SCREENING FOR PERCEIVED STRESSORS of THE ‘
SINGLE PRIMIGRAVZDA ' 

_ Schoiariy Projectfm thegegreecf-MS' N,   ..

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Screening for Perceived Stressors of the Single Primigravida
By

Brenda L. Spach

A Scholarly Project
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Master of Science in Nursing

College of Nursing

1 999

 

ABSTRACT
SCREENING FOR PERCEIVED STRESSORS OF THE SINGLE PRIMIGRAVIDA
By
Brenda Spach

No systematic approach is being used to screen for perceived stressors of the
single primigravida in a rural primary care setting. The purpose of this scholarly project
is to develop a screening tool to assess for the perceived stressors of the single

primigravida that can be easily implemented during prenatal visits in a rural primary care
setting. The conceptual framework used to guide this project was the Women’s
Self-Definition in Adulthood (Peck, 1986). This work focuses on the single primigravida
population. The single primigravida is defined for this project as: (a) a woman who is
pregnant for the first time, (b) who is divorced, widowed, separated, or unwed without a
partner, and (c) who is seeking prenatal care. This definition does not include the
adolescent population of under 18 years of age. This project presents a screening tool
with the purpose of reducing the perceived stressors of the single primigravida in an
attempt to prevent stressor pile-up. The tool is designed to facilitate a more in-depth
assessment to be used as a guide to open discussion in the area of the single
primigravida’s perceived stressors. As a result, this tool may be used to assist in the
promotion of the woman’s self-definition and decrease the risk for poor self-care, poor

pregnancy outcomes, and poor adaptation to motherhood and parenthood.

ii

To my sons, Seth and Luke,

with all my love.

iii

ACKNOWLEDGMENTS

This scholarly project would not have been completed without the assistance of
many people. I am very grateful to Jackie Wright for serving as chairperson for this
committee. I appreciate the patience, guidance, assistance, and all the generous support
that you offered. In addition, I would like to thank the committee members, Brigid
Warren and Millie Omar.

Special thanks go to the following people. Thanks to my little brother Dan and
his wife, Amber, for watching my two little ones and for your underlying support and
love. Amber, you have become a real and beloved sister to me. Thanks to my mom and
dad, who always knew I could do it, from milking cows to the completion of my masters
education. Thanks to Marion for your understanding and words of encouragement.
Thanks to Jenny Read for helping me reach my goal.

I give great thanks to the two most important people in my life, my two wonderful
sons, Seth and Luke. Luke, I waited your arrival with great anticipation and excitement
my first semester of my masters program. Your smiles, laughter, kisses and hugs, along
with watching your progression in your developmental milestones has given me greater
inner strength and resilience. Seth, your overwhelming patience, words of love and
encouragement, and all your hugs and kisses have given me the courage and perseverance
to climb over mountains. A night didn’t go by without a hug, kiss, and a “I love you
mom.” You both kept the sun shining bright, and someday you will surpass all my

achievements. I love you both so very much!

iv

I give the greatest thanks to my God above, who would listen each time that I would need
someone to talk to, would provide me with direction and guidance, would take my hand

and walk with me when no one else could, and would help me move my greatest barriers.

Thanks to all of you for making my dream come true!

TABLE OF CONTENTS

Page
LIST OF FIGURES ...................................................................................................... viii
LIST OF TABLES ......................................................................................................... ix
INTRODUCTION ........................................................................................................... 1
Historical Perspectives ................................................................................................ 2
Background of the Problem ........................................................................................ 2
PROBLEM STATEMENT .............................................................................................. 3
PURPOSE ....................................................................................................................... 3
CONCEPTUAL DEFINITIONS ..................................................................................... 4
Stressor ...................................................................................................................... 4
Single Primigravida ..................................................................................................... 4
Primary Care Rural Setting ......................................................................................... 4
CONCEPTUAL FRAMEWORK: TIE WOMEN’S SELF-DEFINITION
IN ADULTHOOD MODEL (Peck, 1986) ....................................................................... 5
Social-Historical Time Dimension ............................................................................... 6
Sphere of Influences ............................... ‘ .................................................................... 6
Self-Definition ............................................................................................................ 9
APPLICATION OF THE MODEL TO PERCEIVED STRESSORS OF THE
SINGLE PRIMIGRAVIDA ............................................................................................. 9
Social-Historical Time Dimension ............................................................................. 11
Body Image .............................................................................................................. ll
Developmental-Psychological Characteristics ............................................................ 14
‘Stereotyping ............................................................................................................. I6
Sphere of Influence ................................................................................................... 18
Role Changes ............................................................................................................ 18
Family Dynamics ...................................................................................................... 20
Self-Definition .......................................................................................................... 21
SUMMARY OF THE APPLIED MODEL .................................................................... 23
REVIEW OF LITERATURE ........................................................................................ 23
Lack of Provider Focus on Perceived Stressors ......................................................... 24
Impact of Stressors on Seeking Prenatal Care ........................................................... 25
Impact of Stressors on Health and Pregnancy Outcomes ........................................... 27

vi

TABLE or CONTENTS (Cont)

. Page
Stressors and Risk of Low Self-Esteem/Depression in Pregnancy
(Developmental-Psychological Characteristics) ............................................ 30
The Impact of Women’s Role and Family Dynamics on Motherhood/Parenthood ...... 30
Common Stressors Identified in Pregnancy ............................................................... 32
Impact of Social Support for the Single Primigravida ................................................ 34
Summary .................................................................................................................. 34
CRITIQUE OF THE REVIEW OF LITERATURE ....................................................... 35
PROJECT DEVELOPMENT ........................................................................................ 37
Screening Tool Development .................................................................................... 37
Target Group ............................................................................................................ 38
Description of Tool ................................................................................................... 38
Screening Tool Procedure ......................................................................................... 43
IMPLICATIONS FOR THE APN IN PRIMARY CARE .............................................. 45
Implications for Practice ........................................................................................... 45
Implications for Education ........................................................................................ 47
Implications for Research .......................................................................................... 48
Summary .................................................................................................................. 48
FUTURE EVALUATION OF THE TOOL ................................................................... 49
LIST OF REFERENCES ............................................................................................... 50
APPENDIX A: Instructions for Prenatal Screening Tool .............................................. 57
APPENDIX B: Provider Guide for the Prenatal Screening Tool ................................... 58
APPENDIX C: Prenatal Screening Tool ...................................................................... 62

vii

LIST OF FIGURES

Page
Figure l: The Model: Women’s Self-Definition in Adulthood: From a Different
Model? (Peck, 1986) ..................................................................................... 7
Figure 2: An Application of the Model Women’s Self-Definition in Adulthood:
From a Different Model? (Peck, 1986) ......................................................... 12

viii

LIST OF TABLES

Page
Tablel: Grouping of Questions Regarded as Stressors within the Categories of the
Modified Model of Self-Definition .................................................................. 44

INTRODUCTION

The first-time, single, rural pregnant woman is at risk for: (a) poor self-care, (b)
poor pregnancy outcomes, and (c) poor adaptation to parenthood (Curry, Campbell, &
Christian, 1994; Hoffman & Hatch, 1996; Sheehan, 1996). Pregnancy places stressors on
the single primigravida. These stressors include developmental-psychological
characteristics, family dynamics, body image, stereotyping, and role changes. Stressors
can create stress, which is a cluster of life events experienced and defined as an intense
exertion by the woman. Stress is: (a) viewed as damaging, threatening, or challenging,
(b) exceeds the woman’s available resources, (c) exceeds the adaptive capacity of the
woman, (d) results in psychological and biological changes, (e) can be real or imagined, (0
creates a state of disharmony, and (g) necessitates changes in life style. On an average,
one third of all births in the United States are to unmarried women (Monthly Vital
Statistics Report, 1997). As there continues to be an increase in single pregnant women
the focus of antenatal care also needs to be altered to meet the needs of single pregnant
women. Single status increases the risk for a poor pregnancy outcome (Hoffman &
Hatch, 1996). Therefore, assessment of the single primigravida needs to encompass the
stressors associated with pregnancy and being single, in order to meet the needs of these
women and decrease the associated risks to the single female and her fetus.

Prenatal care is ofien the initial contact of the woman with a primary health care
provider. In a rural setting, Advanced Practice Nurses (APN), working with single
pregnant women, are in a key position to assess the woman’s physiological and
psychosocial stressors. APN’s are in a good position to identify those most at risk for
poor self-care, poor pregnancy outcomes, and poor adaptation to parenthood. The

purpose of this scholarly project is to develop a screening tool to assess for the perceived

stressors of the single primigravida that can be easily implemented during prenatal visits in
a rural primary care setting. The model used to guide this project was the Women’s Self-
Definition in Adulthood (Peck, 1986). This model was chosen because of the concept
that stressors create barriers for the single primigravida with regard to her development of
self-definition, thereby having a negative impact on her self-care abilities, pregnancy
outcomes, and adaptation to motherhood and parenthood.
Historifi Perspective

Before looking at the issues supporting the need for this project, I believe it is
crucial to look at the historical perspective to see how society’s view of the single
pregnant woman has evolved. During the industrial revolution, as divorce, separation, and
unmarried pregnant women became a more prevalent part of culture, the concept of a
traditional family changed. The increase in one-parent households accelerated during the
19705, and has continued to grow throughout the 805 and 905. During this period divorce
rates have greatly increased along with the number of out-of-wedlock births (Glick, 1984).
This has resulted in decreased physical and psychological support for the single
primigravida. Because single-mother families do not have a lot of people around, they
may miss consistent and satisfying interpersonal interactions with others, and feel isolated.
According to Eiduson (1983, p.429), single mothers report loneliness, a need for
companionship, and dissatisfaction with their status, “once the blush of being a
pioneering single woman wears off.” Thus, the problems of overload and unhappiness
mitigate the satisfaction the infant initially provides (Eiduson, 1983).
Background of the Problem

The single pregnant woman is at high risk for the development of stressor pile-up,
which can cause problems with successful motherhood, parenthood, and pregnancy self-
care (Curry, Campbell, & Christian, 1994; Hoffman & Hatch, 1996; Sheehan, 1996).

Pregnancy involves profound changes of the self. This involves changes in self-image,

beliefs, values, priorities, behavioral patterns, relationships with others, and one’s problem
solving skills (Lederman, 1990). The mother-to-be has to conduct a reassessment of the
self and significant others in her life, as she prepares for the emergence of this new life and
family. Motherhood marks one of the transitions to maturity and adult responsibility
(Belsky, Lang, & Rovine, 1985; Crouch & Manderson, 1993; Dyer, 1963; Grifith, 1982).
The single pregnant woman must form her own self identity. This transition involves a
loss of the old self and former identity to a new self, a transition that may be viewed as a
part of growth (Lederman, 1990). However, single pregnant women are frequently in
situtations of inadequate social and economic support, resulting in situational crisis states
(Tilden, 1934; Tomlinson, White, & Wilson, 1990). '
Problem Statement

No systematic approach to screening for perceived stressors is available for the
single primigravida in a rural primary care setting. The method most commonly used is
the routine prenatal history and physical that does not fully assess the woman’s perceived
stressors. The opportunity to assess stressors during the prenatal visits in the rural
primary care setting is often limited. The APN needs to have an available screening tool
that is both convenient and practical, one that can be used during the prenatal care visits.
It is critical to assess the perceived stressors of the single primigravida to reduce the
associated risks to both her and the developing fetus.

Purpose

The purpose of this scholarly project is to develop a screening tool to assess for
the perceived stressors of the single primigravida that can be easily implemented during
prenatal visits in a rural primary care setting. This screening tool can be used for this
identified population upon arrival to the clinic for prenatal care in the rural primary care
setting. The primary use of this tool is for early screening of perceived stressors identified

by the woman, which may lead to stressor pile-up and possibly a state of maladaptation.

