Patient-provider communication, maternal anxiety, and self-care in pregnancy

Accepted Manuscript Patient-provider communication, maternal anxiety, and self-care in pregnancy Jennifer Nicoloro-SantaBarbara, Lisa Rosenthal, Melissa V. Auerbach, Christina Kocis, Cheyanne Busso, Marci Lobel PII:

S0277-9536(17)30483-5

DOI:

10.1016/j.socscimed.2017.08.011

Reference:

SSM 11351

To appear in:

Social Science & Medicine

Received Date: 1 February 2017 Revised Date:

3 August 2017

Accepted Date: 12 August 2017

Please cite this article as: Nicoloro-SantaBarbara, J., Rosenthal, L., Auerbach, M.V., Kocis, C., Busso, C., Lobel, M., Patient-provider communication, maternal anxiety, and self-care in pregnancy, Social Science & Medicine (2017), doi: 10.1016/j.socscimed.2017.08.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Patient-Provider Communication, Maternal Anxiety, and Self-Care in Pregnancy

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Cheyanne Busso4, and Marci Lobel1

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Jennifer Nicoloro-SantaBarbara1, Lisa Rosenthal2, Melissa Auerbach1, Christina Kocis3,

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Department of Psychology, Stony Brook University, Stony Brook, New York, USA 2 Department of Psychology, Pace University, New York, USA 3 Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook University Stony Brook, New York, USA 4 Department of Psychiatry, Stony Brook University, Stony Brook, New York, USA

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Corresponding author: Marci Lobel, Department of Psychology, Stony Brook University, Stony Brook, New York 11794-2500 USA. Tel: 1+ 631-632-7651 Email: [email protected]

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Funding: This research was funded in part by a grant from the Society for the Psychological Study of Social Issues [Project #1109640].

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Acknowledgments: We thank the women who participated, the midwives who cared for them, as well as Todd Griffin, Elizabeth Roemer, Elsa Singh, and Ellie Sotomayer, who assisted with this research.

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Abstract Rationale: Favorable relationships with health care providers predict greater patient satisfaction

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and adherence to provider recommendations. However, the specific components of patientprovider relationships that account for these benefits have not been identified. The potential benefits of strong patient-provider relationships in pregnancy may be especially important, as care providers have frequent, intimate interactions with pregnant women that can affect their

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emotions and behaviors. In turn, prenatal emotions and health behaviors have potent effects on

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birth outcomes.

Objective: This study investigated whether pregnant women’s relationships with their midwives predicted better self-care. Specific components of the patient-provider relationship (communication, integration, collaboration, and empowerment) were examined. We also

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investigated a mechanism through which these relationship components may be associated with salutary health behaviors: by alleviating women’s anxiety. Methods: In total, 139 low-risk patients of a university-affiliated midwifery practice in the

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northeastern United States completed well-validated measures assessing their relationship with midwives, state anxiety, and prenatal health behaviors in late pregnancy; state anxiety was also

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assessed in mid-pregnancy.

Results: Women’s perceptions of better communication, collaboration, and empowerment from their midwives were associated with more frequent salutary health behavior practices in late pregnancy. Controlling for mid-pregnancy anxiety, lower anxiety in late pregnancy mediated associations of communication and collaboration with health behavior practices, indicating that these associations were attributable to reductions in anxiety from mid- to late pregnancy.

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Conclusion: Results substantiate that benefits of patient-provider relationships in pregnancy may extend beyond providing medical expertise. Some aspects of patient-provider relationships may offer direct benefits to pregnant women in promoting better health practices; other aspects of

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these relationships may indirectly contribute to better health practices by alleviating negative emotions. The benefits of strong midwife relationships may derive from the reassurance,

comfort, and warmth these relationships offer, as well as the information and education that

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midwives provide to their patients.

