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Psychology in Pregnancy: Cases of 50 Primigravidae Followed up in Prenatal Consultation at the South Abobo General Hospital (Abidjan)

Pregnancy is a time of fragility and maturation, and always involves important psychological adjustments. The primigravidae, who are women carrying their first pregnancy, are not left out of these problems. As a study in Togo has shown, psychological disorders were more frequent in young pregnant women and in primigravidae. In view of this reality, which is observed in all women during their first pregnancy, we felt the need to undertake a study whose general objective was to describe the psychological experience of primigravidae followed in prenatal consultation at the Abobo-Sud General Hospital. This was a cross-sectional prospective study with a descriptive aim. It involved a sample of 50 consenting primigravidae selected according to the technique of accidental or convenience sampling. The results showed that 44% of the primigravidae were under 20 years old and 54% of them did not live in a couple. When the pregnancy was announced, the main reactions observed were: discouragement / sadness (66%), joy (60%) and crying (44%). In 40% of the cases, the pregnancy was unwanted and was negatively perceived by 54% of the primigravidae. The reasons for this negative perception were: parental anger (32%), not being ready to become a mother (28%) and financial difficulties (26%). The desire for an abortion was expressed by 40% of those who did not wish to have a child. Regarding the act of childbirth, 84% of primigravidae were afraid, because of their inexperience and the pain they would experience. The difficulties they encountered were sleep disturbances (80%) and financial difficulties (72%). Although the results of this study already take into account the physical parameters, the results of this study plead in favour of including psychological aspects in the follow-up of primigravidae during prenatal consultations. Hence the importance of training midwives in the care of primigravidae.


Introduction
Pregnancy is a sensitive period in a woman's life, a journey marked by intense physical and mental experiences. Pregnancy is a time of fragility and maturation, and always involves significant psychological changes. Pregnancy prepares the woman for changes in all areas of her life, from her self-image and body image to her relationship with her partner and her social, professional and family life [1].
According to Witt, about 10% of pregnant women in developed countries suffer from mental health problems [2].
Psychological discomfort during pregnancy has repercussions both on the outcome of the pregnancy, neonatal Consultation at the South Abobo General Hospital (Abidjan) complications, maternal mental health in the postpartum period, and on the psychomotor development of the child [3].
Pregnancy experiences vary according to psycho-social factors such as the financial conditions of the household, the support of the partner, the desire for pregnancy, and the culture of the pregnant woman [4]. Pregnant women's mental health can also vary according to the physical symptoms related to the pregnancy [5].
The primigravida, who are women carrying their first pregnancy, are not left out of these problems. Thus Yenkey [6] in his study in Togo, noted that psychological disorders were more frequent in young pregnant women and primigravidae.
In Côte d'Ivoire, much progress has been made in the medical monitoring of pregnancy, but the emotional experience of pregnancy is little explored; hence the present study, whose objective was to describe the psychological experience of primigravidae followed in prenatal consultation at the general hospital of Abobo-Sud (Abidjan).

