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Parental Perceptions and Experiences after Childbirth: A Comparison between Mothers and Fathers of Term and Preterm Infants Anneke Tooten, MSc, Hannah N. Hoffenkamp, MSc, Ruby A.S. Hall, MSc, Johan Braeken, PhD, Ad J.J.M. Vingerhoets, PhD, and Hedwig J.A. van Bakel, PhD ABSTRACT: Background: Parents experience a lot of positive and negative feelings and
emotions after birth. The main purpose of this study was to compare perceptions and experiences of mothers and fathers with term, moderately and very preterm infants. Methods: We included 202 infants with both parents, divided into three groups: 1) term infants (≥ 37 weeks’ gestation), 2) moderately preterm infants (≥32– 40 yr Educational level: Low† Educational level: Medium Educational level: High‡ Paternal demographic data Dutch nationality: Age: < 23 yr Age: 23–40 yr Age: > 40 yr Educational level: Low† Educational level: Medium Educational level: High‡
T
MP
VP
73 37–42 2,030–4,865 36 (49.3) 70 (95.9) 0 (0)
66 32–37 1,220–4,280 38 (57.6) 55 (83.3) 0 (0)
63 25–32 556–2,220 32 (50.8) 52 (82.5) 3 (1.5)
46 (63.0) 38 (52.1)
38 (57.6) 21 (31.8)
34 (54.4) 18 (28.6)
68 0 69 4 7 13 53
(93.2) (0) (94.5) (5.5) (9.6) (17.8) (72.6)
64 3 58 5 12 25 29
(97.0) (4.5) (87.9) (7.6) (18.2) (37.9) (43.9)
56 3 58 2 10 30 23
(88.9) (4.7) (92.1) (3.2) (15.9) (47.6) (36.5)
71 0 61 12 13 14 46
(97.3) (0) (83.6) (16.4) (17.8) (19.2) (63.0)
64 0 58 8 15 15 36
(97.0) (0) (87.9) (12.1) (22.7) (22.7) (54.5)
58 3 50 10 19 22 22
(92.1) (1.5) (24.8) (5.0) (30.2) (34.9) (34.9)
Values are expressed as n (%) unless otherwise indicated. The variable Group has three levels: T = parents of term infants; MP = parents of moderately preterm infants; VP = parents of very preterm infants. *Coded: 0: both parents had no experience; 1: when at least one of the parents had experience, †Coded: Low:1, Medium: 2, High: 3, ‡Significant group differences.
Table 2. Group Differences on CLIP Main Areas
Main Effect Group CLIP: Main Areas Infant’s current condition Pregnancy course Labor and delivery Relationship with infant Hospital and staff Support system Discharge and beyond Quality of narratives
T M (SE) 2.32 10.22 3.70 8.95 4.67 5.28 2.14 3.92
(0.22)* (0.51)* (0.29)* (0.43)* (0.31) (0.34) (0.13)* (0.27)
MP M (SE) 3.01 10.90 5.12 9.35 5.08 5.56 2.45 4.26
(0.19)† (0.45)† (0.25)† (0.38)* (0.28) (0.30) (0.11)† (0.23)
VP M (SE) 4.37 11.08 5.53 10.62 4.83 6.00 2.92 4.28
(0.19)‡ (0.44)† (0.25)‡ (0.37)† (0.27) (0.30) (0.11)‡ (0.23)
F
p
Partial g2
101.16 3.49 48.81 17.81 2.01 4.91 41.71 2.55
< 0.001 0.03 < 0.001 < 0.001 0.14 0.08 < 0.001 0.08
0.51 0.03 0.33 0.15 0.02 0.05 0.30 0.03
Groups with different symbol *, †, ‡significantly differ on the main area indicated in the row label; Adjusted means are reported with paternal and maternal educational levels fixed at medium and previous parenting experience set at no experience.
