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Concerns of mothers in the first month postpartum 1986

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CONCERNS OF MOTHERS IN THE FIRST MONTH POSTPARTUM by SHARON R. TOBERT B.S.N., The U n i v e r s i t y Of B r i t i s h Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of A d m i n i s t r a t i v e , A d u l t And Higher E d u c a t i o n We ac c e p t t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA October 1986 © Sharon R. T o b e r t , 1986 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department o r by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f f\cjrf)ir\ijira-rio() A d m H C M M A MtjKer- Edueafiov The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date O'Q -/O-jH E-6 (3/81) i i ABSTRACT Program p l a n n i n g f o r postpartum mothers r e q u i r e s knowledge of the e f f e c t s of p a r i t y and time s i n c e d i s c h a r g e on the mothers' p e r c e p t i o n s of t h e i r l e v e l of concern r e g a r d i n g s e l f , baby, p a r t n e r and f a m i l y . I t was f o r t h i s pupose that t h i s d e s c r i p t i v e c o r r e l a t i o n a l study was conducted. T h i r t y - o n e p r i m i p a r a s and t h i r t y - s i x m u l t i p a r a s completed a 51 item maternal concerns q u e s t i o n n a i r e d u r i n g t h e i r f i r s t two days a f t e r d i s c h a r g e from h o s p i t a l and again at one month a f t e r d i s c h a r g e . Nonparametric t e s t s were used to determine any s i g n i f i c a n t d i f f e r e n c e i n i n t e n s i t y and frequency of concern between the two groups of mothers and between the two time measures. The d i f f e r e n c e i n i n t e n s i t y of concern between the two groups was not found to be s i g n i f i c a n t f o r the t o t a l concerns at e i t h e r time p e r i o d . There were however, i n d i v i d u a l areas i n which one group had s i g n i f i c a n t l y g r e a t e r concern than the o t h e r . A s i g n i f i c a n t d i f f e r e n c e was found i n the i n t e n s i t y of the t o t a l concerns between the two time measures f o r both p r i m i p a r a s and m u l t i p a r a s . The r e s u l t s demonstrate a need f o r s u p p o r t i v e - e d u c a t i v e programs f o r both p r i m i p a r a s and m u l t i p a r a s i n the f i r s t month postpartum. They a l s o i d e n t i f y s p e c i f i c areas of concern i n which the focus of the i n t e r v e n t i o n s may d i f f e r f o r these two groups of mothers. TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v LIST OF FIGURES v i i ACKNOWLEDGEMENTS v i i i Chapter 1 : I n t r o d u c t i o n to Problem 1 Problem 5 D e f i n i t i o n s of Terms 8 Purpose 9 Chapter 2: Review of the L i t e r a t u r e 10 I n t r o d u c t i o n 10 C h a r a c t e r i s t i c s and Tasks of the Puerperium 11 Assessment of C l i e n t Needs i n Program Planning 21 Concerns of P o s t n a t a l Mothers 25 Research Regarding Concerns of Pr i m i p a r a s 25 Surveys of Concerns of Pr i m i p a r a s and M u l t i p a r a s . 27 Concerns of S p e c i a l Groups of Postpartum Mothers . 29 E f f e c t s of P a r i t y on P o s t n a t a l Concerns 34 Chapter 3: Methodology 38 I n t r o d u c t i o n . . 38 Sample and S e t t i n g 38 Measurement instrument 40 Data C o l l e c t i o n 41 N u l l Hypotheses 42 Chapter 4: A n a l y s i s of Data 46 I n t r o d u c t i o n 46 C h a r a c t e r i s t i c s of the Sample 46 P a r i t y 46 Age 47 Gender of Baby 48 Edu c a t i o n 48 E t h n i c i t y of Mothers 49 Type of In f a n t Feeding 50 P r e n a t a l C l a s s Attendance 50 Return to Work 51 Help a t Home and Use of P r o f e s s i o n a l Resources ... 51 D i f f e r e n c e Between Concerns of Pri m i p a r a s and M u l t i p a r a s at Two Days 52 S e l f 53 Baby 54 Pa r t n e r 56 Family 57 T o t a l Items 59 D i f f e r e n c e i n Concerns of Pri m i p a r a s and M u l t i p a r a s at One Month 60 S e l f 60 Baby 61 Par t n e r 63 i v Family 64 T o t a l Items 65 D i f f e r e n c e i n Concerns of P r i m i p a r a s i n F i r s t Two Days and One Month a f t e r Discharge 67 S e l f 67 Baby 69 Partn e r 71 Family 72 T o t a l Items 73 D i f f e r e n c e i n Concerns of M u l t i p a r a s i n F i r s t Two... Days and One Month 74 S e l f 74 Baby 75 Partn e r 77 Family 78 T o t a l Items 79 Summary 80 Chapter 5: F i n d i n g s and Recommendations 82 I n t r o d u c t i o n 82 The Sample 82 D i f f e r e n c e i n Concerns of P r i m i p a r a s and M u l t i p a r a s During the F i r s t Two Days 84 D i f f e r e n c e i n Concerns of P r i m i p a r a s and M u l t i p a r a s One Month A f t e r Discharge 87 D i f f e r e n c e i n Concerns of P r i m i p a r a s i n the F i r s t Two Days and One Month A f t e r D i s c harge 88 D i f f e r e n c e i n Concerns of M u l t i p a r a s i n the F i r s t Two Days and One Month A f t e r D i s c harge 90 L i m i t a t i o n s of the Study 93 I m p l i c a t i o n s f o r Program Planning 94 Recommendations f o r Future Research 98 Co n c l u s i o n s 100 References 102 Appendix A 109 Appendix B 112 Appendix C 116 Appendix D 119 APPENDIX E 122 APPENDIX F 127 APPENDIX G 131 V LIST OF TABLES Table 1 : D i s t r i b u t i o n of Mothers by Age 48 Table 2: D i s t r b u t i o n of Mothers by Education 49 Table 3: D i s t r i b u t i o n of Mothers by E t h n i c Background 50 Table 4: P r i o r i t y ranking of concerns r e g a r d i n g s e l f (1 s t 2 days) 54 Table 5: Percentage of Responses of 0-4 t o t a l l e d a c r o s s items i n each catego r y (1st 2 days) 55 Table 6: P r i o r i t y ranking of concerns r e g a r d i n g baby (1 s t 2 days) 56 Table 7: P r i o r i t y ranking of concerns r e g a r d i n g p a r t n e r (1 s t 2 days) 57 Table 8: P r i o r i t y ranking of concerns r e g a r d i n g f a m i l y (1 s t 2 days) 58 Table 9: P r i o r i t y Ranking of Highest T o t a l Concerns (1 s t 2 days) 59 Table 10: P r i o r i t y ranking of Concerns r e g a r d i n g S e l f ... (1 month) 61 Table 17: Percentage of responses of 0-4 t o t a l l e d a c r o s s items i n each category (1 month) 62 Table 12: P r i o r i t y ranking of Concerns r e g a r d i n g Baby ... reg a r d i n g s e l f (1st 2 days v s. 1 month) 68 Table 13: P r i o r i t y ranking of concerns r e g a r d i n g p a r t n e r .. (1 month) Table 14: P r i o r i t y ranking of concerns r e g a r d i n g f a m i l y .. (1 month) Table 15: P r i o r i t y Ranking of Highest T o t a l Concerns ... (1 month) Table 16: P r i o r i t y ranking of concerns of p r i m i p a r a s Table 17: Percentage of Responses of 0-4 T o t a l l e d a c r o s s Items i n each Category ( P r i m i p a r a s : 1st 2 days vs. 1 month) 69 Table 18: P r i o r i t y ranking of concerns of p r i m i p a r a s r e g a r d i n g baby (1st 2 days v s. 1 month) 70 Table 19: P r i o r i t y ranking of concerns of p r i m i p a r a s r e g a r d i n g p a r t n e r (1st 2 days v s . 1 month) 71 Table 20: P r i o r i t y ranking of concerns of p r i m i p a r a s r e g a r d i n g f a m i l y (1st 2 days v s. 1 month) 72 Table 21: P r i o r i t y ranking of h i g h e s t t o t a l concerns of p r i m i p a r a s (1st 2 days vs. 1 month) 73 Table 22: P r i o r i t y ranking of concerns of m u l t i p a r a s r e g a r d i n g s e l f (1st 2 days vs. 1 month) 75 Table 23: Percentage of Responses of 0-4 T o t a l l e d a c r o s s Items i n each Category ( M u l t i p a r a s : 1st 2 days vs. 1 month) 76 Table 24: P r i o r i t y ranking of concerns of m u l t i p a r a s r e g a r d i n g baby (1st 2 days v s. 1 month) 77 Table 25: P r i o r i t y ranking of concerns of m u l t i p a r a s r e g a r d i n g p a r t n e r (1st 2 days v s. 1 month) 78 Table 26: P r i o r i t y ranking of concens of m u l t i p a r a s r e g a r d i n g f a m i l y (1st 2 days vs. 1 month) 79 Table 27: P r i o r i t y ranking of h i g h e s t t o t a l concerns m u l t i p a r a s (1st 2 days vs. 1 month) LIST OF FIGURES F i g u r e 1: Representation of r e s e a r c h design v i i i ACKNOWLEDGEMENTS I would l i k e to thank the members of my committee f o r t h e i r guidance and support as w e l l as t h e i r s t a n d a r d s of academic e x c e l l e n c e . I would a l s o l i k e to thank the Vancouver H e a l t h Department l i a s o n nurses working out of Grace H o s p i t a l f o r t h e i r a s s i s t a n c e and perseverance i n d i s t r i b u t i n g the q u e s t i o n n a i r e s , as w e l l as the p r e v e n t i o n community h e a l t h nurses of the South-East U n i t f o r t h e i r h e l p i n c o l l e c t i n g the completed q u e s t i o n n a i r e s . F i n a l l y the encouragement and support of my f a m i l y has been g r e a t l y a p p r e c i a t e d i n seein g t h i s p r o j e c t to i t s c o m p l e t i o n . CHAPTER 1 I n t r o d u c t i o n t o Problem P r o b a b l y one of the most d i f f i c u l t p e r i o d s i n a woman's l i f e t i m e i s t h a t f o l l o w i n g the d e l i v e r y of an i n f a n t (Sumner, 1977). S e v e r a l r e s e a r c h e r s have demonstrated t h a t the t r a n s i t i o n t o parenthood i n v o l v e s some degree of c r i s i s (Dyer,1963; LeMasters, 1957; Hobbs, 1968). Dyer (1963) and LeMasters (1957) found t h a t the m a j o r i t y of c o u p l e s c o n s i d e r e d the f i r s t e x p e r i e n c e of parenthood t o be an e x t e n s i v e or severe c r i s i s . Dyer (1963), c i t e d l o s s of s l e e p , worry over appearance, s o c i a l i s o l a t i o n and l a c k of p r e p a r a t i o n f o r p a r e n t a l r o l e s as f a c t o r s i n the d i f f i c u l t a d justment. G r u i s (1974) i d e n t i f i e d the t a s k s which the mother must a c c o m p l i s h d u r i n g the p o s t n a t a l p e r i o d a s : p h y s i c a l r e s t o r a t i o n ; l e a r n i n g t o c a r e f o r and meet the needs of a dependent i n f a n t , e s t a b l i s h m e n t of a r e l a t i o n s h i p w i t h the i n f a n t and a l t e r a t i o n of l i f e s t y l e and r e l a t i o n s h i p s t o accommodate a new f a m i l y member. She s t a t e s t h a t each of these t a s k s may evoke q u e s t i o n s and c o n c e r n s i n the mother. C i b u l k a & P r i c e , (1978) c a t e g o r i z e d t h e s e c o n c e r n s i n t o f o u r broad c o n t e n t a r e a s which i n c l u d e : c o n c e r n s about the baby, about s e l f , about spouse, and r o l e a d j u s t m e n t s . There has been some attempt i n the l i t e r a t u r e t o 2 e m p i r i c a l l y d e s c r i b e these postpartum maternal concerns (Adams, 1963; B u l l , 1981; C i b u l k a & P r i c e , 1978; G r u i s , 1974; H a r r i s o n & H i c k s , 1983; Pate, 1979; Robinson, 1972; Sumner, 1977). Much of t h i s r e s e a r c h has had a narrow focus l i m i t e d to e i t h e r primiparous or m u l t i p a r o u s mothers. Other r e s e a r c h has been l i m i t e d to only one area of maternal concern such as i n f a n t care (Adams, 1963). A l s o much of the more recent r e s e a r c h on the concerns of postpartum mothers has been done i n the U n i t e d S t a t e s f o r the purpose of demonstrating that some i n t e r v e n t i o n i s necessary a f t e r the mother i s d i s c h a r g e d from h o s p i t a l ( C i b u l k a & P r i c e , 1978; G r u i s , 1974; Pate, 1979; Sumner, 1977). In Canada many p u b l i c h e a l t h agencies have t r a d i t i o n a l l y r e c o g n i z e d the g e n e r a l needs of postpartum mothers and have o f f e r e d u n i v e r s a l s e r v i c e s such as v i s i t s by community h e a l t h nurses or p o s t n a t a l groups f o r mothers d u r i n g t h i s m a t u r a t i o n a l stage. However, d i s p i t e the widespread nature of these programs l i t t l e formal p l a n n i n g , i n c l u d i n g needs assessment and e v a l u a t i o n has been done. H a r r i s o n & H i c k s (1983), d i d conduct a widely focused d e s c r i p t i v e study on postpartum concerns of mothers and t h e i r sources of h e l p i n a Canadian c i t y which had community h e a l t h programs a v a i l a b l e to postpartum mothers. T h i s study i n c l u d e d both primiparous and m u l t i p a r o u s mothers and the i n f o r m a t i o n o b t a i n e d was to h e l p nurses p l a n h e a l t h promotion programs f o r new mothers. The mothers were given 3 a q u e s t i o n n a i r e approximately four to s i x weeks a f t e r d e l i v e r y . They were asked to r e c a l l the concerns they had ex p e r i e n c e d s i n c e the b i r t h of t h e i r i n f a n t and the re s o u r c e s that they used to d e a l with each concern. The f i n d i n g s were s i m i l a r to those of G r u i s (1974), and Pate (1979), who a l s o c o l l e c t e d data r e t r o s p e c t i v e l y and found that the major areas of concern were r e g a r d i n g r e t u r n of f i g u r e to normal, r e g u l a t i n g demands, d i e t , and f a t i g u e . These r e s u l t s d i f f e r e d from those s t u d i e s that looked at concerns d u r i n g the f i r s t two weeks postpartum (Bull,1981; Robinson, 1972) which found that care of the i n f a n t and i n f a n t behaviour as w e l l as concern about s e l f were moderate to major areas of concern. B u l l (1981), found that her h y p o t h e s i s t h a t the mother's focus of concerns on s e l f , and the i n f a n t would s h i f t to concerns r e g a r d i n g f a m i l y and community by the tenth postpartum day was not supported by the d a t a . I t seems that the e f f e c t of the v a r i a b l e of time s i n c e d e l i v e r y on concerns of both primiparous and mu l t i p a r o u s postpartum mothers i s important i n f o r m a t i o n f o r p l a n n i n g and p r i o r i t i z i n g s u p p o r t i v e - e d u c a t i v e programs f o r t h i s c l i e n t group. H a r r i s o n and Hicks (1983), a l s o found that d e s p i t e the f a c t t h a t 68% of the women i n t h e i r study had r e c e i v e d at l e a s t one v i s i t from a community h e a l t h nurse, the nurse ranked l a s t as a source of h e l p . T h i s would l e a d one to q u e s t i o n whether the p o s t n a t a l v i s i t s are made at a time 4 when mothers have a l r e a d y sought h e l p from other sources. With the c o n t i n u i n g r e d u c t i o n of resources a v a i l a b l e f o r community h e a l t h programs and an i n c r e a s i n g emphasis on q u a l i t y assurance i n n u r s i n g , some attempts are being made to p r o v i d e standards f o r n u r s i n g v i s i t s to p o s t n a t a l mothers. The Vancouver H e a l t h Department has r e c e n t l y developed standard care plans and o b j e c t i v e s f o r n u r s i n g v i s i t s to p o s t n a t a l mothers (Munroe & Walker, 1984). The content of these standards were based on the l i t e r a t u r e as w e l l as i n f o r m a t i o n from experts i n the f i e l d . The i n d i v i d u a l s i n v o l v e d i n d e v e l o p i n g the standards r e c o g n i z e d that with l i m i t e d resources i t may not be f e a s i b l e or d e s i r a b l e to implement a l l the standard p l a n s w i t h a l l new mothers and recommended that p r i o r i t i z a t i o n take p l a c e . They suggested that p r i o r i t i z a t i o n c o u l d be a c h i e v e d by examining such t h i n g s as the department's g o a l s and m i s s i o n s , expert o p i n i o n s of nurses i n the f i e l d , , the l i t e r a t u r e and the c u r r e n t resources a v a i l a b l e f o r s e r v i c e s f o r t h i s p a r t i c u l a r c l i e n t group. Much of the a d u l t education program p l a n n i n g l i t e r a t u r e a l s o emphasizes the importance of i n c l u d i n g input from the c l i e n t group i n determining and p r i o r i t i z i n g the needs upon which any program i s based. Boyle (1981) f e e l s that both the a d u l t l e a r n e r and o t h e r s can h e l p i d e n t i f y the gap between what e x i s t s and what i s more d e s i r a b l e . Knowles 5 (1980), a l s o s t a t e s that the i n t e r e s t s of the i n d i v i d u a l s s hould be one of the c r i t e r i a i n p r i o r i t i z i n g needs f o r the purpose of developing o b j e c t i v e s f o r a program. There has a l s o been the tendency i n p r a c t i s e to assume th a t multiparous mothers do not have as s i g n i f i c a n t concerns as primiparous mothers and t h e r e f o r e s e r v i c e s to them should be reduced when resources become s c a r c e . There i s l i t t l e e vidence i n the l i t e r a t u r e to support t h i s assumption. H a r r i s o n and Hicks (1983), i n f a c t found that although p r i m i p a r a s expressed more minor concerns, m u l t i p a r a s had the same number of concerns they c o n s i d e r to be major. A l s o they d i d not f i n d a s i g n i f i c a n t d i f f e r e n c e i n the types of concerns between these two groups. Once again i t must be remembered that t h i s study asked mothers to r e c a l l the concerns that they had experienced over the past s i x to e i g h t weeks. I t i s p o s s i b l e t h a t one group had very d i f f e r e n t concerns i n the e a r l y days at home but that the needs of both groups were q u i t e s i m i l a r a f t e r s e v e r a l weeks of a d j u s t i n g to having a new member i n t h e i r f a m i l y . Such i n f o r m a t i o n would have i m p l i c a t i o n s f o r the type and t i m i n g of i n t e r v e n t i o n s o f f e r e d to the two d i f f e r e n t c l i e n t groups. Problem There i s an apparent d e f i c i t i n e m p i r i c a l knowledge r e g a r d i n g the concerns or needs of mothers d u r i n g the p o s t n a t a l p e r i o d which p r e s e n t s a problem f o r those i n v o l v e d 6 i n p l a n n i n g programs or s e r v i c e s f o r t h i s c l i e n t group. The p a r t i c u l a r l a c k of knowledge concerning the e f f e c t of the v a r i a b l e s of time s i n c e d e l i v e r y and p a r i t y of the mother has l e d to the f o l l o w i n g q u e s t i o n s : 1. Do the concerns of primiparous mothers i n the f i r s t two days a f t e r d i s c h a r g e from the h o s p i t a l d i f f e r from t h e i r concerns one month a f t e r t h e i r d i scharge? 2. Do the concerns of m u l t i p a r o u s mothers i n the f i r s t two days a f t e r d i s c h a r g e from the h o s p i t a l d i f f e r from t h e i r concerns one month a f t e r t h e i r d i s c h a r g e ? 3. Do the concerns of primiparous mothers d i f f e r from multiparous mothers i n the f i r s t two days a f t e r d i s c h a r g e from the h o s p i t a l ? 4. Do the concerns of primiparous mothers d i f f e r from multiparous mothers one month a f t e r d i s c h a r g e from the h o s p i t a l ? The time p e r i o d s of the f i r s t two days at home and one month a f t e r d i s c h a r g e were s e l e c t e d f o r the measurement of the i n t e n s i t y and frequency of concerns because of t h e i r 7 i m p l i c a t i o n s f o r d e l i v e r y of s e r v i c e s to p o s t n a t a l mothers. In the f i r s t few days a f t e r d i s c h a r g e from h o s p i t a l the mother i s o f t e n c a r i n g f o r her i n f a n t on her own f o r the f i r s t time and l i k e l y has not yet sought h e l p f o r concerns that a r i s e . During t h i s time the mother i s a l s o o f t e n i n the t r a n s i t i o n between Rubin's (1961) taking-on and t a k i n g - h o l d phase. T h i s would mean that the mother i s now able to absorb i n f o r m a t i o n about her new r o l e and the new s k i l l s she must a c q u i r e . However, the mother i s s t i l l r e c o v e r i n g p h y s i c a l l y and f a t i q u e has an important e f f e c t on her a b i l i t y to be s e l f - d i r e c t e d and to seek out the in f o r m a t i o n and support she needs. One month a f t e r d i s c h a r g e , which i s o f t e n the i n f a n t ' s f i f t h week of l i f e , the mother i s nea r i n g the completion of her recovery from c h i l d b i r t h . At t h i s time i t i s p o s s i b l e that she has sought h e l p from many of the t r a d i t i o n a l sources, such as f a m i l y doctor or p e d i a t r i t i o n but may s t i l l have concerns. I t i s p o s s i b l e that the mother i s now able to leave the home to seek out a d d i t i o n a l r e s o u r c e s f o r the concerns she i s s t i l l e x p e r i e n c i n g . T r a d i t i o n a l l y community s e r v i c e s such as home v i s i t s from community h e a l t h nurses are o f f e r e d i n the f i r s t weeks at home whereas a f t e r one month i t may be more e f f e c t i v e to o f f e r s e r v i c e s such as p o s t n a t a l c l a s s e s or d r o p - i n s . 8 D e f i n i t i o n s of Terms P r i m i p a r a : a woman who has given b i r t h to her f i r s t c h i l d . M u l t i p a r a : a woman who has given b i r t h to two or more i n f a n t s . Concern: a q u e s t i o n , problem, misconception or area of marked p r e - o c c u p a t i o n r e l a t e d to the p o s t - n a t a l p e r i o d . I n t e n s i t y : the r a t i n g or value a mother a s s i g n s to a concern measured from no concern to much concern. Frequency: The number of repeated occurances of an. item being i d e n t i f i e d as a concern. Puerperium: The p e r i o d of recovery f o l l o w i n g c h i l d b i r t h u s u a l l y l a s t i n g four to s i x weeks. Used i n t e r c h a n g e a b l y with p o s t n a t a l and postpartume p e r i o d i n t h i s study. P a r i t y : The number of p e r i o d of v i a b i l i t y . past pregnancies that c o n t i n u e d to the 9 Purpose The purpose of t h i s study was to d e s c r i b e the e f f e c t of the independent v a r i a b l e s of time s i n c e d e l i v e r y and p a r i t y of the mother on the frequency and i n t e n s i t y of maternal concerns. The concerns of p r i m i p a r a s and m u l t i p a r a s were compared d u r i n g the f i r s t two days a f t e r d i s c h a r g e from h o s p i t a l and again one month l a t e r . T h i s chapter has demonstrated the need f o r f u r t h e r i n f o r m a t i o n r e g a r d i n g the concerns of mothers i n the p o s t n a t a l p e r i o d . The s p e c i f i c r e s e a r c h q u e s t i o n s to be addressed were presented as w e l l as d e f i n i t i o n s of terms used i n the study. The f o l l o w i n g chapter p r o v i d e s an indepth look at the l i t e r a t u r e concerning the puerperium and the c u r r e n t knowledge regarding maternal concerns d u r i n g t h i s p e r i o d . 10 CHAPTER 2 Review of the L i t e r a t u r e I n t r o d u c t i o n A review of the l i t e r a t u r e r e g a r d i n g maternal concerns p o s t d e l i v e r y was undertaken to f u r t h e r e l a b o r a t e and c l a r i f y concerns exper i e n c e d by p r i m i p a r a s and m u l t i p a r a s . The areas of l i t e r a t u r e t h a t were reviewed were d i v i d e d i n t o three s e c t i o n s . The f i r s t i n c l u d e s l i t e r a t u r e r e g a r d i n g the c h a r a c t e r i s t i c s and tasks of the puerperium, i n order to demonstrate t h a t t h i s i s a c r i t i c a l p e r i o d i n the h e a l t h y development of the mother and the f a m i l y she r e p r e s e n t s . I t w i l l a l s o be demonstrated that the c h a l l e n g e s and adjustments f o r the expanding f a m i l y d u r i n g t h i s p e r i o d r e q u i r e p r o f e s s i o n a l , s u p p o r t i v e - e d u c a t i v e i n t e r v e n t i o n . The second area of l i t e r a t u r e review r e p r e s e n t s c u r r e n t i n f o r m a t i o n i n the f i e l d of a d u l t education c o n c e r n i n g the r o l e of needs assessment and p r i o r i t i z a t i o n i n the program p l a n n i n g p r o c e s s . A p a r t i c u l a r focus i s p l a c e d on l i t e r a t u r e that demonstrates the need f o r c l i e n t input i n t o the needs assessment and p r i o r i t i z i n g p r o c e s s . T h i s l i t e r a t u r e p r o v i d e s f u r t h e r r a t i o n a l e f o r determining the mothers' p e r c e p t i o n s of t h e i r concerns as w e l l as those of the p r o f e s s i o n a l s i n the f i e l d i n d e v e l o p i n g a p p r o p r i a t e s e r v i c e s . 