Spirituality in Clinical Practice © 2015 American Psychological Association

2015, Vol. 2, No. 3, 216 –232 2326-4500/15/$12.00 http://dx.doi.org/10.1037/scp0000069

Spiritual Beliefs of Mothers With Potentially

Distressing Pregnancies

Aurelie Athan, Sara Chung, and Jeanette Sawyer Cohen

Teachers College, Columbia University

This study examines the religious/spiritual (r/s) beliefs of mothers who have experi-
enced difficulties in the formation of their families and their association with maternal–
infant attachment and maternal mental health in the pre- and postnatal periods. Groups
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of women with disclosed differences in their pregnancy intention (e.g., wanted,

This document is copyrighted by the American Psychological Association or one of its allied publishers.

planned) and reproductive histories (e.g., infertility, perinatal loss, high-risk) were
profiled on their image of God/spirituality based on their endorsement of 21 charac-
teristics. Women with planned yet unwanted pregnancies fared worse off in maternal
well-being and attachment to their child. Women without complicated reproductive
histories yet risky pregnancies fared similarly. Women who held attributions of God as
loving and knowable and residing within the self, as opposed to a supreme being who
was judging, had better scores on anxiety, depression, perceived stress and social
support. Women with the most complex reproductive profiles viewed God as a teacher
with karmic implications. Findings from this study suggest that r/s beliefs are signif-
icant indicators of whether a nonideal pregnancy will result in distress for the mother
and her child. Clinicians are recommended to explore and encourage positive r/s
cognitions to assist women as they become mothers.

Keywords: God image, mothers, pregnancy, spirituality

Pregnancy and childbirth are typically asso-
ciated with pleasant ideals of motherhood and
positive emotions, but research has shown that
under some circumstances pregnancy can be
seen as a stressful life event (Geller, 2004). To
capture the complexity of how or why a woman
becomes pregnant is a unique challenge. Al-
though pregnancy has been conceptualized as a
unitary construct, it is in fact multidimensional,
and the antecedents to pregnancy a complicated
story only recently told in the psychological
literature. When a woman becomes a mother,
she brings with her a priori a set of attitudes
based on her intentionality of the pregnancy as
Aurelie Athan, Sara Chung, and Jeanette Sawyer Cohen,
Teachers College, Columbia University.
Sara Chung is now at Department of Psychology, Clinical
Science, University of California, Berkeley. Jeanette Saw-
yer Cohen is now at The Parent-Infant Psychotherapy Pro-
gram, Columbia University Center for Psychoanalytic
Training and Research, Columbia University.
Correspondence concerning this article should be ad-
dressed to Aurelie Athan, Teachers College, Columbia Uni-
versity, 525 West 120th Street, New York, NY 10027.
E-mail: ama81@columbia.edu
216
well as a history of fertility-related behaviors
and experiences. Difficulties in the formation of
a family may begin with early reproductive
health issues in the life span of the mother (e.g.,
endometriosis, fibroids, irregular menstruation),
varying levels of infertility (e.g., use of IVF or
egg/sperm donation), one or more perinatal
losses (e.g., abortion, early term miscarriage,
late-term neonatal death, stillbirth), and threat-
ened gestations (e.g., high-risk). The interplay
of a mother’s motivation for her current preg-
nancy and past reproductive complications may
yield a new arena for clinicians to explore, and
has the potential to raise much-needed ques-
tions with regard to the changing procreative
lives of 21st century women. One question
might be whether the above “non-ideal” preg-
nancy scenarios are distressing in themselves or
whether there exist underlying religion/spiritu-
ality (r/s) beliefs that may positively or nega-
tively color a mother’s perception? As Inhorn
(2005) argues, for social scientists to understand
the meaning of a reproductive decision for a
woman it is important to examine the “local
moral worlds” within which it is being per-
formed (e.g., the religious or political context’s
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
attitude toward birth control). Similarly we ar-
gue that mental and medical health profession-
als working with pregnant women might look at
their “inner moral worlds” or internal r/s land-
scape to understand how mothers interpret their
reproductive lives. By taking a closer look at
their perception of God’s qualities, we hope to
facilitate a deeper understanding of the r/s fac-
tors that may help or hinder distressing preg-
nancies. This study focuses on the God images
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
of women with a range of pregnancy complex-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ities or intentionalities and their association
with maternal–infant attachment, as well as
their own mental health.
Pregnancy as Multifaceted
The first attempts at clarity in the classifica-
tion of pregnancy embarked along lines of in-
tentionality, as literature began to delineate dif-
ferences by further dividing ‘unintentional’ into
mistimed/unplanned (not intended at the time)
and unwanted (not desired at any time) (Kler-
man, 2000; Shah et al., 2011). Although the
concept of intendedness is in transition, the
terms “planned,” “intended,” “timed,” or
“wanted” are still used interchangeably though
they may elicit different reactions from mothers
(Klerman, 2000; Santelli et al., 2003). Concep-
tual clarity around a woman’s ability to reach
her reproductive goals may also be necessitated.
Before a live birth is finally achieved, a myriad
of complex fertility-related experiences and be-
haviors likely precede the conception (Harris &
Daniluk, 2010). The term “infertility” may refer
to problems getting pregnant while “impaired
fecundity” may also include problems carrying
a baby to term (Greil, Slauson-Blevins, & Mc-
Quillan, 2010). The current pregnancy can also
have potential complications of its own, such as
the risk status of the mother (because of age) or
health status of the baby (congenital abnormal-
ities). Perinatal loss can range from fetal to
neonatal stages and may not always occur
within the awareness of the mother (early term
miscarriage). The inclusion of abortions under
perinatal loss in this article is also purposeful
because abortions are a form of loss and are not
always unwanted pregnancies, a default as-
sumption of the field. Greil and associates
(2011) point to this oversimplification of preg-
nancy and suggest that most studies “have
treated women with infertility as a monolithic
217
group, thus missing important distinctions . . .
with different types of infertility (primary or
secondary) or degree of ‘intentionality’ during
the infertility episode (trying or open to concep-
tion)” (p. 2102). From this vantage point, the
multifaceted nature of female reproduction is
revealed all the more and the road to mother-
hood branches with infinite possibilities.
Finding statistics for the above “reproduc-
tive identities” is challenging to glean from
the available data—typically National Survey
of Family Growth (NSFG) reports by the
Centers for Disease Control (CDC). Com-
pared with the worldwide incidence of 38%,
the U.S. has one of the highest rates of unin-
tended pregnancies among Western nations,
with nearly [1/2] of all pregnancies (Finer &
Zolna, 2011; Mauldon & Delbanco, 1997). In
2008, an estimated 6,578,000 U.S. pregnan-
cies resulted in 4,248,000 live births, but
1,212,000 ended in abortions and 1,118,000
in fetal loss. For intended pregnancies (51%
of total pregnancies), 80% ended in live births
and the remainder in fetal losses, whereas for
unintended pregnancies (49% of total preg-
nancies), 44% of pregnancies ended in births,
42% in abortions, and 14% in fetal losses
(Finer & Henshaw, 2006). With regard to
miscarriages, it is (under) estimated to be
between 15 and 20% of known pregnancies
but likely more common in nearly 1/3 of
women (Plagge & Antick, 2009; van den Ak-
ker, 2011). For abortion, ⬃35% of U.S.
women will have had one before 45 years of
age, whereas worldwide, 1 in 5 pregnancies
end in abortion or 40 million (Shellenberg et
al., 2011). Of the ⬃62 million U.S. women of
reproductive age in 2002, 15% reported “im-
paired fecundity,” 10% had received infertil-
ity services, with 7.4% of married women
classified as infertile; 51.8% of women 25 to
45 years of age reported an episode of infer-
tility at some point their lives (Greil et al.,
2011; U.S. Department of Health and Human
Services, National Center for Health Statis-
tics, 2011). With the above in aggregate, it
seems that more women may not have as
straightforward reproductive health experi-
ences than is typically assumed, and that a
small percentage of arrived-at pregnancies are
without some form of complexity from the
past.
 218 ATHAN, CHUNG, AND SAWYER COHEN
Religious Beliefs and Images of God
These various reproductive identities may
place mothers at differential levels of risk for
adverse psycho-social outcomes for themselves
and their children (Jacob, McQuillan, & Greil,
2007; Lancaster et al., 2010; Nelson & O’Brien,
2012; McQuillan, Greil, & Shreffler, 2011).
Women experiencing distress in the formation
of their family may be best served by drawing
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
on their faith or sacred resources, because r/s
This document is copyrighted by the American Psychological Association or one of its allied publishers.
beliefs have been well-documented to contrib-
ute positively to people’s health and wellbeing,
particularly when dealing with significant
stress, personal threat, or loss (Gall & Cornblat,
2002). Although a recent growing body of lit-
erature has described r/s as part of motherhood,
it has mainly focused on successful pregnancy
and childbirth, with relatively few studies link-
ing r/s factors to the more distressing spectrum
of reproductive life (Athan & Miller, 2005; Cal-
lister & Khalaf, 2010; Jesse, Schoneboom, &
Blanchard, 2007). Roudsari, Allan, and Smith’s
(2007) literature review revealed a “remarkable
gap” in the scholarship on infertility and reli-
gion, whereas Cowchock et al. (2010) listed
religion as playing an especially important role
for bereaving the loss of a child. Mahoney
(2013) also states that research leaves us with
few clues about what “helps or hinders,” what
“specific spiritual beliefs the client holds about
family life that could be part of the problem or
the solution in the client’s . . . parental difficul-
ties” (p. 365). This is the first study to our
knowledge that examines the link between spe-
cific r/s beliefs about images of God and preg-
nancy intentionality, reproductive complexity
and maternal well-being.
Using the concept of “relational spirituality,”
Mahoney (2013; Mahoney et al., 2003) calls on
psychologists to gain deeper insight into the
“more malleable, specific, and unique spiritual
cognitions or behaviors that contribute to har-
mony or strife across diverse family relation-
ships” (p. 368). A closer examination of the role
of r/s beliefs for unintended and complicated
pregnancies may help us better understand poor
maternal and maternal– child outcomes. For ex-
ample, poor self-concept may be at the heart of
the unhealthy maternal cognitions and behav-
iors of mothers with reproductive lives that fall
“outside the norm” or even purposefully trans-
gress them (Cheng, Schwarz, Douglas, &
Horon, 2009). These mothers may experience
stigmatization from their larger contexts and
incorporate such negative beliefs and percep-
tions into their self-schema as well as their
schemas of God (Shellenberg et al., 2011). In-
fertile women may, for example, hold them-
selves responsible for their role failure as moth-
ers or deem their use of assisted reproductive
technologies (ART) as a spiritually non-
normative path to family formation in the eyes
of God based on traditional r/s concepts (Dut-
ney, 2007; Jennings, 2010; Mahoney, 2013;
Schenker, 2000). Mothers may also view their
perinatal losses (whether volitional or other-
wise) as a “sacred loss” such that a mother may
believe these events to be God’s punishment or
will (Mahoney, 2013; Pargament & Mahoney,
2002). The way a mother interprets her spiritu-
ality may elicit within her a sense of love or
criticism regarding the nature of her pregnancy
that may ultimately compromise her own well-
being and her investment in her child (Parga-
ment & Mahoney, 2002). If she deems her preg-
nancy to be less than ideal (e.g., unwanted
pregnancy), what is her view then of God (e.g.,
as a teacher or a judge)?
The purpose of this study is to examine the
relationship between an underexplored r/s be-
lief, one’s characterization of God, with types of
reproductive distress. This exploration of the
links between women’s images of God and
well-being within the context of pregnancy
aims to illuminate more in-depth perceptions of
r/s factors influencing maternal mental health
beyond traditional examinations such as reli-
gious attendance or affiliation. The authors will
assess a wide variety of possible God images—
the mothers’ unique ways of understanding
their spirituality or God—to identify and longi-
tudinally predict those that may be associated
with their own functioning and quality of family
bond. Three domains guide the present investi-
gation: (a) women’s pregnancy intentionality
and history of reproductive complexity, (b) im-
ages of God/spirituality, (c) maternal psycho-
logical wellbeing and maternal–infant attach-
ment. The first domain of reproductive
intentionality and complexity refers to whether
the participants planned and/or wanted their
pregnancy, and whether they had a high-risk
pregnancy and/or history of reproductive chal-
lenges such as infertility. The participants’ im-
ages of God refer to the range of internalized
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES 219

