The Experience of Pregnancy Discovery and Acceptance: A Descriptive Study Based on free Hierarchical Evocation by Associative Networks
Marie Greve-Bricheux1-3, Rebecca White-Schielke1-3, Annamaria Silvana de Rosa4, Elena Bocci4, Laurent Letrilliart1-3, Jean Iwaz 2,3,5,6 and René Ecochard2,3,5,6*
1Collège Universitaire de Médecine Générale, Université Lyon, France Université de Lyon
2Université de Lyon, France
3Université Lyon 1, Villeurbanne, France
4Sapienza Università di Roma, European/International Joint PhD in Social Representations and Communication, Italy
5Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, France
6CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
Submission: March 11, 2019;Published: March 20, 2019
*Corresponding author: René Ecochard, Service de Biostatistique-Bioinformatique 162 avenue Lacassagne, F-69424-Lyon Cedex, France
How to cite this article: Greve-Bricheux M, White-Schielke R, de Rosa AS, Bocci E, Letrilliart L, et al. The Experience of Pregnancy Discovery and Acceptance: A Descriptive Study Based on free Hierarchical Evocation by Associative Networks. 2019: 14(4): 555893. DOI: 10.19080/JGWH.2019.14.555893
Women’s childbearing experiences vary with pregnancy intentional nature and outcome. An Associative Network study targeted 129 women pregnant >1 year ago and their experiences at pregnancy start and post-pregnancy. Word-associations formed 15 themes and 5 metathemes. The main pregnancy discovery themes were “Affect” (39%), “Relationships with others” (11%), and “Logistics” (7%). The main post-pregnancy themes were “Affect” (18%), “Relationship with the child” (13%), and “Personal progress” (12%). The overall polarity index was higher in intended vs. unintended pregnancies. Whatever pregnancy outcome, women expressed impressions of constructive experience. Discovering pregnancy and deciding about it led anyway to personal and social progress.
The moment of pregnancy discovery is very important and unique but may be sometimes neglected vs. the moment of birth that women and close relatives often consider as the culmination of pregnancy on an emotional level. The physical, physiological, hormonal, and psychological changes of the start of pregnancy, together with the experiences of previous pregnancies, influence women feelings, relationships, and decisions . At the start of pregnancy, many women are particularly sensitive to exchanges, especially with healthcare professionals. Actually, a lot of information needs to be imparted during the first consultation after pregnancy discovery. This varies according to the context within which pregnancy occurred and the intention to carry it to term or not. These circumstances may conceal a serious exploration of how women feel about discovering they are pregnant.
To date, few studies have reported on the experience of the first days of pregnancy. The literature has rather focused on the
experience of the second and third trimesters of pregnancy [2,3], miscarriage (MC) , elective abortion (EA) , or particular maternal or fetal situations [6-9]. However, Hopkins, et al.  have shown that women begin to build up their idea of maternity well before they are pregnant. Thus, the first days are particularly important because women begin to confront their experience with the representation they formed earlier. Moreover, when
a woman announces a pregnancy, she receives a flow of advice and socially-normalized narratives of various experiences that do not necessarily correspond to her personal experience, which may induce feelings of guilt and anxiety .
In addition, up to 25% of pregnancies might not have been intended [12,13]. According to some authors, this has negative consequences on the neonate’s health [14,15], or the mother’s health such as a higher risk of postpartum depression , which is further increased by an unfavorable social context or a negative experience of the delivery . The relationship between the intentional nature of a pregnancy and the way it
is experienced later seems to have been less explored than the
relationships with various medical outcomes.
Women experiences are usually explored via questionnaires
with predefined answers , or semi-structured interviews
[7,18], whereas free answers offer access to the various stages
of the thought process and the unique wealth of feelings. Within
this context, hierarchical evocations allow free and unguided
answers to the researcher’s questions . The method was
originally introduced in the study of social representations then
used in the healthcare field . It is based on the association
of ideas, feelings, perceptions, evaluations, etc. It combines
thematic and statistical analyses and allows calculating an “index
of polarity” for each evoked semantic representation field.