11 The f i n a l body of l i t e r a t u r e reviewed d e a l s with the c h a r a c t e r i s t i c s of the concerns of mothers d u r i n g the puerperium. L i t e r a t u r e searches were done i n the medical, n u r s i n g , s o c i o l o g i c a l , p s y c h o l o g i c a l and e d u c a t i o n a l l i t e r a t u r e and the most recent a r t i c l e s were checked i n the s o c i a l s c i e n c e c i t a t i o n index to ensure that a comprehensive review of l i t e r a t u r e r e g a r d i n g the concerns of mothers d u r i n g t h i s m a t u r a t i o n a l stage was obt a i n e d . C h a r a c t e r i s t i c s and Tasks of the Puerperium Much of the l i t e r a t u r e c o n c e r n i n g the maternal t r a n s i t i o n to parenthood has focused on i d e n t i f y i n g t h i s p e r i o d as a time of c r i s i s . One of the i n i t i a l s t u d i e s that suggested that beginning parenthood i s a c r i s i s was done by LeMasters (1957). He found that 83% of f i r s t time parents experienced e x t e n s i v e or severe c r i s i s i n a d j u s t i n g to t h e i r f i r s t c h i l d . Since that time other s o c i o l o g i s t s have examined the v a r i o u s c r i s i s and g r a t i f i c a t i o n components of e a r l y parenthood and although many found l e s s e r degrees of c r i s i s t h e i r r e s u l t s suggest that the t r a n s i t i o n to parenthood i n v o l v e s some degree of c r i s i s (Dyer, 1963; Hobbs, 1968; R o s s i , 1968; R u s s e l , 1974). Dyer (1963), e s s e n t i a l l y r e p l i c a t e d LeMaster's (1957) study and found that 53% of f i r s t time parents experienced e x t e n s i v e or severe c r i s i s f o l l o w i n g c h i l d b i r t h . Hobbs (1968), f e l t that measurement problems accounted f o r the v a r i a b i l i t y i n the 1 2 f i n d i n g s of the p r e v i o u s s t u d i e s and h i s study f a i l e d to support the h y p o t h e s i s that a d j u s t i n g to a f i r s t c h i l d was p e r c e i v e d as a severe c r i s i s . He found that only 13% e x p e r i e n c e d moderate c r i s i s whereas 87% experienced a s l i g h t c r i s i s . He f e l t that i t would be more a c c u r a t e to view the p e r i o d a f t e r the b i r t h of a c h i l d as a t r a n s i t i o n which i s s t r e s s f u l r a t h e r than as a c r i s i s e x p e r i e n c e . R o s s i (1968), a l s o q u e s t i o n e d the a d v i s a b i l i t y of l a b e l i n g the b i r t h of a c h i l d as a c r i s i s or even as a normal c r i s i s . Russel (1974), sought to i d e n t i f y the p o s i t i v e as w e l l as s t r e s s f u l outcomes of parenthood and concluded that respondents p e r c e i v e d t h e i r f i r s t year of parenthood as o n l y moderately s t r e s s f u l and w e l l s u p p l i e d with rewards. Sheehan (1981), conducted a p i l o t study to assess postpartum adjustment i n the s i x weeks f o l l o w i n g c h i l d b i r t h . Her q u e s t i o n n a i r e s were developed using c r i s i s theory, developmental theory, and a theory of r o l e t r a n s i t i o n and were t e s t e d u s i n g a small ( s i x mothers) s e l f - s e l e c t e d sample of p r i m i p a r a s mothers. Due to the sample s i z e c a u t i o n must be taken i n g e n e r a l i z i n g the r e s u l t s to a g r e a t e r p o p u l a t i o n . However, the f i n d i n g s s u b s t a n t i a t e d the theory that the maternal adjustment d u r i n g the f i r s t s i x weeks a f t e r d e l i v e r y c o n s t i t u t e s a p o t e n t i a l c r i s i s . I t i s a l s o a time when p h y s i c a l demands and the tasks of r o l e t r a n s i t i o n and i d e n t i t y r e f o r m a t i o n make women v u l n e r a b l e to s e l f - c o n f l i c t and i n s e c u r i t y . 1 3 M e l c h i o r (1975), a l s o conducted a small d e s c r i p t i v e study to determine i f mothers viewed the p o s t n a t a l p e r i o d as a time of c r i s i s . The small sample i n c l u d e d three primiparous and three multiparous mothers. Interviews were done on three d i f f e r e n t o c c a s i o n s , i n the f i r s t two or three days a f t e r b i r t h , i n the f i r s t week at home, and du r i n g the s i x t h week postpartum. Three of the s i x mothers p e r c e i v e d the f i r s t week to be a time of c r i s i s . An a d d i t i o n a l mother found the s i x t h week postpartum to be a time of c r i s i s and two of the mothers, one p r i m i p a r a and one m u l t i p a r a , d i d not p e r c e i v e a c r i s i s at any time d u r i n g the p o s t n a t a l p e r i o d . Again the sample i s too smal l to allow g e n e r a l i z a t i o n of the f i n d i n g s to other mothers. However, i t does support the f i n d i n g s t h a t some mothers experience a c r i s i s d u r i n g t h e i r t r a n s i t i o n to parenthood and that i n t e r v e n t i o n i s e s s e n t i a l d u r i n g t h i s p e r i o d . Donaldson (1981), i n d e v e l o p i n g a t h e o r e t i c a l framework grounded i n c r i s i s theory f o r the r o l e of a postpartum nurse c l i n i c i a n , r e c o g n i z e d a v a r i e t y of commonly i d e n t i f i e d s t r e s s o r s which a c t on the p o s t n a t a l mothers. These i n c l u d e d , f i r s t , the p h y s i o l o g i c a l s h i f t s which are a r e s u l t of the r e t u r n of the body to the pre-pregnant s t a t e . The second s t r e s s o r she i d e n t i f i e d i s the i n t e g r a t i o n of the postpartum body image i n t o the maternal p e r c e p t i o n of s e l f . S t r e t c h marks, p r o t r u d i n g abdomen and l e a k i n g n i p p l e s may c o n f l i c t with the back to normal e x p e c t a t i o n s of the 1 4 postpartum mother. Donaldson (1981) a l s o i d e n t i f i e d f a t i g u e as a major s t r e s s o r u n i v e r s a l l y experienced d u r i n g the p o s t n a t a l p e r i o d . R e s u l t i n g i n p a r t from a c t i v i t i e s i n excess of a v a i l a b l e energy and l o s s of s l e e p , f a t i g u e has an important i n f l u e n c e on the process of adjustment d u r i n g the puerperium. She a l s o i d e n t i f i e d r o l e c o n f l i c t and the a b s o l u t e nature of the i n f a n t ' s needs as commonly exp e r i e n c e d s t r e s s o r s which may be a c t i n g on the new mother and which can c r e a t e a c r i s i s s t a t e when the problems cannot be s o l v e d by the usual coping behaviours and i n a t i m e l y f a s h i o n . In a d d i t i o n Donaldson (1981) i d e n t i f i e d u n a n t i c i p a t e d s t r e s s o r s such as a pre-term b i r t h , cesarean d e l i v e r y and b i r t h c o m p l i c a t i o n s or d e f e c t s which may f u r t h e r c o m p l i c a t e the usual s t r e s s o r s of t h i s p e r i o d . Based on t h i s framework she demonstrates the n e c e s s i t y of i n t e r v e n t i o n s to strengthen the e f f e c t i v e n e s s of maternal c o g n i t i v e p e r c e p t i o n , s i t u a t i o n a l supports and coping b ehaviours. Gordon (1965), i n a study designed to examine f a c t o r s i n postpartum emotional adjustment found that i n s t r u c t i o n about r e o r g a n i z i n g a t t i t u d e s and a c t i v i t i e s f o r the r e s p o n s i b i l i t i e s and rewards of the motherhood r o l e reduced the l i k e l i h o o d of postpartum emotional d i s t r e s s . T h i s f i n d i n g a l s o supports the n e c e s s i t y of s u p p o r t i v e e d u c a t i v e i n t e r v e n t i o n d u r i n g the postpartum p e r i o d . 1 5 The i n c o n s i s t e n c i e s i n both the method of measurement and the d e f i n i t i o n s of c r i s i s i n t h i s r e s e a r c h i d e n t i f y i n g the t r a n s i t i o n to parenthood as a p o t e n t i a l c r i s i s must be acknowledged. For example LeMasters (1975) used the d e f i n i t i o n of c r i s i s as any sharp or d e c i s i v e change f o r which o l d p a t t e r n s are inadequate, whereas Melchiour (1975) d e f i n e d c r i s i s as a p e r i o d that i s u n s e t t l e d . D e s p i t e these i n c o n s i s t e n c i e s and need f o r f u r t h e r v a l i d a t i o n of the f i n d i n g s i t i s apparent that the t r a n s i t i o n to parenthood i s s t r e s s f u l f o r many mothers and t h a t s e r v i c e s should be o f f e r e d to meet t h e i r needs d u r i n g t h i s m a t u r a t i o n a l stage. Rubin (1975) s t a t e s that the postpartum p e r i o d i s the most v u l n e r a b l e p e r i o d f o r the mother, f o r the i n f a n t , f o r c o n t i n u i t y of the husband-wife r e l a t i o n s h i p and f o r the n u c l e a r f a m i l y . She f e e l s t h a t the g r e a t myth of motherhood i s t h a t once the baby i s born everyone l i v e s h a p p i l y ever a f t e r . Rubin (1961) d e s c r i b e s the c h a r a c t e r i s t i c s of the p o s t n a t a l p e r i o d i n terms of c e r t a i n behaviours which appear i n the mother whether she i s m u l t i p a r a s or p r i m i p a r a s . She has d e s c r i b e d three phases which are d e s i g n a t e d as the t a k i n g - i n phase, the t a k i n g - h o l d phase and the b u r s t i n g - o u t phase. The t a k i n g - i n phase occurs i n the f i r s t few days of the puerperium and i s the mother's response to excess energy expended d u r i n g labour and d e l i v e r y . During t h i s phase the mother seeks to meet her own needs f o r s l e e p and nourishment 16 b e f o r e she can c o n s i d e r the needs of o t h e r s . She tends to be p a s s i v e and allows o t h e r s to tend to her needs. In t h i s phase the mother a l s o wants to t a l k about her b i r t h e x p e r i e n c e i n order to gi v e r e a l i t y to the recent events i n her l i f e . . I t i s a l s o d u r i n g t h i s phase that the mother must begin to get to know her i n f a n t and Rubin (1961) s t a t e s that f r e q u e n t l y an overwhelming f e e l i n g of r e s p o n s i b i l i t y i s exp e r i e n c e d at t h i s time. The t a k i n g - h o l d phase d e s c r i b e d by Rubin (1961) s t a r t s on approximately the t h i r d postpartum day when the mother g a i n s more c o n t r o l of her b o d i l y f u n c t i o n s and the focus of a t t e n t i o n s h i f t s from h e r s e l f to the baby. T h i s i s a c r u c i a l time f o r the mother to a c q u i r e s k i l l s r e l a t e d to i n f a n t c a r e and a sense of the r e s p o n s i b i l i t i e s of motherhood. I r o n i c a l l y with the p r a c t i s e of d i s c h a r g e from h o s p i t a l on the second or t h i r d postpartum day many mothers are j u s t beginning t h i s t a k i n g - h o l d phase when they go home and t h e r e f o r e do not have a chance to a c q u i r e the necessary s k i l l s and r e c e i v e the necessary support and encouragement from h o s p i t a l s t a f f . Follow-up s e r v i c e s i n the community may or may not be a v a i l a b l e depending on where the mother l i v e s . T h i s second phase i s a l s o o f t e n c h a r a c t e r i z e d by the f a m i l i a r 'baby blu e s ' u s u a l l y a t t r i b u t e d to the p h y s i o l o g i c a l changes that are o c c u r r i n g . Becker (1980), s t a t e s that the s h i f t of a t t e n t i o n from the mother to the i n f a n t a l s o c o n t r i b u t e s to these f e e l i n g s of d e p r e s s i o n . 1 7 The t h i r d phase that Rubin (1961) d e s c r i b e s mothers p a s s i n g through i n the p o s t n a t a l p e r i o d , occurs s e v e r a l weeks a f t e r d e l i v e r y when the woman has recovered p h y s i c a l l y and p s y c h o l o g i c a l l y . The mother must l e t go of c e r t a i n advantages enjoyed before b i r t h , such as l e i s u r e time and being the center of a t t e n t i o n b e f o r e she can adapt to her new r o l e as a mother. M a r t e l l and M i t c h e l l (1984) sought to reexamine the v a l i d i t y of Rubin's concepts today, c o n s i d e r i n g the many changes i n medical c a r e , s o c i a l a t t i t u d e s and p r e n a t a l education which i n f l u e n c e the a t t i t u d e s and behaviours of p o s t p a r t a l women. They found t h a t Rubin's (1961) g e n e r a l n o t i o n of p u e r p e r a l change was supported with the mothers d e c r e a s i n g amounts of t a k i n g - i n and i n c r e a s i n g amounts of t a k i n g - h o l d behaviours d u r i n g t h e i r h o s p i t a l s t a y . However, with t h e i r sample of twenty mothers there was i n s u f f i c e n t evidence to suggest a s t r o n g a t t i t u d e of t a k i n g - i n d u r i n g the f i r s t days and that the t a k i n g - h o l d phase seemed to peak on the second day, e a r l i e r than r e p o r t e d by Rubin (1961). They suggested that t h i s may i n d i c a t e an u n w i l l i n g n e s s on the p a r t of todays women to accept being dependant even f o r a few days, d i f f e r i n g from t h a t of mothers i n 1961. M a r t e l l and M i t c h e l l (1984) c a u t i o n e d a g a i n s t g e n e r a l i z i n g t h e i r r e s u l t s , but they encouraged a c o n t i n u a l reexamination of lo n g s t a n d i n g concepts whose acceptance can i n t e r f e r e with making c u r r e n t o b s e r v a t i o n s and c o n c l u s i o n s r e l e v a n t to 18 present p r a c t i s e . G r u i s (1977), has c h a r a c t e r i z e d the puerperium i n terms of tasks which the mother must accomplish. She i d e n t i f i e s four major tasks which i n c l u d e : p h y s i c a l r e s t o r a t i o n , l e a r n i n g to meet the needs of her i n f a n t , establishment of a r e l a t i o n s h i p with the i n f a n t and a l t e r i n g her l i f e s t y l e and r e l a t i o n s h i p s to accommodate the new f a m i l y member. As i d e n t i f i e d by Rubin (1961) p h y s i c a l r e s t o r a t i o n i s one of the f i r s t t a s k s the mother must accomplish i n the puerperium. The uterus undergoes the process of i n v o l u t i o n , c h a r a c t e r i z e d by r e d u c t i o n i n muscle s i z e , weight l o s s and h e a l i n g of the p l a c e n t a l s i t e . Blood volume decreases by approximately 30% i n the f i r s t few days due to blood l o s s , d i u r e s i s and d i a p h o r e s i s . The abdominal w a l l s s t r e t c h e d d u r i n g pregnancy remain s o f t and fl a b b y and take at l e a s t s i x weeks to become f i r m . Discomfort of the perineum i s l i k e l y due to the common o b s t e t r i c a l procedure of episiotomy or p o s s i b l e p e r i n e a l t e a r s . Breast engorgement as w e l l as l e a k i n g or sore n i p p l e s may a l s o be a source of d i s c o m f o r t ( G r u i s , 1977). Rubin (1977) s t a t e s that any person undergoing such r a p i d p h y s i o l o g i c a l change f o r any other reason would be admitted to h o s p i t a l f o r bed r e s t and c a r e f u l o b s e r v a t i o n and treatment whereas the new mother i s sent home to complete her recovery as w e l l as care f o r her "bundle of j o y " . 19 The second task i d e n t i f i e d by G r u i s (1977) i s l e a r n i n g to meet the needs of the i n f a n t . S e v e r a l s t u d i e s have demonstrated that mothers do not f e e l adequately prepared f o r c a r i n g f o r the i n f a n t on d i s c h a r g e from h o s p i t a l (Adams,1963; F i l l m o r e & T a y l o r , 1976; Jordon, 1973). Extended f a m i l y i s o f t e n u n a v a i l a b l e i n t h i s mobile s o c i e t y to give a s s i s t a n c e and support once pr o v i d e d to the new mother i n the home. The t r e n d towards small n u c l e a r f a m i l i e s i n today's s o c i e t y r e s u l t s i n many women not having the o p p o r t u n i t y to experi e n c e care of an i n f a n t u n t i l they become p a r e n t s . T h i s then i s a task f o r which many mothers r e q u i r e s u p p o r t i v e and e d u c a t i v e a s s i s t a n c e from agencies i n the community. The t h i r d task the mother must accomplish a c c o r d i n g to G r u i s (1977), i s e s t a b l i s h i n g a r e l a t i o n s h i p with her i n f a n t . There has been a great d e a l of i n t e r e s t and re s e a r c h i n the past decade concerning t h i s maternal attachment or bonding p r o c e s s which occurs between mother and baby. A d i s c u s s i o n of t h i s l a r g e c o n t r o v e r s i a l body of l i t e r a t u r e i s beyond the scope of t h i s review. I t has been e s t a b l i s h e d t h at a h e a l t h y m o t h e r - c h i l d r e l a t i o n s h i p does not occur a u t o m a t i c a l l y at b i r t h but has to develop as the mother and c h i l d l e a r n to respond to one another (Ludington-Hoe, 1977). In order to l e a r n to understand her i n f a n t the mother needs i n f o r m a t i o n concerning normal growth and development of i n f a n t s and knowledge of her i n f a n t ' s 20 c r y i n g , s l e e p i n g , f e e d i n g and other behaviour p a t t e r n s (Gruis,1977). The f i n a l task the mother must accomplish i s a d j u s t i n g her l i f e s t y l e and r e l a t i o n s h i p s to accommodate the new i n f a n t . For many new mothers the change i n r o l e t h a t occurs may r e s u l t i n r o l e c o n f l i c t (Gruis,1977). The mother may choose to gi v e up her job, much of her l e i s u r e time and former l i f e s t y l e . Her own view of her r o l e may d i f f e r from that of her pa r t n e r or other s i g n i f i c a n t persons i n her l i f e (Taggart, 1978). The a d d i t i o n of the baby changes a l l the fa m i l y r e l a t i o n s h i p s and i t i s o f t e n the mother who takes r e s p o n s i b i l i t y f o r t h i s i n t e g r a t i v e process (Becker, 1980). Cronenwett (1985) i n examining p a r e n t a l network s t r u c t u r e and p e r c e i v e d support a f t e r the b i r t h of a c h i l d found that more postpartum mothers than f a t h e r s p e r c e i v e d an inc r e a s e d need f o r support. That as c o n t a c t with co-workers decreased the women had to compensate by i n c r e a s i n g c o n t a c t with f r i e n d s or r e l a t i v e s i n order to maintain an adequate support network. Whether the puerperium i s viewed as a c r i s i s p e r i o d or in terms of b e h a v i o u r a l phases or tasks which must be accomplished, i t i s apparent throughout t h i s review of s e l e c t e d l i t e r a t u r e c o n c e r n i n g the c h a r a c t e r i s t i c s of the p o s t n a t a l p e r i o d that i n t e r v e n t i o n i s necessary to meet the needs of mothers d u r i n g t h i s time. S e l e c t e d l i t e r a t u r e c oncerning the n e c e s s i t y of i d e n t i f y i n g and p r i o r i t i z i n g the 21 needs i n order to p l a n e f f e c t i v e s u p p o r t i v e e d u c a t i v e programs w i l l now be examined. Assessment of C l i e n t Needs in Program Planning Authors concerned with program p l a n n i n g regard the process of needs assessment with h i g h esteem ( S o r k , l 9 8 3 ) . Buskey and Sork (1982) i n conducting an a n a l y s i s of program p l a n n i n g l i t e r a t u r e r e v e a l e d that only one of n i n e t y program p l a n n i n g models reviewed f a i l e d to address needs assessment as a component of the program p l a n n i n g p r o c e s s . T h i s suggests that needs assessment i s c o n s i d e r e d to be an e s s e n t i a l step i n the process of producing e f f e c t i v e e d u c a t i o n a l programs. Atwood and E l l i s (1971) suggest that most a d u l t educators o b j e c t to programs based p r i m a r i l y upon su b j e c t matter or the p r e f e r e n c e s of persons i n a d m i n i s t r a t i v e p o s i t i o n s without regard f o r the l e a r n e r s as i n d i v i d u a l s , t h e i r l i v e s and t h e i r i n t e r e s t s . They p o i n t out that i n an approach that i n c l u d e s input from the l e a r n e r s , needs are i d e n t i f i e d before the o b j e c t i v e s of the l e a r n i n g experience are determined. T h i s d i f f e r s from p r e s c r i b i n g programs on the b a s i s of what was a p p r o p r i a t e before or what r e s o u r c e s are a v a i l a b l e . D e s p i t e the f a c t t h a t the concept of need i s so widely used w i t h i n the l i t e r a t u r e of a d u l t education there seems to be a great d e a l of c o n f u s i o n and i n c o n s i s t e n c y r e g a r d i n g the d e f i n i t i o n s and uses of the term. Monette (1977) has 22 determined that the i m p l i c i t and e x p l i c i t d e f i n i t i o n s of need can be s o r t e d i n t o four c a t e g o r i e s : b a s i c human needs; f e l t and expressed needs; comparative needs and v a r i a n t uses of the term. Atwood and E l l i s (1971) p o i n t out that the two major uses of the term need r e f e r to e i t h e r p r e s c r i p t i v e or m o t i v a t i o n a l needs. M o t i v a t i o n a l needs are i d e n t i f i e d by the owner of the need whereas p r e s c r i p t i v e needs are i d e n t i f i e d by someone other than the owner. They a l s o d e s c r i b e other v a r i a t i o n s and s p e c i a l i z e d uses of the concept of need such as r e a l need, e d u c a t i o n a l need and f e l t need. Monette (1977) recog n i z e d t h a t much of the c o n f u s i o n around the term need seems to be due to i t s i n d i s c r i m i n a t e a p p l i c a t i o n to s o c i e t y , communities, i n s t i t u t i o n s and groups as w e l l as i n d i v i d u a l s . Knowles (1980) i d e n t i f i e s three l e v e l s of needs, those of i n d i v i d u a l s , communities and i n s t i t u t i o n s . He d i s t i n g u i s h e d between b a s i c human needs, e d u c a t i o n a l needs and i n t e r e s t s of i n d i v i d u a l s . B o s h i e r and Peters (1976) a l s o i d e n t i f y a d i f f e r e n c e between needs and i n t e r e s t s with needs d e s c r i b i n g the gap that e x i s t s between the c u r r e n t s t a t e of the l e a r n e r and some d e s i r e d c o n d i t i o n whereas i n t e r e s t s are e x p r e s s i o n s of p r e f e r e n c e among a l t e r n a t i v e e x p e r i e n c e s . Some of the s p e c i a l i z e d uses of the term need have emerged from the debate over who can best a ssess the needs of the a d u l t l e a r n e r . Some educators b e l i e v e t h a t a need i s a need only when i t i s recog n i z e d by the p o t e n t i a l l e a r n e r 23 as a need. T h i s would be c o n s i d e r e d a f e l t need. Others h o l d that the most important needs are the ones that can be b e t t e r r e c o g n i z e d by o t h e r s . These would be c o n s i d e r e d r e a l needs which i n d i c a t e that some o u t s i d e observer i s u t i l i z i n g some c r i t e r i a which are not n e c e s s a r i l y the c l i e n t s (Monette, 1977). In l o o k i n g at the q u e s t i o n of who can best determine the needs upon which programs should be planned, Boshier and Peters (1976) s t a t e that unless the intended outcomes of the program conform to the a d u l t ' s needs and i n t e r e s t s i t i s u n l i k e l y that the p o t e n t i a l l e a r n e r w i l l accept and make use of i t s c o n t e n t . They f e e l that i f the needs and i n t e r e s t of the c l i e n t and the program content do not c o i n c i d e then e i t h e r the c l i e n t w i l l r e f u s e to p a r t i c i p a t e or e l s e there w i l l be meaningless i n t e r a c t i o n . Monette (1977) on the other hand s t a t e s that the p e r s p e c t i v e s of both the l e a r n e r and others can h e l p i d e n t i f y the needs. Persons other than the l e a r n e r can s p e c i f y o b j e c t i v e standards to which i n d i v i d u a l ' s can compare themselves i n order to recog n i z e t h e i r needs. He f e e l s that l e a r n e r s may a l s o be a s s i s t e d i n a n t i c i p a t i n g f u t u r e l e a r n i n g needs, but that i n the end only l e a r n e r s can deci d e to l e a r n and a c t upon t h e i r l e a r n i n g s . Knowles (1980) a l s o s t a t e s that i n f o r m a t i o n concerning the needs of the c l i e n t s can come from s e v e r a l sources. The f i r s t being the l e a r n e r s themselves, a second source being experts i n the f i e l d or people i n h e l p i n g r o l e s with the 24 l e a r n e r s and a t h i r d source being the l i t e r a t u r e . I r r e s p e c t i v e of what p o i n t of view i s taken i n i d e n t i f y i n g needs, program pla n n e r s u s u a l l y face the dilemma of having too many needs to address with the a v a i l a b l e r e s o u r c e s . T h e r e f o r e p r i o r i t y s e t t i n g must take p l a c e . Boyle (1981) s t a t e s that the c r i t i c a l s t e p i n p r i o r i t