- Email: [email protected]
Childbearing experiences of abused Hispanic Women1
CHILDBEARING EXPERIENCES OF ABUSED HISPANIC WOMEN Kathie Records,
RN, PhD
and Michael Rice,
ABSTRACT Previous research has documented that abused childbearing women have longer and more difficult labors than non-abused women. Prevalence of abuse differs depending on the ethnic group involved. Hispanic women experience higher rates of abuse and endure higher rates before reporting abuse than do Caucasian women. The purpose of this study was to explore the experience of childbearing for abused Hispanic women to provide guidance for clinical practice and further research. Cognitive dissonance theory guided the study. A sample of seven abused Hispanic women was recruited from a rural prenatal clinic. Criteria for selection of subjects included self-identification as Hispanic, less than 24 months postpartum, disclosure of abuse status, and willingness to be interviewed in English or Spanish. An acculturation scale and demographic form were completed. Interviews were conducted individually, and data were analyzed by using Van Kaam’s 12-step psychophenomenologic technique. Findings indicated that subjects experienced the normal responses associated with having a baby. However, the women also demonstrated a kindled neuroendocrine trauma response that was based on, and often similar to, their prior abuse experiences. The kindled emotional response was triggered by the normative events of childbearing. Understanding of the childbearing experiences of abused Hispanic women will facilitate the development of culturalspecific interventions that may ease the difficulties associated with birth for these women. J Midwifery Womens Health 2002;47:97–103 © 2002 by the American College of NurseMidwives. INTRODUCTION
It is estimated that 8 –12 million women are at risk for abuse at some time during their lives (1). In 1994, nearly 4 million women in the United States were physically hurt by their husbands or boyfriends (2). In Washington State, 20% of all women seeking emergency hospital care were suffering from domestic violence injuries, 53% of the women in a chronic pain clinic had been abused, and domestic violence resulted in more injuries than rape, auto accidents, and mugging combined (3). Furthermore, abuse rates are higher during childbearing compared with other periods of a woman’s life. Current estimates for abuse during pregnancy range from 0.9 to 25% (4,5). A study of 199 abused women Address correspondence to Kathie Records, PhD, RN, Intercollegiate College of Nursing, Washington State University College of Nursing, W. 2917 Ft. Wright Dr., Spokane, WA 99224-5291. The Association of Women’s Health, Obstetric, and Neonatal Nurses awarded this project their Outstanding Clinical Research Poster award at their 2001 Convention.
ARNP, PhD
revealed 30.2% of the women were abused during the year before, but not during, pregnancy (6), making them at high risk for further abuse during the postpartum period. A population-based study of 12,612 mothers of newborns revealed that physical violence toward women was 4.1 times more likely to occur if the pregnancy was unwanted or mistimed than for women with intended pregnancies (7). Researchers (8) have reported that women face a higher risk for violence postpartally (25%) than they do prenatally (19%). During pregnancy, abused women have been found to have higher levels of depression, increased smoking and illicit drug use, poor weight gain, more spontaneous and therapeutic abortions, and earlier age at first pregnancy (5,9 –13). Studies of the labors of abused women have not been as conclusive. Qualitative reports describe a different laboring style for abused women. Observations and interviews with survivors (n ⫽ 7), midwives (n ⫽ 5), and labor and delivery nurses (n ⫽ 3) in one study yielded descriptions of four labor styles unique to sexual abuse survivors (14). Survivors demonstrated fighting, taking control, surrendering, or retreating behaviors during labor. Quantitative studies present conflicting findings of longer labors for survivors of childhood sexual abuse (15), longer labors and higher narcotics usage during labor for physically and sexually abused women (16), and no differences in length of labor for childhood survivors of sexual abuse compared with non-abused women (17). A National Institutes of Health Panel (18) reported that there is a paucity of information on Hispanic individuals with regard to their involvement in aggressive and violent behavior, either as victims or as agents. McFarlane et al (6) reported study results indicating that 51.8% (n ⫽ 199) of African American, Hispanic, and White non-Hispanic women sampled were abused before and during pregnancy, but found no prevalence differences by ethnicity. A study of the severity of abuse to 329 pregnant Hispanic women revealed that 80% had been shaken or roughly handled, 71% pushed or shoved, and 64% slapped on the face and head (19). Abuse prevalence and acculturation have been well explored in the literature. Jasinski (20) used the 1992 National Alcohol and Family Violence Survey and found that generational status was the only measure of acculturation that consistently predicted wife assaults. Using the same database, other researchers have found that the
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most highly acculturated Hispanics had the highest rates of wife assaults (21). Researchers have also found significant differences in attitudes toward traditional family structure, with abused women having more of a traditional view than non-abused women (22). Torres (23) studied similarities and differences in the manifestation of wife abuse between Anglo and Mexican American women. Mexican American women perceived fewer types of behavior as abusive and held a more tolerant attitude toward abuse than did their abused Anglo peers. Other researchers have found that despite differences in acculturation, familism remains the dimension most distinct to this population (24). Because most of the abuse takes place within family systems, the cultural tie to that same family system is an important influence. Lacking in the literature are studies that explore the experience of childbearing for abused Hispanic women. Problem Statement The purpose of this psychophenomenologic study was to explore the experience of childbearing for abused Hispanic women. Understanding of the meaning of the childbearing experience for abused women obtained through qualitative methods may provide guidance for clinical practice and research with this population. METHODOLOGY
Design The psychophenomenologic method was developed by Van Kaam (25) to “describe and analyze scientifically the psychological structures of human experience.” Originally created in the 1960s, this progressive method allows the researcher to identify the impressions, structural elements, integral structure, situational reflection, hypothetical identification, and, finally, paradigms of the subjects’ lived experiences. The data were collected and analyzed by Van Kaam’s 12-step procedure (25). See Table 1. Data collection ended when no new themes emerged and saturation was achieved. Three validity indicators are built into the phenomenologic method. In steps 5, 10, and 11 of the process, the researcher’s interpretations of the data were submitted to a panel of research experts for validity checks. Two doctorally prepared maternity and women’s Kathie Records is an associate professor at the Intercollegiate College of Nursing, teaching childbearing theory and clinical, research, and family nursing. She has current practice experience with labor and delivery patients. Michael Rice is an associate professor at the Intercollegiate College of Nursing and director of the Medically Indigent Rural Access program. He maintains a private practice as a psychiatric nurse practitioner.