We present here the results of a hierarchical evocation study
of women experiences at the time of pregnancy discovery and
post pregnancy. The aim was to describe these experiences first
generally then according to the pregnancy intentional nature
This observational, retrospective, and multicentric study was
carried out in women recruited from three French Départements:
Rhône, Ardèche, and Drôme. The proposals to participate were
made at the end of a consultation (general practitioner, midwife,
family planning, or breastfeeding counselor) through mutual
recruitment or notices posted in waiting rooms. The women had
to be aged 18 to 49 years (inclusive). The maximum of 49 years
was chosen to avoid the potential influence of menopause. The
last pregnancy should have been started at least one year before
to ensure that women had some hindsight of their experience.
The study protocol was approved by the Ethics Committee of the
group of Lyon teaching hospitals (Hospices Civils de Lyon).
The interviews took place between October 2014 and April
2016 and were conducted by two physicians (MGB and RWS).
The choice was made to interview each woman on her first or last
pregnancy considering that the experiences may vary with the
rank of the pregnancy. This was obtained using a randomization
list. Each interview included the administration of a projective
technique: the “associative network” , using two stimulus
expressions. The first stimulus expression “The first days…”
(Box 1) focused on the experience of discovering pregnancy. The
second stimulus expression “Since then…” (Box 2) focused on the
experience of post-pregnancy.
After each stimulus expression, each woman was invited to
write freely words or expressions that came to her mind and join
to each word or expression a number that reflects the order of its
evocation. She had then to:
a) build networks by drawing lines between words or
b) give a polarity to each word or expression; i.e., its
association with a positive, negative, or neutral feeling
c) give a rank to each word or expression; i.e., its
importance in her feelings .
The data collected as responses to the stimulus expressions
“The first days” and “Since then” (i.e., the written words or
expressions) had to be clustered into subthemes, then into
themes, and then again into metathemes.
Each interview included also a questionnaire that collected
sociodemographic data (date of birth, medical history, and
professional activity) as well as data on the pregnancy under
study and on other pregnancies. The following factors were
a) the intentional nature of the pregnancy: intended or
unintended (unplanned or unwanted)
b) the age and marital status at the time of the pregnancy
(marriage, civil union, or else)
c) the outcome of the pregnancy (full-term live birth, MC,
EA, therapeutic abortion).
The outcome criteria were the mean frequency of words
or expressions and the mean polarity index. According to the
Associative Network technique , the polarity index was
defined as the number of positive words minus the number of
negative words divided by the total number of words (the number
of neutral words does not influence the index). This index ranges
thus from -1 to +1 and shows the overall positive or negative
tone of each theme. The outcome criteria were calculated:
a) for each subtheme and theme
b) according to the intentional nature of the pregnancy at
each stimulus expression
c) according to the outcome of pregnancy at stimulus
expression “Since then”.
The participants were described in terms of number of
participants, number of pregnancies per woman, socioeconomic
status, marital status, and intentional nature and outcome of the
pregnancy under study. Pearson’s chi-squared tests were used
to assess possible differences in pregnancy outcomes according
to age, marital status, and pregnancy rank (univariate analysis).
Then the relationships between these factors and pregnancy
outcomes were studied in a multivariate analysis using a logistic
regression. Next, the relationship between the intentional nature
of the pregnancy under study and its outcome was expressed as
an Odds Ratio (OR) with a profile likelihood confidence interval
and the significance of the deviations tested using likelihood
Finally, the most frequently mentioned themes and the
polarity indexes were compared using Pearson’s chi-squared
tests and Wilcoxon-Mann-Whitney’s nonparametric tests,
respectively. Comparisons were carried out according to the
intentional nature of pregnancy with each stimulus expression.
Comparisons were also made according to the outcome of
pregnancy but only with stimulus expression “Since then”.
Finally, 129 women were interviewed. They were aged
18 to 49 years at the time of the interview and 14 to 42
years at the time of pregnancy. These women had had 1 to 8
pregnancies (carried to term or not), which corresponds to an
average of 2.41 pregnancies per woman and a fertility rate of
1.68. The participants included all socioeconomic statuses: 40
had intermediate occupations (31%), 39 were employees or
manual workers (30%), 28 were managers or had high-status
professions (22%), 6 were craftswomen, shopworkers, or selfemployed
workers (5%), 3 were agricultural workers (2%), and
13 women (10%) had no professional activity at the time of the
The 129 women reported on 311 pregnancies of whom 19
(6%) were achieved via medically assisted procreation and
five were twin pregnancies. The pregnancies were intended in
246 cases (79%). Concerning the marital status at the time of
pregnancy, 125 pregnancies occurred in marriage, 38 in civil
union (which totals 52% -- 163 out of 311 -- of pregnancies
that occurred in stable relationships), 127 in cohabitation, 18 in
singlehood, and 3 in divorce.
