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This is to certify that the

dissertation entitled

Psychosocial Stress, Personality, and
Contextual Factors: Links to Pregnancy
and Birth Outcome.

presented by

AnnJanette Ramiro Alejano

has been accepted towards fulﬁllment
of the requirements for

Ph.D. degree in Psychology

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Date 8-26-94

MSU is an Affirmative Action/Equal Opportunity Institution 0- 12771

 

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PSYCHOSOCIAL STRESS, PERSONALITY, AND CONT EXTUAL FACTORS:
LINKS TO PREGNANCY AND BIRTH OUTCOME

By

AnnJanette Ramiro Alej ano

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1 994

ABSTRACT

PSYCHOSOCIAL STRESS, PERSONALITY, AND CONT EXTUAL FACTORS:
LINKS TO PREGNANCY AND BIRTH OUTCOME

By

AnnJanette Ramiro Alejano

The present study examined the inﬂuence of stress, individual characteristics
and contextual characteristics on birth outcome in first time mothers. The proposed
models were patterned after the Institute for Social Research biopsychosocial model of
stress (Kahn, 1981). Within this model, environmental factors, such as social,
psychological and behavioral dimensions are given consideration in their inﬂuence on
health. The results provide evidence for the inﬂuence of personality and
temperamental characteristics on pregnancy outcome.

Participants in the study were 80 predominantly Caucasian middle-class career
women experiencing their ﬁrst pregnancies. The majority of participants were
married, with college degrees. Data in the current study included information
collected during the third trimester of pregnancy and medical information recorded
during labor and delivery.

For this sample of first time mothers, individual characteristics appear to
contribute to the number of complications occurring during labor and delivery.
Contextual characteristics, on the other hand, did not play a factor in the proposed
model. The proposed links between stress and birth outcome were not supported, and
this may be due in part to the homogeneity of the sample. Although the original

proposed model did not yield significant results, further analyses focused on

temperamental and personality characteristics in how they inﬂuence birth outcome.
Results indicated that differences in labor and delivery complications are
apparent for Type A and B career women during their ﬁrst pregnancies.
Temperamental behavioral style appears to have a greater inﬂuence on number of
labor complications for Type A women, and does not affect labor progress for Type
B women. When comparing the inﬂuence of psychological indicators between
personality types, the results revealed that the greater anticipatory excitement and
anxiety felt, the greater the number of complications Type A women experienced in
the labor and delivery room. In contrast, for Type B women, the greater the
anticipatory excitement and anxiety felt, the fewer the number of labor complications
experienced. It is speculative that there may be a connection between raised
emotional state and physiology which in turn inﬂuences the progress of labor and

delivery for ﬁrst time pregnant women.

Dedicated to my parents

Eugenio V. Alejano, Jr., MD.
and
Paz Ramiro Alejano, RN .
For teaching me to use my head

and for reminding me that
"Education is something no one can ever take away from you"

iv

Pa;

ACKNOWLEDGEMENTS

Although social support did not prove to be a key factor in the present study,
the support and encouragement I received from friends and family during the course of
the project was invaluable. They all served as true buffers to my constant barrage of
stressors, and encouraged me through times when I felt managing the project was
overwhelming. I could not have accomplished all I have in the past year, and
especially in the past few months without these special peOple.

I feel extremely fortunate to have been able to work and learn from such a
supportive and encouraging mentor, Dr. Jacqueline Lerner. I also thank Dr. Hiram
Fitzgerald for the opportunities he has provided me along the way. I extend thanks to
Dr. Fernanda Ferreira and Dr. Lawrence VanEgeren for their assistance on my
dissertation committee. Additional thanks goes to Dr. Alexander VonEye for his
statistical assistance.

Special thanks are warranted for my research family. It goes without saying
that I thank Sandra Frassetto, my co-founder of the Transition to Parenthood project.
It is incredible how far we have come from an idea and a conversation. The hundred
headaches were worth it; thank you for pulling me through all the worries,
negotiations, and times of panic. Very special thanks go to Mona Ibrahim for her
thoroughness and capacity to pick up the thousands of details of the project-J feel I
leave the data in very capable hands. I clearly could not have completed this
dissertation without her. A hundred thousand more thanks to many independent study
undergraduates who assisted in the painstaking and monotonous chore of data entry. In

particular, I thank Laurie Falk, Candy Dreves and Matt Taylor for being so eager and
v

helpful at times I needed it most. As Matt would say, "PBORG rules! !"

Additional thanks go to Maria Townsend and Audrey White for their (very
current) ﬁrst-hand knowledge of pregnancy and the baby therapy they provided me
during my most anxious times. I can't begin to say enough about the encouragement
and emotional support Audrey especially provided throughout the project. And
although he doesn't feel like he helped me very much, great big thanks go to Dave
Whitney for providing me laughs, statistical direction, and emergency medical
assistance during the last year. Collectively, the three of you have always been right
there for me, all along and I appreciate it so much. Much love goes out to my family,
the Alejanos, for seeing me through this transition in my life, and for the constant love
and assistance they provided.

Finally, I wish to thank my special source of love and support, Tom Steele, for
helping me through the physical and emotional tolls of the pregnancy project. You
have listened to it all, and your patience and understanding and encouragement have

been immeasurable. Without you, I wouldn't have made it in one piece.

TAB LE OF CONTENTS

 

 

List of Tables ................................................................................................... Viii
List of Figures ................................................................................................... ix
Problem Statement ........................................................................................... 1
Introduction ...................................................................................................... 6
Systems Models .................................................................................... 6
Deﬁning Stress ..................................................................................... 11
The Institute for Social Research Model of Stress ........................... 23
Historical views of stress and pregnancy ........................................... 27
Labor and delivery outcomes ............................................................. 29
Stress and pregnancy outcome research ............................................. 34
Moderators in the Stress-Illness Model ............................................. 52
Contextual Moderators ............................................................ 53
Individual characteristics and personal resources ............... 63
Hypotheses ........................................................................................................ 83
Method ............................................................................................................. 89
Sample .................................................................................................. 89
Procedure .............................................................................................. 90
Measures .................... 92
Results ............................................................................................................... 105
Discussion .......................................................................................................... 138
Appendix: Measures ....................................................................................... 161
List of References ............................................................................................ 204

vii

LIST OF TABLES

Table
1 Review of prospective studies using primiparous subjects in

assessment of stress and birth outcome ......................................................... 4O
2 Constructs and measures ................................................................................. 86
3 Reliability estimates for scales ....................................................................... 106
4 Means, standard deviations and variable correlations .................................. 110
5 Individual indicators used in regression analyses for

hypotheses 3 and 4 116
6 Regression analyses for hypotheses 3 and 4 ................................................ 118
7 Mean differences between Type A and Type B women ............................ 122
8 Regression analyses for Type B sample ....................................................... 124
9 Regression analyses for Type A samme ........................................................ 125
10 Principal components factor analysis for predictors ..................................... 131

ll Latent constructs and individual indicators tested in
structural equation model for hypothesis 2 .................................................... 135

viii

LIST OF FIGURES

Figure
l I Institute for Social Research Model of Stress ............................................. 24
2 ISR Model adapted for present study ........................................................... 26
3 Model of psychosocial stress, personality and contextual factors

and links to pregnancy outcome ................................................................... 82
4 Regression model predicting labor complications ...................................... 120
5 Regression models predicting labor complications for

Type A and Type B groups ........................................................................... 126
6 ISR-based model tested by LISREL ............................................................. 134
7 Reduced LISREL model ................................................................................. 137

PROBLEM STATEMENT

Pregnancy is a time of transition involving 'a matrix of social and
psychological factors on one hand, and a series of structural, endocrinologieal and
metabolic changes on the other." (lstvan, 1986). It is a time of uncertainty and
adjustment on the part of the parents, in anticipation of a successful delivery and
healthy newborn. The birth of a child is a stressful life event, one where control is
desired but not easily achieved. Unfortunately, for many expectant couples,
pregnancy and labor do not progress as expected.

The fact that as many as 5 - 15% of all deliveries in the Western World are
classiﬁed as preterm (Brown, 1984) has led physicians, prenatal health care providers,
and child developmentalists to a shared concern regarding the factors that may play a
role in the onset of preterm labor. Preterm labor is deﬁned as labor occurring
between the beginning of the 21st week and the end of the 37th week of gestation
(World Health Organization, 1977). A major concern for researchers and
practitioners in this area has been the increased jeopardy for optimal development that
preterm delivery poses for the infant. Physieal, cognitive, social and developmental
problems increase in likelihood with prematurity. Infants who survive a premature
birth are more likely than others to be susceptible to neurodevelopmental problems,
learning disorders and behavior problems, and their families also face increased
ﬁnancial and emotional burdens (Brown, 1985).

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soon. These factors include maternal age, poverty, race, low education, drug use and
inadequate prenatal care. Brown (1985) has noted that "of the less documented risk
factors, physical and psychological stress are particularly intriguing and of great
potential importance (p 114)”. Little is known about the impact that daily work and
home stressors have on pregnancy outcome.

With the ever-increasing number of women in today’s workforce, issues
surrounding work and pregnancy come to the forefront. Within the past decade, the
proportion of women entering the workforce has been steadily increasing. The rate of
66.9% of women aged 25 to 64 is expected to increase to 80.8% by the year 2000,
with 66 million women projected to be in the labor force at that time. With the
change in proportion come changes in womens’ occupations. Over time, more
women have taken top-level, managerial or profressional positions. Greater
responsibility, longer work hours and greater stress accompany these male-dominated
positions. Decisions regarding having a child in the midst of a deve10ping career can
be difﬁcult.

As more and more women continue to add to the labor force, women are
exposed to factors in the workplace that require adaptation and adjustment. To the
extent that these work factors are indeed stressful, it has been predicted that ”stress-
related illnesses, coronary heart disease, and even death will increase and perhaps
approximate the rates of men (Detre, Feinleib, Matthews, & Kerr, 1987). It would
appear as though ”women are undergoing a natural experiment of enormous

proportions” (Matthews and Rodin, 1989, p 1389). What implications do these

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potential health changes due to employment have on women who work during
pregnancy?

The current study will attempt to bridge the areas of developmental
psychology, psychophysiology and obstetrics by examining relationships between
individual resources and environmental factors, and how they affect complications
during pregnancy, labor progress and newborn outcome. Under investigation is the
relationship between behavioral challenge (stress) from the environment, individual
personality characteristics and how they inﬂuence potential birth complications and
poor infant viability.

Several models will be proposed as frameworks with which to organize the
multiple events that occur during the transition to ﬁrst time parenthood. These
include systems theory, a biopsychosocial model, and the theoretical viewpoint of
developmental contextualism. The present research utilizes these themes within
Kahn’s (1981) Institute for Social Research stress model which provides a framework
for assessing stress effects on health outcome. The ISR model includes six
components: 1) the objective environment, 2) the psychological environment 3) short
term adaptation response 4) sustained mental and physical health change, 5) enduring
personal properties and 6) interpersonal relations. Each component will be assessed
by the following measures.

The ijmtive enyjrgnment will include contexts held constant across subjects,
such as the condition of pregnancy and the employment situation. Psychglggiﬂ

W includes perceptions of stress, as indicated by depression, anxiety and

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self-reports of daily and extreme life stressors. Work satisfaction and role strain will

also provide measures of perceived stress as triggered by work environment. The

WW will be assessed by a measure of individuals’ coping
style in the face of problem situations. Sewing: mental Ed physical ehange provide

the outcome portion of the model. Resulting labor progress, such as labor stage
length and complications and infant outcome indicators, such as Apgar scores,
birthweight and prematurity will be assessed within this component of the model.

W include individual styles of behavior and mental
health. Personal style includes temperament indices of general activity level, sleep
activity level, ﬂexibility-rigidity, quality of mood, approach-withdrawal, rhythmicity
of sleep, eating and daily habits, and task orientation. Type A personality will also
be assessed, which is characteristic of individuals who are time-conscious,
achievement-striving and competitive. Personal expectations of control during
pregnancy will also be measured. Integgrsgng relations that affect the inﬂuence of
stress on health will be assessed by self-report of marital satisfaction and desired need
for social support during pregnancy. The latter two components of the model may
serve as mediators or buffers to the primary inﬂuence of stress on pregnancy
outcome.

The current study proposes a short-term longitudinal study of 80 pregnant
working women, assessing psychological and physical changes that occur during the
transition to ﬁrst time motherhood. The proposed analyses will utilize questionnaire

data collected during the third trimester of pregnancy, medical data collected during

5

labor and delivery, and questionnaire data collected 8 weeks postpartum.

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INTRODUCTION

The pregnancy event can be represented in terms of a network of
interdependent and interrelated events. Several theoretical models will be used in the
present study as a means of organizing a research plan aimed at looking at the
relationship of interrelated variables during pregnancy. A review of three models,

systems theory, the biopsychosocial model and developmental contextualism follows.

Systems Model

The events that occur during the course of pregnancy can be seen as a
system. A system is deﬁned as "an organized arrangement of elements which
comprise a network of interdependent and coordinated parts, and which functions as a
unit, especially for the purpose of concerted action. The regularized interdependence
makes possible the functioning or performance of the unit as a whole" (Fitzgerald,
1993, p 4). The human system, comprised of differing levels of functioning
(biological, psychological, interpersonal, cultural, or ecological) can be viewed as
overlapping and interpenetrating systems. For example, individuals can be
understood as biopsychological systems or psychosocial systems.

The basic assumption of systems theories is that systems exist within larger
systems. For example, social systems are composed of individuals, individuals are
composed of tissues, and tissues are composed of cells and cells are composed of
molecules and so forth. Nothing exists in isolation. Systems theory has been used to

describe components of a system relative to adaptive functioning. Carlson and

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Cassell (l9 ) note that these components include 1) characteristics of the individual,
2) social and ecological structure of the particular environment, 3) continuous active
exchange processes connecting the individual and environments, and the individual’s
cross-environment transitions, and 4) the negotiation of adaptive ﬁt.

For the purposes of the current research proposal, the pregnancy event is a
system comprised of biological, social and psychological systems operating in concert.
The relationship between mother and father are two independent systems undergoing
change during the transition to parenthood. Meanwhile, the biological system of the
mother undergoes radical change throughout the gestational period, and psychological
perceptions shift in anticipation of the labor and becoming a ﬁrst time mother. One
of the key models in health psychology based on systems theory is the

biospsychosocial model.

The Biopsychosocial Model

The biopsychosocial model of health developed as an extension to the
biomedical model. The biomedical model only considered the biochemical factors of
health and illness, whereas the biopsychosocial model includes the inﬂuence of
environmental factors, such as social, psychological and behavioral dimensions on
health. The model extends beyond the reliance on treatment for health problems.
Instead, prevention, health enhancement and individual responsibility for health are
emphasized.

The biopsychosocial model considers the role that lifestyles play in current

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diseases. It has been documented that behavioral factors are implicated in seven of
the ten leading causes of death in the United States (Raub, 1989). One way of
assessing the inﬂuences of environment on the body has been to measure a biological
change in the body as a response to an external event. One biopsychosocial approach
to health provided by Frankenhaeuser (1989) focuses on endocrine responses to the
psychosocial environment. His work has targeted the coordinating functions of the
nervous and endocrine systems in the adaptation of humans to their environment.
These endocrine changes are hypothesized to develop as indicators as early warnings
of long-term risks, such as heart disease.

For example, Frankenheuser’s effort-affect model (1989) addresses the
possible mechanism for favorable health effects of work conditions that allow for
personal control. This mechanism can be the catecholamine/ cortisol balance of
controllable situations. The theory discusses how effort and positive or negative
affect induced by different work demands may be determinants of physiological/
hormonal responses. In turn, these responses inﬂuence health outcomes. How people
perceive control over their environment mediates the quality of affect experienced. A
more detailed set of examples will be covered in later sections.

The biopsychosocial systems model is an appropriate tool to identify the
multiple systems at work during pregnancy. Although the present study does not
speciﬁcally address nervous and endocrine systems in the model, it is important to
acknowledge the physiological pathways between stress and health. This study will

not measure biological markers, but theoretical notions of the hormonal and

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endocrinological connections between psychology and biological change are possible.
These issues will be addressed in a later section reviewing animal research. Another
way to deﬁne and organize the system of multiple events occurring during the

transition to parenthood is by way of the developmental contextualism model.

Developmental Contextualism

Throughout the history of developmental psychology, a synthesis of method
and theory has evolved to attempt to explain the nature of human beings and how they
are affected by environmental factors. The current task in developmental psychology
is to determine exactly how genetic endowment interacts with experience in the course
of development. In the case of this study, the course of pregnancy will be
highlighted.

The developmental contextual perspective (Lerner, 1986) provides a means of
approaching the relative contributions of nature and nurture. Within this perspective,
organismic characteristics (genes, cells, tissues, organs) as well as the whole organism
itself, function in a bidirectional, reciprocal or "dynamic interactional" relation with
the contexts within which the organism is embedded. What results is a multilevel
exchange of "information" variables. Because changes in the organism always occur
in dynamic connection with changes in the context (and vice versa), changes in
organism-context relations represent the basic change processes in development
(Lerner, 1986). The developmental contextual view of human development provides

a description of the dynamic interaction among biological, psychological and social

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factors inﬂuencing development. Individual outcomes are probabilities, i.e., dependent
on the reciprocal interaction of both internal and external inﬂuences. The model
proposes an ever-changing relationship among factors, providing a description of the
"goodness of ﬁt" between the individual and his/her environment. In the case of the
current study, poor ﬁt results in stress. Individuals are seen as active producers of
their own development by virtue of a dynamic interaction of development with social
contexts (Lerner, Lerner & Tubman, 1988).

The transition to ﬁrst time motherhood is an inherent part of adult
development for many adults. This proposal will examine this transition in the
context of the workplace and its associated stressors. The emphasis will be placed on
the individual who has personal resources (personality and temperament) which are
inﬂuenced by the environment (social and work relationships). The proposal will
focus on these components and how they interact and inﬂuence each other during the
course of pregnancy, or stated alternatively, how constitution and environment coact
and interact to inﬂuence birth outcomes.

For example, as a woman’s body changes, adaptation is continuous, with
changes in appetite, clothing and feelings about the growing fetus inside her and
implications for change for the marriage. The physical and psychological adjustments
inﬂuence how one feels about becoming a ﬁrst time parent. Women who are
accustomed to identifying themselves by marriage and career ﬁnd themselves in
anticipation of adding a new role of parent to their self-deﬁnition. Contextual factors

can be supportive and buffering or they can heighten the stress felt during the

11
transition.

In summary, the systems, biopsychosocial and developmental contextual
models furnish broad theoretical frameworks within which to assess individual and
contextual inﬂuences on pregnancy outcome. The following section will be devoted
to deﬁning the complex issues associated with stress research. A model of stress will
be offered as a more speciﬁc means of investigating pregnancy outcome as inﬂuenced
by stress. The subsequent sections will address the variables of interest in more detail

and how they ﬁt in the proposed stress model.

Deﬁning Stress

We are in the midst of an epidemic of stress that is causing illness and even
death, but few agree about how to deﬁne stress. Approaches from diverse
psychological and medical viewpoints lend to the confusion in how stress is deﬁned.
For example, in the biological sciences, investigators have tended to use stressors
primarily as experimental tools, with most of the major discoveries of potential
biological substrates for stress effects. Alternatively, investigators in the
psychological and social sciences have targeted strong associations between certain
psychosocial events and physical and mental illness. Generally, physicians tend to
describe stress as a response, while psychologists have a tendency to deﬁne stress as a
stimulus.

Stress may be deﬁned as a cause, effect or interaction between the two. A

brief examination of how deﬁnitions of stress have evolved over the past few decades

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is in order before delving into speciﬁc models of health and stress.

Walter Cannon (1935) laid the groundwork for explaining possible effects of
stress on the body. In his work on blood hormones, Cannon studied the effects of
physical or emotional "stress”, by which he meant stimuli that disrupted an
individual’s normal internal environment. Stress which exceeded a critical threshold
could strain people beyond their adaptive limits. Selye (1956, 1975) further extended
the parameters within which to study stress by identifying a three-stage General
Adaptation Syndrome. These stages include 1) an alarm reaction, in which adaptation
has not yet been acquired, 2) a second stage of resistance, in which adaptation is
optimal and 3) a ﬁnal stage of exhaustion, in which the acquired adaptation is lost
again. Selye postulated that this response was nonspeciﬁc, so that any noxious
stimulus would produce the same stages of response (Selye, 1975).

Selye’s subsequent research saw an evolution of change in the deﬁnition of
stress, and his initial work in the 1930’s used "stress" as a synonym for ”stimulus”.
By the 1950’s, Selye proposed that stress should refer instead to the nonspeciﬁc
response of an individual to such stimuli, which he called "stressors". Increased
emphasis was then placed on the importance of the individual. Thus, a stimulus was
a stressor only if it produced a stress response, which consisted of speciﬁc, objective
physiological changes.

Selye’s research in neurobiology and medicine targeted endocrine and
physiological responses to stressful situations. His key contribution to the ﬁeld

included a hypothesis that either physical or emotional stressors might produce stress

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reactions, and this provided strong foundations for psychosomatic research. In spite
of these achievements, stress researchers have yet to agree on issues of deﬁnition and
methodology. Mason (1975a) concluded that scientiﬁc opinion has changed little
since the 1950’s: "There are still some (researchers) who accept Selye’s views on
stress, some who use modiﬁcations of them, some who regard them yet as unproven
working hypotheses, and some who simply reject or ignore them" (p 25).
Historically, stress has been deﬁned as a stimulus, response and interaction between

the two. A brief description follows.

Stress as a Stimulus

As noted earlier, the term ’stressor” was introduced by Selye (1978) to
distinguish between the cause (stressor) and the effect (stress). Stressors are
commonly measured by a variety of life events scales which yield overall life events
indexes. These measures are often quick and simple to administer. Another approach
to stressors included deﬁning certain contexts as inherently stressful. Outcomes are
compared to a control group or by using subjects as their own controls at different
points in time.

Yet it is noteworthy that incompatibility between wishes, desires and what one
is or has might be a source of stress. Deﬁning stressors in terms of solely external

stimuli may miss an important part of the picture.

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Stress as s Physiological Resmnse

Physiologic stress is measured by a variety of techniques including
cardiovascular (heart rate, blood pressure, vagal tone), immunologic (antibody
response, lymphocytic activity, interferon production) and neuroendocrine (galvanic
skin response, corticosteroid secretion). These measures help to clarify possible
pathways connecting external stress with the development of disease states.
Unfortunately, circular reasoning results from determining the connection between
physiologic measures and subjective distress. Which should be validated against
which?

Psychologic stress is also measured by a variety of self-report or interviewer
ratings of anxiety, depression and distress. These types of measures may capture
more closely what people think when considering the deﬁnition of ”being stressed
out". Yet with these measures, subjects who cope well may not report high levels of

distress, even when external stress is great, and vice versa.

Int i n w n h Envir nmen
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This view of stress is similar to the notions behind the model of developmental
contextualism. In considering the interaction between how the individual perceives
the environment and what resources he/ she brings to the situation, people seem to be
distributed on a continuum of ability to withstand stressful circumstances.

Evidence indicates that rare individuals with certain characteristics do well

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even under objective conditions of extreme stress, that some individuals do poorly
even with little stress and for most individuals, increasing stress is generally related to
worse health outcomes. The concept of hardiness (Kobasa, 1979, 1982), includes
personalities with high degree of commitment, control and challenge in their lives.
They view change as normal and as an opportunity rather than a threat.

Genetic vulnerability and earlier experiences with the environment play a role
by affecting physiologic reactivity to stimuli (threshold and recovery effects) and
creating individual differences in vulnerability to biochemical effects of stress in
different target organs or systems (Kobasa, 1982). Social support and coping seem to
act as buffers, by decreasing exposure to stress, increasing ability to c0pe when
exposed, or both. These factors, in turn, are inﬂuenced by past life experiences.
These notions parallel those within the theory of developmental contextualism which
depicts individuals as producers of their own development. None of the subjects in
the present study have had previous experience with childbirth, but they may have
past experience with children and friends’ pregnancies which may help them cope

with their transition to parenthood.

Deﬁning Tyms 9f Stressgrs

Given these conceptualizations of stress and its historical deﬁnitions, attention
must be given to deﬁning variation across types of stressors. Lazarus and Cohen
(1977) identiﬁed three categories of stressors, each varying in intensity of effects.

They are cataclysmic, personal, and background stressors.

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Cataclysmic stressors refer to events that happen to several people or whole
communities at the same time. They are usually unpredictable, have a powerful
impact, and require great coping efforts. These include natural disasters such as
ﬂooding, ﬁre and earthquakes, wars, massive layoffs, and manmade disasters such as
toxic waste dumps and nuclear power plants.

In many ways, reactions to manmade disasters are similar to reactions to
natural disasters. Natural catastrophes are usually time-limited. In contrast,
survivors of manmade disasters cope with the stress of not knowing what serious
illnesses may result and not being able to ﬁnd ways of overcoming it because of
government indecision. Manmade disaster survivors typically have reported cases of
miscarriage, stillbirth, birth defects, respiratory problems, urinary problems and
cancer. Other psychophysiological problems have included family strain, depression,
irritability, dizziness, nausea, weakness, fatigue, insomnia, and numbness in the
extremities (Holden, 1980).

Personal stressors are those that affect individuals, such as failing exams,
becoming employed, or getting divorced. These may or may not be predictable, but
they also have powerful impact and require great coping efforts. Often these are
more difﬁcult to cope with than cataclysmic stressors because of the lack of support
available when they occur. Scales such as the Holmes and Rahe (1967) life events
scale are frequently used to measure personal stressors.

Finally, background stressors include daily work and family stresses. These

types of stressors are the daily hassles of life, which are small but persistent problems

flit?

1 all
mks:

17
that irritate and distress individuals (Lazarus & Folkman, 1984). They include

problems like a noisy workplace, too many responsibilities, or poor lighting. Failure
to seek support or help in solving these stressors may cause more damage in the long

run than cataclysmic or personal stressors.

Appraisal of Stress

Given the variation in types of stressors that occur in our daily lives, the way
individual appraise these stressors varies greatly. Regardless of the type of stressful
event, many of these events themselves are not inherently stressful. Whether they are
stressful depends on the appraisals of the individual. Appraisal of events as being
negative or positive, predictability of events and ambiguity of events are all factored
into the perception of stress. In general, negative events have been found to show a
stronger relationship to both psychological distress and physical symptoms than do
positive ones (e.g., Myers, Lindenthal, & Perrer, 1972; McFarlane et a1, 1980;
Sarason, Johnson & Siegel, 1978; Stokols, Ohlig & Resnick, 1978; Vinokur &
Selzer, 1975).

In addition, perceptions of stress are also affected by the control people feel
they have over stressful situations. When people feel they can predict, modify or
terminate an aversive event or feel they have access to someone who can inﬂuence it,
they experience it as less stressful, even if they actually do nothing about it (e. g.
Frankenhaeuser, 1975; Glass & Singer, 1972; Suls & Mullen, 1981; Thompson,

1981). Finally, when a potential stressor is ambiguous, a person has no opportunity

Wipe

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1‘.

18

to take action. The ability to take confrontative action is usually associated with less
distress and better coping (Gal & Lazarus, 1975). For example, role ambiguity is
reported as one of the major factors contributing to work-related stress (Cooper &
Marshall, 1976). This role ambiguity can result from having no task guidelines, no
clear standards of performance or lack of standards. The speciﬁc processes involved
in appraisal will be discussed in more detail in the following section on early models
of stress and health.

