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The effect of husband participation on reported pain and probability of medication during labor and birth
Journal ofPsychosomatic Research,Vol. 19,pp. 215:lo222.PergamonPress, 1975.Printed in Great Britain
THE EFFECT OF HUSBAND PARTICIPATION ON REPORTED PAIN AND PROBABILITY OF MEDICATION DURING LABOR AND BIRTH*t WILLIAM JAMES HENNEBORN and ROSEMARY COGAN (Received
24 February
1975)
Abstract-The present study investigated the births of women whose husbands attended labor and birth with the births of women whose husbands attended only the first stage of labor. All subjects were enrolled in childbirth education classes and husbands were encouraged to participate as labor coach throughout labor and birth. Those wives whose husbands attended labor and birth reported less pain and had a significantly lower probability of receiving medication during labor and birth. Husbands and wives who attended labor and birth reported more positive feelings about the total birth experience. Developmental implications are discussed. MEAD and Newton [l] have reported that many primitive societies place the husband in an important role during labor and birth. Such has not been the case in the Western world, where traditionally the father has been excluded from the labor and birth process. This exclusion from labor and birth also parallels the husband’s diminished role in early child-rearing in Western culture. Anthropologists, sociologists, and psychologists have suggested several reasons for this diminished child-rearing role. These same reasons may very possibly account for the diminished role of the husband in labor and birth.
Nash [2] suggested that the husband’s reduced role in child-rearing may be due to the economic history of our industrialized civilization, with the result being the husband’s delegating his place in early child-rearing to his wife. His role is then seen as that of being a ‘good provider’. The epitome of this idea is expressed by Bowlby [3]. To him the father is “of no direct importance to the young child, but is of indirect value as an economic support and in his emotional support of the mother.” Josselyn [4] views Western Society’s reasons for down-playing the father’s role as the tendency for it to view fatherhood as being a social obligation and motherhood as having biological roots. Thus early child care (and birth?) is regarded as effeminate and emasculating. With these views it seems plausible to suggest that some husbands may be handicapped in relating to their wife during labor and birth as well as during early child-rearing. Still another possibility is suggested by Kluckhohn 151.He claims that Western women have been freed from many domestic chores while the men have become engrossed in the pursuit of success. The husband is seen as relegating the role of childrearing to the wife. Rohrer and Edmonsone [6] have suggested that because of the matriarchial nature of American society and subsequent alienation, American males have tended to disassociate themselves from areas considered feminine. Elkin [7] moreover claimed that the American male has difficulty in accepting a mature and socialized concept of virility because his development in home and school has been molded largely by women. O’Leary [S] suggested that Freud’s placing of the mother in the critical position of being the source of the child’s entire psychological life has also contributed to Western society’s indifference to the husband’s diminished role in early child-rearing. For whatever reasons, the father’s role during labor, birth, and early childhood has not been reinforced in the Western world. A careful perusal of the literature also reveals the meagerness of husband-related studies dealing with this subject. The importance of husband participation in child-rearing has been suggested by Chertok [9] and Mead and Newton [l] but has generally received little rhetoric and even less objective examination. Tanzer [lo] seems to have been the first to investigate empirically the role of the husband in labor and birth. ‘:‘From Texas Tech University, Department of Psychology, Lubbock, Texas, U.S.A. “yThis work was supported by funds from Public Health Service Research Grant No. MH 24249-01 and from Childbirth Without Pain Education League, Inc. 215
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Tanzer [lo] compared groups in which the husband was or was not present during the second stage of labor. Her findings show the striking effect of a husband’s presence upon his wife’s birth experience. In every case in which the woman reported a rapturous or ‘peak’ experience during birth, her husband had been present in the delivery room. The husband’s presence would seem to indicate that it is an integral part of a peak experience in childbirth. Tanzer’s results indicate that wives experience a positive and highly desirable effect when their husbands are present during birth. The husband’s presence at birth seems to be an important factor in influencing the quality of the birth experience for his wife. This being the case, the question arises as to other possible effects of husband presence during labor and birth. The present investigation focuses upon the effects of husband’s presence or absence during the second stage of labor after having been present during the initial stage of labor. The investigators were interested in the effect of the husband’s presence or absence upon the wife’s birth experience, especially her pain in labor and birth. Women’s social relationships with medical personnel have been found to be significantly related to experienced pain during labor and birth. Conflicts between laboring women and their physicians have been related to longer and more complicated labors [ll]. Relationships with the medical staff during labor have also been related to the degree of pain reported during labor and birth [12]. If these peripheral social relationships influence labor and birth it seems extremely plausible that the relationship with her husband may also influence labor and birth experiences. Labor and birth are generally regarded as involving anxiety and pain. Maternal anxiety is known to inhuence the degree of labor and birth pain 1121,while anxiety in general is associated with reduced tolerance for pain [13]. It should not be surprising to find that anxiety may be associated with increased requirements for medication during labor and birth. The present study investigated couples who elected to attend prenatal classes to prepare for labor and birth. Those couples of which the husband attended his wife as labor coach during labor and birth (Husband Present 1,2) were compared with couples in which the husband attended his wife as labor coach only during the first stage of labor (Husband Present 1). Differences between the groups were considered (1) as they began childbirth education classes during the last trimester of pregnancy, (2) after the fourth class, and (3) after the birth, METHOD Sample A sample group of 49 births were drawn from a survey of births from 317 women who were students of a