Japan Journal of Nursing Science (2010) 7, 29–36 doi:10.1111/j.1742-7924.2010.00134.

ORIGINAL ARTICLE

Nursing intervention to enhance acceptance of pregnancy in

first-time mothers: Focusing on the comfortable experiences of
pregnant women jjns_134 29..36

Yasuka NAKAMURA
Women’s Health Nursing, Course of Nursing, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan

Abstract
Aim: The purpose of the present study was to describe effective nursing care through evaluation of a nursing
intervention that enhanced acceptance of pregnancy and focused on a comfortable experience for pregnant
women.
Methods: Thirty-two subjects who were expected to have a normal pregnancy were assigned into either the
intervention or the control group. The nursing intervention consisted of the use of a pregnancy diary and
four interviews, two of which were held in the first trimester, one in the second and one in the third trimester.
The nursing care given was recorded in tapes and field notes. The data were analyzed using a qualitative
content analysis method.
Results: As a result of analyzing the nursing care of 13 women pregnant for the first time who were provided
with nursing intervention, the following seven categories of nursing care were extracted for the intervention:
encouragement of women to record their experiences using a pregnancy diary; recognizing and acknowl-
edging negative feelings; reducing the negative aspects of pregnancy and reframing; expression and rein-
forcement of positive feelings; clarification and reinforcement of positive meanings; awareness of own
comfortable experiences; promotion of diverse comfortable aspects and continuation of comfortable expe-
riences. The seven nursing care interventions were effective in increasing the comfortable experiences of
pregnant women and enhancing a positive attitude towards pregnancy.
Conclusions: Nursing intervention can aid in enhancing positivity and comfort in pregnant women.
Furthermore, this nursing intervention can be applied to adolescents, socially disadvantaged pregnant
women, and hospitalized women.
Key words: adaptation, intervention studies, pregnant women, psychological, quality of health care.

INTRODUCTION Lederman, 1984). Acceptance of pregnancy affects

various aspects of maternal life, such as motivation in
A woman must adapt to a dramatic shift in her lifestyle adapting to the maternal role (Shindo & Wada, 1990), a
as she changes from an individual responsible primarily positive feeling towards the fetus, internal motivation
for herself to a parent responsible for the life and for self-care behavior (Manabe, Seto, Agari, Kitagawa,
well-being of a child (Klaus, Klaus, & Kennel, 1995; & Kotake, 2001), and adaptation postpartum (Kiehl &
White, 2003). Two reasons for child abuse is an undes-
ired pregnancy and dislike of children (Takakubo et al.,
Correspondence: Yasuka Nakamura, Women’s Health
2005). Therefore, it is important to give support to
Nursing, Course of Nursing, Tohoku University Graduate
School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, enhance acceptance of pregnancy in prenatal nursing
Miyagi 980-8575, Japan. care. So far, nursing care during the antenatal period has
Email: [email protected] focused on reducing the negative aspects of pregnancy,
Received 17 February 2009; accepted 4 October 2009. such as stress and uncomfortable symptoms related to

© 2010 The Author

Journal compilation © 2010 Japan Academy of Nursing Science
Y. Nakamura Japan Journal of Nursing Science (2010) 7, 29–36

Figure 1 Research framework of the

present study.

