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Concerns of mothers in the first month postpartum Tobert, Sharon R. 1986-07-18

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CONCERNS OF MOTHERS IN THE FIRST MONTH POSTPARTUM by SHARON R. TOBERT B.S.N., The University Of British 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 Administrative, Adult And Higher Education We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1986 © Sharon R. Tobert, 1986 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of f\cjrf)ir\ijira-rio() AdmH CMMA MtjKer- Edueafiov The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date O'Q -/O-jH E-6 (3/81) i i ABSTRACT Program planning for postpartum mothers requires knowledge of the effects of parity and time since discharge on the mothers' perceptions of their level of concern regarding self, baby, partner and family. It was for this pupose that this descriptive correlational study was conducted. Thirty-one primiparas and thirty-six multiparas completed a 51 item maternal concerns questionnaire during their first two days after discharge from hospital and again at one month after discharge. Nonparametric tests were used to determine any significant difference in intensity and frequency of concern between the two groups of mothers and between the two time measures. The difference in intensity of concern between the two groups was not found to be significant for the total concerns at either time period. There were however, individual areas in which one group had significantly greater concern than the other. A significant difference was found in the intensity of the total concerns between the two time measures for both primiparas and multiparas. The results demonstrate a need for supportive-educative programs for both primiparas and multiparas in the first month postpartum. They also identify specific areas of concern in which the focus of the interventions may differ for these two groups of mothers. TABLE OF CONTENTS ABSTRACT ii LIST OF TABLES v LIST OF FIGURES viACKNOWLEDGEMENTS viiChapter 1 : Introduction to Problem 1 Problem 5 Definitions of Terms 8 Purpose 9 Chapter 2: Review of the Literature 10 Introduction 1Characteristics and Tasks of the Puerperium 11 Assessment of Client Needs in Program Planning 21 Concerns of Postnatal Mothers 25 Research Regarding Concerns of Primiparas 2Surveys of Concerns of Primiparas and Multiparas . 27 Concerns of Special Groups of Postpartum Mothers . 29 Effects of Parity on Postnatal Concerns 34 Chapter 3: Methodology 38 Introduction . .Sample and SettingMeasurement instrument 40 Data Collection 41 Null Hypotheses 2 Chapter 4: Analysis of Data 6 IntroductionCharacteristics of the Sample 4Parity 4Age 7 Gender of Baby 48 EducationEthnicity of Mothers 49 Type of Infant Feeding 50 Prenatal Class AttendanceReturn to Work 51 Help at Home and Use of Professional Resources ... 51 Difference Between Concerns of Primiparas and Multiparas at Two Days 2 Self 53 Baby 4 Partner 6 Family 7 Total Items 59 Difference in Concerns of Primiparas and Multiparas at One Month 60 SelfBaby 1 Partner 3 i v Family 64 Total Items 5 Difference in Concerns of Primiparas in First Two Days and One Month after Discharge 67 SelfBaby 69 Partner 71 Family 2 Total Items 3 Difference in Concerns of Multiparas in First Two... Days and One Month 74 Self 7Baby 5 Partner 7 Family 8 Total Items 79 Summary 80 Chapter 5: Findings and Recommendations 82 IntroductionThe SampleDifference in Concerns of Primiparas and Multiparas During the First Two Days 84 Difference in Concerns of Primiparas and Multiparas One Month After Discharge 7 Difference in Concerns of Primiparas in the First Two Days and One Month After Discharge 88 Difference in Concerns of Multiparas in the First Two Days and One Month After Discharge 90 Limitations of the Study 93 Implications for Program Planning 94 Recommendations for Future Research 8 Conclusions 10References 102 Appendix A 9 Appendix B 11Appendix C 6 Appendix DAPPENDIX E 12APPENDIX F 7 APPENDIX G 131 V LIST OF TABLES Table 1 : Distribution of Mothers by Age 48 Table 2: Distrbution of Mothers by Education 49 Table 3: Distribution of Mothers by Ethnic Background 50 Table 4: Priority ranking of concerns regarding self (1 st 2 days) 54 Table 5: Percentage of Responses of 0-4 totalled across items in each category (1st 2 days) 55 Table 6: Priority ranking of concerns regarding baby (1 st 2 days) 6 Table 7: Priority ranking of concerns regarding partner (1 st 2 days) 57 Table 8: Priority ranking of concerns regarding family (1 st 2 days) 8 Table 9: Priority Ranking of Highest Total Concerns (1 st 2 days) 9 Table 10: Priority ranking of Concerns regarding Self ... (1 month) 61 Table 17: Percentage of responses of 0-4 totalled across items in each category (1 month) 62 Table 12: Priority ranking of Concerns regarding Baby ... regarding self (1st 2 days vs. 1 month) 68 Table 13: Priority ranking of concerns regarding partner .. (1 month) Table 14: Priority ranking of concerns regarding family .. (1 month) Table 15: Priority Ranking of Highest Total Concerns ... (1 month) Table 16: Priority ranking of concerns of primiparas Table 17: Percentage of Responses of 0-4 Totalled across Items in each Category (Primiparas: 1st 2 days vs. 1 month) 69 Table 18: Priority ranking of concerns of primiparas regarding baby (1st 2 days vs. 1 month) 70 Table 19: Priority ranking of concerns of primiparas regarding partner (1st 2 days vs. 1 month) 71 Table 20: Priority ranking of concerns of primiparas regarding family (1st 2 days vs. 1 month) 72 Table 21: Priority ranking of highest total concerns of primiparas (1st 2 days vs. 1 month) 73 Table 22: Priority ranking of concerns of multiparas regarding self (1st 2 days vs. 1 month) 75 Table 23: Percentage of Responses of 0-4 Totalled across Items in each Category (Multiparas: 1st 2 days vs. 1 month) 76 Table 24: Priority ranking of concerns of multiparas regarding baby (1st 2 days vs. 1 month) 77 Table 25: Priority ranking of concerns of multiparas regarding partner (1st 2 days vs. 1 month) 78 Table 26: Priority ranking of concens of multiparas regarding family (1st 2 days vs. 1 month) 79 Table 27: Priority ranking of highest total concerns multiparas (1st 2 days vs. 1 month) LIST OF FIGURES Figure 1: Representation of research design vi i i ACKNOWLEDGEMENTS I would like to thank the members of my committee for their guidance and support as well as their standards of academic excellence. I would also like to thank the Vancouver Health Department liason nurses working out of Grace Hospital for their assistance and perseverance in distributing the questionnaires, as well as the prevention community health nurses of the South-East Unit for their help in collecting the completed questionnaires. Finally the encouragement and support of my family has been greatly appreciated in seeing this project to its completion. CHAPTER 1 Introduction to Problem Probably one of the most difficult periods in a woman's lifetime is that following the delivery of an infant (Sumner, 1977). Several researchers have demonstrated that the transition to parenthood involves some degree of crisis (Dyer,1963; LeMasters, 1957; Hobbs, 1968). Dyer (1963) and LeMasters (1957) found that the majority of couples considered the first experience of parenthood to be an extensive or severe crisis. Dyer (1963), cited loss of sleep, worry over appearance, social isolation and lack of preparation for parental roles as factors in the difficult adjustment. Gruis (1974) identified the tasks which the mother must accomplish during the postnatal period as: physical restoration; learning to care for and meet the needs of a dependent infant, establishment of a relationship with the infant and alteration of lifestyle and relationships to accommodate a new family member. She states that each of these tasks may evoke questions and concerns in the mother. Cibulka & Price, (1978) categorized these concerns into four broad content areas which include: concerns about the baby, about self, about spouse, and role adjustments. There has been some attempt in the literature to 2 empirically describe these postpartum maternal concerns (Adams, 1963; Bull, 1981; Cibulka & Price, 1978; Gruis, 1974; Harrison & Hicks, 1983; Pate, 1979; Robinson, 1972; Sumner, 1977). Much of this research has had a narrow focus limited to either primiparous or multiparous mothers. Other research has been limited to only one area of maternal concern such as infant care (Adams, 1963). Also much of the more recent research on the concerns of postpartum mothers has been done in the United States for the purpose of demonstrating that some intervention is necessary after the mother is discharged from hospital (Cibulka & Price, 1978; Gruis, 1974; Pate, 1979; Sumner, 1977). In Canada many public health agencies have traditionally recognized the general needs of postpartum mothers and have offered universal services such as visits by community health nurses or postnatal groups for mothers during this maturational stage. However, dispite the widespread nature of these programs little formal planning, including needs assessment and evaluation has been done. Harrison & Hicks (1983), did conduct a widely focused descriptive study on postpartum concerns of mothers and their sources of help in a Canadian city which had community health programs available to postpartum mothers. This study included both primiparous and multiparous mothers and the information obtained was to help nurses plan health promotion programs for new mothers. The mothers were given 3 a questionnaire approximately four to six weeks after delivery. They were asked to recall the concerns they had experienced since the birth of their infant and the resources that they used to deal with each concern. The findings were similar to those of Gruis (1974), and Pate (1979), who also collected data retrospectively and found that the major areas of concern were regarding return of figure to normal, regulating demands, diet, and fatigue. These results differed from those studies that looked at concerns during the first two weeks postpartum (Bull,1981; Robinson, 1972) which found that care of the infant and infant behaviour as well as concern about self were moderate to major areas of concern. Bull (1981), found that her hypothesis that the mother's focus of concerns on self, and the infant would shift to concerns regarding family and community by the tenth postpartum day was not supported by the data. It seems that the effect of the variable of time since delivery on concerns of both primiparous and multiparous postpartum mothers is important information for planning and prioritizing supportive-educative programs for this client group. Harrison and Hicks (1983), also found that despite the fact that 68% of the women in their study had received at least one visit from a community health nurse, the nurse ranked last as a source of help. This would lead one to question whether the postnatal visits are made at a time 4 when mothers have already sought help from other sources. With the continuing reduction of resources available for community health programs and an increasing emphasis on quality assurance in nursing, some attempts are being made to provide standards for nursing visits to postnatal mothers. The Vancouver Health Department has recently developed standard care plans and objectives for nursing visits to postnatal mothers (Munroe & Walker, 1984). The content of these standards were based on the literature as well as information from experts in the field. The individuals involved in developing the standards recognized that with limited resources it may not be feasible or desirable to implement all the standard plans with all new mothers and recommended that prioritization take place. They suggested that prioritization could be achieved by examining such things as the department's goals and missions, expert opinions of nurses in the field,, the literature and the current resources available for services for this particular client group. Much of the adult education program planning literature also emphasizes the importance of including input from the client group in determining and prioritizing the needs upon which any program is based. Boyle (1981) feels that both the adult learner and others can help identify the gap between what exists and what is more desirable. Knowles 5 (1980), also states that the interests of the individuals should be one of the criteria in prioritizing needs for the purpose of developing objectives for a program. There has also been the tendency in practise to assume that multiparous mothers do not have as significant concerns as primiparous mothers and therefore services to them should be reduced when resources become scarce. There is little evidence in the literature to support this assumption. Harrison and Hicks (1983), in fact found that although primiparas expressed more minor concerns, multiparas had the same number of concerns they consider to be major. Also they did not find a significant difference in the types of concerns between these two groups. Once again it must be remembered that this study asked mothers to recall the concerns that they had experienced over the past six to eight weeks. It is possible that one group had very different concerns in the early days at home but that the needs of both groups were quite similar after several weeks of adjusting to having a new member in their family. Such information would have implications for the type and timing of interventions offered to the two different client groups. Problem There is an apparent deficit in empirical knowledge regarding the concerns or needs of mothers during the postnatal period which presents a problem for those involved 6 in planning programs or services for this client group. The particular lack of knowledge concerning the effect of the variables of time since delivery and parity of the mother has led to the following questions: 1. Do the concerns of primiparous mothers in the first two days after discharge from the hospital differ from their concerns one month after their di scharge? 2. Do the concerns of multiparous mothers in the first two days after discharge from the hospital differ from their concerns one month after their discharge? 3. Do the concerns of primiparous mothers differ from multiparous mothers in the first two days after discharge from the hospital? 4. Do the concerns of primiparous mothers differ from multiparous mothers one month after discharge from the hospital? The time periods of the first two days at home and one month after discharge were selected for the measurement of the intensity and frequency of concerns because of their 7 implications for delivery of services to postnatal mothers. In the first few days after discharge from hospital the mother is often caring for her infant on her own for the first time and likely has not yet sought help for concerns that arise. During this time the mother is also often in the transition between Rubin's (1961) taking-on and taking-hold phase. This would mean that the mother is now able to absorb information about her new role and the new skills she must acquire. However, the mother is still recovering physically and fatique has an important effect on her ability to be self-directed and to seek out the information and support she needs. One month after discharge, which is often the infant's fifth week of life, the mother is nearing the completion of her recovery from childbirth. At this time it is possible that she has sought help from many of the traditional sources, such as family doctor or pediatrition but may still have concerns. It is possible that the mother is now able to leave the home to seek out additional resources for the concerns she is still experiencing. Traditionally community services such as home visits from community health nurses are offered in the first weeks at home whereas after one month it may be more effective to offer services such as postnatal classes or drop-ins. 8 Definitions of Terms Primipara: a woman who has given birth to her first child. Multipara: a woman who has given birth to two or more infants. Concern: a question, problem, misconception or area of marked pre-occupation related to the post-natal period. Intensity: the rating or value a mother assigns to a concern measured from no concern to much concern. Frequency: The number of repeated occurances of an. item being identified as a concern. Puerperium: The period of recovery following childbirth usually lasting four to six weeks. Used interchangeably with postnatal and postpartume period in this study. Parity: The number of period of viability. past pregnancies that continued to the 9 Purpose The purpose of this study was to describe the effect of the independent variables of time since delivery and parity of the mother on the frequency and intensity of maternal concerns. The concerns of primiparas and multiparas were compared during the first two days after discharge from hospital and again one month later. This chapter has demonstrated the need for further information regarding the concerns of mothers in the postnatal period. The specific research questions to be addressed were presented as well as definitions of terms used in the study. The following chapter provides an indepth look at the literature concerning the puerperium and the current knowledge regarding maternal concerns during this period. 10 CHAPTER 2 Review of the Literature Introduction A review of the literature regarding maternal concerns postdelivery was undertaken to further elaborate and clarify concerns experienced by primiparas and multiparas. The areas of literature that were reviewed were divided into three sections. The first includes literature regarding the characteristics and tasks of the puerperium, in order to demonstrate that this is a critical period in the healthy development of the mother and the family she represents. It will also be demonstrated that the challenges and adjustments for the expanding family during this period require professional, supportive-educative intervention. The second area of literature review represents current information in the field of adult education concerning the role of needs assessment and prioritization in the program planning process. A particular focus is placed on literature that demonstrates the need for client input into the needs assessment and prioritizing process. This literature provides further rationale for determining the mothers' perceptions of their concerns as well as those of the professionals in the field in developing appropriate services. 