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Childbirth expectations: a qualitative analysis
M 6diLongman w,fiery(© 1990Group133-]39UK ) Ltd 1990
Midwifery
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Childbirth expectations: a qualitative analysis Janet Beaton and Annette Gupton
Maternal childbirth expectations play an i m p o r t a n t role in d e t e r m i n i n g a woman's response to her childbirth experience. As part o f the initial phase in the d e v e l o p m e n t o f a research tool to investigate maternal childbirth expectations, in-depth interviews were c o n d u c t e d with a sample o f eleven u r b a n Canadian w o m e n in their third trimester o f pregnancy. C o n t e n t analysis o f interview data indicated that the w o m e n h a d developed detailed expectations o f the childbirth experience as well as for the roles of support persons and health care personnel. Exploration o f women's childbirth expectations is discussed as an i m p o r t a n t c o m p o n e n t o f childbirth education.
INTRODUCTION During pregnancy, the pregnant woman has a relatively long period of time to develop expectations for the childbirth experience. Given the current emphasis on childbirth preparation coupled with the popular belief that an educated consumer can control events by careful planning, many women enter labour with confident expectations of a positive and personally rewarding experience (Brucker & MacMullen, 1987). Some women will have these expectations confirmed by the reality of their experience; others unfortunately will not (Astbury, 1980; Stolte, 1987). This may be due to obstetric factors such Janet Beaton RN, BN, MA, PhD, Associate Professor and Associate Director, Graduate Program, University of Manitoba, School of Nursing Winnipeg, Manitoba, Canada. Annette Gupton RN, BS, MN, Associate Professor, University of Manitoba, School of Nursing and Associate Director, Maternal-Child Nursing, St. Boniface General Hospital, Winnipeg, Manitoba, Canada. Manuscript accepted 6 march 1990 Requests for offprints to JB
as an unanticipated caesarean section or to the fact that the expectations for childbirth were quite simply unrealistic. A growing body of literature indicates that the degree of congruence between maternal childbirth expectations and the reality of the actual experience has an important impact on perception of the severity of labour pain (Lumley & Astbury, 1980; Fridh et al, 1988), on the subsequent evaluation of both the self and the childbirth experience (Levy & McGee, 1975; Grace, 1978; Leifer, 1980; Lipson & Tilden, 1980) and on the mother-baby relationship (Mercer, 1985; Gottlick & Barrett, 1986). Yet, despite the implications of these findings for the care of childbearing women and for childbirth education, in particular, relatively little is known about the nature of women's childbirth expectations and the variables influencing their development.
METHODS In an effort to understand further this important aspect of the childbirth experience, we have, 133
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for the last 2 years, been involved in designing and testing an instrument to measure women's childbirth expectations. As one small part of the process of instrument development, we conducted in-depth interviews with 11 p r e g n a n t women about their expectations of childbirth. Statements made by these w o m e n were subsequently utilised as one source of data in wording questionnaire items. Additionally, themes emerging f r o m a content analysis of the interview data provided background for the conceptualisation and development of the questionnaire subscales. T h e Childbirth Expectations Questionnaire (CEQ) has now been pilot-tested and revised on a sample of over 200 w o m e n in their third trimester of pregnancy. T h e existence of four distinct subscales has been confirmed by factor analysis and reliability estimates for the total CEQ and for each o f the four subscales - ability to cope with pain, role of partner/coach, role of the nurse, and a m o u n t o f medical i n t e r v e n t i o n - are high. T h e CEQ is currently being used in a series of studies investigating the d e v e l o p m e n t and impact of maternal childbirth expectations on the childbirth experience. Although the interview data used in the construction of the CEQ was intended to serve as one means of grounding the i n s t r u m e n t in the reality of the pregnancy experience, we believe that the themes emerging f r o m this data, as well as the comments m a d e by the w o m e n themselves, are of interest to midwives, nurses and childbirth educators. We recognise that, on the basis of o u r small interview sample, generalisations cannot be made to all p r e g n a n t women. However, we believe that the data does provide useful insight into the importance of assessing and understanding women's childbirth expectations. Interviews were conducted with 11 white, middle-class women in their third trimester of pregnancy attending private and hospital-based childbirth preparation classes in a western Canadian city. All subjects were volunteers recruited at the beginning of a childbirth class by one of the authors who explained the purpose of the study to the class and obtained f r o m each volunteer a signed consent to be interviewed. T h e selection of childbirth education classes for
subject recruitment was deliberate in that the CEQ is intended for use with this population of pregnant women. Subjects ranged in age f r o m 24-35 Years with a mean age of 29 years. All had completed high school and five had university degrees. Nine of the w o m e n were married, one was single and one was living in a common-law relationship. Nine were expecting their first child while two had experienced a previous childbirth. Eight w o m e n had a close friend or family m e m b e r who had given birth within the last year. These sample characteristics are similar to those found by the authors in a larger study of subjects (n = 104) recruited f r o m a similar series of childbirth education classes in which the mean age was 28 years, 93% of the sample had completed high school, over 90% were married, 84% were expecting their first baby, and 85% had a close friend or family m e m b e r who had recently given birth. All interviews were conducted in the subjects' homes and required a m i n i m u m of 1 h o u r to complete. Topics covered during the interviews centred on women's general thoughts and concerns regarding childbirth; their expectations for their own behaviour, that of their husband/partner, and for health professionals; the amount of pain and discomfort to be experienced; and the characteristics of the birth environment. All interviews were taped and transcribed. These transcripts were then analysed by the investigators for thematic content relative to the major interview topics.
