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Interconception Challenges of Women Who Had Prior Preterm Births
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Interconception Challenges of Women Who Had Prior Preterm Births Doris M. Boutain, Shuyuann Wang Foreman, and Jane Hitti
Correspondence Doris M. Boutain, RN, PhD, Department of Psychosocial and Community Health, University of Washington School of Nursing, Box 357263, Seattle, WA 981957263. [email protected] Keywords challenges interconception care prior preterm birth
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ABSTRACT Objective: To describe the interconception challenges of women who had prior preterm births. Design: We used a cross-sectional design and collected data via survey. Setting: King County, Washington. Participants: Ninety-two women who had prior early preterm births (20–33 weeks gestation) were included. Methods: Women were recruited from a larger study focused on exploring the infectious pathways for early preterm birth. Participants were interviewed once using open-ended and close-ended surveys. The primary open-ended survey question was What are the five greatest challenges you experience now? We analyzed data using inductive and summative content analysis and descriptive statistics. Results: Ninety-one participants described challenges. One participant had no challenge. We categorized 11 challenges during the interconception period: Mothering (n ¼ 70, 76%), Self-Care Desires (n ¼ 35, 38%), Finances (n ¼ 31, 34%), Employment (n ¼ 31, 34%), Partner Relationships (n ¼ 29, 32%), Individualized Concerns (n ¼ 25, 27%), Mental Health (n ¼ 23, 25%), Balance (n ¼ 22, 24%), Physical Health (n ¼ 19, 21%), Housing (n ¼ 18, 20%), and Family (n ¼ 17, 19%). Conclusion: Participants described an array of challenges that often related to their roles as mothers, employees, and partners. Our research advances knowledge by describing contemporary challenges of women during the interconception period.
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Doris M. Boutain, RN, PhD, is an associate professor in the Department of Psychosocial and Community Health, University of Washington, Seattle, WA. Shuyuann Wang Foreman, PhD, is a clinical assistant professor in the Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA. Jane E. Hitti, MD, MPH, is a professor in the Department of Obstetrics and Gynecology, School of Public Health, University of Washington, Seattle, WA.
The authors report no conflict of interest or relevant financial relationships.
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omen with prior preterm births (defined as births before 37 weeks gestation; World Health Organization, 2015), are a focal population for interconception research (DeCesare, Jackson, & Phillips, 2015). The interconception period is the vitally important time from the end of one pregnancy to the beginning of the next (Badura, Johnson, Hench, & Reyes, 2008). Women with prior preterm births are at increased risk for subsequent preterm births compared with women without such history (Iams et al., 1998). Although interconception care is part of a comprehensive approach to women’s health, the cost of services is not typically reimbursed (Wise, 2008), and the issue is not commonly researched. Studies about preterm birth are usually conducted when the mother and newborn are monitored in the hospital (Piso, Zechmeister-Koss, & Winkler, 2014), while the preterm infant is hospitalized (Spielman & Taubman-Ben-Ari, 2009), or shortly after hospital discharge (Moore, Parrish, & Black, 2011). Thus, it is not readily known what women
with prior preterm births view as challenges during the interconception period. The optimal timeframe for interconception research is also difficult to define. The World Health Organization (2006) recommended a minimum interconception interval of 24 months. Salihu, August, et al. (2012), who researched Head Start enrollees, noted the importance of studying women with pregnancies more than 60 months apart because they too had risks. Women who birth a second child may not do so until 36 to 48 months after the first child (Wise, 2008). Thus, the timeframe between a preterm birth and a subsequent pregnancy varies considerably.
Background and Significance Researchers have not explicitly asked women with prior preterm births about their challenges during the interconception period. Moore, Parrish, and Black (2011) reviewed the literature about
ª 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Interconception Challenges
Although interconception care is part of a comprehensive approach to women’s health, this issue is not typically researched.
couples’ interconception needs after a miscarriage, fetal death, or neonatal loss. However, this review was not exclusively focused on preterm birth. The extant literature includes a central focus on interconception health care services. Researchers evaluated women’s interconception services and service receptivity (Rosener et al., 2016), identified where women sought care after birth (Bryant, Blake-Lamb, Hatoum, & Kotelchuck, 2016), recommended interconception services (DeCesare et al., 2015; Johnson et al., 2006; Johnson & Gee, 2015; Korst et al., 2005; Zive & Rhee, 2014), or highlighted existing or proposed interconception interventions (Bryant, Haas, McElrath, & McCormick, 2006; Ehrenthal, Chichester, Cole, & Jiang, 2012; Mielke, Kaiser, & Centuolo, 2013; Tieu, Bain, Middleton, & Crowther, 2013). Authors also described lessons learned after the implementation of interconception care (Badura et al., 2008; Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Cheng & Patel, 2011; Handler et al., 2013; Hogan et al., 2013; Loomis & Martin, 2000). Others documented associations between interconception care and birth spacing (Salihu, August, et al., 2012) or interconception service reimbursement issues (Simon & Handler, 2008).
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Another emphasis of the literature on interconception is maternal conditions. Researchers studied continuing prenatal conditions (Klerman et al., 2008; Masho et al., 2013), risks for genetic disease and birth defects (Dolan & Moore, 2007), and maternal weight changes (Sackoff & Yunzal-Butler, 2015) during interconception. Researchers also studied gestational age size and risk for infant mortality in a subsequent pregnancy (Salihu, Salinas, et al., 2012) and other characteristics of women during interconception (Chatterjee, Kotelchuck, & Sambamoorthi, 2008; D’Angelo et al., 2007; Rosenbach, O’Neil, Cook, Trebino, & Walker, 2010). Mulholland, Njoroge, Mersereau, and Williams (2007) described diabetes guidelines during the interconception period, and Lewis et al. (2013) explored couples’ notions about preconception health via telephone interviews during the interconception period. In summary, the extant literature is focused on predesigned interconception services for women.
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We did not find an explicit focus on the life challenges encountered by women during the interconception period who are also at risk for subsequent preterm births. Therefore, the purpose of our study was to describe the challenges expressed by women during the interconception period who had prior preterm births and were considering future pregnancies.
Methods Study Design and Sample We used a cross-sectional design and collected data with an open-ended and close-ended survey as part of a parent study in which we explored the infectious pathways for early preterm birth (i.e., birth at 20–33 weeks gestation). Other inclusion criteria were as follows: (a) born in the United States; (b) an English speaker; (c) a resident of King County, Washington at the time of birth; (d) no hypertensive complications in the index pregnancy; (e) biologically able to become pregnant; and (f) considering another pregnancy. Human subjects approval was acquired before recruitment. We enrolled a sample of 92 women who experienced prior early preterm births. After noting sample similarities and differences based on selfidentified racial identity, participants were stratified accordingly to describe these distinctions (see Table 2). White women (n ¼ 74), African American women (n ¼ 16), and mixed-race women (n ¼ 2) were similar in age and employment status and notably differed in gravidity and income status. Median years from a preterm birth to the study interview was 2 years for White women, 3 years for African American women, and 5.5 years for mixed-race women. The median household income was $80,000 for White women, $16,000 for African American women, and $35,000 for mixed-race women. See Table 2 for more information.