y s e t t i n g i s e s t a b l i s h i n g the c r i t e r i a upon which d e c i s i o n s w i l l be made. He suggests s e v e r a l sources of input such as p o l i t i c a l f e a s i b i l i t y and p e r s o n a l d e s i r e s and needs of the c l i e n t e l e . Knowles (1980) s t a t e s that i n o r g a n i z i n g the needs i n t o a p r i o r i t y system needs must be screened through a p p r o p r i a t e f i l t e r s such as the e d u c a t i o n a l p h i l o s o p h y , the f e a s i b i l i t y of meeting the needs and the i n t e r e s t s of the i n d i v i d u a l s . In reviewing the program p l a n n i n g l i t e r a t u r e i t i s apparent that needs assessment and p r i o r i t i z a t i o n p l a y s a key r o l e . D e s p i t e the c o n f u s i o n i n terminology and the lack of consensus between programmers i t has been r e c o g n i z e d that many program pla n n e r s p l a c e great value on the input from the c l i e n t s r e g a r d i n g t h e i r needs. I t i s a l s o recognized that the c l i e n t s ' p e r c e i v e d needs must be examined i n r e l a t i o n to the l i t e r a t u r e and experts i n the f i e l d when making d e c i s i o n s r e g a r d i n g the outcomes of the program or s e r v i c e s . T h i s l i t e r a t u r e supports examining how p o s t n a t a l mothers p e r c e i v e t h e i r needs or concerns d u r i n g the peurperium p r i o r to p l a n n i n g s e r v i c e s or programs i n the 25 community f o r t h i s c l i e n t group. Concerns of P o s t n a t a l Mothers As s t a t e d i n Chapter One, much of the r e s e a r c h d e s c r i b i n g maternal concerns has had a narrow focus l i m i t e d to e i t h e r p r i m i p a r a s or m u l t i p a r a s or to only one area of concern such as i n f a n t c a r e . The f i n d i n g s of these s t u d i e s vary depending on the c h a r a c t e r i s t i c s of the sample, and the method of determining the concerns. Research Regarding Concerns of P r i m i p a r a s S t u d i e s were conducted by Adams, (1963); Brown, (1967); and F i l l m o r e & T a y l o r (1976) which looked only at concerns of p r i m i p a r o u s mothers r e g a r d i n g i n f a n t c a r e . Adams (1963), conducted i n t e r v i e w s on the second postpartum day, one week a f t e r d i s c h a r g e and one month a f t e r d i s c h a r g e i n order to d e s c r i b e the concerns r e g a r d i n g f e e d i n g , b a t h i n g , c r y i n g or care of the c o r d or c i r c u m c i s i o n and to determine i f they changed over time. She a l s o compared the concerns of the mothers w i t h f u l l t e r m i n f a n t s with those of premature i n f a n t s i n the same study. She found that f e e d i n g was the g r e a t e s t i n f a n t care concern throughout the f i r s t month. She d i d not f i n d a s i g n i f i c a n t d i f f e r e n c e between the concerns of mothers of f u l l t e r m and premature i n f a n t s . C o n s i d e r i n g the many changes i n both the experience of 26 c h i l d b i r t h and the r o l e of the f a m i l y and s o c i e t y at l a r g e s i n c e the 1960's i t i s q u e s t i o n a b l e whether these f i n d i n g s can be a p p l i e d to present day mothers. F i l l m o r e and T a y l o r (1976), sought to determine the c o r r e l a t i o n between concerns r e g a r d i n g i n f a n t care and such f a c t o r s as attendance at p r e n a t a l c l a s s e s , method of f e e d i n g , maternal age and e d u c a t i o n and amount of a s s i s t a n c e at home. Interviews were completed with a sample of f i f t y - t w o p r i m i p a r a s mothers. However, they do not s p e c i f y on which postpartum day the i n t e r v i e w s took p l a c e . The areas of concern were f e e d i n g , c r y i n g , b a t h i n g , e l i m i n a t i o n , r o u t i n e c are and s l e e p i n g . They found t h a t i n using an a n x i e t y model of concerns t h e i r scheme was not e f f e c t i v e i n e x p l a i n i n g v a r i a t i o n s i n s c o r e s , and t h a t only h a l f of t h e i r hypotheses d e r i v e d from the a n x i e t y model were ab l e to p r e d i c t the d i r e c t i o n s of the r e l a t i o n s h i p s between the concern scores and an independent v a r i a b l e . They concluded that t h e i r r e s u l t s were a r t i f i c a l and proposed a two component model combining both w o r r i e s or a n x i e t i e s and i n t e r e s t s and q u e s t i o n s i n t o the concept of concern. Much of the more recent r e s e a r c h on maternal concerns does i n c l u d e both w o r r i e s and i n t e r e s t i n i t s d e f i n i t i o n of concerns. Other r e s e a r c h e r s such as Moss (1981) measured the two components s e p a r a t e l y when l o o k i n g at the concerns of m u l t i p a r a s mothers. 27 Robinson (1972) sought to determine what new mothers p e r c e i v e d they had been taught i n h o s p i t a l and what i n f o r m a t i o n they wished they had had more o p p o r t u n i t y to l e a r n . Data were c o l l e c t e d r e t r o s p e c t i v e l y by q u e s t i o n n a i r e two weeks a f t e r d i s c h a r g e . The sample c o n s i s t e d only of prim i p a r o u s mothers and the focus was on needs concerning p h y s i c a l care of both mother and i n f a n t . Information c o n c e r n i n g common ai l m e n t s i n i n f a n t s , i n f a n t f e e d i n g and emotional changes i n mothers were the most f r e q u e n t l y mentioned i n t e r e s t of the mothers. More than twice as many mothers, as not, s t a t e d that they were unprepared f o r the d i f f i c u l t i e s that arose i n the f i r s t two weeks. Surveys of Concerns of P r i m i p a r a s and M u l t i p a r a s W i l l i a m (1977) surveyed couples from her p r e n a t a l c l a s s , t h i r t y - s e v e n of whom were p r i m i p a r a s and two m u l t i p a r a s and found that 82% f e l t t h a t a postpartum c l a s s would have been h e l p f u l to d e a l with the problems that arose in the p o s t n a t a l p e r i o d . The main concerns mentioned by these parents were c r y i n g , f e e d i n g and the baby's schedule. T o p i c s of i n t e r e s t i n c l u d e d changes i n f a m i l y l i f e , grandparents and l e a r n i n g to p i c k up cues from the baby. T h i s was a l i m i t e d sample of well-educated parents a t t e n d i n g c l a s s e s i n a u n i v e r s i t y s e t t i n g and as such does not add g e n e r a l i z a b l e data to the knowledge r e g a r d i n g maternal concerns. I t does, however, support the f a c t that t h i s i s a 28 p e r i o d i n which parents have f e l t l e a r n i n g needs and seek to have them met. Sumner and F r i t s c h (1977) attempted to document the spontaneous requests by mothers f o r i n f o r m a t i o n and support as evidenced by t h e i r telephone c a l l s to the h e a l t h care f a c i l i t y . A d e s c r i p t i v e survey was done f o r one month documenting the volume of c a l l s , the types of q u e s t i o n s asked and the age of the i n f a n t . They found that 88% of the primiparous mothers e l i g i b l e to c a l l d i d so as w e l l as 25% of the multiparous mothers with the m u l t i p a r a s mothers a s k i n g more q u e s t i o n s per c a l l . Once again the h i g h e s t percentage of q u e s t i o n s was about i n f a n t f e e d i n g (31%). They a l s o found that the age of the i n f a n t seems to s i g n i f i c a n t l y a l t e r the concerns of the parents with the h i g h e s t r a t e of c a l l s i n the f i r s t three weeks of the i n f a n t ' s l i f e . Another i n t e r e s t i n g f i n d i n g was that mothers of male i n f a n t s had more q u e s t i o n s i n the f i r s t four weeks than mothers of females p a r t i c u l a r l y r e g a r d i n g i n f a n t f e e d i n g . T h i s study once again suggests that i n f a n t c a r e concerns are of importance to mothers i n the f i r s t few weeks. Sumner and F r i t s c h (1977), only looked at mothers who d e l i v e r e d at one f a c i l i t y and who chose to use that f a c i l i t y as a source of i n f o r m a t i o n . The study d i d not g i v e any i n f o r m a t i o n r e g a r d i n g the concerns f o r which the mothers turned to other sources f o r h e l p or d i d not f e e l comfortable i n a s k i n g f o r h e l p at a l l . I t i s p o s s i b l e that mothers f e e l 29 t h a t i t i s a c c e p t a b l e to ask f o r h e l p i n c a r i n g f o r t h e i r baby while at the same time having g r e a t e r concerns that they are not w i l l i n g to v o i c e . Concerns of S p e c i a l Groups of Postpartum Mothers Other s t u d i e s have been done which look at the concerns of s p e c i a l groups of mothers. J e n k i n s (1976), Mercer (1979) and Moss (1981) looked only at the concerns of m u l t i p a r a s mothers. C i b u l k a and P r i c e (1978) sought to determine the concerns of p r i m i p a r a s i n the f i r s t few days at home and S t o l t z and Sater (1985) looked at the expressed e d u c a t i o n a l needs of adolescent mothers. Moss (1981) i n examining the concerns of multiparous mothers on the t h i r d postpartum day, and p r i o r to d i s c h a r g e from h o s p i t a l found that they had many i n t e r e s t s and w orries t h a t had not been d e a l t with d u r i n g t h e i r h o s p i t a l s t a y . The mothers were concerned about t h e i r i n f a n t s but were more i n t e r e s t e d i n behaviour and growth and development r a t h e r than p h y s i c a l c a r e . They were a l s o very concerned with f a m i l y r e l a t i o n s h i p s and how the new i n f a n t would be accepted by s i b l i n g s . Moss (1981) used a method of having the mothers s o r t 61 p o s s i b l e concerns i n t o s e c t i o n s of no concern, i n t e r e s t or worry. I n t e n s i t y of i n t e r e s t or worry was not determined and ranking of concern was based only i n terms of frequency. The f i n d i n g s of t h i s study do not i n d i c a t e i f concerns change f o l l o w i n g d i s c h a r g e from 3 0 h o s p i t a l or with the passage of time. Jenkins (1976), a n a l y z e d one indepth case study of the concerns of a multiparous mother and i d e n t i f i e d three c o n f l i c t themes which occur i n the p o s t n a t a l p e r i o d . These i n c l u d e the mother's a b i l i t y to p h y s i c a l l y c a r e f o r two c h i l d r e n . a t the same time, her f e e l i n g of b e t r a y a l and g u i l t as she a n t i c i p a t e d the r e a c t i o n of her o l d e r c h i l d to the new i n f a n t , and her a b i l i t y t o love two c h i l d r e n e q u a l l y . These f i n d i n g s cannot be g e n e r a l i z e d as they are based on only one mother's exper i e n c e but they do support the idea that multiparous mothers a l s o have concerns d u r i n g the pueperium and they are not n e c e s s a r i l y the same as those of primiparous mothers. S t o l t z and Sater (1985), looked at the s e l f - p e r c e i v e d e d u c a t i o n a l needs of p r i m i p a r o u s mothers between 14 and 18 years of age. They found t h a t i n f o r m a t i o n concerning the i n f a n t ' s medical needs were very important to these young mothers as w e l l as p s y c h o s o c i a l needs such as how to make the baby f e e l loved and how to be a good parent. A major l i m i t a t i o n i d e n t i f i e d by these r e s e a r c h e r s was that the time the q u e s t i o n n a i r e s were completed ranged from one to t h i r t y - t h r e e weeks post d e l i v e r y . I t i s very l i k e l y t h a t the p e r i o d of time t h a t had e l a p s e d s i n c e g i v i n g b i r t h a f f e c t e d the p e r c e p t i o n s of the i n f o r m a t i o n the mothers needed soon a f t e r d e l i v e r y . 31 Chapman (1985) looked at the concerns of mothers who were b r e a s t f e e d i n g t h e i r i n f a n t s and c l a s s i f i e d the concerns i d e n t i f i e d i n t o three c a t e g o r i e s ; b r e a s t concerns, i n f a n t concerns and postpartum concerns. The data were c o l l e c t e d from n u r s i n g notes taken of each i n t e r a c t i o n with the mother du r i n g the f i r s t four months postpartum. Most of the concerns i d e n t i f i e d i n the three c a t e g o r i e s were s i m i l a r to those r e p o r t e d i n the l i t e r a t u r e to be of i n t e r e s t t o mothers d u r i n g the e a r l y postpartum p e r i o d . However, the d e f i n i t i o n of concern as the q u a l i t y or s t a t e of b r e a s t f e e d i n g experiences t h a t were important to the mother seems ra t h e r vague and i n need of c l a r i f i c a t i o n . Goodman and Sauve (1985) examined the concerns of mothers who d e l i v e r e d h i g h r i s k i n f a n t s i n comparison to a c o n t r o l group of mothers with normal i n f a n t s . Once a g a i n the mothers of high r i s k i n f a n t s expressed concerns re g a r d i n g f e e d i n g , i n t e s t i n a l problems, s l e e p i n g , c r y i n g , i n f a n t ' s appearance, h e r s e l f and her f a m i l y . Not s u r p r i s i n g l y the c o n t r o l group of mothers a l s o expressed concerns i n these areas but they were l e s s frequent and of a lower i n t e n s i t y . They a l s o found a tendancy f o r the mothers of normal i n f a n t s to have a more p o s i t i v e p e r c e p t i o n of t h e i r i n f a n t . C i b u l k a and P r i c e (1978), looked not only at the concerns of primiparous mothers i n the f i r s t few days a t home but a l s o the concerns of the f a t h e r s . T h e i r sample of 32 twenty couples who had experienced an uncomplicated m a t e r n i t y course and d i d not f i t i n t o any r i s k group completed a concerns p l e a s u r e s c a l e on the second or t h i r d day home from h o s p i t a l . They sought to determine the degree of concern expressed as w e l l as the e f f e c t of s e v e r a l m o d i f ying v a r i a b l e s on the concerns. They found that d e s p i t e the f a v o r a b l e c o n d i t i o n s experienced by t h e i r sample, concern was s t i l l e xperienced with f a t h e r s e x p e r i e n c i n g a s i m i l a r amount of concern as mothers. V a r i a b l e s such as weight of the baby, method of i n f a n t f e e d i n g , p a r e n t a l age and l e n g t h of h o s p i t a l stay were s i g n i f i c a n t l y c o r r e l a t e d with degree of concern. T h e i r s m a l l sample was not r e p r e s e n t a t i v e of the t o t a l p o p u l a t i o n s i n c e they were a l l w e l l educated and the mothers were a l l over the age of twenty-six and had h e l p i n the home. The r e f o r e they r e a l i z e d t h at t h e i r f i n d i n g s c o u l d not be g e n e r a l i z e d and recommended that f u r t h e r study be done to v a l i d a t e the f i n d i n g s . B u l l (1981), a l s o examined the frequency and i n t e n s i t y of concerns r e l a t e d to s e l f , i n f a n t , husband, f a m i l y and community on the t h i r d postpartum day and again one week a f t e r d i s c h a r g e to determine i f the focus of the concerns changed over t h i s time p e r i o d . She found that the concerns r e l a t e d to p h y s i c a l d i s c o m f o r t decreased s i g n i f i c a n t l y a f t e r one week at home whereas the concerns r e l a t e d to emotional s e l f i n c r e a s e d s i g n i f i c a n t l y over t h i s time. Moderate to 33 much concern r e l a t e d to p h y s i o l o g i c a l change as w e l l as i n f a n t behaviour p e r s i s t e d a f t e r one week at home. Concerns r e g a r d i n g husband were c o n s i s t e n t l y ranked as being of l i t t l e or moderate concern by more than h a l f of the mothers and concerns r e l a t e d to f a m i l y presented l i t t l e or no concern a f t e r one week at home. T h i s d i f f e r s from the f i n d i n g s of Moss (1981) that m ultiparous mothers experienced much concern about f a m i l y i n the f i r s t week. B u l l (1981) recommends that f u r t h e r s t u d i e s of the changes i n concerns over time as w e l l as comparative s t u d i e s of the concerns of p r i m i p a r a s and m u l t i p a r a s should be conducted. Her hy p o t h e s i s that the maternal concerns s h i f t from a focus on s e l f to a focus on f a m i l y and community a f t e r one week were not supported. When, one c o n s i d e r s the many p h y s i o l o g i c a l and p s y c h o l o g i c a l changes the mother i s going through d u r i n g that week i t i s not s u r p r i s i n g that she i s not a b l e to r e s o l v e one set of concerns and focus on new ones d u r i n g that s h o r t time p e r i o d . Walker (1986) i n examining s t a b i l i t y and change i n maternal r o l e attainment found that maternal a t t i t u d e s d u r i n g the peurperium demontrated both s t a b i l i t y and change. Mothers were shown to become more s e l f - c o n f i d e n t and p o s i t i v e about themselves from b i r t h to the end of the postpartum p e r i o d . They a l s o tended to view t h e i r i n f a n t s l e s s p o s i t i v e l y at the end of the f i r s t s i x weeks than at 34 the b e g i n n i n g . A l s o , m u l t i p a r a s had more p o s i t i v e a t t i t u d e s than p r i m i p a r a s towards themselves and t h e i r i n f a n t s and i t i s not s u r p r i s i n g t h a t they f e l t more c o n f i d e n t i n i n f a n t c a r e . Mercer (1985) i n l o o k i n g at the process of maternal r o l e attainment over the f i r s t year, i d e n t i f i e d four c a t e g o r i e s of c h a l l e n g e s or demands which emerged from the content a n a l y s i s of the q u a l i t a t i v e d a ta. The demand most f r e q u e n t l y s t a t e d was that of f i n d i n g any p e r s o n a l time. Role s k i l l s t h a t they had not mastered l e a d i n g to a f e e l i n g of incompetence was the second most f r e q u e n t l y i d e n t i f i e d demand. Sleep d e p r i v a t i o n and night care of the i n f a n t as w e l l as p r o b l e m a t i c i n f a n t behaviour were the other f r e q u e n t l y i d e n t i f i e d c h a l l e n g e s d u r i n g the f i r s t year. Mercer (1985) d i d not f i n d a s i g n i f i c a n t d i f f e r e n c e amongst d i f f e r e n t age groups of f i r s t time mothers but r a t h e r found that mothering over the f i r s t year presented s i m i l a r c h a l l e n g e s f o r a l l age groups d e s p i t e d i f f e r e n t l e v e l s of i n i t i a l p r o f i c i e n c y . E f f e c t s of P a r i t y on P o s t n a t a l Concerns There have on l y been a few widely focused s t u d i e s on the concerns of both p r i m i p a r a s and m u l t i p a r a s and most of these were conducted i n the U n i t e d S t a t e s ( G r u i s , 1974; Pate, 1979; Walker, 1973). G r u i s (1974), conducted a study to e x p l o r e the types of concerns experienced i n the f i r s t 35 month postpartum and to determine any d i f f e r e n c e between the concerns of p r i m i p a r a s and m u l t i p a r a s . She a l s o sought to i d e n t i f y the sources of help mothers turn to r e g a r d i n g these concerns. Her sample c o n s i s t e d of 17 p r i m i p a r a s and 23 m u l t i p a r a s who were under the care of one p r i v a t e o b s t e t r i c i a n . The mothers were asked to r e c a l l a f t e r one month postpartum the concerns they had ex p e r i e n c e d d u r i n g t h e i r f i r s t month at home with t h e i r i n f a n t . She found that the most f r e q u e n t l y s t a t e d concern was r e t u r n of f i g u r e to normal with 38 of the 40 mothers i d e n t i f y i n g i t as being of some concern. C l o s e l y r e l a t e d to t h i s 'were the areas of e x e r c i s e and d i e t both of which were of concern to more than t w o - t h i r d s of the mothers. Of the 40 mothers 30 a l s o expressed some concern about r e g u l a t i n g demands of housework, baby and f a m i l y and n e a r l y t h r e e - f o u r t h s were concerned about sexual r e l a t i o n s i n t h e i r marriage. These concerns were ranked s i m i l a r l y f o r both p r i m i p a r o u s and multiparous mothers with p r i m i p a r a s having a s l i g h t l y higher frequency of t o t a l concerns. Some d i f f e r e n c e s i n the two groups were noted i n that p r i m i p a r a s d i d have more concerns r e g a r d i n g i n f a n t behaviour and fe e d i n g while the m u l t i p a r a s were concerned about the adjustment of the f a m i l y to the new member. Pate (1979) conducted a r e p l i c a t i o n of the study done by G r u i s (1974) using a s l i g h t l y l a r g e r and more d i v e r s e sample. She found l i t t l e d i f f e r e n c e i n the frequency of 3 6 concerns and p e r c e i v e d d i f f i c u l t y of the puerperium between the two s t u d i e s . R e g u l a t i n g demands of the f a m i l y , r e t u r n of f i g u r e to normal as w e l l as d i e t and e x e r c i s e were s t i l l found to be the most f r e q u e n t l y s t a t e d concerns. In examining . p a t t e r n s of seeking a s s i s t a n c e f o r concerns she a l s o found that mothers were more l i k e l y to seek h e l p f o r concerns r e l a t e d to the baby than f o r concerns r e l a t e d to s e l f . T h i s was d i s p i t e the f i n d i n g that concerns r e l a t e d to s e l f were p e r c e i v e d as major more o f t e n than concerns r e l a t e d to the baby or f a m i l y . These f i n d i n g s d i f f e r s i g n i f i c a n t l y from those of Sumner and F r i t s c h (1972) and B u l l (1981) who found that concerns r e l a t e d to the i n f a n t and maternal p h y s i o l o g i c a l change were of prime importance d u r i n g the f i r s t week. A l i m i t a t i o n of these s t u d i e s by G r u i s (1974) and Pate (1979) i s the f a c t t h a t the mothers were asked to r e c a l l the concerns e x p e r i e n c e d over the past month. Once again i t i s p o s s i b l e t h a t the passage of time a f f e c t e d the mother's a b i l i t y to r e c a l l the concerns she experienced i n the f i r s t weeks postpartum. The r e s u l t s of these s t u d i e s may i n f a c t r e f l e c t o n l y the concerns experienced one month a f t e r the i n f a n t was born. H a r r i s o n and Hicks (1983), conducted a s i m i l a r study i n Canada u s i n g a random sample of 64 primiparous and 94 multiparous mothers f o r whom b i r t h n o t i f i c a t i o n was r e c e i v e d by the Winnipeg Department of H e a l t h and Community S e r v i c e s . 37 The q u e s t i o n n a i r e s i n t h e i r study were a l s o completed r e t r o s p e c t i v e l y ranging from 23 to 60 days a f t e r d e l i v e r y . T h e i r f i n d i n g s were s i m i l a r to those of G r u i s (1974) and Pate (1979) i n that 70 % or more of the women had some concern about: r e g u l a t i n g demands of f a m i l y , r e t u r n of f i g u r e , f a t i g u e , emotional t e n s i o n , e x e r c i s e , d i e t and f i n d i n g time f o r p e r s o n a l i n t e r e s t s . They a l s o found that although p r i m i p a r a s expressed more minor concerns m u l t i p a r a s had the same frequency of major concerns and there was not a s i g n i f i c a n t d i f f e r e n c e i n the types of concerns between the two groups. Once again these f i n d i n g s o n l y i n d i c a t e that at some time between d e l i v e r y and the completing of the q u e s t i o n n a i r e both groups experienced these same concerns. They do not demonstrate how the focus of the concerns changed over t h i s time p e r i o d . I t has been p o s s i b l e to see through t h i s l i t e r a t u r e review that there has been an attempt to d e s c r i b e the concerns that mothers experience d u r i n g the puerperium. The r e s e a r c h has tended to measure concerns e i t h e r i n the f i r s t few days of t h i s p e r i o d or a f t e r the p a s s i n g of one month. L i t t l e i s known about how the focus of the concerns s h i f t d u r i n g t h i s time p e r i o d f o r both p r i m i p a r o u s and multiparous mothers and whether the time s i n c e d e l i v e r y a f f e c t s the d i f f e r e n c e s noted i n these two groups. I t i s f o r t h i s purpose t h a t the present study was conducted. 