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expressed negative perceptions. This finding may be partly explained by the timing of the CLIP interview, which was conducted 1 month postpartum. Most very preterm infants are still in the NICU at this time. The hospital stay and NICU period may have hindered the development of the intuitive parenting capacities in parents of very preterm infants (30). These findings are in line with the results of recent research, which highlighted that during the NICU period many parents encounter difficulties in forming an optimal parentinfant relationship (31). On the other hand, parents of term and moderately preterm infants are discharged from the hospital 1 month after birth. Being at home with their infant may have promoted the development of their parenting capacities and may have perpetuated the unfolding relationship with their infant. Before discussing the potential clinical implications, two suggestions for further research need to be acknowledged. First, this study focused on identifying common areas of concern after (preterm) birth. However, to date, there are no data available to classify the parents who worry either too much or too little. This finding nevertheless might be useful, as research indicated that “too much” parental preoccupation may lead to obsessive-compulsive behavior and/or PTSD, whereas “too little” preoccupation with the infant may result in withdrawn behavior and/or depression (26,32–35). In addition, as both of these two extremes seem to increase the risk of abuse or neglect in vulnerable and high-risk families, both extremes should be an important objective of further research. Second, this study did not investigate coping capacities of parents, though these aspects may be highly relevant for proper psychosocial care giving (8). Although mothers and fathers were found to have equal levels of worry and concern, the way they try to cope with these specific worries might differ considerably (36,37). Men,
relationship (25,26). This study reveals that mothers and fathers express similar concerns about childbirth-related issues. These findings strongly suggest that both parents are equally emotionally involved during the peri- and postnatal period. This interpretation corresponds with the outcomes of a recent study demonstrating that, in Western societies, the interest of fathers in parental roles, evolving even immediately after birth, is growing (27). In addition, a recent systematic review showed the positive influences of fathers’ involvement on infants’ social, behavioral, and psychological outcomes (28,29). Therefore, infants born preterm, who are at increased risk of developing these kinds of problems, might benefit even more from an emotionally engaged father than their healthier counterparts. This study furthermore showed that the CLIP main areas were related to the gestational age of the infant. The lower the gestational age of the infant at birth, the more negative parental perceptions and experiences were. Although the consequences of very preterm birth are increasingly acknowledged by researchers and clinicians (3), still little attention is given to the parents of moderately preterm infants. Our findings, though, demonstrated that the emotional impact of moderately preterm birth can also be substantial. Negative experiences and perceptions were related to almost all areas, namely a problematic pregnancy course, an unexpected process of labor and delivery, uncertainty about the infants’ medical condition and ambiguity about the moment of discharge or the near future. To put it differently, parents of moderately preterm infants, without serious life-threatening conditions and with high chances to survive, experience significant worries, and have negative perceptions about the prenatal, perinatal and postnatal period. However, with respect to the development of a specific and unique relationship with the infant, only parents of very preterm infants
Table 3. Gender Differences on CLIP Main Areas
Main Effect Gender CLIP: Main Areas Infant’s current condition Pregnancy course Labor and delivery Relationship with infant Hospital and staff Support system Discharge and beyond Quality of narratives
Mothers M (SE) 3.19 10.72 4.57 10.01 5.29 5.60 2.48 4.13
(0.21) (0.52) (0.28) (0.47) (0.34) (0.33) (0.14) (0.25)
Fathers M (SE) 3.28 10.74 5.00 9.26 4.43 5.63 2.52 4.17
(0.20) (0.49) (0.30) (0.47) (0.28) (0.31) (0.12) (0.29)
F
p
Partial g2
0.52 0.21 0.03 0.52 2.14 0.53 0.05 0.64
0.47 0.65 0.96 0.47 0.15 0.47 0.82 0.42
0.00 0.00 0.00 0.00 0.01 0.00 0.00 0.00
Adjusted means are reported with paternal and maternal educational levels fixed at medium and previous parenting experience set at no experience.