This screening tool should be used in conjunction with a routine health and family history
so that the woman’s background information can be incorporated. This screening tool will
assist the advanced practice nurse in determining more comprehensively the perceived
stressors of the single primigravida, including the following: (a) developmental-
psychological characteristics, (b) family dynamics, (c) body image, ((1) stereotyping, and
(e) role change.

Conceptual Definitions

The following conceptual definitions are considered vital in understanding the
perceived stressors of the single primigravida.

Stresssor. For purpose of this scholarly project a stressor is defined as a particular
situation or event which the single primigravida has had little or no prior preparation and
is viewed as problematic by the woman.

Single Primigravida. For this project, the single primigravida is defined as a
woman who is pregnant for the first time; who is either divorced, widowed, separated, or
unwed without a partner, and who is seeking prenatal care. This definition does not
include the adolescent population under 18 years of age.

Primary care in Rural Setting. Primary care is defined as the initial contact of the
patient with the health care system and encompasses a full range of basic health services.
This care should be readily accessible, patient oriented, of high quality, comprehensive,
individualized, and based on a firm foundation, all of which integrates knowledge of the
following sciences: medical, biological, physical, social-psychological, and behavioral
sciences (Silver, 1977). Primary health care includes specific basic elements. Among
those identified one specific element relates to my project. This element is the provision of
psychological and emotional support to help people deal with psychosocial problems,
psychosomatic responses, stress and anxiety, and to help them attain the fullest level of

emotional and physical well-being (Silver, 1977). This concept of primary care is targeted

for the rural setting, which is defined as an area with relatively low population density and
provider shortages; as an area with a shortage of personal health services; as an area which
includes a population group that the Secretary of State has determined as a health
manpower shortage (Harrington & Estes, 1997).
Conceptual Framework
The Women’s Self-Definition in Adulthood Model

The conceptual model used for this project is the Women’s Self-Definition in
Adulthood Model developed by Peck in 1986. This model attempts to describe factors
affecting the way in which a woman’s sense of self is defined and redefined during the
years of adulthood. This model emphasizes the impact of a woman’s relationships and the
timing of events in her life on her development. Within this model is the assumption “that
a woman is self-reflective, capable of understanding her own behavior, and able to
communicate her sense of self to another” (Peck, 1986, p. 279). This model is very useful
in understanding the single primigravida’s stressors during pregnancy and the need for
these stressors to be identified to help her define and redefine herself to help decrease the
risks associated with pregnancy.

This model provides a fiamework for the perceived stressors of the single
primigravida which include: (a) developmental-psychological characteristics, (b) family
development, (c) body image, (d) stereotyping, and (e) role changes. It helps to describe a
woman’s self-definition as an adult by illustrating the importance of the association
between external events and internal experiences. Peck (1986, p. 280) describes a
women’s self-definition in adulthood as“ an ongoing process of self-awareness and
knowledge gained primarily through relationships to other pe0ple and to mastery.” This is
accomplished through connectedness, not through separateness. Within this fi'amework,
the characteristics of a woman’s relationships can either foster or impede the clarity and

certainty through which self-knowledge may develop. It places close attention to

flexibility and elasticity of relationships. It also emphasizes the sensitive nature of self-
definition as a woman strives to remove herself from total dependence upon relationships,
while simultaneously attempting not to hurt the peOple for whom she cares. It illustrates
the complexities unique to each woman’s experience and her knowledge of adult life. This
fiamework for the process of self-definition and understanding will impede or facilitate her
process. The model is shaped like a cylinder, consisting of three main parts: social-
historical time dimension, sphere of influence, and self-definition (see Figure 1).
Social-Historical Time Dimensions

This layer of the model is encompassed by a flexible outer wall within which a
woman lives her adult life. Because the wall is flexible, it may be lax allowing the woman
a greater range of possible roles and experiences, or it may be constraining or
constricting allowing for fewer opportunities for role variations. It also reflects ideas
concerning the impact that the psychological experiencing of time in a social context has
on the woman’s development (Neugarten, 1968). Thus, this layer of the model is
perceived as the social, emotional, and political context within which a woman defines
herself throughout the life cycle.
Sphere of Influence

This layer consists of the sum of relationships that have varying degrees of
closeness such as: a spouse/lover, children, family of origin, friends, and peers
encountered in the work environment. This layer incorporates the degree of satisfaction
and the sense of competence the woman receives from her productive efforts, not simply
from a state of being an employed worker or homemaker. Her identification with a
particular group also plays a central part in her self-definition. The “sphere of influence”

indicates the bi-directional effect of relationships. It may be ways in which a woman

    

 

 

 

 

 

 

 

 

 

 

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exerts influence upon others, thus receiving confirmation of her impact in the world, or
ways in which relationships influence the woman’s sense of self. Peck (1986) states that
relationships have a strong influence upon the woman’s self-definition. An immediate
consequence of this is the degree to which many women experience loss of relationships
with a loss of self and consequent depression (Scarf, 1980).

Two characteristics of the sphere of influence are flexibility and elasticity.
Flexibility implies that the sphere can expand to include new relationships and contract to
prevent new relationships. It includes the way in which a woman redistributes her
emotional involvement with each relationship in order to receive support and reaffirmation
of the self (Peck, 1986). This ability appears to be very important for the maintenance of
emotional well-being and a clear self-definition (Pearlin, 1980). Elasticity is the
importance of individual relationships and their responsiveness to a “woman’s changing
needs, motivations, and self-definition. Elasticity is the primary way in which a woman
can see effects of her own influence upon the people around her and therefore, can see
herself as having some control over the extent to which others’ needs and expectations
affect her behavior and her ability to differentiate others’ concerns from her own” (Peck,
l986,p.280)

A sphere of influence that is flexible and consists of elastic relationships provides
the woman with information about her personality, competence, and her ability to
function in the world. If key relationships are inelastic and the sphere is inflexible, the
woman experiences self-doubt that may result in maladjustment. This suggests that the
lack of elasticity forces a woman to weigh the impact of any developmental changes
against the possible loss of relationships key to her self-definition (Gilligan, 1982; Peck,
1983). Thus, a situation is created in which the woman either lives through her
relationships or attempts to change her relationships and life circumstances, thereby taking

the risk of loss of self and prior identity.

Self-Definition

Self-definition is shown as the firnnel-shaped force emanating from the sphere of
influence. It includes all of the social-historical aspects, and the flexibility and elasticity of
the sphere of influence. This construct is unique for each woman depending on her
motivations, personality characteristics, personal circumstances, and so on. Ifthe fiinnel is
widening, it indicates increasing clarity of self-definition as time passes. Self-definition is a
spiraling motion, that pem1its a woman to constantly observe her own personal growth,
which may impact her valued relationships. This spiraling action also “captures the
importance of the woman’s ability to change subtly her degree of involvement in
relationships as the prime factor in a clearer self-definition” (Peck, 1986, p.281). When a
woman has difficulty negotiating this path, she often experiences depression and anxiety.
This creates responses that can cause the woman to diminish any efl’orts at self-definition
and that underscore the value of elastic relationships, which is a contributing force in a
woman’s self-definition (Peck, 1986). According to Greenspan (1983), women who seek
psychological counseling fiequently demonstrate confusion and anxiety about their sense
of self and their fear of loss of love and relationship.

Application of the Model to Perceived Stressors
of the Single Primigravida

Integrating the perceived stressors of the single primigravida within this model can
easily be done. The single primigravida is reaching adult responsibility. She is meeting a
role change in which she needs to define herself. Her “being” is developing socially,
emotionally and politically while being affected by outside forces such as friends, family,
the fetus growing within, and others. This transition and definition of self is also being
affected by external stressors, those associated with losses such as an important job, a
valued social role, or a loved one; internal stressors are usually related to biological

alterations in integrity (Roberts, 1987; Lederrnan, 1990). A woman’s self-definition can

be altered by the degree of stress that she can tolerate before becoming disorganized. The
perceived stressors for the single primigravida are individualistic. What one woman may
perceive as just a concern may be an actual stressor to another; stress for one woman may
be a crisis for someone else. The major concept, perceived stressors, was further depicted
into more specific categories. The categories identified in the review of literature
associated with perceived stressors are: body image, developmental-psychological
aspects, stereotyping, role changes, family dynamics, and self-definition. Whether each of
the categories represent just merely a concern, or is more intense, becoming a stressor, is
different for each woman. It depends on where she is in the social-historical time
dimension, and whether her sphere of influence is flexible and elastic, all of which are keys
to her self-definition. The concept of self-definition is indicative of the woman’s adaptive
or maladaptive abilities, and her success in the achievement of this new developmental
transition, pregnancy, and parenthood.

Pregnancy and birth are stressful periods that require many coping mechanisms to
deal with the changes that result: changing body images, psychologic adaptations,
socioeconomic stressors, role conflicts, and physical and biochemical changes. According
to Annie and Groer (1991), when the stressors are overwhelming, coping capacity is
limited, or social support is missing, the stresses of pregnancy and birth can produce
deleterious outcomes. Pregnancy can be seen as a turning point in the life of the
individual. Even if pregnancy is viewed as a crisis affecting all pregnant women, no matter
what their state of physical or mental health, then this crisis, as all others, can lead to acute
disequilibrium. However, under favorable conditions, the crisis of pregnancy can result in
specific maturational steps toward new functions and positive consequences on the growth
of her personality (Tilden, 1984). Thus, as the pregnant female defines herself, she begins

to see where she fits into this new role.

10

As a single primigravida, she finds herself vulnerable. According to Tilden (1984)
and Hoffman and Hatch (1996), women without partners are candidates for greater stress,
less social support, and greater emotional disequilibrium. When a situational crises is
superimposed on a developmental crisis, greater psychological disequilibrium is likely to
occur. The woman may experience a split between the past and the future. She may feel
an extraordinary closeness to the life within identified as attachment and a perception of
necessary separation. She may also experience both desire and fear, and the idea that she
will never be the same again (Lederman, 1990). Since these experiences of duality are
unsettling, tension, stress and anxiety may be aroused. Therefore, she needs to look for
satisfaction with herself and new life, and considering her needs, make a variety of
decisions. She may be easily influenced by peers and media. Because pregnancy is a new
stage of development, she may not achieve a high level of flexibility and elasticity. She is
trying to find herself in the new role of motherhood.

The following section describes the Women’s Self-Definition Model integrated
with the concept of perceived stressors of the single primigravida and the categories
identified in the literature associated with perceived stressors (see Figure 2).

Socfil-Historical Time Dimensifl
Body Image

The woman’s concept of body image fits into the social-historical time dimension.
The pregnant female is defining who she is, as a single primigravida, and at the same time
society is influencing this definition by telling her that it depends on what she looks like.
This pressure from society may change her perceptions of her body image fiom a beautifiil
pregnant body to one that is undesirable. Affonso and Mayberry (1990) and Kline,
Martin, and Deyo (1998) found body image to be one of the most frequent stressors

identified in pregnancy and the postpartum period. Fairbum and Welch (1990)

11

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Eiguntl. An adaptation of the model W

W Peck, T. A. (1986). Psychology of Women Quarterly, 10,
278; using the categories of: body image, developmental-psychological
characteristics, stereotyping, role changes, and family dynamics (as defined as

categories of stressors of the single primigravida), and the impact of the
reduction of the perceived stressors on the woman’s self-definition.

12

similarly found that out of 50 women that they included in their study investigating body
image and pregnancy, 6% dieted through pregnancy, 26% were overeating, and 24% felt
distressed about their weight gain in pregnancy.