childbirth education group* offering classes in many parts of the United States. The specific type of prenatal childbirth education class our sample attended was the Lamaze or psychoprophylactic method. These classes provided information about labor and delivery as well as instructions in breathing and relaxing techniques which provide comfort during the birth process. Husbands were encouraged to accompany their wives throughout labor and birth and act as their labor coaches. Births were selected for use in this study only if they were vaginal and all of the following were completed and returned: (1) questionaires filled out by the wives at the initial class in the last trimester of pregnancy; (2) questionaires filled out four weeks later by wives, husbands, and teachers; and (3) questionaires filled out after the birth by wives, husbands, and teachers. Questionaires were also given, by the couple, to physicians at the time of the birth. Questionaires, with return envelopes for the physicians and couples, were given to all participants with their class material at the initial class meeting. The responses of 38 couples in which husbands were present during labor and birth (Husbands Present 1,2) were compared with the responses of 11 couples in which husbands were present only during the first part of labor (Husbands Present 1). The Mann-Whitney U [14] was used to compare differences between groups. RESULTS Couples as classes began As classes began, there were no differences between the groups with respect to education (training beyond high school), parity (2/3 were expecting their first child), and length of marriage (4-6 yr). In the first questionaire, the HP 1,2 wives indicated that a more important reason for taking the childbirth education classes was to increase their (p < 0.01) and their husbands (p < 0.01) emotional participation in the birth experience as compared with the HP 1 wives and their husbands. When asked how their husbands felt about helping during labor and birth, the HP 1,2 wives reported more positive husband attitudes (p < 0.01). When asked if the hospital to be used permitted husbands in * Childbirth
Without Pain League, 3940 Eleventh Street, Riverside, California 92501.
Effect of husband participation
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217
the delivery room, the HP 1,2 wives answered affirmatively more often than did their counterparts (p < 0.01). Changes during childbirth education classes As classes began, the HP 1,2 wives reported more positive attitudes towards the birth experience (p .c 0.05); attitudes of both groups of wives were equally positive after the fourth meeting. The HP 1,2 wives also indicated that their husbands had more positive attitudes about helping during labor (p < 0.01). However, when the husbands were given the same question after the fourth class meeting, members of both husband groups felt equally positive about helping during labor. The HP 1,2 wives indicated that their husbands expressed more positive feelings about helping during the birth itself than the HP 1 wives (p < 0.01). When the husbands were questioned after the fourth class, this difference was reaffirmed (p < 0.05). Participation andpractice: The ‘good student syndrome’ When considering the activity level in relation to practice and knowledge gained in class both groups seem very much alike. The husbands and wives in both groups attended an equal number of classes (6 or more). There were no husband and wife or group differences in the reported understanding of medication alternatives (a ‘good understanding’). The amount of practice in the techniques used during labor and birth also did not differ between husband and wife or the two groups. Wives reported practicing breathing for “30 minutes a day in the past two weeks”. Both groups of husbands reported practicing labor and birth techniques with their wives for “30 minutes a day in the previous two-week period”. Both groups of husbands indicated that they had done equal amounts of reading (‘some reading’) in the past few months and had recently attended a birth movie. When the husbands were asked how well prepared they felt to help during the birth, there was no statistical difference between groups with regard to feelings of preparedness in helping with (1) emotional problems during birth, (2) techniques to be used in labor, and (3) the understanding of relevant theoretical materials on childbirth without pain. A plurality of husbands felt themselves to be ‘well prepared’ or ‘very well prepared’. Labor and birth facis The first stage of labor, or dilation labor may be divided into phases on the basis of the relative speed of dilation. Dilation occurs slowly in early labor and O-5 cm expansion of the cervical opening is considered to be the first phase in this first stage of labor. Dilation occurs more rapidly as labor progresses, with 5-8 cm being identified as the second phase of this initial stage of labor. Dilation slows somewhat as the first stage of labor ends with 8-10 cm being identified as transition or deceleration. The second stage of labor includes expulsion of the baby. The length of the first stage, the transition, and the second stage labor was similar for both groups of wives. There were some differences noted in percentages of episiotomies with 56% of the HP 1,2 wives receiving an episiotomy as compared to 70 ‘A of the HP 1 wives. Activity of husbands in labor O--5 cm dilation. Approximately 60% of the wives in both groups had problems with fearfulness during the initial stage of labor and both groups reported their husbands as being equally reassuring and helpful. Such was not the case when activity was compared. When looking at the husbands’ reported activity (see Fig. la), the HP I,2 group felt more active (p = 0.05) than did their counterparts. The HP 1,2 wives also perceived their husbands as being more active (p = 0.05). 5 cm until transition was felt. In this latter phase of the first stage of labor, the wives in both groups saw their husbands as being ‘very active’. Their husbands agreed. Transition. During this stage of labor there was no statistical difference between the activity levels of the two groups of husbands as reported by both husbands and wives. Second stage. During this stage a hospital nurse became the labor coach for the HP 1 group. When the two groups of wives were asked about the activity level of their labor coaches the HP 1 group reported their nurse as being less active (p < 0.05) as compared to the responses of the HP I,2 group. Pain in labor First stage. In the initial phase of the first stage of labor, (O-5 cm dilation) there was no reported difference in discomfort during contractions (see Fig. lc). In the second phase (5 cm until transition was felt) more discomfort was reported (p < 0.05) by the HP 1 wives. Both groups of husbands were similar in interpreting their wives’ feelings during O-5 cm dilation, with the majority of each group reporting that no pain was encountered. The husbands in the HP 1,2
218
WILLIAM
.4
JAMES HENNEBORN
2
and
ROSEMARY
b HP I wives A HP I,2 Wives
0 HPI Husbands oHPI, Husbmds
A!