The current study will assess reactions to personal and background stressors.
Self-report measures of depression, anxiety, daily work and home stress and extreme
life stressors will be utilized to tap into stressors perceived by pregnant women. Now
that the types of stress under focus have been reviewed, the following section
addresses the connections between perceived stress and its effects on health outcome.
This section will cover how stress affects health, including an evolutionary

perspective, processes of psychological appraisal and responses to stress.

Stress and Physical Health
Frankenhauser (1989) offers an evolutionary perspective of stress inﬂuences on
the body. This perspective combines genetic evolution and the accelerating pace of
social-work evolution. In other words, although human physiology has remained
relatively constant over time, technological advances have changed dramatically in
comparison. Early man’s largest concern was protection from larger dominant

animals. Today’s demands are noted to be more psychological than physical, but both

l9

demands trigger the same bodily stress responses. Frankenhaeuser (1989) notes that
modern stresses result from a mismatch between old biology and a new sociotechnical
world. Early models of stress largely neglected the importance of psychological
factors. This was in part due to the fact that early stress work was conducted on
animals, where emphasis was placed on identiﬁcation of endocrinological indicators of
stress.

Lazarus (1968; Lazarus & Folkman, 1984) has been the chief proponent of
psychological approaches to stress. In his view, the experience of stress involves an
individual’s assessment of his/her changing environment, then engaging in a series of
processes of primary and secondary appraisal. Primary appraisal determines the
meaning of the event, as beneﬁcial, neutral, or negative in their consequences.
Negative or potentially negative events are further appraised for their possible harm,
threat or challenge. Once primary appraisals of potentially stressful events have
occurred, secondary appraisal is initiated. The individual assesses his/her coping
abilities and resources and whether they will be sufﬁcient to meet the harm, threat
and challenge of the event. Ultimately, the subjective experience of stress results
from a balance between primary and secondary appraisal (Lazarus & Folkman, 1986).

These appraisals then yield physiological, cognitive, and emotional
consequences. The primary physiological consequence of stress is arousal. The
stress response involves a series of coordinated nervous system and endocrinological
reactions. Sympathetic nervous system activity increases blood pressure, heart rate,

pulse rate, skin conductivity, and respiration (Taylor, 1986). This activity is also

20

augmented by endocrine responses initiated by the adrenal glands. High levels of
catecholamines (epinephrine or norepinephrine) and heightened levels of
corticosteroids, especially cortisol, have been documented across a wide range of
stressful events (Rose, 1980). These reactions may show some degree of speciﬁcity
as a function of the particular stressor and the individual’s appraisal of it.

Cognitive responses include outcomes of the appraisal process such as speciﬁc
beliefs about the harm or threat of an event and about its causes or controllability.
Cognitive responses include involuntary stress responses such as distractibility and
inability to concentrate; performance disruptions on cognitive tasks (Zajonc, 1965;
Cohen, 1980); and intrusive, repetitive or morbid thoughts (Horowitz, 1975).

Emotional reactions to stressful events range widely, including fear, anxiety,
excitement, embarrassment , anger, and depression. Behavioral responses are
variable, depending upon the nature or the stressful event. Actions may include
confrontative action against the stressor ("ﬁght") and withdrawal from the threatening
event ("ﬂight”).

Given the physiological, cognitive and emotional consequences that may result
from stress, how are these indicators of stress measured? Researchers have used a
wide array of indicators. These include self-reports of perceived stress, life change
and emotional distress; behavioral measures, such as performance on subsequent
tasks; and physiological measures of arousal, such as skin conductivity, heart rate,
and blood pressures. Biochemical indicators are also possible to investigate, such as

blood levels and urinary levels of cortisol and catecholamines (Baum, Grunber, &

21
Singer, 1982).

The present study will attempt to measure types of stressors experienced with
the use of self-report questionnaires. Aspects of the workplace and the daily stresses
associated with occupational environment will furnish a context in which to assess
pregnancy outcome. The next section brieﬂy summarizes the special characteristics of

occupational stress.

The Special Case of Daily Stressors: Occupational Stress

Studies of occupational stress have been increasing in the past several decades.
These studies help to identity some of the most common stressors of everyday life,
and work stress may be one of society’s preventable stressors opening up possibilities
for intervention. Generally, the characteristics of occupational environment and job
content are critical with regard both to job satisfaction and to health (Frankenhaeuser,
1976, 1981; Frankenhaeuser & Gardell, 1976; Frankenhaeuser & Johannsson, 1976;
Gardell, 1980; Johansson et al, 1978; Levy, 1972, 1981).

The key job factors that trigger stress include quantitative work overload,
qualitative work underload, lack of control and lack of social support. Workers who
feel required to work too long and too hard at multiple tasks feel more stressed and
sustain more health risks than do workers not suffering from overload (Caplan &
Jones, 1975; Breslow & Buell, 1960). Perceived work pressure can produce work
overload, as in the case of university faculty members who feel they have to work

longer and harder than their colleagues (French, Tupper & Mueller, 1965; Brooks &

22

Mueller, 1966). In general, workers in high-stress jobs have a higher prevalence and
incidence of wide range of diseases, and the greater the stress the greater the disease.

Lack of control over work has been related to a number of stress indicators,
including heightened catecholamine secretion, job dissatisfaction, and absenteeism.
Two studies by Frankenhaueser (1976, 1981) found that workers with less control
over work also showed high rates of headaches, high blood pressure, and
gastrointestinal disorders including ulcers (see also House et a1, 1979). Occupational
stress does not always result in illness or illness precursors. Stress may also show up
in ways that may be costly to a work organization. Higher rates of absenteeism, job
turnover, tardiness, job dissatisfaction, sabotage, and lower levels of performance on
the job may be evident (Cooper & Marshall, 1976).

Thus, work stress appears to be associated with two types of adverse
consequences: ﬁrst, there may be a direct association between certain objective
conditions at work (physiological and psychological stressors) and ill health. Second,
certain stress conditions may create fatigue or passivity in individuals and thus make
it more difﬁcult for them to involve themselves actively to change working
conditions.

Taking environmental inﬂuences on individuals into consideration, a proposed
model of the relationship between stress and illness is in order. The stress-illness
relationship is very complex, since it is inﬂuenced by a number of preexisting and
intervening factors (Taylor, 1986). The standard model of stress is the direct route

model which explains that stress can produce physiological and psychological changes

23

conducive to the development of illness. Precursors of illness such as fatigue and
achiness then develop, which, untreated, can lead to illness. This oversimpliﬁed
model is subject to considerable variability as people react differently to the same
stressors and the same symptoms. Variation in individuals’ preexisting psychological
or physical conditions may make them more vulnerable to stress, or stress may also

affect illness by altering a person’s health behavior patterns.

A Proposed Model of Research: The ISR Model of Stress

Now that deﬁnitions of stress, types of stressors and health outcomes have
been reviewed, a general theoretical model for stress is now in order. Kahn’s (1970,
1981) ISR Model is a useful organizing device to assess the components of stressful
situations. This model does not view stress as a well-deﬁned concept or phenomenon,
but as a generic label for a set of phenomena and processes involving six classes of
linked variables. The model components are depicted in Figure 1.

Objective organizational environments or situations give rise to psychological
perceptions of those environments,including perceptions of stress--feelings that
environmental demands are excessive relative to the person’s abilities or that
environmental opportunities are inadequate to justify the person’s needs (French,

1974).

24

Properties of the Person
(genetic, demographic, personality)

 

Objective “Psychological _.>Pbysiological __) Mental and Physical
Environment Environment Response Health

A

 

 

 

 

Interpersonal Relations

Figure 1.
Institute for Social Research Model of Stress

25

These perceptions give rise to short-term affective, physiological, or
behavioral responses, including responses that may alter the objective environment or
the person’s perceptions of it. Responses are typically called coping and adaptation.
Finally, depending on their nature, intensity and duration, these responses may lead to
more sustained changes in mental and physical health.

Each of the relationships or effects among each of the four components can be
conceived of as a process occurring and recurring over time, with the nature of the
relationship or effect being conditional on an individual’s enduring characteristics and
interpersonal situation or environment (Kahn, 1981). Pearlin and Johnson (1977)
offer the example of highly competent people who appear to be less likely to perceive
given objective conditions as stressful. In addition, people with trustful or supportive
interpersonal relations are less likely to experience adverse health outcomes following
exposure to stressors (Cassell, 1976; Cobb, 1976).

One scientiﬁc strategy suggested by the model is to identify objective and
subjective environmental factors that may adversely affect a range of health outcomes
and then to work forward in the causal sequence to determine their effects. This is

the goal of the present research, and Figure 2 depicts the model of the current study.

26

Properties of the Person
Individual characteristics

" Type A behavior pattern
" Temperament
‘ Control during transition
" Emotional functioning: depression and anxiety

/ \

 

 

Psychological 9 Respome 3» Physical Health
Environment
Perceived Stressors Not measured Pregnancy Outcomes
*Difﬁcult life circumstances " Preterm delivery
'Daily stressors "' Length of labor stages
" Birthweight
" Labor complications
" Apgar scores
Interpersonal relatiom
Contextual characteristic:
‘Work environment
"Social support
*Marital satisfaction

Figure 2.
InstituteforSocialResearch Modeladapted forthepresent study

ISR Model descriptors are in bold type
Current study descriptors are italicized

27

In summary, the contribution of psychological factors to physical dysfunction
and disease has been brieﬂy reviewed. It has long been believed that health problems
often follow periods of emotional distress or upset (Selye, 1982). As discussed in
previous sections, psychological stress has been examined as an etiological or
exacerbating factor in a variety of physical illnesses such as mononucleosis (Kasl,
Evans & Niederman, 1979), coronary health disease (Jenkins, 1976; Theorell, 1981),
cancer (Sklar & Anisman, 1981), and a variety of other disorders (for a review, see
Istvan, 1986 and Bunney et al, 1982). The ensuing section will review literature on

the inﬂuences of stress on pregnancy.

Historical Views of Stress and Pregnancy

Historically, several folk beliefs regarding emotional factors associated with
dysfunctional pregnancy are described as early as in the Old and New Testaments,
throughout the Middle Ages and into the present century (Ellis, 1906/ 1936).
Ballantyne (1904) discussed several aspects of psychological effects on pregnancy and
childbirth. The ﬁrst is the doctrine of maternal "impressions", that is ”the belief that
exposure during pregnancy to a particular emotionally stressing object or event would
result in some anomalous feature appearing in the neonate that speciﬁcally mimics this
stressor (e.g. a mother frightened by a dog during pregnancy giving birth to a child
with canine features” (Williamson, 1890, cited in Ellis, 1906; 1936)). A variation of
this belief maintains that emotional distress could have nonspeciﬁc adverse effects on

the fetus or the progress of childbirth.

28

Current research on stress and pregnancy has focused on effects of stressors on
the progress of labor and infant outcome. The outcome variables included in the
present study will investigate indicators of poor labor progress and newborn outcome.
Indicators of poor labor progress include the length of labor stages and birthing
complications while indicators of poor infant outcome include Apgar scores, low
birthweight, and poor infant health complications that occur postnatally.

Generally, obstetric complications assessed during pregnancy include a range
of risk indicators including gestational age (<37 weeks), birthweight <2.5kg, blood
group incompatibility, blood pressure during pregnancy ( < 140/90 mmHg), lack of
membrane rupture prior to delivery, spontaneous delivery, duration of ﬁrst and
second stages of labor, knotted umbilical cord, placenta previa or abruptio, and low
Apgar scores (Prechtl, 1990). These risk indicators alert medical practitioners to
potential medical intervention after the labor and delivery. These factors are often the
outcome variables of focus in most pregnancy research. For example, stressful events
that occur during the course of pregnancy, such as a car accident, may send the
mother into the delivery at a premature date. Consequences of naturally stressful
events can then be investigated by assessing labor progress and infant outcome.

Often, labor difﬁculties lead to eventual infant health complications. Postnatal infant
complications that are given special attention include respiratory distress, ventilatory
assistance, infection, noninfectious illness, metabolic abnormality, convulsions,
exchange transfusions, temperature disturbances, and surgery (Prechtl, 1990).

A review of the key outcome variables in the present study follows, with

29

special consideration given to the complexities of assessing premature delivery.

Labor and Delivery Outcomes
n h f r S

The biological process of birth is divided into three overlapping stages. The
ﬁrst stage of labor lasts from the ﬁrst regular intense contractions of the uterus until
the cervix is fully dilated. The length of this stage varies from woman to woman and
from pregnancy to pregnancy, ranging from one hour to several days. This longest
stage of labor lasts on average, 12 to 14 hours (Niswander, 1981). The second stage
of labor begins once the cervix is fully dilated, and the newbom’s head pushes
through the cervix into the vagina. Roughly, this stage lasts 50 minutes for a ﬁrst
delivery and 20 minutes for later births (Niswander, 1981). Finally, the third stage of
labor involves contraction of the uterus, where the placenta separates from the uterine

wall, pulling other fetal membranes with it. This stage roughly lasts 5 to 10 minutes.

A study by Lederman et a1 (1979) assessed the relationship between
psychological factors in the third trimester of pregnancy and progress in the ﬁrst two
stages of labor. Several psychological variables including anxiety, fear, self-esteem
and loss of control correlated signiﬁcantly with length of labor during stage 2. Their
results gave support to the hypotheses that maternal conﬂict and anxiety affect plasma
catecholamine and cortisol production, which in turn affect uterine activity and

progress in labor. A study by Burns (1976), found cortisol levels to correlate with

30

the length of labor. It may be reasoned that if psychological conﬂict and anxiety in
pregnancy have an effect on progress in labor, they may also have consequences for

the well-being of the newborn (Lederman et a1, 1979).

W

The Apgar scoring system (Apgar, 1953) involves rating the newborn at l and
5 minutes after birth. Five different items are scored on a scale from 0 to 2. Two
points are given if the infant is in the best possible condition for a particular sign, no
points are assigned if the sign is not present, and 1 point is given for all conditions
between 0 and 2. Individual scores are totaled to give a measure of the infant’s
overall physical condition. The highest total score an infant can obtain is 10. An
infant with a score of less than 4 is considered to be in poor condition and to require
immediate medical attention.

Research utilizing the Apgar scoring system has attempted to relate Apgar
scores to maternal health variables, infant birth condition, later anomalies and/ or
morbidity, and later neurological conditions (For a review, see Osofsky, 1987).
Although its predictive value is questionable, the clearest ﬁnding regarding the Apgar
test involves its relationship to infant mortality. Early studies documented strong
correlations between low Apgar ratings and infant mortality, particularly during the
neonatal period (e.g. Drage, Kennedy & Schwart, 1964; Richards et al, 1968;

Seunian & Broman, 1975).

31
Biﬂhweight ‘

Generally, babies who are born before 37 weeks of gestation can weigh less
than 5 1/2 pounds (2,500 grams), and this low birthweight helps to classify these low
birth weight infants as premature. A wealth of research indicates that premature
babies are at risk for many problems. Birth weight is the best available predictor of
infant survival and healthy development. Many newborns who weigh less than 3 1/3
pounds (1,500 grams) experience difﬁculties that are not overcome, an effect that
becomes stronger as birth weight decreases. Frequent illness, inattention,
overactivity, and school learning problems are some of the problems that may extend
into childhood (McCormick, Gortmaker, & Sobol, 1990; Vohr & Garcia-Coll, 1988).
Roughly 1 in 14 infants is born underweight (< 6 pounds) in the United States (Kopp
& Kaler, 1988)

A number of studies of the effects of risk factors on heart rate, especially
those of medical condition, birth weight and prematurity have been reported (see
VonBargen, 1983, for a review). For example, two studies report that even for full-
term infants, birth weight may inﬂuence cardiac responding. LeVita et a1 (1980) and
Stamps (1980) suggest that within the normal weight range, lower-weight infants may

be less likely to orient to people and objects than higher-birth-weight infants.

Prematurity

The problems associated with prematurity have long been recognized by

clinicians and studied by epidemiologists. However, these observations have not led

32

researchers any closer to the causes of preterm birth and no effective treatment has
been found. Methodological problems in epidemiological studies of preterm birth
may have misled investigators and contributed to the problems in deﬁning preterm
birth (Bryce, 1991). The main methodological problem that has hampered research in
preterm birth has been its deﬁnition which is extremely broad and varies between
countries (Bryce, 1991).

Preterm birth is deﬁned by the World Health Organization as a birth before 37
completed weeks gestation (or less than 259 days) since the ﬁrst day of the last
menstrual period. This includes both live births and stillbirths. The WHO deﬁnition
of a live birth is internationally accepted as "the complete expulsion or extraction
from its mother of a product of conception, irrespective of the duration of the
pregnancy, which after separation, breathes or shows pulsation of the umbilical cord
or deﬁnite movement of the voluntary muscles, whether or not the umbilical cord has
been cut or the placenta is attached” (World Health Organization, 1977, c.f. Bryce,

1991, p 439).

i Pr Bi h
Differences between countries in the deﬁnition of a stillbirth have contributed
to discrepancies in reported incidence of preterm birth. For example, in 1981 in
France, the incidence of preterm birth was 5%, in the U.S. in 1982 it was 8% for
white infants and 17% for black infants, in Hong Kong in 1981 to 1983, it was 2%,

and in Western Australia in 1986, it was 8% (Papiemik et al, 1985; Paneth, 1986;

33
Drew et al, 1988; Moore, 1988).

Inadequate reporting may be the cause of the variation of rates seen all over
the world. In some countries, abortions and births mainly occur outside of hospitals
and birth attendants may be illiterate and recording systems nonexistent. Reported
differences in the incidence of preterm birth between countries need to be considered
in light of this factor (Bryce, 1991).

In countries where gestational age data have been kept and are reliable,
preterm birth rates have been fairly constant. Another problem with the deﬁnition of
preterm birth is its breadth in deﬁnition. The fact that the deﬁnition of preterm birth
encompasses infants with a wide range of clinical conditions and prognoses from the
previable to the perfectly healthy has also led to problems in studying the condition.
Most studies include cohorts of preterm infants that have large numbers of mildly
preterm infants, while extremely preterm infants have been poorly represented.

Bryce notes that the "retrospective data collection, especially regarding
perinatal mortalities, has been an obstetrical obsession" (Bryce, 1991, p 440). Such
studies have yielded a long list of factors associated with preterm birth, including
previous preterm births, medical illnesses, social disadvantage, and poor lifestyles
(Institute of Medicine, 1985). The methodology used to establish these associates has
varied from cross-sectional observations (Federick & Anderson, 1976) to multivariate
techniques designed to minimize confounding (Berkowitz, 1985; Kaminsky, Goujard
& Rumeau-Rouquette, 1973; Ross, Hobel, Bragonier, Bear & Bemis, 1986) to a

longitudinal cohort study of women with previous preterm births which established

34
their risk of recurrence (Bakketeig & Hoffman, 1981).

Preterm birth remains an outcome of multiple causes. Because 37 complete
weeks gestation was arbitrarily chosen as its upper limit, the preterm category
includes many normal infants who merely have found themselves in the lower tail of a
normal distribution.

While there is still no consensus on the deﬁnitions and criteria of preterm
deliveries, the fact remains that, however deﬁned, it is associated with risk and
jeopardizes the viability of the infant. Efforts must be aimed at reducing preterm
deliveries by delineating the factors that contribute to them. The next section will
review the literature pertinent to the link between stress and pregnancy outcome with

preterm delivery as one of those outcomes.

Stress and Pregnancy Outcome Research

Over the past two decades, the marriage of the two literatures on stress and
poor pregnancy outcome have yielded several inconsistent and contradictory studies.
Comparisons between existing studies are difﬁcult due to the variation in the
constructs and deﬁnitions provided by each study. The studies also vary in the
timepoints of measurement during the course of pregnancy, and they also vary in the
demographic characteristics of the samples, such as parity, age, education,
socioeconomic status and marital status.

A number of studies have shown that women delivering preterm infants have

increased rates of stress as compared to matched controls delivering full term infants

35
(Berkowitz & Kasl, 1983; Blau, Slaff & Easton, 1963; Gunter, 1963; Newton &

Hunt, 1984; Newton , Webster, Binu, Maskrey & Phillips, 1979; Omer, Elizur,
Barnea, Friedlander & Palti, 1986; Schwartz, 1977).

Most current research has focused more on the effects of anxiety or life
change stress on reproductive dysfunction, and less so on physiological underpinnings
of stress as a contributing factor. This is partly attributable to the ethical and
practical restraints on experimental research on humans, as well as the interplay of
medical, behavioral and sociodemographic factors that contribute to obstetric risk.
Therefore, much of the research on stress inﬂuences on pregnancy outcome have been

conducted with animals.

n' rh nind re n rnn tome

Studies on a variety of laboratory animals (pregnant sheep, monkeys, rodents)
provide evidence that maternal exposure to stressors (heat, light, noise, shock,
crowding, handling) has adverse effects on reproductive outcomes in mammals.
Generally, these results implicate stress-related increases in catecholamine secretion as
an underlying mechanism for these effects (Caldwell, 1963). In rats, for example,
exposure to stressors during gestation has been associated with lower birth or fetal
weights and smaller litter sizes or higher rates of fetal resorption, and as little as 10
minutes of restraint during gestation have produced higher rates of growth-retarded
and malformed fetuses (Michel & Fritz-Nigli, 1978). For a more intensive review,

see Istvan, 1986). Yet overall ﬁndings from the animal data suggest that although

36

stress seems to generally produce unfavorable reproductive outcomes in rodents, there
is little evidence from this research that exposure to stressors will result in speciﬁc
unfavorable reproductive outcomes (Istvan, 1986). It is evident that the applicability
of rodent data to humans is accepted with reservations. Some of these reservations
are eliminated by using primate subjects, whose physiology more closely resembled
human physiology.

Research with primates has found that maternal exposure to stressors can
impair placental development, increase the rates of spontaneous abortion, and produce
lower birth weights (Myers, 1972, Small, 1982). Myers (1972) argues that
epinephrine and norepinephrine released as part of the stress response produced by
exposure to aversive events tend to reduce uterine blood ﬂow, resulting in fetal
hypoxia. The corresponding hormonal effects on human pregnancy will be covered

below in more detail.

or r h
Generally, laboratory experiments with humans have demonstrated that
exposure to stressors is associated with increases in adrenal catecholamine secretion
and reports of increased anxiety (Dimsdale & Moss, 1980a). Exposure to
environmental stressors is also associated with levels of increased plasma (Dimsdale
& Mass, 1980b, Levi, 1972) and urinary catecholamines (Frankenhaeuser &
Johansson, 1976). Unfortunately, a direct investigation of stress-related physiological

change in humans during pregnancy is at best shaky or untenable, because procedures

37

for simultaneously assessing maternal and fetal blood gases and endocrine levels are

invasive and can threaten the viability of the fetus.

- ti nn 'r i : m Is es

Studies examining maternal psychosocial factors with obstetric outcome fall
roughly into two categories, those where the outcome measured is a categorization of
birth as normal or abnormal, and those where a quantitative index of neonatal
physical status is utilized, such as gestational age, Apgar score, or birth weight.
However, such analyses make it difﬁcult to determine whether psychosocial factors
have effects on swift; obstetric difﬁculties, such as preterm delivery, high blood
pressure, premature rupture of the membranes and lengthy and difﬁcult deliveries.

Most studies on stress and birth outcome have examined the relation of
self-reports of stress or anxiety to global normal-abnormal categorizations of birth.
Most psychological measures in these types of studies are administered after
childbirth, and one must have reservations with the ﬁndings obtained with such
variation in research designs.

Comparisons across studies are difﬁcult to make because of different
characteristics of the sample populations, the numbers of participants in each study,
the use of different measures across studies, and the variation in ways of measuring
constructs. Many studies include multiparas women--women who have already
delivered one infant. This poses problems for comparisons across studies because

multiparas women have already had the experience of childbirth and come prepared

38

with certain expectations for the process of labor and delivery. Different points of
time of questionnaire administration also contribute to the confusion in making solid
conclusions as to the effects of psychosocial factors on preterm delivery. Most
studies do not include subjects in all phases of childbearing. An additional problem in
comparisons is the retrospective nature of many of the studies.

The retrospective design is inconclusive for several reasons. Preterm women
might have paid more attention to events that would other wise have been ignored. In
addition, these mothers were probably anxious about the health of their infants or
grieving over their deaths--conditions which might have negatively inﬂuenced their
perceptions of life events (Omer & Everly, 1988). Finally, subjects may try to justify
poor pregnancy outcome by searChing for possible events that may have happened
during the course of pregnancy to help explain the poor outcome.

Table 1 includes a brief review of studies pertinent to the design proposed in
the current research. The list includes only studies of primiparous (ﬁrst-pregnancy)
subjects who participated in prospective studies including the third trimester of
pregnancy as part of the design.

A shortcoming of research that attempts to link the relation of psychosocial
variables to health outcomes has been the failure to consider the role of medical and
demographic factors in elevating risk of illness or modifying an individual’s status on
relevant psychosocial dimensions (Kasl, 1983); Krantz & Glass, 1984). These authors
suggest that emotional distress during pregnancy is likely to be linked to pre-existing

medical and demographic risk. The following section reviews representative papers

39

that have attempted to address the relationship between psychosocial factors and poor

pregnancy outcome.

Table 1.

40

Review of prospective studies using primiparous subjects in assessment of stress and birth

outcome

 

 

 

 

Study Predictors Outcome Results
I measures
Scott & Neuroticism Variety of labor "Stable women low in
Thompson, assessed by and delivery neuroticism had the the fewest
1956 Maudsley complications complications. However,
Medical "unstable women” high in
Questionnaire neuroticism had fewer
and global difﬁculties than the two better
stability rating adjusted groups
during the third
trimester
McDonald & MAS and other Variety of labor There was no difference in
Parham, 1964 measures and delivery anxiety between the normal and
administered complications abnormal groups, and no
during third relation between MAS and
trimester length of labor
McDonald, MAS and Women with any Women with abnormlities scored
1965 MMPI one of three higher on the MAS than
completed pregnancy or normals; there were few
during the third delivery differences for the MMPI scales
trimester abnormalities
versus women
with normal
pregnancy and
delivery

 

 

 

 

 

 

—RACK

41

 

Edwards &
Jones, 1970

Trait scale from
STAI during
third trimester,
State scale
every week
until delivery;
staff rating of

Classiﬁcations as
normal or
abnormal based on
pregnancy,
delivery, and
neonatal records

Trait and weekly assessment of
State anxiety were unrelated to
abnormalities, but the abnormal
group was rated as more
maladjusted

 

 

 

 

 

adjustment
Nuckolls, Social assets Classiﬁcation as SRE scores and social assets
Cassel, & questionnaire complications or were non related to
Kaplan, 1972 completed no complications complications. However, a
during second based on combination of high life change
trimester; SRE pregnancy,delivery and low social assets was
completed , and neonatal associated with a higher
during third factors complications rate
trimerster
McDonald & MAS and other Birthweight MAS scores were positively
Parham, 1964 measures related to birth weight
administered
during third
trimester
Burstein, MAS and Birth weight Both anxiety scales were
Kinch & pregnancy unrelated to birth weight
Stern, 1974 anxiety scale
completed at
unspeciﬁed
point during
pregnancy
Standley, Investigator- Apgar scores and Prenatal anxiety was unrelated
Soule & devised prenatal birth weight to either Apgar scores or
Copans, 1979 anxiety birthweight
measures
administered by
interview

 

during third
trimester

 

 

 

 

42

 

 

Newton &
Hunt, 1984

 

LEI completed
during third
trimester

 

Preterm (< 37
weeks gestation)
and low-birth
weight infants (<
2,500 g) compared
with full- term and
normal birthweight
groups

 

Experience of a major life event
was associated with both
prematurity and low birth
weight

 

 

43
ri i f l '

Several investigations have assessed the relationship between maternal stress
and obstetric difﬁculties. These stresses may be physical or mental. Several authors
have noted increased preterm labor, preterm delivery, intrauterine growth retardation,
low maternal weight gain, low birth weight, placental infarction, toxemia, bleeding
and abruption in women working in physically stressful jobs (Armstrong, Nolin &
McDonald, 1989; Axelsson, Rylander & Molin, 1989; Fox, Harris & Brekken, 1977;
Marnelle, Laumon & Lazar, 1984; Naeye & Peters, 1982; Saurel-Cubizolles et al,
1985; Tafari, Naeye & Gobezie, 1980; Teitelman, Welch, Hellenbrand, & Bracken,
1990). Often stressors come in the form of signiﬁcant life events that occur during
pregnancy. This section will cover the representative retrospective and prospective
studies that have addressed the connection between life events stress and obstetric

difﬁculties.

