Promoting positive motherhood among nulliparous

421050

HPQXXX10.1177/1359105311421050Salmela-Aro et al.Journal of Health Psychology

Article

Promoting positive motherhood among nulliparous pregnant women with an intense fear of childbirth:  RCT intervention

Journal of Health Psychology 1­–15 © The Author(s) 2011 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105311421050 hpq.sagepub.com

Katariina Salmela-Aro1, Sanna Read1, Hanna Rouhe2, Erja Halmesmäki2, Riikka Maria Toivanen3, Maiju Ilona Tokola3 and Terhi Saisto2

Abstract This RCT intervention among nulliparous pregnant women with an intense fear of childbirth sought to promote preparedness for childbirth and to enhance positive parenting. Pregnant women (n = 8,611) filled in a ‘fear of childbirth’ questionnaire. Nulliparous women with severe fear of childbirth (n = 355) were randomized into intervention (n = 131; 41 refused) and control (n = 240) groups. They rated themselves on a preparedness scale in middle and late pregnancy, and on a motherhood scale three months after childbirth. The intervention included six psycho-education group sessions during pregnancy and one after childbirth. This intervention increased the mothers’ preparedness for childbirth, which predicted an increase in positive motherhood.

Keywords RCT, fear of childbirth, preparedness, nulliparous pregnant women, positive parenting

Pregnancy, birth and the transition to parenthood are processes with significant social and emotional implications for the life of any woman and her family. The birth of a child into a family is a demanding life situation (Cowan & Cowan, 2000; Deutsch, Ruble, Fleming, Brooks-Gunn, & Stangor, 1988; Grossman, 1987, 1988) that may influence how women think and feel about themselves, their life situations, and their parenting. Even though pregnancy outcomes will always be uncertain (Bewley & Cockburn, 2002), most healthy women in the developed world should be able to experience childbearing as a positive life event that is associated with minimal risk of

an adverse outcome (Geissbuehler & Eberhard, 2002). Fear involves a loss of control and responsibility and recent study indicates the importance of taking personal responsibility for birth satisfaction (Howarth, Swain, & Treharne, 2011).

1University

of Helsinki, Finland Helsinki University Central Hospital, Finland 3 Tunnetila, Helsinki, Finland 2

Corresponding author: Katariina Salmela-Aro, University of Helsink, Box 4, Helsinki 00014, Finland. Email: [email protected]

2 It has been estimated that 6–10% of all pregnant women suffer from a severe fear of childbirth (Areskog, Kjessler & Uddenberg, 1982; Melender, 2002; Rouhe, Salmela-Aro, Halmesmäki & Saisto, 2009; Ryding, 1991; Saisto, Ylikorkala & Halmesmäki, 1999) and this fear of childbirth may overshadow the whole pregnancy, complicate childbirth and lead to difficulties in the mother-infant relationship and to postpartum depression (Melender, 2002; Rouhe et al., 2009; Ryding, 1991; Saisto et al., 1999). The aim of this randomized controlled trial intervention was to promote preparedness for childbirth and to enhance positive parenting among nulliparous pregnant women with an intense fear of childbirth. Women commonly worry about potential maternal complications that may adversely affect them and their unborn baby (Fava et al., 1990). Söderquist, Wijma and Wijma (2002) reported that personal and external conditions play a major role in generating women’s fears of childbirth. These personal conditions are a reflection of women’s anxieties about maintaining a sense of personal control and self-efficacy. In a sample of 100 women suffering from an intense fear of childbirth, more than 65% were worried about their performance in labour and their bodies’ ability to give birth (Sjögren, 1997). Their concerns translated into a low expectation of demonstrating the necessary behaviour to cope with labour and a low expectation of a positive outcome (see also Soet, Brack & Dilorio, 2003). The external conditions influencing women’s fear of childbirth relate to the context or environment in which women give birth and their interactions with health care professionals. In Sjögren’s work (1997), for example, the most common reason for a fear of childbirth was a lack of trust in the obstetric staff. Others have found that many pregnant women are worried about unfriendly staff, being left alone in labour, appearing silly and not being involved in decisions (Lowe, 2000; Melender, 2002; Soet et al., 2003). It has been shown that life management and well-being can be improved by developing