Culture motivates how the woman perceives her body image, meaning that not all
cultures have the same definition of what is the ideal body image. Body image can be
positive or negative depending on the culture. Fairbum and Welch (1990) and Fawcett
(1978) state that how a woman perceives her body will have an effect on her self-image.
According to Schilder (1950) and Rubin (1984), body image is the picture formed in
one’s mind about one’s body, that is to say, the way in which the body appears to one’s
self. Body image encompasses the attitudinal dimension, referring to the feelings and
emotional reaction toward the body, and the perceptual, referring to the mental picture of
the physical appearance of the body.

During pregnancy, the body undergoes an extensive alteration in a short period of
time. As the pregnant woman’s body changes, her perceptions and attitudes towards her
body image are also altered. Affonso (1990) found that the second frequently endorsed
stressor involved body image changes that were primarily associated with weight gain and
feelings of being fat, unattractive, and distorted. A high price is paid by the pregnant
woman in American society because of the increased emphasis placed on thinness for
physical attractiveness. Some women may have irrational beliefs of “fat equals ugly, large
equals distorted, physically restricted equals loss of control, and clothes not fitting equals
never to be the same again” (Alfonso, 1990, p. 339).

The perception of the pregnant woman’s body image has been investigated in
various studies. Findings report that the woman’s perception of her body changes during
pregnancy are mediated by personality factors and attitudes towards pregnancy. Women
that have negative thoughts regarding body image report a disruption in maternal

adaptation and maternal-infant bonding (Burritt & Fawcett, 1980; Phillips & O’Hara,

l3

1991). Richardson (1996) found a correlation between women with preterm labor and
negative thoughts regarding body image. She found that women with preterm labor have
greater difficulty assimilating and accommodating body changes that occur during
pregnancy. Preterm women were either significantly worried or distressed about their
body changes. Their tolerance for body adjustments for the initial 26 weeks of pregnancy
was constrained and women had a less flexible comfort zone related to tolerable
alterations of body change (Richardson, 1996).

Researchers indicate that body image dissatisfaction is soaring among women.
Therefore, this makes body image a concern to any pregnant woman, but especially the
single primigravida, as this is the first time she has ever experienced such a change and she
wants to remain attractive (Garner, 1997; Walker, 1997). She may have distorted
feelings and perceptions of her body, with limited sources or opportunities to share these
feelings.

For purposes of this project, body image is defined as a stressor. I have included
question’s related to women’s feelings and/or perceptions of their bodies during
pregnancy and immediately after (postpartum).

Developmefll-Psychological Characteristics

Developmental-psychological aspects fit with the social-historical time dimension.
The single pregnant woman is trying to make choices regarding the roles of pregnancy,
that she will experience and either accept or not accept. According to Bibring (1959) and
Lederman (1990), pregnancy affects the psychological and emotional life of the expectant
mother even when her complete past histories do not reveal major psychological
symptoms and pathology. As discussed earlier, little attention is given to the
developmental and emotional stages, the behaviors of pregnancy, or how the woman is
interpreting or coping with this new experience. The emphasis in prenatal evaluation is

primarily on the physiological, despite the fact that pregnancy can produce a great deal of

14

stress for the woman. Friederich (1977) and Cooke (1996) suggest that the way a woman
responds to a crisis such as pregnancy, depends on past development and on the

social context. Growth comes from struggle, and because pregnancy forces growth, much
emotional toiling results. Usually, crises present the individual with opportunities for
growth, development, and change. However, danger lies ahead if the individual’s
resources are not equal to the tasks involved.

As the woman’s pregnancy progresses, she may perceive the fetus as sharing her
inner body, and eventually identify more with her childhood. According to Coleman
(1969), this identification, combined with her own childhood memories, phobias, fears,
previous traumatic experiences, and even her possible hostility towards the “intruder”; all
have an important role in structuring the pre-occupations of the woman throughout
pregnancy. Many women have a history of preoccupation with pregnancy during their
early childhood.

Childbearing presents with various developmental tasks that the woman must
encounter. Stolte (1996) identified the developmental tasks of pregnancy, but dealt with
the childbearing family as a couple, not for the single woman. This author believes that
the following tasks are also significant for the single primigravida. First is the task of
accepting the pregnancy, along with the changes that occur as a result. Without this initial
acceptance the woman is unable to proceed with the other developmental tasks. Second is
accepting the actual reality of the fetus. For the single primigravida, parenting roles and
behaviors need to be discovered and evaluated. The infant needs to be viewed as a
separate person, incorporating fantasies of what the fetus willlook like and the personality
that the fetus may have. Third is the integration of the maternal role. This developmental
task begins early in pregnancy and continues after the infant is born. According to
MacMullen, Dulski, and Pappalardo (1992), the psychological objective during pregnancy

is the development and acceptance of a coherent sense of self as parent. Researchers also

15

suggest that maternal confidence plays a central role in adaptation to motherhood. A
strong association has been observed between adaptation to this new role and marital
relationships, emotional state, and maternal confidence (Pond & Kemp, 1992; Williams,
Joy, Travis, Gotowiec, Glum-Steele, Aiken, Painter, & Davidson, 1987).

Tilden (1984) and Raphael-Leif (1994) suggested that pregnancy may be a
significant situational crisis associated with increased anxiety for single women. The
difficulties to which single-mother families are most prone are in the area of psychological
stress. Eiduson (1983) and Lederman (1990) described parental psychological stress as
contributing to high scores, with such events identified as: being unemployed against her
will, suffering extreme financial hardships, or being reported as emotionally disturbed,
even hospitalized for emotional reasons.

The single primigravida’s conflict is an emotional struggle as she encounters each
one of these developmental tasks. The developmental tasks are usually not approached by
the single primigravida without the addition of other negative life events. This
developmental-psychological adaptation for the single primigravida is a demand that
brings about stress.

For purposes of this study, the developmental-psychological characteristics of the
single primigravida is defined as follows: (1) a need for successfiil completion of the
tasks of childbearing, (2) identification and acceptance with this new role, and ( 3)
creating a new self-definition.

Stereogming

The concept of stereotyping also fits into the social-historical time dimension
because it can influence how the single primigravida sees herself within society, and how
she forms her self-definition. An image of pregnancy is created by fiiends, family, and the
media. How the single primigravida forms her self concept is influenced by health care

professionals and society. Her self concept has a direct influence in how she defines

l6

herself and proceeds through the developmental tasks of pregnancy and motherhood. One
of the most important features of stereotyping is the effect it has on the person being
labeled, others around her, and the care given (Bond & Bond, 1989; Ganong & Coleman,
1992). This is likely to affect the way the woman behaves and interacts with others. The
woman is likely to act out the role with which she has identified because of the way others
behave toward her.

Our culture promotes the positive aspects of having a baby: baby showers,
christening rituals, magazine photographs of the model, well adjusted, happy family, and
the “Gerber-baby” image (Searle, 1996; Stichler, Bowden & Reimer, 1978). However, if
the single primigravida is experiencing stress, then she may not be able to perceive the
positive aspects of having a baby.

Some evidence shows that marital status is a cue for stereotyping. Therefore, the
feelings associated with divorce must not go unrecognized, as this can add an additional
strain, not only because of the negative life event itself, but the feelings of culture
associated with it. In addition to being single, the woman may be single as a result of
divorce. She is trying to handle the stereotyping of divorce along with being single and
pregnant. Yates, Bensley, Lalonde, Lewis, and Woods (1995) state that the feelings of
culture associated with divorce might diminish the single primigravida’s perception of
her ability to function and cope as a family. This may create feelings of inadequacy in the
single primigravida, thereby creating a barrier in her self-definition.

Thus, this concept of stereotyping, can lead to maladaptation as the woman
develops an inaccurate picture of herself and the strengths that she possesses. For
purposes of this project stereotyping is defined as: (l) incorrect attributes consisting of
negative characteristics, (2) a set of beliefs about the personal attributes of the woman,

and (3) self perception of one’s ability to fiinction in this new role.

17

Sphere of Influence
Role Changes

The concept of the woman’s role in society fits into the sphere of influence. This
concept encompasses all the outside relationships the single primigravida encounters,
which may bring her strength and direction, or be barriers to her self-definition identified
as stressors. She needs to continue to see herself as productive and flexible, with elastic
relationships in order to provide her information regarding her ability to function in this
new role. She needs to possess a positive identification with this new group, single
pregnant women. These relationships need to be bi-directional, allowing her to
redistribute her emotions to allow for supportive relationships.

The single primigravida may expand her sphere of influence to permit new
relationships with health care providers, clergy, or other single pregnant women. These
relationships could be important in her development toward self-definition. If her sphere
is inflexible due to her feelings of isolation and guilt of becoming pregnant, then her self-
definition would consist of self-doubt and maladjustment in this new role.

Lederman (1995) found that state anxiety is distinct fi'om developmental anxiety,
which is associated with adaptation to pregnancy including maternal progress in
acceptance of pregnancy and resolution of ambivalence, identifying and conceptualizing a
motherhood role, adapting to changes in close and intimate relationships as a result of role
changes, and reaching a state of preparedness for the birth of the infant. Alfonso and
Mayberry (1990) and Jarrahi-Zadeh, Kane, Lachenbmch, Ewing, and Van de Castlf
(1969) found that, as compared to controls, the pregnant woman had a tendency to show
increased concern with health and bodily fiinction, decreased feelings of femininity, and
decreased interest in her social contacts and activities. Researches have suggested that
many American parents, especially those of middle-class, experience some incompatibility

between their parental roles and certain other roles (Dyer, 1963; Hanson & Boyd, 1996).

18

The single primigravida experiences a greater sense of incompatibility as she finds herself
functioning alone with additional responsibilities and constraints brought on by this new
role.

The physiological aspects are also important as they may create stressors for the
woman as she tries to maintain her sense of productivity, competence, and social contacts.
Frequent stressors identified during the prenatal period are fatigue and accompanying
physical distress such as sleep disturbances and physical limitations, weight gain and the
associated body changes, changes in activities, and feelings of morning sickness; all of
which can have an affect on the woman’s productivity (Affonso & Mayberry, 1990).
Atfonso and Mayberry (1990) and Jarrahi-Zadeh et al. (1969) reported that approximately
50% of their normal clinic population reported that they were anxious,iworried,
depressed, experienced mood lability and/or had difficulty in sleeping while they were
pregnant. They also found evidence for the inability of pregnant women and to a lesser
degree postpartum women to concentrate and plan ahead. This all has an afl‘ect on the
woman’s role in society.

Pregnancy may be a source of stress as the woman anticipates changes in life style;
other stressors may include financial concerns, changes in social contacts, and so on.
Women are likely to have more than one role at a time to deal with. Conflicts may arise as
the woman attempts to address the multiple expectations and responsibilities that are
assigned to each role, especially that of being a single primigravida. Expectations that
others have of this new role may conflict with our goals as individuals, as students, and as
close fiiends (Spurlock, 1995). Social support for the woman is crucial. Kaplan (1975)
and Koeske and Koeske (1990) define social support as a person’s basic need (approval,
esteem, succor and so on.), being met by the presence of psychological support from
significant others. According to Koeske and Koeske (1990), social support is said to

reduce mental health problems only in the presence of stressors identified as important life

19

events. Social support will increase self-confidence and self-esteem, and will help in the
design of new interventions, which will help to relieve depressive symptoms for the
woman in society (Hoffman & Hatch, 1996). Care must also be taken not to assume that
the pregnant woman has a large support system available during the perinatal period.
Women may need to be counseled about the need to deal with conflicting support systems
(F erketich & Mercer, 1990).

