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The development of an instrument to assess women’s attitudes to mode of delivery Hewat, Roberta Jean Wilma 1980

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THE DEVELOPMENT OF AN INSTRUMENT TO ASSESS WOMEN'S ATTITUDES TO MODE OF DELIVERY by ROBERTA JEAN WILMA HEWAT .Sc.N., The University of B r i t i s h Columbia, A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1980 (_) Roberta J. Hewat, 1980 In presenting t h i s thesis i n p a r t i a l f u l f i l l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v ailable for reference and study. I further agree that permission for extensive copying of this thesis for s c h o l a r l y purposes may be granted by the Head of my. Department or by h i s representative. It i s understood that copying or p u b l i c a t i o n of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. The University of B r i t i s h Columbia Vancouver, Canada, V6T 1W5 i i i ABSTRACT The purpose of t h i s study was to develop and t e s t an instrument that would r e l i a b l y measure women's a t t i t u d e s towards mode of d e l i v e r y . The technique chosen f o r a t t i t u d e measurement was a semantic d i f f e r e n t i a l . Cesarean and v a g i n a l d e l i v e r i e s were rated using b i p o l a r a d j e c t i v e s separated by a seven p o i n t s c a l e . The a d j e c t i v a l p a i r s represented four f a c t o r s ; e v a l u a t i o n , potency, a c t i v i t y and a n x i e t y - s t r e s s . The instrument was completed by 202 women who were attending pre-n a t a l c l a s s e s i n the Greater Vancouver area. A n a l y s i s i n d i c a t e d that Cesarean d e l i v e r y and v a g i n a l d e l i v e r y occupy separate p o s i t i o n s i n a semantic space. This i s r e f l e c t i v e of d i f f e r e n c e s i n women's a t t i t u d e s towards the two modes of d e l i v e r y . M u l t i p l e r e g r e s s i o n a n a l y s i s revealed that the f a c t o r s e v a l u a t i o n and a n x i e t y - s t r e s s are the most r e l e v a n t p r e -d i c t o r s of women's a t t i t u d e s towards mode of d e l i v e r y ; they accounted f o r at l e a s t 94 percent of the variance of the scores f o r each mode. The r e l i a b i l i t y of the f a c t o r s e v a l u a t i o n and a n x i e t y - s t r e s s f o r both Cesarean d e l i v e r y and v a g i n a l d e l i v e r y was s u b s t a n t i a l . Concurrent v a l i d i t y of the Cesarean d e l i v e r y category was i n d i c a t e d and the instrument i s considered t o have content v a l i d i t y . A semantic d i f f e r e n t i a l technique was u s e f u l i n measuring women's a t t i t u d e s towards Cesarean d e l i v e r y and v a g i n a l d e l i v e r y . Further r e f i n e -ment of the instrument could y i e l d an e f f i c i e n t and r e l i a b l e assessment measure. i v TABLE OF CONTENTS CHAPTER I INTRODUCTION TO THE STUDY 1 Introduction and Rationale f o r the Study 1 Statement of the Problem 5 Purpose of the Study 5 D e f i n i t i o n of Terms 5 Assumptions 6 Limitations 6 Description of the Following Chapters 8 II REVIEW OF THE LITERATURE 9 Overview 9 Psychological Implications of Cesarean Delivery 9 Variables That Influence Women's Attitudes Towards Labor and Delivery 19 An Attitude Measurement Technique 25 Summary and Conclusions 29 III RESEARCH METHODOLOGY 30 Overview 30 Development of the Instrument 30 Selection of the Sample 34 C o l l e c t i o n of the Data 34 S t a t i s t i c a l Procedures 35 V C H A P T E R I V F I N D I N G S A N D D I S C U S S I O N 40 Description of the Sample 40 Mu l t i p l e Regression Analysis 46 R e l i a b i l i t y 48 Sp a t i a l Distance Between the Two Concepts 50 Discriminant Function Analysis 51 V a l i d i t y 54 Summary 56 V SUMMARY AND CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS . . 60 Summary and Conclusions 60 Implications f o r Nursing P r a c t i c e 62 Recommendations for Further Research 64 BIBLIOGRAPHY 67 APPENDICES A Covering Le t t e r 73 B Instructions f o r P a r t i c i p a n t s 75 C Instrument 77 D Demographic Data Form 80 v i LIST OF TABLES TABLE PAGE 1. BIPOLAR ADJECTIVES REPRESENTING EACH FACTOR 32 2. COMPOSITION.OF THE SAMPLE ACCORDING TO GEOGRAPHIC LOCATION AND TYPE OF AGENCY (N=202) 41 3. COMPOSITION OF THE SAMPLE ACCORDING TO AGE, EDUCATION AND INCOME (N=202) 42 4. COMPOSITION OF THE SAMPLE ACCORDING TO PARITY AND DELIVERY EXPERIENCE (N=202). 43 5. COMPOSITION OF THE SAMPLE IN TERMS OF EXPOSURE TO CONTENT REGARDING VAGINAL AND CESAREAN DELIVERY PRIOR TO INVESTIGATION (N=202) 44 6. RESPONSE OF SUBJECTS REGARDING ANTICIPATED FEELINGS OF SATISFACTION ABOUT CESAREAN DELIVERY (N=202) 45 7. SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO CESAREAN DELIVERY TOTAL SCORES (N=202) 46 8. SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO VAGINAL DELIVERY TOTAL SCORES (N=202) 47 9. INTERNAL CONSISTENCY RELIABILITIES OF THE FACTORS FOR CESAREAN DELIVERY (N=202) 49 10. INTERNAL CONSISTENCY RELIABILITIES OF THE FACTORS FOR VAGINAL DELIVERY (N=202) 49 11. DISTANCE BETWEEN THE CONCEPTS, CESAREAN DELIVERY AND VAGINAL DELIVERY IN A SEMANTIC SPACE ( N = 2 0 2 ) . . . . . 51 12. ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN CESAREAN DELIVERY AND VAGINAL DELIVERY 52 13. ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN HIGH - LOW SCORES; CESAREAN DELIVERY CATEGORY 53 14. ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN HIGH - LOW SCORES; VAGINAL DELIVERY CATEGORY 54, 15. SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO GLOBAL QUESTIONS RESPONSE (N=202) 55 v i i ACKNOWLEDGEMENTS I wish to thank the members of my thesis committee f or t h e i r continuous support and encouragement: Elaine Carty, chairman, f or the knowledge and expertise she w i l l i n g l y shared, her advice and pertinent suggestions and her friendship; Dr. Marilyn Willman f or her sincere i n t e r e s t , guidance and e d i t o r i a l comments; Dr. Jack Yensen, for i n s p i r i n g the conception of the study, h i s s t a t i s t i c a l advice and unending patience with a computer novice. Appreciation i s extended to the City of Vancouver Health Department, the North Shore Health Department, the Vancouver C h i l d b i r t h Association and the prenatal i n s t r u c t o r s who allowed me access to t h e i r c h i l d b i r t h education classes. I am e s p e c i a l l y g r a t e f u l to the women who volunteered to p a r t i c i p a t e , f o r i t was t h e i r co-operation that made thi s study p o s s i b l e . Special thanks are due my family, Bob, Jodi and Shelley whose love and understanding sustained me throughout the duration of this s tudy. CHAPTER I INTRODUCTION TO THE STUDY Introduction and Rationale f o r the Study Expectations of the c h i l d b i r t h experience have changed. There i s an increasing emphasis upon a family-oriented approach: both mothers and fathers look forward to p a r t i c i p a t i n g i n t h e i r c h i l d ' s b i r t h , and i n sharing t h i s event. Most women expect a normal, spontaneous delivery without medical intervention. Though most anticipate t h i s kind of c h i l d b i r t h , fewer experience i t . To-day, Cesarean section i s a r e a l i t y many women must face. The Cesarean section rate began increasing towards the end of the 1960's. In the United States, "the nationa l rate [of Cesarean d e l i v e r i e s ] had r i s e n from 5.0 percent i n 1968 to 12.8 percent i n 1977, with i n d i v i d u a l i n s t i t u t i o n s reporting rates of up to 25 percent." (Marieskind 1979, p . l ) . In Canada, a survey of twelve teaching h o s p i t a l s showed that i n 1976 the proportion of Cesarean section d e l i v e r i e s ranged from 9.8 percent to 21.8 percent (Baskett 1978). In B r i t i s h Columbia, the average rate of Cesarean s e c t i o n d e l i v e r i e s for eight h o s p i t a l s reporting more than one thousand d e l i v e r i e s per annum, was 16.5 percent i n 1977 and 18.25 percent i n 1978. In Vancouver, the largest urban area within the province, the average rate of 1 2 Cesareans performed i n the three major h o s p i t a l s was 20 percent i n 1977 and 22 percent i n 1978.* As the incidence of deli v e r y by Cesarean s e c t i o n increases so do the number of women expressing d i s s a t i s f a c t i o n with t h e i r c h i l d b i r t h experience. Women who have had a Cesarean delivery report f e e l i n g s of fear, disappointment, f a i l u r e , anger, resentment, g u i l t and loss of s e l f -esteem (Clark, Affonso and Harris 1979; Cohen 1977; Donovan 1978; Donovan and A l l e n 1977; Hausknecht and Heilman 1979; Marut 1978; Schlosser 1978). Many women expressing these feel i n g s were encountered by the in v e s t i g a t o r i n her pr a c t i c e as a community health nurse. I t seems that: (1) postnatally, these women take longer to recover, both p h y s i o l o g i c a l l y and psyc h o l o g i c a l l y , and, as a r e s u l t , are i n need of more v i s i t s from the community health nurse than those who d e l i v e r v a g i n a l l y ; (2) some women continue to v e n t i l a t e t h e i r f e e l i n g s f o r weeks, months and occasionally years a f t e r the delivery; (3) many pregnant women who are a n t i c i p a t i n g a second Cesarean section are exceptionally anxious about the approaching b i r t h ; fears and concerns related to the surgery and her recovery seem to be aroused when she i s faced with the experience a second time and (4) at c h i l d b i r t h education classes more primiparous women are expressing fears and concerns about Cesarean b i r t h . These observations and experiences i n nursing p r a c t i c e have generated the investigator's i n t e r e s t i n women's attitudes towards mode of d e l i v e r y . _ Dr. James King, Head of Obstetrics and Gynecology, Grace Hospital, Vancouver, B r i t i s h Columbia, 1980: personal communication. 3 The coincidence of increased s u r g i c a l intervention during labor and women's increased anxieties r e l a t e d to Cesarean d e l i v e r y r e i n -troduces the long-standing query of the r e l a t i o n s h i p of the e f f e c t of psychological factors on progress i n labor. Retrospective studies by Kapp, Hornstein and Graham (1963) and McDonald and Christakos (1963) suggest a r e l a t i o n s h i p between anxiety during pregnancy and prolonged labor or poor o b s t e t r i c a l outcome. Findings i n a more recent, psycho-p h y s i o l o g i c a l study (Lederman et a l . 1979) also support the r e l a t i o n s h i p . I t was found that when maternal anxiety increased, c i r c u l a t i n g epine-phrine also increased and " . . . that higher epinephrine l e v e l s are associated with poorer progress i n labor." (Lederman et a l . 1978). Extreme fear or anxiety regarding either Cesarean or vaginal b i r t h w i l l be r e f l e c t e d i n a woman's at t i t u d e towards d e l i v e r y and perhaps i n how her labor progresses. Even though a causal r e l a t i o n s h i p has not been established between psychological factors and labor and deli v e r y out-come, i t i s important to know women's attitudes towards d e l i v e r y during pregnancy. If a woman has extremely negative or p o s i t i v e attitudes towards either Cesarean or vaginal b i r t h , intervention may be planned to f a c i l i t a t e her adjustment and prevent or minimize d i s s a t i s f a c t i o n . Some authors consider t h i s approach e s s e n t i a l i n the pro v i s i o n of preventive health care (Caplan 1957; Godber 1978). The promotion and maintenance of health and the prevention of disease i s the focus of primary health care. This p r a c t i c e i s rec e i v i n g greater emphasis i n the Canadian health care system (Lalonde 1978; Morrison 1978) since p u b l i c a t i o n of the Lalonde Report i n 1974. Franklin (1980b', p.62) states that-"exploration of the patient's 4 general attitudes with the chance to have sensible discussions may lead to important preventive measures." Preventive health care i s more economical than treatment, an important consideration i n current times. The rapid increase of health care costs during the past decade has p r e c i p i t a t e d the more recent emphasis upon e f f i c i e n c y i n the health care system. In keeping with t h i s , i t i s becoming e s s e n t i a l that systematic and r e l i a b l e methods be used to i d e n t i f y patients who are most i n need of preventive care. These i n d i v i d u a l s may then be the r e c i p i e n t s of a greater proportion of the ava i l a b l e health s e r v i c e s . The t h i r d trimester of pregnancy i s a relevant time to assess women's attitudes towards mode of d e l i v e r y . I t i s during t h i s period women focus on labor and deli v e r y (Anthony and Benedek 1970; Coleman and Coleman 1971; Dickason and Schuldt 1979). They frequently approach the event with ambivalent f e e l i n g s . Most women look forward to the termination of the pregnancy and a r r i v a l of the infant yet anxieties concerning the unknown are prevalent. For women who are considered at r i s k i n r e l a t i o n to t h e i r a t t i t u d e towards delivery preventive i n t e r -ventions may commence at t h i s time. However, accurate methods for i d e n t i f y i n g women that may be at r i s k are d i f f i c u l t to f i n d . In nursing, there i s " . . . a growing need f o r a methodological system of data-gathering and patient assessment that i s not only e f f i -cient and economical of time and energy but also r e a l i s t i c and p r a c t i c a l for u t i l i z a t i o n i n a v a r i e t y of health care f a c i l i t i e s . " ( L i t t l e and Carnevali 1966, p.66). P r a c t i c a b i l i t y and a systematic approach are two requirements for nursing assessment t o o l s . A t h i r d and most essen-t i a l c r i t e r i a i s that the measures be based on a s c i e n t i f i c foundation 5 (Zimmerman and Gohrke 1970) . A review of the l i t e r a t u r e revealed that a systematic and r e l i a b l e method of assessing pregnant women's attitudes towards mode of delivery has not yet been developed. Statement of the Problem Concern about Cesarean section i s becoming more prevalent amongst pregnant women. It i s also recognized that a few women have extreme fears and anxieties about vaginal b i r t h . I f pregnant women who have very negative or very p o s i t i v e attitudes towards either Cesarean or vaginal d e l i v e r y can be i d e n t i f i e d , nursing interventions could commence pre-delivery and continue post-partum i f necessary. At present, there i s no systematic or r e l i a b l e method for assessing women's attitudes towards mode of de l i v e r y during pregnancy. Purpose of the Study The purpose of th i s study was to develop and test an instrument that could be used by nurses to assess women's attitudes towards mode of d e l i v e r y . The s p e c i f i c objectives were: (1) to develop an instrument for a t t i t u d e measurement that would be easy to administer, (2) to estimate r e l i a b i l i t y of the instrument, and (3) to determine the v a l i d i t y of the instrument within the time and energy constraints of t h i s study. D e f i n i t i o n of Terms "Attitudes are i m p l i c i t processes having r e c i p r o c a l l y antagonistic properties and varying i n i n t e n s i t y . " (Osgood, Suci and Tannenbaum 1957, p.190). 