCIAL SUPPORT AND
DEPRESSIVE SYMPTOMATOLOGY DURING PREGNANCY
REVISION REQUESTED: N/A
CATEGORY: -E
APPROVAL DATE: 08/08/95

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete.. I am pleased to adv so that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed consent are ap ropriate.
herefore, the UCRIHS approved this project and any rev sions listed

above.)

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be ond one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u date certification. There is a
maximum of four such expedite renewals ossible. Investigators
wishing to continue a project beyond the time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in rocedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year,
send your written request to the CRIHS Chair, requesting reVised
approval and referencing the project's IRB I and title. Include
in your request a description of the change and any revised
instruments, consent forms or advertisements that are applicable.

PROBLEMS]
CHANGES: Should either of the followin arise during the course of the

work, investigators must noti UCRIHS romptly: (1) problems
(unexpected Side effects, comp aints, e c.) involVing uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub'ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do no: hesitate to contact us
at (517)355-2180 or FAX (517)4 2- 171.

   

Sincerel

  
 
   
  

avid E. Wright, h.D.
UCRIHS Chair

DEW:kaa/lcp

59
MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE PRESIDENT FOR RESEARCH EAST lANSING 0 MICHIGAN 0 488244046
AND DEAN OF THE GRADUATE SCHOOL

March 19, 1992

Mildred A. Omar, Ph.D.
Rachel F. Schiffman, Ph.D.
A-230 Life Sciences Bldg.

RE: FACTORS INFLUENCING PREGNANCY OUTCOME, IRB #92-115

Dear Drs. Omar and Schiffman:

The above project is exempt from full UCRIHS review. One of the Committee's
members has reviewed the proposed research protocol and finds that the rights and
welfare of human subjects appear to be protected. You have approval to conduct
the research.

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 one month prior to March 16, 1993.

Any changes in procedures involving human subjects must be reviewed by the UCRII-IS
prior to initiation of the change. UCRIHS must also be notified.prompt1y 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,

  

David E. Wrighfl D.

Chair, UCRIHS

DEW/Pim

MSU is an A/Iinnnte't-e Action/Equal Opportunity Institution

6O
MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE PRESIDENT FOR RESEARCH EAST LANSING 0 MICHIGAN ' 48824-1046
AND DEAN OF THE GRADUATE SCHOOL

March 2. 1993

TO: Rachel Schiffman, Ph.D.
Mildred Omar, Ph.D.

A230 Life Sciences
RE: IRB #: 92-115
TITLE: FACTORS INFLUENCING PREGNANCY OUTCOME

CATEGORY: l-C
REVISION REQUESTED: February 23, 1993
APPROVAL DATE: March 1, 1993

The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complete.
I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and
methods to obtain informed consent are appropriate. Therefore, the UCRIHS approved this project including any
revision listed above.

UCRIHS approval is valid for one calendar year, beginning with the approval date shown above. Investigators
planning to continue a project beyond one year must seek updated certification. Request for renewed approval must
be accompanied by all four of the following mandatory assurances.

1. The human subjects protocol is the same as in previous studies.

2. There have been no ill effects suffered by the subjects due to their participation in the study.

3. There have been no complaints by the subjects or their representatives related to their participation in the
study.

4. There has not been a change in the research environment nor new information which would indicate greater

risk to human subjects than that assumed when the protocol was initially reviewed and approved.

There is a maximum of four such expedited renewals possible. Investigators wishing to continue a project beyond
that time need to submit it again for complete review.

UCRIHS must review any changes in procedures involving human subjects, prior to initiation of the change.
Investigators must notify UCRIHS promptly of any problems (unexpected side effects, complaints, etc.) involving

human subjects during the course of the work.

If we can be of any future help, please do not hesitate to contact us at (517) 355-2180 or FAX (517) 336-1171.

: 1‘
avid E. Wright, Ph.D.
UCRIHS Chair

Sincerely,

 
   

 

DEW:pjm

MSU is an Affirmative Action /Equal Opportunity Institution

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