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care; midwifery; communication

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Keywords: USA; pregnancy; patient-provider relationship; health behaviors; anxiety; prenatal

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Introduction Patient-centered care is a hallmark of high quality healthcare (Institute of Medicine, 2001). Care that is patient-centered strengthens the patient-provider relationship by encouraging

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communication, providing information, and facilitating patients’ involvement in their own care (Epstein et al., 2005; Lewin et al., 2001; Mead and Bower, 2000). Engaging patients as active participants in their health care often improves treatment outcomes and results in greater

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satisfaction (Levit et al., 2013).

Ideal patient-provider relationships involve a trusting connection that can be achieved

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through effective communication, establishment of cooperatively created treatment goals, and patient participation in the decision-making process (Kim et al., 2001). Highly varied studies demonstrate that strong patient-provider relationships are associated with greater patient satisfaction (Hall and Dornan, 1988; Stewart et al., 1999) and adherence to clinician

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recommendations (Cooper and Roter, 2002; Fuertes et al., 2007; Lekas et al., 2016; Stewart, 1995). However, there is little consensus regarding the particular components of patient-provider relationships that account for these benefits (Epstein et al., 2005; Lewin et al., 2001; Mead and

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Bower, 2000).

Patient-Provider Relationships during Pregnancy

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Strong patient-provider relationships may be especially important during pregnancy.

Pregnant women’s physical status, emotional state, and behaviors are monitored closely and frequently across pregnancy by their health care providers because these are known to affect maternal, fetal, and infant outcomes, including the gestational age and weight of the infant at birth, which are strong predictors of subsequent infant, childhood, and even adult health (Betts et al., 2014; Lobel and Dunkel-Schetter, 2016; Raikkonen et al., 2007). Prenatal care typically

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involves frequent visits with the same providers over the course of pregnancy, offering women an opportunity to build trusting relationships with their prenatal care providers (Lori et al., 2011). Existing studies of women’s prenatal care experiences focus primarily on satisfaction with the

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structure of care and not on women’s interpersonal interactions with their care providers (Novick et al., 2012; Oakley et al., 1996; Sword et al., 2012). Yet, it is likely that trusted prenatal care providers can provide emotional reassurance, encourage better self-care and acceptance of

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treatment plans, and connect women to other services (Lori et al., 2011). Pregnant women value not only supportiveness and trustworthiness in their providers but also feeling like their providers

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know them well (Berg et al., 1996). Women who are more satisfied with their prenatal care or feel more supported by their providers use less analgesia during childbirth, participate more in decision making, experience greater satisfaction with their care (Hodnett, 2002; Waldenström et al., 2000), deliver babies with higher Apgar scores (an indicator of newborn health status), are at

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lower risk of postpartum depression, are more responsive to their newborns, and have better breastfeeding outcomes (Collins et al., 1993; Hodnett et al., 2003). Yet, the mechanisms for these associations are largely unknown. It is likely that strong provider-patient relationships –

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involving effective communication and collaboration in decision-making with prenatal care – offer women a sense of control and empowerment. This control and empowerment likely helps

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to protect new mothers from emotional distress and encourages them to take better care of themselves. Pregnancy is a period of uncertainty that many women experience as stressful, particularly if they perceive little control over their health or over the outcome of their pregnancy (e.g., Lobel et al., 2002). Additionally, pregnant women who experience better relationships with their health care providers may be more likely to utilize information from their providers that improves outcomes. Nutritional and psychological counseling in the context of prenatal care, for

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example, have been shown to predict greater birthweight through reduction of target risk factors including smoking, weight gain, and psychosocial problems (Ricketts et al., 2005). Similar benefits accrue from more general health promotion information during prenatal care visits

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(Vonderheid et al., 2007).

The present study is one of the first investigations to examine which specific components of pregnant women’s relationships with their prenatal care providers may contribute to better

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health behavior practices. We measured the patient-provider relationship using the Kim Alliance Scale Revised (KAS-R; Kim et al., 2008), which assesses four distinct components of the

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patient-provider relationship: communication, collaboration, empowerment, and integration. These components are supported by research that establishes them as critical elements of strong patient-provider relationships (e.g., Lancet, 2012; Raine et al., 2010; Rowe et al., 2001; Stewart, 1995). Communication is characterized by provider acceptance and empathy (George, 1997).

