First time pregnant women's experiences in early pregnancy

Abstract

Background

There are few studies focusing on women's experiences of early pregnancy. Medical and psychological approaches have dominated the research. Taking women's experiences seriously during early pregnancy may prevent future suffering during childbirth.

Aim

To describe and understand women's first time experiences of early pregnancy.

Method

Qualitative study using a phenomenological hermeneutic approach. Data were collected via tape-recorded interviews in two antenatal care units in Sweden. Twelve first time pregnant women in week 10–14, aged between 17 and 37 years participated.

Results

To be in early pregnancy means for the women a life opening both in terms of life affirming and suffering. The central themes are: living in the present and thinking ahead, being in a change of new perspectives and values and being in change to becoming a mother.

Conclusions

The results have implications for the midwife's encounter with the women during pregnancy. Questions of more existential nature, instead of only focusing the physical aspects of the pregnancy, may lead to an improvement in health condition and a positive experience for the pregnant woman.

Introduction

Women's overall experiences during childbirth are an important outcome of labour (Waldenström, 2003) and may affect them for years to come (Simkin, 1991, 1992). Therefore, it is important to gain knowledge and understanding of women's experiences, in particular those arising contact with the health care system. However, studies focusing on women's experiences tend to address childbirth rather than pregnancy (Lundgren, 2002), and studies about pregnancy are more focused on late rather than early pregnancy (Coggins, 2002).

Most studies of pregnancy have a medical perspective as a result of the dominance of the obstetric concept of risk in maternity care and research. According to this perspective, pregnancy and childbirth are dangerous and can only be considered non-pathological in retrospect (Davis-Floyd, 1992; Mead, 2008). According to Mead (2008), there should be a shift from approaching childbirth from the perspective of a catastrophe waiting to happen to the conviction that pregnancy and childbirth are normal until proven otherwise.

Pregnancy may also be described as a crisis (Raphael-Leff, 1991) or from a psychological and psychoanalytical perspective (Bondas, 2000; Reid & Garcia, 1989). According to these perspectives, pregnancy is a period of a mature crisis with significant potential for positive development (Eriksson, 1996). However, according to Bondas and Eriksson (2001), the classic crisis, role, and stress paradigms focusing on negative and pathological versus external societal perspectives might no longer provide a full understanding of the experiences of pregnant women in the Western world. Consequently, existential questions seem to be neglected in maternity care organisations (Bondas & Eriksson, 2001). Hence, there is a lack of knowledge about pregnancy as the point of departure in the birthing woman's lifeworld (Bondas, 2000).

However, there are some studies focusing on pregnancy from a caring perspective. Pregnancy may be understood as a transition (Imle, 1990) and as a part of a woman's transition to motherhood (Bergum, 1997). Changing relationships with people around the women (Bondas & Eriksson, 2001) and reflections about their own life situations are seen to be of primary importance (Lundgren & Wahlberg, 1999) during pregnancy. Women with diabetes experience a sense of objectification during pregnancy; combined with a lack of control; and the awareness of having an unwell, high-risk body. They also refer to an exaggerated sense of responsibility, constant worry, pressure, and feelings of self-reproach (Berg, 2005; Berg & Honkasalo, 2000). Coggins (2002) found that women were dissatisfied with the emotional and psychological support they received in early pregnancy. Recognising the importance of women's experiences and posing relevant questions that reveal suffering in both lay and professional caring might prevent the potential postpartum misery of motherhood (Bondas & Eriksson, 2001).

In Sweden, maternity care during pregnancy is integrated in the general health care system and is free of cost for all women. Midwives provide all the antenatal care for healthy women with normal pregnancies (Kaplan, Hogg, Hildingsson & Lundgren, 2009). A Swedish midwife working in antenatal care meets almost every pregnant woman several times during the pregnancy. A woman will often meet the same midwife in maternity care for both her medical check up and care during pregnancy. During these meetings, the midwife also provides information and guidance about pregnancy and childbirth (Socialstyrelsen, Board of Health and Welfare, 1996). Although a midwife's responsibility is normal pregnancy and childbirth, research from Sweden indicates that there is a tendency to neglect a woman's lifeworld and to focus mainly on medical issues (Olsson, 2000).

