ORI GI NAL RESEARCH

Evaluation of a family nursing intervention for distressed pregnant

women and their partners: a single group before and after study
Marga Thome & Stefan a B. Arnardottir
Accepted for publication 12 May 2012
Correspondence to M. Thome:
e-mail: marga@hi.is
Marga Thome MSc PhD RN
Professor
School of Health Science, Faculty of Nursing,
University of Iceland, Reykjavik, Iceland
Stefan a B. Arnardottir MSc RN
Advanced Practitioner in Family Health
Nursing
Primary Health Care of the Capital Area,
Reykjavik, Iceland
THOME M. & ARNARDOTTI R S. B. ( 2013) THOME M. & ARNARDOTTI R S. B. ( 2013) Evaluation of a family nursing
intervention for distressed pregnant women and their partners: a single group before
and after study. Journal of Advanced Nursing 69(4), 805816. doi: 10.1111/j.1365-
2648.2012.06063.x
Abstract
Aim. To report a study of the effects of an antenatal family nursing intervention for
emotionally distressed women and their partners.
Background. High levels of depressive symptoms and anxiety are common in
pregnant women, and their partners are likely to suffer from a higher degree of these
symptoms than those of non-distressed women. Maternal anxiety and depressive
symptoms inuence the development of the foetus and child negatively. Distress-
reducing interventions for couples are scarce.
Design. The design was a pre- and post-test single group quasi-experiment.
Methods. All women distressed during the last two trimesters of pregnancy were
referred by midwives to a family nursing home-visiting service in a primary care
setting in Iceland. They were invited to participate in the study from November
2007September 2009. The nal sample was 39 couples. Assessment of distress was
through self-reporting of depressive symptoms and anxiety, self-esteem, and dyadic
adjustment. The couple received four home visits that were guided by the Calgary
Family Nursing Model.
Results. Women experienced a higher degree of distress than men before the
intervention. Couples distress was interrelated, and improvement was signicant on
all indicators after the intervention.
Conclusion. Healthcare professionals who care for distressed expectant women
should attend to their partners mental health status. The Calgary Family Nursing
Model is an appropriate guide for nursing care of distressed prospective couples in a
primary care setting.
Keywords: Calgary Family Nursing Model, distress, Iceland, intervention, nurses,
pregnancy, transition
Introduction
Pregnancy is a transitional period in the lives of prospective
parents and may affect the mental health of some families, as
well as that of individual family members in a negative way
(Schumacher & Meleis 1994, Meleis et al. 2000, Hayes &
Muller 2004). Studies from Western countries have shown
that distress in pregnant women is common, and prevalence
2012 Blackwell Publishing Ltd 805
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JOURNAL OF ADVANCED NURSING
rates of depressive symptoms and anxiety range from 10
15% (Evans et al. 2001, Bennett et al. 2004, Rubertsson
et al. 2005). Depressive symptoms tend to peak during the
2nd and 3rd trimesters of pregnancy (Eberhard-Gran et al.
2004). In mentally healthy mothers and fathers, they decrease
from the end of pregnancy until 18-month postpartum,
whereas parents with psychopathology in pregnancy show a
tendency towards prolonged depressive phases that peak at
12-month postpartum (Perren et al. 2005). Anxiety symp-
toms during pregnancy are associated with depressive symp-
toms, stress, self-esteem, and other psychosocial variables, as
with anxiety at other times (Gurung et al. 2005, Littleton
et al. 2007, Leigh & Milgrom 2008). Low self-esteem has
been found to be a signicant predictor of both anxiety and
depression in pregnant women (Jomeen & Martin 2005).
Elevated and prolonged levels of anxiety and depressive
symptoms during pregnancy inuence the development of the
foetus and the child negatively (OConnor et al. 2002, Van
den Bergh et al. 2005, Talge et al. 2007). Antenatal depres-
sion predicts postnatal depression and both predict depres-
sion in adolescent offspring (Robertson et al. 2004, Pawlby
et al. 2009). Expression of depression and anxiety during
pregnancy is gender specic. Although men tend to express
distress more through anxiety symptoms, women show
higher levels of depressive symptoms (Matthey et al. 2000).
Pregnancy, rather than the postnatal period, has been found
to be the most stressful period for men undergoing transition
to parenthood, but they report consistently only about half
the rate of depressive symptoms than women (Condon et al.