pregnancy (Takao, 2002; Watabnabe, Kawasaki, Sato, sion criteria were primipara women expecting a normal
Hayatu, & Ueda, 1997). Although nursing care focusing pregnancy, able to read, write and speak Japanese and
on the positive side of pregnancy tends to be included in willing to participate. Exclusion criteria included having
antenatal nursing care (Sato & Takahashi, 2005), severe pregnancy complications, or requiring hospital-
research has found evidence of an absence of detailed ization. To escape from interchange of those mothers,
nursing care. Nakamura and Mori (2005) explored the women who participated in the first half of the research
subjective comfortable experience of pregnant women period were grouped into a control group, and in the
as a positive aspect of pregnancy in longitudinal inter- latter half of the research period were grouped into an
views from 20 to 38 weeks of pregnancy. It was found intervention group.
that women experienced various comfortable experi- The research framework (Fig. 1) considered the fol-
ences from the first trimester, a period of morning lowing: women show various emotional reactions, such
sickness, to the third trimester, a period of activity as positivity, negativity, and ambivalence to the preg-
restriction. In addition, it was suggested that a positive nancy and to the physical, mental, and social changes
attitude improved acceptance of pregnancy (Nakamura accompanying the pregnancy (Rubin, 1984; Shindo &
& Mori, 2005). Nursing care which promotes a com- Wada, 1990). According to Pender (1996) and Ellis and
fortable experience for pregnant women is a positive Harper (1975), behavior that accompanies positive
way to support women and enhance their acceptance of feelings tends to be repeated, and the behavior becomes
pregnancy. It may also help in the process of becoming a an effective motivation. A more comfortable experience
mother and influence a more comfortable delivery expe- for pregnant women would be gained if positive aspects
rience and better child-rearing. Therefore, the purpose of those reactions were to be promoted. Acceptance
of the present study was to describe effective nursing of pregnancy was enhanced by the accumulation of
care through carrying out and evaluating a nursing inter- various comfortable experiences of the pregnant
vention that enhanced acceptance of pregnancy and woman. Based on cognitive restructuring theory by
focused on a comfortable experience for pregnant Ellis and Harper (1975), the nursing intervention was
women. designed to enhance positive emotional reactions,
leading to a comfortable experience and acceptance of
pregnancy. Age, educational background and employ-
METHODS
ment are thought to be other influential factors, but
A longitudinal and quasi-experimental research design, were not analyzed here.
pretest and post-test design with control group, with This study was permitted by a university ethical
convenience sampling was used to recruit pregnant board of review in a school of nursing. Women were
women from a maternity clinic located in urban areas approached by a doctor during a prenatal clinic visit
near Tokyo, Japan, between 2005 and 2006. The inclu- between 8 to 10 weeks of pregnancy and were

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Japan Journal of Nursing Science (2010) 7, 29–36 Enhancing acceptance of pregnancy

informed briefly about the study. If they were inter- The attitudes of both groups of women to being
ested in the study, the researcher explained it in detail pregnant were estimated by asking them the following
and handed out a document for informed consent. questions: “What do you think about being pregnant?”
Pregnant women were given time to think about par- and “What do you think about the physical changes of
ticipation in the study. If they agreed, written informed pregnancy?” Depending on each woman’s reply, their
consent was obtained at the next prenatal visit that acceptance of their pregnancy was characterized as
was about 2–3 weeks later. Women in both groups positive acceptance, passive acceptance or negative
received four nursing consultations on pregnancy- acceptance.
related symptom management which lasted about Verbatim transcribed recorded interviews and field
30 minutes, during the third, fourth, sixth and ninth notes were used as qualitative data in this study. A
months. Moreover, women who belonged to an inter- qualitative conventional content analysis (Hsieh &
vention group were provided the nursing intervention Shannon, 2005) was used for analysis. This is usually
that was developed by the researcher from a previous appropriate when research literature on a phenomenon
study and with maternal nursing experts. Nursing is limited (Hsieh & Shannon), and researchers avoid
counseling and interviews as an intervention focused using preconceived categories (Kondracki, Wellman, &
on the women’s comfortable experiences. In particular, Amundson, 2002). In the present study, because exist-
women were encouraged to express their positive emo- ing nursing care was not applied in this nursing inter-
tional reactions to the pregnancies and to recognize vention and because of the present study’s aim, this
when they felt comfortable mentally, as well as physi- analysis method was selected. First, after the interview
cally, during their pregnancy. Their positive experi- data and field notes were read repeatedly, the nursing
ences were then reinforced via verbalizing the intervention was summarized into a simple sentence and
experience and positive feedback. The original preg- assigned a code. The nursing care codes were then cat-
nancy diary was developed (Nakamura, in press) to egorized into subcategories according to the efficacy of
encourage the pregnant women to record their com- the nursing care in enhancing acceptance of the preg-
fortable experiences during the periods between the nancy. Depending on the relationships between the sub-
interventions and to help them better recall their com- categories, they were combined or organized into
fortable experiences during the subsequent interven- categories. To confirm the reliability and validity of the
tions. The aims of these nursing interventions were as qualitative data, analyses were supervised and discussed
follows: that pregnant women had a positive attitude with maternal nursing experts before transcribing the
toward pregnancy such that they could cope with results to text.
symptoms accompanying the pregnancy by themselves;
that being pregnant and its physical changes was a
RESULTS
comfortable experience for pregnant women; that
pregnant women were made aware of the comfortable Thirty-two women were eligible for the present study,
experience of pregnancy. To maintain consistency of of whom 24 (75%) participated at 9–37 weeks gesta-
the nursing consultation, intervention and counseling, tion. The remainder could not continue because of relo-
all were performed by the same researcher. For this cation to another area, or because of hospitalization for
reason, the sample size of each group was approxi- preterm labor. The number of subjects who completed
mately 15 women. all the nursing consultations and the interventions was
The nursing intervention was recorded in field notes 13 in the intervention group and 11 in the control
and on tape with the subject’s permission. Demographic group. The mean age of each group of subjects was
data were collected from simple questionnaires and 27.8 (SD = 3.5) years in the intervention group and
clinical records. Operational definitions of the patients’ 29.7 (SD = 3.8) years in the control group. The mean
attitudes were as follows: acceptance of pregnancy – age of the male partners was 30.5 years (SD = 4.4) and
accept being pregnant and the physical changes accom- 30.5 (SD = 3.6) years, respectively. Nine of the women
panying pregnancy, and being prepared to become a (69.2%) in the intervention group and eight of the
mother; comfortable experience – a realized or perceived women (72.7%) in the control group were employed,
experience with a positive emotional reaction towards with six of the nine, and five of the eight, respectively,
being pregnant and re-evaluation of the pregnancy as leaving her job during the research period. The mean
being associated with positive feelings such as happi- duration of marriage was 18.7 (SD = 22.6) months
ness, joy, pleasure or relief. (range 0–64) and 28.5 (SD = 36.2) months (range