To summarise, there are few studies focusing on women's experiences of early pregnancy from a caring perspective and especially that take into account the woman's lifeworld. Medical and psychological approaches have dominated the research. According to Coggins (2002), women express a need for midwifery care during early pregnancy. The aim of this study was to describe and understand women's first time experiences of early pregnancy.

Method

The research was conducted using a hermeneutic approach with the lifeworld as a fundament (Dahlberg, Dahlberg, & Nyström, 2008). The intention was to describe the lifeworld of a pregnant woman, but also to reach an understanding of what it means to be in the early stages of pregnancy for the first time. The lifeworld is the foundation of phenomenological philosophy and existential hermeneutics (Dahlberg et al., 2008). In the development of the lifeworld theory, Husserl (1936/1970) referred to natural experience or natural attitude. Meeting the woman from a lifeworld perspective means to be able to see, understand, describe, and to analyse parts of her world, as perceived by the woman soon after she became aware of the pregnancy. This perspective focuses not only on the world or the subject but also on their interaction. The lifeworld perspective is formed by an interest in people's own stories and life histories (Dahlberg et al., 2008). A hermeneutic approach (Gadamer, 1997), with openness as the starting point, was chosen to interpret women's accounts of early pregnancy and to understand their meaning. A hermeneutic approach based on Gadamer's (1997) philosophy regarding the pre-requisites of understanding, existential interpretations can be described as an attempt to understand how the women experience their lives or life situations. From a hermeneutic perspective, the data that is compiled is dependent upon interpretation and any relevant insight or understanding stemming from the authors’ backgrounds (Ödman, 1994). Two of the authors have backgrounds of several years of experience of meetings with pregnant women in antenatal care, experience of the reactions of mothers to the birth of a child, and years of teaching midwifery within the subject field of pregnancy. In addition, they have their own pregnancies as points of reference. One of the authors has no such directly personal or professional background.

The participants

Every woman, pregnant for the first time, was asked to participate in the study by a midwife during their first visit (pregnancy week 10–14) to the midwife at two public antenatal care units in Sweden. One of these was situated in a suburban area and the other in a city. The purpose of inviting women from both suburban and city areas was to reach variation in relation to the studied phenomena. The importance of appreciating linguistic nuances for the interpretation of the interviews, lead the researchers to only select Swedish speaking mothers to participate (Bengtsson, 1999). Of 14 women meeting these criteria, 12 wished to participate. The women were between 17 and 37 years old, healthy, and assessed as having normal pregnancies. Of the 12 participants, 11 had planned their pregnancies and one was unplanned. The midwives at each antenatal care unit, who had been informed about the study by the first author/researcher (CM), gave the women a short verbal introduction to the study at their first visit to the antenatal care unit. The researcher (CM) was present in order to conduct a short verbal presentation of the study and to ask if the women would like to participate. If the women agreed to participate, they then received more detailed written information about the study and confirmation that participation would be confidential. The women were given time to read through the information. The researcher was close by in order to answer any questions. If the women still wished to participate, they were asked to sign a formal consent agreement. Five women chose to participate in an interview some days later. The interviews took place at the public antenatal care unit and lasted between 30 and 40 minutes.

The data collection consisted of two stages. To begin with, the woman was encouraged to draw a picture depicting her experiences of early pregnancy. She was left alone and without distractions for 3–5 minutes until the drawing was finished or until she indicated that she had nothing to add. After that, the tape recorder was switched on and the woman was encouraged to tell about the picture. It was asked, “Please, tell me about your drawing and what you feel or experience right now.” When the telling reached a natural pause, the researcher asked questions about the picture and its description. Follow-up questions were posed as necessary. The conversation ended when the woman did not have anymore to say and when she felt satisfied that they had managed to accurately pin down her experiences. The purpose of a lifeworld phenomenological interview is to get the informant to reflect upon a particular phenomenon or in this case the experience of early pregnancy for the first time (Dahlberg et al., 2008).

