Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The influence of certain variables upon the development of postpartum blues Paull, Dorothy Bowden 1975

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1975_A5_7 P39_4.pdf [ 6.13MB ]
Metadata
JSON: 831-1.0093378.json
JSON-LD: 831-1.0093378-ld.json
RDF/XML (Pretty): 831-1.0093378-rdf.xml
RDF/JSON: 831-1.0093378-rdf.json
Turtle: 831-1.0093378-turtle.txt
N-Triples: 831-1.0093378-rdf-ntriples.txt
Original Record: 831-1.0093378-source.json
Full Text
831-1.0093378-fulltext.txt
Citation
831-1.0093378.ris

Full Text

THE INFLUENCE OF CERTAIN VARIABLES UPON THE DEVELOPMENT OF POSTPARTUM BLUES by DOROTHY BOWDEN PAULL B.ScN., U n i v e r s i t y o f A l b e r t a , 1971 A THESIS SUBMITTED IN PARTIAL FULFUIiMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the Scho o l of Nursing We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1975 In presenting t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission for extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . It i s understood that copying or. p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Depa rtment The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8, Canada ABSTRACT The purpose of t h i s study was to determine the in f l u e n c e of c e r t a i n v a r i a b l e s upon the development of Post-partum Blues. Questions asked were: Do f a c t o r s r e l a t e d to maternal r o l e . c o n f l i c t i n f l u e n c e the' development of . .Postpartum B l u e s ? D o C s p e c i f i c I e n d o c r i n e .factors r e l a t e d to the menstrual c y c l e i n f l u e n c e the development of Postpartum Blues? Does a r e d u c t i o n i n the number of sleep c y c l e s i n -fluence the development of Postpartum Blues? Two semi-structured i n t e r v i e w schedules and a ques t i o n n a i r e were constructed f o l l o w i n g a review of the l i t -e rature to derive i n f o r m a t i o n p e r t i n e n t to the research prob-lem. The Beck Depression Inventory was a l s o administered. The study p o p u l a t i o n c o n s i s t e d of twenty-nine women. The study p o p u l a t i o n was r e s t r i c t e d to women who d e l i v e r e d f u l l -term, apparently healthy i n f a n t s i n one h o s p i t a l i n Vancouver. C e r t a i n other c r i t e r i a of language, demography, h e a l t h , and o b s t e t r i c s were a p p l i e d . A n a l y s i s of the data included des-c r i p t i v e a n a l y s i s , frequency t a b l e s , and the use of the c h i square t e s t . The f i n d i n g s of the study showed that 70 percent of the women experienced Postpartum Blues. The f a c t o r s r e -l a t e d to maternal r o l e c o n f l i c t , e i t h e r i f s i n g l y or i n com-b i n a t i o n , d i d not s i g n i f i c a n t l y i n f l u e n c e the development of- Postpartum Blues. Nor d i d the endocrine f a c t o r s r e l a t e d i i i to the menstrual cycle influence the development of Post-partum Blues. However, i t was found that a reduction i n sleep cycles over a four-day p e r i n a t a l period s i g n i f i c a n t l y influenced the development of Postpartum Blues. Of the wom-en who experienced a sleep deficiency, 85 percent developed Postpartum Blues. The study suggests that more attention be paid to the sleep needs of postpartum women, both i n ho s p i t a l and at home i n the community. 110 pages ACKNOWLEDGEMENTS I wish to express my appreciation to the twenty-nine postpartum women who participated i n t h i s study. I would also l i k e to thank the Director of Nursing and the nursing s t a f f of the hos p i t a l i n which part of the study was conducted. F i n a l l y , I wish to thank Assistant-Professors Helen E l f e r t and S y l v i a Holmes f o r t h e i r advice and encour-agement . v TABLE OF CONTENTS Page ACKNOWLEDGEMENTS • LIST OF TABLES v i i i CHAPTER I. INTRODUCTION TO THE STUDY 1 INTRODUCTION • • 1 STATEMENT OF THE PROBLEM 3 SIGNIFICANCE OF THE PROBLEM 4 ASSUMPTIONS OF THE STUDY 5 DEFINITIONS OF TERMS USED 5 LIMITATIONS OF THE STUDY 8 I I . REVIEW OF THE LITERATURE , . 1 0 INTRODUCTION 1 0 THE PUERPERIUM AS A DEVELOPMENTAL . CRISIS . . 1 0 THE CHANGES OCCURRING IN THE PUERPERIUM 14 ROLE THEORY CONCEPTS 1 6 SLEEP NEEDS 2 0 THE POSTPARTUM BLUES 2 2 SUMMARY 2 6 I I I . RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY 28 SELECTION OF THE STUDY GROUP 2 8 The Setting 28 The Subjects 2 9 / I n i t i a l Contact with the Subjects . . . 3 1 v i CHAPTER Pag INSTRUMENTATION • 31 H o s p i t a l Interview Schedule 32 Home Interview Schedule 3 3 The Beck Depression Inventory . . . . . 3 4 The Blues QuestionSirre . . PRE-TEST 36 THE INTERVIEWING PROCEDURE 37 I n t e r a c t i o n w i t h the Study Group . . . 3 8 STATISTICAL ANALYSIS 40 SUMMARY 41 IV. ANALYSIS OP THE DATA 42 CHARACTERISTICS OF THE STUDY POPULATION 42 ASSESSMENT OF THE INCIDENCE OF POSTPARTUM BLUES 51 INCIDENCE OF STRESS ITEMS RELATED. TO MATERNAL ROLE CONFLICT 57 INCIDENCE OF SPECIFIC ENDOCRINE FACTORS RELATED TO THE MENSTRUAL CYCLE 7 5 INCIDENCE OF SLEEP DEFICIENCY' .. .. . . . .77 SUMMARY 80 V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS . 81 SUMMARY '81 CONCLUSIONS . -83 RECOMMENDATIONS 87 BIBLIOGRAPHY (90 APPENDICES . 9 5 A. Consent Form 96 B. Instruments Used i n the Study . . . . . 98 LIST OF TABLES TABLE Page 1. Percentage D i s t r i b u t i o n of Study-P o p u l a t i o n by Age . . 43 2. Percentage D i s t r i b u t i o n of Study P o p u l a t i o n by B i r t h p l a c e 43 3. Percentage D i s t r i b u t i o n of Study P o p u l a t i o n by Length of Time L i v e d With Father of the I n f a n t 44 4. Percentage D i s t r i b u t i o n of the Study P o p u l a t i o n by Highest E d u c a t i o n a l Attainment 45 5. P a r i t y by Incidence of Postpartum Blues In the Study Sample 46 6. P r o x i m i t y of Confinement Date to . r Estimated Confinement Date by Incidence of Postpartum Blues i n the Study P o p u l a t i o n 4? 7. D u r a t i o n of Labour f o r P r i m i p a r a s and M u l t i p a r a s by Incidence of Post-partum Blues i n the Study P o p u l a t i o n . . 48 • 8 . B i r t h Weight of I n f a n t s by Incidence of Postpartum Blues i n the Study P o p u l a t i o n ,51. 9. Incidence of S t r e s s Items Related to Maternal C o n f l i c t — I n a d e q u a t e Pre-p a r a t i o n f o r Maternal R o l e — B y Incidence of Postpartum Blues i n the Study P o p u l a t i o n . . . . . . . . . . 6l 10. Incidence of S t r e s s Items R e l a t e d to Maternal Role C o n f l i c t — A n x i e t y About Maternal R o l e — b y Incidence of Post-partum Blues i n the Study P o p u l a t i o n . . 66 11. Incidence of S t r e s s Items Re l a t e d to Maternal Role C o n f l i c t — C o n f l i c t with Other Roles and D i s t r e s s i n g Events During the Puerperium—by Incidence of Postpartum Blues i n the Study P o p u l a t i o n 70 v i i i i x TABLE Page 12. S i g n i f i c a n t Help During Labour by Incidence of Postpartum Blues i n the Study P o p u l a t i o n . . . . . 71 13. S i g n i f i c a n t Help During Labour ; by Incidence of Postpartum Blues i n the Study P o p u l a t i o n 72' 14. Incidence of S t r e s s Items R e l a t e d to Maternal Role C o n f l i c t — E m o -t i o n a l and C o g n i t i v e Changes— By Incidence of Postpartum ' Blues i n the Study P o p u l a t i o n . . . . . 73 • 15. Incidence of Menstrual Cycle D i f f i -c u l t i e s A c c o r d i n g to Incidence of Postpartum Blues i n the Study P o p u l a t i o n 77 CHAPTER I . INTRODUCTION TO THE STUDY I . INTRODUCTION The r a p i d socio-economic advances of t h i s century have caused changes which increase the s t r e s s that c h i l d -bearing places upon women. Some of the changes i n c l u d e g r e a t e r u r b a n i z a t i o n , a s h i f t from the extended f a m i l y s t r u c t u r e to that of the nuc l e a r f a m i l y , smaller f a m i l i e s , and the changing s t a t u s of women. C h i l d b e a r i n g has been des-c r i b e d as a developmental c r i s i s , a pe r i o d i n which "there i s marked p h y s i c a l , p s y c h o l o g i c a l , and s o c i a l change th a t i s c h a r a c t e r i z e d by common 'disturbances* i n thought and f e e l i n g . " 1 Although medical science has g r e a t l y i n f l u e n c e d the b i o l o g i c a l outcome of c h i l d b e a r i n g , the emotional out-2 come of c h i l d b e a r i n g has not shown such favourable progress. Postpartum depression has been con s i d e r a b l y s t u d i e d i n psy-xHoward J . Parad, "Part I I . Common Ma t u r a t i o n a l and S i t u a t i o n a l C r i s e s , " C r i s i s I n t e r v e n t i o n t Selected Read-ings, ed. Howard J . Parad (New York: Family Service A s s o c i a -t i o n of America, 1965), p. 73. 2 A.A. Baker, P s y c h i a t r i c Disorders i n O b s t e t r i c s ( S a l i s b u r y : The S a l i s b u r y Press L t d . , 1967), pp. 34-44: James Alexander Hamilton, Postpartum P s y c h i a t r i c Problems (S a i n t Louis: The C.V. Mosby Company, 1962), pp. 107-111: F r e d e r i c k T. Melges, "Postpartum P s y c h i a t r i c Syndromes," Psychosomatic Medicine, XXX.V (January-February. 1968), 955 B r i c e P i t t , " ' A t y p i c a l ' Depression F o l l o w i n g C h i l d b i r t h , " B r i t i s h J o u r n a l of P s y c h i a t r y . CXIV (1968), 1325. 1 2 c h i a t r i c hospitals. However, the much milder form of post-partum depression, known as the Postpartum Blues, has r e c e i -ved l i t t l e attention i n the l i t e r a t u r e . While the incidence rate of Postpartum Blues has been estimated as high as eighty percent, the syndrome i s 3 frequently referred to as a normal sequel to c h i l d b i r t h . In f a c t, P i t t described the syndrome as t r i v i a l and f l e e t -ing. Yalom also concurred with t h i s viewpoint, as did Joseph and Peck.^ On the other hand, one study suggests that more than h a l f of childbearing women showed subjective evidence of anxiety and or depression.^ It has been the writer's experience as a midwife that the Postpartum Blues can be a very d i s t r e s s i n g episode :which i s long remembered by some women who experience the syndrome. In spite of the transit o r y nature of the Postpartum Blues, there i s evidence that a h i s t o r y of Postpartum Blues i s frequently a fa c t o r i n the more severe and longer-lasting postpartum depression.^ "'Hamilton, l o c . c i t . 