6 Vaginal d e l i v e r y i s b i r t h of the fetus through the vagina. Cesarean d e l i v e r y i s the b i r t h of the fetus through i n c i s i o n s i n the abdominal and uterine walls. Concept i s any word, object or stimulus sign that connotates "meaning" to i n d i v i d u a l s (Osgood, Suci and Tannenbaum 1957). In a semantic d i f f e r e n t i a l a concept i s rated by b i p o l a r a d j e c t i v a l scales. In t h i s study, Cesarean d e l i v e r y and vaginal delivery are the two designated concepts. Category r e f e r s to the combination of one concept and the bi p o l a r a d j e c t i v a l s c a l e s . The developed instrument i s comprised of two categories, Cesarean d e l i v e r y and vaginal d e l i v e r y . Third trimester r e f e r s to months seven, eight and nine of a pregnancy. Assumptions The assumptions of th i s study are: 1. That most women desire a vaginal d e l i v e r y rather than a Cesarean d e l i v e r y . 2. That the concepts vaginal d e l i v e r y and Cesarean de l i v e r y have d i f f e r e n t meanings to pregnant women and that the differences w i l l be captured by the b i p o l a r adjectives selected f o r the instrument. 3. That data c o l l e c t e d and analyzed systematically are more use f u l i n nursing assessment than information obtained informally. Limitations The l i m i t a t i o n s of t h i s study are: 1. The c r i t e r i a f o r sample s e l e c t i o n were that a l l p a r t i c i p a n t s must be i n t h e i r t h i r d trimester of pregnancy and able to read and understand the English language. A l l subjects who met these c r i t e r i a and volunteered to p a r t i c i p a t e were accepted and randomization was not attempted. 2. The instrument developed f o r t h i s study i s a s e l f - r e p o r t measure of attitude and i s , therefore, " . . . li m i t e d to what in d i v i d u a l s know about t h e i r attitudes and are w i l l i n g to r e l a t e . " (Nunnally 1978, p.591). 3. Attitudes have both a state and t r a i t component, therefore, a woman's attitude towards mode of delivery may vary depending on numerous extraneous v a r i a b l e s . The terms "st a t e " and " t r a i t " were used by Spielberger, Gorsuch and Lushene (1970) i n r e l a t i o n to anxiety, but are also applicable to other psychological concepts such as atti t u d e s . State " . . . refer s to an empirical process or reaction taking place at a p a r t i c u l a r moment i n time. . . . I t may vary i n i n t e n s i t y and fluctuate over time." (Spielberger, Gorsuch and Lushene 1970, p.3). T r a i t " . . . indicates differences i n the strength of a latent d i s p o s i t i o n to manifest a certain type of re a c t i o n . " The t r a i t component accounts for differences between people and how they respond i n s t r e s s f u l s i t u a t i o n s (Spielberger, Gorsuch and Lushene 1979, p.3). This study does not attempt to d i f f e r e n t i a t e between the two constructs but i t i s recognized that each contributes to the find i n g s . 4. Many va r i a b l e s , i n c l u d i n g the father's a t t i t u d e towards mod of d e l i v e r y , may influence a woman's a t t i t u d e . No attempt was made to measure these intervening variables i n th i s study. 8 Description of the Following Chapters This thesis i s comprised of f i v e chapters. In Chapter I I , selected l i t e r a t u r e i s reviewed under three headings: psychological implications of Cesarean delivery; variables that influence women's attitudes towards labor and delivery and a t t i t u d e measurement. Chapter I I I describes the research methodology, including the develop-ment of the instrument, data c o l l e c t i o n methods and s t a t i s t i c a l procedures. Chapter IV i s a report and discussion of the findings. Chapter V contains the summary and conclusions and discusses i m p l i -cations f o r nursing p r a c t i c e and recommendations f o r further research. CHAPTER II REVIEW OF THE LITERATURE Overvi ew The review of the l i t e r a t u r e i s presented i n three major sections. The f i r s t includes a discussion of the psychological implications of Cesarean d e l i v e r y . As the Cesarean section rate has increased, so has the l i t e r a t u r e reporting women's feeli n g s and reactions following Cesarean b i r t h . I t i s these descriptions of women's feelings following Cesarean section that were the impetus f o r the formulation of t h i s study. The second section contains a discussion of the variables that influence women's attitudes towards labor and d e l i v e r y . Some of the concerns expressed by women during pregnancy about labor and de l i v e r y and factors relevant to perceptions of the c h i l d b i r t h experience are i d e n t i f i e d . The t h i r d section comprises a de s c r i p t i o n of a semantic d i f f e r e n t i a l and a review of c r i t i q u e s of th i s method as they appear i n the l i t e r a t u r e . Psychological Implications of Cesarean Delivery "Cesarean b i r t h sometimes leaves scars, not j u s t the scar you can see on your abdomen or the one hidden away on the wa l l of your uterus but emotional scars that often l a s t j u s t as long and can hurt 9 more." (Hausknecht and Heilman 1978, p.146). Delivery of the baby by Cesarean section, rather than v a g i n a l l y , requires greater psychological adjustment for women during the postpartum period. The psychological impact varies for each i n d i v i d u a l depending on the number and i n t e n s i t y of negative fee l i n g s generated by the experience. Some inf l u e n c i n g factors that a f f e c t a woman's perception of Cesarean d e l i v e r y are cited i n the l i t e r a t u r e . Whether a Cesarean i s e l e c t i v e surgery or emergency surgery w i l l have some bearing on a woman's adjustment. Jensen, Benson and Bobak (1977) suggest three categories of patients based on these two v a r i a b l e s . The f i r s t are those who know p r i o r to labor that a Cesarean d e l i v e r y i s imminent but have.never experienced t h i s type of b i r t h . These women have a longer period of time to psychologically prepare themselves and rec o n c i l e themselves to t h i s mode of d e l i v e r y . However, they w i l l have the fear and apprehension of impending surgery along with concerns of how they w i l l be able to care for t h e i r baby as a po s t - s u r g i c a l p a t i e n t . The second group are the women who must have a repeat Cesarean section. They approach the surgery with the memories of t h e i r past experiences, and, therefore, are influenced by the amount of trauma they suffered both p h y s i c a l l y and psychologically at that time. The remaining category comprises the women who have an emergency Cesarean. For them, labor generally commences as anticipated but f o r some reason, ei t h e r related to the mother or the fetus, vaginal d e l i v e r y i s no longer considered possible and s u r g i c a l intervention ensues. I f these women have been i n labor for a long period of time they are fatigued and anxieties are increased due to concern f o r themselves and t h e i r babies. Often they f e e l cheated and devastated by the sudden change of plans. Other factors that w i l l a f f e c t women's perceptions of the experience are discussed i n the l i t e r a t u r e . Hausknecht and Heilman (1978) suggest that women are more accepting of Cesarean d e l i v e r y i f they are t o l d why the surgery i s necessary and are given an explanation of the procedure. Enkin (1977) proposes that women having Cesarean sections w i l l be able to maintain t h e i r self-esteem i f they know the reasons for doing the Cesareans are v a l i d . Donovan and A l l e n (1977) contend that poor Cesarean b i r t h experiences could be v i r t u a l l y e l i m i -nated with antenatal education, intrapartum nursing interventions and postpartum support. As the number of Cesarean d e l i v e r i e s has increased i n recent years, so have the publications describing women's feelings and reactions following t h i s mode of d e l i v e r y . The feelings commonly reported are: R e l i e f (Donovan and A l l e n 1977; Hausknecht and Heilman 1978). An i n i t i a l reaction of r e l i e f following Cesarean d e l i v e r y i s commonly experienced by most parents, p a r t i c u l a r l y when the outcome i s a healthy i n f a n t . This f e e l i n g of r e l i e f w i l l be even greater i f the woman has had a long and d i f f i c u l t labor or i f concerns for the baby's welfare, during labor, were evident. Fear (Bampton and Mancini 1973; Donovan 1978; Donovan and A l l e n 1977; Mevs 1977). Fear and increased anxiety, p a r t i c u l a r l y of something happening to mother or baby, have been expressed i n r e l a t i o n to the surgery, anes-t h e t i c s , death, pain and the unknown. Disappointment (Donovan and A l l e n 1977; Hausknecht and Heilman 1978; Schlosser 1978). Disappointment i s a common response of couples who have attended prenatal classes, prepared themselves for labor and d e l i v e r y and looked forward to the father's presence at the b i r t h . This f e e l i n g can be even greater for a woman who wishes to be awake when her infant i s born but i s given a general anesthetic f o r the Cesarean d e l i v e r y . Anger and Resentment (Bamptom and Mancini 1973; Cohen 1977; Donovan 1978; Donovan and A l l e n 1977; Hausknecht and Heilman 1978; Reynolds 1977; Schlosser 1978). Feelings of anger and resentment may be experienced but not always a r t i c u l a t e d ; they can also be direc t e d at several sources. The woman may be angry at h e r s e l f for not performing the way she wanted or for having a p e l v i s that i s too small. She may be r e s e n t f u l of the baby for being too large, assuming a wrong p o s i t i o n i n utero or becomin distressed i n labor. She may be angry at her doctor f or deciding to do a Cesarean or not giving her s u f f i c i e n t information. Anger may be directed towards the prenatal classes she attended because she f e e l s she was not warned of t h i s outcome. Some women may even f e e l r e s e n t f u l towards t h e i r husbands for making them pregnant. Gu i l t (Donovan and A l l e n 1977; Hausknecht and Heilman 1978; Schlosser 1978) . Gu i l t i s often experienced but r a r e l y expressed. A woman may f e e l g u i l t y for any of the following reasons: infrequently p r a c t i s i n g her breathing for labor; cheating her husband out of a shared vaginal d e l i v e r y ; gaining too much weight during pregnancy; not t r y i n g hard 13 enough during labor or experiencing many negative feelings even though she has a healthy i n f a n t . F a i l u r e (Cohen 1977; Conklin 1977; Donovan 1978; Hausknecht and Heilman 1978; Marut 1978; Reynolds 1977; Schlosser 1978). Some women f e e l a sense of f a i l u r e because they could not d e l i v e r normally or they could not ac t u a l l y p a r t i c i p a t e i n t h e i r infant's b i r t h . Loss of Self-Esteem (Bamptom and Mancini 1973; Cohen 1977; Conklin 1977; Donovan 1978; Hausknecht and Heilman 1978; Jensen, Benson and Bobak 1977; Marut 1978; Mercer 1977). Feelings of f a i l u r e and inadequacy can lead to lowered s e l f -esteem. For some i t may be i n the i n i t i a l postpartum period when they cannot care f o r t h e i r infant as e a s i l y as other mothers. For others, the i n a b i l i t y to d e l i v e r v a g i n a l l y may af f e c t t h e i r self-concept as a woman or others may be concerned about t h e i r body image even though the abdominal scars tend to be minimal. Affonso and S t i c h l e r (1978) conducted an exploratory study of women's reactions to having a Cesarean b i r t h . Between t h e i r second and fourth day post-delivery, 105 women were interviewed to assess t h e i r f e e l i n g s about t h e i r experiences. A repeat Cesarean section was per-formed on 35 percent of the subjects while 41 percent knew of the need for surgery f o r less than two hours. The type of Cesarean ( e l e c t i v e or emergency), the kind of anesthetic administered or p a r i t y were not control l e d , therefore, the findings may have been influenced by any or a l l of these v a r i a b l e s . Data were co l l e c t e d i n r e l a t i o n to the feeli n g s the women were able to r e c a l l about the time immediately before surgery, i n the recovery room, her feeli n g s about the perceived differences between Cesarean and vag i n a l b i r t h s and her perceptions of her husband's fe e l i n g s about Cesarean b i r t h . In addition, the subjects were asked to state the concerns and fears they experienced when they r e a l i z e d a Cesarean delivery was necessary and those they f e l t during the postpartum period. P r i o r to surgery, 92 percent of the women experienced fear related to the baby's l i f e , the surgery, the anesthesia or dying. Feelings of d i s s a t i s f a c t i o n , anger or depression were reported by 50 percent and 30 percent stated they f e l t r e l i e f of ending a prolonged labor. In the recovery room, 70 percent expressed fee l i n g s of r e l i e f and 59 percent wanted more information about the baby. A l l women f e l t that a Cesarean b i r t h was more d i f f i c u l t than a vaginal d e l i v e r y , f or the following reasons: (1) i t i s more p a i n f u l ; (2) the recovery period i s longer and more s t r e s s f u l ; (3) feelings of inadequacy or loss of womanliness develop because a Cesarean delivery i s not considered normal and (4) the mother i s unable to p a r t i c i p a t e i n the b i r t h . Some women commented that they thought there was more pain associated with labor and vaginal delivery and others thought the joys and discomforts would be equal for both modes of d e l i v e r y . The concerns and fears the women expressed when they knew a Cesarean de l i v e r y was a r e a l i t y were rel a t e d to themselves and the baby. Concerns and fears i n the postpartum period were i n reference to t h e i r r o l e as mother and wife, the longer recovery period, the baby's health, t h e i r own body image (abdominal s c a r ) , weight and future sexual and childbearing r o l e s . Affonso and S t i c h l e r b e l i e v e a woman's feeli n g s about h e r s e l f as a woman, mother and childbearer are dependent on or influenced by her perceptions of how her partner f e e l s about her. When asked how th e i r husbands reacted to the Cesarean b i r t h , 60 percent of the women stated that t h e i r husbands were concerned about them and the baby, 46 percent f e l t t h e i r husbands were disappointed about not being present for the delivery and 26 percent thought t h e i r husbands were angry because they f e l t the Cesarean had not been necessary. More than one statement was reported by some women. A comparative study of primiparas' perceptions of vaginal and Cesarean b i r t h s was conducted by Marut and Mercer (1979). The study included t h i r t y primiparas who delivered v a g i n a l l y and twenty who had an emergency Cesarean s e c t i o n . Within fo r t y - e i g h t hours a f t e r the