2004). Predisposing factors for distress in pregnancy are
different from those of the postpartum (OHara et al. 1983,
Beck 1996, OHara & Swain 1996). Distress of pregnant and
postpartum women has been found to be related to partner
distress, and men living with a distressed partner are more
likely to experience a higher prevalence rate of distressing
symptoms than those living with a non-distressed partner
(Lovestone & Kumar 1993, Burke 2003). In several studies, a
correlation between higher depression and anxiety scores of
partners and with dyadic adjustment has been reported (Cox
et al. 1999, Perren et al. 2005, Figueiredo et al. 2008).
Concordance between maternal and paternal depressive
symptoms has been reported to be high and ranges from
675725% (Raskin et al. 1990, Soliday et al. 1999,
Matthey et al. 2000). Depressed fathers are less satised
with their partner relationship, and dissatisfaction tends to
persist throughout the perinatal period (Matthey et al. 2000,
Florsheim et al. 2003, Condon et al. 2004). Distress in men is
associated with lower social support and difculties in
adjustment to parenthood (Tammentie et al. 2004,
Bielawska-Batorowicz & Kossakowska-Petrycka 2006,
Vesga-Lopez et al. 2008). Emotional disturbances of
expecting parents are related to multiple factors such as
depression and anxiety levels, self-esteem, locus of control,
partner relationship, relationship with own parents,
personality, stressors and psychiatric history, social support,
and employment (Bernazzani et al. 1997, Berthiaume et al.
1998, Matthey et al. 2000). A multitude of prenatal
conditions contributes to variations in parents satisfaction
with family functioning and relationship during transition to
parenthood (Knauth 2000).
Background
To meet the need of both partners for antenatal mental health
care, a nursing service established in a primary care setting in
Iceland and described in this study was based on the
theoretical framework of the Calgary Family Nursing Assess-
ment and Intervention Model (Wright et al. 1996, Wright
2005, Wright & Leahey 2005) and on the concept of
transition in pregnancy and to parenthood (Schumacher &
Meleis 1994). The family systems approach inherent to the
Calgary Family Nursing Model appears to be an appropriate
conceptual framework for mental healthcare interventions
for expecting couples as their distress is interrelated (Matthey
et al. 2001, Wright & Leahey 2005). The model is based on a
theoretical foundation involving systems, cybernetics, com-
munication, and change (Wright & Leahey 2005). Following
the model allows clinicians to focus on clinical issues in such
a way that helps family members deal with complex and
often difcult life situations and to improve their health
(Wright & Leahey 2005, Konradsdottir & Svavarsdottir
2011). According to this model, a family is constituted of
individuals who relate to each other through social and
emotional ties and the client is the family. The focus of care is
on the relationship between family members. The family
member closest to the individual receiving health care is
named as the co-recipient of care (Wright & Leahey 2005).
The Calgary Family Nursing Model consists of two parts:
(1) The Family Assessment (CFAM) and (2) The Intervention
Model (CFIM). The purpose of the family assessment is to
create a description of the familys need for health care and
the context for collaborative and relational, non-hierarchical
relationship between family and nurse. It encourages the
synthesis of complex data about the family to identify its
strengths and problems and to devise a care plan. Major
categories of data are structural, developmental, and func-
tional (Wright & Leahey 2005).The intervention model is
meant to promote mutual cooperation between the family
and the nurse to facilitate change or adjustment to a health
problem. It guides clinicians in facilitating the improvement
M. Thome and S.B. Arnardottir
806 2012 Blackwell Publishing Ltd
and sustainment of effective family functioning in three
domains: cognitive, affective, and behavioural. Interventions
targeted at any or all of these domains can promote, improve,
or sustain family functioning, and changes in one domain can
carry over and affect the other domains (Wright & Leahey
2005).
To achieve commonly set goals described in a care plan, the
nurse must adapt her language to the beliefs of the family and
stimulate the creation of alternative thoughts that suit goals
for change (Wright et al. 1996). Posing interventive questions
is supposed to be a simple yet powerful nursing intervention
tool for families experiencing health problems and signicant
life changes. The questions are of two types: linear versus
circular. Linear questions are meant to inform nurses,
whereas circular questions are assumed to facilitate change
and adjustment. They stimulate the sharing of concerns,
information, challenges, and problems with other family
members and the nurse. Discussion of the material can help
couples to discover new ways of seeing a problem, to accept
differences between partners perspectives, and to discover
solutions to problems (Wright & Leahey 2005, Konradsdot-
tir & Svavarsdottir 2011).