Participants were asked to draw pictures as it is thought that a picture adds a dimension of “communication” to the verbal account according to Dahlberg et al. (2008). Högberg (1996) writes that the process of creating a picture prompts self-reflection. The picture content can be described as building a bridge between the inner and the outer. According to Dahlberg et al. (2008), a drawing can lead the interview dialogue directly into lived experiences, which gives the participants and the interviewer access to the lifeworld. The drawing can be said to exist somewhere between lived and verbally expressed experience. A drawing can also add depth to a subsequent interview, as talking about the picture can make it easier to establish contact. The drawing can also help to give a concrete form to the pregnancy. The recorded interviews were transcribed verbatim.

Data analysis

The data were analysed according to the principles of lifeworld hermeneutics as described by Dahlberg et al. (2008). The purpose of the analysis was to search for “otherness” and to see something “new” (Gadamer, 1997). First, all of the interviews were read through to get a picture of them as a whole. When the researcher had gained a preliminary understanding of the data, a new dialogue with the text began. Meaning units were formed according to the aim of the study. The data were then organised into different themes and sub-themes. The text and the themes were then read again to search for a new whole, a main interpretation, going from the whole to the parts and back to the whole again. The main interpretation was structured at a more abstract level than the earlier interpretation made during the analysis process (Dahlberg et al., 2008).

The research project has been approved by the research committee at Sahlgrenska Academy at the University of Gothenburg and by the operation managers of two public antenatal care units in Western Sweden (Ö 439-02).

Findings

Living in the present, looking back, and thinking ahead

Having a secret

The women describe feelings of happiness and a desire to tell others about their pregnancy. At the same time, they want to keep the pregnancy a secret, something that they and their partner have in common until everyone can tell that they are expecting a child. Keeping the secret of being pregnant can, in turn, lead to a feeling of loneliness. They may also want to share their joy, to tell everybody about their secret, as it is not yet visible. In due time, the pregnancy will become visible and will no longer be a secret. By then, it will be easier to be “different” and also to act differently as this will be understandable from other people's perspective.

Sometimes you don't want people to know either. I feel that I have a secret, that they don't know … if you meet someone you don't know. Then it can be nice to keep it all to yourself and not have to share anything, which will happen later anyway, when it's all visible. By then everybody in town will probably look at you. You know yourself what you do when a pregnant woman comes by. It's very beautiful and you can't help looking. (2)

Sharing the secret

The need to share the happiness of being pregnant is strong; the women express relief once they have told friends and colleagues. While close friends are informed about the pregnancy at an early stage, most women wait to tell their colleagues about their pregnancy. The women express worries about miscarriage. They are also concerned about the potential effect on their jobs and careers. Some of the women express a feeling of uncertainty as to how their colleagues will react. Some women worry about how their careers might be affected. Once a woman has shared her secret, she usually gets support and understanding at work. The opposite can also occur; that is, no perceived understanding or change of working conditions. In the cases where the woman does not like her work, she can experience it as yet more important that the pregnancy ends in delivery of a child.

And then I started to think that it would be noticed, so it was just as well to tell them. It was great to tell people at work since it lead to an acceptance that you might not be able to keep up the same pace and you sometimes might seem irritable. So that worked out well, and then we waited quite a while to tell friends and relatives. It felt good to leave everyone else in the dark, because it felt like it was only my and John's thing to begin with … (4)

I felt at risk of being overtaken. There are others at work, who have passed their childbearing age, so to speak, and who are getting positions and promotions that I know could get. But I'm considered less eligible because I am likely to have children sooner or later. At the moment I don't feel like going back to that position after my maternity leave. I'm counting the months that are left now. (3)

Being a part of a larger context and a longing to give

The women express a sense of security in the relationship with their partner and their partner's family and a sense of community being a part of a larger context. The pregnancy became more real to them when they told their parents that they were expecting a baby. The women refer to both joy and pride when they talk about the moment when their parents got to know about the pregnancy.

Some women relate that they are the only ones that can give their family a grandchild and how this contributes to a sense of power within the family. They see the pregnancy as a gift to their parents. They are proud that they can contribute a new generation to the family. There is a desire for closer and deeper bonds within the family during the wait for the expected baby and this makes the family grow together as a family.

So this is their only chance to become grandparents, through me … Mother must also realise that if it's going to happen it might just as well be now … (10)

Have you noticed a difference with your parents?

