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Postnatal experiences of North Shore women Erickson, Debra Lynn 1992

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POSTNATAL EXPERIENCES OF NORTH SHORE WOMENA NORTH SHORE HEALTH RESEARCH PROJECTbyDEBRA LYNN ERICKSONB. S. W., The University of British Columbia, 1985A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SOCIAL WORKinTHE FACULTY OF GRADUATE STUDIESThe School of Social WorkWe accept this thesis as conformingto/EieTHE UNIVERSITY OF BRITISH COLUMBIAOctober 1992© DEBRA LYNN ERICKSON, 1992in presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. it is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department of Sric I 1 WnrkThe University of British ColumbiaVancouver, CanadaDatejDE-6 (2/88)iiABSTRACTThis study explores and identifies the needs of North Shorewomen during their postpartum period (0-3 months). In order tocompare the perspective of the service users and the professionalcare givers, data were collected from three groups: new mothers,community health nurses and hospital maternity nurses.Discussions resulting from eight focus group interviews werethe primary source of information for this exploratory study.Six groups of mothers, one group of community health nurses andone group of hospital nurses participated in the focus groupdiscussions. The total number of participants were thirty-threemothers, eight community health nurses and six hospitalnurses.Content analysis of the qualitative data identified threethemes: 1) lack of knowledge, 2) role confusion and/or roleredefinition, and 3) lifestyle adjustments. Each theme wasexamined within the context of three developmental time periods:the first week, 1 week to 6 weeks, and 6 weeks to three months.The data indicated that women were concerned with six tasksduring their postnatal period: breast-feeding, infant care,maternal care, maintaining their spousal relationship, siblingcare and household care. The relationship of each task to eachtheme was considered in each time period.In addition to the themes and tasks identified, the focusgroups revealed that assistance and emotional support fromspouses, other family members and friends is one of the mostiiiimportant components in the maternal recovery and adjustmentprocess.The overall findings of the study indicate that during theirpostnatal period the mothers needed information, support andvalidation to assist them in adapting to their role as parents.The results of this study have implications for health careservice providers, agencies and organizations providing servicesand resources to women and their families, and for the family andfriends of new mothers.ivTABLE OF CONTENTS PAGEABSTRACTLIST OF TABLES viiLIST OF DIAGRAMS ViiiACKNOWLEDGEMENT ixCHAPTER 1 - INTRODUCTION 1The Community Context of the Study 3The North Shore Community 3Living and Working on the North Shore 4Health Care on the North Shore 4Relevance to Social Work 6CHAPTER 2 - LITERATURE REVIEW 8Women, Their Postpartum Period and Their Postnatal Care 8Postpartum Period 8Concerns and Needs of New Mothers 9Social Support 11Medical Support 13Conceptual Framework 17Cross Cultural Comparative Model 17Health Promotion Approach 18Focus Group Research 20CHAPTER 3 - STUDY DESIGN AND EXECUTION 30A Qualitative Approach 30Sample 32Recruitment 32Selection 34VConduct of the Focus Groups 34Data Analysis 37Limitations and Strengths of the Study 40CHAPTER 4 - RESULTS OF FOCUS GROUP DISCUSSIONS &COMMUNITY PORTRAITS 44Demographic Information of Focus Group Participants 44Profile of Participating Mothers 44Profile of Participating Nurses 46Results from Focus Group Discussions 48The First Week 49The Next Five Weeks 57Six Weeks to Three Months 65Results of Community Profiles 72People 72Services 72Resources 74CHAPTER 5 - DISCUSSION & CONCLUSION 76Implications of Focus Groups Findings 76The First Week 77The Next Five Weeks 79Six Weeks to Three Months 81Implications of Community Portrait Findings 82Recommendations for Action 85Information 85Support 86Validation 88viImplications for Social Work 90Questions for Future Research 91REFERENCES 94APPENDICES 99viiLIST OF TABLES PAGETable 1 - Profile of Participating Mothers 45Table 2 - Profile of Participating Nurses 47Table 3 - Summary of Issues Reported byFocus Group Participants 71viiiLIST OF DIAGRAMS PAGEDiagram 1 - Research Project Process 2Diagram 2 - Research Design & Execution 31Diagram 3 - Most Useful Supports for New Mothersas Reported by Nurses 73Diagram 4 - Most Useful Supports for New Mothersas Reported by Mothers 73ixACKNOWLEDGEMENTI gratefully acknowledge the mothers and the nurses whoparticipated in the focus groups. Your contribution is thefoundation of this study. In addition, I want to acknowledge theresearch advisory group for their ideas and feedback throughoutthe research process.To Lynne Beddall, thank you for making the work such fun.I also want to thank Nancy Hall and Sharon Manson Singer fortheir time, energy and commitment to this research project.Without your direction and patience this research project andthesis would not have been possible.And finally, I thank my family- Greg, Kendra, Gail, Ron andDaryll. Thank you for the emotional support as well as the extratasks and work you took on in order for me to devote my time andenergy to this study. An extra special thank you to Greg forbelieving in me. Kendra, now we can have our special daystogether again.1CHAPTER 1 - INTRODUCTIONChapter one introduces the purpose of the study and providesan overview of the remaining chapters. It provides backgroundinformation about the community in which the study took place andindicates the significance of this study to social work.In the spring of 1991 North Shore Health and Lions GateHospital formed a partnership to conduct a research project onthe postnatal experiences of North Shore women. The study grewout of the community health nurses’ desire to increase theirunderstanding of women’s needs during the postpartum period andto provide improved service and community support to new mothers.The purpose of this study was to determine the needs of womenduring the immediate (0-3 months) postnatal period.Throughout August and September 1991, a series of eightgroup discussions were held to explore and compare the postnatalexperience from three perspectives: postpartum mothers,community health nurses, and hospital nurses. These eight focusgroup interviews were the primary source of data for this study.In addition to identifying the needs of North Shore womenduring their postnatal period, a significant component of thisstudy was the emphasis placed on developing a research modelwhich included participatory planning. A fundamental concept inpromoting healthy communities is to include the community indetermining its needs, making decisions, and planning andimplementing strategies to promote health (diagram 1 illustratesthe research project process).2Diagram 1Research Project ProcessRepresentatives fromCommunity Organizationsdevelop plans foraction inresponse toidentifiedneeds___________________COMMUNITYDEVELOPMENTHEALTH PROMOTIONMODELCommunity HealthNurses seek toincrease theirunderstanding ofpostnatal experiencesand needsHEALTHNEEDSCOLLABORATIVEPLANNINGDesign andconduct ofneedsassessmentDevelopment ofResearch AdvisoryGroupProj ect developmentand funding throughNorth Shore HealthCommunity HealthPromotion and PreventionProgramNorth ShoreCommunity NCOMMUNITY j •%%\( 2ACTION3In keeping with a health promotion approach, this projecthas been a collaborative effort. Health professionals, newmothers and social service professionals who work with women andfamilies have participated in the project. Representatives fromthese groups formed a research advisory group. The researchadvisory group worked together to design, carry out the researchand develop a final report. In addition, representatives fromcommunity organizations who provide service to the targetpopulation formed a committee. This committee provided feedbackon the research design and are key stakeholders in thedissemination process.THE COMMUNITY CONTEXT OF THE STUDYThe North Shore CommunityThis study was conducted on the North Shore - which is asuburban community across the inlet from downtown Vancouver. TheNorth Shore is composed of three municipalities: the districts ofWest Vancouver, and North Vancouver, and the city of NorthVancouver. With the exception of North Vancouver City, housingconsists largely of single family dwellings, and the privateautomobile is the primary means of transportation. Themountainous environment tends to make shopping and runningerrands on foot difficult.West Vancouver is the municipality with the highest incomeper capita in Canada - only 28.6% of residents are low incomeearners (Eyres, 1990). By contrast, 34.8% of residents of NorthVancouver City are low income earners (Eyres, 1990). In North4Vancouver District 30.4% of residents are low income earners(Eyres, 1990). Poverty is a reality of some of the North Shorecommunities.The North Shore is a culturally diverse community. Themajority of the population is of European descent, and speaksEnglish in the home. The North Shore has a substantial FirstNations population with two Native Indian bands and threereserves on the North Shore (Eyres, 1990).Living and Working on the North ShoreIn the North Shore Health Promotion Survey (1990) it wasreported that 77% of men and 59% of women who live on the NorthShore work outside the home. Findings of this survey indicatedthat almost half the households have two or more persons in thelabour market; and the majority of men work outside of the NorthShore community, while the majority of women work in the NorthShore community (Goldberg, 1990).Health Care on the North ShoreHealth care on the North Shore is delivered by Lions GateHospital, North Shore Health, and community physicians.The number of babies born in 1990 approximated 2100 (NorthShore Health, 1990). The number of births have been slightlyincreasing over the past five years. Statistics gathered for theNorth Shore Community Profile (1990) reveal that on the NorthShore, about half as many births were to mothers in the 20-24year age group compared to B.C. In British Columbia, 60-62% ofall births that occurred between 1985-1989 were to females aged525-34; whereas, on the North Shore, this figure ranged from 69-71% (Eyres, 1990). The percentage of births in the 35-39 agegroup for the North Shore was twice as high compared to the restof B.C. in each year between 1g85-lg8g (Eyres, 1990).Despite the trend towards older parenting, the North Shorehas a growing group of teen parents. The Young Parenting Programat North Shore Neighbourhood House serves approximately 70 youngparents.The majority of births on the North Shore take place atLions Gate Hospital with follow-up postnatal home visits fromcommunity health nurses. This pattern is being slightly alteredby the Early Discharge Planning Program operated by Lions GateHospital. This program provides three home visits by hospitalnurses in the first week postpartum for mothers leaving thehospital within 24 hours of delivery.Community services for mothers during the postnatal periodinclude North Shore Health’s Parent and Infant Drop-In programand Child Health Clinics, the Young Parenting Program at NorthShore Neighbourhood House, La Leche League, North Shore FamilyServices Drop-ins for moms and tots, and the Westcoast PerinatalSupport Association’s new support service for women sufferingfrom postpartum depression. In addition, nurses from North ShoreHealth and the maternity ward at Lions Gate Hospital providetelephone support to new parents. Available statistics do notclearly indicate how many North Shore women are using postnatalservices.6RELEVANCE TO SOCIAL WORKThe primary objective of both social work and healthpromotion is to ensure the well-being of individuals, groupsand/or communities. Information from this study will enablesocial work practitioners to support and strengthen thedevelopment of healthy families through their many roles inhospitals, social service agencies, community organizations andcommunity development. In promoting healthy families and healthycommunities, this study demonstrates the importance ofincorporating the principle of participatory planning in theresearch model. A fundamental aspect of building healthycommunities is determining the needs of that community from theperspective of the community members. This study explores thepostnatal needs of North Shore women utilizing a health promotionresearch model.Chapter two examines the relevant literature which informedthis study. Literature pertaining to women during theirpostpartum period and their postnatal care include a definitionof the postpartum period; the concerns and needs of new mothers;the types of social support available to women in the postnatalperiod; and the postnatal care provided by medical professions.This chapter also reviews the literature used in the developmentof this research project. The three conceptual models usedincluded Kleinman’s cross-cultural model, a health promotionapproach and focus group interviews.Chapter three provides an outline of the study design and7its execution. The methods include: a qualitative approach, thesample, the recruitment, participant selection, conduct of thefocus groups, data analysis, and the limitations and strengths ofthe study.Chapter four presents the findings of the study. Thefindings include demographic information on the focus groupparticipants; the results of the focus group discussions; and theresults of a written exercise, a community portrait whichdescribes the people, services and resources mothers and nursesreported as providing support during the 0-3 month postnatalperiod.A discussion of the findings is provided in chapter five.This final chapter also makes recommendations for action;discusses the implications of the study for social work; andsuggests questions for future research.8CHAPTER 2 - LITERATURE REVIEWChapter two analyzes the relevant literature pertaining towomen during their postpartum period and their postnatal care.This section will be divided into the following sub-headings:the postpartum period, concerns and needs of new mothers, socialsupport, medical support.Chapter two also includes the conceptual framework used toinform this study. This section will review a health promotionapproach, a cross-cultural comparative model, and focus groupresearch.WOMEN, THEIR POSTPARTUM PERIOD AND THEIR POSTNATAL CAREPostpartum PeriodMuch of the research conducted about the postpartum periodfalls into what has traditionally been recognized by the medicalfield as the puerperium. The puerperium is the period in whichthe maternal body returns to its prepregnant physiological state(Gruis, 1977; Newton, 1983). The period during which thesephysiological changes occur is generally between six to eightweeks following the birth of the infant. Most research tends tofall between the first week following delivery up to six weeksfollowing the birth of the baby (Ball, 1981; Ball, 1987; Bull &Lawrence, 1981; Bull, 1985; Brodish, McBride, Bays, 1987; Gruis,1977; Sumner and Fritsch, 1977).The need to extend the postpartum period to three months iswell documented by Newton (1983) in her article the “FourthTrimester”. She cites several authors (Donaldson, 1977; Edwards,91973; Ziegal & Cranely, 1978) who use the term fourth trimester’to indicate that the process of childbirth does not end with thedelivery of the baby and the return of the uterus to itsprepregnant size. Newton believes that the three monthsfollowing the birth of the infant are as important as each of thethree trimesters during pregnancy.Concerns and Needs of New MothersThe needs and concerns of postpartum mothers vary accordingto the timing of the research. Studies conducted during thefirst week postpartum identify issues such as feeding, knowledgeof infant care and maternal care are of concern to new mothers(Brodish et al, 1987; Bull, 1985; Sumner and Fritsch, 1977). Itis important to note that these are studies in which neither themothers nor the infants experienced medical complicationsfollowing delivery. Also, these studies have included primiparas(first time mothers) and, in most cases, multiparas (mothers whohave previously given birth).A study by Bull and Lawrence (1981) found that after oneweek at home mothers continued to be concerned about their owncare and recovery, as well as the care they were providing totheir infants. Seventy-eight new mothers participated in thisstudy by completing a self-administered questionnaire. Thesample included forty-nine multiparas and twenty-nine primiparasall of whom had normal, medically uncomplicated pregnancies anddeliveries and were discharged home with their infants. Thequestionnaire was completed in the mothers’ home five to twenty-10one days following the birth of the baby.In the category of self care, Bull and Lawrence’s study didnote a difference between physical discomfort and the mothers’sense of emotional self. After one week at home, Bull found thatthere was decrease in the intensity and frequency of concernsrelated to physical discomfort, and an increase in the intensityand frequency related to the mothers’ emotional self. Inaddition, this study found a decrease in the number of concernsrelated to the physical care of the infant, whereas, concerns forthe infant’s behaviour remained a concern after one week at home.Gruis (1977) believes the needs of all new mothers involveaccomplishing four tasks: the mother’s physical restoration; theprovision of physical care for the infant, such as feeding;developing a relationship with the infant, and the alteration oflifestyle to accommodate the new family member.In a questionnaire designed to gather information about theconcerns of new mothers, Gruis (1977) found the concerns ofmothers at four weeks postpartum to be somewhat different thanthose during the first week postpartum. The questionnaire wassent to mothers one month after delivery. The sample for thisstudy consisted of forty mothers- seventeen primiparas andtwenty-three multiparas. The sample was selected from privatehospitals in Seattle. Criteria for selection included a normal,medically uncomplicated delivery; both infant and mother beingdischarged home together within four days of delivery; and themothers lived with the father of the baby at the time of the11study.The major concerns reported by the women in this study were:return of their figure to normal, meeting family and householddemands, and emotional tension. First time mothers alsoexpressed concern about infant behaviour and infant feeding;whereas, multiparas identified fatigue and finding time forthemselves as areas of concern.Social SupportThree functions of social support are identified in theliterature as being important needs for women during theirpostpartum period (Barrett, 1990; Curry, 1983; Hiskins, 1983).Pender (1982) defines the functions of social support asproviding support, advice and/or feedback. Support can be givenin a tangible form, for example, the provision of money or activeassistance, or in an intangible form such as encouragement,personal warmth, love and/or emotional support. Advice is theact of providing information or guidance on how to achieve acertain goal or accomplish a task. When providing feedback, oneis providing information on how well one is performing.In studies that ask about the type of support women receiveduring the postnatal period, husbands/spouses are