Journal of Health Psychology preparedness (Ajzen, 1991; Bandura, 1986). Preparedness is defined here as a cognitivemotivational construct which has specific selfefficacy (Bandura, 1986), social support and inoculation against setbacks (Meichenbaum, 1985) as its intertwined ingredients (Vuori & Vinokur, 2005). Preparedness is a goal state of readiness to respond to uncertain outcomes (Sweeny, Carroll & Shepperd, 2006). We assumed that a woman who is well prepared and motivationally ready to manage her delivery has the confidence in her own skills and the knowledge and emotional readiness to deal with the possible setbacks that are frequently encountered during the delivery process and the transition to motherhood. Self-efficacy in terms of the delivery and the transition to motherhood can be defined as confidence in one’s abilities, such as defining one’s personal strengths and related self-efficacy (Bandura, 1986). Both Bandura (1986) and Ajzen (1991) have shown that specific self-efficacy, or a perceived control of a specific behaviour, is a key component of motivation and increases the likelihood of a specific behaviour. Consequently, we expected that selfefficacy related to childbirth could be promoted, which, in turn, would promote the likelihood of positive experiences of motherhood. Previous studies have shown that preparedness for various life transitions can be increased with group interventions that apply the techniques of social modelling and active learning (Caplan, Vinokur, Price & van Ryn, 1989). On this basis, we assumed that preparedness would also play a key role in the transition to motherhood. However, this is one of the first studies to examine preparedness in the context of the transition to motherhood. In the Nordic countries, patients with fear of childbirth have been treated by group psychoeducation and support but previous studies have not been randomized (Saisto, Toivanen, Salmela-Aro & Halmesmäki, 2006). The process leading to inoculation against setbacks has been used in cognitive behavioral therapy and involves the ability to anticipate setbacks and the skills to cope with them. According to Meichenbaum (2007), inoculation

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Salmela-Aro et al. against setbacks can be achieved by providing individuals with experience of minor setbacks and stressors. This fosters psychological preparedness, promotes resilience, and develops a sense of mastery in confronting more stressful setbacks and obstacles. The inoculation process—with anticipated high-risk situations, and accepting lapses as learning opportunities—will maintain the participants’ motivation to perform difficult behaviour in the event of real setbacks and will prevent relapse (Meichenbaum, 2007). Inoculation against setbacks has been shown to be a key underlying preventive dimension of training for those at risk of depression, and in the alleviation of symptoms of depression (Vinokur, Price & Schul, 1995). Based on this we assumed that inoculation in the context of childbirth would prepare women in facing a potential challenges, promote their resilience and sense of mastery in relation to the childbirth if confronted with setbacks during labour. This in turn was assumed to promote their skills in positive motherhood later on. We report the application of growth curve analysis to test more effectively the longitudinal changes of the intervention and to document the role of preparedness from middle to late pregnancy to parenting after childbirth. The study of individual patterns of change and the evaluation of clinical intervention efficacy have been enhanced significantly by growth curve modelling techniques and the use of multiple waves of assessment. By taking advantage of all of the information provided by multiple waves of longitudinal data and by explicitly modelling the individual patterns of change, growth curve analyses are able to characterize change over time more reliably and precisely than traditional statistical methods.

Hypotheses on the impact of the intervention The aim of this randomized controlled trial intervention was to promote the successful transition to motherhood among nulliparous pregnant women with an intense fear of childbirth by

promoting their preparedness for childbirth, which, in turn sought to enhance positive motherhood and related parenting after childbirth. Preventive resource-building programmes have previously been successful during stressful transitions, increasing preparedness for the respective transition, which resulted in beneficial mental health and related outcomes (Caplan et al., 1989; Koivisto, Vuori & Vinokur, 2010; Vinokur et al., 1995; Vuori, Koivisto, Mutanen, Jokisaari & Salmela-Aro, 2008). We expected that the group intervention would result first in, as a proximal effect, an increase in preparedness, and later, as long-term effects, in an increase in positive parenting, Consequently, our first hypotheses regarding the main proximal effect of the programme were: • Hypothesis 1: The randomized controlled trial intervention would increase preparedness for delivery and the transition to motherhood. • Hypothesis 2: The intervention would increase positive motherhood and related parenting later on after childbirth. • Hypothesis 3: The beneficial long-term effects of intervention on parenting would be attributable to the proximal beneficial effects of the intervention on preparedness.