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Empowerment consists of patients taking an active role in their health care (Anderson et al., 1995). Collaboration involves the establishment of mutually agreed upon goals (see review by Stacey et al., 2011), and integration entails mutual respect between patients and providers

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(Buchmann, 1997).

We also examined a mechanism through which these relationship components may be

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associated with salutary health behaviors: through fostering a better emotional state in pregnancy. Specifically, we proposed that communication, empowerment, integration, and collaboration with women’s prenatal care providers would help protect against emotional distress, and that lower emotional distress, in turn, would lead women to take better care of themselves. Examining emotional and behavioral benefits of patient-provider relationships in

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pregnancy is vital because, as elaborated below, both maternal distress and health behaviors have potent effects on pregnancy outcomes (see Lobel and Dunkel-Schetter’s, 2016, review). Emotional Distress and Health Behaviors in Pregnancy

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Pregnancy and birth are life transitions that entail considerable change in roles,

responsibilities, and interpersonal relationships (Lobel et al., 2008a). Pregnant women also experience uncomfortable physical symptoms and unfamiliar bodily changes, and many

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experience fears or worries about childbirth and the health of their developing child. As a result, and in conjunction with other ongoing life stressors, women typically experience some degree of

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anxiety during pregnancy (Alderdice et al., 2012; Dunkel-Schetter and Tanner, 2012). There is a voluminous body of research examining anxiety in pregnant women and its deleterious effects on pregnancy outcomes and maternal and infant health (see reviews by Dunkel-Schetter and Glynn, 2011; Dunkel-Schetter and Lobel, 2012). These effects have been attributed to cardiovascular,

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neuroendocrine, immunological, and metabolic processes that are affected by maternal anxiety and by ensuing health behaviors (e.g., Coussons-Read, 2012; see review by Dunkel-Schetter and Lobel, 2012; Kane et al., 2014). Women who are more emotionally distressed during pregnancy

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take poorer care of themselves (Auerbach et al., 2014; Goedhart et al., 2009; Lobel et al., 2008b; Neggers et al., 2006; Savitz and Dunkel-Schetter, 2006). Thus, good relationships with prenatal

care.

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care providers that mitigate women’s anxiety during pregnancy may contribute to better self-

Prenatal Care

In the U.S., women with access to good health care have as many as ten prenatal care

visits across a single pregnancy: monthly until 28 weeks of pregnancy, biweekly from 28 to 36 weeks, and weekly starting at 36 weeks (Rosen et al., 1991). As recommended by the

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American Congress of Obstetricians and Gynecologists, these visits should include emotional support and information about health behaviors (Baron et al., 2015; see also Leiferman et al., 2014; Mauriello et al., 2011). Pregnant women report that they desire expressions of empathy

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and concern from their prenatal care providers (Novick, 2009) and that they expect accurate information and instruction about health behaviors (Keiffer et al., 2002; Krans et al., 2005). Typically, only pregnant women at low risk, that is, those without a history of obstetric or

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other relevant medical conditions and who are not currently experiencing complications, can receive their prenatal care from midwives. Building strong relationships is at the core of

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midwifery, which provides individualized care that involves women in decision making (American College of Nurse-Midwives, 2010). Women who receive prenatal care from midwives report fewer problems in communication and tend to have longer visits than pregnant women receiving care from other providers (Homer at el., 2002; Kozhimannil et al., 2015).