38 CHAPTER 3 Methodology I n t r o d u c t i o n A d e s c r i p t i v e , c o r r e l a t i o n a l r e s e a r c h design was chosen as the methodology f o r t h i s study. The purpose of d e s c r i p t i v e r e s e a r c h , to gain more i n f o r m a t i o n about the c u r r e n t s t a t u s of phenomena, i s congruent with the purpose of t h i s study which was to p r o v i d e data r e g a r d i n g the e f f e c t s of the v a r i a b l e s of time s i n c e d e l i v e r y and maternal p a r i t y on the frequency and i n t e n s i t y of maternal concerns. T h i s chapter d i s c u s s e s the sample and s e t t i n g used i n t h i s study, the instrument used to measure the maternal concerns, the data g a t h e r i n g procedures and the methods of data a n a l y s i s . Sample and S e t t i n g T h i s study took p l a c e i n a l a r g e urban c i t y i n Canada where s e r v i c e s to p o s t n a t a l mothers are at present a p r i o r i t y of the l o c a l community h e a l t h department. A convenience v o l u n t e e r sample of t h i r t y - o n e p r i m i p a r a s and t h i r t y - s i x m u l t i p a r a s d e l i v e r i n g i n one urban t e a c h i n g h o s p i t a l and r e s i d i n g w i t h i n one h e a l t h u n i t ' s boundaries was used. The h o s p i t a l of d e l i v e r y was a f a m i l y - c e n t e r e d 39 ma t e r n i t y h o s p i t a l whose p h i l o s o p h y emphasized parent t e a c h i n g and p r e p a r a t i o n f o r d i s c h a r g e . However, r e a l i s t i c a l l y there was o f t e n wide v a r i a t i o n i n both the amount of t e a c h i n g p r o v i d e d and the in f o r m a t i o n absorbed p r i o r to d i s c h a r g e from h o s p i t a l . T h i s was recognized as a v a r i a b l e the i n v e s t i g a t o r was unable to c o n t r o l . The area of the c i t y served by the chosen h e a l t h u n i t was a p r i m a r i l y middle c l a s s area w i t h some pockets of upper middle c l a s s homes as w e l l as some s u b s i d i z e d housing. There was a v a r i e t y of e t h n i c groups who r e s i d e d w i t h i n the u n i t boundaries p a r t i c u l a r l y of the East Indian and O r i e n t a l c u l t u r e s . In order to achieve some measure of homogeneity the sample was l i m i t e d to mothers who met the f o l l o w i n g c r i t e r i a : r i ) d e l i v e r e d v a g i n a l l y , a f u l l t e r m , g r e a t e r than 2500 grams, h e a l t h y i n f a n t i i ) were 18 to 38 years of age at the time of d e l i v e r y i i i ) were d i s c h a r g e d from h o s p i t a l with t h e i r i n f a n t w i t h i n f i v e days f o l l o w i n g d e l i v e r y . i v ) r e s i d e d with the i n f a n t ' s f a t h e r v) were ab l e to speak and read the E n g l i s h language 40 Measurement instrument A s e l f - a d m i n i s t e r e d 51 item q u e s t i o n n a i r e that addressed p o t e n t i a l l e v e l s of concern with regards to the c a t e g o r i e s of s e l f , baby, husband and f a m i l y , developed by B u l l (1981) from a c h e c k l i s t of concerns developed by G r u i s (1974), was chosen as the measurement instrument. (Appendix E & F) Some r e v i s i o n s were made i n the instrument i n order t h a t i t i n c l u d e the p o t e n t i a l concerns or problems addressed i n the Vancouver H e a l t h Department Standard Care Plans f o r the Newborn V i s i t (Munroe & Walker, 1984). In p a r t i c u l a r s e v e r a l items were added i n the area of concerns r e g a r d i n g the i n f a n t such as, amount of weight the baby had gained and g e t t i n g the baby immunized. The category of concerns r e g a r d i n g the community was e l i m i n a t e d as t h i s area was not one i n which the community h e a l t h nurse c o u l d r e a d i l y i n t e r v e n e . B u l l (1981), a l s o found that more than 50% of her sample of mothers had no concerns i n t h i s a r e a . Cronbach's Alpha score f o r i n t e r n a l r e l i a b l i t y was obt a i n e d on B u l l ' s Maternal Concerns Score (1981) and ranged from .97 f o r a l l q u e s t i o n s to .82 f o r the category of concerns r e g a r d i n g f a m i l y . A panel of four t e e n mothers who had experienced a b i r t h no more than one year p r i o r and three nurses, reviewed B u l l ' s (1981) q u e s t i o n n a i r e f o r c l a r i t y and content v a l i d i t y p r i o r to data c o l l e c t i o n , and items on which there was at l e a s t 80% agreement were r e t a i n e d . The r e v i s e d instrument was reviewed by a panel of 41 ten community h e a l t h nurses ( s e v e r a l of whom were a l s o mothers) who v i s t e d mothers i n the study area, i n order to determine c l a r i t y and content v a l i d i t y . Demographic data such as p a r i t y , maternal age, number and ages of p r e v i o u s c h i l d r e n and a s s i s t a n c e i n the home were a l s o c o l l e c t e d i n order to d e s c r i b e the sample and compare i t to what i s known about the t o t a l p o p u l a t i o n . Data C o l l e c t i o n Mothers who met the c r i t e r i a f o r acceptance i n the study were c o n t a c t e d i n the h o s p i t a l by the community h e a l t h l i a s o n nurse as p a r t of her u s u a l c o n t a c t with new mothers. The mothers were given a l e t t e r from the re s e a r c h e r e x p l a i n i n g the purpose and d e t a i l s of the study and emphasizing that the mother c o u l d withdraw at any time. I f the mother agreed to p a r t i c i p a t e she signed the a t t a c h e d consent form and took home two c o p i e s of the q u e s t i o n n a i r e i n addressed envelopes. The f i r s t was completed on the f i r s t or second day at home and the second was completed twenty-eight days or one month a f t e r d i s c h a r g e from h o s p i t a l . The l i a s o n nurse r e t u r n e d the signed consent forms to the i n v e s t i g a t o r at the h e a l t h u n i t o f f i c e . The q u e s t i o n n a i r e s and demographic data forms were coded with matched numbers i n order to ma i n t a i n s t r i c t c o n f i d e n t i a l i t y of responses. 42 Community h e a l t h nurses, c o n t a c t i n g the mothers r o u t i n e l y i n the f i r s t few days at home, reminded the mothers to complete the q u e s t i o n n a i r e and p l a c e i t i n the se a l e d envelope, to be e i t h e r mailed to the h e a l t h u n i t or pi c k e d up by the nurse i f she was to v i s i t . A f o l l o w - u p telephone c a l l was made by the i n v e s t i g a t o r four weeks l a t e r to again remind the mother and arrange to have the q u e s t i o n n a i r e p i c k e d up or mailed to the h e a l t h u n i t . The i n v e s t i g a t o r was the onl y person with access to both the completed q u e s t i o n n a i r e s and the names and phone numbers of the s u b j e c t s . Names and phone numbers were d e s t r o y e d as soon as the data c o l l e c t i o n was completed and matching of the s u b j e c t ' s code number and name was done only i f the mother l o s t her second q u e s t i o n n a i r e , i n order to ensure a c c u r a t e matching of the f i r s t and second measure of concern. Completed q u e s t i o n n a i r e s were de s t r o y e d once the data a n a l y s i s was completed. N u l l Hypotheses Data were an a l y z e d i n order to t e s t the f o l l o w i n g n u l l h y p o t h e s i s : 1. There i s no d i f f e r e n c e i n the frequency and i n t e n s i t y of concern of primiparous mothers i n the f i r s t two days at home and t h e i r concerns one month l a t e r . ( F i g u r e 1: A vs. C) 43 2. There i s no d i f f e r e n c e i n the frequency and i n t e n s i t y of concern of multiparous mothers i n the f i r s t two days a t home and t h e i r concerns one month l a t e r . ( F i g u r e 1: B vs. D) 3. There i s no d i f f e r e n c e i n the frequency and i n t e n s i t y of concern of primiparous and multiparous mothers i n the f i r s t two days at home with t h e i r i n f a n t s . ( F i g u r e 1: A vs. B) 4. There i s no d i f f e r e n c e i n the frequency and i n t e n s i t y of concern of primiparous and multiparous mothers a f t e r one month at home with t h e i r i n f a n t . ( F i g u r e 1: C vs. D). For the purpose of a n a l y s i s the q u e s t i o n n a i r e was d i v i d e d i n t o four c a t e g o r i e s with 18 items concerning s e l f ; 21 items c o n c e r n i n g baby; 6 items concerning husband and 5 items concerning f a m i l y . I n t e n s i t y of concern was scored as f o l l o w s : 0: no concern, 1: l i t t l e concern, 2: moderate concern, 3: much concern and 4: c r i t i c a l concern. Frequency counts were determined on the number of concerns mothers had at each l e v e l of i n t e n s i t y f o r each item, f o r each ca t e g o r y and f o r the t o t a l c o n c erns. A s u i t a b l e c h i - s q u a r e t e s t was a p p l i e d to the responses f o r items w i t h i n each category and fo r a l l items a c r o s s c a t e g o r i e s to determine the s t a t i s t i c a l 44 P r i m i p a r a s M u l t i p a r a s 1 s t 2 days 1 month A B C D F i g u r e 1 R e p r e s e n t a t i o n of Research Design s i g n i f i c a n c e of the d i f f e r e n c e between groups. A mean i n t e n s i t y score was c a l c u l a t e d f o r i n d i v i d u a l items, f o r items w i t h i n each category and f o r a l l items ac r o s s a l l c a t e g o r i e s . Nonparametric t e s t s of s i g n i f i c a n c e were chosen f o r data a n a l y s i s as i t was f e l t t h a t the responses may not f o l l o w a normal d i s t r i b u t i o n and the u n d e r l y i n g measurement s c a l e may not q u a l i f y as an i n t e r v a l s c a l e . The Mann-Whitney U t e s t was used to t e s t the degree and d i r e c t i o n of the d i f f e r e n c e i n i n t e n s i t y of concerns between the two independent groups of p r i m i p a r o u s and multiparous mothers a t both time i n t e r v a l s . The Wilcoxon Signed-Rank t e s t was used to determine the s i g n i f i c a n c e of the d i f f e r e n c e of i n t e n s i t y of concerns i n v o l v i n g the two dependent measures of p r i m i p a r a s and m u l t i p a r a s two days 45 f o l l o w i n g d i s c h a r g e from h o s p i t a l and one month f o l l o w i n g d i s c h a r g e r e s p e c t i v e l y . Demographic data such as maternal age, e t h n i c background and l e v e l of education were a l s o a n a l y z e d i n terms of p r o p o r t i o n s f o r the purpose of d e s c r i b i n g the c h a r a c t e r i s t i c s of the sample. 46 CHAPTER 4 A n a l y s i s of Data I n t r o d u c t i o n The data from the q u e s t i o n n a i r e s were an a l y z e d to determine any s i g n i f i c a n t d i f f e r e n c e s i n frequency and i n t e n s i t y of concerns between p r i m i p a r a s and m u l t i p a r a s i n the f i r s t two days a f t e r and one month a f t e r d i s c h a r g e from h o s p i t a l . The concerns were c a t e g o r i z e d i n t o concerns about s e l f , baby, p a r t n e r , f a m i l y and t o t a l concerns. Frequency counts of demographic data r e g a r d i n g the c h a r a c t e r i s t i c s of the sample were determined and percentages c a l c u l a t e d . T h i s chapter r e p o r t s the data r e g a r d i n g the c h a r a c t e r i s t i c s of the sample f o l l o w e d by the data r e l a t i n g to the four hypotheses of the study. D i s c u s s i o n of the s i g n i f i c a n c e of the f i n d i n g s w i l l f o l l o w i n chapter f i v e . C h a r a c t e r i s t i c s of the Sample Par i t y The q u e s t i o n n a i r e s were given out to 95 mothers who met the c r i t e r i a of the study and consented to p a r t i c i p a t e . Over the two and one h a l f month p e r i o d i n which the mothers were approached to p a r t i c i p a t e , 73 mothers r e t u r n e d the 47 f i r s t q u e s t i o n n a i r e which was to be completed one to two days a f t e r d i s c h a r g e . Six of these p a r t i c i p a n t s d i d not complete the second q u e s t i o n n a i r e at one month a f t e r d i s c h a r g e r e s u l t i n g i n a f i n a l sample of 67 mothers which was a 70% r e t u r n r a t e . The 67 mothers i n the sample c o n s i s t e d of 31 p r i m i p a r a s and 36 m u l t i p a r a s . The p r i m i p a r a s made up 46% of the sample and the m u l t i p a r a s 54%. T h i r t y - t w o m u l t i p a r a s (86%) were having t h e i r second c h i l d while t h r e e were having t h e i r t h i r d c h i l d and one d e l i v e r e d her f o u r t h c h i l d . The ages of the pr e v i o u s c h i l d r e n ranged from t h i r t e e n months to twelve y e a r s . Age The ages of the sample mothers ranged from 19 to 38 ye a r s . The ages were d i v i d e d i n t o four c a t e g o r y groups: below 23, 23 to 28, 29 to 34 and above 34. These c a t e g o r i e s were chosen to p r o v i d e r e l a t i v e l y equal age c a t e g o r i e s and to d i s t i n q u i s h between those mothers who were over 30 and those over 35. The modal category was 23 to 28 years with 30 mothers (45%). Twenty -seven mothers (40%) were i n the category 29 to 34 y e a r s . (Table 1). 48 Table 1: D i s t r i b u t i o n of Mothers by Age Years Prim i p a r a s M u l t i p a r a s T o t a l 18-22 4(13)* 2(6) 6(9) 23-28 17(55) 13(36) 30(45) 29-34 8(26) 19(53) 27(40) 35 + 2(7) 2(6) 4(6) * Percentage of t o t a l i n b r a c k e t s Gender of Baby The mothers i n the sample d e l i v e r e d 39 male and 28 female i n f a n t s . E d u c a t i o n The ed u c a t i o n l e v e l of the mothers i n the sample ranged from those having completed some h i g h s c h o o l to those having completed graduate s c h o o l . Seven mothers had some high sc h o o l whereas 23 completed h i g h s c h o o l . E i g h t of the mothers had some v o c a t i o n a l s c h o o l and seven completed v o c a t i o n a l s c h o o l . Six had some u n i v e r s i t y whereas twelve graduated from u n i v e r s i t y and two attended some graduate school and two completed a graduate degree. (Table 2) 49 Table 2: D i s t r i b u t i o n of Mothers by Education E d u c a t i o n L e v e l Pr imiparas M u l t i p a r a s T o t a l Some h i g h school 1 (3 ) * 6(17) 7(10) Completed hi g h s c h o o l 11(36) 12(33) 23(34) Some v o c a t i o n a l / c o l l e g e 7(23) 1(3) 8(12) Completed v o c a t i o n a l / c o l l e g e 3(10) 4(11) 7(10) Some u n i v e r s i t y 3(10) 3(8) 6(9) Completed u n i v e r s i t y 5(16) 7(19) 12(18) Some graduate school 1 (3) 1 (3) 2(3) Completed graduate sc h o o l 0(0) 2(6) 2(3) * Percentage of t o t a l i n br a c k e t s E t h n i c i t y of Mothers Many d i f f e r e n t e t h n i c groups were represented i n t h i s sample. T h i r t y - t w o of the mothers (48%) i d e n t i f i e d themselves as having a Canadian or Caucasion e t h n i c background. Other e t h n i c groups i n c l u d e d Chinese, East Indian, I s m a l i , German, F i l l i p i n o and Portugese. T h i r t y - f o u r of the mothers (51%) s t a t e d they had l i v e d i n Canada f o r more than twenty y e a r s . Seventeen of the mothers had l i v e d i n Canada ten to twenty y e a r s , nine mothers f i v e to ten ye a r s and seven (10%) of the sample had l i v e d i n Canada l e s s than f i v e y e a r s . (Table 3) 50 Table 3: D i s t r i b u t i o n of Mothers by E t h n i c Background E t h n i c i t y Frequency Percent Canadian 32 48 Chinese 1 1 1 6 East Indian 4 6 F i l l i p i n o 5 8 German 2 3 Ism a l i 3 5 Portugese 3 5 Other 10 1 4 Type of Infant Feeding At the time of completing the f i r s t q u e s t i o n n a i r e 46 of the mothers (69%) were b r e a s t f e e d i n g t h e i r i n f a n t s . T h i r t e e n of the mothers (19%) were formula feeding and e i g h t (12%) were combining the two methods. P r e n a t a l C l a s s Attendance Twenty-nine mothers (43%), a l l of whom were p r i m i p a r a s , attended p r e n a t a l c l a s s e s with t h i s pregnancy. Of the twenty-nine mothers nineteen attended the h e a l t h department c l a s s e s , f i v e the h o s p i t a l c l a s s e s and f i v e p r i v a t e agency c l a s s e s . 51 Return to Work At the time of completing the f i r s t q u e s t i o n n a i r e 36 of the mothers (54%) were p l a n n i n g to r e t u r n to work. T h i r t y - o n e (46%) of the sample had not made plans to r e t u r n to the workplace. Help at Home and Use of P r o f e s s i o n a l Resources At the time of completing the f i r s t q u e s t i o n n a i r e 54 of the mothers (81%) s t a t e d that t h e i r husband was the most h e l p f u l person to them at home. Nine of the mothers s t a t e d t h a t t h e i r mother or s i s t e r was the most h e l p f u l at t h i s time. When completing the second q u e s t i o n n a i r e one month a f t e r d i s c h a r g e from h o s p i t a l the mothers r e p o r t e d the number of p r o f e s s i o n a l c o n t a c t s d u r i n g t h e i r f i r s t month at home. S i x t y of the mothers (90%) had had co n t a c t with, a community h e a l t h nurse d u r i n g the month with the number of c o n t a c t s ranging from 0 to 3 and the mean number of c o n t a c t s being 1.3. A l l but one of the mothers had had at l e a s t one c o n t a c t with a p h y s i c i a n , e i t h e r f a m i l y doctor or p e d i a t r i t i o n , s i n c e t h e i r d i s c h a r g e with the number of c o n t a c t s ranging from 0 to 7 and the mean number of c o n t a c t s being 2.2. The mothers d i d not i d e n t i f y any other p r o f e s s i o n a l h e l p sought d u r i n g t h i s time. 52 D i f f e r e n c e Between Concerns of P r i m i p a r a s and M u l t i p a r a s at Two Days In a n a l y z i n g the data from the f i r s t q u e s t i o n n a i r e completed d u r i n g the f i r s t two days a f t e r d i s c h a r g e from h o s p i t a l the f r e q u e n c i e s of responses on the f i v e p o i n t s c a l e (0-4) were ob t a i n e d f o r each item, t o t a l l e d a c r o s s items w i t h i n each categ o r y and acr o s s items over a l l c a t e g o r i e s (i.e.,51 i t e m s ) . A r i t h m e t i c means f o r i n d i v i d u a l items were ob t a i n e d and ranked by category and a c r o s s a l l c a t e g o r i e s to determine i f the ranking of items d i f f e r e d between p r i m i p a r a s and m u l t i p a r a s . Spearman's rho c o r r e l a t i o n was a l s o determined based on the ran k i n g s . The Mann-Whitney U t e s t was used to determine the s i g n i f i c a n c e of any d i f f e r e n c e i n i n t e n s i t y of concern between p r i m i p a r a s and m u l t i p a r a s f o r each item, each category and f o r the sum of a l l 51 items. The mother's mean frequency of responses of 0, 1, 2, 3, 4, were a l s o c a l c u l a t e d f o r the sum of the items i n each category and f o r the t o t a l items and chi - s q u a r e a n a l y s i s used to determine the s i g n i f i c a n c e of the d i f f e r e n c e i n t o t a l frequency of concerns f o r each l e v e l of i n t e n s i t y of concern. Many of the mean f r e q u e n c i e s f o r each category were l e s s than f i v e making the c h i - s q u a r e a n a l y s i s f o r the four c a t e g o r i e s q u e s t i o n a b l e . T h e r e f o r e only the c h i - s q u a r e f o r the mean frequency of responses f o r the t o t a l items i s r e p o r t e d . These f i n d i n g s are r e p o r t e d a c c o r d i n g to the 53 c a t a g o r i e s of s e l f , baby, p a r t n e r , f a m i l y and t o t a l concerns. S e l f There was some d i f f e r e n c e i n the ranking of mean responses between the two groups of mothers with the pri m i p a r a s ranking 'being a good mother' ' f a t i g u e ' and 'pain from ( s t i t c h e s ' as having the h i g h e s t i n t e n s i t y of concern whereas the m u l t i p a r a s found ' f a t i g u e ' and ' r e t u r n of f i g u r e ' to be of g r e a t e s t concern i n t h i s c a t egory. (Table 4) A comparison of ranking of items between p r i m i p a r a s and mu l t i p a r a s showed Spearmans's rho was .833 (p<.05) f o r the ranking of the items i n the category of s e l f . However, i n l o o k i n g at the category of s e l f , the Mann-Whitney t e s t d i d not demonstrate a s i g n i f i c a n t d i f f e r e n c e f o r the ' s e l f c a t e g o r y (U=467; p=.252) or f o r any i n d i v i d u a l items. For the sum of the 18 items i n t h i s category of s e l f the mean frequency of concern at each l e v e l of i n t e n s i t y was very s i m i l a r f o r p r i m i p a r a s and m u l t i p a r a s . Table 5 i n d i c a t e s the percentage of responses of 0-4 t o t a l l e d a c r o s s items f o r a l l c a t e g o r i e s . 54 Table 4: P r i o r i t y Ranking of Concerns Regarding S e l f ( f i r s t 2 days) Primi p a r a s M u l t i p a r a s Item Mean 1 Item Mean Being a good mother 2 .68 Fat i g u e 2 .25 F a t i g u e 2 .38 Return of f i g u r e 2 .22 Pain from s t i t c h e s 2 .07 Being a good mother 2 .03 Return of f i g u r e 2 .00 Labour & d e l i v e r y exp. 1 .78 Breast soreness 1 .93 Breast soreness 1 .75 Labour & d e l i v e r y exp. 1 .90 Emotional t e n s i o n 1 .69 Care of b r e a s t s 1 .83 Care of b r e a s t s 1 .67 Emotional t e n s i o n 1 .81 D i e t 1 .67 D i e t 1 .77 Pain from s t i t c h e s 1 .58 E x e r c i s e h a b i t s 1 .52 E x e r c i s e 1 .47 C o n s t i p a t i o n 1 .52 Loc h i a 1 .42 L o c h i a 1 .45 Personal time 1 .33 Hemorrhoids 1 .45 Return of p e r i o d 1 .25 Unable to conc e n t r a t e 1 .41 Being t i e d down 1 .19 Being t i e d down 1 .38 Unable to c o n c e n t r a t e 1 . 1 7 Personal time 1 .32 C o n s t i p a t i o n 1 .08 Baby blues 1 .23 Baby blues 1 .06 Return of p e r i o d 1 .19 Hemorrhoids 0 .94 Mean of responses on 0-4 s c a l e Baby In examining the concerns r e g a r d i n g baby the Mann-Whitney U t e s t d i d not demonstrate a s i g n i f i c a n t d i f f e r e n c e between the two groups f o r the t o t a l category (U=417.5; p=.0772). There were however i n d i v i d u a l items i n which the d i f f e r e n c e was s i g n i f i c a n t at the .05 l e v e l . The items of 'bathing the i n f a n t ' , 'comfort i n h a n d l i n g the i n f a n t ' , ' i n t e r p r e t i n g behaviour', ' c r y i n g ' , ' r e c o g n i z i n g i l l n e s s ' and ' t r a v e l l i n g with the i n f a n t ' were of s i g n i f i c a n t l y g r e a t e r concern to the p r i m i p a r a s than the m u l t i p a r a s at t h i s time. (Table 6) 55 Table 5: Percentage of Mothers' responses of 0-4 t o t a l l e d a c r o s s items i n each category (1st two days) Category P a r i t y L e v e l of Concern 0 1 2 3 4 S e l f P r i m i p a r a s 19 .4 23. 3 31 . 1 18. 3 7. 70 18 items M u l t i p a r a s 26 . 1 23. 8 27 .7 16. 1 6. 10 Baby Pri m i p a r a s 18 .5 16. 2 29 .5 26. 2 9. 50 21 items M u l t i p a r a s 28 .0 21 . 9 26 .6 19. 0 4. 80 Partner P r i m i p a r a s 25 .5 25. 5 20 .0 20. 0 8. 50 6 items M u l t i p a r a s 28 .3 23. 3 26 .9 18. 3 3. 10 Family P r i m i p a r a s 23 .3 15. 6 33 .3 12. 8 5. 80 6 items M u l t i p a r a s 20 .0 26. 7 28 .3 21 . 7 3. 70 T o t a l P r i m i p a r a s 21 .4 19. 6 29 .4 21 . 1 8. 05 51 items M u l t i p a r a s 26 .3 23. 3 27 .3 18. 0 4. 