Methods Participants.  This study is part of LINNEA study (Rouhe et al., 2011), the goal of which is to develop treatment for fear of childbirth. Between October 2007 and August 2009, a total of 12,000 questionnaires were given to consecutive and unselected Finnish- and Swedish-speaking maternity patients who participated in ultrasound screening at the gestational age of 11–13 weeks in the maternity clinics in the Departments of Obstetrics and Gynaecology in the University of Helsinki. Of these 12, 000 questionnaires 8611 were returned and filled in sufficiently well for our purposes. Fear

4 of childbirth was screened by W-DEQ questionnaire which is a standardized screening method for fear of childbirth and was previously validated for use by the Finnish pregnant population. Of these 8611 pregnant women parous women were excluded and only nulliparous women who exceeded 95 percentile (W-DEQ sum score ≥ 100) in the W-DEQ questionnaire were included in our study. The same limit has been used in previous studies (Zar, Wiljma & Wiljma, 2001). Nulliparous women were chosen as they are more homogenous as a group compared to parious women (Saisto et al., 2001). The final study population consisted of 356 nulliparous women with a severe fear of childbirth. The participants received a letter informing them of the study during their visit for a normal ultrasound screening from a health professional. During this visit they signed their approval to participate in the study. This study has been approved by the Ethics Committee for Gyneacology and Obstetrics, Otology, Ophthalmology, Neurology and Neurosurgery of the Helsinki University Central Hospital (376/E9/05 from 27 October 2005). These 356 nulliparous women with a fear of childbirth were randomized in to either an intervention group or a control group in the proportion of 1:2. Consequently, 131 women were randomized into the intervention group and 224 women into the control group. Participation in intervention was 69%, so finally there were 90 women in the intervention group. The main reasons for not participating were that: they did not want to participate in the intervention group (57%), they could not participate because of their work schedule (16%), they had already moved to another location (8%) or they had had a miscarriage (6%). Of those in the control group, 77 later had a consultation during pregnancy because of their fear of childbirth at their maternity clinic. Those randomized to the control group received a letter in which they were suggested to discuss fear of childbirth in their maternity unit in primary health care.

Journal of Health Psychology The participants completed a questionnaire on their preparedness toward childbirth (Table 1) first during the second trimester and then during the third trimester of pregnancy (about one month before the due date). Three months after childbirth they marked themselves on a motherhood and parenting scale (Kumar, Robson & Smith, 1984). The intervention included six psycho-education group sessions before childbirth and after childbirth (Table 2). If questionnaires were not returned the women were reminded twice by email.

Group intervention for enhancing preparedness The development of the group intervention was based on social cognitive theories on behavioral control and individual coping resilience (Ajzen, 1991; Meichenbaum, 1985, 2007). The aim was to enhance preparedness for childbirth among nulliparous women with an intense fear of childbirth. The group programme was built utilizing earlier experiences in preventive group methods aiming to increase preparedness for various transitions (Koivisto et al., 2010; Salmela-Aro, Mutanen & Vuori, in press; Vinokur et al., 1995). The focus of the intervention was on increasing individual independence and awareness of one’s own abilities, the choices available during one’s delivery and the successful transition to motherhood. A meeting focused on pain relief took place in a delivery room with a midwife who specialized in treating fear of childbirth. Partners participated in one of the group sessions. In addition one session took place after childbirth. Following randomization, women receive a letter with information about the group and telephone numbers of the group leaders. By telephone, group leaders interview participants trying to find out the level of the fear, the motivation for the group and they also give more information about the group. Women with severe psychiatric problems or risk of a suicide and serious problems of alcohol or drug abuse were excluded. In case of exclusion the women

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Salmela-Aro et al. Table 1.  Preparedness for Childbirth Scale How well are you prepared to. . .   1.  identify your strengths in giving birth?   2.  keep active during the delivery?   3.  accept stress and pain as a normal part of delivery?   4.  recover from the burden of delivery?   5.  relax during delivery?   6.  ask for help and advice when preparing for the delivery?   7.  ask for help and advice during delivery?   8.  take care of your own well-being?   9.  negotiate concerning the details of your delivery? 10.  keep calm when facing possible difficulties during the delivery? 11.  face possible difficulties during delivery as you can count on receiving help? 12.  face most of the difficulties related to delivery? 13.  cope if your delivery does not possibly progress as planned? 14.  adjust to changes during delivery such as a sudden operation?