Data Collection Procedures Open-ended and close-ended surveys were used for data collection. Research staff skilled in standardized interviewing methods (Boutain & Hitti, 2006) surveyed participants once in their homes or private work offices at a time chosen by participants for 1 hour. Demographic data were elicited using open-ended and close-ended questions. The primary open-ended survey question was What are the five greatest challenges you experience now? Interviews were transcribed verbatim by a certified
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Table 1: Challenges Reported by Participants (N [ 92) Number of Issues Described per Participant Number of Participants Type of Challenge
Expressing Challenge
% of Total Sample
1
2
Mothering
70
76
56
12
2
Self-Care Desires
35
38
31
3
1
Finances
31
34
31
0
0
Employment
31
34
29
2
0
Partner Relationship
29
32
28
1
0
Individualized Concerns
25
27
21
4
0
Mental Health
23
25
20
2
1
Balance
22
24
20
2
0
Physical Health
19
21
17
2
0
Housing
18
20
18
0
0
Family
17
19
16
1
0
1
0
0
0
0
287
29
4
No challenge Total
transcriptionist within 2 weeks and verified for accuracy by each interviewer. Interviewers typed observation notes from each interview into the transcript. Interviewers also read the transcript while simultaneously listening to the audiotaped interview for transcript verification and correction. This same process was used when a random subset of transcripts was assigned to the co-primary investigator or research assistant for a second review as an additional data quality control measure.
Data Analysis Analysis was completed using inductive and summative content analysis (Elo & Kyngas, 2008) and descriptive statistics. Content analysis was used to code and tabulate textual data as expressed by participants as a way to discern commonly used terms (Elo & Kyngas, 2008). We selected content analysis as an appropriate methodology to identify and quantify the challenges. A total of 320 textual excerpts were read five times to derive codes using the participants’ own words. Codes were initially generated by one primary coder. Transcript sections were also coded by a second researcher. Ambiguous textual excerpts were read aloud, discussed, and coded during in-person meetings to reach
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100% mutual agreement. The final codes were then agreed on by the primary and secondary coders. Similar codes were organized into categories such as Physical Health, Mental Health, and Mothering. We clustered codes into a category if at least 10 or more participants expressed a similar challenge. The final challenge categories represented 17 to 70 participants who expressed that challenge. We identified the category Individualized Concerns after noting that participants had specific concerns of significance that related to their own lives. A complete list of categories and the frequency of each is noted in Table 1 to detail the extent to which the sample shared topically similar challenge categories. Within each challenge, specific issues were also identified, as indicated in Table 1. We examined demographic data to explore potential associations between demographic characteristics and the challenge categories. Categoric data were analyzed as the actual number and the percentage and were tested with the chi-square test. Continuous data were presented as mean and standard deviations (tested using one-way analysis of variance) or median (interquartile range, tested using the Kruskal–Wallis test). No statistically significant
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Interconception Challenges
Table 2: Study Participants With Preterm Birth, Stratified by Race (N [ 92)
Characteristic Age in years, M SD
White Women
African American
Mixed-Race
(n ¼ 74)
Women (n ¼ 16)
Women (n ¼ 2)
32.0 5.5
26.8 5.6
31.0 7.1
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Marital status, n (%) Single Partnered/married
6 (8)
2 (13)
1 (50)
66 (90)
12 (75)
1 (50)
Separated/divorced
1 (1)
0 (0)
0 (0)
Other–dating
0 (0)
2 (13)
0 (0)
54 (73)
12 (75)
1 (50)
Employment status, n (%) Employed Unemployed
3 (4)
1 (6)
0
Student
1 (1)
1 (6)
0
16 (22)
2 (13)
Homemaker Gravidity, M SD
2.5 1.8
4.1 1.9
1 (50) 7.5 0.7
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Parity, n (%) 1
40 (54)
6 (38)
1 (50)
2
24 (32)
7 (44)
0 (0)
3þ
10 (14)
3 (19)
1 (50)
Household incomea Median in thousands of dollars Low income, n (%)
b
Number of people living in household
c
Women with more than one PTB, n (%) Median (range) in years from Index PTB to study interview
80 (0–25)
16 (0–85)
13 (18)
12 (80)
2.5 1.1
2.9 1.6
17 (24) 2.0 (0–10)
35 (10–60) 2 (100) 4.5 2.1
2 (13)
1 (50)
3.0 (0–8)
5.5 (5–6)
PTB gestational ages, n (%) Extremely early preterm (<28 weeks)
11 (15)
3 (19)
0 (0)
Very early preterm (28–31 weeks)
15 (20)
5 (31)
1 (50)
Moderately preterm (32–33 weeks)
25 (34)
5 (31)
0 (0)
Late preterm (34 weeks)
23 (31)
3 (19)
1 (50)
Note. PTB ¼ preterm birth. a The household income cut points were calculated by household size. bMissing income information for three White women and one African American woman. cMissing household size information for one White woman.
associations were noted between demographic variables and the frequency or type of challenge category.
Results Themes About Challenges We identified 11 challenge categories. Ninetyone participants expressed challenges, and one participant had no challenge. As shown in Table 1, we tabulated challenges with Mothering
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(n ¼ 70, 76%), Self-Care Desires (n ¼ 35, 38%), Finances (n ¼ 31, 34%), Employment (n ¼ 31, 34%), Partner Relationships (n ¼ 29, 32%), Individualized Concerns (n ¼ 25, 27%), Mental Health (n ¼ 23, 25%), Balance (n ¼ 22, 24%), Physical Health (n ¼ 19, 21%), Housing (n ¼ 18, 20%), and Family (n ¼ 17, 19%). Mothering. Mothering was used to describe the process of caring for children or wanting to be a
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mother. The mothering role itself was a challenge because mothering a preterm infant was viewed as requiring specialized care. Seventy-six percent of the participants (n ¼ 70) expressed challenges related to mothering. Most voiced one issue (n ¼ 56) within the Mothering category, but others expressed two (n ¼ 12) and three (n ¼ 2) different issues. Taking care of children well was expressed 35 times and was the most common issue in this category. Participants viewed the challenge of mothering as ongoing. When asked about her greatest, one participant replied, “I would say being a mother.” Being a mother encompassed the routine and necessary aspects of caring for children. Six participants expressed specific concerns related to mothering a preterm infant at home, including “well. he’s speech-delayed. so. communicating with him and getting him speaking. [is] the main challenge for me,” “she’s still kind of speech delayed,” and “when [name of child] was in NICU she got discharged [and] nobody gave me any information on premature babies.” Participants also recounted recurrent visits to hospitals and therapists to garner care and consistently voiced how it was a challenge to be a good caretaker of children. It was more of a challenge because they often did not feel able to care for their own children. Self-Care Desires. Participants had pressing desires to care for themselves and simultaneously expressed an inability to do so. Accounts were clustered into the Self-Care Desires category (n ¼ 35, 38%) and included to have more time for self (n ¼ 17), finish educational pursuits (n ¼ 5), exercise (n ¼ 4), remain addiction free (n ¼ 3), and improve motivation (n ¼ 1). Developing hobbies (n ¼ 1), leaving the house more (n ¼ 1), getting organized (n ¼ 1), staying focused on self (n ¼ 1), and maintaining friendships (n ¼ 1) were also Self-Care Desires. Self-Care Desires were voiced as wishes for the future, and activities for self-care varied. One participant said, “I think finding time for myself. as any mom. finding time to. to just read and relax. have time to yourself.” Remarks about self-care desires emphasized how women longed for “finding” themselves again. Self-care was the commonality in this category, even though the activities varied. Finances. Finances were a challenge because participants did not have enough funds to pay
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This study advances knowledge about the challenges voiced by women who had prior preterm births and are considering future pregnancies.