W

Retrospective studies assess life events of women who had preterm and term
labors after the delivery. For example, Gunter (1963) compared life events that had
occurred all through the mothers’ past lives. Only major stressful events (e. g.
bereavement, abandonment, serious illness) were included, and more of these events
were found in the lives of the mothers who delivered prematurely. Schwartz (1977)
found similar results, comparing life events during pregnancy, including the 2 1/2

years preceding the delivery.

dun:
ever
(19'.
pen
W0

CV8

Sin

3311

44
Berkowitz and Kasl (1983) found that the reported number of life events

during pregnancy were higher for women who deliver prematurely, but only if the life
events occurred during the ﬁrst two trimesters of pregnancy. Similarly, Newton et al
(1979) divided their sample into two subsamples of very early deliveries (gestation
period less than 35 weeks) and early deliveries (gestation between 35 and 37 weeks).
Women who had very early deliveries were conﬁrmed to have experienced more life
events, as deﬁned by the Holmes and Rahe (1967) Schedule of Recent Experiences

scale.

'v ie

Alternatively, prospective studies conducted by Omer and colleagues (1986,
1988) were conducted by administering questionnaires during the pregnancy, and
similar relationships were found between life events that occurred during pregnancy
and preterm contractions and preterm delivery. Studies by Newton & Hunt (1988) and
Ching and Newton (1982) yielded similar results.

As an illustration, Norbeck and Tilden (1983) asked pregnant women in the
ﬁrst trimester or early in the second trimester, to complete a variety of assessment
instruments, including the Sarason Life Experience Survey (Sarason, Johnson &
Siegel, 1978), the State/Trait Anxiety Inventory (Spielberger, 1976) two social
support measures, and depression and self esteem scales. Demographic data and
obstetric histories were also obtained. After childbirth, three separate categories of

complications were scored for pregnancy, labor and delivery and general neonatal

45

status. Their results indicated that life change prior to pregnancy was related to
pregnancy complications, whereas a composite "emotional disequilibrium” score
composed of depression, anxiety and self-esteem measures was related to my;
audition complications. In addition, the combination of few life change experiences
and low amounts of tangible support obtained from others was related to higher rates
of labor and delivery complications. Yet the majority of the 117 participants in this
study were multigravidas. Whether or not these results would hold for ﬁrst—time
mothers remains to be seen.

A similar study by Smilkstein, Helsper-Lucas, Ashworth, Montana, and Page]
(1984) focused on risk factors (maternal smoking and drinking, previous pregnancy
complications), and Schedule of Recent Experience (SRE) (Holmes & Rahe, 1967)
reports for both pregnancy and the year preceding pregnancy. These authors reported
that SRE scores for pregnancy were related to three of four complications measures,
though it should be noted that a critical p of .15 was used.

To illustrate the impact of daily stressors as compared to the impact of risk
factors, researchers have also focuses on work stress and its efect on pregnant
employees. Mamelle, Laumon and Lazar (1984) reported that women working more
than 40 hours per week showed a 9% preterm delivery rate, compared with 3.6%
among women working fewer than 40 hours per week. In order to assess pregnancy
outcome as a result of daily life stressors, studies focusing on women under high
daily stress provides a picture of the extreme end of the daily stress continuum. One

occupation that ﬁts this proﬁle is that of physicians in residency training.

46
A 5min} Population of Pregnant Physicians during Residency

The proportion of U.S. medical school students who are women increased
dramatically from 8 percent to 32 percent, between 1965 and 1985 (Crowley, 1986).
Twenty-six percent of the training slots in residence programs are ﬁlled by women.
Residency is a time of high stress for any individual. All residents report that long
work hours, lack of time with family, and inadequate support from peers and/or
faculty are major problems (Schwartz et al, 1987).

A pregnant resident has additional stresses: the physical demands of the
pregnancy, and later the emotional strain of ﬁlling many roles (mother, wife, and
physician). They also face the potential stress that they, in turn, place on other
residents (Shapiro, 1982). Residency entails long periods of walking, running, and
standing, frequent periods of sleep deprivation, and extremely long work weeks and is
thus one of the most physically and emotionally demanding types of work.

Physicians with demanding work schedules have been reported to have an
increased risk of preterm delivery (Miller, Katz & Cefalo, 1989), intrauterine growth
retardation (Grunebaum, Minkoff & Blake, 1987), placental abruption (Schwartz,
1985) and pregnancy-induced hypertension (Phelan, 1988). Speciﬁcally, women who
held positions of ”house ofﬁcer" (who work between 80 and 120 hours per week in
the hospital) were found to be at increased risk of experiencing adverse pregnancy
outcome. They were more likely to deliver a low birth weight, growth retarded
infant during residency than before or after residency (Grunebaum, Minkoff & Blake,

1987; see also Alegre et al, 1984 and Naeye & Peters, 1982).

47

Miller et a1 (1989) found that 60 women physicians were 2.3 times more likely
to deliver preterm infants than a group of control women who had at least 16 years of
education. Grunebaum et a1 (1987) also reported that the delivery of low-birthweight
infants was 3 to 4 times more common among physicians. Yet neither study used a
large scientiﬁcally selected sample of physicians; many were recruited from university
group practices.

In addition, Schwartz’ evaluative study of 37 physicians found an increased
incidence of threatened premature labor and a much higher incidence of abruptio
placentae and associated serious bleeding when compared with the general population
(Schwartz, 1985), but she did not ﬁnd an increased rate of intrauterine growth
retardation.

Phelan (1988) further speciﬁes differences between preterm labor and preterm
delivery in a sample of pregnant physicians. In her study, ten percent of pregnancies
among 1197 (primiparous and multiparous) physicians were complicated by preterm
labor and 6% by preterm delivery. The risks in the general population are estimated
at 5-10% and 8%, respectively (Lamont, Dunlop & Crowley, 1983). The only
complication that may be increased in residency is pregnancy-induced hypertension
(Phelan, 1988). She notes that this may reﬂect the greater age of the woman at the
time of pregnancy.

In contrast, Klebanoff et a1 (1990) found no signiﬁcant differences in the rates
of miscarriage, ectopic gestation, and stillbirth, or in either fetal growth or duration

of pregnancy between their sample of female residents and the wives of male

48

residents.

Unfortunately, a drawback of most of the current research on stress and
pregnancy is in its lack of application to the general population, by taking various
socioeconomic factors into consideration. For example, other women with equally
physically demanding occupations are usually of lower socioeconomic status.

In summary, these studies offer conﬂicting evidence for a relation between
self-reports of anxiety, life change stress, and global ratings of obstetric outcome.
Eight of 23 studies reviewed by Istvan (1986) using global obstetric difﬁculty as an
outcome measure found that life change stress or anxiety was related to poor obstetric

outcome. Istvan (1986) concisely concludes:

"Psychosocial factors may be valuable in
explaining reproductive failure only to the degree
that their contribution to reproductive outcomes
can be disentangled from that of other indicators
of obstetric risk. If it can be proven that
psychosocial factors contribute independently to
obstetric and neonatal problems, either directly or
by modifying health-risk behaviors, the notion of
stress or anxiety-related reproductive dysfunction
would be substantially more compelling (p 342).”

An ideal investigative research program would include psychosocial assessment
that would initially occur prior to conception and would be repeated throughout the
course of pregnancy. Taking note of time constraints associated with most research,
it is difﬁcult to predict which participants will eventually become pregnant.

Assessments of psychophysiological mechanisms at work, such as the measurement of

49

urinary catecholamine and/or corticosteroid levels may be useful marker of stress. As
stated earlier, the present study does not assess hormonal changes, but it is important
to acknowledge the physiological pathways that cannot be ignored in the model of
stress. The following section will focus on the relationship of psychological variables

with physiological stress responses and the role of the autonomic nervous system.

' . u in] i a- '- mn- o r . rin nnC' Hrmonl M hn'
Was:

It has been recognized that the nervous system and the endocrine system
interact to help an individual adapt to the environment (Selye, 1950). Studies of
catecholamines (Lederman et al, 1977, O’Shaughnessy et al, 1987; Zuspan, 1979) and
corticosteroids (Lederman et al, 1978; Sasaki et al, 1987; Kirschbaum &
Hellhammer, 1989) have attempted to capture inter-individual differences in response
to both acute and chronically stressful situations.

External challenges are appraised by the brain from which signals are set to
the hypothalamus, via the autonomic nervous system, and then to the adrenal medulla.
Hypothalamic messages take two pathways, a neural pathway to target tissues by way
of the autonomic nervous system, and a neuroendocrine pathway to target tissues by
way of the pituitary, adrenal and other endocrine glands. The response is the
secretion of stress hormones, chieﬂy epinephrine and norepinephrine. In certain
situations, the brain also sends messages to the adrenal cortex which then secretes

cortisol, another stress hormone that has a role in the immune response. Short term

50

rises in catecholamines and corticosteroids serve to facilitate adaptation to challenges
and therefore can be viewed as beneﬁcial. On the other hand, a sustained rise in
circulating stress hormones has the potential to cause adverse health effects, possibly

including obstetrical complications.

Hormonal Reactions to Stress

Catecholamine secretion in humans is increased in situations made stressful by
a high degree of uncertainty or lack of situational control (Frankenhaeuser, 1975a;
Frankenhaeuser, 1975b; Bassett et al, 1987) as well as in situations involving physical
challenge (Dimsdale & Moss, 1980; Fibeger et al, 1984a). Several factors that have
been associated with increased epinephrine levels are life change and stressful events
(Katz, 1983; Katz et al, 1988; Omer & Everly, 1988; Theorell, 1972). The higher
the ratio of norephinephrine (NE) to epinephrine (E), the greater the effects were as a
result of stress. In other words, people who experience more stress have higher
eatecholamine levels than those experiencing less stress. For the pregnant woman,
both of these catecholamines decrease uterine blood ﬂow (Adamsons, Mueller-
Heubach & Myers, 1971; Rosenfeld & West, 1977; Shnider et al, 1979). This in
turn affects the growing fetus. Catecholamine levels can be measured via urine
collection.

Another mechanism that has been proposed to link maternal stress during
pregnancy with preterm labor and delivery is the action of norepinephrine and

epinephrine on uterine smooth muscle motility. Short term moderate level effects of

51

epinephrine enable the uterus to relax and slow contractions (beta-adrenergic), while
long term higher level effects of epinephrine are alpha-adrenergic, which speed up
contractions (Anton, 1979; Omer & Everly, 1988). For example, a national study of
female resident physicians who worked during their pregnancies in physically
demanding, stressful situations, was twice as likely to have preterm labors (11.3% vs
6.0%) compared with the pregnancies of their male classmates’ wives-- a result that
could be stress-related (Hatch et al, 1991). Generally, catecholamines are favored as
the most sensitive, reliable and practical indicator of a stress response by several
experts in the ﬁeld (Frankenhaeuser, 1975 and 1989, Kasl, 1983). Corticosteroids are
an alternative choice of investigation.

Emory et a1 (1992) propose that psychological stress such as stressful life
events or the perception of a stressful situation might lead to further increases among
pregnant women in the release of catecholamines and corticosteroids. The gravid
woman might easily be predisposed to react because of the natural rise in CRH and
cortisol during the third trimester of pregnancy.

Given the results of several studies, there appears to be a consistent
relationship between psychological state such as anxiety and mood and alterations in
hormone and catecholamine levels. It can be assumed that if these hormones and
catecholamines can be related to preterm labor, then psychological variables may be.
intimately involved in a series of events that eventually lead to premature birth. The
role of stress becomes an important factor in this set of relationships since stress is

implicated in both anxiety and mood disorders as well as changes in circulating

52

hormones and catecholamines.

In summary, Geiser (1989) notes that psychosocial, neuroendocrine and
biochemical factors have an interactive inﬂuence on the immune system. One
important factor from this body of research is that decreases in measures of immune
status accompany a variety of stressful life events and that emotional distress,
individual differences, and social support may mediate the impact of stress on the
immune system.

With the information on stress events and potential inﬂuences on pregnancy
outcome set in place, it is time to return to the original model of stress and consider
the mediational components that inﬂuence the direct pathway between stress and
health outcomes. These include the inﬂuence of individuals’ enduring personal
characteristics and the inﬂuence of interpersonal relations that help to buffer the direct

inﬂuences stress may have on the body.

Assessment of the Environmental Context and the Individual: Moderators in the
Stress-Pregnancy Outcome Model
The path from a stressor to a health consequence is complex. Moderators may
inﬂuence any of the model components through the perceived environment, immediate
emotional, physiological and behavioral reactions, and eventual consequences.
Returning to the proposed ISR model, two moderators in the stress-illness model

include properties of the context and properties of the individual.

53
W

The context in which a person encounters a stressor can alter reactions and
consequences markedly. Contextual factors can be supportive and buffering, or they
can heighten the stress effect. In the proposed research, the contextual or
environmental factors under focus will be the employment situation, social support
and marital satisfaction. Under typical daily life circumstances, each factor can be
inﬂuential on normal functioning. Assessing these external inﬂuences on a pregnant

woman may yield different implications.

Ibo Woﬂg Environment

Within the last few decades, society has experienced a steady increase in the
number of women entering the workforce. One change has been a steady increase in
their rate of participation. In 1960, 37.7% of the female civilian population was
employed, and this number increased to 43.4% in 1970, and again up to 56.6% in
1988 (U .S.Department of Labor, 1989). Another major change has been observed in
the range of jobs that women occupy, with the numbers of female executives and
professionals ever increasing. In 1982, 6,054 women occupied executive/professional
positions. By 1987, this number rose to 8,540 and up to 15,441 in 1993 (U.S. Dept.
of Labor, 1993).

Recent studies suggest that professional women competing in a male-dominated
environment are subject to chronic stress (Hall & Hall, 1980) and that professional

women share common demands with their male counterparts. The job environment

54

provides conditions conducive to stress such as underutilization of skills, lack of
recognition for accomplishment, lack of autonomy, presence of deadlines and
excessive work hours (Haw, 1982. For professional women, particular stressors can
be identiﬁed beyond job demands such as work overload, role conﬂicts, ofﬁce politics
and problematic relationships with coworkers (Johnson & Johnson, 1977; Lein,
Durham, Pratt et al, 1975; Rapoport & Rapoport, 1978). In addition, prestigious
positions sought by women are associated with the types of stressors experienced in
the workplace. Generally, more prestigious occupations are accompanied by greater
work stress, increased responsibility, and greater time restraints which in turn may
inﬂuence health. In contrast, women in occupations low in prestige face low incomes
which are accompanied by economic stressors. Hence, a U-shaped curve may
characterize the relationship between stress and occupational prestige (Mueller &
Parcel, 1981).

Employed women also face demands with which men do not have to cope,
such as discrimination, stereotyping, marriage and work interference, social isolation,
and a greater workload at home (Cooper & Davidson, 1982; Nelson & Quick, 1985;

Puff & Moeckel, 1979).

ﬂarkmﬂualth.
There are many aspects of the employment situation that can affect health.
Unfortunately, the psychophysiological stress response is nondiscriminatory in its

effects on men and women. Both sexes appear equally vulnerable to work stress and

55

its consequences. Early studies examining work inﬂuences on pregnancy found that
for women with long work weeks whose occupation was physically tiring, the
proportion of preterm births was increased (Chamberlain & Garcia, 1983). Results
from the U.S. Collaborative Perinatal Project (Naeye & Peters, 1982) found an
association between low birthweight and work that involved the following factors:
standing, low pre-pregnancy weight, hypertension and low pregnancy weight gain.
For other occupations, psychological stress hazards are present in the work
environment. Much research over the course of the last 30 years suggests that work
may be a signiﬁcant source of stress, and that stress may be tied to serious
consequences in regard to mental and physical ill health (Cooper & Marchall, 1976;
House, 1974; Jenkins, 1971a,b; Kahn et al, 1964; Kasl, 1978; Margolis et al, 1974).
For example, Greenglass (1985) reported signiﬁcant correlations among managerial
women between job/family conﬂict and scores on scales assessing depression,
irritation and job anxiety.

One approach to the assessment of employed women and work stress has
included research on Type A personality and work styles. Since Type A is a
personality construct, the review of this literature will be included in the section of

the model describing individual characteristics and resources.

W
The transition to parenthood is a context in and of itself, involving role

redﬁnition, and balancing two or more roles. Throughout the pregnancy, women

56

increasingly visualize themselves as mothers and not just career women (Liefer,
1980). The years of a woman’s career advancement are also those of childbearing.
In addition, the threat of unemployment and the limitations on wages of their mates
have encouraged women to enter marriage with the plan of having two incomes.

Many women want to combine family life with a career. A common concern
of women is the timing of the pregnancy. Many are concerned that pregnancy will
cause signiﬁcant interruptions in their careers and that a demanding career will
prevent optimal nurturing of their children. Women also worry that delaying
childbearing may result in infertility or pregnancy complications (Roeske & Lake,
1977). They may fear that they will be part of the 10 - 15% of women who will have
relative or absolute fertility, and that the longer they delay a pregnancy, the lower
their conception rate will be (Schwartz, 1985). Taking time away from careers to
nurture children is one of several reasons why many women may seem to be slower
in developing their careers.

Hence, ﬁrst pregnancies become a special time marked by dramatic changes in
self-deﬁnition (Deutch, Ruble, Flemin, Brooks-Gunn & Stangor, 1988). A number of
studies have suggested that the transition to parenthood may be perceived as a crisis
by some women (e.g. Dyer, 1963; LeMasters, 1957). There is sufﬁcient evidence
that those who are able to visualize themselvesa as mothers during this transition are
better able to adjust to the newborn (Leifer, 1980; Oakley, 1980; Shereshefsky &
Yarrow, 1973).

Returning to the special case of pregnant physicians, many investigators feel

57

that managing a medical career and a family takes an unusually high toll on women
physicians (Brodkin, Shrier & Buxton, 1982; Kaplan, 1982), as evidenced by their
higher divorce rate and suicide rate compared with non-physician women. The peak
incidence of divorce and suicide was found to coincide with the time of both early
career development and childbearing (Brodkin, Shrier & Buxton, 1982).

In summary, when considering the effects of stress on health, it is important to
assess the context in which it occurs, such as the work environment and incorporating
the role of "mother” with "employee". The effects of employment on women’s health
vary, depending on the type of job and on the woman’s family situation. The
workplace can serve as a moderator or it can intensify the link between stress and
health. Another component of environment that can serve as a moderator is support

of family, friends, and signiﬁcant others.

SmiaLSlrnmn

A great deal of research exists documenting the physical and psychological
health beneﬁts of social support. Social support has been noted to ”moderate" or
”buffer“ the impact of psychosocial stress on physical and mental health. Social
support has been associated with lower cardiovascular reactivity (Kamarck, Manuck
& Jenninngs, 1990), enhanced immune function (Jemmott & Magloire, 1988; Kiecolt-
Glaser et al, 1984), better adjustment to and recovery from illness (Dunkel—Schetter,
1984; Mumford, Schlesinger & Glass, 1982; Trelawny-Ross & Russell, 1987;

Wortman, 1984), and reduced mortality (Berkman & Syme, 1979; Blazer, 1982;

58
House, Robbins & Metzner, 1982; Ruberman, Weinblatt, Goldberg & Chaudhary,

1984).

Although researchers share a general sense of what social support is, speciﬁc
conceptual deﬁnitions and operational deﬁnitions vary widely, making it difﬁcult to
compare the results of different studies. Some studies have found that support does
buffer the impact of stress on health (e.g. Caplan, 1972; Nuckolls et al, 1972; Cobb
& Kasl, 1977; Eaton, 1978; Gore, 1978; House & Wells, 1978). Others (e.g.
Pinneau, 1975, 1976; Lin et a1, 1979) point out that many of these studies have
methodological limitations. Further, several studies have failed to ﬁnd signiﬁcant
stress-buffering effects of support (e.g. Pinneau, 1975, 1976; Andrews et al, 1978;
Lawa & Jones, 1978a; Lin et al, 1979). A few studies (Hobfoll & London, 1986;
Hobfoll & Walﬁsch, 1984) have suggested that no single resource of support will be
beneﬁcial for all events because resources need to be ecologically congruent with
situations and individuals’ needs.

Many researchers agree that there are at least three main types of social
support: emotional (intimacy, attachment, caring and concern), instrumental
(provision of aid or assistance), and informational (providing advice, guidance or
information relevant to the situation) (House, 1981; House & Kahn, 1985; Kahn &
Antonucci, 1980; Thoits, 1985). Of the three functions, researchers have considered
emotional support to be the primary component (Cohen & Hoberman, 1983; House,
1981; Schaefer, Coyne & Lazarus, 1981). Emotional support is proposed to be most

helpful because it provides one with reassurance that others are available for help.

59

People who feel loved and cared for enjoy a higher state of life satisfaction at all
times, stressful or not. In contrast, informational and instrumental support may
compose the part of support that buffers the effects of stress (Helgeson, 1993).

An individual’s perception of support resources and actual accessing of support
are two components within a complex process of ecological congruence. According
to the model of ecological congruence suggested by Hobfoll (1986a, 1986b), resource
effectiveness is related to a) the availability of resources, b) ﬁt of resources to
situational demands c) time since the event and stage in individual’s development d)
extant personal and cultural values, and e)perceptions regarding degree of threat and
assessment of resource (social support) availability. How this process may operate in

the context of pregnancy is covered in the next section.

r n n

As a time of major social change, pregnancy is a period when the expectant
mother must redeﬁne relationships with and responsibilities to signiﬁcant others in her
life (Richardson, 1982). Supportive relationships may enhance feelings of well-being,
personal control, and positive affect thereby helping women to perceive pregnancy-
related changes as less stressful (Norbeck & Anderson, 1989; Tietjen & Bradley,
1985).

Informational support may provide guidance with respect to adequate prenatal
care, proper nutritional and health-care practices, and preparation for labor and

delivery (Aaronson, 1989; Bumes-Bolton, 1988; Zweig, LeFevre & Kruse, 1988). In

60

addition, assistance with daily tasks with physically taxing demands that may be
harmful to expectant mothers is helpful, especially late in pregnancy (Mamelle,
Laumon & Lazar, 1984; Mamelle & Munoz, 1987; McDonald, McDonald,
Armstrong, et al, 1988)

Social support serves as an environmental mediator and inﬂuences a woman’s
experience and the outcome of pregnancy (Nuckolls et al, 1972). In the presence of
high life stress prior to pregnancy and antepartally, psychosocial assets, including
social support were associated with fewer childbirth complications. Nuckolls, Cassel
& Kaplan (1972) suggested that social support serves as an environmental mediator
that inﬂuences a woman’s experience and the outcome of pregnancy.

Norbeck & Tilden (1983) found that women with high stress and low social
support prior to pregnancy had the highest rate of gestation and infant complications.
Women with low stress and low levels of support had higher rates of labor and
delivery complications. In addition, women who received more prenatal support
experienced better progress in labor and delivered babies who had higher birthweights
and appeared healthier ﬁve minutes after birth, as indicated by Apgar ratings (Collins
et al, 1993).

In line with Hobfoll’s model of ecological congruence, Cohen (1979) asserted
that "a woman’s capacity to adapt to the demands and tasks of pregnancy is generally
related to an overall balance between stresses and supports, both present and past" (p
17).

Problematic relationships have been associated with such unfavorable

61

pregnancy outcomes as spontaneous abortion (Berle & Javert, 1954); toxemia (Glick,
Salerno & Royce, 1965; Nuckolls, Cassel & Kaplan, 1972); and premature delivery
(Blau et al, 1963; Gunter, 1963; Newton, Webster, Binu et al, 1979; Wortis &
Freedman, 1962). Hence, stress appears to be an important force in provoking illness
and social support is a balancing force in mediating health. This is equally true of
everyday problems that cause stress as with major life event stressors (Burks &
Martin, 1985). One of these daily challenges may be related to spousal support and
the marital relationship during pregnancy. The following section reviews this

literature.

Ilfho marital telatjonshio during the transition to parenthood: A more miﬁc
Waggon.

Marital status is often a fulcrum for research into social support and pregnancy
outcome (Kessler & Essex, 1982; Norbeck & Tilden, 1983; Richardson, 1982, 1983;
Tilden, 1983, 1984). Pregnancy is marked by an increasing need for a couple to
modify established patterns in the marriage, as well as to prepare both psychologically
and materially for the arrival of the newborn. This is done in a context of
psychological and physical changes, particularly in the expectant mother (Bibring,
1959; Chalmers, 1982; Colman & Colman, 1971). Sharing in discussion and
disclosure between spouses has been associated with improved health perceptions, and
less rehospitalization one year following a heart attack (Helgeson, 1991). Generally,

dissatisfaction with marriages during pregnancy carries over to dissatisfaction as

62
parents (Belsky, Spanier & Rovine, 1983; Cowan et al, 1985).

Research by Tilden (1984) indicates that pregnant women without partners are
candidates for greater stress, less social support, and greater emotional stability, a
signiﬁcant ﬁnding given the evidence that stress, anxiety, and inadequate social
support contribute to pregnancy complications. Yet marital satisfaction even for
married couples does not remain consistent during pregnancy. On average, for
married couples, marital satisfaction declines for ﬁrst-time parents (Belsky, Spanier &
Rovine, 1983; Feldman & Nash, 1984; Grossman, Eichler, and Winickoff, 1980;
Shereshefsky & Yarrow, 1973)

In studying relationships shared by women and their husbands during
pregnancy, Richardson (1983) found changes in instrumental assistance to be most
critical. Assistance was often used by women as indicators of their husbands’ love and
concern for her or, when absent or begrudgingly given, of his lack of love for her.

In addition, Mercer, Hackley & Bostrom (1983) found that women who received
greater emotional and instrumental support from their mate during pregnancy and
delivery tended to have a more positive perception of their birth experience, as
compared to those who received little support.

Norbeck and Tilden (1983) found emotional support to be signiﬁcantly related
to emotional disequilibrium, while tangible support was not. The authors found
signiﬁcant interactions between negative life events (life stress) and both types of
support. In addition, tangible social support predicted complications of gestation,

labor, delivery and newborn status.

63

In summary, the marital relationship and largersocial support network have
been reviewed to assess their mediational effects on stress and health outcomes. Now
that the contextual factors that exert a mediational inﬂuence on the stress-pregnancy
outcome model are set in place, it is time to review the other set of mediational

factors that are unique to individuals.

Individual Chagacteristics as Moderators

Properties of the individual can be thought of as personal characteristics, such
as vulnerability or resistance to any speciﬁc stressor. These individual characteristics
include personality factors, such as Type A and temperament, desire for control,
coping style and psychological functioning (depression and anxiety as indices of
mental health). Moderators such as temperament, personality and sociodemographic
status are usually considered to be stable characteristics of the individual or
environment, that change slowly over time. Coping strategies, depression and anxiety
are the result of interactions between individuals and their environments and these
may last only during a speciﬁc interaction. Each of these individual characteristic
mediators and how they may play a role in the stress-illness pathway will be reviewed

in the section to follow.