will be advised to speak to her antenatal care midwife. Standard care included referral to a fear of childbirth team for individual counseling when appropriate. The intervention method used was psychoeducative group therapy led by a psychologist with group therapy skills who specialized in pregnancy related issues. Each group consisted of a maximum of six nulliparous women. Six meetings took place during pregnancy, starting at approximately the 28th pregnancy week, and then about 29, 30, 31, 33 and 35 gestation weeks and one meeting was arranged 6–8 weeks after delivery. Every session (2 hours) had a certain structure: a focused topic and a 30-minute guided relaxation exercise using a compact audio disk developed for this purposeThis exercise guided the participants through all stages of delivery in a relaxed state of mind with positive, calming and supportive suggestions. Each participant was encouraged to associate giving birth with images related to opening (e.g. the opening of a flower bud). Every session began with the therapist setting the agenda and with relaxation exercise. In LINNEA study protocol, women in intervention group had no planned visits with the obstetrician. The manual of Psycho-education LINNEA group programme for nulliparous pregnant women with an intensive fear of childbirth is

presented next (see also Table 2). Each session begins with the therapist setting the agenda and the relaxation exercise is usually carried out in the beginning. 1. In the first session the goal is to give information about the group therapy and about anxiety and fear in general. The aim is to enhance feelings of safety in the new situation, to get the women curious and help them to find a little bit of hope in dealing with their fear. In the first session the agenda is as follows: Introduction, sharing feelings about the group, sharing feelings about childbirth, psycho-education about anxiety, a basic relaxation exercise, sharing feelings about the session, handouts and homework. After the therapist has introduced herself, she will give information about all the practical things and procedures about meetings, such as where does the group meet, how long the sessions lasts, and what to do if the member can’t make it to the session. Participants may tell their names and how they feel about participating in the group. Techniques such as guided imagery, discussions within pairs and around the table are used about

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Table 2.  Manual for Psycho-Educative Group Therapy Intervention Group session Gestation week Focused topic (duration Agenda 90 minutes) 1

28

Information about fear and anxiety, group therapy and the effects of relaxation. Enhance feelings of safety and help to find hope of dealing with the fear. Normalization of fear. Information about the fear of childbirth, the normalization of individual reactions and information about the stages of delivery. Hospital routines, the birth process and pain relief.

2

29

3

30

4

31

Involving father-to-be (partner) in a stronger relationship with the birth and enhancing mutual understanding.

5

33

Promoting hope of good motherhood, possible setbacks and enhancing the bonding with the fetus.

6

35

Completing preparations for delivery and organizing written wishes addressed to the midwife.

Relaxation In attendance

Introduction, sharing Guided 30 Therapist feelings about the minutes group and childbirth, psycho-education about anxiety.

Psycho-education Guided 30 Therapist about the fear, stages minutes of the delivery.

Introduction given by midwife, who goes through the process of the birth, what happens in the hospital during the delivery, stages of birth and about painrelief. Present partners and their best qualities and strengths in connection with the delivery. Discussion about what the baby may expect from parents. Psycho-education about the time after birth, sharing feelings about the baby, an imagery exercise of the birth and meeting the baby The feelings of motherhood in particular possible setbacks. Preparedness to delivery, support and possible setbacks.

Guided 30 Therapist, minutes midwife

Guided 30 Therapist, minutes partner

Guided 30 Therapist minutes

Guided 30 Therapist minutes

7

Salmela-Aro et al. Table 2. (Continued) Group session Gestation week Focused topic (duration Agenda 90 minutes) 7

6-8 weeks after Discussion about delivery delivery experiences, detection of trauma and depression symptoms, discussion about mother-infant relationship and positive parenthood.

different issues: what do they fear and hope about giving birth, what do they hope to be the result of the group therapy, what change do they want to obtain, how will they know when they have obtained it. At this session the participants are allowed to feel as frightened as they are and that is accepted by the therapist. Participants can also express strong negative feelings, such as anger and disappointment. Therapists can normalize these feelings by pointing out that all these feelings are common, it is normal to fear all these things and it is very good that they are here to deal with these emotions. Information about the mechanisms of anxiety and fear will be provided. Another target of this session is to give information about relaxation and how it helps in the actual birth, in the pregnancy-time and with breastfeeding. At the first session a basic exercise of relaxation is carried out. After the exercise,