169
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for example have been found to use external coping strategies when facing stressful circumstances whereas women tend to cope more emotionally focused (38). To improve prevention and intervention programs, future studies with a focus on coping strategies and gender differences are recommended. Our findings justify the following practical suggestions to optimize care for parents during the hospitalization period after preterm childbirth. Most important, when interventions are offered, one should invite and stimulate both parents to participate. In particular, parents without previous parenting experience and/or fathers with a low level of formal education might need additional support after preterm childbirth in forming positive perceptions. In addition, in case of anticipated moderately and very preterm birth, nurses or pediatricians should prepare parents on what might happen during pregnancy, labor and delivery, and immediately after birth (e.g., provide information or prenatally introduce parents to the hospital environment). In this way parents can adapt their expectations to the new situation and (re)construct their role as parents, which is in line with recommendations on the prevention of Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD) (39). As not all preterm births are anticipated, psychological support in the perinatal period should be offered to stimulate parents to express themselves and to reflect on their negative experiences. The CLIP interview may be a very useful instrument to facilitate this process (8). In addition, education and training should also focus on preparing parents for the transition from hospital to home, to prevent long-term negative parenting styles and associated negative child developmental outcomes (40).
Conclusion Negative perceptions and experiences after (preterm) childbirth were mainly associated with the gestational age of the infant and not at all with the gender of the parent. Most negatively affected were experiences and perceptions related to a problematic pregnancy course, an unexpected process of labor and delivery, uncertainty about the infants’ medical condition, and ambiguity about the moment of discharge or the near future.
Acknowledgments The study has been funded by the foundation “Stichting Achmea Slachtoffer en Samenleving” (Achmea Victim and Society) (Dutch Project number: NL24021.060.08, METC approval: Catharina Hospital,
Eindhoven, date: 21-10-2008). We would like to thank the editor and anonymous reviewers for their valuable comments and many helpful suggestions that have greatly improved our paper. The authors would also like to express their gratitude to the nursing staff of the following eight hospitals for their help with recruitment and data collection: Maxima Medisch Centrum, Veldhoven; Academisch Ziekenhuis Maastricht, Maastricht; TweeSteden Ziekenhuis, Tilburg; St. Elisabeth Ziekenhuis, Tilburg; Catharina Ziekenhuis, Eindhoven; Laurentius Ziekenhuis, Roermond; Elkerliek Ziekenhuis, Helmond; St. Jans Gasthuis, Weert.
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Appendix A: Adjusted Coding Scheme CLIP Main Area
Items
Infant’s current condition (range 2–7)
Fear of loss of (preterm) infant Perceived condition of the infant’s medical status
Pregnancy course (range 6–2(1)
First reaction to pregnancy Planned pregnancy Course of pregnancy, physical/emotional complications (mothers) Course of pregnancy, emotional complications (fathers) Timing of pregnancy feeling real Feelings that something could go wrong
Labor and delivery (range 2–7)
Readiness for delivery Fear of loss during delivery (mothers) Fear of loss during delivery (fathers) First feelings toward infant Bond with the infant Reasons for delayed or impaired bonding Present feelings toward infant Mutual recognition Confidence in self as parent Raising by own parents
Relationship with infant (range 7–18)
Hospital and staff (range 3–9)
Reaction to staff Reaction to hospital environment Reaction to lack of control over infant
Support system (range 4–1(2)
Experience partner Support spouse Relationship with spouse changed Support system others that is family, friends
Discharge and beyond (range 2–6)
Readiness for discharge* Foreseen development of the infant Foreseen future for the infant, expectations
Quality of narratives (range 3–9)
Affect Organization of content Richness of content
*Adjusted items.
