Women's responses to two models of antepartum high-risk care: Day stay and hospital stay

Article Outline

• Summary
• Literature review
• Setting
  • Antenatal Hospital Unit (ANHU)
  • Pregnancy Day Stay Unit (PDSU)
• Method
  • Sample
  • Data collection
  • Data analysis
• Findings
  • Profile of the women
  • Antenatal stress
  • Mood
  • Family functioning
  • Symptoms
• Discussion
• Limitations and future research
• Implications for practice
• Acknowledgements
• References
• Copyright

Summary 

Aim

To replicate and extend previous research by examining women's responses to two current models of high-risk antenatal care that replaced the traditional bed rest model.

Participants

A sample of 61 women assigned to high-risk antenatal care: 29 in the Antenatal Hospital Unit (ANHU) and 32 in the Pregnancy Day Stay Unit (PDSU).

Methods

A longitudinal study with data collected by a range of validated tools were used to assess mood, family functioning, stress and physical symptoms every 2 weeks from admission into antenatal high-risk care to birthing and at 3- and 6-weeks postpartum. Data were analysed for similarities and differences and change over time between the two groups of women.

Findings

Stress from emotions was the highest antenatal stressor for both groups and highest for those in hospital. Stress about health increased over time for those in the PDSU and varied for those in ANHU. Anxiety was significantly different between the groups over time (p<0.01), being highest for the ANHU group and decreasing from admission to 6-weeks postnatal for both groups. Sensation Seeking (sensory deprivation) showed significant differences (p<0.05) with the highest scores in the ANHU group and increasing over time for both groups. Family relationships were most disrupted for those in ANHU. Both groups were satisfied with support from spouse, family and friends and those in ANHU acknowledged the support received from midwifery staff.

Conclusions and implications

The responses of both the woman and her family differ between the two models of care and vary with time. Midwives can use the patterns of response identified of these findings to address needs for assistance with family relationships, sensory stimulation, information and support and management of anxiety when care is required for complications of pregnancy.

Keywords: Antenatal care, High-risk pregnancy, Day stay, Family functioning

Admission to hospital on bed rest has been the traditional approach to managing women with high-risk or complicated pregnancy. For more than two decades, research has consistently shown bed rest to have detrimental and prolonged physical and psychological effects on the pregnant women and their families.¹, ², ³, ⁴, ⁵, ⁶ This research led to reconsideration of the need for prolonged bed rest and development of new models of care. Currently, most referral hospitals in Australia have a day stay option to hospital admission for selected women. Both models are designed to provide regular observation to identify untoward change in maternal or fetal health status without unnecessarily detaining the woman in hospital or restraining her activities.

Little is known about the experiences of women in these newer models of care. Replication and extension of previous research is needed to determine similarities and differences in women's experiences in these two models and to provide evidence for appropriate protocols and guidelines that accurately support the needs of women, their families and caregivers. This paper reports the women's responses from the quantitative part of a larger study from which the qualitative findings were previously described.⁷

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Literature review 

The majority of studies on antepartum high-risk care have been conducted in the United States and Canada when pregnant women with complications were treated on bed rest. These studies identified numerous physiological symptoms resulting from prolonged bed rest such as dysphoria, muscle loss, gastric functioning changes and later postpartum symptoms of cardiovascular and muscular deconditioning, decreased metabolism, indigestion and reflux due to loss of weight-bearing load upon the skeleton.², ⁴, ⁸ In addition, alterations in family functioning, mood, developmental tasks of pregnancy and preparation for parenting are also described.³, ⁴, ⁹, ¹⁰, ¹¹, ¹² Sleep cycle change, decreased energy, boredom, depression, poor self-image, concern for the fetus, and feelings of fear and anger are consistent findings.¹, ¹¹, ⁵

These studies led to changes in high-risk care and models of care designed to avoid the hazards of bed rest while maintaining vigilance on the maternal–fetal–placental unit required of the specific complication. To date, evaluations of the current models of high-risk care show good maternal and infant physiological outcomes of day stay units for specific conditions such as hypertension.¹³ Studies of the overall impact of these new models of care on Australian women and their families are lacking.