reported to bean important support (Curry, 1983; Evans, 1991; Gruis, 1977;Hiskins, 1983). What remains unclear from these studies is whatkind of support spouses are providing.What seems easier to define, and perhaps to measure, is thesupport provided by formal social networks- postnatal support12groups. The range of postnatal support groups varies from agroup of what is considered to be normal, healthy women duringtheir postpartum period getting together to share theirexperiences and their friendship to groups for women withspecific needs such as breast-feeding or postpartum depression.Hiskins (1983) conducted a study of postnatal support groupswhich looked at how members of postnatal groups react to groupsituations; the support they received from families and friendsand the degree of isolation they experienced. Hiskins found thatas a result of participating in a postnatal support group, themothers experienced a decrease in isolation because of the socialcontact provided by the groups. The groups also served thefollowing purposes: a setting for the children to be with otherchildren; an opportunity for the mothers to meet other mothersand form friendships, and to share problems.In a review of the kinds of breast-feeding supportavailable, Kyenkaya-Isabirye and Magalheas (1990) perceivemothers’ support groups as filling a void in the health caresystem. The authors point out that there is no systematicdocumentation for the majority of these groups. Many areinformal and exist only as long as one mother makes contact withothers. Others, such as Nursing Mothers Association of Australia(NMAA) and La Leche League (LLL) are large organizations whichare more formal in their structure.Kyenkaya-Isabirye and Magaiheas point out that one of themajor differences between group-based support and health care-13based support is that in a support group, the mother is incontrol and able to make decisions for herself and her infant asto her course of action. The authors believe that (1990, p. 90),the energy, enthusiasm, concern, practical skills andextensive knowledge of mothers’ support groups are muchtoo valuable for health care systems to overlook intheir efforts to reverse the decline of breast-feedingand to provide quality service that meet their clients’needs.In follow-up evaluations of support groups for womenexperiencing postpartum depression, Olson, Cutler and Legault(1991) found that participating families received valuablesupport and education from the groups. A comment from theevaluations illustrates the importance of the support groups. “Ithink by talking to other mothers and sharing our feelings is thebest medicine to solving a problem (1991, 135).”Nina Barrett, the author of I Wish Someone Had Told Me, madea similar comment with regards to her experience of supportduring her postpartum period. She states (1990, p. xi),And only slowly did it occur to me that it was theseother new mothers -as hesitant and self-doubting as I-rather than the experts, who were really helping mefeel comfortable with motherhood. What I sought, Ibegan to realize, wasn’t someone else’s answers to thequestions I was asking, but confirmation that someoneelse was asking the same questions.”Medical SupportMedical support during the postpartum period is provided bymaternity nurses, midwives and community health nurses.Using a combination of qualitative data from interviews andquantitative data collected from observational checklists and aself-concept scale, Curry (1983) conducted a descriptive study to14examine variables related to adaptation to motherhood. Twentynew mothers and their infants participated in this study. Thewomen were married, primiparous and had normal pregnancies andpsychosocial histories. Data were collected at three intervalsover a three month time period: at the time of recruitment,thirty-six hours following delivery and three months afterdelivery in the mothers’ homes.Twenty-five percent of the sample experienced a verydifficult adaptation to motherhood. One of the findings of thisstudy suggests that the perception of support from postpartumnurses was related to the adaptation of the women in this study.Curry (1983) points out that what remains unclear is whetherexperiencing a difficult adaptation to motherhood coloured theperception of the difficult adapters or whether a poor careexperience made adaptation more difficult. Curry (1983) did notfind any trends in the analysis to indicate a difference in carebetween those women who experienced an easy adaptation to thosewho experienced a difficult adaptation.Similar findings were reported by Ball (1981) in her study.Data were collected through three sources: the hospital midwife,the community midwife and the mothers. Midwives completed datasheets that gave details of the mothers’ history and carethroughout pregnancy, labour and the postnatal period. Betweensix and eight weeks following their infants’ deliveries, motherswere asked to complete an attitude survey and a questionnaire.The information from these two instruments provided information15on the mothers’ perception of their care and their emotionalstate. One hundred and seventy-eight mothers participated inthis study.The main finding in this study was that differences inlevels of emotional satisfaction experienced by mothers werestatistically significant in relation to each woman’s perceptionof postnatal care, the type of prenatal classes attended and thesocial class of the mother. It is worth noting that Ball’s studywas conducted in England and the postnatal care was provided bymidwives in the hospital and the community. For these reasons,this study is not comparable to a Canadian population. However,the specific areas which were reported as contributors of stressin Ball’s (1981) study have also been reported as problems inNorth American populations. These areas include conflictingadvice from midwives, particularly to do with infant feeding, andconflicting advice in the prenatal classes.In a second study conducted in England by Ball (1987), shefound that conflicting advice was once again one of the majorsources of dissatisfaction with postnatal care and contributed tomothers’ emotional distress. Factor analysis was applied to datacollected from hospital and community midwives and mothers.Mothers responded to questionnaires and interviews. The samplefor this study was two hundred and seventy-nine new mothers.Thirty-five percent of these women were primiparas and sixty-fivepercent were multiparas. The majority of the women were married.Evaluations of a home support program (Evans, 1991) and an16early discharge program (Bradley, Carty, & Hall, 1989) suggestthat maternal satisfaction with postnatal care increases when newmothers (and often their spouses) receive information and supportin their own homes. Readiness for learning and being in controlof the postnatal visit are factors which may contribute to theincrease in this satisfaction. The need to develop moreindividualized and consumer centred postnatal care is welldocumented (Ball, 1981; Bradley et al, 1989; Evans, 1991).Overall the literature on women during their postpartumperiod falls into areas of concerns and needs for new mothers;their adaptation to motherhood; and the types of programs,services and social support available to new mothers. Most ofthese studies are conducted by nurses, and as such, often therecommendations are to increase service delivery to fill the gapbetween the time the women leave the hospital until their firstpostnatal checkup.There is a lack of recent studies in the area of postnatalneeds of women. The majority of the studies are old and do notalways reflect the changing trends in maternity and postnatalcare. For example, hospital stays are becoming shorter. Manyhospitals have early discharge programs which means some women gohome twelve to twenty-four hours following their delivery. Inaddition, the trend towards rooming-in is growing in popularityas it requires less staffing, and therefore, a decrease inhospital cost. There is a need to explore the experiences andperceptions of new mothers postnatal needs.17CONCEPTUAL FRAMEWORKThree complementary conceptual models were used in thedevelopment of this project: a cross-cultural comparative model,a health promotion approach, and focus group research.Cross-Cultural ModelKleinman’s (1978) comparison of medical systems as cross-cultural systems provided a conceptual framework for the study.This interactive model supports a health promotion approach byexamining health care issues in the context of their environment.A fundamental aspect of Kleinman’s theory is his belief that, inany health care system, individuals interact with three sectors:the professional, the folk, and the popular. The professionalsector is composed of organized health care workers such asdoctors and nurses. The folk sector includes healing specialistswho are not always recognized as professionals. For the purposeof this study, the folk sector would include midwives and LaLeche League counsellor. Although the family is the primarysource of the popular sector, social and community networkscontribute to this sector as well.Kleinman’s theory suggests that in order to improve healthand enhance coping skills, we need to recognize the popularsector’s role in managing health care issues and work to enablethis sector to be helpful. Exploring the role of the popularsector was one of the primary objectives of this study.18Health Promotion ApproachHealth has traditionally been defined as the absence ofdisease or illness. Following the 1974 publication of Lalonde’s“A New Perspective on the Health of Canadians”, the definition ofhealth took on a broader meaning. Health was now defined “as astate of complete physical, mental and social well-being” (Healthand Welfare Canada, 1986, p. 3). In contrast to the traditionalbio-medical approach, which emphasizes the prevention andelimination of disease, health promotion encompasses a notion ofhealth which seeks to understand the interaction betweenindividuals and their social and physical environment(Stachtchenko and Jenick, 1990).Health promotion is a term that has several definitions andis often confused as a single strategy or intervention method. Ahealth promotion approach is the integration of several healthareas - health education, public health and public policy.In his article, “What is Health Promotion”, Tannahill (1985)argues that the term health promotion is a highly fashionableterm with many vague definitions. Tannahill (1985) believeshealth promotion should be defined as “a realm of healthenhancing activities which differ in focus from currentlydominant curative’, high technology’ or acuteT healthservices” (p. 167). Tannahill (1985) proposes a model of healthpromotion which is composed of three overlapping spheres ofactivity -health education, prevention, and health protection.Green and Krueter (1991) address the controversy concerning19the scope of health promotion and the need to develop a cohesivedefinition. They define health promotion as “the combination ofeducational and environmental supports for activities andconditions of living conducive to health (p. 3).”A widely acknowledged definition of health promotion isdefined by The World Health Organization (WHO) as “the process ofenabling people to increase control over, and to improve, theirhealth” (WHO, 1986, p. 1).Several strategies used to promote health are outlined inthe Ottawa Charter for Health Promotion (1986). They are:- building healthy public policy;- creating supportive environments;- strengthening community action;- developing personal skills;- re-orienting health services (WHO, p. 1-2).The process of public participation is an importantprinciple to health promotion (Green & Kreuter, 1991; Kelly,1989; Ministry of Health, 1989; Statchenko & Jenicek, 1990). Theprocess of public participation involves two elements - includingthe consumer’s perspective in assessing health care needs andinvesting the initiative and control at the local level.Fostering the participation of the North Shore service providersand new mothers in both planning and participating in theresearch was important for two reasons. First, it is welldocumented that for change to be effective, it is desirable tohave the key stakeholders involved in the process (Bracht, 1990;20Cummings, 1989; Green & Krueter, 1991; Lewin, 1958; Rothman,1979). Secondly, participatory planning and community basedresearch are strategies which promote healthy communities (Healthand Welfare Canada, 1986).The health promotion field encourages building partnershipsto explore health needs and to develop appropriate responses tothese needs.Focus Group ResearchA health promotion research model, using group discussionsto collect information was the research method selected for thisstudy. Focus groups are planned discussion groups that yield theideas, thoughts and perceptions of the participants (Krueger,1988; Morgan, 1988; O’Donnell, 1988). As a form of qualitativeresearch, the focus group is used to obtain information from agroup of participants about a given problem, experience, serviceor such other phenomenon (Basch, 1987). O’Donnell (1988)describes a focus group as “an interactive evaluation method thatcan provide in-depth answers to complex problems (p. 71).”Traditionally, a focus group consists of seven to twelvepeople with a similar background or who share a common interest,such as the use of a similar service or belonging to the sameorganization (Krueger, 1988; O’Donnell, 1988). However, as bothKreuger (1988) and Morgan (1988) point out, the use of small ormoderate sized focus groups- four to eight participants- isbecoming more popular. Small to moderate sized focus groups areeasier to recruit and host; they are more comfortable for the21participants.Focus groups can be used in a variety of ways. They can beused to complement quantitative data by adding in—depthinformation and providing greater understanding to some of thequestions researched. Focus groups can also be used as apreliminary step in the research process to define the researchquestions; to generate a hypothesis for testing; and/or topretest the concepts and language used in a questionnaire. Focusgroup discussions can also be used as a primary data collectionmethod. As a primary data collection method, focus groupdiscussions are suitable for sensitive or personal topics, suchas sexual behaviour among adolescents; for hard-to-reach targetgroups such as people who are illiterate; and for researchquestions designed to explore the topic under investigation.When used as the primary data collection method, it is importantto use caution in the interpretation of the results as they arenot generalizable to larger populations.Focus groups discussions are an established and widely usedresearch method in marketing. In the health field, although theutility of focus groups as a research technique isrecognized (Basch, 1988; Khan, Anker, Paul, Barge, Sadhwani &Khohle, 1991; Kingry, Tiedje & Friedman, 1990), its use is newand rather limited. A survey of the health literature from 1989to 1991 resulted in fourteen studies which used focus groupdiscussions. Of the fourteen studies found, five used focusgroups in the preliminary research stage to help researchers22design questions for a larger survey. Three studies used focusgroups as a follow-up to the surveys conducted in order toexplain and expand on the quantitative data. Seven studies usedfocus group discussions as the primary data collection method.A brief overview of each study will be presented.In Conjunction with Quantitative DataPreliminary StepKlevans and Parrett (1990) used focus group interviews withclinical dieticians to develop a better understanding ofcontinuing professional educational needs from the perspectiveof the learners; to obtain more information about theireducational needs than would be possible from a questionnaire;and to suggest directions for follow-up survey research. Threefocus group sessions were held with a total of twenty-twoparticipants. Analysis of the focus group interviews formed thebasis for developing two questionnaires. This multi-method needsassessment was used to determine the continuing professionalneeds of clinical dieticians in Pennsylvania.Hyland, Finnis and Irvine (1991) developed a scale forassessing the quality of life in adult asthma sufferers. Theyused six focus group interviews with asthma sufferers to generateitems for the questionnaire. Analysis of the focus groupdiscussions resulted in eleven domains which were then used toconstruct the scale.In a study conducted in Thailand to investigate thesocioeconomic and health program effects upon the behavioral23management of diarrhoea among children under five years of age,the researchers used data from focus group discussions to assistthem in the development of questions for a baseline survey. Fivefocus group discussions were held with mothers of children underfive years of age. The purpose of the focus group sessions wasto obtain information on maternal knowledge and beliefs onpreventive and curative health behaviours regarding infant andchild diarrhoea. This information was used to formulatequestions on beliefs and behaviours for the survey.Similarly, researchers in Nigeria used focus groups as apreliminary step to provide input into the preparation ofquestions for a community survey. The purpose of ten focus groupinterviews carried out in rural communities in Nigeria was toinvolve the clients or service consumers in the process ofproblem identification and solving. The focus groups were usedto gain an understanding of community knowledge, attitude andpractice as regards puerperal sepsis as a cause of maternaldeath.The Department of Food and Nutrition in North Dakota usedfocus groups as a preliminary research step in developingeducation programs for rural seniors. Sixty-eight seniorsparticipated in five focus groups. This needs assessment wasused to determine beliefs of older rural Americans aboutnutrition education. The results of the focus groups were usedin two ways: to develop an education intervention appropriate tothe target group of rural seniors; and to develop questions for24a larger survey.In Conjunction with Quantitative DataFollow-up StepIn an American study conducted to understand barriers tofamily planning services among patients in drug treatmentprograms, Armstrong, Kenen and Samost (1991) used focus groups asa follow-up to baseline interviews conducted with five hundredand ninety-nine women in drug treatment programs. Six focusgroups were conducted with patients from drug treatment programsin an attempt to learn about opinions and attitudes that arebarriers to family planning services. Thirty men and thirty-fivewomen, participated in the six focus group discussions.Researchers in Canada (Taylor et al., 1991) plan to usefocus group interviews as one of many qualitative methods toexplore in depth the perspectives of local interest groupsregarding the psychosocial impacts in populations exposed tosolid waste facilities. Following the completion of anepidemiologic survey, the researchers plan to use severalqualitative methods to complement the quantitative data. Focusgroups composed of members of relevant organizations (localinterest groups and individuals representing the interests of thesites, such as, employees, owners, union representatives,executives) are one of the qualitative methods outlined in thestudy design. This article did not outline the number of focusgroups to be included