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TABLE 1
Van Kaam’s Psychophenomenologic Method 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Read each situational description carefully Re-read through the descriptions with another mind-set Reduce subject statements Deduce the probable meaning of the structural elements List compatible and incompatible statements Methodologic phenomenologic reflection Consider possible elements of the integral structure Psychophenomenologic situational reflection Translate and transpose into the language of the profession Submit translations to judges Produce the paradigm of the experience Clearly state the insights gained and the limitations
health researchers and one doctorally prepared psychiatric nursing researcher comprised the panel and assessed validity. As an additional internal validity indicator, the initial situational reflection (step 8) was presented to four of the subjects to ascertain if they felt the understanding was representative of their experience. A glossary of terms is provided in Appendix A. Procedure Abused women were recruited from a prenatal clinic serving a predominately rural and Hispanic population in the Pacific Northwest from January through April 2000. Criteria for selection of subjects included ethnic selfidentification as Hispanic, birth of a live infant within the past 24 months, disclosure of previous or current abuse status to health professionals during prenatal or postpartum care, and willingness to be interviewed in English or Spanish. The study was approved by Washington State University’s Institutional Review Board, and informed consent was obtained before the interviews from all subjects. Two interviewers were trained following Van Kaam’s approach (25). Both interviewers were nurses. One interviewer was English-speaking only, whereas the other was bilingual in Spanish and English. Cuellar’s acculturation scale (26) and a demographic form were completed. See Appendix B. Interviews were conducted individually in a private room in the clinic or in the subject’s home. The general question of “In what ways did your life experiences influence your labor, delivery, and postpartum periods?” started the interviews. A semistructured interview guide was used to solicit information about the labor and delivery process, invite subjects to reflect on past experiences they felt were relevant, and provide an opportunity for them to share their birth stories. Probes such as “Tell me how you felt emotionally during your pregnancy” and “What life experiences do you think influenced your postpartum period” were used.
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Interviews continued until saturation occurred. Data were analyzed by using Van Kaam’s 12-step psychophenomenologic technique (25).
TABLE 2
Physiologic Kindled Response Maternal physical distress (n ⫽ 6)
Sample Seven women agreed to participate in the study. Five were bilingual in English and Spanish, whereas two were Spanish-speaking only. The age of the subjects ranged from 20 to 28. Two of the subjects were single, three were married, one was divorced, and one was living with a significant other. Two of the subjects had one child; five of the subjects had two children. None of the subjects had experienced spontaneous abortions, and one subject had a therapeutic abortion. One of the subjects had completed the 8th grade, five had completed grades 9 –12, and one had a college education. None of the subjects were currently in abusive relationships. Four of the subjects were first, one was second, and two were fourth generation in the United States. Subjects enrolled in prenatal care for the most recent pregnancy at 16 weeks (SD ⫽ 10.13, range 8 –33 weeks). Medical record abstraction revealed that during pregnancy, two subjects had preexisting physical illnesses and two had pregnancy related illnesses. None of the subjects had a previous psychiatric diagnosis. One subject had a vacuum-assisted delivery, whereas two had cesarean sections. Infant Apgar scores at birth were no lower than eight. Infant birth weight ranged from 5.5 to 9 lb. RESULTS
Analysis of the acculturation scale indicated that the subjects did not identify with either the Mexican or Anglo cultures. Yet, all of the subjects scored within 1 SD of the mean scores for all of the subscales of acculturation. The subjects indicated that they had a higher level of Mexican marginality (mean ⫽ 13.3, SD ⫽ 2.37) followed by Mexican Anglo marginality (mean ⫽ 12.25, SD ⫽ 3.86) and Anglo marginality (mean ⫽ 10.2, SD ⫽ 1.28). The subscale scores indicated that there was a strong relationship between the level of Mexican marginality and the number of pregnancies (r ⫽ .889, P ⬍ .02). The scores also indicated that as the number of generations in the United States increased, the number of physical illnesses associated with pregnancy decreased (r ⫽ ⫺.889, P ⬍ .002). Alpha for the acculturation scale was .86. Phenomenologic analysis revealed four basic experiences of the subjects. First, a physiologic kindled response occurred during labor. Both maternal and fetal physical distress were evident. Theresa, a single 22-yearold mother born in Mexico, stated that “the postpartum is more painful than the delivery when the baby got down
Fetal distress (n ⫽ 2)
They told me “You’re gonna feel a little cramp” and I felt like a heap of people had kicked me. Something was lacking in the medication. The pain was terrible all the time. Can’t push. She was turned around and then, go back and turn her around, and then the umbilical cord was wrapped around her. His heart rate went down. My baby was too big.
there . . . [you] feel more with your first child.” Maria at 20 years of age was having her second child. “I panicked because I was in such pain with my first one, so I thought everything was gonna go smooth (this time), but then it started hitting my butt bone and was coming faster and faster and I panicked.” See Table 2. Although pain is expected to some extent during labor, all of the subjects reported pain that was severe and unrelenting, even several months in retrospect. Second, the social context was important to their experience. They defined the social context as consisting of supportive and unsupportive family interactions and behaviors. See Table 3. Family support was described by Rosa, a 28-year-old woman born in Mexico and mother of a 6-year-old girl and newborn son. “Happy, because I say, thanks to God I have my son, now with my husband, my little girl . . . we are together. But sad because one is
TABLE 3
Social Context Supportive family states (n ⫽ 5)
Unsupportive family states (n ⫽ 5)
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Everyone was there that I wanted. I could turn around and there was my mom and sisters, his mom, you know . . . whoever was there. They were all being supportive. There’s a lot of people that tell me, you know, its gonna be OK, the baby’s gonna be OK. My parents were always there for me . . . so was my fiance´ e. I couldn’t laugh; I couldn’t greet anyone. I have two sisters who have babies and they told me it was hard . . . , its going to be bad. He put a lot of pressure on me. I was always scared of her face . . . we were never friends, we were enemies.
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TABLE 4
TABLE 5
Normative Emotional Response
Kindled Hyperemotional Response
Scared (n ⫽ 7)
Depression (n ⫽ 6)
Worried (n ⫽ 7)
Scared if he was OK or not. I was afraid of surgery. It was the needle [epidural]. I wasn’t ready to be here yet—worried a lot about my job and whether to pay a babysitter all the little things and I can’t just walk out the door by myself, now I have to pack the whole house and now I have somebody to worry about for the rest of my life. I worry because I don’t want her to get sick at my breast.