images of a nontheistic or abstract understand- Table 1

ing of the universe or a relationship with spe- Demographic Characteristics of the Sample
cific deity/supreme power which gives guidance Characteristic % n
and purpose to life (Tanyi, 2002). The relation-
Age
ship of these God images to the mother’s en-
ⱕ24 9.6 45
dorsed affiliations with a particular r/s tradition 25–29 30.3 141
(e.g., Christian, Buddhist, etc.) will also be as- 30–34 41.6 194
sessed. The authors hypothesize that positive, 35–40 18.5 86
specific, supportive images would assist with First-time mother
maternal adjustment and infant bonding despite Yes 61.3 298
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

any reproductive hardships, and conversely No 38.7 188

Ethnicity
This document is copyrighted by the American Psychological Association or one of its allied publishers.

would harm if they were negative, diffuse, or Caucasian/White 85.4 414

abstract. Particular God images may also be Multi-racial/other 5.6 27
more likely to be internalized based on r/s af- Asian 3.5 17
filiation. Hispanic/Latina 3.1 15
African American/Black 2.5 12
Religious affiliation
Method Christian 45.5 215
No religion/atheist/agnostic 30.2 142
Participants Non-denominational 11.3 53
Jewish 6.6 31
The research study utilized a longitudinal Other (e.g. Pagan) 1.9 9
pre- and posttest design following women be- Muslim 1.7 8
Buddhist 1.7 8
fore and after the birth using self-report mea- Hindu 1.1 5
sures and a random lottery compensation for Education
one participant for a $200 gift certificate to a Graduate degree 40.2 194
chain baby store. The sample was composed of Bachelor’s degree 35.0 169
primi and multiparas mothers who completed Some college 21.1 102
both time points (n ⫽ 498). Eighty percent had ⱕHigh school 3.7 18
Household income (annual)
babies between 4 to 11.9 months of age. Partic- ⱕ$50,000 150 31.2
ipants were represented internationally, with $51,000–$100,000 183 36.4
most living in the U.S. (n ⫽ 417, 83.7%) in ⬎$100,000 148 29.8
suburban (44.7%) or urban (43.3%) areas, het- Country
erosexual (98.1%), and living with a partner United States 83.7 417
(95.5%). Religious affiliation varied (see Table English-speaking (Canada, UK,
South Africa, Australia) 9.2 46
1): specified affiliation (56.6%); no affiliation Unknown 5.0 25
(13.2%); non-religious (30.2%). Participant’s Other (Bermuda, Mexico,
r/s views were largely secure (50.6%) or seek- Germany, France, Israel) 2.0 10
ing (24.3%) with fewer conflicted (10.0%) or
doubting (2.5%). Experiences of potential preg-
nancy stress included: 100 (20.7%) unplanned,
58 (12%) unwanted, 74 (15.3%) high-risk, 38 ences and maternal-care practitioners, as well as
(7.9%) use of ART, and 112 (22.5%) with his- internationally on mother-related web-boards.
tory of perinatal loss/reproductive complica- Paper surveys were available, but none were
tions. requested, and all were completed online. After
initial participation at Time 1 an electronic in-
Procedure vitation to the Time 2 survey was sent three
months after the anticipated due date with
The study was carried out on an online con- monthly reminder e-mails thereafter. Partici-
venience sample recruited from 2008 to 2010 pants were given the option to opt out and could
through a variety of advertisements addressed at discontinue at any time. Each survey took ap-
mothers above age 18 in their second or third proximately 45 to 60 minutes for completion.
trimesters. Flyers were distributed to New York At both Times 1 and 2, participants were pro-
City-area community locations, national confer- vided with the research description, electroni-
 220 ATHAN, CHUNG, AND SAWYER COHEN
cally signed a participant’s rights form, and
gave informed consent. Participants were
treated in accordance with APA ethics and IRB
standards; IRB approval was received.). Reten-
tion rate was approximately 73%, 498 of the
original 759 participants completed both sur-
veys (see Table 1).
Measures
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Maternal and mother–infant well-being.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Maternal well-being. Pre- and postnatal
depression was measured using the 10-item Ed-
inburgh Postnatal Depression Inventory (EPDS;
Cox, Holden, & Sagovsky, 1987). Scores range
from 0 –30 and items focus on the cognitive and
affective features of depression experienced in
the past 7 days (e.g., I have been so unhappy
that I have been crying). A score of 12 is a
common clinical cut-off suggesting likelihood
of depression. Cronbach’s alpha was .83 at each
time point. Women’s prenatal and postnatal trait
anxiety was assessed using the Trait Anxiety
scale of the State–Trait Anxiety Inventory
(STAI; Spielberger, 1983), a measure of trait
predisposition toward feeling anxious that is
widely used in perinatal research. The 20-item
STAI asks respondents how they generally feel
(e.g., “I feel nervous”) using a 4-point scale
ranging from 1 ⫽ almost never to 4 ⫽ almost
always. Scores range from 20 to 80, with higher
scores indicating higher levels of anxiety. Sub-
jects with STAI scores ⬎40 are considered anx-
ious. Cronbach’s alpha was .82 at each time
point. Women’s pre- and postnatal perceived
stress was assessed using the Perceived Stress
Scale (PSS; Cohen, Kamarck, & Mermelstein,
1983), a measure of the degree to which situa-
tions in one’s life are appraised as stressful. The
10-item version uses a 5-point scale (never to
very often), asking: “In the last month, how
often have you felt . . . nervous and stressed.”
Responses are summed with higher scores indi-
cating greater stress. The PSS has adequate con-
current validity and internal consistency (␣ ⫽
.78) (Cohen et al., 1983). Cronbach’s alpha was
.82 at each time point.
Prenatal and postnatal social support were
also measured with the Multidimensional Scale
of Perceived Social Support (Zimet, Powell,
Farley, Werkman, & Berkoff, 1990). This
summed 12-item self-report measure was de-
signed to assess perceived adequacy of support
in the last 8 weeks from significant others using
a 7-point Likert-type scale. Scale items include,
“There is a special person who is around when
I am in need” and is reported to have good
internal reliability and coefficient alpha levels
with samples including pregnant women. Cron-
bach’s alpha was .85 and .84 for Time 1 and
Time 2.
Mother–infant attachment. The 21-item
Prenatal Attachment Inventory (PAI; Muller &
Mercer, 1993) assesses “the unique, affection-
ate relationship that develops between a woman
and her fetus” (Muller & Mercer, 1993, p. 11).
The PAI has adequate concurrent validity with
positive adaptation to pregnancy and behaviors
indicative of prenatal attachment (Muller &
Mercer, 1993). Example items include, “I
dream about the baby” and “I imagine what part
of the baby I’m touching.” Women indicate
their response to each item on a 4-point Likert
scale ranging from 1 to 4 (almost never to
almost always), with higher scores indicating
greater prenatal attachment. Cronbach’s alpha
in the present study was .87. The 26-item self-
report Maternal Attachment Inventory (MAI;