b i r t h , the women were interviewed and completed a questionnaire i n which they were asked to rate twenty-nine items r e l a t e d to labor and deli v e r y on a f i v e point rating s c a l e . The findings i n r e l a t i o n to the questionnaire revealed that women who experienced an emergency Cesarean viewed t h e i r i n f a n t s ' b i r t h s less p o s i t i v e l y . Factors that had the greatest impact i n d i f f e r e n t i a t i n g between those who delivered v a g i n a l l y or by Cesarean section were; con-t r o l of the s i t u a t i o n , fear during delivery, worry about the baby's con-d i t i o n during labor and the time of mother-infant contact following d e l i v e r y . The Cesarean groups was further categorized depending on the type of anesthetic administered (general or regional) although the num-bers i n each of the subgroups were not reported. Evidence indicated that those who had a regional anesthetic experienced more p o s i t i v e f e e l i n g s than those who were given a general. Reported reasons for t h i s difference were attributed to the women's conscious awareness of the 16 events r e l a t e d to the de l i v e r y and the e a r l i e r i d e n t i f i c a t i o n with and claiming of the in f a n t . Although the women tended to be ambivalent i n t h e i r descriptions of vaginal d e l i v e r i e s the p o s i t i v e aspects outnumbered the negatives. Words such as "hard," " p a i n f u l , " "excruciating," " t e r r i b l e " and "horrendous" were reported as well as "miracle," "great," "marvellous," " b e a u t i f u l , " "amazing" and " e x c i t i n g . " Pride i n t h e i r management and control of labor and d e l i v e r y was expressed by most women. Eighteen of the twenty mothers who had a Cesarean b i r t h des-cribed the experience as a "shock" and a "big disappointment." The two who verbalized the l e a s t negative f e e l i n g s had the greatest d i f f i c u l t y i n r e l a t i n g to t h e i r i n f a n t s . Descriptions of the labors by the Cesarean mothers included, " f r u s t r a t i n g , " " t orture" and "not what I expected." The women who had high expectations of themselves severely c r i t i c i z e d themselves and others when they l o s t c o n t r o l . Feelings of torture and fears of death i n the d e l i v e r y room were stated by f i f t e e n of the women. These reactions were more pronounced for women who were given a general anesthetic. Feelings expressed postpartum included "being hurt by the baby" and " f e e l i n g wounded." Concerns expressed were being seen as "weak" for r e q u i r i n g a Cesarean and nurses and husbands not understanding t h e i r hesitancy i n assuming care of the i n f a n t . The need for a time to adjust to the b i r t h experience was evident. The study by Marut and Mercer i s li m i t e d to women's reported f e e l i n g s within two days following d e l i v e r y . It i s recognized that the post-operative pain and discomfort experienced by the women who had a Cesarean may have influenced t h e i r perceptions of the t o t a l exper-ience. In a study of the e f f e c t s of h o s p i t a l experience on postpartum feeli n g s and attitudes of women, Bradley (1977), compared those women experiencing a vaginal d e l i v e r y (N=73) with those who had a Cesarean d e l i v e r y (N=21) i n r e l a t i o n to attitudes towards t h e i r babies, a t t i -tudes towards t h e i r labors and d e l i v e r i e s and depressive a f f e c t . Her findings revealed that, during the immediate postpartum period and at two and s i x weeks postpartum, no d i f f e r e n c e was found between the two groups i n t h e i r attitudes towards t h e i r babies but those having a Cesarean b i r t h had a less p o s i t i v e a t t i t u d e towards t h e i r labors and d e l i v e r i e s . "Depressive a f f e c t r e f e r s to a basic f e e l i n g of sadness which i s a part of the f a b r i c of l i f e and which i s noted i n states of gr i e f and periods of disappointment." (Bradley 1977, p.113). It was measured during the l a s t month of pregnancy, the immediate postpartum period and at two and s i x weeks postpartum, using the Depression Adjective Checklist developed by Lubin (DACL). The o v e r a l l f i n d i n g was that those who had a Cesarean d e l i v e r y experienced a greater degree of depressive a f f e c t than those who had a vaginal d e l i v e r y . It i s i n t e r e s t i n g to note that, although the l e v e l . o f depressive a f f e c t was higher for the Cesarean mothers, both groups followed the same pattern u n t i l s i x weeks postpartum. Depressive a f f e c t peaked on the t h i r d day aft e r d e l i v e r y and f e l l to i t s lowest point at two weeks post-delivery. Four weeks l a t e r , the vaginal group showed l i t t l e change but the Cesarean group exhibited a sudden increase i n depressive a f f e c t . I t was suggested that the increase i n depressive a f f e c t f o r the Cesarean women may be the beginning of a continuing trend, therefore, a long-term follow-up of these women i s warranted. Similar findings are reported i n a study of the development of maternal attachment (Williams et a l . 1979). At one month postpartum there was no s i g n i f i c a n t difference between the mothers having a Cesarean or vag i n a l d e l i v e r y i n r e l a t i o n to the development of maternal attachment or maternal behavior. In the o v e r a l l sample of the study (N=189), there was a marginally s i g n i f i c a n t tendency f o r women who experienced a Cesarean b i r t h (N=40) to describe themselves as being more depressed at four weeks postpartum, than those who delivered v a g i n a l l y (N=149). However, i n a sub-sample of the study (N=86), there was no difference i n reported feelings of depression at four weeks post-del i v e r y between those who experienced a vaginal delivery (N=70) and those who had a Cesarean delivery (N=16). This group received home v i s i t s from a nurse during the postpartum period. The authors query whether the fi n d i n g of greater postpartum depression may be rela t e d to disappointment at not having achieved a vaginal d e l i v e r y . A study of 156 primiparas p a r t i c i p a t i n g i n a comprehensive p e r i n a t a l program was conducted by Bradley, Ross and Warnyca (1978). A comparison of those who delivered v a g i n a l l y and.ithose who delivered by Cesarean section (25 percent) was made for depressive a f f e c t , anxiety and attitudes towards t h e i r babies. At one month postpartum, no d i f -ferences were found between the two groups. The authors have stated that they f e e l t h i s f i n d i n g i s a r e f l e c t i o n of the comprehensive pro-gram the women were p a r t i c i p a t i n g i n . Both prenatally and postnatally the p a r t i c i p a n t s had frequent contact with, and support from, the same community health nurse. Further research i s needed to i d e n t i f y the psychological ramifications of Cesarean d e l i v e r y . Regarding her experience, Schlosser (1978, p.57) writes, " i t was three months before I overcame my negative f e e l i n g s , experienced bonding with my c h i l d , and worked through the resentment with my husband." How common are these fee l i n g s amongst women who have had a Cesarean delivery? How long does i t take them to rec o n c i l e t h i s experience? What e f f e c t do the reports of women who have had a Cesarean section have on those who are pregnant? Variables That Influence Women's Attitudes  Towards Labor and Delivery " C h i l d b i r t h i s an emotional and immeasurably complex aspect of existence, and the experience means a great deal to the in d i v i d u a l s involved both at the time i t s e l f and l a t e r " (Macfarlane 1978, p.2). A woman's attitude towards labor and delivery i s affected by many variables and these should influence the development of the instrument. Some of the variables that are i d e n t i f i e d i n the l i t e r a t u r e are d i s -cussed . Fears Related to Labor and Delivery During pregnancy women have fears about the approaching b i r t h . Clark, Affonso and Harris (1979, p.264) have i d e n t i f i e d these fears as: (1) pain df labor and delivery; (2) operative procedures (episiotomy, forceps and Cesarean section); (3) anesthetics; (4) being alone during labor and (5) a safe outcome f o r he r s e l f and her c h i l d . The r i s i n g incidence of Cesarean sections may be an a d d i t i o n a l fear for some women i f they f e e l they may be a candidate for t h i s mode of d e l i v e r y . Based on the data from studies by Marieskind (1979), 20 P e t i t t i , Olson and Williams (1979) and Williams and Hawes (1979), a des c r i p t i o n of the women whose pregnancies most frequently terminate with Cesarean d e l i v e r y i s beginning to emerge. Marieskind (1979, p.41) summarizes these findings: Although supporting data are at t h i s point scant, further study w i l l probably f i n d the Caesarean section population to be bimodally d i s t r i b u t e d according to socioeconomic c h a r a c t e r i s t i c s , although f o r widely varying reasons. What data do exi s t suggest that women with the least and the most education, women with the lowest and the highest incomes, women of the youngest and the oldest ages, women with the lowest and highest p a r i t y , women with p u b l i c insurance and women with the most comprehensive pr i v a t e insurance, women who have no prenatal care and women who have the most prenatal care, and women who use general municipal hospitals and women who use exclusive private h o s p i t a l s have the highest incidence of Caesarean sections. Another source of fear i n r e l a t i o n to Cesarean delivery i s reports of increased r i s k to both mother and inf a n t with this mode of d e l i v e r y . When compared with vaginal d e l i v e r i e s , the incidence of maternal death has been c i t e d as being twice as great ( P e t i t t i , Olson and Williams 1979), to twenty-six times as great (Evrard and Gold 1977), for women delivered by Cesarean se c t i o n . Maternal morbidity i s also increased. In a study of Cesarean d e l i v e r i e s done in a p u b l i c h o s p i t a l , Hibbard (1975) reported that 50 percent of the patients had one or more oper-ative complications, many being s u f f i c i e n t l y severe to a f f e c t further childbearing. The most common complications are inf e c t i o n s of the i n c i s i o n , uterus and bladder, hemorrhage and adhesions (Hausknecht and Heilman 1978; Marieskind 1979). It i s generally believed by physicians that Cesarean sections have contributed to improved p e r i n a t a l morbidity and mortality rates although the causal r e l a t i o n s h i p has not been established (Marieskind 1979, p.108). Evidence does p e r s i s t that infants delivered by Cesarean section are at higher r i s k for developing re s p i r a t o r y d i s t r e s s syndrome (Marieskind 1979; P e t i t t i , Olson and Williams 1979). F e t a l mortality d i r e c t l y related to Cesarean section i s d i f f i c u l t to ascertain because the cause of death may be due to events that l e d to the surgery and not the surgery i t s e l f . A study i n the United States i n 1974 and 1975 indicates that for f u l l - t e r m infants delivered by Cesarean section a c a s e - f a t a l i t y rate of 34 per 10,000 occurred whereas for vaginal b i r t h s the rate was 12 per 10,000 (Marieskind 1979, p.60). To-day, there seems to be an increasing number of primiparous women who are t h i r t y years of age or more, w e l l educated and have sought early prenatal care, often from a s p e c i a l i s t . They are aware that they belong to the group of women i d e n t i f i e d as those most frequently requiring a Cesarean section. They also know of the increased r i s k s t h i s mode of d e l i v e r y presents for them and t h e i r i n f a n t s . The fears and anxieties these women often have of Cesarean delivery are j u s t i f i e d and may influence t h e i r attitudes towards mode of de l i v e r y . Active P a r t i c i p a t i o n During Labor The importance of active p a r t i c i p a t i o n i n the b i r t h process i s discussed by several authors. Deutsch (1945, p.225) states that "women's contribution i n delivery i s manifested not only by the product - the c h i l d - but above a l l by her active p a r t i c i p a t i o n i n the b i r t h . " In a d e s c r i p t i o n of the second stage of labor, Kopp (1971, p.1143) suggests that a " . . . mother gains s a t i s f a c t i o n from p a r t i c i p a t i n g a c t i v e l y and capably i n the deli v e r y of her baby." Moore (1978, p.365) contends that "active p a r t i c i p a t i o n usually leads to joy and heightened self-esteem f o r both mother and father." The s i g n i f i c a n c e of t h i s con-cept i s validated i n a study by Davenport-Slack and Boylan (1974). Their findings revealed that "the most underlying f a c t o r contributing to a p o s i t i v e c h i l d b i r t h experience appears to be the woman's desire to be an active p a r t i c i p a n t i n her labor and d e l i v e r y . " (Davenport-Slack and Boylan 1974, p.215). Loss of Control During Labor Loss of control has been i d e n t i f i e d by Coleman and Coleman (1971) as the most important psychological aspect of the experience of labor. This i s v e r i f i e d i n Willmuth's study (1975) of 145 women who had attended c h i l d b i r t h education classes and delivered v a g i n a l l y . She reported that the major factor associated with a p o s i t i v e c h i l d b i r t h experience was the woman's perception that she had been able to maintain control during labor and d e l i v e r y . Conversely, the loss of cont r o l was viewed as a very negative experience. Control of d i f f e r e n t aspects of the experience was defined as control of pain, control of one's emotions and actions and control i n the interpersonal r e l a t i o n s h i p s with the s t a f f . This l a t t e r type of control was interpreted as the woman having influenced decisions made during labor and deli v e r y and was related to the feelings of active p a r t i c i p a t i o n i n the process. The two factors that were c i t e d as being most important i n helping the mothers maintain control were the presence of her husband or coach during labor and a l l content included i n c h i l d b i r t h education classes. P a r i t y Research findings i n d i c a t e that p a r i t y influences a woman's attitude towards the b i r t h experience. In a study of maternal attitudes and t h e i r r e l a t i o n s h i p to behaviour during pregnancy and de l i v e r y , Winokur and Werboff (1956) reported that the primiparous women (N=69) 23 i n t h e i r study were l e s s apprehensive about labor and deli v e r y than the multiparous women (N=55) . Similar findings were described i n a recent study by Norr et a l . (1979). During pregnancy, the multiparous women (N=131) indicated they were more worried about c h i l d b i r t h than the primiparous women (N=118). The r e l a t i o n s h i p of p a r i t y and women's reactions to childbearing was studied r e t r o s p e c t i v e l y by Westbrook (1978). The findings of t h i s study include the following: (1) the multiparous women (N=108) had s i g n i f i c a n t l y more fear of p h y s i c a l i n j u r y and tiss u e damage than the primiparous women (N=92) and (2) that as p a r i t y increased the p h y s i c a l problems of fatigue, nausea and awkwardness increased; the women's feelings of well-being decreased and p o s i t i v e reactions from the extended family decreased. Willmuth concludes that "childbearing i s an event arousing both strong p o s i t i v e and negative emotional reactions and there i s no lessening of the arousal with successive b i r t h s . " (Westbrook 1978, p.169). Cul t u r a l B e l i e f s and Values and L i f e Experiences I n d i v i d u a l perceptions and reactions are dependent on l i f e experiences and the general b e l i e f s , values and attitudes of the society or culture i n which one l i v e s . Those related to childbearing may influence a woman's attitude towards labor and d e l i v e r y . Clark, Affonso and Harris (1979) suggest that c h i l d b i r t h w i l l be viewed as a meaningful event i f : (1) the culture or society emphasizes c h i l d b i r t h as a s i g n i f i c a n t l i f e experience, for example, i f c h i l d r e n are valued and women receive status or prestige through childbearing and (2) i f ind i v i d u a l s believe that s e l f - f u l f i l l m e n t can occur through c h i l d b i r t h . 