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Stressful events related to childbearing in African-American women
STRESSFUL EVENTS RELATED TO CHILDBEARING IN AFRICAN-AMERICAN WOMEN A Pilot Study
NannyL. Green, CNM,
MHS
AESTRACT This pilot study replicated the Arkmendi and AHonso study that Identified the frequency and intensity of strew1s related to childbearing.’ The ori$nal study (n = 221) targeted chiefly middle&s white women. To date. there is no literature on stressful events as reported by African-Amedcan childbearing women.It was hypothesized that African-Amedcan women would identify diierential patterns of stressfulevents in childbeadn9. A cc.nvenience sample of 50 AfWan-American childbearing women were intewiewd. Demographicr were presented and compared with the o,iginal study. The frequent: and intensl@ of streso~ were analyzed and compared It was proposed that the differential sbessorsbetween the chiefly white middle-clan sample and the AfricanAmelican sample relates to both the life expedences and the differentil birth outcomea of A&an-American childbearing women. Areas for future research are targeted
The disparity in birth outcomes in the African-American childbearing family Is a harsh reality of vital concern. Low birth weighUpr&rm delivery and ths resdtent high inf+~t mortality are significant health issues In Africa, Aa, and Latin America. The technology and health advances In North America ought to have resulted in unilateml improved birth outcomes here. They have not Low bit.: weight rates for African-American chIldbearingwomen remain appnximately hulce the rates for white women.2-0 Most signlfkantly, the gap is r~ng5 Despite a multitude of
the
studtes in literature, !he v%rabla examined do not explain the r&al differences in iow birth weight rates. It has been documented that .val%xE pear f&a! OL?hGnv9a?? associated with stress during pregnancy.The following selectedstudies related maternal shess tith obstetrical and newborn complications,includinglow birth weight and pretenn delivery. From these studies, theoretical relationships between maternal stress in pregnancy and poor outcome, specifically, low birth weight and preterm delivery, can be valid&d. Tbii validation provided the rationale for the pilot investi9ation of stressful events related to childbearingin African-Americanwomen. McDonald and Christako8 studied the relationship of increased maternal anxiety with obstetrical cornplicatlons in a sample of white. gravid, 89).
workin9-class
wane”
In =
The women were seen in the
prenatal clinic ar;d receiwd a battq of ~hcdogical tests at six months gestation. After delivery, patients were dassified accordin to the P” ence oi abnormalI&. ShPiy results indicaied that women demo-tin9 a signiicmtly degreeof aaxiety experienceda variety of obnet rival complications, although there were no si@fkant re!anonship with birth weight Althou~ &is study was conducted over 20 years ago and summafzed a variety of obstebical ccmplfcawn5, It demonstrated posiwe rektionships between hish ax+ iety and poor pregnancywtcome. Davids and DeVauP studied 50 cflnk patients In the third bimesta of pregnancy. As with the McIXlnilld and Chdstakos sh~dy,~a battety of psg;l~!qjcal tests were admlnistered before detivey. Attending @b’,stemdam rated deliwty complications and childbirth abnormalitlss. Through these assessments. the pa-
geater
tients were divided into a normal group and en abnormal group that demonstmted delivey complications and childbirth abnormalities. The psychological test data was examined blindly to ascertain if there were significant differences between the two groups. No significant differences were found between the two groups in age or 1.9. However, the abnormal group demonstreted signit?wmtly higher fores on five emiety measuree It < .Ol). a positive correletion with anxiety and greater pregnancy complications. Bku et 9 examined the relationship of psychological factors to pmterm births. Two matched groups of mothels, one group in = 3U) who delivered prematurely with no esscctated medical factors was matched with a group (n = 30) who delivered term infan& Both groups were assessed cltnicaUy and by psychological tits. The authors reported delinitive differences within the hvo groups regarding negative attitudes toward pregnarxy. emotional immaturity, and family problems. Despite a strong l-radian orientation, the study’s focal question was found to be significant. Were there any piychological diiferences between mothers who delivered prematurely and those who delivered et term? Because preterm delivey is highly associated with low birth weight,& this study, demonstrating psychosoClel factors es correlates of preteml &livery, supports further investiga-
Nmmy L. Green @n~erly Bowel, aw, ~1% is a nurse-midwifeand jamily nurse pmditioner. She has been assistant dnlcul professor in the Decwtmeti of Fc?ily Hee!!h Cc= .N~!ng, S&o; qj Nursing, Untwsify of Califomio, San FmnW, and is cunenily #Ph.D. cendfdete in nursing et thn! tnstituhon. She ha had intemrdione, imining expsencz in Nicamguo and Malawi. In odditbn to hcrfull-lime studier, she is omently a member o, the NweMidwifey Serulce at Highland Ho.@@ Oakland, Cal#omia.