in the study.Focus groups were used by Trenker and Achterberg (191) to25evaluate nutrition education materials. In this study, focusgroups were used to augment individual interviews. Six focusgroups were conducted with a total of thirty men and womenparticipating. The groups provided feedback on the usability ofa variety of nutrition education material.Primary Data Collection MethodRoche, Guray and Saunders (1991) conducted a study inAustralia to determine what general practitioners considered tobe the main obstacles and disincentives to the effectivemanagement of persons with drug and alcohol problems. Sevenfocus groups involving forty-four general practitioners wereconducted. The results of this study generated a hypothesis ofa typology of doctors. This hypothesis was tested in asubsequent study.The remaining five studies used focus group interviews toassess health educational materials or to develop healtheducation materials and programs.Cahill and Mathis (1990) used focus groups to pretest achildbirth booklet. Based on the results of eight focus groupsinvolving eighty-nine women, the booklet was revised beforedistributing to the general target population. In addition,based on the information received through the focus groups, newmaterial on prenatal care and birth were developed by the NewYork State Department of Health.Basch, DeCicco and Malfetti (1989) conducted forty focusgroup discussions to explore reasons that may support a decision26by young drivers to drink and drive. Three hundred and sixteenyoung drivers from ten cities in the United States and two citiesin Canada participated in this study. The utility of this studylies in understanding the factors involved in influencing youngdrivers to drink and drive in order to develop effective healtheducation programs.Focus groups were used by the Office of Disease Preventionand Health Promotion of the Public Health Service to gain abetter understanding of how hard-to-reach Americans perceivehealth and the role of diet, exercise and weight in the controland prevention of certain chronic illnesses. Twenty-four focusgroups were held in cities across the United States. Eight focusgroups were held for each of three racial-ethnic groups: black,Hispanic and white. The information gathered from these focusgroups was used to develop intervention methods to promotehealthy lifestyles.Gold and Kelly (1991) conducted a study using focus groupsto examine and identify important cultural issues related to AIDSeducation programs and materials. Six focus groups wereconducted in the United States. Three focus groups of white,black and Hispanic secondary high school teachers and three focusgroups of white, black and Hispanic secondary high schoolstudents likely to be exposed to AIDS education programs in theschools were included in the study. In total, fifty-one teachersand students participated. Based on the results of the focusgroup discussions, this study makes several recommendations for27the development of culturally sensitive AIDS education programsand materials.Researchers in the United States used focus groups in thedevelopment of community-based public health education designedto lower the mortality rate from cervical cancer among blackwomen in Forsyth County, North Carolina. A total of thirty-ninewomen participated in four focus groups. Results from the focusgroups were used in the development of educational messages andmaterials.Focus groups have been used internationally in the healthfield to gain a better understanding of issues and/or of targetgroups’ beliefs, opinions and experiences. These studies haveused focus groups for a variety of reasons: to develop questionsfor a survey; to add depth to quantitative data; to identifyneeds of a particular target group; to assess the usability ofand the appropriateness of health education materials; and, todevelop health education materials and/or programs.For several of the reasons outlined above, the researchmethod of focus group interviews fit well with the principles andobjectives of the North Shore Research project. Because of thesynergistic effect of focus groups, the researchers believed thismethod would yield more information about postnatal needs thanpersonal interviews. One of the primary aims of this study wasto increase our understanding of postnatal needs from theperspective of new mothers. Focus group discussions provided anappropriate method to meet this objective. Focus groups28emphasize understanding the participants perspective (Basch,1987; Kreuger, 1988; Morgan, 1988). Basch states (1987, P. 436),understanding the target group’s perspective isintegral to achieve a key goal of health education -empowerment- and focus group interviews are anappropriate method for understanding and developing asensitivity toward those we serve.Focus groups also provided a cost-effective way to meet theobjective of community-wide participation of new mothers.Finally, the use of focus groups was an appropriate researchtechnique to conduct a needs assessment (Basch, 1987; Krueger,1988; O’Donnell, 1988).A priority of health promotion research is to move away fromhospital-based medicine towards health policy and health status(Kelly, 1989). Using Kleinman’s cross-cultural model places thepostnatal experiences and needs of women in a cultural contextrather than solely in a medical one.Through the collaborative efforts of the inter-disciplinaryresearch advisory group and the multi-professionalrepresentatives of community organizations, this study is meetingan additional health promotion research priority. Kelly (1989)states that health promotion research should be “inter-sectoral,multi-disciplinary and multi-professional (p. 319).A community development approach to health promotion wasemphasized throughout the development of this research project tofacilitate a process of enabling the community in determining itsneeds regarding postnatal issues and developing strategies toimprove services and community supports to new mothers on the29North Shore.The questions this study asked were to identify and comparethe postnatal experiences and perceptions of mothers with healthcare providers and to explore the role of spouses, family andfriends in the postnatal period within a health promotionresearch model.30CHAPTER 3 - STUDY DESIGN AND EXECUTIONThe first two sections of this chapter provide an outline ofthe research design and the sample for the study (diagram 2illustrates the stages of the research design and execution).The next four sections of the chapter describe the proceduresfollowed in recruiting subjects, selecting subjects, conductingthe focus groups and analyzing the data. The final section ofthe chapter will discuss the strengths and limitations of thestudy.A Qualitative ApproachA qualitative approach was selected as the method ofresearch for this study in order to meet the objective ofobtaining in depth information about postnatal needs from thetarget population. Qualitative research involves collecting andinterpreting information which emphasizes what is said ratherthan how often it is said. Methods used to collect qualitativedata include participant observations, interviews, and/or writtenmaterials.Discussions resulting from eight focus group interviews werethe primary source of information for this needs assessment. Theresearch was designed to explore postnatal needs from a varietyof points of view: new mothers, community health nurses andhospital nurses.Diagram 2 31Research Design and ExecutionRESEARCH ADVISORY GROUP1research design4,focus group interviewsdata analysisSTAGES OFRESEARCHrecursive analysiswith focus groupparticipantsilfurther data analysispreliminary reportfinal report1KEY STAKEHOLDERS REPRESENTATIVES OFIN DI SSEMINATION COMMUNITY ORGANI ZATIONS1NEXT STEPIN PROJECT development of plansPROCESS for action32SampleThe sample for this study consisted of one group ofcommunity health nurses, one group of nurses from the maternityward at Lions Gate Hospital, and six groups of mothers. Thegroups of mothers included two groups of first time mothers(primiparous), two groups of mothers with two or more children(multiparous), one group of young mothers (16-21 years old), andone group of Native mothers.Purposive sampling was used to select these groups. Mothersare not a homogeneous group, and it was therefore important toincorporate this diversity into the study deliberately. Fourtarget groups of mothers were included in the study. Two groupseach of primiparous and multiparous mothers were chosen to allowfor an internal comparison of the groups. A group of mothersfrom the North Shore Neighbourhood House Young Parent Program wasincluded as a target group because of the high number of teenparents on the North Shore. As the North Shore hosts two Nativebands and three reserves, a Native group was chosen to explorethe needs of women from aboriginal cultures. In total, fourteennurses and thirty-three mothers participated in the focus groups.RecruitmentFocus group participants were recruited from the targetpopulation through the distribution of flyers (see appendix A,page 100), a display board in a public market, an advertisementand a write-up in the local newspaper (see appendix B & C, pages101-102), and verbal presentations made to specific target groups33which included the community health nurses and young parents.The majority of recruitment for the study occurred during thefirst two weeks of August 1991. Recruitment for the native groupoccurred throughout August and the first two weeks of September.The display board included a 11” x 17” enlargement of theflyer mounted on coloured dryboard, a flow chart of the researchprocess also enlarged to 11” x 17” and mounted on dryboard (seeappendix D, page 103, for a sample of the flowchart), andphotographs of infants with their mothers and/or additionalfamily members. Flyers were available for people to pick up asthey passed the display board. The display board was set up inthe Lonsdale Quay, a popular public market in North Vancouver,for one week in early August. The display was unstaffed.Flyers were also distributed through doctors offices,recreation centres, North Shore Health’s Parent and Infant groupsand the Child Health Clinics, La Leche League groups, North ShoreNeighbourhood House, the Squamish Band, and through the advisorygroup members which included representatives from North ShoreFamily Services, Lions Gate Hospital, North Shore Health, and theWestcoast Perinatal Support Association.The flyer also provided the proof for the advertisement runin the North Shore News on August 9, 1991 (refer to appendix B,page 101). In addition, the North Shore News published a storydescribing the study on August 11, 1991 (see appendix C, page102).34SelectionThe greatest source of respondents came from thepublications in the North Shore News. All of the recruitmenttools asked women who were interested in participating to callthe project coordinator. When potential focus group participantscalled, eligibility was established and an overview of the studywas provided. If callers were eligible and interested, theyselected a date to participate in the focus group best suited tothem. In order to maximize focus group accessibility day andevening meetings were scheduled. An information sheet outliningthe research project was mailed to women who agreed toparticipate (see appendix E, pages 104-105). A maximum of eightparticipants were allotted per group.Conduct of the Focus GroupsIt was important to hold the focus group meetings at a sitewhich was accessible, comfortable, and which had an additionalroom for child care. Seven of the focus groups were held in theboard room at North Shore Health. The hospital nurses met in aconference room at Lions Gate Hospital to enable nurses on dutyto participate.The groups were conducted by two moderators: the role ofone being to facilitate the discussion, and the second’s to takenotes of the discussion. The sessions were also audiotaped toensure accuracy, and simplicity of analysis. The number ofparticipants in each group varied from three to eight. Theinterviews were approximately ninety minutes long. However,35mothers requiring child care were asked to arrive thirty minutesearly to introduce their children to the child care providers.The session began with introductions of moderators andparticipants. In addition to their introductions, the moderatorsexplained what their roles would be during the discussion. Thepurpose of the study was reviewed and consent forms signed (seeappendix F, page 106). Confidentiality was assured for allparticipants. Participating mothers completed a sociodemographic information form (see appendix G, pages 107-108).This form requested the following information:- area of residence- marital status- employment status- location of infant’s birth- mother’s age- infant’s age- age of any additional children- level of mother’s educationThe same format was followed for each group. To ensure astandard format, all participants received a written agenda (seeappendix I, page 110) which outlined the question for discussionas well as the allotted time given to each section of the agenda.The remainder of the session was divided into two sections -the discussion, and the community portrait exercise.The discussion was divided into three time periods; thefirst week; 1 week to 6 weeks; and 6 weeks to 3 months.36The division of the discussion into these time periods was basedon the assumption that issues for new mothers change over time.Structuring the discussion in periods of time also facilitatedaccuracy of data and simplicity of analysis. These time frameswere chosen because 1) most women are home within five to sevendays of giving birth; 2) six to eight weeks postpartum isgenerally considered a transition point for mothers and babies bythe medical profession; and 3) an objective of this study was toexplore the needs of women past the traditional puerperium period(physiologically defined as the period of several weeks betweenthe termination of labour and the return of the reproductivetract to its normal state, Gruis, 1977).During each of these time periods participants were asked todescribe what their postnatal experience was like. The moderatorused four tasks outlined by Gruis (1977) to provide a context forthe question. For each time period, participants were asked toreflect on what it was like to provide care for the baby - thefeeding and changing; what this time period was like for themothers physically and emotionally; what it was like to establisha relationship with the infant; and what lifestyle adjustmentsthey made or experienced. The participants were then asked todescribe what this time was like for them.Finally participants were asked to complete a writtenexercise. The community portrait generated specific informationon the people, services, and resources these mothers found to bethe most helpful to them during the first three months37postpartum.The session formally ended with all participants receivinga small gift in acknowledgement for their contribution to thestudy. Participants were invited to remain for refreshments.The groups of nurses dispersed immediately upon completion oftheir sessions. In contrast, many of the mothers remained andcontinued informal and unrecorded discussions.Three attempts were made to verify information obtained fromparticipants. The first attempt was made during the focus groupsession. Throughout the discussions, one of the moderators notedcommon issues on a flipchart. Participants were invited toverify, clarify and add to this list. The second attempt wasmade two to three days after the focus group sessions. Follow-uptelephone calls were made to all participants to ask if theyexpressed everything they wanted. This telephone call providedan opportunity for participants to add any information which theyfelt unable to express in the groups and/or that they thought ofas a result of participating in the groups. Finally, followingthe completion of all focus groups, the participants were invitedto a meeting to provide feedback on the first phase of analysis.Data AnalysisQualitative analysis was used to analyze data. In a line byline analysis, notes from the focus group sessions were coded andcategorized. In order for this process to be accurate andfeasible, the notes from focus group sessions were photocopiedonto 11” x 17” paper (see appendix J, pages 111-118 for an sample38of the coding and categorization method used). This gave theresearchers enough room to code and categorize directly besidethe raw data, as well as to add comments from the audio tape.The next step in the analysis was to listen to the audio tape ofeach session. Additional coding and categories were added ifnecessary. Once all the groups were coded and categorized,common themes were identified. Major differences between groupswere also noted.Both moderators independently coded and categorized thefirst session. The purpose of having two researchers analyze thefirst session was to provide an opportunity to assess thereliability of the coding process. Following completion of thisprocess the moderators compared their findings and found they hadused similar codes and categories. A single researcher coded andcategorized the remaining seven focus groups.Three themes emerged through the data analysis:1. lack of knowledge (“...nobody told me...”)2. role confusion and/or role redefinition (“...what is myrole here...”)3. lifestyle adjustments.In addition, six tasks were identified:a) breast-feedingb) infant carec) maternal cared) spousal relationshipe) sibling care39f) household maintenance.The next step in the data analysis was to consider each ofthese six tasks in context of each time period and theirrelationship to each theme.The data from the community portrait was analyzed by notingthe type and frequency of responses.Three methods used in this study contribute to thereliability and validity of the findings. The first is themethod of triangulation. Triangulation of data sources andinvestigator triangulation were used to reduce systematic bias inthe data (Patton, 1980). Comparing the perspectives of differentgroups of mothers with that of the community health nurses andthe hospital nurses provided multiple sources of data for thestudy. The use of two moderators provided a check on bias indata collection. In an additional effort to reduce researcherbias, the second moderator conducted spot checks of the dataanalysis.The second method which contributes to the validity of thestudy was the use of recursive analysis. Once the first phase ofanalysis was completed -the coding and categorization- all focusgroup participants were invited to a meeting to provide feedbackon the results. Five of the total thirty-three participantsattended the follow-up meeting which took place in early October1991, anywhere from four to six weeks after the focus groupinterviews. Those that attended agreed with the analysis andprovided positive feedback on the preliminary results.40The research advisory committee met monthly to providedfeedback on the data analysis and to provide suggestions toimprove the method.The final method used to provide internal reliability andvalidity to the study was the use of systematic proceduresthroughout the data collection and analysis. During the datacollection, the same format was used for each focus groupsessions. A standardized open-ended interview guide was used tominimize interviewer effect and to make data analysis easier andefficient (Patton, 1980). During