24 Conversely, c h i l d b i r t h w i l l not be as meanintful i f : (1) i t i s viewed i n a society as a s t r e s s f u l event e i t h e r because of the dangers related to labor and de l i v e r y or b e l i e f s about overpopulation; (2) negative experiences are emphasized through s t o r i e s of d i f f i c u l t labors and (3) attitudes are negative toward the feminine r o l e i n r e l a t i o n to repro-duction, for example, " . . . i f motherhood i s not a desired r o l e , labor can be very threatening." (Clark, Affonso and Harris 1979, p.347). Jensen, Benson and Bobak (1977, p.138) further discuss l i f e exper-iences re l a t e d to childbearing. Those i d e n t i f i e d include: (1) childhood memories of mothering; (2) b e l i e f s and values r e l a t e d to expression of the feminine r o l e , f o r example, motherhood versus career or dependent versus independent; (3) experiences sought by some i n d i v i d u a l s because they are important to t h e i r self-esteem; (4) past experiences providing r o l e learning, f or example, babysitting; (5) negative or p o s i t i v e r e l a -tionships with r o l e models; (6) the choice of pregnancy provided by b i r t h control and (7) l i m i t e d support systems both economical and s o c i a l . Some of the variables that may influence a woman's attitude towards mode of deli v e r y have been i d e n t i f i e d . Because the variables are perceived d i f f e r e n t l y by each i n d i v i d u a l , attitudes vary, both i n the way they are f e l t ( p o s i t i v e or negative) or i n the i n t e n s i t y of these f e e l i n g s . In assessing women's attitudes towards mode of delivery i t i s important to u t i l i z e a method that w i l l be s e n s i t i v e to both the d i f -ferences and i n t e n s i t i e s . This was one c r i t e r i o n for the s e l e c t i o n of a s u i t a b l e a t t i t u d e measurement technique. The other c r i t e r i a were r e l i a b i l i t y and ease of administration. An Attitude Measurement Technique For the assessment instrument, the technique chosen f o r a t t i t u d e measurement was a semantic d i f f e r e n t i a l , developed by Osgood, Suci and Tannenbaum (1957). It i s " . . . a method of observing and measuring the psychological meaning of concepts." (Kerlinger 1973, p.566). "Psychological meaning describes a person's subjective perception and a f f e c t i v e reactions to segments of language." (Szalay and Deese 1978), p.2). Individuals communicate t h e i r f e e l i n g s or impressions through use of adjectives. "If i t i s reasonable to assume that much of 'meaning' can be and usually i s , communicated with adjectives, i t i s also reasonable to assume that adjectives can be used to measure facets [aspects] of meaning." (Nunnally 1978, p.608). The variance i n meaning, such as good-bad or posdtive-negative, i s expressed through bi p o l a r adjectives. The i n t e n s i t y of the variance i n e i t h e r d i r e c t i o n can be i l l u s t r a t e d by employing a r a t i n g scale between each p a i r of adjectives. A semantic d i f f e r e n t i a l i s comprised of selected concepts and a c o l -l e c t i o n of scales anchored by b i p o l a r adjectives that are used to d i r e c t l y rate the concepts both i n d i r e c t i o n ( p o s i t i v e or negative) and i n t e n s i t y . In t h i s study the concepts are Cesarean de l i v e r y and vaginal d e l i v e r y . The r a t i n g of each concept on each a d j e c t i v a l scale designates a point for that concept i n a conceptualized space that Osgood c a l l s a semantic space (Osgood, Suci and Tannenbaum 1957). This space i s defined by the sample of the s p e c i f i c a d j e c t i v a l scales used. Because each scale represents a s t r a i g h t l i n e function passing through the o r i g i n s of the space, a multidimensional area i s created. Each r a t i n g of a concept on an a d j e c t i v a l scale l o c a l i z e s that concept at a point i n a semantic space. "Differences i n the meaning between two concepts i s then merely the function of the differences i n t h e i r semantic a l l o c a t i o n s within the same space, i . e . , i t i s a function of the multidimensional distance between the two po i n t s . " (Osgood, Suci and Tannenbaum 1957, p.25). To s i m p l i f y the multidimensionality created by the coordinates representing the a d j e c t i v a l s c a l e s , Osgood conducted numerous factor, a n a l y t i c investigations of the a d j e c t i v a l s c a l e s . It was found that c e r t a i n b i p o l a r adjectives c l u s t e r to form groups or f a c t o r s . The extracted factors that represent the a d j e c t i v a l scales can then be designated as the dimensionality of a semantic space. Three major factors that consistently appear i n the Osgood studies, i n d i c a t i n g three dimensions of meaning are c a l l e d evaluation, potency and a c t i v i t y . The evaluative factor i s the most prominent and has been found to account f o r at least one-half to three-quarters of the extractable variance, whereas potency and a c t i v i t y account f o r much less (Osgood, Suci and Tannenbaum 1957). In one s p e c i f i c study (Osgood 1976, p.19), evaluation was designated as accounting f o r 70 percent, potency 15 percent and a c t i v i t y 12 percent of the common variance. Nunnally (1978) reports two a d d i t i o n a l factors that he has found to be s i g n i f i c a n t , depending on the nature of the research. The f a c t o r , f a m i l i a r i t y , has been important f o r the s c a l i n g of s t i m u l i to be used i n controlled experiments and a factor c a l l e d anxiety-stress has been useful i n studying subjective f e e l i n g s of anxiety i n r e l a t i o n to s t r e s s f u l s i t u a t i o n s . A semantic d i f f e r e n t i a l i s recognized as a valuable technique i n obtaining measures of attitudes and sentiments (Kerlinger 1973; Nunnally 1978). Attitude i s described by Osgood, Suci and Tannenbaum (1957, p.190) " . . . as a learned i m p l i c i t process which i s p o t e n t i a l l y b i p o l a r , varies i n i t s i n t e n s i t y , and mediates evaluative behavior, . . . Therefore, the evaluation factor, measured by i t s r e l a t e d a d j e c t i v a l scales i s p a r t i c u l a r l y u s e f u l i n representing an i n d i v i d u a l ' s a t t i t u d e towards a concept, both i n d i r e c t i o n and i n t e n s i t y . Osgood, Suci and Tannenbaum (1957, p.198) suggest that attitudes are given a d d i t i o n a l meaning when scales representing other factors are included i n the measurement. The combination of the evaluation factor with the other dimensions provides a better representation. In reviewing the l i t e r a t u r e r e l a t e d to the general use of a semantic d i f f e r e n t i a l , a compilation of many studies u t i l i z i n g the technique and c r i t i q u e s of the method i s presented by Snider and Osgood (1969). The response to t h i s technique of those conducting research i n r e l a t i o n to psychological meaning i s favourable. Jenkins (1966) describes the relevance of a semantic d i f f e r -e n t i a l as a measurement technique i n the health f i e l d . He states i t i s u s e f u l i n obtaining " . . . quantitative estimates of health-relevant perceptions whose q u a l i t y and i n t e n s i t y are often d i f f i c u l t for respondents to v e r b a l i z e . " (Jenkins 1966, p.550). Modified versions of the technique have been found valuable i n studies of b e l i e f s about diseases, both i n r e l a t i o n to how s p e c i f i c diseases are perceived and how these perceptions may vary amongst d i f f e r e n t cultures. 28 The most frequent c r i t i c i s m of a semantic d i f f e r e n t i a l i s the question of whether i t adequately measures meaning. Weinreich (1958) and C a r r o l l (1959) both e s t a b l i s h that a semantic d i f f e r e n t i a l does not measure r e f e r e n t i a l meaning, however, Osgood does not make t h i s claim. Most authors and researchers concur that i t measures psych-o l o g i c a l meaning ( C a r r o l l 1959; Snider and Osgood 1969; Szalay and Deese 1978) . Weinrich further challenges t h i s and suggests that a semantic d i f f e r e n t i a l measures some aspect of the a f f e c t of words, t h e i r "emotive i n f l u e n c e " and t h e i r power to produce e x t r a - l i n g u i s t i c emotional reactions (Weinrich 1958). He recognizes the r e l i a b i l i t y of the evaluative factor but states t h i s i s a measure of a f f e c t or attitude but not meaning. Szalay and Deese (1978) applaud a semantic d i f f e r e n t i a l f o r i t s measurement of psychological meaning but c r i t i c i z e i t s f i x e d -response format. Using a semantic d i f f e r e n t i a l f o r a base, they have replaced the technique with "the method of asso c i a t i v e group a n a l y s i s , " a free response technique using word association. This new method i s generally more cumbersome to administer and more d i f f i c u l t to analyse. The dimensionality of a semantic space i s discussed by C a r r o l l (1959). He f e e l s that i n order to e s t a b l i s h the dimensions, one must adequately sample the e n t i r e space and t h i s has not yet been accom-plis h e d . On the other hand, C a r r o l l i s generally supportive of a semantic d i f f e r e n t i a l as a measurement method and praises Osgood for i d e n t i f y i n g a manageable set of dimensions f or describing the meaning of adjectives ( C a r r o l l 1959, p.73). He urges that more research should be undertaken u t i l i z i n g t h i s technique. Summary and Conclusions During the past three years, a number of studies describing women's feelings and reactions following Cesarean d e l i v e r y have been published. These feelings and reactions are i d e n t i f i e d as: r e l i e f , fear, disappointment, anger and resentment, g u i l t , f a i l u r e , loss of self-esteem and increased depressive a f f e c t . With the r i s e i n i n c i -dence of Cesarean sections, pregnant women are faced with a greater p r o b a b i l i t y of experiencing t h i s type of d e l i v e r y . Because of the negative f e e l i n g s and reactions reported by some women following a Cesarean sec t i o n , assessment of women's attitudes, during pregnancy, to both Cesarean and vaginal d e l i v e r y i s considered important. I n t e r -ventions could then commence for women that were i d e n t i f i e d as having very negative or very p o s i t i v e attitudes towards ei t h e r mode of d e l i v e r y . A search of the l i t e r a t u r e did not reveal a s u i t a b l e method for assess-ment . Women's attitudes towards mode of deli v e r y w i l l be influenced by many variables related to childbearing. Several have been discussed i n the l i t e r a t u r e . They are: fear of labor and del i v e r y , active p a r t i c i -pation during labor, loss of control during labor, p a r i t y and c u l t u r a l values and b e l i e f s and l i f e experiences. It was these variables and the feelings and reactions reported by women following Cesarean b i r t h that provided the basis for the s e l e c t i o n of the b i p o l a r adjectives used i n the instrument. A semantic d i f f e r e n t i a l technique was chosen for the framework of the instrument. Differences and i n t e n s i t i e s i n fe e l i n g s and reactions perceived by i n d i v i d u a l s , are captured by t h i s method, therefore, i t i s considered a valuable technique for a t t i t u d e assessment. CHAPTER III RESEARCH METHODOLOGY Overview An instrument based on a semantic d i f f e r e n t i a l technique was developed to assess women's attitudes towards Cesarean and vaginal d e l i v e r y . The sample was obtained from prenatal classes i n the greater Vancouver area; a l l p a r t i c i p a n t s were women i n t h e i r t h i r d trimester of pregnancy. The data were subjected to s t a t i s t i c a l procedures to deter-mine the following: (1) the r e l i a b i l i t y of the instrument; (2) the distance i n a semantic space between the two modes of delivery; (3) the most relevant factors comprising the instrument and (4) the a d j e c t i v a l scales that were the best discriminators between Cesarean delivery and vaginal d e l i v e r y . The r e s u l t s from a c r i t e r i o n measure and the Cesarean delivery scores of the instrument were correlated to ascer t a i n concurrent v a l i d i t y of the Cesarean delivery category of the instrument. Demographic data were analyzed to describe the sample. Development of the Instrument A semantic d i f f e r e n t i a l u t i l i z e s a c o l l e c t i o n of bi p o l a r adjec-t i v a l scales that rate concepts. Any object that can be named may be a concept (Nunnally 1978, p.608). Since scales and concepts i n t e r a c t d i f f e r e n t l y , depending on the concept being judged, a semantic d i f f e r -e n t i a l should be developed for every s i t u a t i o n . In t h i s study a semantic 30 31 d i f f e r e n t i a l was used to investigate pregnant women's attitudes towards mode of d e l i v e r y . Cesarean de l i v e r y and vaginal d e l i v e r y were the con-cepts selected. Each concept, or mode of de l i v e r y and the c o l l e c t i o n of bi p o l a r a d j e c t i v a l scales formed one category of the instrument. Two c r i t e r i a dictated the choice of the b i p o l a r a d j e c t i v a l s c a l e s . F i r s t , adjectives were selected that represent relevant f a c t o r s , based on research by Osgood, Suci and Tannenbaum (1957) and Nunnally (1978). Second, i t was important that the adjectives have face v a l i d i t y i n r e l a -t i o n to women's descriptions of Cesarean or vag i n a l delivery as reported i n the l i t e r a t u r e . Factors represent a d j e c t i v a