11 The final body of literature reviewed deals with the characteristics of the concerns of mothers during the puerperium. Literature searches were done in the medical, nursing, sociological, psychological and educational literature and the most recent articles were checked in the social science citation index to ensure that a comprehensive review of literature regarding the concerns of mothers during this maturational stage was obtained. Characteristics and Tasks of the Puerperium Much of the literature concerning the maternal transition to parenthood has focused on identifying this period as a time of crisis. One of the initial studies that suggested that beginning parenthood is a crisis was done by LeMasters (1957). He found that 83% of first time parents experienced extensive or severe crisis in adjusting to their first child. Since that time other sociologists have examined the various crisis and gratification components of early parenthood and although many found lesser degrees of crisis their results suggest that the transition to parenthood involves some degree of crisis (Dyer, 1963; Hobbs, 1968; Rossi, 1968; Russel, 1974). Dyer (1963), essentially replicated LeMaster's (1957) study and found that 53% of first time parents experienced extensive or severe crisis following childbirth. Hobbs (1968), felt that measurement problems accounted for the variability in the 1 2 findings of the previous studies and his study failed to support the hypothesis that adjusting to a first child was perceived as a severe crisis. He found that only 13% experienced moderate crisis whereas 87% experienced a slight crisis. He felt that it would be more accurate to view the period after the birth of a child as a transition which is stressful rather than as a crisis experience. Rossi (1968), also questioned the advisability of labeling the birth of a child as a crisis or even as a normal crisis. Russel (1974), sought to identify the positive as well as stressful outcomes of parenthood and concluded that respondents perceived their first year of parenthood as only moderately stressful and well supplied with rewards. Sheehan (1981), conducted a pilot study to assess postpartum adjustment in the six weeks following childbirth. Her questionnaires were developed using crisis theory, developmental theory, and a theory of role transition and were tested using a small (six mothers) self-selected sample of primiparas mothers. Due to the sample size caution must be taken in generalizing the results to a greater population. However, the findings substantiated the theory that the maternal adjustment during the first six weeks after delivery constitutes a potential crisis. It is also a time when physical demands and the tasks of role transition and identity reformation make women vulnerable to self-conflict and insecurity. 1 3 Melchior (1975), also conducted a small descriptive study to determine if mothers viewed the postnatal period as a time of crisis. The small sample included three primiparous and three multiparous mothers. Interviews were done on three different occasions, in the first two or three days after birth, in the first week at home, and during the sixth week postpartum. Three of the six mothers perceived the first week to be a time of crisis. An additional mother found the sixth week postpartum to be a time of crisis and two of the mothers, one primipara and one multipara, did not perceive a crisis at any time during the postnatal period. Again the sample is too small to allow generalization of the findings to other mothers. However, it does support the findings that some mothers experience a crisis during their transition to parenthood and that intervention is essential during this period. Donaldson (1981), in developing a theoretical framework grounded in crisis theory for the role of a postpartum nurse clinician, recognized a variety of commonly identified stressors which act on the postnatal mothers. These included, first, the physiological shifts which are a result of the return of the body to the pre-pregnant state. The second stressor she identified is the integration of the postpartum body image into the maternal perception of self. Stretch marks, protruding abdomen and leaking nipples may conflict with the back to normal expectations of the 1 4 postpartum mother. Donaldson (1981) also identified fatigue as a major stressor universally experienced during the postnatal period. Resulting in part from activities in excess of available energy and loss of sleep, fatigue has an important influence on the process of adjustment during the puerperium. She also identified role conflict and the absolute nature of the infant's needs as commonly experienced stressors which may be acting on the new mother and which can create a crisis state when the problems cannot be solved by the usual coping behaviours and in a timely fashion. In addition Donaldson (1981) identified unanticipated stressors such as a pre-term birth, cesarean delivery and birth complications or defects which may further complicate the usual stressors of this period. Based on this framework she demonstrates the necessity of interventions to strengthen the effectiveness of maternal cognitive perception, situational supports and coping behaviours. Gordon (1965), in a study designed to examine factors in postpartum emotional adjustment found that instruction about reorganizing attitudes and activities for the responsibilities and rewards of the motherhood role reduced the likelihood of postpartum emotional distress. This finding also supports the necessity of supportive educative intervention during the postpartum period. 1 5 The inconsistencies in both the method of measurement and the definitions of crisis in this research identifying the transition to parenthood as a potential crisis must be acknowledged. For example LeMasters (1975) used the definition of crisis as any sharp or decisive change for which old patterns are inadequate, whereas Melchiour (1975) defined crisis as a period that is unsettled. Despite these inconsistencies and need for further validation of the findings it is apparent that the transition to parenthood is stressful for many mothers and that services should be offered to meet their needs during this maturational stage. Rubin (1975) states that the postpartum period is the most vulnerable period for the mother, for the infant, for continuity of the husband-wife relationship and for the nuclear family. She feels that the great myth of motherhood is that once the baby is born everyone lives happily ever after. Rubin (1961) describes the characteristics of the postnatal period in terms of certain behaviours which appear in the mother whether she is multiparas or primiparas. She has described three phases which are designated as the taking-in phase, the taking-hold phase and the bursting-out phase. The taking-in phase occurs in the first few days of the puerperium and is the mother's response to excess energy expended during labour and delivery. During this phase the mother seeks to meet her own needs for sleep and nourishment 16 before she can consider the needs of others. She tends to be passive and allows others to tend to her needs. In this phase the mother also wants to talk about her birth experience in order to give reality to the recent events in her life. . It is also during this phase that the mother must begin to get to know her infant and Rubin (1961) states that frequently an overwhelming feeling of responsibility is experienced at this time. The taking-hold phase described by Rubin (1961) starts on approximately the third postpartum day when the mother gains more control of her bodily functions and the focus of attention shifts from herself to the baby. This is a crucial time for the mother to acquire skills related to infant care and a sense of the responsibilities of motherhood. Ironically with the practise of discharge from hospital on the second or third postpartum day many mothers are just beginning this taking-hold phase when they go home and therefore do not have a chance to acquire the necessary skills and receive the necessary support and encouragement from hospital staff. Follow-up services in the community may or may not be available depending on where the mother lives. This second phase is also often characterized by the familiar 'baby blues' usually attributed to the physiological changes that are occurring. Becker (1980), states that the shift of attention from the mother to the infant also contributes to these feelings of depression. 1 7 The third phase that Rubin (1961) describes mothers passing through in the postnatal period, occurs several weeks after delivery when the woman has recovered physically and psychologically. The mother must let go of certain advantages enjoyed before birth, such as leisure time and being the center of attention before she can adapt to her new role as a mother. Martell and Mitchell (1984) sought to reexamine the validity of Rubin's concepts today, considering the many changes in medical care, social attitudes and prenatal education which influence the attitudes and behaviours of postpartal women. They found that Rubin's (1961) general notion of puerperal change was supported with the mothers decreasing amounts of taking-in and increasing amounts of taking-hold behaviours during their hospital stay. However, with their sample of twenty mothers there was insufficent evidence to suggest a strong attitude of taking-in during the first days and that the taking-hold phase seemed to peak on the second day, earlier than reported by Rubin (1961). They suggested that this may indicate an unwillingness on the part of todays women to accept being dependant even for a few days, differing from that of mothers in 1961. Martell and Mitchell (1984) cautioned against generalizing their results, but they encouraged a continual reexamination of longstanding concepts whose acceptance can interfere with making current observations and conclusions relevant to 18 present practise. Gruis (1977), has characterized the puerperium in terms of tasks which the mother must accomplish. She identifies four major tasks which include: physical restoration, learning to meet the needs of her infant, establishment of a relationship with the infant and altering her lifestyle and relationships to accommodate the new family member. As identified by Rubin (1961) physical restoration is one of the first tasks the mother must accomplish in the puerperium. The uterus undergoes the process of involution, characterized by reduction in muscle size, weight loss and healing of the placental site. Blood volume decreases by approximately 30% in the first few days due to blood loss, diuresis and diaphoresis. The abdominal walls stretched during pregnancy remain soft and flabby and take at least six weeks to become firm. Discomfort of the perineum is likely due to the common obstetrical procedure of episiotomy or possible perineal tears. Breast engorgement as well as leaking or sore nipples may also be a source of discomfort (Gruis, 1977). Rubin (1977) states that any person undergoing such rapid physiological change for any other reason would be admitted to hospital for bed rest and careful observation and treatment whereas the new mother is sent home to complete her recovery as well as care for her "bundle of joy". 19 The second task identified by Gruis (1977) is learning to meet the needs of the infant. Several studies have demonstrated that mothers do not feel adequately prepared for caring for the infant on discharge from hospital (Adams,1963; Fillmore & Taylor, 1976; Jordon, 1973). Extended family is often unavailable in this mobile society to give assistance and support once provided to the new mother in the home. The trend towards small nuclear families in today's society results in many women not having the opportunity to experience care of an infant until they become parents. This then is a task for which many mothers require supportive and educative assistance from agencies in the community. The third task the mother must accomplish according to Gruis (1977), is establishing a relationship with her infant. There has been a great deal of interest and research in the past decade concerning this maternal attachment or bonding process which occurs between mother and baby. A discussion of this large controversial body of literature is beyond the scope of this review. It has been established that a healthy mother-child relationship does not occur automatically at birth but has to develop as the mother and child learn to respond to one another (Ludington-Hoe, 1977). In order to learn to understand her infant the mother needs information concerning normal growth and development of infants and knowledge of her infant's 20 crying, sleeping, feeding and other behaviour patterns (Gruis,1977). The final task the mother must accomplish is adjusting her lifestyle and relationships to accommodate the new infant. For many new mothers the change in role that occurs may result in role conflict (Gruis,1977). The mother may choose to give up her job, much of her leisure time and former lifestyle. Her own view of her role may differ from that of her partner or other significant persons in her life (Taggart, 1978). The addition of the baby changes all the family relationships and it is often the mother who takes responsibility for this integrative process (Becker, 1980). Cronenwett (1985) in examining parental network structure and perceived support after the birth of a child found that more postpartum mothers than fathers perceived an increased need for support. That as contact with co-workers decreased the women had to compensate by increasing contact with friends or relatives in order to maintain an adequate support network. Whether the puerperium is viewed as a crisis period or in terms of behavioural phases or tasks which must be accomplished, it is apparent throughout this review of selected literature concerning the characteristics of the postnatal period that intervention is necessary to meet the needs of mothers during this time. Selected literature concerning the necessity of identifying and prioritizing the 21 needs in order to plan effective supportive educative programs will now be examined. Assessment of Client Needs in Program Planning Authors concerned with program planning regard the process of needs assessment with high esteem (Sork,l983). Buskey and Sork (1982) in conducting an analysis of program planning literature revealed that only one of ninety program planning models reviewed failed to address needs assessment as a component of the program planning process. This suggests that needs assessment is considered to be an essential step in the process of producing effective educational programs. Atwood and Ellis (1971) suggest that most adult educators object to programs based primarily upon subject matter or the preferences of persons in administrative positions without regard for the learners as individuals, their lives and their interests. They point out that in an approach that includes input from the learners, needs are identified before the objectives of the learning experience are determined. This differs from prescribing programs on the basis of what was appropriate before or what resources are available. Despite the fact that the concept of need is so widely used within the literature of adult education there seems to be a great deal of confusion and inconsistency regarding the definitions and uses of the term. Monette (1977) has 22 determined that the implicit and explicit definitions of need can be sorted into four categories: basic human needs; felt and expressed needs; comparative needs and variant uses of the term. Atwood and Ellis (1971) point out that the two major uses of the term need refer to either prescriptive or motivational needs. Motivational needs are identified by the owner of the need whereas prescriptive needs are identified by someone other than the owner. They also describe other variations and specialized uses of the concept of need such as real need, educational need and felt need. Monette (1977) recognized that much of the confusion around the term need seems to be due to its indiscriminate application to society, communities, institutions and groups as well as individuals. Knowles (1980) identifies three levels of needs, those of individuals, communities and institutions. He distinguished between basic human needs, educational needs and interests of individuals. Boshier and Peters (1976) also identify a difference between needs and interests with needs describing the gap that exists between the current state of the learner and some desired condition whereas interests are expressions of preference among alternative experiences. Some of the specialized uses of the term need have emerged from the debate over who can best assess the needs of the adult learner. Some educators believe that a need is a need only when it is recognized by the potential learner 23 as a need. This would be considered a felt need. Others hold that the most important needs are the ones that can be better recognized by others. These would be considered real needs which indicate that some outside observer is utilizing some criteria which are not necessarily the clients (Monette, 1977). In looking at the question of who can best determine the needs upon which programs should be planned, Boshier and Peters (1976) state that unless the intended outcomes of the program conform to the adult's needs and interests it is unlikely that the potential learner will accept and make use of its content. They feel that if the needs and interest of the client and the program content do not coincide then either the client will refuse to participate or else there will be meaningless interaction. Monette (1977) on the other hand states that the perspectives of both the learner and others can help identify the needs. Persons other than the learner can specify objective standards to which individual's can compare themselves in order to recognize their needs. He feels that learners may also be assisted in anticipating future