outgoing debts, and they lacked financial resources to pay for routine and emergency bills. Finances were a concern for 34% of the participants (n ¼ 31). For example, one noted, “Finances are definitely a challenge.” Another participant asserted that “having a single income in [name of city]” was a challenge. Participants in partnered relationships also spoke of insufficient economic resources given their living expenses. Some financial challenges resulted from the preterm birth: “total medical bills. they were about a quarter million. And we found out that, after the fact, that our insurance wasn’t very good, but we thought we had insurance, so we didn’t apply [to] DHSA, DSHS?” One participant was unaware of the sum of her medical expenses and the amount of the outstanding debt after deductions were finalized. Participants often spoke of paying routine or medical bills as a financial challenge. However, two described creating financial goals (n ¼ 1) or saving money (n ¼ 1) as challenges. Employment. Employment challenges included participants concerns about current or future work outside of the home. Thirty-one participants (34%) described Employment challenges that included managing work demands (n ¼ 14), finding a job (n ¼ 7), determining a future employment direction (n ¼ 6), seeking job stability while employed (n ¼ 2), and working while being bored (n ¼ 2). They recounted how employment challenges were related to job demands. They were unable to remain at work later than scheduled or complete job-related work at home as they had done before they had a child (or children). One participant expressed that “so often times things get left still on my desk unfinished” because of the need to leave work and travel to the child care facility. Conversely, some women sought positions with higher salaries to afford working outside of the home. One participant related that she was “trying to find work because I don’t. I’m having problems with [a state agency] helping pay for the child care.” She sought stable employment, but was amenable to any employment to pay essential bills. Partner Relationships. Participants viewed their intimate partner relationships as important and challenging and often focused on their roles as
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Interconception Challenges
caretakers of partner relationships to maintain their stability. Twenty-nine participants (32%) described these challenges, including caring for their partner relationships (n ¼ 27) or seeking consistent partner relationships (n ¼ 2). When participants (n ¼ 27) spoke of caring for existing partner relationships, they described challenges with making time for the partner (n ¼ 11), maintaining a good relationship (n ¼ 6), or specific partnership issues (n ¼ 10). Twenty-eight participants expressed a single issue as a challenge in their partner relationships, and one woman described two issues. Participants overall spoke about “making sure that it [the partner relationship] stays good” or “maintaining a strong marriage” as challenges. Two other women sought stable partner commitment while dating. Individualized Concerns. In the Individualized Concerns category, the various issues participants encountered during the interconception period were emphasized. Twenty-five participants (27%) expressed concerns related to the contexts of their lives, and most often they wanted to manage time to address specific issues. Time was viewed as a finite resource to be managed: “just trying to fit it all in and making sure I’m spending enough time. taking care of the responsibilities that I need to take care of.” Participants wanted to manage time to address specific issues (n ¼ 6) or manage time for homerelated housekeeping (n ¼ 9). Individualized concerns also focused on uncertainty in participants’ lives, and they discussed issues related to the unknown future (n ¼ 5). One participant mentioned meetings, lactation, isolation, commuting, and religion. All participants expressed an array of specific issues as challenges. Mental Health. Mental Health included participants’ concerns about their thoughts, moods, or emotions. Twenty-three (25%) spoke about their mental health issues as challenges. More (n ¼ 19) spoke of mental well-being concerns rather than specific mental disorders (n ¼ 4). Of the 23 participants who voiced mental health issues as challenges, most (n ¼ 20) described only one issue. A few others described two (n ¼ 2) or three (n ¼ 1) issues. Thus, 27 issues were voiced in the Mental Health challenge category, and those issues varied and included worries (n ¼ 7), stress (n ¼ 6), emotions related to preterm birth (n ¼ 5), and depression (n ¼ 3). Other issues expressed by one participant only were anger management,
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anxiousness, grief, emotional exhaustion, emotional needs, and a panic disorder. Balance. Balance described the challenge to effectively manage two or more important life areas simultaneously, and 22 participants (24%) described challenges within this category. Most participants (n ¼ 20) voiced at least two issues that needed balance, and two expressed two or more balance concerns. The most common balance issues involved managing the needs of self and others (n ¼ 8), managing work and other needs (n ¼ 13), and managing father and child needs (n ¼ 1). One participant stated, “balancing full-time work and parenthood is probably the number one” concern. Physical Health. The Physical Health category represented physical ailments and issues, including specific physical needs, disease conditions, disabilities, and limitations. Participants (n ¼ 19, 21%) spoke of physical health issues as challenges that involved themselves, not their children or families. For example, they had issues with managing health ailments (n ¼ 9), weightrelated issues (n ¼ 6), or sleep needs (n ¼ 4). Overall, physical health challenges focused on current physical conditions and limitations. Housing. Challenges in this category included leaving a residence or wanting another residence more than not having a residence. Eighteen participants (20%) identified housing challenges. Nine participants were moving, some to reduce housing costs (n ¼ 3) and others as a result of relocation (n ¼ 6). Four participants were having homes remodeled in anticipation of a future intended birth. One participant noted that remodeling was a challenge because she was “moving out within the next month to a rental” and her “house is basically being torn practically down.” Two participants were “house hunting.” Others communicated issues related to owning a home (n ¼ 1), sharing housing (n ¼ 1), or living in a small home (n ¼ 1). One participant shared that moving was a result of a change in government housing support and noted, “We are section eight [a government subsidy] so now we have to downsize. We have a three-bedroom now. We have to go to a two-bedroom. And the voucher is way less and it’s hard.” Family. All challenges in this category involved family members other than spouses or partners within or outside the participants’ primary residences. Seventeen participants (19%) spoke of
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family challenges, and most (n ¼ 16) had only one family challenge. Some participants spoke of “staying in touch with long-distance family” as an issue, and others verbalized issues with grandparents, sisters, brothers, or other relatives as challenges. Family challenges were caused by communication issues, the location of the residence, or family activities.
Discussion Through this study we contribute to knowledge development because of our focus on women’s holistic concerns during interconception. We categorized and tabulated an array of challenges women noted as important. The expressed challenges were relational and contextual. Caring for children was the most pressing Mothering challenge and is a common concern of mothers after preterm birth (Swartz, 2005). Infants born preterm present long-term situational and anticipatory challenges, and some researchers found parent functioning concerns 7 years after a preterm birth (Treyvaud, Lee, Doyle, & Anderson, 2014). Parenting a preterm infant is challenging because of the infant’s developmental vulnerability, possibility of continued health concerns, need for specialized care, and parental trauma with the birth or experiences of parenthood (Bakewell-Sachs & Gennaro, 2004; Swartz, 2005; Treyvaud et al., 2014). Mothers of preterm infants also viewed birth as a crisis stress event, whereas mothers of full-term infants viewed birth as a normative stress event (Spielman & Taubman-Ben-Ari, 2009). Mothers of preterm infants were more also likely to report and appraise stress than fathers of preterm infants (Spielman & Taubman-Ben-Ari, 2009). It is plausible that these issues continue to concern women, and taken together, set the context for the prominence of Mothering as a challenge category. The next three challenge categories were Self-Care Desires, Finances, and Employment. Current interconception care models focus on caring for individual health ailments that increase women’s risk for a future preterm birth (Handler et al., 2013). We did not find any studies in which the authors highlighted women’s own self-care interests during interconception. In our study, participants were challenged to engage in self-defined, holistic care practices (such as focusing on time for self, etc.). Their longings were repeatedly noted and slightly surpassed the Finance and Employment challenge categories.