I O-5CM
I 5CM-
COGAN
I Transition
I Second stage
TWll.
FIG. 1
group reported their wives as feeling significantly less pain (‘moments of discomfort’ vs ‘some pain was felt’) during the 5 cm-until-felt-transition phase (p < 0.01). Transition. The HP 1,2 wives reported less pain (p < 0.01) than the HP 1 wives. This difference in discomfort (‘some moments of discomfort’ vs ‘severe pain’) was also reported by the respective husbands (p < 0.05). Second stage. No significant differences between groups were found for this final stage of labor. Both groups reported feeling no pain, however they felt that ‘much effort was needed’. No comparison of husband responses was possible because of the absence of the HP 1 husbands. Medication
during labor
In all stages of labor the HP 1 wives had a higher probability (p < 0.01) of receiving medication (see Fig. lb). During the first and transition stages the HP 1 wives usually received a ‘muscle relaxant or tranquilizer’ while in the second stage they received a ‘local injection which led to numbness to all or part of the pelvic area.’ After the birth:
The hindsight
experience
When asked about ‘emotional preparedness for birth’ after the delivery, both groups of wives reported that they had felt ‘very well prepared’. Among the husbands, the HP 1,2 group reportedly had felt more emotionally prepared for birth (p < 0.05) than their counterparts and better prepared to help with ‘neuromuscular release’ (p < 0.01) and ‘deep chest breathing’ (p < 0.01). When asked about their feelings concerning the overall birth experience, the HP 1,2 wives felt more ‘highly pleased and enthusiastic’ (p < 0.05) than did the HP I wives. The same was true for the HP I,2 husbands (p -c 0.01). DISCUSSION
Although the mechanisms by which childbirth education classes affect the birth experience are not yet understood [9, 121 it has become increasingly clear that prenatal childbirth education classes do affect the birth experience. Tanzer [lo] found that attendance by couples at prenatal child-birth classes reduced pain during labor and increased positive responses concerning labor, as well as being positively related to the wives’ perception of their husbands’ competence. These results were associated
Effect of husband participation
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with class attendance, whether couples voluntarily participated or were assigned to the classes by their physicians. Similarly, Enkin et al. [15] found that attendance at prenatal classes was the critical variable associated with reduced pain and probability of medication when comparing wives who elected to attend classes with wives who elected to, but did not and women who neither elected to, nor attended classes. These studies indicate that motivation for electing classes is not an important variable in predicting reported pain in labor and birth and probability of medication. The results of the present investigation, however, suggest that among couples who attend prenatal education classes, certain motivational factors are important in predicting husband participation in the second stage of labor, as well as the wives’ reported pain and probability of medication during the birth process. The HP 1,2 wives reportedly wanted to participate in childbirth education classes to ‘increase emotional participation’ for themselves and their husbands significantly more often than the HP 1 wives. The HP 1,2 wives had their husband as a labor coach throughout labor and birth, reported significantly less pain throughout most of labor and had a lower probability of receiving medication at all stages of labor. The present investigation indicates that childbirth education classes have little positive effect upon the HP 1 husband’s attitude about helping during the second stage of labor. Before classes began, a hospital had been chosen, with the HP 1 couple more likely to select a facility that would not allow the husband to be present during delivery. And although it appears that the HP 1 husbands do change their attitude about helping during the first stage of labor, there is no change in attitude about helping during the second stage. It appears that a basic attitude is present before classes begin and is not changed by factors of attendance, information, or practice of labor techniques. Chertok [9] has summarized and evaluated the effectiveness of psychosomatic approaches to preparation for childbirth and has suggested that all techniques contain three components : psychophysical techniques learned during pregnancy and used during labor and birth, intellectual components, and emotional components. Although the relationship between these components and their exact role in reducing pain during labor and birth is not clear, literature concerning pain which is not related to childbirth is suggestive. Many studies have reported reduction of the emotional impact of stress when information is provided about a distressing experience in advance of the experience [16-191. Bobey and Davidson [13] have also found that relaxation techniques were effective in raising pain tolerance measures. It thus seems plausible that information given about labor and birth during childbirth education classes may serve to reduce anxiety, while psychophysical techniques, learned and practiced for use in labor, reduces tension and physiological stress, reducing anxiety further still. In the present investigation, knowledge of the subject matter, previous education, parity, attendance of classes, and practice of techniques were similar for both groups. However, when the HP 1,2 husbands attended labor and birth, it had a positive effect on their wives’ reported feelings of pain, the probability of medication, and the couples overall attitude about the hindsight birth experience. It appears that a social-emotional component, provided by the HP 1,2 husband, was important in affecting reported pain during labor. The exact nature of this social-emotional component is not presently known, however.