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Prenatal Health Behaviors

Pregnancy may be an ideal time for women to acquire evidence-based information on health behaviors because they are in frequent contact with their health care providers (McBride

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et al., 2003; Phelan, 2010). There is some evidence that the information provided from prenatal care providers can affect women’s commitment and beliefs about health behaviors such as

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exercise (Krans et al., 2005). Providers are particularly important because pregnant women often receive information about how they should care for themselves from friends, family, and other sources, and are thus commonly misinformed about the safety and advisability of certain health behavior practices (Cannella et al., 2010). Receiving comprehensive, accurate information is associated with more favorable attitudes toward prenatal activity (Cannella et al., 2010), and

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predicts activity itself: Leiferman et al. (2014) found that pregnant women in their study were not sure which types of exercise were safe and as a result, were often sedentary. Salutary health behaviors during pregnancy, including adequate exercise, sleep, and

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proper nutrition, contribute to better birth outcomes (Chomitz, et al., 1995; Clapp, 2003; Savitz and Dunkel-Schetter, 2006). For example, exercise during pregnancy predicts adequate gestational weight gain (Phelan et al., 2011; Streuling et al., 2011), decreased physical

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discomfort, and better postpartum recovery (Clapp, 2000), as well as lower risk of gestational diabetes, pre-eclampsia (Bung and Atal, 1996; Dempsey et al., 2005; Sorensen et al., 2003), and

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preterm birth (Evenson et al., 2002). Proper nutrition and body mass index are associated with lower risk of gestational diabetes, preclampsia, birth defects, and intrauterine growth restriction (Streuling et al., 2011). Conversely, unhealthful behaviors, including fasting and especially smoking and other substance use, are strong risk factors for adverse outcomes such as preterm

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delivery and low birth weight (Madsen et al., 2009; Neggers et al., 2006; Powers et al., 2013; Savitz and Dunkel-Schetter, 2006). Fortunately, these behaviors are uncommon in most pregnant women, particularly women who are well-educated about their dangers (e.g., see review by

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Schneider and Schutz, 2008). The Current Study

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The present investigation examined benefits of strong patient-provider relationships in

pregnancy. First, we hypothesized that women who perceived better patient-provider relationships overall would practice more salutary health behaviors during pregnancy. We also explored associations of specific components of the patient-provider relationships (communication, integration, collaboration, and empowerment; Kim et al., 2008) with salutary health behaviors. Second, we hypothesized that women who perceived better patient-provider

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relationships, and who specifically perceived better communication, integration, collaboration, and empowerment, would experience lower anxiety in late pregnancy, controlling for midpregnancy anxiety. This longitudinal feature of the study enabled us to examine whether patient-

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provider relationships are associated with changes in anxiety across the latter period of

pregnancy, when anxiety is common. Finally, we hypothesized that decreased anxiety would mediate associations of better patient-provider relationships with salutary health behaviors. To

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our knowledge, this study is the first to examine how patient-provider relationships, in pregnancy

distress.

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or in any other health context, may result in better patient behaviors by lowering emotional

Methods

Participants and Procedure

Study participants (N = 139) usually were White, in a committed relationship, college-

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educated, employed, and multigravida (Supplementary Table S1 provides additional detail). Participants were from a larger study conducted from 2013 to 2016 at a university hospital affiliated midwifery practice for low-risk pregnancy located in the northeastern United States,

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with certified nurse-midwives providing care. The study was approved by the Institutional

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Review Board of Stony Brook University and was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki). To be eligible for the larger study, women had to fluent in English and be at least 18-years old. Participants provided written informed consent and completed a study questionnaire on four occasions during pregnancy. Data for the current investigation were from mid-pregnancy (average gestation = 19.58 weeks, SD = 5.14) and late pregnancy (average gestation = 30.23 weeks, SD = 4.17) questionnaires with an average interval of 10.82 weeks (SD = 4.62). Women’s perceptions of their relationship with

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their midwives and their health behaviors were reported in the late pregnancy questionnaire; state anxiety was assessed in both the mid-pregnancy and late-pregnancy questionnaires. Measures

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Patient-provider relationship. The 16-item Kim Alliance Scale Revised (KAS-R; Kim et al., 2001; 2008) is an abbreviated version of the 30-item KAS. We adapted the wording of some items (e.g., from “my provider” to “my midwives”) for this study. Items are rated 0 (never) to 3

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(always). Internal consistency was excellent for three of the four factors (4 items each): Communication (e.g., “it is easy to understand my midwives’ instructions;” α = .87);

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Collaboration (e.g., “we have mutual goals for my care”, α = .78); and Empowerment (e.g., “my midwives encourage me to make decisions”, α = .78). Because the Integration subscale (e.g., “my midwives respect me”) exhibited poor reliability (α = .51), we did not conduct further analyses with this variable, although we retained it in the correlation matrix of study variables

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(see Table 1).