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Consistent with other interconception research (Handler et al., 2013), we found that some participants had challenges with finances, which is also consistent with women’s health equity research (Wise, 2008). Our participants were often employed workers who experienced financial challenges. Insurance status, as a proxy for employment, is described in the interconception literature. Women with private health insurance reported more access to resources and positive behaviors supportive of a healthy pregnancy (D’Angelo et al., 2007). Insurance policies, whether by private insurers or public providers, define the availability and scope of interconception care (D’Angelo et al., 2007; Handler et al., 2013; Wise, 2008). Although there is not a robust focus on employment in the interconception literature (Handler et al., 2013), our participants expressed employment challenges related to work conditions and their earning potential. Our findings may encourage researchers to inquire about employment issues in addition to health insurance coverage. There is a need for more research about the economic debt and burden incurred by families of preterm infants and how that may affect women’s own health care–seeking behaviors during the interconception period. Women were also challenged by their work hours and salary limitations. Other researchers found that African American women with income inequalities wanted economic support during the interconception period (Handler et al., 2013). However, there is limited research about how women who identify as White or mixed-race or who are of middle income status may benefit from support given the medical expenditures that result from preterm birth. We did not locate any studies in which researchers explored partner relationships as an interconception challenge, except when those relationships involved violence. For example, D’Angelo et al. (2007) focused on partner violence against women as an interconception risk factor. Overall, few scholars have documented women’s interconception concerns about partner relationships (Moore et al., 2011) but instead have studied preterm birth, family functioning, and stress overall, with more heightened experiences noted among families of preterm versus term infants (Spielman & Taubman-Ben-Ari, 2009; Treyvaud et al., 2014). We reviewed research related to several challenge categories. Similar to Handler et al. (2013),
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Interconception Challenges
Health care providers can tailor questions to ensure that women’s specific, individualized challenges are discussed during clinical encounters.
participants in our study described specific mental health concerns, including depression symptoms (D’Angelo et al., 2007). An analysis by the Centers for Disease Control and Prevention of 55% of U.S. births in 2009 showed that 12% of women reported postpartum depression or mental health concerns (Robbins et al., 2014). Participants in our study also discussed mental health wellness. However, we did not use specific mental health surveys to describe the array of mental health issues. In a meta-synthesis of 10 qualitative studies, Swartz (2005) found that women had multiple competing demands. Women in our study termed this challenge Balance and were usually managing two major life areas. Interconception research has also been done on women’s weight and postpregnancy chronic diseases (Zive & Rhee, 2014); we categorized those concerns in the category of Physical Health, which included physical health ailments and weight management. Our participants viewed Housing as a challenge. Housing is not typically researched as an interconception challenge for women, unless the focus is on homelessness (D’Angelo et al., 2007). Concerns in the Housing category were related to resizing residences. Research about housing challenges requires further inquiry. A few participants highlighted challenges in the Family category that involved extended family members. More research is needed to understand the nature and degree of family challenges because these issues varied. No study was found with a focus on extended family members as an interconception challenge for women.
Implications for Practice and Further Research Research designed to enroll women after a preterm birth, subsequent to hospital or early transition home care, is not often funded (Wise, 2008). This limits knowledge about challenges that affect women’s everyday lives between pregnancies. Thus, modifiable challenges may not get researched, known, or communicated to health care providers.
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Three of the top five challenges involved women’s caring concerns, whether caring for a child (Mothering ranked first), wanting to care for self (ranked second), or caring for a partner relationship (ranked fifth). Thus, it is important for providers to inquire if women’s caring foci are supportive or unsupportive of their health. Providers can focus on women’s roles as mother, person, employee, and partner as a way to personalize care and assess challenges. Personalization could promote discussions about modifiable actions to address those challenges. Because women also shared many self-care desires, it is certainly feasible to incorporate a broader view of self-care into current interconception care approaches. This may appeal to women’s holistic health focus and simultaneously attend to pressing future pregnancy risk factors. A broader view of interconception care also could include a focus on the social determinants of health. In our study, the economic resources of women were depleted because of preterm birth– related medical experiences. Providers can advocate for affordable child care for employed women and transparent health care insurance legislation related to medical cost disclosure. Providers can connect women to services to help them navigate health insurers and anticipate and communicate medical costs related to pre- and postdischarge care provision (Swartz, 2005). These support measures would benefit women earning low, middle, and high household incomes, because these income groups shared financial challenges. Health care providers have the power to introduce, encourage, or inhibit conversations about challenges. An important interconception care practice is to allow some clinical time to discuss women’s individualized concerns (Handler et al., 2013). However, a focus on women’s specific concerns has been seen as usurping other pressing clinical discussions deemed important by providers (Handler et al., 2013). Our research highlights the need to inquire about women’s specific concerns first. Direct questions about mental illness and wellness are also important because women might not volunteer such information because of social stigma. Providers can coach women to improve their mental and physical health status between pregnancies. The topic of family member involvement and possible challenges, for example, can be introduced early
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during discharge planning discussions (Swartz, 2005) and well-child visits. In summary, interconception models often focus on the biological or behavioral risks of women, not the experiences that created women’s vulnerability to such risks (D’Angelo et al., 2007). Because interconception care is not usually reimbursed, providers must create opportunities for supportive encounters. Kamel et al. (2013), for example, noted how providers in Egypt use the child vaccination visit to engage women in interconception care. Other clinical opportunities to elicit and address women’s challenges can occur during women’s well visits, contraceptive counseling sessions, lactation visits, or family planning sessions. It is important for clinicians to focus on interconception health in the context of women’s holistic health.
Strengths and Limitations Our study described the challenges of women during interconception. Such information can inform providers of what women deem important and showcase challenges that are not readily or spontaneously shared during health care encounters. Women spoke of what they considered challenges and highlighted what was important to them during interconception after prior preterm births. This study had three limitations. First, the main disadvantage of a survey approach with a content analysis methodology is that the depth of meaning is not fully described. With the use of follow-up focus groups or in-depth interviews, we could have showcased nuances within and between challenge categories. A second limitation was that women were not specifically asked about challenges related to preterm birth to allow for open-ended responses. This broadened the data shared by women and limited the specific focus on clinical needs during interconception after a preterm birth. Third, our research participants were primarily White American women and included only women with a prior early preterm birth. Women with hypertensive pregnancy complications, who are often African American, were not fully represented in the sample because of the parent study’s focus on unknown causes of preterm birth. There was also not enough racial identity, income, partnership status, or geographic diversity to explore statistical associations between the demographic characteristics and the types of challenges.
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Conclusion We categorized women’s discrete challenges during interconception. Women’s top five interconception challenges related to their concerns as mothers, as women with desires, as related to finances, as employed workers, and as partners. Many of the identified challenges women appraised during interconception involved relational and contextual concerns. We identified interconception challenges that require further research using scientific approaches to explore the depth of women’s accounts such as storytelling or narrative analysis. Documenting what women perceive as challenges during interconception will continue to reveal new insights for interconception practice and research advancement.
Acknowledgment A Better Chance project was funded by the Institute of Child Health and Human Development, National Institutes of Health (HD-41682) and the University of Washington School of Nursing (UWSON) Research and Intramural Funding Program. This publication was supported by the UWSON Dean’s Research Intramural Fund and the National Institutes of Health Biobehavioral Nursing Research Training Program (5T32NR007106). The authors thank the researchers and staff of A Better Chance Project, Joycelyn Thomas, Katie Paul, Kristen Swanson, Joseph Fletcher III, and the Whiteley Center.