Classification (Likert Scale) No fear of loss (1), Minor fear of loss (2), Fear of loss, no preoccupation (3), Preoccupation with loss (4).* Good medical condition (1), Average medical condition with potential medical health risks (2), Severe, worrisome medical condition (3).* Positive (1), Ambivalent (2), Negative (3). Yes (1), No (2). No complications (1), Minor complications (2), Several complications (3), Severe complications (4).* No complications (1), Minor complications (2), Several complications (3), Severe complications (4).* Pregnancy test (1), 1st Ultrasound (2), Fetal movements (3), Delivery (4), Never (5). No concerns (1), Common concerns (2), Severe concerns (3).* Expected (1), Somehow expected (2), Totally unexpected (3). No fear (1), Fear for herself (2), Fear for infant (3), Fear for infant and herself (4).* No fear (1), Fear for partner (2), Fear for infant (3), Fear for infant and partner (4).* Positive (1), Ambivalent (2), Negative (3). Yes, immediately after birth (1), Yes, developed during first few weeks (2), No, not (yet) developed (3).* Unexpected delivery, caesarian section/unable to breastfeed the infant/incubator/medical cause infant/separation from infant/unable to take care for the infant/other (multiple answers possible).* Positive (1), Ambivalent (2), Negative (3). Definitely (1), In doubt (2), None (3). Secure (1), Not secure (2), Insecure (3). Positive (1), Ambivalent (2), Negative (3). Total confidence (1), Partial confidence (2), No confidence (3).* Hospital enhances feeling of security (1), Hospital is securing but frightening (2), Hospital is frightening and not securing (3).* Not bothered with passive role or not mentioned (1), Bothered with passive role but no influence on parental feelings (2), Bothered with passive role and parental feelings are negatively influenced (3).* Positive (1), Ambivalent (2), Negative (3). Full spousal support (1), Partial spousal support (2), Absent spousal support (3). Positive change (1), Relationship unaffected (2), Negative change (3). Full social support (1), Partial social support (2), Absent social support (3). Parent feels ready (1), Parent feels partially ready (2), Parent feels not ready at all (3).* Positive (1), Ambivalent (2), Negative (3). Appropriate expectations (1), Partially appropriate expectations (2), Discrepant expectations (3). Positive (1), Mixed (2), Negative (3). Well-organized (1), Moderately organized (2), Poorly organized (3). Full answers (1), Partial answers (2), Laconic answers (3).
164
Parental Perceptions and Experiences after Childbirth: A Comparison between Mothers and Fathers of Term and Preterm Infants Anneke Tooten, MSc, Hannah N. Hoffenkamp, MSc, Ruby A.S. Hall, MSc, Johan Braeken, PhD, Ad J.J.M. Vingerhoets, PhD, and Hedwig J.A. van Bakel, PhD ABSTRACT: Background: Parents experience a lot of positive and negative feelings and
emotions after birth. The main purpose of this study was to compare perceptions and experiences of mothers and fathers with term, moderately and very preterm infants. Methods: We included 202 infants with both parents, divided into three groups: 1) term infants (≥ 37 weeks’ gestation), 2) moderately preterm infants (≥32– 40 yr Educational level: Low† Educational level: Medium Educational level: High‡ Paternal demographic data Dutch nationality: Age: < 23 yr Age: 23–40 yr Age: > 40 yr Educational level: Low† Educational level: Medium Educational level: High‡
T
MP
VP
73 37–42 2,030–4,865 36 (49.3) 70 (95.9) 0 (0)
66 32–37 1,220–4,280 38 (57.6) 55 (83.3) 0 (0)
63 25–32 556–2,220 32 (50.8) 52 (82.5) 3 (1.5)
46 (63.0) 38 (52.1)
38 (57.6) 21 (31.8)
34 (54.4) 18 (28.6)
68 0 69 4 7 13 53
(93.2) (0) (94.5) (5.5) (9.6) (17.8) (72.6)
64 3 58 5 12 25 29
(97.0) (4.5) (87.9) (7.6) (18.2) (37.9) (43.9)
56 3 58 2 10 30 23
(88.9) (4.7) (92.1) (3.2) (15.9) (47.6) (36.5)
71 0 61 12 13 14 46
(97.3) (0) (83.6) (16.4) (17.8) (19.2) (63.0)
64 0 58 8 15 15 36
(97.0) (0) (87.9) (12.1) (22.7) (22.7) (54.5)
58 3 50 10 19 22 22
(92.1) (1.5) (24.8) (5.0) (30.2) (34.9) (34.9)
Values are expressed as n (%) unless otherwise indicated. The variable Group has three levels: T = parents of term infants; MP = parents of moderately preterm infants; VP = parents of very preterm infants. *Coded: 0: both parents had no experience; 1: when at least one of the parents had experience, †Coded: Low:1, Medium: 2, High: 3, ‡Significant group differences.