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Y. Nakamura Japan Journal of Nursing Science (2010) 7, 29–36

0–98), respectively. Nine women lived with their part- (i.e. enlarged abdomen), social changes (i.e. managing
ners, with one of nine leaving her partner to live with work), and physiological changes (i.e. mood swings).
her parents. Previously, three women in the interven- First, women were encouraged to verbalize their feel-
tion group and two women in the control group had ings and events by answering questions about their
experienced spontaneous abortion. In the intervention pregnancy, distress and uncomfortable symptoms. At
group, one had an elective abortion, and one had infer- the same time, those negative feelings were recognized
tility treatment. as such. Women were encouraged to understand that
As a result of analyzing the nursing care codes, 45 every pregnant woman might have some negative atti-
subcategories were recorded as nursing behavior. Then, tudes towards their pregnancy and to not necessarily
the characteristics of the nursing care, which was feel bad about this, but recognize that negative feelings
carried out as a series or combined with the nursing naturally arise. The nursing care was carried out from
behaviour in each pregnancy period, were integrated the first to the third trimesters, but was particularly
and the following seven categories of nursing care were emphasized in the first trimester. Negative feelings
extracted for the intervention: encouragement of occurred not only in pregnant women who had nega-
women to record their experiences using a pregnancy tive attitudes to pregnancy because they were unmar-
diary; recognizing and acknowledging negative feelings; ried or had an unexpected pregnancy, but also in those
reducing the negative aspects of pregnancy and refram- who had a positive attitude to their pregnancy, but
ing; expression and reinforcement of positive feelings; who had vague feelings of anxiety and some slight
clarification and reinforcement of positive meanings; concerns. In the second trimester, some women
awareness of own comfortable experiences; promotion expressed dissatisfaction with their husband or partner.
of diverse comfortable aspects and continuation of In the third trimester, although women complained
comfortable experiences. The seven nursing care inter- about uncomfortable symptoms accompanying their
ventions were effective in increasing the comfortable enlarged abdomen, talking about their feelings made
experiences of pregnant women and enhancing a posi- them feel better.
tive attitude towards pregnancy.

Reducing the negative aspects of pregnancy

Encouraging memories of pregnancy and reframing
experiences using a pregnancy diary This nursing care was carried out after “recognizing and
This nursing intervention was to encourage descriptions acknowledging negative feelings”. Women were encour-
of events that had mainly positive feelings, but also to aged to clarify the reasons why they felt negative, such
record events associated with negative feelings, such as as discomfort or anxiety. Suggestions were made for
anxiety, in a pregnancy diary. Women were asked to coping with the symptoms, with support and encourage-
record entries daily, if possible, but at a minimum of ment given to regard their pregnancy in a different way.
once a week. Most women made diary entries more than For changes accompanying pregnancy, women were
once a week, with greater detail and increased frequency assured that these changes were a result of pregnancy
as the pregnancy progressed. In the first trimester, they and were normal. Technical knowledge about physi-
described their anxiety and nervousness more than their ological changes occurring throughout pregnancy was
positive feelings, but this made their concerns obvious at given. Women were encouraged to explore the positive
interview. Moreover, their pregnancy was analyzed aspects of their feelings and events; for example, confir-
objectively by reading the diary. It also led to a positive mation of their pregnancy, recognizing that changes
aspect of looking for pleasurable experiences in order to were temporary during the pregnancy period, proof of
describe them in the diary. the baby’s health, and opportunities for child care after
giving birth. Nursing care included recognition of the
husband’s, partner’s, or surrounding people’s behavior
Recognizing and acknowledging and discussing their feelings to encourage positivity;
negative feelings such as the anticipation of becoming a father and affec-
This nursing care focused on negative emotional reac- tion for the baby. Moreover, after recognizing their
tions, such as anxiety, uncomfortable symptoms, dis- negative attitudes to pregnancy, women were encour-
satisfaction, hatred, shock caused by the pregnancy aged to take the opportunity to think about the different
itself, morning sickness, tiredness, physical changes aspects of their pregnancy.