The Calgary Family Nursing Model has been implemented
in several countries, most often regarding chronic health
problems in families (Bell 2009, Svavarsdottir & Jonsdottir
2011). In Iceland, the model was recently implemented in a
hospital setting (Svavarsdottir 2008) and has already led to
several quantitative evaluations of family nursing interven-
tions for long-term health problems in paediatric care and
results indicate benets for families (Svavarsdottir & Sigur-
dardottir 2005, 2011, Konradsdottir & Svavarsdottir 2011).
The model has been infrequently tested with couples in
transition to parenthood and in primary care settings. A study
involving postpartum couples from Canada shows that they
welcome the opportunity to be approached by nurses as a
family (Holtslander 2005). Despite the importance of family
and partner relationships in determining well-being during
pregnancy and for transition to parenthood, little research
has focused on healthcare assessment and interventions for
families and couples (Field et al. 2008). Because of the severe
consequences of anxiety, depression, and stress during
pregnancy on mothers, partners, and children alike, it has
been suggested that clinicians may identify a range of
psychosocial distress in pregnant women and provide effec-
tive distress-reducing interventions (Dennis et al. 2007,
Austin et al. 2008). As distress in couples is interrelated, it
is recommended that primary healthcare workers assess
distress in fathers as well as in mothers, provide supportive
interventions, and/or refer to a specialist service (Matthey
et al. 2001, NICE 2007). Nurses and midwives working in
primary care settings are able to assess different levels of
emotional distress in pregnant women. They may also
provide support to those who suffer from mild to moderate
distress (NICE 2007, Furber et al. 2009). Effective psycho-
social interventions are crucial to reduce distress at any level,
and interpersonal psychotherapy has been shown to be
effective for treatment of severe distress (Spinelli & Endicott
2003). However, there is a general lack of evidence-based
intervention studies related to pregnancy-related distress of
prospective fathers (Dennis et al. 2007). This paper contrib-
utes to the literature by redressing the lack of family and
relationship-based interventions for distressed couples during
pregnancy.
Origin
This study originated during the development of a primary
antenatal mental healthcare service for distressed women
living in Iceland during 2007. The service started as a home-
visiting programme by psychiatric community nurses for
mentally and chronically ill patients living in the community.
Although community nurses provided services to postpartum
distressed mothers at the time, there was no specic service
for antenatal distressed women. This gave rise to the
establishment of the new nursing service described in this
paper. Midwives started referring an increasing number of
distressed pregnant women to the service, although there was
no evidence at the time it would benet the prospective
parents. This study was developed in response to this lack of
evidence.
Based on the review of the literature and the theoretical
framework guiding this study, the following hypotheses were
tested:
1. Before the intervention, there is a signicant difference
between womens and mens self-reports on:
(a) Depressive symptoms (EDS),
(b) Trait anxiety (STAI),
(c) State anxiety (STAI),
(d) Self-esteem (RSES),
(e) The quality of dyadic adjustment (DAS).
2. Couples improvement on the following indicators is
interrelated with regard to:
(a) Depressive symptoms (EDS),
(b) Trait anxiety (STAI),
(c) State anxiety (STAI),
(d) Self-esteem (RSES),
(e) The quality of dyadic adjustment (DAS).
3. After the intervention, there is a signicant difference in
couples:
(a) Depressive symptoms (EDS),
JAN: ORIGINAL RESEARCH Family nursing, pregnancy, and distress
2012 Blackwell Publishing Ltd 807
(b) Trait anxiety (STAI),
(c) State anxiety (STAI),
(d) Self-esteem (RSES),
(e) The quality of dyadic adjustment (DAS).
The study
Aim
The aim of this study was to evaluate the clinical effects of an
antenatal family nursing intervention for distressed women
and their partners on depressive symptoms, anxiety, self-
esteem, and dyadic adjustment.
Design
A single group, before and after, quasi-experimental study
was designed with the purpose of testing the family nursing
intervention in standard practice.
Participants
Women attending antenatal care at community health centres
who were found to be distressed by midwives were referred to
the service. These women and their partners were eligible for
the study (n = 70). The couples providing consent were
recruited (n = 61). Inclusion criteria were pregnancy had
progressed to the second or third trimester and the woman
herself had conrmed experiencing distress. Exclusion criteria
were no understanding of Icelandic and the notication of
treatment elsewhere. Due to the lack of distress-reducing
intervention studies for pregnant women that address sample
size, the number of participants recruited for this study was
oriented on intervention studies for postpartum depressed
women. It has been found that there is a 32% difference in
the rate of recovery at 3-month postpartum between groups
of treated and untreated depressed women (Holden et al.