Anxiety. The State Anxiety subscale of the State-Trait Personality Inventory (STPI;

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Spielberger, 1995) includes 10 items (e.g., “I feel worried,” “I feel calm” [reverse scored]), rated

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on a 4-point scale from 0 (not at all) to 3 (very much). Internal consistency was excellent (α = .87 in mid-pregnancy, α = .91 in late pregnancy). The STPI and its parent measure, the State-Trait Anxiety Inventory (Spielberger et al., 1970) have well-established validity as measures of anxiety in pregnant women (Meades and Ayers, 2011). Prenatal health behaviors. Salutary health behaviors were assessed using a 9-item subscale of the Prenatal Health Behavior Scale (PHBS; Auerbach et al., 2014; DeLuca and Lobel, 1995). Items include a range of healthful behaviors, such as “in the last two weeks, how

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often did you…” “exercise for at least 15 minutes,” “get enough sleep,” “eat a balanced meal,” or “take vitamins.” Participants responded on a scale from 0 (never) to 4 (very often). Internal consistency was moderate (α = .68), as would be expected because the behaviors are somewhat

patient populations (Brener et al., 2003; Ford et al., 2001). Data Analytic Approach

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independent. Self-report measures of health behaviors have demonstrated validity in various

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First, we used bivariate correlations to examine whether total KAS-R and component scores were related to salutary health behaviors. Next, to examine the hypothesized mediation of

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associations of patient-provider relationships (and their specific components) with health behaviors through the mechanism of anxiety, also referred to as indirect associations, bootstrap mediation analyses with 1,000 bootstrapping samples were conducted utilizing Hayes’ (2012) PROCESS macro for SPSS Version 24. We tested four separate models predicting health

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behaviors (PHBS score): one model examining the total KAS-R score, and one model each examining Communication, Collaboration, and Empowerment. In each model, the patientprovider variable (total KAS-R or a component) was the predictor, the mediator was change in

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anxiety from mid- to late pregnancy (by entering late anxiety as the mediator with midpregnancy anxiety included as a control variable), and PHBS was the outcome. In these analyses,

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there is evidence of significant mediation, or an indirect association, if the confidence intervals for the estimate of the indirect association do not include 0. Results

Associations Among Patient-Provider Relationships, Health Behaviors, and Anxiety As displayed in Table 1, the overall patient-provider relationship score and the three specific components (Communication, Collaboration, and Empowerment) correlated positively

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with salutary health behaviors and inversely with anxiety at both time points. Integration was inversely correlated with anxiety in late pregnancy only, but given the low reliability of the Integration scale, this association should be interpreted with caution. The salutary health

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behaviors variable was also inversely correlated with anxiety at both time points. Correlations among components of patient-provider relationships ranged from r = .367 (Communication and Collaboration) to r = .718 (Communication and Empowerment). On average, anxiety did not

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differ from mid- to late pregnancy, t (122) = -0.819, p = .41. Mediation

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As shown in Figure 1, in mediation analyses, the total KAS-R score and its components of Communication and Collaboration predicted a decrease in anxiety, and a decrease in anxiety predicted salutary health behaviors. For total KAS-R, including change in anxiety (the mediator) reduced the statistically significant direct association of total KAS-R with health

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behaviors to nonsignificance, whereas the indirect association was positive and statistically significant (Indirect effect estimate = .08, SE = .04, 95% CI = .02 to .19). This supports full mediation of the association of total KAS-R with health behaviors by change in anxiety. Full