learning needs, but that in the end only learners can decide to learn and act upon their learnings. Knowles (1980) also states that information concerning the needs of the clients can come from several sources. The first being the learners themselves, a second source being experts in the field or people in helping roles with the 24 learners and a third source being the literature. Irrespective of what point of view is taken in identifying needs, program planners usually face the dilemma of having too many needs to address with the available resources. Therefore priority setting must take place. Boyle (1981) states that the critical step in priority setting is establishing the criteria upon which decisions will be made. He suggests several sources of input such as political feasibility and personal desires and needs of the clientele. Knowles (1980) states that in organizing the needs into a priority system needs must be screened through appropriate filters such as the educational philosophy, the feasibility of meeting the needs and the interests of the individuals. In reviewing the program planning literature it is apparent that needs assessment and prioritization plays a key role. Despite the confusion in terminology and the lack of consensus between programmers it has been recognized that many program planners place great value on the input from the clients regarding their needs. It is also recognized that the clients' perceived needs must be examined in relation to the literature and experts in the field when making decisions regarding the outcomes of the program or services. This literature supports examining how postnatal mothers perceive their needs or concerns during the peurperium prior to planning services or programs in the 25 community for this client group. Concerns of Postnatal Mothers As stated in Chapter One, much of the research describing maternal concerns has had a narrow focus limited to either primiparas or multiparas or to only one area of concern such as infant care. The findings of these studies vary depending on the characteristics of the sample, and the method of determining the concerns. Research Regarding Concerns of Primiparas Studies were conducted by Adams, (1963); Brown, (1967); and Fillmore & Taylor (1976) which looked only at concerns of primiparous mothers regarding infant care. Adams (1963), conducted interviews on the second postpartum day, one week after discharge and one month after discharge in order to describe the concerns regarding feeding, bathing, crying or care of the cord or circumcision and to determine if they changed over time. She also compared the concerns of the mothers with fullterm infants with those of premature infants in the same study. She found that feeding was the greatest infant care concern throughout the first month. She did not find a significant difference between the concerns of mothers of fullterm and premature infants. Considering the many changes in both the experience of 26 childbirth and the role of the family and society at large since the 1960's it is questionable whether these findings can be applied to present day mothers. Fillmore and Taylor (1976), sought to determine the correlation between concerns regarding infant care and such factors as attendance at prenatal classes, method of feeding, maternal age and education and amount of assistance at home. Interviews were completed with a sample of fifty-two primiparas mothers. However, they do not specify on which postpartum day the interviews took place. The areas of concern were feeding, crying, bathing,elimination, routine care and sleeping. They found that in using an anxiety model of concerns their scheme was not effective in explaining variations in scores, and that only half of their hypotheses derived from the anxiety model were able to predict the directions of the relationships between the concern scores and an independent variable. They concluded that their results were artifical and proposed a two component model combining both worries or anxieties and interests and questions into the concept of concern. Much of the more recent research on maternal concerns does include both worries and interest in its definition of concerns. Other researchers such as Moss (1981) measured the two components separately when looking at the concerns of multiparas mothers. 27 Robinson (1972) sought to determine what new mothers perceived they had been taught in hospital and what information they wished they had had more opportunity to learn. Data were collected retrospectively by questionnaire two weeks after discharge. The sample consisted only of primiparous mothers and the focus was on needs concerning physical care of both mother and infant. Information concerning common ailments in infants, infant feeding and emotional changes in mothers were the most frequently mentioned interest of the mothers. More than twice as many mothers, as not, stated that they were unprepared for the difficulties that arose in the first two weeks. Surveys of Concerns of Primiparas and Multiparas William (1977) surveyed couples from her prenatal class, thirty-seven of whom were primiparas and two multiparas and found that 82% felt that a postpartum class would have been helpful to deal with the problems that arose in the postnatal period. The main concerns mentioned by these parents were crying, feeding and the baby's schedule. Topics of interest included changes in family life, grandparents and learning to pick up cues from the baby. This was a limited sample of well-educated parents attending classes in a university setting and as such does not add generalizable data to the knowledge regarding maternal concerns. It does, however, support the fact that this is a 28 period in which parents have felt learning needs and seek to have them met. Sumner and Fritsch (1977) attempted to document the spontaneous requests by mothers for information and support as evidenced by their telephone calls to the health care facility. A descriptive survey was done for one month documenting the volume of calls, the types of questions asked and the age of the infant. They found that 88% of the primiparous mothers eligible to call did so as well as 25% of the multiparous mothers with the multiparas mothers asking more questions per call. Once again the highest percentage of questions was about infant feeding (31%). They also found that the age of the infant seems to significantly alter the concerns of the parents with the highest rate of calls in the first three weeks of the infant's life. Another interesting finding was that mothers of male infants had more questions in the first four weeks than mothers of females particularly regarding infant feeding. This study once again suggests that infant care concerns are of importance to mothers in the first few weeks. Sumner and Fritsch (1977), only looked at mothers who delivered at one facility and who chose to use that facility as a source of information. The study did not give any information regarding the concerns for which the mothers turned to other sources for help or did not feel comfortable in asking for help at all. It is possible that mothers feel 29 that it is acceptable to ask for help in caring for their baby while at the same time having greater concerns that they are not willing to voice. Concerns of Special Groups of Postpartum Mothers Other studies have been done which look at the concerns of special groups of mothers. Jenkins (1976), Mercer (1979) and Moss (1981) looked only at the concerns of multiparas mothers. Cibulka and Price (1978) sought to determine the concerns of primiparas in the first few days at home and Stoltz and Sater (1985) looked at the expressed educational needs of adolescent mothers. Moss (1981) in examining the concerns of multiparous mothers on the third postpartum day, and prior to discharge from hospital found that they had many interests and worries that had not been dealt with during their hospital stay. The mothers were concerned about their infants but were more interested in behaviour and growth and development rather than physical care. They were also very concerned with family relationships and how the new infant would be accepted by siblings. Moss (1981) used a method of having the mothers sort 61 possible concerns into sections of no concern, interest or worry. Intensity of interest or worry was not determined and ranking of concern was based only in terms of frequency. The findings of this study do not indicate if concerns change following discharge from 30 hospital or with the passage of time. Jenkins (1976), analyzed one indepth case study of the concerns of a multiparous mother and identified three conflict themes which occur in the postnatal period. These include the mother's ability to physically care for two children.at the same time, her feeling of betrayal and guilt as she anticipated the reaction of her older child to the new infant, and her ability to love two children equally. These findings cannot be generalized as they are based on only one mother's experience but they do support the idea that multiparous mothers also have concerns during the pueperium and they are not necessarily the same as those of primiparous mothers. Stoltz and Sater (1985), looked at the self-perceived educational needs of primiparous mothers between 14 and 18 years of age. They found that information concerning the infant's medical needs were very important to these young mothers as well as psychosocial needs such as how to make the baby feel loved and how to be a good parent. A major limitation identified by these researchers was that the time the questionnaires were completed ranged from one to thirty-three weeks post delivery. It is very likely that the period of time that had elapsed since giving birth affected the perceptions of the information the mothers needed soon after delivery. 31 Chapman (1985) looked at the concerns of mothers who were breastfeeding their infants and classified the concerns identified into three categories; breast concerns, infant concerns and postpartum concerns. The data were collected from nursing notes taken of each interaction with the mother during the first four months postpartum. Most of the concerns identified in the three categories were similar to those reported in the literature to be of interest to mothers during the early postpartum period. However, the definition of concern as the quality or state of breastfeeding experiences that were important to the mother seems rather vague and in need of clarification. Goodman and Sauve (1985) examined the concerns of mothers who delivered high risk infants in comparison to a control group of mothers with normal infants. Once again the mothers of high risk infants expressed concerns regarding feeding, intestinal problems, sleeping, crying, infant's appearance, herself and her family. Not surprisingly the control group of mothers also expressed concerns in these areas but they were less frequent and of a lower intensity. They also found a tendancy for the mothers of normal infants to have a more positive perception of their infant. Cibulka and Price (1978), looked not only at the concerns of primiparous mothers in the first few days at home but also the concerns of the fathers. Their sample of 32 twenty couples who had experienced an uncomplicated maternity course and did not fit into any risk group completed a concerns pleasure scale on the second or third day home from hospital. They sought to determine the degree of concern expressed as well as the effect of several modifying variables on the concerns. They found that despite the favorable conditions experienced by their sample, concern was still experienced with fathers experiencing a similar amount of concern as mothers. Variables such as weight of the baby, method of infant feeding, parental age and length of hospital stay were significantly correlated with degree of concern. Their small sample was not representative of the total population since they were all well educated and the mothers were all over the age of twenty-six and had help in the home. Therefore they realized that their findings could not be generalized and recommended that further study be done to validate the findings. Bull (1981), also examined the frequency and intensity of concerns related to self, infant, husband, family and community on the third postpartum day and again one week after discharge to determine if the focus of the concerns changed over this time period. She found that the concerns related to physical discomfort decreased significantly after one week at home whereas the concerns related to emotional self increased significantly over this time. Moderate to 33 much concern related to physiological change as well as infant behaviour persisted after one week at home. Concerns regarding husband were consistently ranked as being of little or moderate concern by more than half of the mothers and concerns related to family presented little or no concern after one week at home. This differs from the findings of Moss (1981) that multiparous mothers experienced much concern about family in the first week. Bull (1981) recommends that further studies of the changes in concerns over time as well as comparative studies of the concerns of primiparas and multiparas should be conducted. Her hypothesis that the maternal concerns shift from a focus on self to a focus on family and community after one week were not supported. When, one considers the many physiological and psychological changes the mother is going through during that week it is not surprising that she is not able to resolve one set of concerns and focus on new ones during that short time period. Walker (1986) in examining stability and change in maternal role attainment found that maternal attitudes during the peurperium demontrated both stability and change. Mothers were shown to become more self-confident and positive about themselves from birth to the end of the postpartum period. They also tended to view their infants less positively at the end of the first six weeks than at 34 the beginning. Also, multiparas had more positive attitudes than primiparas towards themselves and their infants and it is not surprising that they felt more confident in infant care. Mercer (1985) in looking at the process of maternal role attainment over the first year, identified four categories of challenges or demands which emerged from the content analysis of the qualitative data. The demand most frequently stated was that of finding any personal time. Role skills that they had not mastered leading to a feeling of incompetence was the second most frequently identified demand. Sleep deprivation and night care of the infant as well as problematic infant behaviour were the other frequently identified challenges during the first year. Mercer (1985) did not find a significant difference amongst different age groups of first time mothers but rather found that mothering over the first year presented similar challenges for all age groups despite different levels of initial proficiency. Effects of Parity on Postnatal Concerns There have only been a few widely focused studies on the concerns of both primiparas and multiparas and most of these were conducted in the United States (Gruis, 1974; Pate, 1979; Walker, 1973). Gruis (1974), conducted a study to explore the types of concerns experienced in the first 35 month postpartum and to determine any difference between the concerns of primiparas and multiparas. She also sought to identify the sources of help mothers turn to regarding these concerns. Her sample consisted of 17 primiparas and 23 multiparas who were under the care of one private obstetrician. The mothers were asked to recall after one month postpartum the concerns they had experienced during their first month at home with their infant. She found that the most frequently stated concern was return of figure to normal with 38 of the 40 mothers identifying it as being of some concern. Closely related to this 'were the areas of exercise and diet both of which were of concern to more than two-thirds of the mothers. Of the 40 mothers 30 also expressed some concern about regulating demands of housework, baby and family and nearly three-fourths were concerned about sexual relations in their marriage. These concerns were ranked similarly for both primiparous and multiparous mothers with primiparas having a slightly higher frequency of total concerns. Some differences in the two groups were noted in that primiparas did have more concerns regarding infant behaviour and feeding while the multiparas were concerned about the adjustment of the family to the new member. Pate (1979) conducted a replication of the study done by Gruis (1974) using a slightly larger and more diverse sample. She found little difference in the frequency of 36 concerns and perceived difficulty of the puerperium between the two studies. Regulating demands of the family, return of figure to normal as well as diet and exercise were still found to be the most frequently stated concerns. In examining . patterns of seeking assistance for concerns she also found that mothers were more likely to seek help for concerns related to the baby than for concerns related to self. This was dispite the finding that concerns related to self were perceived as major more often than concerns related to the baby or family. These findings differ significantly from those of Sumner and Fritsch (1972) and Bull (1981) who found that concerns related to the infant and maternal physiological change were of prime importance during the first week. A limitation of these studies by Gruis (1974) and Pate (1979) is the fact that the mothers were asked to recall the concerns experienced over the past month. Once again it is possible that the passage of time affected the mother's ability to recall the concerns she experienced in the first weeks postpartum. The results of these studies may in fact reflect only the concerns experienced one month after the infant was born. Harrison and Hicks (1983), conducted a similar study in Canada using a random sample of 64 primiparous and 94 multiparous mothers for whom birth notification was received by the Winnipeg Department of Health and Community Services. 