Emotional and Educational Components of Pregnancy

Behavior during pregnancy and childbirth is not as much biologically dictated as it is a result of the cultural process. In general, our society tends to treat pregnancy as a solitary, clinical event. In many nonindustrialized societies, pregnancy is invested with great religious significance. It is seen as an altered physical and psychic state to be celebrated. Birth in all cultures is a symbol for acts of creation and renewal.¹ Most societies place some importance on birth and regard pregnancy as a time when special rules apply to the pregnant woman. Often, extra physical and emotional support is given. What varies considerably is whether birth is seen as an event of illness or of normal physiology.²

Before the twentieth century, pregnancy and birth were viewed as a recurrent part of the female life cycle as well as a social and familiar event.³ Wertz and Wertz,⁴ authors of an extensive study of childbirth in America, depict birth as an important social occurrence, “a fundamental occasion for the expression of care and love among women.” In the United States, the history of childbirth can be divided into three periods. Until the late nineteenth century, birth was primarily a female affair, managed by midwives and attended by friends and relatives. From the late nineteenth century through the first decades of the twentieth century, birth was transformed into a medical event as physicians replaced midwives. This transition was complete by the 1920s, when the medical profession consolidated its control of birth management.⁵

Anticipation of either death or permanent injury was an important part of a woman's childbirth experience throughout most of American history.⁶ Hence, the belief that pregnancy was a disease was prevalent. Joseph DeLee,⁷ whom many consider the father of modern obstetrics, wrote: “pregnancy is a disease of nine months duration.” The great achievement of modern obstetrics has been a reduction in both maternal and neonatal morbidity and mortality. Modern obstetrics has also been criticized for viewing pregnancy as an illness and routinizing childbirth. Problems develop because hospitals attempt to create a homogenized birth experience for all women, despite the diversity of expecting women.⁶ This has resulted in an emphasis on education and increased involvement of the woman and her family throughout the childbearing process. Today, providers must blend advances in medical technology with the family's desire for autonomy.

Pregnancy, birth, and parenting are pivotal events in a woman's life and are considered biopsychosocial events. Once a woman has been pregnant, there is no turning back to a prepregnant psychology. The desire for motherhood appears to be based not only on an inherent biologic drive but also on identification of what is essentially female, although women do not need to have children to achieve a sense of femininity. Pregnancy is viewed as a developmental task, a time of crisis, and a critical phase by different social scientists. For many women, pregnancy is also an opportunity for growth and reworking of self-concept.⁸

All women experience pregnancy both emotionally and physically. The neuroendocrine and biologic changes that occur during pregnancy have profound psychological effects on expectant mothers.⁹ During the first trimester, a woman's feelings are related to physiologic changes (nausea, fatigue), whereas during the last trimester anxiety related to the approaching birth becomes the predominant emotion. A woman's socioeconomic status, her number of previous births, and her personality type can affect the extent of these emotions as well as her ability to cope with them.^{10, 11} Several studies have reported that pregnant women with high levels of anxiety are more likely to experience obstetric complications. Others have demonstrated improved postnatal adjustment in women with moderate levels of anxiety. The difficulty in interpreting many of these studies is the failure of researchers to differentiate between anxiety as a stable trait of personality and anxiety as a transitory emotional state.¹² Thus, the psychological elements relating to pregnancy that appear to affect pregnancy and childbirth include the personality and emotional disposition of the woman, the psychosocial background of the woman, and life events that occur during the pregnancy.¹³

Normal psychological adaptation to pregnancy and attainment of the maternal role are much less researched areas in modern obstetrics than are physiologic adaptations. Two notable researchers in the field are Newton and Rubin. In the 1950s, Newton⁹ explored maternal emotions during pregnancy and childbirth and their relation to other aspects of women's lives. At the time, the general psychological factors that were believed to affect birth focused on societal influences that prevented women from accepting labor as a natural physiologic function. Newton found that women who had negative feelings about pregnancy were more likely to wish they were men and had fewer motherly desires. Women who felt positively toward pregnancy had more motherly tendencies and were less likely to wish they were men. She also noted that feelings about pregnancy often progress from those of rejection to those of acceptance. After delivery, women who felt negatively about birth were more likely to dislike breastfeeding, avoid rooming-in care of their babies, and have fewer children. Conversely, women who had positive feelings after birth were more likely to enjoy breastfeeding and rooming-in and have more children.

Newton's research noted that women who are rendered unconscious for delivery are more likely to have negative feelings about childbirth. Her review of birth practices at that time revealed that pharmacologic methods of pain control led to more operative vaginal deliveries and depressed babies at birth. Newton became an avid supporter of Dick-Read's childbirth preparation methods and the natural, unmedicated approach to labor that was gaining popularity in the 1960s. This influence and her studies of women's responses to the birth process led her to conclude that psychological methods of pain relief were preferable to pharmacologic methods because they emphasized the need for continuous emotional and physical support of the laboring woman.