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Interconception Challenges of Women Who Had Prior Preterm Births Doris M. Boutain, Shuyuann Wang Foreman, and Jane Hitti
Correspondence Doris M. Boutain, RN, PhD, Department of Psychosocial and Community Health, University of Washington School of Nursing, Box 357263, Seattle, WA 981957263. [email protected] Keywords challenges interconception care prior preterm birth
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ABSTRACT Objective: To describe the interconception challenges of women who had prior preterm births. Design: We used a cross-sectional design and collected data via survey. Setting: King County, Washington. Participants: Ninety-two women who had prior early preterm births (20–33 weeks gestation) were included. Methods: Women were recruited from a larger study focused on exploring the infectious pathways for early preterm birth. Participants were interviewed once using open-ended and close-ended surveys. The primary open-ended survey question was What are the five greatest challenges you experience now? We analyzed data using inductive and summative content analysis and descriptive statistics. Results: Ninety-one participants described challenges. One participant had no challenge. We categorized 11 challenges during the interconception period: Mothering (n ¼ 70, 76%), Self-Care Desires (n ¼ 35, 38%), Finances (n ¼ 31, 34%), Employment (n ¼ 31, 34%), Partner Relationships (n ¼ 29, 32%), Individualized Concerns (n ¼ 25, 27%), Mental Health (n ¼ 23, 25%), Balance (n ¼ 22, 24%), Physical Health (n ¼ 19, 21%), Housing (n ¼ 18, 20%), and Family (n ¼ 17, 19%). Conclusion: Participants described an array of challenges that often related to their roles as mothers, employees, and partners. Our research advances knowledge by describing contemporary challenges of women during the interconception period.
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Doris M. Boutain, RN, PhD, is an associate professor in the Department of Psychosocial and Community Health, University of Washington, Seattle, WA. Shuyuann Wang Foreman, PhD, is a clinical assistant professor in the Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA. Jane E. Hitti, MD, MPH, is a professor in the Department of Obstetrics and Gynecology, School of Public Health, University of Washington, Seattle, WA.
The authors report no conflict of interest or relevant financial relationships.
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omen with prior preterm births (defined as births before 37 weeks gestation; World Health Organization, 2015), are a focal population for interconception research (DeCesare, Jackson, & Phillips, 2015). The interconception period is the vitally important time from the end of one pregnancy to the beginning of the next (Badura, Johnson, Hench, & Reyes, 2008). Women with prior preterm births are at increased risk for subsequent preterm births compared with women without such history (Iams et al., 1998). Although interconception care is part of a comprehensive approach to women’s health, the cost of services is not typically reimbursed (Wise, 2008), and the issue is not commonly researched. Studies about preterm birth are usually conducted when the mother and newborn are monitored in the hospital (Piso, Zechmeister-Koss, & Winkler, 2014), while the preterm infant is hospitalized (Spielman & Taubman-Ben-Ari, 2009), or shortly after hospital discharge (Moore, Parrish, & Black, 2011). Thus, it is not readily known what women
with prior preterm births view as challenges during the interconception period. The optimal timeframe for interconception research is also difficult to define. The World Health Organization (2006) recommended a minimum interconception interval of 24 months. Salihu, August, et al. (2012), who researched Head Start enrollees, noted the importance of studying women with pregnancies more than 60 months apart because they too had risks. Women who birth a second child may not do so until 36 to 48 months after the first child (Wise, 2008). Thus, the timeframe between a preterm birth and a subsequent pregnancy varies considerably.
Background and Significance Researchers have not explicitly asked women with prior preterm births about their challenges during the interconception period. Moore, Parrish, and Black (2011) reviewed the literature about
ª 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Interconception Challenges
Although interconception care is part of a comprehensive approach to women’s health, this issue is not typically researched.
couples’ interconception needs after a miscarriage, fetal death, or neonatal loss. However, this review was not exclusively focused on preterm birth. The extant literature includes a central focus on interconception health care services. Researchers evaluated women’s interconception services and service receptivity (Rosener et al., 2016), identified where women sought care after birth (Bryant, Blake-Lamb, Hatoum, & Kotelchuck, 2016), recommended interconception services (DeCesare et al., 2015; Johnson et al., 2006; Johnson & Gee, 2015; Korst et al., 2005; Zive & Rhee, 2014), or highlighted existing or proposed interconception interventions (Bryant, Haas, McElrath, & McCormick, 2006; Ehrenthal, Chichester, Cole, & Jiang, 2012; Mielke, Kaiser, & Centuolo, 2013; Tieu, Bain, Middleton, & Crowther, 2013). Authors also described lessons learned after the implementation of interconception care (Badura et al., 2008; Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Cheng & Patel, 2011; Handler et al., 2013; Hogan et al., 2013; Loomis & Martin, 2000). Others documented associations between interconception care and birth spacing (Salihu, August, et al., 2012) or interconception service reimbursement issues (Simon & Handler, 2008).
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Another emphasis of the literature on interconception is maternal conditions. Researchers studied continuing prenatal conditions (Klerman et al., 2008; Masho et al., 2013), risks for genetic disease and birth defects (Dolan & Moore, 2007), and maternal weight changes (Sackoff & Yunzal-Butler, 2015) during interconception. Researchers also studied gestational age size and risk for infant mortality in a subsequent pregnancy (Salihu, Salinas, et al., 2012) and other characteristics of women during interconception (Chatterjee, Kotelchuck, & Sambamoorthi, 2008; D’Angelo et al., 2007; Rosenbach, O’Neil, Cook, Trebino, & Walker, 2010). Mulholland, Njoroge, Mersereau, and Williams (2007) described diabetes guidelines during the interconception period, and Lewis et al. (2013) explored couples’ notions about preconception health via telephone interviews during the interconception period. In summary, the extant literature is focused on predesigned interconception services for women.
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We did not find an explicit focus on the life challenges encountered by women during the interconception period who are also at risk for subsequent preterm births. Therefore, the purpose of our study was to describe the challenges expressed by women during the interconception period who had prior preterm births and were considering future pregnancies.
Methods Study Design and Sample We used a cross-sectional design and collected data with an open-ended and close-ended survey as part of a parent study in which we explored the infectious pathways for early preterm birth (i.e., birth at 20–33 weeks gestation). Other inclusion criteria were as follows: (a) born in the United States; (b) an English speaker; (c) a resident of King County, Washington at the time of birth; (d) no hypertensive complications in the index pregnancy; (e) biologically able to become pregnant; and (f) considering another pregnancy. Human subjects approval was acquired before recruitment. We enrolled a sample of 92 women who experienced prior early preterm births. After noting sample similarities and differences based on selfidentified racial identity, participants were stratified accordingly to describe these distinctions (see Table 2). White women (n ¼ 74), African American women (n ¼ 16), and mixed-race women (n ¼ 2) were similar in age and employment status and notably differed in gravidity and income status. Median years from a preterm birth to the study interview was 2 years for White women, 3 years for African American women, and 5.5 years for mixed-race women. The median household income was $80,000 for White women, $16,000 for African American women, and $35,000 for mixed-race women. See Table 2 for more information.