FINDINGS Childbirth concerns At least half of the w o m e n reported having mixed feelings about their impending birth experience. T h e y were concerned primarily about the pain of childbirth and having a healthy baby, but at the same time expressed feelings of w o n d e r m e n t and excitement as the event drew near. Fear o f the u n k n o w n and not knowing what to expect in childbirth were c o m m o n themes. A primipara commented: 'It's frightening and it's exciting. I may feel no pain or
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excruciating pain. I don't know. That's the unknown.' Interestingly, a multipara voiced similar concerns: 'I guess I would say it conjures u p a bit of apprehension for me 'cause I've done it once. I've never really felt that kind o f pain before. I think most of it is excitement, but I think a lot about the event because you don't know what is going to happen; how long it is going to take. Yon don't know what kind o f complications you are going to encounter.' Another woman s u m m e d u p this inability to predict the future by saying: 'It's not knowing how long it's going to be or what's going to h a p p e n or just how I ' m going to r e s p o n d to i t . . . I don't know what is in store for me.' Four women said they did not know or could not think about what to expect f r o m childbirth even though they were all currently attending childbirth preparation classes. One w o m a n said she was just trying to 'shut it out'. T h e s e women all identified fear of the unknown as their major reason for not wanting to think about childbirth. While the primiparae in the sample had no personal past experience on which to base their expectations for childbirth, the muliparae obviously did. Two major themes dominated their comments regarding their expectations for the experience the second time around. First of all, they believed they were well p r e p a r e d for the a m o u n t o f pain associated with childbirth. T h e i r first labour had been painful and they expected to have the same experience again. This expectation, however, was not a major source of concern. Both multiparae in the sample accepted the pain o f labour as given. T h e y had coped with it before and they expected to be able to cope with it again. What was of concern to them was whether their second experience would be like their first with regard to such specifics as length, time of r u p t u r e of the m e m b r a n e s or use of syntocinon. As one woman stated: ' I ' m wondering if the m e m b r a n e s are going to r u p t u r e again and am I going to be hooked up to all those machines . . . . You never know, nobody can give you an answer to that . . . . Is it going to go like it went last time?'
Childbirth emotions Early labour was anticipated as a time of nervous excitement. Finally the time for birth had come bringing with it the expectation of joy and happiness. Late labour, in contrast, was viewed as totally negative. W o m e n expected to be very tired by this stage of labour, cranky and anxious for the experience to be over. T h e y also expected to be having difficulty maintaining control and several women stated they expected to be 'out of it'. All subjects expected late labour to be the low point of the childbirth experience and the most difficult time for them. During the delivery of the baby, women stated they expected to feel a sense of excitement and a relief that labour was almost over. Several thought they would be so overcome with emotion that they would probably cry. T h e period of time immediately after birth was anticipated as an intense emotional high, a peak experience. Expectations for feelings of happiness, love and relief predominated.
Pain and coping When asked what they expected the pain of childbirth to feel like, many women used vivid, if not gruesome, analogies such as 'chopping off two fingers' or 'stretching your lip over your head' to describe anticipated sensations. Some likened labour to dental surgery or severe menstrual cramps. Most quite frankly admitted they had no basis of comparison f r o m which to formulate expectations. For them, the pain of childbirth was another large unknown that provoked anxiety and fear. 'I really don't know what to expect because I've never even had menstrual cramps. I couldn't even compare it to that. I just don't know what to expect and I guess that is what really scares me.'