37 The questionnaires in their study were also completed retrospectively ranging from 23 to 60 days after delivery. Their findings were similar to those of Gruis (1974) and Pate (1979) in that 70 % or more of the women had some concern about: regulating demands of family, return of figure, fatigue, emotional tension, exercise, diet and finding time for personal interests. They also found that although primiparas expressed more minor concerns multiparas had the same frequency of major concerns and there was not a significant difference in the types of concerns between the two groups. Once again these findings only indicate that at some time between delivery and the completing of the questionnaire both groups experienced these same concerns. They do not demonstrate how the focus of the concerns changed over this time period. It has been possible to see through this literature review that there has been an attempt to describe the concerns that mothers experience during the puerperium. The research has tended to measure concerns either in the first few days of this period or after the passing of one month. Little is known about how the focus of the concerns shift during this time period for both primiparous and multiparous mothers and whether the time since delivery affects the differences noted in these two groups. It is for this purpose that the present study was conducted. 38 CHAPTER 3 Methodology Introduction A descriptive, correlational research design was chosen as the methodology for this study. The purpose of descriptive research, to gain more information about the current status of phenomena, is congruent with the purpose of this study which was to provide data regarding the effects of the variables of time since delivery and maternal parity on the frequency and intensity of maternal concerns. This chapter discusses the sample and setting used in this study, the instrument used to measure the maternal concerns, the data gathering procedures and the methods of data analysis. Sample and Setting This study took place in a large urban city in Canada where services to postnatal mothers are at present a priority of the local community health department. A convenience volunteer sample of thirty-one primiparas and thirty-six multiparas delivering in one urban teaching hospital and residing within one health unit's boundaries was used. The hospital of delivery was a family-centered 39 maternity hospital whose philosophy emphasized parent teaching and preparation for discharge. However, realistically there was often wide variation in both the amount of teaching provided and the information absorbed prior to discharge from hospital. This was recognized as a variable the investigator was unable to control. The area of the city served by the chosen health unit was a primarily middle class area with some pockets of upper middle class homes as well as some subsidized housing. There was a variety of ethnic groups who resided within the unit boundaries particularly of the East Indian and Oriental cultures. In order to achieve some measure of homogeneity the sample was limited to mothers who met the following criteria: r i) delivered vaginally, a fullterm, greater than 2500 grams, healthy infant ii) were 18 to 38 years of age at the time of delivery iii) were discharged from hospital with their infant within five days following delivery. iv) resided with the infant's father v) were able to speak and read the English language 40 Measurement instrument A self-administered 51 item questionnaire that addressed potential levels of concern with regards to the categories of self, baby, husband and family, developed by Bull (1981) from a checklist of concerns developed by Gruis (1974), was chosen as the measurement instrument. (Appendix E & F) Some revisions were made in the instrument in order that it include the potential concerns or problems addressed in the Vancouver Health Department Standard Care Plans for the Newborn Visit (Munroe & Walker, 1984). In particular several items were added in the area of concerns regarding the infant such as, amount of weight the baby had gained and getting the baby immunized. The category of concerns regarding the community was eliminated as this area was not one in which the community health nurse could readily intervene. Bull (1981), also found that more than 50% of her sample of mothers had no concerns in this area. Cronbach's Alpha score for internal reliablity was obtained on Bull's Maternal Concerns Score (1981) and ranged from .97 for all questions to .82 for the category of concerns regarding family. A panel of fourteen mothers who had experienced a birth no more than one year prior and three nurses, reviewed Bull's (1981) questionnaire for clarity and content validity prior to data collection, and items on which there was at least 80% agreement were retained. The revised instrument was reviewed by a panel of 41 ten community health nurses (several of whom were also mothers) who visted mothers in the study area, in order to determine clarity and content validity. Demographic data such as parity, maternal age, number and ages of previous children and assistance in the home were also collected in order to describe the sample and compare it to what is known about the total population. Data Collection Mothers who met the criteria for acceptance in the study were contacted in the hospital by the community health liason nurse as part of her usual contact with new mothers. The mothers were given a letter from the researcher explaining the purpose and details of the study and emphasizing that the mother could withdraw at any time. If the mother agreed to participate she signed the attached consent form and took home two copies of the questionnaire in addressed envelopes. The first was completed on the first or second day at home and the second was completed twenty-eight days or one month after discharge from hospital. The liason nurse returned the signed consent forms to the investigator at the health unit office. The questionnaires and demographic data forms were coded with matched numbers in order to maintain strict confidentiality of responses. 42 Community health nurses, contacting the mothers routinely in the first few days at home, reminded the mothers to complete the questionnaire and place it in the sealed envelope, to be either mailed to the health unit or picked up by the nurse if she was to visit. A follow-up telephone call was made by the investigator four weeks later to again remind the mother and arrange to have the questionnaire picked up or mailed to the health unit. The investigator was the only person with access to both the completed questionnaires and the names and phone numbers of the subjects. Names and phone numbers were destroyed as soon as the data collection was completed and matching of the subject's code number and name was done only if the mother lost her second questionnaire, in order to ensure accurate matching of the first and second measure of concern. Completed questionnaires were destroyed once the data analysis was completed. Null Hypotheses Data were analyzed in order to test the following null hypothesis: 1. There is no difference in the frequency and intensity of concern of primiparous mothers in the first two days at home and their concerns one month later. (Figure 1: A vs. C) 43 2. There is no difference in the frequency and intensity of concern of multiparous mothers in the first two days at home and their concerns one month later. (Figure 1: B vs. D) 3. There is no difference in the frequency and intensity of concern of primiparous and multiparous mothers in the first two days at home with their infants. (Figure 1: A vs. B) 4. There is no difference in the frequency and intensity of concern of primiparous and multiparous mothers after one month at home with their infant. (Figure 1: C vs. D). For the purpose of analysis the questionnaire was divided into four categories with 18 items concerning self; 21 items concerning baby; 6 items concerning husband and 5 items concerning family. Intensity of concern was scored as follows: 0: no concern, 1: little concern, 2: moderate concern, 3: much concern and 4: critical concern. Frequency counts were determined on the number of concerns mothers had at each level of intensity for each item, for each category and for the total concerns. A suitable chi-square test was applied to the responses for items within each category and for all items across categories to determine the statistical 44 Primiparas Multiparas 1st 2 days 1 month A B C D Figure 1 Representation of Research Design significance of the difference between groups. A mean intensity score was calculated for individual items, for items within each category and for all items across all categories. Nonparametric tests of significance were chosen for data analysis as it was felt that the responses may not follow a normal distribution and the underlying measurement scale may not qualify as an interval scale. The Mann-Whitney U test was used to test the degree and direction of the difference in intensity of concerns between the two independent groups of primiparous and multiparous mothers at both time intervals. The Wilcoxon Signed-Rank test was used to determine the significance of the difference of intensity of concerns involving the two dependent measures of primiparas and multiparas two days 45 following discharge from hospital and one month following discharge respectively. Demographic data such as maternal age, ethnic background and level of education were also analyzed in terms of proportions for the purpose of describing the characteristics of the sample. 46 CHAPTER 4 Analysis of Data Introduction The data from the questionnaires were analyzed to determine any significant differences in frequency and intensity of concerns between primiparas and multiparas in the first two days after and one month after discharge from hospital. The concerns were categorized into concerns about self, baby, partner, family and total concerns. Frequency counts of demographic data regarding the characteristics of the sample were determined and percentages calculated. This chapter reports the data regarding the characteristics of the sample followed by the data relating to the four hypotheses of the study. Discussion of the significance of the findings will follow in chapter five. Characteristics of the Sample Par ity The questionnaires were given out to 95 mothers who met the criteria of the study and consented to participate. Over the two and one half month period in which the mothers were approached to participate, 73 mothers returned the 47 first questionnaire which was to be completed one to two days after discharge. Six of these participants did not complete the second questionnaire at one month after discharge resulting in a final sample of 67 mothers which was a 70% return rate. The 67 mothers in the sample consisted of 31 primiparas and 36 multiparas. The primiparas made up 46% of the sample and the multiparas 54%. Thirty-two multiparas (86%) were having their second child while three were having their third child and one delivered her fourth child. The ages of the previous children ranged from thirteen months to twelve years. Age The ages of the sample mothers ranged from 19 to 38 years. The ages were divided into four category groups: below 23, 23 to 28, 29 to 34 and above 34. These categories were chosen to provide relatively equal age categories and to distinquish 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 in the category 29 to 34 years. (Table 1). 48 Table 1: Distribution of Mothers by Age Years Primiparas Multiparas Total 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 total in brackets Gender of Baby The mothers in the sample delivered 39 male and 28 female infants. Education The education level of the mothers in the sample ranged from those having completed some high school to those having completed graduate school. Seven mothers had some high school whereas 23 completed high school. Eight of the mothers had some vocational school and seven completed vocational school. Six had some university whereas twelve graduated from university and two attended some graduate school and two completed a graduate degree. (Table 2) 49 Table 2: Distribution of Mothers by Education Education Level Pr imiparas Multiparas Total Some high school 1 (3)* 6(17) 7(10) Completed high school 11(36) 12(33) 23(34) Some vocational/ college 7(23) 1(3) 8(12) Completed vocational/ college 3(10) 4(11) 7(10) Some university 3(10) 3(8) 6(9) Completed university 5(16) 7(19) 12(18) Some graduate school 1 (3) 1 (3) 2(3) Completed graduate school 0(0) 2(6) 2(3) * Percentage of total in brackets Ethnicity of Mothers Many different ethnic groups were represented in this sample. Thirty-two of the mothers (48%) identified themselves as having a Canadian or Caucasion ethnic background. Other ethnic groups included Chinese, East Indian, Ismali, German, Fillipino and Portugese. Thirty-four of the mothers (51%) stated they had lived in Canada for more than twenty years. Seventeen of the mothers had lived in Canada ten to twenty years, nine mothers five to ten years and seven (10%) of the sample had lived in Canada less than five years. (Table 3) 50 Table 3: Distribution of Mothers by Ethnic Background Ethnicity Frequency Percent Canadian 32 48 Chinese 1 1 1 6 East Indian 4 6 Fillipino 5 8 German 2 3 Ismali 3 5 Portugese 3 5 Other 10 1 4 Type of Infant Feeding At the time of completing the first questionnaire 46 of the mothers (69%) were breastfeeding their infants. Thirteen of the mothers (19%) were formula feeding and eight (12%) were combining the two methods. Prenatal Class Attendance Twenty-nine mothers (43%), all of whom were primiparas, attended prenatal classes with this pregnancy. Of the twenty-nine mothers nineteen attended the health department classes, five the hospital classes and five private agency classes. 51 Return to Work At the time of completing the first questionnaire 36 of the mothers (54%) were planning to return to work. Thirty-one (46%) of the sample had not made plans to return to the workplace. Help at Home and Use of Professional Resources At the time of completing the first questionnaire 54 of the mothers (81%) stated that their husband was the most helpful person to them at home. Nine of the mothers stated that their mother or sister was the most helpful at this time. When completing the second questionnaire one month after discharge from hospital the mothers reported the number of professional contacts during their first month at home. Sixty of the mothers (90%) had had contact with, a community health nurse during the month with the number of contacts ranging from 0 to 3 and the mean number of contacts being 1.3. All but one of the mothers had had at least one contact with a physician, either family doctor or pediatrition, since their discharge with the number of contacts ranging from 0 to 7 and the mean number of contacts being 2.2. The mothers did not identify any other professional help sought during this time. 52 Difference Between Concerns of Primiparas and Multiparas at  Two Days In analyzing the data from the first questionnaire completed during the first two days after discharge from hospital the frequencies of responses on the five point scale (0-4) were obtained for each item, totalled across items within each category and across items over all categories (i.e.,51 items). Arithmetic means for individual items were obtained and ranked by category and across all categories to determine if the ranking of items differed between primiparas and multiparas. Spearman's rho correlation was also determined based on the rankings. The Mann-Whitney U test was used to determine the significance of any difference in intensity of concern between primiparas and multiparas for each item, each category and for the sum of all 51 items. The mother's mean frequency of responses of 0, 1, 2, 3, 4, were also calculated for the sum of the items in each category and for the total items and chi-square analysis used to determine the significance of the difference in total frequency of concerns for each level of intensity of concern. Many of the mean frequencies for each category were less than five making the chi-square analysis for the four categories questionable. Therefore only the chi-square for the mean frequency of responses for the total items is reported. These findings are reported according to the 53 catagories of self, baby, partner, family and total concerns. Self There was some difference in the ranking of mean responses between the two groups of mothers with the primiparas ranking 'being a good mother' 'fatigue' and 'pain from (stitches' as having the highest intensity of concern whereas the multiparas found 'fatigue' and 'return of figure' to be of greatest concern in this category. (Table 4) A comparison of ranking of items between primiparas and multiparas showed Spearmans's rho was .833 (p<.05) for the ranking of the items in the category of self. However, in looking at the category of self, the Mann-Whitney test did not demonstrate a significant difference for the 'self category (U=467; p=.252) or for any individual items. For the sum of the 18 items in this category of self the mean frequency of concern at each level of intensity was very similar for primiparas and multiparas. Table 5 indicates the percentage of responses of 0-4 totalled across items for all categories. 54 Table 4: Priority Ranking of Concerns Regarding Self (first 2 days) Primiparas Multiparas Item Mean1 Item Mean Being a good mother 2 .68 Fatigue 2 .25 Fatigue 2 .38 Return of figure 2 .22 Pain from stitches 2 .07 Being a good mother 2 .03 Return of figure 2 .00 Labour & delivery exp. 1 .78 Breast soreness 1 .93 Breast soreness 1 .75 Labour & delivery exp. 1 .90 Emotional tension 1 .69 Care of breasts 1 .83 Care of breasts 1 .67 Emotional tension 1 .81 Diet 1 .67 Diet 1 .77 Pain from stitches 1 .58 Exercise habits 1 .52 Exercise 1 .47 Constipation 1 .52 Lochia 1 .42 Lochia 1 .45 Personal time 1 .33 Hemorrhoids 1 .45 Return of period 1 .25 Unable to concentrate 1 .41 Being tied down 1 .19 Being tied down 1 .38 Unable to concentrate 1 . 