Wen

Increasing attention has been given to the stressors associated with higher level

occupations that play a large part in the development of cardiovascular disease

64

(Friedman and Rosenman, 1974). A way of assessing this connection has been
through conceptualizations of the Type A behavior pattern.

The Type A behavior pattern (TABP) is associated with lifestyle descriptors
such as hard driving, hostile, competitive, ambitious, impatient, and motivated. This
type of behavior, typical of upper managerial and professional positions, has been
associated with proneness to coronary heart disease (Rosenman & Friedman, 1974).
Type B persons, on the other hand, are labeled as coronary resistant, and possess few
of the mentioned characteristics for Type As. Instead, these individuals tend to be
unhurried and relaxed.

TABP is often associated with those individuals who exhibit a chronic sense of
time urgency combined with a near-permanent state of irritability. This behavior
pattern has also been described as the individual’s way of controlling his/her
surrounding world, "by being aggressive and competitive, by overcoming
environmental resistance (being impatient and in control), by gaining privileged access
to resources via high social status (being ambitious), and by hoarding resources as a
hedge against future shortages" (Van Egeren, Abelson, & Sniderman, 1983 p 386).

Yet the means by which Type A behavior pattern increases the risk for
premature coronary heart disease is uncertain. A hypothesis posed by Kelly and
Houston (1985) suggests that Type A experiences increase neuroendocrine arousal that
results in the increase of atheroscleroses and increases in the likelihood of a clinical
event.

Research on Type A women has been fairly limited in scope, due to the

65

majority of studies of males in executive positions most susceptible to the Type A
behavior pattern. For example, the Western Collaborative Group Study assessed the
Type A coronary-prone behavior pattern which was found to relate to coronary heart
disease (Mathews et al, 1977). In this study, 3,524 professional men aged 39 to 59
were assessed for Type A behaviors. No women were included in the study.

The initial theories involving Type A behavior originated in the late 1960’s, a
period when fewer women were part of the workforce. As these studies progressed
into the 1970’s, populations of women were gradually included, yet the occupations
were most commonly nursing, teaching and library positions (Waldron, 1978; Haynes
and Feinleib, 1980). Few studies have included women in male-oriented positions.
Hence, the studies completed in the seventies found few differences between Type A
and B women. These studies made it difﬁcult to assess differences between male and
female Type As as well. Women are only recently assuming similar competitive
positions, and more female investigators and physicians are pursuing sex differences
in Type A and B behavior patterns.

Relatively recent research investigated Type A/B differences in college
women, and took into consideration family history (Lane, White, and Williams,
1984). Iane et al (1984) studied college aged women, and used the student version
of the Jenkins Activity Survey to determine subject types (A or B). They concluded
that Type A women were hyperresponsive compared to Type B subjects, but only if
they also had a positive family history of hypertension. Another college sample

collected by Lawler, Schmeid, Mitchell and Rixse (1984) assessed coronary-prone

66

behavior pattern and physiological responses to stress in women aged 18-27. They
compared women in traditional (feminine) vs. non-traditional (masculine) majors.
Their ﬁndings concluded no physiological differences between Types A and B
women.

Several problems using college age samples arise when comparing Type A and
B behaviors. Lawler et a1 (1983) suggest that women below the age of 25 are less
likely to have children, and more likely to be working, even if they are not Type A.
The older group may experience more time pressures, because of added
responsibilities. This would explain why women 26-44 years of age in a study by
Jenkins, Rosenman, and Friedman (1967) were equally susceptible to Type A as their
male counterparts. They concluded that their sample of 25-50 year old women had
similar behavioral and physical responses as their male counterparts. They noted that
the key factor, education level, helped determine whether or not individuals were
Type A or B. Unfortunately, the study neglected to specify the employment
characteristics of their female sample.

Another study by Iawler, Rixse, and Allen (1983) supports the results of
Jenkins et a1 (1967). This research team compared professional/ executive women
(Type As) to another sample of housewives (Type As and B3) in measures of heart
rate, blood pressure, and skin conductance. These measures were taken during
periods of rest, during math problem solving, and solving visual puzzles. The sample
included women ages 25-55, and their results revealed higher heart rates and higher

systolic blood pressures for the Type A women. They concluded that many employed

67

women are as Type A as men, not that Type B women are less likely to work.

Unfortunately, their samples were unbalanced for behavior types in each
comparison group. Their Employed sample included only professionals or executives,
all registering as Type A. Their housewife sample included both Type As and Bs.
No comparison group of Employed Type B5 was incorporated into the design. In
addition, their small sample (n=41), left room for speculation on these results.
Perhaps failure to ﬁnd Type B employed women was due to their restriction to
executive females in their sample. As more women in the workforce continue to ﬁll
executive! managerial positions, better comparisons can be made today.

A more recent study by Kelly and Houston (1985) assessed differences in
characteristics of Type A and Type B women as related to work factors. Type A
women typically have higher educational attainment that in turn inﬂuences the higher
occupational positions they occupy. They seek and attain more demanding and taxing
job experiences, and have more preference to work more hours per week. Type As
also work more overtime. Given these preferences, it is no surprise that Type A
employed women report more quantitative workload at their jobs. The single gender
difference that Kelly and Houston (1985) uncovered was that women did not perceive
their skills as being underutilized, a ﬁnding consistent with male Type A’s.

Generally, across studies, Type A women are found to be no less Type A than
men, especially when education, occupation, or socioeconomic status (SES) are
controlled. As with men, Type A scores are positively correlated with education and

occupational status in women. Over all, Type A women are found to be more

68
reactive physiologically than their Type B counterparts. In a study by Dearbom &

Hastings (1987), Type A women had more stressful jobs, and reported more
symptoms of physical and psychological strain in response to job stress and job
dissatisfaction. Type A women may experience more symptoms of strain than do

Type Bs, in part because they perceive having more work stress than do the Type Bs.

Iljyoe A Qatar motivation,

For women who occupy prestigious occupations, Type A classiﬁcations are
generally higher, career motivations are often stronger, and they have orientations
toward achievement and career aspirations (Greenglass, 1990). Greenglass (1990)
noted that the higher the Type A scores, the more the respondent wanted to attain
higher positions of authority, the greater her perceived chances of an authority ﬁgure,
and the higher her career aspirations were for career recognition.

As career women, Type A’s have high expectations of themselves, and feel
greater pressure to perform. In attempting to meet multiple role demands, A’s
experience greater time pressures and as a result, greater conﬂict. Despite a heavy
workload for Type A working mothers, women did not consider themselves
overworked. “In admitting they were overworked, they felt they could and should be
able to be feminine, successful in careers, good mothers and have a happy marriage--
without feeling overloaded” (Greenglass, 1990 p 313). Hence, Type A working
women appear to have high standards for combining career and family.

Given these characteristics of the motivated Type A woman, how might these

69

women incorporate childbearing into their career goals? Although no literature exists
examining Type A expectant mothers, several scenarios are possible. One can
speculate that Type A career-oriented women may be more likely to postpone
childbirth in order to pursue and fulﬁll career goals, or may be more likely to plan
for a speciﬁc future time to have a child. Alternatively, Type A women may look at
childbearing as an additional goal to master. Labor and delivery may be seen as

achievement goals and therefore take precedence over a career.

0 in

Control is an aspect of coping in the face of challenging situations. Separating
control and coping style is difﬁcult. Folkman (1984) discusses two forms of control:
expectations for control in general and situational appraisals of the possibilities for
control in speciﬁc situations. When applied to problem situationsw, a form of coping
is to gain control over the situation. Generalized peliofs about control are likened to
locus of control (e. g. Rotter, 1966) and are discussed in terms of primary appraisal of
potential stressors. Alternatively, situational appraisals of control are part of
secondary appraisal, when attention is focused not on evaluating the stressor but on
gauging appropriate responses. The assessment of a challenging situation reﬂects
speciﬁc expectations of control over speciﬁc events.

Control is an important determinant of these appraisals in the face of coping
with difﬁcult situations. Folkman (1984) suggests that greater effort is invested in

situations that offer the promise of control. If the use of a control-based strategy is

70

seemingly successful, stress may be greatly reduced or eliminated. In contrast,
failure of a control-based strategy may bring about not only the deleterious
consequences of the stressor but also the effects of failure to reestablish control, such

as frustration or learned helplessness (Seligman, 1975; Wortman & Brehm, 1975).

r n r n 0

Standard conceptualizations of control have included two constructs-- internal
and external loci of control. An internal person is one who tends to take
responsibility for her own actions and views herself as having control over her own
future. External individuals tend to see control as residing elsewhere and attributes
success or failure to outside forces (Rotter, 1966). Expectancy of control beliefs have
been shown to predict health-related behaviors (see reviews by Strickland, 1978;
Wallston & Wallston, 1978). The bulk of this research using generalized locus of
control expectancies has supported the assumption that individuals who hold internal
as opposed to external expectancies are more likely to engage in health-promoting
behaviors (Strickland, 1978).

Womens’ perceptions of control have been found to be related to compliance
with prenatal health regimens during pregnancy that were related to actual pregnancy
and birth outcomes (Tinsley et al, 1993). Other researchers have focused on control
in the context of health locus of control. These studies measure a woman’s belief that
she is directly responsible for the health of her unborn child (internal) and two

external dimensions assessing beliefs that health professionals and chance factors

71
determine the newbom’s health (Labs & Wurtele, 1986).

A study by Oliver (1972) assessed expectancy for and recalled experience of
control, coping and mastery during childbirth, as measured by self-report scales. He
found that participation in Lamaze preparation classes was associated with
expectancies for and recalled experiences of control, master and coping during labor
and delivery. He concluded that personality, demographic, historical, background,
situational and contextual variables have relative importance to expectations about
experiences and to actual experiences during the events of labor and delivery.

When stress is a signiﬁcant factor added to perceived control, difﬁculties
during pregnancy may result. For example, a study by Floyd (1988) found that
women experiencing high levels of stress were at greater risk of complication of
pregnancy, if they were low in one measure of perceived control.

In summary, evidence suggests that perceptions of control and the use of
available coping strategies may inﬂuence the progress of pregnancy, labor, and
delivery. These personal characteristics serve as resources with which to handle
stressors that may occur during pregnancy. Psychological states, such as depression
and anxiety may also inﬂuence the perceptions of coping and control. Understanding
how emotions ﬁt into the picture of individual resources will be discussed brieﬂy in

the next section.

Psychological Eonotiooing; Doprossioo and onioty

Finally, the last individual characteristic component in the stress-health model

72

includes an index of emotional functioning that is unique to individuals. How people
function emotionally has an impact on how they perceive events that occur during
pregnancy. Clinical episodes of depression and anxiety also have connections to poor
pregnancy outcome.

Investigators view pregnancy as a time of emotional upheaval, crisis, stress, or
as some sort of illness inﬂicted on the woman (Bibring et al, 1959; Chapple &
Furneaux, 1964; Grimm, 1961; Hanford, 1968; Lips, 1985; Nilsson & Almgren,
1970; Rothstein, 1972; Rubenstein, 1977). Spielberger and Jacobs (l979a,b)
reviewed evidence noting that the biological and neuroendocrinal changes that occur
during pregnancy may have profound psychological effects upon expectant mothers.
Some of these changes may occur as the result of anxiety and depression.

Anxiety about the pregnancy, approaching birth and anticipated care of the
child may occur throughout the transition to new motherhood. These are natural
occurrences that happen for every expectant mother. For some women, the anxiety
may be manifested in depressive behaviors, which together may inﬂuence her attitude
towards the pregnancy. For example, a woman’s perception of her marital
relationship and support from her spouse have been found to relate to depressive
symptomatology during pregnancy and after delivery (O’Hara, 1986; O’Hara et al,
1983).

Stress and its related anxiety or tensions have been shown in some way to
translate into health compromises for childbearing women. Walker (1989) suggests

the possibility that high levels of stress may lead to the abandonment of health-

73

promotive activities. Various studies provide evidence for a link between high
anxiety during pregnancy and the onset of certain obstetric and neonatal complications
(McDonald & Christakos, 1963; Brown et al, 1972; Gorsuch & Key, 1974; Crandon,
1979a,b; Standley et al, 1979; Barnett & Parker, 1986). For example, stressed and
highly anxious women have higher incidence of pregnancy-induced hypertension,
prolonged or precipitous labor, forceps delivery, fetal distress, and infants with
congenital abnormalities and lower Apgar scores (Ascher, 1978; Crandon, 1979a, b).
Lederman et al (1979, 1981) also associated psychological conﬂict and anxiety in
pregnancy with prolonged labor and suggested the latter may have detrimental
consequences for the fetus and the development of the infant.

However, other authors failed to conﬁrm this relationship (Burstein et al,
1974; Newton & Hunt, 1984). For example, Edwards et al (1987) found different
patterns of change in emotional functioning in the last trimester of pregnancy.
Women with normal deliveries showed a reduction in state anxiety at the beginning of
the third trimester and an increase near delivery, while women with complicated
pregnancies showed an increase in state anxiety at the beginning of the third trimester
and a reduction near delivery. It is not clear if a relationship between state anxiety
and abnormal pregnancy depends on higher levels of anxiety in a particular period of
pregnancy or on particular patterns of change in anxiety levels during pregnancy
(Rizzardo et al, 1988).

Several investigators have charted change in emotional distress during the

course of pregnancy (Edwards et al, 1987; Lubin et a1., 1975; Rizzardo et al, 1988;

74

Rofe, Blittner & Lewin, 1993), and found patterns in psychological functioning from
one trimester to the next. Rofe, Blittner & Lewin (1993) suggest that the major
causes of women’s emotional experiences during the ﬁrst trimester are certain
physiological changes that occur with pregnancy. As the pregnancy progresses, an
approach-avoidance conﬂict with regard to delivery and its possible consequences
evolves, and this constitutes one of the major elements in determining women’s
psychological condition during the last trimester. In other words, expectant mothers
may spend more time considering complications and feeling greater emotional distress
during the third trimester. Lubin et a1 (1975) have supporting evidence that during
the course of pregnancy, anxiety decreases in the second trimester and rises again to
its initial level in the third trimester, whereas depressive mood showed no variation
over the trimesters.

Evidence suggests that the levels of emotional distress vary according to parity
status. Women with primiparae status report less emotional distress during all
trimesters as well as fewer headaches, less dizziness and pain during the second and
third trimesters than did women with multiparae status (Rofe, Blittner & Lewin,
1993). A possible explanation may be that primiparous women have no previous
experience to base their emotional distress and may attribute their feelings to other
sources. They may feel distress is a natural part of the transition and they enter labor
and delivery with a certain amount of naive fear and anticipation for any possible
consequences.

On the more extreme end of psychological functioning, emotional disorder in

75

late pregnancy is more likely to be experienced by those women in whom there was
evidence of pre-pregnancy psychological difﬁculties and symptoms. For some
pregnant women, depression and anxiety may not be a speciﬁc result of being
pregnant, but rather that pregnancy is just one additional stress which they have
difﬁculty in coping with satisfactorily (Zajicek & Wolkind, 1978).

In summary, individual characteristics are comprised of multiple components:
Type A behavioral tendencies, temperament, coping style, desired control and
indicators of emotional state. Yet each component does not exist independently of the
others. The next section will review literature pertinent to the links between

individual characteristics.

een Individ l haracteris ics
m m n 1 le.

Type A pattern is the product of an interaction between an underlying
behavioral or temperamental style and a set of socialization experiences (Steinberg,
1985). Steinberg (1985), in a study assessing adolescent characteristics, found that
the achievement-striving component of Type A is associated with temperamental
characteristics of high adaptability to new or challenging situations, negative mood,
high approach towards other people, and low rhythmicity (predictability in time of
sleep, hunger, eating and elimination functions). In addition, the Type A
characteristic of impatience-anger was found to have as its temperamental antecedents

low sensory threshold, low persistence, and low adaptability. Although these ﬁndings

76

apply to adolescent personality development, certain aspects of temperament appear to
be related to the Type A behavior pattern. Together, these dimensions may comprise
underlying behavioral style which in turn may inﬂuence how a woman experiences the
transition throughout ﬁrst-time pregnancy. Personality may inﬂuence how women

access social support, coping style, and desire for control.

w in i 1

Type A and B women differ in the extent to which they seek social support. In
a study by Kelly & Houston (1985), Type A’s reported both more stress and tension
if they reported high general availability of social support, but not if they reported
low general availability of social support. Suls (1982) has argued that under certain
circumstances for certain people, social support may be a liability rather than a
beneﬁt.

Several explanations for the relationship between support and Type A behavior
pattern are possible. Perhaps Type A employed women feel intruded upon or
burdened when they perceive that others, particularly supervisors or husbands, are
ready sources of support. Alternatively, social support may contribute to employed
Type A women striving harder because they feel the support to do so or because they

feel expected to do so (Greenglass, 1990).

Caningandlma.

Researchers have begun to suspect that certain styles of coping with stress may

77

have pathophysiologic consequences, and that Type A’s may rely on more
maladaptive coping strategies than Type B’s. Glass ( 1977) conceptualized the Type A
behavior pattern as a characteristic style of c0ping with threats to one’s sense of
control. The COping strategy of Type A behavior seems maladaptive enough to
increase susceptibility to coronary heart disease (Rosenman, Brand, Sholtz, &
Friedman, 1976), and stress on a human biological system (Friedman, Byers,
Diarnant, & Rosenman, 1975).

It may be reasonable to expect that Type A’s will show a greater tendency to
rely on achievement related, solution-oriented, problem-focused coping. Hart (1988)
notes that the relationship between ways of coping and Type A behavior is different
among males than females. Type A and B individuals may cope with taxing
situations differently. Type A’s tend to engage in signiﬁcantly more problem-focused
coping than Type B’s (Burke & Weir, 1980; Zeichner et al, 1983; Vingerhoets &
Flor, 1984; Smith & Brehm, 1981; Heppner, Kampa & Brunning, 1984; Heppner,
Reeder & Larson, 1983) which is consistent with theory relating Type A behavior and
personal control to the stress and coping process. Type A behaviors may be
interpreted as efforts directed at bolstering a perception of controllability (Folkman,
1984; Fleming, Baum & Singer, 1984). Hart (1988) found that female Type A’s
employed more cognitive restructuring coping than their female Type B counterparts.
He suggests that female A’s may be particularly sensitive to and concerned about
losing control of their emotions. Folkman (1984) has also proposed that self-

denigration coping strategies may serve to reinforce internal control beliefs by

78

creating an illusion of control.

1 T A

An outcome is controllable by a person if and only if that individual’s
voluntary activity can change the probability that the outcome will occur (Lacey,
1979). When faced with an unpredictable situation, people may cope by trying to
gain control or withdraw from the situation. People who feel in control believe that
they will overcome current failures or tragedies, whereas people who feel helpless
feel overwhelmed and without recourse when faced with life stressors (Abramson,
Seligman & Teasdale, 1978)

A study by Lawler et a1 (1988) revealed that Type A scores and desire for
control were positively correlated. Studies with adult women have suggested that
nwd for control may be an important moderator of Type A effects. Type A women
who have high desire for control were found to be more reactive to reaction time
stressors. They concluded that desire for control may be a coronary-prone component
of Type A behavior. Desire for control may be a critical factor linking Type A
behavior to physiological reactivity in women. For example, high desire for control
women exhibited larger heart rate or blood presure responses either in anticipation of
a task and throughout testing (Lawler et al, 1990).

Several studies have suggested that Type As may prefer competition over
cooperation (Gotay, 1981; VanEgeren, 1979), and that they will choose to work alone

rather than in the presence of others while under stress (Dembroski & MacDougall,

79

1978). One possible explanation for Type A’s choice to remain in control is that they
believe it will ensure the best possible outcome. Control reduces the level of
aversiveness in a situation (Miller, 1979, 1980). These individuals may alternatively
be more concerned with achieving a sense of personal satisfaction and/ or may have a
desire for control in and of itself (Clark & Miller, 1990).

Clark & Miller (1990) conducted a study which revealed that Type A’s choose
to work alone, avoid cooperation and thereby retain control signiﬁcantly more than
Type Bs. These differences were not inﬂuenced by differential levels of anxiety,
commitment to the task, desire for self-evaluation, or desire to make the task more
enjoyable. The factor that appeared to distinguish between the two types was desire
for responsibility. For Type As, there was a strong relationship between desire for
responsibility and preference to work alone. In a similar study, Strube, Boland,
Manfredo and Al-Falaij (1987) found that Type As were more likely than Type Bs to
seek out diagnostic information about their abilities, under conditions of uncertainty.

With the connection between Type A behavior and control set in place, what
implications does this pose for the pregnant Type A woman? For many, the time of
pregnancy poses a situation of uncertainty in which control is not necessarily possible.
Type A women appear accustomed to maintaining control in their home and
occupational responsibilities; what might happen once focus is shifted to their
changing bodies where biological control is not possible? The next section details
how the issues and constructs surrounding individual, contextual characteristics and

stress will be addressed in the present study.

THE PRESENT STUDY
PSYCHOSOCIAL STRESS, PERSONALITY AND CONTEXTUAL FACTORS:

LINKS TO PREGNANCY AND BIRTH OUTCOMES

The literature review up to this point has attempted to integrate, from an
Institute for Social Research model perspective, research on stress and its impact on
pregnancy outcome. It has covered the different components within the construct of
stress, individual characteristics, context characteristics and pregnancy outcome.
Hence, the present investigation attempts to evaluate this process model by examining
the moderating effects that personal disposition and context have on the established
relationship between stress and health.

Consistent with the ISR model, individuals perceive stressors depending on 1)
the context in which the stressor occurs and 2) the individual’s resources and personal
disposition that enable him/ her to react to the stressful situation. Past literature
suggests that stressors experienced in the third trimester of pregnancy are capable of
jeopardizing pregnancy outcome. Social support during pregnancy has been one
established moderator of this stress-health relationship. Yet, in accordance with
systems theory, multiple domains, such as the workplace, the marital relationship, and
personality style must be considered in concert.

Therefore, exploratory analyses examine possible relationships between
personal disposition and pregnancy outcome, for example, assessing links between
Type A personality, desire for control during the transition, and pregnancy outcome.

80

81

Given their hard-driving competitive nature and tendencies for cardiovascular
functioning, will Type A women have more difﬁcult labor and deliveries? Or does a
composite of personality characteristics and emotional functioning together play a
moderational role in buffering stress that may prove detrimental to pregnancy
outcome? The current study attempts to address Type A mothers and the effects that
their lifestyles may have on their infants.

Figure 3 depicts the model under focus. Arrows between variables are the
relationships that will be examined for this study. The hypotheses under investigation
are discussed in the next section. The method by which the relationships among the

variables of interest will be evaluated in the following section.

INDIVIDUAL CHARACTERISTICS

* Type A Behavior Pattern

'1‘ Temperament

"‘ Desired control during transition
* Emotional functioning: depression
* Emotional functioning: anxiety

 

PERCENED S'I'RFSSORS > PREGNANCY OUTCOME
* Difﬁcult Life Circumstances A * Preterm delivery
* Daily stressors * Length of labor stages

* Birth weight

* Labor complications
* Apgar scores

 

CONTEXTUAL CHARACTERISTICS

"‘ Work Environment: Prestige, Role strain, role
satisfaction, job satisfaction
* Social Support: Pregnancy-related support
Aid, Afﬁrmation, Information
* Marital Satisfaction

Figure 3.

Model of psychosocial stress, personality and contextual factors and the links to
pregnancy outcome '

HYPOTHESES
The goal of this dissertation is to examine, from an ISR model of stress, the
relationship between stress and pregnancy outcome. Moderators that may be involved
in this relationship will also be analyzed. In sum, the following research inquiries

will be addressed:

1. The initial purpose of the proposed exploratory study is to assess the
relationship between experienced stressors and pregnancy outcome. Experience with
many stressors is expected to be highly associated with labor and delivery

complications and poor infant outcome.

2. In accordance with systems theory, contextual inﬂuences on the stress-birth
outcome connection must also be considered. One purpose of the present research is
to investigate the relationship between stress and pregnancy outcome as moderated by
contextual characteristics of work environment, social support and marital satisfaction.
The different types of contextual constructs are proposed to be potential predictors or

moderators of the stress-pregnancy outcome relationship.

3. Individual differences exist in how personal resources help individuals to
cope with stressors. The third purpose of the study is to assess the relationship
between stress and pregnancy outcome across time as moderated by the individual’s
personality characteristics of Type A personality, temperament, control, coping style,

83

84

expected social support, and emotional functioning (depression and anxiety).
Individual personality constructs may play the role of predictors or moderators in the
stress-pregnancy outcome relationship. These personality constructs include Type A,

easy/difﬁcult temperament, desired control, social support, and emotional functioning.

4. Based on evidence previously presented, Type A behavior pattern has been
associated with poor health and links to the development of cardiovascular disease.
Can the same linkages be made in relation to pregnancy progress and labor and
delivery? Given the literature associating Type A behavior and poor health outcomes,
Type A women are predicted to have more labor and delivery complications, rely less
upon others, and desire more control over the course of the pregnancy. More
speciﬁcally, are the mean levels of all variables signiﬁcantly different for Type A and

Type B expectant career women?

5. Another purpose of the proposed study is to assess different pathways that
may exist for Type A and Type B women, utilizing the same individual and

contextual constructs as speciﬁed in Hypotheses 2 and 3.

6. The ﬁnal purpose of the study is to test the proposed model patterned after
the ISR model of stress, including individual characteristics, contextual characteristics
and how these play a role in the relationship between stress and pregnancy outcome

will be tested. Unhealthy individual characteristics and unsupportive environment will

85

negatively inﬂuence the relationship between stress and pregnancy outcome. Type A,
Control and Psychological Indicators of stress, social support, and work satisfaction

will jointly predict poor pregnancy outcome.

This study uses data from the MSU Becoming A Parent Study, a short-term
comparative study of psychosocial changes during the transition to parenthood.
Speciﬁcally, measures are employed that are pertinent to the third trimester of
pregnancy and post reports of labor and delivery.

The measures utilized to index constructs related to the perceived stress
experience in daily life include those assessing: difﬁcult life circumstances and daily
life stress and satisfaction, as perceived by the mother to be. The particular stress
measures that are used to assess stressors and the scores derived from these measures
are shown in Table 2.

Indexes of pregnancy outcome used in this study pertain to both positive and
negative birth outcomes. The following constructs will be measured in order to index
birth outcome: length of gestation period (preterm delivery of less than 37 weeks),

length of labor stages, labor complications, infant birthweight, infant Apgar scores.