1989). Based on these ndings, it has been suggested that a
sample of 44 in an experimental group is sufcient to achieve
80% power (5% signicance) to detect a signicant differ-
ence (Cooper et al. 2003).
Data collection
Data collection took place from the beginning until the end of
the intervention study which lasted from November 2007
October 2009. Four self-report scales were mailed to the
couple before the intervention with a letter informing
participants about the study and their rights. They were
asked to return informed and signed consent with the
completed scales during the rst home visit. The self-report
scales answered, before and after, are as follows: EDS
Edinburgh Depression Scale (Cox et al. 1987), STAI State
and Trait Anxiety Inventory (Spielberger 1983), RSES
Rosenberg Self-Esteem Scale (Rosenberg et al. 1995, Vilhj-
almsson et al. 1998), and the DAS Dyadic Adjustment Scale
(Spanier 1976). In addition, assessment by a genogram was
carried out during the rst home visit as part of the CFAM
(Wright & Leahey 2005). The self-report scales selected for
this study are related to the cognitive and affective domains
of family functioning, and this information is complemented
by a genogram (Wright & Leahey 2005).
Edinburgh Depression Scale
The Edinburgh Postpartum Depression Scale (EPDS) is a self-
report scale that was originally designed to identify post-
partum depressed women (Cox et al. 1987). It has been
renamed Edinburgh Depression Scale (EDS) after evaluation
for antenatal women and for couples during transition to
parenthood (Murray & Cox 1990, Matthey et al. 2001, Cox
& Holden 2003). The scale consists of ten items, and its sum
yields a score ranging from 030. The cut-off point for the
diagnosis of depression is based on studies from other
Western European countries for postpartum women and set
at 12, indicating a high degree of psychiatric morbidity
(Appleby et al. 1997, Guedeney & Fermanian 1998).
Matthey et al. (2001) suggest that a lower cut-off point
should be set for depression or anxiety disorders in fathers
compared with mothers and a score of 5/6 to indicate a dis-
tress case. A validation study for the Icelandic version of the
EDS is not yet available. Two tests of reliability have
conrmed the homogeneity of the translated Icelandic version
with a national sample of 734 postpartum mothers (Cron-
bachs alpha 087; split-half 083) (Thome 1996, 2000).
Cronbachs alpha for women in this study was 081 pre-test
and 089 post-test; for men, respectively, 081 pre-test and
077 post-test.
State and Trait Anxiety Inventory
The measure distinguishes anxiety as either situational or
personality related (Spielberger 1983). The State Anxiety
Scale is used to assess anxiety as a situation-specic response,
whereas the Trait Anxiety Scale assesses personality-related
anxiety. Each scale consist of 20 items that asses the intensity
of anxiety symptoms. Scores for each scale can vary from a
minimum of 20 to a maximum of 80, and scores 40 on
either scale indicate severe anxiety. An Australian study
found that men are more likely than women to experience
anxiety disorders without depression in the perinatal period,
and it has been concluded that their anxiety levels should be
M. Thome and S.B. Arnardottir
808 2012 Blackwell Publishing Ltd
assessed, as well as their depression levels (Matthey et al.
2001). The Icelandic version of the STAI has been tested with
a sample of postpartum women aged 1939 and was shown
to be reliable (Cronbachs alpha: Trait anxiety 087 and State
anxiety 082). Mean values of this sample for Trait anxiety
are 354 (SD SD 63) and for State anxiety 302 (SD SD 66) (Thome
1996). Cronbachs alpha of State anxiety for women in this
study was 088 pre-test and 091 post-test; for men, respec-
tively, 087 pre-test and 089 post-test. Cronbachs alpha of
Trait anxiety for women was 091 pre-test and 094 post-test;
for men, respectively, 097 pre-test and 095 post-test. Inter-
pretation of these results must take into account little varia-
tion in responses and few respondents.
Rosenbergs Self-esteem Scale
The scale is a 10-item self-report measure of self-esteem. It
has been shown to have test-retest reliability, as well as
convergent and concurrent validity (Rosenberg et al. 1995).