Rubin¹⁴ describes pregnancy as a time for identification reformulation, a time for reordering of interpersonal relationships, and a time of great personal growth and maturation. Pregnant women turn inward, with a subsequent reduction of attention and energy available for other tasks. In 1975, she outlined four maternal tasks necessary for women to complete during pregnancy as a prelude to motherhood. These tasks are: (1) seeking safe passage for herself and her child through pregnancy, labor, and delivery, (2) ensuring the acceptance of the child she bears by significant persons in her family, (3) binding in to her unknown child, and (4) learning to give of herself. Safe passage is associated with trying to protect the child and herself from danger. Seeking prenatal care and obtaining information about pregnancy and birth reflect the working through of this task. The second task, ensuring acceptance of the pregnancy by family, is important because it leads to acceptance of the child by significant family members who will contribute to the raising of the child. Binding in is the bond between mother and child that for some women is apparent immediately—the sense at birth of already knowing the child. Giving of oneself is the final task and marks the beginning of a mother's nurturing behavior to her child. Each task is accomplished during pregnancy in a unique manner by the individual woman and forms what Rubin calls the qualitative matrix of mothering. Not all of Rubin's publications are based on research findings and both Rubin's and Newton's research contain strong Freudian perspectives.¹⁵ Although these works are somewhat dated, they remain classics in the field and provide important insight into the psychological tasks of pregnancy and new parenthood.

The psychological responses to pregnancy are summarized in Table 1. Dunbar¹⁶ recommended that “[w]hen a physician is first consulted by a pregnant woman he should assess not only the changes in her body but also in her environment and her capacity to compensate for the stress these changes have engendered.” Simply asking “How do you feel about being pregnant?” will often elicit information sufficient to assess a woman's emotional state. The most common response to the diagnosis of pregnancy is ambivalence. A survey of a large sample of expectant mothers and fathers found two predominant and conflicting views: approaching parenthood meant both existential satisfaction and restriction of freedom.¹⁷ It is important to stress the normalcy of ambivalent feelings in pregnancy and the transition to parenthood, because it takes most women time to adapt to the changes in self-perception and life-style.¹⁸

Table 1. Psychological issues in pregnancy and childbirth

 First trimester
 Ambivalence
 Discomforts of early pregnancy
 Awaiting results of diagnostic testing
 Second trimester
 Quickening makes fetus a reality
 Physical changes make pregnancy a reality
 Process of maternal attachment begins
 Lowest incidence of physical and emotional problems
 Third trimester
 Pronounced alteration in body image and discomfort
 Fear of loss of attractiveness
 Fear, anxiety, vulnerability
 Preoccupation with birth
 Concerns for health of the baby
 Plans for child care and impact on life-style
 Third trimester (postpartum)
 Need to review the birth experience
 Acceptance of realities and outcome of childbirth
 Acceptance of infant gender, appearance, behavior
 Choices of infant feeding
 Resumption of sexual activity, family planning

(Adapted from Stotland N: Psychiatric issues. In Barron WM, Lindheimer MD (eds): Medical Disorders During Pregnancy, p605. St. Louis, Mosby-Year Book, 1991.)

The physical complaints of nausea, vomiting, breast tenderness, and profound exhaustion common for many women in the first trimester may compound ambivalent feelings and lessen the initial excitement. There also tends to be a preoccupation with self and a concern for safety that encourages most women to seek obstetric services. Women must accept the idea and reality of the pregnancy before they can accept and bond to the child to come. Nonetheless, from the moment conception is confirmed, the pregnant woman is a mother.¹⁹ As the discomforts of the first trimester pass and the mother first feels fetal movement, the baby becomes a reality. The mother begins to see the baby as an identity separate from herself and begins to feel responsible for the baby and think of herself in a maternal role. Some women feel passive or dependent and very sensitive to the attitudes and comments of others.²⁰ For most women, the feelings of ambivalence common to the first trimester tend to change to feelings of acceptance as the pregnancy progresses. At the conclusion of the second trimester, the pregnant woman has become aware of the child within her and begins the process of maternal attachment.¹⁴ Although health care providers focus on the fetus, the pregnant woman in the second trimester has a heightened sense of this living being within her, the fetus that is to be her child. Prenatal care for her is now much more focused on this child and its well-being than on herself.