the analysis, the sameprocedures were followed for each focus group session resultingin systematic analysis.Krueger states that focus groups are valid if they are usedcarefully for a problem that is suitable for focus group inquiry(1988, p. 41). An important consideration in the validity ofthis research project is the fact that the research design andmethods used in the study are appropriate and well suited to thequestion under investigation.Limitations and Strengths of the StudyThere are several limitations to this study. These include,the research method, a sampling bias, the use of focus groups andthe question design. The greatest limitation of this qualitativestudy is that purposive sampling and a small sample size make itimpossible to infer the results to the general population. Theresults cannot be generalized to understand the needs of all newmothers. Purposive sampling also contributes to sampling bias.41An additional sampling limitation in this study was the processof self selection. Most likely the people who chose toparticipate in the focus groups were people who felt comfortablesharing and expressing their thoughts in a group setting. Womenwho do not feel comfortable talking in groups may not havevolunteered to participate and perhaps would have had differentexperiences and possibly different needs. Finally in terms ofthe sample, the study has limitations because, with the exceptionof the native group, all participating mothers were caucasian,leaving out the perceptions of postnatal needs from differentethnic and cultural groups.The use of focus groups also has its limitations.Interpretation of focus group data is a subjective process andmore difficult to analyze than quantitative measures such as themeans and standard deviations. Therefore, with focus groupsthere is a greater chance of introducing bias into theinterpretation of the data. Another limitation of the use offocus groups is that the interviewer has less control over theinterview process. The focus group interview process allows theparticipants to interact with one another, and therefore, toinfluence the direction of the discussion. Limitations resultingfrom this process include the introduction of unrelated issuesand getting off track from the question asked. Because theresearch question used in this study was very broad and openended there was an increased chance of participants controllingthe direction of the discussion and introducing irrelevant42issues. In addition, this study explored only one question.Although focus group interviews have several limitations,they also have advantages. The synergistic effect of the groupinteraction has the potential to uncover information which wouldprobably not be apparent in individual interviews. In addition,conducting focus groups was a cost effective method to reach agreater number of new mothers than individual interviews wouldhave permitted. The greatest strength of using focus groupdiscussions for this needs assessment was that it allowed theresearchers to identify and compare the postnatal needs fromthree perspectives: mothers, community health nurses, andhospital nurses.One of the greatest strengths of this project was thecollaborative effort used to design and conduct the study.Health professionals, new mothers and social serviceprofessionals who work with women and families have participatedin the project (refer to diagram 1, page 2). Representativesfrom these groups formed a research advisory committee. Thiscommittee worked together to design and carry out the research.In addition, representatives from community organizations thatwork with women and their families formed a committee to providefeedback of the research design and to participate in thedissemination process.The use of participatory planning in the research design andthe use of focus group interviews as the primary data source fitwell with the objectives of this research project. The questions43this study asked were to identify and compare the perceptions ofthe target population with the service providers; to explore therole of spouses, family and friends in the postnatal period,within a health promotion approach. The overall researchquestion of this study was to determine the needs of North Shorewomen during the immediate (0-3 month) postpartum period.44CHAPTER 4- RESULTS OF FOCUS GROUPS AND COMMUNITY PORTRAITSChapter four reports the findings of this study. Theresults will be presented in three sections; first, ademographic profile of the mothers and the nurses whoparticipated in the focus groups; second, the findings of thefocus groups; and third, the findings from the community portraitexercise, will provide a description of the people, services andresources mothers used during the first three months postpartum.DEMOGRAPHIC INFORMATION OF FOCUS GROUP PARTICIPANTSProfile of the Mothers (see Table 1)Participating mothers live in all three North Shoremunicipalities. The greatest number of mothers (43%) live in thedistrict of North Vancouver. Thirty percent of the mothers livein the city of North Vancouver. The remaining 27% live in WestVancouver.The majority of mothers reported being married or livingwith their spouse (79%).All participating mothers gave birth in a hospital. Therange of hospitals included Lions Gate, Grace, St. Paul’s, RoyalColumbian, and Burnaby General. The majority of births (76%)took place at Lions Gate hospital.Fifty-five percent of the women indicated they were notparticipating in the labour market. Of the remaining forty-fivepercent, 21% were employed and 24% were on maternity leave.45Table 1Profile of the MothersPercent n (n=33)RESIDENCEW Vancouver 27% 9N Vancouver District 30% 10N Vancouver City 43% 14LOCATION OF INFANT’S BIRTHLions Gate Hospital 76% 25Grace 6% 2St. Paul’s 6% 2Other 12% 4MARITAL STATUSMarried 70% 23Common-law 9% 3Single 21% 7EMPLOYMENT STATUSemployed 21% 7maternity leave 24% 8not in labour market 55% 18MOTHERS’ EDUCATIONAL LEVEL7-10 15% 511—12 37% 12some university 27% 9degree 9% 3post graduate 12% 4MOTHERS’AGE *15—19 9% 320-24 15% 525—29 15% 530-34 30% 1035-39 27% 940-44 3% 1INFANTS’ AGE (months)0-3 months 9% 34-8 months 67% 229-12 months 24% 8* rounding percentages does not total 100%46Ages of mothers ranged from 16-41 years old. The majorityof mothers (61%) were thirty years or older. Thirty percent ofthe women were between 30-34 years of age and 30% were 36 yearsand older. Ages most frequently reported were thirty and thirty-seven.Levels of education completed ranged from grade seven tomasters degree. Thirty-seven percent of the mothers completed11-12 years of school. Twenty-seven percent had some postsecondary education.The majority (67%) of participating mothers had babiesbetween four and eight months old.Of the multiparous mothers, nine had two children and fourhad three children. No participant reported having more thanthree children.Profile of the Nurses (see Table 2)The majority (86%) of nurses lived on the North Shore. Twoof the nurses resided in Vancouver and Langley.The majority (79%) of nurses were married. Three nurseswere single. Twelve (86%) of the nurses reported havingchildren.Ages of the nurses ranged from 33-60 years of age. Five(36%) of the nurses were between 31 and 45 years of age. Themajority (64%) were 45 years and older.The community health nurses had worked for North ShoreHealth between three and thirty years. Two had worked for NorthShore Health ten years and less; five had worked between47Table 2Profile of NursesPercent n (n=14)RESIDENCENorth Shore 86% 12Vancouver .07% 1Langley .07% 1MARITAL STATUSMarried 79% 11Single 21% 3DEPENDENTSyes 86% 12no 14% 2AGE31-40 28% 441-50 21% 351—60 50% 7ACADEMIC/PROFESSIONAL CREDENTIALSDiploma 57% 8Bachelor of Science in Nursing 43% 6Registered Nurse# OF YEARS EMPLOYED:North Shore Health1-10 25% 211-20 63% 521-30 12% 1Lions Gate Hospital1-10 67% 411-14 33% 2TOTAL # OF YEARS IN NURSING *1-10 14% 211-20 28.5% 421-30 28.5% 430 > 28.5% 4* rounding percentages does not total 100%48eleven and twenty years; and one had worked for thirty years.The hospital nurses had worked for Lions Gate Hospital betweenfour and fourteen years. Three had worked between four and fiveyears; three had worked between ten and fourteen years.The total number of years the community health nurses hadworked as nurses ranged from twelve to thirty-six years. Themajority of their work was in the community health field. Thetotal number of years the hospital nurses had worked as nursesranged from nine to thirty-three years. Primarily these years innursing were in hospitals. One nurse reported working as apsychiatric nurse for three years; one nurse reported working ina doctors office; and one other nurse reported working as aprenatal educator and a lactation consultant in addition tonursing.Six of the community health nurses had their Bachelor ofScience in Nursing (BSN) degrees. Two community health nurseshad diplomas in community health and public health respectively.All of the hospital nurses had diplomas in General Nursing. Onewas working towards completing a BSN degree; and two hospitalnurses reported having midwifery training. All nurses wereRegistered Nurses.RESULTS FROM FOCUS GROUP DISCUSSIONSData analysis of the focus group discussions resulted in theemergence of three themes: 1) lack of knowledge, 2) roleconfusion and role redefinition, and 3) lifestyle adjustments.Each theme was examined within the context of three developmental49time periods: the first week, 1 week to 6 weeks, and 6 weeks tothree months following the birth of the baby. Analysis of thedata revealed that there were six tasks that women were concernedwith in their postpartum period: breast-feeding, infant care,maternal care, maintaining their spousal relationship, siblingcare and household care. The relationship of each task to eachtheme was considered in each time period. The presentation ofthe findings therefore follows this framework of time periods,major themes, and tasks.The First Week1) lack of knowledge C”.. .nobody told me...”)A common statement from the mothers during their hospitalstay was that “no one told me”. This theme was prevalent inrelationship to breast-feeding, infant care and maternal care.The main issue focus group participants identified inrelation to breast-feeding was the lack of consistent informationthe new mothers received. With the exception of Focus Group #2 -a multiparous group - all groups of mothers and nurses reportedthat conflicting information regarding breast-feeding wasproblematic. The following statement from one mother is typicalof comments from the majority of mothers. She said,“One thing that was frustrating, was I wastrying to breast-feed and she wouldn’t latchon and every nurse had a different way ofdoing it. ... I went home four days laternot having a clue how to breast-feed.”Both groups of nurses identified conflicting informationregarding breast-feeding as the biggest problem new mothers have50to deal with during their hospital stay. The following statementby one of the hospital nurses demonstrates their perception ofwhat new mothers face with respect to breast-feeding. Shestated,“The biggest thing I think is inconsistencyor different opinions from all the differentpeople who are their care givers.”The community health nurses had a similar view. As onecommunity health nurse stated regarding the feedback she hearsfrom new mothers,“I think it’s really confusing for thembecause of the fact that they get suchdifferent information from every nursethat comes in, they’re still doing this evenafter all the teaching and coordinationIt’s still confusing for them, they justdon’t get the unity in what we are saying.I think that is the number one issue...”Four out of the six groups of mothers reported that theywere unprepared for and/or not told how to care for theirinfants. These four groups included both primiparous andmultiparous mothers. The following statement by a first timemother is typical of comments many mothers made regarding theirperception that no one told them what to do to provide infantcare.“After the baby was born, nobody asked me ifthis was my first child, nobody told meanything, I was in absolute panic ... Theywheeled the baby into me and left it there.I had no idea how to change a diaper. Theyuse cloth diapers there, no one told me, Iwouldn’t have known anyway we didn’t knowhow to change any sort of diaper. Theynever told me about this chart thing, that Iwas supposed to fill it out. They nevertold me how to feed the baby, I had no idea51how to breast-feed.”The hospital nurses identified lack of infant care knowledgeas an issue new mothers deal with in the first week postpartum.Although the hospital nurses saw this as an issue primarily forprimiparous mothers, they did note that in their experience, moreand more women having a second child with a substantial agedifference between their first and second baby were also lackingin infant care knowledge. The nurses defined infant care asfeeding, cord care, diapering, bathing and proper positions forholding the baby. From their perspective the nurses believethat,“... a major concern for the mother is thebaby care, especially the feeding of thisbaby.”While they were in the hospital, first time mothers reportedbeing unprepared for the changes to their bodies and the degreeof fatigue they felt. The following statement by one motherillustrates what many mothers expressed.“I was totally unprepared for what washappening to my own body. I was totallyexhausted. I wasn’t prepared for thebleeding, I tore quite badly, I had anepisiotomy. I was terrified about having abowel movement, ... the bleeding, thesoreness, all that stuff around my own bodythat part of it I had very littleinformation before the birth.”In addition, both primiparous and multiparous groups ofmothers reported receiving conflicting and/or unclear informationabout their own care. Mothers did not know how to perform theirperineal care, and were unaware of where to locate perineal care52supplies. Mothers described the following situations,“... never explained you could get up andhelp yourselves to the pen care supplies.”“No one told me how to clean myself or whatto do with a sitz bath.”The community health nurses had heard similar statementsfrom women on their caseloads. One of the community healthnurses described a story she heard.“As one mother said to me, that cart wassitting outside my room, if it hadn’t beenfor the women in the bed next to me, I neverwould have known what to do with it’, Iguess there’s pen care and everything onthis cart, but [the mother] said that’swhere I got my instructions.’”Although both the community health nurses and the hospitalnurses identified maternal care as an issue facing new mothers,it was also their belief that while in the hospital new mothersare overloaded with information. As one hospital nurse said,“... there is so much information we arehanding them — information overload.”A community health nurse expresses a similar opinion.“... we are barraging the mother ... .“2) role confusion (“...What is my role here?...”)Five of the six groups of mothers reported that during theirhospital stay they experienced role confusion regarding self andinfant care. They felt that nurses made decisions and performedtasks which were properly the responsibility of the mother. Thefollowing comments from mothers demonstrate the lack of controlmany of the mothers expressed with regard to directing the careof their infants.53“They tried to supplement her with water”“They kept taking the baby away from me atnight”“I took the baby in bed with me once, to getsome sleep. We were resting peacefully whenthe nurse came in and just took him rightout of bed with me. ... Took him out of mybed and put him back in his bassinet - shedidn’t ask at all.”The community health nurses also identified lack of controlin directing the care of the infant as a contributing factor tothe role confusion new mothers experience. A community healthnurse states,“On the part of breast-feeding versus theneeds, as seen by the staff, for the babiesfeeding, it seems to be out of the mother’scontrol, from day one, as to whether thebabe needs to have a bottle or not, formulais given - it is right out of her hands. Ithink that’s forfeiting a lot right at thevery beginning, and telling the mother thebaby isn’t really yours. She’s not managingand making decisions right off, she’s notsupported in that.”In addition, the majority of mothers expressed confusion andfrustration as to what tasks they were expected to be responsiblefor while in the hospital. They described several situations inwhich the nurses expected the mothers to perform tasks withoutclarifying that it was the mother’s role to do so. Unclear roleexpectations are expressed in the following examples provided bymothers.“They don’t tell you to chart down all thisinformation about the baby.”“I was told if I wanted an ice pack to buzzfor it, so two days later I’m buzzing for anice pack and they told me to get it myself54and I didn’t know there was an ice machineon the floor and where it was.”“My bed linen was pretty badly soiled and Iasked if someone could change it and theysaid there is clean linen just around hereBoth the mothers and the community health nurses identifiedunclear care expectations as contributing to the problem of roleconfusion. The mothers perception of the problem was the needfor an orientation. One mother summarized the problem as,“I didn’t really get an orientation as towhat to expect the next day in the hospital,like when meals would come, what I would beexpected to do on my own, what I would beexpected to do with the baby, so I wasalways kind of guessing. ... a nurse said,SWell, have you changed her?’ And I go,Change her? No, no one told me I had tochange her.’ . . . It was like trying to guessyour way through the day. . . .It’s hard tofigure out what to expect.”Similarly, the community health nurses believed the problemof role confusion in the hospital stems from a lack of clearguidelines as to what new mothers can expect on the maternitywards.“I think maybe they’re a bit confused in thehospital too because of a lack of generalguidelines as to how they’re supposed toconduct themselves on the maternity ward. Alot of people have told me they felt, theyweren’t sure if they were supposed to puttheir baby in the nursery at night time, orwhat was expected of them, would someonewatch their baby while they had a shower, orwould the baby just be stuck there all byitself, or was someone going to come andhelp them with the nursing, or were theyjust to go ahead and do it on their own. Ijust think they weren’t quite sure how muchthey should be independent about it and howmuch they should be waiting for guidelines55and advice.”Although the hospital nurses did not identify role confusionas an issue for new mothers during their hospital stay, throughtheir discussion it became evident that the hospital nurses havedifferent opinions as to what the role of the new mother shouldbe during their hospital stay. Some nurses were of the opinionthat the mother’s primary concern should be resting andrecovering from the birth to enable her to cope once she goeshome. This opinion is reflected in the following comment from ahospital nurse.“I think they [new mothers] are starting tofeel guilty about bringing their babies intothe nursery so they can have a rest. ... Weshould allow them to rest.”Whereas, other hospital nurses believe that it is importantfor the new mother to learn to meet her needs and the needs ofher infant during the hospital stay. This view is illustrated inthe following comment.