90 Note: Prim i p a r a s n=3l M u l t i p a r a s n=36 In the p r i m i p a r a group ' r e c o g n i z i n g s i g n s of i l l n e s s ' was i d e n t i f i e d as the g r e a t e s t concern i n t h i s c a t e g o r y f o l l o w e d by ' s a f e t y ' , 'growth and development' and ' f e e d i n g ' . The m u l t i p a r a s a l s o i d e n t i f i e d ' s a f e t y ' , 'growth and development' and 'feeding' as t h e i r g r e a t e s t concerns. The ranking of the items i n t h i s category was not s i g n i f i c a n t l y d i f f e r e n t between the two groups as Spearmans'rho was .783 (p<.05) There was a l s o l i t t l e d i f f e r e n c e i n the frequency of concerns at each l e v e l of i n t e n s i t y of concern f o r the sum of the 21 items i n t h i s category (Table 5) 56 Table 6: P r i o r i t y Ranking of Concerns Regarding Baby (1st 2 days) Pr i m i p a r a s M u l t i p a r a s Item Mean 1 Item Mean Recognizing i l l n e s s 2 .74 Safety 2 .08 Sa f e t y 2 .45 Growth and Development 1 .94 Growth and development 2 .35 Feeding baby 1 .92 Feeding baby 2 .32 Recognizing i l l n e s s Baby's weight gain 1 .91 Baby's weight g a i n Baby's Behaviour Baby's c r y i n g 2 .19 1 .77 2 .19 Baby's s l e e p i n g 1 .64 2 .13 Immunizing baby 1 .64 T r a v e l l i n g with baby 2 .07 Dr e s s i n g baby 1 .64 D r e s s i n g baby Baby's s l e e p i n g 2 .03 Care of c o r d 1 .56 2 .00 Baby's Behaviour 1 .47 Bathing baby Baby's b r e a t h i n g 1 .90 Baby's rashes 1 .47 1 .87 P h y s i c a l appearance 1 .44 F u s s i n e s s 1 .87 F u s s i n e s s 1 .44 Vitamins & F l o r i d e 1 .80 Baby's c r y i n g 1 .44 Immunizing baby 1 .74 T r a v e l l i n g with baby 1 .44 Comfort i n h a n d l i n g Baby's b r e a t h i n g 1 .39 baby 1 .74 Bowel movements 1 .74 Bowel movements 1 .39 Care of cord 1 .67 Vitamins and f l o r i d e 1 .36 P h y s i c a l appearance Baby's rashes 1 .58 Bathing baby 1 .25 1 .54 Comfort i n h a n d l i n g baby 1 .06 Care of c i r c u m s i o n 0 .74 Care of c i r c u m s i o n 0 .50 1 Mean of responses on 0-4 s c a l e Partner The Mann-Whitney U t e s t d i d not demonstrate a s i g n i f i c a n t d i f f e r e n c e i n the category of p a r t n e r , f o r the t o t a l c a t e g o r y (U=491; p=.3885) or f o r any of the s i x i n d i v i d u a l items. The p r i m i p a r a s ' mean i n t e n s i t y of concern f o r 'time alone together' was ranked h i g h e s t while m u l t i p a r a s found ' b i r t h c o n t r o l ' to be of g r e a t e s t concern 57 i n t h i s c a t e g o r y . The remaining f i v e items were ranked s i m i l a r l y between the two groups. (Table 7) Spearman's rho f o r comparison of ranks was .657 (p<.05). Table 7: P r i o r i t y Ranking of Concerns Regarding Partner ( f i r s t 2 days) Pr i m i p a r a s M u l t i p a r a s I tern Mean 1 I tern Mean Time alone together 1 .87 B i r t h c o n t r o l 1.81 Time f o r r e c r e a t i o n 1.81 Time alone together 1 .56 R e l a t i o n s h i p with Time f o r r e c r e a t i o n 1 .47 p a r t n e r 1 .68 B i r t h c o n t r o l 1.61 R e l a t i o n s h i p w i t h p a r t n e r 1 .36 Sexual r e l a t i o n s 1 .58 Sexual r e l a t i o n s 1 .33 Partner being a good Partner being a good f a t h e r 1 .36 f a t h e r 1 .33 Mean of responses on 0-4 s c a l e For the sum of the s i x items i n t h i s c a t e g o r y the mean frequency at each l e v e l of concern was very s i m i l a r f o r both groups. (Table 5) Family The d i f f e r e n c e between the i n t e n s i t y of concerns f o r the two groups of mothers was a l s o not s i g n i f i c a n t f o r the c a t e g o r y of f a m i l y (U=480; p= .3254). The o n l y item i n which the d i f f e r e n c e was s i g n i f i c a n t was i n ' s e t t i n g l i m i t s 58 on v i s i t o r s ' (p=.0325). 'Reaction of s i b l i n g s ' was not i n c l u d e d i n t h i s c a l c u l a t i o n as i t was not of concern to any of the p r i m i p a r a s . The r a n k i n g of the mean i n t e n s i t y of concern scores was i n v e r t e d and y i e l d e d a negative e f f e c t between the two groups with the m u l t i p a r a s f i n d i n g ' r e a c t i o n of s i b l i n g s ' to be of g r e a t e s t concern and the p r i m i p a r a s i d e n t i f y i n g 'change i n f a m i l y l i f e s t y l e ' to be of g r e a t e s t concern i n t h i s c a t e g o r y . (Table 8) Spearmans's rho f o r comparison of ranks was -406 (p<.05). Table 8: P r i o r i t y Ranking of Concerns Regarding Family (1st 2 days) P r i m i p a r a s M u l t i p a r a s Item Mean 1 Item Mean Family l i f e s t y l e change 2 .04 Reaction of s i b l i n g s 2 .19 L i m i t i n g v i s i t o r s 1 .80 Demands of household 1 .89 Demands of household 1 .77 Finances 1 .58 Finances 1 .64 Family l i f e s t y l e change 1 .58 A v a i l a b i l i t y of A v a i l a b i l i t y of resources 1 .35 r e s o u r c e s 1 .25 Reaction of s i b l i n g s 0 .00 L i m i t i n g v i s i t o r s 1 .22 Mean of responses on 0-4 s c a l e The frequency of responses at each l e v e l of concern f o r the sum of the items i n the category of f a m i l y was again very s i m i l a r between the two groups of mothers. (Table 5) 59 T o t a l Items The d i f f e r e n c e i n i n t e n s i t y of concern between the p r i m i p a r a s and m u l t i p a r a s i n the f i r s t two days a f t e r d i s c h a r g e was not s i g n i f i c a n t f o r a c r o s s a l l 51 items (U=429.5; p=.1061). Table 9 demonstrates that the ranking of the mean i n t e n s i t y s cores of the items v a r i e d somewhat between the two groups with the p r i m i p a r a s i d e n t i f y i n g ' r e c o g n i z i n g i l l n e s s ' and 'being a good mother' as t h e i r g r e a t e s t concerns and m u l t i p a r a s f i n d i n g ' r e t u r n of f i g u r e ' and ' f a t i g u e ' to be of g r e a t e s t concern. Spearmans's rho f o r the .ranking of the t o t a l items f o r the two groups was .585 (p<.05) See Appendix A f o r the ranki n g of a l l items by mean i n t e n s i t y . Table 9: P r i o r i t y Ranking of Highest T o t a l Concerns (1st 2 days) P r i m i p a r a s Mult i p a r a s I tern Mean 1 I tern Mean Recognizing i l l n e s s 2. 74 F a t i g u e 2.25 Being a good mother 2. 68 Return of f i g u r e 2.22 S a f e t y 2. 45 Reaction of s i b l i n g s 2.19 F a t i g u e 2. 38 S a f e t y 2.08 Growth & Development 2. 35 Being a good mother 2.03 Feeding baby Baby's weight g a i n Baby's behaviour 2. 32 Growth & development 1 .94 2. 19 Baby's f e e d i n g 1 .92 2. 19 Reco g n i z i n g i l l n e s s 1 .91 Baby's c r y i n g 2. 1 3 Demands of household 1 .89 T r a v e l l i n g with baby 2. 07 B i r t h c o n t r o l 1.81 Pain from s t i t c h e s 2. 07 Labour & d e l i v e r y exp. 1 .78 D r e s s i n g baby 2. 03 Baby's weight g a i n 1 .77 1 Mean of responses on 0-4 s c a l e 60 The mean frequency of responses at each l e v e l of i n t e n s i t y f o r the sum of the t o t a l items was again not s i g n i f i c a n t l y d i f f e r e n t between the two groups. Chi-square = .73 (df=4) (p>.05) (Table 5) D i f f e r e n c e i n Concerns of P r i m i p a r a s and M u l t i p a r a s at One Month The mothers completed a q u e s t i o n n a i r e with the same 51 items one month a f t e r t h e i r d i s c h a r g e from h o s p i t a l and t h e i r responses were analyzed i n the same manner as the f i r s t q u e s t i o n n a i r e . S e l f In the category of concerns about s e l f the d i f f e r e n c e between the i n t e n s i t y of concerns was not found to be s i g n i f i c a n t u s ing the Mann-Whitney U t e s t (U=487.5; p=.3751). I n d i v i d u a l items i n which the d i f f e r e n c e was found to be s i g n i f i c a n t were 'discomfort from s t i t c h e s ' and 'being a good mother' with the p r i m i p a r a s i d e n t i f y i n g g r e a t e r concern than m u l t i p a r a s . The ranking of the mean i n t e n s i t y of concern was s i m i l a r between the two groups with 'being a good mother', ' f a t i g u e ' and ' r e t u r n of f i g u r e ' as the g r e a t e s t concerns. (Table 10) Spearman's rho f o r the comparison of ranks was .877 (p<.05). 61 Table 10: P r i o r i t y Ranking of Concerns Regarding S e l f (one month) Pr imiparas M u l t i p a r a s I tern Mean 1 I tern Mean Being a good mother 2 .22 Return of f i g u r e 2 .06 Return of f i g u r e 2 .20 Fat igue 1 .69 F a t i g u e 2 .00 P e r s o n a l time 1 .69 E x e r c i s e 1 .90 Being a good mother 1 .60 D i e t 1 .81 E x e r c i s e 1 .58 Emotional t e n s i o n 1 .70 Emotional t e n s i o n 1 .56 P e r s o n a l time 1 .61 D i e t 1 .47 Being t i e d down 1 .48 Care of b r e a s t s 1 .08 Lack of c o n c e n t r a t i o n 1 .45 Being t i e d down 1 .'19 Return of p e r i o d 1 .30 Lack of c o n c e n t r a t i o n 1 .06 Baby Blues 1 .10 Return of p e r i o d 1 .06 C o n s t i p a t i o n 1 .03 Breast soreness 0 .92 L o c h i a 1 .00 Baby Blues 0 .89 Labour & d e l i v e r y exp. 1 .00 L o c h i a 0 .86 Care of b r e a s t s 1 .00 C o n s t i p a t i o n 0 .83 Pain from s t i t c h e s 0 .94 Labour & d e l i v e r y exp. 0 .81 Hemorrhoids 0,84 Hemorrhoids 0 .78 Breast soreness 0 .84 Pain from s t i t c h e s 0 .47 Mean of responses on 0-4 s c a l e The mean frequency of responses at each l e v e l of concern were not s i g n i f i c a n t l y d i f f e r e n t f o r the sum of the eighteen items i n t h i s c a t e g o r y . Table 11 shows the percentage of responses of 0-4 f o r a l l c a t e g o r i e s at one month. Baby The d i f f e r e n c e i n i n t e n s i t y of concerns between the two groups was not s i g n i f i c a n t f o r the c a t e g o r y of baby one month a f t e r d i s c h a r g e (U= 417; p=.076l). However, the d i f f e r e n c e was found to be s i g n i f i c a n t f o r the items of 62 T a b l e 11: Percentage of Mothers' Responses of 0-4 T o t a l l e d Across Items i n each Category (one month) Category P a r i t y L e v e l of Concern 0 1 2 3 4 S e l f P rimiparas 28. 9 27. 2 22 .8 1 5 .6 5 .40 18 items M u l t i p a r a s 36. 1 25. 6 22 .8 12 .2 2 .80 Baby Primiparas 29. 5 22. 9 20 .0 20 .4 7 .10 21 items M u l t i p a r a s 37. 6 30. 4 19 .0 1 1 .0 2 .10 P a r t n e r Primiparas 30. 0 15. 8 25 .0 25 .0 5 .30 6 items M u l t i p a r a s 30. 0 25. 0 25 .0 15 .0 4 .80 Family Primiparas 36. 7 28. 3 18 .3 1 2 .3 3 .80 6 items M u l t i p a r a s 26. 7 30. 0 30 .0 1 1 .5 3 .70 T o t a l P r i m i p a r a s 30. 2 24. 3 21 .2 18 .4 5 .90 51 items M u l t i p a r a s 34. 7 28. 1 22 .4 1 1 .8 2 .70 Note: Primiparas n=31 M u l t i p a r a s n=36 'baby's b r e a t h i n g ' , 'bowel movements', ' f u s s i n e s s ' and ' s l e e p i n g ' , ' i n t e r p r e t i n g behaviour' and ' r e c o g n i z i n g s i g n s of i l l n e s s ' with the p r i m i p a r a s e x p r e s s i n g g r e a t e r concern. (Table 12) There was some v a r i a t i o n i n the ranking of mean i n t e n s i t y of concern between the two groups with Spearman's rho being .863 (p<.05) The mean frequency of responses at each l e v e l of concern were again not s i g n i f i c a n t l y d i f f e r e n t f o r the sum of the 21 items i n t h i s c a t e g o r y . (Table 11) 63 Table 12: P r i o r i t y Ranking of Concerns Regarding Baby (one month) Pri m i p a r a s M u l t i p a r a s I tern Mean 1 I tern Mean Recognizing i l l n e s s 2.30 S a f e t y 1 .56 F u s s i n e s s 2.03 Recognizing i l l n e s s 1 .50 Baby's Behaviour 2.00 Growth & Development 1 .36 S a f e t y 1 .94 F u s s i n e s s 1 .33 Growth & Development 1 .94 Baby's s l e e p i n g 1 .33 Baby's s l e e p i n g Baby's f e e d i n g 1 .90 Baby's feeding Baby's rashes 1 .31 1 .87 1 .31 Baby's c r y i n g 1 .81 Baby's c r y i n g 1 .31 D r e s s i n g baby 1 .74 D r e s s i n g baby 1 .22 T r a v e l l i n g with baby 1 .61 Immunizing baby 1 .19 Baby's weight g a i n 1 .58 Baby's Behaviour 1 .14 Baby's b r e a t h i n g 1 .52 T r a v e l l i n g with baby 1 .08 P h y s i c a l appearance 1 .48 Baby's weight gain 1 .08 Bowel movements 1 .42 P h y s i c a l appearance 1 .06 Baby's rashes 1 .42 Bowel movements 0 .94 Immunizing baby 1 .32 Baby's Breathing 0 .89 Comfort i n h a n d l i n g Baby 1 .07 Bathing baby 0 .81 Bathing baby 1 .07 Vitamins and f l o r i d e 0 .75 Vitamins and f l o r i d e 1 .03 Comfort i n h a n d l i n g baby . 0 .67 Care of c o r d 0.65 Care of cord 0 .61 Care of c i r c u m s i o n 0.26 Care of c i r c u m s i o n 0 .42 Mean of responses on 0-4 s c a l e Partner The d i f f e r e n c e i n i n t e n s i t y of concern was not s i g n i f i c a n t f o r the t o t a l c a t e g o r y of partner one month a f t e r d e l i v e r y (U=492; p= .4020) or f o r any of the s i x items. The ranking of the mean i n t e n s i t y of concern d i f f e r e d s i g n i f i c a n t l y f o r the two groups of mothers with both groups i d e n t i f y i n g 'time alone together' to be of g r e a t e r concern. (Table 13) Spearman's rho f o r the comparison of ranks was .232 (p>.05). 64 Table 13: P r i o r i t y Ranking of Concerns Regarding Partner (1 month a f t e r d i s c h a r g e ) Primiparas M u l t i p a r a s I tern Mean 1 I tern Mean Time alone together 1 .74 B i r t h c o n t r o l 1 .72 Sexual r e l a t i o n s 1 .68 Time alone together 1 .53 R e l a t i o n s h i p with Time f o r r e c r e a t i o n 1 .50 pa r t n e r 1 .68 Time f o r r e c r e a t i o n 1 .64 R e l a t i o n s h i p with p a r t n e r 1 .22 B i r t h C o n t r o l 1 .48 Sexual r e l a t i o n s 1.19 Partner being a good Partner being a good f a t h e r 1 .36 f a t h e r 1 .05 Mean of responses on 0-4 s c a l e The mean frequency of responses at each l e v e l of concern was again q u i t e s i m i l a r between the two groups f o r the s i x items. (Table 11) Family In a n a l y z i n g the data r e g a r d i n g the category of f a m i l y one month a f t e r d i s c h a r g e , the d i f f e r e n c e i n i n t e n s i t y of concern between the two groups was not s i g n i f i c a n t (U=525.5; p=.68'15). The ranking of the mean i n t e n s i t y of concern on each item d i f f e r e d between the two groups with the p r i m i p a r a s f i n d i n g 'household demands' to be of h i g h e s t concern i n t h i s category and the m u l t i p a r a s i d e n t i f y i n g ' r e a c t i o n of s i b l i n g s ' to be of g r e a t e s t concern. (Table 14) Spearman's rho f o r the comparison of ranks was -.086 (p>.05). 65 Table 14: P r i o r i t y Ranking of Concerns Regarding Family (one month) Pr i m i p a r a s M u l t i p a r a s I tern Mean 1 I tern Mean Household demands 1 .68 Reaction of s i b l i n g s 1 .72 Family l i f e s t y l e change 1 .58 Finances 1 .69 Finances 1 .26 Household demands 1 .65 L i m i t i n g v i s i t o r s 1 .23 Family l i f e s t y l e change 1 .25 A v a i l a b i l i t y of A v a i l a b i l i t y of resources 1 . 1 9 resources 1 .00 Reaction of s i b l i n g s 0 .00 L i m i t i n g v i s i t o r s 0.97 1 Mean of responses on 0-4 s c a l e The mean frequency of responses f o r each l e v e l of concern was again very s i m i l a r f o r the two groups. (Table 11) T o t a l Items The d i f f e r e n c e i n i n t e n s i t y of the t o t a l concerns was not found to be s i g n i f i c a n t (U=448.5; p=.1684) d e s p i t e the i n d i v i d u a l items f o r which there was a s i g n i f i c a n t d i f f e r e n c e between the two groups of mothers one month a f t e r d i s c h a r g e . The ranking of the mean i n t e n s i t y of concern of the t o t a l items were v a r i e d between the two groups with the p r i m i p a r a s i d e n t i f y i n g , ' r e c o g n i z i n g s i g n s of i l l n e s s ' , 'being a good mother' and 'r e t u r n of f i g u r e ' as t h e i r g r e a t e s t concerns and the m u l t i p a r a s i d e n t i f y i n g ' r e t u r n of f i g u r e ' , ' b i r t h c o n t r o l ' and ' r e a c t i o n of other s i b l i n g s ' as 66 t h e i r g r e a t e s t concerns. (Table 15) Spearmans rho f o r the comparison of ranks was .644 (p<.05). See Appendix B f o r the ranking of a l l items by mean i n t e n s i t y of concern. Table 15: P r i o r i t y Ranking of Highest T o t a l Concerns (one month) Pr i m i p a r a s M u l t i p a r a s I tern Mean 1 I tern Mean Recognizing i l l n e s s 2.30 Return of f i g u r e 2 .06 Being a good mother 2.22 B i r t h c o n t r o l 1 .72 Return of F i g u r e 2.20 Reaction of s i b l i n g s 1 .72 F a t i g u e 2.00 F a t i g u e 1 .69 Baby's behaviour 2.00 Personal i n t e r e s t s 1 .69 Safety 1 .94 Finances 1 .69 Growth & development 1 .94 Household demands 1 .68 Baby's s l e e p i n g 1 .90 Being a good mother 1 .60 e x e r c i s e 1 .90 Exerc i s e 1 .58 Baby's f e e d i n g Baby's c r y i n g 1 .87 Emotional t e n s i o n 1 .56 1.81 S a f e t y 1 .56 D i e t 1 .81 Recognizing i l l n e s s 1 .50 Mean of responses on 0-4 s c a l e The mean frequency of responses f o r each l e v e l of concern f o r the sum of the t o t a l concerns was not s i g n i f i c a n t l y d i f f e r e n t f o r the two groups. Chi-square = 5.54 (df=4) (p>.05) (Table 11) 67 D i f f e r e n c e i n Concerns of Primiparas i n F i r s t Two Days and One Month a f t e r D ischarge The data from the two q u e s t i o n n a i r e s was a l s o a n a lyzed to determine i f there was a s i g n i f i c a n t d i f f e r e n c e i n frequency arid i n t e n s i t y of concern i n the two groups of mothers over the f i r s t month a f t e r d i s c h a r g e from h o s p i t a l . The W i l c o x i n signed rank t e s t f o r matched p a i r s was used to determine the s i g n i f i c a n c e of the d i f f e r e n c e i n i n t e n s i t y of concern. The mean of the f r e q u e n c i e s of responses f o r each l e v e l of i n t e n s i t y of concern on each item were again ranked and Spearman's c o r r e l a t i o n c o e f f i c i e n t was determined. Chi-square was used to determine any d i f f e r e n c e i n the f r e q u e n c i e s of responses f o r the t o t a l concerns. S e l f The d i f f e r e n c e i n the i n t e n s i t y of concerns f o r pr i m i p a r a s between the f i r s t two days at home and one month a f t e r d i s c h a r g e was s i g n i f i c a n t at the .05 l e v e l f o r the t o t a l c ategory of concerns about s e l f u s i n g the W i l c o x i n s i g n rank f o r matched p a i r s (Z= -2.42; P=.0155.) The d i f f e r e n c e was not s i g n i f i c a n t f o r such i n d i v i d u a l items as ' d i e t ' , ' r e t u r n of f i g u r e ' , ' r e t u r n of p e r i o d ' , ' f a t i g u e ' , ' t e n s i o n ' , ' c o n c e n t r a t i o n ' , ' f e e l i n g s of being t i e d down', 'baby blu e s ' and 'time f o r s e l f . Spearman's c o r r e l a t i o n c o e f f i c i e n t f o r the ranking of the mean i n t e n s i t i e s of 68 concern was .107 (p>.05). The items of 'being a good mother', ' f a t i g u e ' and 'return of f i g u r e ' were s t i l l ranked as the s t r o n g e s t concerns, however 'pain from s t i t c h e s ' dropped to being of l e s s concern one month a f t e r d i s c h a r g e . (Table 16) Table 16: P r i o r i t y Ranking of Concerns of P r i m i p a r a s Regarding S e l f (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 Item Mean Being a good mother 2, .68 F a t i g u e 2, .38 Pain from s t i t c h e s 2, .07 Return of f i g u r e 2, .00 Breast soreness 1 , .93 Labour & d e l i v e r y exp. 1 , .90 Care of b r e a s t s 1 , .83 Emotional t e n s i o n 1 . .81 D i e t 1 , .77 E x e r c i s e 1 .52 C o n s t i p a t i o n 1 .52 L o c h i a 1 .45 Hemorrhoids 1 .45 Lack of c o n c e n t r a t i o n 1 .41 Being t i e d down 1 .38 Personal time 1 .32 Baby blues 1 .23 Return of p e r i o d 1 .19 Mean of responses on 0-4 s c a l e Being a good mother 2 .22 Return of f i g u r e 2 .22 F a t i g u e 2 .00 E x e r c i s e 1 .90 D i e t 1 .81 Emotional t e n s i o n 1 .70 P e r s o n a l time . 1 .61 Being t i e d down 1 .48 Lack of c o n c e n t r a t i o n 1 .45 Return of p e r i o d 1 .30 Baby blues 1 .10 C o n s t i p a t i o n 1 .03 L o c h i a 1 .00 Labour & d e l i v e r y exp. 1 .00 Care of b r e a s t s 1 .00 Pain from s t i t c h e s 0 .94 Hemorrhoids 0 .84 Breast soreness 0 .84 The d i f f e r e n c e between the mean frequency of concerns at each l e v e l of i n t e n s i t y was not s i g n i f i c a n t f o r the sum of the eighteen items i n the category of concerns about s e l f . Table 17 shows the percentage of responses of 0-4 t o t a l l e d a c r o s s items f o r a l l c a t e g o r i e s . 69 Table 17: Percentage of P r i m i p a r a s ' Responses of 0-4 T o t a l l e d across Items i n each Category ( f i r s t 2 days versus 1 month) Category Time L e v e l of Concern Measure 0 1 2 3 4 S e l f 1st 2 days 19.4 23. 3 31 . 1 18.3 7.70 18 items 1 month 28.9 27. 2 22. 8 15.6 5.40 Baby 1st 2 days 18.5 16. 2 29. 5 26.2 9.50 21 items 1 month 29.5 22. 9 20. 0 20.4 7.10 Partner 1st 2 days 25.5 25. 5 20. 0 20.0 8.50 6 items 1 month 30.0 15. 8 25. 0 25.0 5.30 Family 1st 2 days 23.3 15. 6 33. 3 12.8 5.80 6 items 1 month 36.7 28. 3 18. 3 12.3 3.80 T o t a l 1st 2 days 21 .4 19. 6 29. 4 21.1 8.00 51 items 1 month 30.2 24. 3 21 . 2 18.4 5.90 Baby There was a s i g n i f i c a n t d i f f e r e n c e i n i n t e n s i t y of concern between the two measures of p r i m i p a r a s f o r the t o t a l c a tegory of concerns about baby (Z= -3.32; p= .0009) with a l l items being of lower mean i n t e n s i t y of concern on the second measure. I n d i v i d u a l items f o r which the d i f f e r e n c e was not s i g n i f i c a n t i n c l u d e d , ' i n f a n t ' s p h y s i c a l appearance', ' c i r c u m s i o n ' , 'bowel movements', 'rashes', ' f u s s i n e s s ' , ' s l e e p i n g ' , ' c r y i n g ' , ' d r e s s i n g ' and ' i n t e r p r e t i n g i n f a n t behaviour'. The ranking of mean i n t e n s i t y of concern remained s i m i l a r on the second measure. Spearman's rho f o r the comparison of ranks was .787 (p<.05). 70 'Recognizing s i g n s of i l l n e s s ' c o n t i n u e d to be the hi g h e s t concern i n t h i s c a t e g o r y . (Table 18) Table 18: P r i o r i t y Ranking of Concerns of P r i m i p a r a s Regarding Baby (1st 2 days) 1st 2 days One Month Item Mean 1 Item Mean Recognizing i l l n e s s 2 .74 Recognizing i l l n e s s 2 .30 Safe t y 2 .45 F u s s i n e s s 2 .03 Growth and development 2 .35 Baby's Behaviour 2 .00 Feeding baby 2 .32 Sa f e t y 1 .94 Baby's weight gain Baby's Behaviour 2 .19 Growth & Development 1 .94 2 .19 Baby's s l e e p i n g Baby's f e e d i n g Baby's c r y i n g 1 .90 Baby's c r y i n g 2 . 13 1 .87 T r a v e l l i n g with baby 2 .07 1 .81 D r e s s i n g baby 2 .03 D r e s s i n g baby 1 .74 Baby's s l e e p i n g 2 .00 T r a v e l l i n g w i t h baby Baby's weight g a i n 1 .61 Bathing baby Baby's b r e a t h i n g 1 .90 1 .58 1 .87 Baby's b r e a t h i n g 1 .52 F u s s i n e s s 1 .87 P h y s i c a l appearance 1 .48 Vitamins & F l o r i d e 1 .80 Bowel movements 1 .42 Immunizing baby 1 .74 Baby's rashes 1 .42 Comfort i n h a n d l i n g Immunizing baby 1 .32 baby 1 .74 Bowel movements 1 .74 Comfort i n h a n d l i n g Baby 1 .07 Care of c o r d 1 .67 Bathing baby 1 .07 P h y s i c a l appearance 1 .58 Vitamins and f l o r i d e 1 .03 Baby's rashes 1 .54 Care of c o r d 0 .65 Care of c i r c u m s i o n 1 .54 Care of c i r c u m s i o n 0 .26 Mean of responses on 0-4 s c a l e The d i f f e r e n c e between the mean f r e q u e n c i e s of concerns was not s i g n i f i c a n t f o r the sum of the 21 items i n t h i s c a t e g o r y . (Table 17) 71 P a r t n e r The d i f f e r e n c e i n i n t e n s i t y of concern between the two measures was not s i g n i f i c a n t f o r e i t h e r the t o t a l category of p a r t n e r (Z= -.90; p=.3684) or f o r any of the s i x items i n t h i s c a t e g o r y . The ranking of the mean i n t e n s i t y of concerns s c o r e s a l s o stayed somewhat s t a b l e f o r the two measures i n t h i s category with Spearman's rho being .667 (p<.05). The item of g r e a t e s t concern i n t h i s category c o n t i n u e d to be ' f i n d i n g time alone t o g e t h e r 1 . (Table 19) Table 19: P r i o r i t y Ranking of Concerns of Pr i m i p a r a s Regarding Partner (1st 2 days vs. ' 1 month) 1st 2 days One month I tern Mean 1 I tern Mean Time alone together 1 .87 Time alone together 1 .74 Time f o r r e c r e a t i o n 1.81 Sexual r e l a t i o n s 1 .68 R e l a t i o n s h i p with R e l a t i o n s h i p with p a r t n e r 1 .68 pa r t n e r 1 .68 Sexual r e l a t i o n s 1 .58 B i r t h c o n t r o l 1 .48 Partner being a good Partner being a good f a t h e r 1 .36 f a t h e r 1 .36 Mean of responses on 0-4 s c a l e Table 17 a l s o shows that the mean responses at each l e v e l of concern f o r the s i x items a l s o remained very s i m i l a r . 72 Family The d i f f e r e n c e between the p r i m i p a r a s two measures of concern was s i g n i f i c a n t f o r the c a t e g o r y of f a m i l y . (Z= -2.2; p= .0279). Items f o r which the d i f f e r e n c e was not s i g n i f i c a n t i n c l u d e d , 'household demands', ' a v a i l a b i l i t y of r e s o u r c e s ' and ' r e a c t i o n of s i b l i n g s ' . There was some v a r i a t i o n i n the ranking of the mean i n t e n s i t y scores with 'household demands' and ' f i n a n c e s ' i n c r e a s i n g i n p r i o r i t y at one month a f t e r d i s c h a r g e . (Table 20) Spearman's rho f o r the comparison of ranks was .714 (p<.05) Table 20: P r i o r i t y Ranking of Concerns of Primiparas Regarding Family (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 Item Mean Family l i f e s t y l e change 2 .00 Household demands 1 .68 L i m i t i n g v i s i t o r s 1 .80 Family l i f e s t y l e change 1 .58 Household demands 1 .77 Finances 1 .26 Finances 1 .64 L i m i t i n g v i s i t o r s 1 .23 A v a i l a b i l i t y of A v a i l a b i l i t y of r e s o u r c e s 1 .35 r e s o u r c e s 1 .19 R e a c t i o n of s i b l i n g s 0 .00 Reaction of s i b l i n g s 0 .00 Mean of responses on 0-4 s c a l e Table 17 demonstrates that the mean responses f o r each l e v e l of concern f o r the sum of the items i n the category of f a m i l y f o r p r i m i p a r a s remained s i m i l a r at both measures. 