Toward the end of pregnancy, a woman's emotional state is different from that in the first or second trimester. Rofe and colleagues²¹ conducted a study of 282 women and found that all women, to some degree, experience an approach/avoidance of conflict with regard to delivery. Women want the pregnancy to end, but fear of the birth process promotes anxiety. Maternal concerns focus on both self and baby, and women experience a heightened sense of vulnerability as a result of the enormous physical changes of the third trimester. Women often verbalize anxiety about the approaching labor, birth, and health of the infant, as well as concerns about their ability to mother and their partner's love and support. Some women experience insomnia and/or vivid dreams. Most questions for health care providers focus on the mechanics of labor and delivery and on the postpartum period.²⁰

An individual woman's ability to cope with the new situations and tasks of pregnancy appears related to the overall balance of past and present stresses and the process of maternal adaptation to pregnancy, birth, and parenting. The obstetric provider needs to be alert to the signs of maladaptation. Cohen²² described numerous maternal behaviors that he recommends providers screen for during the antepartum, intrapartum, and postpartum periods (Table 2). He cautions providers to be especially alert for patients who have continued faulty acceptance or nonacceptance of pregnancy beyond quickening, an inability to develop an emotional affiliation with the fetus, and an inability to perceive the neonate as a separate individual.

Table 2. Etiologic factors contributing to maladaptation

 Lack of maternal figure in woman's life
 Chronic conflict with own mother or other female relatives
 Prior birth of a child with anomalies or neurodevelopmental delays
 Chronic marital discord, especially if focused on childbearing/ child rearing
 Little or no preparation for sexual experience
 Reporting fears of having harmed the baby
 Third-trimester rejection of the pregnant state (overt or disguised)
 Absence of plans for care of baby after birth
 Inability to identify individual characteristics of newborn

(Adapted from Cohen RL: Maladaptation to pregnancy. Semin Peritanol 3:1, 1979.)

Maladaptation is also more likely to occur in the presence of psychosocial risk factors, which can be divided into social factors, psychological factors, and adverse health behaviors. Social factors associated with increased risk include low income, inadequate housing, less than high school education, a physically strenuous or potentially toxic work environment, and single marital status. Adolescence (younger than 18 years of age), communication barriers, and inadequate nutritional resources are other social risks. Psychological factors include inadequate personal support systems and coping mechanisms, excessive ambivalence about the pregnancy, living in an abusive environment, and feelings of chronic stress and anxiety. Finally, smoking, illicit drug use, alcohol abuse, poor nutritional choices, and excessive exercise are health behaviors that place women at risk for an adverse pregnancy outcome. The degree of risk associated with some factors requires judgment, because exceptions to these categorical classifications often occur.²³

Early identification requires a risk-responsive approach and allows for ongoing assessment and monitoring. Understanding a woman's emotional conflicts and establishing a positive relationship between the health care provider and the woman at risk are essential components of prenatal care, and this is often the only successful way to elicit compliance. Some women require more frequent or longer visits, adjustment of the content of the visits, and/or follow-up phone calls from the provider's office staff. Others may benefit from intervention involving a team approach, with consultations from a social worker, psychologist, or psychiatrist. Although few studies are available on intervention and outcome, a proactive approach to maternal adaptation is often more effective and economical than a reactive approach. All providers of obstetric services should incorporate preventive psychosocial risk assessment and screening into their prenatal care routines.^{22, 23} Women and their families must adapt to a multitude of changes during and after pregnancy. Physiologic changes are immense and ongoing, affecting body image, mood, and energy level. Interactions with and expectations of significant others change and can be a great source of strength or discord. Society presents many conflicting overt and covert messages about labor, birth, and motherhood to the pregnant woman. Hidden fears, preoccupations, and ambivalent feelings may surface. Women often feel vulnerable and dependent, especially primiparous women who lack prior experience with pregnancy and birth, or those women without strong female role models.²⁴ Providers must recognize the normalcy of a wide variety of emotional responses. One woman summarized her pregnancy this way: “I felt at the same time more vulnerable and more powerful than ever.”²⁵ A willingness to listen to the pregnant woman's concerns, in conjunction with providing the clinical elements of prenatal care, is essential.

Some men actually experience physical symptoms of pregnancy similar to those their partner is feeling. One study compared expectant fathers with a control group of men whose wives were not pregnant and found that the expectant fathers experienced significantly more somatic symptoms, such as loss of appetite, nausea, toothaches, indigestion, and abdominal pain, than did the control group.²⁶ Most men, however, do not experience this couvade syndrome. Fathers should be encouraged to be present at prenatal visits and should always given an opportunity to ask questions regarding pregnancy and birth. This will decrease anxiety and promote paternal participation in the birth process.

There was a dramatic change in the role of the father in the late 1960s and early 1970s. Promoting the role of husband as coach and ombudsman, women, patient advocates, childbirth educators, and consumer groups demanded more flexibility in allowing fathers and other support people to accompany women to the delivery room or operating suite if a cesarean section was necessary. Medical professionals responded to this change with various feelings of anger, neutrality, or acceptance. Hospital administrators became much more receptive to consumer demands for family-centered care as competition for these services increased and obstetrics came to be seen as an entry into the health care system. Thus, over the last 20 years, the presence of the father or support person has gone from being a rarity to being commonplace and expected. Today, very few obstetric providers would belittle the importance of having the father present to support his wife and bond with the infant. Childbirth education prepared the father or support person for what to expect during labor and how to assist the laboring woman using nonpharmacologic methods of pain relief.