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Setting 

The setting in which this study was undertaken is a large, referral centre in Sydney, Australia. The hospital currently provides two models of care for women with high-risk pregnancies:

Antenatal Hospital Unit (ANHU) 

Women are admitted to the hospital antenatal care unit for days, weeks or longer. Within their rooms, they have an ensuite bathroom, telephone, television and access to an outside area. Once their condition is stabilised, ambulation is encouraged, and they may have short periods of leave to go outside or home. The Acute Care Unit is immediately adjacent to the ANHU where women who develop critical care needs either antepartum or postpartum receive high dependency care.

Pregnancy Day Stay Unit (PDSU) 

Women spend 2 or more days per week in a room specially furnished with recliner chairs and two hospital beds. Monitoring and tests are undertaken, the results are interpreted and the care plan revised as indicated. A Clinical Midwifery Specialist is dedicated to care for this group of women.

For both groups, activity is encouraged and individualised to the woman's needs and condition. If there is the possibility of a preterm or unwell infant, parents are orientated to the Newborn Care Centre. The focus of care is always a safe outcome for both mother and infant. Fathers or other family members may room-in if desired.

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Method 

A longitudinal repeated measures study was designed to replicate and extend the previous research that had measured symptoms, mood, stress and family functioning of women in antenatal bed rest care. Approval was obtained from the Human Research Ethics Committees of the hospital, health service and university.

Sample 

Women admitted into high-risk antenatal care at the study hospital were eligible for this study if they understood and spoke English, intended to keep their baby and had a home phone number. Women with a known fetal anomaly were not approached.

After consultation with or referral from unit midwives, eligible women were invited to participate in the study during their first week of antepartum high-risk care. Over the study period, a sample of 61 consenting women was acquired who were medically assigned to their model of care: 29 women in ANHU and 32 in the PDSU.

Data collection 

Each woman completed the set of instruments used in the previous research studies every 2 weeks until the birth of her infant. The first measure taken within 1–3 days following admission to high-risk care was titled Antenatal 1 (AN1) and those following every 2 weeks were labeled sequentially as AN2, AN3 and so on until birth occurred. The instruments were:

•The Antepartum Hospital Stressors Inventory (AHSI) measures stress associated with being in hospital for a high-risk pregnancy.¹ It consists of 49 items, women rate their stress on a five-point scale of no stress=1 to great deal of stress=5. The items provide a score for seven categories: separation, environment, health status, communication with professionals, self-image, emotions and family status.

•The Antepartum Symptom Checklist measures the incidence of physical and psychosocial symptoms of women on bed rest care.⁴ For each of 52 symptoms, the degree of severity is measured on a four-point scale of mild=1, moderate=2, severe=3, not applicable=4.

At 3 weeks and 6 weeks following the birth of their infant(s) women were asked to complete The Postpartum Symptom Checklist that measures the incidence and severity of physical and psychosocial symptoms with scores of mild=1; moderate=2, severe=3, not applicable=4⁴, ⁸ as well as the MAACL-R and FFFS. Those who were at home when data collection was due were either sent the questionnaires by post or given the set of questionnaires at their postnatal clinic visit with a return pre-stamped, envelope.

Data analysis 

The data were entered into a Statistical Package for the Social Sciences (SPSS 11.0) database. Analysis searched for differences between the responses of women in the two models of care and across time within the women's experience. Chi-square analyses were conducted to assess associations between categorical variables. Repeated Measures Analysis of Variance compared differences between groups and across time. Data were compared between the ANHU and the PDSU groups with an alpha level of p<0.05.

Antenatal stress scores from the Antenatal Hospital Stressors Inventory (AHSI) were calculated. A mean was calculated by comparing the total domain scores before dividing by the number of items identified.

Comparisons were made on the data from MAACL-R Checklist, the Feetham Family Functioning Survey and the Antenatal and Postnatal Symptom Checklists. To identify change over time, scores for the first antenatal measure (AN1), the first postnatal measure at 3 weeks (PN1) and 6 weeks (PN2) for each of the instruments were compared. Data from each of the three time periods were analysed using 2 (groups)×3 (times) Repeated Measures Analysis of Variance. Main effect contrasts relating to group and time as well as their interactions were examined.