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WILLIAM JAMESHENNEBORNand ROSEMARYCOGAN
Tanzer’s results [lo] were quite provocative in the rather surprising finding that the involvement of the husband during childbirth is of tremendous importance in the reported experience of the wife. The present study indicates that effects of husband presence are even more far-reaching than had been previously suggested. As has already been noted, the HP 1,2 wives wanted to participate in childbirth education classes to increase the emotional participation of themselves and their husbands. After the fourth class, both groups of husbands reported that they felt ‘very well prepared’ to help with labor and birth exercises and were equally well prepared to help with possible emotional problems during labor and birth. When asked identical questions after the birth, the HP I,2 husbands continued to feel ‘very well prepared’ to help with emotional problems but such was not the case for the HP 1 group. This was also the case in the birth and labor exercises ‘neuromuscular release’ and ‘deep chest breathing’. Thus, in retrospect, the HP I,2 husbands seem to feel more confident about some of their labor skills and their general ability. These group differences cannot be accounted for by informational or practice variables and appear to reflect an emotional or confidence factor. Further research is needed concerning the husband’s decision to participate in the second stage of labor. The decision to attend labor and birth may reflect basic differences between the two groups of husbands, or couples, may be a response of couples to hospital regulations, or perhaps joint agreement to participate in labor and birth before the start of childbirth education classes may change labor, birth, and post partum feelings. Numerous social psychological studies have shown that when individuals are required to cooperate with one another for the achievement of mutually desired goals, they are more likely to improve their attitude towards each other [20, 211. It might be inferred from these findings that if a husband and wife are able to actually work together during labor and birth, they may develop more favorable attitudes towards each other. They may also achieve some common grounds upon which to establish improved communications [lo, 22, 231. Another area of future investigation should be the effect of the husband’s participation in birth upon the development of the child. The husband-wife relationship may have indirect physiological and behavioral effects upon the developing fetus and infant. Maternal stress has been related to hyperactivity of the fetus during the latter months of pregnancy and such later difficulties as feeding problems, sleep disturbances, and the general irritability of the infant [24-321. The implications of a relationship described as ‘anxious’ during pregnancy and the possible effects upon fetal development are obvious. In addition, medication and other obstetrical elements have been shown to play a significant part in discussions of both cognitive and emotional difficulties in development [33-381 and point to the possible indirect effect of the husband-wife relationship, and the decision on the husband’s part to attend labor and birth on a developing fetus. The emotional and interpersonal aspects of a marital relationship may be part of a spiral of alterations in behavior affecting the mother, the developing fetus, the birth experience, and the mother-father-child triad during the early days and years of development. If this is the case, the question of the husband attending his wife during labor and birth may have long-reaching effects upon the child which they will bring into this world.
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MEAD M. and NEWTONN. Cultural patterning of perinatal behavior. In Childbearing: Its Social and Psychological Aspects (Edited by RICHARDSONS. A. and GUTTMACIXER A. F.). Williams and Wilkins, New York (1967). NASH J. The father in contemporary culture and current psychological literature. ChiZdDevelopment 36,264 (1965). BOWLBYJ. Maternal Care and Mental Heaftfr. World Health Organization, Geneva (1951). JOSSELYNI. M. Cultural forces, motherliness and fatherliness. Am. J. Orthopsychiatry 26, 264 (1956). KLUCKHO~NC. Mirror of Man. McGraw-Hill, New York (1949). ROHRERJ. H. and EDMONDSONM. S. The Eighth Generation. Harper, New York (1960). ELKIN H. Aggressive and erotic tendencies in army life. Am. J. Social. 51, 408 (1946). O’LEARYS. Mother-father-infant interaction in the first two days of life. Unpublished doctoral dissertation, Univ. of Wisconsin (1972). CHERTOKI,. Psvchosomatic Methods in Painless Childbirth. Pergamon. New York (1959). TANZERS. The-psychology of pregnancy and childbirth: an investigatibn of natural‘childbirth. Unpublished doctoral dissertation, Brandeis University (1967). ROSENGRENW. R. Some social and psychological aspects of delivery room difficulties. J. Nervous Mental Dis. 132 (1961). CHERTOK L. Motherhood and Personality: Psychosomatic Aspects of ChiIdbirth. Lippincott, Philadelphia (1969). BOBEYM. J. and DAVIDSONP. 0. Psychological factors affecting pain tolerance. J. Psychosom. Res. 14, 371 (1970). SIEGALS. Nonparametric Statisticsfor the Behavioral Sciences. McGraw-Hill, New York (1956). ENKIN M. W., SMITHS. L., DERMERS. W. and EMMETTJ. 