Data Collection Procedures Open-ended and close-ended surveys were used for data collection. Research staff skilled in standardized interviewing methods (Boutain & Hitti, 2006) surveyed participants once in their homes or private work offices at a time chosen by participants for 1 hour. Demographic data were elicited using open-ended and close-ended questions. The primary open-ended survey question was What are the five greatest challenges you experience now? Interviews were transcribed verbatim by a certified
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Table 1: Challenges Reported by Participants (N [ 92) Number of Issues Described per Participant Number of Participants Type of Challenge
Expressing Challenge
% of Total Sample
1
2
Mothering
70
76
56
12
2
Self-Care Desires
35
38
31
3
1
Finances
31
34
31
0
0
Employment
31
34
29
2
0
Partner Relationship
29
32
28
1
0
Individualized Concerns
25
27
21
4
0
Mental Health
23
25
20
2
1
Balance
22
24
20
2
0
Physical Health
19
21
17
2
0
Housing
18
20
18
0
0
Family
17
19
16
1
0
1
0
0
0
0
287
29
4
No challenge Total
transcriptionist within 2 weeks and verified for accuracy by each interviewer. Interviewers typed observation notes from each interview into the transcript. Interviewers also read the transcript while simultaneously listening to the audiotaped interview for transcript verification and correction. This same process was used when a random subset of transcripts was assigned to the co-primary investigator or research assistant for a second review as an additional data quality control measure.
Data Analysis Analysis was completed using inductive and summative content analysis (Elo & Kyngas, 2008) and descriptive statistics. Content analysis was used to code and tabulate textual data as expressed by participants as a way to discern commonly used terms (Elo & Kyngas, 2008). We selected content analysis as an appropriate methodology to identify and quantify the challenges. A total of 320 textual excerpts were read five times to derive codes using the participants’ own words. Codes were initially generated by one primary coder. Transcript sections were also coded by a second researcher. Ambiguous textual excerpts were read aloud, discussed, and coded during in-person meetings to reach
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100% mutual agreement. The final codes were then agreed on by the primary and secondary coders. Similar codes were organized into categories such as Physical Health, Mental Health, and Mothering. We clustered codes into a category if at least 10 or more participants expressed a similar challenge. The final challenge categories represented 17 to 70 participants who expressed that challenge. We identified the category Individualized Concerns after noting that participants had specific concerns of significance that related to their own lives. A complete list of categories and the frequency of each is noted in Table 1 to detail the extent to which the sample shared topically similar challenge categories. Within each challenge, specific issues were also identified, as indicated in Table 1. We examined demographic data to explore potential associations between demographic characteristics and the challenge categories. Categoric data were analyzed as the actual number and the percentage and were tested with the chi-square test. Continuous data were presented as mean and standard deviations (tested using one-way analysis of variance) or median (interquartile range, tested using the Kruskal–Wallis test). No statistically significant
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Table 2: Study Participants With Preterm Birth, Stratified by Race (N [ 92)
Characteristic Age in years, M SD
White Women
African American
Mixed-Race
(n ¼ 74)
Women (n ¼ 16)
Women (n ¼ 2)
32.0 5.5
26.8 5.6
31.0 7.1
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Marital status, n (%) Single Partnered/married
6 (8)
2 (13)
1 (50)
66 (90)
12 (75)
1 (50)
Separated/divorced
1 (1)
0 (0)
0 (0)
Other–dating
0 (0)
2 (13)
0 (0)
54 (73)
12 (75)
1 (50)
Employment status, n (%) Employed Unemployed
3 (4)
1 (6)
0
Student
1 (1)
1 (6)
0
16 (22)
2 (13)
Homemaker Gravidity, M SD
2.5 1.8
4.1 1.9
1 (50) 7.5 0.7
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Parity, n (%) 1
40 (54)
6 (38)
1 (50)
2
24 (32)
7 (44)
0 (0)
3þ
10 (14)
3 (19)
1 (50)
Household incomea Median in thousands of dollars Low income, n (%)
b
Number of people living in household
c
Women with more than one PTB, n (%) Median (range) in years from Index PTB to study interview
80 (0–25)
16 (0–85)
13 (18)
12 (80)
2.5 1.1
2.9 1.6
17 (24) 2.0 (0–10)
35 (10–60) 2 (100) 4.5 2.1
2 (13)
1 (50)
3.0 (0–8)
5.5 (5–6)
PTB gestational ages, n (%) Extremely early preterm (<28 weeks)
11 (15)
3 (19)
0 (0)
Very early preterm (28–31 weeks)
15 (20)
5 (31)
1 (50)
Moderately preterm (32–33 weeks)
25 (34)
5 (31)
0 (0)
Late preterm (34 weeks)
23 (31)
3 (19)
1 (50)
Note. PTB ¼ preterm birth. a The household income cut points were calculated by household size. bMissing income information for three White women and one African American woman. cMissing household size information for one White woman.
associations were noted between demographic variables and the frequency or type of challenge category.
Results Themes About Challenges We identified 11 challenge categories. Ninetyone participants expressed challenges, and one participant had no challenge. As shown in Table 1, we tabulated challenges with Mothering
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(n ¼ 70, 76%), Self-Care Desires (n ¼ 35, 38%), Finances (n ¼ 31, 34%), Employment (n ¼ 31, 34%), Partner Relationships (n ¼ 29, 32%), Individualized Concerns (n ¼ 25, 27%), Mental Health (n ¼ 23, 25%), Balance (n ¼ 22, 24%), Physical Health (n ¼ 19, 21%), Housing (n ¼ 18, 20%), and Family (n ¼ 17, 19%). Mothering. Mothering was used to describe the process of caring for children or wanting to be a
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mother. The mothering role itself was a challenge because mothering a preterm infant was viewed as requiring specialized care. Seventy-six percent of the participants (n ¼ 70) expressed challenges related to mothering. Most voiced one issue (n ¼ 56) within the Mothering category, but others expressed two (n ¼ 12) and three (n ¼ 2) different issues. Taking care of children well was expressed 35 times and was the most common issue in this category. Participants viewed the challenge of mothering as ongoing. When asked about her greatest, one participant replied, “I would say being a mother.” Being a mother encompassed the routine and necessary aspects of caring for children. Six participants expressed specific concerns related to mothering a preterm infant at home, including “well. he’s speech-delayed. so. communicating with him and getting him speaking. [is] the main challenge for me,” “she’s still kind of speech delayed,” and “when [name of child] was in NICU she got discharged [and] nobody gave me any information on premature babies.” Participants also recounted recurrent visits to hospitals and therapists to garner care and consistently voiced how it was a challenge to be a good caretaker of children. It was more of a challenge because they often did not feel able to care for their own children. Self-Care Desires. Participants had pressing desires to care for themselves and simultaneously expressed an inability to do so. Accounts were clustered into the Self-Care Desires category (n ¼ 35, 38%) and included to have more time for self (n ¼ 17), finish educational pursuits (n ¼ 5), exercise (n ¼ 4), remain addiction free (n ¼ 3), and improve motivation (n ¼ 1). Developing hobbies (n ¼ 1), leaving the house more (n ¼ 1), getting organized (n ¼ 1), staying focused on self (n ¼ 1), and maintaining friendships (n ¼ 1) were also Self-Care Desires. Self-Care Desires were voiced as wishes for the future, and activities for self-care varied. One participant said, “I think finding time for myself. as any mom. finding time to. to just read and relax. have time to yourself.” Remarks about self-care desires emphasized how women longed for “finding” themselves again. Self-care was the commonality in this category, even though the activities varied. Finances. Finances were a challenge because participants did not have enough funds to pay
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This study advances knowledge about the challenges voiced by women who had prior preterm births and are considering future pregnancies.