For this project, women’s role changes encompass: (l) the number and level of
new attachments and social support, (2) self perception of her new role as a single
primigravida, and (3) level of conflict with her role in society.

Emily Dynomics

The concept of family dynamics also fits into the woman’s sphere of influence.
This concept encompasses the internal relationships that the single primigravida has in her
sphere of influence. These relationships can be redistributed to allow for more supportive
relationships. Today the concept of interdependence of families is the main focus, as the
size of American families has greatly decreased, lacking the nests of supporting families
with which to share troubles and concerns regarding pregnancy (Hanson & Boyd, 1996).
Therefore, the woman may be forced to live alone in an enforced anonymity, relying on
second-hand information from friends and media as to what to expect.

Zachariah (1994) found that the importance of support from the mother’s own
mother was essential, and additional support for single women was crucial. Ballou’s
(1978) research suggested that if a pregnant woman’s relationship with her mother was
problematic, her relationship with her child may also be adversely affected. In order to
prevent the feeling of failure, the woman must have a lifelong feeling that she is “good
enough” for her mother, and not define herself as inadequate or a “lousy human being”
(Peck, 1986, p. 281).

A family’s definition of an event reflects partly the value system held by the family,

20

previous experience in meeting crises, and mechanisms employed in previous definitions of
events (Hill, 1958; Klien & White, 1996). If the woman’s parents had a difficult time with
childbearing and childrearing, then the single primigravida may have these additional fears
and cencems. Thus, she may be dealing with feelings of inadequacy.

As small children we are taught that having a baby is very special, an exciting
event. Researches have found that little girls were praised when mothering behaviors
were demonstrated toward their dolls (Lederman, 1990; Stichler et al., 1978). Now, as
the single primigravida is faced with this event, she may not feel this sense of praise, but
rather imperfection and fear within herself.

For this project family dynamics encompasses: (l) the relationship between the
mother-daughter dyad, (2) learned behaviors of dealing with crises, and (3) the value
system held by the family.

Self-Definition

Perceived stressors of the single primigravida is the concept that prevents the
development of self-definition. Single primigravida’s may find themselves maladapting if
their self-definition is not strong and positive in ways such as using tobacco, drugs, and
alcohol for coping mechanisms, over eating or under eating, and not complying with
medical regimens (Young, McMahon, Bowman, & Thompson, 1990). The goal of the
single primigravida is to find ways to cope with this new role, pregnancy and motherhood,
and to reduce stressor pile-up. The extent of adaptation depends on what is happening to
the woman in the social-historical time dimension and her sphere of influence.

Negative life events have been associated with negative effects on the status of
maternal health during the prenatal period. In a classic study by Tilden (1983), stress
fi'om negative life events accounted for 29.7% of the emotional disequilibrium among 141
women experiencing a normal pregnancy. Primiparas have been found to be significantly

more anxious during pregnancy than multiparas (Grossman, Eichler, Winickofi‘, Anzalone,

21

Gofseyeft, & Sargent, 1980). According to Ferketich and Mercer (1990) and Grossman
et al. (1980), maternal stress levels during pregnancy were observed to be: (1) the
strongest predictors of the woman’s ability to adapt, and (2) correlated with postpartal
well-being and mother-child interactions at two months.

Self-enhancement is part of self-definition that involves acquiring beliefs about
one’s values and worth during the presence of a threatening or stressfiil event, such as
childbirth, through mental appraisals that judge the self favorably (Affonso, Maybeny,
Lovett, & Paul, 1994). Self-enhancement is crucial in the construction of new
attachments and self-definition for the single primigravida, and reduction of the stressors .
associated with pregnancy. Self-esteem also has an impact on the woman’s self-definition,
which is closely related to self-enhancement. Merkatz (1978) and Pond and Kemp (1992)
found that stress from pregnancy risk situations was linked to decreased self-esteem.
Pregnant women with high self-esteem may be more likely to feel in control of their lives,
form social relationships, and engage in healthier behaviors, which could have a positive
impact on pregnancy outcomes (Curry, Campbell, & Christian, 1994). However, single
pregnant women are usually seen as having lowself-esteem and low psychosocial assets
(Hoffman & Hatch, 1996; Tilden, 1984). Therefore, the single primigravida has a less
flexible and rigid sphere of influence, thereby decreasing her ability to change to this new
definition of self, pregnancy, motherhood, and parenthood.

Pregnancy is a period of preparation for giving up rights and privileges to
accommodate a set of new relationships. She has to loosen existing relationships, untie
some commitments, and avoid making commitments that are less relevant. Women
usually find it difiicult to give up any aspect of a particular relationship. Rubin (1970)
suggests that a little of herself is lost with every loosening of former attachments of a
satisfying relationship during pregnancy. Thus, the pregnant woman has to form a new

self-definition of herself.

22

The fiinnel shape of self-definition for the single primigravida is narrow, meaning
that she does not have a clear definition of what it is like to be pregnant or of herselfin
this new role. As she is able to share her experiences and vent her stressors of pregnancy,
this definition of self will become clearer. She will have more self-confidence in herself
and will be less likely to look at pregnancy as a barrier to self-definition. She will finally
begin to understand how her external events and internal emotions respond to each other.

Summary of the Applied Model

Pregnancy has been identified as a time in the woman’s life when she experiences a
loss of self. With a loss of self, depression is evident (Affonso, Lovett, Paul, & Sheptalg
1990; Scarf, 1980). Therefore, the single primigravida must maintain a flexible layer and a
variety of options surrounding her self-definition. When a woman has difficulty in
adhering to this path, a woman will often experience anxiety and depression.
The negative influences that she has needs to be counterbalanced by positive influences
from either the woman’s mother, friends, clergy or health professionals (Lederman, 1995).
The model of Women’s Self-Definition in Adulthood (Peck, 1986) provides a fi'amework
to allow the APN the ability to assess for stressors of the single primigravida. Using this
model, the APN can encourage the woman to verbalize the stressors regarding pregnancy
to assist the woman in attaining her self-definition. Once the stressors are identified, the
APN can assist the woman in mobilizing her existing strengths, identify available
resources, and promote new and existing relationships that may provide a means of
support for the woman. As her self-definition becomes more clear, a higher degree of self-
esteem and self-confidence may occur, which is crucial for a positive self-definition in the
single primigravida.

Review of Literature
This review of literature identifies an association between the single primigravida

seeking prenatal care in a rural primary care setting and her perceived stressors. Much

23

literature exists in relation to stressors experienced as a couple during pregnancy, in
relation to postpartum depression, and postpartum functional difficulties. However, little
to no attention is given to how the single primigravida perceives stressors that already
exist or that are brought on by pregnancy, or the impact that the stressors may have on the
woman. No studies specifically attempt to describe this association. The following
sections address areas of perceived stressors that impact the single primigravida’s positive
self-definition.

Lack of Provider Focus on Perceived Stressors

The focus of antenatal care of the pregnant woman has changed. Today, the
health care team is more focused on the physical health outcomes of the mother-infant
dyad, limiting the opportunities for discussing fears and concerns with the expectant
mother (F erketich & Mercer, 1990; Larson, Spangberg, Theorell, & Wager, 1987;
Vartiainen, 1990). This problem can be attributed to heavy patient loads, as well as the
challenge of cost containment and managed care (Harrington & Estes, 1997). Often the
provider is responding to the woman without looking for emotional overtones or
understanding the woman’s true message. Caregivers are missing her cues, which
aggravates an already inadequate support system. This deters effective communication
with the result that the single primigravida’s stressors are often unheard. As the single
primigravida progresses through her first-time pregnancy, with limited opportunity to
express her perceived stressors, stressors can continue to pile-up and lead to crisis and
maladaptation (Hanson & Boyd, 1996).

In a cross-sectional survey analyzing 264 patient-physician interviews, Marvel,
Epstein, Flowers, and Beckman (1999) found a decreased opportunity for the expression
of patient concerns in primary care. They analyzed the main outcome between patient-
physician verbal interactions, including physician solicitations of concerns, rate of

completion of patient responses, length of time of the responses, and frequency of late-

24

arising patient concerns. They found that the physicians redirected the patient’s opening
statement after a mean of 23.1 seconds. They also found that patients who were allowed
to complete their statement of concerns used only six seconds more on average than those
who were redirected before completion of concerns. In conclusion, physicians often
redirect patient’s initial descriptions of their concerns, and once redirected, the
descriptions are rarely completed. They further found that consequences of incomplete
initial descriptions include late-arising concerns and missed opportunities to gather
potentially important patient data.
Ma of Stressors on Seeking Prenatal Care

In a study by Young, McMahon, Bowman, and Thompson (1990), at least 5% of
pregnant women in the United States will wait until the third trimester to seek prenatal
services or receive no prenatal care. In interviews of 201 new prenatal care patients
entering a health department for prenatal care in the third trimester gave self-reported
reasons for delaying prenatal care. The population consisted of: (a) less than high school
education (48%), (b) member of a minority group (66%), (c) unmarried (90%), and (d)
unemployed (90%). Interviews were completed with 70% of the women. Analysts found
that these women exhibited several high-risk behaviors such as smoking during pregnancy,
closely spaced pregnancies, and self-reported low weight gain. Women (20 and older)
reported barriers to be unemployment, single parenthood, psychological stress,
interpersonal conflicts with the father of the baby, and family crises. They identified single
motherhood and unemployment as factors in social and psychological isolation. The
researchers found that the process of acknowledgment and acceptance of the pregnancy in
this. population was prolonged and filled with conflict. The women were also more
reluctant to assume the roles of motherhood. Social support was lacking for many
women, the majority being single mothers. Therefore, the analysts suggested that

psychological and social factors influence the delay of prenatal care. Factors related to

25

this delay were found to be: low self-esteem, poor communication patterns with parents
and partner, depression, and an inability to plan for childbearing.

Although it is known that early and continuous prenatal care reduces the frequency
of low birth weight, large numbers of women in the United States continue to seek late or
no prenatal care (Children’s Defense Fund, 1992). Education, parity, marital
status, income, and demographic variables are associated with levels of prenatal care
(Hughes, Johnson, Rosenbaum, Simmons, & Butter, 1988). Women with less than a high
school education, who are unmarried, have incomes below the federal poverty level, and
live in inner cities or in isolated areas, tend to have inadequate or no care (Hughes et al.,
1988). External barriers to receiving prenatal care were identified as: (a) inadequate
financial services, with 25% of childbearing women with no insurance, (b) lack of
transportation, and (c) dissatisfaction with care services (Bramadat & Driedger, 1993).
The identified caregiver barriers included: (a) negative personal characteristics, such as
rudeness and insensitivity, (b) poor communication between caregivers, (c) inadequate
teaching, communication, and counseling skills, and (d) discrimination against clients
(Bramadat & Driedger, 1993). Although health providers have made great efforts,
prenatal care has become routine in many communities (Bramadat & Driedger, 1993).
Pregnancy testing, prenatal care, nutrition counseling, social work counseling, and
education are usually offered, but researchers rarely if ever assess self-esteem and social
support (Higgins, Murray, & Williams, 1994).

Higgins, Murray, and Williams (1994) did a descriptive, retrospective study using
a convenience sample of 193 low-risk, postpartal women who obtained early or late
prenatal care. They evaluated levels of self-esteem, social support, and satisfaction with
prenatal care. They used the Coopersmith self-esteem inventory, the personal resource
questionnaire, and prenatal care satisfaction inventory for data collection. They found that

women who received early prenatal care had significantly higher self-esteem and more

26

social support. This suggests that psychosocial variables differ in women who seek
adequate prenatal care and those who delay it.