1 7 Personal time 1 .32 Constipation 1 .08 Baby blues 1 .23 Baby blues 1 .06 Return of period 1 .19 Hemorrhoids 0 .94 Mean of responses on 0-4 scale Baby In examining the concerns regarding baby the Mann-Whitney U test did not demonstrate a significant difference between the two groups for the total category (U=417.5; p=.0772). There were however individual items in which the difference was significant at the .05 level. The items of 'bathing the infant', 'comfort in handling the infant', 'interpreting behaviour', 'crying', 'recognizing illness' and 'travelling with the infant' were of significantly greater concern to the primiparas than the multiparas at this time. (Table 6) 55 Table 5: Percentage of Mothers' responses of 0-4 totalled across items in each category (1st two days) Category Parity Level of Concern 0 12 3 4 Self Primiparas 19 .4 23. 3 31 . 1 18. 3 7. 70 18 items Multiparas 26 . 1 23. 8 27 .7 16. 1 6. 10 Baby Primiparas 18 .5 16. 2 29 .5 26. 2 9. 50 21 items Multiparas 28 .0 21 . 9 26 .6 19. 0 4. 80 Partner Primiparas 25 .5 25. 5 20 .0 20. 0 8. 50 6 items Multiparas 28 .3 23. 3 26 .9 18. 3 3. 10 Family Primiparas 23 .3 15. 6 33 .3 12. 8 5. 80 6 items Multiparas 20 .0 26. 7 28 .3 21 . 7 3. 70 Total Primiparas 21 .4 19. 6 29 .4 21 . 1 8. 05 51 items Multiparas 26 .3 23. 3 27 .3 18. 0 4. 90 Note: Primiparas n=3l Multiparas n=36 In the primipara group 'recognizing signs of illness' was identified as the greatest concern in this category followed by 'safety', 'growth and development' and 'feeding'. The multiparas also identified 'safety', 'growth and development' and 'feeding' as their greatest concerns. The ranking of the items in this category was not significantly different between the two groups as Spearmans'rho was .783 (p<.05) There was also little difference in the frequency of concerns at each level of intensity of concern for the sum of the 21 items in this category (Table 5) 56 Table 6: Priority Ranking of Concerns Regarding Baby (1st 2 days) Primiparas Multiparas Item Mean1 Item Mean Recognizing illness 2 .74 Safety 2 .08 Safety 2 .45 Growth and Development 1 .94 Growth and development 2 .35 Feeding baby 1 .92 Feeding baby 2 .32 Recognizing illness Baby's weight gain 1 .91 Baby's weight gain Baby's Behaviour Baby's crying 2 .19 1 .77 2 .19 Baby's sleeping 1 .64 2 .13 Immunizing baby 1 .64 Travelling with baby 2 .07 Dressing baby 1 .64 Dressing baby Baby's sleeping 2 .03 Care of cord 1 .56 2 .00 Baby's Behaviour 1 .47 Bathing baby Baby's breathing 1 .90 Baby's rashes 1 .47 1 .87 Physical appearance 1 .44 Fussiness 1 .87 Fussiness 1 .44 Vitamins & Floride 1 .80 Baby's crying 1 .44 Immunizing baby 1 .74 Travelling with baby 1 .44 Comfort in handling Baby's breathing 1 .39 baby 1 .74 Bowel movements 1 .74 Bowel movements 1 .39 Care of cord 1 .67 Vitamins and floride 1 .36 Physical appearance Baby's rashes 1 .58 Bathing baby 1 .25 1 .54 Comfort in handling baby 1 .06 Care of circumsion 0 .74 Care of circumsion 0 .50 1 Mean of responses on 0-4 scale Partner The Mann-Whitney U test did not demonstrate a significant difference in the category of partner, for the total category (U=491; p=.3885) or for any of the six individual items. The primiparas' mean intensity of concern for 'time alone together' was ranked highest while multiparas found 'birth control' to be of greatest concern 57 in this category. The remaining five items were ranked similarly between the two groups. (Table 7) Spearman's rho for comparison of ranks was .657 (p<.05). Table 7: Priority Ranking of Concerns Regarding Partner (first 2 days) Primiparas Multiparas I tern Mean1 I tern Mean Time alone together 1 .87 Birth control 1.81 Time for recreation 1.81 Time alone together 1 .56 Relationship with Time for recreation 1 .47 partner 1 .68 Birth control 1.61 Relationship with partner 1 .36 Sexual relations 1 .58 Sexual relations 1 .33 Partner being a good Partner being a good father 1 .36 father 1 .33 Mean of responses on 0-4 scale For the sum of the six items in this category the mean frequency at each level of concern was very similar for both groups. (Table 5) Family The difference between the intensity of concerns for the two groups of mothers was also not significant for the category of family (U=480; p= .3254). The only item in which the difference was significant was in 'setting limits 58 on visitors' (p=.0325). 'Reaction of siblings' was not included in this calculation as it was not of concern to any of the primiparas. The ranking of the mean intensity of concern scores was inverted and yielded a negative effect between the two groups with the multiparas finding 'reaction of siblings' to be of greatest concern and the primiparas identifying 'change in family lifestyle' to be of greatest concern in this category. (Table 8) Spearmans's rho for comparison of ranks was -406 (p<.05). Table 8: Priority Ranking of Concerns Regarding Family (1st 2 days) Primiparas Multiparas Item Mean1 Item Mean Family lifestyle change 2 .04 Reaction of siblings 2 .19 Limiting visitors 1 .80 Demands of household 1 .89 Demands of household 1 .77 Finances 1 .58 Finances 1 .64 Family lifestyle change 1 .58 Availability of Availability of resources 1 .35 resources 1 .25 Reaction of siblings 0 .00 Limiting visitors 1 .22 Mean of responses on 0-4 scale The frequency of responses at each level of concern for the sum of the items in the category of family was again very similar between the two groups of mothers. (Table 5) 59 Total Items The difference in intensity of concern between the primiparas and multiparas in the first two days after discharge was not significant for across all 51 items (U=429.5; p=.1061). Table 9 demonstrates that the ranking of the mean intensity scores of the items varied somewhat between the two groups with the primiparas identifying 'recognizing illness' and 'being a good mother' as their greatest concerns and multiparas finding 'return of figure' and 'fatigue' to be of greatest concern. Spearmans's rho for the .ranking of the total items for the two groups was .585 (p<.05) See Appendix A for the ranking of all items by mean intensity. Table 9: Priority Ranking of Highest Total Concerns (1st 2 days) Primiparas Mult iparas I tern Mean1 I tern Mean Recognizing illness 2. 74 Fatigue 2.25 Being a good mother 2. 68 Return of figure 2.22 Safety 2. 45 Reaction of siblings 2.19 Fatigue 2. 38 Safety 2.08 Growth & Development 2. 35 Being a good mother 2.03 Feeding baby Baby's weight gain Baby's behaviour 2. 32 Growth & development 1 .94 2. 19 Baby's feeding 1 .92 2. 19 Recognizing illness 1 .91 Baby's crying 2. 1 3 Demands of household 1 .89 Travelling with baby 2. 07 Birth control 1.81 Pain from stitches 2. 07 Labour & delivery exp. 1 .78 Dressing baby 2. 03 Baby's weight gain 1 .77 1 Mean of responses on 0-4 scale 60 The mean frequency of responses at each level of intensity for the sum of the total items was again not significantly different between the two groups. Chi-square = .73 (df=4) (p>.05) (Table 5) Difference in Concerns of Primiparas and Multiparas at One  Month The mothers completed a questionnaire with the same 51 items one month after their discharge from hospital and their responses were analyzed in the same manner as the first questionnaire. Self In the category of concerns about self the difference between the intensity of concerns was not found to be significant using the Mann-Whitney U test (U=487.5; p=.3751). Individual items in which the difference was found to be significant were 'discomfort from stitches' and 'being a good mother' with the primiparas identifying greater concern than multiparas. The ranking of the mean intensity of concern was similar between the two groups with 'being a good mother', 'fatigue' and 'return of figure' as the greatest concerns. (Table 10) Spearman's rho for the comparison of ranks was .877 (p<.05). 61 Table 10: Priority Ranking of Concerns Regarding Self (one month) Pr imiparas Multiparas I tern Mean1 I tern Mean Being a good mother 2 .22 Return of figure 2 .06 Return of figure 2 .20 Fat igue 1 .69 Fatigue 2 .00 Personal time 1 .69 Exercise 1 .90 Being a good mother 1 .60 Diet 1 .81 Exercise 1 .58 Emotional tension 1 .70 Emotional tension 1 .56 Personal time 1 .61 Diet 1 .47 Being tied down 1 .48 Care of breasts 1 .08 Lack of concentration 1 .45 Being tied down 1 .'19 Return of period 1 .30 Lack of concentration 1 .06 Baby Blues 1 .10 Return of period 1 .06 Constipation 1 .03 Breast soreness 0 .92 Lochia 1 .00 Baby Blues 0 .89 Labour & delivery exp. 1 .00 Lochia 0 .86 Care of breasts 1 .00 Constipation 0 .83 Pain from stitches 0 .94 Labour & delivery exp. 0 .81 Hemorrhoids 0,84 Hemorrhoids 0 .78 Breast soreness 0 .84 Pain from stitches 0 .47 Mean of responses on 0-4 scale The mean frequency of responses at each level of concern were not significantly different for the sum of the eighteen items in this category. Table 11 shows the percentage of responses of 0-4 for all categories at one month. Baby The difference in intensity of concerns between the two groups was not significant for the category of baby one month after discharge (U= 417; p=.076l). However, the difference was found to be significant for the items of 62 Table 11: Percentage of Mothers' Responses of 0-4 Totalled Across Items in each Category (one month) Category Parity Level of Concern 0 12 3 4 Self Primiparas 28. 9 27. 2 22 .8 1 5 .6 5 .40 18 items Multiparas 36. 1 25. 6 22 .8 12 .2 2 .80 Baby Primiparas 29. 5 22. 9 20 .0 20 .4 7 .10 21 items Multiparas 37. 6 30. 4 19 .0 1 1 .0 2 .10 Partner Primiparas 30. 0 15. 8 25 .0 25 .0 5 .30 6 items Multiparas 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 Multiparas 26. 7 30. 0 30 .0 1 1 .5 3 .70 Total Primiparas 30. 2 24. 3 21 .2 18 .4 5 .90 51 items Multiparas 34. 7 28. 1 22 .4 1 1 .8 2 .70 Note: Primiparas n=31 Multiparas n=36 'baby's breathing', 'bowel movements', 'fussiness' and 'sleeping', 'interpreting behaviour' and 'recognizing signs of illness' with the primiparas expressing greater concern. (Table 12) There was some variation in the ranking of mean intensity of concern between the two groups with Spearman's rho being .863 (p<.05) The mean frequency of responses at each level of concern were again not significantly different for the sum of the 21 items in this category. (Table 11) 63 Table 12: Priority Ranking of Concerns Regarding Baby (one month) Primiparas Multiparas I tern Mean1 I tern Mean Recognizing illness 2.30 Safety 1 .56 Fussiness 2.03 Recognizing illness 1 .50 Baby's Behaviour 2.00 Growth & Development 1 .36 Safety 1 .94 Fussiness 1 .33 Growth & Development 1 .94 Baby's sleeping 1 .33 Baby's sleeping Baby's feeding 1 .90 Baby's feeding Baby's rashes 1 .31 1 .87 1 .31 Baby's crying 1 .81 Baby's crying 1 .31 Dressing baby 1 .74 Dressing baby 1 .22 Travelling with baby 1 .61 Immunizing baby 1 .19 Baby's weight gain 1 .58 Baby's Behaviour 1 .14 Baby's breathing 1 .52 Travelling with baby 1 .08 Physical appearance 1 .48 Baby's weight gain 1 .08 Bowel movements 1 .42 Physical appearance 1 .06 Baby's rashes 1 .42 Bowel movements 0 .94 Immunizing baby 1 .32 Baby's Breathing 0 .89 Comfort in handling Baby 1 .07 Bathing baby 0 .81 Bathing baby 1 .07 Vitamins and floride 0 .75 Vitamins and floride 1 .03 Comfort in handling baby . 0 .67 Care of cord 0.65 Care of cord 0 .61 Care of circumsion 0.26 Care of circumsion 0 .42 Mean of responses on 0-4 scale Partner The difference in intensity of concern was not significant for the total category of partner one month after delivery (U=492; p= .4020) or for any of the six items. The ranking of the mean intensity of concern differed significantly for the two groups of mothers with both groups identifying 'time alone together' to be of greater concern. (Table 13) Spearman's rho for the comparison of ranks was .232 (p>.05). 64 Table 13: Priority Ranking of Concerns Regarding Partner (1 month after discharge) Primiparas Multiparas I tern Mean 1 I tern Mean Time alone together 1 .74 Birth control 1 .72 Sexual relations 1 .68 Time alone together 1 .53 Relationship with Time for recreation 1 .50 partner 1 .68 Time for recreation 1 .64 Relationship with partner 1 .22 Birth Control 1 .48 Sexual relations 1.19 Partner being a good Partner being a good father 1 .36 father 1 .05 Mean of responses on 0-4 scale The mean frequency of responses at each level of concern was again quite similar between the two groups for the six items. (Table 11) Family In analyzing the data regarding the category of family one month after discharge, the difference in intensity of concern between the two groups was not significant (U=525.5; p=.68'15). The ranking of the mean intensity of concern on each item differed between the two groups with the primiparas finding 'household demands' to be of highest concern in this category and the multiparas identifying 'reaction of siblings' to be of greatest concern. (Table 14) Spearman's rho for the comparison of ranks was -.086 (p>.05). 65 Table 14: Priority Ranking of Concerns Regarding Family (one month) Primiparas Multiparas I tern Mean 1 I tern Mean Household demands 1 .68 Reaction of siblings 1 .72 Family lifestyle change 1 .58 Finances 1 .69 Finances 1 .26 Household demands 1 .65 Limiting visitors 1 .23 Family lifestyle change 1 .25 Availability of Availability of resources 1 . 1 9 resources 1 .00 Reaction of siblings 0 .00 Limiting visitors 0.97 1 Mean of responses on 0-4 scale The mean frequency of responses for each level of concern was again very similar for the two groups. (Table 11) Total Items The difference in intensity of the total concerns was not found to be significant (U=448.5; p=.1684) despite the individual items for which there was a significant difference between the two groups of mothers one month after discharge. The ranking of the mean intensity of concern of the total items were varied between the two groups with the primiparas identifying, 'recognizing signs of illness', 'being a good mother' and 'return of figure' as their greatest concerns and the multiparas identifying 'return of figure', 'birth control' and 'reaction of other siblings' as 66 their greatest concerns. (Table 15) Spearmans rho for the comparison of ranks was .644 (p<.05). See Appendix B for the ranking of all items by mean intensity of concern. Table 15: Priority Ranking of Highest Total Concerns (one month) Primiparas Multiparas I tern Mean1 I tern Mean Recognizing illness 2.30 Return of figure 2 .06 Being a good mother 2.22 Birth control 1 .72 Return of Figure 2.20 Reaction of siblings 1 .72 Fatigue 2.00 Fatigue 1 .69 Baby's behaviour 2.00 Personal interests 1 .69 Safety 1 .94 Finances 1 .69 Growth & development 1 .94 Household demands 1 .68 Baby's sleeping 1 .90 Being a good mother 1 .60 exercise 1 .90 Exerc ise 1 .58 Baby's feeding Baby's crying 1 .87 Emotional tension 1 .56 1.81 Safety 1 .56 Diet 1 .81 Recognizing illness 1 .50 Mean of responses on 0-4 scale The mean frequency of responses for each level of concern for the sum of the total concerns was not significantly different for the two groups. Chi-square = 5.54 (df=4) (p>.05) (Table 11) 67 Difference in Concerns of Primiparas in First Two Days and  One Month after Discharge The data from the two questionnaires was also analyzed to determine if there was a significant difference in frequency arid intensity of concern in the two groups of mothers over the first month after discharge from hospital. The Wilcoxin signed rank test for matched pairs was used to determine the significance of the difference in intensity of concern. The mean of the frequencies of responses for each level of intensity of concern on each item were again ranked and Spearman's correlation coefficient was determined. Chi-square was used to determine any difference in the frequencies of responses for the total concerns. Self The difference in the intensity of concerns for primiparas between the first two days at home and one month after discharge was significant at the .05 level for the total category of concerns about self using the Wilcoxin sign rank for matched pairs (Z= -2.42; P=.0155.) The difference was not significant for such individual items as 'diet', 'return of figure', 'return of period', 'fatigue', 'tension', 'concentration', 'feelings of being tied down', 'baby blues' and 'time for self. Spearman's correlation coefficient for the ranking of the mean intensities of 68 concern was .107 (p>.05). The items of 'being a good mother', 'fatigue' and 'return of figure' were still ranked as the strongest concerns, however 'pain from stitches' dropped to being of less concern one month after discharge. (Table 16) Table 16: Priority Ranking of Concerns of Primiparas Regarding Self (1st 2 days vs. 1 month) 1st 2 days One month Item Mean1 Item Mean Being a good mother 2, .68 Fatigue 2, .38 Pain from stitches 2, .07 Return of figure 2, .00 Breast soreness 1 , .93 Labour & delivery exp. 1 , .90 Care of breasts 1 , .83 Emotional tension 1 . .81 Diet 1 , .77 Exercise 1 .52 Constipation 1 .52 Lochia 1 .45 Hemorrhoids 1 .45 Lack of concentration 1 .41 Being tied down 1 .38 Personal time 1 .32 Baby blues 1 .23 Return of period 1 .19 Mean of responses on 0-4 scale Being a good mother 2 .22 Return of figure 2 .22 Fatigue 2 .00 Exercise 1 .90 Diet 1 .81 Emotional tension 1 .70 Personal time . 1 .61 Being tied down 1 .48 Lack of concentration 1 .45 Return of period 1 .30 Baby blues 1 .10 Constipation 1 .03 Lochia 1 .00 Labour & delivery exp. 1 .00 Care of breasts 1 .00 Pain from stitches 0 .94 Hemorrhoids 0 .84 Breast soreness 0 .84 The difference between the mean frequency of concerns at each level of intensity was not significant for the sum of the eighteen items in the category of concerns about self. Table 17 shows the percentage of responses of 0-4 totalled across items for all categories. 69 Table 17: Percentage of Primiparas' Responses of 0-4 Totalled across Items in each Category (first 2 days versus 1 month) Category Time Level of Concern Measure 0 1 2 3 4 Self 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 Total 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 significant difference in intensity of concern between the two measures of primiparas for the total category of concerns about baby (Z= -3.32; p= .0009) with all items being of lower mean intensity of concern on the second measure. Individual items for which the difference was not significant included, 'infant's physical appearance', 'circumsion', 'bowel movements', 'rashes', 'fussiness', 'sleeping', 'crying', 'dressing' and 'interpreting infant behaviour'. The ranking of mean intensity of concern remained similar on the second measure. Spearman's rho for the comparison of ranks was .787 (p<.05). 