Muller, 1994) was used to measure maternal–
infant attachment postpartum with Cronbach’s
alpha reliability coefficients reported at .85, .76,
and .85, respectively. Criterion-related validity
has been established with comparable measures
(Muller, 1994). Scale items include “My
thoughts are full of my baby.” Cronbach’s alpha
in the present study was .86.
Pregnancy intention (PI) and reproductive
complexity (RC). Because pregnancy can be
viewed as multifaceted, potentially distressing
pregnancies were characterized by whether they
were planned, wanted, high risk, or associated
with a history of perinatal loss/infertility. Con-
sequently, the sample was regarded in two dif-
ferent ways based on these ratings using the
notion of intention (PI) and complexity (RC).
Pregnancy Intention (PI) was calculated by
the creation of four groups according to re-
sponses to 2 items in the Time 1 survey assess-
ing the planned nature of the pregnancy (Plan ⫽
Had you been planning to get pregnant?; Yes/
No) and its desirability (Want ⫽ Please answer
how much you wanted your pregnancy when
you first learned you were pregnant; Likert scale
1–7, not at all to very much). The continuous
variable of “Want” was transformed into an
artificial dichotomous variable. Responses of 5
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
and greater were ranked as “Want,” whereas 4
(neutral) and below were collapsed into “Un-
wanted.” Based on each participant’s response
on both dimensions, four groups where created
regarding the nature of the mother’s PI: 1 ⫽
Unwanted/Unplanned, 2 ⫽ Unwanted/Planned,
3 ⫽ Wanted/Planned, 4 ⫽ Wanted/Unplanned.
Reproductive Complexity (RC) was calcu-
lated by the creation of four groups according to
responses to the dichotomous variable in the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Time 1 survey assessing the current risk-level of
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the pregnancy (Risk ⫽ “Is your pregnancy con-
sidered: low risk/uncomplicated; high risk/
complicated?”) and an open-ended inquiry into
past pregnancies (Reproductive Complica-
tions ⫽ “Please describe your pregnancy his-
tory”) which was then quantitatively coded. Of
note, all 498 participants provided in-depth re-
sponses to pregnancy history question although
not required. Participants received a score of
(0 ⫽ No; 1 ⫽ Yes) for each of the following
themes if it was disclosed in their written de-
scriptions: “Miscarriage,” “Multiple Miscar-
riage,” “Infertility,” “Assisted Reproductive
Technology,” “Donor Egg or Sperm,” “Repro-
ductive Health Issues” (e.g., endometriosis),
“Forced Pregnancy Termination,” “Abortion,”
“Multiple Abortion.” Of the 101 participants in
the sample, (20.3%) disclosed having had expe-
rienced one or more perinatal losses (e.g., abor-
tion, miscarriage, neonatal death) and 41 (8.2%)
disclosed a history of reproductive difficulties
(e.g., use of ART, donor egg/sperm, health is-
sues, infertility). Participants received a sum
total score—a new quantitative variable named
“Reproductive Complications” which was fur-
ther artificially dichotomized (0 ⫽ none dis-
closed, 1 ⫽ one or more). Based on each par-
ticipant’s response on both dimensions, four
groups were created regarding the mother’s RC:
1 ⫽ Complicated/Risky, 2 ⫽ Uncomplicated/
Risky, 3 ⫽ Uncomplicated/Not Risky, 4 ⫽
Complicated/Not Risky. The Time 2 dichoto-
mous variable, “Assisted” (Yes/No), indicating
whether the pregnancy was conceived ART
(e.g., IVF, hormone therapy, etc.) was also in-
cluded as a check of the coding of the descrip-
tive pregnancy histories (see Table 1). The
number of women who said they used ART to
conceive using the Time 2 survey item were 38
(7.9%) and those who disclosed it in Time 1 in
their narrative description were 41 (8.2%).
221
R/S affiliation, views, and God image.
Participants selected from standard demographic
r/s affiliation options with regard to denomination
(see Table 1). To further assess r/s profiles, two
questions were borrowed from the College Stu-
dents’ Beliefs and Values (CSBV) Survey from
the University of California–Los Angeles
(UCLA) Higher Education Research Institute de-
signed to measure students’ r/s orientations (Astin
et al., 2005). This instrument was selected based
on the authors’ grounding in extensive r/s schol-
arship and their explicit intention to accommodate
those who define their r/s primarily in terms of
conventional beliefs and practices and beyond. As
of 2007, the survey had been used on 14,527
students. Question #55 was selected to rate the
degree to which a participant’s R/S Views were in
question: “How would you describe your current
views about spiritual/religious matters?” Question
#49 from the CSVB was enlisted and modified:
“Which of the following best characterizes your
conception of or experience with God?” The ques-
tion was further altered to be inclusive of nonthe-
istic language: “Spirituality is sometimes defined
as one’s relationship to God. It can also be what-
ever you perceive to be ultimately transcendent,
sacred, or divine . . . and may or may not have
anything to do with religion or a personal deity
. . . we would like you to keep in mind . . . your
own conception of God or Spirituality.” Along
with the following 14 options (“Universal
spirit,” “Love,” “Father-figure,” “Mother-
figure,” “Teacher,” “Part of me,” “Divine mys-
tery,” “Protector,” “Creator,” “Nature,” “Su-
preme being,” “Judge,” “Enlightenment,” and
“None of the above”) an additional 7 were
added based on the literature and brainstorming
(“People,” “Life/living things,” “Judge,”
“Karma,” “Unknowable,” “Interconnected-
ness,” and “Energy”). Participants could mark
more than one response. All r/s items were
given prenatally at Time 1.
Data Analysis Strategy
Frequencies for demographic, r/s, and repro-
ductive/obstetric variables were calculated for
the entire sample (see Table 1). Pearson r cor-
relations were computed for the sample to ex-
amine associations between continuous psycho-
logical variables as well as the God Image
variables. To compare adjustment and attach-
ment scores between the participants who
 222 ATHAN, CHUNG, AND SAWYER COHEN

dropped out of the study versus those who com-
pleted, Welch’s t tests were performed. Based
on group belonging within Pregnancy Intention
(PI) or Reproductive Complexity (RC), chi-
square tests were performed to determine if
group differences across demographic, r/s, and
reproductive/obstetric categories were present.
A factor analysis on the 21 God Images was
performed to determine presence of meaningful,
yet latent groups. In addition, for each of the PI
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
establish longitudinal associations of mother–
infant attachment and maternal well-being
based on God Images. Lastly, chi-squares were
performed for group differences between en-
dorsed r/s affiliation and the 21 God Images or
their latent factors.
Results
A series of Welch’s t tests assuming unequal

and RC groups, proportions of Yes responses to

This document is copyrighted by the American Psychological Association or one of its allied publishers.