l scales that have been found to clu s t e r together i n fac t o r a n a l y t i c studies. The four factors chosen were evaluation, potency, a c t i v i t y and anxiety-stress. The f i r s t three factors are suggested by the Osgood studies as being the factors that account f o r the greatest proportion of the t o t a l variance i n the measurement of meaning. Anxiety-stress (Nunnally 1978, p.612) was included because of i t s appropriateness to the concepts being studies. The b i p o l a r adjectives that represent each f a c t o r are presented i n Table 1. The evaluation factor/has been found to be the most valuable i n the measurement of attitudes (Kerlinger 1973; Nunnally 1978; Osgood, Suci and Tannenbaum 1957), therefore, one-half of the t o t a l b i p o l a r adjectives were chosen to represent t h i s f actor. A seven step scale was used to separate the b i p o l a r adjectives. Kerlinger (1973), Nunnally (1978), and Osgood, Suci and Tannenbaum (1957) have suggested t h i s i s an e f f e c t i v e r a t i n g measure for a semantic d i f f e r e n t i a l . I t permits a subject to indicate a ne u t r a l response (the middle i n t e r v a l ) or to report three degrees of i n t e n s i t y i n either a p o s i t i v e or negative d i r e c t i o n . The i n s t r u c t i o n s (see Appendix B) 32 TABLE 1 BIPOLAR ADJECTIVES REPRESENTING EACH FACTOR F a c t o r B i p o l a r A d j e c t i v e s E v a l u a t i o n Potency A c t i v i t y A n x i e t y - s t r e s s s u c c e s s f u l - u n s u c c e s s f u l o p t i m i s t i c - p e s s i m i s t i c t i m e l y - u n t i m e l y m e a n i n g f u l - m e a n i n g l e s s h e a l t h y - s i c k p o s i t i v e - n e g a t i v e c o m p l e t e - i n c o m p l e t e p l e a s u r a b l e - p a i n f u l i m p o r t a n t - u n i m p o r t a n t good-bad f r e e - c o n t r a i n e d l e n i e n t - s e v e r e strong-weak i n t e n t i o n a l - u n i n t e n t i o n a l a c t i v e - p a s s i v e simple-complex calm-anxious u n d i s t u r b e d - d i s t u r b e d u n a f r a i d - a f r a i d q u i e t - u p s e t describe to the p a r t i c i p a n t how she should i n d i c a t e her response on the a d j e c t i v a l scale i n r e l a t i o n to the mode of d e l i v e r y being judged. The sequence of the a d j e c t i v a l scales on the instrument (see Appendix C) was determined by random s e l e c t i o n . In order to counteract possible response bias tendencies of p a r t i c i p a n t s checking a l l scales at the same i n t e r v a l , ten a d j e c t i v a l scales were randomly chosen for r e v e r s a l . Those scales reversed were the second, t h i r d , f i f t h , seventh, tenth, twelfth, t h i r t e e n t h , f i f t e e n t h , eighteenth and twentieth, as l i s t e d on the instrument. Each mode of d e l i v e r y with the a d j e c t i v a l scales was presented on a separate page (see Appendix C). The order of presentation of the pages was reversed i n one-half of the instruments to counteract a possible reponse b i a s . The instruments were randomly d i s t r i b u t e d to the p a r t i c i p a n t s . Each i n t e r a c t i o n of a mode of delivery with an a d j e c t i v a l scale i s considered one item, therefore, the instrument was comprised of fo r t y items (two modes of delivery times twenty s c a l e s ) . According to Nunnally (1978, p.605), t h i s i s an adequate, number of items for the measurement of a t t i t u d e s . In addition to the instrument, each subject was asked to provide demographic data (see Appendix D). Information considered relevant was age, p a r i t y , previous d e l i v e r y experience, years of education and economic status based on the family's t o t a l annual income. A gl o b a l question, " I f your baby i s born by Cesarean de l i v e r y how do you think you w i l l f e e l ? " was also included. This served as a c r i t e r i o n measure for c o r r e l a t i o n with the Cesarean delivery scores to determine con-current v a l i d a t i o n . 34 Selec t i o n of the Sample Nunnally (1970, p.279) recommends that i n test construction, a sample of ten times as many subjects as items i s desirable but that f i v e times as many subjects as items i s t o l e r a b l e . Since the i n s t r u -ment has fo r t y items, a minimum number of two hundred subjects was required f o r the study. Prenatal classes, located throughout the City of Vancouver, i n North and West Vancouver and i n the Municipality of Burnaby, sponsored by health units and a pri v a t e association, were the sample source. P a r t i c i p a t i o n was voluntary and anonymous. In a covering l e t t e r (see Appendix A), each subject was informed of the following: (1) the nature of the research; (2) that she could withdraw from the study at any time; (3) that a l l data were c o n f i d e n t i a l and (4) that non-participation would not a f f e c t the subject's r e l a t i o n s h i p with her prenatal i n s t r u c t o r . Because p a r t i c i p a t i o n was voluntary, consent of the subject was implied when she agreed to complete the instrument and demographic data form. C o l l e c t i o n of the Data The coordinators, responsible f o r the prenatal programs at the health units included i n the study and the Vancouver C h i l d b i r t h Association were contacted to obtain schedules of prenatal classes that were pr i m a r i l y comprised of women i n t h e i r t h i r d trimester of pregnancy. The in v e s t i g a t o r contacted the prenatal i n s t r u c t o r s to explain to them the nature of the study and ask t h e i r permission to attend one of t h e i r classes. If they complied, the i n s t r u c t o r was asked to s e l e c t the class and time most s u i t a b l e f o r the v i s i t . The 35 times most frequently suggested were the mid-time break or the end of the c l a s s . At the prenatal class the i n v e s t i g a t o r explained to those i n attendance the purpose of the study and the c r i t e r i a f o r p a r t i c i p a t i o n . The subjects were asked to volunteer and i t was observed that the majority of the women i n the cl a s s responded. The instrument, covering l e t t e r , i n s t r u c t i o n s , demographic data form and an envelope were d i s t r i b u t e d to interested p a r t i c i p a n t s who were asked to complete the requested information at that time. The i n v e s t i g a t o r was a v a i l a b l e during t h i s period to answer questions. The respondents were instructed to enclose t h e i r completed instrument and demographic data form i n the envelope provided and place i t i n a large manila envelope l e f t i n a convenient l o c a t i o n i n the classroom. S t a t i s t i c a l Procedures A l l data were analyzed using computer programs designed f o r the S t a t i s t i c a l Package for the S o c i a l Sciences (SPSS) (Nie et a l . 1975) . An explanation of the procedures employed and the purposes for the analyses follows: Multiple Regression Analysis "Multiple regression i s a method of analyzing the c o l l e c t i v e and separate contributions of two or more independent variables to the v a r i a t i o n of a dependent v a r i a b l e . " (Kerlinger and Pedhazur 1973, p.3). In t h i s study, separate analyses were performed for the two dependent v a r i a b l e s , Cesarean d e l i v e r y and vaginal d e l i v e r y , with four independent v a r i a b l e s , the factors evaluation, potency, a c t i v i t y and anxiety-stress. Since the i n v e s t i g a t o r wished to determine the best p r e d i c t i o n equation using the minimum number of f a c t o r s , the forward stepwise multiple regression procedure was employed. In t h i s s o l u t i o n the c o r r e l a t i o n s of a l l the factors with the dependent v a r i a b l e are computed. The f a c t o r that correlates most highly with the dependent v a r i a b l e i s then entered i n t o the regression equation. In successive steps, each factor i s added to the equation i n the order of the one contributing the greatest increment to the R 2 a f t e r taking i n t o account the factor(s) already i n the equation. Before entering the equation each factor must also s a t i s f y a predetermined c r i t e r i o n . In t h i s study, an F r a t i o s i g n i f i c a n t at the 0.01 l e v e l was required for the regression c o e f f i c i e n t to be added. The r e s u l t of t h i s analysis i n d i -cates the optimum combination of the independent v a r i a b l e s that account for the greatest variance on the dependent v a r i a b l e . This information i s also u s e f u l i n r e l a t i o n to the r e l i a b i l i t y of the instrument, for the factors that contribute most to the p r e d i c t i o n equation are the most r e l i a b l e . R e l i a b i l i t y " R e l i a b i l i t y i s the accuracy or p r e c i s i o n of a measuring instrument." (Kerlinger 1973, p.443). The subprogram r e l i a b i l i t y i n the SPSS system i s designed to evaluate the r e l i a b i l i t y of m u l t i p l e -item additive scales through computation of c o e f f i c i e n t s of r e l i a b i l i t y ( H u l l and Nie 1979, p.110). An i n d i v i d u a l estimate of r e l i a b i l i t y was established for the four factors i n r e l a t i o n to each of the two modes of d e l i v e r y . A two way analysis of variance (items by subjects) by factors was employed to determine error variance and t o t a l variance from which the standardized item alpha was computed. This r e l i a b i l i t y 37 c o e f f i c i e n t i s c l o s e l y related to Cronbach's alpha. In essence, the observations on each item are standardized by d i v i d i n g them by the standard deviation of the item, for use i n the computational formula (Hull and Nie 197 9, p.126). S p a t i a l Distance Between the Two Concepts The semantic s i m i l a r i t y or d i f f e r e n t i a t i o n of the concepts Cesar-ean d e l i v e r y and vaginal d e l i v e r y was determined by measuring the distance between the p o s i t i o n each occupies i n a semantic space. This space i s geometrically defined by the coordinates of the four f a c t o r s , evaluation, potency, a c t i v i t y and anxiety-stress and i s , therefore, four dimensional. The distance was computed using the generalized distance formula of s o l i d geometry. Where D-iZ i s the l i n e a r distance between the points i n the semantic space representing concepts i. and £ and d<LZ i s the algebraic d i f f e r e n c e between the coordinates of -L and t on the same dimension or factor /. Summation i s over the k dimensions. (Osgood, Suci and Tannenbaum 1957, p.91) Discriminant Function Analysis Discriminant function analysis provides information that i s u s e f u l i n s t a t i s t i c a l l y d i s t i n g u i s h i n g two i d e n t i f i e d groups. Three separate pro-cedures were performed. The intent of the f i r s t was to determine which of the a d j e c t i v a l scales were the best discriminators i n the semantic meaning of Cesarean de l i v e r y and vaginal d e l i v e r y . The purpose of the second and t h i r d analyses was to i d e n t i f y the a d j e c t i v a l scales that were the best discriminators between the high and low scores on the Cesarean d e l i v e r y and v a g i n a l d e l i v e r y categories of the instrument. I t i s these scales that contribute the most to the s e n s i t i v i t y of each category. 38 "The mathematical objective of discriminant analysis i s to weight and l i n e a r l y combine the discriminating v a r i a b l e s i n some fashion so the groups are forced to be as s t a t i s t i c a l l y d i s t i n c t as p o s s i b l e . " (Nie et a l . 1975, p.435). The l i n e a r equation that i s formed i s c a l l e d the discriminant function. A stepwise s e l e c t i o n method was u t i l i z e d i n these analyses. This means the independent v a r i a b l e (the a d j e c t i v a l scale) with the greatest d i s c r i m i n a t i n g power was selected to enter the equation f i r s t and t h i s procedure continued u n t i l the optimum set of variables f o r d i s c r i m i n a t i o n was selected. The c r i t e r i o n used to s e l e c t the variables was the " . . . o v e r a l l m u l t i v a r i a t e F r a t i o f o r the test of differences among the group centroids." (Nie et a l . 1975, p.447). V a l i d i t y " V a l i d i t y i s concerned with the extent to which a technique a c t u a l l y measures what i t was intended to measure." (Lovel and Lowes 1970, p.65). V a l i d a t i o n i s an ongoing process and i s a matter of degree rather than being absolute. The v a l i d i t y of an instrument can be determined i n d i f f e r e n t ways. This study was p r i m a r i l y concerned with content v a l i d i t y of the instrument and concurrent v a l i d i t y of the Cesarean d e l i v e r y category. "Content v a l i d i t y i s the representativeness or sampling adequacy of the content - the substance, the matter, the topics - of a measuring instrument." (Kerlinger 1973, p.458). Nunnally (1978, p.92) suggests "the two major standards f o r ensuring content v a l i d i t y are: (1) a representative c o l l e c t i o n of items and (2) sensible methods of test construction." Both these c r i t e r i a were addressed i n the develop-ment of the instrument. 39 Concurrent v a l i d i t y i s one aspect of p r e d i c t i v e v a l i d i t y i n that i t p redicts the present s i t u a t i o n . A synonymous term frequently used i s c r i t e r i o n - r e l a t e d v a l i d i t y which Kerlinger (1973, p.459) states " . . . i s studied by comparing test or scale scores with one or more external v a r i a b l e s , or c r i t e r i a , known or believed to measure the at t r i b u t e under study." A p o s i t i v e and s i g n i f i c a n t c o r r e l a t i o n of the two measures w i l l i n d i c a t e concurrent or c r i t e r i o n - r e l a t e d v a l i d i t y . To ascertain concurrent v a l i d i t y of the Cesarean d e l i v e r y category of the instrument, the c r i t e r i o n measure used was a global question asking, " I f your baby i s born by Cesarean d e l i v e r y , how do you think you w i l l f e e l ? " The response from the glo b a l question and the scores from the Cesarean d e l i v e r y category were correlated using Spearman's rho, a nonparametric c o r r e l a t i o n c o e f f i c i e n t . For t e s t i n g the s i g n i f i c a n c e of the re l a t i o n s h i p of the two measures a s i g n i f i c a n c e l e v e l of 0.01 was chosen. I t i s recognized that concurrent v a l i d i t y i s only as r e l i a b l e as the c r i t e r i o n measure employed. Anticipated feelings of s a t i s f a c t i o n or d i s s a t i s f a c t i o n of having a Cesarean d e l i v e r y should be r e f l e c t e d i n a woman's attitude towards this mode of d e l i v e r y , therefore, the global question i s considered to have face v a l i d i t y . It was f e l t that the use of the procedures discussed above would provide for the most accurate analysis of this type of instrument. The following chapter presents the fi n d i n g s . CHAPTER IV FINDINGS AND DISCUSSION Description of the Sample During a two month period the inv e s t i g a t o r v i s i t e d twenty-six prenatal classes i n the greater Vancouver area. The number of women attending each class varied from f i v e to f i f t e e n . The instrument was di s t r i b u t e d and c o l l e c t e d as described i n Chapter I I I . Of the 220 instruments returned, eighteen (8 percent) were incomplete, leaving a sample s i z e of 202. Of the 202 instruments 50 percent (N=101) had the Cesarean d e l i v e r y category presented f i r s t . Prenatal classes conducted by the Vancouver C h i l d b i r t h Association, a priv a t e agency, were attended on the North Shore and i n the Municipality of Burnaby. The government sponsored classes were those provided by the City of Vancouver Health Department and the North Shore Union Board of Health. These classes were located i n seven health units throughout Vancouver and North and West Vancouver ( i d e n t i f i e d as the North Shore). The composition of the sample i n r e l a t i o n to type of agency sponsoring the class and the geographic locations of the classes are reported i n Table 2. Age, education and income of the pa r t i c i p a n t s i s presented i n Table 3 and p a r i t y and previous de l i v e r y experience of the women i s shown i n Table 4. 