The Icelandic version was tested in a health survey with a
random sample of 1200 adults and has been found reliable
(Cronbachs alpha = 084) (Vilhjalmsson et al. 1998). Cron-
bachs alpha for women in this study was 091 pre-test and
093 post-test; for men, respectively, 090 pre-test and 081
post-test.
Dyadic Adjustment Scale
The self-report scale consists of 32 items and assesses dyadic
adjustment to couple and similar dyadic relationships
(Spanier 1976). Most items are constructed as a Likert-type
scale indicating how well a characteristic ts the subjects
perception of his or her relationship. The sum of weighted
scores varies from a minimum of 0 to a maximum of 151.
The higher the score, the more satisfaction there is with the
relationship and the higher the commitment level to contin-
uing the relationship (Elek et al. 2003). Scores between 92
107 have been proposed to distinguish satised partners from
those who are dissatised with their relationship (Prouty
et al. 2000, Graham et al. 2006). The scale has been used in
studies internationally and distinguishes between distressed
and non-distressed samples (Crane et al. 1990). It has inter-
nal consistency (Cronbachs alpha = 084) (Spanier 1976).
Because of little variation in responses and few respondents in
the sample of this study, internal consistency of the Icelandic
version of the scale was determined by GuttmanFlanagan
split-half. For women pre-test, it was 095 and post-test 095;
for men, respectively, pre-test 093 and post-test 094.
Genogram
The assessment by a genogram generates data on demo-
graphics, the family, and health status. Demographics include
residence, parental age, and parity. Data on family relate to
family structure and relationships, patterns of relationships,
and family response to previous change and difcult life
experience. The health status describes general health and
perceived trauma (Wright & Leahey 2005).
The family nursing intervention
The family nursing intervention consisted of four home visits,
either weekly or monthly depending on the starting point of
the intervention in the second or third trimester. The closing
visit was scheduled near to the due date. Male partners were
offered attendance during the rst and last visit, and the
importance of their participation was emphasized. A hypoth-
esis was constructed for each visit according to suggestions by
the authors of the family nursing model (Wright & Leahey
2005). The hypothesis constituted the focus of the conver-
sation with the couple. Each hypothesis followed one opening
question. The sequence of visits, the hypotheses, and the
opening questions are summarized in Table 1.
After opening the conversation, the remainder of the
conversation was guided by the items that were uppermost in
the minds of the partners. The conversation was related to
pregnancy and expected parenthood as a transitional period
(Schumacher & Meleis 1994). During the last home visit, the
couple viewed a short video of interaction and communica-
tion between infant and parents and was invited to discuss it
afterwards. After the four home visits, the nurse nalized the
intervention by writing a letter to the couple for the purpose
of enhancing mutual affective and cognitive support and to
remind them of their strengths (Moules 2002, Bohn et al.
2003).
Ethical considerations
Permission for the study was granted by the Icelandic
National Bioethics Committee (VSNb2007030017/03-7). A
prerequisite to participate in the study was informed and
written consent by the medical and nursing directors of the
Primary Health Care of the Capital area. Participation was
voluntary and contained no known risk factors, and all data
were kept condential.
Data analysis
Differences in mean scores before the intervention between
women and men were analysed by paired t-test. The change for
couples over time was analysed in R (version 2.14.0 obtained
from r-project.org) using the package lme4. The data on
couples improvement on all relevant scores were analysed
JAN: ORIGINAL RESEARCH Family nursing, pregnancy, and distress
2012 Blackwell Publishing Ltd 809
separately using an augmented version of repeated measures
ANOVA ANOVA to account for the correlation between partners with a
random effect representing couples in addition to the usual
subject effect. The signicance of the couple effect and
treatment effect was tested using a likelihood ratio test, whose
test statistic is distributed according to the chi-squared distri-
bution, with signicance level of 5%.
Results
The sample and response
The majority of women (95%) who consented to the study
along with their partners named their partner as the closest
family member. One participant named her mother, as the
partner was imprisoned and two women had long-distance
relationships with their partners. The pre-test was completed
by 61 women and 51 men. Data from the post-test were
available for 39 pairs for the EDS, STAI-Trait and State, and
RSES and for 35 pairs for the DAS. There were no signicant
differences on the self-report scales between men and women
completing and those not completing the study with excep-
tion of the EDS for men. Non-completing men had a
signicantly lower mean score on the EDS compared with
completers, or 388 (SD SD 12) vs. 642 (SD SD 41); t(49) = 173,
P < 0002. Explanations for not completing the post-test
were inferred from the genogram and the conversations:
problematic relationship (n = 5), heavy workload of partner
or working away from home (n = 6), severe illness (2),
imprisonment of partner (n = 1), moved away (n = 1), and no
clear reason (n = 6). All women participated initially in the
conversations and one dropped out after two home visits. Of
their partners, 32% participated twice or more often, 49%
attended once, and 19% never attended. Two-thirds of those
never attending did not complete the post-test.