0. An adequately controlled study of the effectiveness of PPM training. In Psychosomatic Medicine in Obstetrics and Gynecology, 3rd Znt. Congress, London, 1971 (Edited by MORRISN.). Steiner, Base1 (1972). JANISI. Psychological Stress. Wiley, New York (1958). LAZARUSR. S., SPEISMANJ. C., MORDKOFFA. N. and DAVIDSONL. A laboratory study of psychological stress produced by a motion picture film. Psychological Monographs 76, 1 (1962). LAZARUSR. S. and ALFERT E. Short-circuiting of threat by experimentally altering cognitive appraisal. J. Abnormal Social Psychol. 69, 195 (1964). EGBERTL. D.. BAIT G. E.. WELCH C. E. and BARTLETTM. K. Reduction of nest-onerative pain by encouiagement and instruction of patients. New England J. Medicine 270~(1964j. LOTTA. J. and LOTTB. E. Group cohesiveness, communication level, and conformity. J. Abnormal Social Psychol. 62,408 (1961). MORGAN G. Dyadic attraction and orientational concensus. J. Personality Social Psychof. 4, 94 (1966). AUZ~ASG. Personal communication. In Psychosomatic Methods irz Painless Childbirth (Edited by CHERTOKL.). Pergamon, New York (1969). PAWSONM. and MORRISN. The role of the father in pregnancy and labor. In Psychosomatic Medicine in Obstetrics and GynecoZogy (Edited by MORRISN.). 3rd Int. Congress, London, 1972. Karger, New York (1972). DAVIDS A., DEVAULTS. and TALMADGEM. Anxiety, pregnancy and childbirth abnormalities. J. Consult. Psychol. 25, 74 (1961). DAVIDSA., DEVAULTS. and TALMADGEM. Psychological study of emotional factors in pregnancy: a preliminary report. Psychosom. Med. 23, 93 (1961). DAVIDSA. and DEVAULTS. Maternal anxiety during pregnancy and childbirth. Psycfzosom. Med. 24,464 (1962). DAVIDS A., HOLDEN R. and GRAY G. Maternal anxiety during pregnancy and adequacy of mother and child adjustment eight months following childbirth. Child Development 34, 993 (1963). HURLOCKE. B. Developmental Psychology. (3rd. Ed.). McGraw-Hill, New York (1968). RICHARDST. W. and FALLGO~TERR. Studies in fetal behavior-II. Activity of the human foetus in utero and its relation to other parental conditions, particularly the mother’s basal metabolic rate. Child Development 9, 69 (1938). SONTAG L. W. Differential etiological factors in psychopathic behavior in children. Am. J. Orthopsychiatry 22, 223 (1952). TURNER E. K. The syndrome in the infant resulting from maternal emotional tension during pregnancy. Med. J. of Australia 1,221 (1956). Cited by E. R. GRIMM, Psychological and Social Factors in Pregnancy, Delivery and Outcome. In Childbearing: Its Social and Psychological Aspects (Edited by RICHARDSONS. A. and GUTTMACHER A. F.). Williams and Wilkins, New York (1967).
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32. TURNER E. K. Teratogenic effects on the human fetus through maternal emotional distress: Report of a case. Med. J. Australia 47, 402 (1960). Cited by E. R. GRIMM, Psychological and SoEial Factors in Pregnancy, Delivery a& Outcome. In ChiIdbearing: Its Social aid Psychological Aspects (Edited by RICHARDSONS. A. and G~?TMAC~ER A. F.). Williams and Wilkins, New York (1967). 33. COCHRANL. J. Concerning birth injuries. Medical Times 84, 1336, 1340 (1956). 34. STANDLEYK.. SOULEA. B. III, COPANSS. A. and DUCHOWNYM. C. Local-regional anesthesia during childbirth: effect on newborn behaviors. Science 186,634 (1974). 35. BUXTONC. L. Study of Psychophysical Methods for Relief of Childbirth Pain. Saunders, Philadelphia (1962). 36. WINDELW. F. Brain damage at birth: Functional and structural modifications with time. J. Am. Medical Assoc. 209, 1967 (1968). 37. SECVZERJ. A. Memory deficit in monkeys brain damaged by asphyxia neonatorium. Experimental Neural. 24,497 (1969). 38. BOWESW. A., JR., BRACKBILLU., CONWAYE. and STEINSCHNEIDER A. The effects of obstetrical medication on fetus and infant. Monographs of the Society for research in Child Development 35, 137 (1970).
THE EFFECT OF HUSBAND PARTICIPATION ON REPORTED PAIN AND PROBABILITY OF MEDICATION DURING LABOR AND BIRTH*t WILLIAM JAMES HENNEBORN and ROSEMARY COGAN (Received
24 February
1975)
Abstract-The present study investigated the births of women whose husbands attended labor and birth with the births of women whose husbands attended only the first stage of labor. All subjects were enrolled in childbirth education classes and husbands were encouraged to participate as labor coach throughout labor and birth. Those wives whose husbands attended labor and birth reported less pain and had a significantly lower probability of receiving medication during labor and birth. Husbands and wives who attended labor and birth reported more positive feelings about the total birth experience. Developmental implications are discussed. MEAD and Newton [l] have reported that many primitive societies place the husband in an important role during labor and birth. Such has not been the case in the Western world, where traditionally the father has been excluded from the labor and birth process. This exclusion from labor and birth also parallels the husband’s diminished role in early child-rearing in Western culture. Anthropologists, sociologists, and psychologists have suggested several reasons for this diminished child-rearing role. These same reasons may very possibly account for the diminished role of the husband in labor and birth.