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mediation by change in anxiety was also observed for the associations of Communication and Collaboration with health behaviors. For each of these relationship components, the indirect

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associations were statistically significant (for Communication, indirect effect estimate = .06, SE = .04, 95% CI = .003 to .17; for Collaboration, indirect effect estimate = .05, SE = .02, 95% CI = .01 to .12), and the previously significant direct associations with health behaviors became nonsignificant when the mediator was included in the model. Empowerment did not predict change in anxiety. Therefore, the indirect association of Empowerment with health behaviors

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through change in anxiety was nonsignificant (Indirect effect estimate = .03, SE = .02, 95% CI = -.004 to .09).

Discussion Summary of Findings

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The current investigation examined benefits of a woman’s relationships with the

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midwives who care for her during pregnancy. Women who appraised these relationships more

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favorably overall – perceived better communication, collaboration, and empowerment – practiced healthful behaviors more frequently in late pregnancy and also experienced lower anxiety during mid- to late pregnancy. Tests of mediation indicated that associations with health behaviors of the overall midwife relationships and two of their components – communication and collaboration – were completely explained by reductions in anxiety from mid- to late

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pregnancy experienced by women who perceived better relationships with their midwives. Thus, women who felt that they had overall good relationships with their midwives, and perceived better communication and collaboration in these relationships, experienced a larger

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reduction in anxiety from mid- to late pregnancy compared with other women in this sample.

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This attenuation of anxiety, in turn, predicted greater vigilance in practicing healthful behaviors. Women who felt more empowered by their relationships with their midwives also practiced healthful behaviors more frequently than those who felt less empowered, but this pattern was not attributable to changes in anxiety. Explanations and Implications Results suggest that strong relationships with prenatal care providers, especially relationships that are perceived as involving good communication, collaboration, and

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empowerment, result in better self-care in pregnancy, including behaviors such as moderate physical activity, nutritious eating, getting sufficient rest, and using prenatal vitamins. These behaviors help to protect against adverse birth outcomes such as low birthweight and preterm

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delivery (Cannella et al., 2010; Chomitz et al., 1995; Clapp, 2003; Savitz and Dunkel-Schetter, 2006), which are major contributors to infant mortality, and in survivors, to poor infant, child, and adult health and development. Thus, relationships with one’s midwives have substantial

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secondary consequences for the health and well-being of a woman’s offspring.

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Results of the mediation analyses showed that the tempering of anxiety among women who reported better relationships with their midwives (due to better communication and collaboration) is what accounted for the benefits of good midwife relationships in promoting salutary health behaviors. Anxiety and other forms of emotional distress have also been shown in previous studies to be associated with unhealthy behaviors in pregnant women (Auerbach et al.,

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2014; Lobel et al., 2008b; Rodriguez et al., 2000) and in general populations (Carr and Umberson, 2013; Ng and Jeffery, 2003; Stetson et al., 1997; Stults-Kolehmainen and Sinha, 2015). Although not examined here, risky behaviors such as cigarette smoking and other

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substance use are more common in women who experience heightened emotional distress during

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pregnancy (Borrelli et al., 1996; Chomitz et al., 1995; Hutchins and DiPietro, 1997; Zuckerman et al., 1989). These behaviors are especially dangerous to the health of pregnant women and their offspring.