All couples resided in the Capital area. The mean age of the
women was 27 (SD SD 51) years, and the mean age of the men
was 30 (SD SD 56); 44% of the women were primiparas and
56% were multiparas. Sedative drugs were taken by 246%
(n = 15) of the women, although they had reported receiving
no treatment elsewhere.
Symptoms of depression and anxiety, self-esteem, and
dyadic adjustment before the intervention
Testing of hypothesis one revealed that men and women differ
signicantly onall self-report scale before the intervention with
exception of dyadic adjustment: EDS t(50) = 951,
P < 0001); STAI-trait [t(48) = 293, P < 0005; STAI-state
t(49) = 595, P < 0001; RSES t(49) = 437, P < 0001 and
DAS t(39) = 071, P < 047]. Hypothesis 1(ad) stating
Before the intervention there is a signicant difference
between womens and mens self-reports on depressive
symptoms (EDS), Trait and State anxiety (STAI), and self-
esteem (RSES) is accepted. Hypothesis 1(d) stating Before
the intervention there is a signicant difference between
womens and mens self-reports on the quality of dyadic
adjustment (DAS) is rejected.
Table 1 Sequence of home visits, hypotheses, and opening questions.
Sequence of home visit Hypotheses Opening question
First Pregnancy is a transition period and affects
expectant parents physically, mentally,
and socially
How did you notice the uncomfortable
feelings that affect you now?
Second Couple relationship will change during
pregnancy and positive, supportive
communication between partners can be
helpful in diminishing their distress.
Attachment to the unborn baby is
important for its development before and
after birth
How does the pregnancy affect your
relationship as a couple and your
life together?
Third Support and understanding from the
partner are likely to facilitate maternal
adjustment to parenthood and attachment
to the baby
How do your feelings affect what
you do jointly these days and did you
think about how the baby will affect
your life after birth?
Fourth The change from constraining towards
facilitating beliefs will diminish distress
during pregnancy
Did you notice any change in your
feelings during the last weeks?
If there was any change could you
explain what was constraining or
helpful to you?
M. Thome and S.B. Arnardottir
810 2012 Blackwell Publishing Ltd
Change in depressive symptoms, anxiety, self-esteem, and
dyadic adjustment after the intervention
Hypothesis 2(a), (c), and (e) stating Couples improvement is
interrelated with regard to depressive symptoms (EDS), State
anxiety (STAI), and the quality of dyadic adjustment (DAS)
is accepted. Hypothesis 2(b) and (d) stating that Couples
improvement is interrelated with regard to Trait anxiety
(STAI) and self-esteem (RSES) is rejected.
Hypothesis 3(ae) stating After the intervention there is a
signicant difference in couples depressive symptoms (EDS),
Trait and State anxiety (STAI), self-esteem (RSES), and the
quality of dyadic adjustment (DAS) is accepted. Results for
hypothesis two and three are summarized in Table 2.
Distress over time
Of the women entering the study (n = 61), 573% scored 12
on the EDS. Forty-nine women concluded both pre- and
post-test, and 24 of them or 49% had a clinically signicant
improvement on the EDS as their scores dropped between 4
14 points. Despite clinical improvement, ve of them
remained in the clinical range, scoring 12 on the EDS. Of
the 49 women, 14 (286%) remained in the clinical range for
depression and scored 12 on the EDS and 26 women (51%)
maintained scores in the clinical range, on either or both of
the EDS and STAI scales after the intervention.
Of the men entering the study (n = 51), 40 completed the
EDS pre-test. Of them, 10 (25%) scored 9 on the EDS. Of
the men that completed both pre- and post-tests, ten (25%)
had a clinically signicant improvement on the EDS as their
scores dropped between 410 points. Two men who were not
in the clinical range before the intervention worsened over
time as their EDS scores progressed into the clinical range and
rose from 410. Scores on the combined STAI scales
remained high for eight men (19%). Six of the ten men
who reported high scores on either the EDS or STAI scales
after the intervention lived with partners who also main-
tained high scores on either one or both scales.