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Japan Journal of Nursing Science (2010) 7, 29–36 Enhancing acceptance of pregnancy

Expression and reinforcement of pregnancy progressed, empathy and support were

positive feelings mainly given in the third trimester.
This nursing care encouraged a positive emotional Awareness of own comfortable experiences
reaction, such as happiness, joy, relaxation, ease with
This nursing care was carried out after women’s recog-
the pregnancy itself, physical changes (i.e. enlarged
nition of the positive feelings towards their pregnancy
abdomen and fetal movement), social changes (i.e.
and the accompanying changes. Having a comfortable
becoming a mother), psychological changes (i.e. becom-
experience was reinforced by repeating verbalized feel-
ing calm), and seeing the partner’s attitude change.
ings and meanings and promoting diverse comfortable
Women recalled the time they recognized they were
experiences. This awareness was also recognized by
pregnant, and were encouraged to have receptive atti-
positive evaluation of the husband’s and surrounding
tudes, such as showing interest and talking about them-
people’s behaviors. A pregnant woman objectively
selves. Pregnant women who did not mention any
evaluated the comfortable experience of her pregnancy,
happiness about their pregnancy were encouraged to
and the comfortable experience was impressed upon her
recognize positive feelings of events accompanying preg-
by appreciating that she had many of these. In the first
nancy such as enlarged breasts and abdomen, ultra-
trimester, because women did not talk about comfort-
sound findings, preparation of baby goods and the
able experiences, this nursing care was carried out
husband’s and family’s behavioral changes. Reinforce-
repetitively. When women came to talk about their expe-
ment of positive feelings was carried out by promoting
riences with positive feelings and positive meanings,
expression and verbalization of positive feelings, verbal-
empathizing care was mainly performed.
ized feedback, providing support and empathizing with
their positive feelings. Promotion of diverse comfortable aspects and
Women with ambivalent feelings first expressed their continuation of comfortable experiences
negative feelings, and then a relative reduction of the This nursing care was carried out at the same time as
negative aspect was promoted by expression and rein- “awareness of own comfortable experiences”. After the
forcement of the positive side of pregnancy. In the first full expression of a comfortable experience, this was
trimester, expressing positive feelings in their own voice expanded by asking about other pleasant events, and
was particularly encouraged. As the pregnancy pro- other aspects of the comfortable experience were
gressed, women could find pleasure in an event and expressed and reinforced. Behavior that produced posi-
verbalize their feelings. Empathy was mainly given in the tive feelings was supported and approved, and women
third trimester. were encouraged to continue the comfortable experi-
ence. In circumstances where a woman did not talk
Clarification and reinforcement of much, she was encouraged to talk about a previous
positive meanings comfortable experience and was reassured and praised
This nursing care was carried out after “expression and for continuing. A new comfortable experience was
reinforcement of positive feelings”. Verbalization and expected by supporting a forward-looking attitude, such
clarifying the meaning of positive feelings was encour- as trying to enjoy the pregnancy and trying to make time
aged by asking how joyful and happy the woman was to feel happy. In the first trimester, a comfortable expe-
feeling. This nursing care was carried out for women rience relevant to the woman was mainly encouraged. A
who were not good at verbalizing their feelings. A posi- comfortable experience relevant to the fetus was mainly
tive outlook was recognized and reinforced by feedback encouraged in the second trimester and, in the third
by talking about their feelings again. Reinforcement of trimester, various aspects of the comfortable experience,
the positive aspect of comfortable experiences was done including its relevance to surrounding people, were pri-
by positive feedback at the same time. From the first marily encouraged.
trimester, clarification of the reasons accompanying
positive feelings was carried out carefully one by one DISCUSSION
This nursing care helped pregnant woman analyze more
objectively why they were happy, and encouraged them Nursing care directed towards negative
to reassess the husband’s, baby’s and surrounding emotional reactions
people’s feelings. Since they were then able to express Effective nursing care to reduce negative emotional reac-
the reasons for positive feelings by themselves as the tions focusing on a comfortable experience with two