Values are number (% of total) - *Pearson’s chi-squared test - † Number and percentage over 257 observations.
Of the 311 pregnancies, 218 (70%) were carried to term,
whereas 50 (16%) ended in MC, 39 (13%) in EA, and 4 (1%)
in therapeutic abortion. Among the 129 pregnancies that were
focuses of the evocations, 82 (64%) were carried to term, whereas
13 (10%) ended in MC, 31 (24%) in EA, and 3 (2%) in therapeutic
abortion (Figure 1). Table 1 shows the characteristics linked with
the 257 pregnancies that were carried to term or ended in an EA.
EA was significantly more frequent among young women having
a non-committed relationship and concerned mainly the first
pregnancy. In the logistic analysis, an age under 25 (OR 4.2; 95%
CI: 2.0-8.7) and non-commitment were associated with increased
frequency of EAs (OR=4.2; 95% CI: 2.0-8.7 and OR= 2.1; 95% CI:
1-4.7, respectively). In the analysis of the relationship between
the intention to become pregnant and pregnancy outcome, 96%
of intended pregnancies (191/199) were carried to term vs.
only 43% of the unintended pregnancies (25/58); i.e., the OR
for continuing pregnancy when intended vs. unintended was 31
(95% CI: 13-71).
The words or expressions written in response to stimulus
expressions “The first days” and “Since then” could be clustered
into 70 subthemes, 15 themes, and 5 metathemes. This hierarchy
is shown in Figure 2. The “Medical” metatheme concerned
the physical signs of pregnancy, its medical aspects, lifestyle,
fertility as well as the stages of pregnancy (diagnosis, childbirth,
breastfeeding, etc.). The “Contextual” and “Emotional”
metathemes had only one theme each; these were, respectively,
the logistics of going through with the pregnancy and all the
affects related to this period of life. The “Relational” metatheme
had one theme per type of relationship: the child, the family
members, the friends and colleagues, and various aspects of
parenthood. The “Cognitive” metatheme could include four
themes: desire of pregnancy, personal progress brought about
by pregnancy, uncertainties, and projections for the future.
a) the “Affect” (406 out of 1084 words; i.e., 37%, with
subthemes joy, anxiety, and surprise)
b) the “Relationships with others” (123 words, 11%)
with main subthemes announcement of pregnancy and
relationship with the father of the child
c) “Logistics” (79 words, 7%,) with subthemes finances,
time management, logistical organisation. The average
number of words written per woman was 8.2 words. When
this was examined according to the intentional nature of the
pregnancy, themes “Affect” and “Relationships with others”
remained the first mentioned regardless of the outcome of
the pregnancy (Figure 3). Theme “Logistics” (n=54, 7%) was
the third most often mentioned in intended pregnancies,
whereas it was “uncertainty” (n=40, 12%) that held the third
place in unintended pregnancies with subthemes such as
questioning and ambivalence. The polarity index that ranges
from -1 to +1 was shifted by +0.26 units in intended vs.
unintended pregnancies (95% CI: 0.12-0.42).
During this second evocative setting, the women spoke
about “affect” (229 out of 1,250 words collected; i.e., 18%),
“Relationship with the child” (164 words, 13%), and “Personal
progress” (156 words, 12%, with subthemes “growth, maturity”,
“quest for meaning”, “acceptance of having had an abortion”).
Comparing theme frequencies according to the intentional nature
of the pregnancy, the notion of “Personal progress” appeared
first (71 times, 22%) in unintended pregnancies, then “affect”
(57 times, 18%), then “Relationship with the child” (36 times,
11%), whereas in intended pregnancies, “Affect” was mentioned
first (172 times, 18%), before “Relationship with the child” (128
times, 14%) and “Family” (96 times, 10%).
The mean polarity index over all themes was not significantly
different between intended and unintended pregnancies. In
response to stimulus expression “Since then”, the women wrote
fewer words when they had had an EA or a MC (10.1, 7.9, and 6.6
terms on average in case of childbirth, MC, and EA, respectively).