86

Table 2.
Constructs and Measures

Stress Measures ,1

Measure

 

 

 

 

 

 

 

 

 

 

 

 

 

Construct
Long term stressors Difﬁcult Life Circumstances I
Daily stressors Life Stress &. Disappointrnents

Contextual Measures
Construct Measure I
Employment history Women's Life Situation Survey
Role satisfaction Women’s Life Situation Survey
Role strain Women’s Life Situation Survey J
Satisfaction with job Women’s Life Situation Survey J
Satisfaction with division of labor in home Women’s Life Situation Survey
Work satisfaction (speciﬁcs) Work Satisfaction Seale
Occupational Prestige Dunean Socioeconomic Index
Functional social support Norbeck Social Support Seale
Number in support network Norbeck Social Support Scale

 

Marital satisfaction

 

Dyadic Adjustment stare

 

Individual Characteristic Measures

 
 

    

Measure

 

 

  

Dimensions of Temperament Survey

 

 

 

 

Jenkins Activity Survey

 

 

Expectations Questionnaire

 

  

 

 

 

Desired pregnancy-related social support Expectations Questionnaire
Depression Center for Epidemiologieal Studies
Depression Scale

 
     

 

 

Anxiety

 

 

 

  

State-Trait Anxiety Inventory

Table 2. (con’t)

Pregnancy Outcome Measures

  

Construct Measure

Preterm delivery Medical record in formation

 
  
  
 
   

 

 

Length of labor stages Medical record information

 

 

Labor Complications Medical record information & Maternal
self-report

Birthweight Medical record information & Maternal
self-report

 

Medical record information

 

 

    

Apgar scores

88

Moderators that could potentially inﬂuence the relationship between stress and
pregnancy outcome will also be examined. The potential moderating role of the
following individual characteristic variables will be assessed: Type A personality,
temperament, control, coping style, and emotional functioning, more speciﬁcally, the
levels of depression and anxiety felt during the third trimester. In addition, the
moderating role of contextual characteristic variables will be examined. These include
aspects of work environment (prestige, role strain, role satisfaction, job satisfaction),
social support (pregnancy-related support and aid, afﬁrmation and information), and
marital satisfaction.

A more detailed description of the measures utilized, the sample examined,
and the procedure used to collect the data for this investigation is presented in the

following section.

METHOD

Method

Soojoots The participants were 80 pregnant women, ranging in age from
18-37 yrs (M= 26.77, SD= 4.1), each expecting their ﬁrst child. The mean
education level for the sample was a college degree, and the mean level of
occupational prestige was 45 on a scale of 18 to 88.1. The sample was primarily
Caucasian (78%), and married (80%). By focusing on ﬁrst births, this bars any
women who have already experienced past births. Employment status, age of
subjects, and socioeconomic status are balanced for an education minimum of high
school completion. Examining a sample of women 18-37 years of age increases the
likelihood that Type A behavior will be more readily expressed. This sample includes
a variety of occupations, ranging from unskilled and clerical workers to managers and

executives.

W All ﬁrst time mothers—to—be were volunteers, recruited through
Sparrow Hospital’s Family Care Clinic, Michigan State University Clinical Center,
Butterworth OB Gyn Clinic, The Physician’s group and through Lansing and Grand
Rapids area prenatal classes. A focus on these two areas insures both ethnic and
socioeconomic diversity. Women were recruited into the study at the time for their
ﬁrst prenatal visit. Each participant met the following criteria: 1. Length of
pregnancy < 24 weeks at ﬁrst prenatal visit, 2. nulliparous, 3. no chronic diseases,

e.g. Diabetes mellitus, hypertension, cancer, etc. which would place the woman in a

89

90

”high-risk" pregnancy category and 4. singleton pregnancy.

Procedure

All women were approached by a nurse in the hospital/ clinic waiting room.
He/she brieﬂy described the research project, to see if the patient was interested in
participating in the project. Each woman was given a ﬂyer explaining the study, and
consent forms were distributed. A phone call followed, to make arrangements for the
woman to receive the questionnaires. Adjustments were made for the researcher to
go to the subject’s home or workplace when difﬁculties arose. Each woman was given
a ﬂyer explaining the study, and consent forms were distributed.

Questionnaires were mailed to the woman’s home, and participants were able
to return the completed packets using prepaid return envelopes. Upon receipt of the
completed questionnaire packet, the women were reimbursed $5.00 for their time

spent completing the questionnaires.

Design

Data were gathered in two different methods. The original project design
involved data collection at three points in time: upon entrance into the study at the
ﬁrst prenatal care visit, at the middle of the third trimester, and eight weeks
postpartum. We anticipated that some subjects would deliver prematurely, and were
prepared for the possibility of not being able to obtain three data collection points for

all participants. The group that was administered 3 sets of questionnaires throughout

91

the pregnancy were named "3-wave" subjects.

Initial recruiting attempts proved difﬁcult and slow, due to the number of
women under the age of 18 who were ineligible for participation. We decided to
recruit additional subjects from expectant parent organizations. Since most
participants do not begin classes until the last trimester of the pregnancy, an
adjustment to the original design was made. The second method of data collection
then required administration of packets at two points: during the last trimester of the
pregnancy and 8 weeks postpartum. These subjects were labeled "2-wave" subjects.
The current sample under investigation included 40 "3-wave" subjects and 43 "2-
wave" subjects.

In order to conduct the current analyses, data from the third trimester of
pregnancy was utilized, as well as the data collected eight weeks after the birth of the
babies. For the subjects who received three "waves" of questionnaires, demographic
information, Type A scores and the Women’s Life Situation Survey were extracted
from the ﬁrst set of questionnaires. All remaining questionnaires data were extracted
from the second set of questionnaires administered in the last trimester of pregnancy.
For the subjects who received two "waves" of questionnaires, all questionnaire
information was extracted from the ﬁrst set of questionnaires, also administered in the
last trimester of pregnancy. The only information abstracted from the last "waves" of
questionnaires for both types of} subjects included self-reported birth complications

that occurred during labor and delivery.

92

Measures

The ISR model of stress (Kahn, 1981) emphasizes the importance of studying
contextual and individual characteristics as mediators that inﬂuence the pathway
between stress and health. In keeping with this model, the purpose of the present
study is to examine the relationship between perceived stressors experienced during
the third trimester of pregnancy and their relationship to birth outcome as mediated by
individual and contextual inﬂuences.

In order to assess mediational inﬂuences on stress and pregnancy outcome,
information regarding perceived levels of stress, individual characteristics, and
contextual characteristics were collected during the third trimester of pregnancy.
Assessment of individual characteristics was obtained by having participants complete
self-ratings of 1) number and types of long term stressors, 2) daily stressors, 3)
temperamental style, 4) Type A behavior, 5) depression, 6) anxiety, and 7) coping
style.

In order to assess contextual characteristics during the third trimester,
information from each participant was obtained regarding 1) social support network,
2) perceived desire of pregnancy-related social support, 3) marital satisfaction, and 4)
employment characteristics (occupational prestige, role strain and satisfaction, and job
satisfaction).

Finally, pregnancy outcome was obtained from participants and medical chart
information. Indices of the progress of labor and delivery and infant outcome include

premature delivery, length of labor stages, complications in labor, infant viability as

93

measured by Apgar scores, and infant birthweight.
The Appendix contains copies of all measures relevant to the present study, in

the order listed below. Scale reliabilities for each of these measures is included in the

results section.

Stress Measures

Difﬁoolt Lifo Ciroumstanogs

The Difﬁcult Life Circumstances Scale (Barnard, Johnson, Booth & Bee,
1989) is a 28-item scale that assesses the presence of long-term family stressors.
Examples of these stressors include: having problems with a credit rating, having an
abusive partner, having a household member with a long-term illness, having trouble
ﬁnding a suitable place to live, incarceration, and dependency on drugs. Two of the
questions were deleted because they assessed situations involving children. The
subject is asked to answer yes or no, depending on whether the situation is a current
problem for them. Scores were based on the number of circumstances that applied,
and could range from 0 to 26. A cutoff score of 6 indicated a case at high risk for
family, parenting and child outcomes (Barnard et a1, 1989). In a study by Krener et
a1 (1986), the mean number of difﬁcult life circumstances was 5.0; chronic problem
families reported a mean of 6.2, and more successfully functioning families reported a
mean of 4.2. Barnard et a1 (1989) report test-retest reliabilities ranging between .4
and .7. The present study is the ﬁrst one to be utilized in a population of expectant

pregnant women.

94
Life Stress and Disappointments

This instrument assesses the amount of stress the individual perceives he/she
has in different aspects of daily life. The instrument was created by Alejano (1992),
as an adaptation of the Hassles and Uplifts Scale (Kanner, Coyne, Schaefer &
Lazarus, 1981). The scale was designed to assess how daily events impacted on their
happiness, stress levles and amount of time spent thinking about the event. The scale
uses similar items as the hassles and uplifts scale, but goes beyond indicating how
often each event occurred in the last month. Three scales are used for the 53 items,
and the subject is asked to rate 1. How happy/ satisﬁed they are with the situation, 2.
Whether or not it is a source of stress, and 3. The amount of time they spend thinking
about the situation. They are also asked to list the three items with which they are
most satisﬁed and the three items with which they are most disappointed. Additional

reliability and validity analyses are currently underway with other adult samples.

Contextual Measures

Tho Women’s Life Situation Survey

Since being employed may be stressful for most pregnant women, detailed
information was collected on each woman’s occupation, education, employment
situation, reasons for working, physical exertion required on the job, job satisfaction,
and plans for employment after the birth of the baby. The Women’s Life Situation
Survey (WLSS; Lerner, 1989) was used for this purpose. The WLSS was designed to

assess the characteristics of a woman’s employment and living situation and was

95
modiﬁed for this sample, speciﬁcally by deleting questions regarding children. This

close-ended questionnaire includes information about 1) the mother’s ﬁnal level of
education, 2) employment history, 3) role satisfaction and strain, 4) how satisﬁed the
woman is with her employment situation, satisfaction with the division of labor in the
home, and current marital status.

The satisfaction items are rated on a ﬁve-point forced-choice scale, with high
scores indicating greater satisfaction. Perceived role difﬁculty is rated similarly, with
increasing scores corresponding to an increase in experienced difﬁculty.

One subscale was formed within the WLSS, which pertained to satisfaction
with one’s own employment situation, consisting of ﬁve items in which the
respondent rated her satisfaction with following aspects of employment: the job, the
salary, the hours, the responsibility, and the status. This subscale on past studies
(Hess, 1990) has yielded a Cronbach alpha internal consistency coefﬁcient of .83 for

women .

Work Satisfaotioa

The Work Satisfaction scale created by Pistrang (1984), assessed the degree to
which the respondent obtained speciﬁc satisfactions of psychological rewards from her
work. Items include questions regarding aspects of the occupation, including
accomplishment, job usefulness, and opportunities for self-expression. Each item is
rated on a 5-point forced choice scale, ranging from "never" to ”very often. This 25-

item scale has yielded a coefﬁcient alpha of .94 (Pistrang, 1984). Additional

96

information on reliability and validity of this measure does not currently exist.

Qooopational Prostige

The revised Duncan Socioeconomic Index Scores (Featherman & Hauser,
1980) were utilized, for establishing occupational prestige scores for each of the
participants in the study. The original index (Duncan, 1961) was developed to
estimate the Nort-Hatt prestige ratings for census occupations. Each score is derived
using a regression equation. These index scores assign prestige score which takes
into consideration years of education, salary, and social prestige associated with each
occupation. Stevens & Featherman (1980) updated the scale for 1970 census
occupation codes. These three-digit scores range from 13.8 (private household

workers- allocated) to 88.4 (physicians and lawyers).

k ' l u c 1

Each woman rated the type and degree of social support she received from her
partner, friends, family and employer. The Norbeck Social Support Questionnaire
was used to measure three dimensions of social support: functional support (affect,
afﬁrmation and aid), network, and loss (Norbeck, Lindsey & Carrieri, 1981). This
scale assesses the amount of social support the individual feels they receive from
family and friends. The nine items ask the subject to rate how dependable they feel
their family members and friends are in several situations. Responses are made on a

5-point forced-choice scale, varying from "Not at all" to "A great deal". Evidence

97

for construct and concurrent validity, strong internal consistency (range .95 to .98)
and excellent test-retest reliability (range .85 to .92) have been demonstrated among
various ethnic groups (Norbeck, Lindsey & Carrieri, 1981; Norbeck, Lindsey &

Carrieri, 1983).

Mm‘ﬂ Satisfaction: The Dyadic Adjustment Scale
The Dyadic Adjustment Scale (DAS; Spanier, 1976) was used to assess the

perceived quality of the subjects’ marital relationships. The DAS is a frequently used
measure of marital adjustment (e.g., Jacobson & Moore, 1981; Johnson & Greenberg,
1985) that assesses aspects of the marriage such as satisfaction, communication,
affection, similarity of values and global adjustment. Several investigations have
demonstrated that the DAS is a psychometrically reliable and valid measure that
discriminates happily married from unhappily married and divorced samples (e.g.
Jacobson & Margolin, 1979; Whiffen & Gottlib, 1991). Spanier (1976; Spanier &
Thompson, 1982) reports evidence for content, criterion-related, concurrent, and
construct validity. Alphas ranging from .73 to .96 have been reported for the DAS

and its subscales.

Individual Characteristics Measures

Tommgamont; Tho Dimonsions of Tompgtamont Survoy.

Each woman rated her temperament or behavioral style using the Dimensions

of Temperament Survey (Windle & Lerner, 1986, Windle et al, 1986). This 54-item

le‘

1::

Sc

10

de

an

98

questionnaire assesses temperament along nine orthogonal dimensions: 1. Activity
level-general; 2. Activity level- sleep; 3. Approach-Withdrawal; 4.
Flexibility-rigidity; 5. Mood; 6. Rhythmicity-sleep; 7. Rhythmicity-eating; 8.
Rhythmicity- daily habits; and 9. Task orientation.

The response format for each item is 1: usually false to 4: usually true.
Scoring DOTS-R involves forming attribute scores by summing the scores on
individual items. Higher DOTS-R scores indicate higher levels of activity, a tendency
to approach, higher ﬂexibility, a positive mood, higher levels of rhythmicity in sleep,
eating, and daily habits, and a higher task orientation level.

Internal consistency coefﬁcients (Cronbach alphas) for the above nine DOTS
attributes are .75, .81, .77, .62, .80, .69, .75, .54, and .70, respectively for a sample
of 244 sixth graders. Construct validity for the DOTS-R has been reported for

college students by Windle et al (1986).

fljym A Personality: The ankins Activity Survey

The Jenkins Activity Survey (Jenkins, 1978) assessed whether each woman
could be classiﬁed as having a Type A personality. This classiﬁcation’s major
descriptive elements are extremes of competitive achievement striving, impatience,
and hostility. Of the several measures of Type A behavior, the Jenkins Activity
Survey (Jenkins, 1978) has the strongest construct validity (Matthews et al, 1982),
and has the broadest'use in studies of Type A behavior involving women (Lawler et

al, 1983, 1984, Van Egeren,1979, Jenkins et al, 1967). The self-administered Jenkins

11

Sr

g:

(its

hO‘J

99

Activity Survey assesses the major behavioral manifestations of Type A behavior
(Jenkins et al, 1967 and Matthews et al, 1982).

Each woman was screened for the Type A behavior pattern, using the Jenkins
Activity Survey (Jenkins, 1978). This measure determines whether or not an
individual has tendencies to be Type A (driven, competitive) or Type B (less stressed,
less time-conscious). The 52 items ask about different aspects of patience, time
commitments, work habits, hurried behaviors, emotions and social interactions.

The survey is a self-report multiple-choice questionnaire of 52 items designed
to measure the Type A behavior pattern found to be strongly associated with the risk
of coronary heart disease. The test is scored on four scales: the Type A scale, which
assesses the multifactorial clinical construct of the coronary-prone behavior pattern,
and three factorially independent components of this broad construct: speed and
impatience, job involvement, and hard-driving and competitive. Examples of these
subscales are included in Table 3.

Jenkins et a1 (1965) have reported an alpha .83 for female subjects, and a
general range of .73 to .85 for all populations for all Jenkins Activity Survey

subscales.

x ion e i nnaire Subscales: Desired ontrol and ocial Su
The Expectations Questionnaire Battery (Alejano & Frassetto, 1992) was
designed to assess each woman’s expectations regarding the pregnancy (wantedness,

how she expects it to go), delivery, parenting competence, paternal involvement in

in

(n.

100

childcare and parenting, and expectations regarding her future employment.

This measure addresses the participants’s expectations on several aspects of the
pregnancy. Areas include physical changes, expectations about the course of the
pregnancy, expectations for labor and delivery, child care expectations, and
expectations for becoming a ﬁrst time parent. This measure also includes sections on
personal beliefs about pregnancy, and choices and control during the course of
pregnancy. Several ﬁve-point forced-choice scales allow individuals to indicate
whether they agree or disagree with statements.

As a newly created measure, no reliability information has yet been
established. Yet in past analyses including 39 subjects from the current study, alphas
of .72 for the desire for control scale and .63 for the pregnancy-related support scale

were obtained.

1 i nin ' D r s i ii

To assess each woman’s experience of stress, we used the Center for
Epidemiological Studies Depression Scale (CESD). This scale is a self-report ”state"
measure of depressive symptomatology that was developed for research applications,
initially for use in epidemiologic surveys of depression within the general
(nonpsychiatric) population. It assesses three components of depressive symptoms: 1.
behavioral, 2. cognitive, and 3. happiness-sadness. Subjects are asked to respond to
20 statements describing particular ways they might have felt during the past week,

with answers ranging from 0)"Rarely or none of the time" to 3) "Most or all of the

101

time". The possible range of total scores is 0-60, with higher scores reﬂecting
greater distress. The CESD appears to have adequate psychometric properties
(Radloff, 1977; Roberts & Vernon, 1983; Weissman et al, 1977) Radloff (1977) has

reported coefﬁcient alphas of .84, .85, .90

Marital Health Functioning; Anxiety.

In the present investigation, the State-Trait Anxiety Inventory Form Y by
Spielberger (1983) yields information on the individual’s level of both "state" anxiety
and "trait" anxiety. The 20 state-anxiety items ask the subject to respond to
statements describing how they feel "right now". The 20 trait-anxiety items ask the
subject to respond to statements describing how they "usually feel". Items were rated
on a 4-point scale ranging from "not at all ( 1) to "very much" (4). Higher totals
indicate greater anxiety levels. Concurrent validity and test-retest reliability (range
.73 to .86) has been reported by Spielberger et al, 1970. Alpha coefﬁcients for state

anxiety was reported at .93 for women, and .91 for trait anxiety.

Pregnancy Outcome Measures

Mﬁjm Rgotd Information

Information abstracted from medical charts were quantiﬁed for analyses. The
outcomes include the following list.
W Dates of delivery and number of weeks of gestation were recorded

for each birth. An infant born less than 37 weeks gestation was deﬁned as a preterm

102

baby. Hence, the expected range of weeks of gestation was between 30 weeks and 40
weeks. Medical charts contain many different calculations of gestational age,
including those based on self-report of last menstrual period, physician-based
estimates based on pelvic examinations, and ultrasound results. Time of delivery was
coded as clearly full term (38 or more weeks gestational age) at birth, marginally
preterm (36 or 37 weeks gestational age), or clearly preterm (fewer than 36 weeks

gestational age).

W The length of labor stages were recorded in minutes for the
three stages of labor. The ﬁrst stage is deﬁned as the period when regular intense
contractions begin until the cervix is fully dilated. The second stage begins once the
cervix is fully dilated, and the newbom’s head pushes through the cervix into the
vagina. The third labor stage is deﬁned as the period when the placenta separates

from the uterine wall, and afterbirth is delivered.

Qompljgtjoos The number of birth complications was quantiﬁed according to the
number of complications that occurred during labor progress and delivery. Examples
of birth complications are umbilical cord complications (wrapped around the infant’s
neck), and emergency c-sections. The variable is a summation of the number of
complications that appear on the complications checklist. A copy of the complications

checklist is attached to the appendix, at the end of the measures.

103
Birthweight Birthweights in grams were recorded for each newborn. Birthweight

were used as a continuous dependent variable in analyses because categorical birth
outcomes such as normal versus low birthweight are less reliable and yield poorer
statistical power in data analyses. Newborns who weigh less than 2500 grams were
classiﬁed as a low birthweight infant. Generally, normal full-term babies weigh 3500

gms.

W The Apgar Scale (Apgar, 1953) is an assessment scale conducted at l
and 5 minutes after birth. Infant characteristics of heart rate, respiratory effort,
muscle tone, reﬂex irritability and color are scored on a scale from 0 to 2. Two
points are given if the infant is in the best possible condition for a particular sign, and
no points are assigned if the sign is not present. 1 point is given for all conditions
between 0 and 2. Individual scores are totaled to give a measure of the infant’s
overall physical condition. The highest total score an infant can obtain is 10. An
infant with a score of less than 4 is considered to be in poor condition and to require
immediate medical attention. Total scores at l and 5 minutes were recorded for data

analysis.

lf-r i h m
8 weeks after the birth of the baby, mothers completed a questionnaire
regarding her perceptions of how the labor and delivery proceeded. These open-

ended questions were coded into a complications scheme, and were compared to

104

information abstracted from medical records. The responses may also be

dichotomized as the absence or presence of birth complications.

Results

W

Data were entered into a computer ﬁle and screened for accuracy. Frequency
analyses were run to further check the accuracy of the data, which revealed a small
number of missing cases for some outcome variables. This was expected, considering
that some information from medical records was not available due to the fact that
these participants were from out-of-state. The effect of missing values on the
analyses was examined by computing a dummy variable, coding subjects l= present,
2= missing. A comparison of the two samples revealed no signiﬁcant differences on
all other variables. To preserve an adequate sample size, all further analyses were
conducted using the regression substitution for all missing values. According to Little

and Rubin (1987), this method is a conservative procedure for coping with item non-

response.

W

Scale reliabilities were examined using coefﬁcient alpha internal consistency
estimates. Initial estimates of internal consistency reliability ranged from .60 to .95

across scales. These alphas are recorded in Table 3.

105

Table 3. 106
Reliability Estimates for Scales

Stress Measures

 

   

 

Measure

  

Scale Alpha

 

 

Difficult Life Circumstances

.66

    

 

 

 

 

Life Stress 8 Disappointments

Contextual nessures

rueasure

.91

Scale Alpha

    

 

Norbeck Social Support Scale:
. Affect, Affirmation and Aid

.95

 

 

 

Dyadic Adjustment Scale: .95

Marital Satisfaction

Feelings About Work Scale .96
.84

Expectations of mate during pregnancyf

 

. Single item measures: no alphas reported
Role difficulty
Work Satisfaction

 

Satisfaction with division of labor in home

Duncan Socioeconomic Index of Occupational
Prestige

 

 

Number in support network

Individual Characteristic neesures

Measure

Dimensions of Temperament Survey (DOTS)
* Approach-Withdrawal

Activity Level: General
Activity Level: Sleep
Flexibility-Rigidity
Mood

Task Orientation

 

Easy] Difficult Temperament Scale

Scale Alpha

.72
.85
.91
.84
.89
.79

.73

 

 

107

 

Jenkins Activity Survey

 

 

  

 

* Type A personality .70
* Speed-Impatience .59
* Hard-Driving & Competitive .82
* Job Involvement .74
Ctr for Epidemiological Studies Depression Scale .89
State-Trait Anxiety Inventory: State .92
Psychological Indicators Scale .77
.60

 

Expectations Questionnaire: Desired control

 

 

 

108

Item-total correlations were examined to determine whether some of the scales
exhibiting lower internal consistency estimates might be altered to increase reliability.
For each of the scales, none of the items were dropped.

It is worthy to note that for the Difﬁcult Life Circumstances Questionnaire,
high alphas were not expected due to the variation in types of difﬁcult life
circumstances. For example, the severity of items "Does your mate physically abuse
you?”, and ”Do you have difﬁculty making payments on bills?" do not necessarily

imply a relationship. The questionnaire serves as a checklist of long term stressors.

W

On average, the labor and delivery characteristics of these women do not
include many extreme or severe complications. Eighteen caesarean sections were
performed, and the range of number of complications were from 0 to 7, out of a
possible 30. Eighty-ﬁve percent of the sample had 3 or fewer complications. Six
percent of the births were premature, as deﬁned by 37 or fewer weeks of gestation.
The average birthweight of the infants was 7 lbs, 11 02., with Apgar scores of 9 on
average for the infants. As illustrated, this sample of women did not appear to have a

great range of complications or problem pregnancies.

109
iv n 1

Means, standard deviations, and variable intercorrelations were calculated for
all of the measures used in the study, and are presented in Table 4.

As described earlier in the sample section, the group of women in the study
are highly educated with a mean age of 27, have fairly prestigious occupations, and
are primarily caucasian career women. Yet, within this seemingly homogenous
sample, the long term stressors experienced by these women were positively
correlated with levels of anxiety and depression, and negatively correlated with work

satisfaction and marital satisfaction.

110

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115

In addition, examination of the correlations revealed that the role difﬁculty
experienced by these participants was positively related to levels of depression and
anxiety, and negatively related to marital satisfaction and expectations that the mate
would assist throughout the pregnancy.

Finally, the last set of correlations that are of interest to note are those
associated with psychological indicators, which is a combination of anxiety and
depression. The level of psychological anxiety and depression was found to be
positively correlated with difﬁcult life circumstances, desired control during
pregnancy, daily hassles, and negatively correlated with feelings about work and

number of complications experienced during labor and delivery.

' n l s

In order to determine which of the independent variables was most predictive
of poor pregnancy outcome, regression analyses were performed. In accordance with
the ISR model of stress, hypothesis I noted that experience with many stressors was
expected to be highly associated with labor complications and poor infant outcome.
Table 5 includes the list of individual indicators used in the series of regression
analyses. Number of labor complications was used to predict psychological indicators
and difﬁcult life circumstances, using a forced entry procedure. The lack of
predictive relationship between long term stress and number of complications leads to

the conclusion that hypothesis 1 received no support.

Te

116
TdﬂeS.

Individual indicators used in regression analyses for hypOtheses 3 and 4.

Dependant Variables

Number of labor and delivery complications
Psychological indicators

Tested Predictors
Individual Chararacteristics

Type A personality
Temperament
Desired control

Contextual Characteristics
Social Support
Work Satisfaction
Feelings about work
Marital Satisfaction

Stressors
Difficult Life Circumstances

117

To test the possibility that other variables may be more directly predictive of
labor complications, a step-wise regression procedure was used to regress number of
complications upon the remaining independent variables. The only variable to enter
the equation was the scale for easy/difﬁcult temperament. This single variable
produced a multiple R of .25 (F(l,78)= 5.39, p< .05), indicating that temperament
accounted for approximately 6 % of the variance in number of labor complications.
in this case, easy temperament was associated with more complications.

Another set of step-wise regressions was performed with psychological
indicators, in order to investigate a possible relationship with difﬁcult life
circumstances. It was possible that somehow psychological indicators would be the
key link between stress and number of complications. Three variables entered the
equation predicting labor complications: easy temperament, increasing numbers of
difﬁcult life circumstances, and high desire for control. These three variables
produced a multiple R of .61 (F(3,76)= 14.95, p< .01), indicating that together these
three variables accounted for approximately 37% of the variance in degree of

psychological indicators. These regression analyses are presented in Table 6.

118
Table 6.

Regression Results for Hypothesis 2 and 3

Dependent Variable: Number of Complications
Mister Beta
Temperament .25

Dependent Variable: Psychological Indicators

Minter: Beta
Difﬁcult Life Circumstances .39
Temperament -.35
Control .19
"' denotes p < .05
“ denotes p < .01

N=80

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.065 .065“

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.18

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119

The results of these regressions provides partial support for hypothesis 3 and
provides no support for hypothesis 2. Since the results yielded no support for the
primary stress-poor birth outcome relationship, it was not possible to test individual
characteristic and contextual characteristic variables as mediators of the relationship.
Only individual characteristics appear to contribute to the number of complications
occurring during labor and delivery.

The model resulting from these analyses is depicted in Figure 4.

As illustrated, the model does not include any contextual variables of social
support, marital satisfaction or work-related constructs. This reduced model of
individual characteristic inﬂuences on birth outcome was utilized in the remaining

analyses.

ari T n T B W men
For the entire sample, the environmental variables did not contribute as
predicted. Instead, the focus was placed exclusively on personality and temperament.
Although Type A behavior did not prove to be a predictor of labor complications, the
sample was divided into two groups (based on scores on the Jenkins Activity Survey)
of Type A (n=33) and Type B (n=47), to assess possible differences in labor and

delivery progress between the two groups.