In terms of how they expected to cope with the pain of labour, w o m e n described a progression from hectic activity in early labour to almost total passivity by the time of delivery. In early labour they expected to be very much in control, walking, practising breathing techniques,
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making last minute a r r a n g e m e n t s and generally trying to keep busy as a means of distraction. Most women's descriptions of what they would be doing during early labour were finely detailed and quite romanticised. T h e y a p p e a r e d to have developed specific fantasies about what labour would be like for them. One w o m a n who said that in her mind she had the 'perfect labour all p r e p a r e d ' related the following expectations: 'We're planning on staying h o m e for as long as possible. I will be in a very large d e e p warm bath. As time wears on, more breathing, more activity. I want to be walking and moving around as much as possible.' Another women said: 'I think I'll probably keep myself preoccupied a lot. We'll drink a little bit of tea and we'll talk and we won't make a big deal of it.' By late labour, women expected to have to rely on a support person or coach to help t h e m cope. They expected to use breathing techniques learned in prenatal classes and changes in position to maintain control. T h e y wanted to avoid using analgesics if at all possible, but were willing to do so if necessary. As one woman said: ' I f it's really bad they can give you stuff, but o f course, we all say we're not going to take anything.' T h e actual delivery o f the baby was seen as occupying a relatively short period of time during which the forces of nature would take over completely. Several women said they expected to scream, but in general, w o m e n had only a hazy picture of what they would be doing during the birth o f the baby. Interestingly, women were optimistic about their ability to tolerate pain. When asked how they would rate their pain threshold in relation to other people's, they described it as 'average', 'in the middle or m e d i u m ' or 'pretty good'. However, their responses also reflected their lack of real experience with pain and their concern that they would not know just how good their ability to tolerate pain was until they were actually in labour. An element o f wishful thinking was present in some of their comments as though these women were almost t r y i n g - t o convince themselves that they would be able to cope. One woman said:
'I think I can tolerate pain. I think I can tolerate a fair a m o u n t o f pain. I don't know as I have never really had to tolerate it. I think I can tolerate a fair a m o u n t o f pain though.' While several women stated they expected to be able to maintain control o f their behaviour and emotions as long as labour did not last too long or the pain was not overwhelming, most women either did not ~know how they would react or just h o p e d they would be able to maintain control.
Role of support person All the women expected their husband or labour coach to be a busy, active participant in the childbirth process. In early labour, they were described as coaching, massaging, timing contractions, giving back rubs, holding hands, offering encouragement, walking and talking with the labouring w o m a n and taking care of little details such as the feeding of the family pets. In late labour, w o m e n saw their husband/ coach being engaged in many of the same activities as in early labour, but in addition, they also c o m m e n t e d he/she would be helping them maintain control. Husbands/coaches were expected to be a source o f e n c o u r a g e m e n t and support, sometimes simply by virtue of their presence. During delivery, women expected their husband/coach to be at their side, telling them what to do; r e m i n d i n g them about breathing and 'pushing'. T h e y were viewed as the orienting agents who would tell the woman what was going on and act as a go-between for her with the hospital staff.
Role of health professionals In Canada the final responsibility for care during labour and the delivery rests with the physician. However, the labour and delivery nurse will be responsible for monitoring progress. T h e women in o u r sample expected their physician to be present only for the delivery of the baby unless a complication arose. T h e physician was viewed as someone who was very busy, who would check in 'off and on' during labour,
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arrive for the delivery, deliver the baby, 'wash up' and go home. W o m e n were unable to articulate any role for the physician during labour apart f r o m giving instructions to the nurses and recognising complications. During delivery, women expected the physician to deliver the baby, cut the cord, deliver the placenta and 'stitch them up'. With regard to the a m o u n t of time that nurses would spend with them in labour, w o m e n generally expected that the nurse would be in and out during early labour and would spend most o f late labour with them. W o m e n viewed the nurse's role in labour as primarily assisting the physician and monitoring the progress of labour. Nurses were expected to take vital signs, p e r f o r m examinations, check the fetal heart rate and change the sheets. Only four w o m e n expected the nurse to offer e n c o u r a g e m e n t and emotional support. Most women did not know what the nurse would be doing d u r i n g delivery. Those women who did venture a guess thought she would probably be helping the physician and 'cleaning up'. T h e following example is typical of women's comments: 'I think they put on the monitor. T h e y check internal, check your blood pressure. Everything like that. [Check] what stage you're in. All the technical things they have to do. During late labour, I guess m u c h of the same thing and seeing if I need any medication or if there is any complication. I don't know. I guess if there's monitors on, she'll be reading monitors. I f there's not, she'll be standing by with things. I ' m not sure what they do.'
Intervention When asked what kinds o f treatments and procedures they expected to have d u r i n g labour and delivery, women were able to e n u m e r a t e a lengthy list. Six women mentioned having a 'shave p r e p ' and enema, five thought they would have fetal monitoring, five expected an intravenous infusion to be established and five anticipated an episiotomy. However, although women generally knew what procedures to expect, they wanted to be consulted about what
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was done to them. T h e i r comments also suggested that they did not really want to have many of the procedures done, but expected that they would be done anyway. As one woman stated: 'I would like to think that I won't be shaved, but I probably will be.' Similarly, when asked whether they expected to use analgesics or anaesthetics during labour and delivery, w o m e n again distinguished between what they would like to have h a p p e n and what they expected would actually occur. While most women said they would like to be ' d r u g free', they expected they might need something, particularly if the labour were long. Demerol was mentioned as a d r u g that was 'very effective', would 'make you sleep' and that would 'take the edge o f f the pain'. Nitrous oxide was described as 'better than nothing'. An epidural was expected to completely block pain.