Referrals
The couples who did not improve after the intervention were
offered referrals to specialist services as follows: Nine to a
psychiatric service specialized in mental health problems
during pregnancy, two to general practitioners, and one to
psychological trauma therapy. Couples with older children
were referred to one of the following: Group therapy to
empower parenting, child-psychiatry, and/or social services
including child-protection and parentinfant psychotherapy.
Some were referred to more than one service and eight
declined referral. The women were asked whether they would
accept that their primary healthcare centre was informed of
them having received the family nursing intervention during
pregnancy and all accepted.
Discussion
Improvement of distress
A main nding of this study is that couples improvement is
interrelated regarding depressive symptoms, state anxiety,
and dyadic adjustment. Furthermore, couples improved
signicantly after the intervention on all scales. These results
are supported by ndings from other studies in that couples
distress correlates with regard to depressive symptoms,
anxiety, and dyadic adjustment (Cox et al. 1999, Perren
et al. 2005, Figueiredo et al. 2008). There is also support for
the conclusion of couples improved antenatal distress from a
study on the effectiveness of massage therapy which shows
similar results to ours about the alleviation of antenatal
depression and anxiety and improvement of the couple
relationship (Field et al. 2008).
Table 2 Prospective couples (n = 39) change after the family nursing intervention.
Measure
Mean Pair Change SE SE
Father Mother Change v
2
P v
2
P Father Mother Change
EDS 703 1277 285 1386 0001** 3040 0001** 059 056 046
STAI-trait 2158 2979 598 0 01 4365 0001** 208 190 084
STAI-state 1760 2552 435 550 0001** 1338 0001** 147 141 110
RSES 2388 1928 197 037 054 1702 0001** 077 073 046
DAS 11312 11081 687 1589 0001** 1617 0001** 265 243 163
EDS, Edinburgh Depression Scale; STAI-Trait and State, STAI Anxiety Inventory; RSES, Rosenberg Self-Esteem Scale; DAS, Dyadic Adjustment
Scale.
Repeated measures ANOVA ANOVA, **P < 001.
JAN: ORIGINAL RESEARCH Family nursing, pregnancy, and distress
2012 Blackwell Publishing Ltd 811
The signicant improvement in the men challenges the
conclusion from another study that distress in expecting
fathers persists over the perinatal period (Condon et al. 2004,
Matthey 2004). Benets of psychotherapy have been reported
for depressed pregnant women (Spinelli & Endicott 2003).
The ndings from our study add to these as they show that a
brief and a conceptually different intervention based on the
Calgary Family Nursing Model may benet prospecting
parents. Mens participation in the conversations during
home visits is considered modest, as only about one-third
followed the recommendation of attending at least two
conversations. Their participation may therefore not suf-
ciently explain improvement. Concordance between a cou-
ples distressing symptoms found in other studies offers
another explanation of their improvement (Matthey et al.
2000, Condon et al. 2004, Perren et al. 2005). It is also
possible that men improved due to the focus in conversations
on the cognitive, affective, and behavioural domains of
family functioning implied in the CFIM. This could have
helped them to think family and thereby affect family
functioning, even though they were not all the time physically
present. Furthermore, an intervention effect on mens cogni-
tive domain of family functioning could have carried over to
the affective and/or behavioural domain and affected them as
well (Wright & Leahey 2005). The high drop-out rate of men
in the beginning and during the course of the study could
have rendered data with insufcient power for detecting a
real difference after the intervention. Nevertheless, the
signicant improvement found on all scales favours the
conclusion of a real change having occurred.