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Y. Nakamura Japan Journal of Nursing Science (2010) 7, 29–36

interventions, “recognizing and acknowledging negative able to express their positive feelings using their own
feelings” and “reducing the negative aspects of preg- initiative. Beck (1976) proposed that expressing one’s
nancy and reframing” were derived. It was reported that positive emotions verbally has the effect of allowing the
listening and empathizing allowed people to feel at ease person to transform these into enhancing experiences.
and accept their condition. Doing so makes self-help By considering the positive emotions and their related
solutions easier (Yoshimoto & Kojima, 1999). This causes, pregnancy can become a more pleasant experi-
allows recognition and expression of the pregnant ence for the woman as she can gain a greater awareness
women’s negative feelings as an aid to discussing vague of her experiences. Taking stock of experiences can
and ambivalent feelings that are often experienced by allow the woman to become more comfortable about
pregnant women in the first trimester, and to gain accep- this important life event.
tance of the pregnancy. Another report found that relief Greenspoon (1955) said that a client’s behavior was
of negative feelings by counseling of pregnant women formed by “ah-hah” and other consensual actions and,
required acceptance of the pregnancy (Shindo & Wada, in later research, he also showed how an interviewer
1990) and supported the efficacy of nursing intervention could encourage the client to verbalize with repeated
in promoting acceptance of the pregnancy. Attentive simple actions. This nursing intervention had the effect
listening and empathy deepened the relationship of of making pregnant women speak more often and
mutual trust (Yoshimoto & Kojima, 1999). This report strongly by using continuous interviews and nursing
found that someone being available to affirm, accept care, such as agreement, empathy, and approval. During
and respect attitudes was important for the woman to this nursing care, some women talked about their
accept her own attitudes. Hirose (2003) also found that anxiety and concerns about their pregnancies. Nursing
this type of nursing care was effective and important. In care towards a positive emotional reaction was ineffec-
Japanese culture, Japanese people are required to always tive if the nursing care towards negative emotional reac-
show socially acceptable behavior (Kudo & Matsu- tions was not adequately carried out at the same time.
moto, 1996). The Japanese way is that women should be Maternity life can be made comfortable to some extent
happy with pregnancy and should not have a negative after ensuring the pregnant women’s safety. So, with
attitude. For these reasons, Japanese do not express respect to the reinforcement of positive feelings, nursing
negative feelings even when they have them (Kudo & care towards negative emotional reactions is required at
Matsumoto, 1996). Therefore, pregnant women cannot the same time.
express negative attitudes toward pregnancy and so
keep them to themselves. They can be relieved of nega- Nursing care towards a comfortable experience
tive feelings about pregnancy and can accept the preg- As effective nursing care towards a comfortable experi-
nancy positively when those negative feelings are ence, three nursing interventions, “encouragement of
recognized as a normal reaction to pregnancy. In the the memory of experiences using a pregnancy diary”,
present study, the midwife who performed the nursing “awareness of own comfortable experiences”, and “pro-
intervention became not only a person who could be motion of diverse comfortable aspects and continuation
consulted, but also a partner who empathized with and of the comfortable experiences”, were derived. Even if
understood the pregnant woman. there were some opportunities to discuss anxieties and
concerns about pregnancy with a friend or family
Nursing care towards a positive member, the opportunity to share pleasure and joy with
emotional reaction people does not occur very frequently. It is often difficult
For effective nursing care towards a positive emotional to find a companion to share pleasant experiences of
reaction that focused on a comfortable experience, two pregnancy, due to urbanization and the cultural shift
nursing interventions, “expression and reinforcement of from extended families towards nuclear families.
positive feelings” and “clarification and reinforcement However, the subjects in the present study had an oppor-
of positive meaning”, were derived. Because the Japa- tunity to recognize the positive aspects of their preg-
nese nature is such that it is not favorable to express nancy and be in a place where they could express their
one’s feelings (Kudo & Matsumoto, 1996), most preg- positive experiences. Once people experience comfort,
nant women were not good at verbally expressing them- their wish for it becomes stronger, and reward further
selves about their experiences. However, verbalization strengthens it. As a result, people will cope with work
focusing on the positive aspects was carried out continu- more enthusiastically and productively (Beck, 1976). In
ously throughout the pregnancy, and the women became this study, pregnant women had their comfortable expe-

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Japan Journal of Nursing Science (2010) 7, 29–36 Enhancing acceptance of pregnancy

riences recognized. It was found that they could increase who needs hospitalization, this nursing intervention
their variety of comfortable experiences by receiving could be applied once the acute situation has passed.
praise at regular prenatal check-ups and could cope with
the events accompanying positive feelings better and
more productively. Moreover, it has been suggested that
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