Men's participation in the birth process can be described as coach (those taking an active role), teammate (those more comfortable following suggestions from the woman in labor or nurse), or witness (those who are present as a companion and witness to the birth). Men who are more comfortable in the witness role are more likely to recruit another woman to assist at the birth.²⁷ Some childbirth educators and professionals believe that perhaps too much is expected of most men—to witness the pain of a loved one and still encourage her, and to act as an advocate in the authoritative environment of most hospitals. Exploring which role the man is most comfortable assuming during birth can help the couple prepare for who they would like present for support.²⁸

Women without partners deserve special attention. They are more vulnerable and often lack adequate support systems. The single mother may be at high risk for economic, social, and physical problems. Whether the pregnancy is planned or unplanned, there are still a multitude of decisions to be faced alone. Single mothers need to be assessed for adequacy of social support during pregnancy, during delivery, and especially during the adjustment to parenthood. The patient with minimal support benefits from a consistent provider throughout pregnancy, additional labor support, and postpartum follow-up care. Single women with adequate family and friends for support are at no greater risk than are women with partners.²⁰

To support or be'with woman' during pregnancy and especially labor has been an essential component of midwifery for centuries. Support is defined as both verbal and nonverbal behavior that conveys caring and understanding to enhance an individual's ability to cope. Supportive care activities include physical comfort measures, emotional support, instructions and information, and advocacy.²⁹ As advances in obstetric technology continue to concentrate on fetal well-being, there may be a tendency among professionals to focus on the needs of the fetus at the expense of the mother, with pregnant women perceived as little more than vessels for their unborn children. Researchers and providers must not lose sight of the importance of incorporating a philosophy of caring into the services provided to mothers and children. Reviews of controlled trials of enhanced support during pregnancy showed that social and psychological support results in improved outcomes.³⁰ Women who received support during pregnancy were less likely to feel unhappy, nervous, or worried; had fewer negative feelings about the approaching birth; and were more confident about motherhood. Women assisted during labor by a laywoman called a doula (a Greek word meaning 'woman's servant') experienced fewer childbirth complications. Psychological and social support also enhances postpartum mental and physical health and prolongs the length of time women continue breastfeeding.³¹ A review of a controlled trial found no negative effects of enhanced social and psychological support.^{32, 33}

The effect of a supportive companion on perinatal problems, length of labor, and mother–infant interaction was studied by Sosa and associates³⁴ in a public hospital in Guatemala. Women in the control group received routine care. Women in the experimental group received constant support from a doula, who guided the new mothers in their infant care tasks. The experimental group had significantly shorter labors (8.8 versus 19.3 hours), were awake more after delivery, and interacted more with their babies than did the control group.

Continuous emotional support during labor at a US hospital was studied by Kennell and co-workers.³⁵ Four hundred and twelve healthy primiparous women were randomly assigned to three groups. The first received the continuous support of a doula, the second group was monitored by an inconspicuous observer who kept a record of all staff contacts but never spoke or interacted with the laboring women, and the third group served as the control. Continuous labor support reduced the rate of cesarean section (supported group 8%, observer group 13%, control group 18%) and also reduced forceps deliveries, epidural and oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever. Even an untrained observer who simply sat in the room with the laboring woman had a positive effect on the labor.

Nurses are an essential part of the labor support team, but their time is often filled with other activities, such as extensive documentation, that have little to do with labor support. One study measured the amount of time labor and delivery nurses spent at the bedside engaged in supportive care activities versus all other activities and found it to be 9.9%.²⁹ A trained doula may be appropriate for women who lack support or whose partners are more comfortable in the witness role. The doula is not meant to replace either the father or nurse but rather serves to augment labor support with her training and experience. Certified nurse-midwives consider support to be an integral part of caring for the laboring woman. They will usually provide one-on-one support from the onset of active labor through delivery.

In summary, labor support empowers women; it puts the woman, not the technology, in the foreground of the birth process.³⁶ A review of the literature clearly shows a benefit in terms of decreased interventions and cesarean sections. Few countries leave laboring women as alone as ours. Immobilizing and isolating women in labor tends to increase the fear, pain, and tension triad and leads to the increased use of pharmacologic pain relief.³⁷ Hospital routines that forbid or restrict support persons in labor must be abandoned, and every laboring woman should be allowed the supportive companions of her choosing. The challenge, as Kennell³⁵ aptly noted, is to “turn to obstetric technology only when necessary, relying instead on the practice of continuous labor support to help the birth process follow its natural, normal course.”