70 'Recognizing signs of illness' continued to be the highest concern in this category. (Table 18) Table 18: Priority Ranking of Concerns of Primiparas Regarding Baby (1st 2 days) 1st 2 days One Month Item Mean1 Item Mean Recognizing illness 2 .74 Recognizing illness 2 .30 Safety 2 .45 Fussiness 2 .03 Growth and development 2 .35 Baby's Behaviour 2 .00 Feeding baby 2 .32 Safety 1 .94 Baby's weight gain Baby's Behaviour 2 .19 Growth & Development 1 .94 2 .19 Baby's sleeping Baby's feeding Baby's crying 1 .90 Baby's crying 2 . 13 1 .87 Travelling with baby 2 .07 1 .81 Dressing baby 2 .03 Dressing baby 1 .74 Baby's sleeping 2 .00 Travelling with baby Baby's weight gain 1 .61 Bathing baby Baby's breathing 1 .90 1 .58 1 .87 Baby's breathing 1 .52 Fussiness 1 .87 Physical appearance 1 .48 Vitamins & Floride 1 .80 Bowel movements 1 .42 Immunizing baby 1 .74 Baby's rashes 1 .42 Comfort in handling Immunizing baby 1 .32 baby 1 .74 Bowel movements 1 .74 Comfort in handling Baby 1 .07 Care of cord 1 .67 Bathing baby 1 .07 Physical appearance 1 .58 Vitamins and floride 1 .03 Baby's rashes 1 .54 Care of cord 0 .65 Care of circumsion 1 .54 Care of circumsion 0 .26 Mean of responses on 0-4 scale The difference between the mean frequencies of concerns was not significant for the sum of the 21 items in this category. (Table 17) 71 Partner The difference in intensity of concern between the two measures was not significant for either the total category of partner (Z= -.90; p=.3684) or for any of the six items in this category. The ranking of the mean intensity of concerns scores also stayed somewhat stable for the two measures in this category with Spearman's rho being .667 (p<.05). The item of greatest concern in this category continued to be 'finding time alone together1. (Table 19) Table 19: Priority Ranking of Concerns of Primiparas 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 for recreation 1.81 Sexual relations 1 .68 Relationship with Relationship with partner 1 .68 partner 1 .68 Sexual relations 1 .58 Birth control 1 .48 Partner being a good Partner being a good father 1 .36 father 1 .36 Mean of responses on 0-4 scale Table 17 also shows that the mean responses at each level of concern for the six items also remained very similar. 72 Family The difference between the primiparas two measures of concern was significant for the category of family. (Z= -2.2; p= .0279). Items for which the difference was not significant included, 'household demands', 'availability of resources' and 'reaction of siblings'. There was some variation in the ranking of the mean intensity scores with 'household demands' and 'finances' increasing in priority at one month after discharge. (Table 20) Spearman's rho for the comparison of ranks was .714 (p<.05) Table 20: Priority Ranking of Concerns of Primiparas Regarding Family (1st 2 days vs. 1 month) 1st 2 days One month Item Mean1 Item Mean Family lifestyle change 2 .00 Household demands 1 .68 Limiting visitors 1 .80 Family lifestyle change 1 .58 Household demands 1 .77 Finances 1 .26 Finances 1 .64 Limiting visitors 1 .23 Availability of Availability of resources 1 .35 resources 1 .19 Reaction of siblings 0 .00 Reaction of siblings 0 .00 Mean of responses on 0-4 scale Table 17 demonstrates that the mean responses for each level of concern for the sum of the items in the category of family for primiparas remained similar at both measures. 73 Total Items In analyzing the difference between the total concerns of primiparas at two days and one month after discharge, the Wilcoxin matched pairs test showed the difference in intensity of concern to be significant (Z= -3.14; p=.0017). The ranking of the mean intensity scores showed variation with 'return of fiqure' increasing in priority on the second measure. (Table 21) Spearmans's rho for the comparison of the ranks was .501 (p<.05). See Appendix A and B for ranking for total items by mean intensity of concern. Table 21: Priority Ranking of Total Concerns of Primiparas (1st 2 days vs. 1 month) 1st 2 days One month I tern Mean1 I tern Mean Recognizing illness 2 .74 Recognizing illness 2.30 Being a good mother 2 .68 Being a good mother 2.22 Safety 2 .45 Return of figure 2.20 Fatigue 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 crying 2 .32 Safety 1 .94 2 . 1 9 Growth & Development 1 .94 2 .19 Baby's sleeping 1 .90 2 . 1 3 Exercise 1 .90 Travelling with baby 2 .07 Baby's feeding Baby's crying 1 .87 Pain from stitches 2 .07 1.81 Dressing baby 2 .03 Diet 1.81 Mean of responses on 0-4 scale 74 The chi-square of 2.15 (df=4) (p>.05) for the mean frequencies of responses at each level of concern for the sum of the total items did not demonstrate a significant difference for the total 51 concerns. (Table 17) Difference in Concerns of Multiparas at First Two Days  and One Month Self The Wilcoxin ranked test for matched pairs indicated a clearly significant difference in the intensity of the concerns of multiparas between the first two days and one month after discharge for the category of self (Z = -3.73; p=.0002). There were individual items for which the difference was not significant which included: 'diet', 'exercise', 'return of fiqure' and 'period', 'hemorrhoids', 'tension' and 'feelings of being tied down'. The item of 'finding time for personal interests' was of significantly greater concern on the second measure (p=.047). The rankings of the mean intensity of concerns differed somewhat for the two measures with Spearman's rho being .506 (p<.05). The item of 'finding personal time' moved up to the second highest concern for this category on the second measure. (Table 22) 75 Table 22: Priority Ranking of Concerns of Multiparas Regarding Self (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 I tern Mean Fatigue 2 .25 Return of figure 2 .06 Return of figure 2 .22 Fat igue 1 .69 Being a good mother 2 .03 Personal time 1 .69 Labour & Delivery exp. 1 .78 Being a good mother 1 .60 Breast soreness 1 .75 Exerc i se 1 .58 Emotional tension 1 .69 Emotional tension 1 .56 Care of breasts 1 .67 Diet 1 .47 Pain from stitches 1 .58 Care of breasts 1 .08 Diet 1 .67 Being tied down 1 .19 Exercise 1 .47 Lack of concentration 1 .06 Lochia 1 .42 Return of period 1 .06 Personal time 1 .33 Breast soreness 0 .92 Return of period 1 .25 Baby Blues 0 .89 Being tied down 1 .19 Lochia 0 .86 Lack of concentration 1 .17 Constipation 0 .83 Constipation 1 .08 Labour & delivery exp. 0 .81 Baby blues 1 .06 Hemorrhoids 0 .78 Hemorrhoids 0 .94 Pain from stitches 0 .47 1 Mean of responses on 0-4 scale Table 23 shows that the percentage of responses of 0 to 4 for the sum of the items in the category of self were not significantly different for the two measures in this category. Baby The difference in intensity of concern for the category of baby was found to be significant (Z -2.91; p= .0036) for the total category. Individual items for which the 76 Table 23: Percentage of Multiparas' Responses of 0-4 Totalled across Items in Each Category (first 2 days versus 1 month) Category Time Level of Concern Measure 0 12 3 4 Self 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 Total 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 difference was not significant included 'infant's rashes', 'fussiness', 'sleeping', 'crying' and 'interpreting infant's behaviour'. The ranking of the mean intensity of concern scores as seen in Table 24 show some variation with Spearman's rho for comparison of ranks being .763 (p<.05). Table 23 gives the percentage of responses of 0 to 4 for the sum of the 21 items in the category of baby. 77 Table 24: Priority Ranking of Concerns of Multiparas Regarding Baby (1st 2 days vs. 1 month) I tern 1st 2 days One month Mean1 Item Mean Safety 2 .08 Safety 1 .56 Growth & Development 1 .94 Recognizing illness 1 .50 Feeding baby 1 .92 Growth & Development 1 .36 Recognizing illness Baby's weight gain Baby's sleeping 1 .91 Fussiness 1 .33 1 .77 Baby's sleeping 1 .33 1 .64 Baby's feeding Baby's rashes 1 .31 Immunizing baby 1 .64 1 .31 Dressing baby 1 .64 Baby's crying 1 .31 Care of cord 1 .56 Dressing baby 1 .22 Baby's behaviour 1 .47 Immunizing baby 1 .19 Baby's rashes 1 .47 Baby's Behaviour 1 . 1 4 Physical appearance 1 .44 Travelling with baby 1 .08 Baby's fussiness Baby's crying 1 .44 Baby's weight gain 1 .08 1 .44 Physical appearance 1 .06 Travelling with baby 1 .44 Bowel movements 0 .94 Baby's breathing 1 .39 Baby's Breathing 0 .89 Bowel movements 1 .39 Bathing baby 0 .81 Vitamins and floride 1 .36 Vitamins and floride 0 .75 Bathing baby 1 .25 Comfort in handling baby 0 .67 Comfort in handling baby 1 .06 Care of cord 0 .61 Care of circumsion 0 .50 Care of circumsion 0 .42 Mean of responses on 0-4 scale Partner The difference in the intensity of the concerns for the category of partner was not significant for the two measures of the multiparas (Z= -1.12; P=.2608). (Table 25) The ranking of the mean intensity scores were the same for both measures in this category and Spearmans's rho was .10 (p<.05) 78 Table 25: Priority Ranking of Concerns of Multiparas Regarding Partner (1st 2 days vs. 1 month) 1st 2 days One month I tern Mean 1 I tern Mean Birth control 1 .81 Birth control 1 .72 Time alone together 1 .56 Time alone together 1 .53 Time for recreation 1 .47 Time for recreation 1 .50 Relationship with Relationship with partner 1 .36 partner 1 .22 Sexual relations 1 .33 Sexual relations 1 .19 Partner being a good Partner being a good father 1 .22 father 1 .05 1 Mean of responses on 0-4 scale The difference in the percentage of concerns at each level of intensity of concern were also not significant for the sum of the items in this category. (Table 23) Family In analyzing the responses to the category of family the difference in intensity of concern between the two measures of the multiparas was found to be significant (Z= -2.22; p =.0267). Individual items in which the difference was significant included: 'change in family lifestyle' and 'reaction of siblings'. There were some changes in the ranking of mean intensity of concern scores with 'finances' becoming of greater concern on the second measure. (Table 26) Spearman's rho for the comparison of the ranks between the two measures was .899 (p<.05) 79 Table 26: Priority Ranking of Concerns of Multiparas Regarding Family (1st 2 days vs. 1 month) 1st 2 days One month Item Mean1 Item Mean Reaction of siblings 2 .19 Reaction of siblings 1 .72 Demands of household 1 .89 Finances 1 .69 Finances 1 .58 Household demands 1 .65 Family lifestyle change 1 .58 Family lifestyle change 1 .25 Availability of Availability of resources 1 .25 resources 1 .00 Limiting visitors 1 .22 Limiting visitors 0 .97 1 Mean of responses on 0-4 scale Table 23 shows the mean frequencies of responses at each level of concern for the sum of the items in the category of family. Total Items In analyzing the difference in the intensity of total concerns between the two questionnaires completed by the multiparas for the total items, the difference was found to be significant (Z=-3.45; p=.0006). The ranking of the mean intensity of concern scores for all items shows variation with 'return of figure' and 'birth control' becoming the most intense concerns at one month after discharge. Spearman's rho for the comparison of ranks was .599 (p<.05) (Table 27) 80 Table 27: Priority Ranking of Total Concerns of Multiparas (1st 2 days vs. 1 month) 1st 2 days One month Item Mean 1 I tern Mean Fatigue 2.25 Return of figure 2.06 Return of figure 2.22 Birth control 1 .72 Reaction of siblings 2.19 Reaction of siblings 1 .72 Safety 2.08 Fatigue 1 .72 Being a good mother 2.03 Personal interests 1 .69 Recognizing illness 1 .91 Finances 1 .69 Demands of household 1 .89 Demands of household 1 .68 Birth control 1.81 Being a good mother 1 .60 Labour & delivery exp. 1 .78 Exercise 1 .58 Baby's weight gain 1 .77 Emotional tension 1 .56 Breast soreness 1 .'75 Safety 1 .56 Emotional tension 1 .69 Recognizing illness 1 .50 1 Mean of responses on 0-4 scale The mean frequencies of responses at each level of concern for the sum of the total items for multiparas did not show a significant difference between the first two days and one month after discharge. Chi-square =2.92 (df=4) (p>.05). (Table 23). Summary The results of the analysis of data have been reported in this chapter for the purpose of identifying any significant difference in the concerns of primiparas and multiparas in the first two days or one month after discharge as well as any significant difference between 81 these two time measures. The analysis of the demographic data has also been reported in order to describe the characteristics of the sample group of mothers. Analysis using the Mann-Whitney U test has shown no significant difference in intensity of concern between the two groups of mothers for the total concerns or any of the four categories at either time measure. There were individual items however, in which the difference between the two groups was significant. Analysis of the data using the Wilcoxin ranked test for matched pairs has shown a significant difference for both groups of mothers between the first two days at home and one month after discharge for the total concerns and for all categories except partner. There were again individual items in which the difference was not significant between the two time measures. Chi-square analysis also did not indicate any significant difference between the number of concerns mothers had at each level of intensity of concern for the sum of the 51 items on the questionnaire. The following chapter will now discuss the significance of these findings, their implications for program planning and recommendations for further research in this area. 82 CHAPTER 5 Findings and Recommendations Introduction The significance of the findings of the previous chapter as well as a comparison with the findings in the literature will now be discussed. The significance of the characteristics of the sample will be discussed first in terms of the characteristics of the total population. The remaining findings will be discussed in relation to their significance to the four hypotheses of the study. Implications for program planning for this client group will be identified as well as recommendations for future research in this area. The Sample During the two and a half month period in which mothers were approached to participate in the study 210 live births occurred within the study boundries. Seventy-five of these births were known not to meet the study criteria because of cesarean section or low birth weight of the infant. Ninety-five mothers consented to participate in the study when approached in the hospital. The remaining 35 live births during this time period involved mothers who were 83 single, who did not speak English, who delivered in a different hospital or for whom there were physical complicat ions. The ages of the mothers were spread across the acceptable criteria with the modal category being 23-28 for primiparas and 29-34 for multiparas, which is typical for the population of mothers in this area. There was also a wide range of educational backgrounds within the sample mothers with the largest group having completed high school which was also characteristic of the study population. The distribution of the ethnic backgrounds of the mothers closely resembled the distribution found in the 1981 Canada Census information for mother tonque for the study area. The percentage of East Indian and Chinese ethnic groups were slightly lower which was not surprising considering the exclusion of non english speaking mothers. Canada census for 1981 also identified 10% of the population in this area as having lived in Canada for less than five years. The percentage of mothers breastfeeding their infants and returning to work fit with the opinions of the community health nurses working in the study area. The number of mothers who attended prenatal classes was consistent with previous fiqures with the majority of primiparas having attended while only a minority of multiparas attended with their second pregnancy. The findings regarding help at home 84 were consistent with those of Gruis (1974) and Pate (1979) who also found that husbands were most frequently identified as being the most helpful at home. It appears that the sample was representative of the population of mothers who met the criteria for inclusion in the study. Care must be taken in generalizing the findings to mothers who do not meet the criteria for participation, particularly single mothers and those who do not speak English. Difference in Concerns of Primiparas and Multiparas During  the First Two Days The finding of no significant difference between the overall concerns of primiparas and multiparas in the first few days after discharge is consistent with the findings of Gruis (1974), Pate (1979) and Harrison and Hicks (1983). They found no difference in frequency of concerns over the total postpartum period. In the category of concerns regarding self there were no individual items in which the difference was significant and the ranking of the priority of concerns was very similar. All of the items were found to be of some concern to more than 70% of the mothers. These findings support the need for supportive-educative services which focus on the mother for both primiparas and multiparas soon after discharge from hospital. 85 In the category of baby there were items for which the difference between the two groups was significant. Items such as 'bathing the baby' and 'feeling comfortable in handling the baby' are infant care items for which it is logical to assume that the multiparas' previous experience would make a difference. Items which relate to the well being of the baby such as 'safety', 'normal growth and development', 'weight gain' and 'feeding the baby' were of concern to both groups of mothers which would indicate a need for support and reassurance in the early days after discharge .in regards to the well being of this baby. Once again the findings indicate a need for professional support soon after discharge with the primiparas receiving additional assistance and support in areas of infant care. In regards to their partner both groups of mothers had similar concerns about 'finding time to be together' and 'for recreation' which again is to be expected considering the increased demands placed on both partners during the early days at home. 