Relaxation In attendance

Information about Guided 30 Therapist, motherhood. minutes babies Presentation of the babies. Telling and sharing the birth stories. Summarizing the group experience. Information how to receive help if needed. Encourage to discuss the difficulties and happiness as a mother and enhance feelings to be good enough mothers. In the end they are asked what greetings they would send to next group.

there is a discussion about how it felt and how the participants have felt in the first session. A CD with the relaxation exercise is handed out. Every session ends by presenting the homework and giving out handouts. Handouts include the rules of the group, relaxation and information about anxiety and fear. Homework was to do the relaxation exercise daily, to read the handouts and to do something that feels good during the week or give a present to oneself. 2. The goal of the second session is to give information about the specific fear of childbirth, normalizing the individual reactions to fear and give information about the stages of birth. The agenda for second session is as follows: Thoughts and feelings after the last session, current homework, psycho-education about fear of childbirth, and sharing of feelings and then handouts and homework are given. Information about causes and symptoms

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Journal of Health Psychology of fear of childbirth is given in a way which enhances the participants’ sharing experiences. Stages of birth are discussed: how the stages feel inside, what their meanings are, and what happens to the baby during the different stages of the birth. Then discussion about the different feelings arising in the group. Handouts are given about fear of childbirth, and stages of birth. Homework is to carry out the relaxation exercise daily, to read the handouts, and bring something for the next session which reminds them of the baby. 3. The third session is in the delivery ward with an experienced midwife. The goal is to give information about hospital routines, birth process and pain-relief and to enhance feelings of safety in the delivery ward. The agenda is as follows: Introduction of the midwife, sharing feelings about the last session, handouts and homework. The midwife goes through the process of the birth, giving information about what happens in the hospital during the delivery, about stages of the birth and about painrelief. The participants are encouraged to ask all the ´silly questions` they have. Homework includes the relaxation exercise daily, to think about and summarize strengths in connection with the delivery and to think about and summarize their strengths of their partner in connection with the delivery. 4. The goal of the fourth session is to involve the fathers-to-be (or other partners) in the process of becoming more secure in relation to childbirth. The aim is to enhance mutual understanding and to mobilize the men/partners as important resources, at birth and in parenthood. The agenda is as follows: Presentation of the participants and participants present their partner and their best qualities and strengths in connection with the delivery. Technique is the ‘two circles’ exercise. Men are instructed

to sit in the middle of a circle and women will sit around the men. Men are instructed to discuss the feelings towards the coming fatherhood, their strengths, hopes and fears and what the baby may expect from parents. Women will just listen. After 15-minutes of discussion, the women are allowed to saywhat they heard men talking about. Then women are placed in the inside-ring and men are sat around them. Then women are asked to talk about their feelings towards the delivery and motherhood, their strengths, hopes and fears and what the baby may expect from parents. Men listen to the women talking and later they are asked to saywhat they heard. Then sharing feelings about the session and homework. Homework is to carry out the relaxation exercise daily and to bring in something in connection with the baby. 5. The goal of the fifth session is to give hope of a good enough motherhood, and in particular possible setbacks and to enhance bonding with the fetus. The agenda is as follows: The relaxation exercise, thoughts and feelings after the last session, current homework, psychoeducation about the time after birth, sharing feelings about the baby, an imagery exercise of the birth and meeting the baby. The sharing of feelings about the session, handouts and homework. The fifth session is about the time after birth, the feelings of motherhood especially the contradictory feelings and possible setbacks, baby blues, dyad coming triad and sexuality after birth. A handout is given out about the time after delivery. Homework is to do the relaxation exercise daily, to read the handout and to begin filling in the form ‘Letter to the midwife’. 6. The goal of the sixth session is to complete preparation for the delivery, increase preparedness to delivery, support and