Materials and Methods
Our study was carried out by the prenatal consultations unit of the gynaecological-obstetrics department of the Urban Health Training Abobo-Sud (FSU AS), which was set up as the General Hospital of Abobo-Sud by decree n° 080 of 23 March 2007 of the Ministry of Health and Public Hygiene. This was a prospective cross-cutting study with a descriptive aim that concerned primigravidae coming for prenatal consultations. The study took place from 09 July to 06 August 2018. We opted for accidental or convenience sampling, which consisted of questioning primigravidae as they presented themselves for prenatal consultation.
Thus were included in our study: 1) primigravidae in the second trimester of pregnancy, 2) received in prenatal consultation by midwives, 3) primigraviders who have given their consent to participate in the survey. Irregularly followed primigravidae refusing to participate in the survey were not included in our study.
On this basis, 50 primigravidae were retained. It was therefore to this sample of 50 primigravidae that we administered our questionnaire developed for this purpose. This questionnaire was administered in the form of a semi-directive interview and made it possible to collect data on the following points sociodemographic data, data relating to the psychological experience of pregnancy and apprehensions about childbirth.
The data was processed using Excel and presented in the form of tables. During the course of our study, we respected the anonymity of the primigravidae and their consent to participate or not in the study.
Nearly half (44%) of the primigravidae were under 20 years of age and were pupils/students in 44%, as were the perpetrators of the pregnancy in 40% of cases. In 54% they were not living with a partner. (Table 1) Pregnancy was desired in 60% of the cases and the reasons given were to strengthen the household (50%), to please the spouse (46%) and to have proof of fertility (40%).   On the other hand, in 40% of the cases pregnancy was not desired. Parental anger (32%), not being ready (28%) and financial difficulties (26%) were the reasons given for the unwillingness of these primigravidae to become pregnant, 40% of whom had considered abortion.
In addition to the results recorded in the tables, the study also showed that the primigravidae had a history of body changes due to pregnancy. Thus, 48% of the respondents had a negative perception of these body changes. This perception was expressed in 30% by the shame of their body, 10% by disapproval of the curves due to pregnancy and 8% by a feeling of ugliness due to these changes.