'Limiting visitors' was the only item besides 'reaction of siblings' in the category of family in which the difference in intensity of concern was significantly different for the two groups at this time. The different ranking of priority of the items between the two groups was again to be expected with the primiparas experiencing a greater change in family lifestyle and more frequent 86 visitors for the first baby. As reported by Moss (1981) the multiparas found the 'reaction of the other children at home' and 'meeting demands of the household' to be the greatest concerns in this category. In examining the difference in the ranking of the total items between the two groups at this time, concern regarding 'return of figure to normal' and 'managing the demands of the household' were of greatest concern for the multiparas whereas 'recognizing illness in the baby', 'being a good mother', 'safety' and 'feeding the baby' were of 'much' to 'critical concern' for more than 50% of the primiparas. Gruis (1973), Pate (1979) and Harrison and Hicks (1983) found 'return of figure' and 'household demands' to be the greatest overall concerns of their sample, which may have been due to the fact that their sample included more multiparas than primiparas. It was the expectation that during the first few days at home the primiparas would be more concerned about caring for the baby and their ability to mother effectively than their own body image. This expectation is supported by these findings as well as those of Bull (1981). It is evident therefore that the null hypothesis of no significant difference in frequency and intensity of concern between primiparas and multiparas in the first two days at home must be accepted for the total concerns. There are however, significant differences in specific areas which have implications for those planning 87 programs for these clients. Difference in Concerns of Primiparas and Multiparas One  Month After Discharge The data analysis has demonstrated that the null hypothesis of no significant difference in the frequency and intensity of concerns of primiparas and multiparas one month after discharge also must be accepted for the total items of concern. Once again there were specific areas related to the baby in which the differences were significant that must be identified. The primiparas continued to have greater concern regarding 'interpreting infant behaviour', 'recognizing signs of illness' and the 'baby's fussiness', which again is logical considering the multiparas' experience in these areas. In looking at the total concerns of the two groups of mothers one month after discharge it was apparent that the multiparas had greater concerns regarding self and family. Items such as 'return of figure', 'birth control', 'reaction of siblings', 'fatigue' and 'household demands' were of some concern to more than 70% of the multiparas. More than 80% of the primiparas still had some concern regarding 'recognizing illness', 'normal growth and development' and 'baby's sleeping' and 'feeding'. It is apparent therefore that although the overall difference in means of intensity of concern are not statistically significant, there are 88 differences in how the priority of the concerns between the two groups are ranked at one month which have implicatons for services directed towards these two groups of mothers. Difference in Concerns of Primiparas in the First Two Days  and One Month After Discharge The data analysis has demonstrated a significant difference in the intensity of the concerns after one month at home with the baby for primiparas for the overall concerns. All of the items for which the difference in intensity of concern was statistically significant involved a decrease in mean intensity of concern one month after discharge. For many of the items in which the difference was not significant at .05 there was an increase in the mean intensity score. Items such as 'diet', 'exercise', 'return of figure', 'being tied down' and 'personal time' in the category of self, increased in their mean level of intensity of concern on the second measure. Although the increase was not statistically significant the fact that there was not a reduction in the concern is logical considering the mother's ability to focus more on herself at one month and to recognize her lack of time to do many of the activities she engaged in prior to motherhood. The significant decrease in items related to physical discomfort is consistent with Bull's (1981) findings of a decrease in intensity of concern of these items after one week at home. 89 In the category of baby the items in which the difference was not significant were those which either continued to be of high priority, such as the 'baby's fussiness', 'sleeping' and 'crying' and 'interpreting behaviour' or continued to be of low priority such as 'care of the circumsision'. The items for which there was the greatest decrease in concern involved acquiring a skill such as 'bathing the baby' or 'caring for the cord', which again is consistent with Bull's finding that infant care items decreased in intensity of concern after one week. Bull (1981) also found no significant change in concerns regarding partner and family after one week. The findings of this study also do not identify a difference in concerns regarding partner after one month indicating that concerns in this area such as 'finding time alone together' and 'relationship with partner' may have existed prior to delivery or which continue beyond the immediate postpartum period. This study did find a difference in the total category of family after one month for the primiparas, with items such as 'limiting visitors' and 'change in family lifestyle' decreasing significantly in intensity of concern. It is logical to assume that it takes longer than the one week allowed in Bull's (1981) study for these concerns to be resolved. The concern regarding 'managing the demands of the household' did not decrease significantly after one 90 month for the primiparas. This is not surprising since initial help, which the mother may have had in the early days at home, may no longer be available. Also many of the normal household tasks which the mother may have ignored during the first few weeks at home may now begin to demand her attention. In looking at how the ranking of the total concerns differs for the primiparas after one month at home it is apparent that the overall change in priority is not significant. Items such as 'return of figure to normal', 'diet' and 'exercise' have increased in priority after one month which is more consistent with the previous literature, however many items focusing on the infant also continue to be of higher priority at one month for the primiparas which differs from the findings of Gruis (1974) Pate (1979) and Harrison and Hicks (1983) who found 'return of figure', 'diet' and 'meeting demands' to be of greatest concern. These authors also found 'fatigue', 'infant behaviour' and 'safety' to be of moderate concern for both groups of mothers which is consistent with the findings of this study. Difference in Concerns of Multiparas in the First Two Days  and One Month After Discharge The data analysis indicates that the null hypothesis of no difference in concerns of multiparas between the first two days and one month after discharge must also be rejected 91 for the total concerns. As with the primiparas there are areas in which the difference is not significant which have implications for program planning. Once again the items in which the intensity of concern was significantly different involved a. decrease in the mean intensity of concern. In the category of self, again items such as 'return of figure', 'diet', 'emotional tension' and 'being tied down' maintained their mean intensity of concern after one month and therefore increased in their priority in the overall ranking of items. In the category of baby the items which maintained their intensity of concern were areas in which mothers frequently seek assistance beyond the initial postpartum period. These include 'baby's rashes', 'fussiness', 'sleeping', 'crying' and 'interpreting infant behaviour'. These are also areas in which the mothers' experience with one infant may be very different from that with another infant and therefore multiparas may continue to have concerns because this baby is very different from her others. As with the primiparas the null hypothesis was supported in the category of partner with none of the items being significantly different in intensity after one month. Birth control continued to be the highest priority for the multiparas in this category. It is possible that the multiparas were reexamining the issue of 'birth control' in 92 terms of whether they felt their family was now complete and were considering alternative options than they did after their first infant. In regards to the multiparas' concerns regarding family, the intensity of concern regarding 'reaction of siblings' did decrease significantly after one month even though it remained of highest priority in this category. It seems likely that many of the mothers found that after the initial reaction of their other children to the new baby their concerns were resolved. In the families in which a problem did occur with other siblings it is likely that the concern would have continued to be of importance beyond the initial postpartum period. The overall ranking of the priority of concerns for the total items again identifies many similarities but also some differences from the previous literature in which primiparas and multiparas were not considered separately. Items such as 'return of figure to normal', 'fatigue' and 'household demands' were included in the ten highest ranked concerns as found by Harrison and Hicks (1983) and Pate (1979). Items such as 'birth control', 'reaction of siblings', 'finances' and 'being a good mother' were however also found to be of highest priority in this study. The previous studies while looking at the effect of parity on the overall number of concerns and finding no significant difference did not separate the two groups of mothers when examining the 93 intensity of concerns regarding individual items. This may account for the specific difference in the findings of this study despite the agreement in the finding of no overall difference in the concerns between the two groups. Limitations of the Study A limitation of the study was the use of a volunteer, sample of convenience. Comparing demographic characteristics of the sample with those of the target population was an attempt to support generalizability. However, care must be taken in generalizing findings to mothers with characteristics similar to those of the sample. The use of a questionnaire for data collection has certain advantages such as providing anonymity of the respondents and eliminating observer error as a source of bias. However, disadvantages of this method must also be recognized. It could only be used for those subjects who could read and write the language and had the patience and motivation to respond. There was also an increased chance of response error and limitations in the depth of the responses obtained. Also, being a structured tool, it did not allow for variation in response and the absence of an interviewer did not permit the clarification of unusual or ambiguous responses. An additional limitation of this study is the fact that the original questionnaire was revised and therefore previous information concerning reliability and 94 validity could not be applied. As mentioned in Chapter 3 content validity for this questionnaire was established by a panel of community health nurses working in the study area. Hoyt's estimate of reliability was calculated and ranged from .97 for the total items to .81 for the category of family on the first measure. For the questionnaires completed one month after discharge, Hoyt's reliability measure ranged from .98 for the total items to .85 for the category of family. Chronbach's Alpha scores for internal reliability were also calculated for the total items on both time measures. The score for the administration of the questionnaire two days after discharge was .82 for the total items and .83 when the questionnaires were completed one month later. It is possible to see therefore, that the revisions that were made in the questionnaire did not have a significant effect on the internal reliability of the original instrument. Implications for Program Planning The findings of this study support the need identified in the literature for supportive-educative services during the postpartum period for both primiparas and multiparas. Specific recommendations can be drawn from the findings for the differing foci of these services for the two types of mothers as well as over the postpartum period. In planning services for the new mother during the 95 first days after discharge, factors such as the mothers' level of fatigue, pain and emotional tension must also be considered and therefore it is unlikely that the mother will be able to participate in programs outside of the home. Home visits or telephone contacts by community health nurses have traditionally been offered to new mothers and this study supports their necessity for both primiparas and multiparas soon after discharge from hospital. Many of the items which were of concern during these early days at home require hands on reassurance from the supportive individual. The only way to relieve the mother's concern regarding the baby's weight gain and feeding is to weigh the baby and assess the adequacy of the gain and method of feeding. Both groups of mothers identified a need for reassurance of their ability to mother effectively and it is unlikely that a mother would be reassured by a telephone contact from someone who had not met her or her.infant. The primiparas identified a need for reassurance in their ability to physically care for the infant despite their stay in a hospital whose philosophy supported patient teaching. This type of educative support would also require a direct client approach with the infant. This study provides evidence for a home visit for both primiparas and multiparas in the first week after discharge from hospital. 96 For the primiparas there would need to be increased focus on the physical care of the infant and reassurance of wellness and effective mothering. Anticipatory guidance should be given at this time regarding the normality of the mothers' present and future concerns. The mother should have an opportunity to express her concerns about the sudden change in lifestyle and lack of personal time and time management strategies and effective use of resources discussed to help decrease the level of fatigue and feelings of being tied down. Visits to the multiparas should focus more on the mothers' concerns regarding their infants' behaviour, which may be different from their previous children, and growth and development. The mothers' concern regarding the reaction of the other children also needs to be addressed in the first days at home and teaching and support given for the attempts to make the adjustment as easy as possible. The multiparas concerns regarding birth control may also be addressed during these early days and information and options discussed which assist in decision making. The multiparas also identify a need for reassurance of their ability to mother effectively and for strategies and resources to help them effectively manage the increased demands of their household. 97 The findings regarding the concerns one month after discharge indicate a significant decrease in the mean intensity of many of the areas of concern. This may be partially due to the fact that all of the mothers made use of professional resources available to them during this time. All of the sample mothers indicated that they had some support at home and all of them had had some contact with a community health nurse or physician with the majority having had several contacts during the one month interval. It is unknown whether these contacts were initiated by the mother or the professional. It is likely that the resources that were available to the mothers in this study were effective in reducing many of the concerns identified in the early days. It is apparent however that there continues to be a need for supportive educative services to new mothers that go beyond the initial postpartum period. Many of the concerns identified as being of priority one month after discharge such as 'exercise', 'return of figure to normal', 'lack of personal time' and 'emotional tension' cannot be effectively dealt with in a clinic or physician's office. By this point mothers are usually able to get out of the house and postpartum programs which combine exercise with discussion of topics of concern may be more effective and cost efficient than individual contacts with professionals. The programs could allow for sharing of concerns among the mothers and promote support from the peer group as well as 98 reassurance from the professionals running the program as to the wellness of the baby. Making exercise a component of the program could be an important motivator for participation since 'return of figure to normal' is a high priority concern for both primiparas and multiparas at this time. The findings of this study also have some implications for programs offered to mothers during their pregnancy such as prenatal and fitness classes. Anticipatory quidance before the delivery could be helpful in reducing the concern regarding such items as 'change in lifestyle', 'reaction of other siblings', 'limiting visitors' and 'emotional tension'. Several of the mothers commented that completing the questionnaire reassured them that other mothers must experience these same concerns. Being aware of some of the common concerns of the postpartum prior to delivery may not change the postpartum experience for the mother but particularly in the early days at home may reassure her that other mothers share her concerns. Recommendations for Future Research The findings regarding the overall frequency and intensity of concerns of primiparas during the postpartum period have now been replicated in several studies. Further replication of the data regarding the difference between primiparas and multiparas will be necessary to validate 99 these findings. Research into the differences