Yeah, yeah I think so and it's great, they have reacted extremely positively which was really nice, a relief, because one wants anyway, even though you are grown up you listen to what your parents say. It was really nice to have their full support and feel that they were really happy, they are already getting involved and talking about what it will be like and all the toys and so on. My mother thinks this is truly wonderful. At the same time you start to think about the fact that they live quite far away, 300 kilometres from here. What are we going to do afterwards, you want your children to see your parents and also John's parents and so on, you want to see your family more often and make sure the children get to see your family … I haven't felt like that really before … I feel that I've had little contact with my parents, not so often, perhaps once a week or every other week or something or talked on the phone … whereas now we speak more often … (2)

Hesitating to share the joy

The women who do not dare to tell their mothers often miss this contact and can feel loneliness, which in turn affects their experience of being pregnant. Those women who do not have a good relationship with their mothers hesitate to share their joy; they feel uncertain and are unsure of their mothers’ feelings. They want to share their joy about being pregnant but hesitate to do so. The women whose mothers seem to display a lack of interest in their pregnancies express sadness and describe a lack of supportive contact and affirmation.

And so I have thought a lot about my parents and what they are going to say and how they will react and so on, because this is what I have been most worried about, telling my mother, I haven't told her yet, I will do it this week-end … (10)

In the interviews, the women also refer to something being missing, to not dare or be able to talk to their mothers about their pregnancy. This can stir up childhood memories. Those women who have had a poor relationship to their mother and have taken a lot of responsibility as a child recall less than fond memories, things they would rather not pass on to their own children.

I don't have such a good relationship with my mother and of course this stirs up a lot of thoughts now … because I both really want her closeness but at the same time I don't … I don't want her to be too involved in my life though … and I really want to ask her about how she felt when she was expecting me and my brother but I know that she doesn't really want to tell me anything. It's a bit of a complicated relationship quite frankly, so it certainly sets your mind racing … (4)

Looking back in sadness

The women say that the pregnancy has made them aware of their own life and family histories. Grief over the death of a parent is brought back, stirring up feelings of loss and longing. The women feel sadness over the fact that the deceased parent will not experience and share the joy regarding the pregnancy.

Well, I think quite a lot about my father who is no longer with us, not frightening thoughts, more a sense that life carries on in spite of the fact that he is no longer here and that he is still with me. It feels a bit, when I think about Father in such moments, when I think of him very intensely then I get sad that he can't be a part of this. But then again, I know that he will anyhow. Something like that, it feels like I think of him both in a positive and a negative way well … the grieving is like, it came back in a way now when I became pregnant. I thought a lot about him but then … back then I could become very sad, as if attacked by grief. Now I think about it in a more practical way, well that the family will live on now, Mother will have a life again, it will make her happy … well things like that, I think quite a lot about family … (1)

Thinking about the future

The women start thinking about their future family and what it will be like, how they will be as mothers and about work in the future. They also share their reflections about their partners—maybe he was more mature about starting a family than they were. They are aware of the fact that there will be a huge difference and are eager to know what will happen and how they will be as mothers. The women happily anticipate being able to put all their focus on caring, being with the baby, and being off work. However they also speak about living here and now; they try to delay thinking about the actual birth.

John is the kind of a person who takes one day at a time. He has always been like that, but I float away in my thoughts and think ahead more … Not that I plan my future but I think about the future so it's good in a way that he holds me back sometimes and makes me think a bit more about the present … I feel that it is extra important now that I actually take one day at a time both because I don't know what will happen if all goes well and of course it's an exciting time, a wonderful time. I don't want it to just fly by … (4)

Being in a change of new perspectives and values

Feeling disappointed about not feeling happy

The texts from the interviews indicate that the women feel happiness over their love for their partner and the expected baby. They also feel that their partner loves them. There are, however, women who express astonishment over their feelings of unhappiness, something they could not have imagined prior to the pregnancy. They are expected to be happy but feel unable to do so. The women also say that in spite of being happy about the pregnancy, they feel unwell and that this surprises them. Physical sickness and faintness counteract their joy and cause disappointment.

Growing closer in relationships

Some women hope that the love between them and their partner will become deeper and stronger and that they will grow closer. The pregnancy has made them feel a new sense of caring for their partner; they realise the importance of him being there for her and a fear that something might happen to him and that they might not become a family.