73 T o t a l Items In a n a l y z i n g the d i f f e r e n c e between the t o t a l concerns of p r i m i p a r a s at two days and one month a f t e r d i s c h a r g e , the W i l c o x i n matched p a i r s t e s t showed the d i f f e r e n c e i n i n t e n s i t y of concern to be s i g n i f i c a n t (Z= -3.14; p=.0017). The r a n k i n g of the mean i n t e n s i t y scores showed v a r i a t i o n w ith ' r e t u r n of f i q u r e ' i n c r e a s i n g i n p r i o r i t y on the second measure. (Table 21) Spearmans's rho f o r the comparison of the ranks was .501 (p<.05). See Appendix A and B f o r r a n k i n g f o r t o t a l items by mean i n t e n s i t y of concern. T a b l e 21: P r i o r i t y Ranking of T o t a l Concerns of P r i m i p a r a s (1st 2 days vs. 1 month) 1st 2 days One month I tern Mean 1 I tern Mean Re c o g n i z i n g i l l n e s s 2 .74 Reco g n i z i n g i l l n e s s 2.30 Being a good mother 2 .68 Being a good mother 2.22 S a f e t y 2 .45 Return of f i g u r e 2.20 F a t i g u e 2 .38 Fat igue Baby's behaviour 2.00 Growth & Development 2 .35 2.00 Feeding baby Baby's weight gain Baby's behaviour Baby's c r y i n g 2 .32 S a f e t y 1 .94 2 . 1 9 Growth & Development 1 .94 2 .19 Baby's s l e e p i n g 1 .90 2 . 1 3 E x e r c i s e 1 .90 T r a v e l l i n g with baby 2 .07 Baby's f e e d i n g Baby's c r y i n g 1 .87 Pain from s t i t c h e s 2 .07 1.81 D r e s s i n g baby 2 .03 D i e t 1.81 Mean of responses on 0-4 s c a l e 74 The c h i - s q u a r e of 2.15 (df=4) (p>.05) for the mean f r e q u e n c i e s of responses at each l e v e l of concern f o r the sum of the t o t a l items d i d not demonstrate a s i g n i f i c a n t d i f f e r e n c e f o r the t o t a l 51 concerns. (Table 17) D i f f e r e n c e i n Concerns of M u l t i p a r a s at F i r s t Two Days and One Month S e l f The W i l c o x i n ranked t e s t f o r matched p a i r s i n d i c a t e d a c l e a r l y s i g n i f i c a n t d i f f e r e n c e i n the i n t e n s i t y of the concerns of m u l t i p a r a s between the f i r s t two days and one month a f t e r d i s c h a r g e f o r the c a t e g o r y of s e l f (Z = -3.73; p=.0002). There were i n d i v i d u a l items f o r which the d i f f e r e n c e was not s i g n i f i c a n t which i n c l u d e d : ' d i e t ' , ' e x e r c i s e ' , ' r e t u r n of f i q u r e ' and ' p e r i o d ' , 'hemorrhoids', ' t e n s i o n ' and ' f e e l i n g s of being t i e d down'. The item of ' f i n d i n g time f o r p e r s o n a l i n t e r e s t s ' was of s i g n i f i c a n t l y g r e a t e r concern on the second measure (p=.047). The rankings of the mean i n t e n s i t y of concerns d i f f e r e d somewhat f o r the two measures with Spearman's rho being .506 (p<.05). The item of ' f i n d i n g p e r s o n a l time' moved up to the second h i g h e s t concern f o r t h i s c a t e g o r y on the second measure. (Table 22) 75 Table 22: P r i o r i t y Ranking of Concerns of M u l t i p a r a s Regarding S e l f (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 I tern Mean F a t i g u e 2 .25 Return of f i g u r e 2 .06 Return of f i g u r e 2 .22 Fat igue 1 .69 Being a good mother 2 .03 Personal time 1 .69 Labour & D e l i v e r y exp. 1 .78 Being a good mother 1 .60 Breast soreness 1 .75 Exerc i se 1 .58 Emotional t e n s i o n 1 .69 Emotional t e n s i o n 1 .56 Care of b r e a s t s 1 .67 D i e t 1 .47 Pain from s t i t c h e s 1 .58 Care of b r e a s t s 1 .08 D i e t 1 .67 Being t i e d down 1 .19 E x e r c i s e 1 .47 Lack of c o n c e n t r a t i o n 1 .06 L o c h i a 1 .42 Return of p e r i o d 1 .06 P e r s o n a l time 1 .33 Breast soreness 0 .92 Return of p e r i o d 1 .25 Baby Blues 0 .89 Being t i e d down 1 .19 L o c h i a 0 .86 Lack of c o n c e n t r a t i o n 1 .17 C o n s t i p a t i o n 0 .83 C o n s t i p a t i o n 1 .08 Labour & d e l i v e r y exp. 0 .81 Baby blues 1 .06 Hemorrhoids 0 .78 Hemorrhoids 0 .94 Pain from s t i t c h e s 0 .47 1 Mean of responses on 0-4 s c a l e Table 23 shows t h a t the percentage of responses of 0 to 4 f o r the sum of the items i n the category of s e l f were not s i g n i f i c a n t l y d i f f e r e n t f o r the two measures i n t h i s c a t e g o r y . Baby The d i f f e r e n c e i n i n t e n s i t y of concern f o r the category of baby was found to be s i g n i f i c a n t (Z -2.91; p= .0036) f o r the t o t a l c a t e g o r y . I n d i v i d u a l items f o r which the 76 Table 23: Percentage of M u l t i p a r a s ' Responses of 0-4 T o t a l l e d a c r o s s Items i n Each Category ( f i r s t 2 days versus 1 month) Category Time L e v e l of Concern Measure 0 1 2 3 4 S e l f 1st 2 days 26. 1 23 .8 27 .7 1 6 . 1 6. 10 18 items 1 month 36. 1 25 .6 22 .8 1 2 .2 2. 80 Baby 1st 2 days 28. 0 21 .9 26 .6 19 .0 4. 80 21 items 1 month 37. 6 30 .4 19 .0 11 .0 2. 10 Partner 1st 2 days 28. 3 23 .3 26 .7 18 .3 3. 10 6 items 1 month 30. 0 25 .0 25 .0 15 .0 4. 80 Family 1st 2 days 20. 0 26 .7 28 .3 21 .7 3. 70 6 items 1 month 26. 7 30 .0 30 .0 1 1 .5 3. 70 T o t a l 1st 2 days 26. 3 23 .3 27 .3 10 .0 4. 90 51 items 1 month 34. 7 28 . 1 22 .4 1 1 .8 2. 70 d i f f e r e n c e was not s i g n i f i c a n t i n c l u d e d ' i n f a n t ' s rashes', ' f u s s i n e s s ' , ' s l e e p i n g ' , ' c r y i n g ' and ' i n t e r p r e t i n g i n f a n t ' s behaviour'. The ranking of the mean i n t e n s i t y of concern scores as seen i n Table 24 show some v a r i a t i o n with Spearman's rho f o r comparison of ranks being .763 (p<.05). Table 23 g i v e s the percentage of responses of 0 to 4 f o r the sum of the 21 items i n the category of baby. 77 Table 24: P r i o r i t y Ranking of Concerns of M u l t i p a r a s Regarding Baby (1st 2 days vs. 1 month) I tern 1st 2 days One month Mean 1 Item Mean Safe t y 2 .08 Saf e t y 1 .56 Growth & Development 1 .94 Recognizing i l l n e s s 1 .50 Feeding baby 1 .92 Growth & Development 1 .36 Recognizing i l l n e s s Baby's weight gain Baby's s l e e p i n g 1 .91 F u s s i n e s s 1 .33 1 .77 Baby's s l e e p i n g 1 .33 1 .64 Baby's f e e d i n g Baby's rashes 1 .31 Immunizing baby 1 .64 1 .31 D r e s s i n g baby 1 .64 Baby's c r y i n g 1 .31 Care of cor d 1 .56 D r e s s i n g baby 1 .22 Baby's behaviour 1 .47 Immunizing baby 1 .19 Baby's rashes 1 .47 Baby's Behaviour 1 . 1 4 P h y s i c a l appearance 1 .44 T r a v e l l i n g with baby 1 .08 Baby's f u s s i n e s s Baby's c r y i n g 1 .44 Baby's weight gain 1 .08 1 .44 P h y s i c a l appearance 1 .06 T r a v e l l i n g with baby 1 .44 Bowel movements 0 .94 Baby's b r e a t h i n g 1 .39 Baby's Br e a t h i n g 0 .89 Bowel movements 1 .39 Bathing baby 0 .81 Vitamins and f l o r i d e 1 .36 Vitamins and f l o r i d e 0 .75 Bathing baby 1 .25 Comfort i n h a n d l i n g baby 0 .67 Comfort i n h a n d l i n g baby 1 .06 Care of c o r d 0 .61 Care of c i r c u m s i o n 0 .50 Care of c i r c u m s i o n 0 .42 Mean of responses on 0-4 s c a l e Partner The d i f f e r e n c e i n the i n t e n s i t y of the concerns f o r the category of p a r t n e r was not s i g n i f i c a n t f o r the two measures of the m u l t i p a r a s (Z= -1.12; P=.2608). (Table 25) The ranking of the mean i n t e n s i t y scores were the same f o r both measures i n t h i s category and Spearmans's rho was .10 (p<.05) 78 Table 25: P r i o r i t y Ranking of Concerns of M u l t i p a r a s Regarding Partner (1st 2 days vs. 1 month) 1st 2 days One month I tern Mean 1 I tern Mean B i r t h c o n t r o l 1 .81 B i r t h c o n t r o l 1 .72 Time alone together 1 .56 Time alone together 1 .53 Time f o r r e c r e a t i o n 1 .47 Time f o r r e c r e a t i o n 1 .50 R e l a t i o n s h i p with R e l a t i o n s h i p with p a r t n e r 1 .36 partner 1 .22 Sexual r e l a t i o n s 1 .33 Sexual r e l a t i o n s 1 .19 Partner being a good Partner being a good f a t h e r 1 .22 f a t h e r 1 .05 1 Mean of responses on 0-4 s c a l e The d i f f e r e n c e i n the percentage of concerns at each l e v e l of i n t e n s i t y of concern were a l s o not s i g n i f i c a n t f o r the sum of the items i n t h i s c a t e gory. (Table 23) Family In a n a l y z i n g the responses to the category of f a m i l y the d i f f e r e n c e i n i n t e n s i t y of concern between the two measures of the m u l t i p a r a s was found to be s i g n i f i c a n t (Z= -2.22; p =.0267). I n d i v i d u a l items i n which the d i f f e r e n c e was s i g n i f i c a n t i n c l u d e d : 'change i n f a m i l y l i f e s t y l e ' and ' r e a c t i o n of s i b l i n g s ' . There were some changes i n the ranking of mean i n t e n s i t y of concern scores with ' f i n a n c e s ' becoming of g r e a t e r concern on the second measure. (Table 26) Spearman's rho f o r the comparison of the ranks between the two measures was .899 (p<.05) 79 Table 26: P r i o r i t y Ranking of Concerns of M u l t i p a r a s Regarding Family (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 Item Mean Reaction of s i b l i n g s 2 .19 Reaction of s i b l i n g s 1 .72 Demands of household 1 .89 Finances 1 .69 Finances 1 .58 Household demands 1 .65 Family l i f e s t y l e change 1 .58 Family l i f e s t y l e change 1 .25 A v a i l a b i l i t y of A v a i l a b i l i t y of resources 1 .25 resources 1 .00 L i m i t i n g v i s i t o r s 1 .22 L i m i t i n g v i s i t o r s 0 .97 1 Mean of responses on 0-4 s c a l e Table 23 shows the mean f r e q u e n c i e s of responses at each l e v e l of concern f o r the sum of the items i n the category of f a m i l y . T o t a l Items In a n a l y z i n g the d i f f e r e n c e i n the i n t e n s i t y of t o t a l concerns between the two q u e s t i o n n a i r e s completed by the m u l t i p a r a s f o r the t o t a l items, the d i f f e r e n c e was found to be s i g n i f i c a n t (Z=-3.45; p=.0006). The ranking of the mean i n t e n s i t y of concern scores f o r a l l items shows v a r i a t i o n with ' r e t u r n of f i g u r e ' and ' b i r t h c o n t r o l ' becoming the most i n t e n s e concerns at one month a f t e r d i s c h a r g e . Spearman's rho f o r the comparison of ranks was .599 (p<.05) (Table 27) 80 Table 27: P r i o r i t y Ranking of T o t a l Concerns of M u l t i p a r a s (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 I tern Mean F a t i g u e 2.25 Return of f i g u r e 2.06 Return of f i g u r e 2.22 B i r t h c o n t r o l 1 .72 Reaction of s i b l i n g s 2.19 Reaction of s i b l i n g s 1 .72 S a f e t y 2.08 F a t i g u e 1 .72 Being a good mother 2.03 Pers o n a l i n t e r e s t s 1 .69 Recognizing i l l n e s s 1 .91 Finances 1 .69 Demands of household 1 .89 Demands of household 1 .68 B i r t h c o n t r o l 1.81 Being a good mother 1 .60 Labour & d e l i v e r y exp. 1 .78 E x e r c i s e 1 .58 Baby's weight g a i n 1 .77 Emotional t e n s i o n 1 .56 Breast soreness 1 .'75 Sa f e t y 1 .56 Emotional t e n s i o n 1 .69 Recognizing i l l n e s s 1 .50 1 Mean of responses on 0-4 s c a l e The mean f r e q u e n c i e s of responses at each l e v e l of concern f o r the sum of the t o t a l items f o r m u l t i p a r a s d i d not show a s i g n i f i c a n t d i f f e r e n c e between the f i r s t two days and one month a f t e r d i s c h a r g e . Chi-square =2.92 (df=4) (p>.05). (Table 23). Summary The r e s u l t s of the a n a l y s i s of data have been r e p o r t e d i n t h i s chapter f o r the purpose of i d e n t i f y i n g any s i g n i f i c a n t d i f f e r e n c e i n the concerns of p r i m i p a r a s and m u l t i p a r a s i n the f i r s t two days or one month a f t e r d i s c h a r g e as w e l l as any s i g n i f i c a n t d i f f e r e n c e between 81 these two time measures. The a n a l y s i s of the demographic data has a l s o been r e p o r t e d i n order to d e s c r i b e the c h a r a c t e r i s t i c s of the sample group of mothers. A n a l y s i s u s i n g the Mann-Whitney U t e s t has shown no s i g n i f i c a n t d i f f e r e n c e i n i n t e n s i t y of concern between the two groups of mothers f o r the t o t a l concerns or any of the four c a t e g o r i e s a t e i t h e r time measure. There were i n d i v i d u a l items however, i n which the d i f f e r e n c e between the two groups was s i g n i f i c a n t . A n a l y s i s of the data using the W i l c o x i n ranked t e s t f o r matched p a i r s has shown a s i g n i f i c a n t d i f f e r e n c e f o r both groups of mothers between the f i r s t two days at home and one month a f t e r d i s c h a r g e f o r the t o t a l concerns and f o r a l l c a t e g o r i e s except p a r t n e r . There were again i n d i v i d u a l items i n which the d i f f e r e n c e was not s i g n i f i c a n t between the two time measures. Chi-square a n a l y s i s a l s o d i d not i n d i c a t e any s i g n i f i c a n t d i f f e r e n c e between the number of concerns mothers had at each l e v e l of i n t e n s i t y of concern f o r the sum of the 51 items on the q u e s t i o n n a i r e . The f o l l o w i n g chapter w i l l now d i s c u s s the s i g n i f i c a n c e of these f i n d i n g s , t h e i r i m p l i c a t i o n s f o r program p l a n n i n g and recommendations f o r f u r t h e r r e s e a r c h i n t h i s a r e a . 82 CHAPTER 5 F i n d i n g s and Recommendations I n t r o d u c t i o n The s i g n i f i c a n c e of the f i n d i n g s of the p r e v i o u s chapter as w e l l as a comparison with the f i n d i n g s i n the l i t e r a t u r e w i l l now be d i s c u s s e d . The s i g n i f i c a n c e of the c h a r a c t e r i s t i c s of the sample w i l l be d i s c u s s e d f i r s t i n terms of the c h a r a c t e r i s t i c s of the t o t a l p o p u l a t i o n . The remaining f i n d i n g s w i l l be d i s c u s s e d i n r e l a t i o n to t h e i r s i g n i f i c a n c e to the four hypotheses of the study. I m p l i c a t i o n s f o r program p l a n n i n g f o r t h i s c l i e n t group w i l l be i d e n t i f i e d as w e l l as recommendations f o r f u t u r e r e s e a r c h i n t h i s a r e a . The Sample During the two and a h a l f month p e r i o d i n which mothers were approached to p a r t i c i p a t e i n the study 210 l i v e b i r t h s o c c u r r e d w i t h i n the study boundries. S e v e n t y - f i v e of these b i r t h s were known not to meet the study c r i t e r i a because of cesarean s e c t i o n or low b i r t h weight of the i n f a n t . N i n e t y - f i v e mothers consented to p a r t i c i p a t e i n the study when approached in the h o s p i t a l . The remaining 35 l i v e b i r t h s d u r i n g t h i s time p e r i o d i n v o l v e d mothers who were 83 s i n g l e , who d i d not speak E n g l i s h , who d e l i v e r e d i n a d i f f e r e n t h o s p i t a l or f o r whom there were p h y s i c a l c o m p l i c a t i o n s . The ages of the mothers were spread across the a c c e p t a b l e c r i t e r i a with the modal c a t e g o r y being 23-28 f o r p r i m i p a r a s and 29-34 f o r m u l t i p a r a s , which i s t y p i c a l f o r the p o p u l a t i o n of mothers i n t h i s a r e a . There was a l s o a wide range of e d u c a t i o n a l backgrounds w i t h i n the sample mothers with the l a r g e s t group having completed high school which was a l s o c h a r a c t e r i s t i c of the study p o p u l a t i o n . The d i s t r i b u t i o n of the e t h n i c backgrounds of the mothers c l o s e l y resembled the d i s t r i b u t i o n found i n the 1981 Canada Census i n f o r m a t i o n f o r mother tonque f o r the study a r e a . The percentage of East Indian and Chinese e t h n i c groups were s l i g h t l y lower which was not s u r p r i s i n g c o n s i d e r i n g the e x c l u s i o n of non e n g l i s h speaking mothers. Canada census f o r 1981 a l s o i d e n t i f i e d 10% of the p o p u l a t i o n i n t h i s area as having l i v e d i n Canada f o r l e s s than f i v e y e a r s . The percentage of mothers b r e a s t f e e d i n g t h e i r i n f a n t s and r e t u r n i n g to work f i t with the o p i n i o n s of the community h e a l t h nurses working i n the study a r e a . The number of mothers who attended p r e n a t a l c l a s s e s was c o n s i s t e n t with p r e v i o u s f i q u r e s with the m a j o r i t y of p r i m i p a r a s having attended while only a m i n o r i t y of m u l t i p a r a s attended with t h e i r second pregnancy. The f i n d i n g s r e g a r d i n g h e l p at home 84 were c o n s i s t e n t with those of G r u i s (1974) and Pate (1979) who a l s o found that husbands were most f r e q u e n t l y i d e n t i f i e d as being the most h e l p f u l at home. I t appears that the sample was r e p r e s e n t a t i v e of the p o p u l a t i o n of mothers who met the c r i t e r i a f o r i n c l u s i o n i n the study. Care must be taken i n g e n e r a l i z i n g the f i n d i n g s to mothers who do not meet the c r i t e r i a f o r p a r t i c i p a t i o n , p a r t i c u l a r l y s i n g l e mothers and those who do not speak E n g l i s h . D i f f e r e n c e i n Concerns of P r i m i p a r a s and M u l t i p a r a s During the F i r s t Two Days The f i n d i n g of no s i g n i f i c a n t d i f f e r e n c e between the o v e r a l l concerns of p r i m i p a r a s and m u l t i p a r a s i n the f i r s t few days a f t e r d i s c h a r g e i s c o n s i s t e n t with the f i n d i n g s of G r u i s (1974), Pate (1979) and H a r r i s o n and Hicks (1983). They found no d i f f e r e n c e i n frequency of concerns over the t o t a l postpartum p e r i o d . In the category of concerns r e g a r d i n g s e l f there were no i n d i v i d u a l items i n which the d i f f e r e n c e was s i g n i f i c a n t and the ranking of the p r i o r i t y of concerns was very s i m i l a r . A l l of the items were found to be of some concern to more than 70% of the mothers. These f i n d i n g s support the need f o r s u p p o r t i v e - e d u c a t i v e s e r v i c e s which focus on the mother f o r both p r i m i p a r a s and m u l t i p a r a s soon a f t e r d i s c h a r g e from h o s p i t a l . 85 In the category of baby t h e r e were items f o r which the d i f f e r e n c e between the two groups was s i g n i f i c a n t . Items such as 'bathing the baby' and ' f e e l i n g comfortable i n h a n d l i n g the baby' are i n f a n t c a r e items f o r which i t i s l o g i c a l to assume that the m u l t i p a r a s ' p r e v i o u s experience would make a d i f f e r e n c e . Items which r e l a t e to the w e l l being of the baby such as ' s a f e t y ' , 'normal growth and development', 'weight gain' and 'f e e d i n g the baby' were of concern to both groups of mothers which would i n d i c a t e a need f o r support and reassurance i n the e a r l y days a f t e r d i s c h a r g e . i n regards to the w e l l being of t h i s baby. Once again the f i n d i n g s i n d i c a t e a need f o r p r o f e s s i o n a l support soon a f t e r d i s c h a r g e with the p r i m i p a r a s r e c e i v i n g a d d i t i o n a l a s s i s t a n c e and support i n areas of i n f a n t c a r e . In regards to t h e i r p a r t n e r both groups of mothers had s i m i l a r concerns about ' f i n d i n g time to be together' and ' f o r r e c r e a t i o n ' which again i s to be expected c o n s i d e r i n g the i n c r e a s e d demands p l a c e d on both p a r t n e r s d u r i n g the e a r l y days at home. ' L i m i t i n g v i s i t o r s ' was the o n l y item besides ' r e a c t i o n of s i b l i n g s ' i n the category of f a m i l y i n which the d i f f e r e n c e i n i n t e n s i t y of concern was s i g n i f i c a n t l y d i f f e r e n t f o r the two groups at t h i s time. The d i f f e r e n t r a n k i n g of p r i o r i t y of the items between the two groups was again to be expected with the p r i m i p a r a s e x p e r i e n c i n g a g r e a t e r change i n f a m i l y l i f e s t y l e and more frequent 86 v i s i t o r s f o r the f i r s t baby. As r e p o r t e d by Moss (1981) the m u l t i p a r a s found the ' r e a c t i o n of the other c h i l d r e n at home' and 'meeting demands of the household' to be the g r e a t e s t concerns i n t h i s c a t e g o r y . In examining the d i f f e r e n c e i n the ranking of the t o t a l items between the two groups at t h i s time, concern r e g a r d i n g ' r e t u r n of f i g u r e to normal' and 'managing the demands of the household' were of g r e a t e s t concern f o r the m u l t i p a r a s whereas ' r e c o g n i z i n g i l l n e s s i n the baby', 'being a good mother', ' s a f e t y ' and 'feeding the baby' were of 'much' to ' c r i t i c a l concern' f o r more than 50% of the p r i m i p a r a s . G r u i s (1973), Pate (1979) and H a r r i s o n and Hicks (1983) found 'return of f i g u r e ' and 'household demands' to be the g r e a t e s t o v e r a l l concerns of t h e i r sample, which may have been due to the f a c t t h a t t h e i r sample i n c l u d e d more m u l t i p a r a s than p r i m i p a r a s . I t was the e x p e c t a t i o n that d u r i n g the f i r s t few days at home the p r i m i p a r a s would be more concerned about c a r i n g f o r the baby and t h e i r a b i l i t y to mother e f f e c t i v e l y than t h e i r own body image. T h i s e x p e c t a t i o n i s supported by these f i n d i n g s as w e l l as those of B u l l (1981). I t i s evident t h e r e f o r e that the n u l l h y p o t h e s i s of no s i g n i f i c a n t d i f f e r e n c e i n frequency and i n t e n s i t y of concern between p r i m i p a r a s and m u l t i p a r a s i n the f i r s t two days at home must be accepted f o r the t o t a l c o ncerns. There are however, s i g n i f i c a n t d i f f e r e n c e s i n s p e c i f i c areas which have i m p l i c a t i o n s f o r those p l a n n i n g 87 programs f o r these c l i e n t s . D i f f e r e n c e i n Concerns of P r i m i p a r a s and M u l t i p a r a s One Month A f t e r Discharge The data a n a l y s i s has demonstrated that the n u l l h y p o t h e s i s of no s i g n i f i c a n t d i f f e r e n c e i n the frequency and i n t e n s i t y of concerns of p r i m i p a r a s and m u l t i p a r a s one month a f t e r d i s c h a r g e a l s o must be accep t e d f o r the t o t a l items of concern. Once again there were s p e c i f i c areas r e l a t e d to the baby i n which the d i f f e r e n c e s were s i g n i f i c a n t that must be i d e n t i f i e d . The p r i m i p a r a s c o n t i n u e d to have g r e a t e r concern r e g a r d i n g ' i n t e r p r e t i n g i n f a n t behaviour', ' r e c o g n i z i n g s i g n s of i l l n e s s ' and the 'baby's f u s s i n e s s ' , which again i s l o g i c a l c o n s i d e r i n g the m u l t i p a r a s ' experience i n these a r e a s . In l o o k i n g at the t o t a l concerns of the two groups of mothers one month a f t e r d i s c h a r g e i t was apparent that the m u l t i p a r a s had g r e a t e r concerns r e g a r d i n g s e l f and f a m i l y . Items such as ' r e t u r n of f i g u r e ' , ' b i r t h c o n t r o l ' , ' r e a c t i o n of s i b l i n g s ' , ' f a t i g u e ' and 'household demands' were of some concern to more than 70% of the m u l t i p a r a s . More than 80% of the p r i m i p a r a s s t i l l had some concern r e g a r d i n g ' r e c o g n i z i n g i l l n e s s ' , 'normal growth and development' and 'baby's s l e e p i n g ' and ' f e e d i n g ' . I t i s apparent t h e r e f o r e that although the o v e r a l l d i f f e r e n c e i n means of i n t e n s i t y of concern are not s t a t i s t i c a l l y s i g n i f i c a n t , there are 88 d i f f e r e n c e s i n how the p r i o r i t y of the concerns between the two groups are ranked at one month which have i m p l i c a t o n s f o r s e r v i c e s d i r e c t e d towards these two groups of mothers. D i f f e r e n c e i n Concerns of Pr i m i p a r a s i n the F i r s t Two Days and One Month A f t e r Discharge The data a n a l y s i s has demonstrated a s i g n i f i c a n t d i f f e r e n c e i n the i n t e n s i t y of the concerns a f t e r one month at home with the baby f o r p r i m i p a r a s