Nash [2] suggested that the husband’s reduced role in child-rearing may be due to the economic history of our industrialized civilization, with the result being the husband’s delegating his place in early child-rearing to his wife. His role is then seen as that of being a ‘good provider’. The epitome of this idea is expressed by Bowlby [3]. To him the father is “of no direct importance to the young child, but is of indirect value as an economic support and in his emotional support of the mother.” Josselyn [4] views Western Society’s reasons for down-playing the father’s role as the tendency for it to view fatherhood as being a social obligation and motherhood as having biological roots. Thus early child care (and birth?) is regarded as effeminate and emasculating. With these views it seems plausible to suggest that some husbands may be handicapped in relating to their wife during labor and birth as well as during early child-rearing. Still another possibility is suggested by Kluckhohn 151.He claims that Western women have been freed from many domestic chores while the men have become engrossed in the pursuit of success. The husband is seen as relegating the role of childrearing to the wife. Rohrer and Edmonsone [6] have suggested that because of the matriarchial nature of American society and subsequent alienation, American males have tended to disassociate themselves from areas considered feminine. Elkin [7] moreover claimed that the American male has difficulty in accepting a mature and socialized concept of virility because his development in home and school has been molded largely by women. O’Leary [S] suggested that Freud’s placing of the mother in the critical position of being the source of the child’s entire psychological life has also contributed to Western society’s indifference to the husband’s diminished role in early child-rearing. For whatever reasons, the father’s role during labor, birth, and early childhood has not been reinforced in the Western world. A careful perusal of the literature also reveals the meagerness of husband-related studies dealing with this subject. The importance of husband participation in child-rearing has been suggested by Chertok [9] and Mead and Newton [l] but has generally received little rhetoric and even less objective examination. Tanzer [lo] seems to have been the first to investigate empirically the role of the husband in labor and birth. ‘:‘From Texas Tech University, Department of Psychology, Lubbock, Texas, U.S.A. “yThis work was supported by funds from Public Health Service Research Grant No. MH 24249-01 and from Childbirth Without Pain Education League, Inc. 215
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WILLIAMJAMESHENNEBORNand ROSEMARYCOGAN
Tanzer [lo] compared groups in which the husband was or was not present during the second stage of labor. Her findings show the striking effect of a husband’s presence upon his wife’s birth experience. In every case in which the woman reported a rapturous or ‘peak’ experience during birth, her husband had been present in the delivery room. The husband’s presence would seem to indicate that it is an integral part of a peak experience in childbirth. Tanzer’s results indicate that wives experience a positive and highly desirable effect when their husbands are present during birth. The husband’s presence at birth seems to be an important factor in influencing the quality of the birth experience for his wife. This being the case, the question arises as to other possible effects of husband presence during labor and birth. The present investigation focuses upon the effects of husband’s presence or absence during the second stage of labor after having been present during the initial stage of labor. The investigators were interested in the effect of the husband’s presence or absence upon the wife’s birth experience, especially her pain in labor and birth. Women’s social relationships with medical personnel have been found to be significantly related to experienced pain during labor and birth. Conflicts between laboring women and their physicians have been related to longer and more complicated labors [ll]. Relationships with the medical staff during labor have also been related to the degree of pain reported during labor and birth [12]. If these peripheral social relationships influence labor and birth it seems extremely plausible that the relationship with her husband may also influence labor and birth experiences. Labor and birth are generally regarded as involving anxiety and pain. Maternal anxiety is known to inhuence the degree of labor and birth pain 1121,while anxiety in general is associated with reduced tolerance for pain [13]. It should not be surprising to find that anxiety may be associated with increased requirements for medication during labor and birth. The present study investigated couples who elected to attend prenatal classes to prepare for labor and birth. Those couples of which the husband attended his wife as labor coach during labor and birth (Husband Present 1,2) were compared with couples in which the husband attended his wife as labor coach only during the first stage of labor (Husband Present 1). Differences between the groups were considered (1) as they began childbirth education classes during the last trimester of pregnancy, (2) after the fourth class, and (3) after the birth, METHOD Sample A sample group of 49 births were drawn from a survey of births from 317 women who were students of a childbirth education group* offering classes in many parts of the United States. The specific type of prenatal childbirth education class our sample attended was the Lamaze or psychoprophylactic method. These classes provided information about labor and delivery as well as instructions in breathing and relaxing techniques which provide comfort during the birth process. Husbands were encouraged to accompany their wives throughout labor and birth and act as their labor coaches. Births were selected for use in this study only if they were vaginal and all of the following were completed and returned: (1) questionaires filled out by the wives at the initial class in the last trimester of pregnancy; (2) questionaires filled out four weeks later by wives, husbands, and teachers; and (3) questionaires filled out after the birth by wives, husbands, and teachers. Questionaires were also given, by the couple, to physicians at the time of the birth. Questionaires, with return envelopes for the physicians and couples, were given to all participants with their class material at the initial class meeting. The responses of 38 couples in which husbands were present during labor and birth (Husbands Present 1,2) were compared with the responses of 11 couples in which husbands were present only during the first part of labor (Husbands Present 1). The Mann-Whitney U [14] was used to compare differences between groups. RESULTS Couples as classes began As classes began, there were no differences between the groups with respect to education (training beyond high school), parity (2/3 were expecting their first child), and length of marriage (4-6 yr). In the first questionaire, the HP 1,2 wives indicated that a more important reason for taking the childbirth education classes was to increase their (p < 0.01) and their husbands (p < 0.01) emotional participation in the birth experience as compared with the HP 1 wives and their husbands. When asked how their husbands felt about helping during labor and birth, the HP 1,2 wives reported more positive husband attitudes (p < 0.01). When asked if the hospital to be used permitted husbands in * Childbirth
Without Pain League, 3940 Eleventh Street, Riverside, California 92501.