232
of
lion snessas a factor associated with low birth weight in the AfricenAmerican childbeartng women. Crandone demonstrated slgnificently lower Apgar scores (n = 147. P ( ,001) in babies born to highanxiety mothers. The IPAT Anxiety Self-Analysis Form was used es a measure of anxiety. Although this study did not swcificell~ address low bi& weight, ii demon&ted sign& cant positive relationships between poor fetal outcome (low Apgar scores) with high-anxiety mothers. Norbeck and Tildenm studied the effects of selected stresson on pregnancy complications in a convenience sample (n = 117) of varied, medically normal women. High life stress a; measured by the Samson Life Expedeoces Survey” predicted ge&t& complicationsthet-included labor. with or without delivery, before 37 weeks. High life stress alternatelv did not oredict infant comolicetio&, including low birth weight (<2.500 ql. Anxietv measured bv the Spielberger St&-Treit Am&& Inventoy’e was defined es an emotional dlseqotltbdum factor and not es high life stress. A significant reletionship was established between stress and gestafionel complications. High life stress from the previous year predicted gestation compllcattons (P < ,011 and the lnterection of tangible support snd life stress during pregnancy was a significant predictor of gestaticn. labor, and infant mmolications IP < ,011. The p;evtous &dies attempted to establish relationships between stress and other psychosocial variables in pregnancy wiul poor outcome, including preterm labor and low birth weighr. One assumption made in review& ihijr stodies is that a meesure poor fetal outcome can be defined specifically es low birth wzlgbt. Arizmendi and Affonsn’ identified the frequency and Intensity of stressful events reported by pregnant and postpartum women. The authors concluded that: II) the imwrtance of e stressful e&t depwded
o?
on the intensity or the frequency of the event; (2) sti varied across the childbearing petiod: and (3) internal rather than external events geoerated the greatest anxiety. Unfotinately. the sample targeted only middle-class white women. To date, there is no literabxe on stressful events as re- rted by Afdcan-American childbeetins women. This pilot study replicated the Arizmendi and Affonso study and hvpothesized that there would be dirferences In the patterns of st~essors es determined in the original study. It was projected that differential stressors documented in the pilot study would target areas for f&e research related to differential low birth weight outcomes in the AfticenAmerican childbearing woman.
METHODS Description
of the Site
Highland Hospital, located in Oakland, is the county hospital for Alameda County in California. II serves the poor, the disenfranchised, and the overexploited of Alameda County. In 1987, there were 2,079 live bii and 184 low btrth weight births et Highland. African-Am&can birihs numbered 736 with a low birth weight rate of 17.0. White births numbered 7.33 with a low birth weight rate of 3.O.“At Highland, the rate of Medt-Cal fee-for-service hwpitel deltveries was 56.9% (rate per 100 hospital delivertesl. Highland Hospital represented 29.7% of the total county Medi-Cal hospital delivelks.‘4
Participants A convenience sample was recruited from the prenatal and postnatat clerics at Highlend Hospital. The indusion clttelie were that the peti& pant was: (11 Ahican-American; (2) pregnant or within the six-week postpartum period; (3) between 18 and 40 years of age; and (4) without medical or obstebical complications.
Joemel of NerwMtdwtfery
. Vol. 35, No. 4. JulylAuaust 1990
A total of 55 women were approached for consent. Two women were excluded because of high-risk status.Two we”’ unabk to complete the study due io time const&!s, and one was African. A !otal of 50 women represented the final study sample. Procedures The participants were asked to list five to 10 stressful events that the” had experienced during the pregnancy. For each sbessfulevent, they were instructed to use an interval scale from 1 to 100 to rank the intensity of the stressor. They were also asked to rate the stressh;levent as posftive or negative. Participant respo”s?s were analyzed using Ategories previously developed in the Adzmendi and Affonso study.’
Years of education
Mean SD
Employment (frequency) Unemployed Employed Homemaker Publicas&ta”ce Student Dliler
RESULTS
In the original study, socioeconomic status was not determined furmallv: however, it was assumed to de middle class.In this study, the typical participant was in her e&y 20s.& = 23.8). single lj = 43). hating less than $5,ooO as yearly income lj = 34), and educated th:sugh hfgh school (ji = 12.3 years). The women were largely in the third (f = 26) or second lj = 19) trimester of pregnancy. A greater number of women were nulliparous (f = 31) and fewer were multfuarous If = 19). Comparative de&raphi& of both studies are presented in Tt?ble 1. Although income and education were not specifically determkwd in the Arfzmendi and Affonso study.’ the investigators assumed middleclass status. In the current study, 69% of the participants were poor, having a yearly income of less than $5,000. Trimester Comparisons in the Arizmendi and Affonsa study,’ significant comparisons were made
12.38 1.8
6 7
Nd stated
2z 2”
by demographics and by himester (fkst, thud. and postpartum women). In the current study, no eig”ificant differences were found in the frequency or intensity of stressful events when demographics or trimesters were considered. The majodh/ of the wmen in the current &dy were either in the second (38%) or third (52%) trimester of pregnancy. Stressful Events In the Current Study The categories of stressful eventi were replfcated from the Adzmendf and Affonso studri exceut for three categories that”emerged in the present study. The first additional category was a desperate need for housfng; the second was waiting
doumaf d Nurse-Midwifery . Vol. 35. No. 4. JdylAugus, 1990
1455 3.a3
time in the clinic and the third was a categcw (other1 that included those *e%iul evens not any other These as well as examples 0; item5 reported from the current study are presented in Table 2. In Table 3 the stwssars of both shxliesare ranked in u&r of dexendlng frequency and presented their mean intensitks.