the 21 individual God Image variables grouped
according to the factor analysis results were
calculated (see Table 2). Group profile dissim-
ilarity based on proportion of “Yes” responses
was examined using hierarchical cluster analy-
sis (see Figure 1) and also plotted visually (see
Figure 2). One-way ANOVAs and ANCOVAs
were conducted to examine group differences
on PI and RC across the psychological vari-
ables. Multivariate regression analyses were
conducted using Time 1 r/s variables to predict
Time 2 continuous psychological measures to
variances were performed to assess differences
in the means across the continuous variables of
adjustment for the sample that stayed on for
both time points (N ⫽ 498) versus those who
dropped out (N ⫽ 261). For the measures of
depression and perceived stress, a significant
differences was found, t(110) ⫽ 2.55, p ⬍ .05,
and t(91) ⫽ 2.06, p ⬍ .05 with the group that
did not continue having higher mean EPDS and
PSS scores. There was no significant effect
found for anxiety. For measures of mother– child
attachment, the group that did not continue had a

Table 2
Proportion of God Image by Pregnancy Intention (PI) and Reproductive Complications (RC) Groups
Pregnancy intention Reproductive complications
Group 1 Group 2 Group 3 Group 4 Group 1 Group 3 Group 4
Unwanted Unwanted Wanted Wanted Complicated Group 2 Uncomplicated Complicated
unplanned planned planned unplanned risky Uncomplicated not risky not risky
God image (n ⫽ 36) (n ⫽ 21) (n ⫽ 362) (n ⫽ 64) (n ⫽ 27) risky (n ⫽ 47) (n ⫽ 326) (n ⫽ 84)
Theistic
Creator .56 .33 .41 .44 .41 .32 .44 .38
Love .61 .43 .58 .70 .59 .45 .60 .62
Father-figure .25 .14 .24 .27 .11 .21 .27 .18
Teacher .36 .14 .27 .28 .37 .23 .28 .21
Protector .36 .14 .33 .33 .26 .30 .36 .24
Supreme being .25 .19 .35 .36 .33 .28 .34 .35
Judge .19 .14 .17 .11 .15 .21 .15 .14
Non-theistic
Part of me .19 .19 .36 .42 .37 .23 .35 .40
Me .06 .05 .10 .11 .15 .04 .09 .13
Nature .36 .52 .49 .58 .52 .36 .50 .58
People .17 .19 .19 .20 .15 .15 .21 .15
Living things .39 .29 .47 .55 .37 .32 .49 .50
Enlightenment .25 .10 .25 .30 .37 .19 .23 .32
Energy .36 .29 .39 .52 .37 .26 .38 .55
Interconnected .39 .62 .43 .44 .52 .36 .43 .49
Agnostic
Universal spirit .42 .48 .41 .44 .48 .30 .40 .51
Divine mystery .31 .29 .26 .27 .30 .30 .25 .27
Unknowable .25 .29 .22 .17 .26 .26 .19 .29
Karma .31 .14 .21 .27 .37 .13 .22 .21
Feminine
Mother-figure .11 .00 .12 .16 .00 .09 .14 .10
None of above .00 .00 .03 .00 .00 .04 .02 .02
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES 223
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 1. Hierarchical cluster analyses for God images based on pregnancy intention (PI)
and reproductive complexity (RC).

lower mean attachment than those who completed
both time points, t(123) ⫽ ⫺3.80, p ⬍ .001.
Chi-square tests of independence were per-
formed on contingency tables to detect the in-
dependence between demographic variables
and PI or RC group belonging. Significant dif-
ferences were found in age for both PI and RC
groups: ␹2(9, N ⫽ 463) ⫽ 37.17, p ⬍ .001, and
␹2(9, N ⫽ 464) ⫽ 31.84, p ⬍ .001, respectively.
Income and education were found to be signif-
icant for PI groups only: ␹2(6, N ⫽ 469) ⫽
19.27, p ⬍ .01, and ␹2(9, N ⫽ 481) ⫽ 26.18, 9,
 224 ATHAN, CHUNG, AND SAWYER COHEN
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. Proportions plot for four groups according to pregnancy intention (PI) and
reproductive complexity (RC).

p ⬍ .01. No significance was found for religious
affiliation or views. The Unwanted/Planned and
Uncomplicated/Risky group had the oldest
mothers, with 86% and 90% between 30 and 40
years of age. The Wanted/Unplanned group had
the greatest number of youngest mothers
age ⬍24 years (23%) followed by the Unwant-
ed/Unplanned group (15%). Of note, the Com-
plicated/Risky group had a fairly even distribu-
tion of age ranges. For PI, household income
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
was lowest for the Unwanted/Unplanned group
(46%, ⬍$50,000), followed by Wanted/Un-
planned (42%). The Unwanted/Planned group
was most educated, with 100% holding a BA or
higher.
Additional chi-square tests of independence
were performed to detect the independence be-
tween the demographic variables of specific r/s
affiliation (e.g., Christian, Buddhist, etc.) or
broader r/s categories (e.g., Specified R/S affil-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
iation, No R/S affiliation, etc.) and the 21 indi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
vidual God Images and latent factors (Theistic,
Nontheistic, Agnostic, or Feminist). All were
found to be significant except for the individual
God Image of “Karma.” This suggests that the
self-endorsed belonging to a particular r/s de-
nomination or tradition was significantly related
to what God Image was internalized by a sub-
ject and/or what factor they belonged to.
Group Profiles on Images of God
A factor analysis on 20 God Image items
(‘None of the above’ was dropped) was per-
formed to reduce the data to factors and to
determine whether any latent variables exist.
Using a scree test, a 4-factor model, explaining
43% of the variance, was decided on. The four
factors were Theistic (Creator, Love, Father-
figure, Teacher, Protector, Supreme being,
Judge; k ⫽ 7); Non-theistic (Part of me, Me,
Nature, People, Living things, Enlightenment,
Energy, Interconnected; k ⫽ 8); Agnostic (Uni-
versal spirit, Divine mystery, Karma, Unknow-
able; k ⫽ 4); and Feminine (Mother-figure; k ⫽
1). Factor sum scores were created for all of the
subjects who completed Time 1 and Time 2
across each endorsed item of 0 or 1. ANOVAs
were used to test group differences across the PI
and RC groups on each of the factor scores. No
significant results were found for the PI groups.
The RC groups differed on the Non-theistic
factor (p ⫽ .03). A Tukey’s post hoc test re-
vealed that the Uncomplicated/Risky group was
least likely to endorse a naturalistic spirituality,
while the Complicated/Risky group was the
most likely.
The overview of God Image group profiles
for PI as seen in Table 2 demonstrates variabil-
ity in both individual as well as group responses
with proportions ranging from 0 to 0.70, with
the highest mean proportion of Yes responses in
the Wanted/Unplanned group (M ⫽ .33, SD ⫽
225
.18) and the lowest in the Unwanted/Planned
group (M ⫽ .24, SD ⫽ .17). As both groups
share similar variability, they can be described
as having more extreme views and greater range
of responses as compared with the Wanted/
Planned (M ⫽ .30, SD ⫽ .14) and Unwanted/
Unplanned groups (M ⫽ .29, SD ⫽ .15). The
plot revealed the Unwanted/Planned group as
departing from the rest (see Figure 2). A hier-
archical cluster analysis, measuring profile dis-
similarity on God Images, confirmed that the
Unwanted/Planned group indeed had a statisti-
cally dissimilar profile from the others across
the 21 variables—and that the two wanted PI
groups clustered together (see Figure 1). In nar-
rating the individual God Image selections of
the Unwanted/Planned PI group, a picture
emerges of participants who least endorsed
nearly all the God Images, with few exceptions.
The Unwanted/Planned group particularly de-
parted from other PI groups in their lowest
endorsed Love, Teacher, Protector, Life, and
Enlightenment. Comparably, the Wanted/
Unplanned group most strongly endorsed nearly
all the God Images. The lowest endorsements
included Judge, None, and Unknowable,
whereas the highest included Love, Part of me,
Nature, Life, and Energy. The two unplanned
pregnancy groups similarly characterized God
as Karma, Teacher, and Love, whereas the two
unwanted pregnancy groups tracked quite dif-
ferently.
The overview of God Image profiles for RC
as seen in Table 2 demonstrates variability in
both individual as well as group responses with
proportions ranging from 0 to 0.62, with the
highest mean proportion of Yes responses in the
Complicated/Not Risky group (M ⫽ .32, SD ⫽
.17) and the lowest in the Uncomplicated/Risky
group (M ⫽ .24, SD ⫽ .11). Both groups had
the most extreme responses, with the Compli-
cated/Not risky having the greater range of re-
sponses, compared to the rest: Uncomplicated/
Not Risky (M ⫽ .30, SD ⫽ .15) and
Complicated/Risky (M ⫽ .31, SD ⫽ .16). The
plot revealed the Uncomplicated/Risky group as
departing from the rest (see Figure 2). A hier-
archical cluster analysis confirmed that the Un-
complicated/Risky group indeed had a statisti-
cally dissimilar profile from the others across
the 21 God Image variables—and that the two
complicated RC groups clustered together (see
Figure 2). In narrating the individual God Image
 226 ATHAN, CHUNG, AND SAWYER COHEN