far from the family one loves . . . from her mother . . . from her father . . . from her brothers.” The geographic separation from the family of origin was also voiced by Michelle, a 22-year-old mother of one. “I wanted that my mother would have been here. Close? Yes.” Unsupportive families were perceived as placing pressure on the woman, particularly through relaying expectations regarding the difficulty of childbirth. “Someone who is close says ‘Oh you poor one’ and then she feels worse” (Michelle). Bobby’s sisters told her “it (labor) was hard . . . it’s going to be bad.” Subjects described abuse from family members or partners as a significant contributor to their experiences during childbearing. Bobby, a 24-year-old mother of one, described her memories of her mother that were foremost in her mind during childbearing and still haunt her as she looks at her 2-month-old baby. “My mom didn’t show me love, and with a brush she’d spank me . . . I was big scared like . . . she’s going to beat me here tonight . . . like she’s really going to kill me. I could never trust her.” Third, a normative emotional response occurred. See Table 4. Women described being afraid for the health of their infants, of pain, and of medical procedures. Rosa described “the fears one has . . . because of what’s going to happen? What can happen with an infant? What is so very good, is that, it is logical that the pains that one has, well that one is scared.” They worried about their changed role. These experiences are normative in that most, if not all, women experience these feelings during childbearing. For this sample, however, the normative responses served as emotional triggers for a kindled hyperemotional response. Finally, the women in the sample all experienced the hyperemotional kindled response during which depression, anxiety, and/or panic were the predominant descriptors. See Table 5. The childbearing experiences, combined with distance from family and expectations of pain during birth, were reminiscent of their previous abuse experiences as children and adults. Indeed, even with
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Panic (n ⫽ 5) Anxiety (n ⫽ 4)
I would start crying when I looked at her because I didn’t get the feeling. I felt bad. I was sad and crying. I was distanced from my family. To be surrounded in the depression. I didn’t spend too much attention in the beginning (on the baby) because I was out of it. I was panicking. The pain was out of control. A million things pass through my head. Just seeing everyone’s expression, I knew something was wrong. I took my baby to a neighbor and he was crying and I didn’t know what to do. I was so nervous, . . . I didn’t know what to do. I was always on the defensive.
presentation of their new infant, some of the subjects were unable to celebrate its birth. Michelle described how her depression occurred. “I felt fear . . . because one doesn’t know what you have to do, how to educate, how they get when they are sick, . . . like it’s an encounter of ideals in one’s head of that love . . . one has to . . . to get depressed a little. When I get depressed, I get very depressed. I tried to tranquilize that feeling because if not, I would be in a very bad place.” Several women, months after birth, reported that they knew they should be happy but still felt that something was not right. They watched others revel in the joy of their infants and felt isolated emotionally. Implications Although the sample size was small, one of the goals of qualitative methods is to describe the experiences of participants so that health care providers have a better understanding that can be incorporated into care for clients. Knowledge about previous abuse experiences and a deeper insight into how abused pregnant women tend to view the world are directly relevant to health care providers. Information gleaned from this study will facilitate the development of culture-specific interventions that may ease the difficulties associated with the childbearing period for these mothers. Familism is important for Hispanic women (24). Communication about the labor process among family members, particularly female members, is a developmental need during pregnancy. However, communication within some of these Hispanic families was focused on the difficulty of the birth experience and how painful it would be. This was perceived by
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some of the mothers-to-be as non-supportive and conflicted with their inherent belief in familism. The acculturation level of families and individuals should be attended to as well, because there is some evidence to suggest that familism changes with increasing contact with U.S. mainstream culture (24). Cognitive dissonance theory (27) adds meaning to the phenomenologic analysis. Previous research has shown that abused women attempt to decrease the conflict between their value on commitment and their abuse experiences by remaining hopeful that their partners will change (28). For the women in this study, conflict was also evident during the kindled hyperemotional response (29) when mothers were unable to give to their infants as they believed they should. Interventions must be directed toward decreasing the conflict experienced. Cultural understanding of the meaning and experience of physical illnesses for this population needs to be gained by prenatal care providers. The women who have been in the United States the shortest period of time reported significantly more physical illnesses to their health care provider. This could be indicative of the subject’s needs for care that are not entirely met within the Anglo system of health care. Few clinics integrate the participation or valuing of native healers with their practice, resulting in a gap in quality of care for populations who consider this integration requisite. Abused women may be at a higher risk of receiving an operative delivery. The women in this sample had a cesarean section rate of 28%. The statewide average for cesarean sections among Hispanic women is 15% (30). Other interventions, such as relaxation or counseling, may be more effective at decreasing surgical risk while addressing the underlying problem of kindled trauma response. Further research needs to be accomplished to explore the physiologic implications of abuse during the childbearing process. All of the women solicited for this study had a history or current experience with abuse. However, the abuse in the general population continues to be an area needing more rigor in both assessment and evaluation. Recently, the Centers for Disease Control and Prevention (31) produced systematic reviews of the literature on violence during pregnancy, focusing specifically on prevalence, measurement, and outcomes (4,7). The report clarifies definitions of and measurement periods for violence during and around the time of childbearing. Recommendations include interview assessments repeated during the prenatal and postpartum periods to maximize abuse disclosure probability. Biophysical measures of abuse are in development (32). The subjects in this study described the effect of their life experiences, including histories of abuse, on their delivery and postpartum experiences. The combined recall of trauma events and the labor and delivery
experience provided the foundation for their sadness and isolation in the postpartum period. Seng and Hassinger (33) explain this experience as “a contextual factor that can have a powerful potentially damaging impact. . . .” These “emotions, sensations or experiences that resemble aspects associated with abuse can serve as triggers that kindle a post-traumatic stress response” (33). Abused women may need additional support and guidance during childbearing to decrease the potential for postpartum depression. SUMMARY
Research and practice in the area of abuse are an important focus. As the women in this study described, contextual factors have implications for the family far beyond the period of childbearing. Abused Hispanic women describe depression, anxiety, and panic in addition to the normal childbearing experiences. Women reported supportive and unsupportive family interactions that reminded them of their past abusive experiences as they proceeded through pregnancy and the postpartum period. Additional studies with larger samples must be completed to gain a broader understanding of the role abuse plays in the entire childbearing process.
Grant support: Carl M. Hansen Foundation and the Intercollegiate College of Nursing. Dr. Records and Dr. Rice received the Outstanding Clinical Research Poster Award from the Association of Women’s Health, Obstetric, and Neonatal Nurses, 2001.