Table 2. Group Differences on CLIP Main Areas
Main Effect Group CLIP: Main Areas Infant’s current condition Pregnancy course Labor and delivery Relationship with infant Hospital and staff Support system Discharge and beyond Quality of narratives
T M (SE) 2.32 10.22 3.70 8.95 4.67 5.28 2.14 3.92
(0.22)* (0.51)* (0.29)* (0.43)* (0.31) (0.34) (0.13)* (0.27)
MP M (SE) 3.01 10.90 5.12 9.35 5.08 5.56 2.45 4.26
(0.19)† (0.45)† (0.25)† (0.38)* (0.28) (0.30) (0.11)† (0.23)
VP M (SE) 4.37 11.08 5.53 10.62 4.83 6.00 2.92 4.28
(0.19)‡ (0.44)† (0.25)‡ (0.37)† (0.27) (0.30) (0.11)‡ (0.23)
F
p
Partial g2
101.16 3.49 48.81 17.81 2.01 4.91 41.71 2.55
< 0.001 0.03 < 0.001 < 0.001 0.14 0.08 < 0.001 0.08
0.51 0.03 0.33 0.15 0.02 0.05 0.30 0.03
Groups with different symbol *, †, ‡significantly differ on the main area indicated in the row label; Adjusted means are reported with paternal and maternal educational levels fixed at medium and previous parenting experience set at no experience.
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expressed negative perceptions. This finding may be partly explained by the timing of the CLIP interview, which was conducted 1 month postpartum. Most very preterm infants are still in the NICU at this time. The hospital stay and NICU period may have hindered the development of the intuitive parenting capacities in parents of very preterm infants (30). These findings are in line with the results of recent research, which highlighted that during the NICU period many parents encounter difficulties in forming an optimal parentinfant relationship (31). On the other hand, parents of term and moderately preterm infants are discharged from the hospital 1 month after birth. Being at home with their infant may have promoted the development of their parenting capacities and may have perpetuated the unfolding relationship with their infant. Before discussing the potential clinical implications, two suggestions for further research need to be acknowledged. First, this study focused on identifying common areas of concern after (preterm) birth. However, to date, there are no data available to classify the parents who worry either too much or too little. This finding nevertheless might be useful, as research indicated that “too much” parental preoccupation may lead to obsessive-compulsive behavior and/or PTSD, whereas “too little” preoccupation with the infant may result in withdrawn behavior and/or depression (26,32–35). In addition, as both of these two extremes seem to increase the risk of abuse or neglect in vulnerable and high-risk families, both extremes should be an important objective of further research. Second, this study did not investigate coping capacities of parents, though these aspects may be highly relevant for proper psychosocial care giving (8). Although mothers and fathers were found to have equal levels of worry and concern, the way they try to cope with these specific worries might differ considerably (36,37). Men,
relationship (25,26). This study reveals that mothers and fathers express similar concerns about childbirth-related issues. These findings strongly suggest that both parents are equally emotionally involved during the peri- and postnatal period. This interpretation corresponds with the outcomes of a recent study demonstrating that, in Western societies, the interest of fathers in parental roles, evolving even immediately after birth, is growing (27). In addition, a recent systematic review showed the positive influences of fathers’ involvement on infants’ social, behavioral, and psychological outcomes (28,29). Therefore, infants born preterm, who are at increased risk of developing these kinds of problems, might benefit even more from an emotionally engaged father than their healthier counterparts. This study furthermore showed that the CLIP main areas were related to the gestational age of the infant. The lower the gestational age of the infant at birth, the more negative parental perceptions and experiences were. Although the consequences of very preterm birth are increasingly acknowledged by researchers and clinicians (3), still little attention is given to the parents of moderately preterm infants. Our findings, though, demonstrated that the emotional impact of moderately preterm birth can also be substantial. Negative experiences and perceptions were related to almost all areas, namely a problematic pregnancy course, an unexpected process of labor and delivery, uncertainty about the infants’ medical condition and ambiguity about the moment of discharge or the near future. To put it differently, parents of moderately preterm infants, without serious life-threatening conditions and with high chances to survive, experience significant worries, and have negative perceptions about the prenatal, perinatal and postnatal period. However, with respect to the development of a specific and unique relationship with the infant, only parents of very preterm infants
