Fundamentals of Midwifery: A Textbook for Students (32 page)

Figure 4.1
An adaptive coping response.model was revised to include health motivation – readiness to be concerned about health matters – and perceived control – belief in personal ability to enact the behaviour (Becker and Rosenstock 1987).The protection motivation theory developed by Rogers (1975; 1983; 1985) extended the HBM to include additional aspects. This theory describes five components: severity, susceptibility and fear as relating to‘threat appraisal’; response effectiveness and self-efficacy as relating to‘coping appraisal’. There are two types of information source:

Environmental: such as verbal persuasion, observational learning.

Intrapersonal: such as prior learning.This information influences the five components outlined in Figure 4.1 which then elicit an adaptive (behavioural intention) or a maladaptive (avoidance/denial) coping response.
Theory of Planned Behaviour
The Theory of Planned Behaviour (TPB) proposes that behaviour is informed by attitudes and behavioural intentions. Three factors predict behavioural intentions, which then link to behav- iour itself:

Attitude towards a behaviour – positive or negative evaluation and beliefs about the outcome.

Subjective norms – the beliefs of important others and the individuals motivation to comply.

Perceived behavioural control – can the individual carry out the behaviour in light of internaland external control factors.Using the same example as above, a woman would have high intentions to stop smoking if she believes the following factors (Box 4.1).
Box 4.1 Theory of planned behaviour applied to practice‌‌

Stopping smoking will be beneficial to either the woman’s heath or her baby’s health.68
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The important people in the woman’s life want her to stop.

The woman is capable of stopping due to previous behaviour and evaluation of internal andexternal control factors (high behavioural control).The model also predicts that perceived behavioural control can predict behaviour without the influence of intentions. So if the woman does not believe she can stop smoking because she has tried in the past and failed then intention becomes less relevant.
Activity 4.1 Many pregnant women continue to smoke even though they know smoking is bad for them– using the above models of behaviour think about the potential reasons why this might be?
Summary
Psychology clearly has a role to play in helping to understand how childbearing women engage with the public health agenda in a maternity care context. This agenda tends to assume several things, first that achieving good health is a shared objective; second there is agreement on what being healthy means; third there is scientific consensus on the behaviours necessary to facilitate good health.Understanding why people engage in unhealthy behaviours and the psychological aspects relating to cessation or behaviour change is significant for practitioners who are applying health promotion and support interventions. The theories presented above help to explain why some- times women might not change unhealthy behaviours, despite the evidence presented to them that certain health behaviours are harmful.
Emotions across the childbearing experience
The onset of pregnancy heralds a period of physiological and psychological transition (Darvillet al. 2010). While the physiological transitions can be obvious for example, changing body shape, nausea, fatigue, the psychological changes may not be as transparent or expected by women. It is important therefore that midwives are aware of the emotional challenges in preg- nancy to differentiate between normal anxieties and abnormal pathological psychiatric condi- tions, for example, tocophobia – a morbid fear of pregnancy and childbirth – which can impact on the woman’s daily functioning (Hofberg and Ward 2003).
Antenatal considerations
Primiparous women are faced with the transition from ‘maid to mother’ and the complexities involved with physiological adaptations and changes in identity and social status. Equally,multiparous women will have their own transitions and may have negative echoes from their previous experiences, which they carry into their present pregnancy. While many women report great joy at the onset of pregnancy, for some, it results in tensions, which have their basis in fear and anxiety. These can include:‌

fear of pregnancy 69

tocophobia (fear of childbirth)