Impact of Stressors on Health and Pregmncy Outcomes

 

Stress is defined as an intense exertion experienced by the person in response to a
stimulus (negative life events). Stress is an essential body response to environmental
stimuli arising fi'om a transaction between the person and her environment when the
stimuli are viewed as damaging, threatening, or challenging (Roberts, 1987). In general,
stress situations involve awareness of demands that exceed the available resources of the
individual and exceed the adaptive capacity of the woman, resulting in psychological and
biological changes that may place her at risk for disease. Stress is defined as either real or
imagined and includes behavioral manifestations such as: irritability, hyperactivity, panic,
hyperattentiveness, or reactions of social withdrawal, apathy, and sadness (Lederman,
1995). Such a state of disharmony can threaten the single pregnant woman’s homeostasis
(Annie & Groer, 1991).

Stress appears to represent a variety of responses that can be manifested as
anxiety, emotional tension or fi'ustration, anger, inability to adjust to a situation, or
difficulty with judgment and the decision-making process. Stress can either be temporary,
recurrent, or continual. If stress is recurrent or continual, physiological and psychological
exhaustion can result (Lederman, I995). Epidemiologic research and experimental stress
research have demonstrated relationships between morbidity and mortality; stress in animal
and human studies indicate that infections, malignancies, and autoimmune processes
appear with increased incidence in people and animals experiencing stress (Annie & Groer,
1991). According to Lederman (1995), the increased secretion of glucocorticoids during
stress responses is associated with undesired effects including immunosuppression, fluid
and electrolyte imbalance, delayed wound healing, and suppression of the secretion of the

growth hormone. Chronic and excess stress system activation can lead to pathogenesis or

27

disease (Lederman, 1995). In a review of previous research, Lederman (1995) found that
prenatal maternal stress has been related to neonatal hyperactivity and irritability in
documented research for more than 30 years. This is due to the failure of the person’s
counter regulation mechanism. Stress in pregnancy is related to poor health behavior.

Ferketich and Mercer (1990) did a study to determine the efi‘ects of antepartal
stress on health status during early motherhood. In order to index stress concepts more
precisely, they measured stressful life events, pregnancy risk, and intrapartal risk. They
used an initial pilot study of 30 women to test the response and length of time for
completion of the instruments used. All the instruments used in the study have been used
extensively in other studies, demonstrating reliability. The sample consisted of 151 high-
risk women and 212 low-risk women. Selection criteria included: (a) 24 to 34 weeks
gestation, (b) 18 years or older, (c) spoke and read English, (d) were married or living
with the father of the expectant infant. They found that high-risk women reported
significantly greater stress from negative life events and had higher pregnancy risk scores.
Low-risk women reported a more Optimal health status than high-risk women. They also
found that a sense of mastery or a feeling of control of the situation was an important
predictor of health status. This study supported the need for providing an opportunity to
explore concerns, stressors, and questions during pregnancy.

Lou, Hansen, Nordentofi, Pryds, Jensen, Nim, and Hemmingsen (1994) did a
study on prenatal stressors and their affect on fetal brain development using a sample of
2,382 women. These researches analyzed questionnaires with respect to the following
items: employment status, housing, social support (including the presence or absence of
the father in the household), stressful life events in the preceding year (such as marital
discord, major illness, death of a close relation, financial difficulties), fatigue at work,
chemical environment (including smoking, alcohol, and other drugs), and psychological

well-being. The study confirmed that psychosocial factors have adverse effects on both

28

the gestational age of the fetus and birth weight. Stress and smoking significantly afi‘ected
birth weight and head circumference of the fetus in this sample. When the birth weight was
corrected, stress remained a significant determinant of small head circumference,
indicating a specific effect on brain development.

A unique study by Annie and Groer (1991) examined salivary irnmunoglobulin A
(IgA) concentrations during pregnancy and at birth. The researchers examined potential
sources of stress during pregnancy and birth and their relationship to maternal immune
function. The final sample size included 30 primigravidas who were recruited from a
private obstetrical practice. All subjects were white, mean age of 23, mean income of
$23,000, and a mean education of 13 years. Twenty-six subjects were married and four
were single. The instruments used were the Spielberger State-Trait Anxiety Inventory
(STAI) and the Holmes and Rahe Social Readjustment Rating Scale. The instruments
exhibited a high level of validity and reliability. A significant drop in salivary IgA
(p<0.001) occurred at birth. State anxiety appeared to account for some of the variance in
IgA concentrations during pregnancy and at childbirth. Mothers who had very low or
undetectable IgA concentrations when they gave birth had increased incidences of
postpartum complications, and their infants had more illness during the first six weeks
following birth.

Hedegaard, Henriksen, Sabroe, and Secher (1993) investigated whether
psychological distress during pregnancy was associated with increased risk of preterm
delivery. A sample size of 5,459 women completed general health questionnaires that
measured psychological distress. Approximately half of the subjects were primigravidas,
with the majority either being married or cohabiting. They attempted to control for
extraneous variables in this study. They found that psychological distress later in

pregnancy was associated with an increased risk of preterm delivery.

29

Stressorflnd Risk for Low Self—Esteem/Depression in Pregnanoy (Qovoloomentol-
Psychological Chgagteristics)

Zuckerman, Amaro, Bauchner, and Cubral (.1989) state that depressive symptoms
occur in as many as 30% to 38% of all pregnant women. Phillipps and O’Hara (1991)
report that depression also affects a woman’s ability to bond with the infant and develop
the role of motherhood. To support these findings, Affonso, Lovett, Paul, and Sheptak
(1990) conducted a prospective longitudinal study of 202 primigravidas. Most sample
subjects were married, indicating a planned pregnancy; they were primigravidas, middle
class, and emotionally stable. The subjects were assessed for depression using the
National Institute of Mental Health’s (N lMI-l) standardized clinical interview, the
Schedule for Affective Disorders and Schizophrenia, and Research Diagnostic Criteria.
The study noted that a majority of women do experience uncomfortable, depressive
symptoms during pregnancy.
The Impact of Women’s Role and flamilLDfliamics on Motherhood/Paronthooo

Single mothers experience conflicts about child care and often have to weigh
decisions about their work even more carefiJlly than married mothers, to allow for always
being available to the working environment, and at the same time, maintaining and
promoting the healthy development of their children (McVeigh, 1997). Single mothers
ofien provide the only financial support and are the sole providers of health insurance,
with minimal to no alternatives to consider (Young, McMahon, Bowman, & Thompson,
1990). Role strains and conflicts are especially burdensome for single mothers, who never
married or are divorced, especially those who struggle to reach middle class status by
gaining a college education and at the same time holding a full-time job (Spurlock, 1995).
Society often forgets to place emphasis on the importance of the psychogenic factors
associated with pregnancy and the many adjustments demanded. The feelings of fear,

uncertainty, feelings of being at risk, and anxieties about what the future may hold should

3O

not go unrecognized, especially for the single pregnant woman who is at a greater risk for
maladaptation and disequilibrium (Hoffman & Hatch, 1996).

McVeigh (1997) specifically studied motherhood experiences from the perspective
of first-time mothers. She used a convenience sample of 100 first-time mothers in a large
city. The majority of the sample was married with a mean age of 28. She used the
Inventory of Functional Status After Childbirth (IFSAC) as the main focus.

The five main categories recognized as areas of stress were: (a) the difficulty of the role
of motherhood, (b) being so tired, (c) lack of time for self, (d) lack of preparation for the
realities of motherhood and infant care, and (e) and needing support. Richardson (1993)
and Gjerdingen and Chaloner (1994) suggest that as long as mothers are expected to do it
all, with little or no support, mothers will evidently experience that fi'ustration, anger, and
disappointment with motherhood. Koeske and Koeske (1990) found similiar results when
identifying parenting as a potential source of role adaptation and stress. They

suggested that parenting stress may result in outcomes like parent dissatisfaction, low self-
esteem, or symptomatology (Koeske & Koeske, 1990).

Tomlinson, White, and Wilson (1990) did a study to measure family dynamics in
160 women in the third trimester of pregnancy. They used questionnaires to elicit
information. They found that families in which couples were married and who enjoyed a
higher social status had more positive family dynamics in the dimensions of individuation,
stability, flexibility, mutuality and communication. Their study shows that strengths in
families who have more positive dynamics may be associated with societal approval of
marriage and internal family support systems.

Pond and Kemp (1992) did a study to investigate anxiety and self-confidence in
adolescent and adult pregnant women and the impact on adaptation to parenthood. The
majority of the sample was black and unmarried, and adult women rather than adolescent.

The sample size included 93 first-time pregnant women. Using the STAI and Pharis’ Self-

31

Confidence Scale, they found significant negative correlations for anxiety during
pregnancy and self-confidence for all women. These results suggest that the adaptation
process may create stress because of the many psychological and physiological changes
that occur during pregnancy and birth, and can manifest itself as anxiety. High levels of
anxiety and low self-confidence may impair the pregnant woman’s adaptation to
parenthood.

W

A study conducted by Affonso and Mayberry (1990) on a group of 221 women
identified stressors common to pregnancy and qualified their intensity using an interval
rating scale. They used a cross-sectional convenience sample. Most of the women were
married (77.8%), white, multigravidas (61.5%), and employed (63.8%). They all reported
a normal course of pregnancy. Frequent stressors identified during the prenatal period
were fatigue and accompanying physical distress such as sleep disturbances and physical
limitations, weight gain and the associated body changes, concerns about whether the baby
will be healthy and normal, changes in activities and household arrangements, emotional
distress related to fears, worries, or feeling depressed, fears of complications and preterm
labor, management of the newborn, and problems associated with the relationship with the
baby’s father. This supports the goal in women’s health care of helping women with
positive cognitive self-appraisals as their bodies and moods change over the course of their
pregnancy and postpartum period.

The woman’s perception of her body image was also found to be a stressor during
pregnancy. Abraham, King, and Llewellyn-Jones (1994) studied the eating behaviors and
attitudes toward body weight. The sample consisted of 100 primiparous women three
days postpartum and found that 41% reported weight control issues, while 20%
considered their weight and eating problems to be greater during pregnancy than at any

previous time in their lives. They used a questionnaire to obtain information about the

32

woman’s eating behavior, body image, and concern about weight before and during
pregnancy.

Pregnancy and childbirth are viewed by society as a joyfiil and exciting time in a
woman’s life. However, many single women are in conflict about having children; society
attaches stigma to the status of the single pregnant woman, thus placing her at additional
risk for maladaptation (Spurlock, 1995). Stereotyping was found as an area for stress for
the single primigravida. Ganong and Coleman (1992) studied the impact of
stereotyping on pregnancy. The sample consisted of 83 female undergraduate nursing
students in a nursing program. The subjects who volunteered for the study were mostly
single, had parents who were still married, and were white. The student recruits listened
to taped interviews between a nurse and client, responded to some questions, and
completed several questionnaires. The students were assigned to one of two experimental
groups married client or never-married client. The study found that a more negative
environment was created in the experimental group, never-married client. In conclusion,
nursing students held stereotypes of married and unmarried mothers that were consistent
with the culture. Information on family status of the client served as one way data about
the client could be cognitively organized.

Searle (1996) conducted another study in reference to stereotyping. This cross-
sectional and qualitative study of 376 postnatal women in a major public teaching hospital
focused identifying the origination of fears. The majority of subjects was over 18 years of
age, with half being primigravidas. Fears originated primarily fi'om word of mouth,
previous experience, the media, and the role of society and its expectations. Fears
identified by the study included: (a) health, normality, well-being of the baby, (b)
disability, abnormality of the baby, (c) labor and delivery experience, (d) loss of the
pregnancy, baby, (e) inability to cope postdelivery, and (0 effects of maternal behavior on

the pregnancy.