Childbirth environment When women were asked what their expectations were for the childbirth setting, their responses were d e p e n d e n t u p o n whether they had had a hospital tour of the labour and delivery suite. W o m e n who had received a t o u r in particular of the birthing rooms - described the environment as 'home-like', 'very comfortable' and 'private'. W o m e n who had not been on a hospital tour described the birth setting as analogous to an operating r o o m - cold, white, bright and impersonal. For those women who anticipated using a birthing room, the major advantage was the opportunity it afforded for privacy. This privacy was regarded as an important factor in helping the woman relax and as an essential c o m p o n e n t in the creation of a shared birth experience between the woman and her significant other.
DISCUSSION T h e findings of this study must be regarded with caution since the sample is small, f r o m one area of Canada, and reflective of the Canadian health care system. In Canada care of the p r e g n a n t woman is the jurisdiction of the physician, the
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practice of midwifery is not legal except in remote areas. Prenatal classes are taught by childbirth educators who may or may not be nurses. As already stated, during childbirth, the labour and delivery nurse will be responsible for monitoring progress, but final responsibility for care of the woman and for the birth itself resides with the physician. It is within this context that the findings of this study must be viewed. Although the interview data were primarily intended for use in the construction of scale items for the CEQ, a n u m b e r of themes emerged from the data which may have implications for childbirth educators. Even though the respondents were attending childbirth education classes, had discussed childbirth with friends and family m e m b e r s and in two cases had a previous labour experience, all stated that they did not know what to expect in childbirth. However, they were still able to clearly articulate a complex and often detailed set of childbirth expectations. T h e fact that women did not know what to expect did not prevent t h e m f r o m developing images of what the experience would be like. Janis (1958) has postulated that the anticipatory thought processes preceding a stressful event play a major role in determining how an individual will cope during the conditions of imposed threat as well as during the period after the event has taken place. T h e 'work of worry' described byJanis has a parallel in the childbirth expectations developed by p r e g n a n t women. By attending childbirth education classes, women can increase their knowledge o f what to expect during childbirth and in so doing, work through some of their fears and anxieties. A major challenge then for childbirth educators is to find ways of preparing w o m e n for the realities of the childbirth experience. W o m e n coming to childbirth education classes have already developed expectations for the experience. Exploration of these expectations and of women's birth fantasies can serve as a means of promoting expectations that are realistic. Many women in this study had developed highly detailed and romanticised birth fantasies. O f concern is how women can be helped to avoid scripting their birth fantasies so tightly that they
set themselves up for failure. I n h e r e n t in the development of birth plans, is the danger that women may be encouraged to think that planning the 'perfect' birth is possible. Ideally, a birth plan should be used as a means o f exploring what is realistically possible and enabling women to set goals for their birth experience that cover a range of circumstances and make allowances for change. T h e women in this study held very high expectations of the ability of their husband/ coach to help them t h r o u g h the experience. T h e question could be raised whether these women were placing too m u c h faith in their husband's ability to help them maintain control. Perhaps more consideration in childbirth education classes needs to be given to the experience o f labour f r o m the perspective of the father and how he feels u n d e r the weight of the expectations placed upon him. In this regard, opportunities could be provided during classes for couples to discuss their mutual expectations for each other and for the childbirth experience. As well, the role o f the midwife/nurse in providing help to the childbearing couple during labour could be emphasised so that the woman need not feel she is totally d e p e n d e n t on her husband/ coach and the father need not feel that he is without support or guidance in his role. Perhaps the greatest challenge facing childbirth educators is to p r e p a r e w o m e n for the realities o f childbirth without destroying the excitement, the sense o f wonder and the joyful anticipation of the experience. How can we help couples have the childbirth experience they desire within the boundaries of what is realistic? How can we ensure that women have a sense of accomplishment rather than feelings of failure about birth and how can those feelings of mastery o f the experience be used to p r o m o t e confidence in m o t h e r i n g abilities? An understanding of the i m p o r t a n c e o f childbirth expectations and their incorporation into childbirth education is one way of helping us meet these challenges.