between the concerns of primiparas and multiparas for the groups of mothers excluded from this study would also be of interest. They would include: mothers who delivered by cesarean section rather than vaginal birth; mothers who by choice or circumstances were parenting their infant alone; and mothers who were not comfortable with the English language. The effects of the variables of age, education, type of infant feeding and ethnic background on the differences of concerns of primiparas and multiparas would also be of value to those planning programs for these clients. The assumption was made in the present study that the use of professional resources during the first month may have reduced the concerns on the second measure. Research evaluating the effectiveness of home visits by the community health nurse or visits to the physician in reducing the maternal concerns are necessary to validate this assumption. A comparison of the cost effectiveness of the services to new mothers provided by the different profesionals would be of assistance considering the financial strain on the health care system. Research into how the mothers view the role of these professionals and their expectations in having specific concerns addressed would also be of value. Descriptive information regarding the types of maternal and paternal concerns which may persist or change throughout the infant's first year of life would also assist in 100 planning ongoing parenting classes or discussion groups. Finally it would increase the body of knowledge in this area to have further indepth studies into specific areas of concern which have consistently been rated as being of importance to the mothers throughout the literature in order to effectively intervene with those concerns. For an area of concern such as 'return of figure to normal' for example it is not known if there is a problem with body image, the physiological changes which are occuring, or a lack of knowledge regarding how the mother can help herself get back to normal. It is also not known if normal is the same as before or a desired state. Other significant items could also be examined in more depth to increase the knowledge in this area. Conclusions In conclusion, this study has attempted to add to the body of knowledge regarding the concerns or needs of both primiparas and multiparas during the first month after discharge from hospital. It has been shown that there is no significant overall difference in the frequency and intensity of concerns of primiparas and multiparas either in the early days or one month after discharge. The findings along with others in the literature do not support the assumption made in practise that multiparas have had experience and therefore do not require supportive educative 101 services during the postpartum period. Differences in the focus of the concerns of the two groups of mothers have been identified which have implications for those planning programs for the postpartum period. The results of the study also show that there is a significant difference in intensity of concerns between the early days at home and one month after discharge from hospital. 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Nursing Research, 35, 68-71. Williams, J.K. (1977). Learning needs of new parents. American Journal of Nursing, 77, 1173. 108 APPENDIX A PRIORITY RANKING OF TOTAL CONCERNS (1 ST 2 DAYS) 109 APPENDIX A Priority Ranking* of Total Concerns (1st 2 days) Percent of Mothers Responding: 0 = no concern 1-2 = little to moderate concern 3-4 = much to critical concern Primiparas Percent Multiparas Percent I tern 0 1 -2 3-4 I tem 0 1-2 3-4 Recognize illness 0 39 58 Fatigue 1 1 47 42 Be a good mother 6 35 59 Return of figure 1 1 39 50 Safety 10 39 51 Safety 22 39 39 Fatigue 6 55 38 Reaction of sibs 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 Infant feeding 1 7 44 39 Interpreting baby behaviour 1 6 35 48 Recognize illness 22 36 42 Baby's crying 1 9 42 39 Demands of home 1 1 50 39 Travel with baby 1 3 48 39 Birth control 1 9 47 33 Pain from Labour & delivery stitches 26 32 42 experience 17 53 30 Dressing baby 16 42 42 Infant wt gain 25 42 33 Baby's sleeping 19 42 39 Breast soreness 8 47 31 Return of figure 10 55 35 Emotional tension 25 47 28 Change in family 10 55 35 li festyle 10 65 26 Care of breasts 25 44 31 Breast soreness 1 0 55 36 Diet 1 7 61 22 Labour & delivery experience 19 42 39 Baby's sleeping 22 53 25 Bathing the baby 1 6 48 35 Immunizing baby 33 33 34 Breathing of baby Baby's fussiness 1 3 64 23 Dressing baby 22 58 20 1 6 52 32 Finances 1 4 64 22 Finding time alone Change in family together 1 3 58 30 1i festyle 22 56 22 Care of breasts 19 42 39 Pain - Stitches 1 7 64 1 9 Time for Finding time alone recreation 10 65 26 together 25 47 28 Emotional tension 1 6 55 29 Care of cord 19 53 28 * Priority determined by mean intensity scores in Tables 4-27 110 Appendix A continued Primiparas Percent Multiparas Percent Item 0 1-2 3-4 Item 0 1-2 3-4 Giving vitamins Time for or floride 19 61 19 recreation 25 53 22 Setting limits 19 61 19 Interpreting baby on visitors 19 52 29 behaviour 22 59 19 Demands of home 10 64 26 Baby's rashes 30 44 25 Diet 23 43 36 Exercise 19 67 1 4 Baby's bowel Travelling with movements 1 3 58 29 baby Baby's physical 25 53 22 Immunizing baby 1 3 62 26 appearance 25 53 22 Comfort in handling baby 26 39 35 Baby's crying 22 66 1 1 Relationship with partner 32 26 42 Baby's fussiness 22 62 1 7 Care of cord 23 48 29 Lochia Baby's bowel 28 55 1 7 Finances 26 48 26 movements 25 64 1 1 Family planning 29 39 32 Breathing of baby Giving vitamins 28 56 1 6 Sexual relations 23 48 30 or floride 33 48 19 Baby's physical Relationship with appearance 23 55 23 partner 33 50 1 7 Baby skin rashes 23 55 23 Sexual relations Time for personal 28 58 1 4 Exercise 1 9 71 9 interests Availability of 28 64 9 Constipation 29 55 1 6 resources 28 58 1 4 Hemorrhoids 36 45 19 Bathing the baby 33 50 1 7 Lochia 19 61 1 9 Return of period 31 59 10 Inability to Partner being a concentrate 23 61 1 6 good father 36 47 1 7 Feelings of being tied down 26 61 1 3 Limiting visitors 25 69 6 Partner being a Feelings of being good father 42 29 29 tied down 31 58 1 1 Availability of Inability to resources 29 55 1 6 concentrate 36 50 1 4 Time for personal interests 1 6 81 3 Constipation Comfort in 33 58 8 Baby blues 23 71 6 handling baby 44 36 19 Return of period 26 65 10 Baby blues 44 41 1 4 Circumsion 81 10 9 Hemorrhoids 50 39 1 1 Reaction of Care of siblings 100 0 0 c ircumsion 75 1 7 9 111 APPENDIX B PRIORITY RANKING OF TOTAL CONCERNS (1 MONTH) APPENDIX B Priority Ranking* of Total Concerns (1 month) Percent of Mothers Responding: 0 = no concern 1-2 = little to moderate concern 3-4 = much to critical concern Primiparas Percent Multiparas Percent I tern 0 1-2 3-4 I tern 0 1 -2 3-4 Recognize illness 3 52 45 Return of figure 1 1 50 39 Be a good mother 16 39 45 Birth control 28 44 28 Return of figure 10 45 45 Reaction of sibs 1 7 39 44 Fatigue 1 0 58 32 Fatigue Time for personal 1 7 64 19 Baby's fussiness 7 52 42 interests 1 7 64 19 Infant behaviour 10 52 38 Finances 1 7 67 1 7 Safety 26 32 42 Household demands 1 7 64 19 Normal growth and development 1 9 45 35 Be a good mother 31 44 25 Infant's sleeping 10 52 39 Exercise 19 53 28 Exerc i se 10 68 23 Emotional tension 17 61 22 Baby's feeding 1 3 61 26 Safety Time alone 22 55 27 Baby's crying 1 6 52 32 together 25 50 25 Diet 19 52 29 Recognize illness 1 7 63 19 Time alone Time for together 23 42 35 recreation 22 53 25 Dressing baby 1 6 55 30 Diet 25 53 22 Normal growth Emotional tension 1 3 61 26 and development 33 47 20 Relationship with -partner 32 32 36 Baby's fussiness Baby's sleeping 22 70 8 Household demands 1 6 68 22 28 52 19 Sexual relations 26 45 30 Feeding baby 22 58 20 Time for recreation 19 59 22 Baby's rashes 28 55 1 7 Travelling with baby 23 51 26 Baby's crying 22 67 1 1 Time for personal Change in interests 1 6 65 19 lifestyle 25 64 1 1 1 1 3 Appendix B continued Primiparas Percent Multiparas Percent I tern 0 1-2 3-4 I tern 0 1-2 3-4 Baby's weight gain 32 39 29 Dressing baby 25 64 1 1 Change in Relationship with li festyles 1 6 62 22 partner 36 50 1 4 Baby's breathing Baby's physical 29 45 26 Sexual relations 33 56 1 1 appearance 32 39 30 Immunizing baby 39 44 1 7 Birth control 36 32 32 Feeling tied down 28 67 6 Interpreting Feeling tied down 16 61 22 behaviour 25 70 5 Inability to concentrate 23 65 13 Care of breasts 42 44 1 4 Baby's bowel Baby's weight movements 39 29 32 gain Travelling with 39 47 1 4 Baby's rashes 23 58 20 Baby 30 59 1 1 Partner being a good father 45 30 26 Return of period Inability to 36 53 1 2 Immunizing baby 36 39 26 concentrate Baby's physical 39 50 1 1 Return of period 26 58 1 6 appearance Partner being a 39 50 1 1 Finances 32 52 1 6 good father Availability of 39 50 1 1 Limiting visitors 32 52 1 7 resources 39 50 1 1 Availability of resources 29 55 1 6 Limiting visitors Baby's bowel 33 61 6 Baby blues 29 65 6 movements 44 52 1 4 Comfort in handling baby 48 32 19 Breast soreness 56 31 1 4 Bathing baby 42 45 1 3 Baby blues 42 53 6 Giving vitamins or flouride 45 42 1 3 Baby's breathing 50 36 1 4 Constipation 45 42 1 6 Lochia 42 55 3 Lochia 39 46 1 6 Constipation 58 33 9 Labour & delivery Labour & delivery experience 52 32 1 7 experience 47 44 19 Care of breasts 48 32 20 Bathing baby 50 42 8 Pain of st itches 48 36 1 6 Hemorrhoids 56 36 10 1 1 4 Appendix B continued Primiparas Percent Multiparas Percent Item 0 1-2 3-4 Item 0 1-2 3-4 Giving vitamins Hemorrhoids 55 35 10 or flouride Comfort in 47 47 6 Breast soreness 52 39 10 handling baby 58 33 8 Care of cord 68 23 10 Care of cord Discomfort from 64 28 9 Care of circumsion 87 7 7 st itches 72 23 6 Reaction of Care of siblings 100 0 0 c i rcumsion 81 1 1 9 * Priority determined by mean intensity scores in Tables 4-27 APPENDIX C MANN-WHITNEY U TEST PRIMIPARAS VERSUS MULTIPARAS 1 16 APPENDIX C Mann-Whitney U Test Values and Probabilities: Primiparas versus Multiparas 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* Total Self 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 Total Baby 418 .077 417 .076 1 1 7 Appendix C continued 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 Total Partner 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 Total Family 480 .325 529 .682 Total 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 Wilcoxin Signed Ranked Test for Matched Pairs Values and Probabilities (first 2 days versus 1 month) Primiparas Mult iparas 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* Total Self -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* Total Baby -3.32 .001* -2.91 .004* 1 20 Appendix D continued Primiparas Multiparas 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 Total 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* Total Family -2.20 .028* -2.22 .027* Total I terns -3.14 .002* -3.45 .001* * P<.05 APPENDIX E MATERNAL CONCERNS QUESTIONNAIRE (1st 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 after the birth of a baby. A concern is anything that- is a question, worry, or problem to you. Please read each item and decide how much the item concerns you. Then circle your response according to the following scale: 0 No concern 1 Little concern 2 Moderate concern 3 Much concern 4 Critical concern Please answer the items as to how you feel NOW A. Concerns about yourself. . J^Q Concern 1. Food you eat 0 2. Exercise habits3. Return of figure to normal 0 4. Return of menstrual period 0 5. Vaginal discharge (lochia) 0 6. Discomfort from stitches (episiotomy) 0 7. Constipation8. Hemorrhoids 0 9. Breast soreness10. Care of breasts 0 11. Fatigue (lack of sleep) 0 12. Emotional tension 0 13. Inability to concentrate 0 . 14. Your labour and delivery experiences 0 15- Feelings of being tied down 0 16. "Baby Blues"(feeling depressed) Q 17. Finding time for personal interests 0 Little 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 Critical Concern 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 123 Concerns about babv No Little Moderate Much Critical 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 movements28. Rashes on the baby's skin 0 29. Baby's fussiness 0 30. How the baby sleeps31. When to give vitamins or floride 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 illness 0 37. Travelling with baby 0 38. Safety (preventing accidents) 0 39. How to dress baby (clothing that is too warm or too cold for the environment) 0 Concerns about partner No Concern Little Concern Moderate Concern Much Concern Critical Concern 40. Your relationship 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 relations 0 45. Family planning (birth control) 0 124 D. Concerns about'Family No Little Moderate Much Critical Concern Concern Concern Concern Concern. 46. Managing the demands of the household .0 1 2 3 4 47. Change in the family's lifestyle 0 12 3 4 48. Setting limits on visitors 0 12 ' 3 4 49. Finances 0 12 3 4 50. The availability of community resources (i.e. babysitters, clinics, parent classes) 0 12 3 4 51. Reaction of your other children to the baby 0 12 3 4 COMMENTS Do you have other concerns that are not listed? 1 25 BACKGROUND INFORMATION Please fill in or circle the answer as appropriate. 1. What is your present age? 2. Is this your first child? Yes No 3. If no, what are the ages of your other children? 4. What is the sex of your baby? Male Female 5. How many days did you spend in hospital with this delivery? 6. What is the main method of feeding the baby? Breast Bottle Both 7. Check your MOST recent level of formal education: some high school some university completed high school completed university some vocational/college some graduate school completed vocational/college completed graduate school 8. Did you attend prenatal classes with this pregnancy? Yes No 9. If so, circle which type: Health Department Hospital Private Agency Private Individual 10. What is your ethnic origin? 11. How many years have you lived in Canada? 12. Are you planning to return to work? Yes No 13. Who is the most helpful person at home during the first week? 14. Who else is helpful to you? 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 Discharge Date of Delivery The following are some concerns experienced by some mothers after the birth of a baby. A concern is anything that is a question, worry, or problem to you. Please read each item and decide how much the item concerns you. Then circle your response according to the following scale: 0 No concern 1 Little concern 2 Moderate concern 3 Much concern A Critical concern Please answer the items as to how you feel NOW A. 1. 2. 3. A. 5. 6. 9. 10. 11. 12. 13. IA. 15. 16. Concerns about yourself. Food you eat Exercise habits Return of figure to normal Return of menstrual period Vaginal discharge (lochia) Discomfort from stitches (episiotomy) Constipation Hemorrhoids Breast soreness Care of breasts Fatigue (lack of sleep) Emotional tension Inability to concentrate Your labour and delivery experiences Feelings of being tied down No Concern 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Little Concern "Baby Blues"(feeling depressed) 0 Finding time for personal interests 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 Critical Concern A A A A A A A A A A A A A A A 1 28 B. Concerns about babv No Little Moderate Much Critical 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 movements28. Rashes on the baby's skin 0 29. Baby's fussiness 0 30. How the baby sleeps31. When to give vitamins or floride 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 illness 0 37. Travelling with baby 0 38. Safety (preventing accidents) 0 39. How to dress baby (clothing that is too warm or too cold for the environment) 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. Concerns about partner No Concern Little Concern Moderate Concern Much Concern Critical Concern 40. Your relationship with the baby's father 0 41. Partner being a good father 0 42. Finding time to be alone together 0 4 3. Finding time for recreation 0 44. Sexual relations 0 45. Family planning (birth control) 0 129 D. Concerns about- Family No Little Moderate Much Critical Concern Concern Concern Concern Concern. 46. Managing the demands of the household 0 12 3 4 47*. Change in the family's lifestyle 0 1 2 3 4 48. Setting limits on visitors 0 12 3 4 49. Finances 0 12 3 4 50. The availability of community resources (i.e. babysitters, clinics, parent classes) 0 12 3 4 51. Reaction of your other children to the baby 0 12 3 4 COMMENTS Do you have other concerns that are not listed? 1. What professional have you consulted since coming home with your baby? Type Number of Contacts Family Doctor Community Health Nurse Pediatrition Other 2. Have there been any extraordinary events that have occurred in your family since the birth of your infant that may effect your degree of concern? If yes, briefly explain. APPENDIX G Letter of Consent 131 SOUTH EAST UNIT SOUTH OFFICE 6405 KNIGHT STREET. VANCOUVER. B.C. V5P 2V9 VANCOUVER HEALTH DEPARTMENT TELEPHONE 321-6151 Dear New Mother: I am a Community Health Nurse who is currently working towards a Master's degree at the University of B.C. In order to effectively improve services to new mothers in the community I am requesting your participation in this study that looks at the concerns of new mothers in the first month after delivery. You will be asked to complete a questionnaire regarding your concerns on the first or second day at home and then again one month after your discharge from hospital. It will take you approximately ten minutes to complete the questionnaire. You will receive a phone call from a community health nurse to remind you to complete the questionnaire at these two times. The questionnaires will be number coded and your responses will be completely confidential. It is important for you to understand that you can withdraw from the study at any time and that refusing to participate will not effect the services you receive from the health department. If you have any questions about your participation in this study please do not hesitate to call me or to ask the community health liason nurse in the hospital. Thank-you for considering participation in this study, Sharon Tobert R.N. B„S.N. Community Health Nurse South Health Unit 321-6151 MEMBER OF THE METROPOLITAN HEALTH SERVICE OF GREATER VANCOUVER 

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