f o r the o v e r a l l concerns. A l l of the items f o r which the d i f f e r e n c e i n i n t e n s i t y of concern was s t a t i s t i c a l l y s i g n i f i c a n t i n v o l v e d a decrease i n mean i n t e n s i t y of concern one month a f t e r d i s c h a r g e . For many of the items i n which the d i f f e r e n c e was not s i g n i f i c a n t at .05 there was an i n c r e a s e i n the mean i n t e n s i t y s c o r e . Items such as ' d i e t ' , ' e x e r c i s e ' , ' r e t u r n of f i g u r e ' , 'being t i e d down' and 'personal time' i n the category of s e l f , i n c r e a s e d i n t h e i r mean l e v e l of i n t e n s i t y of concern on the second measure. Although the i n c r e a s e was not s t a t i s t i c a l l y s i g n i f i c a n t the f a c t t h at there was not a r e d u c t i o n i n the concern i s l o g i c a l c o n s i d e r i n g the mother's a b i l i t y to focus more on h e r s e l f at one month and to recognize her lack of time to do many of the a c t i v i t i e s she engaged i n p r i o r to motherhood. The s i g n i f i c a n t decrease i n items r e l a t e d to p h y s i c a l d i s c o m f o r t i s c o n s i s t e n t with B u l l ' s (1981) f i n d i n g s of a decrease i n i n t e n s i t y of concern of these items a f t e r one week at home. 89 In the category of baby the items i n which the d i f f e r e n c e was not s i g n i f i c a n t were those which e i t h e r c o n t i n u e d to be of h i g h p r i o r i t y , such as the 'baby's f u s s i n e s s ' , ' s l e e p i n g ' and ' c r y i n g ' and ' i n t e r p r e t i n g behaviour' or c o n t i n u e d to be of low p r i o r i t y such as 'care of the c i r c u m s i s i o n ' . The items f o r which there was the g r e a t e s t decrease i n concern i n v o l v e d a c q u i r i n g a s k i l l such as 'bathing the baby' or ' c a r i n g f o r the c o r d ' , which again i s c o n s i s t e n t with B u l l ' s f i n d i n g t h at i n f a n t care items decreased i n i n t e n s i t y of concern a f t e r one week. B u l l (1981) a l s o found no s i g n i f i c a n t change i n concerns r e g a r d i n g p a r t n e r and f a m i l y a f t e r one week. The f i n d i n g s of t h i s study a l s o do not i d e n t i f y a d i f f e r e n c e i n concerns r e g a r d i n g p a r t n e r a f t e r one month i n d i c a t i n g t h a t concerns i n t h i s area such as ' f i n d i n g time alone t o g e t h e r ' and ' r e l a t i o n s h i p with p a r t n e r ' may have e x i s t e d p r i o r to d e l i v e r y or which c o n t i n u e beyond the immediate postpartum p e r i o d . T h i s study d i d f i n d a d i f f e r e n c e i n the t o t a l c a t e g o r y of f a m i l y a f t e r one month f o r the p r i m i p a r a s , with items such as ' l i m i t i n g v i s i t o r s ' and 'change i n f a m i l y l i f e s t y l e ' d e c r e a s i n g s i g n i f i c a n t l y i n i n t e n s i t y of concern. I t i s l o g i c a l to assume that i t takes longer than the one week allowed i n B u l l ' s (1981) study f o r these concerns to be r e s o l v e d . The concern r e g a r d i n g 'managing the demands of the household' d i d not decrease s i g n i f i c a n t l y a f t e r one 90 month f o r the p r i m i p a r a s . T h i s i s not s u r p r i s i n g s i n c e i n i t i a l h e l p , which the mother may have had i n the e a r l y days at home, may no longer be a v a i l a b l e . A l s o many of the normal household tasks which the mother may have ignored d u r i n g the f i r s t few weeks at home may now begin to demand her a t t e n t i o n . In l o o k i n g at how the ranking of the t o t a l concerns d i f f e r s f o r the p r i m i p a r a s a f t e r one month at home i t i s apparent that the o v e r a l l change i n p r i o r i t y i s not s i g n i f i c a n t . Items such as ' r e t u r n of f i g u r e to normal', ' d i e t ' and ' e x e r c i s e ' have i n c r e a s e d i n p r i o r i t y a f t e r one month which i s more c o n s i s t e n t with the pr e v i o u s l i t e r a t u r e , however many items f o c u s i n g on the i n f a n t a l s o c o n t i n u e to be of higher p r i o r i t y at one month f o r the p r i m i p a r a s which d i f f e r s from the f i n d i n g s of G r u i s (1974) Pate (1979) and H a r r i s o n and Hicks (1983) who found ' r e t u r n of f i g u r e ' , ' d i e t ' and 'meeting demands' to be of g r e a t e s t concern. These authors a l s o found ' f a t i g u e ' , ' i n f a n t behaviour' and 's a f e t y ' to be of moderate concern f o r both groups of mothers which i s c o n s i s t e n t with the f i n d i n g s of t h i s study. D i f f e r e n c e i n Concerns of M u l t i p a r a s i n the F i r s t Two Days and One Month A f t e r Discharge The data a n a l y s i s i n d i c a t e s that the n u l l h y p o t h e s i s of no d i f f e r e n c e i n concerns of m u l t i p a r a s between the f i r s t two days and one month a f t e r d i s c h a r g e must a l s o be r e j e c t e d 91 f o r the t o t a l concerns. As with the p r i m i p a r a s there are areas i n which the d i f f e r e n c e i s not s i g n i f i c a n t which have i m p l i c a t i o n s f o r program p l a n n i n g . Once again the items i n which the i n t e n s i t y of concern was s i g n i f i c a n t l y d i f f e r e n t i n v o l v e d a. decrease i n the mean i n t e n s i t y of concern. In the category of s e l f , again items such as 'r e t u r n of f i g u r e ' , ' d i e t ' , 'emotional t e n s i o n ' and 'being t i e d down' maintained t h e i r mean i n t e n s i t y of concern a f t e r one month and t h e r e f o r e i n c r e a s e d i n t h e i r p r i o r i t y i n the o v e r a l l ranking of items. In the ca t e g o r y of baby the items which maintained t h e i r i n t e n s i t y of concern were areas i n which mothers f r e q u e n t l y seek a s s i s t a n c e beyond the i n i t i a l postpartum p e r i o d . These i n c l u d e 'baby's rashes', ' f u s s i n e s s ' , ' s l e e p i n g ' , ' c r y i n g ' and ' i n t e r p r e t i n g i n f a n t behaviour'. These are a l s o areas i n which the mothers' experience with one i n f a n t may be very d i f f e r e n t from that with another i n f a n t and t h e r e f o r e m u l t i p a r a s may continue to have concerns because t h i s baby i s very d i f f e r e n t from her o t h e r s . As with the p r i m i p a r a s the n u l l h y p o t h e s i s was supported i n the categor y of partner with none of the items being s i g n i f i c a n t l y d i f f e r e n t i n i n t e n s i t y a f t e r one month. B i r t h c o n t r o l c o n t i n u e d to be the h i g h e s t p r i o r i t y f o r the m u l t i p a r a s i n t h i s c a t e gory. I t i s p o s s i b l e that the m u l t i p a r a s were reexamining the is s u e of ' b i r t h c o n t r o l ' i n 92 terms of whether they f e l t t h e i r f a m i l y was now complete and were c o n s i d e r i n g a l t e r n a t i v e o p t i o n s than they d i d a f t e r t h e i r f i r s t i n f a n t . In regards to the m u l t i p a r a s ' concerns r e g a r d i n g f a m i l y , the i n t e n s i t y of concern r e g a r d i n g ' r e a c t i o n of s i b l i n g s ' d i d decrease s i g n i f i c a n t l y a f t e r one month even though i t remained of hi g h e s t p r i o r i t y i n t h i s c a t e g o r y . I t seems l i k e l y t h a t many of the mothers found t h a t a f t e r the i n i t i a l r e a c t i o n of t h e i r other c h i l d r e n to the new baby t h e i r concerns were r e s o l v e d . In the f a m i l i e s i n which a problem d i d occur with other s i b l i n g s i t i s l i k e l y t h a t the concern would have continued to be of importance beyond the i n i t i a l postpartum p e r i o d . The o v e r a l l ranking of the p r i o r i t y of concerns f o r the t o t a l items again i d e n t i f i e s many s i m i l a r i t i e s but a l s o some d i f f e r e n c e s from the p r e v i o u s l i t e r a t u r e i n which p r i m i p a r a s and m u l t i p a r a s were not c o n s i d e r e d s e p a r a t e l y . Items such as ' r e t u r n of f i g u r e to normal', ' f a t i g u e ' and 'household demands' were i n c l u d e d i n the ten h i g h e s t ranked concerns as found by H a r r i s o n and Hicks (1983) and Pate (1979). Items such as ' b i r t h c o n t r o l ' , ' r e a c t i o n of s i b l i n g s ' , ' f i n a n c e s ' and 'being a good mother' were however a l s o found to be of hi g h e s t p r i o r i t y i n t h i s study. The p r e v i o u s s t u d i e s while l o o k i n g at the e f f e c t of p a r i t y on the o v e r a l l number of concerns and f i n d i n g no s i g n i f i c a n t d i f f e r e n c e d i d not separate the two groups of mothers when examining the 93 i n t e n s i t y of concerns regarding i n d i v i d u a l items. T h i s may account f o r the s p e c i f i c d i f f e r e n c e i n the f i n d i n g s of t h i s study d e s p i t e the agreement i n the f i n d i n g of no o v e r a l l d i f f e r e n c e i n the concerns between the two groups. L i m i t a t i o n s of the Study A l i m i t a t i o n of the study was the use of a v o l u n t e e r , sample of convenience. Comparing demographic c h a r a c t e r i s t i c s of the sample with those of the t a r g e t p o p u l a t i o n was an attempt to support g e n e r a l i z a b i l i t y . However, c a r e must be taken i n g e n e r a l i z i n g f i n d i n g s to mothers with c h a r a c t e r i s t i c s s i m i l a r to those of the sample. The use of a q u e s t i o n n a i r e f o r data c o l l e c t i o n has c e r t a i n advantages such as p r o v i d i n g anonymity of the respondents and e l i m i n a t i n g observer e r r o r as a source of b i a s . However, disadvantages of t h i s method must a l s o be r e c o g n i z e d . I t c o u l d only be used f o r those s u b j e c t s who c o u l d read and w r i t e the language and had the p a t i e n c e and m o t i v a t i o n to respond. There was a l s o an i n c r e a s e d chance of response e r r o r and l i m i t a t i o n s i n the depth of the responses o b t a i n e d . A l s o , being a s t r u c t u r e d t o o l , i t d i d not allow f o r v a r i a t i o n i n response and the absence of an i n t e r v i e w e r d i d not permit the c l a r i f i c a t i o n of unusual or ambiguous responses. An a d d i t i o n a l l i m i t a t i o n of t h i s study i s the f a c t t h a t the o r i g i n a l q u e s t i o n n a i r e was r e v i s e d and t h e r e f o r e p r e v i o u s i n f o r m a t i o n c o n c e r n i n g r e l i a b i l i t y and 94 v a l i d i t y c o u l d not be a p p l i e d . As mentioned i n Chapter 3 content v a l i d i t y f o r t h i s q u e s t i o n n a i r e was e s t a b l i s h e d by a panel of community h e a l t h nurses working i n the study area. Hoyt's estimate of r e l i a b i l i t y was c a l c u l a t e d and ranged from .97 f o r the t o t a l items to .81 f o r the category of f a m i l y on the f i r s t measure. For the q u e s t i o n n a i r e s completed one month a f t e r d i s c h a r g e , Hoyt's r e l i a b i l i t y measure ranged from .98 f o r the t o t a l items to .85 f o r the categor y of f a m i l y . Chronbach's Alpha scores f o r i n t e r n a l r e l i a b i l i t y were a l s o c a l c u l a t e d f o r the t o t a l items on both time measures. The score f o r the a d m i n i s t r a t i o n of the q u e s t i o n n a i r e two days a f t e r d i s c h a r g e was .82 f o r the t o t a l items and .83 when the q u e s t i o n n a i r e s were completed one month l a t e r . I t i s p o s s i b l e to see t h e r e f o r e , that the r e v i s i o n s that were made in the q u e s t i o n n a i r e d i d not have a s i g n i f i c a n t e f f e c t on the i n t e r n a l r e l i a b i l i t y of the o r i g i n a l instrument. I m p l i c a t i o n s f o r Program Planning The f i n d i n g s of t h i s study support the need i d e n t i f i e d i n the l i t e r a t u r e f o r s u p p o r t i v e - e d u c a t i v e s e r v i c e s d u r i n g the postpartum p e r i o d f o r both p r i m i p a r a s and m u l t i p a r a s . S p e c i f i c recommendations can be drawn from the f i n d i n g s f o r the d i f f e r i n g f o c i of these s e r v i c e s f o r the two types of mothers as w e l l as over the postpartum p e r i o d . In p l a n n i n g s e r v i c e s f o r the new mother duri n g the 95 f i r s t days a f t e r d i s c h a r g e , f a c t o r s such as the mothers' l e v e l of f a t i g u e , pain and emotional t e n s i o n must a l s o be c o n s i d e r e d and t h e r e f o r e i t i s u n l i k e l y t h a t the mother w i l l be a b l e to p a r t i c i p a t e i n programs o u t s i d e of the home. Home v i s i t s or telephone c o n t a c t s by community h e a l t h nurses have t r a d i t i o n a l l y been o f f e r e d to new mothers and t h i s study supports t h e i r n e c e s s i t y f o r both p r i m i p a r a s and m u l t i p a r a s soon a f t e r d i s c h a r g e from h o s p i t a l . Many of the items which were of concern d u r i n g these e a r l y days at home r e q u i r e hands on reassurance from the s u p p o r t i v e i n d i v i d u a l . The o n l y way to r e l i e v e the mother's concern r e g a r d i n g the baby's weight gain and feed i n g i s to weigh the baby and ass e s s the adequacy of the gain and method of f e e d i n g . Both groups of mothers i d e n t i f i e d a need f o r reassurance of t h e i r a b i l i t y to mother e f f e c t i v e l y and i t i s u n l i k e l y that a mother would be reassured by a telephone c o n t a c t from someone who had not met her or h e r . i n f a n t . The p r i m i p a r a s i d e n t i f i e d a need f o r reassurance i n t h e i r a b i l i t y to p h y s i c a l l y care f o r the i n f a n t d e s p i t e t h e i r stay i n a h o s p i t a l whose philosophy supported p a t i e n t t e a c h i n g . T h i s type of e d u c a t i v e support would a l s o r e q u i r e a d i r e c t c l i e n t approach with the i n f a n t . T h i s study p r o v i d e s evidence f o r a home v i s i t f o r both p r i m i p a r a s and m u l t i p a r a s i n the f i r s t week a f t e r d i s c h a r g e from h o s p i t a l . 96 For the p r i m i p a r a s there would need to be i n c r e a s e d focus on the p h y s i c a l care of the i n f a n t and reassurance of we l l n e s s and e f f e c t i v e mothering. A n t i c i p a t o r y guidance should be given at t h i s time r e g a r d i n g the no r m a l i t y of the mothers' p r e s e n t and f u t u r e concerns. The mother should have an o p p o r t u n i t y to express her concerns about the sudden change i n l i f e s t y l e and lack of p e r s o n a l time and time management s t r a t e g i e s and e f f e c t i v e use of reso u r c e s d i s c u s s e d to h e l p decrease the l e v e l of f a t i g u e and f e e l i n g s of being t i e d down. V i s i t s to the m u l t i p a r a s should focus more on the mothers' concerns r e g a r d i n g t h e i r i n f a n t s ' behaviour, which may be d i f f e r e n t from t h e i r p r e v i o u s c h i l d r e n , and growth and development. The mothers' concern regarding the r e a c t i o n of the other c h i l d r e n a l s o needs to be addressed i n the f i r s t days at home and t e a c h i n g and support given f o r the attempts to make the adjustment as easy as p o s s i b l e . The m u l t i p a r a s concerns r e g a r d i n g b i r t h c o n t r o l may a l s o be addressed d u r i n g these e a r l y days and in f o r m a t i o n and o p t i o n s d i s c u s s e d which a s s i s t i n d e c i s i o n making. The m u l t i p a r a s a l s o i d e n t i f y a need f o r reassurance of t h e i r a b i l i t y to mother e f f e c t i v e l y and f o r s t r a t e g i e s and res o u r c e s to h e l p them e f f e c t i v e l y manage the i n c r e a s e d demands of t h e i r household. 97 The f i n d i n g s r e g a r d i n g the concerns one month a f t e r d i s c h a r g e i n d i c a t e a s i g n i f i c a n t decrease i n the mean i n t e n s i t y of many of the areas of concern. T h i s may be p a r t i a l l y due to the f a c t t h a t a l l of the mothers made use of p r o f e s s i o n a l resources a v a i l a b l e to them d u r i n g t h i s time. A l l of the sample mothers i n d i c a t e d that they had some support at home and a l l of them had had some co n t a c t with a community h e a l t h nurse or p h y s i c i a n with the m a j o r i t y having had s e v e r a l c o n t a c t s d u r i n g the one month i n t e r v a l . I t i s unknown whether these c o n t a c t s were i n i t i a t e d by the mother or the p r o f e s s i o n a l . I t i s l i k e l y that the resources t h a t were a v a i l a b l e to the mothers i n t h i s study were e f f e c t i v e i n reducing many of the concerns i d e n t i f i e d i n the e a r l y days. I t i s apparent however that there c o n t i n u e s to be a need for s u p p o r t i v e e d u c a t i v e s e r v i c e s to new mothers t h a t go beyond the i n i t i a l postpartum p e r i o d . Many of the concerns i d e n t i f i e d as being of p r i o r i t y one month a f t e r d i s c h a r g e such as ' e x e r c i s e ' , ' r e t u r n of f i g u r e to normal', 'lac k of p e r s o n a l time' and 'emotional t e n s i o n ' cannot be e f f e c t i v e l y d e a l t with i n a c l i n i c or p h y s i c i a n ' s o f f i c e . By t h i s p o i n t mothers are u s u a l l y a b l e to get out of the house and postpartum programs which combine e x e r c i s e with d i s c u s s i o n of t o p i c s of concern may be more e f f e c t i v e and c o s t e f f i c i e n t than i n d i v i d u a l c o n t a c t s with p r o f e s s i o n a l s . The programs c o u l d allow f o r s h a r i n g of concerns among the mothers and promote support from the peer group as w e l l as 98 reassurance from the p r o f e s s i o n a l s running the program as to the w e l l n e s s of the baby. Making e x e r c i s e a component of the program c o u l d be an important motivator f o r p a r t i c i p a t i o n s i n c e ' r e t u r n of f i g u r e to normal' i s a hig h p r i o r i t y concern f o r both p r i m i p a r a s and m u l t i p a r a s at t h i s time. The f i n d i n g s of t h i s study a l s o have some i m p l i c a t i o n s f o r programs o f f e r e d to mothers d u r i n g t h e i r pregnancy such as p r e n a t a l and f i t n e s s c l a s s e s . A n t i c i p a t o r y quidance before the d e l i v e r y c o u l d be h e l p f u l i n reducing the concern r e g a r d i n g such items as 'change i n l i f e s t y l e ' , ' r e a c t i o n of other s i b l i n g s ' , ' l i m i t i n g v i s i t o r s ' and 'emotional t e n s i o n ' . S e v e r a l of the mothers commented that completing the q u e s t i o n n a i r e reassured them that other mothers must experience these same concerns. Being aware of some of the common concerns of the postpartum p r i o r to d e l i v e r y may not change the postpartum e x p e r i e n c e f o r the mother but p a r t i c u l a r l y i n the e a r l y days at home may reassure her that other mothers share her concerns. Recommendations f o r Future Research The f i n d i n g s r e g a r d i n g the o v e r a l l frequency and i n t e n s i t y of concerns of p r i m i p a r a s d u r i n g the postpartum p e r i o d have now been r e p l i c a t e d i n s e v e r a l s t u d i e s . F u r t h e r r e p l i c a t i o n of the data r e g a r d i n g the d i f f e r e n c e between p r i m i p a r a s and m u l t i p a r a s w i l l be necessary to v a l i d a t e 99 these f i n d i n g s . Research i n t o the d i f f e r e n c e s between the concerns of p r i m i p a r a s and m u l t i p a r a s f o r the groups of mothers excluded from t h i s study would a l s o be of i n t e r e s t . They would i n c l u d e : mothers who d e l i v e r e d by cesarean s e c t i o n r a t h e r than v a g i n a l b i r t h ; mothers who by c h o i c e or circumstances were p a r e n t i n g t h e i r i n f a n t alone; and mothers who were not comfortable with the E n g l i s h language. The e f f e c t s of the v a r i a b l e s of age, educati o n , type of i n f a n t f e e d i n g and e t h n i c background on the d i f f e r e n c e s of concerns of p r i m i p a r a s and m u l t i p a r a s would a l s o be of value to those p l a n n i n g programs f o r these c l i e n t s . The assumption was made i n the present study that the use of p r o f e s s i o n a l r e s o u r c e s d u r i n g the f i r s t month may have reduced the concerns on the second measure. Research e v a l u a t i n g the e f f e c t i v e n e s s of home v i s i t s by the community h e a l t h nurse or v i s i t s to the p h y s i c i a n i n reducing the maternal concerns are necessary to v a l i d a t e t h i s assumption. A comparison of the c o s t e f f e c t i v e n e s s of the s e r v i c e s to new mothers p r o v i d e d by the d i f f e r e n t p r o f e s i o n a l s would be of a s s i s t a n c e c o n s i d e r i n g the f i n a n c i a l s t r a i n on the h e a l t h care system. Research i n t o how the mothers view the r o l e of these p r o f e s s i o n a l s and t h e i r e x p e c t a t i o n s i n having s p e c i f i c concerns addressed would a l s o be of va l u e . D e s c r i p t i v e i n f o r m a t i o n r e g a r d i n g the types of maternal and p a t e r n a l concerns which may p e r s i s t or change throughout the i n f a n t ' s f i r s t year of l i f e would a l s o a s s i s t i n 100 p l a n n i n g ongoing p a r e n t i n g c l a s s e s or d i s c u s s i o n groups. F i n a l l y i t would i n c r e a s e the body of knowledge i n t h i s area to have f u r t h e r indepth s t u d i e s i n t o s p e c i f i c areas of concern which have c o n s i s t e n t l y been r a t e d as being of importance to the mothers throughout the l i t e r a t u r e i n order to e f f e c t i v e l y i n t e r v e n e with those concerns. For an area of concern such as ' r e t u r n of f i g u r e to normal' f o r example i t i s not known i f there i s a problem with body image, the p h y s i o l o g i c a l changes which are o c c u r i n g , or a l a c k of knowledge r e g a r d i n g how the mother can h e l p h e r s e l f get back to normal. I t i s a l s o not known i f normal i s the same as before or a d e s i r e d s t a t e . Other s i g n i f i c a n t items c o u l d a l s o be examined i n more depth to in c r e a s e the knowledge i n t h i s a r e a . C o n c l u s i o n s In c o n c l u s i o n , t h i s study has attempted to add to the body of knowledge r e g a r d i n g the concerns or needs of both p r i m i p a r a s and m u l t i p a r a s d u r i n g the f i r s t month a f t e r d i s c h a r g e from h o s p i t a l . I t has been shown that there i s no s i g n i f i c a n t o v e r a l l d i f f e r e n c e i n the frequency and i n t e n s i t y of concerns of p r i m i p a r a s and m u l t i p a r a s e i t h e r i n the e a r l y days or one month a f t e r d i s c h a r g e . The f i n d i n g s along with others i n the l i t e r a t u r e do not support the assumption made i n p r a c t i s e t h at m u l t i p a r a s have had experience and t h e r e f o r e do not r e q u i r e s u p p o r t i v e e d u c a t i v e 101 s e r v i c e s d u r i n g the postpartum p e r i o d . D i f f e r e n c e s i n the focus of the concerns of the two groups of mothers have been i d e n t i f i e d which have i m p l i c a t i o n s f o r those p l a n n i n g programs f o r the postpartum p e r i o d . The r e s u l t s of the study a l s o show that there i s a s i g n i f i c a n t d i f f e r e n c e i n i n t e n s i t y of concerns between the e a r l y days at home and one month a f t e r d i s c h a r g e from h o s p i t a l . T h i s f i n d i n g i m p l i e s that the mothers r e q u i r e s u p p o r t i v e e d u c a t i v e s e r v i c e s soon a f t e r d i s c h a r g e which have a d i f f e r e n t focus than programs that are planned to meet the needs of the new mothers which go on beyond the i n i t i a l postpartum p e r i o d . F i n a l l y i t must be remembered that while t h i s study has examined the data i n terms of the mean frequency and i n t e n s i t y of concerns of the sample mothers, there were wide v a r i a t i o n s i n the responses of i n d i v i d u a l mothers i n many areas of concern. T h e r e f o r e while the g e n e r a l t r e n d s i n areas of concerns are v a l u a b l e to program planners and those working i n the f i e l d , the importance of the assessment of the concerns of the i n d i v i d u a l mother must be s t r e s s e d f o r the p r o f e s s i o n a l p r o v i d i n g the s u p p o r t i v e e d u c a t i v e s e r v i c e s to i n d i v i d u a l c l i e n t s . 