NSG210 Durham Ch. 5: The Psycho-Social-Cultural Aspects of Pregnancy

Source: Durham & Chapman, Maternal-Newborn Nursing: The Critical Components of Nursing Care 4e, Chapter 5, pp. 97-129 (textbooks/DURHAM_OB_CH05.pdf, also in textbooks/exam01/). Week 03 reading; on Exam 1 (maternal and paternal adaptation, cultural care, and birth preparation fall under the Exam 1 OB items). See also nsg210-week-03b-summary.

Learning Outcomes

1. Describe expected emotional changes of the pregnant woman and appropriate nursing responses.
2. Identify the major developmental tasks of pregnancy for maternal, paternal, and family adaptation.
3. Identify critical variables that influence adaptation: age, parity, social, cultural, and sexual orientation.
4. Identify nursing assessments and interventions that promote positive psycho-social-cultural adaptation.
5. Analyze critical factors in preparing for birth: choosing a provider and setting, creating a birth plan.
6. Identify key components of childbirth preparation education.
7. Analyze current evidence on psycho-social-cultural adaptation to pregnancy.
8. Identify one’s own assumptions and biases that contribute to health disparities.
9. Create a safe environment for informed, respectful, inclusive care.
10. Describe the difference between cultural competence and cultural humility.

I. Maternal Adaptation to Pregnancy

• Patient-centered respectful care is central: the patient (or designee) is the source of control and a full partner in care
• Psychological adaptation is as profound as physical; the 9 months are used to restructure the self toward motherhood
• Psychosocial support for the woman and family is a distinct, major nursing responsibility in the antepartum period

A. Rubin’s maternal tasks (1975, 1984)

• Ensuring safe passage for herself and her child (knowledge, care-seeking)
• Ensuring social acceptance of the child by significant others
• Attaching or “binding-in” to the child (maternal-fetal attachment)
• Giving of oneself to the demands of motherhood

B. Lederman’s seven dimensions of maternal role development

1. Acceptance of the pregnancy - responding to mood changes, ambivalence, nausea/fatigue, financial concerns, increased dependency. Expected: happy feelings, acceptance of body changes, minimal ambivalence by the end of pregnancy; may dislike being pregnant yet love the unborn child
2. Identification with the motherhood role - moves from woman-without-child to woman-with-child; seeks other pregnant women; vivid dreams and rehearsal (fantasizing) are normal. Fetal attachment helped by hearing the FHR, seeing the fetus on ultrasound, feeling movement. Transmasculine patients may not identify as “mothers”; use neutral terms such as “parent”
3. Relationship to her mother - availability past and present, mother’s reaction to the pregnancy, relating to her as an adult, reminiscing about her own childbearing; unresolved conflicts may surface
4. Reordering partner relationships - partner support linked to well-being and earlier, continuous prenatal care; partners influence maternal psychological state and smoking; open communication about sexuality eases changes
5. Preparation for labor - classes, reading, apps, fantasizing, dreaming; more preparation means less fear; “nesting” late in pregnancy
6. Prenatal fear of losing control in labor - control over body and emotions; depends on trust in staff and attitude toward medication/anesthesia
7. Prenatal fear of losing self-esteem in labor - assess source, response, and intensity of the threat; expected: realistic expectations, asserts herself, verbalizes fears without feeling judged

C. Critical Component: Ambivalence

• Ambivalence is common and expected in the first trimester and decreases as pregnancy progresses
• Ambivalence that persists into the third trimester may indicate unresolved conflict - assess the reason and intensity

D. Nursing actions by trimester (Critical Component)

• Nurse roles: teacher, advocate, counselor, clinician, resource person, role model
• First trimester: begin psychosocial assessment at first contact; promote pregnancy as a family experience; assess learning needs; anticipatory guidance on ambivalence, vulnerability, mood changes, active dream life; refer if anxiety exceeds normal; listen, validate, reassure; discuss paternal phases
• Second trimester: encourage verbalizing grief over body image and loss of old life; discuss normal changes in sexual activity; encourage “tuning in” to fetal movement; ask family to give extra support
• Third trimester: encourage childbirth classes; assess partner comfort with the labor coach role and suggest a second support person; parenting and breastfeeding guidance; refer to social work, nutrition, community agencies if psychosocial complications develop; help identify support systems (decreases postpartum depression risk)

II. Variables Influencing Adaptation

Factors: parity, maternal age, sexual orientation, single parenting, planned vs unplanned, multiple gestation, socioeconomic factors, culture, history of abuse.