You become more … more afraid … I am not usually like that I am not worried if John, my fiancé, is away. But now I have started to think like that, what if something happens to him and this just cannot happen. I have never been like that because I have always felt that he can manage, he always takes care of himself. It is much harder when he is away or is doing something else and I don't know if something might happen to him, it's kind of an odd feeling. You also feel that you are more protective of close friends and loved ones and that you want more contact with your parents (2)

Not daring to be happy

The women try to commit themselves to the expected baby in different ways. They say that they try to understand that they are pregnant by patting and stroking their tummy. This helps to reinforce the experience of being pregnant and make it more real. There is a desire to indulge in daydreams and thoughts about the baby and to give him/her a name. Some express this in terms of feelings of joy and others as happiness. There are also women who hold back their thoughts and feelings and are wary of feeling joy or happiness in advance, which can be seen as a way of protecting themselves in case something goes wrong.

I don't dare to buy a pram or anything like that yet, what if something happens, we thought about that a lot. Should we perhaps buy one and leave it at my parents’ in the meantime, but then I thought, no I don't want to do that, no, ugh, bad luck too I'd say. (3)

Fears and doubts and feeling lost

The women express doubts and describe feeling lost in their new situation and they wonder if they are mature enough to be pregnant or to become a mother. They say that they were surprised and unprepared for their feelings of both joy but also of frustration. They wonder about what they have entered into, struggle with feelings of inadequacy, and worry that they are too old to be pregnant, at the same time as they have high expectations and demands on themselves to be prepared properly for the pregnancy. The women are preoccupied with the changes they feel within their body and thoughts about the pregnancy. They think about the seriousness of life and whether they are mature enough to become a parent with all the responsibility that entails.

I am afraid, afraid of becoming a mother … or I am afraid that I am not finished with myself? It could be that that I am afraid that I thought I wanted this but that I'm not really ready. I didn't want to have children before, it was just a feeling that came all of a sudden a year ago and then I have thought a lot about it and when I did get pregnant it felt like, do I really want this now, so I am a bit lost … (1)

The women also indicate that it is difficult to grasp the impact this will have on their lives because at the same time as they experience joy about the pregnancy they also struggle to gather their thoughts, which sometimes makes them feel lonely and lost. In spite of that, they cannot control these thoughts or understand their feelings of, for example, fatigue; they do not think too much of it, they hope that everything will be better. At the same time, they do not want to think too much about the pregnancy but in spite of that there are a lot of thoughts and thinking. They do not really recognise themselves and they indulge in day dreaming about the baby who is inside their tummy.

How the pregnancy feels … well it's double-edged, I can just really say that I'm feeling both joy and fear … and sometimes one is stronger … sometimes I am more afraid and sometimes I am more happy … so it's just about those feelings that I have … and how it can make you feel lonely, the feeling of fear one can make you feel a bit lonely sometimes I think … (3)

Facing choices and feeling alone

The women also refer to loneliness in making decisions, for example, whether they should take an amniotic fluid test that could harm the baby and what they would do if the amniotic test results show that the baby carries a defect or is not healthy in some way. This is a new situation that puts their relationship with their partner to the test and the women can feel disappointment when they find out more about their own and their partner's true values. Even if they agree with their partner, the women confirm that in the end they alone make the decision. Some feel that they cannot talk to their partners about this; instead, they would prefer to discuss the issue with another woman. The women who decide to take the amniotic fluid test claim that they postpone thinking about the baby and do not dare to feel joy about the pregnancy until they have received the test results.