REFERENCES 1. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800 –2. 2. Warshaw C, Ganley AL, Salber PR. Improving the health care response to domestic violence: a resource manual for health care providers. San Francisco: Family Violence Prevention Fund, 1995. 3. Washington State Coalition Against Domestic Violence Report. Washington State Department of Social and Health Services. Olympia: Office of Research and Data Analysis, 1997. 4. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996; 275:1915–20. 5. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323– 8. 6. McFarlane J, Parker B, Soeken K, Silva C, Reed S. Severity of abuse before and during pregnancy for African American, Hispanic, and Anglo women. Nurse Midwif 1999;44:139 – 44. 7. Gazmararian JA, Adams MM, Saltzman LE, Johnson CH, Bruce FC, Marks JS, et al. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85:1031–38. 8. Geilen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med 1994;39:781–7. 9. Esperza DV, Esperat MC. The effects of childhood sexual abuse on
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minority adolescent mothers. J Obstet Gynecol Neonatal Nurs 1996;25: 321– 8. 10. McFarlane J, Parker B, Soeken K. Abuse during pregnancy: associations with maternal health and infant birth weight. Nurs Res 1996;45: 37– 42. 11. Webster J, Chandler J, Battistutta D. Pregnancy outcomes and health care use: effects of abuse. Am J Obstet Gynecol 1996;174:760 –7. 12. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc 1993;149:1257– 63. 13. Torres CS. Battering during pregnancy: an exploratory study. Dissertation, Doctorate of Education, University of Rochester, Rochester (NY), 1992. 14. Rhodes N, Hutchinson S. Labor experiences of childhood sexual abuse survivors. Birth 1994;21:213–20. 15. Jacobs JL. Child sexual abuse victimization and later sequelae during pregnancy and childbirth. Child Sexual Abuse 1992;1:103–12. 16. Records K, Rice M. Abuse and labor progression. Toronto, Canada: Conference proceedings of the International Research Utilization Conference, 1998. 17. Benedict MI, Paine LL, Paine LA, Brandt D, Stallings R. The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes. Child Abuse Neglect 1999; 23:659 –70. 18. National Institutes of Health. Report of the panel of NIH research on antisocial, aggressive, and violence-related behaviors and their consequences. Washington (DC): National Institutes of Health, 1994. 19. Wiist WH, McFarlane J. Severity of spousal and intimate partner abuse to pregnant Hispanic women. Health Care Poor Underserved 1998; 9:248 – 61. 20. Jasinski JL. The role of acculturation in wife assault. Hispanic Behavi Sci 1998;20:175–91. 21. Kaufman KG, Jasinski JL, Aldarondo E. Sociocultural status and
incidence of marital violence in Hispanic families. Violence Victims 1994; 9:207–22. 22. Champion JD. Women abuse, assimilation, and self-concept in a rural Mexican community. Hispanic Behav Sci 1996;18:508 –21. 23. Torres S. A comparison of wife abuse between two cultures: perceptions, attitudes, nature and extent. Issues Mental Health Nurs 1991;12: 113–31. 24. Sabogal F, Marin G, Otero-Sabogal R, Marin B, Perez-Stable FJ. Hispanic familism and acculturation: what changes and what doesn’t? Hispanic Behav Sci 1987;9:397– 412. 25. Van Kaam AA. Formative spirituality: scientific formation. New York: Crossroad Publishing, 1987:99. 26. Cuellar I, Arnold B, Maldonado R. Acculturation rating scale for Mexican Americans. II. A revision of the original ARSMS scale. Hispanic Behav Sci 1995;17:275–304. 27. Festinger L. A theory of cognitive dissonance. Evanston (IL): Row, Peterson, 1957. 28. Rice MJ, Marden M. The use of hope as a coping mechanism in abused women. Holistic Nurs 1995;13:70 – 82. 29. Van Der Vold BA, McFarlane AC. The black hole of trauma. In: Van Der Volk BA, McFarlane AC, Weisaeth L, editors. Traumatic stress. New York: Guilford Press, 1996, Chapter 1. 30. Retrieved December 2001 from the World Wide Web. Available: http://198.246.96.90/cgi-bin/broker.exe 31. Centers for Disease Control and Prevention. Key scientific issues for research on violence occurring around the time of pregnancy. Atlanta (GA): Author, 1997. 32. Rice MJ, Records K. Identifying abused childbearing women: methodological approaches. Nat Academies Pract Forum 2000;2:21– 6. 33. Seng J, Hassinger J. Relationship strategies and interdisciplinary collaboration. Improving maternity care with survivors of childhood abuse. J Nurse Midwif 1998;43:287–95.
APPENDIX A GLOSSARY OF TERMS Cognitive Dissonance Theory:
Cuellar’s Acculturation Scale: Familism: Kindled Hyperemotional (Traumatic) Response: Psychophenomenologic Method:
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A theory in which the relationships between thoughts of a person are described. Multiple thoughts are held simultaneously; some are congruent and some are not. The theory specifies how a person attempts to decrease the non-congruent or dissonant thoughts based on how uncomfortable the person is with the discrepancy (27). An instrument measuring acculturation to the mainstream American community by collecting data on place of birth of informant and parents, language ability, and ethnic self-identification (26). Strong feelings of loyalty, reciprocity, and solidarity among members of Hispanic families (24). A biopsychological process in which the anticipation of overwhelming threat causes changes in attention and concentration. The person has distorted perceptions and normal physical reactions take on threatening significance (29). A qualitative research method; a set of procedures for phenomenology developed by Van Kaam (25).
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APPENDIX B KEY COMPONENTS OF CUELLAR’S ACCULTURATION RATING SCALE A. Subjects are asked to identify the generation that best applies to them. 1. First generation ⫽ You were born in Mexico or other country. 2. 2nd generation ⫽ You were born in USA; either parent born in Mexico or other country. 3. 3rd generation ⫽ You were born in USA, both parents born in USA and all grandparents born in Mexico or other country. 4. 4th generation ⫽ You and your parents born in USA and at least one grandparent born in Mexico or other country with remainder born in the USA. 5. 5th generation ⫽ You, your parents, and all grandparents were born in the USA. B. The following items are answered from 1 (not at all) to 5 (extremely often) 1. I have difficulty accepting some ideas held by Anglos. 2. I have difficulty accepting certain attitudes held by Anglos. 3. I have difficulty accepting some behaviors exhibited by Anglos. 4. I have difficulty accepting some values held by some Anglos. 5. I have difficulty accepting certain practices and customs commonly found in some Anglos. 6. I have, or think I would have, difficulty accepting Anglos as close personal friends. 7. I have difficulty accepting ideas held by some Mexicans. 8. I have difficulty accepting certain attitudes held by Mexicans. 9. I have difficulty accepting some behaviors exhibited by Mexicans. 10. I have difficulty accepting some values held by some Mexicans. 11. I have difficulty accepting certain practices and customs commonly found in some Mexicans. 12. I have, or think I would have, difficulty accepting Mexicans as close personal friends. 13. I have difficulty accepting ideas held by some Mexican Americans. 14. I have difficulty accepting certain attitudes held by Mexican Americans. 15. I have difficulty accepting some behaviors exhibited by Mexican Americans. 16. I have difficulty accepting some values held by Mexican Americans. 17. I have difficulty accepting certain practices and customs commonly found in some Mexican Americans. 18. I have, or think I would have, difficulty accepting Mexican Americans as close personal friends.