Rtthlg categories. cat~rfe5
The resulb of thts pilot study hlghlighted five signtRcantissues: (1) in both studies. the must freouent stressorwas dhyskal sympbnn;; (2) in the AdanendUAffonsr studu.1the events that were per&Ed to-bigger the most anxiety were Internal events as anticfpatoly fears ?I eoncems, whereas in the cunerd study, 233
TABLE2 Categmies of Stressful Events -CdWY Physicalsymptoms
f
Percent of Sampk
35
70%
18
36%
ExampleoffternsReported
Monetay fS”e5
17
34%
Bills. no money. house burglarized
Family sWssors
14
28%
Disappointed my parents. not enough suppat. family pmblema. miss leaving mother. family “in our business”
Job/Career/Schwl
14
28%
Unable to attend school. can’t And a lob, can’t work, had to work 10 hours a day. daesn’t wad to leave baby to 6.x back to work
13
26%
Feelingalone, shorttemper,“my nerves” husband murdered in
Body image
11
22%
Other children
11
22%
Have to take care of my other chlldren too
Need chan9e in howin inew category)
10
20%
Derpemte nepdfor housing. livtngv.$tha fdend. need my own place
9
18%
Is the baby &i&t? Wonies about baby
Changes in living patterns
7
14%
Moving, housecleaningis dtfflcult
others (new categoly,
7
14%
34 years old and firet pregnancy, “broad et the re~stratton desk
1988 v can’t m, don’t likebeing fat, dcn’t like the way 1 look
-a
nastyattitudi~
incarceration
Parenting concerns
234
3
6%
Am I ready? What kind ot parent uill be?Whet kind of child MJ have?
3
6%
wait too long
3
6%
Fear aboutwhat to expect
1
2%
Baby c@ing
0
0
None statedin study
0
0
None statedin study
I I
external events,such as stress related Lo the lack of money, mate/ spousr issues, family, and-job, career, school issueswere the most frequent sourcesof slwzs: (3) the mean intensity of the ranked stmssorswas higher in the current study; (4) although only 20% of the sample In the current study had less than a high school education. 70% of the sample earned less than $5,000 per yew anJ (5) 86% of the study ,ample we singIl2f_f= 43) as cornpared with 19.9% in the Adzmendi and Affonso study.] Each of these issueswill he discussedin turn. Physical symptoms resulting from pregnancy created a etressor that crossed class and race in terms of frequency of occurrence (see Table 31. The current study showed no significant difference by trimester of the frequency or intensity of this strexor. However, the mean intensity of the stressramted was higher in the curstuily (F = 65.f?)than in the oduinal stud” If = 49.071. Given the-hfstottcal&l present e&dence of African-American famflies,ts~t6it is not surprising that the childbeadng women would articulate a greater inter&y of skessassociatedwith physical symptoms of pregnancy than their white counterpark. In the Arizmandi and Affonso study, the four most frequent stressors following physical symptoms were: body image, concerns about the baby, changes in living situation. and emotional stressowl These streasors. except those related to changes In Ilvlng, can be defined as internal anti&atoy fears Of concerns.’ In the current study, the four most frequent stressors after physical symptoms were external events related to mate/ spouse, monetary Issues,famtfy, and job or school issues.Again, the identBcaUon of these external stressorsis not surprising. lnkospection Is passibk when external necessitiesare in order. As one partlctpant stated when discussing money concerns, “Christmas was hell.” The third issue concerns intensity
rent
Journal of Nuree.Midwifeay
. Vol. 35. No. 4. duly/August 1990
Physkal symptoms Mate/Spouseissues
Monetmw stressoa
Family &exors JdXareer/schcol Emotionalstresors MY image Other children Need changein how!ng PregnancycorKem Changein living &wt.?ms Mher concerns Labor and delivery parentingC(m”CemS watt L”clinic Newborn behavior Baby welfare SC&l stressors
66.73 41.92 78.58 71.07 5754 75.31 58&l 71.91
49.07 52.01 68.55 47 13 54.75 62?4 6761 61.37 5623 52.56 52 62 42 15 59.77 ‘?6?4 6156
9Q.00 75.56 so.00 91.42 MM ax3
56.67 1wJ.w None Nana
ratings. Table 3 illustratesa trend toward higher mean intensity rathws of the str&sors in the c&ent study than in the orisinal stu& Althouah statistical significancs *cannot i;e ascertained, this trend Is dramatic. What in the life, the poverty. the race, or the experience of the Afrlcan-Am&can wanen in the currant study increases the intensity of stressful events related to child-
baing?