outgoing debts, and they lacked financial resources to pay for routine and emergency bills. Finances were a concern for 34% of the participants (n ¼ 31). For example, one noted, “Finances are definitely a challenge.” Another participant asserted that “having a single income in [name of city]” was a challenge. Participants in partnered relationships also spoke of insufficient economic resources given their living expenses. Some financial challenges resulted from the preterm birth: “total medical bills. they were about a quarter million. And we found out that, after the fact, that our insurance wasn’t very good, but we thought we had insurance, so we didn’t apply [to] DHSA, DSHS?” One participant was unaware of the sum of her medical expenses and the amount of the outstanding debt after deductions were finalized. Participants often spoke of paying routine or medical bills as a financial challenge. However, two described creating financial goals (n ¼ 1) or saving money (n ¼ 1) as challenges. Employment. Employment challenges included participants concerns about current or future work outside of the home. Thirty-one participants (34%) described Employment challenges that included managing work demands (n ¼ 14), finding a job (n ¼ 7), determining a future employment direction (n ¼ 6), seeking job stability while employed (n ¼ 2), and working while being bored (n ¼ 2). They recounted how employment challenges were related to job demands. They were unable to remain at work later than scheduled or complete job-related work at home as they had done before they had a child (or children). One participant expressed that “so often times things get left still on my desk unfinished” because of the need to leave work and travel to the child care facility. Conversely, some women sought positions with higher salaries to afford working outside of the home. One participant related that she was “trying to find work because I don’t. I’m having problems with [a state agency] helping pay for the child care.” She sought stable employment, but was amenable to any employment to pay essential bills. Partner Relationships. Participants viewed their intimate partner relationships as important and challenging and often focused on their roles as
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caretakers of partner relationships to maintain their stability. Twenty-nine participants (32%) described these challenges, including caring for their partner relationships (n ¼ 27) or seeking consistent partner relationships (n ¼ 2). When participants (n ¼ 27) spoke of caring for existing partner relationships, they described challenges with making time for the partner (n ¼ 11), maintaining a good relationship (n ¼ 6), or specific partnership issues (n ¼ 10). Twenty-eight participants expressed a single issue as a challenge in their partner relationships, and one woman described two issues. Participants overall spoke about “making sure that it [the partner relationship] stays good” or “maintaining a strong marriage” as challenges. Two other women sought stable partner commitment while dating. Individualized Concerns. In the Individualized Concerns category, the various issues participants encountered during the interconception period were emphasized. Twenty-five participants (27%) expressed concerns related to the contexts of their lives, and most often they wanted to manage time to address specific issues. Time was viewed as a finite resource to be managed: “just trying to fit it all in and making sure I’m spending enough time. taking care of the responsibilities that I need to take care of.” Participants wanted to manage time to address specific issues (n ¼ 6) or manage time for homerelated housekeeping (n ¼ 9). Individualized concerns also focused on uncertainty in participants’ lives, and they discussed issues related to the unknown future (n ¼ 5). One participant mentioned meetings, lactation, isolation, commuting, and religion. All participants expressed an array of specific issues as challenges. Mental Health. Mental Health included participants’ concerns about their thoughts, moods, or emotions. Twenty-three (25%) spoke about their mental health issues as challenges. More (n ¼ 19) spoke of mental well-being concerns rather than specific mental disorders (n ¼ 4). Of the 23 participants who voiced mental health issues as challenges, most (n ¼ 20) described only one issue. A few others described two (n ¼ 2) or three (n ¼ 1) issues. Thus, 27 issues were voiced in the Mental Health challenge category, and those issues varied and included worries (n ¼ 7), stress (n ¼ 6), emotions related to preterm birth (n ¼ 5), and depression (n ¼ 3). Other issues expressed by one participant only were anger management,
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anxiousness, grief, emotional exhaustion, emotional needs, and a panic disorder. Balance. Balance described the challenge to effectively manage two or more important life areas simultaneously, and 22 participants (24%) described challenges within this category. Most participants (n ¼ 20) voiced at least two issues that needed balance, and two expressed two or more balance concerns. The most common balance issues involved managing the needs of self and others (n ¼ 8), managing work and other needs (n ¼ 13), and managing father and child needs (n ¼ 1). One participant stated, “balancing full-time work and parenthood is probably the number one” concern. Physical Health. The Physical Health category represented physical ailments and issues, including specific physical needs, disease conditions, disabilities, and limitations. Participants (n ¼ 19, 21%) spoke of physical health issues as challenges that involved themselves, not their children or families. For example, they had issues with managing health ailments (n ¼ 9), weightrelated issues (n ¼ 6), or sleep needs (n ¼ 4). Overall, physical health challenges focused on current physical conditions and limitations. Housing. Challenges in this category included leaving a residence or wanting another residence more than not having a residence. Eighteen participants (20%) identified housing challenges. Nine participants were moving, some to reduce housing costs (n ¼ 3) and others as a result of relocation (n ¼ 6). Four participants were having homes remodeled in anticipation of a future intended birth. One participant noted that remodeling was a challenge because she was “moving out within the next month to a rental” and her “house is basically being torn practically down.” Two participants were “house hunting.” Others communicated issues related to owning a home (n ¼ 1), sharing housing (n ¼ 1), or living in a small home (n ¼ 1). One participant shared that moving was a result of a change in government housing support and noted, “We are section eight [a government subsidy] so now we have to downsize. We have a three-bedroom now. We have to go to a two-bedroom. And the voucher is way less and it’s hard.” Family. All challenges in this category involved family members other than spouses or partners within or outside the participants’ primary residences. Seventeen participants (19%) spoke of
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family challenges, and most (n ¼ 16) had only one family challenge. Some participants spoke of “staying in touch with long-distance family” as an issue, and others verbalized issues with grandparents, sisters, brothers, or other relatives as challenges. Family challenges were caused by communication issues, the location of the residence, or family activities.
Discussion Through this study we contribute to knowledge development because of our focus on women’s holistic concerns during interconception. We categorized and tabulated an array of challenges women noted as important. The expressed challenges were relational and contextual. Caring for children was the most pressing Mothering challenge and is a common concern of mothers after preterm birth (Swartz, 2005). Infants born preterm present long-term situational and anticipatory challenges, and some researchers found parent functioning concerns 7 years after a preterm birth (Treyvaud, Lee, Doyle, & Anderson, 2014). Parenting a preterm infant is challenging because of the infant’s developmental vulnerability, possibility of continued health concerns, need for specialized care, and parental trauma with the birth or experiences of parenthood (Bakewell-Sachs & Gennaro, 2004; Swartz, 2005; Treyvaud et al., 2014). Mothers of preterm infants also viewed birth as a crisis stress event, whereas mothers of full-term infants viewed birth as a normative stress event (Spielman & Taubman-Ben-Ari, 2009). Mothers of preterm infants were more also likely to report and appraise stress than fathers of preterm infants (Spielman & Taubman-Ben-Ari, 2009). It is plausible that these issues continue to concern women, and taken together, set the context for the prominence of Mothering as a challenge category. The next three challenge categories were Self-Care Desires, Finances, and Employment. Current interconception care models focus on caring for individual health ailments that increase women’s risk for a future preterm birth (Handler et al., 2013). We did not find any studies in which the authors highlighted women’s own self-care interests during interconception. In our study, participants were challenged to engage in self-defined, holistic care practices (such as focusing on time for self, etc.). Their longings were repeatedly noted and slightly surpassed the Finance and Employment challenge categories.