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RN, PhD
and Michael Rice,
ABSTRACT Previous research has documented that abused childbearing women have longer and more difficult labors than non-abused women. Prevalence of abuse differs depending on the ethnic group involved. Hispanic women experience higher rates of abuse and endure higher rates before reporting abuse than do Caucasian women. The purpose of this study was to explore the experience of childbearing for abused Hispanic women to provide guidance for clinical practice and further research. Cognitive dissonance theory guided the study. A sample of seven abused Hispanic women was recruited from a rural prenatal clinic. Criteria for selection of subjects included self-identification as Hispanic, less than 24 months postpartum, disclosure of abuse status, and willingness to be interviewed in English or Spanish. An acculturation scale and demographic form were completed. Interviews were conducted individually, and data were analyzed by using Van Kaam’s 12-step psychophenomenologic technique. Findings indicated that subjects experienced the normal responses associated with having a baby. However, the women also demonstrated a kindled neuroendocrine trauma response that was based on, and often similar to, their prior abuse experiences. The kindled emotional response was triggered by the normative events of childbearing. Understanding of the childbearing experiences of abused Hispanic women will facilitate the development of culturalspecific interventions that may ease the difficulties associated with birth for these women. J Midwifery Womens Health 2002;47:97–103 © 2002 by the American College of NurseMidwives. INTRODUCTION
It is estimated that 8 –12 million women are at risk for abuse at some time during their lives (1). In 1994, nearly 4 million women in the United States were physically hurt by their husbands or boyfriends (2). In Washington State, 20% of all women seeking emergency hospital care were suffering from domestic violence injuries, 53% of the women in a chronic pain clinic had been abused, and domestic violence resulted in more injuries than rape, auto accidents, and mugging combined (3). Furthermore, abuse rates are higher during childbearing compared with other periods of a woman’s life. Current estimates for abuse during pregnancy range from 0.9 to 25% (4,5). A study of 199 abused women Address correspondence to Kathie Records, PhD, RN, Intercollegiate College of Nursing, Washington State University College of Nursing, W. 2917 Ft. Wright Dr., Spokane, WA 99224-5291. The Association of Women’s Health, Obstetric, and Neonatal Nurses awarded this project their Outstanding Clinical Research Poster award at their 2001 Convention.
ARNP, PhD
revealed 30.2% of the women were abused during the year before, but not during, pregnancy (6), making them at high risk for further abuse during the postpartum period. A population-based study of 12,612 mothers of newborns revealed that physical violence toward women was 4.1 times more likely to occur if the pregnancy was unwanted or mistimed than for women with intended pregnancies (7). Researchers (8) have reported that women face a higher risk for violence postpartally (25%) than they do prenatally (19%). During pregnancy, abused women have been found to have higher levels of depression, increased smoking and illicit drug use, poor weight gain, more spontaneous and therapeutic abortions, and earlier age at first pregnancy (5,9 –13). Studies of the labors of abused women have not been as conclusive. Qualitative reports describe a different laboring style for abused women. Observations and interviews with survivors (n ⫽ 7), midwives (n ⫽ 5), and labor and delivery nurses (n ⫽ 3) in one study yielded descriptions of four labor styles unique to sexual abuse survivors (14). Survivors demonstrated fighting, taking control, surrendering, or retreating behaviors during labor. Quantitative studies present conflicting findings of longer labors for survivors of childhood sexual abuse (15), longer labors and higher narcotics usage during labor for physically and sexually abused women (16), and no differences in length of labor for childhood survivors of sexual abuse compared with non-abused women (17). A National Institutes of Health Panel (18) reported that there is a paucity of information on Hispanic individuals with regard to their involvement in aggressive and violent behavior, either as victims or as agents. McFarlane et al (6) reported study results indicating that 51.8% (n ⫽ 199) of African American, Hispanic, and White non-Hispanic women sampled were abused before and during pregnancy, but found no prevalence differences by ethnicity. A study of the severity of abuse to 329 pregnant Hispanic women revealed that 80% had been shaken or roughly handled, 71% pushed or shoved, and 64% slapped on the face and head (19). Abuse prevalence and acculturation have been well explored in the literature. Jasinski (20) used the 1992 National Alcohol and Family Violence Survey and found that generational status was the only measure of acculturation that consistently predicted wife assaults. Using the same database, other researchers have found that the
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most highly acculturated Hispanics had the highest rates of wife assaults (21). Researchers have also found significant differences in attitudes toward traditional family structure, with abused women having more of a traditional view than non-abused women (22). Torres (23) studied similarities and differences in the manifestation of wife abuse between Anglo and Mexican American women. Mexican American women perceived fewer types of behavior as abusive and held a more tolerant attitude toward abuse than did their abused Anglo peers. Other researchers have found that despite differences in acculturation, familism remains the dimension most distinct to this population (24). Because most of the abuse takes place within family systems, the cultural tie to that same family system is an important influence. Lacking in the literature are studies that explore the experience of childbearing for abused Hispanic women. Problem Statement The purpose of this psychophenomenologic study was to explore the experience of childbearing for abused Hispanic women. Understanding of the meaning of the childbearing experience for abused women obtained through qualitative methods may provide guidance for clinical practice and research with this population. METHODOLOGY
Design The psychophenomenologic method was developed by Van Kaam (25) to “describe and analyze scientifically the psychological structures of human experience.” Originally created in the 1960s, this progressive method allows the researcher to identify the impressions, structural elements, integral structure, situational reflection, hypothetical identification, and, finally, paradigms of the subjects’ lived experiences. The data were collected and analyzed by Van Kaam’s 12-step procedure (25). See Table 1. Data collection ended when no new themes emerged and saturation was achieved. Three validity indicators are built into the phenomenologic method. In steps 5, 10, and 11 of the process, the researcher’s interpretations of the data were submitted to a panel of research experts for validity checks. Two doctorally prepared maternity and women’s Kathie Records is an associate professor at the Intercollegiate College of Nursing, teaching childbearing theory and clinical, research, and family nursing. She has current practice experience with labor and delivery patients. Michael Rice is an associate professor at the Intercollegiate College of Nursing and director of the Medically Indigent Rural Access program. He maintains a private practice as a psychiatric nurse practitioner.