The fourth issue presented deals with the demographics in the current study. Only 20% of the women had less than high shwl education (12 years of school), and approtimately 70% had a yearly income of less than $5,fJ30. For the AMcan-AmerIcan, education has historically been the key to improved statusin this soclety.“.‘e If high school education for the African-American woman mean* only poverty-level income, and If the African-American man has less education. lower income, and less employment than the w~man.‘~ then what dws the future hold for them, indlvldually or colleciively? Dverall. a white woman with nine to 11 years of school has approxi-
mately the same prematurity rate (10.4) as an African.American woman with 16 years or more of schcol (10.5) 3 Education is not an equaber. The fifth issue p-esented fwuses on the marital status of the current study. fn the Adzrnendi and Affonso study, 77.8% were married and 19.9% were single. In the current study, 12% were ma&d and 86% single. Current literature has addressedthe concept of single-female headed African-American familie~.‘~.~~ Yet mate/spouse issue5 ranked with medium intensity Iji = 41.19) in this studv and were the sacoind frequent sLurce of stress. Does this present a challenge to the current concept?It is possiblethat viable and functional pairing occ”rs outside of conventional definition? The listing of matekpoure issuesas ‘. stwssful event supports the concept of the man included in the family stmchlre.
stressful events related to childbearing in a sample of African-American women and to compare them with the &es~ors Identified by the largely white sample in the Arizmendi and Affonso study. Three problems presented themselves in this analysis. first, the samples. although unm&hed in terms of race. were also unmatched in te:ms of class. The n@Ial study group, by assumption. was middle class; the current study group, by demo(paphlcs. was poor. Poverty is a coniounder with those stressors that might be attributable to the effectsof race. Second the wtiinqs where the Interviews occurred weredifferent fn the original study. clients we interviewedin a univ&ibj hmpitak in the pilot study the intewtew were conduced in the county faclli?+ Were there effectsrelated to these different settings. apart from the effects of race and class?Third, the assumption that the categories dev&ped from the original study could be r=z. licated for the pilot study is chd!. lengeable. New categudesin a larger shrdy might be generated independenily oi prior &dies, and &mpared retmsy&vely. Despite these difticulties. viable research are presented. Future investigations need to examine5~ in pregnancy in the Akican-Americanfamily in rel&ion to such outc.xne5 as pre!ezm delivery and low bir!! weight The pregnant womzn and her family rep resent present and future generations. Action is mandatr_‘.
lMPLlCAllONS
REFERENcEs
This study was a pilot effort to identify the frequency and intensity of
1. Adzmend T. Affonw, D: Stressful eventsrelated !o przggnancy dnd port-
Journal of Nurse.MkiwUery . Vol. 35. No. 4. July/August1990
23.5
paxturn. .I Psychworn Res 31.74X-756. 1987. 2. Deparnnent of Health Services. Health and Welfare Agency. State of %arnnJital statistfa of Califomla. 3. U.S. Dcpadment of Health, Education ana Welfare: Characteristics of births: U..ited States. 1973-1975. Hyatt& :1, Md.. Nz.aonal Cw:er fcr He&b stwics, 1978. 4. fns6tufe of Medicine. Committee to Stud> the Prevention of Low Birthweight: Preventing low birthweight. Washington, D.C., Nbtional Academy PEE, 1985. 5. Kleinman JC, Kesrel s5: Racial diffe,e”cos in low binh weigbt. N El@ J Med 317~749-753. 1907. 6. McDonald RL, Chrfstakor AC: Relationship of emotianal adjustment during pregnancy to obstetncs complications. Am J Obstet Gynecol 86:341348.1963. 7. David* A, DeVaiuir S: Maternal
anxiety during pregnancy and childbirth abnormallaes Pwhcaom M .d 24:464470. 1952. 8. Blau A, Slaff B. Eason SK, et al: The psyxbwenic etiology of premature births: a preffminary report. Psychosom Med25:201-211, 1963. 9. Cmndon Al: Maternal anxiety and neonatal wellbeIng. J Psychosan RCI 23:113-115.1979 10. Norbeck JS, Tilden VP: Life stress.social sumr,r~ and emotional disequilibdum in’&plicationr of pregnancy a prospecliue, multfvaiate study. J Health See Behav 2430-46. 1983. 11. Samson I. Johnson J. Siegel J: Assawing the impact of life changer dovelopment of the life eqaiencn survey. J Consul, Clin Psycho, 46:932--946, 1978. 12. Spielberger C, Gorwch R. Lushene H: STAl-manual for State-Tra!t Anxiety Inventory. Palo Alto, Calif., Consulting Psycholc$st Press, 1970. 13. Caftfomla Health Services Admir-
ishation. Alameda Coumy Information Systems.vital Records, 1987. 14. Depatient of Health Services, State of California. Medical Care StaWCS, 1987. 15. Billlngsley A: Black families in white America. New York, Simon & SEhustn. 1968. XC. K-far Fk S&q s&al statis and psychological distress. J Health Sot Rehav x):259-72,1979. 17. Dati A: Women. race and class Boston, Uttle, Brown &Co, 198’3. 18. Franklin J: From slavery to freedom: a hirtoy of Negro Amencans, 4th ed. New York, Alked A Knopf. 1974. 19. Gibbs ST: Young, btack and male in America: an endangered species:. Dover, Massachusetts, Auburn House, 1988. 20. Wilson JW: The truly dlsadvantaged: Le inner city, the under&s, and public policy. Chicago, Un:wsibj of Chlcage Press. 1987.