There is probably no other role as important or rewarding as that of educator of women and their families. From the first prenatal visit onward, education is a component of every encounter. The amount of information available to women can be overwhelming, especially to first-time mothers. A good rule of thumb is to let the woman be the guide as to what to teach when. Encourage her to carry a note pad and jot down any questions or concerns so she can discuss them at each visit.

Health education during pregnancy is important because education leads to better self-care and because women today must make informed decisions regarding both their health and the health of the fetus.³⁸ Although most obstetric health care professionals believe in the inherent importance of education, few rigorous research studies have been performed in this area. Those that exist focus on third-trimester teaching. One study asked private- and public-care women at the first prenatal visit to indicate their level of interest in 38 topics. Fetal development, nutrition, vitamins, and danger signs held the greatest interest for all clients. Public-care clients then rated forceps, when to go to the hospital, and medical tests in pregnancy as topics of interest. Private-care clients were interested in exercise, travel, and bottle-feeding information.³⁹ The challenge to providers is the great diversity of needs: different women want different levels of information regarding pregnancy and birth at different times and in different amounts of detail. Research has shown that the more information women receive, the less anxious they become, especially when nonroutine tests are ordered. Most women prefer a call or an office visit to review the results of all tests performed.¹⁸

Who should provide the extensive education desired by women? The concept of a team approach to modern health care and education has been a successful one. As medical and health knowledge increases in scope and complexity, it becomes impossible for any one provider to meet all the needs of the pregnant woman. A team consisting of physicians, nurse-midwives, nurse practitioners, nurses, social workers, nutritionists, psychologists, childbirth educators, genetic counselors, and physical therapists needs to be assembled and used as needed.⁴⁰ Every office or clinic must decide who will be responsible for the routine teaching required in each trimester of pregnancy. This varies depending on the size of the office, the volume of patients, the preferences of the provider, and the educational background of the office staff.

Ideally, preparation for childbirth begins before pregnancy during a preconception visit. Organogenesis occurs 17–56 days after fertilization, which precedes the traditional initiation of prenatal care. Preconception counseling is an excellent opportunity to provide primary care with a focus on prevention.⁴¹ Preconception counseling should be standard practice every time a health care provider sees a woman of childbearing age. Every annual gynecologic exam or episodic visit is an opportunity to assess teaching needs and evaluate risks. Components of the preconception visit are listed in Table 3 and include a detailed medical history, a physical examination, and laboratory tests. Counseling to promote healthful behavior includes nutrition and folic acid supplementation, safer sex, and avoidance of smoking, alcohol, illicit drugs, and teratogens. The need for early entry into prenatal care must be stressed.^{42, 43, 44}

Table 3. Components of preconception counseling

 Medical/obstetric risk assessment
 Genetic screening/counseling
 Vaccination/immunization status
 Understanding fertility/menstrual cycle
 Discontinuing birth control method
 Exercise
 Folic acid/vitamins/nutrition
 Sexually transmitted disease screening
 Cigarette/alcohol/recreational drug abuse
 Exposure to teratogens
 Emotional readiness

It is important to remember that only 40% of all pregnancies are planned. Even when a pregnancy is planned, many women experience a normal sense of ambivalence.⁴⁵ These feelings, coupled with the common discomforts of the first trimester, leave most women receptive to brief teaching interludes and printed materials to review at home. The new or first visit should be scheduled to last 45 minutes to 1 hour to accommodate history-taking, laboratory tests, teaching, and questions. Information can be given in print form, in a slide/tape presentation, or directly by the nurse or provider. What is taught when and by whom varies depending on the setting. A certified nurse-midwife or nurse practitioner is an ideal professional to conduct the first prenatal visit because this is a time-intensive visit that is heavily focused on teaching. The essential education elements of the first visit include answering the woman's questions, stressing the importance of avoiding teratogens, and ensuring an understanding of after-hours access for emergencies.

Table 4 provides an example of a checklist used to guide teaching during pregnancy. New clients, especially primiparas, will need to review the typical schedule of office visits. The classic visit schedule, recommended by the American College of Obstetricians and Gynecologists for women with uncomplicated pregnancies, is a visit every four weeks for the first 28 weeks of pregnancy, every two weeks until 36 weeks, and then weekly until delivery.⁴⁶ The average American woman who follows this recommendation is seen 13 times by her health care provider. Women with complicated pregnancies require closer surveillance and are seen at intervals determined by the nature and severity of the problem. However, a number of authors have found that reducing the number of visits does not compromise perinatal outcome or patient satisfaction. Stressing the importance of prenatal visits, but allowing flexibility for patient needs, especially in the low-risk population, is crucial.^{47, 48} Women often have questions or concerns that arise between scheduled office visits. They should leave the first visit with permission to telephone with these concerns and guidelines on how to best access the appropriate provider. It is also helpful to conclude the first visit with references for some of the excellent lay literature on pregnancy and childbirth.