33

Imoact of Social Support for the Single Primigravida

Zachariah (1994) did an exploratory study using a short-term single group pretest-
posttest design. The sample size consisted of 15 mothers enrolled in a parenting program.
The majority of subjects was never married, the others were separated or going through a
process of divorce. Various sources of concerns that were expressed included: lack of
finances, emotional difficulties, child care, and informational support, disappointment and
disgust about relationships with the father of the baby, the feeling of not being important,
lack of a meaningful relationship in life, lack of a close friend, and difficulties in decision
making experienced in relation to the care of the infant. The major source of support for
these mothers varied among: own mother (28.5%), a friend (28.5%), grandmother
(14.2%), and no support (28.5%). Only one mother in the group reported having daily
contact with her major source of support. Their frequent comments included the
following: (a) having no support, (b) not really having fiiends, and (c) wishing for more
frequent family contact. The observations in the study also suggested that the single
mothers’ relationships with the mother and partner were strained and that the mothers
were socially isolated. The findings suggested a need for additional support for single
women, and increasing the single mother’s perceptions of sources and availability of
support.
Summary

As evidenced by the review of literature, stressors can be very predictive as to the
outcome for the single primigravida. One single variable probably is not a stressor
because human beings are multidimensional in nature. To date no studies have specifically
examined the stressors of the single primigravida in a rural primary care setting or
developed screening tools to assess for these stressors. Therefore, as evidenced by the

review of literature, investigating the relationship between stressors and the single

34

primigravida and her development of self-definition and adaptation to pregnancy and
motherhood is imperative.

Changes in health care have resulted in greater complexity in the nature and scope
of health care. Time constraint issues of the health care provider is becoming a major
problem in meeting the needs of health care consumers (Harrington & Estes, 1997). As
the number of single primigravidas continue to increase in the American population,
caregivers need a screening tool for perceived stressors to target this population. This will
provide more efficient, cost-effective, health care delivery. This tool will meet both the
needs of the single primigravida and the health care system.

With the introduction of this tool in a rural primary care setting the APN will have
more time for a holistic perspective to be incorporated into the care of the single
primigravida. The APN can explore with the woman her perceived stressors, identify
available community resources and make referrals as necessary, identify community needs
assessment, and assist the woman in her self-definition as a single mother. The prenatal
period establishes ground work for learning to adjust and cope with previous and present
stressors. This can have an affect on the woman’s present and fiiture health behaviors,
bonding, and parenting coping skills.

Critique of the Review of Literature

As indicated in the literature review, studies exploring the impact of perceived
stressors in pregnancy exist. However, literature does not describe the impact specifically
associated with the single primigravida in a rural setting. No specific tools designed to
assess the perceived stressors of the single primigravida were found in the literature or in
practice. Most of the literature found was based on former classic research, and continues
to be represented in the more current literature. Most literature is based on the traditional
family rather than the single primigravida. Therefore, 1 have identified a void in the area

of the single primigravida.

35

A majority of the studies consist of samples from urban or inner city locations, and
mainly in teaching hospital settings. Researches have not explored rural primary care
settings. Most studies had adequate sample sizes, with a range in variability from 15
to 5,459 subjects (Hedegaard et al., 1993; Zachariah, 1994). The sample sizes were
adequate for the variables discussed. Literature is lacking for the single primigravida.

The instruments used were primarily questionnaires and self-report interviews.
The smaller studies most commonly used personal interviews (Ganong & Coleman, 1992;
Zachariah, 1994). Large studies tended to use questionnaires or surveys (Hedegaard et
al., 1993; Marvel et al., 1999). A majority of the instruments used supported validity and
reliability due to their extensive use throughout previous research (NIMH standardized
clinical interview, IFSAC, STAl). The studies did not include the instruments. This
prevents the reader from easily duplicating the study. The studies generally lacked
information regarding the questions asked, and also whether subjects answered all
questions. Researchers did not include the reliability and validity for some questionnaires
(Hedegaard et al., 1993; Tomlinson et al., 1990). Most studies included complete
information regarding statistical analysis and the limitations of the study.

Most samples were convenience samples (Higgins et al., 1994; McVeigh, 1997),
that lack ethnic diversity and may suggest bias. Researchers identified the demographic
makeup of the population, which can assist in the generalization of the results to a broader
and diverse population.

The design method used was indicated in most of the studies. The retrospective
design used limits the findings from being generalized or used to predict behavior of
pregnant women (Higgins et al., 1994). A prospective, randomized design may prove to
be more effective in making generalizations and eliminating bias (Affonso et al., 1990).

In their study, Annie and Groer (1991) used saliva lgA assays. One might

question its accuracy for measuring immunocompetence. Another problem identified

36

was the number of subjects in the study, which limited power to the analysis. Also,
individual subjects produced different amounts of saliva. This can alter the results and be
difficult to control for. In this study the researchers did account for some extraneous
factors.)

Conceptually, limits also existed. Current research was found regarding body
image, role changes, and family dynamics. However, limits existed in the areas of
developmental-psychological characteristics, stereotyping, and specifically self-definition.
Majority of this information was based on more former classic research.

Pregnancy itself, or stressfiil life events occurring during a pregnancy, may cause
high stress levels in many pregnant women, especially that of the single primigravida. The
APN must increase her awareness of the stressors during pregnancy. Thus, screening
stressors needs to be an integral part of the antepartum care. Clumping stressfirl life
events into a single measure may mask the influence of individual stressors. This creates a
piecemeal and a totally fragmented approach, and neglects possible collinearity or lack of
independence among the stressful life events (Sheehan, 1996).

Few will deny that stressors of the pregnant woman are of prime importance, and
that stress is probably due to the many adjustments demanded of the newly pregnant
woman (Lennane & Lennane, 1973; McVeigh, 1997). When this is coupled with the
single primigravida, even greater adjustments are demanded, thus, making the single
primigravida a primary target population. The literature is deficient in research on the
single primigravida and the stressors that often accompany with pregnancy. Therefore,
developing a sufficient screening tool for this purpose is crucial.

Project Development
Scre’eningTool Development
The tool to assess for perceived stressors of the single primigravida was designed

integrating various concepts identified in the review of literature. The tool was organized

37

around the conceptual framework of the Woman’s Self-Definition in Adulthood (Peck,
1986). For this project no pilot testing of the tool was done because the tool was
developed fi'om the review of literature.

Target gong

The focus population for this project was rural, first-time, single primigravidas.
This population consisted of women who were pregnant for the first time, who were
divorced, widowed, separated, or unwed without a supportive partner, and who sought
prenatal care in a rural primary care setting. This definition did not include the adolescent
population under the age of 18 years. Socioeconomic status was not a factor for
exclusion. This population was identified in the review of literature as the population at
greatest risk for maladaptation and having fewer intact support systems. A consent form
was not required because the tool will be a part of the initial history and physical, and
prenatal screening. The woman will always have the option of refiising to complete the
tool.

For this study I targeted primary care for the rural population. Primary care is the
initial contact of the single primigravida, seeking prenatal care within the health care
system. Rural is defined as an area with relatively low population density and provider
shortages, a shortage of personal health services, and is a population group the Secretary
of State determines has a health manpower shortage (Harrington & Estes, 1997).
Description of Tool

I divided the perceived stressors of the single primigravida into the categories of
body image, developmental-psychological characteristics, stereotyping, role changes,
family dynamics, and self-definition. Demographic data were included. The review of
literature showed that what one woman may perceive as stressful may not be stressfirl for
another. This indicates that the concepts are individualistic, and dependent upon each

individual, and develop over time. The tool for this scholarly project consisted of sections

38

that asked about: (I) demographics, (2) the concept of body image, (3) developmental-
psychological characteristics, (4) stereotyping, (5) role change, (6) a section asking
questions regarding family dynamics, and (7) self-definition. Each section was composed
of various questions, bringing the total to 45.

Domograohio Data. Questions one through eight of the screening tool address
demographic data. Race, education, employment status, income, marital status, medical
insurance coverage, and religion comprise this section. In the review of literature, it was
found that these variables may be associated with levels of prenatal care in relation to the
woman’s tendency to have inadequate or no care (Huges et al., 1988). This data identifies
potential areas for external barriers and caregiver barriers (Bramadat & Driedger, 1993).
Researchers found an association between this information and low self-esteem, poor
communication patterns with parents and partner, depression, and an inability to plan for
childbearing (Young et al., 1990). Therefore, it was identified that this information is vital
in identifying perceived stressors of the single primigravida. Once specific areas are
identified, the APN can assist the woman in eliminating or coping with potential external
or caregiver barriers, incorporate support/community systems that are available to help the
woman meet her needs, and to foster self-esteem.

Body Image. Questions nine through twelve address perceived stressors
associated with body image. The literature identifies body image as one of the most
frequent stressors identified in pregnancy and the postpartum period (Affonso &
Mayberry, I990; Kline et al., 1998). How a woman perceives her body will have an affect
on her self-image (F airbum & Welch, 1990; Fawcett, 1998). Exploring questions relating
to body image with the woman, the APN is given an opportunity to open discussion
regarding the woman’s perception of her body. The APN can then assist the woman to
focus on positive thoughts regarding her changing body image. This can promote an

increase in self-esteem, and enhance a positive self-definition.

39

Stereotyping. Questions 13-16 address stereotyping. Stereotyping is important
because it can influence how the single primigravida sees herself within society and how
she forms her self-definition (Bond & Bond, 1989; Gangong & Coleman, 1992). This is
likely to affect the way the woman behaves, interacts with others, and complies to medical
regimens. Our culture promotes the positive aspects of having a baby such as the model,
well adjusted, happy family (Searle, 1996; Stichler et al., 1978). The single primigravida
may not be able to view this positive picture, thereby increasing stress and decreasing
self-definition. In addition to being single, the woman may also be single as a result of
separation or divorce. The feelings associated with divorce may diminish the woman’s
perception of her ability to function and cope as a family, creating feelings of inadequacy
(Yates et al., 1995). Identifying the woman’s feeling related to stereotyping, the APN can
assist the single primigravida by recognizing her positive attributes, and fostering positive
self-definition.

Developmental-Psycho]ogical Chogcteristics. The developmental-psychological
characteristics are covered by questions 17-25, and 45. According to Bibring (1959) and
Lederman (1990), pregnancy affects the psychological and emotional life of the expectant
mother even when her complete past histories do not reveal major psychological
symptoms and pathology. The literature shows that little attention is given to the
developmental and emotional stages, the behaviors of pregnancy, or how the woman is
interpreting or coping with this new experience (Lederman, 1990). Childbearing relates to
various developmental tasks that the woman must encounter. Stolte (1996) identified the
developmental tasks of pregnancy, but focused on the childbearing family as a couple.
Researchers have observed a strong association between adaptation to this new role and
marital relationships, emotional state, and maternal confidence (Pond & Kemp, 1992;
Williams et al., 1987). Also, researchers suggest that pregnancy may be a significant

situational crisis associated with increased stress and anxiety for single women (Tilden,

4o

1984; Raphael-Leif, 1994). Therefore, this developmental-psychological adaptation for
the single primigravida is a demand that brings about stress. The APN is in a key position
to assist the woman in reducing stressors associated with these tasks by explaining the
developmental tasks and the associated expectations.