Jo,,,,,al of Nurse.M!dwUerv . Vol. 95, No, 4, Juf~lAuguU 1990
NannyL. Green, CNM,
MHS
AESTRACT This pilot study replicated the Arkmendi and AHonso study that Identified the frequency and intensity of strew1s related to childbearing.’ The ori$nal study (n = 221) targeted chiefly middle&s white women. To date. there is no literature on stressful events as reported by African-Amedcan childbearing women.It was hypothesized that African-Amedcan women would identify diierential patterns of stressfulevents in childbeadn9. A cc.nvenience sample of 50 AfWan-American childbearing women were intewiewd. Demographicr were presented and compared with the o,iginal study. The frequent: and intensl@ of streso~ were analyzed and compared It was proposed that the differential sbessorsbetween the chiefly white middle-clan sample and the AfricanAmelican sample relates to both the life expedences and the differentil birth outcomea of A&an-American childbearing women. Areas for future research are targeted
The disparity in birth outcomes in the African-American childbearing family Is a harsh reality of vital concern. Low birth weighUpr&rm delivery and ths resdtent high inf+~t mortality are significant health issues In Africa, Aa, and Latin America. The technology and health advances In North America ought to have resulted in unilateml improved birth outcomes here. They have not Low bit.: weight rates for African-American chIldbearingwomen remain appnximately hulce the rates for white women.2-0 Most signlfkantly, the gap is r~ng5 Despite a multitude of
the
studtes in literature, !he v%rabla examined do not explain the r&al differences in iow birth weight rates. It has been documented that .val%xE pear f&a! OL?hGnv9a?? associated with stress during pregnancy.The following selectedstudies related maternal shess tith obstetrical and newborn complications,includinglow birth weight and pretenn delivery. From these studies, theoretical relationships between maternal stress in pregnancy and poor outcome, specifically, low birth weight and preterm delivery, can be valid&d. Tbii validation provided the rationale for the pilot investi9ation of stressful events related to childbearingin African-Americanwomen. McDonald and Christako8 studied the relationship of increased maternal anxiety with obstetrical cornplicatlons in a sample of white. gravid, 89).
workin9-class
wane”
In =
The women were seen in the
prenatal clinic ar;d receiwd a battq of ~hcdogical tests at six months gestation. After delivery, patients were dassified accordin to the P” ence oi abnormalI&. ShPiy results indicaied that women demo-tin9 a signiicmtly degreeof aaxiety experienceda variety of obnet rival complications, although there were no si@fkant re!anonship with birth weight Althou~ &is study was conducted over 20 years ago and summafzed a variety of obstebical ccmplfcawn5, It demonstrated posiwe rektionships between hish ax+ iety and poor pregnancywtcome. Davids and DeVauP studied 50 cflnk patients In the third bimesta of pregnancy. As with the McIXlnilld and Chdstakos sh~dy,~a battety of psg;l~!qjcal tests were admlnistered before detivey. Attending @b’,stemdam rated deliwty complications and childbirth abnormalitlss. Through these assessments. the pa-
geater
tients were divided into a normal group and en abnormal group that demonstmted delivey complications and childbirth abnormalities. The psychological test data was examined blindly to ascertain if there were significant differences between the two groups. No significant differences were found between the two groups in age or 1.9. However, the abnormal group demonstreted signit?wmtly higher fores on five emiety measuree It < .Ol). a positive correletion with anxiety and greater pregnancy complications. Bku et 9 examined the relationship of psychological factors to pmterm births. Two matched groups of mothels, one group in = 3U) who delivered prematurely with no esscctated medical factors was matched with a group (n = 30) who delivered term infan& Both groups were assessed cltnicaUy and by psychological tits. The authors reported delinitive differences within the hvo groups regarding negative attitudes toward pregnarxy. emotional immaturity, and family problems. Despite a strong l-radian orientation, the study’s focal question was found to be significant. Were there any piychological diiferences between mothers who delivered prematurely and those who delivered et term? Because preterm delivey is highly associated with low birth weight,& this study, demonstrating psychosoClel factors es correlates of preteml &livery, supports further investiga-
Nmmy L. Green @n~erly Bowel, aw, ~1% is a nurse-midwifeand jamily nurse pmditioner. She has been assistant dnlcul professor in the Decwtmeti of Fc?ily Hee!!h Cc= .N~!ng, S&o; qj Nursing, Untwsify of Califomio, San FmnW, and is cunenily #Ph.D. cendfdete in nursing et thn! tnstituhon. She ha had intemrdione, imining expsencz in Nicamguo and Malawi. In odditbn to hcrfull-lime studier, she is omently a member o, the NweMidwifey Serulce at Highland Ho.@@ Oakland, Cal#omia.