References Astbury J 1980 Labor pain: the role of childbirth education, information, and expectation. In: Peck C,
MIDWIFERY 139 Wallace M (ed) Problems in Pain. Pergamon Press, Sydney Brucker M C, MacMullen N J 1987 Delivery Scripts: Fantasy Versus Reality. Ethicon 24:20-21 Fridh G, Kopare T, Gasaton-Johahsson F et al 1988 Factors Associated with More Intense Labor Pain. Research in Nursing and Health 11 : 117-124 Gottlick S E, Barrett D E 1986 Effects of Unanticipated Cesarean Section on Mothers, Infants and Their Interaction in the First Month of Life. Developmental and Behavioral Pediatrics 7:180-185 Grace J 1978 Good Grief: Coming to Terms with the Childbirth Experience. Journal of Obstetric, Gynecologic and Neonatal Nursing 7:18-22 Janis T L 1958 Psycholanalytic and Behavioral Studies of Surgical Patients. John Wiley and Sons, New York Leifer M 1980 Psychological Effects of Motherhood: A
Study of First Pregnancy. Praeger Publishers, New York Levy J, McGee R 1975 Childbirth as a Crisis: A Test of Janis's Theory of Communication and Stress Resolution. Journal of Personality and Social Psychology 31 : 171-179 Lipson J, Tilden V 1980 Psychological Integration of the Cesarean Birth Experience. American Journal of Orthopsychiatry 50:598-609 Lumley J, Astbury J 1980 Birth Rites, Birth Rights: Childbirth Alternatives for Australian Parents. Thomas Nelson, Melbourne Mercer R T 1985 Relationship of the Birth Experience to Later Mothering Behaviors. Journal of NurseMidwifery 30:204-211 Stolte K 1987 A Comparison of Women's Expectations of Labour with the Actual Event. Birth 14:99-103
Midwifery
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Childbirth expectations: a qualitative analysis Janet Beaton and Annette Gupton
Maternal childbirth expectations play an i m p o r t a n t role in d e t e r m i n i n g a woman's response to her childbirth experience. As part o f the initial phase in the d e v e l o p m e n t o f a research tool to investigate maternal childbirth expectations, in-depth interviews were c o n d u c t e d with a sample o f eleven u r b a n Canadian w o m e n in their third trimester o f pregnancy. C o n t e n t analysis o f interview data indicated that the w o m e n h a d developed detailed expectations o f the childbirth experience as well as for the roles of support persons and health care personnel. Exploration o f women's childbirth expectations is discussed as an i m p o r t a n t c o m p o n e n t o f childbirth education.
INTRODUCTION During pregnancy, the pregnant woman has a relatively long period of time to develop expectations for the childbirth experience. Given the current emphasis on childbirth preparation coupled with the popular belief that an educated consumer can control events by careful planning, many women enter labour with confident expectations of a positive and personally rewarding experience (Brucker & MacMullen, 1987). Some women will have these expectations confirmed by the reality of their experience; others unfortunately will not (Astbury, 1980; Stolte, 1987). This may be due to obstetric factors such Janet Beaton RN, BN, MA, PhD, Associate Professor and Associate Director, Graduate Program, University of Manitoba, School of Nursing Winnipeg, Manitoba, Canada. Annette Gupton RN, BS, MN, Associate Professor, University of Manitoba, School of Nursing and Associate Director, Maternal-Child Nursing, St. Boniface General Hospital, Winnipeg, Manitoba, Canada. Manuscript accepted 6 march 1990 Requests for offprints to JB
as an unanticipated caesarean section or to the fact that the expectations for childbirth were quite simply unrealistic. A growing body of literature indicates that the degree of congruence between maternal childbirth expectations and the reality of the actual experience has an important impact on perception of the severity of labour pain (Lumley & Astbury, 1980; Fridh et al, 1988), on the subsequent evaluation of both the self and the childbirth experience (Levy & McGee, 1975; Grace, 1978; Leifer, 1980; Lipson & Tilden, 1980) and on the mother-baby relationship (Mercer, 1985; Gottlick & Barrett, 1986). Yet, despite the implications of these findings for the care of childbearing women and for childbirth education, in particular, relatively little is known about the nature of women's childbirth expectations and the variables influencing their development.
METHODS In an effort to understand further this important aspect of the childbirth experience, we have, 133
134
MIDWIFERY
for the last 2 years, been involved in designing and testing an instrument to measure women's childbirth expectations. As one small part of the process of instrument development, we conducted in-depth interviews with 11 p r e g n a n t women about their expectations of childbirth. Statements made by these w o m e n were subsequently utilised as one source of data in wording questionnaire items. Additionally, themes emerging f r o m a content analysis of the interview data provided background for the conceptualisation and development of the questionnaire subscales. T h e Childbirth Expectations Questionnaire (CEQ) has now been pilot-tested and revised on a sample of over 200 w o m e n in their third trimester of pregnancy. T h e existence of four distinct subscales has been confirmed by factor analysis and reliability estimates for the total CEQ and for each o f the four subscales - ability to cope with pain, role of partner/coach, role of the nurse, and a m o u n t o f medical i n t e r v e n t i o n - are high. T h e CEQ is currently being used in a series of studies investigating the d e v e l o p m e n t and impact of maternal childbirth expectations on the childbirth experience. Although the interview data used in the construction of the CEQ was intended to serve as one means of grounding the i n s t r u m e n t in the reality of the pregnancy experience, we believe that the themes emerging f r o m this data, as well as the comments m a d e by the w o m e n themselves, are of interest to midwives, nurses and childbirth educators. We recognise that, on the basis of o u r small interview sample, generalisations cannot be made to all p r e g n a n t women. However, we believe that the data does provide useful insight into the importance of assessing and understanding women's childbirth expectations. Interviews were conducted with 11 white, middle-class women in their third trimester of pregnancy attending private and hospital-based childbirth preparation classes in a western Canadian city. All subjects were volunteers recruited at the beginning of a childbirth class by one of the authors who explained the purpose of the study to the class and obtained f r o m each volunteer a signed consent to be interviewed. T h e selection of childbirth education classes for