Why might better communication and collaboration with one’s health care providers

reduce anxiety as was observed among women in this study? Good communication was operationally defined in the KAS-R as using clear instructions and plain language, and as “supporting a woman’s point of view.” Relationships perceived as collaborative were those in

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which a woman and her midwives were “working towards mutually-created goals” [paraphrase]. Pregnancy has been characterized as a period of great uncertainty during which women may experience unpredictable physical changes and symptoms of unknown significance, and a time

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when they are approaching an important life event – childbirth – that some view with fear

(DeLuca and Lobel, 2014; Fair and Morrison, 2012). Under these circumstances, women desire clear, trustworthy information and rapport (Heaman et al., 2004; Lerman et al., 2007; Stanton et

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al., 2002). Supportive provider relationships that involve effective communication and

collaboration may promote feelings of well-being and a sense of control, thereby enabling

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women to perceive pregnancy-related changes as less stressful (Norbeck and Anderson, 1989; Tietjen and Bradley, 1985). These factors may help explain why good communication and collaborative relationships with the midwives who are overseeing the pregnancy and imminent birth may help alleviate the patient’s anxiety. Creating strong relationships with women and their

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families is, in fact, a stated goal of midwife care (American College of Nurse-Midwives, 2012). An additional, complementary explanation for the observed benefits of midwife relationships in reducing anxiety is the education that midwives provided about pregnancy and

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childbirth. In addition to the instruction and education that midwives provide informally during interactions with their patients about such topics as proper ways to exercise, good nutrition, and

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appropriate gestational weight gain, the midwives caring for women in this study also offered informational materials and encouraged women to attend childbirth education classes. There is considerable evidence that information helps alleviate distress in stressful and uncertain situations in general (Miller and Mangan, 1983; Taylor and Clark, 1986), and in pregnancy in particular (Collins et al., 1993; DeLuca and Lobel, 2014; Zweig et al., 1988). Thus, the emotional benefits of a strong midwife relationship may derive both from the reassurance,

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comfort, and warmth this relationship offers, and from the explicit information and education that it provides. Limitations and Strengths

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Several caveats must be considered before drawing firm conclusions from the current study, including its correlational design. Some of the findings may reflect bidirectional

associations. For example, better communication with one’s health care providers may both

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contribute to and result from lower anxiety, although the study’s statistical control for anxiety at an earlier time point helps to substantiate the presumed direction of associations. In addition,

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although the magnitude of indirect associations involving communication and collaboration appeared to be of similar magnitude, we did not have sufficient statistical power to examine whether one component of relationships exhibited stronger associations than the other. Also, this investigation focused exclusively on women receiving health care from female

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health care providers, which may limit its generalizability, given evidence of gender differences in patient-provider communication and related outcomes (Hall et al., 1994; Roter et al., 2002). Furthermore, the women in the current study may be distinctive, as they were advantaged in

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various ways. They were predominantly White and socioeconomically well-off, all were at low obstetric risk, and most had experienced pregnancy previously. Notably, none of the participant

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characteristics was associated with patient-provider relationship variables, meaning that women perceived equivalent amounts of communication and other benefits from their midwives regardless of women’s age, race, education, income, or prior pregnancy experience. Despite its limitations, a number of study features bolster confidence in its findings. For

one, the overall patient-provider relationship score and scores on two of this measure’s subscales predicted late pregnancy anxiety even after controlling for anxiety earlier in pregnancy, a

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conservative statistical approach which limits the amount of variance in anxiety left to predict. Furthermore, despite intercorrelations among components of the patient-provider relationships, we found distinct patterns of associations with them. For example, communication and

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empowerment were highly correlated, but communication predicted reduced anxiety, whereas empowerment did not. Empowerment was correlated with salutary health behaviors, but this association was not explained by decreases in anxiety, suggesting that other mechanisms for

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explaining the benefits of this component of patient-provider relationships are important to explore in future research. Such differences in patterns of association substantiate the

their benefits are independent.

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discriminant validity of the patient-provider relationship components and suggest that some of

All of the prenatal care providers in the current study were midwives, which is not as common among women in the U.S. as receiving prenatal care from obstetricians or other

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physicians (Sandall et al., 2016). It is unknown whether findings can be generalized to high risk women or to other women under the care of physicians, although we have no reason to expect that communication or other aspects of one’s relationships with prenatal care providers would be

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any less important for such women. Nevertheless, some have suggested that a midwife’s primary

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responsibility is to support and encourage women through teaching and guidance (Kelly et al., 2013; McCrae and Cuter, 1991) and that these interpersonal skills may neither be cultivated nor valued to the same extent in care provided by physicians (Oakley et al., 1996). Some research identifies more favorable attitudes and perceptions of control experienced by pregnant women receiving care from midwives than from physicians (Hatem et al., 2009; Oakley et al., 1996; Murphy et al., 1993). Nonetheless, such differences may also reflect pre-existing differences between women who receive prenatal care from midwives versus physicians.