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, 121
Descriptive analyses

Results from independent samples T-tests reveal that few differences between
the two groups existed. The results for these analyses are presented in Table 7.

The only signiﬁcant differences were with temperament ﬂexibility (Type A
mean= 16.31, Type B mean=17.96, p< .01) and division of labor in the home (Type
A mean=2.10, Type B mean=2.99, p< .01). These results failed to support any of
the proposed differences between Type A and B women. Although these analyses
failed to ﬁnd signiﬁcant differences between the two types of personality, regression

analyses were performed to assess path differences speciﬁed in Hypothesis 5.

Regression Analyses

In order to determine the different pathways hypothesized for each Type
group, regression analyses were performed in much the same manner as with the
entire sample. Again, for each group, contextual variables did not enter equations
predicting number of complications. A different picture emerged for each group.
The results from these regressions are found in Tables 8 and 9, and are illustrated in

Figure 5.

Table 7.

122

Mean differences between Type A and Type 3 women

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measure Type A Type B
Mean (SD) Mean (SD)
| Stres Measures J
I Difﬁcult Life Circumstances 2.8 (2.4) 3.0 (2.6) I
I Life Stress/ Disapppointments 102.0 (25.2) 97.7 (23.9) I
I Individual Characteristics J
I Depression 14.8 (7.3) 14.6 (9.7) J
Type A“ 27.9 (4.7) 14.2 (5.0) I
Speed-Impatience" 22.5 (7.5) 14.2 (6.3) 1
Hard-Driving/ Competitive" 22.6 (8.0) 16.3 (6.1)
I Job Involvement 18.3 (8.8) 17.6 (7.1)
I Approach-Withdrawal 15.7 (3.1) 16.7 (2.7) I
I raslt Orientation 21.0 (3.0) 20.3 (3.7) I
Mood 23.8 (3.8) 24.3 (3.7)
I Flexibility-Rigidity“ 16.3 (4.1) 18.0 (3.1) I
I State Anxiety 34.6 (10.4) 33.4 (11.3)
I Activity level: general 18.5 (4.1) 18.1 (4.4)
I Activity level: sleep 12.6 (2.8) 11.4 (3.4)
I Desired control 22.9 (4.2) 21.4 (4.6)
I Contextual Characterktics
[Social Support Scale 191.0(106.2) 227.0( 97.8)
Work Satisfaction 4.0 (1.4) 4.1 (1.1)
Work Satisfaction: Salary 3.5 (1.1) 3.5 (1.3)
Work Satisfaction: Status 4.0 (0.7) 3.7 (1.1)
Role difﬁculty 2.6 (0.5) 2.4 (0.6)

 

123

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I Expectations of mate 73.2 (12.7) 74.7 (9.7)

Feelings About Work 92.1 (15.7) 91.5 (17.4)
Work Satis: Responsibility 4.0 (.85) 3.9 (.96)
Occupational Prestige 45.7 (23.4) 45.5 (17.0)
Marital Satisfaction 108.8 (31.0) 111.4 (23.0)
Satisfaction with division of labor in 2.1 (1.6) 3.0 (1.5)
home“
Pregnancy Outcomes

I Weeks Gestation 39.3 (1.6) 39.4 (1.4)
Length of Stage 1 labor 342.0 (320.9) 396.5 (236.1)
Length of Stage 2 labor 49.9 (48.3) 59.3 (48.5)
Number of complications 1.9 (1.3) 2.2 (1.7)
Apgar at 5 minutes 8.9 (0.4) 8.6 (1.4)
Birthweight 5.9 (2.2) 6.1 (2.1)
Caesarean section 1.6 (0.5) 1.8 (0.4)

* denotes mean difference signiﬁeant at p< .05
*"' denotes mean difference signiﬁeant at p< .01

 

124

Table 8.
Regression results for Type B sample

Type B swap
Dependent Variable: Number of Complieations

Predictor Esta 19131.8 5211311813.
Psychologies] -.33 .1 1 . 1 1 *
Indicators

Dependent Variable: Psychologieal Indieators

213112191 km W Chm
Difﬁcult Life .43 .28 .28“
Circumstances

Desire for Control .36 .40 .12“

" denotes p< .05

'"' denotes p< .01

N=47

Table 9. ‘25
Regression analyses for Type A sample

Type A stoop

Dependent Variable: Number of Complieations

2mm Beta ImaLB Chm
Temperament .71 .13

Edueation -.41 .32

Psychologieal

Indieators .35 .38 .06 (.07 signif)

Dependent Variable: Psychologieal Indieators

Mm: Beta 191313 21139818
Temperament -.69 .48 .48"

" denotes p<.05

" denotes p< .01

N =33

126

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In: 3 women

For Type B individuals, psychological indicators accounted for approximately
10 % of the variance in the number of labor complications. The greater the amount
of anxiety and depression felt by these women predicted the larger number of labor
complications experienced. This variable produced a multiple R of .33 (F(1,45)=
5.40, p< .05). In turn, difﬁcult life circumstances and desire for control both entered
the equation predicting psychological indicators. A multiple R of .63
(F(2,44)=14.42, p< .01), resulted, accounting for approximately 40% of the
variance.

Testing mediators in this case was not possible because of the lack of
signiﬁcance in the relationship between difﬁcult life circumstances and number of

complications.

ﬁlm A women
For Type A individuals, temperament, education level, and psychological

indicators accounted for approximately 37% of the variance in number of labor
complications. These variables yielded a multiple R of .61 (F(3,29)= 5.87, p< .05).
It is important to note that the change in F resulting from the addition of
psychological indicators was close to signiﬁcance (.073), and that the addition of the
link between psychological indicators and labor complications is therefore tentative.
Easy temperament also accounted for 48% of the variance in psychological

indicators, with a multiple R of .69 (F(l,3l)= 28.66, p< .01).

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128

r m i r /m rat r

Hierarchical regression was used to test for the potential mediating relationship
between psychological indicators, temperament and number of complications, using
the method suggested by James and Brett (1984). These results were not found to be
signiﬁcant. An alternative test to see if temperament played a moderational role in
the relationship between psychological indicators and number of complications was
also conducted using the method suggested by Bartlett, Bobko, Mosier & Hanan
(1978), and this relationship was also found to be not signiﬁcant. Therefore, it
appears that temperament, education level and psychological indicators jointly predict

number of complications.

Regsessien Analysis Qenelusiens

For the present sample, individual personality characteristics and behavioral
style appear to have signiﬁcant effects on the number of complications experienced
during ﬁrst-time labor and delivery. Contextual characteristics did not contribute to
predictions of labor and delivery outcome as predicted. These results do not provide
support for the direct links between long term stressors affecting the labor and
delivery of ﬁrst-time mothers, as proposed in hypotheses l, 3, and 6.

When the sample was divided into Type A and Type B personality groupings,
a different pattern among predictors emerged. Temperament appears to play a greater

role in its influence on number of labor complications for Type A women. The

129

psychological indicators as predictors for number of complications were found to be
negatively related for Type B women, whereas predictors for number of complications
were positively related for Type A women.

Given these ﬁndings on individual personality characteristics, a ﬁnal series of
analyses was performed to test the overall ISR-based model of stress and birth

complications.

We;

Exploratory factor analysis using SPSS for Windows was performed in order
to test the factor structure of constructs to be used in further analyses. Principal
components factor analyses with varimax (and oblimin) rotation of 10 and
speciﬁcation of eigenvalues greater than 1.0 produced 10 factors. These factors are
presented in Table 10.

Upon examination of the intercorrelations between individual characteristic
variables, attempts to create new scales were made wherever possible. For example,
temperament subscales "Approach-withdrawal", "Mood" and "Flexibility-Rigidity"
factored together, and as a result were combined to create an "Easy/Difﬁcult" scale
since there are several of the Easy/ Difﬁcult characteristics as asserted by Thomas
and Chess (1977). This new scale yielded a reliability alpha of .73, and was utilized
in subsequent analyses.

Seven factors (Type A, Stress Indicators, Control, Work Satisfaction, Social

Support and Birth Outcomes) were retained for analysis. The difﬁculty in

130

interpretation of the remaining factors suggested that they be excluded from further

analyses.

131

Tﬂﬂclo.
Principal Components Factor Analysis for Predictors

FACTORS

 

1. STRESS INDICATORS

 

Depression

-.77

 

State Anxiety

-.78

 

Difficult Life Circumstances

-059

 

 

2. TYPE A BEHAVIOR

 

Type A

.87

 

Speed-Impatience

.72

 

Hard-Driving] Competitive

.68

 

 

3. WORK SATISFACTION

 

Work Satisfaction: Status

.93

 

Work Satis: Responsibility

.85

 

Work Satisfaction: Salary

.74

 

 

4. ACTIVITY LEVEL

 

Activity level: general

.72

 

Activity level: sleep

.71

 

Work Satisfaction

-.48

 

 

5. SOCIAL SUPPORT

 

Social Support Scale

.67

 

 

Life Stress] Disapppointments

.64

 

 

Task Orientation

-055

 

 

 

 

 

 

 

 

132

 

PACTORS

10

 

6. TEMPERAMENT

 

 

  

Approach-Withdrawal

.87

 

 

Mood

.72

 

Flexibility-Rigidity

.64

 

 

 

7. JOE INVOLVEMENT

 

‘Job Involvement

.86

 

 

S. ROLE DIPPICULTY

 

Role difficulty

-.78

 

 

Expectations of mate

.46

 

Feelings About Work

-.45

 

 

9. PRESTIGE

 

Occupational Prestige

.80

 

Marital Satisfaction

.56

 

 

10. CONTROL

 

Satisfaction with division of

labor in home

-.86

 

 

 

 

 

 

 

,Desired sentrol

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late

the

St

sl

 

 

133
Testing the prepesed stmctugal eguetien model

Once factors were established, they were ﬁt into the model patterned after the
ISR model of stress (Kahn, 1984). This model is depicted in Figure 6, and the
multiple indicators creating each latent construct are described in Table 11.

The path analysis program used in the analyses was LISREL 7 (Joreskog &
Sorbom, 1981), a program designed to give a measure of ﬁt of the model to the data.
LISREL allows one to test the degree to which some hypothesized model ﬁts a set of
data. The program determines whether or not measured variables are "indicators" of
underlying latent constructs, and also tests the hypothesized relationships between the
latent variables.

PRELIS was run as a preliminary step to create a covariance matrix that would
then be utilized in subsequent LISREL analyses. Once the variables were entered into
the program, several problems occurred.

The model failed to converge to a solution, after as many as 1000 iterations.
Standard estimates, T-values, modiﬁcation indices and standardized residual could not
be computed, therefore disallowing any indices that would indicate which factors

should be dropped from the model for re-analysis.

134

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135

Latent constructs and individual indicators tested in structual
equation model for hypothesis 2.

mm
Type A personality

Control

Stress Indicators

Work Satisfaction

Social Support

Birth Outcome
Labor Progress

Complications

Birthweight

Ingixidggl Indicators
Type A

Hard Driving] Competitive
Speed-Impatience

Division of labor in home
Desired control during pregnancy

Depression
Anxiety
Long term stressors

Satisfaction with salary
Satisfaction with job status
Satisfaction with responsibility

Total support received
Daily life stress] disappointments
Task orientation

Length of stage 1 labor
Langth of stage 2 labor
Caesarean section

Number of complications
Apgar score at 5 minutes

Birthweight
Weeks gestation

136

A preliminary solution provided for the purpose of tracing the source of the
problem was calculated, with a chi-square of 151.31 with 68 degrees of freedom
(p=.000), goodness of fit index of.803, and the adjusted goodness of ﬁt index of
.695.

Low sample size may be the primary reason for failure of model convergence.
A sample size of 80 is small for LISREL analyses. Another primary reason may be
poor overall model ﬁt, in which case, the combination of chosen variables may be
poor predictors of birth outcome. Alternatively, designated paths may be incorrectly
hypothesized. With this in mind, an attempt was made to reduce the number of
model components. The reduced model is illustrated in Figure 7.

Again, problems occurred with the revised model, in which the solution was
found non-admissible after 250 iterations. For this model, the preliminary solution
yielded results of a chi-square of 79.02 (p=.023), goodness of ﬁt index of .878, and
an adjusted goodness of ﬁt index of .803. Even after several attempts were made to
modify the LISREL program, it was decided that the problems of low sample size and

poor model ﬁt plagued the model and would not yield any usable results.

137

 

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DISCUSSION ‘

This prospective study examined the influence of stress, individual
characteristics and contextual characteristics on birth outcome in ﬁrst time mothers.
The models presented were patterned after the Institute for Social Research model of
stress which depicts the contributions of multiple individual and contextual indicators
on health outcome. The results provide evidence for the inﬂuence of personality and
temperamental characteristics on pregnancy outcome.

The characteristics of the present sample were homogeneous in nature. The
majority of participants in the current study were Caucasian, in their late 20's, with at
least a college degree, married and pursuing a career. Although variability in the
sample is warranted in a study of pregnancy outcome, the homogeneous nature of the
sample controlled for any influences of education or income that could have
contributed to the outcomes. The results are applicable solely to middle class
Caucasian working women.

Some of the proposed hypotheses were not empirically supported. In the next
section the major ﬁndings of the present study will be discussed. The theoretical and
practical implications of these ﬁndings will then be considered, along with the

limitations of the present study. Finally, further research directions will be discussed.

We
The initial set of analyses assessed the relationship between experienced

138

139

stressors and pregnancy outcome. Experience with many stressors was expected to be
highly associated with labor and delivery complications and poor infant outcome.
Results from correlations showed no direct relationship between stress and pregnancy
outcomes. Instead, relationships between long term stressors, role difﬁculty and
psychological indicators provided insight to what individual and contextual variables
were related to each other. The results provided a composite picture of relationships
between difﬁcult life circumstances, low marital satisfaction, higher levels of anxiety
and depression, and low work satisfaction. The difﬁculty these women were
experiencing in balancing wife and employee roles was related to increased levels of
depression and anxiety, low marital satisfaction, and low expectations of their mates
helping during the transition to parenthood. This ﬁnding supports existing literature
on role strain and overload (Verbrugge, 1986; Repetti, Matthews & Waldron, 1989).

When the psychological indicators of depression and anxiety were combined
into a single variable, they were also found to be positively correlated with desire for
control, negative feelings about work and decreased number of labor complications. In
summary, the psychological states of these women during the third trimester appear to
be closely linked with marital, occupational and role difﬁculty factors. These ﬁndings
are well supported by past literature linking depression and marital difﬁculties,
(Ballinger et al, 1979), internal conﬂict regarding becoming a mother, and feminine
identiﬁcation during the transition (Hopkins et al, 1984).

Although the direct link between indicators of daily and long term stress and

other variables did not yield signiﬁcant results, other indicators were hypothesized to

140

also contribute to birth outcome.

Hypotheses 2 and 3 were then assessed using multivariate regression analyses
utilizing single scale scores. Together, these hypotheses attempted to assess the
contribution of contextual and personality constructs as additional predictors and/or
moderators of the weak relationship between stress and pregnancy outcome for this
sample.

Previous research has indicated that moderators may inﬂuence the pathway
between stressors and health consequences (Kahn, 1984). The context in which a
person encounters a stressor can alter reactions and consequences (Caplan, 1972;
Nuckolls et al, 1972; Cobb & Kasl, 1977; Eaton, 1978; Gore, 1978; House & Wells,
1978). The contextual factors of work environment, social support and marital
satisfaction were used in regression analyses predict the number of labor
complications. The results revealed that none of the proposed contextual variables
were found to predict labor complications, nor were they found to moderate the
relationship between difﬁcult life circumstances and labor complications. This
contradicts ﬁndings asserted by Kahn (1984).

Contextual characteristics do not seem to play a role in labor complications
with this sample, and this may be for several reasons. Restriction in variance for each
of the contextual variables may be the key to reasons for their lack of inﬂuence on
pregnancy outcome. Since the majority of participants in the study have at least a
college degree and established careers, they may be occupying positions where they

are satisfied with most aspects of their employment. This ﬁnding is not surprising,

141

and supports large population-based studies that indicate that sociodemographic
characteristics such as disadvantaged community, non-Caucasian race, younger
maternal age and low maternal education attainment are associated with poor labor
outcome, such as low birthweight (Kramer, 1987; also see Istvan, 1986 for a review).
In addition, extreme difﬁculty in balancing the roles of wife and employee may
not be an issue in this sample. It could be that because of their educational level and
income coupled with the fact that they have no children, the role strain of these
women is not high enough to have an impact on the daily stressors they experience.
The amount of social support the present sample is receiving may also be at a
level where differences between people receiving low and high amounts of support do
not contribute to or buffer the stress experienced by these women. This also provides
indirect support for existing studies linking social support and birth outcome, such as
key studies by Norbeck and Tilden (1983) and Schaefer, Coyne and Lazarus (1981).
Finally, marital satisfaction for this group of expectant mothers is also
relatively high, and at the third trimester, these couples may be feeling more happy
and secure in anticipation of the impending birth of their ﬁrst child. Findings by
Meyerowitz and Feldman (1966), Wallace and Gottlib (1990) and Belsky et a1 (1983)
support this result.
In summary, contextual variables do not seem to contribute to the stress in the
daily lives of these women, nor do these variables interact with other variables to
inﬂuence number of labor complications. The sample appears to have the

characteristics of satisfactorily employed, happily married, and adequately supported

142

working women. With the consistency of contextual variables across subjects
relatively established, the focus will now turn to individual characteristics as
contributors and moderators of number of labor complications experienced by these

women.

11$ .1. [11"llCl ..

Individual characteristics include aspects of personality and behavioral style, in
particular Type A behavior pattern, temperament, desire for control and psychological
functioning. These individual characteristics can help to determine how an individual
is prone to react in situations, in this case, in an anticipatory health situation which is
fraught with anxiety, worry, and excitement over the uncertainty of labor and the
health of their newborn child.

Individual scale scores for Type A behavior were used in similar regression
equation models to predict the number of labor complications as well as in the
prediction of psychological indicators. The results of these analyses indicated that
temperamental style inﬂuenced the number of labor complications that occurred during
labor and delivery. This inconsistent ﬁnding revealed that the easier the
temperamental style of the mother during pregnancy (i.e, approaches others, has
generally positive mood and is ﬂexible), the more labor complications she is likely to
experience.

These results appear counterintuitive, which would indicate that easy

temperamental style would help to buffer the mother from poor birth outcome.

143

Currently, no studies exist to support the connection between temperament and health.
One possible interpretation may be that the easy temperament behavioral style implies
that they did not feel they had control, and that they felt they could rely on others to
help them with any difﬁculties. This may have affected how they followed prenatal
regimens, which may have been lax. As a result, they may have been ill-prepared,
which may have inﬂuenced their prenatal care. In addition, their "easy"
temperamental style may have led them to have expectations for labor and delivery
that did not match their actual experience. For example, if they expected an "easy"
time during labor and delivery, their anxiety could have increased dramatically when
they actually went into labor and delivery. This potential dramatic increase could have
precipitated more difﬁculties for these women. In turn, these behaviors and
expectations may have led to unanticipated complications.

Of course, other factors may also be accountable for this relationship that were
not measured in the present study. For example, women with easy temperament may
have poor coping skills in stressful situations so stress moderated the effects. Difﬁcult
temperamental women may have good coping skills, and may take labor and delivery

as a challenge.

C'l' [Ell'lll'

Additional analyses used individual characteristic variables to predict
psychological indicators. These analyses were done in order to determine what

variables may be contributing to the emotional state of these women, and to see if

144

long term stressors would enter the predictive equation. Difﬁcult life circumstances,
difﬁcult temperament, and desired control were found to signiﬁcantly relate to
psychological indicators. To reiterate, the more difﬁcult life circumstances the mother
experienced, along with the amount of desired control she wished to have during the
course of pregnancy and the more difﬁcult temperament she possessed, the greater the
amount of depression and anxiety she was likely to experience during the third
trimester of pregnancy.

This result is consistent with past literature linking stress and depressive
symptomatology during pregnancy (O'Hara, 1986; O'Hara et al, 1983). In addition,
desire to retain control during pregnancy results in emotional distress if the woman
feels she will not be able to count on others to help. Her expectations for being the
sole person to make decisions, prepare and provide for the baby add to her anxiety and
stress. Further, if these individuals also possess a difﬁcult temperament, they are apt
to withdraw from assistance, have negative mood states and are rigid in behavior. In
the context of pregnancy and impending motherhood, which requires ﬂexibility,
positive and approach behaviors, these temperamental characteristics are likely to
result in higher levels of depression and anxiety, and could make it more difﬁcult to

handle daily challenges.

AMMQSE’J

The model resulting from the set of analyses for hypotheses 2 and 3 is shown

in Figure 6. In summary, for this sample of ﬁrst time mothers, individual

145

characteristics appear to contribute to the number of complications occurring during
labor and delivery. The proposed links between stress and birth outcome were not
supported, and this may be due in part to the homogeneity of the sample. Sample
limitations will be discussed at length in a later section.

For the overall sample of women, Type A behavior did not appear to have any
inﬂuence over pregnancy progress, as predicted. To review, Type A women are
characterized as individuals who are generally more time conscious, impatient, hard
driving, competitive, and are more involved with their careers. A series of analyses
were designed to investigate hypotheses 4 and 5, which assessed differences between

Type A and B women.

WW

Given the literature associating Type A behavior and poor health outcomes,
hypothesis 4 stated that Type A women would have more labor and delivery
complications, rely less upon others for support, and desire more control over the
course of the pregnancy. Because Type A behaviors are viewed as pervasive work
style characteristics, it was expected that Type A women would exhibit these
behaviors in relation to the pregnancy.

The results from a series of T-tests found few signiﬁcant differences between
Type A and Type B women, in which Type B women had more temperamental
ﬂexibility and greater satisfaction with division of labor at home. This may be due to

the controlling nature of Type A individuals who are apt to take care of everything

146

themselves, rather than delegate and share responsibility with others (Clark & Miller,
1990).

It is important to note that in spite of the personality differences between the
two groups of women, the labor and delivery progress and outcomes were essentially
identical. Given these results, hypothesis 4 was not supported. Type A and B women
did not differ in labor and delivery complications, social support, or desire for control
over the course of pregnancy.

Hypothesis 5 alternatively addressed the differences in relationships between
individual variables within each group of women.

A similar series of regression analyses conducted for hypotheses 2 and 3 were
conducted for each of the groups as speciﬁed in hypothesis 5. Figure 7 illustrates the
signiﬁcant pathways found for Type A and Type B women. Upon investigation of
these two resulting models, one can see differences in the variables and directional
pathways. When these models are compared to the model including the entire sample,
one can see key relationships emerge between psychological indicators and number of
complications. The model for Type B individuals will be discussed ﬁrst, followed by

the model for Type A individuals.

m. As found in the total sample model (Figure 6), the model for Type B
women notes that the more life stressors and the more control they desire during the
course of pregnancy, the more depressed and anxious they become during the third

trimester. This repeats the same pattern found with the entire sample, and is not

147

surprising. A surprising link between psychological indicators and number of
complications was found, however. For Type B women, the more emotional distress
they experience during the third trimester of pregnancy, the fewer the number of
complications they have in labor and delivery. Yet psychological indicators were found
to account for 10% of the variance, which leaves the possibility that other variables
may account for more variance. It is likely that alternative variables including prenatal
care regimen, health status, and physiological reactivity to stressors, may all add
additional variance to this outcome.

It is clear that other variables probably intervene or are better predictors for
birth outcome. Type B women are characterized as less anxious about time, less
competitive, and are more patient than their Type A counterparts. Perhaps they are
less anxious about the birth, take more time to make preparations, and do not handle
situations with last-minute urgency. Perhaps the less-urgent nature of Type B women
may be buffering them from having complications in spite of the stress, depression and
anxiety they are feeling. Alternatively, although Type B women are reporting higher
levels of depression and anxiety, there may be differences in how they are perceiving
their own distress and therefore in how it is affecting their physiology.

It is key to note that temperament does not enter the picture for Type B
individuals, perhaps because they all possess similar constant levels of approachability,
positive mood and ﬂexibility. Type A women, on the other hand, display a different

proﬁle.

148
ELIE—A- Figure 7 illustrates the alternative pathways between a different

combination of variables. For this sample, the key results revealed that three
indicators predicted number of labor complications. For Type A individuals, easy
temperament, high emotional distress and lower educational level predict the number
of complications.

The pathway linking third-trimester emotional distress and number of
complications has been supported by the literature (Rofe, Blittner & Lewin, 1993;
McDonald & Christakos, 1963; Brown et al, 1972; Gorsuch & Key, 1974; Crandon,
1979a,b; Standley et al, 1979; Barnett & Parker, 1986), and the link between education
and number of complications may be explained by the amount of knowledge these
women have about the process of labor and delivery and prenatal care. Women who
have attained higher levels of education are likely to be more prone to educating
themselves. If they were less informed about the importance of prenatal care and did
not enroll in preparatory classes, or take precautions, their lack of knowledge may
inﬂuence the course of labor and eventual complications. The difﬁcult component to
explain, as with the larger sample, is the additive effect of easy temperament.
Together these three variables account for 37% of the variance.

What can be said for the role of temperament in Type A women? As the sole
predictor of psychological indicators, difﬁcult temperament was signiﬁcantly related to
an increase in emotional distress. Results from a hierarchical regression concluded
that temperament did not serve as a moderator or mediator in the pathway between

psychological indicators and number of complications. The effect of possessing Type

149

A personality with the addition of difﬁcult, rigid inﬂexible behavioral style appear to
contribute to the levels of anxiety and depression experienced during third trimester
pregnancy.

Yet within the same model, easy temperament appears to contribute to the
number of complications a Type A woman experiences in labor and delivery. This
ﬁnding appears counterintuitive, yet this result was also found with the entire sample.
The relationship between these two variables is stronger for Type A women than in
the entire sample, yet the inﬂuence of temperament is also accompanied by the
inﬂuence of psychological indicators and education level.

As implied in the conclusion for the overall sample, perhaps the concept of
easy temperament serves as a relative indicator of "laziness" or "unpreparedness",
whereupon these individuals may be less prepared for the labor and delivery. The
"lax" aspect may be measured by lack of attendance in Lamaze classes and adherence
to prenatal care regimens. Since the actual participation and preparedness of these
women was not assessed, it is not possible to know whether this explanation or other
indicators may better explain this counterintuitive link between temperament and labor
complications for this sample. At the very least, it provides an interesting possibility
about the role of temperament in adaptive functioning. While easy temperament is
found to have the strongest link to adaptive functioning in interpersonal relationships,
as documented in literature on parent-child relations and teacher-child relationships,
perhaps there are some situations where "easy" characteristics are not adaptive. For

example, nursing home residents who exhibited difficult temperamental behaviors were

150

found to live longer and experienced fewer health-related problems during their stay (I.
Lerner, 1994, personal communication). It appears that the senior citizens who
adamantly and continually vocalized their needs and complaints received more
attention and proper care. In parallel, perhaps women who are demanding and
difﬁcult receive better prenatal care which enhances smooth transition during labor and
delivery.

In summary, differences in progress are apparent for Type A and B career
women transitioning through their ﬁrst pregnancy. Temperament appears to have a
greater inﬂuence on number of labor complications for Type A women, and does not
enter the model for Type B women. When comparing the inﬂuence of psychological
indicators between the two personality types, the results reveal a positive relationship
with labor complications for Type A women, and a negative relationship with labor
complications for Type B women. Because of the confusion in interpretation of these

relationships, a reevaluation of the variables is in order.