“I think they [new mothers] need to learn torest with baby, that’s what reality is athome ... they need to learn to live a normallife around a child.”3) lifestyle adjustmentsDuring the first week postpartum, neither the mothers ornurses reported issues of lifestyle adjustment. The mothers wereoccupied with learning the tasks of breast-feeding, infant careand self care.With respect to the provision of care during the hospitalstay, there are three variances in the data that are worth56noting: the care experience of the young group of mothers (16-21years of age) and the native mothers; different culturalexpectations of care as reported by the nurses; greatersatisfaction in care from new mothers who participated in anearly discharge program.Compared to the other four groups of mothers, both the younggroup of mothers and the native group of mothers described theirhospital stay as a positive experience. In addition, neithergroup discussed issues around infant or maternal care duringtheir hospital stay. They made statements like,“I enjoyed the time in the hospital.”“The staff were wonderful.”“I loved the staff.”In addition, the young mothers focused much more on theirreaction to having a baby. They said,“I thought she was just the best ... she wasall mine.”“I loved having my baby.”“I totally fell in love with [baby].”Unlike the groups of mothers, both groups of nursesidentified cultural differences as an issue related to careprovision during the hospital stay. The nurses identified thatdifferent cultures have different expectations in relation tobreast-feeding and infant and maternal care. Common statementsfrom both groups of nurses included:“Many women from different cultures wait tobreast-feed until their milk comes in.”57“In a lot of cultures, child bearing is theonly time in life where they [mothers] arevalued ... they don’t have to do anyphysical care for themselves or any babycare.”“Some cultures assume they [mothers] will betaken care of while in hospital... •“Although only two women (one primiparous and onemultiparous) reported participating in an early dischargeprogram, both of these women preferred the care provided in thisprogram in comparison to the care they received during theirshort stay in the hospital. The biggest difference for them wasreceiving consistent information in an unhurried manner. Thefollowing statements from these two mothers illustrate theirsatisfaction with the early discharge program.“Nurses from the ward came to visit me athome and there they were totally different.They would be there for about an hour, theywould take the time and you could ask themanything ... it was quite nice - any kind ofquestions we had she would answer and at thesame time you could phone them at night.”“I really liked the early discharge program.The same nurse who I dealt with at thehospital came to visit me at homesomebody I knew and we were able to have aone-to-one.”The Next Five Weeks1) lack of knowledge (“....nobody told me...”)In the one to six weeks time period, three groups ofmothers, and both groups of nurses identified lack of knowledgeas an issue in breast-feeding and infant care. Several of thefirst time mothers experienced problems breast-feeding.The lack of knowledge regarding breast-feeding is expressed58by one mother in the following comment. She said,“I thought breast-feeding came naturally.I didn’t put her on properly and developedmastitis. I never asked how to properlybreast-feed.”Many first time mothers made comments such as,“I had a lot of problems breast-feeding.”It was the perception of both groups of nurses that newmothers experience difficulties breast-feeding. The hospitalnurses anticipated breast-feeding problems for mothers during thefirst weeks at home based on the problems they were experiencingas they left they hospital. The following statement from one ofthe hospital nurses illustrates the perceived breast-feedingproblem. She said,“Very often the mother goes home and thebaby isn’t taking the breast well at all.Her breasts are engorged, the baby can’tgrasp the nipple - I anticipate that thismom has a great deal of difficulty withbreast-feeding when she goes home. I thinka fair number of our patients going home arelike that - they are having a lot ofproblems breast-feeding.”From their experiences in visiting and talking to newmothers, the community health nurses believed that,“If [moms] don’t get support for breast-feeding right away, it’s game over. If weare not aware they are having difficultiesbreast-feeding, by the time we call or visitthey have had enough problems with it thatthey have already made the decision to giveit up.”Both primiparous and multiparous mothers expressed concernabout providing care for their infants. The following commentfrom a primiparous mother illustrates the lack of infant care59knowledge expressed by several mothers.“I didn’t know how to bath the babyThe baby wasn’t feeding properly, I didn’tknow how to take care of her ...Multiparous mothers also expressed a need for infant careinformation. As one mother stated,“You need to be reminded of infant careinformation, you forget.”With respect to mothers providing infant care during theirfirst five weeks at home, the hospital nurses also identified theneed for information about infant care. They believed newmothers had the following needs.“They need information.”“They need to be reassured they are caringfor baby well.”2) role redefinition (“...what is my role here...”)The most prevalent theme identified by mothers and nursesduring this time period was role confusion and/or roleredefinition - suggesting that this period places heavy demandson mothers to adapt their roles. Although all six tasks werediscussed in relation to this theme the majority of thediscussions revolved around the recovery needs of the mother andthe kind of support systems they needed during this time.All groups identified maternal care as a major issue duringthis time period. Issues such as fatigue, maternal nutrition,lack of time for the new mother to spend alone, and the need forthe new mother to receive both physical and emotional supportwere discussed. Common statements from the mothers included,60“There were times when I was so exhausted Icouldn’t even eat.”“I just didn’t have any time for myself.”“You don’t have time to cook - basicallycaring for yourself in terms of brushingyour teeth and having a shower is a majoraccomplishment for the day ... you’re tootired, I found if I had time, I needed toshower, but I also needed to sleep and Iwould take the sleep first because thathelped me emotionally.”The community health nurses emphasized the need for mothersto rest and to eat well during this time period. As onecommunity health nurse stated,“[moms] need extra rest and nutrition.They’ll feel better, heal better and breast-feed better if they can get the propernutrition they need.”The community health nurses also discussed that unrealisticexpectations of this early postpartum period on the part of themother can contribute to the role confusion she maybeexperiencing.“I think most of them [new mothers]-prenatally-envision what it is going to belike, the baby will eat and sleep and I willdo my housekeeping and I will get the mealsready and it will all be lovely when husbandor partner comes home. Then when they findit is not this way, their whole image ofwhat they are and their role is goes downthe drain.”The hospital nurses identified rest and support as key areasto help new mothers in their recovery. One of the hospitalnurses summarized the needs during this time period as,“First one to six weeks is the need for agreat deal of support in that time, a lot ofsupport ... and a great deal of rest ...“61The need for emotional support, validation andphysical help around the house was a major focus of thediscussions during this time period. Four of the sixgroups of mothers and the community health nursesidentified the spouse as an important support duringthis time. Mothers made comments such as,“I found my greatest support was myhusband.,..”“I don’t know where I would be without thehelp of my husband.”The community health nurses reported the need for the fatherto take an active role in providing support to his partner duringthis time period. As one community health nurse stated,“Dads need to understand the kinds of thingsthat are happening to his wife or partner -support things [he] can do the first whileto really help out.”In addition mothers found emotional support through friends,particularly other mothers. Typical comments from mothersincluded,“1 called my girlfriends, to me they were mystrength.”• . I meet weekly with a group of other moms- four of us •.. if I didn’t have them tomeet with every week I probably would not besane now. And I really notice it in myselfif for some reason I can’t make a meetingone week. But I think that’s been thebiggest source of help out of all of thesupport things, is having somebody else whois going through the same thing, hearinginput from all the members ...A similar comment from one of the mothers illustrates theimportance for new mothers to have their feelings and experiences62validated. She reported,“I talked to two people on a regular basiscomforting to have someone else say yes,this is happening to me.”Whether or not they had a support system, most of themothers expressed a need to talk to someone during this period.Several mothers made statements such as,“It would have helped to get out and talk toother parents.”“I think it would be nice to have anexperienced volunteer mom to comesomeone to come sit and chat.”During this time period all participants (with the exceptionof hospital nurses) introduced the service provided by communityhealth nurses as a subject for discussion. Many mothersexpressed a desire to talk to a community health nurse. Thefollowing statements illustrate the mother’s need for educationalinformation and support from the community health nurses.“Nothing was happening the way I thought itwould happen, I needed somebody to come inand help me out.”“I just really found I wanted someone totalk to a lot.”“I think that was one of my greatestdisappointments, was with the second baby,the nurse doesn’t come around anymoreshe said phone, but sometimes it’s reallydifficult to get on phone ... I wantedsomeone to come by and talk to me.”In terms of receiving useful information several mothers madecomments like,“The health nurse was really wonderful, sheexplained everything to me.”“The community health nurse’s advice really63helped me.”Although the mothers identified the community health nurseas a provider of information and emotional support, the majorityof mothers reported inconsistencies in service from the communityhealth nurses.“I had one visit from the health nurse, itwas a good two weeks before somebody camebut I needed her a week earlier. Andone visit isn’t enough ...“Health nurse didn’t come til 4 weekspostpartum”“I didn’t get a call at all with my secondchild, she came twice with my first ... .““I didn’t get a visit or a call.”The community health nurses recognized that they are notalways available to assist the new mother when she needs it. Onecommunity health nurse reported,“We do so many different things, I haveChild Health Clinics and schools- we don’talways get in as soon as we should.”3) lifestyle adjustmentsIssues of lifestyle adjustment received very littleattention during the discussions of the 1 to 6 weeks postpartumperiod.During this time period, there were variances in the data.Different issues were identified by the young mothers group, thenative mothers and the multiparous mothers.Three of the five women from the youth group reported thatthey experienced postpartum depression (only 1 other mother froma multiparous group reported experiencing postpartum depression).64Generally, mothers in the youth group reported that theiremotions ran higher than did other groups during this period.The younger mothers made comments such as,“The only thing that freaked me out was my emotionswere so touchy. I like to have control, ... somebodywould say something and I’m bawling my eyes out.”“I would wake up crying ... for no reason.”“I’d watch Night Court and cry ... any commercials withbabies on them I’m like, ahhh.”The Native mothers discussed what it was like to copewithout the infant’s father. Unlike other groups in whichspouses were most often discussed in time period two in terms ofhow much or how little support they provided, the two nativewomen who were parenting on their own did not report missing orwishing for spousal support. Rather, they described how theassumptions people make about the father’s parenting role addedpressure to an already stressful time.“It got to me ... when I’d go out, shopping,people would come up to me and say where’sthe daddy, don’t know what to say.”“It’s hard when dad’s not there, and peoplebound to think you are married or engaged.Both groups of multiparous mothers described this timeperiod as one in which they were challenged to balance thedemands of the newborn and older child(ren).“For me it was keeping the house organized,getting up and getting two of them dressed,I was lucky if I was dressed by 11 or 12o ‘clock.”“It would be nice to have someone take thefirst one for a couple of hours a week, I65needed time with the second, felt I wasletting first one down.”Six Weeks to Three Months1) lack of knowledge (“...nobody told me...”)The majority of participants did not report issues relatingto lack of knowledge during this time period.2) role redefinition (“...what is my role here...”)The majority of participants did not report issues relatingto role confusion or role redefinition during this time.3) lifestyle adjustmentsThe most prevalent theme identified by participants during6 weeks to 3 months postpartum period involved the lifestyleadjustments the mothers experienced. All six tasks werediscussed in relation to this theme. Seven of the eight groupsidentified an additional issue relevant to this time period -returning to the labour market.Five groups raised adjustment issues in relation to breast-feeding. Mothers reported difficulties finding public facilitiesto breast-feed infants, particularly when mothers have siblingsin their care. As one mother stated,“I found it really difficult getting outwith the baby when you have other children,finding a place to breast-feed is not thateasy if you’ve got other kids, I find itvirtually impossible to get anywhere.Both groups of nurses reported that during this time periodmothers are making decisions regarding the length of time theywill choose to breast-feed. The groups of nurses comments like,“How long do I breast-feed for is a big66issue for some mothers.”Three groups of mothers reported that during this timeperiod they enjoyed interacting with their. infant and had anincreased understanding of their infant’s needs. Bothprimiparous and multiparous mothers expressed the enjoyment theyfelt in their interaction with their infants. They madestatements such as,“It is fun to watch her [baby]. She’sbecoming more of a person now. Doing littlethings, fun to play with her, she’s gettinga lot more personality now.”All of the focus groups discussed changes in mothers’ senseof self. The mothers described problems they had experienced:less time available for themselves; feelings of isolation andloneliness; concern regarding their body image; and changes intheir sexuality. Mothers made statements such as:“I think you get house bound, you thinkeverybody is having a life but you ...““I found it really lonely, lonely and a bitbored.”“Frustrating to get back into shape ...““I wasn’t prepared for sex at six weeks ...“The nurses also identified issues related to mothers’ emotionalsense of self during this time period. Both groups of nursesmade statements like,“A lot of mothers feel isolated in thistime.”“At this time, women are starting to look attheir body image and getting in to losingweight.”67Several participants, both mothers and the community healthnurses, reported that couples spend time less together duringthis time period. Several mothers made comments about thefrequency of having time together as a couple. For example, onemother states,“We haven’t gone out as a couple, solely,yet. I am hoping to now, it’s getting tothe point that I want to get back a littleof my own life - time to get back a wife-and-husband feel.”The community health nurses also identified six weeks to threemonths as a time for couples to re-establish their relationship.A community health nurse said,“This is a period when they [couples] haveto look at their relationship with theirpartner and see where they can rebuild wherethey let things slide.”One group of mothers and the community health nurses alsonoted the adjustment process is often different during this timefor the mothers and the fathers. They reported that spousesexpect to resume or maintain the activities they were doing priorto the birth of the baby while at the same time the mothers areexperiencing an adaptation in their lifestyle, and a loss oftheir former lifestyle. As one mother pointed out,“This was the hardest time for us because he[baby] wasn’t going anywhere- he needed alot of attention - it’s been a lot ofadjustments for the two [couple] of us.I’ve come to the realization that my lifehas changed and he [baby] is reallyimportant and he needs someone to look afterhim. My husband still thinks we can do whatwe did when he wasn’t here. But it’s notthat easy anymore ...68The community health nurses made a similar comment.“Moms often feel abandoned by the father.The father resumes his golf games and normalactivities and she doesn’t get to do any ofthat- a lot of women express frustrationover that.”Sibling care was an issue identified by the multiparousmothers and the community health nurses. The mothersreported a change in the amount and type of interaction they hadwith the infant’s siblings. They also reported that during thistime period they experienced a change in the sibling’s behaviour.The mothers described their older children as acting out anddemanding attention. Both the mothers and the nurses reportedthat the mothers experienced increased difficulty coping withthese problems, felt guilty when they lost their tempers, andremorseful when they overlooked the needs of the olderchild(ren). Multiparous mothers made comments such as thefollowing.“You worry so much about the other ones. Mykids were both really good in the beginning,but [baby] developed colic and was beingcarried twelve hours a day. Of course, itwasn’t long before my son needed to becarried everywhere, he couldn’t do anythingfor himself anymore - he became reallydemanding.”“I also felt some guilt because I wasn’table to hold the second baby as much as Icould with the first“Mine did little things to annoy melittle attention grabbers. and of course,when you are tired you don’t handle thesituations as well.”“I feel like I could wring his little neck -I don’t- but it’s kind of frightening to69feel that. This is the child that before Ihad the baby, I was so worried that hisfeelings would be hurt or he’d feelabandoned and now I just want to get rid ofhim myself.”“I also felt some guilt because I wasn’table to hold the second baby as much as Icould with the firstSimilarly, the community health nurses recognized the mixedfeelings the multiparous mothers experience with respect to theirolder children. One community health nurse reported what shehears from the mothers she visits.