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Implications Taken together, results of the present investigation suggest that patient-provider relationships, and their components of communication, collaboration, and empowerment, may

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offer a combination of direct and indirect benefits to pregnant women, with empowerment

directly encouraging better self-care, and communication and collaboration mitigating anxiety from mid- to late pregnancy, and via this benefit, indirectly contributing to better self-care. The

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present study adds to a larger body of findings indicating that health care providers’ relationships with patients can affect important health outcomes (Roter and Hall, 2006; Safran et al., 1998;

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Stewart, 1995). Given the variety of evidence that emotional states and health behaviors affect critical outcomes of pregnancy that determine infant, child, and adult health and well-being (Betts et al., 2014; Lobel and Dunkel-Schetter, 2016; Raikkonen et al., 2007), and the frequent interaction that most pregnant women have with their prenatal care providers, patient-provider

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relationships in pregnancy may be a target of intervention to improve the health of childbearing women and their offspring. Existing interventions to improve health care providers’ communication skills have shown success in general rehabilitation settings (Oliveira et al., 2015)

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and in maternal care (Rowe et al., 2001). Results of this study demonstrate that the benefits of patient-provider relationships extend beyond providing medical expertise. Enhancing

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interpersonal connections between those who give and receive medical care may offer an inexpensive and effective way to improve the health of our population.

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References American College of Nurse-Midwives, 2010. Our philosophy of care. Retrieved from http://www.midwife.org/Our-Philosophy-of-Care.

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5 .818** .744** .526** .872**

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4 .718** .434** .383**

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Table 1 Correlations Among Major Study Variables Variable 1 2 3 1. Communication .367** .449** 2. Collaboration .113 3. Integration 4. Empowerment 5. Patient-Provider Relationship Total 6. Mid-Pregnancy Anxiety 7. Late Pregnancy Anxiety 8. Salutary Prenatal Health Behaviors M 11.14 8.91 11.59 SD 1.54 2.31 1.05 α 0.87 0.78 0.51 Note. Sample sizes for each correlation range from 116 to 132. * p < .05, ** p < .01.

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10.34 2.09 0.79

42.14 5.35 0.87

6 -.277** -.247** -.174 -.226* -.291**

5.92 5.26 0.87

7 8 -.315** .207* -.355** .238** -.230** .131 -.227* .244** -.353** .265** .516** -.304** -.346** 6.24 5.69 0.91

26.32 4.28 0.68

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C’ .17, SE = .13

Salutary Prenatal Health Behaviors

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Communication

.09, SE = .11

Salutary Prenatal Health Behaviors

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Patient-Provider Relationship Total

Change in Anxiety

Collaboration

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Change in Anxiety

Salutary Prenatal Health Behaviors

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Change in Anxiety

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.09, SE = .08

Empowerment

C’ .07, SE = .08

Salutary Prenatal Health Behaviors

Change in Anxiety

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Figure 1. Models predicting salutary health behaviors from the patient-provider relationship variable as mediated by changes in anxiety from mid- to late pregnancy. * indicates p < .05. The indirect associations of Patient-Provider Relationship Total, Communication, and Collaboration with Salutary Prenatal Health Behaviors were statistically significant; the indirect association of Empowerment with Salutary Prenatal Health Behaviors was nonsignificant.

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Research Highlights

Better patient-provider relationships correlate with lower anxiety in pregnancy

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Better patient-provider relationships correlate with better self-care in pregnancy

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Patient-provider relationship benefits extend beyond providing medical expertise

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