E l . E l' l l l . l . l'
The distribution of levels of Type A and Type B personality were analyzed to

further deﬁne the subsamples. For Type A women, the distribution was fairly even
across the range of Type A scores, therefore degree of "Type A-ness” was made
possible for interpretation. On the other hand, the distribution of "Type B—ness" was

skewed towards the neutral end of the Type B continuum. In other words, there were

151

fewer individuals on the extreme end of the scale, as compared to the larger number of
individuals who were more neutral, or closer to the lower end of the Type A scale.
The Type B group was then more neutral than true Type B5. The skewedness of the
distribution may be partly responsible for the surprising link found between
psychological indicators and number of complications. The skewed sample of Type B
women may have attenuated these results. Perhaps the inclusion of more extreme
Type B individuals might bring the correlation to a more positive direction, with the
reasoning that a greater range across the Type B continuum might experience similar
anxiety and depression levels similar to their Type A counterparts.

In addition, examination of the depression and anxiety scores yielded ﬁndings
that 68% of the entire sample would be classiﬁed as "not depressed", as designated by
the Center for Epidemiologic Studies guidelines (Devins & Orme, l9 ). Only 6%
would be classiﬁed as severe in depressive symptoms, with the remaining 26%
classiﬁed as "mil " and "moderate". In addition, the anxiety levels of the entire
sample (mean= 33.4) fall below the normative sample of working women (mean=
35.2, SD=10.6). Within this sample of 80 pregnant women, depression and anxiety
are not necessarily indicators of negative extreme psychological state, but rather are
indicators of anxious anticipation, apprehension and worry about a health event that is
both positive and uncertain. This score may be an indicator of "good stress", which
prOpels an individual to take action rather than to withdraw from the situation.
Instead, the scale might be renamed "Emotional Anticipatory Excitement".

With this alternative label in mind, the models for Type A and B might be

152

interpreted quite differently. Instead, the negative relationship between "anticipatory
excitement" and number of complications for Type B women may be explained that
for these normally low-urgency, patient women, the excitement they feel is not one of
which they are normally accustomed. Therefore, their emotional state is brought up to
a level which is actually beneﬁcial or necessary for the labor and delivery to progress.
The raised emotional state inﬂuences their physiology, which in turn positively
inﬂuences the progress of the labor and delivery.

As for the Type A women, they are already accustomed to feelings of
anticipatory excitement in the urgent way they cope with challenges. The additional
emotional excitement they feel with the pregnancy pushes them beyond the suitable
level of arousal, which negatively inﬂuences the progress of the labor and delivery.
Finally, further investigation is needed as to the meaning of temperament as applied to
an adult population. Measures of temperament are widely used for populations of
children in the context of parental care for eaw or difﬁcult children. As noted earlier,
it is still unclear as to the true deﬁnition of "easy" and "difﬁcult" temperament are for

adults.

5 E S l E . l I l l'
The ﬁnal set of analyses attempted to address Kahn‘s (1984) ISR model of

stress in the context of pregnancy outcome. By taking a biopsychosocial and

developmental contextualism approach, key constructs were examined in a system.

The ﬁrst task at hand was to reduce the large number of data points into

153

interpretable factors. Factor analysis of the multiple indicators suggested that the
reduced number of components for the present sample were Type A personality,
control, stress indicators, work satisfaction, social support, and three indicators of birth
outcome: labor progress, complications and birthweight. All of these factors made
conceptual sense with the exception of social support which was a combination of
social support, daily stressors, and less of a temperamental task orientation.
Conceptually, people with many daily hassles who have access to a support network
might also have difﬁculty focusing on tasks, if they feel they can rely on others or feel
overwhelmed by the daily stressors. The factor was named after its largest loading
factor-~total support received from the network of friends and family. How these
variables play a concerted role in predicting pregnancy outcome were examined by
subjecting them to a structural equation model analysis.

Hypothesis 6 proposed the testing of a systems model assessing the
contribution of individual characteristics and contextual characteristics in the
relationship between stress and pregnancy outcome. Taken together, unhealthy
individual characteristics with an unsupportive environment were expected to
negatively inﬂuence the relationship between stress and pregnancy outcome. Together
as a system, Type A, Control and Psychological Indicators of stress, social support,
and work satisfaction were hypothesized to conjointly predict poor pregnancy outcome.

The analyses involved in testing the relationships between constructs in Figure
3 included the use of LISREL, a path analysis program that assesses goodness of ﬁt of

the proposed model to the data. These constructs were created by submitting

154

individual scale scores to a factor analysis and then using the resulting factors in the
structural equation model, depicted in Figure 6.

Failure of convergence of the model within the program led to the conclusion
that the proposed models were not testable on a small sample size, or alternatively, the
combination of chosen factors were incorrect, and that an alternative combination of
predictors would better ﬁt the sample. Several combinations were subjected to the
program (e.g., Figure 6), and still no convergence estimates resulted. It was decided
that a different combination of constructs could be tested at a later time with a larger

sample size.

I] '11 1..

Past research has examined inﬂuences on poor pregnancy outcome from
psychological and physiological viewpoints, all culminating in a body of conﬂicting
and inconsistent research. The present study examined a testable model of the
inﬂuences of individual personality and environmental context on pregnancy outcome,
as an attempt to model how these inﬂuences coact and interact to inﬂuence labor and
delivery and infant outcome.

The data failed to support the key component of the model, the link between
life stressors and pregnancy outcome. Instead, a new model was created where
individual personality characteristics and behavioral style accounted for part of the
puzzle that explains poor labor outcome. At present, no other studies take these

personality variables into consideration when addressing labor outcome.

155

An attempt was made in the present study to examine the linear relationship
between individual and contextual variables and their joint effect on pregnancy
outcome. In this study, individual characteristics were deﬁned as beginning points, to
be altered by context with experience. It is possible that the relationship between
these variables is not linear, but instead constantly interact throughout the entire course
of pregnancy. Statistical power issues prevented testing of this type of relationship.
Although the current study was prospective in nature, the data only offer a snapshot of
one point in time during the third trimester of pregnancy and how it inﬂuences labor

and delivery outcome.

1 I l 1 B . .
Currently, no overall empirical model has been proposed to combine the merits
of all studies, to link the multiple aspects of individual differences and environmental
differences which play a role in predicting birth outcome. Several researchers continue
to isolate populations, testing smaller models, explaining parts of the very Complex
picture of psychology and psychophysiology. For the current sample, the adaptation of
the ISR model of stress might be revised. For example, contextual moderators in the
present model may be tested as stressors themselves. Moderators in this model may
be key predictors, such as emotional functioning.
Overall, partial support for the developmental-contextual view and the
biopsychosocial model has been gained in the present study. Links between

personality characteristics, behavioral style characteristics (temperament) and birth

156

outcomes have been uncovered for future investigations. Larger, more in-depth studies
need to continue to assess these links and the process by which personality and

behavioral characteristics inﬂuence physiological and physical states.

Sll"'

Consideration of several limitations of the present study is warranted. First, the
original intention for sampling a pregnant population was to avoid selecting a
restricted sample. Recruitment for the pregnancy project was aimed at two low to
middle class communities-- Lansing and Grand Rapids, Michigan. Unfortunately, due
to limited resources to compensate participants, most women who accepted the
invitation to participate tended to be those knowledgeable about the process and
importance of research. Although the project's goal was to include a diverse
population, time constraints dictated acceptance of those who were willing to
participate, regardless of SES background, education and ethnicity. The recruitment of
119 couples to participate took over eighteen months. The sample was then comprised
of college educated Caucasian women with access to health care. Time restrictions
did not allow for the further recruitment of a more diverse sample.

Therefore, the restriction in sample diversity led to additional restrictions in
range of life stress experiences and poor pregnancy outcome such as low birthweight,
incidence of c-sections and preterm delivery. In order to ﬁnd representative ratios
similar to the larger population, sample sizes up to the 1,0003 may be necessary.

Hence, the makeup of the sample was biased against ﬁnding signiﬁcant

157

differences from the beginning. In addition, from the original 119 women recruited to
the study, only 80 had completed data that were usable. All participants had
completed questionnaires during their third trimester as well as questionnaires eight
weeks after their babies were delivered. In addition, medical information had to be
made available by abstraction from medical records or by phone for out-of-state
participants.

In addition, a sample size of 80 is moderate in comparison to many studies
involving pregnancy. Much of the problem of low sample sizes has arisen from
problems in sample attrition over time for longitudinal studies. For example, the birth
of a baby may also include a move for ﬁrst-time parents to a larger home, hence
increasing the chance of losing subjects. Although 80 is a moderate sample size for
pregnancy research, the number is low enough to be subject to power issues when
statistical analyses are conducted. For example, the sample size may have constricted
variance so that it produced a problem with the model analyses. Low sample size
affects correlation matrices which in turn constrict the variance! covariance matrix and
can ultimately hinder a structural equation modeling attempt. Power issues become
even more important when dividing the sample into even two smaller groupings.
Many of the analyses run in the present study were subject to power problems,
beginning with the interpretation of relationships based on an "almost signiﬁcant" level
of p=.07 and ending with the LISREL analyses. It is clear that a larger sample size
may weaken or strengthen the results of the present study.

Another source of study limitations deals with measurement issues. Most of

158

the measures were well-established highly-used instruments. Yet, there is always the
chance of missing a key questionnaire that would contribute more meaningful
information, or alternatively the questionnaires did not tap into the actual constructs
adequately. Many of the measures had never been used with pregnant samples, hence
this raises the question of validity of the measures.

The questionnaires in the present study may not have been the best instruments
to yield variance in this restricted sample. For example, the marital satisfaction scale
perhaps measured what spouses actually did, rather than measured the amount of
satisfaction felt and received by these expectant mothers. As an additional example,
other constructs that could have been measured include individual differences in
primary and secondary appraisal of stress, and a health locus-of-control questionnaire
designed to measure adherence to prenatal regimens.

Finally, an obvious missing piece to the study was measurement of
physiological changes that were occurring during the third trimester of pregnancy
when the questionnaires were completed. Physiological indicators of stress reactivity

would have provided the missing component within the model.

E B l D' .
Although sample limitations in the present study precluded a resolution of

several interesting questions, several future directions to continue research are

indicated from these ﬁndings. First, it is evident that future research should include a

larger sample of individuals from a more diverse population to enable an examination

159

of the inﬂuence of stress on pregnancy outcomes. Although past research has viewed
poor birth outcome as resulting from multiple environmental causes, the results of the
present study suggest that birth outcome is also strongly inﬂuenced by personality
characteristics. Further research examining the mechanisms behind the inﬂuence of
temperament on birth outcome is suggested by the present study. With larger
numbers, additional research can assess the relationships between paths that are weak
or not evident, for example, the relationship between difﬁcult life circumstances and
birth outcome.

For future studies, very large samples will be needed to assess differences in
labor and delivery outcome to reach population norms of 6-15% preterm or problem
deliveries. This way, examination of a group of individuals in extreme situations may
be better assessed. Additional research directions should also include measurement of
physiological inﬂuences and prenatal regimens. Within a biopsychosocial wstems
model, future studies might attempt to address nervous and endocrine systems in the
model by inclusion of biological markers such as catecholamines and corticosteroids.
Mapping changes in the level of hormones across time may provide insight as to what
is taking place in the environment of the developing fetus. It may provide a
physiological marker for how stress is inﬂuencing the body during pregnancy.
Medical information can be further examined such as physiological changes that may
change during labor, such as blood pressure readings.

Furthermore, inclusion of prenatal education, frequency of checkups and

prenatal regimen would help provide measurement of the amount of knowledge each

160

woman gains before she enters the delivery room. For the current sample, every
participant except three reported attending prenatal education classes, but the more
interesting point would be to measure what they actually learned and practiced from
the classes. Frequency of monthly checkups and prenatal regimen would also serve to
provide information on prenatal precautions, monitoring diet and health during the
gestational period, and whether or not they adhere to their physician's instructions.
Personality factors may be linked to adherence to prenatal regimen, determining who
is more apt to follow strict or lax prenatal regimens.

The current study is part of a larger study examining the transition to
parenthood of couples expecting their ﬁrst infants. Additional research using this
sample is possible, for inclusion of points of data collection (n=38). Changes across
ﬁrst trimester, third trimester and 8 weeks postnatal may be assessed for stability of
personality constructs during two phases of pregnancy, rather than a single third
trimester timepoint. Other future studies may attempt to include measurement points
at every month of the pregnancy.

Finally, future research directions in the ﬁeld of pregnancy research call for
multidisciplinary collaboration amongst colleagues in psychology, obstetrics and
gynecology, medical anthropology, epidemiology and nursing. Each discipline has
taken attempts at solving parts of the pregnancy puzzle. Taking a biopsychosocial
approach in combination with a developmental contextualism approach would be a
way to integrate multiple disciplines to organize the multiple factors at work during

the transitional event of pregnancy.

APPENDIX

APPENDIX

MEASURES USED IN THE PRESENT STUDY

I. Stress Measures

Difﬁcult Life Circumstances *
Life Stress & Disappointments

II. Contextual Measures

Women’s Life Situation Survey
Feelings About Work Scale
Duncan Socioeconomic Index
Norbeck Social Support Scale
Spanier Dyadic Adjustment Scale

III. Individual Characteristic Measures
Dimensions of Temperament Survey
Jenkins Activity Survey *
Expectations Questionnaire
Center for Epidemiological Studies Depression Scale
State-Trait Anxiety Inventory *

IV. Pregnancy Outcome Measures

Obstetric Complications Scale

* Because of copyright laws, these questionnaires are not included in the Appendix

Today's date
Week of pregnancy

162

IDI: _
Have: _ _
Form: 1 9 1

DEMOGRAPHIC INFORMATION

 

 

Due Date

1.
2.

 

Gender: Female __ Hale

A9. (Y‘u') _

Are you currently employed? Full time ___
Part time ___
What is your occupation?

 

Do you do volunteer work? Please describe briefly

what is the highest level of education you have
completed?

High School or less

Technical or trade school

Some college

College degree

Some graduate study

Graduate degree

Marital Status

Single
Cohabitating
Divorced, remarried
Married

Separated

Divorced

Widowed

Widowed, remarried

Have you ever fathered a child before?

YO.

How many children would you eventually like to have?

 

Do you have plans for your mate to work during the

pregnancy?

Yes, full time ___
Yes, part time __;
No ,

163

10!: _

10. Do you plan for your mate to return to work after
the birth of your child?
Yes ___
No

11. Were you using birth control when you learned your
mate was pregnant?
No
Yes What method?

 

12. This pregnancy was
___ expected
___ unexpected
___jplanned

13. Do you belong to any organizations or groups?
Yes

NO

Please list them below, and indicate your level of
involvement in each

a. Paid membership only

b. Officer

c. Involvement in activities] projects

d. Attend meetings

 

 

 

 

 

 

Organizations Level of Involvement

l.

2.

3.

‘0

5.

14. Ethnic Background

Asian
Black
Caucasian
Hispanic

Native American
Other (specify)

 

164

10!:

Please indicate what your total family income last year was before
deductions and taxes.

.0
b.
c.
d.
e.
to

< $5.000

$3.000 - 9,990

$10,000
815.000
320.000
$25,000
330,000
335,000
$40,000
345.000
330.000
355.000
360.000

> 363.00

14,999
19,999
24,999
29,990
34,999
39,999
44.999
49.999
34.909
50.990
64,999

Include family income from all sources.

max YOU van! HUGE FOR YOU! PARTICIPHIOIIIH

165 [DI

Wave
Form 116

Life Stru and Dlsappelnhnemts Quatlonmh's

Thefollowinghaliuofdiﬁoortaspecuofdailylifedumoetofusmyaboutatom
timeoranother. Wewouldlikstoseejusthowmtmhthescvottslmvcaﬂcctedyourlife

dwingyourpregnancy(thelast9rnonths).

Mmdwhmtlfmwknaapplmbyou,plasdmckme'ﬂa
Applicabletorne'bou.

Fortherernainingficolumns,A,BandC.wewouldlihyoutousethefollowingscaleeto
indicatehowyoufeelabouteechstatenmt. Wemuedgoingdrmughdreordrehgoing
downColumnA,thengotoColumnBthottoColumnC.

Atthemofthelist,womldlikeyoutoaddhhortmngoelsmdﬂoogumgoelsthat
applytoyou. Youshouldalaoanswerqueetionsaborutheeegoalsinthemmeway.

ForCOLUMNA:
Rmdﬂemtenmtmhtd’mwhahaornayoumhppymsmmmamumppy
anleSAPPONrEDwiththesinmtion.Plaseusemefollowingsmle:

I 2 3 4 3

Veryﬂqpyl WW WEI." ”’06."!qu

Yum mm m my Vuyw
We! w

ForCOLUMNB:
mumtandindiamwhemerornotitiuSOURCEOFSl'RESSform
Pleaseusethefollowingscale:

I 1 J c 5
Mana- lalely Samson may Very
meter Sue-kl M M She-ht
ForCOLUMNC:

ReedthcsmtonentandhtdicatedeAMOUNTOFnMEyouspotddﬁnkingammis
sitrmtion. Heueusedtefollowingscale:

I 2 J 4 5
Mid! holy Sometimes PM Alisha

ForExample: inane-tea s c
IYourmlary I Izlalsl

166

 

 

 

Your salary

 

Your budget

 

Your savings

 

Your workload

 

Your workplace

 

Your supervisor

 

Your eo-workers

 

Your occupation

 

Your marital] dating
relationship

 

Intimacy with mate

 

Intimacy with friends

 

Open communication with
mate

 

Open communication with
friends

 

Possessionsl toys

 

Amount of vacation time
taken

 

Relationship with parents

 

Relationship with siblings

 

Relationship with children

 

 

Relationship with
grandparents

 

[Your pets

 

Amount of free time you_
have

 

 

I Time for hobbies

 

 

 

 

 

167

 

 

I
Slammed Not A I C
Applicable Ho- Iatlﬂaa bayou ~-
tama. happyer Seareael mlakahaet
satisﬁed? Stress? arm
Amountoftimeallotted for
exercise

 

Results from your exercise

 

Your diet (foods eaten)

 

Your weight

 

Your body shape

 

Your appearance in general

 

Feelings about yourself

 

How much you procrastinate
or put things off

 

Your sex life

 

Your neighborhood
conditions

 

Your living (home)
conditions

 

The I of people you live
with

 

Your roommates

 

Your earl form of
transportation

 

Amount of stress in life

 

Life in general

 

Division of household
chores in general

 

Division of household
chores: Cooking

 

Division of household
chores: Cleaning

 

 

 

Division of household
I chores: Laundry

 

Home improvement

 

Meeting your family’s
demands

 

 

 

 

 

 

‘ f
Sums.

 

 

 

Living up to your family's
expectations

 

Getting daily errands done

 

Mamgingl Running the
household

 

The economy

 

The environment

 

Religion

 

The state of the world

 

Government! Political issues

 

News events

 

Pleaselistthreeshortterm

goals:
1.

 

 

2.

 

3.

 

goals:
1.

Pleaselistthreelongterrn

 

2.

 

3.

_;_

 

 

 

 

 

 

 

Plaselistthe3items(beginningwiththehappiest)withwhichyouaremosthappyand

satisﬁed.
1.
2.
3.

 

 

 

Pleaselistthe3items(beginningwiththemostdisappointing)withwhichyouaremost

disappointed or unhappy.
l.

2.
3.

 

 

 

169

ID! a
ﬂower

Perms I i A
W's LI" 312“?!“ m than! 3W

Your Iirthdates _
ﬂier 'b'a'y_ Y's—er

l. have there been any changes in your family in the last 6 months,
aside from your pregnancy? If 'yes', please explain.

 

 

2. has there been a change in your marital status in the last 6 months?
—’.. m. 1"”..Oxhueeeeeeeeee

 

Remarried
Separated
Divorced
widowed
harried

“QUNP

3. how long have you been married to your current spouse? _ _
Te'srs IIonEEs

4. Areyoucurrentlyemployedt. . . . . . . . .lo
Yes, part-time
Yes. full-time

“NH

3. If you are presently .ployed. please circle the number below which
best describes your job. If your job is m described below. please
write it down on the last blank line marked am. Please circle only

one response.

m. such as bank teller, bookkeeper. secretary.
gypt.t' o: “*1 cm“: 0 O O O O O O O O O O O O O O I O 01

m. such as baker. automobile mechanic, machinist.
painter.plumber.orcarpenter ... .......... 02

m,orfarmmanager................... 03

m, such as construction worker. car washer. sanitary
worker.orfarmlaborer.................~ 04

We El. M. such as sales manager, office
manager, school administrator. or restaurant manager . . 05

mm. such as career officer. or enlisted
manorwoman inthehrmedPorces............O¢

m such as meat cutter. assubler, machine
operator. welder. or taxicab, bus. or truck driver . . . 07

W m. such as accountant. artist. registered

 

170

IDS:

nurse. engineer. librarian. social worker. actor. actress.
athlete. politician. has up; gaginging gggghg; . . . . .

, such as clergyman. dentist. physician.
lawyer. scientist. or college teacher . . . . . . . . . . 09

Mammals. suchutheownsrofaseall
business. a contractor. or a restaurant owner . . . . . . lo

llzzigg 29:33:. such as a detective. police officer
or guard, sheriff, or fire fighter . . . . . . . . . . . 11

31111 39:31;, such as a salesperson, an advertising or insurance
agent. or a real estate broker . . . . . . . . . . . . . l2

ﬁshes} slashgg, such as an elementary or secondary school
t..cm 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 13

, such as barber. beautician. practical nurse.
private household worker. janitor. waiter. or waitress. . 14

Technical 39:31:, such as draftsman. medical or dental technician.
or computer programmer . . . . . . . . . . . . . . . . . rs

ma.’ 0 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 O O 1‘
(Please describe 1
6. Please circle the number which most closely represents how
satisfied you are with being employed or with not being employed.
very Dissatisfied
Somewhat Dissatisfied
neutral

Somewhat Satisfied

BOUND-9

Very Satisfied

1. If you are pggggnglx gnplgygg, please circle the number which best
represents how satisfied you are with the following aspects of your

jobs
° very Somewhat Somewhat Pery
Dissatisfied Dissatisfied Deetrel Satisfied Satisfied
Salary 1 2 3 4 S
ﬂours l 2 3 4 5
Responsibility 1 2 3 4 5
Status 1 2 3 4 S

S. Whether you are employed or not, there are no doubt many tasks that

171

10!:

you face each day (for example. those related to being a wife]
girlfriend. employee. or cosmunity volunteer). We would like you
to rate the degree of giggignlsx you find in trying to balance all
of your various roles. Do you find it to be:

lasy all the time

Sasy most of the time

Sasy half of the time: difficult half of the time

Difficult most of the time

Difficult all of the time

“.0030‘

9. Which response best describes the division of labor in your home
with respect to household chores?

Wife does major share of household chores

husband does major share of household chores

housekeeper/paid employee does major share of household chores
husband and wife share the household chores equally

WOUND-0

Other
(please indicate )

10. Please circle the response which most closely represents how
satisfied you are with each of the following aspects of marital
life:

Very Somewhat Weutral Somewhat very Does Wot
Dis- Dis- Satisfied Satisfied Apply
satisfied satisfied

Division of

labor for

household

chores . l 2 . 3 4 s 6

husband's
employment 1 2 3 4 S 6

2"P00'
sibilities l 2 3 4 . S 6

172

10!:

husband's

status at his

place of

employment 1 2 3 4 S 6

m: If you are dissatisfied with any of the above. please
indicate why:

 

 

 

ll. The next set of questions are about things that may affect your
general health. Please tell us if any of these have applied to you
over the last six months.

W8 m &

nave you ever needed a strong cup of coffee first thing
in the morning to calm your nerves?

have you ever needed to exercise regularly to feel good? 1 2
have you ever had a drink first thing in the morning to

steady your nerves or get rid of a hangover (eye-opener)? l 2
have people annoyed you by criticising your eating habits? l 2
have people annoyed you by criticising your drinking

habits? l 2
have people annoyed you by criticising your smoking

habits? l 2
have you ever felt bad or guilty about your drinking? 1 2
Have you ever felt you ought to cut down on your eating? 1 2
have you‘ ever felt you ought to cut down on your drinking? 1 2

'ttyoverallhealthis. .. . . .... . . . .- (Choosesne):

Sscellent 1
Good 2
Pair 3
Poor 4

W. Any additional cos-ants about yourself or your
husband that you would care to provide would be most welcome and
appreciated.

173

Fem us
"rust: m hat

Directim: reesle differ in how they feel aheet their daily activities at
cert. fer enseele. ee- seeple feel that their werh eehes then feel eeafel.
rhile ethers dee't feel this at all. think sheet your daily activities at werh
ad fer esch iten circle hew eften yee credence it. nest yee fer yeer
ceeperatien.

soc- m2
one SIX-NI 2133 can an:

 

te 6‘". . ‘ m. ‘ a“l“”eeeeeeeee ‘ 3 ’ ‘ ,
2. Circe a a feeling ef self-fulfill”: l 2 2 5 3
2. fishes - feel like f'n contributing

a minty............u.............. 1 2 J ‘ ,
‘. elves - en cpsert-ity ts lesrs new

u£.'.eeeeeeeeeeeeeeeeeeeeeeeeeeeeneee ‘ 1 , ‘ ,
,e In“! - :‘C‘ m:“‘eeeeeeeeeeenoee ‘ 2 3 ‘ 3
C. Gives a a feeling of aethsrity....... l 2 ' J O 3
1. i get respect frsn ethets fer ey tech l 2 2 ‘ S
f. Gives a an enertenity ts ese ey

“ICC‘. 8d tbiilfillouo.............. ‘ 2 3 ‘ ’
9. Gives a a feeling I prestige er

etatnn....nu.........o.............. t 1 J ‘ ,
l0. Ishss - feel good aheet eyself....... l 2 J 6 3
lie “in - u it m“‘”eeeeeeeeeeenee ‘ 1 J ‘ 3
11. Gives - a feeling d independence-.. 1 2 J ‘ 3
i3. Gives es the opportuity fer ceetant

with "heeeeeeeeeeeeeeeeeeeeeeeenee 1 2 3 ‘ 3
ll. 2 get feedhech that l'n deisg a good

eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee ‘ 2 J ‘ ’

13. dives - an enectuity fer indepen-

m‘ an.‘ It -.heeeeeeeeoeeeeooee t 1 - 3 ‘ 3

1.. m. - ...t ”d.‘eneeeeeeeeeeeneoee ‘ 1 3 ‘ ,

174

m. - ‘CCt WCC.‘eeeeeeeeeeeesee

Gives a a sense of sstoeplisheeet
“ “.‘CMI‘seeeeeeseeeeeeeeeeeeeeee

allows u to eshs ioperteot decisions.

Gives a so opportunity for self-

6"...“‘eeeeeeeeeeeseeeeeeeeoeeeeeee
Gives - a feeling of eelf-worth......

i get appreciation frsn others for ey

Gives es the opportunity for personal
“0". all “”1m.‘eeeeeeeeeeeeeeee

Gives ee satisfaction froe knowing i
u. “‘3' . 1.. “tieeeeeeeeeeeeeeeeee

Gives on an opportunity to echo

I’h“.eeeeeeeeeeeeeeeeeeeeeeeeeeeeeee

nun- '22!
runs was our

 

I'll 22m
1 2
l 2
l 2
i 2
i 2
l 2
i 2
i 2
l 2

2 C 2
J b 3
J b 3
3 f S
3 h 3
J b 2
J o S
2 f 3
2 b 5

175
In a

Directions: Below are soon state-ants about your eeploynant. fleass read each
one carefully and check one box for each statonent. Thanh yoe.

Yes In Don't Know
1. People where 2 work are very friendly. — — --
2. ﬂy job is very boring.