4 Brice P i t t , "Maternity Blues," B r i t i s h Journal of  Psychiatry, CXX (1973). 432-433. ^ I r v i n Yalom and Others, "'Postpartum Blues' Syn-drome," Archives of General Psychiatry. XVIII (January, 1968), 26« Sharon Serena Joseph and Rana Limbo Peck, "Postpartum Needs of the Family," Maternity Nursing Today, ed. Joy P. Clausen (New Yorkt McGraw H i l l Book Company, 1973)# P« 557. ^Francis J . Kane, Jnr. and Others, "Emotional and Cognitive Disturbance i n the Early Puerperium," B r i t i s h  Journal of Psychiatry. CXIV (January, 1968), 101. ^Melges, op. c i t . , p. 98? P i t t , "'Atypical' De-pression Following C h i l d b i r t h , " p. 1332; Yalom, l o c . c i t . The curre n t medical and n u r s i n g l i t e r a t u r e d e a l -i n g w i t h Postpartum Blues i n d i c a t e s the importance of a s s i s t -i n g women to meet t h e i r emotional needs. A study by Gordon, Kapostins, and Gordon revealed that a s s i s t a n c e from nurses and doctors i n overcoming emotional d i f f i c u l t i e s experienced i n the puerperium had extremely b e n e f i c i a l r e s u l t s . L i k e -wise, Auerback urged that nurses and doctors lend emotional support to postpartum women to help them cope with the new and changing demands of parenthood.^ Yet, there i s l i t t l e agreement i n the l i t e r a t u r e as to the cause of these emotional d i f f i c u l t i e s . Many d i f f -erent f a c t o r s have been a t t r i b u t e d to Postpartum Blues, but 1 0 there i s no.firm evidence p o i n t i n g to common f a c t o r s . I t was f e l t t hat f u r t h e r study of r e l a t e d f a c t o r s to the develop ment of Postpartum Blues could provide stronger g u i d e l i n e s f o r people i n v o l v e d i n the care of postpartum women. I I . STATEMENT OF THE PROBLEM i. The purpose of t h i s d e s c r i p t i v e study was to deters mine the i n f l u e n c e of c e r t a i n v a r i a b l e s upon the development of Postpartum Blues. The f o l l o w i n g . q u e s t i o n s provided the focus of the "Richard E. Gordon, E l i E. Kapostins, and Katherine K. Gordon, "Factors i n Postpartum Adjustment," O b s t e t r i c s and  Gynecology, XXV (February, 1965), 158-166. ^ A l i n e G. Auerback, "Meeting the Needs of New Moth-ers, " C h i l d and Family, VI (Winter, 196?), 10-13. *°Yalom, op. c i t . , pp. 16-2?; Gordon, l o c . c i t . ; P i t t , "Maternity Blues," p. 431. 4 study: (1) Do f a c t o r s r e l a t e d to maternal r o l e c o n f l i c t i n f l u e n c e the development of Postpartum Blues? (2) Do s p e c i f i c endocrine f a c t o r s r e l a t e d to the menstrual c y c l e i n f l u e n c e the development of Postpartum Blues? (3) Does a r e d u c t i o n i n the number of s l e e p c y c l e s i n f l u e n c e the develop-ment of Postpartum Blues? I I I . SIGNIFICANCE OF THE PROBLEM Postpartum Blues, a c c o r d i n g to Riker , "gets scanty a t t e n t i o n from m e d i c a l r e s e a r c h e r s , so the exact causes remain o b s c u r e . " 1 1 In Canada, as elsewhere, nurses are i n -v o l v e d i n the care of postpartum women. In a study c a r r i e d out i n Calgary, A l b e r t a , Jordan r e p o r t e d t h a t more women i n a f a m i l y - c e n t r e d m a t e r n i t y care group i n h o s p i t a l sought h e l p w i t h p s y c h o l o g i c a l problems from the nurse than from the 12 d o c t o r . Moreover, her f i n d i n g s showed t h a t new mothers a t home i n the community wished that they c o u l d c a l l upon a pred e s i g n a t e d nurse f o r assurance and a d v i c e . Joseph and Peck noted t h a t the developmental c r i s i s of c h i l d - b e a r i n g "provides a unique o p p o r t u n i t y f o r the nurse 13 to i n t e r v e n e . " J The c r i s i s i n t e r v e n e r i s d e f i n e d by Parad as "one who,enters the problem s i t u a t i o n and h e l p s those Audrey Rik e r , "New Parent B l u e s , " C h i l d and Family, VI ( S p r i n g , 1967), 14. 12 Dorreen Jordan, An E v a l u a t i o n of a Family-Centred M a t e r n i t y Care H o s p i t a l Program (unpublished r e s e a r c h pro-j e c t , Calgary, 1971), pp. 264-66. 13 ^Joseph and Peck, op. c i t . , p. 554. 5 i n v o l v e d m o b i l i z e t h e i r s t r e n g t h s i n order to move out of the c r i s i s or c r i s i s - l i k e s t a t e i n a manner which i s a c c e p t -a b l e to those i n v o l v e d . " C l e a r l y , then, the nurse i s i n an i d e a l p o s i t i o n to a s s i s t postpartum women to reduce the s t r e s s e s o f t h i s p e r i o d . The nurse as i n t e r v e n e r , must understand the f a c t o r s which cause the d i s t r e s s of postpartum b l u e s . F u r t h e r study of i m p l i c a t e d v a r i a b l e s would i n c r e a s e the n u r s e ' s understanding of the Postpartum Blues syndrome. Thus postpartum women may be f u r t h e r a s s i s t e d to minimize the e f f e c t of the snydrome or t o maximize t h e i r r e s o u r c e s to cope with i t . IV. ASSUMPTIONS OF THE STUDY The study was based on the assumption t h a t : (1) Postpartum Blues i s an e n t i t y t h a t can be d i s t i n g u i s h e d from other forms of d e p r e s s i o n by (a) i t s d u r a t i o n , and (b) i t s degree of s e v e r i t y , a c c o r d i n g t o the Beck Depression Inven-t o r y and the s e l f - d e c l a r e d statements of the respondents. (2) That each s u b j e c t i n t e r v i e w e d i s s u f f i c i e n t l y c o g n i z a n t of her own f e e l i n g s and i n t e r p e r s o n a l behaviour t h a t she can s e l e c t from the i n t e r v i e w q u e s t i o n n a i r e s the statement most a p p r o p r i a t e to her f e e l i n g s and behaviour. V. DEFINITIONS OF TERMS USED For the purpose of t h i s study the f o l l o w i n g terms are d e f i n e d . Parad, op. c i t . , p. 2. 6 Apgar Score T h i s s c o r i n g system was devised to enable a c l i n -i c a l e v a l u a t i o n to be made of a baby's c o n d i t i o n a t one minute a f t e r b i r t h . The f i v e v i t a l s i g n s , shown i n Table 1, are each scored 0; 1, or 2, the t o t a l of which may be 1-10 (poor t o ex-c e l l e n t s t a t u s ) . Table I1* Apgar Scoring.System S i g n 0 1 2 Heart r a t e Not d e t e c t -a b l e Slow (below 100) Over-100 R e s p i r a t o r y Absent e f f o r t Slow, i r r e g -u l a r Good, c r y i n g Muscle tone F l a c c i d Some f l e x i o n of e x t r e m i t i e s A c t i v e motion R e f l e x i r r i t a -b i l i t y No 'response .1. response to s l a p on s o l e of f o o t Grimace Cry 2. response No response to c a t h e t e r i n n o s t r i l ( t e s t -ed a f t e r oro-pharynx i s c l e a r ) Grimace Cough or '.i sneeze C o l o r Blue, p a l e Body pink, e x t r e m i t i e s blue Completely pink 1 5 v Z i e g e l , Erna and C a r o l y n C. Van Blarcom. Obstet-r i c a l N ursing. New York: The Macmillan Company, 1972. pp. 3 9 2 - 9 3 . ' F F 7 Childbearing Process The period frpm conception unt i l the reproductive organs have returned to normal. Confl ict with Maternal Role The d i f f i cu l ty experienced in the assumption of the new responsibi l i t ies and feelings of motherhood and their integration with existing roles and interests. Dysmenorrhoea Painful menstruation. Early Menarche Menarche refers to the appearance of the f i r s t menstrual period, usually occurring between the age of eleven and f i f teen years. Early menarche i s considered to be under the age of eleven years. Multipara A woman who has experienced two or more labours in the bearing of viable infants. Postpartum Blues, Postpartum Blues Syndrome These terms are used interchangeably and are often referred to in the l i terature as Postpartum ''Blues " or ^Post-partum Blues" syndrome. The terms refer to the transitory mild depression occurring within the postpartum period. Premenstrual Tension A state of depression or anxiety which may occur several days before menstruation. 8 P r i m i p a r a A woman who has experienced one l a b o u r i n - t h e bear-i n g of a v i a b l e i n f a n t or v i a b l e i n f a n t s . Puerperium, Postpartum P e r i o d The terms are used i n t e r c h a n g e a b l y and r e f e r to the six-week p e r i o d f o l l o w i n g c h i l d b i r t h , d u r i n g which the r e p r o d u c t i v e organs r e t u r n to t h e i r p r e g r a v i d s t a t e . S o c i a l D e s i r a b i l i t y A systematic way of answering q u e s t i o n s about one-s e l f i n a s o c i a l l y approved manner r a t h e r than i n r e l a t i o n to the content of the q u e s t i o n . VI. LIMITATIONS OF THE STUDY Recognized l i m i t a t i o n s of the study were as f o l l -ows: (1) The s m a l l sample s i z e of the p o p u l a t i o n r e s i d e n t i n the G r eater Vancouver a r e a and s e l e c t e d from one hos-p i t a l r e s t r i c t e d the f i n d i n g s of the study to t h i s sample only. Because of t h i s , the f i n d i n g s cannot be g e n e r a l i z e d to other p o p u l a t i o n s . (2) The study was conducted d u r i n g the months of December and January, a. time of f e s t i v i t y , which may have caused the sample to be u n r e p r e s e n t a t i v e of the p o p u l a t i o n a t other times of the year. (3) The data-g a t h e r i n g instruments used i n the study, with the e x c e p t i o n of a Depression Inventory, were r e l a t i v e l y u n t e s t e d . There-f o r e , the degree of v a l i d i t y and r e l i a b i l i t y of the i n s t r u -mentation were not e s t a b l i s h e d . A l s o , the p o s s i b i l i t y of s o c i a l d e s i r a b i l i t y b i a s i n g the f i n d i n g s of the study cannot be ruled out because a test f o r s o c i a l d e s i r a b i l i t y was not administered. CHAPTER I I . REVIEW OF THE LITERATURE I. INTRODUCTION Although reference had been made to Postpartum Blues i n the nineteenth century, i t was not u n t i l 1952 tha t the syndrome aroused s u f f i c i e n t i n t e r e s t f o r study. 