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TABLE 1
Van Kaam’s Psychophenomenologic Method 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Read each situational description carefully Re-read through the descriptions with another mind-set Reduce subject statements Deduce the probable meaning of the structural elements List compatible and incompatible statements Methodologic phenomenologic reflection Consider possible elements of the integral structure Psychophenomenologic situational reflection Translate and transpose into the language of the profession Submit translations to judges Produce the paradigm of the experience Clearly state the insights gained and the limitations
health researchers and one doctorally prepared psychiatric nursing researcher comprised the panel and assessed validity. As an additional internal validity indicator, the initial situational reflection (step 8) was presented to four of the subjects to ascertain if they felt the understanding was representative of their experience. A glossary of terms is provided in Appendix A. Procedure Abused women were recruited from a prenatal clinic serving a predominately rural and Hispanic population in the Pacific Northwest from January through April 2000. Criteria for selection of subjects included ethnic selfidentification as Hispanic, birth of a live infant within the past 24 months, disclosure of previous or current abuse status to health professionals during prenatal or postpartum care, and willingness to be interviewed in English or Spanish. The study was approved by Washington State University’s Institutional Review Board, and informed consent was obtained before the interviews from all subjects. Two interviewers were trained following Van Kaam’s approach (25). Both interviewers were nurses. One interviewer was English-speaking only, whereas the other was bilingual in Spanish and English. Cuellar’s acculturation scale (26) and a demographic form were completed. See Appendix B. Interviews were conducted individually in a private room in the clinic or in the subject’s home. The general question of “In what ways did your life experiences influence your labor, delivery, and postpartum periods?” started the interviews. A semistructured interview guide was used to solicit information about the labor and delivery process, invite subjects to reflect on past experiences they felt were relevant, and provide an opportunity for them to share their birth stories. Probes such as “Tell me how you felt emotionally during your pregnancy” and “What life experiences do you think influenced your postpartum period” were used.
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Interviews continued until saturation occurred. Data were analyzed by using Van Kaam’s 12-step psychophenomenologic technique (25).
TABLE 2
Physiologic Kindled Response Maternal physical distress (n ⫽ 6)
Sample Seven women agreed to participate in the study. Five were bilingual in English and Spanish, whereas two were Spanish-speaking only. The age of the subjects ranged from 20 to 28. Two of the subjects were single, three were married, one was divorced, and one was living with a significant other. Two of the subjects had one child; five of the subjects had two children. None of the subjects had experienced spontaneous abortions, and one subject had a therapeutic abortion. One of the subjects had completed the 8th grade, five had completed grades 9 –12, and one had a college education. None of the subjects were currently in abusive relationships. Four of the subjects were first, one was second, and two were fourth generation in the United States. Subjects enrolled in prenatal care for the most recent pregnancy at 16 weeks (SD ⫽ 10.13, range 8 –33 weeks). Medical record abstraction revealed that during pregnancy, two subjects had preexisting physical illnesses and two had pregnancy related illnesses. None of the subjects had a previous psychiatric diagnosis. One subject had a vacuum-assisted delivery, whereas two had cesarean sections. Infant Apgar scores at birth were no lower than eight. Infant birth weight ranged from 5.5 to 9 lb. RESULTS
Analysis of the acculturation scale indicated that the subjects did not identify with either the Mexican or Anglo cultures. Yet, all of the subjects scored within 1 SD of the mean scores for all of the subscales of acculturation. The subjects indicated that they had a higher level of Mexican marginality (mean ⫽ 13.3, SD ⫽ 2.37) followed by Mexican Anglo marginality (mean ⫽ 12.25, SD ⫽ 3.86) and Anglo marginality (mean ⫽ 10.2, SD ⫽ 1.28). The subscale scores indicated that there was a strong relationship between the level of Mexican marginality and the number of pregnancies (r ⫽ .889, P ⬍ .02). The scores also indicated that as the number of generations in the United States increased, the number of physical illnesses associated with pregnancy decreased (r ⫽ ⫺.889, P ⬍ .002). Alpha for the acculturation scale was .86. Phenomenologic analysis revealed four basic experiences of the subjects. First, a physiologic kindled response occurred during labor. Both maternal and fetal physical distress were evident. Theresa, a single 22-yearold mother born in Mexico, stated that “the postpartum is more painful than the delivery when the baby got down
Fetal distress (n ⫽ 2)
They told me “You’re gonna feel a little cramp” and I felt like a heap of people had kicked me. Something was lacking in the medication. The pain was terrible all the time. Can’t push. She was turned around and then, go back and turn her around, and then the umbilical cord was wrapped around her. His heart rate went down. My baby was too big.
there . . . [you] feel more with your first child.” Maria at 20 years of age was having her second child. “I panicked because I was in such pain with my first one, so I thought everything was gonna go smooth (this time), but then it started hitting my butt bone and was coming faster and faster and I panicked.” See Table 2. Although pain is expected to some extent during labor, all of the subjects reported pain that was severe and unrelenting, even several months in retrospect. Second, the social context was important to their experience. They defined the social context as consisting of supportive and unsupportive family interactions and behaviors. See Table 3. Family support was described by Rosa, a 28-year-old woman born in Mexico and mother of a 6-year-old girl and newborn son. “Happy, because I say, thanks to God I have my son, now with my husband, my little girl . . . we are together. But sad because one is
TABLE 3
Social Context Supportive family states (n ⫽ 5)
Unsupportive family states (n ⫽ 5)
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Everyone was there that I wanted. I could turn around and there was my mom and sisters, his mom, you know . . . whoever was there. They were all being supportive. There’s a lot of people that tell me, you know, its gonna be OK, the baby’s gonna be OK. My parents were always there for me . . . so was my fiance´ e. I couldn’t laugh; I couldn’t greet anyone. I have two sisters who have babies and they told me it was hard . . . , its going to be bad. He put a lot of pressure on me. I was always scared of her face . . . we were never friends, we were enemies.
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TABLE 4
TABLE 5
Normative Emotional Response
Kindled Hyperemotional Response
Scared (n ⫽ 7)
Depression (n ⫽ 6)
Worried (n ⫽ 7)
Scared if he was OK or not. I was afraid of surgery. It was the needle [epidural]. I wasn’t ready to be here yet—worried a lot about my job and whether to pay a babysitter all the little things and I can’t just walk out the door by myself, now I have to pack the whole house and now I have somebody to worry about for the rest of my life. I worry because I don’t want her to get sick at my breast.