1 02 REFERENCES Adams, M. (1963). E a r l y concerns of the p r i m i g r a v i d a mothers re g a r d i n g i n f a n t care a c t i v i t i e s . Nursing Research, 19, 72-77 Atwood, H.M. & E l l i s , J . (1971). The concept of need: An a n a l y s i s f o r a d u l t e d u c a t i o n . Adult L e a d e r s h i p , 19, 210-244. Beatty, P.T. (1981). The concept of need: Proposal f o r a working d e f i n i t i o n . J o u r n a l of the community development s o c i e t y , 12, 39-46. Becker, C. (1980). The postpartum p e r i o d . Canadian Nurse, Y2, 24-27 B e l l , D. (1978). 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American J o u r n a l of Nursing, 77, 1173. 108 APPENDIX A PRIORITY RANKING OF TOTAL CONCERNS (1 ST 2 DAYS) 109 APPENDIX A P r i o r i t y Ranking* of T o t a l Concerns (1st 2 days) Percent of Mothers Responding: 0 = no concern 1-2 = l i t t l e to moderate concern 3-4 = much to c r i t i c a l concern P r i m i p a r a s Percent M u l t i p a r a s Percent I tern 0 1 -2 3-4 I tem 0 1-2 3-4 Recognize i l l n e s s 0 39 58 F a t i g u e 1 1 47 42 Be a good mother 6 35 59 Return of f i g u r e 1 1 39 50 S a f e t y 10 39 51 S a f e t y 22 39 39 F a t i g u e 6 55 38 Rea c t i o n of s i b s 1 7 39 44 Normal growth & development 1 3 42 45 Be a good mother Normal growth 22 23 45 Feeding baby 10 35 54 and development 19 47 39 Baby Weight Gain 1 3 42 45 I n f a n t f e e d i n g 1 7 44 39 I n t e r p r e t i n g baby behaviour 1 6 35 48 Recognize i l l n e s s 22 36 42 Baby's c r y i n g 1 9 42 39 Demands of home 1 1 50 39 T r a v e l with baby 1 3 48 39 B i r t h c o n t r o l 1 9 47 33 Pain from Labour & d e l i v e r y s t i t c h e s 26 32 42 experience 17 53 30 D r e s s i n g baby 16 42 42 In f a n t wt gain 25 42 33 Baby's s l e e p i n g 19 42 39 Breast soreness 8 47 31 Return of f i g u r e 10 55 35 Emotional t e n s i o n 25 47 28 Change i n f a m i l y 10 55 35 l i f e s t y l e 10 65 26 Care of b r e a s t s 25 44 31 Breast soreness 1 0 55 36 D i e t 1 7 61 22 Labour & d e l i v e r y experience 19 42 39 Baby's s l e e p i n g 22 53 25 Bathing the baby 1 6 48 35 Immunizing baby 33 33 34 Br e a t h i n g of baby Baby's f u s s i n e s s 1 3 64 23 D r e s s i n g baby 22 58 20 1 6 52 32 Finances 1 4 64 22 F i n d i n g time alone Change i n f a m i l y together 1 3 58 30 1i f e s t y l e 22 56 22 Care of b r e a s t s 19 42 39 Pain - S t i t c h e s 1 7 64 1 9 Time f o r F i n d i n g time alone r e c r e a t i o n 10 65 26 together 25 47 28 Emotional t e n s i o n 1 6 55 29 Care of c o r d 19 53 28 * P r i o r i t y determined by mean i n t e n s i t y scores i n Tables 4-27 110 Appendix A con t i n u e d Primiparas Percent M u l t i p a r a s Percent Item 0 1-2 3-4 Item 0 1-2 3-4 G i v i n g vitamins Time f o r or f l o r i d e 19 61 19 r e c r e a t i o n 25 53 22 S e t t i n g l i m i t s 19 61 19 I n t e r p r e t i n g baby on v i s i t o r s 19 52 29 behaviour 22 59 19 Demands of home 10 64 26 Baby's rashes 30 44 25 D i e t 23 43 36 E x e r c i s e 19 67 1 4 Baby's bowel T r a v e l l i n g with movements 1 3 58 29 baby Baby's p h y s i c a l 25 53 22 Immunizing baby 1 3 62 26 appearance 25 53 22 Comfort i n han d l i n g baby 26 39 35 Baby's c r y i n g 22 66 1 1 R e l a t i o n s h i p with p a r t n e r 32 26 42 Baby's f u s s i n e s s 22 62 1 7 Care of cord 23 48 29 L o c h i a Baby's bowel 28 55 1 7 Finances 26 48 26 movements 25 64 1 1 Family p l a n n i n g 29 39 32 Br e a t h i n g of baby G i v i n g v i t a m i n s 28 56 1 6 Sexual r e l a t i o n s 23 48 30 or f l o r i d e 33 48 19 Baby's p h y s i c a l R e l a t i o n s h i p with appearance 23 55 23 pa r t n e r 33 50 1 7 Baby s k i n rashes 23 55 23 Sexual r e l a t i o n s Time f o r pe r s o n a l 28 58 1 4 E x e r c i s e 1 9 71 9 i n t e r e s t s A v a i l a b i l i t y of 28 64 9 C o n s t i p a t i o n 29 55 1 6 resources 28 58 1 4 Hemorrhoids 36 45 19 Bathing the baby 33 50 1 7 L o c h i a 19 61 1 9 Return of p e r i o d 31 59 10 I n a b i l i t y to Partner being a concentrate 23 61 1 6 good f a t h e r 36 47 1 7 F e e l i n g s of being t i e d down 26 61 1 3 L i m i t i n g v i s i t o r s 25 69 6 Partn e r being a F e e l i n g s of being good f a t h e r 42 29 29 t i e d down 31 58 1 1 A v a i l a b i l i t y of I n a b i l i t y to resources 29 55 1 6 con c e n t r a t e 36 50 1 4 Time f o r p e r s o n a l i n t e r e s t s 1 6 81 3 C o n s t i p a t i o n Comfort i n 33 58 8 Baby blues 23 71 6 h a n d l i n g baby 44 36 19 Return of p e r i o d 26 65 10 Baby blues 44 41 1 4 Circumsion 81 10 9 Hemorrhoids 50 39 1 1 Rea c t i o n of Care of s i b l i n g s 100 0 0 c ircumsion 75 1 7 9 111 APPENDIX B PRIORITY RANKING OF TOTAL CONCERNS (1 MONTH) APPENDIX B P r i o r i t y Ranking* of T o t a l Concerns (1 month) Percent of Mothers Responding: 0 = no concern 1-2 = l i t t l e to moderate concern 3-4 = much to c r i t i c a l concern Primiparas Percent M u l t i p a r a s Percent I tern 0 1-2 3-4 I tern 0 1 -2 3-4 Recognize i l l n e s s 3 52 45 Return of f i g u r e 1 1 50 39 Be a good mother 16 39 45 B i r t h c o n t r o l 28 44 28 Return of f i g u r e 10 45 45 Reaction of s i b s 1 7 39 44 Fat i g u e 1 0 58 32 Fa t i g u e Time f o r p e r s o n a l 1 7 64 19 Baby's f u s s i n e s s 7 52 42 i n t e r e s t s 1 7 64 19 Infant behaviour 10 52 38 Finances 1 7 67 1 7 Safe t y 26 32 42 Household demands 1 7 64 19 Normal growth and development 1 9 45 35 Be a good mother 31 44 25 I n f a n t ' s s l e e p i n g 10 52 39 E x e r c i s e 19 53 28 Exerc i se 10 68 23 Emotional t e n s i o n 17 61 22 Baby's feed i n g 1 3 61 26 Sa f e t y Time alone 22 55 27 Baby's c r y i n g 1 6 52 32 together 25 50 25 D i e t 19 52 29 Recognize i l l n e s s 1 7 63 19 Time alone Time f o r together 23 42 35 r e c r e a t i o n 22 53 25 Dre s s i n g baby 1 6 55 30 D i e t 25 53 22 Normal growth Emotional t e n s i o n 1 3 61 26 and development 33 47 20 R e l a t i o n s h i p with - partner 32 32 36 Baby's f u s s i n e s s Baby's s l e e p i n g 22 70 8 Household demands 1 6 68 22 28 52 19 Sexual r e l a t i o n s 26 45 30 Feeding baby 22 58 20 Time f o r r e c r e a t i o n 19 59 22 Baby's rashes 28 55 1 7 T r a v e l l i n g with baby 23 51 26 Baby's c r y i n g 22 67 1 1 Time f o r p e r s o n a l Change i n i n t e r e s t s 1 6 65 19 l i f e s t y l e 25 64 1 1 1 1 3 Appendix B continued P r i m i p a r a s Percent M u l t i p a r a s Percent I tern 0 1-2 3-4 I tern 0 1-2 3-4 Baby's weight gain 32 39 29 D r e s s i n g baby 25 64 1 1 Change i n R e l a t i o n s h i p with l i f e s t y l e s 1 6 62 22 par t n e r 36 50 1 4 Baby's b r e a t h i n g Baby's p h y s i c a l 29 45 26 Sexual r e l a t i o n s 33 56 1 1 appearance 32 39 30 Immunizing baby 39 44 1 7 B i r t h c o n t r o l 36 32 32 F e e l i n g t i e d down 28 67 6 I n t e r p r e t i n g F e e l i n g t i e d down 16 61 22 behaviour 25 70 5 I n a b i l i t y to conce n t r a t e 23 65 13 Care of b r e a s t s 42 44 1 4 Baby's bowel Baby's weight movements 39 29 32 gain T r a v e l l i n g with 39 47 1 4 Baby's rashes 23 58 20 Baby 30 59 1 1 Partner being a good f a t h e r 45 30 26 Return of p e r i o d I n a b i l i t y to 36 53 1 2 Immunizing baby 36 39 26 co n c e n t r a t e Baby's p h y s i c a l 39 50 1 1 Return of p e r i o d 26 58 1 6 appearance Partner being a 39 50 1 1 Finances 32 52 1 6 good f a t h e r A v a i l a b i l i t y of 39 50 1 1 L i m i t i n g v i s i t o r s 32 52 1 7 resources 39 50 1 1 A v a i l a b i l i t y of resources 29 55 1 6 L i m i t i n g v i s i t o r s Baby's bowel 33 61 6 Baby blues 29 65 6 movements 44 52 1 4 Comfort i n ha n d l i n g baby 48 32 19 Breast soreness 56 31 1 4 Bathing baby 42 45 1 3 Baby blues 42 53 6 G i v i n g v i t a m i n s or f l o u r i d e 45 42 1 3 Baby's b r e a t h i n g 50 36 1 4 C o n s t i p a t i o n 45 42 1 6 Lo c h i a 42 55 3 Lo c h i a 39 46 1 6 C o n s t i p a t i o n 58 33 9 Labour & d e l i v e r y Labour & d e l i v e r y experience 52 32 1 7 experience 47 44 19 Care of b r e a s t s 48 32 20 Bathing baby 50 42 8 Pain of st i t c h e s 48 36 1 6 Hemorrhoids 56 36 10 1 1 4 Appendix B continued P r i m i p a r a s Percent M u l t i p a r a s Percent Item 0 1-2 3-4 Item 0 1-2 3-4 G i v i n g v i t a m i n s Hemorrhoids 55 35 10 or f l o u r i d e Comfort i n 47 47 6 Breast soreness 52 39 10 h a n d l i n g baby 58 33 8 Care of c o r d 68 23 10 Care of c o r d Discomfort from 64 28 9 Care of c i r c u m s i o n 87 7 7 st i t c h e s 72 23 6 Reaction of Care of s i b l i n g s 100 0 0 c i rcumsion 81 1 1 9 * P r i o r i t y determined by mean i n t e n s i t y s c o r e s i n Tables 4-27 APPENDIX C MANN-WHITNEY U TEST PRIMIPARAS VERSUS MULTIPARAS 1 16 APPENDIX C Mann-Whitney U Test Values and P r o b a b i l i t i e s : P r i m i p a r a s versus M u l t i p a r a s 1st 2 days 1 month I tem U P U P 1 527 .688 467 .236 2 538 .796 466 .234 3 481 .312 518 .599 4 549 .901 471 .249 5 558 .995 535 .753 6 447 . 1 55 421 .047* 7 462 .209 491 .362 8 445 .346 546 .868 9 496 .420 555 .967 10 513 .561 518 .598 1 1 526 .671 471 .256 12 518 .604 512 .544 1 3 474 .270 434 . 1 04 1 4 528 .694 542 .833 1 5 489 .366 491 .375 1 6 489 .365 482 .311 17 545 .868 534 .753 18 413 .061 391 .031* T o t a l S e l f 467 .252 488 .375 1 9 513 .559 463 .215 20 459 .199 426 .087 21 458 . 1 96 450 . 1 57 22 383 .023* 493 .379 23 524 .659 549 .893 24 531 .641 521 .465 25 452 . 1 63 407 .050* 26 417 .065 395 .031* 27 459 .199 459 .190 28 460 .755 533 .743 29 431 .099 366 .012* 30 462 .211 409 .052 31 520 .621 499 .431 32 538 .791 431 .724 33 393 .031* 471 .230 34 368 .014* 305 .001* 35 374 .015* 434 . 107 36 371 .015* 337 .004* 37 397 .037* 421 .075 38 478 .302 474 .280 39 442 .130 419 .071 T o t a l Baby 418 .077 417 .076 1 1 7 Appendix C co n t i n u e d I tern 1 st U 2 days P 1 U month P 40 487 .353 457 .189 41 542 .829 507 .501 42 477 .294 502 .463 43 462 .212 520 .617 44 504 .488 437 .115 45 507 .507 510 .535 T o t a l P a r t n e r 491 .399 492 .402 46 517 .587 546 .876 47 456 .179 467 .234 48 395 .033* 512 .542 49 549 .902 435 .107 50 535 .759 505 .483 T o t a l Family 480 .325 529 .682 T o t a l I terns 430 .106 449 .168 * p<.05 118 APPENDIX D FIRST TWO DAYS VERSUS ONE MONTH WILCOXIN SIGNED RANKED TEST FOR MATCHED PAIRS 119 APPENDIX D W i l c o x i n Signed Ranked Test f o r Matched P a i r s Values and P r o b a b i l i t i e s ( f i r s t 2 days versus 1 month) Primip a r a s Mult i p a r a s I tem Z Score P Z score P 1 -0.28 .776 -1 .40 .159 2 -2.35 .019* -0.77 .443 3 -1 .09 .276 -1.16 .247 4 -0.78 .435 -1.16 .246 5 -1 .96 .050* -2.67 .007* 6 -3.05 .002* -4.28 .000* 7 -1 .94 .052 -1 .23 .219 8 -2.59 .013* -0.69 .489 9 -3.31 .001* -4.20 .000* 1 0 -3.04 .002* -3.40 .007* 1 1 -1 .69 .091 -2.57 .010* 12 -0.50 .614 -0.83 .409 13 -0.21 .836 -0.62 .535 1 4 -3.40 .001* -3.92 .001* 1 5 -0.62 .535 -0.13 .900 16 -0.59 .551 -1 .05 .295 1 7 -1.41 .158 -1 .79 .074 18 -2.51 .012* -2.37 .018* T o t a l S e l f -2.42 .015* -3.73 .002* 19 -0.66 .509 -1 .96 .049* 20 -2.48 .013* -2.30 .012* 21 -2.59 .009* -2.94 .003* 22 -3.41 .007* -2.47 .014* 23 -3.66 .003* -3.88 .001 * 24 -1 .60 . 1 08 -0.53 .594 25 -2.42 .016* -2.85 .004* 26 -1 .94 .052 -2.01 .044* 27 -1 .23 .218 -1 .88 .061 28 -0.71 .476 -0.96 .339 29 -0.71 .478 -0.54 .588 30 -0.49 .627 -1 .33 . 185 31 -2.26 .024* -2.65 .008* 32 -2.38 .017* -1 .85 .064 33 -2.95 .003* -2.41 .016* 34 -1 .28 .201. 1 -1.57 .115 35 -1 .70 .089 -0.69 .487 36 -2.36 .018* -1 .80 .073 37 -2.13 .033* -2.16 .031* 38 -2.90 .003* -2.70 .007* 39 -1 .60 . 1 05 -2.20 .026* T o t a l Baby -3.32 .001* -2.91 .004* 1 20 Appendix D c o n t i n u e d P r i m i p a r a s M u l t i p a r a s I tern Z Score P Z score P 40 -0.28 .776 -1 .26 .209 41 -0.31 .755 -1 .05 .296 42 -0.91 .363 -0.05 .959 43 -0.70 .485 -0.33 .740 44 -0.34 .733 -1.19 .233 45 -0.47 .641 -0.45 .653 T o t a l Partner -0.90 .368 -1.12 . .261 46 -0.43 .668 -1 .53 .126 47 -2.02 .043* -1 .89 .057 48 -2.69 .007* -1 .56 .118 49 -1 .93 .054 -0.92 .356 50 -1 .02 .306 -1 .58 .114 51 -1 .00 • .317 -2.24 .025* T o t a l Family -2.20 .028* -2.22 .027* T o t a l I terns -3.14 .002* -3.45 .001* * P<.05 APPENDIX E MATERNAL CONCERNS QUESTIONNAIRE ( 1 s t two days) 1 22 PLEASE COMPLETE ON YOUR FIRST OR SECOND DAY AT HOME WITH YOUR INFANT MATERNAL CONCERNS Date today Date of Discharge Date of Delivery The following are some concerns experienced by some mothers af t e r the b i r t h of a baby. A concern i s anything that- i s a question, worry, or problem to you. Please read each item and decide how much the item concerns you. Then c i r c l e your response according to the following scale: 0 No concern 1 L i t t l e concern 2 Moderate concern 3 Much concern 4 C r i t i c a l concern Please answer the items as to how you fee l NOW A. Concerns about yourself. . Ĵ Q Concern 1. Food you eat 0 2. Exercise habits 0 3. Return of figure to normal 0 4. Return of menstrual period 0 5. Vaginal discharge (lochia) 0 6. Discomfort from s t i t c h e s (episiotomy) 0 7. Constipation 0 8. Hemorrhoids 0 9. Breast soreness 0 10. Care of breasts 0 11. Fatigue (lack of sleep) 0 12. Emotional tension 0 13. I n a b i l i t y to concentrate 0 . 14. Your labour and d e l i v e r y experiences 0 15- Feelings of being t i e d down 0 16. "Baby Blues"(feeling depressed) Q 17. F i n d i n g time for personal i n t e r e s t s 0 L i t t l e Concern Beinc ='ood mother Moderate Concern 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Much Concern 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 C r i t i c a l Concern 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 123 Concerns about babv No L i t t l e Moderate Much C r i t i c a l Concern Concern Concern Concern Concern 19. Infant's physical appearance 0 20. Normal growth and development 0 21. The amount of weight the baby has gained 0 22. Bathing the baby 0 23. Care of the cord/umbilicus 0 24. Care of the circumsion 0 25. Feeding the baby 0 26. The way the baby breathes 0 27. Baby's bowel movements 0 28. Rashes on the baby's skin 0 29. Baby's fussiness 0 30. How the baby sleeps 0 31. When to give vitamins or f l o r i d e 0 32. Getting the baby immunized 0 33. Feeling comfortable handling baby 0 34. Interpreting infant's behaviour 0 35. Baby's crying 0 36. Recognizing signs of i l l n e s s 0 37. T r a v e l l i n g with baby 0 38. Safety (preventing accidents) 0 39. How to dress baby (clothing that i s too warm or too cold for the environment) 0 Concerns about partner No Concern L i t t l e Concern Moderate Concern Much Concern C r i t i c a l Concern 40. Your re l a t i o n s h i p with the baby's father 0 41. Partner being a good father 0 42. Finding time to be alone together 0 43. Finding time for recreation 0 44. Sexual r e l a t i o n s 0 45. Family planning ( b i r t h control) 0 124 D. Concerns about'Family No L i t t l e Moderate Much C r i t i c a l Concern Concern Concern Concern Concern. 46. Managing the demands of the household . 0 1 2 3 4 47. Change i n the family's l i f e s t y l e 0 1 2 3 4 48. Setting l i m i t s on v i s i t o r s 0 1 2 ' 3 4 49. Finances 0 1 2 3 4 50. The a v a i l a b i l i t y of community resources ( i . e . babysitters, c l i n i c s , parent classes) 0 1 2 3 4 51. Reaction of your other children to the baby 0 1 2 3 4 COMMENTS Do you have other concerns that are not l i s t e d ? 1 25 BACKGROUND INFORMATION P l e a s e f i l l i n o r c i r c l e t h e a n s w e r a s a p p r o p r i a t e . 1 . W h a t i s y o u r p r e s e n t a g e ? 2 . I s t h i s y o u r f i r s t c h i l d ? Y e s N o 3 . I f n o , w h a t a r e t h e a g e s o f y o u r o t h e r c h i l d r e n ? 4 . W h a t i s t h e s e x o f y o u r b a b y ? M a l e F e m a l e 5 . H o w m a n y d a y s d i d y o u s p e n d i n h o s p i t a l w i t h t h i s d e l i v e r y ? 6 . W h a t i s t h e m a i n m e t h o d o f f e e d i n g t h e b a b y ? B r e a s t B o t t l e B o t h 7 . C h e c k y o u r M O S T r e c e n t l e v e l o f f o r m a l e d u c a t i o n : s o m e h i g h s c h o o l s o m e u n i v e r s i t y c o m p l e t e d h i g h s c h o o l c o m p l e t e d u n i v e r s i t y s o m e v o c a t i o n a l / c o l l e g e s o m e g r a d u a t e s c h o o l c o m p l e t e d v o c a t i o n a l / c o l l e g e c o m p l e t e d g r a d u a t e s c h o o l 8 . D i d y o u a t t e n d p r e n a t a l c l a s s e s w i t h t h i s p r e g n a n c y ? Y e s N o 9 . I f s o , c i r c l e w h i c h t y p e : H e a l t h D e p a r t m e n t H o s p i t a l P r i v a t e A g e n c y P r i v a t e I n d i v i d u a l 1 0 . W h a t i s y o u r e t h n i c o r i g i n ? 1 1 . H o w m a n y y e a r s h a v e y o u l i v e d i n C a n a d a ? 1 2 . A r e y o u p l a n n i n g t o r e t u r n t o w o r k ? Y e s N o 1 3 . W h o i s t h e m o s t h e l p f u l p e r s o n a t h o m e d u r i n g t h e f i r s t w e e k ? 1 4 . W h o e l s e i s h e l p f u l t o y o u ? APPENDIX F MATERNAL CONCERNS QUESTIONNAIRE (one month) 1 27 PLEASE COMPLETE ONE MONTH AFTER COMING HOME WITH YOUR INFANT MATERNAL CONCERNS Date today Date of D i s c h a r g e Date of D e l i v e r y The f o l l o w i n g a re some concerns e x p e r i e n c e d by some mothers a f t e r the b i r t h o f a baby. A concern i s a n y t h i n g t h a t i s a q u e s t i o n , worry, or problem to you. P l e a s e read each i t e m and d e c i d e how much the i t e m concerns you. Then c i r c l e your response a c c o r d i n g to the f o l l o w i n g s c a l e : 0 No concern 1 L i t t l e c o n c e r n 2 Moderate c o n c e r n 3 Much c o n c e r n A C r i t i c a l c o n c e r n P l e a s e answer the it e m s as t o how you f e e l NOW A. 1. 2. 3. A. 5. 6. 9. 10. 11. 12. 13. IA. 15. 16. Concerns about y o u r s e l f . Food you eat E x e r c i s e h a b i t s R e t u r n o f f i g u r e t o normal Return o f m e n s t r u a l p e r i o d V a g i n a l d i s c h a r g e ( l o c h i a ) D i s c o m f o r t from s t i t c h e s ( e p i s i o t o m y ) C o n s t i p a t i o n Hemorrhoids B r e a s t s o r e n e s s Care o f b r e a s t s F a t i g u e ( l a c k o f s l e e p ) E m o t i o n a l t e n s i o n I n a b i l i t y to c o n c e n t r a t e Your l a b o u r and d e l i v e r y e x p e r i e n c e s F e e l i n g s o f b e i n g t i e d down No Concern 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 L i t t l e Concern "Baby B l u e s " ( f e e l i n g depressed) 0 F i n d i n g time f o r p e r s o n a l i n t e r e s t s i; 18. Being a good mother Moderate Concern 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Much Concern 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 C r i t i c a l Concern A A A A A A A A A A A A A A A 1 28 B . C o n c e r n s a b o u t b a b v N o L i t t l e M o d e r a t e M u c h C r i t i c a l C o n c e r n C o n c e r n C o n c e r n C o n c e r n C o n c e r n 1 9 . I n f a n t ' s p h y s i c a l a p p e a r a n c e 0 2 0 . N o r m a l g r o w t h a n d d e v e l o p m e n t 0 2 1 . T h e a m o u n t o f w e i g h t t h e b a b y h a s g a i n e d 0 2 2 . B a t h i n g t h e b a b y 0 2 3 . C a r e o f t h e c o r d / u m b i l i c u s 0 2 4 . C a r e o f t h e c i r c u m s i o n 0 2 5 . F e e d i n g t h e b a b y 0 2 6 . T h e w a y t h e b a b y b r e a t h e s 0 2 7 . B a b y ' s b o w e l m o v e m e n t s 0 2 8 . R a s h e s o n t h e b a b y ' s s k i n 0 2 9 . B a b y ' s f u s s i n e s s 0 3 0 . H o w t h e b a b y s l e e p s 0 3 1 . W h e n t o g i v e v i t a m i n s o r f l o r i d e 0 3 2 . G e t t i n g t h e b a b y i m m u n i z e d 0 3 3 . F e e l i n g c o m f o r t a b l e h a n d l i n g b a b y 0 3 4 . I n t e r p r e t i n g i n f a n t ' s b e h a v i o u r 0 3 5 . B a b y ' s c r y i n g * 0 3 6 . R e c o g n i z i n g s i g n s o f i l l n e s s 0 3 7 . T r a v e l l i n g w i t h b a b y 0 3 8 . S a f e t y ( p r e v e n t i n g a c c i d e n t s ) 0 3 9 . H o w t o d r e s s b a b y ( c l o t h i n g t h a t i s t o o w a r m o r t o o c o l d f o r t h e e n v i r o n m e n t ) 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 C . C o n c e r n s a b o u t p a r t n e r N o C o n c e r n L i t t l e C o n c e r n M o d e r a t e C o n c e r n M u c h C o n c e r n C r i t i c a l C o n c e r n 4 0 . Y o u r r e l a t i o n s h i p w i t h t h e b a b y ' s f a t h e r 0 4 1 . P a r t n e r b e i n g a g o o d f a t h e r 0 4 2 . F i n d i n g t i m e t o b e a l o n e t o g e t h e r 0 4 3. F i n d i n g t i m e f o r r e c r e a t i o n 0 4 4 . S e x u a l r e l a t i o n s 0 4 5 . F a m i l y p l a n n i n g ( b i r t h c o n t r o l ) 0 129 D . C o n c e r n s a b o u t - F a m i l y N o L i t t l e M o d e r a t e M u c h C r i t i c a l C o n c e r n C o n c e r n C o n c e r n C o n c e r n C o n c e r n . 4 6 . M a n a g i n g t h e d e m a n d s o f t h e h o u s e h o l d 0 1 2 3 4 47*. C h a n g e i n t h e f a m i l y ' s l i f e s t y l e 0 1 2 3 4 4 8 . S e t t i n g l i m i t s o n v i s i t o r s 0 1 2 3 4 4 9 . F i n a n c e s 0 1 2 3 4 5 0 . T h e a v a i l a b i l i t y o f c o m m u n i t y r e s o u r c e s ( i . e . b a b y s i t t e r s , c l i n i c s , p a r e n t c l a s s e s ) 0 1 2 3 4 5 1 . R e a c t i o n o f y o u r o t h e r c h i l d r e n t o t h e b a b y 0 1 2 3 4 C O M M E N T S D o y o u h a v e o t h e r c o n c e r n s t h a t a r e n o t l i s t e d ? 1 . W h a t p r o f e s s i o n a l h a v e y o u c o n s u l t e d s i n c e c o m i n g h o m e w i t h y o u r b a b y ? T y p e N u m b e r o f C o n t a c t s F a m i l y D o c t o r C o m m u n i t y H e a l t h N u r s e P e d i a t r i t i o n O t h e r 2 . H a v e t h e r e b e e n a n y e x t r a o r d i n a r y e v e n t s t h a t h a v e o c c u r r e d i n y o u r f a m i l y s i n c e t h e b i r t h o f y o u r i n f a n t t h a t m a y e f f e c t y o u r d e g r e e o f c o n c e r n ? I f y e s , b r i e f l y e x p l a i n . APPENDIX G L e t t e r of Consent 131 SOUTH EAST UNIT SOUTH OFFICE 6405 KNIGHT STREET. VANCOUVER. B.C. V5P 2V9 V A N C O U V E R H E A L T H D E P A R T M E N T TELEPHONE 321-6151 D e a r N e w M o t h e r : I a m a C o m m u n i t y H e a l t h N u r s e w h o i s c u r r e n t l y w o r k i n g t o w a r d s a M a s t e r ' s d e g r e e a t t h e U n i v e r s i t y o f B . C . I n o r d e r t o e f f e c t i v e l y i m p r o v e s e r v i c e s t o n e w m o t h e r s i n t h e c o m m u n i t y I a m r e q u e s t i n g y o u r p a r t i c i p a t i o n i n t h i s s t u d y t h a t l o o k s a t t h e c o n c e r n s o f n e w m o t h e r s i n t h e f i r s t m o n t h a f t e r d e l i v e r y . Y o u w i l l b e a s k e d t o c o m p l e t e a q u e s t i o n n a i r e r e g a r d i n g y o u r c o n c e r n s o n t h e f i r s t o r s e c o n d d a y a t h o m e a n d t h e n a g a i n o n e m o n t h a f t e r y o u r d i s c h a r g e f r o m h o s p i t a l . I t w i l l t a k e y o u a p p r o x i m a t e l y t e n m i n u t e s t o c o m p l e t e t h e q u e s t i o n n a i r e . Y o u w i l l r e c e i v e a p h o n e c a l l f r o m a c o m m u n i t y h e a l t h n u r s e t o r e m i n d y o u t o c o m p l e t e t h e q u e s t i o n n a i r e a t t h e s e t w o t i m e s . T h e q u e s t i o n n a i r e s w i l l b e n u m b e r c o d e d a n d y o u r r e s p o n s e s w i l l b e c o m p l e t e l y c o n f i d e n t i a l . I t i s i m p o r t a n t f o r y o u t o u n d e r s t a n d t h a t y o u c a n w i t h d r a w f r o m t h e s t u d y a t a n y t i m e a n d t h a t r e f u s i n g t o p a r t i c i p a t e w i l l n o t e f f e c t t h e s e r v i c e s y o u r e c e i v e f r o m t h e h e a l t h d e p a r t m e n t . I f y o u h a v e a n y q u e s t i o n s a b o u t y o u r p a r t i c i p a t i o n i n t h i s s t u d y p l e a s e d o n o t h e s i t a t e t o c a l l me o r t o a s k t h e c o m m u n i t y h e a l t h l i a s o n n u r s e i n t h e h o s p i t a l . T h a n k - y o u f o r c o n s i d e r i n g p a r t i c i p a t i o n i n t h i s s t u d y , S h a r o n T o b e r t R . N . B „ S . N . C o m m u n i t y H e a l t h N u r s e S o u t h H e a l t h U n i t 3 2 1 - 6 1 5 1 MEMBER OF THE METROPOLITAN HEALTH SERVICE OF GREATER VANCOUVER

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