1 Yet, the s t u d i e s that have been done are meagre and l a c k d e f i n i -t i v e answers t o the syndrome. In the l a s t twenty years a number of small s t u d i e s were reported i n the United States of America and i n Europe. However, apart from these, no major s t u d i e s appeared i n the a c c e s s i b l e l i t e r a t u r e . The l i t e r a t u r e reviewed here discusses theory and research under the f i v e main headings of the puerperium as a developmental c r i s i s ; the changes occuring i n the puerperium; some concepts of r o l e theory; sleep needs; and the Postpartum Blue s" syndrome. I I . THE PUERPERIUM AS A DEVELOPMENTAL CRISIS • The puerperium i s g e n e r a l l y accepted as the p e r i o d between the t e r m i n a t i o n of labour and the r e t u r n of the reproductive organs to t h e i r normal c o n d i t i o n , u s u a l l y de-i James Alexander Hamilton, Postpartum P s y c h i a t r i c  Problems (Sa i n t Louis: The C.V. Mosby Company, 1962), p. 108. 10 f i n e d as forty-two days. T h i s i s a p e r i o d i n which the young woman i s c a l l e d upon to adapt r a p i d l y to enormous b i o -p h y s i c a l , p s y c h o s o c i a l , and environmental changes. T h e r e f o r e , the puerperium may be viewed as a developmental stage, d u r i n g which time an i n d i v i d u a l i s much more s u s c e p t i b l e to s t r e s s . Regarding the woman as more v u l n e r a b l e i n the puerperium, H i g h l e y noted t h a t an e f f e c t i v e a d a p t i v e process i s r e q u i r e d i n o rder t o meet the marked changes i n the s t a t u s and l i f e -2 s t y l e c r e a t e d by c h i l d b e a r i n g . , F u r t h e r s t o t h i s , Kane regarded the puerperium as a developmental c r i s i s , a viewpoint a l s o supported by Robisch-3 on and Scott.- 1 Parad commented t h a t developmental c r i s e s are f r e q u e n t l y seen as "normal" c r i s e s because the experiences are common to a l l people i n t h a t p a r t i c u l a r stage o f develop-er ment. During a developmental c r i s i s there are tasks which must be e f f e c t i v e l y accomplished i n order t h a t the next develop-mental stage may r e a l i z e i t s f u l l p o t e n t i a l f o r f u r t h e r growth and development.^ The tasks to be achieved i n the puerperium ''Betty Highely, "Maternal Role I d e n t i t y , " D e f i n i n g  C l i n i c a l Content, V o l . 1 (Boulders Western I n t e r s t a t e Comm-i s s i o n f o r Higher Education, 196?), p. 32. -^Francis J . Kane, J n r . and Others, "Emotional and C o g n i t i v e Disturbance i n the E a r l y Puerperium," B r i t i s h J o u r - n a l of P s y c h i a t r y , XCIV (January, 1968), 99: P a u l e t t e Robis-chon and Diane S c o t t , "Role Theory and i t s A p p l i c a t i o n i n Family Nursing," Nursing Outlook XXVII ( J u l y , 1969), 5^. h Howard J . Parad, "Part I I . Common M a t u r a t i o n a l and S i t u a t i o n a l C r i s e s , " C r i s i s I n t e r v e n t i o n : S e l e c t e d Readings, ed. Howard J . Parad (New York: Family S e r v i c e A s s o c i a t i o n o f America, 1965)1 p. 73. I b i d . 12 f a l l i n t o the b i o p h y s i c a l , p s y c h o s o c i a l , and environmental c a t e g o r i e s p r e v i o u s l y mentioned, and to be discussed under the changes occuring i n the puerperium. Should these tasks not be adequately achieved, then some degree of disturbance ensues. S t a t i n g t h i s another way, Caplan s a i d that a c r i s i s may occur when a person i s faced w i t h a problem he cannot s o l v e . According to Caplan, a person's a b i l i t y to withstand a c r i s i s depends on three f a c t o r s : (1) the capa-c i t y to deal with a n x i e t y and s t r e s s , and to maintain e q u i l -ibrium, ( 2 ) the c a p a c i t y to e f f e c t i v e l y solve problems, based on r e a l i t y , and ( 3 ) the r e p e r t o i r e of e f f i c i e n t coping mech-anisms which f a c i l i t a t e the maintenance of e q u i l i b r i u m . Parad defined a c r i s i s as f o l l o w s : a hazardous circumstance or s t r e s s which c o n s t i -tutes a t h r e a t f o r i n d i v i d u a l s and f a m i l i e s because (a) the s t r e s s jeopardized important l i f e goals such as health-, •;/security, and a f f ect.ional t i e s , and (b) -the problems posed cannot be immediately solved by the immediate resources of the ego, thereby generating a high l e v e l of u n c e r t a i n t y , a n x i e t y , and tens i o n . 8 A study by LeMasters, i n which f o r t y - s i x middle c l a s s couples p a r t i c i p a t e d , found that new parenthood con-s t i t u t e s a c r i s i s s i t u a t i o n f o r 83 percent of the sample.^ ^Gerald Caplan, An Approach to Community Mental  Health (New York: Grune & S t r a t t o n , Inc., 1961), p. 18. 7 I b i d . , pp. 38-41. 8 Howard J . Parad, "Preventative Casework: Problems and I m p l i c a t i o n s , " C r i s i s I n t e r v e n t i o n : Selected Readings, ed. Howard J . Parad (New York: Family Service A s s o c i a t i o n of America, 1 9 6 5 ) , pp. 288-89. Q E.E. LeMasters, "Parenthood as a C r i s i s , " C r i s i s  I n t e r v e n t i o n : S elected Readings, ed. Howard J . Parad (New York: Family S e r v i c e A s s o c i a t i o n of America, 1965), p. 111. LeMasters p o i n t e d out that the upheaval o c c u r r i n g i n the f a m i l y as a s o c i a l system, causes r o l e s to he r e d e s i g n a t e d , s t a t u s p o s i t i o n s to be s h i f t e d , v a l u e s to be r e a d j u s t e d , and new ways to be found f o r meeting needs. Yoshioka sugg-ested t h a t the l i f e experiences of some women are l i m i t e d and t h a t t h e i r r e s o u r c e s f o r coping with c r i s e s are inade-quate. 1 0 I f the s t r e s s e s of a c r i s i s are p o o r l y coped with, Rapaport assumed t h a t o l d p s y c h o l o g i c a l c o n f l i c t s may be r e -v i v e d or new c o n f l i c t s may appear, e i t h e r of which reduce the s t a t e of mental h e a l t h . 1 1 On the other hand, Rapaport s t a t e d , i f the c r i s i s i s well-managed, then the i n d i v i d u a l w i l l g a i n i n m a turation or development. I t was a l s o noted t h a t i n d i v i d u a l s i n c r i s i s s i t u a t i o n s are more amenable to 12 t h e r a p e u t i c c o u n s e l l i n g . In s u p p o r t i n g t h i s view, Bloom r e l a t e d t h a t a s s i s t -i n g i n d i v u d u a l s when they are i n c r i s i s s i t u a t i o n s can s i g -13 n i f i c a n t l y improve t h e i r mental h e a l t h . J Ruth Yoshioka, "Maturation C r i s i s of Pregnancy," M a t u r a t i o n a l C r i s i s of C h i l d b e a r i n g . ed. Ann C l a r k (Hono-l u l u ! U n i v e r s i t y of Hawaii, 1971), p. 16. 1 : LRhona Rapaport, "Normal C r i s e s , Family S t r u c t u r e , and Mental H e a l t h , " C r i s i s I n t e r v e n t i o n s S e l e c t e d Readings, ed. Howard J . Parad (New York: Family S e r v i c e A s s o c i a t i o n of America, 1965), P« 75 1 2 I b i d . 1 -^Bernard L. Bloom, " D e f i n i t i o n a l Aspects of the C r i s i s Concept," C r i s i s I n t e r v e n t i o n s S e l e c t e d Readings, ed. Howard J . Parad (New York: Family S e r v i c e A s s o c i a t i o n of America, 1965). P. 303. 14 I I I . THE CHANGES OCCURRING IN THE PUERPERIUM B i o p h y s i c a l Changes The b i o p h y s i c a l changes o c c u r r i n g i n the puerper-^ ium are enormous. With the b i r t h of the baby there i s immed-i a t e r e l e a s e of pre s s u r e on crowded i n t e r n a l organs, as w e l l as the i n s t a n t weight l o s s of the baby. By the end of one week the t o t a l weight l o s s experienced by the postpartum woman i s about twenty pounds. W i t h i n twenty-four hours o f d e l -i v e r y , the additional ' . " 36 "percent^blood volume,, wfiieh jeyolved d u r i n g pregnancy, i s e l i m i n a t e d . The puerperium i s a l s o the time d u r i n g which the g e n e r a t i v e organs r e t u r n to t h e i r p r e g r a v i d s t a t e . Thus, the weight of the uterus, which i s two pounds f o l l o w i n g labour, i s reduced to two and one h a l f ounces by 1 the end of s i x weeks. J L o c h i a , the discharge from the uterus a f t e r b i r t h , c ontinues f o r ten to f i f t e e n days. Other changes t a k i n g p l a c e i n the puerperium are dramatic endocrine changes. L a c t a t i o n i s i n i t i a t e d by the hormone p r o l a c t i n , which i s produced by the a n t e r i o r p i t u i t -a r y g l and. The pregnancy hormones, the oestrogens and proges-terone, are produced by the p l a c e n t a i n i n c r e a s i n g amounts dur-i n g pregnancy. Immediately p r i o r t o c h i l d b i r t h , the p r o d u c t i o n of oestrogens i s t e n - f o l d the maximal pre-pregnancy l e v e l , Reva Rubin, "Puerperal Change," Nursing Outlook, IX (December, 1 9 6 1 ) , 7 5 3 . 1 ^ M a r g a r e t P. Myles, A Textbook f o r Midwives, ( E d i n -gurgh: E. & S. L i v i n g s t o n e L t d . , 1 9 6 1 ) , p. 4 6 3 . l 6 w h ile that of progesterone i s increased twenty-five times. With the ex p u l s i o n of the pl a c e n t a there i s an abrupt f a l l i n the l e v e l s of these hormones and the l e v e l s remain very 17 low u n t i l the menstrual c y c l e i s resumed. ' The e f f e c t of the sudden changes i n these hormone l e v e l s has ofte n been a t t r i b u t e d , although not proven, to the l a b i l i t y " o f mood 18 observed i n postpartum women. Psyc h o s o c i a l and Environmental Changes The l a b i l i t y of mood i s shown by sudden swings from expressions of happiness to those' of sadness and by an over-19 s e n s i t i v i t y to the remarks and a c t i o n s of others. As w e l l as l a b i l i t y of mood, a s t a t e of m i l d confusion has of t e n 20 been reported as f r e q u e n t l y o c c u r r i n g i n postpartum women. The changes i n the r o l e s of postpartum women are considerable and w i l l be discussed s e p e r a t e l y . Environmental changes are a l s o marked. The l i t e r a t u r e commonly c i t e d d i s r u p t i o n i n the a c t i v i t i e s of d a i l y l i v i n g i n c u r r e d by the h o s p i t a l stay. The changes r e q u i r e d i n a d j u s t i n g to h o s p i t a l r o u t i n e s are •^Hamilton, op. c i t . , pp. 112-13. 1 7 I b i d . , p. 113. 1 R A.A. Baker, P s y c h i a t r i c Disorders i n O b s t e t r i c s ( S a l i s b u r y ! The S a l i s b u r y Press L t d . , 1967), p. 39; Kane, op. c i t . , p. 101; A.A. Robin, "The P s y c h o l o g i c a l Changes of Normal P a r t u r i t i o n , " P s y c h i a t r i c Quarterly. XXXVI (January, 1962), 139; I r v i n Yalom and Others, "'Postpartum Blues' Syn-drome," Archives of General P s y c h i a t r y , XVIII (January, 1968), 16. 