• .there’s some guilt in the multiprevolving around What have I done to myfirst born by having a second one?’ I haveheard that expressed a lot.”Whether or not to return to work, and how to achieve this,was introduced as a topic for discussion by seven of the groupsduring this time period. Several mothers reported a reduction intheir motivation to return to work. Some mothers decided not toreturn to work following the birth of the baby. Mothers’ concernabout arranging and securing quality child care was expressed bymothers and nurses.Typical comments from mothers included:“I have a lot of going back to work stress.I don’t want to go back to work and I wastotally career-oriented. I don’t want toleave my baby for somebody else to lookafter.”“I have my own business and wanted to keepworking, but somehow, having a second, I’mnot that keen about going back.”“I’m at the point of deciding whether or notI want to go back [to work], and I wouldreally like to stay home and look after70[baby] but I think for my sake, the sake ofour marriage and all the rest that I willneed to work at least part-time.”“I’ve chosen to stay home and I don’t regretit.”“I decided not to go back to work, so it’s abig financial adjustment and that’s beentremendous.”“I started work and that was hard jugglingwork and finding a good sitter.”Both groups of nurses identified changes in mothers’ desire towork as an adjustment issue for mothers during this time period.They made comments such as,“A lot mothers are having mixed feelingsthey are wondering if they really want to goback- there is a lot there in terms oftheir economic situation and theirexpectations.”The group of young mothers was the only group that did notdiscuss issues regarding employment.The only major variance in the data during this time periodwas reported by the nurses. Unlike any of the mothers, bothgroups of nurses introduced the issue of birth control in thistime period. The following statement illustrates the perceptionof the nurses. One nurse stated,“I think along with getting their body imageback again, they [mothers] are concernedabout birth control ...“See Table 3 for a summary of the issues reported by focusgroup participants.71Table 3Issues as reported by focus group participants summarized inorder of frequency0-1 Week 1-6 Weeks 6 wks-3 mthsLack of accurate Need for mothers Adjustments inand consistent to physically and mothers’ senseinformation on emotionally recover of self -breast-feeding from the birth emotionallyphysicallysexuallyLack of preparation Need for educational Changesand clear information information, regardingon infant care emotional support return to theand physical help labour marketwith householdtasksLack of clear and Several mothers Increasedconsistent experienced understandinginformation problems of infants’on maternal care breast-feeding needs andgreaterenjoyment ofinteractionwith infantUnclear role Lack of information Changes inexpectations on infant care breast-feedingregarding infant issuesand maternal carePerceived lack of Changes incontrol in directing the amount ofcare of the infant time spousesspend togetheras couplesChanges inanunt and typeof interactionwith infants’siblings72RESULTS OF THE COMMUNITY PORTRAITSThe community portrait exercise provides information aboutthe range of people, services and resources the mothers usedduring the three months following the birth of their infants.The results also illustrate who and or what support systems werethe most useful (see diagram 3 for supports nurses reported asbeing the most useful and diagram 4 for supports mothers reportedas the most useful).PeopleThe range of people who provided help to the mothersincluded: spouses, siblings, relatives, friends, neighbors,church members, previous co-workers, and informal support groups.The range of people the nurses identified as helpful to motherswas the same as that reported by the mothers, with the exceptionof co-workers. For both mothers and nurses, the most frequentlyreported supporters were spouses, family and friends.ServicesThe services mothers reported using included: doctors,lactation consultants, La Leche League, hospital nurses, ChildHealth Clinics, community health nurses, Parent & Infant Drop-inprograms, diaper services, homemaking support services, nannies,housecleaning services, recreation centres, and supermarketdelivery services. The services reported by the nurses includedthose reported by the mothers as well as the following: theVancouver Breast-feeding Clinic, North Shore73Diagram 3Most Useful Supports for New Mothers as Reported by NursesDiagram 4Most Useful Supports for New Mothers as Reported by MothersNort,Nei74Family Services Drop-in, welcome wagon, Chesterfield House,transition houses, food banks, the Ministry of Social Servicesand Housing, drug and alcohol programs, postpartum supportprograms, drop-in babysitting, and babysitting co-ops. Althoughthere was a broad range of services reported, the most frequentresponses from mothers and nurses were related to theprofessional medical services.ResourcesBoth mothers and nurses reported usage of the sameresources. The range included: parks, infant care books,educational videos, and the library story time. The mostfrequently reported resource used by mothers was infant carebooks.Two additional support systems were reported by specificgroups. The group of young mothers all reported using the YoungParent Program at North Shore Neighbourhood House. The localband office was reported as a resource by the Native group.Several participants reported more than one support systemto be helpful to them. However, an overwhelming majority (77%)of the mothers reported the most useful support was their spouse.Only 50% of the nurses perceived spouses to be the mostuseful of the support systems. In addition, 50% of the nursesreported North Shore postpartum services as being the most usefulto new mothers. Only 2 of the twenty-five mothers who used orreceived these services indicated they were the most useful tothem.75It is also worth noting the variances in the data betweenthe mothers and the nurses. Whereas, 18% of those mothers whoreported using infant care books found them to be one of theirmost useful resources, only 1 nurse reported books as one of themost useful resources. In addition, the findings of thecommunity portraits showed that none of the mothers reportedusing the Vancouver Breast-feeding Clinic, whereas, 43% of thenurses reported the clinic as resource available to mothers.Only 2% of the mothers reported using La Leche League as aresource, whereas, 64% of the nurses noted the availability ofthis community based support.76CHAPTER 5 - DISCUSSION OF THE FINDINGSThis chapter will discuss the findings from the focus groupswithin the framework of the three time periods that wereexplored. Data from the community portraits will also bediscussed. The final sections of this chapter will include:recommendations for action; implications of this study for socialwork; and further questions for researchIssues raised in the focus groups parallel findings fromother studies (Ball, 1981; Ball, 1987; Bradley, 1989; Curry,1983; Evans, 1990; Gruis, 1977; Sumner and Fritsch, 1977).Although the question and the accompanying probes which generatedthe data were derived from the literature, participants’responses concurred with and built upon information from otherstudies. It was assumed that additional issues would be raisedbecause the time frame for this study extends beyond thetraditional postpartum period.IMPLICATIONS OF FOCUS GROUP FINDINGSThe results of the focus groups illustrate an overalltendency for mothers’ needs to change as the baby grows and thefamily and infant learn to adapt to one another. Throughout thethree month period there is a process of learning and adjusting.The first weeks are ones of acquiring knowledge to carry out thetasks of caring for the infant and the mother’s recovery frombirth. Following the acquisition of information, the findingsindicated a phase - primarily during the 1 to 6 week period -where the women were clarifying their roles as new mothers,77developing skills as well as meeting their own recovery needs.Finally, the discussion groups demonstrated a progression to aperiod of adjustment. The mothers talked about the types oflifestyle adjustments they and their families were making. Themajority of adjustment issues had to do with siblings, spousesand employment. This process of learning and adjusting wasreported by both nurses and mothers.The First WeekIssues commonly noted during the first week were adiscrepancy in care expectations and methods in which informationis imparted to new mothers. In terms of discrepant careexpectations there are two issues to note: mothers lack clearand consistent information to perform the tasks of breast-feeding, and providing care for their infants and themselves; andmothers need clear guidelines explaining the role of a patient onthe maternity ward. In two studies conducted by Ball (1981;1987) she found one of the major dissatisfactions with postnatalcare during hospitalization was the conflicting informationmothers received, particularly in the area of breast-feeding.With respect to the acquisition of information, it wasprimarily first time mothers who felt that “nobody told them” howto perform tasks to do with the care of their infants and theirown care. Whereas, all groups of mothers reported experiencingfrustration and problems because they received unclear guidelinesand conflicting information from the hospital staff. There is adiscrepancy between the perception of the mothers and the78perception of the nurses with respect to the acquisition ofinformation. It was the perception of several of the mothersthat they did not receive the necessary information to performbreast-feeding and infant and maternal care tasks. Yet, thenurses reported that information about breast-feeding and infantand maternal care is imparted to women, either prenatally and/orduring their hospital stay. This discrepancy in perceptionraises two questions. Is the information new mothers need toacquire in their first week postpartum being communicatedclearly? Does the anticipation and complexity of the birthingprocess interfere with the ability of new mothers to acquirepostnatal information? Evans (1991) presents research thatsupports difficulty in nurses being able to meet the learningneeds of new mothers during their hospital stay. She also arguesthat new mothers may not be ready to learn about infant andmaternal care until they go home.Mothers’ experience of this first week, specifically interms of the hospital stay, suggest a difference between theexpectations of care between the groups in this study. The youngparents (16-21 yrs) and the Native mothers did not report thesame degree of difficulty in their care experience. Unlike theother groups of mothers, the women from the Native group and mostof the women from the youth group enjoyed their hospital stay andfound it to be restful. Differences may relate to culture,education or experience- all of which may relate to expectationsof role and power. Those groups of women who may more commonly79experience powerlessness seemed to fare better in the hospital.Those women who may more commonly be, or perceive themselves tobe, in control of their experience may have had difficultyaccepting their role as a patient in a hospital. The lack ofclarity regarding that role may have just compounded thesedifficulties. Health care workers need to be sensitive to thegrowing trend of maternity patients actively participating intheir own care, and that of their infant (Bradley, 1989; Evans,1990).Bradley (1989) found that women who participated in an earlydischarge program were significantly more satisfied with the careprovided by visiting nurses than those who received the majorityof nursing care during their hospital stay. In addition, thisstudy found those women who went home within twenty-four toforty—eight hours felt that they were able to take more controlof their care and were validated by the visiting nurses for themethods of infant care they were using.Evans (1991) supports the concept of nursing care providedat home. Evans believes that when nursing care is provided inthe home environment it is designed to meet the needs of thefamily rather than to fit the hospital’s time table andregulations.The Next Five WeeksFor most of the mothers this period required a transitionfrom hospital to home. In comparison to the previous timeperiod, where professional support was readily available, this80was a time when the mothers were primarily on their own - copingwith the tasks of infant care, maintaining relationships withtheir children and spouses, managing household tasks and theirown recovery.Although the need for information regarding breast-feeding,infant and maternal care remained issues during this time period,there was less anxiety, and loss of control reported during thesefirst 1-6 weeks at home in comparison to the hospital stay.Bradley’s (1989) study supports the home environment as beingmore conducive to permitting control, competence and comfort.All groups discussed what it was like for new mothers tomanage looking after a new baby, attend to their recovery, andtake care of other family members in addition to the household.In comparing the experiences of mothers with the perceptions ofnurses, there is fairly consistent congruency. On the whole,nurses understand the complex problems of adjustment faced bymothers.Most mothers expressed a need to talk to someone during thistime period. Although the timing of the visit by the communityhealth nurse was not always the most beneficial or appropriate,many mothers expressed a desire or need to talk to a communityhealth nurse or an experienced mother. The data suggest thatthere are different kinds of support needed. One has to do withthe need for educational information. The other has to do withreceiving emotional support. Several studies and programdescriptions (Barrett, 1990; Bull & Lawrence, 1985; Curry, 1983;81Evans, 1991; Gruis, 1977; Hiskins, 1983; Sumner & Fritsch, 1977)document the need for new mothers to talk to other mothers and/ora health professional for emotional support, problem solvingtechniques and educational information.Three of the five women from the youth group reported thatthey experienced postpartum depression (only one other motherfrom a multiparous group reported experiencing postpartumdepression). Generally, mothers in the youth group reported thattheir emotions ran higher than did other groups during thisperiod. Given these findings, the need for a support program foryoung parents - like the Young Parent Program operated by theNorth Shore Neighbourhood House - becomes obvious.Six Weeks to Three MonthsDuring this time period, there was a greater range of topicsdiscussed in comparison to the first six weeks. The commonelement in all the stories was the experience of adapting to anew lifestyle. Issues relating to all six tasks (breast-feeding,infant care, maternal care, spousal relationship, sibling care,and household maintenance) were raised during this time frame aswell as the issue of employment.Concentration of health care services is intense during thefirst two weeks following the birth. With relation to the fourpostpartum tasks which served as a framework for the study,health care workers primarily focus on the care of the infant andmother. Findings from this study indicate that although theseare needs mothers have in the early weeks, mothers need more82support around lifestyle and role adjustments in becoming newparents. In keeping with the health promotion framework, thisdoes not mean there needs to be the development of postpartumclasses or professionally led workshops on postpartumadjustments. Rather, concentration needs to be on facilitatinga process for mutual-aid and developing more integrated communityservices.IMPLICATIONS OF THE COMMUNITY PORTRAIT FINDINGSThe results of the community portraits supports theconceptual framework put forth by Kleinman (1980). Kleinmanargues that in any health care system individuals interact withthree sectors: the professional, the folk, and the popular.The professional sector is composed of organized health careworkers. The folk sector includes healing specialists who areoften not recognized as professional. In relation to this study,La Leche League counsellors would fall into this category.Although the family is the primary source of the popular sector,social and community networks contribute to this sector as well.Kleinman believes that in any health care system it is thepopular sector (individual, family, social and communityactivities -- informal support systems) that provide the majorityof support to an individual requiring health care intervention.The people, services and resources reported by focus groupparticipants indicate that mothers did interact with all threesectors. From the professional sector, nurses and mothersreported using services provided by doctors, nurses and community83health services. From the folk sector, nurses and mothersreported using resources provided by La Leche League counsellors.For groups of mothers and nurses alike, the most frequentlyreported person/service/resource to provide support during thepostnatal period examined was family (spouses, and relatives) andfriends. Fifty percent of the nurses perceived spouses to be themost helpful resource to new mothers. In contrast, the majorityof mothers indicated their spouse as the most useful/helpfulsupport.Similar findings were reported in several studies. Gruis(1977) found the vast majority of mothers in her study soughthelp from their husbands. Ball (1981) reported that it was thequality of support rather than the quantity of support providedby husbands and family that was important in relation to themother’s emotional needs and well-being. Curry (1983) found thepostnatal variables that were related to adaptation to motherhoodwere help from husbands, postpartum nurses and self-concept.Particularly for mothers coming home from the hospital early,Bradley (1989) reported that family support was essential inorder for the mothers to be able to take control of their own andtheir infants’ care. Without emotional, psycho-social andphysical support, the women who participated in this earlydischarge evaluation believed it would be preferable to stay inthe hospital.In terms of North Shore Health services - Parent & InfantGroups, Child Health Clinics and community health nurses - all of84the nurses indicated mothers use one or all of these services.Fifty percent of the nurses perceived North Shore Healthpostpartum services to be the most usefulservice/support/resource to new mothers. Whereas, seventy-sixpercent of the mothers reported using North Shore Healthpostpartum services, only two of the twenty-five mothers who usedor received these services indicated these to be the most usefulto them. Moreover, nine out of these twenty-five indicated NorthShore Health services to be the least helpful to them.Participating mothers made comments to the effect that the Parentand Infant group sizes were too large or that the home visit fromthe community health nurse was made at a time when they did notneed help. These findings suggest a discordance with regard tothe utility of services.The results also raise the question of appropriateness ofhealth service utilization. For example, 75% of the mothersreported the doctor as a support, yet