Salmela-Aro et al. possible setbacks. The aim is to enhance hope for a good enough birth, and longing for the baby. The agenda of the session is as follows: Relaxation exercise, thoughts and feelings after the last session, preparedness to delivery, support and possible setbacks sharing feelings about the birth and the baby, sharing feelings about the session and encouragement to continue the relaxation training. The sixth session consists filling in a form about the wishes for the birth, the midwife, pain-relief, and what the woman really wants to avoid during the birth. Discussion about the coming birth and the feelings knowing that next time they will have the babies with them. Imagery exercise to the time the baby already has born is carried out, and participants are asked to send wishes to the future themselves like: you will make it … or it wasn´t as bad as you thought, or whatever comes tomind. Homework is to do the relaxation exercise daily. 7. The goal of the seventh session is to finish the group and to give the new mothers the possibility to tell the story about their deliveries: how it was in comparison with expectations and prepare for positive parenting. The agenda is as follows: Presentation of the babies, telling of the birth stories, sharing of feelings, summarizing the group experience, information about possibilities to receive help when needed post partum, information about positive motherhood, greetings to the next group and saying goodbye. The seventh session is post partum at about 6–8 weeks with the babies. It is possible to go back to the things talked about during the first session—what changes did they wish for and did they reach their goals. Participants are encouraged to discuss any difficulties and happiness as a mother and enhance feelings to be good enough mothers. The group-members may also exchange phone-numbers/email-addresses.

9 Measures.  Preparedness for childbirth (see Table 1) was measured using 14 questions about self-efficacy (e.g. How well do you think you can keep active during childbirth?), social support (e.g. How easily do you think you can ask for help and advice during the childbirth?) and dealing with possible setbacks (e.g. If there is a problem during childbirth, I trust that I will receive help) on a seven-point scale ranging from 1 = not at all to 7 = a lot. The sum scores were calculated and they showed very good internal consistency (Cronbach’s alpha = 0.88 and 0.90, respectively). Motherhood and parenting was measured by using 12 statements based on Kumar, Robson and Smith (1984). The statements dealt with feelings about being a mother (e.g. I am happy that I have a child), worries (e.g. I am worried that I may not be a good mother), and effects on everyday life (e.g. Have you had enough time for yourself after you had the baby?) and assessed on a four-point scale. The negative items were reverse coded. A sum score was calculated and it showed adequate internal consistency (Cronbach’s alpha = 0.79). A higher sum score indicated a more positive motherhood and parenting. Covariates from the baseline included age, educational level (a five point scale used as continuous, see Table 1), work status (1 = fulltime or part-time, 0 = other), mother and father live together (1 = yes, 0 = no), and mother’s country of birth (1 = Finland, 0 = other). Depression was measured by the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden & Sagovsky, 1987). The scale has 10 items on a four-point scale ranging from 0–3. All items were recoded in the same direction so that a higher score indicated a higher level of depressive symptoms. The scale showed good internal consistency (Cronbach’s alpha = 0.88). Intimate relationship satisfaction was measured with a short 14-item version of The Dyadic Adjustment Scale (DAS) (Spanier, 1976). The scale showed good internal consistency (Cronbach’s alpha = 0.85). Depressive symptoms and

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Table 3.  Distribution of the variables, % or M (SD), at the baseline among all mothers (n = 355), mothers who participated in the follow-ups (n = 204) and mothers who dropped out (n = 151). Variable

All

Participated in follow-ups (1)

Dropped out (2)

Difference test 1-2

Age Work status  Fulltime  Part-time  Studying  Unemployed  Homemaker  Other Educational level  Comprehensive school   Vocational school  Polytechnics   Bachelor degree   University degree Mother and father live together Place of birth  Finland  Other country in Europe   Outside Europe Depressive symptoms Intimate relationship satisfaction

29.6 (4.56)

29.8 (4.63)

29.4 (4.70)

p = 0.319

78.6 5.1 7.9 3.7 0.8 3.9

82.8 4.4 7.8 1.0 0.0 3.9

73.3 6.0 8.0 6.7 2.0 4.0

p = 0.017          

7.9

4.4

12.6

p = 0.031

13.5 14.4 26.2 38.0 93.3

12.3 14.8 25.6 42.9 95.5

15.2 13.9 26.5 31.8 90.2

        p = 0.055

96.0 2.3

97.0 1.5

94.7 3.3

   

1.7 8.7 (5.48)

1.5 8.6 (5.37)

2.0 8.7 (5.55)

  p = 0.773

50.9 (7.51)

50.6 (7.37)

51.2 (7.74)

p = 0.451

Note: No difference in the distributions between the intervention and the control groups. The difference test results were based on an independent samples t-test for continuous variables and an χ2 test for categorical variables.