subject recruitment was deliberate in that the CEQ is intended for use with this population of pregnant women. Subjects ranged in age f r o m 24-35 Years with a mean age of 29 years. All had completed high school and five had university degrees. Nine of the w o m e n were married, one was single and one was living in a common-law relationship. Nine were expecting their first child while two had experienced a previous childbirth. Eight w o m e n had a close friend or family m e m b e r who had given birth within the last year. These sample characteristics are similar to those found by the authors in a larger study of subjects (n = 104) recruited f r o m a similar series of childbirth education classes in which the mean age was 28 years, 93% of the sample had completed high school, over 90% were married, 84% were expecting their first baby, and 85% had a close friend or family m e m b e r who had recently given birth. All interviews were conducted in the subjects' homes and required a m i n i m u m of 1 h o u r to complete. Topics covered during the interviews centred on women's general thoughts and concerns regarding childbirth; their expectations for their own behaviour, that of their husband/partner, and for health professionals; the amount of pain and discomfort to be experienced; and the characteristics of the birth environment. All interviews were taped and transcribed. These transcripts were then analysed by the investigators for thematic content relative to the major interview topics.
FINDINGS Childbirth concerns At least half of the w o m e n reported having mixed feelings about their impending birth experience. T h e y were concerned primarily about the pain of childbirth and having a healthy baby, but at the same time expressed feelings of w o n d e r m e n t and excitement as the event drew near. Fear o f the u n k n o w n and not knowing what to expect in childbirth were c o m m o n themes. A primipara commented: 'It's frightening and it's exciting. I may feel no pain or
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excruciating pain. I don't know. That's the unknown.' Interestingly, a multipara voiced similar concerns: 'I guess I would say it conjures u p a bit of apprehension for me 'cause I've done it once. I've never really felt that kind o f pain before. I think most of it is excitement, but I think a lot about the event because you don't know what is going to happen; how long it is going to take. Yon don't know what kind o f complications you are going to encounter.' Another woman s u m m e d u p this inability to predict the future by saying: 'It's not knowing how long it's going to be or what's going to h a p p e n or just how I ' m going to r e s p o n d to i t . . . I don't know what is in store for me.' Four women said they did not know or could not think about what to expect f r o m childbirth even though they were all currently attending childbirth preparation classes. One w o m a n said she was just trying to 'shut it out'. T h e s e women all identified fear of the unknown as their major reason for not wanting to think about childbirth. While the primiparae in the sample had no personal past experience on which to base their expectations for childbirth, the muliparae obviously did. Two major themes dominated their comments regarding their expectations for the experience the second time around. First of all, they believed they were well p r e p a r e d for the a m o u n t o f pain associated with childbirth. T h e i r first labour had been painful and they expected to have the same experience again. This expectation, however, was not a major source of concern. Both multiparae in the sample accepted the pain o f labour as given. T h e y had coped with it before and they expected to be able to cope with it again. What was of concern to them was whether their second experience would be like their first with regard to such specifics as length, time of r u p t u r e of the m e m b r a n e s or use of syntocinon. As one woman stated: ' I ' m wondering if the m e m b r a n e s are going to r u p t u r e again and am I going to be hooked up to all those machines . . . . You never know, nobody can give you an answer to that . . . . Is it going to go like it went last time?'
Childbirth emotions Early labour was anticipated as a time of nervous excitement. Finally the time for birth had come bringing with it the expectation of joy and happiness. Late labour, in contrast, was viewed as totally negative. W o m e n expected to be very tired by this stage of labour, cranky and anxious for the experience to be over. T h e y also expected to be having difficulty maintaining control and several women stated they expected to be 'out of it'. All subjects expected late labour to be the low point of the childbirth experience and the most difficult time for them. During the delivery of the baby, women stated they expected to feel a sense of excitement and a relief that labour was almost over. Several thought they would be so overcome with emotion that they would probably cry. T h e period of time immediately after birth was anticipated as an intense emotional high, a peak experience. Expectations for feelings of happiness, love and relief predominated.
Pain and coping When asked what they expected the pain of childbirth to feel like, many women used vivid, if not gruesome, analogies such as 'chopping off two fingers' or 'stretching your lip over your head' to describe anticipated sensations. Some likened labour to dental surgery or severe menstrual cramps. Most quite frankly admitted they had no basis of comparison f r o m which to formulate expectations. For them, the pain of childbirth was another large unknown that provoked anxiety and fear. 'I really don't know what to expect because I've never even had menstrual cramps. I couldn't even compare it to that. I just don't know what to expect and I guess that is what really scares me.'