only 16% of those mothersfound the doctors to be the most useful resource. Given thatmost of this service provision has to do with infant care andfeeding issues, it begs the question that perhaps these needs canbe met in a less expensive and more accessible fashion.The findings of the community portraits showed that none of themothers reported using the Vancouver Breast-feeding Clinic,whereas, 43% of the nurses reported the clinic as a resourceavailable to mothers. In addition, only 2% of the mothersreported using La Leche League as a resource, whereas, 64% of the85nurses noted the availability of this community based support.Data from the focus groups indicated that many of themothers experienced problems breast-feeding. Whereas theinformation from the community portraits suggests new mothers donot frequently use breast-feeding services that would likely helpthem. These findings raise three questions. Are new mothersaware of existing breast-feeding resources? If they are aware ofbreast-feeding resources, are these resources accessible to newmothers? And, if these breast-feeding services are accessible,are mothers satisfied with the services they provide?RECOMMENDATIONS FOR ACTIONFocus group and community portrait findings indicate thatduring their postnatal period the mothers needed information,support and validation to assist them in adapting to their roleas parents.InformationThere is a growing trend in health care to recognize theprinciples of adult learning in service delivery. In thematernity field, this trend is being acknowledged through theimplementation of the Postpartum Parent Support Program sponsoredby the federal Ministry of Health and Welfare. While thePostpartum Parent Support Program is an attempt to incorporateadult learning principles into maternity health care, it isimportant to recognize that the learning needs of mothers extendbeyond the time they are in hospital.To meet the learning requirements that accompany the birth86of a baby - information about infant care and self-care - on theneed basis of the mother, professionals could be availablethrough a telephone consultation service providing information toindividuals as the need arose. In keeping with and strengtheningcommunity health practice, such a service could be carried out byseveral North Shore organizations: North Shore Health, LionsGate Hospital, and North Shore Family Services.Mothers identified the need to acquire educationalinformation with respect to infant and maternal care. Whetherthis information is being delivered by another mother or aprofessional, the emphasis needs to be on experiential learning.The mothers who felt most satisfied with learning to meet theirrecovery needs and to care for their infants, reportedexperiences with hospital nurses, community health nurses and/orother mothers who provided demonstrations of what to do. It isimportant to note that in these learning situations it was themother who asked for the information and that the information wasdelivered in an unhurried manner.SupportCurrent literature in the Health Promotion field supportsenhancing mutual aid and self care (Health and Welfare Canada,1986). Although new mothers clearly need support, particularlyduring the first six weeks postpartum, it is important forservice providers to recognize that they are not the primarysource for the majority of this support. What is needed is a wayfor mothers to be able to talk to other mothers. For example,87instead of a professional leading an educational program formothers, professionals could organize and facilitateneighbourhood support groups for mothers and their children.Another forum for facilitating mutual aid by mothers couldinclude a self-help network of volunteer mothers who visit and/orprovide telephone support to new mothers. Such a self-helpnetwork would meet the needs expressed by several mothers in thestudy who did not have friends with children, or who did not haverelatives living near to them. Another strategy, reported bymothers who gave birth at St. Paul’s hospital, could be thedevelopment of a “buddy system” for new mothers to use once theyleft the hospital.If, as the data suggests, family and friends are the primaryand most useful support, then more needs to be done byprofessionals to enable the popular sector. Several mothers andnurses in the focus group discussions suggested that a pamphletor a seminar for fathers to learn what to expect during thepostpartum period and what they can do to be helpful would beuseful. It would be appropriate to extend such educationalstrategies to family and friends as they too were identified asprimary support systems in this study. It is curious that inother cultures where the popular sector has an acknowledgedresponsibility for postpartum care and support, emphasis is onfacilitating the development of the relationship between themother and baby and there are fewer reported difficulties withbreast-feeding (Kitzinger, 1990).88ValidationValidating women in their role as new mothers is animportant need identified in this study. In a service orientedsociety such as ours, ways to validate women in their role as newmothers include facilities and services designed to accommodatechildren. Mothers in this study identified the need for publicfacilities that are conducive to breast-feeding. A particularneed in relation to public facilities for breast-feeding, is thatthey include a small play area that can accommodate siblings.Several women in the study also raised the need for services,such as programs for their older children and exercise classesfor the mothers, to include a child care component for theirinfants.Another way for women to feel validated as new mothers isfor them to have opportunities to express their needs. The focusgroups provided the mothers with the opportunity to express theirneeds, to raise issues that are important to them, and to findsupport in other mothers. A community forum to present theresults of this study, and possibly other related research, wouldprovide new mothers with another opportunity to discuss theirpostpartum needs, develop strategies for improved services andsupport, and in addition, educate the community as to the needsof women during their postnatal period.On a more personal level, people wanting to provide supportto new mothers need to ask how they can be helpful. Many mothersin the study expressed that it was difficult for them to ask for89help or that the help they received was not what was needed atthe time. Supporters could offer a variety of suggestions, suchas preparing some meals, providing child care for siblings, ortaking care of the baby so the mother can rest, enabling mothersto respond to offers of support that are comfortable to them andwithin the expectations and capabilities of the people offeringto provide the help.Professional and lay people need to develop a newperspective of the postpartum period. Providing a learningatmosphere for new mothers that emphasizes experiential learningand imparting information on the need basis of the mother,facilitating mutual aid by new mothers, supporting the supportersof new mothers, and validating women in their role as new mothersare steps towards developing such a new perspective. In orderfor this goal to be achieved, the community needs to understandwhat the postpartum period is like for new mothers and what theycan do to be helpful. As one of the nurses aptly stated “peopleshould bring casseroles instead of flowers.”There are many strategies that could be used to educate thecommunity as to new mothers’ needs during the postnatal period.These include postpartum educational materials, such aspamphlets, videos, and television and radio programs; a communityforum; and a public awareness week.This study makes recommendations for future action thathopefully the committee of community organization representativeswill consider implementing. Above all, this study reminds usgothat whatever “next step” is taken, it is important to involvecommunity members in the process.IMPLICATIONS FOR SOCIAL WORKSocial work practitioners will be interested in the resultsof this exploratory study because it contributes to literature onthe social support needs of women and families during thepostnatal period; the importance of self-help and communitynetworks; and health promotion research models.Also social work practitioners will find the psycho-socialneeds of postnatal women identified in this study useful in termsof developing intervention strategies, - clinical, preventativeand/or community-based. In their practice, social workers willbe able to incorporate the knowledge that the postnatal periodinvolves a developmental process in which mothers’ needs changeover time. It is important for practitioners to recognize thatnew mothers are not a homogeneous group and, depending on severalvariables - age, labour and delivery, number of children, andethnic and cultural background - their needs vary. Informationfrom this study will enable social work practitioners to supportand strengthen the development of healthy families through theirpractice in hospitals, social service agencies, communityorganizations and community development.On a policy level, social workers will find this studyuseful from two perspectives. First, social workers advising onpolicy, public expenditure and/or developing programs will beinterested to learn what kind of support systems are important to91new mothers. Although a great deal of research focuses on theprovision of service by health care workers, and thereforediscusses methods for improving service, most of the support awoman receives during her postnatal recovery is from informal andcommunity networks. This study demonstrates the important rolespouses, relatives and friends have in providing physical andemotional support to new mothers. Social workers have animportant role to play in educating and enabling these informalsupport systems.From a policy perspective, the second aspect of this studysocial workers will find useful is the model used in thisresearch project. A fundamental concept of this project was toinclude the community in all phases of the research. Inpromoting healthy families and healthy communities, this studydemonstrates the importance of including the target population,service providers and other key stakeholders in determining theneeds, disseminating the findings, planning and implementingstrategies for change.QUESTIONS FOR FUTURE RESEARCHSeveral questions arise from this study which are importantfor further research. Even though the majority of mothers inthis study reported receiving conflicting information aboutbreast-feeding from the health care professionals, the study didnot determine the difference between those women who haddifficulty breast-feeding and those who did not. An importantquestion for future research is what is the difference between92those women who have problems breast-feeding from those who donot?An additional area for future research includesinvestigating the learning readiness of new mothers. This studysuggests that there is a discrepancy in perception betweenmothers and nurses with respect to the acquisition ofinformation. What is not clear from this study is if, in fact,new mothers are receiving the necessary information they need toperform infant and maternal care tasks, or if they havedifficulty processing the information they receive. A questionfor future research is to determine what steps can be taken toensure the acquisition of infant and maternal care informationtakes place?It is important to recognize that women are not a homogenousgroup and that different groups of women may have differentpostnatal needs. Two areas that require further exploration ofpostnatal needs have to do with single mothers and women fromdifferent ethnic groups.Given that the majority of mothers who participated in thisstudy were married, the study did not identify needs specific tosingle mothers. Moreover, given that the majority of mothersreported that their spouses were the most important support tothem, it raises the question, what support systems are availableto single mothers?Both groups of nurses reported that in their nursingexperience they found new mothers from different cultures have93different postnatal care expectations. Although this studyacknowledges the potential differences in postnatal needs betweenwomen from different cultural and/or ethnic background, the studydoes not identify what those differences are. Given thatdifferent care expectations may translate into different needs,a future research question worthwhile asking is what are thepostnatal needs of women from different cultural and/or ethnicgroups?The answers to these questions would contribute to a betterunderstanding of the postnatal needs of women and providerecommendations to improve services and community supportsavailable to all new mothers.Support in the postpartum period is essential to ensureadjustment to parenting. The mothers in this study asked formore information, support and validation in making thistransition. 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Vol. 105, No. 3,pp. 224-231.World Health Organization (1986). Ottawa Charter for HealthPromotion: An International Conference on HealthPromotion: The Move Towards a New Public Health.Ottawa: Supply and Services Canada.APPENDICES99100APPENDIX A - SAMPLE OF FLYERctd 1€ &€e tfuá c,ca 6a4?‘ccae/ec4 e41iedWe are inviting you to participate in a discussion groupas part of a North Shore Health and Lions Gate HospitalResearch Project. We want to know about your postnatalexperiences to improve community care for new mothers.‘€44I* Attend a two-hour meeting with other mothers* Child care provided* A small gift to all participating mothers64* Mothers with a 4 to 12 month-old baby* Can be first-time mothers or mothers with other children* North Shore residentFor more information, please callDebbie Erickson, Community Health PromotionNorth Shore Health983-6710____101We are inviting you to participate in a discussion groupas part of & North Shore Health and Lions Gate HospttalResearch ProjecL We want to know about your postnatalexpeiienccs to improve community care for ncw mothers.1cce cr€ce?• Attend a two-bow meeting with other mothers* Child care provided• A small gift to all participating mothers• Mothers with a 4 to 12 month-old baby• Can be first-time mothers or mothers whh other children• North Shore resident______For more WomaUon please caJDebbie Etldson. Community Health PromoltonNoli Shore Health903-6710APPENDIX B - SAMPLE OF PROOF FOR ADVERTISEMENT PUBLISHEDIN NORTH SHORE NEWS1c4s e€4 6J 1a47JO4€/drA4 e4e4. coa7LW102APPENDIX C - SAMPLE OF WRITE-UPPUBLISHED IN THE NORTH SHORE NEWSN. Shore Health initiatespost-natal research studyNORTH SHORE Health is undertaking a research projectto assess the needs of post-natal women living on theNorth Shore.Conducted in conjunction witha multi-agency committee, the By Elizabeth ColIlngs$10,000 study will focus on News Rerterwomen’s needs during the initialthree-month post-natal period.According to project coor- natal period.dinator Debbie Erickson, the im- It will also examine the addipews for the study came from tional supports and resourceslocal nurses, women think they need and how“The community health nurses the mothers’ perceptions compareat North Shore Health identified with those of community healththere were needs that women nurses and hospital nurses.have, but they weren’t Erickson said some recurringdocumented or researched,” issues for the mothers ofErickson said, newborns may Include their physi.Erickson said North Shore cal recovery after giving birth,Health is recruiting North Shore care for their infant, establishing amothers with babies aged from relationship with their newbornfour months to one year to join and altering their lifestyle to acgroup discussions for the study. commodate an infant.The study will be based on eight Between 60 and 70 mothers arefocus groups that will include needed to participate in the study.first-time mothers, mothers with Participants must be North ShoretwQ or more children, teen residents who can volunteer twomoThers, native mothers, corn- hours for the group discussion.munity health nurses and hospital Child care will be provided.nurses. The results of the study will beErickson stressed that the released at a community forumresearch project is not a study of and will also be used for programpost-partum depression, but will planning, services and communityinstead explore the supports and education initiatives.resources women used during the To participate in the study, callfirst three months of the post- Erickson at 983-6710.103APPENDIX D - SAMPLE OF THE FLOWCHARTENLARGED TO 11’ X 17’ FOR THE DISPLAY BOARDPOSTNATAL EXPERIENCESOF NORTH SHORE WOMENA North Shore Health Research ProjectRESEARCH PROJECT PROCESSResearchDesignIIPresent ResultsIFollow-upGroup ofParticipants______Advisory> CommitteeICommun1ityForumIFinal’ReportResearch104APPENDIX E - SAMPLE OF THE INFORMATIONSHEETS PROVIDED TO PARTICIPANTSTHE UNIVERSITY OF BRITISH COLUMBIASchool ol Social Woit6201 Ccci) Green Park RoadVancouver, B.C. Canada V6T IZIPOSTNATAL EXPERIENCESOF NORTH SHORE WOMEN:A NORTH SHORE RESEARCH PROJECTWe are inviting you to participate in afocus group interview as a part ofa NorthShore Health research project. We are interested in hearingfrom you about yourpostnatal experience.• What was it like for you after the birth of your baby?• What/who helped you?• What are some of your postnatal stories?WHAT 1W ARE DOINGThe North Shore Health department is conducting a research project to determinethe needs of North Shore women during the immediate postnatal period (0-3months). North Shore community health nurses are interested in exploring andunderstanding the needs of women during the postpartum period.Using focus group interviews, this study will explore and compare the postnatalexperience from three perspectives:1. recent mothers2. community health nurses3. hospital nursesThe results of this study will provide information which will be used for programplanning, implementation of services and community education initiatives.105-2-WHAT’S hVVOLVEDThe time commitment we are asking you to make is approximately three hours.During the focus group interview, you and other mothers will have the opportunityto let us know about your postnatal experiences. We will be providing childcarefor you if it is necessary. Day or evening groups are available.Following the completion of the focus groups, we will be holding an optionalmeeting for focus group participants to provide us with feedback on the dataanalysis. This second meeting will be approximately two hours long.WHO IS ElIGIBLETo be eligible for the study you must be a resident of the North Shore and themother of an infant 4-12 months old. If you are interested in participatingplease call Debbie Erickson, Project Coordinator, at 983-6710.You are under no obligation to participate in the study. If you decide toparticipate, you may withdraw at any time and/or decline from answering anyquestions without reprisal of any kind.In addition to providing a needs assessment for North Shore Health, this study willbe submitted as a thesis towards partial fiilfilment of Debbie Erickson’s MSWdegree at the University of British Columbia.RESEARCH SUPERVISORSDr. Nancy Hall Dr. Sharon Manson WillmsDirector Faculty AdvisorCommunity Health Promotion School of Social WorkNorth Shore Health UBC983-6710 822-3251106APPENDIX F - SAMPLE OF PARTICIPANT CONSENT FORMTHE UNIVERSITY OF BRITISH COLUMBIASchool of Social Work620k Cedi Green Park RoadVancouver, D.C. Canada V6T IZIPOSTNATAL EXPERIENCES OF NORTH SHORE WOMEN:A NORTH SHORE HEALTH RESEARCH PROJECTINTERVIEW CONSENT FORMResearchers Research SupervisorsDebbie Erickson Dr. Hall Dr. Hanson Wilinra/Lynne Coyle Project Manager Faculty Advisor983—6710 983—6710 822—3251I, the undersigned, do hereby consent to participate ina focus group interview for the purpose of research forNorth Shore Health under the following conditions:— That the data gathered through this process will only be usedfor the project stated; the purpose of which is to determinethe needs of North Shore women during the inanediate postnatalperiod (0-3 months) and to formulate recomoendations for servicedelivery and comunity action. In addition, the researchproject will be submitted as a thesis for Debbie Erickson’sHSW degree.