Implications for nursing and midwifery
It is unknown how midwives in Iceland identify distressed
women although it was found in one study that they may do
so (Furber et al. 2009). Whether clinical guidelines for
antenatal health care affect midwives assessment of womens
mental health is also unknown (NICE 2007, Land-
lknisembtti 2008). The results of this study show
nevertheless that all distressed women that were referred by
midwives to the primary antenatal mental health service
suffered from a mental health problem that was conrmed by
self-report scales of frequent depressive symptoms, anxiety,
problematic dyadic adjustment, low self-esteem, or a combi-
nation of these. The proportion of mothers scoring 12 on
the EDS found in this study is high (573%) compared with
the population mean of 14% in Iceland and to the prevalence
rates of depression of 1015% reported from other countries
(Thome 2000, Evans et al. 2001, Bennett et al. 2004,
Rubertsson et al. 2005). With a view to these prevalence
rates, it is assumed that the small clinical sample identied by
midwives could represent the tip of an iceberg. Mens report
of lower rates of distress than that of women is consistent
with ndings from other studies (Ballard et al. 1994, Matthey
et al. 2001, Condon et al. 2004). However, couples interre-
lated distress and its improvement after the intervention
suggest that healthcare professionals should attend to the
mental health of partners of distressed pregnant women as
well. It is suggested from the ndings that midwives and
nurses clinical assessment of mental health of prospecting
parents should be studied further. Prenatal assessment should
be comprehensive enough to identify the majority of clients
who are in need of mental health care during pregnancy
What is already known about this topic
Womens emotional distress during pregnancy is
common and is frequently expressed by symptoms of
depression and anxiety.
Men living with distressed partners are more likely to
also suffer from a higher degree of depressive symptoms
and anxiety than those living with non-distressed ones.
Psychosocial interventions benet distressed women
during child-bearing.
What this paper adds
After a brief intervention for expecting couples based on
the Calgary Family Nursing Model, they experience
reduced symptoms of depression and anxiety and
enhanced self-esteem and dyadic adjustment.
Distressed prospective fathers are likely to improve after
the family nursing intervention.
Midwives clinical judgement on antenatal emotional
distress is valid and concurrent with self-report
assessments.
Implications for practice and/or policy
The Calgary Family Nursing model for families in
transition to parenthood is appropriate for the care of
distressed prospective couples in a primary care setting.
Partners of distressed pregnant women may be attended
to by healthcare professionals to promote their mental
health.
Prospective parents who do not improve after the brief
family nursing intervention should be referred to
specialist services and be followed up.
M. Thome and S.B. Arnardottir
812 2012 Blackwell Publishing Ltd
(Austin et al. 2008). Assessment should, furthermore, form a
base from which to decide whether midwives and nurses
ought to manage mild to moderate distress or refer clients to
specialist care (NICE 2007, Furber et al. 2009).
Limitations of the study
The design of this clinical quasi-experimental study with only
one group and testing before and after limits the conclusion
that can be drawn as to the effects of the intervention. As
there was no group for comparison and because couples did
not have a psychiatric diagnosis, there remains some uncer-
tainty as to the specic effect of the intervention and probable
confounding factors. The small sample size and the high
drop-out rate of men limit the conclusion that can be drawn
regarding change over time.
Conclusion
The ndings of this study support the appropriateness of the
Calgary Family Nursing model for the care of distressed
prospective couples. It was tested for the rst time in a
primary care setting in Iceland and requires further testing
and development as a theoretical framework for family
nursing care during life transitions in various cultures and
settings. The application of the model is recommended for
use by healthcare providers who are trained in its application.
The brief family nursing intervention for distressed couples
tested in this study was effective for women and men and was
acceptable to both partners. Regarding the studys limita-
tions, interventions for couples distress should be studied
further by trials and be compared with different distress-
reducing interventions for prospective parents. As about half
of the participants did not improve, follow-up studies are
needed to understand the course and management of perina-
tal distress in the longer term. The Icelandic version of the
dyadic adjustment scale and the State Anxiety Inventory
require further testing with larger sample sizes and greater
variation of responses by men and women than discovered in
this study.
Acknowledgements
Statistical advice and support with data analysis is acknowl-
edged by Agusta Edda Bjo rnsdottir, project manager of the
Social Science Research Institute, University of Iceland, and
by Bjarki Thor Elvarsson, MSc, Statistics Centre of the
University of Iceland. The authors thank Margaret E. Wilson,
Professor, for reading over and commenting on the rst draft
and Margaret M. Hansen, Associate Professor, and Fulbright
Scholar for reading and commenting on the nal draft.
Funding
The study was supported by grants from the University of
Iceland Research Fund and the Science Fund of the Icelandic
Nurses Association.
Conict of interest
No conict of interest has been declared by the authors.
Author contributions
All authors meet at least one of the following criteria
(recommended by the ICMJE: http://www.icmje.org/ethi-
cal_1author.html) and have agreed on the nal version:
substantial contributions to conception and design, acqui-
sition of data, or analysis and interpretation of data;
drafting the article or revising it critically for important
intellectual content.
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