19 ^Robin, l o c . c i t . 20 Hamilton, op. c i t . , p. 109; Kane, op. c i t . , ;p. 101; Robin, op. c i t . , p. 147. u s u a l l y q u i t e e x a c t i n g . In a d d i t i o n , postpartum women must contend with h o s p i t a l n o i s e s , i n t e r r u p t i o n of sl e e p , and phy-s i c a l d i s c o m f o r t s . F o l l o w i n g the h o s p i t a l stay the mother's r e t u r n home with a new f a m i l y member c o n s t i t u t e s f u r t h e r changes. For the mother with her f i r s t baby the a r r i v a l home means t h a t she must now assume the r e s p o n s i b i l i t y of meeting the baby's needs when she may be u n c e r t a i n of what those needs are or how they can be met. For the mother t a k i n g a baby to a home i n which there i s a l r e a d y a c h i l d or c h i l d r e n , she must not only care f o r the new baby but meet the needs of the o l d e r o f f s p r i n g i n t h e i r adjustment to a new s i b l i n g . In e i t h e r case, the mother must be prepared to reduce her u s u a l amount of s l e e p and r e s t , as w e l l as cope with any other changes i n -vol v e d i n adding a new member to the f a m i l y u n i t . IV. ROLE THEORY CONCEPTS Role theory has been d e s c r i b e d by Wrightsman as" an 21 o r i e n t a t i o n toward i n t e r p e r s o n a l behaviour. Wrightsman agreed with S a r b i n t h a t r o l e theory regards human conduct as 22 the product of the i n t e r a c t i o n of s e l f and r o l e . The term r o l e i s g e n e r a l l y d e f i n e d as "the s e t of behaviours or func-t i o n s a p p r o p r i a t e f o r a person h o l d i n g a p a r t i c u l a r p o s i t i o n w i t h i n a p a r t i c u l a r s o c i a l context." 2-^ Rubin concurred w i t h Lawrence S. Wrightsman, S o c i a l Psychology i n the  Sev e n t i e s (Montereys Brooks/Cole P u b l i s h i n g Company, 1972), P. 23. 2 2 I b i d . I b i d . Linton i n defining a p o s i t i o n as "the achieved or ascribed s o c i a l status r e s u l t i n g from the performed or anticipated a c t i v i t i e s of persons enacting s p e c i f i c roles, a cognitive organization of r i g h t s and obligations i n a s o c i a l l y defined ok. s i t u a t i o n . " Thus, every person occupies a number of p o s i -tions and enacts a number of r o l e s . Robischon and Scott defined a role as a pattern of needs and goals, b e l i e f s , feelings, values, attitudes, and actions, expected by the community, which should be c h a r a c t e r i s t i c of the occupant of 2 5 a p o s i t i o n . J Accordingly, role behaviours are learned, con-ditioned, and reinforced. That poorly defined roles may lead to role c o n f l i c t i s noted by Robischon and many other researchers. Other factors leading to role c o n f l i c t are con-f l i c t i n g pressures, complexity of ro l e s to be learned, and 2.f> difference between role and emotional needs. Robischon em-phasized that r o l e c o n f l i c t i s appropriate at times and that the anxiety and tension aroused may be used to f a c i l i t a t e healthy .'adaptation. 2 7 The goal i n the process of role-taking i s i d e n t i t y . Rubin, concurring with Erickson, described an established i d e n t i t y as a sense of being i n a r o l e , a sense of ease about ^Reva Rubin, "Attainment of Maternal Role. Part 1, Processes," N u r s i n g Research, XVI (Summer, 1967). 237. 2^Robischon and Scott, op. c i t . , p. 52 2 6 I b i d . , p. 53. 2 7 I b i d . , p. 54. 18 the past and the f u t u r e . Rubin reported a study to d e t e r -29 mine how the maternal r o l e i d e n t i t y i s achieved. 7 She / b u i l t 'upon Mead's concept of " T a k i n g - i n - t h e - r o l e - o f - o t h e r " and Sarbin's concept of "adopting the ways of others" t o describe the attainment of the maternal r o l e . According to Rubin there are three dimensions to becoming a mother; the s e l f - c o n c e p t or s e l f system as object, the process as>mode, and the model or r e f e r r a n t as the sub-j e c t . - * 0 The data obtained by the study of the s e l f system Vwere" c l a s s i f ie.d. i n t o - t h r e e c a t e g o r i e s as the i d e a l image, .the s e l f image, and the body image. Rubin s t a t e d that the t a k i n g i n of the maternal r o l e i s a continuous process c a r r i e d out by a s e r i e s of o p e r a t i o n s . 3 1 These operations f i t i n t o f i v e c a t e g o r i e s which ares mimicry, r o l e - p l a y , fantasy, i n t r o -j e c t i o n - p r o j e c t i o n - r e j e c t i o n , and g r i e f work. The f i v e oper-a t i o n s occur i n s e q u e n t i a l order and vary i n the time taken f o r each. Rubin c l a s s i f i e d the f i v e operations i n t o the f o l l o w i n g phases: (1) the "taking-on" phase, (2) the " t a k i n g -i n " phase, and (3) the " l e t t i n g - g o " phase. The taking-on phase i n c l u d e s the operations of mimicry and r o l e p l a y . Mimi-c r y r e f e r s to the adapting of behaviours, such as dress, to 28 Rubin, "Attainment of Maternal Role. P a r t 1. Pro-cesses," i b i d . , p. 243. 29 30 I b i d . , pp. 237-45. I b i d . , p. 240. 3 1 I b i d . , pp. 240-45. those which symbolize the status the woman wishes to a t t a i n . Although s i m i l a r to mimicry, role play symbolizes and acts ou,t the expected behaviour. The taking-in phase involves the operation of fantasy and the operation of i n t r o j e c t i o n -projection-reject ion. Fantasy d i f f e r s from r o l e play i n that there i s no acting-out. Wishes, fears, day-dreams, and dreams involve the s e l f . The baby i s seen as "an.extension 32 of s e l f , the wished-for s e l f , and the dreaded-self."-^ The fantasy operation promotes a c t i v i t y such as planning, e f f o r t s to be r e a l i s t i c , and e f f o r t s to gain more information by which to v e r i f y or negate the fantasy material. The i n t r o -j e c t i o n - p r o j e c t i o n - r e j e c t i o n operation i s s i m i l a r to mimicry but the d i s t i n c t i o n i s that i t begins with s e l f ( i n t r o j e c t i o n ) , moves to f i n d a role model from without (projection), and com-pares the behaviour of the role model with the behaviour being experienced. In the event that there i s poor correspondence, that role model i s rejected and another sought. Rubin des-cribed the operation i n the letting-go phase as g r i e f work. Grief work i s the letting-go of former i d e n t i t i e s which are associated with roles incompatible with the anticipated new r o l e . F i n a l l y , Rubin examined the model i n r e l a t i o n to attainment of maternal role.33 <phe study showed that a l l of -^Ibid., p. 242. -'-'Reva Rubin, "Attainment of Maternal Role, P,art 11, Models and Referrants." Nursing Research. XVI ( F a l l , 1967), 343-346. 20 the subjects began with t h e i r own mothers, or revived mem-ories of t h e i r mothers, f o r each phase of role attainment. The mothers were then replaced by peers i n p a r a l l e l or higher stages toward role attainment. I t was found that primiparas mostly chose peer models from the extended family. The g r i e f work i n r e l a t i o n to the subject's mothers involved longing 34 for and separation from comforting maternal care. V. SLEEP NEEDS During the l a s t twenty years considerable research has been 'carried out on the many aspects of sleep. Conse-quently, sleep needs have become more predictable. Research into the nature of sleep has shown that sleep occurs i n cycles of approximately eighty-five to ninety minutes i n the young adult.35 During a t o t a l of about seven and one-half hours sleep the average adult,has about four to s i x sleep cycles per n i g h t . A sleep cycle consists of two phases, the f i r s t of which Is termed non-rapid eye movement (NREM) sleep, and the second of which i s termed rapid eye movement (REM) sleep. NREM sleep consists of four stages. Stage 1 i s a l i g h t sleep from which a person may be, e a s i l y woken. The sleep increases i n depth with each stage and i s deepest i n stage 4. An adult goes from wakefulness to stage 1 when he 3 ^ I b i d . , p. 344. 35 -'-'Nathaniel Kleitman, Sleep and Wakefulness (Chicago: University of Chicago Press, 1963), p. 112. -^Susanna Lee Garner and Pamela M i t c h e l l , "Comfort and Sleep," Concepts Basic to Nursing (McGraw H i l l Book Company, 1973), p. 438. 21 f a l l s asleep and then proceeds to stage 2, then to stage 3, and then to Stage 4 over a period of around twenty to t h i r t y minutes. The i n d i v i d u a l remains i n stage 4 f o r around t h i r t y minutes, a f t e r which time he moves back through the stages to stage 1 or 2. The i n d i v i d u a l then moves into a period of REM sleep which may l a s t f o r ten to t h i r t y minutes. At the end of the REM period the i n d i v i d u a l progresses from stage 1 or 2 to stages 3 and 4, thereby beginning another sleep cycle. 3''' The character of the sleep cycle changes with the length of time the i n d i v i d u a l remains asleep. The majority of stage 3 and 4 sleep occurs during the f i r s t h a l f of the night's sleep while the majority of REM sleep occurs i n the l a s t h a l f of the night's s l e e p . J If, however, an i n d i v i d u a l i s awakened, the sleep cycle i s not resumed at the stage i n which the interruption occurred but, rather, i t begins again at stage I . 3 9 Furthermore, when there has been a d e f i c i t of sleep, the missed NREM sleep i s made-up before the missed stage 1-REM sleep. Also, i t was noted by Garner and M i t c h e l l that "people who are deprived of stage 1-REM sleep have d i f f i -c u lty i n coping with recent s t r e s s f u l experiences." Some of the behavioural changes manifested with stage 1-REM sleep deprivation are increased appetite, anxiety, i r r i t a b i l i t y , and d i f f i c u l t y i n concentrating. Stage 1-REM sleep depriva-3 7 I b i d . , pp. ,k38-39. 3 8 I b i d . , p. 439. 