A. Multiparity

• Do not assume she needs less help; tasks may be more complex
• Challenges: attention to all children, sibling adaptation, grieving the special relationship with the first child, finances

B. Adolescent mothers

• Conflicting developmental tasks: forming her own identity while forming a maternal identity
• Only about 50% of teen mothers earn a diploma by age 22 (vs about 90% of those who do not give birth as teens)
• Teens in foster care more than twice as likely to become pregnant
• Delayed entry into prenatal care is common; younger teens have more trouble with body image and acknowledging the pregnancy
• Complications: low birth weight, preeclampsia/gestational hypertension, IUGR, preterm labor
• Keys to success: assured confidentiality, alone time with the provider apart from parent/guardian, partner support, comprehensive community/school-based programs
• Early adolescence 11-13: self-centered, present-oriented; higher chance pregnancy resulted from abuse or coercion; grandmothers play a major role
• Middle adolescence 14-18: more abstract thinking, understands consequences
• Late adolescence 19-20: more capable, active participant in decisions
• Interventions must be age- and developmentally appropriate

C. Older mothers (35 and older)

• Most deliver at term without problems, but higher risk of: Down syndrome and chromosomal abnormalities, miscarriage, chronic disease (HTN), low birth weight, preterm birth, multiples
• Over 40: more placenta previa, abruption, cesarean, preeclampsia, gestational diabetes; 47.4% of babies born to women over 40 delivered by cesarean
• Often better equipped psychosocially, but may have heightened ambivalence and difficulty giving up a controlled, predictable life

D. Lesbian mothers and LGBTQ families

• Barriers: homophobia, heteronormative assumptions, heterosexist language, stigma, lack of family support
• Unique challenges: finding a caregiver, conception options, partner involvement, legal parenthood
• Most plan pregnancies; often equal division of childcare (protective against perinatal depression)
• Nonbiological (co-) mothers receive less social recognition than fathers
• Nursing: inclusive language, no assumptions about orientation, include the birth partner in all activities the mother wants

E. Single parenting

• More stress and anxiety, less tangible support
• Assess circumstances: single by choice vs unintended (death, divorce, casual partner)
• Solo parents raise about 20% of US children; 81% are mothers; 27% live in poverty vs 16% of cohabiting parents
• Added tasks: telling family, legal guardianship plans, father’s name on the birth certificate

F. Multiple gestation

• Rising due to older maternal age and assisted reproductive technology (ART)
• High-risk; added stress, anxiety; specialized education; parents-of-multiples groups
• More than three fetuses: counseling on selective reduction (ethical dilemma)

G. Women who are abused (IPV)

• IPV includes physical and sexual violence, stalking, psychological aggression by a current or former partner
• Pregnancy often triggers or increases abuse; about 1 in 6 pregnant women abused by a partner (March of Dimes); about 1 in 3 US women in a lifetime
• Higher-risk groups: immigrants, adolescents; screen every woman (see Ch. 4 and 7)

H. Military deployment

• Deployed spouse: 2.8-fold higher risk of depression, 1.9-fold higher self-reported stress
• Veterans: pregnancy can worsen mental health conditions; screen with the Edinburgh Postnatal Depression Scale (EPDS)
• On-base community support and CenteringPregnancy group care help

III. Psychosocial Screening and Health Equity

• Assess adaptation at every prenatal visit; establish trust, repeat first-visit questions later, reassure confidentiality
• ALPHA (Antenatal Psychosocial Health Assessment) tool areas: social support, recent stressful life events, couple’s relationship, onset of prenatal care, plans for prenatal education, feelings toward pregnancy after 20 weeks, relationship with parents in childhood, self-esteem, psychiatric history, depression in this pregnancy, alcohol/drug use, family violence
• Antenatal Risk Questionnaire (ANRQ) is another validated tool
• Social determinants of health (SDOH): conditions where people are born, live, learn, work, play, worship, and age; barriers include finances (most important factor for inadequate prenatal care), homelessness, immigrant status, bias against transgender patients