selections of the Uncomplicated/Risky RC interaction. The Unwanted/Unplanned group

group, a picture emerges of participants who
least endorsed nearly all the God Images, with
exceptions on Mystery and Judge. This group
particularly distinguished themselves in their
lowest endorsement of Love, Part of me, and
Nature. Conversely, the Complicated/Not Risky
group had the most strongly endorsed God Im-
ages, with the lowest being Protector. Interest-
ingly, the Complicated/Risky group, with both
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
had the greatest mean anxiety scores. For the
RC groups, ANCOVAs revealed no significant
effects. Significant main effects were found for
PI Prenatal Attachment, F(3, 399) ⫽ 12.30, p ⬍
.001, and Postnatal Attachment, F(3, 402) ⫽
4.42, p ⬍ .01. Post hoc Tukey’s HSD mean
comparisons revealed multiple significant (p ⬍
.05) differences between groups on PI for Pre-
natal Attachment; Unwanted/Planned group re-

reproductive complications and a high-risk ported having significantly less than the other
This document is copyrighted by the American Psychological Association or one of its allied publishers.

pregnancy, most endorsed Karma, Teacher, and
Enlightenment. The two risky pregnancy groups
tracked quite differently.
Maternal and Mother–Infant Well-Being
Analysis of variance and covariance.
Table 3 displays descriptive statistics for PI
groups related to “Maternal and Mother–Infant
Well-being” and include psychometric proper-
ties for each variable. ANCOVAs were con-
ducted for all maternal adjustment variables to
exploit the longitudinal pre–post design, con-
trolling for prenatal measures. An ANOVA was
used for the mother– child attachment variables
since they were not identical measures at both
time points. No statistically significant effects
were found for Depression or Perceived Stress
among the four PI groups. With regard to Anx-
iety, statistically significant main effects were
found for PI group belonging, F(3, 382) ⫽ 7.10,
p ⫽ .001, and the covariate Prenatal Anxiety,
F(1, 382) ⫽ 288.0, p ⫽ .001, but not for their
three. For Postnatal Attachment, the significant
difference was most between the Unwanted/
Planned group and the two wanted groups. No
significant main effects were found for RC on
the pre- or postnatal attachment measures. The
scatterplots of MAI versus PAI for the four PI
groups yielded interesting observations. Albeit
a small group size, the Unwanted/Planned
mothers showed far less prenatal attachment
and proportionally far lower postnatal attach-
ment scores, than the others.
Multivariate regression analysis.
Multivariate regression analysis on each of the
Time 2 maternal adjustment and maternal– child
attachment variables were performed using
their Time 1 measures as a covariate along with
the factor scores (Theistic, Non-theistic, Agnos-
tic, Feminine) and categorical variables repre-
senting want, plan for the PI groups, and risk
and complexity for the RC groups respectively
as predictors for the Time 2 measures. When the
Time 1 measures were included as covariates,