satisfaction with intimate relationship at baseline were used as continuous measures. Analysis.  Latent growth curve models (Muthén & Muthén, 2007) were carried out to study the individual level of and rate of change in preparedness and the extent to which the level and rate of change in preparedness is associated with positive motherhood after childbirth. The analyses were carried out using Mplus Version 5.21 (Muthén & Muthén, 2007). On the latent growth curve, random effects are used to capture individual differences and fixed effects to estimate

the average growth of the entire sample. Because two measurements were taken on two occasions for preparedness for childbirth, only two growth parameters—the individual level and linear change—could be estimated. The fit of the models was assessed with multiple fit indices, as recommended by Hu and Bentler (1999). These indices were chi square, Comparative Fit Index (CFI) and Root Mean Square Error of approximation (RMSEA) (Steiger, 1990). A value at or below 0.08 for RMSEA and at or above 0.95 for CFI is considered to be an acceptable fit for the model.

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Salmela-Aro et al. Table 4.  Means and Standard deviations of Preparedness for childbirth Scale and Motherhood Scale. All

Participated in follow-ups

 

Intervention group

Control group

Intervention group

Control group

Baseline   Preparedness 1 month before childbirth   Preparedness 3 months after childbirth   Motherhood

(n = 131) 3.67 (0.90) (n = 96) 4.36 (0.97) (n = 92) 3.15 (0.36)

(n = 224) 3.70 (0.92) (n = 158) 4.18 (0.97) (n = 160) 3.03 (0.42)

(n = 81) 3.72 (0.76) (n = 81) 4.38 (0.98) (n = 81) 3.14 (0.37)

(n = 123) 3.69 (0.88) (n = 123) 4.15 (0.94) (n = 123) 3.02 (0.43)

Results Descriptive results.  Table 3 shows the distributions of the background factors. The average age of the mothers was just under 30 years (the average age of primiparous mothers was 28.1 in 2008, Official Statistics of Finland Statistical, 2009). The majority of mothers were working fulltime at the beginning of their pregnancy. About a third had completed a university Master’s degree. Their work status and educational level reflected the average for women in this age group in the Helsinki area (Official Statistics of Finland Statistical, 2009). Over 90% of the mothers were born in Finland and lived with the father of their expected child. The average number of depressive symptoms was relatively high. A total of 39% of the mothers exhibited possible depression (scoring 10 or more on the EPDS scale). However, this is in line with studies among women with severe fear of child birth (Rouhe, Salmela-Aro, Halmesmäki, Gessler, & Saisto, in press). Those who dropped out of the study (n = 151) had a lower educational level and were less likely to have been working fulltime at baseline than those who participated in the follow-ups (Table 3). Participation in the intervention was 69% (n = 90) among those who were invited in intervention. Women’s reasons for not attending the group (n = 41) were moving to other are in Finland (n = 4), having had a miscarriage (n = 1), not suitable for group

work because of very severe mental health problems (n = 1), no time to participate (n = 12), language difficulties (n = 2) and did not consider themselves fearful or did not want group therapy (n = 21). Altogether 76 control women out of 224 were sent to out-patient maternity clinic for special consultation because of fear of childbirth and they met obstetrician 1–5 times and/or midwife 1–4 times. Further, 30 control women sought at special childbirth preparation class led by midwife 2–6 times during pregnancy. Thus altogether 106 searched for or were sent to specific consultation because of fear of childbirth when the remaining 118 were taken care of by the community health nurses. Table 4 shows the distributions for the variables of preparedness for childbirth and positive motherhood. Preparedness increased in both the intervention and the control group, but the increase was sharper in the intervention group. The intervention effect was tested by a latent growth curve model. Those who dropped out of the study did not differ in preparedness at baseline from those who participated in the follow-ups (p = 0.729). Latent growth curve modeling on the associations between preparedness and positive motherhood.  A model assessing the associations between the level of and change in preparedness and positive motherhood, and the impact of intervention in changing preparedness were tested (Figure 1). The model fitted the data well (χ2= 10.47 (df = 8),

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Figure 1. The associations between the level of and change in preparedness for childbirth and positive motherhood and the impact of intervention on the change in preparedness for childbirth. Unstandardized path estimates (standard errors) are shown. The model is controlled for age, work status, educational level, parents living together, place of birth, depressive symptoms and marital satisfaction at the baseline.