You think ahead, what will happen if we don't take an amniotic fluid test, what will happen if we have a baby that is mongoloid or a baby with chromosome defects that we could have chosen not to be born. What will life be like in that case, will I commit to the baby, yes I will do so, and I will probably love him/her even more than I would love other children. But how will I react when people will look at me, oh, well, you had a mongoloid baby, well, ok, what a sad thing for you. And what happens if I take the amniotic fluid test and we don't have a miscarriage and we start thinking about the fact that we are expecting a mongoloid baby. I will get to know just before Christmas and I usually say that we will either have a great Christmas or an awful Christmas. Because it's not so easy, it's not black or white, terminate or not terminate. It's still a pretty hard decision. I don't really think that John is always such a good support in this discussion. I need support from someone that has gone through the same thing. I need support from a woman instead. (3)

To becoming a mother

To be identified as a mother-to-be

Being pregnant means changes in the relationship and contact with parents. Contact with parents increases, especially with mothers that want to give the women support. Their mothers get a central role, become more important, and are often the first to know that their daughter is pregnant. The women who have close relationships with their mothers, refer to an increased intimacy and openness with their mothers. The women identify themselves with their mothers. They notice a shift in roles, from being their mother's daughter to becoming a mother. At the same time, as the closeness to the mother is increased, the women feel that having a baby is a part of the process of liberating themselves from their mothers and from their parents. The women experience that they mature as a woman and that they become respected as adult women by their mothers. Even if the relationship with their mother is complicated, it seems that the pregnancy often leads to changed and better relationships.

We have a very strong relationship me and my mother, for better or worse but it has become stronger in a good way now. I have struggled and fought with our relationship over the years. I have felt that she has wanted to control and steer me and that she has never seen me as an individual. I get the feeling, that she let go just a bit and has started to see me as an adult woman for once, she listens to me in another way. She might have done so all along, but she speaks to me in another way, she uses different words now. (1)

To feel an inner change: new perspectives and values

The women relate that they are happy and preoccupied with the pregnancy and that they like to talk about it with others. They are also surprised about the mood swings that they experience. They feel that they do not react in the same way as before, they react more strongly, become angry more easily, and feel intensely engaged. The women are also more sensitive or emotional in terms of how easily they are moved by things. They feel humility towards life and express this as an inner change, an inner calm, and as if they are taking a new path in their lives and that they have changed mentally. The women claim that knowledge about their pregnancy leads to change and development of their personality through a process of reflecting on their thoughts and core values and about the changes that are taking place within them. They say that they have developed a new self-esteem. The pregnancy in this context brings a new understanding of what is important and essential in life and what is not. This can result in the forming of new values.

I feel a calm in my body that I haven't had before in my life … so I feel that I am in balance with myself thanks to this force. I haven't got time for unnecessary things or place or time, you know what I mean, it doesn't feel so important anymore to think of myself so much whereas before I kept analysing what I felt. But I don't anymore and it's nice to not have to do that... (1)

To feel a miraculous vigour

The women refer to a sense of the divinity of life, a supernatural force within their body, and that they feel the soul of the foetus within themselves. This and the feeling of a miracle awaken almost religious thoughts. The experience of being in balance is a joyous one and being pregnant also gives the women a sense of calm within their body. The women discuss being pregnant as something great; it is a natural part of life connecting them to the meaning of life and life is great. They feel gratitude towards life. At the same time, they think about the responsibility they will have as a parent.

Then there are grander thoughts about, well the whole world and the state of things. Being pregnant feels like an amazing miracle but it also awakens a lot of thoughts. I'm not religious, but it prompts some kind of religious contemplation, about whether there is something greater that controls things, well, I don't know how to explain. I have thought more about … the circle of life, people that were born and people that die and well, that it goes around all the time like this and one wonders what happens afterwards, if something happens afterwards, a lot of thoughts like that … that life actually feels fantastic and beautiful really and that what one thinks about, is if there really is somebody pulling the strings after all, some kind of greater force or something … (4)

Interpreted wholeness

To be in early pregnancy for the first time represents a life opening, including both life affirmation and suffering and that is a process of opening up different dimensions of life. The women express themselves as being chosen and refer to a feeling of holiness. For the women, a life opening is to be confronted with questions of life and to see certain values from a wider perspective. This means to meet and reflect on their own existential and spiritual values. The women become aware of their own lives at the same time as becoming aware of the fact of giving a new life. This may cause loneliness and a feeling of being lost, both in trying to understand the meaning of life and in making important decisions. Becoming and being pregnant does not always generate happiness and joy and this can be difficult in the face of people's expectations. Bodily discomforts and an increased sensitivity may contribute to feelings of being alien to oneself. Not being able to share the pregnancy and joy with parents, especially mothers, awakens feelings of loss, sadness, and disappointment. Relations with others mean that the women see themselves as a part of a greater context, from a girl to a woman becoming a mother; they are integrated with other human beings and especially with their mothers and families. The love for the children and the security of their partner are expressed as being the most life enhancing. For the women who have lost a parent, the grief is brought back again and they feel a loss over the fact that the deceased parent will never know his or her grandchild. At the same time, the women express joy about the fact that the expected child will bring a new generation to the family. When reflecting on becoming a mother and starting a family, the women say that they have developed as a person and that a new consciousness about life has grown within them, a life opening.