Table 3. Gender Differences on CLIP Main Areas
Main Effect Gender CLIP: Main Areas Infant’s current condition Pregnancy course Labor and delivery Relationship with infant Hospital and staff Support system Discharge and beyond Quality of narratives
Mothers M (SE) 3.19 10.72 4.57 10.01 5.29 5.60 2.48 4.13
(0.21) (0.52) (0.28) (0.47) (0.34) (0.33) (0.14) (0.25)
Fathers M (SE) 3.28 10.74 5.00 9.26 4.43 5.63 2.52 4.17
(0.20) (0.49) (0.30) (0.47) (0.28) (0.31) (0.12) (0.29)
F
p
Partial g2
0.52 0.21 0.03 0.52 2.14 0.53 0.05 0.64
0.47 0.65 0.96 0.47 0.15 0.47 0.82 0.42
0.00 0.00 0.00 0.00 0.01 0.00 0.00 0.00
Adjusted means are reported with paternal and maternal educational levels fixed at medium and previous parenting experience set at no experience.
169
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for example have been found to use external coping strategies when facing stressful circumstances whereas women tend to cope more emotionally focused (38). To improve prevention and intervention programs, future studies with a focus on coping strategies and gender differences are recommended. Our findings justify the following practical suggestions to optimize care for parents during the hospitalization period after preterm childbirth. Most important, when interventions are offered, one should invite and stimulate both parents to participate. In particular, parents without previous parenting experience and/or fathers with a low level of formal education might need additional support after preterm childbirth in forming positive perceptions. In addition, in case of anticipated moderately and very preterm birth, nurses or pediatricians should prepare parents on what might happen during pregnancy, labor and delivery, and immediately after birth (e.g., provide information or prenatally introduce parents to the hospital environment). In this way parents can adapt their expectations to the new situation and (re)construct their role as parents, which is in line with recommendations on the prevention of Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD) (39). As not all preterm births are anticipated, psychological support in the perinatal period should be offered to stimulate parents to express themselves and to reflect on their negative experiences. The CLIP interview may be a very useful instrument to facilitate this process (8). In addition, education and training should also focus on preparing parents for the transition from hospital to home, to prevent long-term negative parenting styles and associated negative child developmental outcomes (40).
Conclusion Negative perceptions and experiences after (preterm) childbirth were mainly associated with the gestational age of the infant and not at all with the gender of the parent. Most negatively affected were experiences and perceptions related to a problematic pregnancy course, an unexpected process of labor and delivery, uncertainty about the infants’ medical condition, and ambiguity about the moment of discharge or the near future.
Acknowledgments The study has been funded by the foundation “Stichting Achmea Slachtoffer en Samenleving” (Achmea Victim and Society) (Dutch Project number: NL24021.060.08, METC approval: Catharina Hospital,
Eindhoven, date: 21-10-2008). We would like to thank the editor and anonymous reviewers for their valuable comments and many helpful suggestions that have greatly improved our paper. The authors would also like to express their gratitude to the nursing staff of the following eight hospitals for their help with recruitment and data collection: Maxima Medisch Centrum, Veldhoven; Academisch Ziekenhuis Maastricht, Maastricht; TweeSteden Ziekenhuis, Tilburg; St. Elisabeth Ziekenhuis, Tilburg; Catharina Ziekenhuis, Eindhoven; Laurentius Ziekenhuis, Roermond; Elkerliek Ziekenhuis, Helmond; St. Jans Gasthuis, Weert.