40 41 TABLE 2 COMPOSITION OF THE SAMPLE ACCORDING TO GEOGRAPHIC LOCATION AND TYPE OF AGENCY (N=202) Number of % of Obtained Subjects Sample Type of Agency Government 160 , 79 Private 42 21 202 100 Geographic Location of  Prenatal Class City of Vancouver West Health Unit 23 11.4 East Health Unit 11 5.4 South Health Unit 18 8.9 North Health Unit 09 4.5 Mid-Main Health Unit 17 8.4 Burrard Health Unit 28 13.9 Robson Health Unit 13 6.4 North Shore 58 28.7 Burnaby 25 12.4 202 100.0 42 TABLE 3 COMPOSITION OF THE SAMPLE ACCORDING TO AGE, EDUCATION AND INCOME (N=202) Number of Subjects % of Obtained Sample Age 16-19 years 20-24 years 25-29 years 30-34 years 35-39 years 3 47 89 51 12 202 1.5 23.3 44.1 25.2 5.9 100.0 Education 8-10 grades completed 11-12 grades completed Community college or t e c h n i c a l school completed University degree completed Post baccalaureate degree completed 10 73 52 56 11 202 5. 36. 25. 27. 5. 100.0 Combined Annual Income (Mother and Partner) Less than $5,000 $5,000 - $9,999 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 or over 3 11 11 29 35 43 25 45 1. 5, 5. 14. 17. 21. 12. 22. 202 100.0 43 TABLE 4 COMPOSITION OP THE SAMPLE ACCORDING TO PARITY AND DELIVERY EXPERIENCE (N=202) Number of % of Obtained Subj ects Sample Primiparous 168 83.2 Multiparous One previous vaginal d e l i v e r y 26 12.8 Two previous vaginal d e l i v e r i e s 4 2.0 Three previous vaginal d e l i v e r i e s 2 1.0 One previous Cesarean de l i v e r y 2 1.0 202 100.0 The majority of the women p a r t i c i p a t i n g i n the study were twenty years of age or over (98.5 percent), had completed at le a s t grade eleven i n school (95 percent) and were pregnant with t h e i r f i r s t c h i l d (83.2 percent). An annual income of $15,000 or more for the woman and her partner was reported by 87.8 percent and 56.0 percent earned more than $25,000. The number of r e l a t i v e l y high incomes reported may be r e f l e c -t i v e of the families i n which both partners work. It i s worth noting that only a few families could have been either unemployed or rec e i v i n g government assistance because only 6.9 percent reported an income less than $10,000. The high number of primiparas compared to multiparas confirms the fact that most women attending prenatal classes are expecting t h e i r f i r s t c h i l d . The discrepancy would have been even larger had the data been c o l l e c t e d only from regular prenatal classes, but the invest i g a t o r v i s i t e d one class that was attended only by multiparous women. 44 I t i s not known whether information the woman receives about c h i l d b i r t h i n prenatal classes influences her a t t i t u d e towards d e l i v e r y . It was f e l t s u f f i c i e n t l y relevant, however, to document the amount of content about Cesarean and vaginal d e l i v e r y that had been covered i n c l a s s . For consistency, the investigator completed t h i s part of the instrument following a discussion with the prenatal i n s t r u c t o r as to what content had been discussed and what-was planned for subsequent classes. This information i s presented i n Table 5. TABLE 5 COMPOSITION OF THE SAMPLE IN TERMS OF EXPOSURE TO CONTENT REGARDING VAGINAL AND CESAREAN DELIVERY PRIOR TO INVESTIGATION (N=202) Number of % of Obtained Subjects Sample Vaginal Delivery Not yet discussed 14 6 .9 B r i e f , informal discussion 0 0 Labor and d e l i v e r y class completed 21 1 0 . 4 Labor and b i r t h f i l m completed 167 82 .7 202 1 0 0 . 0 Cesarean Delivery Not yet discussed 14 6 . 9 B r i e f , informal discussion 39 19 .3 Planned content completed i n class 141 6 9 . 8 Planned discussion and Cesarean f i l m 8 4 . 0 202 1 00 . 0 45 In the majority of the prenatal classes the discussion of v a g i n a l del i v e r y had been completed (93.7 percent) and a b i r t h f i l m had been shown (82.7 percent). Information about Cesarean d e l i v e r y had been covered for 73.8 percent of the p a r t i c i p a n t s . Only 4 percent had seen a Cesarean b i r t h f i l m . It i s i n t e r e s t i n g to report that, although the p a r t i c i p a n t s had been instructed not to complete t h i s section of the demographic data f i f t e e n respondents from various classes d i d . Of t h i s number, t h i r t e e n indicated that they had only had a b r i e f , informal discussion of Cesarean d e l i v e r y , yet the i n s t r u c t o r reported completion of the planned content on t h i s subject. The p a r t i c i p a n t s were asked the global question, " I f your baby i s born by Cesarean d e l i v e r y , how do you think you w i l l f e e l ? " Their responses are reported i n Table 6. TABLE 6 RESPONSE OF SUBJECTS REGARDING ANTICIPATED FEELINGS OF SATISFACTION ABOUT CESAREAN DELIVERY (N=202) Level of S a t i s f a c t i o n Number of % of Obtained Subjects Sample Extremely S a t i s f i e d 7 3.5 Very S a t i s f i e d 14 6.9 Rather S a t i s f i e d 21 10.4 Neither S a t i s f i e d nor D i s s a t i s f i e d 63 31.2 Somewhat D i s s a t i s f i e d 7 0 34.7 Very D i s s a t i s f i e d 11 5.4 Extremely D i s s a t i s f i e d 16 7.9 202 100.0 46 Some degree of anticipated d i s s a t i s f a c t i o n of a Cesarean b i r t h ( t o t a l of somewhat d i s s a t i s f i e d to extremely d i s s a t i s f i e d responses) was indicated by 48 percent of the women. This may be compared with 20.8 percent of the women a n t i c i p a t i n g some degree of s a t i s f a c t i o n . On the extremes of the s a t i s f a c t i o n - d i s s a t i s f a c t i o n continuum, 3.5 percent reported anticipated f e e l i n g s of extreme s a t i s f a c t i o n and 7.9 percent expressed anticipated f e e l i n g s of extreme d i s s a t i s f a c t i o n with a Cesarean d e l i v e r y . Anticipated f e e l i n g s of neither s a t i s f a c t i o n nor d i s s a t i s f a c t i o n were indicated by 31.2 percent of the respondents implying that t h i s number of women were not sure how they would f e e l about t h i s mode of d e l i v e r y . M u l t i p l e Regression Analysis The r e s u l t s of the stepwise multiple regression analysis of the four factors with each of the dependent v a r i a b l e s , Cesarean d e l i v e r y and vaginal d e l i v e r y , are reported i n Tables 7 and 8. TABLE 7 SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO CESAREAN DELIVERY TOTAL SCORES (N=202) Factor Multiple R R 2 Standard Error g Evaluation 0. 890 0'. '7.92 8.785 0. .570 Anxiety Stress 0. 973 0. .947 4.457 0. .297 A c t i v i t y 0. 990 0. ,980 2.708 0. .190 Potency 1. 000 1. ,000 0.000 0. ,000 47 TABLE 8 SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO VAGINAL DELIVERY TOTAL SCORES (N=202) Factor M u l t i p l e R R 2 Standard Error 3 Evaluation 0.881 0.776 7.508 0.511 Anxiety Stress 0.970 0.940 3.899 0.326 A c t i v i t y 0.989 0.978 2.332 0.208 Potency 1.000 1.000 0.000 0.201 A l l four factors were added to the regression equation f o r each o dependent v a r i a b l e , meaning that the increment of the R added by each fa c t o r i n the successive steps of the regression had a s i g n i f i c a n t F r a t i o at the 0.01 l e v e l . As each factor i s added i n the procedure the c o e f f i c i e n t of the multiple c o r r e l a t i o n (Multiple R) increases and since a l l factors were added the perfect c o r r e l a t i o n of 1.00 was reached. This i s because the sum of the four factor scores i s equivalent to the t o t a l scores of the dependent v a r i a b l e . The prime i n t e r e s t of the invest i g a t o r was to determine the factor or combination of factors that correlated most highly with the dependent v a r i a b l e , thus producing the best p r e d i c t i o n equation. The Multi p l e R squared (R 2) s t a t i s t i c a l l y indicates the proportion of var-iance accounted for by a fac t o r . Thus, the factor evaluation explains 79.2 percent of the variance of the t o t a l scores f o r Cesarean de l i v e r y and 77.6 percent for vaginal d e l i v e r y . The next most relevant factor i s anxiety-stress. In combination with evaluation, 94.7 percent (Cesarean delivery) and 94.0 percent (vaginal delivery) of the v a r i a t i o n 48 i s defined. The two remaining fa c t o r s , a c t i v i t y and potency, i n combina-t i o n , contribute 5.3 percent (Cesarean delivery) and 6 percent (vaginal delivery) to the variance of the t o t a l scores. The standard error of estimate (SEE) i s the standard deviation of the act u a l scores for the predicted scores of the dependent v a r i a b l e . This means that f o r evaluation only, the actual scores would deviate from the predicted scores by 8.785 points (Cesarean delivery) and 7.508 points (vaginal d e l i v e r y ) . As a d d i t i o n a l factors are added to the equation the SEE decreases u n t i l i t becomes 0.000 when the Multiple R reaches 1.000. The g reported f o r the factors i s the regression weight i n standard score form. This weighting c o e f f i c i e n t indicates the factor's contribution i n forming the optimum p r e d i c t i o n equation; the higher the c o e f f i c i e n t , the more the factor contributes. The regression weight for evaluation i s the highest, followed by anxiety-stress, a c t i v i t y and potency f o r both dependent v a r i a b l e s . R e l i a b i l i t y The standardized item alpha r e l i a b i l i t y c o e f f i c i e n t s f o r each factor in..relation to each mode of delivery are presented i n Tables 9 and 10. The degree of r e l i a b i l i t y that i s considered s a t i s f a c t o r y for any t e s t , instrument or questionnaire i s dependent on the use of the measure. Nunnally (1978, p.245) suggests that " i n the early stages of research on predictor tests . . . r e l i a b i l i t i e s of 0.70 or higher w i l l s u f f i c e . . . . For basic research i t can be argued that increasing r e l i a b i l i t i e s much beyond 0.80 i s often wasteful of time and funds." 49 TABLE 9 INTERNAL CONSISTENCY RELIABILITIES OF THE FACTORS FOR CESAREAN DELIVERY (N=202) Factor R e l i a b i l i t y C o e f f i c i e n t Evaluation Potency A c t i v i t y Anxi ety -S t r es s 0.82 0.53 0.27 0.77 TABLE 10 INTERNAL CONSISTENCY RELIABILITIES OF THE FACTORS FOR VAGINAL DELIVERY (N=202) Factor R e l i a b i l i t y C o e f f i c i e n t Evaluation Potency A c t i v i t y Anxiety-Stress 0.78 0.52 0.29 0.71 In r e l a t i o n to t h i s standard, the r e l i a b i l i t y of the two factors evaluation and anxiety-stress i s s u f f i c i e n t for both Cesarean and vaginal d e l i v e r y . For both modes of de l i v e r y the r e l i a b i l i t y of the potency f a c t o r i s low and the r e l i a b i l i t y of the a c t i v i t y factor i s unacceptable. by the two concepts, Cesarean de l i v e r y and vaginal d e l i v e r y , i n the semantic space was computed as twenty-four. The minimum and maximum distance possible f o r the concepts on the developed i n s t r u -ment were calculated as zero and seventy, r e s p e c t i v e l y . The p o s i t i o n of the two concepts within a semantic space may be conceptualized as twenty-four points apart on a one to seventy s c a l e . To determine i f the posi t i o n s of the two concepts would be altered i f any of the factors were excluded from the instrument, the distance between the concepts was computed with each factor eliminated. The distance was also calculated with both potency and a c t i v i t y factors omitted because they contributed minimally to the regression equation. With the exclusion of a factor, the maximum distance possible between the concepts i s reduced, there-fore, the D s t a t i s t i c was calculated so the r e l a t i o n s h i p of the concepts might be more e a s i l y conceptualized. Table 11 summarizes the r e s u l t s . S p a t i a l Distance Between the Two Concepts Using the generalized distance formula of s o l i d geometry the distance (D) between the p o s i t i o n occupied 51 TABLE 11 DISTANCE BETWEEN THE CONCEPTS, CESAREAN DELIVERY AND VAGINAL DELIVERY IN A SEMANTIC SPACE (N=202) Distance D Four Factors 24 Factors Removed: Evaluation 13 Potency 23 A c t i v i t y 23 Anxiety-Stress 23 Potency and A c t i v i t y 21 Minimum Maximum % of T o t a l D D Possible Difference 0 70 34.4 0 35 37.1 0 67 34.3 0 67 34.3 0 65 35.3 0 64 32.8 The exclusion of eit h e r the potency or a c t i v i t y factors would not a f f e c t the r e l a t i o n s h i p of the two concepts i n a semantic space. If both factors were eliminated a small but n e g l i g i b l e portion (1.5 percent) of the t o t a l possible distance would be l o s t . Discriminant Function Analysis The purpose of the f i r s t discriminant analysis procedure was to determine which of the a d j e c t i v a l scales were the best discriminators between the two dependent v a r i a b l e s , Cesarean d e l i v e r y and vaginal d e l i v e r y . The a d j e c t i v a l scales from both categories of the instrument were combined r e s u l t i n g i n f o r t y independent v a r i a b l e s . A stepwise procedure was employed, therefore the va r i a b l e s entered the discriminant function i n successive steps i n the order of t h e i r discriminating power. 