p = 0.234, CFI = 0.99, RMSEA = 0.029). The results showed that intervention increased a mother’s preparedness supporting Hypothesis 1, which, in turn, predicted an increase in positive parenting after childbirth among those in the intervention group, thus supporting Hypothesis 3. The direct effect of intervention on positive motherhood was also tested, but it was nonsignificant, and this path was excluded in the model and thus Hypothesis 2 was not supported. There was, however, a significant indirect effect of intervention via preparedness on positive motherhood (unstandardized path estimate for indirect effect = 0.11 with standard error = 0.048), thus supporting Hypothesis 3. This finding supports the theoretical model which

proposed that increased preparedness is a mediator between a decrease in the fear of childbirth and experiencing of positive motherhood later. The model was controlled for age, work status, educational level, parents living together, mother’s place of birth, depressive symptoms and intimate relationship satisfaction at the baseline. Of these factors, depressive symptoms were associated with a lower initial level of preparedness for childbirth (unstandardized estimate = -0.072, standard error = 0.011, p < 0.001). Those born in Finland expressed a lower initial level of preparedness for childbirth than those born in other countries than Finland (unstandardized estimate = -0.679, standard error = 0.304, p < 0.05).

Salmela-Aro et al.

Discussion The current randomized intervention study aimed to increase women’s preparedness for childbirth and the transition to motherhood, which, it was assumed, would have beneficial effects on motherhood subsequently among women with a severe fear of childbirth. The results supporting Hypothesis 1 showed that the intervention increased a mother’s preparedness for childbirth, which, in turn, supporting Hypothesis 3, predicted an increase in positive motherhood and related parenting after childbirth among those in the intervention group. The direct effect of intervention on positive motherhood was non-significant, and thus Hypothesis 2 was not supported. The results regarding the main effects of the intervention both during the intervention and at the three month follow-up were well in line with our hypotheses. The proximal impact of the intervention was a very significant increase in preparedness, fulfilling the primary goal that we had set for it. In the longer run at the three month follow-up, the intervention programme had significantly increased positive motherhood among intervention group participants compared to the controls. This is an important result, showing that it is feasible and effective to enhance women’s resources for acting competently and proactively during childbirth and that this can have a longer term beneficial effect on parenting and early child-mother bonding. The main effect of the intervention on the increase of mental resources was statistically significant. Mediation analyses demonstrated that the beneficial effects of the intervention were due to the proximal effect of the intervention on the increase in preparedness. This is an important finding which shows that better management of one’s childbirth has beneficial parenting outcomes in the longer run. This underlines the possibility of enhancing women’s preparedness, which can be expected to have the wide beneficial outcomes mentioned for their transition, which, further, can also be expected to benefit the child. Our intervention

13 and concept of preparedness was somewhat broader than usual, comprising also the elements of sustainable and positive parenting. Taken together, the positive intervention results seem promising. They suggest that resilience can be strengthened and capacity can be built. The main effects of the intervention appear to have been relatively small in scale at the three month follow-up. The effect sizes (Cohen’s d) can be regarded as small or medium (Cohen, 1992). In total, the factors in the model could account for about 12% of the variation in motherhood. However, the major methodological strength of our study was that we were able to employ a randomized controlled trial. As the randomization was successful, the results can be regarded as reliable, while also depending somewhat on the characteristics of the measures. The study design used and the theory driven intervention also brings us closer to conclusions about causality compared to other controlled study designs. There are some limitations to our study. First, the retention rate could have been higher. Though the participants did not differ from those who dropped out in many factors, including preparedness for childbirth of the baseline, a lower educational level and not being in work was characteristic of those who dropped out. In the future, it is important to find an intervention that would be attractive to these groups. It is also important to include minority groups. The results suggested that there are differences in preparedness for childbirth depending on the mother’s country of birth. However, because of the very small number of mothers born in countries other than Finland, it was not possible to investigate the ethnic differences in detail in the present study. It is important to study preparedness for childbirth in other countries where ethnic diversity is greater than in Finland. Moreover, it would be also important to include more single parents. In addition, there might be many other mechanisms besides preparedness such as how well the birth succeeded, how well the breast feeding succeeded, and if a partner was available and able to support the mother. In future intervention

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