A. Racial and ethnic disparities

• Black women are 3 to 4 times more likely to die of pregnancy-related causes and have more than twofold greater risk of severe maternal morbidity than White women
• Race/language concordance between patient and provider may improve communication and outcomes
• Nursing: raise awareness, understand provider bias, support recruiting minority nurses, advocate for policy

B. Implicit bias and respectful maternity care

• Implicit bias: unconscious attitudes or stereotypes affecting decisions; worst in high-stress settings such as L&D and the ED
• 2003 IOM report documented unequal treatment of racial minorities
• Respectful maternity care (RMC): dignity, privacy, confidentiality, freedom from harm, informed choice, continuous labor support
• AWHONN: knowledge matters, language matters, action matters, accountability

C. Weathering hypothesis

• Chronic exposure to social and economic disadvantage accelerates decline in physical health (cellular aging, neuroendocrine, CV, immune dysregulation); partially explains racial disparities in perinatal outcomes

IV. Paternal and Partner Adaptation

• Worry is the most common shared experience of expectant partners
• Partners often feel neglected or underutilized in prenatal care; reality sets in when seeing/feeling fetal movement
• Abuse may begin or escalate and risk of infidelity increases with the news of pregnancy
• Couvade syndrome (sympathetic pregnancy): partner has nausea, weight gain, abdominal pain, disturbed sleep - reassure it is normal

May’s three phases (1982, Table 5-1)

Nursing: explore response to the news, reassure ambivalence is common, normalize Couvade, encourage childbirth education, help partner negotiate labor role, explore paternity leave.

V. Sexuality in Pregnancy

• No contraindication to intercourse or masturbation to orgasm if membranes intact, no vaginal bleeding, and no current problems or history of preterm labor
• Desire: decreases in first trimester (fatigue, nausea, breast tenderness), variable or increased in second (well-being, pelvic congestion), decreases sharply in third (bulk)
• More comfortable positions: side-by-side, woman-above, rear-entry
• Common fears: hurting the fetus, birth changing the genitals, body image
• Nursing: ask about sexual activity at visits, encourage communication and humor, nonsexual affection matters, explore cultural beliefs

VI. Family Adaptation

• Pregnancy is a developmental (maturational) crisis for the family
• Identify who the woman defines as family and care on that basis
• Family types: nuclear, extended, single-parent (solo), three-generational, dyad, stepparent, blended, cohabiting, gay or lesbian, adoptive
• Duvall’s 8 family life-cycle stages
• Childbearing family developmental tasks: knowledge and plans for pregnancy/birth/parenting, physical care of newborn, adapt finances, realign tasks, adjust sexual expression, expand communication, reorient relationships with relatives and friends

A. Sibling adaptation (by age)

• Under 2: unaware of pregnancy
• 2-4: sensitive to physical changes and environmental disruption; move from crib to bed at least 2 months before the due date
• 4-5: enjoy hearing FHR; may resent mother’s inability to lift them
• School age 6-12: enthusiastic, many questions, want to help
• Adolescents: may be embarrassed by evidence of parents’ sexuality
• Regression (diapers, bottle, tantrums) is normal; praise age-appropriate behavior
• Box 5-2: bring child to a prenatal visit, sibling class, quality one-on-one time, involve in baby care, gift from the baby, visitors greet older child first, supervise the newborn with the sibling
• Siblings at birth: need a preparation class and a dedicated familiar adult with no other role

B. Grandparent adaptation

• Often first told; source of family history and support
• May assume care (teen pregnancy, incarceration, substance use); caregiving grandparents report higher distress
• Nursing: assess response, explore as resource, involve social services as needed

VII. Mental Health in Pregnancy

• Up to 1 in 5 to 10 women have anxiety or depression in pregnancy; anxiety disorders about 1 in 5
• Perinatal depression is often missed because sleep, appetite, and libido changes are blamed on pregnancy; screen with EPDS
• Untreated depression leads to poor sleep, poor nutrition and weight gain, missed visits, substance use, less adherence
• Maternal stress lowers uteroplacental blood flow; linked to low birth weight, shorter gestation, labor problems
• Assess mood by frequency, duration, intensity, source
• Severe and persistent mental illness (SPMI): affects 1 in 17; needs interdisciplinary care and risk-benefit medication decisions