However, this difference was not statistically significant (p=0.3).
Comparing theme frequencies according to the outcome of
pregnancy, themes “Affect” (153 times, 17%), “Relationship
with the child” (139 times, 15%) and “Family” (100 times, 11%)
were the most frequent in pregnancies carried to term (Table 2).
In MCs and EAs, three main themes were the most frequently
mentioned but not in the same order: “Personal progress” (10
times, 9% in MC vs. 66 times, 31% in EA), “affect” (31 times, 27%
in MC vs. 39 times, 18% in EA), and “Relationship with others”
(17 times, 15% in MC vs. 24 times, 11% in EA).
Values are number (% of total).
In women who had had a MC, theme “Fertility” (9 times, 8%)
appeared in the fourth position, whereas it was not mentioned
by women who carried pregnancies to term. The mean polarity
index over all themes collected in response to stimulus
expression “Since then” was not significantly different according
to the outcome of the pregnancy.
In this study of women responses to two stimulus expressions,
women asked to recall their thoughts about discovering
they were pregnant mentioned most often themes “Affect”,
“Relationships with others”, and “Logistics” when pregnancy
was intended, whereas, when the pregnancy was unintended,
the women mentioned more frequently “Uncertainty” than
“Logistics” and the polarity index was significantly higher when
the pregnancies were intended. Late after a pregnancy, the
most often mentioned themes were “Affect” then “Relationship
with the child”. Comparing theme frequencies according to
the intentional nature of the pregnancy showed that theme
“Family” appeared in the third place in intended pregnancies,
whereas it was “Personal progress” that appeared in the third
place in unintended pregnancies. Comparing theme frequencies
according to the outcome of pregnancy showed that themes
“Affect”, “Relationship with the child”, then “Family” appeared
first in women with pregnancies carried to term but that
themes “Personal progress”, “Affect”, and “Relationships with
others” appeared first in women with pregnancies that ended
in MC or EA. These results illustrate the ways women feelings
differ according to the intentional nature of pregnancy and the
outcome of pregnancy.
One advantage of the use of Associative Networks for this
research is that women are able to express themselves freely
because the method was developed to reduce or even eliminate
the influence of an investigator or that of “social desirability”
of the answers. This is very important in an area where social
standards are constantly present. For example, in 2012, Menuel
mentioned an “injunction to be happy” for pregnant women
as well as an “injunction to remain silent” regarding the
inconveniences of pregnancy.
Another advantage is the interesting scale of the study (129
women) that involved a wide socioeconomic diversity and a
glowing wealth of feelings. Although common themes were
obviously found, each interview was unique regarding the words
used to talk about the start of pregnancy or the post-pregnancy
period. A third advantage is data saturation in pregnancies
carried to term. Indeed, the geographical distribution of
the women (rural, semi-rural, and urban) allowed access to
populations of very different socioeconomic levels.
One limitation of the study is that nearly one third of the
women volunteered to participate after reading a flyer in a
medical or paramedical waiting room or after sharing information
with other participants. This could have led to a selection bias
by increasing the proportion of women who had particular
experiences. For example, here, 6% of the pregnancies resulted
from MAP techniques vs. only 3% in the general population .
Besides, women who had had an EA were more difficult to recruit
than others (refusal to participate or missing appointment); this
led to a lack of data saturation in this population. Furthermore,
in choosing the first or last pregnancy, we could not access all contexts. Finally, the responses to stimulus expression “The first
days” concerned experiences lived a few but sometimes up to
18 years ago. The time elapsed since the pregnancy under study
could have toned down some feelings but one aim of the study
was collecting feelings after a settle down over time.
Some data concerning pregnancy outcomes are roughly
comparable to those of other French or European reports from
the same period: a 1.68 fertility rate vs. 2.01 (Eurostat data),
20% of unintended pregnancies vs. 25% [12,22], a 16% rate
of MCs vs. 20% , 59% of abortions in women <25 years of
whom 38% in primiparae vs. 20-24%  of whom 42.8% in
primiparea . However, the 13% rate of EA found here was
reached through consistent recruitment effort and cannot be
compared with other rates from the literature (e.g., 26.4 EAs per
100 live births in 2011 ).