Table 3
Descriptive Statistics for the Four Groups by Pregnancy Intention (PI) for Maternal and Mother–Infant
Well-Being
Group 1
Unwanted Group 2 Group 3 Group 4
unplanned Unwanted planned Wanted planned Wanted unplanned
(n ⫽ 36) (n ⫽ 21) (n ⫽ 362) (n ⫽ 64)
Variable M SD M SD M SD M SD
Depression T1 8.21 3.72 10.10 5.51 7.01 4.16 7.37 4.78
Depression T2 8.26 5.08 7.45 4.14 6.78 4.32 7.93 4.48
Anxiety T1 43.47 8.12 44.53 11.40 37.72 8.59 38.29 10.07
Anxiety T2 44.21 10.84 44.61 9.76 39.47 9.25 40.21 10.55
Perceived stress T1 26.24 8.47 27.25 8.48 22.38 8.53 22.62 9.66
Perceived stress T2 26.79 8.30 27.74 8.66 23.69 8.44 24.06 9.46
Perceived social support T1 66.47 17.13 68.30 17.00 73.29 9.66 73.47 10.94
Perceived social support T2 66.13 13.22 70.75 10.86 70.77 12.21 69.67 14.51
Prenatal attachment T1 57.19 10.17 46.35 9.26 58.83 10.57 62.52 9.98
Postnatal attachment T2 94.09 7.77 91.47 8.49 95.60 4.67 95.41 4.93
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
none of the other predictor variables were sig-
nificant. This was true both in the PI and RC
groupings. As such, the 21 individual God Im-
age variables were returned to as dichotomous
predictors instead of the factor scores for anal-
yses.
All of the 21 individual God Images were
simultaneously added independently into the
initial regression model with the Want, Plan,
and then the interaction of Want/Plan for PI (or
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Complications/Risk and then the interaction for
This document is copyrighted by the American Psychological Association or one of its allied publishers.
RC), to identify which would emerge as the
strongest predictors of Maternal or Maternal–
Infant Well-Being. Nonsignificant variables
were removed until a reduced model with only
the significant variables yielding the largest R2
was kept. R2 were adjusted for the degrees of
freedom making them comparable. This was
repeated and confirmed using selected God Im-
age variables deemed relevant based on the
visual plots (see Figure 2). Multivariate regres-
sion analyses for only the following variables of
Maternal or Mother–infant Well-being yielded
significant predictors of interest: Prenatal At-
tachment, Prenatal Depression, Pre- and Post-
natal Anxiety, and Pre- and Postnatal Perceived
Stress. When predicting Maternal–Infant Well-
being using the Prenatal Attachment Inventory
(PAI) as the predicted variable, the God Images
of Love and Unknowable arose when Want,
Plan, and their interaction were significant, ad-
justed R2 ⫽ .09, F(6, 450) ⫽ 10.36, p ⬍ .001.
The multiple regression results suggest that PAI
increases when participants endorse Love and
decreases if it is Unknowable. Similarly, if the
pregnancy is wanted, PAI increases, and if
planned it decreases, pointing to an interaction
effect such that Unwanted/Planned pregnancies
yield the lowest PAI score of 46.35 with 9% of
the variance.
When predicting Maternal Well-being via
Prenatal Depression, the God Images of Love,
Supreme, and Me, and only the Want of PI were
significant, adjusted R2 ⫽ .08, F(4, 466) ⫽
10.89, p ⬍ .001. The results suggest that Pre-
natal Depression is decreased when participants
endorse Love or Me, but is increased when
Supreme Being is chosen. If the pregnancy is
wanted, depression decreases. This model ex-
plains approximately 8% of the variance. Iden-
tical results were found when using Prenatal
Anxiety as the predicted variable, R2 ⫽ .13,
F(4, 448) ⫽ 17.13, p ⬍ .001, as well as Prenatal
227
Perceived Stress, R2 ⫽ .08, F(4, 419) ⫽ 10.71,
p ⬍ .001. These models explain approximately
13% of the variance of Prenatal Anxiety, and
8% of the variance of Prenatal Perceived Stress
respectively. For predicting Postnatal Anxiety,
the God Images of Supreme Being and Me and
only Want of PI were found to be significant,
R2 ⫽ .05, F(3, 413) ⫽ 8.43, p ⬍ .001, whereas
for Postnatal Perceived Stress, the God Image
of Karma and only Want of PI were significant
predictors, R2 ⫽ .03, F(2, 419) ⫽ 6.30, p ⬍
.003. Endorsing Karma and Want reduced the
Postnatal Perceived Stress. This last model,
however, had the least explanatory power. Of
note, findings on the regression analyses across
psychological variables for Maternal Well-
being were correlated with Prenatal Anxiety
(r ⫽ .78, p ⬎ .001) and Prenatal Perceived
Stress (r ⫽ .73, p ⬎ .001), as was Postnatal
Anxiety with Postnatal Perceived Stress (r ⫽
.81, p ⬎ .001). Prenatal Attachment was not
highly correlated with Maternal Well-being
variables and resulted in the only model that
contained both PI variables of Want and Plan
and their interaction.
Discussion
Having women engage more actively in their
family planning is listed as one of the 10 most
important U.S. public health goals because of its
potential impact for the wellbeing of women
and children (Finer & Zolna, 2011). Prevailing
wisdom suggests that some types of reproduc-
tive identities, such as intended pregnancies
with minimal fertility-related complications, are
more optimal than others. However, the reality
remains that few pregnancies are entirely prob-
lem-free and the rates of successful behavioral
management are “50/50” despite ongoing at-
tempts to reduce national levels of unplanned
ones. In addition to the lack of public health
factors such as access to sexual and reproduc-
tive health education, a growing body of evi-
dence suggests that it is the mother’s poor sense
of worth and self-care that may be actually
mediating the negative outcomes associated
with non-ideal pregnancies (Cheng et al., 2009;
Mauldon & Delbanco, 1997). This research
identified additional psychological-level vari-
ables, this time mothers’ underlying r/s beliefs
that may explain why some pregnancies regard-
 228 ATHAN, CHUNG, AND SAWYER COHEN
less of their outward appearance may be poten-
tially distressing.
Examining the r/s beliefs of certain groups of
pregnancy presentations ranging from the less
to more “ideal” scenarios yielded surprising re-
sults. Although one might expect pregnancies
that are both planned and wanted to be associ-
ated with the most positive profiles, they turned
out to be unremarkable. It is in fact the unex-
pected pregnancies (unplanned yet wanted) that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
beheld God as loving, imbued in living things/
This document is copyrighted by the American Psychological Association or one of its allied publishers.
life and residing within the fabric of the self; not
as unknowable, inaccessible, or in judgment of
their pregnancies as might have been predicted.
In fact unplanned pregnancies of all kinds were
associated with a view of God as a (loving)
teacher whose karmic laws extended beyond
human control. These findings point to the
eventual joy available in surprise pregnancies
with their attendant pleasure and the sense of
God’s positive will in their lives, despite these
women’s lack of “planning.” As D’Angelo et al.
(2004) reports, “over time, women may come to
view the intendedness of a given pregnancy in
an increasingly positive light” (p. 195). These
findings defy public perceptions that a mother
should mature and be fully intentional and pre-
pared when spacing her family (Mauldon &
Delbanco, 1997). On the contrary, the “better-
off and worse-off” groups were the youngest,
least wealthy and educated (unplanned but
wanted) versus those who had the most educa-
tion and financial resources, as well as the wis-
dom of age (planned, but unwanted). The latter
did not experience God/Spirituality as loving or
in livings things, and did not feel protection,
learning, or enlightenment from their arguably
very equipped, planned for, and informed preg-
nancies.
Interestingly it is mothers with pregnancies
that are planned but not wanted who are the
least well. It is this paradoxical interplay of
desire and intention that makes these mothers so
distinctive: to try for a child that is not wished
for is to compromise one’s mental health and
the future quality of the familial bond. These
mothers start out far less attached to their fetus
and do not reach the same heights as the others
even after the baby is born. This may herald a
deep ambivalence about the pregnancy along
the internal absence of a loving God who is
knowable accessible within. They were also
both the least Theistic and least Feminist in the
factors leading one to question: what then do
they believe? The combination of psychological
incongruity and the potential de-sanctification
of children as being part of a higher purpose, or
lack of r/s orientation of any specification, may
be underlying this subgroup’s unique distress.
This dimension of “ambivalence” is supported
by Klerman (2000) and Mohllajee, Curtis, Mor-
row, & Marchbanks (2007) who suggest, “that
disaggregating those women who are ambiva-
lent from the overall group of women with
unwanted pregnancies may highlight a group of
women who have unique characteristics and
risks” (p. 683). It appears it is the wanting (or
lack thereof) of a child that defines whether a
pregnancy is significantly distressing for a
mother in the form of poorer scores on prenatal
depression, anxiety, perceived stress, and per-
ceived social support, as well as longitudinally
for anxiety in the postnatal period. These find-
ings are supported by the literature, as women
with unwanted pregnancies have been found to
have substantially higher amounts of stressors,
anxiety, and depressive symptoms than those
with intended or mistimed pregnancies (Orr &
Miller, 1997; Takahashi et al., 2012). Other
studies have demonstrated that mothers with
unwanted pregnancies utilized physical punish-
ment at higher rates, spent less leisure time, and
had less positive attention devoted to their chil-
dren (Barber, Axinn, & Thornton, 1999; Geller,
2004; Mohllajee et al., 2007). Future research