232
of
lion snessas a factor associated with low birth weight in the AfricenAmerican childbeartng women. Crandone demonstrated slgnificently lower Apgar scores (n = 147. P ( ,001) in babies born to highanxiety mothers. The IPAT Anxiety Self-Analysis Form was used es a measure of anxiety. Although this study did not swcificell~ address low bi& weight, ii demon&ted sign& cant positive relationships between poor fetal outcome (low Apgar scores) with high-anxiety mothers. Norbeck and Tildenm studied the effects of selected stresson on pregnancy complications in a convenience sample (n = 117) of varied, medically normal women. High life stress a; measured by the Samson Life Expedeoces Survey” predicted ge&t& complicationsthet-included labor. with or without delivery, before 37 weeks. High life stress alternatelv did not oredict infant comolicetio&, including low birth weight (<2.500 ql. Anxietv measured bv the Spielberger St&-Treit Am&& Inventoy’e was defined es an emotional dlseqotltbdum factor and not es high life stress. A significant reletionship was established between stress and gestafionel complications. High life stress from the previous year predicted gestation compllcattons (P < ,011 and the lnterection of tangible support snd life stress during pregnancy was a significant predictor of gestaticn. labor, and infant mmolications IP < ,011. The p;evtous &dies attempted to establish relationships between stress and other psychosocial variables in pregnancy wiul poor outcome, including preterm labor and low birth weighr. One assumption made in review& ihijr stodies is that a meesure poor fetal outcome can be defined specifically es low birth wzlgbt. Arizmendi and Affonsn’ identified the frequency and Intensity of stressful events reported by pregnant and postpartum women. The authors concluded that: II) the imwrtance of e stressful e&t depwded
o?
on the intensity or the frequency of the event; (2) sti varied across the childbearing petiod: and (3) internal rather than external events geoerated the greatest anxiety. Unfotinately. the sample targeted only middle-class white women. To date, there is no literabxe on stressful events as re- rted by Afdcan-American childbeetins women. This pilot study replicated the Arizmendi and Affonso study and hvpothesized that there would be dirferences In the patterns of st~essors es determined in the original study. It was projected that differential stressors documented in the pilot study would target areas for f&e research related to differential low birth weight outcomes in the AfticenAmerican childbearing woman.
METHODS Description
of the Site
Highland Hospital, located in Oakland, is the county hospital for Alameda County in California. II serves the poor, the disenfranchised, and the overexploited of Alameda County. In 1987, there were 2,079 live bii and 184 low btrth weight births et Highland. African-Am&can birihs numbered 736 with a low birth weight rate of 17.0. White births numbered 7.33 with a low birth weight rate of 3.O.“At Highland, the rate of Medt-Cal fee-for-service hwpitel deltveries was 56.9% (rate per 100 hospital delivertesl. Highland Hospital represented 29.7% of the total county Medi-Cal hospital delivelks.‘4
Participants A convenience sample was recruited from the prenatal and postnatat clerics at Highlend Hospital. The indusion clttelie were that the peti& pant was: (11 Ahican-American; (2) pregnant or within the six-week postpartum period; (3) between 18 and 40 years of age; and (4) without medical or obstebical complications.
Joemel of NerwMtdwtfery
. Vol. 35, No. 4. JulylAuaust 1990
A total of 55 women were approached for consent. Two women were excluded because of high-risk status.Two we”’ unabk to complete the study due io time const&!s, and one was African. A !otal of 50 women represented the final study sample. Procedures The participants were asked to list five to 10 stressful events that the” had experienced during the pregnancy. For each sbessfulevent, they were instructed to use an interval scale from 1 to 100 to rank the intensity of the stressor. They were also asked to rate the stressh;levent as posftive or negative. Participant respo”s?s were analyzed using Ategories previously developed in the Adzmendi and Affonso study.’
Years of education
Mean SD
Employment (frequency) Unemployed Employed Homemaker Publicas&ta”ce Student Dliler
RESULTS
In the original study, socioeconomic status was not determined furmallv: however, it was assumed to de middle class.In this study, the typical participant was in her e&y 20s.& = 23.8). single lj = 43). hating less than $5,ooO as yearly income lj = 34), and educated th:sugh hfgh school (ji = 12.3 years). The women were largely in the third (f = 26) or second lj = 19) trimester of pregnancy. A greater number of women were nulliparous (f = 31) and fewer were multfuarous If = 19). Comparative de&raphi& of both studies are presented in Tt?ble 1. Although income and education were not specifically determkwd in the Arfzmendi and Affonso study.’ the investigators assumed middleclass status. In the current study, 69% of the participants were poor, having a yearly income of less than $5,000. Trimester Comparisons in the Arizmendi and Affonsa study,’ significant comparisons were made
12.38 1.8
6 7
Nd stated
2z 2”
by demographics and by himester (fkst, thud. and postpartum women). In the current study, no eig”ificant differences were found in the frequency or intensity of stressful events when demographics or trimesters were considered. The majodh/ of the wmen in the current &dy were either in the second (38%) or third (52%) trimester of pregnancy. Stressful Events In the Current Study The categories of stressful eventi were replfcated from the Adzmendf and Affonso studri exceut for three categories that”emerged in the present study. The first additional category was a desperate need for housfng; the second was waiting
doumaf d Nurse-Midwifery . Vol. 35. No. 4. JdylAugus, 1990
1455 3.a3
time in the clinic and the third was a categcw (other1 that included those *e%iul evens not any other These as well as examples 0; item5 reported from the current study are presented in Table 2. In Table 3 the stwssars of both shxliesare ranked in u&r of dexendlng frequency and presented their mean intensitks.