- That the interview will take approximately two hours and will beaudiotaped.— That my identity will be kept strictly confidential; that allidentifiable information of individuals included in this studywill be removed for reporting purposes; persons having access tothe data include Debbie Erickson and Lynn. Coyle, Researchers,Nancy Hall, Project Manager, and Sharon Hanson Wilma, FacultyAdvisor, School of Social Work, UBC.— That no monetary remuneration will be provided for myparticipation.— That I may ask any question of the interviewers at any time andhave a right to a debriefing following the interview if I wish.- That I may refuse to participate; that I may withdraw from thestudy at any time; that I may refuse to answer any questionwithout penalty of any kind.signature of focus group participant dateI hereby acknowledge that I previously received a letter of introduction from theresearchers, and I have now received a copy of this consent form.signature of focus group participant date107APPENDIX G - SAMPLE OF DEMOGRAPHIC INFORMATION FORM(MOTHERS)INFORMATION ABOUT YOU FOR OUR STUDYPLEASE CHECK 771E FOLLOWING ONE WHiCH APPLIES 70 YOU:1. Where do you live?_____NORTH VANCOUVER DISTRICTWEST VANCOUVERNORTH VANCOUVER CITY2. Marital Status___MARRIEDLWING WITH SPOUSAL EQUIVALENTSEPARATEDDIVORCEDSINGLE3. Are you presently employed outside your home?YESNOMATERNiTY LEAVE5. Where was your infant was born?LIONS GATE HOSPITALGRACE HOSPITAL_HOMEOTHER.. ./2You under no obligation to answer any qzestiou.108-2-PLE4SE PROVIDE TIlE FOLLOWING INFORMATION:5. Your Age:6. Your Infant’s age:7. If you have other children, what are their ages:8. How many years of education have you completed?You are wider no obligation to anrwer any question.109APPENDIX H - SAMPLE OF DEMOGHRAPIC INFORMATION FORM(NURSES)INFORMATION ABOUT YOU FOR OUR STUDYPLEASE CHECK THE FOLLOWING ONE WHICH APPLIES TO YOU:1. Where do you live?__________North Shore__________Surrey____Vancouver____LangleyBurnaby DeltaNew Westminster Other2. Marital StatusMarried DivorcedLiving with spousal SeparatedequivalentSingle Widowed3. Do you have any children?YesNoPLEASE PROVIDE THE FOLLOWING INFORMATION:4. Your age:5. The number of years you have worked for Lions Gate Hospital:6. The number of years you have worked as a nurse:__________7. Your academic credentials:________8. Your professional credentials:You are under no obligation to answer any question.110APPENDIX I - SAMPLE OF THE AGENDA FOR FOCUS GROUP SESSIONSFOCUS GROUP SESSIONSEPTEMBER 5, 1991TIME AGENDA ITEMS1:30 • Begin Focus group session1:30 -1:50 20 mins •• Introductions -- leaders/participants• Overview of study -- purpose- research process (handout)• Housekeeping details- info sheet (handout)- consent form (handout)- schedule/running of group- agenda -- demo/cm mty mapping1:50-2:15 25 mins • HOSPiTAL STAY (04 WEEK)- visualization of stay in hospital using 4 tasks as prompts- *at is this lime likefor new moms?2:15 -2:30 15 mins • BREAK2:30 -2:55 25 mins • 1- 6 WEEKS- same as above2:55 -3:15 2Omins •6WKS-3MONTHS- same as above3:15 -3:30 15 mins • COMMUNITY MAPPING EXERCISE• wrap up111APPENDIX J - SAMPLE OF CODING AND CATEGORIZATIONEXCERPTS TAKEN FROM INTERVIEW NOTES - FOCUS GROUP #1RAW DATA CODES CATEGORIESTHE FIRST WEEKPARTICI PANTIt was a nightmare. Born negative hospitaland raised in North hospital experienceVancouver. In Lions Gate experienceHospital five or six times.Like food. No qualms.Took prenatal, went in atthree a.m. Labour and Labour and hospitaldelivery fantastic people, delivery postive experienceAfter baby born, no one experienceasked my first child, no body told me expectations ofone told me anything. careabsolute panic - right outof it. No one read my nurses unawarechart. Didn’t know how to of patient’schange diaper, how to feed conditionbaby. Baby bruises, cone patient feeling feelings rehead, knew from prenatal. neglected careCare so bad- Got Breast-feeding - expectationshysterical talking to mom lack of of careon phone. No one read my knowledgechart in eight days. Don’t nobody told me caring for babywant to be rude - you’re re chart,dependent. If anyone diapers, feedingtalked to me that way in my care bad hospital careJob they’d be fired. patient feltHospital nurse a friend of dependent on expectations ofmy father so didn’t want nurses for care carethem to know. Care isterrible. Other moms,other hospitals, care OK.PARTICIPANTUntil baby born nurses physical setting facilitygreat. After birth sad great - nurses + hospitalsaying goodbye. Ward grand care great in experiencecentral station - don’t deliveryhave time to care for you - staffing - lack staffdifferent faces. Didn’t of continuity in availabilityhave time to teach breast- care, confusion continuity infeeding. Posters, demos, of care carecram into station to breast-feeding expectations ofobserve. Wanted to get no time to careout. Smooth easy delivery, instructNurses at home visit - wanting to leave hospital careentirely hospital112different- lots of time.Any questions answered andcould phone them-st-feeding problems andtalked to them. On earlydischarge. Would do again.Day and night delivery vsward. Felt nurseoverloaded.PARTICIPANTDelivered at Grace, samething. Long labour,detected problems with babyand wanted to do procedurewith baby.communication with me. Noone said forcep delivery.Upstairs, no baby with me,in special care nursery,other moms had babies.Couldn’t go to bathroom onbedpan. Walked me totoilet and told me not toget off until she came andnever told no to do this soone nurse said not to wasteher time buzzing. Neededan ice pack - told to getyourself. To use awheelchair and buzz. Sowould wait for person toget me. Doctor wanting meto stay. By the fourth daybuzzed to go down and toldto go yourself- wantedmore time with baby andone told me to do this.Told to do moreconstructive things thant.v and watch demos.Didn’t want to because Ididn’t have baby.hospitalnursing careEDP- goodBreast-feedingproblem -resourceavailable in EDPdifference inL&D and PP wardstaffing-nurses notenough timecommunication(not told) reprocedures(delivery)nobody told me(informed orasked opinion)conflictinginformationconflictinginformationinappropriatecommunicationcommunication—nobody told mehospital careEDP Careproblemsbreast- feedingEDP Carehospitalexperiencestaffingavailabilityunclearcommunicationexpectations ofcareconflictinginformationexpectations ofcareperception ofcareunclearcommunicationPART ICI PANTI work at Lions GateHospital in radiology. Sofelt fairly comfortablegoing to Lions GateHospital. Went tophysician I wanted. Wasinduced. Nurse didn’tcheck me in labour and113delivery how far dilated Iwas. Everything gotrolling and baby bornnieces etc, handled babyok. Like you, when I wentto ward felt totally felt abandoned perception ofabandoned except for one on PP ward carenurse that tried to helpme. Baby had high bilirubin. Had to have bloodtests. Used to that, butdifferent with own baby.Thought she might havesomething else- so urinecollection. Felt nurses nursing- didn’t perception ofdidn’t handle well, handle procedure infant careDesparately wanted private wellgot two bed. Had twodifferent persons. Onecaesarean section- got allthe attention. Other keptcurtains drawn- so no sun- depressing. Rooming in a rooming in a rooming inmistake. Felt sorry for mistakenurses. Only two breast- staffing issue staffingfeeding had babies at night availability- all in nursery. Staffingdifficult to get nurses. staffing issue staffingDidn’t have an episiotomy, availabilityknew where things were,felt they liked me becausethey didn’t have to worryabout me. Read my chart -but kept checking me for lack of perception ofstitches which I didn’t awareness re carehave. Three days after patientbaby was born, had the conditionblues - intensified because 3 day blues 3 day bluesbili going up and otherthing but it was ok. Nexttime I’ll take early EDP next time hospital caredischarge, not happy withcare1 - 6 WEEKSPARTICIPANTWhen I left hospital one ofnurses sympathetic. Said nursing- nursing caretwenty-four hour rest and sympatheticbottle feed and give nipple misinformation breast-feedingrest. Milk in misinformation114couldn’t stand own problem breast-feedingit. So short time nursing, solving to deal problemsOnly 2 bottles, husband with soresterilizing, did feed at nipplesnight. I physically, once spouse supportiveI got home, could not sleep supportive spousein one postion more thanone hour at time. Ribsfelt like a knife goingthrough them. Woke up inagony, fifteen minutes toget out of bed. Ended upsleeping with lots ofpillows - to get any sleep. physically physical painA wreck physically. Would wreckedphone hospital to get help phoned hospital seeking breast-with breast-feeding. nurses for help feeding infoWhoever I could think of. breast-feedingWent to La Lech League, LLL - not seeking breast-said doing it all wrong, helpful feeding infoSpnt one and a half hours. breast-feeding breast-feedingbaby frantic, I was in wrong problemstears. Home and pumped allnight. Rented electric breast-feeding efforts topump. Went to hospital and tried at great breast-feedput on double machine, lengthsPumped 4 days and gave it ago but didn’t likesensation and tried threeto four times. Wanted to associates breast-feedingbe a good mom. Anyway I breast-feeding maternalquit and world lifted off with being good expectationsmy shoulders. One visit momfrom health nurse. Husband stopped breast- quit breast-said could someone come feeding - relief feedingright away. Guess on CHN - not timing of CHNholiday, didn’t come right involved soon visitaway - two weeks. Needed enoughher earlier, one visit not 1 visit not it of CHN visitsenough. Needed someone to enoughtalk to and needed support, needed someone emotionalHave no family here. to talk to support neededDifference to talk to support emotionalsomeone. Wasn’t fun. emotionally support neededDidn’t like at all, needednot a happy time experience 1-6PARTICIPANT weeksWhen I got home - loved it. happy time experience 1-6Husband off two weeks. Got husband weeksto sleep and he looked supportive supportiveafter. Health nurse came CHN visit - spousein few days.115Visit not as informativespent more time talkingabout her kids. Sister hadtwo older children-support- phoned her.Better at home and morerelaxed.not helpfulsister SupporthelpfulsatisfactionCHN visitextended familysupportPARTICIPANTThe breast-feeding thoughtit came naturally and_whenfirst latched on - nursesaid she was a natural.Home one and a half weeks -not on properly developedmastitis. To emergency andantibiotics. Doctor saidhave to let baby emptybreasts or would have toput little hose in anddrain it out. Two weeks -painful. Lots of timesthought this is it. Babyreally enjoyed breast-feeding just recently onbottle. Never asked how toproperly breast-feed.Heard about football hold -what kind of football?Would have liked someone totalk to. La Leache Leaguehelpful and supportive-spent one hour.PARTICIPANTI had a wonderful time athome. As soon as feathersruffled at hospital gothelp breastfeeding. Aftersomeone took time. Nobodycame to show how to put onpampers. Everything athome went as with a duck towater. Lucky good baby. Isympathize with momsgetting up. Odd inhospital- nurses saidopposite things. One saidbaby in nursery- othershould keep baby. don’tseem they have a standardbreast-feeding-not naturalhospital nurseswrong infobreast-feeding-poor latch,developedmastitisDr. gave misinfobreast-feeding-thought ofquittingbreast-feeding-baby enjoyedbreast-feeding-never requestedinfoneeded someoneto talk toLLL helpfulwonderful timeat homebreast-feeding-problems -hospital staylack ofknowledge-nobody told me -hospital staytime at homewent wellconflicting info- hospitalobservation oflack of policy -hospitalperception ofbreast-feedingbreast- feedingmisinformationbreast- feedingproblemsbreast-feedingmisinformationefforts tobreast- feedbaby enjoyedbreast- feedinglack of breast-feeding inforequiredsupportLLL positiveresourceexperience athomebreast-feedingproblems-hospital stayexpectations ofcare- hospitalstayexperience 1-6weeksconflictinginformationhospitalstay116Makes you feel like your feeling conflictingdoing something wrong. inadequate informationbecause of hospital stayPARTICIPANT conflicting infoDepends on circumstances, hospital stayBy time I saw him all hairoff. I didn’t know lack of info re lack of infantanything. Nurses called up infant care care knowledgeto see if my milk came in - hospital stay hospital staygave formula - didn’t ask not asked for lack of parentopinion. Came home he was permission informedin the hospital. hospital stay consenthealth nurse came- didn’t CHN - didn’t hospital stayneed her- Lots of need at time of timing of CHNquestions re bathtub, visit visitsimple things. Could have could have used timing of CHNused her in a few weeks. CHN later visitWe muddled our way through.6 WEEKS - THREE MONTHSPARTICIPANTI found it really lonely, lonely, feeling experience of 6A bit bored- feeding and bored wks- 3 mthschanging. A lot of waysbaby more settled, more fun settled baby experience of 6- real little person. A wks- 3 mthsperiod of time when I wasquite bitchy. Minor things irritable maternaland I’d be gone. Making emotionsdinner by then - a bit of astrain. Husband need support at task supporthad done reading and knew dinnertimewhat to expect, husband aware of spousal levelwhat to expect of awarenessPARTICIPANTHad an idea of what mom expectations re maternal roleshould be I don’t think I role of mother expectationsthought I’d be super mom.Registered in photographycourse and got me out and out of house time for selfwas wonderful. Went without infantthrough trauma with cloth diapers info lack of infantdiapers- thought I wanted needed lack of care knowledgeto be super mom. Went to knowledgestore in labour to getdiapers. Wasn’t preparedfor mixture in diapers- diaper info lack of infantgrew out of size of diaper needed care knowledgeand no one mentioned to me no one told me lack of infant- got a bit much. Phoned (diapers) care knowledgehusband117- call diaper service.Went to pampers and goteasier. Phoned diaperservice - shoulduse pampers first anddiapers later - Can talk onboth sides. She would becovered everywhere. Usedto call my girlfriend - I’mhaving a Kalhua and milkand I’m not supposed to -breast-feeding. Wentthrough a lot of guilt anddidn’t have another- butthink everyone is having alife but me. A littledevil came out - great.friend forsupportfeeling shut in,no life,houseboundsupportisolatedPARTICIPANTBefore baby could go out -harder after. Went outfirst time baby was tenleave her. Father came fora visit and first time wewent out - strange. Didn’thave much trouble adjustingweeks mygained asshe shouldsupplementand it’sSupportive familyso nice to get outhim - sometimesnt away by 1f- car and turn upmusic. so don’t stay homeif I don’t want to.Haven’t gone out as acouple yet. Would like toget my old life back now.Like to get back wifehusband deal. Sometimeshard to get outno family- lackof extendedfamily supportbreast- feedingand going out -difficult tocoordinateadjustment Okbreast- feedingsupplementingand going outsupportiveextended fantilygetting out byself and enjoytime aloneno couple timealoneadjustment-resuming oldlife as husbandand wifenap in day -fatiguegoing outextended familysupportcoordinatingoutings andbreast-feedingmaternal roleexperiencecoordinatingoutings andbreast- feedingextended familysupporttime for selfspousalrelationshipspousalrelationshipfatigue levelmonths - no family-breast-feeding hard to- used to do lots at home -I’m quite occupied.PARTICIPANTLast couple ofdaughter hasn’tmuch weight asso Doctor saidbreast— feedinanice.memberswithoutnice tnaet inneed nap118during the day - one day aweek. On go constantly.Don’t get a chance to inability to tasktotally accomplish one complete tasks accomplishmentthing. Lucky to get onething done. I’ve read somebooks on development - funto play with her, more enjoying infant experience of 6personality. wks - 3 mthsPARTICIPANTMuch similar - lucky I knowthat very good baby. Takehim all over place. Go outevery day. My husband and couple time spousalI mak a point of going out alone relationshipevery two weeks. Awkward —try not to talk about baby.I’d love to talk about desiring change insomething more stimulating. conversation spousalHe looks at me like I’m other than re relationshipsimple. I’m at the point babyof deciding to go back to decision re work employmentwork. For the sake of the issuesmarriage, need to go back.119APPENDIX K- ETHICAL REVIEW FORMSThe University of British Columbia B91-268Office of Research ServicesBEHAVIOURAL SCIENCES SCREENING COMMITTEE FOR RESEARCHAND OTHER STUDIES INVOLVING HUMAN SUBJECTSCERTIFICATE of APPROVALINVESTIGATOR: Manson Wilims, S.UBC DEPT: Social WorkINSTITUTION: North Shore Health Lions Gate HospitalTITLE: Postnatal experiences of north shore women:a north shore health research projectNUMBER: B9l-268CO-INVEST: Erickson, D.APPROVED: SEP 5 1991The protocol describing the above-named project has beenreviewed by the Committee and the experimental procedures werefound to be acceptable on ethical grounds for researchinvolving human subjects.Dr. R.D. flratley /V ‘Directo Research Servicesand Acting ChairmanTHIS CERTIFICATE OF APPROVAL IS VALID FOR THREE YEARSFROM THE ABOVE APPROVAL DATE PROVIDED THERE IS NOCHANGE IN THE EXPERIMENTAL PROCEDURES120LIONS GATE HOSPITAL RESEARCH COMMITTEECERTIFICATE OF APPROVAL1. TITLE OF STUDY: Postnatal Experiences of North Shore Women: A North ShoreHealth Research Project2. INVESTIGATOR: Nancy Hall, Ph.D.Name and Title North Shore Health3. LGH DEPT/AFFILIATION: North Shore Health4. DATE OF APPROVAL: 5LofruThe Lions Gate Hospital Research Committee has examined the protocol describing theabove—named project and consider the experimental procedures outlined by the principalinvestigator to be acceptable on ethical grounds for research involving human subjects.Chairman, Lions Gate Resear1r’Committee10121NORTH SHORE HEALTH RESEARCH COMMITTEE.CERTIFICATION OF APPROVAL‘S.1. TIThE OF STUDY“POSTNATAL EXPERIENCES OF NORTH SHORE WOMEN:A NORTH SHORE RESEARCH PROJECT”2. INVES11GATORName and Thie -Nancy Hall, Director3. DEPARTMENT/AFFILIATION:CoItuflunity Health Promotion4. DATE OF APPROVAL / 7/’/NORTH SHORE BEALTH RESEARCH COMMr1TEE has examined the protocol describingthe above—named prqect and consider the experimental procedures outlined by the principalinvestigator to be acceptable on ethical grounds for research involving human subjects.‘Ci4nan, No Shore Health Research Committee

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