Discussion
The majority of primigravidae (44%) in our study had become pregnant before the age of 20, with a peak in the 15-19 age group.
According to the World Health Organization (WHO, 2013), [7] each year about 16 million girls aged 15-19 give birth to a child. Children born to adolescent mothers account for approximately 11 per cent of the total number of births worldwide, and 95 per cent of adolescent births occur in developing countries.
In On the other hand, 6% of the respondents had had their first pregnancy at the age of 35 and over. From the age of 35 onwards, we speak of advanced obstetrical age for women. Elderly primiparous women are defined as women having their first child at an age of thirty-five or more (35 years). This lower age limit is not unanimous in the literature but is justified by the physiological decline in fertility from the age of thirty-five onwards, which accelerates sharply after the age of forty. Also, female physiology remains the same, in spite of medical progress which now makes it possible to achieve pregnancy later (Assisted Reproduction): the woman has the possibility of procreating from puberty to the unavoidable limit of menopause which takes place between forty and fifty-eight years of age (average at 50.1 years of age) (1). [9].
In 54% of cases, the primigravidae did not live in a couple. This result is close to that of the UNFPA's final report in Senegal [10] in November 2015, which found that 60.80% of primigravidae did not live in a couple. This could be explained by the fact that most of our respondents are adolescents.
In developed countries and some African countries, most adolescent girls are single, unlike in Muslim countries such as Morocco and especially in rural areas where girls are often married in their teens [11].
Concerning the socio-professional situation of the respondents, our results showed that more than half (58%) of our primigraduates were without income (44% pupils/students and 14% unemployed) as were the majority of the authors of their pregnancy (52%) with 40% pupils/students and 12% unemployed. Our figures are higher than those of Coulibaly et al [12] who, in their study on the socio-professional factors and practice of exclusive breastfeeding by primiparous women in Abidjan (Ivory Coast,), noted that primiparous women had no income in 31.94% of cases, and the authors of the pregnancy in 14.36% of cases.
Pregnant women have no income and are themselves dependent on a third person (especially the parents). This situation constitutes a stress and destabilisation factor for primigravida.
The comparative study between primiparous and multiparous women conducted by Munan [13] in Lubumbashi summarised the socio-demographic characteristics of primiparous women as being 11 times more likely to be younger (under 20 years of age), 7 times more likely to be single and 5 times more likely to be pupils/students.
The lack of sex education in families and schools due to the discomfort experienced by parents and educators in talking about sexuality associated with low contraceptive use among girls could explain the early onset of sexuality among girls, often resulting in unplanned pregnancies. Pregnancy was desired in 60% of the primigravidae surveyed. Their reaction to the announcement of pregnancy was joy (60%), which was justified for them by the consolidation of the household (50%), by the fact that they were pleasing their partner (46%) and finally by proof of their fertility (40%). Indeed, motherhood is considered a duty. Women have a mission to give birth, therefore to have offspring that will perpetuate the lineage and inherit the family patrimony. This requirement is internalized by them, because it gives them a status in society, as the saying goes: "No daughter who does not wish to become a woman, no woman who does not wish to become a mother". Pregnancy and childbirth are essential stages in women's socialisation [14]. All women therefore feel this pressure because they have to prove their ability to give birth, testifying to their femininity. [15] On the other hand, in 40% of cases pregnancy was not desired by the primigravidae, who had shown this through a reaction of discouragement/sorrow (66%) and crying (44%).
The experience of an unwanted pregnancy would be painful for the expectant mother, who would be at risk of consciously or unconsciously neglecting the foetus in her womb. For Abessolo [16], an unwanted pregnancy, whatever its causes, is likely to lead to psychiatric complications.
The reasons given for not wanting to become pregnant were parental anger (32%), not being ready to become a mother (28%) and financial difficulties (26%). All these reasons had led the unwilling primigraviders to consider abortion in 40% of them. Thus, pregnancy, instead of being a means of affirming femininity, becomes a source of psychological suffering. This situation puts the motherto-be in conflict with herself on the one hand and with her entourage (especially her parents) on the other. [17]. Many pregnancies are not only unplanned but also unwanted, as can be seen from the estimated 2.2 to 4 million adolescents who have recourse to abortion every year [18].
Geissbuehler [19] also noted these reasons, and found that fear for the health of the unborn baby (49.60%) and fear of pain (39.80%) were the same.
Fisher [20] explains this as fear of the unknown, because according to him, women do not have the cultural background of medical knowledge to ask questions, which reinforces their feeling of powerlessness. They also feel a form of social pressure that they are "made for childbirth".
Major medical advances have led to a significant reduction in maternal mortality and morbidity and neonatal mortality during childbirth. However, as with all physiological phenomena, there is an element of unpredictability that is inherent in nature. Even though childbirth is a natural phenomenon, there is no such thing as "zero risk" and complications inherent in childbirth can occur. [21].
The difficulties encountered by primigravidae were dominated by sleep disturbances (80%) and financial problems (72%), but 14% of the difficulties encountered at school were also identified among our respondents.
Pregnancy leads to numerous physiological, hormonal, morphological and even psychological changes that can influence and disturb the sleep patterns of pregnant women. The quality and duration of sleep is reduced during pregnancy [22]. In the second trimester, total sleep time decreases, and night-time awakenings are more frequent, always linked to the "little aches and pains" of pregnancy, but also to other causes such as increased nightmares, night cramps, low back pain and restless legs syndrome [23].
Pregnancy care is expensive, and the majority of primigravida were unemployed, as were those who became pregnant.
On the other hand, 14% of the respondents were experiencing difficulties at school, which could be explained by difficulties in attending classes due to the symptoms of pregnancy (daytime sleep, vomiting and hypersalivation) and shame related to the bodily changes due to their new condition.
In fact, 48% of the respondents were disturbed by the physical changes made during pregnancy. This could be explained by their ignorance of the bodily changes women undergo during pregnancy.
During pregnancy, a woman's body landmarks change and can be a source of anxiety and concern over the fear of not regaining her former figure after childbirth. This is what led Karst [24] to say that a personalised accompaniment would be useful to help them live through this trying period in the best possible way.

Conclusion
The primigravidae followed at the Abobo-Sud general hospital are vulnerable because they are adolescents, pupils or students and have no income. Pregnancy is a problem for them because of the reaction of their entourage, their young age and the fact that they are not ready to assume this new physiological state, all of which is a source of psychological suffering for them. Inexperience, pain and fear made them fear the coming birth. In addition to the physical aspect, the monitoring of the pregnancy during prenatal consultations must also focus on the psychological aspects in order to identify psychological problems related to the pregnancy at an early stage and to take care of them. This implies strengthening the midwives' capacities in the psychology of the pregnant woman and her environment, thus enabling holistic care of pregnant women in general and primigravidae in particular.