3 9 I b i d . , p. 442. k°Ibid., p. 443. t i o n i s thought to occur when an i n d i v i d u a l sleeps at i n t e r -v a l s of l e s s than one hour or f o r a t o t a l of only three to hi f o u r hours every twenty-four hours. W r i t i n g on sleep needs during the maternity c y c l e , Williams drew a t t e n t i o n to the f a c t that women may be i n a s t a t e of acute sleep d e p r i v a t i o n immediately f o l l o w i n g 42 d e l i v e r y . VI. THE POSTPARTUM BLUES In the few s t u d i e s that have been done on the development of Postpartum Blues the scope has been l i m i t e d . Hamilton commented on the inadequacy of the l i t e r a t u r e i n i n t h i s area. In h i s review of the l i t e r a t u r e Hamilton sta t e d that i n I838 E s q u i r o l suggested t h a t the incidence of mental i l l n e s s i n the puerperium f a r exceeded the number of cases h o s p i t a l i z e d . J Later i n the nineteenth century others described a t r a n s i t o r y mental i l l n e s s i n which there was con-f u s i o n , excitement, and insomnia. This t r a n s i t o r y mental i l l n e s s , Hamilton s a i d , was r e f e r r e d to as "milk f e v e r " be-cause i t s occurrence was observed to c o i n c i d e w i t h the beginn i n g of m i l k flow. Moloney, i n 1952* described a m i l d depress i o n r e a c t i o n of despondency, f a t i g u e , i n a b i l i t y to t h i n k 44 c l e a r l y , and t e a r f u l n e s s i n the f i r s t week postpartum. ^ I b i d . , p. 442. ^ B a r b a r a W i l l i a m s "Sleep Needs During the M a t e r n i t y C y c l e , " Nursing Outlook, XIV (February, 1967), 54. ^ H a m i l t o n , op. c i t . , p. 107. ^ I b i d . , p. 108. 23 In 1955 Selare reported that a high percentage of women expressed f e e l i n g s of m i l d to moderate depression toward the end of the f i r s t postpartum week. J Hamilton c i t e d a study by Pleschete and others i n 1956 which revealed that s i x t y percent of puerperal women reported some degree of depression a t some time i n the six-week p e r i o d . Due to the shortcomings of the l i t e r a t u r e , Hamilton conducted an e x p l o r -a t o r y study undertaken to f u r t h e r d e l i n e a t e Postpartum Blues. The study showed l a c k of energy and f a t i g u a b i l i t y , episodes of c r y i n g , a n x i e t y and f e a r , confusion, headaches, insomnia, worry about p h y s i c a l symptoms and s t a t e s , and negative a t t i -tudes toward the husband. Hamilton noted the s i m i l a r i t y of the symptoms to the prodromal symptoms of the more severe puerperal depress-i o n . He suggested t h a t severe insomnia i s f r e q u e n t l y an ante-cedent to puerperal depression. Yet insomnia was reported only o c c a s i o n a l l y by women i n t h i s study. Therefore, Hamilton suggested the p o s s i b i l i t y t h a t the syndromes may be s i m i l a r i n cause and s t r u c t u r e and tha t r a p i d recovery or d e t e r i o r a t i o n may be determined by the a b i l i t y or i n a b i l i t y to sleep. A study by Yalom and others showed a c o r r e l a t i o n of s l e e p l e s s n i g h t s w i t h high depression s e l f - r a t i n g scores 47 i n the puerperium. ' The authors l i k e w i s e p o s t u l a t e d that some of the v a r i a b l e s a s s o c i a t e d w i t h postpartum depression ^ I D i d . 46 ^°Ibid., pp. 108-111. 47 'Yalom and Others, op. c i t . , p. 20. 24 a l s o c o r r e l a t e w i t h Postpartum Blues. The v a r i a b l e s c i t e d i n the study were low p a r i t y and high recurrence r a t e of 48 Postpartum Blues. Other s t u d i e s have a l s o c i t e d Postpartum 49 Blues as a f a c t o r m the development of puerperal depression. 7 In a d d i t i o n to these f a c t o r s the study by Yalom et a l showed other f a c t o r s of past h i s t o r y r e l a t e d t o the d e v e l -opment of'Postpartum Blues. The f a c t o r s were g r e a t e r d i s t r e s s of previous pregnancy, g r e a t e r menstrual d i f f i c u l t i e s , lower age of menarche, i r r e g u l a r i t y of per i o d s , and a s h o r t e r l e n g t h of menstrual flow.-5° The menstrual d i f f i c u l t i e s given were dysmenorrhoea and premenstrual t e n s i o n , each of which have ~ been c i t e d i n another study as a f a c t o r i n puerperal depress-ion.51 The .occurrence of Postpartum 31ues a t a time when hormone l e v e l s are d r a s t i c a l l y changed i s noted i n the l i t e r -a t u r e . Baker compared the mood changes of Postpartum Blues to the emotional i n s t a b i l i t y o c c u r r i n g at puberty, i n the pre-menstrual phase, and a t the menopause, when major a l t e r -a t i o n s i n hormonal l e v e l s o c c u r . ^ 2 Although reference to the l i k e l y r e l a t i o n s h i p of hormone l e v e l s t o mood i s commonplace 48 *°Ibid., p. 26. 49t ^ H a m i l t o n , op. c i t . , p. 111$ Melges, "Postpartum P s y c h i a t r i c Syndromes," Psychosomatic Medicine, XXX, (January-February, 1968), 10?$ R. Paffenbarger, "The P i c t u r e Puzzle of the Postpartum Psychoses," J o u r n a l of Chronic D i s -eases, X I I I (February, 1961), 161-73. ^°Yalom and Others, op. c i t . , p. 25. ^ B r i c e P i t t , " • A t y p i c a l " Depression F o l l o w i n g C h i l d -b i r t h , " B r i t i s h J o u r n a l of P s y c h i a t r y , CXIV (1968), 1329; Melges, op. c i t . , p. 98. ^ 2Baker, op. c i t . , p. 34. i n the l i t e r a t u r e , no d e f i n i t i v e studies to date have proved a r e l a t i o n s h i p . Referring to common emotional reactions i n the puerperium, Baker suggested that hospital r e s t r i c t i o n s cause anxiety and f r u s t r a t i o n to bu i l d up so that when the mothers go home they experience reactions to these f e e l i n g s . ^ In a study by Larsen, lack of emotional support from nurses, doc-tors, and husbands during labour was c i t e d as the most stress-f u l feature of the ho s p i t a l stay.^* During the puerperium at home, the stresses were reported as d i f f i c u l t y adjusting to the baby's needs, to housework routine, and to other c h i l d -ren's needs, and to interference from members outside of the household, increased company, and worry over a b i l i t y to cope with the family's needs. Gordon, Kapostins, and Gordon reported a study which showed maternal role c o n f l i c t and personal inse c u r i t y as factors related to abnormal emotional reactions to preg-nancy and c h i l d b e a r i n g . ^ Items related to c o n f l i c t with maternal r o l e were: no r e l a t i v e s available f o r help with baby care; differences i n l e v e l s of education and occupation of the parents of the new baby and th e i r parents: and the 5 3 I b i d . , p. 41. J V i r g i n i a L. Larsen, "Stresses of the Childbearing Year," American Journal of Public Health. LVI (January, 1 9 6 6 ) , 3 3 . 5 5 I b i d . , p. 3 4 - 3 5 . 6 6 J. Richard E. Gordon, E l i E. Kapostins and Katherine K. Gordon, "Factors i n Postpartum Adjustment," Obstetrics and Gynecology. XXV (February, 1 9 6 5 ) , 1 5 9 - 6 6 . 26 husband o f t e n away from home. The personal i n s e c u r i t y items were p r i m i p a r i t y ; complications of pregnancy i n the f a m i l y h i s t o r y ; the husband's f a t h e r dead; the woman's mother dead; the woman's education incomplete; and no previous experience w i t h babies. I l l n e s s during or apart from pregnancy were items r e l a t e d to both f a c t o r s . In another study, Larsen and Others l i s t e d s o c i a l s t r e s s items as those c i t e d and others used by Gordon and Gordon. Among the other items were unplanned pregnancy, i n t e r - r e l i g i o u s marriage, parents separated, and husband's parents separated.-'' A d d i t i o n a l l y , two s t r e s s f a c t o r s r e -ported by B i b r i n g were noted. These f a c t o r s were a weak r e l a t i o n s h i p between the woman and her male partner and a weak r e l a t i o n s h i p between the woman and her mother. VI I . SUMMARY This review of the l i t e r a t u r e was presented i n f i v e p a r t s . The f i r s t p a r t reviewed the l i t e r a t u r e which considered the puerperium as a developmental c r i s i s . The puerperium was viewed as a stage of development, dur i n g which time c e r t a i n tasks must be adequately achieved. The nature of the tasks to be achieved was seen to f r e q u e n t l y c o n s t i t u t e a c r i s i s s i t u a t i o n . The l i t e r a t u r e a l s o pointed out t h a t 57 V i r g i n i a L. Larsen and Others, P r e d i c t i o n and Im-. ~- —^ f w . » vuucis i xx cuxu uxuu e&nu im-provement of Postpartum Adjustment (unpublished research rep-o r t , Washington, 1968), 13-25. -^Grete L. B i b r i n g , "Recognition of P s y c h o l o g i c a l S t r e s s o f t e n Neglected i n 0 B Care" H o s p i t a l Topics. IL (September, 1966), 101-102. 2? professional assistance i n the management^of a c r i s i s can improve the i n d i v i d u a l ' s strength and maturity. The second part reviewed the l i t e r a t u r e which i d e n t i f i e d some of the many normal changes occurring i n the puerperium. It was found that biophysical and psychosocial changes are profound, e s p e c i a l l y i n the early puerperium. Environmental changes involved i n adjustment to the hospi-t a l environment and routines, and then reintegration to a family with a new structure and an altered pattern of needs were shown to be great. The t h i r d section reviewed the l i t e r a t u r e which dealt with some concepts of role theory. I t was indicated that attainment of the maternal role i s a process reached by sequential steps. The fourth part reviewed the l i t e r a t u r e on sleep needs. Frequent interruptions of sleep or an inadequate amount of sleep was shown to be detrimental. F i n a l l y , the l i t e r a t u r e reviewed i n the f i f t h part examined factors r e l a t i n g to the Postpartum Blues. The many c o n f l i c t s and needs created by the changing role of t h i s period were shown to be prominent. However, the scar-c i t y of research i n the area pointed to the usefulness of a study to further examine some of the factors implicated i n the development of Postpartum Blues. CHAPTER I I I . RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY T h i s study was conducted i n the Gr e a t e r Vancouver area of B r i t i s h Columbia u s i n g the d e s c r i p t i v e method of r e s e a r c h . Information p e r t i n e n t to the study was gathered by means of the i n t e r v i e w method of data c o l l e c t i o n . Be-cause of the nature of the i n f o r m a t i o n r e q u i r e d and the s m a l l sample s i z e of the p o p u l a t i o n , the i n t e r v i e w seemed the most s u i t a b l e method. P a t i e n t r e c o r d s were reviewed i n the hos-p i t a l from which the s u b j e c t s were chosen. These r e c o r d s p r o v i d e d r e l e v a n t medical h i s t o r y and demographic data. Twanty-nine postpartum women were i n t e r v i e w e d once i n h o s p i t a l and once i n t h e i r u s u a l p l a c e s of r e s i d e n c e . I. SELECTION OF THE STUDY GROUP The S e t t i n g The s u b j e c t s were chosen from the p o p u l a t i o n of an o b s t e t r i c s and gynecology h o s p i t a l i n the Gr e a t e r Vancouver area f o l l o w i n g a p p r o v a l by the h o s p i t a l a d m i n i s t r a t i o n . A l e t t e r r e q u e s t i n g p e r m i s s i o n to conduct the f i r s t p a r t of the study i n the h o s p i t a l was sent to the D i r e c t o r of Nursing of t h a t h o s p i t a l , t o g e t h e r with a summr .ary ;of the proposed r e s e a r c h . The l e t t e r requested permiss-i o n to view p a t i e n t r e c o r d s and to approach p o t e n t i a l s u b j e c t s . 