52 Because the a d j e c t i v a l scales are repeated i n the two categories, f i v e of the scales are i d e n t i f i e d twice, each from a separate category. The a d j e c t i v a l scales are l i s t e d i n the order i n which they entered the discriminant function i n Table 12. TABLE 12 ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN CESAREAN DELIVERY AND VAGINAL DELIVERY Scale Factor Concept o p t i m i s t i c - p e s s i m i s t i c Evaluation Cesarean good - bad Evaluation Vaginal timely - untimely Evaluation Vaginal meaningful - meaningless Evaluation Cesarean lenient - severe Potency Cesarean important - unimportant Evaluation Vaginal calm - anxious Anxiety-Stress Cesarean undisturbed - disturbed Anxiety-Stress Cesarean *meaningful - meaningless Evaluation Vaginal health - s i c k Evaluation Vaginal active - passive A c t i v i t y Vaginal unintentional - i n t e n t i o n a l A c t i v i t y Vaginal simple - complex A c t i v i t y Vaginal p o s i t i v e - negative Evaluation Vaginal strong - weak Potency Vaginal *timely - untimely Evaluation Cesarean successful - unsuccessful Evaluation Vaginal *lenient - severe Potency Vaginal * p o s i t i v e - negative Evaluation Cesarean *important - unimportant Evaluation Vaginal complete - incomplete Evaluation Vaginal *Second entry i n t o the equation Twenty-one of the fo r t y a d j e c t i v a l paris are i d e n t i f i e d as the best discriminators between Cesarean and vaginal d e l i v e r y . Scales representing a l l four of the factors are included, but the greatest proportion belongs to the f a c t o r , evaluation. A discriminant function analysis, stepwise method, was per-formed to determine which of the a d j e c t i v a l scales were the best discriminators between the high and low scores on the Cesarean delivery category of the instrument. Those i d e n t i f i e d contribute the most to the s e n s i t i v i t y of t h i s category. The scales are l i s t e d i n Table 13 i n the order they entered the discriminant function. TABLE 13 ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN HIGH - LOW SCORES: CESAREAN DELIVERY CATEGORY Scale Factor p o s i t i v e - negative Evaluation free - - constrained Potency strong - weak Potency lenient - severe Potency pleasurable - p a i n f u l Evaluation o p t i m i s t i c - p e s s i m i s t i c Evaluation unintentional - i n t e n t i o n a l A c t i v i t y Seven of the twenty scales are i d e n t i f i e d as contributing most to the s e n s i t i v i t y . Evaluation and potency were the factors p r i m a r i l y represented by the scales. A s i m i l a r discriminant function analysis was completed f o r the vaginal d e l i v e r y category. The findings are reported i n Table 14. 54 TABLE 14 ADJECTIVAL PAIRS THAT DIFFERENTIATE BETWEEN HIGH - LOW SCORES; VAGINAL DELIVERY CATEGORY Scale Factor healthy - s i c k Evaluation important - unimportant Evaluation calm - anxious Anxiety-Stress strong - weak Potency undisturbed - disturbed Anxiety-Stress meaningful - meaningless Evaluation simple - complex A c t i v i t y active - passive A c t i v i t y p o s i t i v e - negative Evaluation Nine of the twenty scales are the best contributors to the sen-s i t i v i t y of the vaginal d e l i v e r y category. A l l factors are represented by the di s c r i m i n a t i n g s c a l e s . V a l i d i t y The instrument i s considered to have content v a l i d i t y to the extent that the a d j e c t i v a l pairs represent women's attitudes towards mode of d e l i v e r y . The two concepts, Cesarean delivery and vaginal d e l i v e r y , the •four factors and the a d j e c t i v a l p a i r s were selected a p r i o r i f o r t h e i r relevance to the study. C r i t e r i a recommended by Nunally (1978, p.92), for instrument construction were attended to; f o r t y items for attitu d e measure-ment were included and a sample siz e of f i v e times as many women as the number of items was obtained for t e s t i n g the instrument. Concurrent v a l i d i t y was ascertained for the Cesarean d e l i v e r y category of the instrument by c o r r e l a t i n g the scores from t h i s category with those of a c r i t e r i o n measure. Since a sui t a b l e c r i t e r i o n measure has not been constructed and tested a global question considered to have face v a l i d i t y was employed. The pa r t i c i p a n t s i n t h i s study were asked, " I f your baby i s born by Cesarean d e l i v e r y how do you think you w i l l f e e l ? " Spearman's rho, a nonparametric c o r r e l a t i o n c o e f f i c i e n t , was computed as r g = 0.541; (p< 0.001). I t was s i g n i f i c a n t at the chosen oc l e v e l of 0.01. Since the c o r r e l a t i o n was p o s i t i v e and s i g n i f i c a n t , a stepwise multiple regression analysis was computed with the glob a l question as the dependent v a r i a b l e and the four f a c t o r s , evaluation, potency, a c t i v i t y and anxiety-stress, as the independent v a r i a b l e s . The r e s u l t s are presented i n Table 15. TABLE 15 SUMMARY OF STEPWISE MULTIPLE REGRESSION OF FACTORS ONTO GLOBAL QUESTION RESPONSE (N=202) 2 Factor M u l t i p l e R R. Standard Error 3 Evaluation 0.573 0.328 1.120 0.457 Anxiety-Stress 0.598 0.358 1.098 0.163 Potency 0.601 0.361 1.098 0.071 Three f a c t o r s , evaluation, anxiety-stress and potency were included i n the pr e d i c t i o n equation. The a c t i v i t y f a c t o r did not contribute s u f f i c i e n t l y to the equation, therefore i t was omitted. Evaluation i s the factor that contributes the most, anxiety-stress adds minimally and the addition of potency i s n e g l i g i b l e to the p r e d i c t i o n equation. In combination, evaluation and anxiety-stress account for 35.8 percent of the variance of the global question response These findings may be interpreted i n two ways. F i r s t , v a r i a b l e s other than those representing evaluation and anxiety-stress may contribute to a woman's anticipated s a t i s f a c t i o n or d i s s a t i s f a c t i o n with Cesarean d e l i v e r y . Secondly, the global question asked i s too l i m i t i n g ; s a t i s -f a c t i o n or d i s s a t i s f a c t i o n may not be the only or the best i n d i c a t o r s of a woman's attitude towards Cesarean d e l i v e r y . The p o s i t i v e and s i g n i f i c a n t c o r r e l a t i o n between the global question response and the Cesarean de l i v e r y category indicates con-current v a l i d i t y . However, the r e s u l t s of the multiple regression analysis suggest that the global question i t s e l f , i s not s u f f i c i e n t l y i n c l u s i v e to be a predictor of women's attitudes towards Cesarean de l i v e r y . Summary A de s c r i p t i o n of the pa r t i c i p a n t s i n the study i s provided from the analyses of the demographic data. A l l subjects were i n t h e i r t h i r d trimester of pregnancy and were currently attending c h i l d b i r t h education classes. Gf the t o t a l sample, 21 percent were enrolled i n classes sponsored by a private organization and 79 percent attended classes provided by public health agencies. The classes were geographically located throughout the Cit y of Vancouver and two adjacent areas, Burnaby and the North Shore. Content re l a t e d to labor and vaginal and Cesarean d e l i v e r y had been discussed i n most of the prenatal classes. The majority of the p a r t i c i p a n t s were expecting t h e i r f i r s t c h i l d (85 percent), were at least twenty years of age, had completed a minimum of grade eleven education and reported an annual income (mother and partner's combined) of at least $15,000. Annual earnings of more than $25,000 were reported by 56 percent and only 6.9 percent earned less than $10,000. In response to a question asking the women to rate t h e i r anticipated s a t i s f a c t i o n or d i s s a t i s f a c t i o n with a Cesarean d e l i v e r y , 48.0 percent expressed the expectation of d i s s a t i s f a c t i o n while 20 percent anticipated s a t i s f a c t i o n . The following findings are the..outcomes of the several analyses ca r r i e d out on the responses to the instrument: 1. The two concepts, Cesarean d e l i v e r y and vaginal d e l i v e r y , occupy separate positions i n a semantic space. They may be conceptualiz as being twenty-four points apart on a scale of zero to seventy. The two factors that contribute most to the semantic s i m i l a r i t i e s and d i f -ferences of Cesarean d e l i v e r y and vaginal d e l i v e r y are evaluation and anxiety-stress. 2. The r e l i a b i l i t y of the two f a c t o r s , evaluation and anxiety-st r e s s , i s sub s t a n t i a l i n r e l a t i o n to the two modes of d e l i v e r y . The r e l i a b i l i t y c o e f f i c i e n t s f o r evaluation are 0.82 (Cesarean delivery) and 0.78 (vaginal delivery) and for anxiety-stress they are 0.77 (Cesarean delivery) and 0.71 (vaginal d e l i v e r y ) . The r e l i a b i l i t y of the factor potency i s considered minimal, the c o e f f i c i e n t s being 0.53 and 0.52 and those of a c t i v i t y are unacceptable at 0.27 and 0.29. 3. The f a c t o r s , evaluation and anxiety-stress, are the most valuable predictors of the t o t a l scores on the instrument. Together, 58 they account for 94.7 percent of the variance on the Cesarean d e l i v e r y category scores and 94.0 percent of the variance on the vaginal d e l i v e r y category scores. These two factors i n combination provide the optimum pr e d i c t i o n equation. 4. The one factor i n t h i s study that affords the greatest r e l i a b i l i t y and contributes the most to the regression equation i s evaluation. This f i n d i n g i s congruent with those of Osgood, Suci and Tannenbaum (1957) and Nunnally (1978), that evaluation i s the most relevant factor of a semantic d i f f e r e n t i a l i n a t t i t u d e measurement. 5. The discriminant function analysis between the two concepts, Cesarean d e l i v e r y and vaginal d e l i v e r y , revealed that, although the a d j e c t i v a l scales designated as the best discriminators were represen-t a t i v e of a l l four f a c t o r s , the greatest proportion were from evaluation. 6. The s e n s i t i v i t y of the Cesarean d e l i v e r y and vaginal d e l i v e r y categories could be decreased i f the f a c t o r s , potency and a c t i v i t y , were excluded because a d j e c t i v a l scales that represented both f a c t o r s were found to have discriminating power i n d i f f e r e n t i a t i n g between the high and low scores of each category. The Cesarean d e l i v e r y category w i l l be most affected i f the factor potency i s omitted. 7. Concurrent v a l i d i t y of the Cesarean d e l i v e r y category i s indicated because the response from the global question, asking about women's anticipated f e e l i n g s of s a t i s f a c t i o n i n r e l a t i o n to Cesarean d e l i v e r y , correlated p o s i t i v e l y and s i g n i f i c a n t l y with the Cesarean d e l i v e r y category scores. However, further analysis revealed that the fa c t o r s , evaluation and anxiety-stress, accounted f or only 35.8 percent of the variance of the global question response. Evidently, other 59 v a r i a b l e s not yet explored contribute to a woman's anticipated f e e l i n g of s a t i s f a c t i o n or d i s s a t i s f a c t i o n i f she were to have a Cesarean del i v e r y . CHAPTER V SUMMARY AND CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Summary and Conclusions The intent of t h i s study was to develop and test an instrument that would r e l i a b l y assess pregnant women's attitudes towards mode of del i v e r y , and would be easy to administer. A semantic d i f f e r e n t i a l , a s p e c i f i c technique for a t t i t u d e measurement was employed. Cesarean de l i v e r y and vaginal d e l i v e r y were the two modes of de l i v e r y selected. The meaning of each to the subjects was ascertained from ratings on bipolar a d j e c t i v a l scales. The p a r t i c -u l a r b i p o l a r adjectives were selected because of (!) t h e i r representa-tiveness of the factors evaluation, potency, a c t i v i t y and anxiety-stress, based on previous research by Osgood, Suci and Tannenbaum (1957) and Nunnally (1978) and (2) t h e i r congruency with women's descriptions of c h i l d b i r t h , as reported i n the l i t e r a t u r e . The instrument was tested with a sample of 202 women. A l l par-t i c i p a n t s were i n t h e i r t h i r d trimester of pregnancy and were currently attending prenatal classes i n the greater Vancouver area. The instrument was e a s i l y administered and well accepted by the p a r t i c i p a n t s , a l l of whom completed i t i n ten minutes or l e s s . The findings of t h i s study lead to the following conclusions: 1. The i n i t i a l phase i n development of an instrument based on 60 61 a semantic d i f f e r e n t i a l , to assess pregnant women's attitudes towards mode of de l i v e r y was successful. The two concepts, Cesarean d e l i v e r y and vaginal d e l i v e r y , representing the deli v e r y modes are relevant i n that each occupies a d i f f e r e n t p o s i t i o n i n a semantic space and t h i s d i f f e r e n c e i n meaning i s r e f l e c t i v e of differences i n women's attitudes (Osgood, Suci and Tannenbaum 1957, p.190). The instrument was well accepted and easy to administer. The r e l i a b i l i t y of the evaluation and anxiety-stress factors included i n the instrument was su b s t a n t i a l . 2. The instrument could be revised to include only the factors evaluation and anxiety-stress f or the following reasons: (1) they are the factors that have the highest r e l i a b i l i t y c o e f f i c i e n t s f o r both modes of deli v e r y and (2) they are the most relevant i n assessing women's attitudes towards Cesarean d e l i v e r y and vaginal d e l i v e r y because, i n combination, they account for the greatest proportion of the variance of the scores on the two concepts. 3. The factors potency and a c t i v i t y could be omitted i n the r e v i s i o n of the instrument because of th e i r l i m i t e d contributions to r e l i a b i l i t y , p r e d i c t i o n and the semantic meaning of the two concepts. The exclusion would a f f e c t the instrument i n the following ways: (1) the semantic dimensionality would be reduced from four to two, a l t e r i n g the p o s i t i o n of the two concepts i n a semantic space, although t h i s a l t e r a t i o n has been calculated as being minimal; (2) the s e n s i t i v i t y of the Cesarean de l i v e r y and vaginal d e l i v e r y categories would be decreased, but (3) the instrument would be more concise, easier to administer, score and int e r p r e t and, i n t o t a l , more meaningful. 4. Concurrent v a l i d i t y of the Cesarean d e l i v e r y category was determined. The scores from t h i s category correlated p o s i t i v e l y and s i g n i f i c a n t l y with those from a related c r i t e r i o n . Because of the adherence to recommendations for instrument construction and the se l e c t i o n of relevant b i p o l a r adjectives, the instrument i s considered to have content v a l i d i t y . Implications for Nursing P r a c t i c e To-day, nurses working with c l i e n t s i n the childbearing years are responsible f o r providing comprehensive care that w i l l influence the p h y s i c a l , psychological and s o c i a l growth of i n d i v i d u a l s and fa m i l i e s . Pregnancy i s a c r i t i c a l time for events that occur during t h i s period can af f e c t pregnancy outcomes and family r e l a t i o n s h i p s (Caplan 1961). A woman's psychological adjustment following c h i l d b i r t h may be dependent on the congruency of her perception of her actual d e l i v e r y experience and her pre-delivery expectations. An in f l u e n c i n g v a r i a b l e that a f f e c t s her perceptions i s her at t i t u d e towards mode of d e l i v e r y and, as the incidence of Cesarean d e l i v e r y r i s e s , t h i s f a c t o r becomes incre a s i n g l y important. Prenatal assessment of women's attitudes towards de l i v e r y i s considered a necessary component i n providing preventive and comprehensive nursing care to pregnant women. At present, nurses make t h i s assessment by discussing the subject with women. This i s time consuming and the need for care i s generally based on subjective judgment. A systematic and r e l i a b l e method of assessing women's attitudes towards mode of deli v e r y would be more accurate and e f f i c i e n t . The instrument i n i t s present form i s not intended f o r general use. However, when the second phase of the development i s completed, i t could be a valuable measure for nurses to employ as part of t h e i r 63 t o t a l assessment of pregnant women. Since the instrument i s a s e l f -report measure, i t can be administered e a s i l y to both i n d i v i d u a l s and groups. The instrument may be u t i l i z e d i n the following ways: 1. To accurately i d e n t i f y pregnant women who have very negative or very p o s i t i v e attitudes towards either v aginal or Cesarean d e l i v e r y . These are the i n d i v i d u a l s who may require support and counselling. 