VIII. Adaptation to Pregnancy Complications

• Response depends on condition, perceived threat to mother or fetus, coping skills, support and resources
• Responses: disequilibrium, powerlessness, anxiety, fear, loss; woman may emotionally distance from the fetus (affects attachment)
• Antepartum hospitalization and activity restriction increase depression
• Crisis prevented by: realistic perception of the event, adequate situational support, positive coping
• Crisis risk increased by: poor self-esteem, low confidence as mother, feeling blamed, inability to communicate concerns
• High-risk pregnancy is a risk factor for postpartum anxiety and depression - follow up
• Priority: reestablish physiological stability first, then psychosocial support - frequent clear explanations, encourage questions, support coping and support systems, referrals

IX. Social Support

• Types: material (instrumental - chores, meals, money), emotional (affection, approval), informational, comparison (someone in a similar situation), spiritual
• Perceived social support (matching her expectations) is what benefits her; unmet expectations cause distress
• Support programs may reduce cesarean birth and antenatal admission (not LBW or preterm birth)
• High-risk groups: adolescents, complications, low income, recent immigrants (language barriers, lost attachments, depression risk)
• Assessment: who helps with what, strongest relationships, conflict or violence, who lives with her, finances, work support, other children
• Nursing: rehearse asking for help, invite support persons to visits, CenteringPregnancy, faith communities, culturally compatible resources

X. Trauma-Informed Care

• Trauma ranges from IPV, assault, military sexual trauma, childhood neglect, refugee experience, to traumatic birth
• Obstetric violence: disrespect, indignity, or abuse by providers or systems (e.g., repeated unnecessary vaginal exams, unindicated episiotomy, forced cesarean, minimizing symptoms)
• SAMHSA principles: safety, choice, collaboration, trustworthiness, empowerment
• Practices: ask permission before touching, describe procedures before and during, let clothing be shifted rather than removed, stop exam on request, use a framing statement before screening
• 4 Cs (Kimberg and Wheeler): Calm, Contain, Care, Cope
• Refugee and migrant women: loss, violence, mistrust, language barriers; holistic, culturally grounded approach

XI. Childbearing and Culture

• Culture: behaviors, beliefs, practices, and values transmitted within a group; adherence depends on acculturation, length of time in the US, generation, language
• Treat each woman as an individual; avoid stereotyping
• Dimensions to assess: decision making (who decides), concept of time (past, present, future - US is future-oriented; non-future-oriented cultures may not seek preventive or prenatal care), communication (eye contact, touch, a smile may mean confusion not agreement), religion, worldview and explanation of illness, modesty and gender norms

A. Cultural beliefs (Box 5-4)

• Prescriptive: expected behaviors (e.g., stay active, satisfy cravings, chamomile tea)
• Restrictive: limited activities (e.g., no reaching overhead, no photos, avoid cold)
• Taboos: restrictions believed to have supernatural consequences (e.g., avoid funerals, no early baby shower, avoid eclipse)
• Functional (helpful) - promote; neutral (harmless) - respect/tolerate; nonfunctional (harmful, e.g., eating clay) - first understand its meaning, then negotiate change

B. Barriers to culturally competent care

• Ethnocentrism: belief that one’s own culture’s customs are superior
• Stereotyping: assuming everyone in a group is the same
• Cultural imposition: forcing one’s own beliefs and values on another culture
• Communication barriers, lack of interpreters, rigid policies
• RN workforce about 80.8% White - lack of diversity
• Health literacy: about half of US adults lack needed skills; linked to more hospitalizations, less preventive care

C. Culturally responsive practice

• Mandates: The Joint Commission (cultural and spiritual assessment in the plan of care), AACN competencies, CLAS standards (HHS Office of Minority Health)
• Leininger’s Theory of Culture Care: promote helpful practices, tolerate neutral ones, educate to renegotiate harmful ones
• Cultural competence: knowledge and skills about cultural groups, comfort with differences
• Cultural humility: lifelong self-evaluation and critique, redressing power imbalances, recognizing limits of one’s own knowledge, open-ended questions
• Nursing: greet respectfully, identify who the client calls “family,” determine decision makers and include them if the mother permits, professional interpreter when needed or requested, do not assume nodding means understanding, combine scientific and folk practices