In terms of how they expected to cope with the pain of labour, w o m e n described a progression from hectic activity in early labour to almost total passivity by the time of delivery. In early labour they expected to be very much in control, walking, practising breathing techniques,
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making last minute a r r a n g e m e n t s and generally trying to keep busy as a means of distraction. Most women's descriptions of what they would be doing during early labour were finely detailed and quite romanticised. T h e y a p p e a r e d to have developed specific fantasies about what labour would be like for them. One w o m a n who said that in her mind she had the 'perfect labour all p r e p a r e d ' related the following expectations: 'We're planning on staying h o m e for as long as possible. I will be in a very large d e e p warm bath. As time wears on, more breathing, more activity. I want to be walking and moving around as much as possible.' Another women said: 'I think I'll probably keep myself preoccupied a lot. We'll drink a little bit of tea and we'll talk and we won't make a big deal of it.' By late labour, women expected to have to rely on a support person or coach to help t h e m cope. They expected to use breathing techniques learned in prenatal classes and changes in position to maintain control. T h e y wanted to avoid using analgesics if at all possible, but were willing to do so if necessary. As one woman said: ' I f it's really bad they can give you stuff, but o f course, we all say we're not going to take anything.' T h e actual delivery o f the baby was seen as occupying a relatively short period of time during which the forces of nature would take over completely. Several women said they expected to scream, but in general, w o m e n had only a hazy picture of what they would be doing during the birth o f the baby. Interestingly, women were optimistic about their ability to tolerate pain. When asked how they would rate their pain threshold in relation to other people's, they described it as 'average', 'in the middle or m e d i u m ' or 'pretty good'. However, their responses also reflected their lack of real experience with pain and their concern that they would not know just how good their ability to tolerate pain was until they were actually in labour. An element o f wishful thinking was present in some of their comments as though these women were almost t r y i n g - t o convince themselves that they would be able to cope. One woman said:
'I think I can tolerate pain. I think I can tolerate a fair a m o u n t o f pain. I don't know as I have never really had to tolerate it. I think I can tolerate a fair a m o u n t o f pain though.' While several women stated they expected to be able to maintain control o f their behaviour and emotions as long as labour did not last too long or the pain was not overwhelming, most women either did not ~know how they would react or just h o p e d they would be able to maintain control.
Role of support person All the women expected their husband or labour coach to be a busy, active participant in the childbirth process. In early labour, they were described as coaching, massaging, timing contractions, giving back rubs, holding hands, offering encouragement, walking and talking with the labouring w o m a n and taking care of little details such as the feeding of the family pets. In late labour, w o m e n saw their husband/ coach being engaged in many of the same activities as in early labour, but in addition, they also c o m m e n t e d he/she would be helping them maintain control. Husbands/coaches were expected to be a source o f e n c o u r a g e m e n t and support, sometimes simply by virtue of their presence. During delivery, women expected their husband/coach to be at their side, telling them what to do; r e m i n d i n g them about breathing and 'pushing'. T h e y were viewed as the orienting agents who would tell the woman what was going on and act as a go-between for her with the hospital staff.
Role of health professionals In Canada the final responsibility for care during labour and the delivery rests with the physician. However, the labour and delivery nurse will be responsible for monitoring progress. T h e women in o u r sample expected their physician to be present only for the delivery of the baby unless a complication arose. T h e physician was viewed as someone who was very busy, who would check in 'off and on' during labour,
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arrive for the delivery, deliver the baby, 'wash up' and go home. W o m e n were unable to articulate any role for the physician during labour apart f r o m giving instructions to the nurses and recognising complications. During delivery, women expected the physician to deliver the baby, cut the cord, deliver the placenta and 'stitch them up'. With regard to the a m o u n t of time that nurses would spend with them in labour, w o m e n generally expected that the nurse would be in and out during early labour and would spend most o f late labour with them. W o m e n viewed the nurse's role in labour as primarily assisting the physician and monitoring the progress of labour. Nurses were expected to take vital signs, p e r f o r m examinations, check the fetal heart rate and change the sheets. Only four w o m e n expected the nurse to offer e n c o u r a g e m e n t and emotional support. Most women did not know what the nurse would be doing d u r i n g delivery. Those women who did venture a guess thought she would probably be helping the physician and 'cleaning up'. T h e following example is typical of women's comments: 'I think they put on the monitor. T h e y check internal, check your blood pressure. Everything like that. [Check] what stage you're in. All the technical things they have to do. During late labour, I guess m u c h of the same thing and seeing if I need any medication or if there is any complication. I don't know. I guess if there's monitors on, she'll be reading monitors. I f there's not, she'll be standing by with things. I ' m not sure what they do.'