Rtthlg categories. cat~rfe5
The resulb of thts pilot study hlghlighted five signtRcantissues: (1) in both studies. the must freouent stressorwas dhyskal sympbnn;; (2) in the AdanendUAffonsr studu.1the events that were per&Ed to-bigger the most anxiety were Internal events as anticfpatoly fears ?I eoncems, whereas in the cunerd study, 233
TABLE2 Categmies of Stressful Events -CdWY Physicalsymptoms
f
Percent of Sampk
35
70%
18
36%
ExampleoffternsReported
Monetay fS”e5
17
34%
Bills. no money. house burglarized
Family sWssors
14
28%
Disappointed my parents. not enough suppat. family pmblema. miss leaving mother. family “in our business”
Job/Career/Schwl
14
28%
Unable to attend school. can’t And a lob, can’t work, had to work 10 hours a day. daesn’t wad to leave baby to 6.x back to work
13
26%
Feelingalone, shorttemper,“my nerves” husband murdered in
Body image
11
22%
Other children
11
22%
Have to take care of my other chlldren too
Need chan9e in howin inew category)
10
20%
Derpemte nepdfor housing. livtngv.$tha fdend. need my own place
9
18%
Is the baby &i&t? Wonies about baby
Changes in living patterns
7
14%
Moving, housecleaningis dtfflcult
others (new categoly,
7
14%
34 years old and firet pregnancy, “broad et the re~stratton desk
1988 v can’t m, don’t likebeing fat, dcn’t like the way 1 look
-a
nastyattitudi~
incarceration
Parenting concerns
234
3
6%
Am I ready? What kind ot parent uill be?Whet kind of child MJ have?
3
6%
wait too long
3
6%
Fear aboutwhat to expect
1
2%
Baby c@ing
0
0
None statedin study
0
0
None statedin study
I I
external events,such as stress related Lo the lack of money, mate/ spousr issues, family, and-job, career, school issueswere the most frequent sourcesof slwzs: (3) the mean intensity of the ranked stmssorswas higher in the current study; (4) although only 20% of the sample In the current study had less than a high school education. 70% of the sample earned less than $5,000 per yew anJ (5) 86% of the study ,ample we singIl2f_f= 43) as cornpared with 19.9% in the Adzmendi and Affonso study.] Each of these issueswill he discussedin turn. Physical symptoms resulting from pregnancy created a etressor that crossed class and race in terms of frequency of occurrence (see Table 31. The current study showed no significant difference by trimester of the frequency or intensity of this strexor. However, the mean intensity of the stressramted was higher in the curstuily (F = 65.f?)than in the oduinal stud” If = 49.071. Given the-hfstottcal&l present e&dence of African-American famflies,ts~t6it is not surprising that the childbeadng women would articulate a greater inter&y of skessassociatedwith physical symptoms of pregnancy than their white counterpark. In the Arizmandi and Affonso study, the four most frequent stressors following physical symptoms were: body image, concerns about the baby, changes in living situation. and emotional stressowl These streasors. except those related to changes In Ilvlng, can be defined as internal anti&atoy fears Of concerns.’ In the current study, the four most frequent stressors after physical symptoms were external events related to mate/ spouse, monetary Issues,famtfy, and job or school issues.Again, the identBcaUon of these external stressorsis not surprising. lnkospection Is passibk when external necessitiesare in order. As one partlctpant stated when discussing money concerns, “Christmas was hell.” The third issue concerns intensity
rent
Journal of Nuree.Midwifeay
. Vol. 35. No. 4. duly/August 1990
Physkal symptoms Mate/Spouseissues
Monetmw stressoa
Family &exors JdXareer/schcol Emotionalstresors MY image Other children Need changein how!ng PregnancycorKem Changein living &wt.?ms Mher concerns Labor and delivery parentingC(m”CemS watt L”clinic Newborn behavior Baby welfare SC&l stressors
66.73 41.92 78.58 71.07 5754 75.31 58&l 71.91
49.07 52.01 68.55 47 13 54.75 62?4 6761 61.37 5623 52.56 52 62 42 15 59.77 ‘?6?4 6156
9Q.00 75.56 so.00 91.42 MM ax3
56.67 1wJ.w None Nana
ratings. Table 3 illustratesa trend toward higher mean intensity rathws of the str&sors in the c&ent study than in the orisinal stu& Althouah statistical significancs *cannot i;e ascertained, this trend Is dramatic. What in the life, the poverty. the race, or the experience of the Afrlcan-Am&can wanen in the currant study increases the intensity of stressful events related to child-
baing?