regarding pregnancy intention may therefore
necessitate sensitivity to the specific conditions
surrounding the use of each term, with attention
given to what is elicited by the particular use of
“unwanted” or its correlates (Mohllajee et al.,
2007). Furthermore, the images of God of moth-
ers with unwanted pregnancies may be the tar-
get of interventions, as increases or decreases in
their psychological well-being depend on
whether God is perceived as a Supreme Being
outside of themselves or not. Experiencing God
as directly connected to the self, and more spe-
cifically, a God that is characterized by love is
significantly predictive of more positive out-
comes. A relationship with a loving God that
dwells within the heart/self may play a signifi-
cant part in a woman’s intentionality for family
planning—such that a mother who sees God as
supportive may feel pulled to parenthood as a
sacred calling, or welcome a surprise pregnancy
as a bid from God, which further promotes the
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
attachment to her child by sanctifying the bond
(Mahoney, 2013).
Similar conventions as those for intentional-
ity might warrant us to expect the least complex
pregnancies to be the most rewarding— ones
not loaded with prior reproductive complica-
tions or fetal risk. Instead we found a more
nuanced narrative that depends on their inter-
play as well. For example, we might expect
mothers who suffered from multiple challenges,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
(a history of fertility-related difficulties or peri-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
natal losses) and high-risk pregnancies, to be
the worse off. Perhaps women with these repro-
ductive profiles might feel God to be unloving,
judging or unsupportive as a result of these
compounded disadvantages (e.g., a past elective
abortion followed by problems conceiving and
then a risky gestation). According to Harris and
Daniluk (2010) feelings of grief, injustice, loss
of control, personal accountability, and ques-
tioning of beliefs are widely cited in the infer-
tility literature, as is guilt for abortions. Domar
et al. (2005) stated that some infertile women
may find comfort by believing that it is part of
a divine plan, whereas others may interpret it as
a punishment from a higher power for past sins
and indiscretions. Yet we found these women
invoking once more the image of a teacher
whose karmic laws brought enlightenment. In-
terestingly, unlike mothers with unplanned and
unwanted pregnancies who viewed God’s will
as equated with love, these mothers did not
endorse love but did introduce the element of
self-realization and learning. Suffering as a ve-
hicle for knowledge of a spiritual reality has
been the subject of most perennial wisdom tra-
ditions and may reflect these mothers own
meaning-making processes of the complexities
they faced. This was unlike Roudsari and asso-
ciate’s (2007) findings, whereby women viewed
their infertility as God’s will, a loving, compas-
sionate, merciful higher power. They also nota-
bly felt more isolated as reflected by the lowest
levels of perceived social support.
Mothers with uncomplicated reproductive
pasts yet high-risk pregnancies appeared to be
the most vulnerable to poor psychological out-
comes. They reported greater levels of depres-
sion and perceived stress, perhaps because of
the lack of previous real-world preparation for
their newly encountered obstetric difficulty.
Mothers who had experienced ongoing chal-
lenges before facing their high-risk pregnancies
229
fared better. Naïve mothers inexperienced in the
trials of infertility and perinatal loss viewed
God as a mysterious judge that was less loving
and accessible within, whereas the more expe-
rienced mothers in terms of reproductive dis-
tress perceived God’s love as residing in the
self—though this loving God was unknowable,
and poignantly the least protective. In the end it
was the risk-status of the pregnancy that sug-
gested the most anxiety for the mothers, regard-
less of past failures, that placed them at risk for
their own psychological disease. This was best
demonstrated by the mothers with negative re-
productive histories whose current nonrisk
pregnancies made them no longer as vulnerable,
taking there past in stride in light of the positive
present (Côté-Arsenault & Morrison-Beedy,
2001). It is of interest that no implications for
the mother– child attachment system for repro-
ductive complexity were found. A belief in a
loving, guiding God and a resulting healthy
baby despite all odds may trump the bumpy
road beforehand, and count the most for a moth-
er’s positive adjustment (Jennings, 2010).
Conclusions
The limitations of this study include the pre-
dominantly heteronormative, privileged sample
with regards to social class, race, and sexuality.
Findings did show that mothers with less in-
come and education certainly overrepresented
the groups of unintended pregnancies, but that
interestingly the most unique group (planned
but not wanted) was the older mothers with the
most resources (education and income). How-
ever, regardless of demographic location, it was
the reproductive identities of these mothers that
revealed the most striking differences in their
views of God and maternal and maternal–infant
health outcomes. The mothers with the most
“deviant” reproductive identities according to
traditional notions of intentionality (unplanned)
and complexity (IVF) fared surprisingly well.
Unplanned or high-risk pregnancies were not as
detrimental as expected. Particularly captivating
are the women who planned but did not want
their children and the reasons behind why they
decided to such mothers in the first place given
their poor mental health outcomes. It is these
mothers with more paradoxical pregnancy sto-
ries and their associated positive or negative r/s
cognitions that hold the most intrigue, strongly
 230 ATHAN, CHUNG, AND SAWYER COHEN
suggesting that r/s factors have an impact on
how infertility and motivation to form a family
is negotiated (Jennings, 2010). Although the
impact of these r/s cognitions were statistically
limited with only a small proportion of the
variance in maternal adjustment explained by
the God images, suggesting they may be subtle
in their influence, they are still very much pres-
ent and may have importance clinically. It is of
note that no mothers endorsed “none of the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
above” as an option. Regardless of their out-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
wardly endorsed r/s affiliation (agnosticism/
atheism), the mothers internalized at least some
type of r/s cognition— each had something
imagined when asked about their r/s beliefs.
Applications of these findings would be best
suited for health care professionals working first
hand with women who become mothers, who
would do well to ask the simple question: “How
does your faith or spirituality positively or neg-
atively affect your pregnancy if at all” or “Do
you have any spiritual beliefs that will help us
care for you during your pregnancy and birth?”
(Jesse et al., 2007, pp. 151, 157). As Jesse et al.
(2007) further suggests, holistic prenatal clini-
cians are “encouraged to view the women they
care for through many ‘lenses’—physical, emo-
tional, psychological, social, and spiritual.”
Only recently has psychology welcomed the
notion of ‘reproductive and maternal mental
health,’ and these authors invite the creation of
a new interdisciplinary field that acknowledges
a wrap-around approach for women that honor
women’s bodily experience as interconnected
with their socioemotional, and now spiritual
life. A woman’s procreative potential is partic-
ularly resonant to be interpreted through an r/s
lens as the origins and creation of life is central
to most sacred texts, which in turn often dictate
women’s decision-making in this area. Further-
more it is suggested that future research explore
the pluralistic and sometimes seemingly contra-
dictory internal landscapes of people’s r/s be-
liefs as well as their reproductive experiences.
Rather than merely studying r/s affiliation to
particular organizations, or even overarching
dogmas, women have a rich internal r/s ecology
replete with a mixture philosophies, and it is the
study of the full range of their unique, specific,
nuanced beliefs that may be most malleable and
ripe for intervention (e.g., targeting negative
images of God as a punisher). The same could
be said of women’s attitudes regarding their
reproductive histories because these too are
rarely black or white. Future research would
also do well to explore the near absence of
feminine conceptualizations of supportive r/s
beliefs, which is remarkable in light of the gen-
dered nature of pregnancy and motherhood.
References
Astin, A. W., Astin, H. S., Lindholm, J. A., Bryant,
A. N., Szelényi, K., & Calderone, S. (2005). The
spiritual life of college students: A national study
of college students’ search for meaning and pur-
pose. Los Angeles, CA: UCLA Higher Education
Research Institute.
Athan, A., & Miller, L. (2005). Spiritual awakening
through the motherhood journey. Journal of the
Motherhood Initiative for Research and Commu-
nity Involvement, 7, 17–31.
Barber, J. S., Axinn, W. G., & Thornton, A. (1999).
Unwanted childbearing, health, and mother– child
relationships. Journal of Health and Social Behav-
ior, 40, 231–257. http://dx.doi.org/10.2307/
2676350
Callister, L. C., & Khalaf, I. (2010). Spirituality in
childbearing women. Journal of Perinatal Educa-
tion, 19, 16 –24. http://dx.doi.org/10.1624/
105812410X495514
Cheng, D., Schwarz, E. B., Douglas, E., & Horon, I.
(2009). Unintended pregnancy and associated ma-