fear of pain and access to analgesia

fear of enforced analgesia

fear of clinical intervention

fear of their own death

fear of fetal damage or demise

fear of the ability to cope postnatally. (Maier 2010)Anxieties may arise for many reasons and psychological, social and emotive issues can impact on maternal wellbeing. These may include: weight gain, altered body image (Nicholson et al. 2010), mood swings, the impact of physiological changes (such as hyperemesis and fatigue), financial worries, and identity renegotiation. Whilst many women will adapt to these changes normally, for others they create a state of psychological vulnerability (Raynor and England 2010).
Psychological factors in the antenatal period
Beck (2001) identifies that the strongest predictors of postnatal depression (PND) are depression in the antenatal period, particularly if the woman has low self-esteem or stress related to child- care or antenatal anxiety. Furthermore Misri et al. (2010) noted a correlation between antenatal depression (AND) and postpartum parenting stress. This highlights how the emotional journey for women begins early in the perinatal period and forms part of a continuum across the spec- trum of childbirth (Alderdice et al. 2013).In the context of relationships, couples may have concerns about the financial impact of having a baby, lack of a support network and their own ability to parent, which can result in stress within the relationship and impact on the pregnancy (Raynor 2006; Salonen et al. 2009; Zachariah 2009).
Psychosocial factors in the antenatal period
Marital conflicts may surface in the antenatal period and it is well documented that domestic violence increases in pregnancy, with negative impact on the woman and fetal wellbeing, with an increased risk of preterm delivery and antepartum haemorrhage. This can, in some inci- dences, lead to miscarriage or maternal death (Field et al. 2010; Shah and Shah 2010).
Clinical consideration
In the general population, one in three women will have been abused by an intimate partner; the onset of pregnancy increases the risk of domestic violence with one in four pregnant women report- ing abuse (Keeling and Mason 2011).
This could in part be related to the raised anxiety and depression levels that have been noted for both partners in the first and third trimester (Teixeira et al. 2009). Noteworthy, was that greater anxiety in the third trimester was identified in multiparous women and their partners; the authors suggest that this could be related to previous birth experience. These authors highlight the need for interventions by health professionals to reduce antenatal anxiety, to70 promote maternal, paternal and fetal wellbeing.The UK National Institute for Health and Care Excellence (NICE) guidelines on Antenatal and Postnatal Mental Health (2007), which will be discussed in more detail in Chapter 13, give mid- wives a clear remit with regard to the prediction and detection of mental health illness at the booking appointment.The Nursing and Midwifery Council (NMC) 2012 states that the midwife should provide safe, responsive, compassionate care in an appropriate environment to facilitate her physical and emotional care through the childbearing period. This aims to facilitate the identification of women with both a pre-existing severe psychological condition, for example, schizophrenia or bipolar disorder, and those who develop psychological distress during pregnancy. Identification then enables referral to appropriate services.The impact of antenatal stressors on postnatal outcomes has been reported but women still report on their voices not being heard, with midwives being ‘
too busy to care
’ (Green 2012). The significance of psychological status has been well-documented, with implications for clinical obstetric outcomes, long-term mental health of the mother and the quality of the mother– infant relationship all well-acknowledged (Jomeen and Martin 2008b). Fransson et al. (2011) identify that women experiencing antenatal depression are at greater risk of preterm birth. Furthermore, antenatal depression and anxiety can result in low birth weight, complications in childbirth and poor fetal outcomes compared to women with positive mental states who experi- ence better fetal and maternal outcomes (Hernandez-Martinez et al. 2011). Jomeen (2004) noted increased epidural analgesia, assisted deliveries and neonatal admissions, together with the risk of spontaneous abortion, fetal malformations and pre-eclampsia in women with ante- natal depression.Antenatal depression can impact postnatally with women experiencing difficulty interacting with their infant (Alhusen 2008; Hayes et al. 2013). However it has been noted that when a women has a positive pregnancy experience it can be empowering and can positively impact on the woman’s self-esteem and bonding with her baby (Clement 1998).
Birth
The birth of a baby is a life-changing experience for a woman and it can impact positively ornegatively on her psychological wellbeing. Some of the negative factors include: loss of control, fear and pain. The sense of being in control is woven through childbirth literature. Bandura (1997) describes being in control as ‘self-efficacy’, which increases when women believe and know, at a fundamental psychological and physiological level, that they have the ability to cope with labour.Bandura notes that‘
self-efficacy predicts the use of behavioural and cognitive strategies to relieve pain
’ and can ‘
lessen the extent to which painful stimulation is experienced as conscious
’ (Bandura 1997, p. 268).O’Hare and Fallon (2011) noted that women reported a high degree of self-efficacy when taking control and mastering their breathing through labour. By contrast, women reporting negative birth experiences describe feeling violated, vulnerable, excluded, cheated, frightened, undignified and depersonalised (Mercer et al. 2012).
Fear of childbirth is well-documented and can be attributed to physiological (pain) and psy- chological (stress, anxiety) functions. The number of Caesarean sections (CS) on maternal request has risen and this is partly due to psychosocial factors, such as convenience and body image. It can also be associated with previous birth trauma, sexual abuse or lack of self-efficacy (D’Souza 2012). However some women request CS due to a pathological fear of childbirth,known as tocophobia, and incidence has been reported as high as 1:5 pregnant woman. Televi-
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sion programmes like ‘One Born Every Minute’ in the UK, have focused, in the main, on painful medicated controlled childbirth and Talbot (2012) suggests that ‘catastrophising’ labour pain increases the woman’s sense of helplessness and fear of labour. Salomonsson et al. (2013) state the midwife could identify and promote strategies and behaviours to support women to con- sider vaginal birth and enhance self-efficacy. Goodin and Griffiths (2012) suggest that women requesting CS should be referred to psychological services with the caveat that where the woman has severe tocophobia, denial of a CS could lead to post-traumatic stress disorder (PTSD).
Postnatal considerations
The transition to parenthood heralds a major change in a woman’s life and most women willexperience the birth of a baby as a joyous experience; however some women experience con- flicting emotions ranging from despair to euphoria. In the postnatal period, women need to adapt to the challenging physical, emotional and psychological demands of motherhood, the immediate postnatal period, especially notable in first-time mothers, creates new situations for women to navigate and are reflected in Box 4.2.
Box 4.2 Physical, emotional and social changes in the immediate postnatal period