28 29 The S u b j e c t s The s u b j e c t s s e l e c t e d were t h i r t y - o n e postpartum women, s i x t e e n of whom were p r i m i p a r a s and f i f t e e n o f whom were m u l t i p a r a s . No r e s t r i c t i o n s were p l a c e d on p a r i t y i n order t h a t Postpartum Blues c o u l d be s t u d i e d i n r e l a t i o n to whatever p a r i t y the sample i n c l u d e d . Two p r i m i p a r a s were dropped from the study due to t h e i r h o s p i t a l i z a t i o n a t and beyond the time when the home i n t e r v i e w was scheduled. The f o l l o w i n g c r i t e r i a f o r e l i g i b i l i t y t o the study were a p p l i e d : S u b j e c t s must be w i l l i n g to p a r t i c i p a t e i n the study. Two p o t e n t i a l s u b j e c t s who were approached showed some h e s i t a n c e when i n v i t e d t o p a r t i c i p a t e i n the study and t h e r e f o r e were not i n c l u d e d . The i n v e s t i g a t o r c o n s i d e r e d t h a t any h e s i t a n c y before agreement t o p a r t i c i p a t e i n . t h e study may reduce the commitment t o c o r r e c t i n f o r m a t i o n -g i v i n g , and to the second i n t e r v i e w a t home. Su b j e c t s must speak f l u e n t E n g l i s h , must have spent the l a s t three years i n Canada, and must be of Anglo-Saxon or s i m i l a r e t h n i c o r i g i n . These c r i t e r i a l i m i t e d the sample populjation t o a more homogeneous background. I t was c o n s i d -ered t h a t v a s t l y d i f f e r e n t background experiences among the su b j e c t s c o u l d i n f l u e n c e the i n t e r p r e t a b i l i t y of the r e s u l t s of the study. S u b j e c t s must have l i v e d with the f a t h e r of the new baby f o r a t l e a s t two y e a r s . T h i s c r i t e r i a was d i r e c t e d toward s e l e c t i n g s u b j e c t s whose m a r i t a l or p a r t n e r r e l a t i o n -s h i p s were more l i k e l y to be s t a b l e . 30 The age of the subject must be between s i x t e e n and t h i r t y - f i v e years. This c r i t e r i a was set because of a higher incidence r a t e of both f o e t a l and maternal complica-t i o n s under s i x t e e n years and over t h i r t y - f i v e years of age. 1 Subjects must have had no major disease throughout the c h i l d b e a r i n g process, or any chronic handicapping disease, according to s e l f - r e p o r t . This c r i t e r i a was set to avoid c o n f l i c t i n g f a c t o r s b i a s i n g the r e s u l t s of the study. Subjects must have had a v e r t e x - p r e s e n t i n g v a g i n a l d e l i v e r y . For primiparas - w i t h i n the time p e r i o d of eighteen hours from the s t a r t of r e g u l a r c o n t r a c t i o n s ten minutes apart to the e x p u l s i o n of the p l a c e n t a , and f o r multiparas - twelve hours. The average d u r a t i o n of labour i s considered to be about fourteen hours f o r primiparas and about e i g h t hours f o r 2 m u l t i p a r a s . O u t l e t - f o r c e p s a s s i s t a n c e i n the d e l i v e r y of the head was considered a d m i s s i b l e . A l s o , e p i s i o t o m i e s and f i r s t and second degree p e r i n e a l l a c e r a t i o n s were accepted. Beyond these l i m i t s extraneous f a c t o r s again might b i a s the r e s u l t s of the study. The newborn i n f a n t s of subjects must show no e v i -dence of i l l n e s s or deformity and must equal or exceed the b i r t h weight of s i x pounds. The i n f a n t ' s medical h i s t o r y data were examined f o r t h i s i n f o r m a t i o n . The Apgar Scores recorded a t one and a t f i v e minutes a f t e r b i r t h ranged be-Erna Z i e g e l and Carolyn C. Van Blarcom, Obstet- r i c a l Nursing (New York: The Macmillan Company, 1972), p. 233. 2 I b i d . 31 tween e i g h t and ten a t each a p p r a i s a l and the P e d i a t r i c i a n ' s assessment of each baby's c o n d i t i o n was f a v o u r a b l e . In a d d i t i o n , s u b j e c t s were r e q u i r e d t o s i g n a w r i t t e n consent form, a copy of which i s i n c l u d e d i n Appen-d i x A. I n i t i a l Contact w i t h the Su b j e c t s P a t i e n t r e c o r d s were i n i t i a l l y reviewed f o r e l i g i -b i l i t y of s u b j e c t s f o r the study. The e l i g i b l e s u b j e c t s were then approached by the i n t e r v i e w e r a t a convenient time f o r the s u b j e c t s and the h o s p i t a l . s t a f f . The i n v e s t i g a t o r then i n t r o d u c e d h e r s e l f by'name and s t a t e d t h a t she was a graduate student a t the U n i v e r s i t y of B r i t i s h Columbia and th a t she was conducting a study on mothers' f e e l i n g s i n the f i r s t s i x weeks f o l l o w i n g the b i r t h of t h e i r b a b i e s . C o n f i -d e n t i a l i t y was e x p l a i n e d . The p o t e n t i a l s u b j e c t s were a l s o t o l d t h a t the study i n v o l v e d one i n t e r v i e w i n the h o s p i t a l and one i n the s u b j e c t s ' homes about three and one-half weeks l a t e r . P a r t i c i p a t i o n i n the study was then requested o f the postpartum women. I I . INSTRUMENTATION A v a r i e t y of instruments were used to o b t a i n data i n t h i s study. Two s e m i - s t r u c t u r e d i n t e r v i e w schedules, one f o r use i n the h o s p i t a l i n t e r v i e w and one f o r use i n the home in t e r v i e w , were developed. These were designed f o l l o w i n g a review of the l i t e r a t u r e and were intended to o b t a i n i n f o r -mation relevant" to the r e s e a r c h problem. The Beck Depression 32 Inventory, a standardized instrument to measure the degree of depression, was used i n t h i s study. A l s o , a q u e s t i o n -n a i r e on Postpartum,Blues, was developed to ob t a i n the s e l f -perceptions of the s u b j e c t s . The instruments used i n t h i s study are shown i n Appendix B. Each i n t e r v i e w conducted i n the h o s p i t a l and i n the subject's home took between t h i r t y and seventy minutes to com-p l e t e . To ensure anonymity, numbers were used to i d e n t i f y data r a t h e r than the names of the s u b j e c t s . H o s p i t a l Interview Schedule Some of the questions i n t h i s schedule were i n c l u -ded to ob t a i n background i n f o r m a t i o n . Such questions con-cerned place of residence, m a r i t a l s t a t u s , p a r i t y , expected date of confinement, sex of baby, and drugs administered while i n the h o s p i t a l . Some questions were used to ob t a i n data to ensure that respondents met the c r i t e r i a of e l i g i b i l i t y to the study. These questions concerned age, n a t i o n a l i t y , and length of time i n Canada, h i s t o r y of any major i l l n e s s or p s y c h i a t r i c d i s -order, length of time l i v e d w i t h partner, confinement date and time, length of labour, c o n d i t i o n of perineum, weight of baby and Apgar Score of baby, and current h e a l t h s t a t u s of the respondent and of her baby. Other questions were used to obtai n i n f o r m a t i o n i n regard to f a c t o r s mentioned i n the l i t e r a t u r e as i m p l i c a t e d i n the development of Postpartum Blues. To provide informa-t i o n to a s s i s t i n answering question 1 ( c o n f l i c t w i t h mater-33 nal r o l e ) of the study questions on factors l i k e l y to cause r o l e - c o n f l i c t included: the marital status, residence, education, and occupation of the parents of the respondent and the par-ents of her husband? the respondent's early expectation of motherhood: the number of children at home and the age of the youngest child 5 the incidence of any physical or emotion-a l problems with any previous childbearing or with the preg-nancy, labour, and b i r t h just concluded? any problems i n childbearing experienced by the respondent's immediate f e -male r e l a t i v e s : the amount of educational preparation f o r childbirth? concerns experienced during t h i s pregnancy, labour, or b i r t h , the amount of time the husband i s away fr.om home overnights expectations regarding the labour and b i r t h experience} the presence of the husband during the labour and b i r t h process} self-perceptions of s i g n i f i c a n t a i d during the labour and b i r t h process} and infant feeding s t y l e . To provide information to answer question II (endo-crine factors related to the menstrual cycle) of the study questions of menstrual hi s t o r y and length of time t r y i n g to conceive were included. F i n a l l y , to provide information to a s s i s t i n answer-ing question III (reduction i n sleep cycles) of the study questions on sleep were included. This schedule was verbally administered by the investigator. Home Interview Schedule This schedule was prepared to c o l l e c t data to a s s i s t i n answering two questions asked i n the study. Questions asked to provide information f o r question I ( c o n f l i c t with maternal r o l e ) included concerns ahout the baby, adjustment d i f f i c u l t i e s , and extra help; r e l a t i o n s h i p with mother and husband; feelings of happiness, recent memory, d i s t r a c t -a b i l i t y , and concentration power, feelings of dependency, blocked goals, and entrapment. These questions were struc-tured i n a s i m i l a r manner to those i n the Beck Depression Inventory, as was the ordering of the questions. The reason f o r t h i s was that the respondent was asked to answer the Beck Depression Inventory immediately following the verbal administration of the schedule. The same format f o r both was used to f a c i l i t a t e the respondent's task of s e l e c t i n g the most appropriate answer. Questions regarding sleep provided information f o r question III of the study. The Beck Depression Inventory This instrument f a c i l i t a t e s the recognition of a person who i s depressed. The inventory was developed to quanti t a t i v e l y assess the degree of depression based on char-a c t e r i s t i c symptoms and attitudes established i n the l i t e r a -ture. The inventory consists of twenty-one categories of symptoms and attitudes, each of which describes a p a r t i c u l a r behavioural manifestation of depression. The symptom-attitude categories include mood, g u i l t , pessimism, s e l f -accusation, s o c i a l withdrawal, and others. Each category contains four questions which have numerical values ranked in. order of severity from zero to three. Beck's s t a t i s t i c a l tests showed the instrument to be v a l i d and r e l i a b l e . J The inventory was used i n a study of postpartum mood change i n Jamaican women i n 1972. Aitken and Zealley confirmed the v a l i d i t y of the Beck instrument, and more recently, Purnell proved i t to be an accurate aid.