J. i get the feeling of achieving sonething
worthwhile in '7 job.

6. I only do ey job because i need the eoney.

5. My boss is always ready to discuss people's

probleu. — -—
6. ﬂy boas takes the work i do too nah for

granted. _ ._ _
1. i wish I had nore security in ey job. _ _
8. There is a happy atmosphere in the place

where I work. _ — _
9. I really dislike up job.
l0. Hy boss is fair to everyone. -
ll. ”here 2 work. nanagenent asks workers first

about changing anything that affects thu. _ _ _

12. l - unhappy with ey working conditions.

 

 

 

 

 

176
2 . D. I
Have

Pore ﬁr—

 

OOCIAL SUPPORT QUISTIOINAIRI

PLIASI RIAD ALL 01326710"! 0' rate ’36! 882038 STARTING.

Please list each significant person in your life on the right. Consider all the
persons who provide personal support for you or who are inportant to you.

use only first nanes or initials, and then indicate the relationship, as innthe
following example:

 

 

 

 

 

 

 

 

 

 

 

 

Ina-plot
first none or initials Relationship
1. 477/4
2. ‘hendi’
3. (I. 12W
4. ’ [74/5
.. ﬁaﬁz
r
etc.

Use the following list to help you think of the people inportant to you. and list
as nany people as apply in your case.

-spouse or partner

-fanily eenbers or relatives
-friends

-worh or school associates
-neighbors

-health care providers
-counselor or therapist
-ninieter/priest/rahbi
-other

You do not have to use all 24 spaces. Uee’as nany spaces as you have inportant
persons in your life.

177 2JL I

 

Pirst ones or initials Relationship

1.

 

 

 

 

J.
.0.
5e
6.
7.
I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.
11.
12.
13.
14.
1’.
1‘.
17.
12.
19.
2°.
21.
22.
22.
24.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

2: not at all
2: a little

3: noderately
d: quite a hit
5: a great deal

6.
3.
6.
7.
I.
O.
10.
11.
12.
13.
1‘.
13.
16.
17.
12.
19.

21.
22.
23.
26.

1.
2.
3.
h.
S.
6.
7.
I.
9.
10.
11.
12.
13.
1‘.
13.

17.
12.
19.
20.
21.
22.
23.
2h.

blow-chdsssthlspsrsn-he
ysufsel Ilhoderlovcd?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. launch on you confide
In this pare-I?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

178

1.0. l
Have _
Porn 105

2. law much are this parse! ate
you feel respected er salted?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. launch dsss thls pars-e spree
with or apart your action
cthouﬂts?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.
2.
3.
i.
3.
6.
7.
2.
9.
10.
11.
12.
13.
1‘.
13.
16.
17.
12.
19.
20.
21.

23.
2‘.

S. I? you needed to honour no. a
rib to the doctor, or so-
other l-adlete help. how lath
could this person uuslly help?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

179

6. If you were confined to had for
several waste. haw nah could
thle perm help you?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

180

1.0. I

7. lies long have you Ina-n 0. law irmntly do you wally
this person? have contact with this perm?
(Phsrle cells, visits. or letters}

1- loss that 6 unths Se aily

2- e to 12 nnths ‘8 weeth

3- 1 to 2 years 3- eanthly
“Ztoiyoers Zesiewtieesayosr
SeserethanSyoars helicesyesr

1.
2.
3.
‘.
S.
6.
7.
I.
9.
10.
11.
12.
13.
1‘.
12.
1‘.
17.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. During the past year. have you lost any inortant relationships the te mine, a job chaise. divorce
or separatism death. or sane other reason?

1.
if '22:
9s. Please indicate the tutor of person iru each category to are no longer available
‘. We '

spams or partner

i-ily esters of relatives
trim '
wort or school associates
nei'nhers

health care providers
omelet or thornist
einistorlpriostlrabi
other (specify)

 

 

 

181

1.5. I

 

Overall, how nth of your swport was provided by these people die are no longer
available to you?

0. none at all

1. a little

2. a ndereto wt
3. quite a bit

6. a great deal

 

182

 

 

 

meats
neecperseaehavedisegre-sncsintheirrelatieeanipe. Pleeaeisdlsatehelswthe

appruuauent-nefagre-nsuusegree-ntheo-eey—andyeerpartncfocoeehit-
eethefellawiaglisc.

 

ilweys hlneet Gase- Pro- hlnset hieaye I
Agree Always eieeally gently hlways his-
_“_‘5_".?_ 3%.”— .2232. .22..

 

1. handling fanny
finances

 

 

2. letters of
recreation

‘ 2. hlgione setters

d. Matinee of
affection

 

 

 

2 e '21.“.

 

 

 

 

 

 

 

 

things belie-on
___E‘JELL
ii. lenses of ti-
___m
12. m u,"
decisions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

183

 

 

”A

 

iii
If?!

 

it. how often do you
discuss or have yon
considered divorce.
separation. at
terninating your
relationsnig?

“Gn-
sis-ally

lately

 

 

l1. lowoftaedeyonoc
yournateleevetbe
heuuafteca

. fﬂ' r:

 

ll. 2sgenecai.hew
oftendeyeecainn
restrain-«serve.

‘ New”

partneracegoing

well?

 

1!. heyoeconfidein

—“ A‘AAA-A ___ —- .‘ _—

 

2G. leyeeeverm
thatywnsarriod?

ior livod :ooetnerl

 

22. lswofteedeyoe

annyoerpartnor
. auarrel?

 

 

to often do you
an your sate 'got
on eacn acnec‘s
nee-veer.

 

 

 

 

 

 

 

 

22. Beyonkiseyoereate?

i

Boy-nosed
insetside
W2

5
3

‘5 W"
l ‘il

hl-et

heryhay siaeally

”I.

 

2.02

184

2.3. '

 

 

Porn

10“

q

 

how often would you say the following events occur hecween you and your sate?

 

hover Lees Once or Once or Once a horn
than twice a twice a day often
once a not: weeh
sooth

 

2S.

lave a etinlating
snchang of ideas. ~

 

‘ 23.
27.

2|.

 

 

h or.

Gnlely discuss
m

Inch together on a
3:01.33.

 

 

 

 

 

 

 

 

 

 

Maroon-staineaboutwhichcoupleeeueti-eagreeandsueti-disagrse. Indicate
if either it- helow caused differences of opinions or were prohl-e in your relationship
duringthepastfewwseks (chechyeeorno).

29.
20.

21.

 

fee In

heingtotirodforser.
lotshowinglove.

 

fhedotsonthefouowinglineupresencdiffersntdogrmofhappineselnyosr
relationship. the eiddle point. 'happy.' represents the degree of happiness of not
relationships. Please circle the dot which hoot describes the degree of happiness.
all things considered. of your relationship.

0
..s
M
0 ha
0
I.
O

 

htr-ely Perfect

very
hm

nor-sly Pairly h little happy

mm mm mm

185

2.3. f
levee

Porn loa‘

 

 

 

 

22. Ihlch of the following stats-eats heat descrihee how you feel about the future of
your rnlatlonahip?

2went desperately forsyrelationshiptesucceod. andwonldgoto
alsostanylengthtoeeethatitdoee.

2wsntveryeschforsyrelatlosshiptosucceed.andwilldoallfcan
toseethatitdoes.

2 went very non for sy relationship to succeed. and will do sy fair
share to see that it does.

ny relationship succeeded. hut 2 can't do mch ears
to help it succeed.

it succeodad.hut2refueetodoanysorethan2ae
ingnowtohseptherelationshlp going.

do
hyrelationshlpoannevsrsuccsed.andthsreisnosorethat2candeto
heeptherolationshipgoing. .

186

Please circle the answer that best describes how you generally behave.
Please circle gnly_gng_nnnpgg for each statement.

heally Sort of tort of heally
Phil! Phil! 230! flu!
for se for se for so for so

1. It takes me a long time to

get used to a new thing in

my home. 1 2 3 4
2. 2 can't stay still for long. 1 2 3 4

3. I laugh and smile at a lot of
things. 1 2 3 4

4. Once I am involved in a task.
nothing can distract me from

it. 1 2 3 4
5. 2 keep working at a task until

it's finished. 1 2 3 4
6. 2 move around a lot. i 2 3 4

7. 2 can make myself at home
anywhere. l 2 3 4

f. I can always be distracted by
something else, no matter what
2 may he doing. 1 2 3 4

9. 2 stay with an activity for
a long time. 1 2 3 4

10. If I have to stay in one
place for a long time. I get
very restless. l 2 3 4

ll. 2 usually move towards new
objects shown to mo. 1 2 3 4

12. It takes me a long time to
adjust to now schedules. 1 2 3 4

l3. 2 do not laugh or sndle at
many things. 1 2 3 4

1‘.

15.

16.

17.

18.

19.

20.

21.

22.

23.
2‘.
25.

26.
27.

22.
29.

2f 2 am doing one thing. some-
thing else occurring won't get
me to stop.

ﬂy first reaction is to reject

something new or unfamiliar to
me.

Changes in plans make me
restless.

2 often stay still for long
periods of time.

Things going on around me can
pg; tahe me away from what I
am doing.

Once I tahe something up. 2
stay with it.

2ven when 2 am supposed to he
still. 2 get very fidgety after
a few minutes.

2 am hard to distract.

On meeting a new person I tend
to move towards him or her.

I smile often.
I never seem to stop moving.

it takes me no time at all to
get used to new people.

I move a great deal in my sleep

2 do not find that I laugh
often.

2 move toward new situations.

10!: ‘__ __ __ __
Waves
forms‘fx If;
leally Sort of fort of Really
Phhsl I!!! 2108
for me for me for so for me
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 ~ 3 4
2 3 4

2 move a lot in bed.

187

. 1

188

heslly fort of tort of heally
PILSI P238! that 210!
for me for so for se for me

30. In the morning. 2 am still in
the same place as 2 was when 2
fall asleep.

31. When things are out of place.

it takes me a long time to
get used to it.

32. 2 don't move around much at
all in my sleep.

33. My mood is generally cheerful.
34. I resist changes in routine.
3!. I laugh several times a day.
36. My first response to anything

2:w is to move my head toward
3?. Generally I am happy.

38. 2 never seem to be in the same
place for long.

39. 2 wake up at different times
40. 2 eat about the samezamount
for dinner whether 2 am home.
visiting someone. or traveling.

41.2 take a nap, rest. or break
at the same times every day.

42.2 usually get the same amount
of sleep each night.

43. 2 seem to get sleepy just about
the same time every night.

44.2 get hungry about the same
time each day.

HHHH

”MN”

N

UUUU

ﬁbbh

.

189

m: — — - —

have:

You: '1 n
heelly fort of tort of Really
PM '12.“ m not

for me for me for me for me

45.1ihen 2 am away from home 2 still
wake up at the same time each
morning. 1 2 3 4

46.2 set about the same amount at
breakfast from day to day. l 2 3 4

47.2 feel full of pop and energy at
the same time each day. l 2 3 4

48.2 eat about the same amount at
supper from day to day. l 2 3 4

49.2 wake up at the same time on
weekends and holidays as on other
days of the weeh. l 2 3 4

SO.hy appetite seems to stay the same
day after day. l 2 3 4

Sl.2he number of times 2 have a bowel
movement on any day varies from
day to day. l 2 3 4

52.2 usually eat the same amount each
day. 1 2 3 4

53.2 have bowel movements at about
the one time each day. l 2 3 4

54.11o matter when 2 go to sleep, 2 wake
up at the same time each morning. 1 2 3 4

 

190

1.0. I
liave
Porn no A

 

 

EXPECTATIONS QUESTIONNAIRE BATTERY (Mothers)

Please indicate on a scale of l to 5 how much you agree/disagree
with the following statements about what you expect from your

husband/mate.

 

1
Disagree
Strongly

2
Disagree

3 4 5
Agree Agree
Somewhat

 

To read inforsation
about the pregnancy.

 

help in preparing
for the baby (room,
clothes, etc.)

 

To attend Lamaze
classes.

 

Consoling
you/tend ng to your
needs.

 

Accompanying you to
doctor's office.

 

Being sensitive to
changes in your body
and moods.

 

7.

During labor 2 want
my husband/mate
there.

 

2 want my mate to be
actively involved in
labor (coaching,
comforting, etc.)

 

To be an advocate
(during labor) to
help you get what
you want.

 

 

10.

Giving physical
comfort (bachruhs._

helping you up).

 

 

 

 

 

 

Strongly

 

191

I.D. I

 

l
Disagree
Strongly

2
Disagree

‘91..

3%.:

Agree

Agree
Strong
1!

 

11.

Cutting the
umbilical cord.

 

12.

holding the baby.
getting to know
him/her.

 

13.

2 expect my mate to
help with caregiving
activities for the
baby. like changing
diapers . feeding.
soothing.

 

1‘.

My mate and 2 will
share financial
duties (i.e., paying
bills. car payments.
balancing accounts).

 

13.

ﬂy mate should do
half of the
household chores.
like laundry.
cooking. grocery
shopping.
housecleaning.

 

16.

Childcare
arrangements will be
equally our
responsibility.

 

17.

If our child cries
during the night. I
expect us to share
responsibility for
soothing/tending the
child's needs.

 

 

12.

when the child is
sich. we will
equally take
responsibility for
childcare and doctor
visits.

 

 

 

 

 

 

 

 

 

 

 

 

 

192

1.0. I

 

Mamas

1.
2.
3.

4.

pregnancy?

how much weight do you expect to gain?
Do you have any feelings regarding weight gain?

Do you expect your body to be the same after the baby's born?
If your body isn't the same after the baby.

will this pose a problem?

how long do you think it wIlI take to regain your

figure after the baby?____

how much weight do you expect to gain during your pregnancy?
what hind of side effects. if any. do you expect

from

 

 

 

7. what hind of positive effects do you expect from pregnancy?

 

fxsrclaaLﬂaalth

1.
2.
3.

4.
5.
6.

7.

I currently exercise regularly.
My exercise level now is different from preprognancy.
ﬂow is it different?

 

2 exercise times per week.
how long are your exercise periods?
List the types of exercise activities that you do:

1.

2.

3.

4.

5.

 

Are you eating differently now that you are pregnant?
If so. how?

I feel restricted by other people's views about what 2 set during my
pregnancy?
ho

__ fee

Please feel free to expand on any of your responses-(below and on the
hack of the page.

 

 

 

193

 

 

 

keep track of my
weight.

2.D. f
mitss
l 2 3 4 5
Not at Dnl ike Like me Somewhat Very
all me like me much
like like
me me
i. 2 need to be able to

 

2 need to be able to
exercise regularly.

 

2 need to maintain a
balanced diet.

 

2 am aware of my
menstrual cle and

when my per od
occurs.

 

Changes in my body
make me
uncomfortable.

 

I feel the need to
see a physician

regularly.

 

2 pay close attention
to my physical
appearance.

 

2 want to be the sole
person making
decisions about pain
relief during my
labor.

 

 

It is important for
so to chose the
setting in which I
deliver (i.e., home.
hospital delivery
room. hospital
birthing room.

 

 

 

 

 

 

 

194

 

 

2.D. I .__
l 2 3 4 5
Not at Unlike Like me Somewhat Very
all me like me much
like like
me so

 

lo. 2 want to be the only
person to make
decisions about the
pregnancy and birth.
in the case of an

emergency.

11. In the case of an
emergency. during
labor and delive . 2
would leave decis one
totally up to the
staff.

12. 2 would feel self-
conscious if 2 were
to make a lot of
noise during
delivery.

 

 

 

13. I feel the need to
have the baby quickly
(a short labor)?

 

14. 2 need to have
everything planned in
advance?

 

 

 

 

 

 

 

1. What is your current occupation?
2. when do you intend to stop working to have the baby?
3. When do you intend to return to work after the baby?
4. When you return to work. do you intend to work full or part tine?
5. Does your place of work have a Haternal/ Paternal heave Policy?

If there is such a policy. is it a flexible one?(P1ease describz)

 

 

 

CHILDCARE EXPECTATIONS

1. I expect to place my child in a childcare arrangement when
2 return to work.

2. 2 plan to take sole responsibility for making childcare
arrangements. ‘ A

 

 

195

 

 

2 plan to take sole responsibility for transporting sy

child to childcare.

4. 2 expect my husband to help in getting the child ready
for childcare in the morning.

3. 2 expect my husband to share equally in the financial costs
of childcare.

e. 2 expect childcare to be a stress-free arrangement.

7. It is very important that the person who cares for my child
to have the same philosophy on childresring. -

s. 2 expect my child to spend ___ hours per week in childcare.

On a scale of 1 to 3 please rate the following statements:

 

1 2 3 4 f
Disagree Disagree Agree Agree Agree
Strongly Somewhat Strongl

 

1. It is important
that 2 breastfeed
my child.

2. If 2 nurse my

 

major source of
nourishment for
the first 4
months.

3. 2 want to
bottlefoed my
child exclusively.

4. 2 want sy child to
be able to nurse
from the bottle on
that my
husband/family can
share in the
feeding
experience.

3. EOIOdly I want to

be my child's best
friend.

 

 

 

 

 

 

 

 

 

 

 

196

1.0. I

 

 

1
Disagree
Strongly

Disagree

Mr
Somewhat

A920.

hat.-
Strongly

 

2 do not feel
it important to
be my child's
best friend.

 

7.

2 expect the
relationship
between myself
and my child to
be a close one
throughout
their
childhood.

 

I expect to
read as much as
2 can to be
informed about
child

development
issues.

 

I expect to
rely on other's
advice on
childrearing
issues.

 

10.

I expect to use
my family and
friends'
support
throughout my
child's
development.

 

 

11.

Discipline: I
expect to rely
on others'
advice on
discipline.

 

 

 

 

 

 

 

197
3.0. .

 

1. have you had any special cravings? Please describe.

 

 

2. 2s continuing the family line an important issue for this pregnancy?

 

 

 

3. Do you worry about physical problems with your baby?

 

 

4. Do you worry about the possibility of a pregnancy complication
(miscarriage. stillbirth. preterm delivery. caesarean section)?

 

 

5. Do you have any fears about your pregnancy?

 

 

 

EXPECTATIONS FOR CEILDBIRTE

1. Are you planning on attending any childbirth preparation classes?
fee. 2 am currently enrolled
fee. 2 plan to enroll ___
No

If yes. who are these classes arranged by?

If you are not planning to attend childbirth classes. please check below
(you may check off more than one):

__ 2 know all 2 need to know from things I've read. and] or talking to
other women who have had babies.

__ It is not convenient for me to attend classes (distance. time. cost)
___There is no point. you can't learn how to give birth.

__ 2 get the information 2 need from my clinic or doctor.

Other: please describe:

 

 

198

1.0. I

 

During your pregnancy. you will probably have seen various different
professionals (doctors. clinicians. nurses. etc.). We are interested in
the information that they give you about labor and birth.

2. Hhen talking to these professionals. are you able to discuss the
things you want to with them fully?

Yes. always

Yes. most of the time

Only occasionally

hardly ever

NO. never

3. When talking to medical practitioners. are you as assertive as you want
to be?
Yes. I am always as assertive as I want to be

Sometimes I am. but sometimes I am not

No. I am hardly ever as assertive as I want to be

 

4. now much do you want to know about what might happen during labor and
delivery?

I'd rather not know anything

I just want to know the basics

I want to know most things. but not things that will upset or worry
I want the staff to decide how much I ought to know

I want to know as much as possible

 

5. below are some things that women may be given during labor. How do you
feel about each of the following?

Please choose one of the following

Don't know Definitely Prefer Don't Would Definitely
enough to don't not to mind like do

make a want have went
choice

1 2 3 4 5 6

A.

An enema

D. To be shaved

c. External fetal heart monitoring at intervals
D. External Petal heart monitoring continuously
D. Internal Petal heart monitoring continuously
2. Intravenous fluids

P. An episiotomy

G. Pelvic exams

 

lilil.llll:13119§l

lo are interested in how

in labor. Please read the

that apply to you:

199

1.0.

 

woeen think about the sensations they experience

following questions. Please checkm

thebones

 

1
strongly

1
Disagree

foeewhat

51300
Strongly,

 

I expect the
labor to be
peinful.

 

7.

I cannot
tolerate sost
kinds of pain
well at all.

 

I I. worried
about dealing
with the psin in
labor.

 

I worry about
situations that
say be
potentially
pen in
everyday life
(for exasple.
like going to
the dentist)?

 

10.

I want the soot
pain-free labor
that drugs can
give so.

 

I intend to use
breathing and
relaxation
exercises during
labor?

 

 

I expect
breathing and
relaxation
exercises to be
very useful in
controlling the
pain

 

 

 

 

 

 

 

1.0. I

 

 

13.

I s. thinking of

1

Disagree
Strongly

2
Disagree

3

m0.

Sosewhat

Agree

Agree

 

using on

slternetive method

of psin relief

( 1 . e . hypnosis,
scupuncture,

sssssge)
it sees to be able

strongly

 

15.

to handle pain
better than soot
people.

I use the nininel

 

16.

amount of drugs to
keep pain
nanageable (i.e.
for headache
relief)

I plan to use the

 

17.

nininal anount of
drugs to keep
labor pains
nanageable.

I want to have a

 

 

cospletely drug-
free labor.

 

 

 

 

 

 

 

it. Do you see labor pain as different froe other kinds of pain?

lo
I don't know

_ If yes, please explain:

 

 

 

201

1.0. I

 

W

Pregnancy is often thought to be a special time by families with certain

unique privileges and restrictions, we would like you to describe sons of
these.

Please describe any restrictions pregnant wonen should follow...

 

 

 

 

W

Are there any special privileges which pregnant wonen have? Please list:

 

 

 

 

Are there any beliefs or superstitions in your fanin which relate to
pregnancy....... (Please list and state if you agree/disagree with them)

 

 

 

 

Is there anything special which a pregnant wonan should be careful about?

 

 

 

 

Should pregnant women be treated differently than nonpregnant wonen?

 

 

 

 

 

202

 

1.0. p
. :ave
mum-nan! "'1 2057103-

Circle the n-ber for each stateeent which best describes how often you
felt or behaved this way-m we ran VIII.

Occasionally
larely or fees or a or a liost or
lens of Little of hoderste all of
choline the l'ine Anount of the rise
(Less then fine
' l W) (14 Del") (3-6 days) (3-7 Days)
must nu: ran all:
l. l was bothered by things
that usually don‘t bother se. 0 l 2 3
2. I did not feel like eating: 0 l 2 l
ay appetite was poor”...
3. I felt that I could not shake 0 l 2 3
off the blues even with help
froe ey faeily or friends.
b. lfeltthatlwasjustasgood 0 l 2 3
as other people.........
5. lhadtrouble keeping-y D l 2 3
nind on what I was doing.
3. I felt depressed........ 0 l 2 l
7. i felt that everything I did 0 l 2 3
was an effort...........
2. i felt hopeful about the future. 0 l 2 3
9. ltboughtsylifebsdbeena l 2 3
“£1mOOOOOOICOOOOOOOOO
10. i felt fearful.......... 0 l 2 3
ll. My sleep was restless... 0 l 2 3
l2. lwas happy............. 0 l 2 3
ll. I talked less than usual. 0 l 2 3
lb. i felt lsnely........... 0 l 2 3
1:. People were unfriendly.. o 1 z. 3
l‘. l enjoyed life.......... 0 l 2 3
ll. lbedcrying spells..... 0 l 2 J
1.. If.“ MOOOOOOOOOOOOOO o 1 z ’
ll. i felt that people disliked se. 0' l 2 3
20. I could not get 'goiu'. O l 2 3

 

 

1.

203
c at' e*

Gestational age <37 wks or >42 wks

Birth weight (2.5 Kg or >4 Kg

Previous abortions

Disproportionate pelvis

Blood group incompatibility

Bleeding during pregnancy

Infections or acute medical problems during pregnancy
Drugs given during pregnancy

Maternal chronic disease

Drug abuse

‘Blood pressure during pregnancy (140/90 mm Hg
Albumiuria

Hyperemesis

. Hemoglobin at delivery >12 gm
. Multiple birth

. Membranes ruptured prior to delivery

Caesarean section

. Forceps delivery

Duration, first stage >20 hrs

. Duration, second stage >120 min

Duration, third stage >30 min

. Administration of oxytocin

Intrapartum drugs

. Stained amniotic fluid

non-cephalic fetal presentation
Intrapartum fetal heart rate (IOU/min or >160/min

. Nuchal or knotted cord
. Cord prolapse

. Placental infarction
. Placental previa or abruptio

Onset of newborn respiration within >6 min

. Resuscitation needed

. Apgar score at 1 min <7

. Apgar score at 5 min <7

. Incomplete membranes

. Manual delivery of placenta
. Placental weight <300 g

. Amniotomy

. Oedema

. Ketonuria
. Threatened abortion-bleeding

* Compilation of Prechtl Scale and Chalmers Scale

LIST OF REFERENCES

204

LIST OF REFERENCES

Aaronson, L. S. (1989). Perceived and received support: Effects on health behavior
during pregnancy W 3.8 4- 9

Abramson, L.Y., Seligman, M.E., & Teasdale, JP. (1978). Learned helplessness in

humans, critique and reformulation. MW, 81, 47-
74.

Adamson, K., Mueller-Heubach, E., & Myers R. E. (1971). Production of fetal
asphyxia in the rhesus monkey by administration of catecholamines to the

mother W 102 248-262

Albrecht, SA., & Rankin, M. (1989). Anxiety levels, health behaviors, and social

support systems of pregnant women. W, 18, 49-
59.

Alegre, A. Rodriguez-Escudero, F..,J Cruz, E., et a1. (1984). Influence of work during
pregnancy on fetal weight. MW, 22, 334 336

Andrews, 6., Tennant, C., Hewson, DM., Vaillant, GE. (1978). Life event stress,
social support, coping style, and risk of psycholigiical impairment. W
W. 1.6.6. 307-316.

Apgar, V. (1953). A proposal for a new method of evaluation of the newborn infant.

Whiz 260- 267

Armstrong, B ..,G Nolin, A .D., & McDonald, A. D. (1989). Work in pregnancy and

birth weight for gestational age. WW, 4_Q. 196-
199.

Ascher, B ..H (1978). Maternal anxiety in pregnancy and fetal homeostasis. W
W 1 18- 21.

Axelsson, G., Rylander, R., & Molin, I. (1989). Outcome of pregnancy in relation to

irregular and inconvenient work schedules. Wm,
49, 393-398.

205

Bakketeig, LS. & Hoffman, HJ. (1981). Epidemiology of preterm birth: results from
a longitudinal study of births in Norway. In M.G. Elder & C.H. Hendricks
(Eds). mum. Butterworths, London:

Ballantyne, J.W. (1904). ' V l I The
Embryo. Edinburgh: William Green & Sons.

Ballinger, C.G., Buckley, D.E., Naylor, G.1., & Stansfield, DA. (1979). Emotional
disturbance following childbirth: Clinical ﬁndings and urinary excretion of

Cyclic AMP W. 293-300

Barnett, B., & parker, G. (1986). Possible determinants, correlates and consequences

of high levels of anxiwety in primiparous mothers. W,
16,177-185.

Bartlett, C.1., Bobko, P., Mosier, S.B. & Harman, R. (1978). Testing for raimess with
a moderated multiple regression strategy: An alternative to differential

analysis. Wall. 233-241.

Baruch, G.K., Biener, L., & Barnett, RC. (1987). Women and gender in research on
work and family stress. W. 512, 130-136.

Baum, A., Grunberg, N .E., & Singer, 1E. (1982). The use of psychological and
neuroendocrinological measurements in the study of stress. W
1, 217-236.

Belsky, 1., Lang, M ..,E & Rovine, M. (1985). Stability and change in marriage across

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