2. Once a c l i e n t has been i d e n t i f i e d by use of the instrument further assessment and follow-up can be planned. For example, the nurse may counsel the woman i n d i v i d u a l l y , helping her explore her feelin g s and the reasons why she f e e l s negatively about d e l i v e r y . This woman can also be followed more c l o s e l y through the intrapartum and postpartum periods. I f her labor and de l i v e r y experience i s not con-s i s t e n t with her expectations, she may again require a d d i t i o n a l nursing care to help her resolve her disappointment. 3. Use of the instrument i n prenatal classes could be a means for f a c i l i t a t i n g discussion about attitudes towards d e l i v e r y . Two other noteworthy findings i n t h i s study have implications for nursing p r a c t i c e . The f i r s t i s the small number (16.8 percent) of multiparous women attending prenatal classes. Studies by Westbrook (.1978) and Norr et a l . (1980) report that anxieties of b i r t h increase with p a r i t y . Why then, do fewer multiparous women attend prenatal classes? Are there not s u f f i c i e n t classes offered or i s the content not considered relevant? I t i s the r e s p o n s i b i l i t y of nurses to f i n d out and r e c t i f y the s i t u a t i o n . Perhaps more prenatal classes s p e c i f i c a l l y designed for multiparous women are required. Second, nurses teaching prenatal classes might evaluate the 64 content they teach about Cesarean d e l i v e r y . Thirteen out of f i f t e e n women indicated the discussion regarding Cesarean b i r t h had been b r i e f and informal when, i n fact,, the i n s t r u c t o r s f e l t they had s u f f i c i e n t l y covered the subject. Recommendations for Further Research Recommendations for further research are r e l a t e d to the develop-ment of the instrument and future studies using i t . With regard..to.the development of the instrument, the investigator proposes the following: 1. The instrument should be revised to include only the bipolar a d j e c t i v a l scales that represent the factors evaluation and anxiety-stress. 2. The revised instrument should be tested and the r e l i a b i l i t y c o e f f i c i e n t s determined. It i s anticipated that the r e l i a b i l i t y co-e f f i c i e n t s w i l l be attenuated because of the fewer a d j e c t i v a l scales. Therefore, the Spearman-Brown formula should be u t i l i z e d i n the compu-t a t i o n of the c o e f f i c i e n t s . 3. Instructions should be devised for nurses to administer and score the instrument and i n t e r p r e t the r e s u l t s . A p r o f i l e based on the mean of each a d j e c t i v a l scale could be prepared to enhance the i n t e r p r e t a t i o n . 4. The v a l i d i t y of the instrument should be further investigated. Concurrent v a l i d i t y of the vaginal d e l i v e r y category might be determined by asking a relevant global question s i m i l a r to that used for the Cesarean d e l i v e r y category. P r e d i c t i v e v a l i d i t y of t h i s measure of women's attitudes towards mode of d e l i v e r y could be determined by administering the instrument during pregnancy and following d e l i v e r y and co r r e l a t i n g the r e s u l t s . A confounding v a r i a b l e i n t h i s s i t u a t i o n might be the woman's perceptions of her actual d e l i v e r y experience with her pr i o r expectations of c h i l d b i r t h , but t h i s could be addressed i n the study. Construct v a l i d i t y could be determined. For example, the re l a t i o n s h i p of very negative attitudes towards Cesarean or vaginal d e l i v e r y during pregnancy and adjustment post-delivery may be pursued. Nunnally (1978, p.593) states "to explicate a p a r t i c u l a r a t t i t u d e as a construct requires a m u l t i - i n d i c a t o r approach." These measures might include behavioural t e s t s , p r o j e c t i v e techniques and verbal reports. Substantial c o r r e l a t i o n of the measures would i n d i c a t e construct v a l i d i t y . Again, the post-delivery adjustment would l i k e l y be influenced by the actual d e l i v e r y experience, therefore, t h i s v a r i a b l e could be included i n the study. Further studies u t i l i z i n g the instrument might include: 1. Administration of the instrument at s p e c i f i c i n t e r v a l s throughout pregnancy and the puerperium to assess possible changes i n women's attitudes during these periods. 2. A study comparing the attitudes of multiparous women and primiparous women towards mode of de l i v e r y so that knowledge about p a r i t y and attitudes towards del i v e r y may be extended. 3. Research to assess fathers' attitudes towards mode of del i v e r y . The father's r o l e i n the childbearing experience i s becoming inc r e a s i n g l y s i g n i f i c a n t . I t i s reasonable to assume that h i s a t t i t u d e towards mode of d e l i v e r y w i l l a f f e c t the mother's a t t i t u d e , p a r t i c u l a r l y i f he antici p a t e s being present during the de l i v e r y . 66 4. Studies of pregnant women's attitudes towards mode of del i v e r y i n other cultures. 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Nursing Care Planning. Toronto: J.B. Lippincott Co. L o v e l l , K., and Lowen, K. 1970. Understanding Research i n Education. London: University of London Press. McDonald, R.L., and Christakos, A.C. 1963. Relationship of Emotional Adjustment During Pregnancy to Obstetric Complications. American Journal of Obstetrics and Gynecology 86:3:341-348. Macfarlane, A. 1977. The Psychology of C h i l d b i r t h . Cambridge, Mass.: Harvard U n i v e r s i t y Press. Marieskind, H.I. 1979. An Evaluation of Caesarean Section i n the United  States. Washington, D.C.: Department of Health, Education and Welfare. Marut, J.S. 1978. The Special Needs of the Cesarean Mother. The  American Journal of Maternal Child Nursing 3:4:202-206. Marut, J.S., and Mercer, R.T. 1979. Comparison of Primiparas' Perceptions of Vaginal and Cesarean B i r t h s . Nursing Research 28:5:260-266. Mercer, R.T. 1977. Nursing Care for Patients at Risk. Thorofare, N.J.: Charles B. Slack Inc. Mevs, L. 1977. The Current Status of Cesarean Section and Today's Maternity Patient. Journal of Obstetrics and Gynecological  Nursing 6:4:44-47. 70 Moore, M.L. 1978. R e a l i t i e s i n Childbearing. Toronto: W.B. Saunders Co. Morrison, A.B. 1978. Prevention i n the Canadian Health System. Preventive Medicine 7:4:498-509. Nie, N.H.; H u l l , C.H.; Jenkins, J.G.; Steinbrenner, K.; and Brent, D.H. 1975. S t a t i s t i c a l Package for the S o c i a l Sciences. 2nd. ed. Toronto: McGraw-Hill Book Co. Norr, K.L.; Block, C.R.; A l l a n , G.C.; and Meyering, S. 1980. The Second Time Around: P a r i t y and B i r t h Experience. Journal  of Obstetric and Gynecological Nursing 9:1:30-36. Nunnally, J.C. 1970. Introduction to Psychological Measurement. Toronto: McGraw-Hill Book Co. . 1978. Psychometric Theory. Toronto: McGraw-Hill Book Co. Osgood, C.E. 1976. Focus on Meaning. The Hague: Mouton and Co. Osgood, C.E.; Suci, G.J.; and Tannenbaum, P.H. 1957. The Measurement  of Meaning. Chicago: University of I l l i n o i s Press. P e t i t t i , D.; Olson, R.O.; and Williams, R.L. 1979. American Journal  of Obstetrics and Gynecology 133:4:391-397. Reeder, S.J.; Mastroianni, L.; and Martin, L.L. 1980. Maternity  Nursing. 14th ed. Toronto: J.P. Lippincott Co. Ringquist, M.A. 1976. Psychologic Stress i n the Last Three Months of Pregnancy. Current Practice i n Obstetric and Gynecologic  Nursing, edited by McNall, K.L., and Galeener, J.T. Saint Louis: C.V. Mosby Co. Reynolds, -CB. 1977. Updating Care of Cesarean Patients. Journal of  Obstetrics and Gynecological Nursing 6:4:48-51. Schlosser, S. 1978. The Emergency C-Section Patient, Why She Needs Help. Registered Nurse 41:7:53-57. Snider, J.G., and Osgood, C.E. 1969. Semantic D i f f e r e n t i a l Technique:  A Sourcebook. Chicago: Aldine Publishing Co. Spielberger, CD.; Gorsuch, R.L.; and Lushene, R.E. 1970. STAI Manual for the S t a t e - T r a i t Anxiety Inventory. 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Willmuth, L.R. 1975. Prepared C h i l d b i r t h and the Concept of Control. Journal of Obstetrics, Gynecological and Neonatal Nursing 4:5:38-42. Winokur, G., and Werboff, J . 1956. The Relationship of Conscious Maternal Attitudes to Certain Aspects of Pregnancy. The  P s y c h i a t r i c Quarterly 30:1:61-71. Zi e g e l , E., and Cranley, M. 1978. Obstetric Nursing. 7th ed. New York: Macmillan Publishing Co. Inc. Zimmerman, D.S., and Gohrke, C. 1970. The Goal-Directed Nursing Approach: I t Does Work. American Journal of Nursing 70:2:306-310. APPENDIX A Covering Lett 72 Dear P a r t i c i p a n t : As a graduate student at the University of B r i t i s h Columbia, I am studying women's attitudes towards vaginal and Cesarean d e l i v e r y . The enclosed questionnaires have been designed to a s s i s t with t h i s assessment. They w i l l take approximately f i f t e e n minutes to complete. Please do not i d e n t i f y any pages with your name. The completion of the questionnaire i s your consent for t h i s information to be used i n the study. If you wish, you may withdraw from the study before completing the questionnaires. If you choose not to p a r t i c i p a t e , you are assured i t w i l l not a f f e c t your r e l a t i o n s h i p with your prenatal i n s t r u c t o r . Please read the i n s t r u c t i o n s c a r e f u l l y . When the question-naires have been completed, return them i n the enclosed envelope. Thank you f o r your help and co-operation. Yours s i n c e r e l y , Roberta J. Hewat, R.N., B.Sc.N., Graduate Student, M.S.N. Program, Univ e r s i t y of B r i t i s h Columbia. 73 APPENDIX B Instructions for P a r t i c i p a n t s 74 INSTRUCTIONS In the following questionnaires you w i l l be asked to i n d i c a t e your f e e l i n g s towards both Cesarean and vaginal d e l i v e r i e s . For each type of d e l i v e r y there i s a seri e s of scales consisting of two words with seven spaces between each word. Think about how you f e e l about the type of d e l i v e r y printed at the top of the page and then mark the space between each of the words where i t best indicates the strength of your f e e l i n g . For example, i f you f e e l the designated method of del i v e r y i s very f a i r , place your mark as follows: f a i r | X | | | | | | | u n f a i r Or i f i t i s very u n f a i r , place your mark as follows: f a i r J | | | | | | X | unfair Or i f i t i s neither f a i r nor u n f a i r , place your mark i n the center: f a i r | | | | X [ | | | u n f a i r Of i f i t i s somewhat f a i r , place your mark i n space 2 or 3, or i f i t i s somewhat u n f a i r , place your mark in. space 5 or 6, depending on the strength of your f e e l i n g . f a i r | | | | | | | | u n f a i r 2 3 5 6 Please be sure to put one mark, X, between a l l of the opposite words. Complete page one before s t a r t i n g page two and do not r e f e r back to page one. There are no " r i g h t " or "wrong" answers. Work ra p i d l y , i t is; your f i r s t impressions that are important. 75 APPENDIX C Instrument 76 CESAREAN DELIVERY successful pessimistic untimely meaningful unintentional free passive lenient calm s i c k undisturbed negative weak complete p a i n f u l unafraid important bad simple upset unsuccessful o p t i m i s t i c timely meaningless i n t e n t i o n a l constrained active severe anxious healthy disturbed p o s i t i v e strong incomplete pleasurable a f r a i d unimportant good complex quiet 77 78 VAGINAL DELIVERY .successful p e s s i m i s t i c untimely meaningful unintentional free passive lenient calm s i c k undisturbed negative weak complete p a i n f u l unafraid important bad simple upset unsuccessful o p t i m i s t i c timely meaningless i n t e n t i o n a l constrained ac t i v e severe anxious healthy disturbed p o s i t i v e strong incomplete pleasurable a f r a i d unimportant good complex quiet APPENDIX D Demographic Data Form 79 PLEASE COMPLETE THE FOLLOWING INFORMATION 1. How many vaginal deliveries have you previously experienced? 1. zero 4. three 2. one 5. four 3. two 6. over four 2. How many Cesarean deliveries have you previously experienced? 1. zero 3. two 2 . one 4 . three If you had a Cesarean, when did you f i r s t know i t would be necessary? 3. First Cesarean 1. Before labor started 2. After labor started 4. Second Cesarean 1. Before labor started 2. After labor started 5. Third Cesarean 1. Before labor started 2. After labor started How old are you? __ !• 16-19 years 2. 20-24 years 3. 25-29 years 4. 30-34 years 5. 35-39 years 6. over 40 years 7. How many grades have you completed? 1. less than 8 2. 8-10 .3. 11-12 5. university 6. post baccalaureate degree 4. community college or technical school 80 What are the combined annual earnings of your partner and yourself? 1. less than $5,000 5. $20,000-$24,000 2. $5,000-$9,999 6. $25,000-$29,999 3. $10,000-$14,999 7. $30,000-$34,999 4. $15,000-$19,999 8. $35,000 or over I f your baby i s born by Cesarean delivery, how do you think you w i l l f e e l ? 1. extremely s a t i s f i e d 5. somewhat d i s s a t i s f i e d 2. very s a t i s f i e d 6. very d i s s a t i s f i e d 3. rather s a t i s f i e d 7. extremely d i s s a t i s f i e d 4. neither s a t i s f i e d nor d i s s a t i s f i e d TO BE COMPLETED BY RESEARCHER 82 10. Location of prenatal class, 1. West 2. East 3. South 4. North 5. Mid-Main 6. Burrard 7. Robson 8. North Shore 9. Ri chmond 10. Burnaby 11. Type of agency conducting the class. 1. government 2. private 12. Content re vaginal d e l i v e r y discussed i n classes before i n v e s t i g a t i o n . 1. Not yet discussed. 2. B r i e f , informal discussion. 3. Labor and delivery class completed. 4. Labor class and b i r t h f i l m completed. 13. Content re Cesarean delivery discussed i n classes before i n v e s t i g a t i o n . 1. Not yet discussed. 2. B r i e f , informal discussion. 3. Planned content completed i n cl a s s . 4. Planned discussion and cesarean f i l m . 

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