In a study by the French IPSOS on pregnancies carried
to term, pregnancy is first a happy event and then a source of
anxiety (97% and 89% of women, respectively) . In the
present study, the mean rank of “joy” was 3.5 (mentioned 115
times) and that of “stress” 4.2 (mentioned 86 times) . In
another study performed in 2004, Courtial and Le Dreff made
a distinction between two groups: “women without apparent
problems” and “fragile women” . In the first group, the
authors found narratives organized around “joy”, “the importance
for the husband”, and “the construction of the relationship”.
These authors also reported on “proof”, developed as “proof of
oneself, of love, of fertility”; in short, “proof of life”. These themes
were present in our verbatims under “fulfilment”, “practical
outworking of my love story”, “intensity of life”, “wonder at the
miracle of life”, and “creative force”. In “fragile women”, “fear”
was cited and associated with many aspects of pregnancy
(particularly parturition). One important difference between the
present study and that of Courtial and Le Dreff  is that the
latter was carried out in primiparae.
Concerning the post-pregnancy period, the present study
found once again themes already mentioned by Courtial and
Le Dreff . In the latter study, women “without apparent
problems” mentioned “not being able to give themselves
personally to their baby, associated with fear, suffocated by
people around them” and “fragile” women felt “constraints”,
“difficulty of being a mother” and “tiredness” (qualified as
psychological tiredness because it was related to difficulties with
the partner). These authors insisted on the difference between
this tiredness and the physical fatigue mentioned by the women
“without apparent problems” because the latter associated
fatigue with joy.
Concerning the experience of MC, previous studies Séjourné
et al. ; Stirtzinger, et al,  have reported the importance of
themes “Fertility” and “Relationship with the partner” because
MC strengthened or weakened the marriage or the partnership.
Séjourné et al.  examined the issue of guilt after a MC and
emphasized that MC could be felt and expressed in many different
ways, which was also the case in the evocations we collected.
In the present study, it was interesting to note that the women
who had had a MC or an EA mentioned “personal progress”
significantly more often than others. This suggests that these
events were experienced as sufferings (words used: “suffering”,
“sacrifice”, “trauma”, “emptiness”) associated with a need to
overcome the event and find meaning for it. Nevertheless, for
some women, EAs had no effect on their lives. These women
wrote, for example, “nothing, no trace”, “no consequence”, or “a
closed subject”. The literature review performed by Bradshaw &
Slade  found a 30% rate of anxiety one month after EA but
did not report a higher percentage of anxiety among women who
had had a MC or a pregnancy carried to term. This observation
supports the hypothesis that EA may be experienced as a
painful event but that women develop strategies to overcome
this pain. In the present study, after an EA, the women talked
about “confidence in life and its purpose”; some wrote: “I have
integrated it into my history”, “this event helped me grow”, “I
will not have another EA”. In women who carried pregnancy to
term, “family” ranked third in frequency, whereas, in women who
aborted, it was “Personal progress” that ranked third (the first
two themes were identical in the two groups). This emphasizes
the importance of the changes that these women experience in
becoming mothers (be it for the first time or not).
The present study shows that the occurrence of pregnancy is
a time that is particularly rich in emotions, feelings, and questions
that may be sometimes contradictory. Healthcare professionals
should thus be attentive to women’s life contexts, especially at
announcing pregnancy and at prenatal check-ups. In fact, (re)
discovering the diversity of women feelings moves healthcare
professionals closer to women’s concerns and improves their
dialogue. Also, the study highlights the importance of keeping in
mind that each woman is unique and expresses her thoughts and
feelings in a personal way; this prevents the interviewer from
projecting general or personal views onto the women.
From a medical perspective, as nearly 25% of the women
in the present study expressed feelings of fatigue, or even
exhaustion, health professionals should remain attentive to this
issue in the mothers at each medical visit.
From a psychological perspective, women who carry
pregnancy to term speak generally about a constructive life
experience (couple, parent-child, and family relationships) and
women who had had MC or EA speak generally about personal
progress and development of strategies to overcome pain and
regain confidence in life. Finally, discovering a pregnancy and
deciding about its outcome raise a variety of problems that
receive various solutions but participate anyway to personal
growth and better awareness of social responsibility.