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Findings 

Profile of the women 

The characteristics of the sample (Table 1) show the similarities and differences between the two groups of women. The model of care to which the women were assigned was determined by the medically assessed need for care. No statistical comparisons between the demographics of the two groups were made as the women were not randomly assigned and it was not expected that their characteristics would necessarily be comparable. The PDSU group was admitted at a later stage of pregnancy and had a slightly lower, not statistically significant, emergency caesarean rate (52%) than the ANHU group (53%) both of which are higher than the annual total caesarean delivery rate of 32% in the study hospital.

Table 1. Characteristics of the sample

Reason for admission (women may have more than one)		Gestation (weeks)	Mode of delivery	Infants to NICU	Postnatal length of stay (days)	Outcomes
Antenatal Hospital Unit Group (n=29)
Preeclampsia	10	Admission (23–28), delivery (28–40)	Caesarean (53.1%) 17, (8 emergency), assisted vaginal 4, normal vaginal 11	(57%) 16	Mean 5.3, range=2–13	Neonatal death 1, stillbirth 1
Threatened premature labour	6
Antepartum hemorrhage or placenta praevia	6
Premature ruptured membranes	4
Incompetent cervix and cervical sutures	2
Insulin dependent diabetes mellitus	2
Gastrointestinal disease	1
Essential hypertension	1
Pregnancy Day Stay Group (n=32)
Preeclampsia	25	Admission (30–39), delivery (31–41)	Caesarean (51.6%) 16, (7 emergency), assisted vaginal 5, normal 11	(38.7%) 12	Mean=6.0, range 3–8
IDDM/GDM	4
PPROM*	1
Connective tissue disease	1
Hyperemesis	1

The outcomes for the ANHU group include infant deaths: one of a set of twins was stillborn. This mother was unable to continue in the study due to her distress; one infant was a neonatal death from prematurity following prolonged rupture of membranes. The maternal death in the PDSU group was at 3 months postpartum from a pre-pregnancy collagen disease.

Antenatal stress 

The number of women completing this instrument decreased over time with only 5 of the women in the PDSU group and 7 in the ANHU group in care continuing for 6 weeks to obtain three antenatal measurement times. The analysis is therefore descriptive based on a total possible score of 5 for each domain. Stressors varied over time (Table 2). Initially (AN1), both groups reported that their environment produced the least amount of antenatal stress. Women in the ANHU group had higher scores than women in the PDSU for stress related to separation, environment, health, self-image and family status.

Table 2. Mean antenatal stressor scores over time

Domain	PDSU, N=29, week 1	PDSU, N=8, week 3	PDSU, N=5, week 5	Mean PDSU	ANHU, N=30, week 1	ANHU, N=12, week 3	ANHU, N=7, week 5	Mean ANHU
Environment	1.99	1.81	1.95	1.92	2.09	2.45	2.75	2.33
Health	2.04	2.39	2.94	2.45	2.44	2.84	2.74	2.68
Communication with professionals	2.20	2.12	2.24	2.19	2.42	2.44	2.78	2.56
Family status	2.23	2.53	1.64	2.13	2.59	3.37	3.27	3.08
Self-image	2.27	2.29	2.66	2.41	2.77	2.67	2.76	2.73
Separation	2.35	2.62	2.50	2.49	2.91	3.12	3.02	3.02
Emotions	2.58	2.78	3.10	2.82	3.08	3.25	3.20	3.18
Mean	1.92	2.36	2.43	2.34	2.61	2.88	2.93	2.80

Emotions caused the women both in the PDSU and ANHU the greatest level of stress. For all domains, women in hospital had higher total mean stress scores than the women in the PDSU.

Although no significant differences emerged for AN2 and AN3, women in the ANHU group had higher total mean stressor scores than the PDSU group. At AN2, women in the PDSU still reported the environment caused the least amount of stress, and emotions the most. For women in hospital, communication with professionals and the environment caused the least amount of stress, and family status was most stressful. Stress scores changed over time. At AN3, issues related to family status caused the lowest levels of stress for women in the PDSU, and emotions still caused the most stress. By AN3, stressors that caused the least amount of stress for women in the PDSU caused the most amount of stress for women in hospital. Family status stress was highest at AN2 for those in ANHU and increased until delivery while this stressor decreased over time for those in the PDSU. Of particular note is that stress about health status increased over time for those in the PDSU and decreased for those in ANHU.