Effect of husband participation
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the delivery room, the HP 1,2 wives answered affirmatively more often than did their counterparts (p < 0.01). Changes during childbirth education classes As classes began, the HP 1,2 wives reported more positive attitudes towards the birth experience (p .c 0.05); attitudes of both groups of wives were equally positive after the fourth meeting. The HP 1,2 wives also indicated that their husbands had more positive attitudes about helping during labor (p < 0.01). However, when the husbands were given the same question after the fourth class meeting, members of both husband groups felt equally positive about helping during labor. The HP 1,2 wives indicated that their husbands expressed more positive feelings about helping during the birth itself than the HP 1 wives (p < 0.01). When the husbands were questioned after the fourth class, this difference was reaffirmed (p < 0.05). Participation andpractice: The ‘good student syndrome’ When considering the activity level in relation to practice and knowledge gained in class both groups seem very much alike. The husbands and wives in both groups attended an equal number of classes (6 or more). There were no husband and wife or group differences in the reported understanding of medication alternatives (a ‘good understanding’). The amount of practice in the techniques used during labor and birth also did not differ between husband and wife or the two groups. Wives reported practicing breathing for “30 minutes a day in the past two weeks”. Both groups of husbands reported practicing labor and birth techniques with their wives for “30 minutes a day in the previous two-week period”. Both groups of husbands indicated that they had done equal amounts of reading (‘some reading’) in the past few months and had recently attended a birth movie. When the husbands were asked how well prepared they felt to help during the birth, there was no statistical difference between groups with regard to feelings of preparedness in helping with (1) emotional problems during birth, (2) techniques to be used in labor, and (3) the understanding of relevant theoretical materials on childbirth without pain. A plurality of husbands felt themselves to be ‘well prepared’ or ‘very well prepared’. Labor and birth facis The first stage of labor, or dilation labor may be divided into phases on the basis of the relative speed of dilation. Dilation occurs slowly in early labor and O-5 cm expansion of the cervical opening is considered to be the first phase in this first stage of labor. Dilation occurs more rapidly as labor progresses, with 5-8 cm being identified as the second phase of this initial stage of labor. Dilation slows somewhat as the first stage of labor ends with 8-10 cm being identified as transition or deceleration. The second stage of labor includes expulsion of the baby. The length of the first stage, the transition, and the second stage labor was similar for both groups of wives. There were some differences noted in percentages of episiotomies with 56% of the HP 1,2 wives receiving an episiotomy as compared to 70 ‘A of the HP 1 wives. Activity of husbands in labor O--5 cm dilation. Approximately 60% of the wives in both groups had problems with fearfulness during the initial stage of labor and both groups reported their husbands as being equally reassuring and helpful. Such was not the case when activity was compared. When looking at the husbands’ reported activity (see Fig. la), the HP I,2 group felt more active (p = 0.05) than did their counterparts. The HP 1,2 wives also perceived their husbands as being more active (p = 0.05). 5 cm until transition was felt. In this latter phase of the first stage of labor, the wives in both groups saw their husbands as being ‘very active’. Their husbands agreed. Transition. During this stage of labor there was no statistical difference between the activity levels of the two groups of husbands as reported by both husbands and wives. Second stage. During this stage a hospital nurse became the labor coach for the HP 1 group. When the two groups of wives were asked about the activity level of their labor coaches the HP 1 group reported their nurse as being less active (p < 0.05) as compared to the responses of the HP I,2 group. Pain in labor First stage. In the initial phase of the first stage of labor, (O-5 cm dilation) there was no reported difference in discomfort during contractions (see Fig. lc). In the second phase (5 cm until transition was felt) more discomfort was reported (p < 0.05) by the HP 1 wives. Both groups of husbands were similar in interpreting their wives’ feelings during O-5 cm dilation, with the majority of each group reporting that no pain was encountered. The husbands in the HP 1,2
218
WILLIAM
.4
JAMES HENNEBORN
2
and
ROSEMARY
b HP I wives A HP I,2 Wives
0 HPI Husbands oHPI, Husbmds
A!
I O-5CM
I 5CM-
COGAN
I Transition
I Second stage
TWll.
FIG. 1
group reported their wives as feeling significantly less pain (‘moments of discomfort’ vs ‘some pain was felt’) during the 5 cm-until-felt-transition phase (p < 0.01). Transition. The HP 1,2 wives reported less pain (p < 0.01) than the HP 1 wives. This difference in discomfort (‘some moments of discomfort’ vs ‘severe pain’) was also reported by the respective husbands (p < 0.05). Second stage. No significant differences between groups were found for this final stage of labor. Both groups reported feeling no pain, however they felt that ‘much effort was needed’. No comparison of husband responses was possible because of the absence of the HP 1 husbands. Medication
during labor
In all stages of labor the HP 1 wives had a higher probability (p < 0.01) of receiving medication (see Fig. lb). During the first and transition stages the HP 1 wives usually received a ‘muscle relaxant or tranquilizer’ while in the second stage they received a ‘local injection which led to numbness to all or part of the pelvic area.’ After the birth:
The hindsight
experience
When asked about ‘emotional preparedness for birth’ after the delivery, both groups of wives reported that they had felt ‘very well prepared’. Among the husbands, the HP 1,2 group reportedly had felt more emotionally prepared for birth (p < 0.05) than their counterparts and better prepared to help with ‘neuromuscular release’ (p < 0.01) and ‘deep chest breathing’ (p < 0.01). When asked about their feelings concerning the overall birth experience, the HP 1,2 wives felt more ‘highly pleased and enthusiastic’ (p < 0.05) than did the HP I wives. The same was true for the HP I,2 husbands (p -c 0.01). DISCUSSION
Although the mechanisms by which childbirth education classes affect the birth experience are not yet understood [9, 121 it has become increasingly clear that prenatal childbirth education classes do affect the birth experience. Tanzer [lo] found that attendance by couples at prenatal child-birth classes reduced pain during labor and increased positive responses concerning labor, as well as being positively related to the wives’ perception of their husbands’ competence. These results were associated
Effect of husband participation