-* The questions on weight loss were; considered un-suitable f o r use with postpartum women because of the weight loss normally occurring i n th i s period. Therefore, four questions were substituted f o r the o r i g i n a l ones. It was i n -tended to analyze these questions on weight separately to detect any^differences that ^ maychave Resulted from the substi tution. However, i n view of the i n s i g n i f i c a n t findings of the inventory, separate analysis was not done. The Blues Questionnaire This was an open-ended questionnaire to e l i c i t the s e l f perception and knowledge of subjects concerning Post-partum Blues. The data obtained from t h i s questionnaire was useful i n assessing the degree of d i s t r e s s f e l t by those who experienced the Postpartum Blues. The omission of the f i r s t two questions and the addition of another two questions was -^ A.T. Beck and. Others, "An Inventory f o r Measuring Depression," Archives of General Psychiatry, IV (June, 1968), 564-69. 4 J.R.T. Davidson, "Postpartum Mood Change m Jamai-can Womens A Description and Discussion on i t s Significance," B r i t i s h Journal of Psychiatry, C;XX, (1972), 66O-63. ^R.C.B. Aitken and^A.K. Zeally, "Measurement of Moods," B r i t i s h Journal of Hospital Medicine, IV (August, 1970), 221-24; Margery D. F u m e l l , "Adolescent Depression and Interpersonal Behaviour" (Unpublished Master's Thesis, Uni-v e r s i t y of B r i t i s h Columbia, 1973), 98-102. 36 made f o r the home interview. The modified Blues Question-naire i s shown i n Appendix B. I I I . PRE-TEST The instruments used were reviewed by a nurse-educator i n the maternal-child area, a nurse-educator i n the research area, and a psychologist engaged i n nursing research. Several adjustments were made to reduce ambiguity. The i n -struments, with the exception of the Home Interview Schedule, were administered to two subjects i n the same hos p i t a l i n which the study was conducted. A few further adjustments were made for the purpose of c l a r i t y . The Home Interview Schedule was administered to two postpartum women i n t h e i r own homes i n the Greater Vancouver area. Likewise, a few, adjustments were made to the schedule to reduce ambiguity. The use of the pretest, as suggested by Abdellah and Levine, increased the v a l i d i t y and r e l i a b i l i t y of the data-collecting instruments.^ Moreover, the pretest enabled the investigator to gain some profi c i e n c y i n the use of the instruments. The Blues Questionnaire was a d d i t i o n a l l y pretested on twelve postpartum women i n th e i r f i r s t ten days at home. The questionnaire was administered by nursing students i n the baccalaureate program of the University of B r i t i s h Columbia. Faye G. Abdellah and Eugene Levine, Better Patient  Care Through Nursing Research (New York* The Macmillan Com-pany, 1965), P. :."3.21. No changes were made as the instrument seemed to obtain the required information. IV. THE INTERVIEWING PROCEDURE The h o s p i t a l interview was conducted during the afternoon, excluding the times that meals were served, babies were being fed, v i s i t o r s were present, nursing treatment was i n progress, or the subject was otherwise engaged. The Hos-p i t a l Interview Schedule was verbally administered, except for the data which was obtained from the patient record. At the conclusion of the interview the subject was given the investigator's name i n writing, her telephone number, and the date agreed upon f o r the home interview. It was stated that the investigator would telephone the subject on the day p r i o r to the interview to es t a b l i s h the time of the interview. Any questions the subject had were discussed and then the Beck Depression Inventory and Blues Questionnaire were given to the. subject. The subject was instructed i n the use of the se l f - r e p o r t instruments. The investigator l a t e r c o l l e c t e d the instruments and thanked the subject f o r her assistance. The Home Interview Schedule was used i n the home interview. The f i r s t part was administered verbally by the investigator and the second part was self-administered by the subject, along with the Beck Depression Inventory. The Blues Questionnaire, revised f o r the home interview, was then administered v e r b a l l y . Any questions were discussed. The subject was again thanked f o r her p a r t i c i p a t i o n and told 38 t h a t a summary of r e s u l t s of the study would be mailed on completion of the study. Each s u b j e c t had p r e v i o u s l y r e q u e s t -ed a summary of the r e s u l t s of the study. I n t e r a c t i o n s With the Study Group During the time a v a i l a b l e to the i n v e s t i g a t o r f o r c o l l e c t i o n of the data, only two s u b j e c t s of the p o t e n t i a l study p o p u l a t i o n were not i n c l u d e d i n the study. Most of the remaining t h i r t y - o n e s u b j e c t s who i n i t i a l l y formed the study group openly expressed t h e i r d e s i r e to be of a s s i s t a n c e to the i n v e s t i g a t o r i n o r d e r t h a t the study might h e l p f u t u r e mothers. The remainder of the study group i n d i c a t e d t h e i r w i l l i n g n e s s to cooperate by a s k i n g q u e s t i o n s about the study. Approximately t w o - t h i r d s of the group were i n rooms c o n t a i n i n g two or more beds. A separate i n t e r v i e w i n g s i t e was offered^ . but the s u b j e c t s a l l suggested t h a t they remain i n t h e i r own rooms, as they were not concerned about c o n f i d e n t i a l i t y . As t h i s was l e s s d i s r u p t i v e to the f u n c t i o n i n g of the u n i t , the s u g g e s t i o n was r e a d i l y accepted. There were no i n d i c a t i o n s t h a t a p o s s i b l e r e d u c t i o n i n c o n f i d e n t i a l i t y i n any way r e s -t r i c t e d the content of the i n f o r m a t i o n requested. Up to one hour was allowed f o r each i n t e r v i e w and where p o s s i b l e the time f o r the i n t e r v i e w was scheduled on the day p r i o r . I t was d i s c o v e r e d t h a t postpartum women i n h o s p i t a l r a r e l y have much time t h a t can be guaranteed f r e e of i n t e r r u p t i o n s . Consequently, the i n v e s t i g a t o r ' s a p p o i n t -ment system became extremely f l e x i b l e . E s t a b l i s h m e n t of r a p p o r t was f a c i l i t a t e d by the presence of f l o w e r s and cards 39 i n the rooms or the forthcoming Christmas season. It was also observed how eager postpartum women are to discuss the recent events encompassing the b i r t h of the baby. Attention to t h i s need was preferably given at the conclusion of the administration of the Hospital Interview Schedule. However, on a few occassions the order of the schedule was foregone i n order to deal with the content the subject urgently wished to express. Any requests f o r advice were discussed. When the investigator gave information the respondent was encouraged to form her own conclusions rather than to accept a ready-made decision. Several of the questions asked could be best answered by the respondent's physician and the suggestion was made to that e f f e c t . On telephoning the respondents at t h e i r homes, without exception, they a l l said that they had been expecting the c a l l . Times were arranged f o r the v i s i t s and f o r some places directions f o r best routes of access to the lo c a t i o n were obtained. Most of the v i s i t s lasted between f o r t y - f i v e and seventy minutes, although the interview instruments r e-quired only twenty to twenty-five minutes to complete. The respondents displayed a need to discuss home a c t i v i t i e s and future plans. Of the two respondents eliminated from the study, one remained under psychiatric care i n ho s p i t a l at seven weeks a f t e r confinement. The husband reported taking h i s wife to ho s p i t a l three weeks a f t e r confinement because of manic be-haviour. The second respondent eliminated from the study 40 was also admitted to a psychiatric unit three weeks a f t e r confinement because of manic behaviour. This woman was d i s -charged from the unit a f t e r two weeks of h o s p i t a l i z a t i o n . The investigator telephoned to enquire how the woman was managing at home and v i s i t e d once at the woman's request. No unusual behaviour was noted. The woman spoke f r e e l y of her thoughts and feelings during the manic state experienced and described some of her a c t i v i t i e s . The investigator i n -formed the woman about the Postpartum Counselling Service i n Vancouver, and gave her a pamphlet describing the services offered.' V. STATISTICAL ANALYSIS Responses f o r each item of the data which was cite d i n the l i t e r a t u r e as influencing the development of Postpartum Blues were divided into "yes" and "no" categories. Then the two categories f o r each item were compared to the incidence of Postpartum Blues by means of the Chi-square t e s t . The chi-square test i s a non-parametric test of significance based on the chi-square d i s t r i b u t i o n and used when the size of the study population i s s m a l l . 