Mood 

Results for mood measured with the MAACL Checklist varied between the two groups and over time (Table 3). Significant differences were found for Anxiety (F=10.44, d.f. 1, p<0.01) and Sensation Seeking (F=5.23, d.f. 1, p<0.05). These differences occurred over time, between AN1 and the 6th week postnatal. The mean Anxiety score reduced for both groups over the study period, although there were no differences between the groups and no interaction between time and group.

Table 3. Comparison of moods over time

Variable	Mean (S.D.)
	ANHU (n=25a)			PDSU (n=20a)
	Antenatal (1 week)	Postnatal (3 weeks)	Postnatal (6 weeks)	Antenatal (1 week)	Postnatal (3 weeks)	Postnatal (6 weeks)
Anxiety	2.1 (2.2)	1.7 (2.4)	1.0 (1.8)	1.6 (1.7)	1.3 (1.7)	0.5 (0. 9)
Depression	1.1 (1.5)	1.4 (2.6)	1.2 (2.3)	0.6 (1.8)	0.8 (1.2)	0.4 (0.9)
Hostility	0.6 (1.0)	1.5 (3.1)	1.4 (2.3)	0.3 (0.7)	0.5 (0.8)	0.5 (0.9)
Positive Affect	7.3 (6.5)	5.6 (5.8)	7.6 (6.8)	5.8 (5.9)	6.7 (5.8)	7.2 (6.1)
Sensation Seeking	1.8 (1.4)	1.8 (1.9)	2.9 (1.6)	1.4 (1.5)	1.3 (1.3)	1.6 (1.6)
Dysphoriab	3.8 (3.9)	4.7 (7.3)	3.6 (5.7)	3.2 (3.5)	3.7 (5.8)	2.6 (4.6)
PASSc	9.1 (7.3)	7.4 (7.2)	10.5 (8.4)	7.2 (6.8)	7.9 (6.6)	9.7 (7.9)

The Sensation Seeking score showed a significant increase over time, particularly for the women in the hospital group. This mood variable is described as the “need to seek novel sensations through the mind and senses” (Zuckerman and Lubin, 1985, p. 14). There were no differences between the groups, and no interaction between time and group. As with the Anxiety score, the difference occurred between the AN1 and 6th week postnatal for both groups. Dysphoria is calculated by adding raw scores for Anxiety, Depression and Hostility (Zuckerman and Lubin, 1985, p. 5).

Although not statistically significant, scores for the ANHU group on Depression, Hostility and Dysphoria were highest and Positive Affect was lowest at 3-weeks postnatal. For the PDSU group scores for Depression and Dysphoria were highest at 3-weeks postnatal, while scores for Hostility (although higher at the 3 and 6-weeks postnatal than at the first antenatal measure), showed no change across the postnatal period.

Family functioning 

Family functioning as measured with the FFFS is shown in Table 4, Table 5. As with the Checklist, the mean discrepancy scores are accompanied by large standard deviations, indicating considerable variability in how the women responded.

Table 4. Family functioning: highest and lowest discrepancy items

	ANHU	PDSU
1st antenatal
Highest discrepancy	The amount of time ill	The amount of time work routine (including housework) is disrupted
Lowest discrepancy	The amount of discussion with friends regarding concerns and problems AND The amount of emotional support from relatives	The amount of time spent with neighbours
3 Weeks postnatal
Highest discrepancy	Amount of satisfaction with the sexual relations with spouse	Amount of time spent on leisure and recreational activities
Lowest discrepancy	Amount of time spent with neighbours	The amount of time spent with neighbours
6 Weeks postnatal
Highest discrepancy	Amount of satisfaction with the sexual relations with spouse	Amount of satisfaction with the sexual relations with spouse
Lowest discrepancy	Amount of help from friends with family tasks	Amount of emotional support from friends

Table 5. Family functioning: comparison of mean discrepancy scores

Variable	Mean (S.D.)
	ANHU (n=25)			PDSU (n=22)
	Antenatal (1 week)	Postnatal (3 weeks)	Postnatal (6 weeks)	Antenatal (1 week)	Postnatal (3 weeks)	Postnatal (6 weeks)
Total discrepant score	27.6 (21.1)	24.9 (20.0)	24.0 (19.6)	17.0 (10.5))	20.4 (12.2)	16.4 (11.3)