ternal preconception, prenatal and postpartum be-
haviors. Contraception, 79, 194 –198. http://dx.doi
.org/10.1016/j.contraception.2008.09.009
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A
global measure of perceived stress. Journal of
Health and Social Behavior, 24, 385–396. http://
dx.doi.org/10.2307/2136404
Côté-Arsenault, D., & Morrison-Beedy, D. (2001).
Women’s voices reflecting changed expectations
for pregnancy after perinatal loss. Journal of Nurs-
ing Scholarship, 33, 239 –244. http://dx.doi.org/10
.1111/j.1547-5069.2001.00239.x
Cowchock, F. S., Lasker, J. N., Toedter, L. J., Sku-
manich, S. A., & Koenig, H. G. (2010). Religious
beliefs affect grieving after pregnancy loss. Jour-
nal of Religion and Health, 49, 485– 497. http://dx
.doi.org/10.1007/s10943-009-9277-3
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987).
Detection of postnatal depression. Development of
the 10-item Edinburgh Postnatal Depression Scale.
The British Journal of Psychiatry, 150, 782–786.
http://dx.doi.org/10.1192/bjp.150.6.782
D’Angelo, D. V., Gilbert, B. C., Rochat, R. W.,
Santelli, J. S., & Herold, J. M. (2004). Differences
between mistimed and unwanted pregnancies
among women who have live births. Perspectives
 SPIRITUAL BELIEFS IN DISTRESSED PREGNANCIES
on Sexual and Reproductive Health, 36, 192–197.
http://dx.doi.org/10.1363/3619204
Domar, A. D., Penzias, A., Dusek, J. A., Magna, A.,
Merarim, D., Nielsen, B., & Paul, D. (2005). The
stress and distress of infertility: Does religion help
women cope? Sexuality, Reproduction and Meno-
pause, 3, 45–51. http://dx.doi.org/10.1016/j.sram
.2005.09.007
Dutney, A. (2007). Religion, infertility and assisted
reproductive technology. Best Practice & Re-
search Clinical Obstetrics & Gynaecology, 21,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
169 –180. http://dx.doi.org/10.1016/j.bpobgyn
This document is copyrighted by the American Psychological Association or one of its allied publishers.
.2006.09.007
Finer, L. B., & Henshaw, S. K. (2006). Disparities in
rates of unintended pregnancy in the United States,
1994 and 2001. Perspectives on Sexual and Repro-
ductive Health, 38, 90 –96. http://dx.doi.org/10
.1363/3809006
Finer, L. B., & Zolna, M. R. (2011). Unintended
pregnancy in the United States: Incidence and dis-
parities, 2006. Contraception, 84, 478 – 485. http://
dx.doi.org/10.1016/j.contraception.2011.07.013
Gall, T. L., & Cornblat, M. W. (2002). Breast cancer
survivors give voice: A qualitative analysis of spir-
itual factors in long-term adjustment. Psycho-
Oncology, 11, 524 –535. http://dx.doi.org/10.1002/
pon.613
Geller, P. A. (2004). Pregnancy as a stressful life
event. CNS Spectrums, 9, 188 –197.
Greil, A. L., Shreffler, K. M., Schmidt, L., & Mc-
Quillan, J. (2011). Variation in distress among
women with infertility: Evidence from a popula-
tion-based sample. Human Reproduction, 26,
2101–2112. http://dx.doi.org/10.1093/humrep/
der148
Greil, A. L., Slauson-Blevins, K., & McQuillan, J.
(2010). The experience of infertility: A review of
recent literature. Sociology of Health & Illness, 32,
140 –162. http://dx.doi.org/10.1111/j.1467-9566
.2009.01213.x
Harris, D. L., & Daniluk, J. C. (2010). The experi-
ence of spontaneous pregnancy loss for infertile
women who have conceived through assisted re-
production technology. Human Reproduction, 25,
714 –720. http://dx.doi.org/10.1093/humrep/
dep445
Inhorn, M. C. (2005). Religion and reproductive
technologies: IVF and gamete donation in the
Muslim world. Anthropology News, 46, 14. http://
dx.doi.org/10.1525/an.2005.46.2.14
Jacob, M. C., McQuillan, J., & Greil, A. L. (2007).
Psychological distress by type of fertility barrier.
Human Reproduction, 22, 885– 894. http://dx.doi
.org/10.1093/humrep/del452
Jennings, P. K. (2010). “God had something else in
mind”: Family, religion, and infertility. Journal of
Contemporary Ethnography, 39, 215–237. http://
dx.doi.org/10.1177/0891241609342432
231
Jesse, D. E., Schoneboom, C., & Blanchard, A.
(2007). The effect of faith or spirituality in preg-
nancy: A content analysis. Journal of Holistic
Nursing, 25, 151–158. http://dx.doi.org/10.1177/
0898010106293593
Klerman, L. V. (2000). The intendedness of preg-
nancy: A concept in transition. Maternal and Child
Health Journal, 4, 155–162. http://dx.doi.org/10
.1023/A:1009534612388
Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H.,
Marcus, S. M., & Davis, M. M. (2010). Risk
factors for depressive symptoms during preg-
nancy: A systematic review. American Journal of
Obstetrics and Gynecology, 202, 5–14. http://dx
.doi.org/10.1016/j.ajog.2009.09.007
Mahoney, A. (2013). The spirituality of us: Rela-
tional spirituality in the context of family relation-
ships. In K. I. Pargament, J. J. Exline, & J. W.
Jones (Eds.), APA handbook of psychology, reli-
gion, and spirituality: Vol. 1. Context, theory, and
research (pp. 365–389). Washington, DC: Amer-
ican Psychological Association. http://dx.doi.org/
10.1037/14045-020
Mahoney, A., Pargament, K. I., Murray-Swank, A.,
& Murray-Swank, N. (2003). Religion and the
sanctification of family relationships. Review of
Religious Research, 44, 220 –236. http://dx.doi
.org/10.2307/3512384
Mauldon, J., & Delbanco, S. (1997). Public percep-
tions about unplanned pregnancy. Family Plan-
ning Perspectives, 29, 25–29, 40. http://dx.doi.org/
10.2307/2953350
McQuillan, J., Greil, A. L., & Shreffler, K. M.
(2011). Pregnancy intentions among women who
do not try: Focusing on women who are okay
either way. Maternal and Child Health Journal,
15, 178 –187. http://dx.doi.org/10.1007/s10995-
010-0604-9
Mohllajee, A. P., Curtis, K. M., Morrow, B., &
Marchbanks, P. A. (2007). Pregnancy intention
and its relationship to birth and maternal out-
comes. Obstetrics and Gynecology, 109, 678 – 686.
http://dx.doi.org/10.1097/01.AOG.0000255666
.78427.c5
Müller, M. E. (1994). A questionnaire to measure
mother-to-infant attachment. Journal of Nursing
Measurement, 2, 129 –141.
Muller, M. E., & Mercer, R. T. (1993). Development
of the prenatal attachment inventory. Western
Journal of Nursing Research, 15, 199 –215. http://
dx.doi.org/10.1177/019394599301500205
Nelson, J. A., & O’Brien, M. (2012). Does an un-
planned pregnancy have long-term implications
for mother– child relationships? Journal of Family
Issues, 33, 506 –526. http://dx.doi.org/10.1177/
0192513X11420820
Orr, S. T., & Miller, C. A. (1997). Unintended preg-
nancy and the psychosocial well-being of pregnant
 232 ATHAN, CHUNG, AND SAWYER COHEN
women. Women’s Health Issues, 7, 38 – 46. http://
dx.doi.org/10.1016/S1049-3867(96)00017-5
Pargament, K. I., & Mahoney, A. (2002). Spiritual-
ity: Discovering and conserving the sacred. In K. I.
Pargament, J. J. Exline, & J. W. Jones (Eds.), APA
handbook of psychology, religion, and spirituality:
Vol. 1. Context, theory, and research (pp. 365–
389). Washington, DC: American Psychological
Association.
Plagge, J., & Antick, J. R. (2009). Perceptions of
perinatal loss: Miscarriage versus stillbirth. Wom-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
en’s Health & Urban Life, 8, 113–127.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Roudsari, R. L., Allan, H. T., & Smith, P. A. (2007).
Looking at infertility through the lens of religion
and spirituality: A review of the literature. Human
Fertility, 10, 141–149. http://dx.doi.org/10.1080/
14647270601182677
Santelli, J., Rochat, R., Hatfield-Timajchy, K., Gil-
bert, B. C., Curtis, K., Cabral, R., . . . the Unin-
tended Pregnancy Working Group. (2003). The
measurement and meaning of unintended preg-
nancy. Perspectives on Sexual and Reproductive
Health, 35, 94 –101. http://dx.doi.org/10.1363/
3509403
Schenker, J. G. (2000). Women’s reproductive
health: Monotheistic religious perspectives. Inter-
national Journal of Gynaecology and Obstetrics:
The Official Organ of the International Federation
of Gynaecology and Obstetrics, 70, 77– 86. http://
dx.doi.org/10.1016/S0020-7292(00)00225-3
Shah, P. S., Balkhair, T., Ohlsson, A., Beyene, J.,
Scott, F., & Frick, C. (2011). Intention to become
pregnant and low birth weight and preterm birth: A
systematic review. Maternal and Child Health
Journal, 15, 205–216. http://dx.doi.org/10.1007/
s10995-009-0546-2
Shellenberg, K. M., Moore, A. M., Bankole, A.,
Juarez, F., Omideyi, A. K., Palomino, N., & Tsui,
A. O. (2011). Social stigma and disclosure about
induced abortion: Results from an223 exploratory
study. Global Public Health, 6, S111–S125.
Spielberger, C. D. (1983). Manual for the Slate-Trait
Anxiety Inventory (revised ed.). Palo Alto, CA:
Consulting Psychologists Press.
Takahashi, S., Tsuchiya, K. J., Matsumoto, K., Su-
zuki, K., Mori, N., Takei, N., & the HBC Study
Team. (2012). Psychosocial determinants of mis-
timed and unwanted pregnancy: The Hamamatsu
Birth Cohort (HBC) study. Maternal and Child
Health Journal, 16, 947–955. http://dx.doi.org/10
.1007/s10995-011-0881-y
Tanyi, R. A. (2002). Towards clarification of the
meaning of spirituality. Journal of Advanced Nurs-
ing, 39, 500 –509. http://dx.doi.org/10.1046/j
.1365-2648.2002.02315.x
van den Akker, O. B. (2011). The psychological and
social consequences of miscarriage. Expert Review
of Obstetrics & Gynecology, 6, 295–304. http://dx
.doi.org/10.1586/eog.11.14
U.S. Department of Health and Human Services,
National Center for Health Statistics. (2011). Na-
tional survey of family growth, cycle 7, 2006 –
2010. Hyattsville, MD: Author [Producer and Dis-
tributor].
Zimet, G. D., Powell, S. S., Farley, G. K., Werkman,
S., & Berkoff, K. A. (1990). Psychometric charac-
teristics of the multidimensional scale of perceived
social support. Journal of Personality Assessment,
55, 610 – 617. http://dx.doi.org/10.1080/00223891
.1990.9674095
Received January 15, 2015
Revision received April 20, 2015
Accepted April 21, 2015 䡲