The fourth issue presented deals with the demographics in the current study. Only 20% of the women had less than high shwl education (12 years of school), and approtimately 70% had a yearly income of less than $5,fJ30. For the AMcan-AmerIcan, education has historically been the key to improved statusin this soclety.“.‘e If high school education for the African-American woman mean* only poverty-level income, and If the African-American man has less education. lower income, and less employment than the w~man.‘~ then what dws the future hold for them, indlvldually or colleciively? Dverall. a white woman with nine to 11 years of school has approxi-
mately the same prematurity rate (10.4) as an African.American woman with 16 years or more of schcol (10.5) 3 Education is not an equaber. The fifth issue p-esented fwuses on the marital status of the current study. fn the Adzrnendi and Affonso study, 77.8% were married and 19.9% were single. In the current study, 12% were ma&d and 86% single. Current literature has addressedthe concept of single-female headed African-American familie~.‘~.~~ Yet mate/spouse issue5 ranked with medium intensity Iji = 41.19) in this studv and were the sacoind frequent sLurce of stress. Does this present a challenge to the current concept?It is possiblethat viable and functional pairing occ”rs outside of conventional definition? The listing of matekpoure issuesas ‘. stwssful event supports the concept of the man included in the family stmchlre.
stressful events related to childbearing in a sample of African-American women and to compare them with the &es~ors Identified by the largely white sample in the Arizmendi and Affonso study. Three problems presented themselves in this analysis. first, the samples. although unm&hed in terms of race. were also unmatched in te:ms of class. The n@Ial study group, by assumption. was middle class; the current study group, by demo(paphlcs. was poor. Poverty is a coniounder with those stressors that might be attributable to the effectsof race. Second the wtiinqs where the Interviews occurred weredifferent fn the original study. clients we interviewedin a univ&ibj hmpitak in the pilot study the intewtew were conduced in the county faclli?+ Were there effectsrelated to these different settings. apart from the effects of race and class?Third, the assumption that the categories dev&ped from the original study could be r=z. licated for the pilot study is chd!. lengeable. New categudesin a larger shrdy might be generated independenily oi prior &dies, and &mpared retmsy&vely. Despite these difticulties. viable research are presented. Future investigations need to examine5~ in pregnancy in the Akican-Americanfamily in rel&ion to such outc.xne5 as pre!ezm delivery and low bir!! weight The pregnant womzn and her family rep resent present and future generations. Action is mandatr_‘.
lMPLlCAllONS
REFERENcEs
This study was a pilot effort to identify the frequency and intensity of
1. Adzmend T. Affonw, D: Stressful eventsrelated !o przggnancy dnd port-
Journal of Nurse.MkiwUery . Vol. 35. No. 4. July/August1990
23.5
paxturn. .I Psychworn Res 31.74X-756. 1987. 2. Deparnnent of Health Services. Health and Welfare Agency. State of %arnnJital statistfa of Califomla. 3. U.S. Dcpadment of Health, Education ana Welfare: Characteristics of births: U..ited States. 1973-1975. Hyatt& :1, Md.. Nz.aonal Cw:er fcr He&b stwics, 1978. 4. fns6tufe of Medicine. Committee to Stud> the Prevention of Low Birthweight: Preventing low birthweight. Washington, D.C., Nbtional Academy PEE, 1985. 5. Kleinman JC, Kesrel s5: Racial diffe,e”cos in low binh weigbt. N El@ J Med 317~749-753. 1907. 6. McDonald RL, Chrfstakor AC: Relationship of emotianal adjustment during pregnancy to obstetncs complications. Am J Obstet Gynecol 86:341348.1963. 7. David* A, DeVaiuir S: Maternal
anxiety during pregnancy and childbirth abnormallaes Pwhcaom M .d 24:464470. 1952. 8. Blau A, Slaff B. Eason SK, et al: The psyxbwenic etiology of premature births: a preffminary report. Psychosom Med25:201-211, 1963. 9. Cmndon Al: Maternal anxiety and neonatal wellbeIng. J Psychosan RCI 23:113-115.1979 10. Norbeck JS, Tilden VP: Life stress.social sumr,r~ and emotional disequilibdum in’&plicationr of pregnancy a prospecliue, multfvaiate study. J Health See Behav 2430-46. 1983. 11. Samson I. Johnson J. Siegel J: Assawing the impact of life changer dovelopment of the life eqaiencn survey. J Consul, Clin Psycho, 46:932--946, 1978. 12. Spielberger C, Gorwch R. Lushene H: STAl-manual for State-Tra!t Anxiety Inventory. Palo Alto, Calif., Consulting Psycholc$st Press, 1970. 13. Caftfomla Health Services Admir-
ishation. Alameda Coumy Information Systems.vital Records, 1987. 14. Depatient of Health Services, State of California. Medical Care StaWCS, 1987. 15. Billlngsley A: Black families in white America. New York, Simon & SEhustn. 1968. XC. K-far Fk S&q s&al statis and psychological distress. J Health Sot Rehav x):259-72,1979. 17. Dati A: Women. race and class Boston, Uttle, Brown &Co, 198’3. 18. Franklin J: From slavery to freedom: a hirtoy of Negro Amencans, 4th ed. New York, Alked A Knopf. 1974. 19. Gibbs ST: Young, btack and male in America: an endangered species:. Dover, Massachusetts, Auburn House, 1988. 20. Wilson JW: The truly dlsadvantaged: Le inner city, the under&s, and public policy. Chicago, Un:wsibj of Chlcage Press. 1987.
Jo,,,,,al of Nurse.M!dwUerv . Vol. 95, No, 4, Juf~lAuguU 1990