Discussion

The interviews in our study consisted of two stages. First the woman had to draw a picture about her experiences of pregnancy. The picture was the starting point for the interview (Högberg, 1996). The aim was to give the women an opportunity to reflect on her experiences. This may be one explanation as to why so many existential questions were raised during the interviews. This format is unique to studies about pregnancy. The limitation of our study is that it is conducted in a Swedish context with a small group of women. All qualitative studies must be related to a particular context and, thus, never to be understood as presenting universal claims (Dahlberg et al., 2008). This is also in accordance with Davis-Floyd (1992) who states that pregnancy is a culturally, socially, and physically transformative event that must be viewed in the context in which it occurs. However, the fact that these results are contextual does not imply that they are inapplicable and have no meaning in other contexts. Application of the results to new contexts could be understood as entailing an open-ended process of understanding, which is also depicted in the metaphor of the hermeneutic circle (Dahlberg et al., 2008). In order to establish confidence in the interpretations of the meaning of the data, quotations are included so that the reader can judge if these interpretations are reasonable or not. The ambition has been to be aware of the subtle voices of the women and true to the phenomena that are studied. In order to achieve this, two of the authors (CM and IB) made the analysis and the third (IL) read and reviewed the analysis in relation to the themes and sub-themes.

The results from this study show that early pregnancy for first time pregnant women is a life opening. Life opening in early pregnancy may be understood as a starting point for women's development during the childbearing process (defined as the period from pregnancy to birth). Confronting one's own values and tackling existential questions is important according to our study. The importance of existential questions for women during early pregnancy may be a result of the fact that the women during birth, as mentioned by Hall (2002), border the very edges of life and death. The act of birth has a raw earthiness that leads women to the very roots and bareness of their being (Hall, 2002). Furthermore, pregnancy is a rite of passage (Davies, 2002) whereby existential and spiritual questions are emphasised. This is also verified by Callister (2004), who states that a transcendent emotional and spiritual experience is essential for women's experiences of birth. Seibold (2004) also shows how pregnancy changes the woman. Pregnancy marks a transition to adulthood and a positive, evolving sense of identity. This is further verified by Hall (2006), who claims that the birth of a child has the potential to have a profound effect on women's personal wholeness. Thus the concept of life opening has similarities with the concepts of transition (Imle, 1990) and transformation (Bergum, 1997), especially concerning motherhood.

According to our study, becoming a mother can generate unusual feelings, feelings touching on holiness, power, and life. This is verified by Hall (2002), who states that there is more to the period of childbearing than just the physical and emotional experience. There is potential for spirituality in all humans and it can be expressed in many ways. Callister, Semenic, and Foster (1999) discussed in their study the possibility that religious beliefs help women define the meaning of birth and may provide coping mechanisms for the intensity of giving birth. In the light of our study the meaning of early pregnancy can be understood as an integral part of the spiritual dimensions of the women's lives. It is interesting that this existential dimension is so central in our secularised society.

Another aspect of life opening is about making connections with other women. Bondas (2005) calls this sisterly communion, which is central for women's experiences of pregnancy,birth and the first days with the new baby. According to Callister (2004), connectedness with women across the generations is important for pregnant women. Women want to be connected to other women and to share both joy and suffering. To connect to other women is also to prepare for the new role as a mother. Wiktorell and Saveman (1996) show how the pregnant woman is influenced by both her mother and grandmother. During early pregnancy, the woman's knowledge of childbirth and raising children is often gained through contact with mothers and grandmothers (Wiktorell & Saveman, 1996). The importance of contact across the generations is verified by our study. Our study shows that the woman's own mother is important and that pregnant women often want more contact with them. For women with bad relationships, this experience may stir up intense feelings. Women express pleasure in providing a next generation through the expected child according to the results of our study. Seibold (2004) has similar findings.