Table 4. Prenatal teaching checklist

 First trimester
 Choice of provider
 Frequency of visits
 Toxoplasmosis precautions
 Nutrition/weight gain/vitamins
 Caffeine/alcohol/smoking/substance abuse
 Work/exercise/sex/travel
 Genetic screening tests
 Common discomforts of pregnancy and relief measures
 Over-the-counter medication
 Emergency telephone numbers/when to call
 Suggested reading list or bibliography
 Second trimester
 Prepared childbirth classes
 Routine testing
 Common pregnancy discomforts and relief measures
 Premature labor warning signs
 Rh factor (if applicable)
 Third trimester
 Changes in fetal movement
 Labor signs and symptoms
 Touring the birth facility
 Birth plans/cord blood donation
 Perineal massage technique
 Pain management options
 Infant feeding
 Choosing a pediatric provider
 Basic newborn care
 Circumcision
 Sibling preparation
 Infant CPR/child safety/car seat
 Insurance and length of stay
 Postpartum family planning

After the first visit, education in the first trimester focuses on testing and health behaviors. Genetic testing options and/or referral to a genetic counselor after the first visit will depend on the woman's age at delivery, family history, past obstetric history, and personal preferences. Use of over-the-counter and prescription medications should be discussed in detail with all patients. Fetal alcohol syndrome is the leading cause of preventable mental retardation in the United States today. Because the minimum safe level of alcohol during pregnancy is unknown, current guidelines recommend that women abstain from alcohol during pregnancy and lactation. Cigarette smoking has been associated with first-trimester pregnancy loss, placental abnormalities, and low birthweight. Street drugs, especially cocaine, have been linked with numerous adverse outcomes. Although many women are aware of the dangers of substance abuse, it is important to counsel women and to document counseling as well as follow-up.

With many of the discomforts of the first trimester alleviated, the second trimester becomes an ideal time for education. Because women feel better and are more physically active in the second trimester, questions regarding exercise, diet, and weight gain are common. Women need information on childbirth preparation classes and should be encouraged to register and begin classes by 26–30 weeks' gestation. Many locales now offer expectant grandparents classes to discuss current approaches to childbirth and breastfeeding as well as the special role grandparents play in the developing family. Premature labor warning signs should be explained to all women in the second trimester. One survey found that almost one half of women questioned did not know how many weeks constituted a term pregnancy, and one third did not know that infants born prematurely could have significant health problems.⁴⁹ Considering the enormous societal costs of premature labor and birth, this aspect of prenatal education must not be overlooked.

As their due date approaches, women have questions and concerns regarding labor, delivery, and the postpartum period. All clients should be given written and verbal instructions that include the signs and symptoms of labor, when to notify the provider, and where to go for delivery. Selection of a pediatrician and preparation for a 24- or 48-hour stay after a vaginal delivery should be discussed. Many couples will write a birth plan to outline their preferences for the labor and delivery staff. It is imperative that the provider discuss the birth plan at a prenatal visit. If there are any controversial issues, a dialogue can take place between the couple and the provider. This prevents conflict in the labor and delivery suite, resulting in a safe and satisfying birth experience for both family and provider.

The alternative birth movement can be viewed as a consumer protest to the mechanistic and paternalistic obstetric practices that developed in the United States at the turn of the century.⁵⁰ The natural childbirth movement converged with emerging feminist and consumer movements in the late 1960s and early 1970s. Women increasingly questioned obstetric routines and demanded choices in providers, location of birth, and nonpharmacologic alternatives for pain relief. A study of over 2000 women found that desires for the childbirth experience were relatively simple: husband (or significant other) present during labor and birth, support and cooperation from hospital staff in using prepared childbirth techniques, assistance and encouragement for breastfeeding women, unrestricted access to the newborn, and sibling visitation. All of this has become the mainstay of revamped maternity units across the country.⁵¹ Additionally, in North America there has been a growing interest in alternatives to the traditional hospital birth, such as home birth or free-standing birth centers. Studies exploring women's preferences for alternative styles of birth yielded the not surprising finding that families may be dissatisfied with the technological features of conventional hospital obstetrics.¹⁸ Consumer demands have forced providers to rethink practices such as the routine withholding of food and drink in labor, the use of intravenous fluids, performing an episiotomy, the restriction of position and movement, and forced expulsive efforts in the second stage of labor. There is continued evidence that many of these obstetric routines used in the past are no longer necessary or indicated in every woman and may lead to iatrogenic complications.^{52,53,54,55,56}