XII. Preparing for Childbirth

A. Choosing a provider

• Physicians (OB and family practice) attend about 91% of US births; low- and high-risk
• Midwives attend fewer than 10%; noninterventionist, emphasize normal birth; 94.6% of CNM births in hospitals
• CNM: RN plus graduate midwifery education; practice and prescribe in all 50 states (ACNM/AMCB)
• CM: graduate education without nursing; practice in 5 states, prescribe in 3
• CPM: high school diploma plus apprenticeship (NARM); 28 states; mostly home and birth centers
• Lay midwives: no formal credentials; about 1% of births
• AWHONN supports CNMs as independent providers with consultation and referral

B. Choosing a place of birth

• Hospital 98.4%, home 0.99%, freestanding birth center 0.52%
• LDR: labor, delivery, first 2 hours of recovery in one room; LDRP: whole stay in one room
• Birth centers: low-risk women only; home-like; emergency equipment out of view; may need hospital transfer (no epidural, induction, cesarean, NICU)
• Home birth criteria: comfortable with decision, good health (not high-risk), reliable transportation, well-trained attendant with resuscitation equipment
• Nursing: support access to unbiased information, respect her choice, smooth transitions of care

C. Birth preference plan

• Documents what she prefers for labor, birth, postpartum, newborn care; guides discussion with provider and admitting nurse; promotes autonomy
• Childbirth education class and/or birth plan associated with higher odds of vaginal delivery (Afshar 2017)

D. Doula care

• Nonclinical support (no meds, no exams); no required training or certification
• Continuous doula support: shorter labor, less analgesia and fewer interventions, higher satisfaction

E. Childbirth education

• History: Dick-Read (natural childbirth), Lamaze (psychoprophylaxis), Bradley (husband-coached)
• Now eclectic, emphasizes normal birth and informed decision making; traditionally in the third trimester
• Content (Box 5-6): signs and stages of labor, breathing and relaxation, labor support, variations (back labor, precipitous), cesarean, procedures (IV, EFM, Pitocin, epidural), newborn care, breastfeeding, postpartum
• Specialized classes: breastfeeding, sibling, refresher, exercise, grandparents, teens, twins, over 35
• Text4Baby: free texts timed to due date through the baby’s first year (text BABY or BEBE to 511411)
• Point families to trusted online sources (Box 5-7)

High-Yield Numbers

• Ambivalence normal in first trimester; persisting into third trimester is a red flag
• Early adolescence 11-13; middle 14-18; late 19-20
• Teen mothers: about 50% diploma by 22 (vs 90%)
• Advanced maternal age 35; over 40: 47.4% cesarean
• IPV: 1 in 6 pregnant women; 1 in 3 women lifetime
• Deployed spouse: depression 2.8-fold, stress 1.9-fold
• Black women 3-4 times pregnancy-related death rate
• Move sibling from crib to bed at least 2 months before birth
• Sex safe if membranes intact, no bleeding, no preterm labor history
• Physicians about 91% of births; midwives under 10%; hospital 98.4%
• CNM in 50 states; CM practice 5 states, prescribe 3; CPM 28 states
• LDR: first 2 hours recovery in same room

Priority Nursing Actions and Red Flags

• Assess psychosocial adaptation at every prenatal visit; repeat sensitive questions once trust is built
• Red flags: ambivalence persisting into the third trimester, anxiety beyond normal (refer), signs of depression (EPDS), IPV, lack of support
• Screen for IPV privately; pregnancy often starts or escalates abuse
• Adolescents: confidentiality and time alone with the provider
• With complications, physiological stability first, then psychosocial support and clear repeated explanations
• Use a professional interpreter; nodding does not equal understanding
• Respect functional and neutral cultural practices; understand then negotiate harmful ones
• Identify who the patient defines as family and who makes decisions
• Trauma-informed care: ask permission, explain before touching, allow stopping
• Use inclusive, gender-neutral language unless the patient states otherwise

Related

• nsg210-durham-ch03-genetics-conception-fetal-development
• nsg210-exam-2-outline-durham-ch04 - Durham Ch. 4 physiologic changes and prenatal care (IPV screening)
• nsg210-durham-ch02-ethics-and-standards - health disparities
• nsg210-week-03b-summary
• INDEX