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Consistent with other interconception research (Handler et al., 2013), we found that some participants had challenges with finances, which is also consistent with women’s health equity research (Wise, 2008). Our participants were often employed workers who experienced financial challenges. Insurance status, as a proxy for employment, is described in the interconception literature. Women with private health insurance reported more access to resources and positive behaviors supportive of a healthy pregnancy (D’Angelo et al., 2007). Insurance policies, whether by private insurers or public providers, define the availability and scope of interconception care (D’Angelo et al., 2007; Handler et al., 2013; Wise, 2008). Although there is not a robust focus on employment in the interconception literature (Handler et al., 2013), our participants expressed employment challenges related to work conditions and their earning potential. Our findings may encourage researchers to inquire about employment issues in addition to health insurance coverage. There is a need for more research about the economic debt and burden incurred by families of preterm infants and how that may affect women’s own health care–seeking behaviors during the interconception period. Women were also challenged by their work hours and salary limitations. Other researchers found that African American women with income inequalities wanted economic support during the interconception period (Handler et al., 2013). However, there is limited research about how women who identify as White or mixed-race or who are of middle income status may benefit from support given the medical expenditures that result from preterm birth. We did not locate any studies in which researchers explored partner relationships as an interconception challenge, except when those relationships involved violence. For example, D’Angelo et al. (2007) focused on partner violence against women as an interconception risk factor. Overall, few scholars have documented women’s interconception concerns about partner relationships (Moore et al., 2011) but instead have studied preterm birth, family functioning, and stress overall, with more heightened experiences noted among families of preterm versus term infants (Spielman & Taubman-Ben-Ari, 2009; Treyvaud et al., 2014). We reviewed research related to several challenge categories. Similar to Handler et al. (2013),
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Health care providers can tailor questions to ensure that women’s specific, individualized challenges are discussed during clinical encounters.
participants in our study described specific mental health concerns, including depression symptoms (D’Angelo et al., 2007). An analysis by the Centers for Disease Control and Prevention of 55% of U.S. births in 2009 showed that 12% of women reported postpartum depression or mental health concerns (Robbins et al., 2014). Participants in our study also discussed mental health wellness. However, we did not use specific mental health surveys to describe the array of mental health issues. In a meta-synthesis of 10 qualitative studies, Swartz (2005) found that women had multiple competing demands. Women in our study termed this challenge Balance and were usually managing two major life areas. Interconception research has also been done on women’s weight and postpregnancy chronic diseases (Zive & Rhee, 2014); we categorized those concerns in the category of Physical Health, which included physical health ailments and weight management. Our participants viewed Housing as a challenge. Housing is not typically researched as an interconception challenge for women, unless the focus is on homelessness (D’Angelo et al., 2007). Concerns in the Housing category were related to resizing residences. Research about housing challenges requires further inquiry. A few participants highlighted challenges in the Family category that involved extended family members. More research is needed to understand the nature and degree of family challenges because these issues varied. No study was found with a focus on extended family members as an interconception challenge for women.
Implications for Practice and Further Research Research designed to enroll women after a preterm birth, subsequent to hospital or early transition home care, is not often funded (Wise, 2008). This limits knowledge about challenges that affect women’s everyday lives between pregnancies. Thus, modifiable challenges may not get researched, known, or communicated to health care providers.
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Three of the top five challenges involved women’s caring concerns, whether caring for a child (Mothering ranked first), wanting to care for self (ranked second), or caring for a partner relationship (ranked fifth). Thus, it is important for providers to inquire if women’s caring foci are supportive or unsupportive of their health. Providers can focus on women’s roles as mother, person, employee, and partner as a way to personalize care and assess challenges. Personalization could promote discussions about modifiable actions to address those challenges. Because women also shared many self-care desires, it is certainly feasible to incorporate a broader view of self-care into current interconception care approaches. This may appeal to women’s holistic health focus and simultaneously attend to pressing future pregnancy risk factors. A broader view of interconception care also could include a focus on the social determinants of health. In our study, the economic resources of women were depleted because of preterm birth– related medical experiences. Providers can advocate for affordable child care for employed women and transparent health care insurance legislation related to medical cost disclosure. Providers can connect women to services to help them navigate health insurers and anticipate and communicate medical costs related to pre- and postdischarge care provision (Swartz, 2005). These support measures would benefit women earning low, middle, and high household incomes, because these income groups shared financial challenges. Health care providers have the power to introduce, encourage, or inhibit conversations about challenges. An important interconception care practice is to allow some clinical time to discuss women’s individualized concerns (Handler et al., 2013). However, a focus on women’s specific concerns has been seen as usurping other pressing clinical discussions deemed important by providers (Handler et al., 2013). Our research highlights the need to inquire about women’s specific concerns first. Direct questions about mental illness and wellness are also important because women might not volunteer such information because of social stigma. Providers can coach women to improve their mental and physical health status between pregnancies. The topic of family member involvement and possible challenges, for example, can be introduced early
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during discharge planning discussions (Swartz, 2005) and well-child visits. In summary, interconception models often focus on the biological or behavioral risks of women, not the experiences that created women’s vulnerability to such risks (D’Angelo et al., 2007). Because interconception care is not usually reimbursed, providers must create opportunities for supportive encounters. Kamel et al. (2013), for example, noted how providers in Egypt use the child vaccination visit to engage women in interconception care. Other clinical opportunities to elicit and address women’s challenges can occur during women’s well visits, contraceptive counseling sessions, lactation visits, or family planning sessions. It is important for clinicians to focus on interconception health in the context of women’s holistic health.
Strengths and Limitations Our study described the challenges of women during interconception. Such information can inform providers of what women deem important and showcase challenges that are not readily or spontaneously shared during health care encounters. Women spoke of what they considered challenges and highlighted what was important to them during interconception after prior preterm births. This study had three limitations. First, the main disadvantage of a survey approach with a content analysis methodology is that the depth of meaning is not fully described. With the use of follow-up focus groups or in-depth interviews, we could have showcased nuances within and between challenge categories. A second limitation was that women were not specifically asked about challenges related to preterm birth to allow for open-ended responses. This broadened the data shared by women and limited the specific focus on clinical needs during interconception after a preterm birth. Third, our research participants were primarily White American women and included only women with a prior early preterm birth. Women with hypertensive pregnancy complications, who are often African American, were not fully represented in the sample because of the parent study’s focus on unknown causes of preterm birth. There was also not enough racial identity, income, partnership status, or geographic diversity to explore statistical associations between the demographic characteristics and the types of challenges.
953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008
Conclusion We categorized women’s discrete challenges during interconception. Women’s top five interconception challenges related to their concerns as mothers, as women with desires, as related to finances, as employed workers, and as partners. Many of the identified challenges women appraised during interconception involved relational and contextual concerns. We identified interconception challenges that require further research using scientific approaches to explore the depth of women’s accounts such as storytelling or narrative analysis. Documenting what women perceive as challenges during interconception will continue to reveal new insights for interconception practice and research advancement.
Acknowledgment A Better Chance project was funded by the Institute of Child Health and Human Development, National Institutes of Health (HD-41682) and the University of Washington School of Nursing (UWSON) Research and Intramural Funding Program. This publication was supported by the UWSON Dean’s Research Intramural Fund and the National Institutes of Health Biobehavioral Nursing Research Training Program (5T32NR007106). The authors thank the researchers and staff of A Better Chance Project, Joycelyn Thomas, Katie Paul, Kristen Swanson, Joseph Fletcher III, and the Whiteley Center.
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