Role Changes. Role changes are addressed in questions 26-32. Vital in the
establishment of a pregnant woman’s positive self-definition are maternal progress in
acceptance of pregnancy and resolution of ambivalence, identifying and conceptualizing a
motherhood role, adapting to changes in close and intimate relationships as a result of role
changes, and reaching a state of preparedness for the birth of the infant. Studies have
shown that pregnant women have a tendency to show increased concern with health and
bodily fiinctions, decreased feelings of femininity, and decreased interest in her social
contacts and activities (Affonso & Mayberry, 1990; Jarrahi-Zadeh et al., 1969).
Researchers have suggested that many American parents, especially those of middle-class,
experience some incompatibility between their parental roles and certain other roles (Dyer,
1963; Hanson & Boyd, 1996). The single primigravida experiences a greater sense of
incompatibility as she generally finds herself functioning alone with additional
responsibilities and constraints brought on by this new role. The physiological aspects are
also important as they may create stressors for the woman as she tries to maintain her
sense of productivity in school or the working environment, competence, and social
contacts. Conflicts may arise as the woman attempts to address the multiple expectations
and responsibilities that are assigned to each role. The APN is in a position to provide
social support that increases self-confidence and self-esteem (Hoffman & Hatch, 1996).
This will help promote a positive self-definition that can promote healthier outcomes, and
positive adaptation to motherhood/parenthood. The APN can also design new

interventions that will help relieve depressive symptoms for the pregnant woman (Hoffman

41

& Hatch, 1996). This will also foster a positive self-definition that in turn impacts
outcomes.

Family Dmamics. Questions 33-39 pertain to family dynamics. A family’s
definition of an event such as pregnancy, reflects partly the value system held by the
family, previous experiences in meeting crises, and mechanisms employed in previous
definitions of events (Hill, 1978; Klien & White, 1996). If the woman’s parents had a
difficult time with childbearing and childrearing, then the single primigravida may have
these additional fears. Researchers also found that support from the mothers’ own mother
was essential, and additional support for single women was crucial, especially that of her
own mother (Zachariah, 1994). Ballou’s (1978) research suggests that if a pregnant
woman’s relationship with her mother was problematic, her relationship with her child
may also be adversely affected. In order to prevent the feeling of failure, the woman must
have a lifelong feeling that she is “good enough” for her mother, and not define herself as
inadequate or a “lousy human being” (Peck, 1986, p. 281). Because of the potential for
lack of support for the single primigravida due to a decrease in the nests of supporting
extended families, the woman may experience increased stress because she lacks someone
with whom to share troubles and concerns regarding pregnancy (Hanson & Boyd, 1996).
Therefore, this is an important area to screen for perceived stressors.

Self-Definition. The perceived stressors of the single primigravida may prevent the
development of positive self-definition. Questions 40-44 address self-definition issues.
These questions are not all inclusive, but were chosen as screening questions in this area.

. Single primigravida’s may find themselves maladapting if their self-definition is not strong
and positive (Young et al., 1990). Self-enhancement is the part of self-definition that
involves acquiring beliefs about one’s values and worth during the presence of a
threatening or stressful event, such as childbirth, through mental appraisals that judge the

self favorably (Affonso et al., 1994). The goal of the APN is to help the single

42

primigravida find ways to cope with this new role, pregnancy and motherhood, and to
prevent stressor pile-up.

Using this screening tool, the APN can address individual areas of perceived
stressors that influence the single primigravida’s development of self-definition, and
reduce the perceived stressors of the woman in an attempt to prevent stressor pile-up. To
attempt to incorporate all aspects of assessment into one tool would be overwhelming.
This tool is designed to facilitate a more in-depth assessment to be used as a guide to open
discussion in the area of the single primigravida’s perceived stressors. As a result, the tool
can increase the prospects for good self-care, positive pregnancy outcomes, and improve
the single primigravida’s adaptation to motherhood and parenthood.

The questions were developed from the review of literature. Responses were
based on a 4-point response scale: (1) almost always, (2) some of the time, (3) hardly
ever, and (4) never. For each statement the person was asked to give the best answer.
Each group of statements were categorized according to the concepts of: (a) body
image, (b) stereotyping, (c) developmental-psychological characteristics, (d) role changes,
(e) family dynamics, and (f) self-definition (see Table I). Table 1 will provide quick
reference for the APN to see where the woman fits into the modified original model,
Woman’s Self-Definition in Adulthood (Peck, 1986). The actual tool that will be
administered to the client can be found as Appendix C.

Screeninflool Procedure

The tool for this project was designed to be a self-administered tool, given to the
woman at the first prenatal visit. The receptionist can give the tool to the woman when
she registers. The woman is asked to complete the tool while waiting for her appointment
or take it home if unable to complete it during the first visit. If taken home, she will bring
it back at her next scheduled prenatal visit. The APN will encourage the woman to

prioritize each group of statements with #1 taking first priority. The APN can review the

Table 1.

gouging of Qoestions Reggded os Stressors within the Categorios of tho Moofi Q
Model of Self-Definition

 

Concepts ‘ Questions
Body Image . 9-12
Stereotyping 13-16
Developmental-Psychological 17-25, and 45
Role Changes 26-32

Family Dynamics 33-39
Self-Definition 40-44

 

tool during the first visit or at the next, depending upon the time of completion of the tool.
The tool can be used throughout the prenatal period, during each prenatal visit, so all
areas of perceived stressors can be addressed. This tool can be used as a primary
technique for preventing maladaptation and for promoting the woman’s self-definition.
This tool can be used in conjunction with the routine health, family history, and prenatal
history. The APN can use his/her assessment and interviewing techniques to facilitate a
more in-depth assessment. This screening tool may be used as a guide to open discussion
and allow for listing priorities to be addressed throughout the prenatal period. This
screening tool can serve as a guide in identifying needed resources for the woman and the
community. The woman should be educated regarding the purpose of the tool and be
encouraged to complete the tool. The woman can also include additional issues. The
woman always has the option to refirse to complete the tool.

When using this tool, the APN will also need to have a referral source and be
aware of the community services for those women requiring counseling or services beyond
the APN’s scope of practice. These aspects will need to be treated with a team approach.
Once the perceived stressors are identified, then a plan needs to be made to help the

woman understand and cope with these issues.

44

Implications for the APN in Primary Care
Implications for Practice

Nursing implications for advanced practice nurses in the primary care setting
should include assisting the single primigravida in identifying sources of prenatal maternal
stress, coping mechanisms, methods of building adaptive resources, and mobilizing the
strengths that already exist. This is crucial not only for the well-being of the mother, but
for that of the health of the fetus, as the developing fetus is an integral part. This can be
very important for her transition to parenthood. I believe using this tool will help increase
the mother’s well-being, self-definition, and in essence, positively affect fetal health.

Using this tool throughout each of the prenatal visits, the APN will be able to address each
of the woman’s identified areas of concern and/or perceived stressors. In retrospect, this
tool may need to be re-administered at different trimesters of the pregnancy, as the
woman’s perceptions may’change dependent upon where she is in her pregnancy. A
woman with a clear self-definition can better focus on health promotion issues than a
woman with a poor self-definition. Therefore, this tool will be useful in health promotion
and in the prevention of disease, as the perceived stressors of the single primigravida are
identified and reduced.

A goal in woman’s health care is to help women with positive cognitive self-
appraisals in relation to prenatal maternal stress (Affonso & Mayberry, 1990). The role of
assessment is the most important initial step. The APN and other health care professionals
must target the prenatal assessment to learn what prenatal maternal stress means to the
single primigravida. This will aid in identifying the presence of her inner conflict. This
tool will function as the initial screening in the assessment process; all health care
professionals can use it in a primary care setting.

The role of counselor is also essential for the APN in the primary care setting, as

well as for physicians, as many pregnant women are noted to be fiustrated due to lack of

45

control over their bodies, their environment, their lifestyles, and their pregnancy outcomes
(MacMullen, Dulski, & Pappalardo, 1992). Counseling will address body image,
stereotyping, developmental-psychological characteristics, role changes, family dynamics,
and self-definition. The types of interventions may include educational counseling,
anticipatory guidance, behavioral and lifestyle modifications, and reminiscence. Clear
communication and mutual trust need to be exercised in this role in order for the
counseling process to be effective. I believe that this screening tool will open up an
avenue for discussion, and to impress upon the client that this aspect of her care is as
important as the physiological. The establishment of support groups can also be a
dynamic entity for the role of the counselor because it can provide problem solving, social
support formation, self-help, identifying and mobilization of existing strengths. The APN
can fimction as a leader, to direct, facilitate, negotiate, and supervise the group to meet
common goals that are mutually satisfying. The APN can also serve as an interpreter for
the single primigravida to assist her in ventilating her feelings in relation to prenatal
maternal stress (Phillips, 1992). This tool can identify specific areas to concentrate on
specific to each woman. The APN can firnction as a case manager for the single
primigravida in order to continue to facilitate further identification of health care needs,
for this nontraditional family, and ensure continuity and advocacy for the client. Due to
time constraints within the managed care system, an assessment tool to identify needs of
the single primigravida population for a given, community may prove to be beneficial as
well as cost effective.

This tool can be used to identify specific areas requiring further evaluation and
education. The APN as an educator can inform the pregnant woman, and family systems,
in the awareness of the inner conflict that may exist. The APN can formulate a pamphlet
describing common perceived stressors that the single primigravida may go through. This

can also include various feelings that the client may experience specific to each trimester.

46

As educator, the APN can also identify this as another form of the family unit, and not one
to be scrutinized against. The role of evaluator is essential in determining the outcomes in
relation to the interventions elicited by the APN in the primary care setting. It is crucial to
determine if interventions aimed at decreasing the single primigravida’s inner conflict,
positive coping, and alleviation of stress are effective. This tool will identify common
perceived stressors of the single primigravida and interventions or strategies that are most
effective in reducing the perceived stressors. This is especially critical when health care
costs are under close scrutiny and third-party payers need to be convinced that
interventions will result in improved outcomes for childbearing, and that they will be cost
effective.
Implications for Educotion

The APN is also in a position to fimction as educator and evaluator. Educating
other health care providers in the specialized needs and concerns for these clients is also
important. A pamphlet may also be designed to include all of the available community
resources. Health care professionals need to be aware of the impact of social policies on
single childbearing women such as leave for childbirth, Medicaid reform, and managed
care coverage for counseling. Perhaps, social policies also need to be developed or
revised to assist with women who are single parents, and not eligible for Medicaid. Public
policies often place single-parent families in conflicting circumstances (Bowen, Desimore,
& McKay, 1995). The woman may be able to find a job, but make too much money to
qualify for state-assisted health insurance, and not have enough to pay for other health
insurance. Public policies also need to be revised in reimbursement of child care costs.
Women may be able to get a job, but the costs of child care may out weigh the benefits.
Their income may just be enough to disqualify them from assistance with child care costs,
and yet the woman still has to pay tax on the total gross income at the end of the year,

irrespective of the amount the woman had to pay out in child care costs in order to work.