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Appendix A: Adjusted Coding Scheme CLIP Main Area
Items
Infant’s current condition (range 2–7)
Fear of loss of (preterm) infant Perceived condition of the infant’s medical status
Pregnancy course (range 6–2(1)
First reaction to pregnancy Planned pregnancy Course of pregnancy, physical/emotional complications (mothers) Course of pregnancy, emotional complications (fathers) Timing of pregnancy feeling real Feelings that something could go wrong
Labor and delivery (range 2–7)
Readiness for delivery Fear of loss during delivery (mothers) Fear of loss during delivery (fathers) First feelings toward infant Bond with the infant Reasons for delayed or impaired bonding Present feelings toward infant Mutual recognition Confidence in self as parent Raising by own parents
Relationship with infant (range 7–18)
Hospital and staff (range 3–9)
Reaction to staff Reaction to hospital environment Reaction to lack of control over infant
Support system (range 4–1(2)
Experience partner Support spouse Relationship with spouse changed Support system others that is family, friends
Discharge and beyond (range 2–6)
Readiness for discharge* Foreseen development of the infant Foreseen future for the infant, expectations
Quality of narratives (range 3–9)
Affect Organization of content Richness of content
*Adjusted items.
Classification (Likert Scale) No fear of loss (1), Minor fear of loss (2), Fear of loss, no preoccupation (3), Preoccupation with loss (4).* Good medical condition (1), Average medical condition with potential medical health risks (2), Severe, worrisome medical condition (3).* Positive (1), Ambivalent (2), Negative (3). Yes (1), No (2). No complications (1), Minor complications (2), Several complications (3), Severe complications (4).* No complications (1), Minor complications (2), Several complications (3), Severe complications (4).* Pregnancy test (1), 1st Ultrasound (2), Fetal movements (3), Delivery (4), Never (5). No concerns (1), Common concerns (2), Severe concerns (3).* Expected (1), Somehow expected (2), Totally unexpected (3). No fear (1), Fear for herself (2), Fear for infant (3), Fear for infant and herself (4).* No fear (1), Fear for partner (2), Fear for infant (3), Fear for infant and partner (4).* Positive (1), Ambivalent (2), Negative (3). Yes, immediately after birth (1), Yes, developed during first few weeks (2), No, not (yet) developed (3).* Unexpected delivery, caesarian section/unable to breastfeed the infant/incubator/medical cause infant/separation from infant/unable to take care for the infant/other (multiple answers possible).* Positive (1), Ambivalent (2), Negative (3). Definitely (1), In doubt (2), None (3). Secure (1), Not secure (2), Insecure (3). Positive (1), Ambivalent (2), Negative (3). Total confidence (1), Partial confidence (2), No confidence (3).* Hospital enhances feeling of security (1), Hospital is securing but frightening (2), Hospital is frightening and not securing (3).* Not bothered with passive role or not mentioned (1), Bothered with passive role but no influence on parental feelings (2), Bothered with passive role and parental feelings are negatively influenced (3).* Positive (1), Ambivalent (2), Negative (3). Full spousal support (1), Partial spousal support (2), Absent spousal support (3). Positive change (1), Relationship unaffected (2), Negative change (3). Full social support (1), Partial social support (2), Absent social support (3). Parent feels ready (1), Parent feels partially ready (2), Parent feels not ready at all (3).* Positive (1), Ambivalent (2), Negative (3). Appropriate expectations (1), Partially appropriate expectations (2), Discrepant expectations (3). Positive (1), Mixed (2), Negative (3). Well-organized (1), Moderately organized (2), Poorly organized (3). Full answers (1), Partial answers (2), Laconic answers (3).