Today, prepared childbirth means the woman's knowledgeable, active participation in the natural process of childbearing; it does not mean childbirth without pain or medications.⁵⁷ In the 1930s, Dick-Read³⁷ coined the term “natural childbirth” and introduced the concept of prenatal education to remove fear and decrease pain and anxiety in labor. In the 1940s, the role of father as coach to the laboring woman became popular and was taught by way of the Bradley method. Psychoprophylaxis originated in the Soviet Union from concepts based on Pavlov's theories and was introduced in the West by Lamaze. Lamaze become popular in the United States in the 1960s and stressed the importance of breathing and relaxation. There is tremendous variation in the content and emphasis of prepared childbirth classes currently taught in the United States. Evaluation of the effectiveness of these classes has been difficult because of discrepancies in content, attitude, and style of instruction, all of which complicate the design of well-controlled trials. However, there does appear to be some reduction in the amount of analgesics used in labor and an increase in overall satisfaction with the childbirth experience for those women who participate in prepared childbirth classes.⁵⁸

Critics of psychoprophylaxis and alternative birth choices charge that the ideal of “natural birth” dooms many women to failure, because not everyone will have an uncomplicated birth or feel positive or transformed after delivery. Women may blame themselves if their experience fails to be the one they fantasized about or were told would occur if they took classes and relaxed.⁵⁰ Assisting women to prepare for a variety of birth experiences with flexibility is the art of childbirth preparation. Women need to be taught that they are consumers who have every right to critique and question information given to them in classes, in books, and from other couples. Providers should encourage couples to discuss birth issues of concern and explain the considerable debate regarding interventions during labor and birth. Decisions should be made jointly based on clinical judgment and individual philosophy. Providers must be well versed on the content of various classes, as well as on the expertise of individual childbirth educators, to ensure appropriate referrals.

The postpartum period is perhaps the most neglected aspect of modern maternity care. This critical time for mothers and infants has been the most vulnerable to the draconian cost-cutting measures in health care. In the United States, early discharge has become a universal policy for low-risk women, and research has shown that it can be safe for some women.⁵⁹ However, providers and researchers agree that screening for normal and abnormal postpartum adaptation can be hampered by early discharge programs. Infant readmissions after discharge before 48 hours are increased; the major morbidity is hyperbilirubinemia. The impact of this on maternal–fetal attachment and breastfeeding has been poorly studied.⁶⁰ Home health care visits postpartum may decrease the problems associated with early discharge but are not routinely covered by insurance companies in the United States. In the Netherlands, women are visited daily by a health care professional for five days; in the United Kingdom, women are visited for 10 days after delivery.⁶¹ A move away from a fixed postpartum length of stay to a flexible approach based on a woman's individual circumstances and desires is preferable because length of stay may be less of a concern to many women than the quality of postpartum care they receive.¹⁸ A two week office visit,  before the traditional 6-week postpartum check may be appropriate for those women at medical or psychosocial risk. For all women, home health or lactation consultant visits, community and support group referrals, and follow-up telephone calls are strategies providers can use to facilitate adaptation during the postpartum period.

Although the physical and emotional changes of pregnancy occur gradually, the changes that occur postpartum are abrupt and can be a source of disequilibrium to many women (see Table 1). Four tasks or needs of the postpartum period have been described. The first is the need for physical restoration of the mother. Second, women need to become competent in caring for the infant. Establishing a relationship with the newborn is third. Finally, life-style and relationship alterations occur that facilitate incorporating the infant into the family.⁶² Facilitation of these tasks requires physical care and education. Exhaustion and physical discomforts complicate the teaching process postpartum. Educational components include maternal physiologic changes, care and feeding of the newborn, follow-up care for mother and child, contraceptive choices, and when to call the health care provider. Resumption of sexual intercourse and exercise are often overlooked. Instead of relying on fixed teaching checklists and classes, it is important to ask women what information they need and desire.

Many mothers describe intense feelings of exhilaration and pride after giving birth coupled with an initial lack of real affection for the baby. Facilitating bonding to the newborn remains the primary goal of postpartum care. Bonding refers to the process immediately after birth in which the mother attaches to her infant. Bonding research and theory is most often associated with the work of Klaus and Kennell in the 1960s.⁶³ Activities that facilitate bonding include skin-to-skin contact, suckling, mutual visual regard, and touching. There is no evidence supporting the long-standing policy of separating well infants from their mothers at birth. Evidence does exist that restrictive policies are undesirable and lead to breastfeeding failure and adversely altered maternal behavior. Any institutional impediment to maternal/infant contact after delivery is unacceptable.⁶⁴