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with class attendance, whether couples voluntarily participated or were assigned to the classes by their physicians. Similarly, Enkin et al. [15] found that attendance at prenatal classes was the critical variable associated with reduced pain and probability of medication when comparing wives who elected to attend classes with wives who elected to, but did not and women who neither elected to, nor attended classes. These studies indicate that motivation for electing classes is not an important variable in predicting reported pain in labor and birth and probability of medication. The results of the present investigation, however, suggest that among couples who attend prenatal education classes, certain motivational factors are important in predicting husband participation in the second stage of labor, as well as the wives’ reported pain and probability of medication during the birth process. The HP 1,2 wives reportedly wanted to participate in childbirth education classes to ‘increase emotional participation’ for themselves and their husbands significantly more often than the HP 1 wives. The HP 1,2 wives had their husband as a labor coach throughout labor and birth, reported significantly less pain throughout most of labor and had a lower probability of receiving medication at all stages of labor. The present investigation indicates that childbirth education classes have little positive effect upon the HP 1 husband’s attitude about helping during the second stage of labor. Before classes began, a hospital had been chosen, with the HP 1 couple more likely to select a facility that would not allow the husband to be present during delivery. And although it appears that the HP 1 husbands do change their attitude about helping during the first stage of labor, there is no change in attitude about helping during the second stage. It appears that a basic attitude is present before classes begin and is not changed by factors of attendance, information, or practice of labor techniques. Chertok [9] has summarized and evaluated the effectiveness of psychosomatic approaches to preparation for childbirth and has suggested that all techniques contain three components : psychophysical techniques learned during pregnancy and used during labor and birth, intellectual components, and emotional components. Although the relationship between these components and their exact role in reducing pain during labor and birth is not clear, literature concerning pain which is not related to childbirth is suggestive. Many studies have reported reduction of the emotional impact of stress when information is provided about a distressing experience in advance of the experience [16-191. Bobey and Davidson [13] have also found that relaxation techniques were effective in raising pain tolerance measures. It thus seems plausible that information given about labor and birth during childbirth education classes may serve to reduce anxiety, while psychophysical techniques, learned and practiced for use in labor, reduces tension and physiological stress, reducing anxiety further still. In the present investigation, knowledge of the subject matter, previous education, parity, attendance of classes, and practice of techniques were similar for both groups. However, when the HP 1,2 husbands attended labor and birth, it had a positive effect on their wives’ reported feelings of pain, the probability of medication, and the couples overall attitude about the hindsight birth experience. It appears that a social-emotional component, provided by the HP 1,2 husband, was important in affecting reported pain during labor. The exact nature of this social-emotional component is not presently known, however.
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WILLIAM JAMESHENNEBORNand ROSEMARYCOGAN
Tanzer’s results [lo] were quite provocative in the rather surprising finding that the involvement of the husband during childbirth is of tremendous importance in the reported experience of the wife. The present study indicates that effects of husband presence are even more far-reaching than had been previously suggested. As has already been noted, the HP 1,2 wives wanted to participate in childbirth education classes to increase the emotional participation of themselves and their husbands. After the fourth class, both groups of husbands reported that they felt ‘very well prepared’ to help with labor and birth exercises and were equally well prepared to help with possible emotional problems during labor and birth. When asked identical questions after the birth, the HP I,2 husbands continued to feel ‘very well prepared’ to help with emotional problems but such was not the case for the HP 1 group. This was also the case in the birth and labor exercises ‘neuromuscular release’ and ‘deep chest breathing’. Thus, in retrospect, the HP I,2 husbands seem to feel more confident about some of their labor skills and their general ability. These group differences cannot be accounted for by informational or practice variables and appear to reflect an emotional or confidence factor. Further research is needed concerning the husband’s decision to participate in the second stage of labor. The decision to attend labor and birth may reflect basic differences between the two groups of husbands, or couples, may be a response of couples to hospital regulations, or perhaps joint agreement to participate in labor and birth before the start of childbirth education classes may change labor, birth, and post partum feelings. Numerous social psychological studies have shown that when individuals are required to cooperate with one another for the achievement of mutually desired goals, they are more likely to improve their attitude towards each other [20, 211. It might be inferred from these findings that if a husband and wife are able to actually work together during labor and birth, they may develop more favorable attitudes towards each other. They may also achieve some common grounds upon which to establish improved communications [lo, 22, 231. Another area of future investigation should be the effect of the husband’s participation in birth upon the development of the child. The husband-wife relationship may have indirect physiological and behavioral effects upon the developing fetus and infant. Maternal stress has been related to hyperactivity of the fetus during the latter months of pregnancy and such later difficulties as feeding problems, sleep disturbances, and the general irritability of the infant [24-321. The implications of a relationship described as ‘anxious’ during pregnancy and the possible effects upon fetal development are obvious. In addition, medication and other obstetrical elements have been shown to play a significant part in discussions of both cognitive and emotional difficulties in development [33-381 and point to the possible indirect effect of the husband-wife relationship, and the decision on the husband’s part to attend labor and birth on a developing fetus. The emotional and interpersonal aspects of a marital relationship may be part of a spiral of alterations in behavior affecting the mother, the developing fetus, the birth experience, and the mother-father-child triad during the early days and years of development. If this is the case, the question of the husband attending his wife during labor and birth may have long-reaching effects upon the child which they will bring into this world.
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