47

At a public policy level, the APN must advocate for adequate and growth promoting day-
care facilities for the single primigravida with 24-hour coverage. This tool can identify
this need. In order for variations in communities to occur, the APN must fimction as a
change agent to collaborate and coordinate activities to bring about positive alterations.
Implications for Rewch

Research could focus on identifying risk factors for the single primigravida and to
assist all health care providers in focusing their interventions. A question that might be
asked is: What is the impact of the perceived stressors of the single primigravida on a
child’s development, performance and/or behavior in school and/or at home. Patterns
could be identified that are cues for firture problems and also explore the efficacy of
interventions. This tool can facilitate early screening and interventions, which are efficient
and cost-saving strategies. The APN can function as an assessor in which data bases are
utilized to identify health care, community, or system needs. I believe this tool will
provide information to help identify these needs.
Summag

The APN needs to be cognizant of the influence of prenatal maternal stress on
subsequent outcomes of the single primigravida in the primary care setting, as well as on
the fetus. Nurses need to assess and effectively employ resources available from within
the single primigravida’s environment, community, and from within the health care system.
All the APN roles must be utilized, not only to maintain a successfirl practice, but to
maintain or promote the single primigravida back to a state of equilibrium and to promote
her self-definition within this transition to motherhood. This author believes that this tool
will be very beneficial in this step. I believe that once the tool is revised and refined, it will
have potential for broader applications. It may be used for all pregnant women,

independent of their gravida and marital status. It may be possible that many of the

48

postpartum depression episodes and dysfunctional parenting problems may be reduced
with the early implementation of this tool.
Future Evaluation of the Tool

This author would like a peer review by providing the tool to other APN’s
working in rural primary care settings that provide prenatal services and to workers in
clinics in urban settings. This may provide recommendations toward this author’s tool. A
self questionnaire may be administered postnatally at the first postpartum visit, to the
single mothers who participated in the tool, to help determine its effectiveness. This
would also provide information regarding questions the woman may not understand or
would like to have added. The tool’s stability should also be assessed by using the tool
over a period of time; this would help to prove its reliability and its effectiveness in
screening for perceived stressors for the specific population identified in this author’s
project. I would also like a peer review to determine if this tool could be generalized to all
prenatal women within a rural primary care setting, and not just to be used for the first

time single primigravida.

49

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56

APPENDICES

Appendix A

Instructions for Prenatal Screening Tool

The following tool will be given to all single primigravida patients in rural primary
care settings at their first prenatal visit. It will firnction as a guide in identifying perceived
stressors during pregnancy. The receptionist will give the tool to the woman when she
registers. The patient will be asked to answer each item, as it best describes herself. She
may take it home if unable to finish it during the first visit, but will be asked to bring it
back at her next visit. The APN will review each of the items with the woman and ask her
which items take highest priority. Each of the items will be addressed at each visit
according to priority, until all items have been addressed. The APN will inform the
woman that the tool will be used to help provide care and to help the provider respond to

her needs.

57

Appendix B

Provider Guide for the Prenatal Screening Tool

The prenatal screening tool is designed for use prenatally with the single
primigravida, who is either divorced, widowed, separated, or unwed without a partner,
and who is seeking prenatal care. This definition does not include the adolescent
population under 18 years of age. The tool is designed to facilitate a more in-depth
assessment to be used as a guide to open discussion in the area of the single primigravida’s
perceived stressors. The purpose is to reduce the perceived stressors of the woman in an
attempt to prevent stressor pile-up. This tool can be used to assist in the promotion of the
woman’s self-definition and decrease the risk for poor self-care, poor pregnancy
outcomes, and poor adaptation to motherhood and parenthood. The tool is composed of
a self-administered 4-point scale for the screening of perceived stressors. Demographic
data is included directly in the tool. The tool was developed for single primigravidas to fill
out at the initial prenatal visit. The receptionist can give the self-administered tool to the
client to be completed while in the waiting room. If the woman is unable to complete the
tool at the initial visit, she may take it home and be asked to bring it back on her next visit.
The nurse can make a follow-up phone call the week of her next visit, to remind the
woman to bring it with her. The woman always has the option of refusing to complete the
tool.

The prenatal screening tool is based upon the conceptual framework, Women’s
Self-Definition in Adulthood (Peck, 1986). It incorporates categories within the social-
historical time dimensions, sphere of influence, and the self-definition. These categories
are: (a) body image, (b) developmental-psychological characteristics, (c) stereotyping,
(d) role changes, and (e) family dynamics. The questions were taken fi'om prior surveys of

pregnant women, that were found in the review of literature.

58

The completed tool is to be reviewed by the primary care provider in order to
promote the woman’s self-definition. This can be accomplished throughout the prenatal
visits. Identifying areas of perceived stressors allows for individualized focus. Space is
provided for notes.

Domogtaphio Data. This section includes questions 1-8. According to my review
of literature, this section can identify external barriers, potential caregiver barriers, and
information associated with low self-esteem, poor communication patterns with parents
and partner, depression, and an inability to plan for childbearing and childrearing. These
characteristics are generally associated with women with less than a high school education
who are unmarried, have incomes below the federal poverty level, and live in inner cities
or in isolated areas. Also identified with single motherhood and unemployment are factors
associated with social and psychological isolation. The researchers found that the process
of acknowledgment and acceptance of the pregnancy in this population was prolonged and
filled with conflict.

Body Image. Questions 9-12 address perceived stressors associated with body
image. Researchers found that this was one of the most frequent stressors identified in
pregnancy and the postpartum period. This can have an impact on the woman’s self-
definition.

Stereotyping. Questions 13-16 address stereotyping. This important area can
influence how the single primigravida sees herself within society and how she forms her
self-definition. The feelings associated with stereotyping can diminish the woman’s
perception of her ability to firnction and cope as a family, creating feelings of inadequacy,
and possibly social isolation.

Developmengl-Psychologigrl Chimeristics. Questions 17-25, and 45 identify
issues associated with this area. Research literature shows that pregnancy affects the

psychological and emotional life of the expectant mother. A strong association has been

59

observed between adaptation to this new role and marital relationships, emotional state,
and maternal confidence. Perceived stressors are associated with this area and can impact
self-definition, self-care, pregnancy outcomes, and adaptation to motherhood/parenthood.

Role Chahgos. Role changes are addressed in questions 26-32. Maternal progress
in acceptance of pregnancy and resolution of ambivalence, identifying and conceptualizing
a motherhood role, adapting to changes in close and intimate relationships as a result of
role changes, and reaching a state of preparedness for the birth of the infant is vital in the
establishment of a positive self-definition. Studies have shown that pregnant women have
a tendency to show increased concern with health and bodily functions, decreased feelings
of femininity, and decreased interest in her social contacts and activities. The
physiological factors are also included in this section as they may create barriers for the
woman in maintaining her present roles, thus being perceived as stressors.

Family mamics. Questions 33-39 address family dynamics. A family’s definition
of an event such as pregnancy, reflects partly the value system held by the family, previous
experiences in meeting crises, and mechanisms employed in previous definitions of events
(Hill, 1978; Klien & White, 1996). If the woman’s parents had a difficult time with
childbearing and childrearing, then the single primigravida may have these additional fears.
Researchers found that the importance of support from the mothers’ own mother was
essential, and additional support for single women was crucial, especially that of her own
mother (Zachariah, 1994). Ballou’s (1978) research suggested that if a pregnant woman’s
relationship with her mother was problematic, her relationship with her child may also be
adversely affected. In order to prevent the feeling of failure, the woman must have a
lifelong feeling that she is “good enough” for her mother, and not define herself as
inadequate or a “lousy human being” (Peck, 1986, p. 281). Because of the potential for
lack of support for the single primigravida due to a decrease in the nests of supporting

families, the woman may experience increased stress because she lacks someone with

60

whom to share troubles and concerns regarding pregnancy (Hanson & Boyd, 1996).
Therefore, this is an important area to screen for perceived stressors.

Self-Definition. The perceived stressors of the single primigravida may prevent the
development of positive self-definition. Questions 40-44 address self-definition issues.
These questions are not all inclusive, but were chosen as screening questions in this area
Single primigravida’s may find themselves maladapting if their self-definition is not strong
and positive (Young et al., 1990). Self-enhancement is part of self-definition that involves
acquiring beliefs about one’s values and worth during the presence of a threatening or
stressful event, such as childbirth, through mental appraisals that judge the self favorably
(Affonso et al., 1994). The goal of the APN is to help the single primigravida find ways to
cope with this new role, pregnancy and motherhood, and to identify stresses to prevent
pile-up.

The Women’s Self-Definition in Adulthood (Peck, 1986) guides the practitioner in
the incorporation of the information obtained from the prenatal screening tool. The
categories identify areas of perceived stressors that have an influence on the single
primigravida’s self-definition. These factors affect the likelihood that the woman will have
a successful transition from pregnancy and into motherhood. Anticipating certain
perceived stressors, the APN can minimize the negative effects associated with a poor

self-definition.

61

Appendix C

Prenatal Screening Tool

Congratulations on your pregnancy. Your health care provider is here to care for
you during this time of change. Among the many things to think about is how you feel
about your pregnancy, and any concerns that may be of importance to you. Please
complete the following questions about your feelings and concerns with your pregnancy.
Your answers are intended to give your health care provider information that can help
support you during your pregnancy. All responses are confidential. There are no right or
wrong answers, so feel free to tell us just how you feel. Your responses are greatly

appreciated.

62

Prenatal Screening Tool

These questions are to help your provider in providing care for you and to identify areas
that you may need help with. There are no right or wrong answers. It will be helpfirl if
you can answer all questions, even if you have answered them at another time. This will
provide a quicker way for your provider to help you.

Demographic Characteristics (Circle the most appropriate answer):

1.

What is your age? years.

2. Race

a. Caucasian

b. African-American
c. Hispanic

d. Asian

e. Other

. What level of education have you obtained?

a. less than 12 years

b. 12 years

c. more than 12 years
Are you employed?

a. No

b. Yes If yes, are you employed: full-time or part-time (please

check)

. What is your average income?

a. Under $15,000

b. $15,000 to $19,999
c. $20,000 to 29,999
(1. $30,000 or greater

. What is your marital status?

a. Single

b. Separated
c. Widowed
d. Divorced

e. Single and living with boyfriend or with significant other

Do you have health insurance?
a. No

b. Yes If yes, what type of insurance do you have?

What is your religion?

. Roman Catholic
. Protestant

. Latter Day Saints
. Christian Reform
. Other

(DO-00‘”

63

 

Indicate which statement best describes yourself by using one of the following:

(1) Almost Always (2) Some of the time (3) Hardly ever
9. I fear that pregnancy will make me feel fat and unattractive.

10. I feel not having my clothes fit means never to be the same
again.

11. I feel that I have lost control over my body since becoming
pregnant.

12. I have tried to lose weight during my pregnancy.
13. I feel that having a baby will be a happy event.

14. I feel that others will say things about me and treat me
differently because I am single and pregnant.

15. I feel guilty about becoming pregnant.

16. I am concerned about how my fiiends will react to my
pregnancy.

17. I accept my pregnancy and the changes that are occurring.
18. I am concerned with how my baby may look.

19. I wony about my baby being normal.

20. I feel I will be a good parent.

21. I have childhood memories and fears about pregnancy.

22. I have fears regarding the birth of my baby.

23. I have fears about losing my baby.

24. I feel a sense of loneliness.

25. I feel hopeful about the firture.

26. I feel that I will be tied down at home after having my baby.

27. I feel that I will have too many responsibilities and time
constraints after having my baby.

64

(4) Never

1234

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

I feel this pregnancy is going to decrease my time for
work, school, close fiiends, or other firn activities.

I have worries regarding fatigue, morning sickness,
sleep disturbances, and physical limitations since becoming

pregnant.

I have someone to share my daily worries and personal
concerns with.

I have worries about daycare for my baby.
I have close fiiends that I talk with and do things with.

I am worried about how my mother/family will react to
me being pregnant.

I get help from my mother.

I have a good relationship with my mother.
I have a good relationship with my father.
I feel that I am not good enough.

I enjoy and can talk easily with my mother.
I remember my childhood as being good.

I feel sad.

I feel good about myself.

I still enjoy the things that I used to.

I feel I have control over my life.

I feel like crying a lot of the time.

65

45. I have been worried about a lot of things since my pregnancy. (Check all that you are
worried about)

_loss of job _unemployment

_school _loss of someone I love

_money problems _loss of friends

_housing arrangements _living alone

_death of a family member _history of verbal/physical/sexual abuse
_friend/family in jail _involvement of the baby’s father
_divorce

_separation from my partner

other (please explain)

 

66

 

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