Attachment is defined as a gradual, reciprocal relationship that is influenced by psychological variables such as the timing and pacing of encounters.⁶⁵ Temporary delays in attachment have not been associated with long-term effects on the baby, but children who suffer from an ongoing lack of maternal attachment are at risk for failure to thrive, stunted emotional and cognitive development, and abuse. Disorders of the mother–infant relationship are reported in about 10% of all births and range from delayed attachment to infanticide. In primiparous women, about 40% experience mild detachment and negative feelings that gradually increase in strength during the postpartum period. In severe disorders, the mother may express disinterest in her infant and may neglect and/or fail to interact with him or her. Prior psychiatric disorders, cultural and social factors, a woman's own inadequate mothering, a difficult birth, and the presence of a congenital anomaly can contribute to delayed attachment. Mild delays in attachment usually resolve within the first weeks postpartum; some women benefit from support groups or counseling. Hostility or obsessional thoughts toward the baby necessitates immediate referral for psychotherapy, possible pharmacotherapy, and, occasionally, joint hospitalization of mother and infant.⁶⁶

Maternity blues or postpartum blues is a common transitory condition occurring during the first 10 days after delivery. The incidence ranges from 50–70%. Typically, crying, low spirits, and emotional lability are described 3–4 days postpartum and peak on day four or five. Exhaustion, irritability, a feeling of unreality or depersonalization, a lack of affection for the newborn, and hostility toward the father have also been reported. No clear correlations have been established between postpartum blues and various psychosocial, biologic, and obstetric factors. Many multiparous women complain of experiencing the blues with each pregnancy. Treatment is based on reassurance and support. Women should be evaluated if symptoms worsen or persist longer than two weeks. Screening all women postpartum with a validated tool, such as the Edinburgh Postnatal Depression Scale, is recommended.⁶⁷ Screening, and ongoing discussion of normal and abnormal adjustment, allow for interventions and stategies to support a woman's transition to motherhood.⁶⁸

Postpartum depression commonly presents 3–6 months after delivery. The incidence of postpartum depression is 10–15%. The blues may have continued, or the woman may report a symptom-free period before the onset of despondency, emotional lability, feelings of guilt and inadequacy, anorexia, and sleep disturbances. Women may worry excessively and describe themselves as bad mothers. A personal or family history of depression, a lack of familial or social support, and the occurrence of multiple major life events around the time of delivery predispose women to postpartum depression. Treatment involves psychotherapy and antidepressants. Postpartum depression usually lasts several months, and women with this diagnosis are more likely to experience future episodes of depression.⁶⁶

All pregnancies carry with them an element of uncertainty, and this uncertainty is heightened with the diagnosis of a high-risk pregnancy. The woman's reaction to the diagnosis depends on her coping skills and reactions to past stressors. A woman's self-esteem is affected by this diagnosis, and she may feel as if she has failed as a woman and a mother. This injury to self-esteem makes negotiation of the emotional and developmental tasks of pregnancy all the more difficult.⁸ It is essential that providers consider the psychological, social, and economic impact of a high-risk pregnancy on both the woman and her family. Special educational needs, standard childbirth preparation and preparation for more invasive monitoring or a cesarean birth, and the risks of preterm birth must be discussed.

Most women diagnosed with a high-risk pregnancy manage fairly well. Wolreich⁶⁹ hypothesizes that this adjustment is facilitated by several factors particular to pregnancy. Feelings of dependency and the normal passivity and regression of pregnancy make the heightened scrutiny more tolerable and facilitate compliance. Women are often comforted by the time-limited nature of pregnancy, knowing the end is in sight. However, prolonged hospitalization or bed rest and home health care are inherently stressful for the woman and her family. Recommendations to assist the family include: tours of the neonatal intensive care unit, meetings with pediatric specialists, early psychosocial screening and assessment of adaptation, modified hospital routines that promote autonomy and independence, and continued contact with the primary care provider if the patient was transferred to a tertiary care facility. Flexibility, added support, and the patient's involvement in all aspects of her treatment are essential components of the emotional care of high-risk women.²⁴

Although beyond the scope of this chapter, the possibility of an adverse outcome must be considered. Pregnancy loss is an obstetric responsibility, and the primary provider must coordinator short- and long-term care for affected families. Several publications outline in detail the medical and psychological care recommended for families experiencing a pregnancy loss.^{70, 71}

In summary the authors would like to concur with Oakley, who stated: “human communication may contribute more to the health of women than obstetric technology.”⁷² Although tremendous technological advances have occurred in obstetrics in the last century, the emotional and educational needs of pregnant women have often been neglected. The challenge for the next century is to recognize the importance of individualized education and emotional support for pregnant women and their families. Only then will providers be able to develop true partnerships with women. What is needed is a partnership in which power is shared, and acknowledgement that all health care decisions involve consideration of not only the physical ramifications but also the emotional and social consequences. Birth practices in the twenty-first century must reflect the best of these efforts, as we continue to seek a balance between technology and humanity.