far from the family one loves . . . from her mother . . . from her father . . . from her brothers.” The geographic separation from the family of origin was also voiced by Michelle, a 22-year-old mother of one. “I wanted that my mother would have been here. Close? Yes.” Unsupportive families were perceived as placing pressure on the woman, particularly through relaying expectations regarding the difficulty of childbirth. “Someone who is close says ‘Oh you poor one’ and then she feels worse” (Michelle). Bobby’s sisters told her “it (labor) was hard . . . it’s going to be bad.” Subjects described abuse from family members or partners as a significant contributor to their experiences during childbearing. Bobby, a 24-year-old mother of one, described her memories of her mother that were foremost in her mind during childbearing and still haunt her as she looks at her 2-month-old baby. “My mom didn’t show me love, and with a brush she’d spank me . . . I was big scared like . . . she’s going to beat me here tonight . . . like she’s really going to kill me. I could never trust her.” Third, a normative emotional response occurred. See Table 4. Women described being afraid for the health of their infants, of pain, and of medical procedures. Rosa described “the fears one has . . . because of what’s going to happen? What can happen with an infant? What is so very good, is that, it is logical that the pains that one has, well that one is scared.” They worried about their changed role. These experiences are normative in that most, if not all, women experience these feelings during childbearing. For this sample, however, the normative responses served as emotional triggers for a kindled hyperemotional response. Finally, the women in the sample all experienced the hyperemotional kindled response during which depression, anxiety, and/or panic were the predominant descriptors. See Table 5. The childbearing experiences, combined with distance from family and expectations of pain during birth, were reminiscent of their previous abuse experiences as children and adults. Indeed, even with
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Panic (n ⫽ 5) Anxiety (n ⫽ 4)
I would start crying when I looked at her because I didn’t get the feeling. I felt bad. I was sad and crying. I was distanced from my family. To be surrounded in the depression. I didn’t spend too much attention in the beginning (on the baby) because I was out of it. I was panicking. The pain was out of control. A million things pass through my head. Just seeing everyone’s expression, I knew something was wrong. I took my baby to a neighbor and he was crying and I didn’t know what to do. I was so nervous, . . . I didn’t know what to do. I was always on the defensive.
presentation of their new infant, some of the subjects were unable to celebrate its birth. Michelle described how her depression occurred. “I felt fear . . . because one doesn’t know what you have to do, how to educate, how they get when they are sick, . . . like it’s an encounter of ideals in one’s head of that love . . . one has to . . . to get depressed a little. When I get depressed, I get very depressed. I tried to tranquilize that feeling because if not, I would be in a very bad place.” Several women, months after birth, reported that they knew they should be happy but still felt that something was not right. They watched others revel in the joy of their infants and felt isolated emotionally. Implications Although the sample size was small, one of the goals of qualitative methods is to describe the experiences of participants so that health care providers have a better understanding that can be incorporated into care for clients. Knowledge about previous abuse experiences and a deeper insight into how abused pregnant women tend to view the world are directly relevant to health care providers. Information gleaned from this study will facilitate the development of culture-specific interventions that may ease the difficulties associated with the childbearing period for these mothers. Familism is important for Hispanic women (24). Communication about the labor process among family members, particularly female members, is a developmental need during pregnancy. However, communication within some of these Hispanic families was focused on the difficulty of the birth experience and how painful it would be. This was perceived by
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some of the mothers-to-be as non-supportive and conflicted with their inherent belief in familism. The acculturation level of families and individuals should be attended to as well, because there is some evidence to suggest that familism changes with increasing contact with U.S. mainstream culture (24). Cognitive dissonance theory (27) adds meaning to the phenomenologic analysis. Previous research has shown that abused women attempt to decrease the conflict between their value on commitment and their abuse experiences by remaining hopeful that their partners will change (28). For the women in this study, conflict was also evident during the kindled hyperemotional response (29) when mothers were unable to give to their infants as they believed they should. Interventions must be directed toward decreasing the conflict experienced. Cultural understanding of the meaning and experience of physical illnesses for this population needs to be gained by prenatal care providers. The women who have been in the United States the shortest period of time reported significantly more physical illnesses to their health care provider. This could be indicative of the subject’s needs for care that are not entirely met within the Anglo system of health care. Few clinics integrate the participation or valuing of native healers with their practice, resulting in a gap in quality of care for populations who consider this integration requisite. Abused women may be at a higher risk of receiving an operative delivery. The women in this sample had a cesarean section rate of 28%. The statewide average for cesarean sections among Hispanic women is 15% (30). Other interventions, such as relaxation or counseling, may be more effective at decreasing surgical risk while addressing the underlying problem of kindled trauma response. Further research needs to be accomplished to explore the physiologic implications of abuse during the childbearing process. All of the women solicited for this study had a history or current experience with abuse. However, the abuse in the general population continues to be an area needing more rigor in both assessment and evaluation. Recently, the Centers for Disease Control and Prevention (31) produced systematic reviews of the literature on violence during pregnancy, focusing specifically on prevalence, measurement, and outcomes (4,7). The report clarifies definitions of and measurement periods for violence during and around the time of childbearing. Recommendations include interview assessments repeated during the prenatal and postpartum periods to maximize abuse disclosure probability. Biophysical measures of abuse are in development (32). The subjects in this study described the effect of their life experiences, including histories of abuse, on their delivery and postpartum experiences. The combined recall of trauma events and the labor and delivery
experience provided the foundation for their sadness and isolation in the postpartum period. Seng and Hassinger (33) explain this experience as “a contextual factor that can have a powerful potentially damaging impact. . . .” These “emotions, sensations or experiences that resemble aspects associated with abuse can serve as triggers that kindle a post-traumatic stress response” (33). Abused women may need additional support and guidance during childbearing to decrease the potential for postpartum depression. SUMMARY
Research and practice in the area of abuse are an important focus. As the women in this study described, contextual factors have implications for the family far beyond the period of childbearing. Abused Hispanic women describe depression, anxiety, and panic in addition to the normal childbearing experiences. Women reported supportive and unsupportive family interactions that reminded them of their past abusive experiences as they proceeded through pregnancy and the postpartum period. Additional studies with larger samples must be completed to gain a broader understanding of the role abuse plays in the entire childbearing process.
Grant support: Carl M. Hansen Foundation and the Intercollegiate College of Nursing. Dr. Records and Dr. Rice received the Outstanding Clinical Research Poster Award from the Association of Women’s Health, Obstetric, and Neonatal Nurses, 2001.