The discrepancy scores between “how much there is now” and “ how much there should be” were lower overall for the PDSU group compared to the ANHU group (Table 5). This difference was slightly above statistical significance at p=0.07. Results indicate that there was little change in the discrepancy scores for family functioning factors over time, although scores for the ANHU group did decrease somewhat by 6-weeks postnatal, compared to the first antenatal scores. The mean scores on the FFFS for the PDSU group increased at 3-weeks postnatal, indicating a slight increase in discrepancy levels, although by the 6th postnatal week the score was similar to that reported at AN1.

When, the highest and lowest discrepancy items for the two groups were compared, women in both groups at AN1 were most concerned with the amount of time spent being ill (ANHU) or away from routine (PDSU). At 3- and 6-weeks postnatal, women in the ANHU group were more concerned about their sexual relationship with their partner. At 3-weeks postnatal, women in the PDSU group were more concerned with the amount of time spent on leisure and recreational activities, but by 6-weeks postnatal, the greatest level of discrepancy occurred for their sexual relationship with their partner. By 6-weeks postnatal, women in both groups appeared to be receiving the adequate support from spouse, family and friends. Support from the hospital staff was specifically noted as supportive in comments by the ANHU group.

Symptoms 

The Postnatal Symptom Checklist (PSC) contains many items similar to those in the Antenatal Symptom Checklist (ASC), as well as items that only relate to postnatal symptoms. Participants who completed all 3 of the 1st antenatal, 3-week postnatal and 6-week postnatal measures were compared across the study period for items shared by the ASC and PSC. Statistical comparisons have not been made due to the small number of cases in many of the cells.

Most of the reported symptoms decreased over the study period, particularly those symptoms that can be directly attributed to pregnancy, such as indigestion, reflux and breathlessness. For women in the ANHU group, back soreness declined (although still reported by more than 50% of respondents at 6-weeks postnatal), while women in the PDSU group reported similar levels of back soreness 6 weeks after giving birth as they did at AN1. Symptoms reported by the ANHU group that increased from the first antenatal to 3-weeks postnatal were: decreased appetite, dry skin, sore skin, visual problems, faintness, difficulty concentrating, mood changes and nightmares. However, by 6-weeks postnatal, these had reduced to levels lower than or similar to those reported at AN1. For the PDSU group, symptoms showing an increase at 3-weeks postnatal were: dry skin, headache, constipation, painful urination, difficulty concentrating, mood changes and tenseness. With the exception of “difficulty concentrating”, which showed another increase at the 6-weeks postnatal, all other measures showed a decrease again by 6-weeks to levels lower than those reported at AN1. Of interest is that for the ANHU group, symptoms related to urination – “painful urination”, “urine dribbling” and “having to get to bathroom quickly” did not reduce, but were the same at 6-weeks postnatal as at the first antenatal measure.

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Discussion 

This longitudinal, replication study with measurements used in previous studies with women on bed rest showed some important similarities and differences in the patterns of responses of women in these two models of care that do not require complete bed rest. Most importantly, this study reveals that being assigned to care in the PDSU does not eliminate the anxiety and stress associated with a complicated pregnancy.

Stress increased over time in the PDSU as it did for women admitted to the hospital, although to a lesser degree. In particular, the increased stress levels regarding their health in the PDSU group signals a need for additional reassurance and support for these women and their families. They described not feeling as ‘safe’ as actually being hospitalised.⁷

Both groups of women experienced a disruption to their own lives and to family relationships. This is consistent with other studies of women on bed rest in the USA and Canada², ⁴, ⁹, ¹¹, ¹⁷. These disruptions seem to be common responses of women experiencing complications of pregnancy regardless of country or model of care.

There were no significant differences in physical symptoms between the two groups and the physical symptoms measured with the tools scored low or not experienced at all. This suggests that women are benefiting from the new models of care that encourage mobility and are not experiencing the previously described detrimental effects of prolonged bed rest in Maloni's program of research. The symptoms associated with urinary incontinence are of interest given other findings in a recent Australian study.¹⁸, ¹⁹ As so many of the symptoms listed on both the antenatal and postnatal inventories were bed rest related, it is not recommended that these instruments be used in future studies of women in these new models of care.