Support is very important throughout the pregnancy according to Schneider (2002), and women seek the reassurance of important others. They wonder about changing relationships with their partners, friends, and mothers. Even if support during childbirth has been evaluated as one important aspect of labour (Hodnett, Gates, Hofmeyr, & Sakala, 2007), very little research has focused on pregnancy. Pregnancy at a young age brought a renewed sense of closeness and appreciation of the women's mothers. According to Bergum (1997), women hope that they will be transformed so they can be the mothers they want to be. Their own mother is the most important woman to connect to but other women can also give hope to go through the unknown in the pregnancy.

Early pregnancy can be a balancing act between sharing with others and keeping the pregnancy a secret according to our study. The women keep the pregnancy a secret, since they are not sure that everything will end as hoped. Pregnancy is a patchwork of joy and suffering. A woman's altered mode of being involves worries and variations in moods (Bondas & Eriksson, 2001).

According to Melander (2002) and Melander and Lauri (1999), all the women in their study expressed fear that was associated with pregnancy, childbirth, or stemming from feelings of uncertainty. As in our study, Melander (2002) found that primiparous women's fears were based on uncertainty because they had no prior experience of pregnancy. Schneider (2002) considers that most of the women have experienced anxiety about the possibility of having a miscarriage or foetal abnormalities.

Further aspects of life opening involve making important decisions that may cause feelings of loneliness and suffering. Melander and Lauri (1999) have similar findings in their study. During the early stages of pregnancy, some of the women did not dare to speak about how they felt and suffered quietly by themselves (Melander & Lauri, 1999). Some of the women felt fearful and uncertain according to Schneider (2002) and the need for support from family and friends became obvious. In our study similar feelings and experiences were expressed by the women. Some women have a close contact with others and can discuss existential questions of life. The support friends give a woman can be described as natural care (Eriksson, 1997). However, professional care (Eriksson, 1997) has other dimensions, which are of importance for all women. A midwife's professional care may give the woman a feeling of connecting to other women. This can equip the woman to cope with health issues during pregnancy, to prepare for birth, and the contact with the baby. Meetings with a supportive midwife during early pregnancy can encourage the woman to talk about existential questions. This form of care may be seen as health promoting. It is a challenge for maternity care to not only emphasise the medical aspects of care, as earlier research has indicated is often the case (Olsson, 2000).

This is further verified by Coggins (2003) who claims that it is time for midwives to re-examine their role and responsibilities in the first trimester, and develop practice accordingly for the sake of the profession and for the women and families it cares for. According to Coggins (2003), early contact with a midwife may be important from a family perspective, concerning lifestyle alterations, and to reduce the need for medical interventions in later pregnancy. Hall (2006) also claims that there is little discussion about meeting spiritual needs and personal wholeness at the beginning of life compared to the end of life.

For some women, the suffering associated with being pregnant was overwhelming and they even questioned what they were a part of and the existence of life. To find meaning they tried to motivate themselves and endure. According to Wiklund (2000), meaning provides an opportunity to integrate suffering. The suffering becomes a part of the process of becoming, whereby the woman shapes herself and her being. Bergum (1997) considers that women expect to be different as mothers; they are continually reminded by everyone that they will never be the same again. In choosing to become mothers, women worry about this change.

Becoming a mother also implies change in relationships with colleagues at work. Women may be more irritable at work, but when they finally tell their colleagues they receive understanding. Do women want to be treated in a special way during pregnancy? Schneider (2002) suggests that when the women told their colleagues they became supportive and interested in the pregnancy and they were notably more protective. However, the women in our study expressed worries about being left behind in terms of their future careers.

Implications for health care

The findings from our study describe how first time pregnant women articulate their experiences of being in the early stages of pregnancy. Early pregnancy is a life opening, which may prompt reflections on existential questions, a process that might lead to loneliness. Therefore, it is important that women have an opportunity to meet a midwife in early pregnancy, something which is lacking in Sweden and other countries today.

Conflict of interest and funding

There is no conflict of interest. The authors have not received any funding for conducting this study.