Intervention When asked what kinds o f treatments and procedures they expected to have d u r i n g labour and delivery, women were able to e n u m e r a t e a lengthy list. Six women mentioned having a 'shave p r e p ' and enema, five thought they would have fetal monitoring, five expected an intravenous infusion to be established and five anticipated an episiotomy. However, although women generally knew what procedures to expect, they wanted to be consulted about what
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was done to them. T h e i r comments also suggested that they did not really want to have many of the procedures done, but expected that they would be done anyway. As one woman stated: 'I would like to think that I won't be shaved, but I probably will be.' Similarly, when asked whether they expected to use analgesics or anaesthetics during labour and delivery, w o m e n again distinguished between what they would like to have h a p p e n and what they expected would actually occur. While most women said they would like to be ' d r u g free', they expected they might need something, particularly if the labour were long. Demerol was mentioned as a d r u g that was 'very effective', would 'make you sleep' and that would 'take the edge o f f the pain'. Nitrous oxide was described as 'better than nothing'. An epidural was expected to completely block pain.
Childbirth environment When women were asked what their expectations were for the childbirth setting, their responses were d e p e n d e n t u p o n whether they had had a hospital tour of the labour and delivery suite. W o m e n who had received a t o u r in particular of the birthing rooms - described the environment as 'home-like', 'very comfortable' and 'private'. W o m e n who had not been on a hospital tour described the birth setting as analogous to an operating r o o m - cold, white, bright and impersonal. For those women who anticipated using a birthing room, the major advantage was the opportunity it afforded for privacy. This privacy was regarded as an important factor in helping the woman relax and as an essential c o m p o n e n t in the creation of a shared birth experience between the woman and her significant other.
DISCUSSION T h e findings of this study must be regarded with caution since the sample is small, f r o m one area of Canada, and reflective of the Canadian health care system. In Canada care of the p r e g n a n t woman is the jurisdiction of the physician, the
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practice of midwifery is not legal except in remote areas. Prenatal classes are taught by childbirth educators who may or may not be nurses. As already stated, during childbirth, the labour and delivery nurse will be responsible for monitoring progress, but final responsibility for care of the woman and for the birth itself resides with the physician. It is within this context that the findings of this study must be viewed. Although the interview data were primarily intended for use in the construction of scale items for the CEQ, a n u m b e r of themes emerged from the data which may have implications for childbirth educators. Even though the respondents were attending childbirth education classes, had discussed childbirth with friends and family m e m b e r s and in two cases had a previous labour experience, all stated that they did not know what to expect in childbirth. However, they were still able to clearly articulate a complex and often detailed set of childbirth expectations. T h e fact that women did not know what to expect did not prevent t h e m f r o m developing images of what the experience would be like. Janis (1958) has postulated that the anticipatory thought processes preceding a stressful event play a major role in determining how an individual will cope during the conditions of imposed threat as well as during the period after the event has taken place. T h e 'work of worry' described byJanis has a parallel in the childbirth expectations developed by p r e g n a n t women. By attending childbirth education classes, women can increase their knowledge o f what to expect during childbirth and in so doing, work through some of their fears and anxieties. A major challenge then for childbirth educators is to find ways of preparing w o m e n for the realities of the childbirth experience. W o m e n coming to childbirth education classes have already developed expectations for the experience. Exploration of these expectations and of women's birth fantasies can serve as a means of promoting expectations that are realistic. Many women in this study had developed highly detailed and romanticised birth fantasies. O f concern is how women can be helped to avoid scripting their birth fantasies so tightly that they
set themselves up for failure. I n h e r e n t in the development of birth plans, is the danger that women may be encouraged to think that planning the 'perfect' birth is possible. Ideally, a birth plan should be used as a means o f exploring what is realistically possible and enabling women to set goals for their birth experience that cover a range of circumstances and make allowances for change. T h e women in this study held very high expectations of the ability of their husband/ coach to help them t h r o u g h the experience. T h e question could be raised whether these women were placing too m u c h faith in their husband's ability to help them maintain control. Perhaps more consideration in childbirth education classes needs to be given to the experience o f labour f r o m the perspective of the father and how he feels u n d e r the weight of the expectations placed upon him. In this regard, opportunities could be provided during classes for couples to discuss their mutual expectations for each other and for the childbirth experience. As well, the role o f the midwife/nurse in providing help to the childbearing couple during labour could be emphasised so that the woman need not feel she is totally d e p e n d e n t on her husband/ coach and the father need not feel that he is without support or guidance in his role. Perhaps the greatest challenge facing childbirth educators is to p r e p a r e w o m e n for the realities o f childbirth without destroying the excitement, the sense o f wonder and the joyful anticipation of the experience. How can we help couples have the childbirth experience they desire within the boundaries of what is realistic? How can we ensure that women have a sense of accomplishment rather than feelings of failure about birth and how can those feelings of mastery o f the experience be used to p r o m o t e confidence in m o t h e r i n g abilities? An understanding of the i m p o r t a n c e o f childbirth expectations and their incorporation into childbirth education is one way of helping us meet these challenges.
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