REFERENCES 1. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800 –2. 2. Warshaw C, Ganley AL, Salber PR. Improving the health care response to domestic violence: a resource manual for health care providers. San Francisco: Family Violence Prevention Fund, 1995. 3. Washington State Coalition Against Domestic Violence Report. Washington State Department of Social and Health Services. Olympia: Office of Research and Data Analysis, 1997. 4. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996; 275:1915–20. 5. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323– 8. 6. McFarlane J, Parker B, Soeken K, Silva C, Reed S. Severity of abuse before and during pregnancy for African American, Hispanic, and Anglo women. Nurse Midwif 1999;44:139 – 44. 7. Gazmararian JA, Adams MM, Saltzman LE, Johnson CH, Bruce FC, Marks JS, et al. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85:1031–38. 8. Geilen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med 1994;39:781–7. 9. Esperza DV, Esperat MC. The effects of childhood sexual abuse on
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minority adolescent mothers. J Obstet Gynecol Neonatal Nurs 1996;25: 321– 8. 10. McFarlane J, Parker B, Soeken K. Abuse during pregnancy: associations with maternal health and infant birth weight. Nurs Res 1996;45: 37– 42. 11. Webster J, Chandler J, Battistutta D. Pregnancy outcomes and health care use: effects of abuse. Am J Obstet Gynecol 1996;174:760 –7. 12. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc 1993;149:1257– 63. 13. Torres CS. Battering during pregnancy: an exploratory study. Dissertation, Doctorate of Education, University of Rochester, Rochester (NY), 1992. 14. Rhodes N, Hutchinson S. Labor experiences of childhood sexual abuse survivors. Birth 1994;21:213–20. 15. Jacobs JL. Child sexual abuse victimization and later sequelae during pregnancy and childbirth. Child Sexual Abuse 1992;1:103–12. 16. Records K, Rice M. Abuse and labor progression. Toronto, Canada: Conference proceedings of the International Research Utilization Conference, 1998. 17. Benedict MI, Paine LL, Paine LA, Brandt D, Stallings R. The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes. Child Abuse Neglect 1999; 23:659 –70. 18. National Institutes of Health. Report of the panel of NIH research on antisocial, aggressive, and violence-related behaviors and their consequences. Washington (DC): National Institutes of Health, 1994. 19. Wiist WH, McFarlane J. Severity of spousal and intimate partner abuse to pregnant Hispanic women. Health Care Poor Underserved 1998; 9:248 – 61. 20. Jasinski JL. The role of acculturation in wife assault. Hispanic Behavi Sci 1998;20:175–91. 21. Kaufman KG, Jasinski JL, Aldarondo E. Sociocultural status and
incidence of marital violence in Hispanic families. Violence Victims 1994; 9:207–22. 22. Champion JD. Women abuse, assimilation, and self-concept in a rural Mexican community. Hispanic Behav Sci 1996;18:508 –21. 23. Torres S. A comparison of wife abuse between two cultures: perceptions, attitudes, nature and extent. Issues Mental Health Nurs 1991;12: 113–31. 24. Sabogal F, Marin G, Otero-Sabogal R, Marin B, Perez-Stable FJ. Hispanic familism and acculturation: what changes and what doesn’t? Hispanic Behav Sci 1987;9:397– 412. 25. Van Kaam AA. Formative spirituality: scientific formation. New York: Crossroad Publishing, 1987:99. 26. Cuellar I, Arnold B, Maldonado R. Acculturation rating scale for Mexican Americans. II. A revision of the original ARSMS scale. Hispanic Behav Sci 1995;17:275–304. 27. Festinger L. A theory of cognitive dissonance. Evanston (IL): Row, Peterson, 1957. 28. Rice MJ, Marden M. The use of hope as a coping mechanism in abused women. Holistic Nurs 1995;13:70 – 82. 29. Van Der Vold BA, McFarlane AC. The black hole of trauma. In: Van Der Volk BA, McFarlane AC, Weisaeth L, editors. Traumatic stress. New York: Guilford Press, 1996, Chapter 1. 30. Retrieved December 2001 from the World Wide Web. Available: http://198.246.96.90/cgi-bin/broker.exe 31. Centers for Disease Control and Prevention. Key scientific issues for research on violence occurring around the time of pregnancy. Atlanta (GA): Author, 1997. 32. Rice MJ, Records K. Identifying abused childbearing women: methodological approaches. Nat Academies Pract Forum 2000;2:21– 6. 33. Seng J, Hassinger J. Relationship strategies and interdisciplinary collaboration. Improving maternity care with survivors of childhood abuse. J Nurse Midwif 1998;43:287–95.
APPENDIX A GLOSSARY OF TERMS Cognitive Dissonance Theory:
Cuellar’s Acculturation Scale: Familism: Kindled Hyperemotional (Traumatic) Response: Psychophenomenologic Method:
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A theory in which the relationships between thoughts of a person are described. Multiple thoughts are held simultaneously; some are congruent and some are not. The theory specifies how a person attempts to decrease the non-congruent or dissonant thoughts based on how uncomfortable the person is with the discrepancy (27). An instrument measuring acculturation to the mainstream American community by collecting data on place of birth of informant and parents, language ability, and ethnic self-identification (26). Strong feelings of loyalty, reciprocity, and solidarity among members of Hispanic families (24). A biopsychological process in which the anticipation of overwhelming threat causes changes in attention and concentration. The person has distorted perceptions and normal physical reactions take on threatening significance (29). A qualitative research method; a set of procedures for phenomenology developed by Van Kaam (25).
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APPENDIX B KEY COMPONENTS OF CUELLAR’S ACCULTURATION RATING SCALE A. Subjects are asked to identify the generation that best applies to them. 1. First generation ⫽ You were born in Mexico or other country. 2. 2nd generation ⫽ You were born in USA; either parent born in Mexico or other country. 3. 3rd generation ⫽ You were born in USA, both parents born in USA and all grandparents born in Mexico or other country. 4. 4th generation ⫽ You and your parents born in USA and at least one grandparent born in Mexico or other country with remainder born in the USA. 5. 5th generation ⫽ You, your parents, and all grandparents were born in the USA. B. The following items are answered from 1 (not at all) to 5 (extremely often) 1. I have difficulty accepting some ideas held by Anglos. 2. I have difficulty accepting certain attitudes held by Anglos. 3. I have difficulty accepting some behaviors exhibited by Anglos. 4. I have difficulty accepting some values held by some Anglos. 5. I have difficulty accepting certain practices and customs commonly found in some Anglos. 6. I have, or think I would have, difficulty accepting Anglos as close personal friends. 7. I have difficulty accepting ideas held by some Mexicans. 8. I have difficulty accepting certain attitudes held by Mexicans. 9. I have difficulty accepting some behaviors exhibited by Mexicans. 10. I have difficulty accepting some values held by some Mexicans. 11. I have difficulty accepting certain practices and customs commonly found in some Mexicans. 12. I have, or think I would have, difficulty accepting Mexicans as close personal friends. 13. I have difficulty accepting ideas held by some Mexican Americans. 14. I have difficulty accepting certain attitudes held by Mexican Americans. 15. I have difficulty accepting some behaviors exhibited by Mexican Americans. 16. I have difficulty accepting some values held by Mexican Americans. 17. I have difficulty accepting certain practices and customs commonly found in some Mexican Americans. 18. I have, or think I would have, difficulty accepting Mexican Americans as close personal friends.
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