Women in the two groups followed a very similar pattern of mood change. This finding underlines how complications in pregnancy necessitate special care for impact on mood. Combining mood changes with the increasing levels of stress, signals aspects of the woman's experience that may need more exploration using the stressors domains and mood variables as cues for assessment and further research. Emotional stress increased over time for all women and most particularly for those in the PDSU.

These responses to high-risk care are important for midwives and other caregivers to understand and assess. In particular, the significance of sensation seeking by women in both groups albeit, not surprisingly, more so for women hospitalised is noteworthy. The need to express their varying needs and feelings is not surprising given the disruption to their lives and family functioning. This finding is a prominent part of the response of women in this study and has recently been reported again in a study of Brazilian women in high-risk care.²⁰ The women's postpartum symptoms, particularly postpartum back pain and urine leaking, are difficult to differentiate from those commonly related to epidurals, caesarean birth, haemorrhage or length of restricted activity.²¹ These morbidities are distressing and require appropriate assessment, management and referral as indicated.

There is also a need for increased attention to the effects of disruption to life, family functioning, changing emotions and decreased sensory stimulation. In this study, by the end of the pregnancy, family status caused the least amount of antepartum stress for women in the PDSU, but caused the most amount of stress for women in the ANHU. Stress from separation was understandably higher for hospitalised women but interestingly reduced somewhat by the end of pregnancy for both groups. As might be expected, ‘emotions’ increased over time in women in both groups. Midwives working with women in PDSU can use these findings to provide focused support for women who are stressed about their health on an day stay care model and experience emotional and family stressors that vary from those in ANHU. For women in both models of care, it is important to determine the source of her anxiety and stress and then provide as much relief and reassurance as possible. Running a support group on the unit can be helpful to some women and their families.²² Others may require referrals to social work, psychologists or access to meditation or massage.

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Limitations and future research 

The women in this study were not randomly assigned to the model of care and the effect the small cell sizes had on the reliability and validity of some of the factors in the study have been acknowledged. However, the consistency of the responses with findings of previous studies and the differences in the patterns of responses revealed within and between women in the two care models, provide useful knowledge for planning and providing evidence-based care as well as assuring women that their responses are not unique. Further research is needed to identify ways to reduce stress and to enhance sensory stimulation and family relationships for women in long-term care for complications of pregnancy.

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Implications for practice 

This study has identified family relationships and sensory stimulation requiring more attention to minimise the negative impact of a complicated pregnancy, particularly for those requiring hospital admission. In the unit where this study was conducted, massage and hairdressing have been made available by appointment and have been a welcome addition to care. There is also increased attention to providing some additional social interaction with staff and other patients. A small library is available as are educational videotapes and DVD's. Plans are being made to have a pattern of upper body weight-bearing exercise with small hand weights and physiotherapy assistance available to provide maintenance of muscle strength. Given the urinary leaking reported by these women, pelvic floor strengthening exercises are being added to the plan. It is important to recognise and acknowledge anxiety and uncertainty as legitimate responses to the need for special care during pregnancy. A poster with the outcomes of this study is on the unit and has been of considerable interest to women and their families who find the responses noted both affirming and reassuring.

The understanding needed by women with complications of pregnancy requires continuity of both care and caregiver through the antepartum to postpartum and neonatal care experience such as can be possible within CMC and CNC roles. Ongoing advocacy during postpartum and neonatal care is also needed for these women who demonstrate inattention to their own morbidity following a complicated pregnancy especially when their infant requires neonatal intensive care.²³ Debriefing and interest in the outcome from all those who provide care is critical in helping these women and their families with the extended emotional and physiological recovery required after a complicated pregnancy.

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Acknowledgements 

Funding provided by a Royal Hospital for Women Foundation Research Award supported this study. The women and their families who devoted considerable time to the repeated measures required for this study when their lives were disrupted made the study possible. We are grateful for the editorial assistance of Avon Strahle, Sandy Hackworth and Michele Simpson.

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