7 The value provided by the computation of chi-square i s a measure of o the p r o b a b i l i t y of obtaining the value by random sampling. The minimum significance l e v e l was set at < .05. 7 'Abdellah and Levine, op. c i t . , p. 350. 8 I b i d . ' 4 1 VI. SUMMARY Th i s chapter o u t l i n e d the d e s c r i p t i v e method of r e s e a r c h used f o r t h i s study and the i n t e r v i e w method used to g ather i n f o r m a t i o n r e q u i r e d f o r the study. The s e l e c t i o n of the study group was d e s c r i b e d . The instruments which were developed f o r the study and the Beck Depression Inventory were d e s c r i b e d . The p r e - t e s t and the i n t e r v i e w i n g procedure were d e s c r i b e d . F i n a l l y , the method of s t a t i s t i c a l a n a l y s i s was d e s c r i b e d . CHAPTER IV. ANALYSIS OF THE DATA C h a r a c t e r i s t i c s of the study p o p u l a t i o n are des-c r i b e d and shown i n frequency d i s t r i b u t i o n t a b l e s . The i n -cidence of Postpartum Blues i n the study p o p u l a t i o n was a s s e s s -ed. F u r t h e r a n a l y s i s of the data was c a r r i e d out to answer the q u e s t i o n s asked i n the study. Thus the data were examined to pr o v i d e i n f o r m a t i o n concerning the i n c i d e n c e of f a c t o r s r e l a t e d to maternal r o l e c o n f l i c t , c e r t a i n d i f f i c u l t i e s r e l a t e d to the menstrual c y c l e and s l e e p d e f i c i e n c i e s . These data were then compared with the i n c i d e n c e of Postpartum Blues i n the study p o p u l a t i o n . The c h i square t e s t was used to d e t e c t any s i g n i f i c a n t d i f f e r e n c e be-tween the two groups. D e s c r i p t i v e a n a l y s i s and frequency d i s -t r i b u t i o n s were used i n the a n a l y s i s of these data. I. CHARACTERISTICS OF THE STUDY POPULATION The study p o p u l a t i o n c o n s i s t e d of twenty-nine p o s t -partum women who had g i v e n b i r t h to a p p a r e n t l y h e a l t h y f u l l -term i n f a n t s a t a s e l e c t e d h o s p i t a l d u r i n g the month of Decern-ber. The age, b i r t h - p l a c e , education, and l e n g t h of time l i v e d with the f a t h e r of the baby were c h a r a c t e r i s t i c s of the study p o p u l a t i o n d e s c r i b e d and t a b u l a t e d . The remaining c h a r a c t e r i s -t i c s are d e s c r i b e d and shown i n r e l a t i o n to the i n c i d e n c e of Postpartum Blues. C h i square t e s t s showed no s i g n i f i c a n t d i f f -erences. Age The ages of the women ranged from twenty to t h i r t y -f i v e years, w i t h a mean average of twenty-six years and f o u r months. Table 1 i l l u s t r a t e s t h i s i n f o r m a t i o n . Table 1 Percentage D i s t r i b u t i o n of the Study P o p u l a t i o n by Age Age Number Percentage 20-24 years 8 28 25-29 years 58 30-35 years _4 14 TOTAL 29 100 B i r t h p l a c e The m a j o r i t y of the study p o p u l a t i o n (80 percent) was bom i n Canada. Two women (7 percent) were born i n Great B r i t -a i n : two women (7 percent) were born i n Holland: one woman (3 percent) was born i n Denmark, and one woman (3 percent) was born i n the United States of America, as shown i n Table 2. Table 2 Percentage D i s t r i b u t i o n of the Study Population by B i r t h p l a c e B i r t h p l a c e Number f Percentage Canada 23 80 Great B r i t a i n 2 7 Holland 2 7 Denmark 1 3 United States of America 1 3 TOTAL 29 100 kk M a r i t a l Status Twenty-seven (93 percent) of the women i n the study group were married. The remaining two (7 percent) were l i v i n g i n a s t a b l e common-law r e l a t i o n s h i p . The range i n the length of time l i v e d w ith the f a t h e r of the newborn i n f a n t was from two years and s i x months to ten years as i l l u s t r a t e d i n Table 3« The mean average length of time was four years and nine months. Table 3 Percentage D i s t r i b u t i o n of the Study Population by Length of Time Lived with Father Of Newborn Infant Time Number Percentage 2-4 years 19 65 5-7 years 8 28 8-10 years _2 7 TOTAL 29 100 Education The l e v e l of edu c a t i o n a l attainment ranged from Grade ten to a U n i v e r s i t y degree as shown i n Table 3« Five women (17 percent) had not completed high school, fourteen women (48 percent) had graduated from high school, four- women (14 percent) had some post-high school t r a i n i n g , w hile s i x women (21 percent) were u n i v e r s i t y graduates. Table 4 Percentage D i s t r i b u t i o n of the Study Population by Highest Edu- - • . cational, Attainment . ' : • ' ". . Level Completed Number Percentage Grade X or XI 5 17 High School 14 48 Some Post High School Training 4 14 University Degree _6 21 TOTAL 29 100 Occupation A l l of the women except one had been employed following completion of t h e i r education. Nevertheless, a l l of the women stated that they had no intentions of seeking employment for at least one to two years following the b i r t h of t h e i r infants. Parity Parity was c l a s s i f i e d into four categories: primiparity, multiparity with no other c h i l d at home, multiparity with one c h i l d at home, and multiparity with two children at home. There were fourteen women (forty -eight percent) i n the f i r s t category, 3 women (10 per- . ' cent) i n the second category, ten women (35 percent) i n the t h i r d category, and two women ( 7 percent) i n the l a s t category. Table 5 shows thi s information dichotomized 46 into those who experienced Postpartum Blues and those who did not. Table 5 Parity by Incidence of Postpartum Blues i n the Study Population Parity Postpartum Blues No Postpartum Blues Number Number Primipara , 8 6 Multipara - no other c h i l d 3 0 Multipara - 1 other c h i l d l 7 3 Multipara - 2 other children _2 0 TOTAL 20 9 Confinement Date The proximity of the confinement date to the estimated confinement date varied between seventeen days early and seventeen days l a t e . Of the women who delivered t h e i r infants one to seven days early six developed Post-partum Blues while f i v e did not develop the episode, and of those who delivered t h e i r infants eight to seventeen days early one developed Postpartum Blues while two did not devel op the episode. However, of. the women who delivered t h e i r infants one to seven days l a t e , eight developed Postpartum Blues while one did not develop the episode, and of those who delivered t h e i r infants eight to seventeen days l a t e f i v e developed Postpartum Blues while one did not. A l -though the difference was not s i g n i f i c a n t when the chi square test was used, the discrepancies are probably best explained by the fac t that the majority of the hos p i t a l interviews were conducted before Christma's Day. The women who were confined a f t e r t h e i r expected date a l l stated that they were ).anxious to be home before Christmas Day. The women also expressed 1 t h e i r disappointment over the extension of t h e i r pregnancies beyond t h e i r expected dates of confine-ment as they were t i r e d of the pregnant state. The informa-t i o n on confinement dates i s shown i n Table 6. Table 6 Proximity of Confinement Date^ to Estimated '"Confinement Date by Incidence <• \. of Postpartum Blues i n ' the Study Populati on . r Difference In Time Postpartum Blues Number No Postpartum Blues Number 1 - 7 days early 6 5 8 - 1 7 days early 1 2 1 - 7 days late 8 1 8 - 1 7 days l a t e -1 1 TOTAL 20 9 Duration of Labour The duration of labour f o r primiparas varied from three hours and f o r t y - f i v e minutes to fourteen hours and ten minutes, with a mean average time of ten hours and eleven minutes. This was almost four hours shorter than 48 the average quoted i n the l i t e r a t u r e . 1 Of the primiparas studied one had a labour of less than f i v e hours duration, nine had a labour of between f i v e and ten hours duration, and four had a labour of between ten and f i f t e e n hours, as shown i n Table ?. The duration of labour for multiparas varied from one hour and t h i r t y minutes to eleven hours and t h i r t y -f i v e minutes, with a mean average time of f i v e hours and f o r t y - f i v e minutes. This average time also was considerably less than the average of eight hours quoted i n the l i t e r a -2 ture. Of the multiparas studied f i v e had labours of les s than f i v e hours, nine had labours of between f i v e and ten hours, and one had a labour of between ten and f i f t e e n hours # This information i s also i l l u s t r a t e d i n Table ?. Table 7 Duration of-Labour f o r Primiparas and .Multiparas by Incidence.of ." Postpartum Blues i n the . Study Population - -\ Duration of - ; Postpartum Blues ,_No Postpartum Blues Labour Primiparas"Multiparas: Primiparas Multiparas 1 - 5 hours 0 4 1 1: 5 - 1 0 hours 6 7 3 2 10 - 15 hours 2 1 2 0 TOTAL 8 12 6 3 1 -it E r n a z i e S e l and Carolyn C. Van Blarcom, Obstetric Nursing (6th ed.; New York: The Macmillan Company, 1972), p.285. 2 I b i d . 49 M e d i c a t i o n A n a l g e s i c drugs a d m i n i s t e r e d d u r i n g l a b o u r were predominantly Demerol, Phenergan and Lidocaine.' E i g h t e e n women (62 p e r c e n t ) r e c e i v e d 50, 75, or 100 m i l l i g r a m s o f Demerol i n t r a m u s c u l a r l y . Two women (7 p e r c e n t ) had the dose repeated once. In a d d i t i o n to Demerol three women ( 10 per-cent) were g i v e n 100 m i l l i g r a m s of Seconal o r a l l y d u r i n g the f i r s t stage of la b o u r . Nine women (31 p e r c e n t ) r e c e i v e d e i t h e r 25 or 50 m i l l i g r a m s of Phenergan i n t r a m u s c u l a r l y , s e p a r a t e l y or i n cdnouncfeoh Jwith . Demerol i" One woman (3 p e r c e n t ) had the dose repeated once. Twenty-six o f the study group (90 p e r c e n t ) r e c e i v e d i n j e c t i o n s of L i d o c a i n e i n t o the lumbar e p i d u r a l space o u t s i d e of the dura mater i n the s p i n a l c a n a l to e f f e c t r e g i o n a l a n a e s t h e s i a . One woman (3 p e r c e n t ) r e c e i v e d an i n j e c t i o n of L i d o c a i n e i n t o each pudendal nerve by way of the vagina, a l s o to e f f e c t r e g i o n a l a n a e s t h e s i a . N i t r o u s oxide and Pentrane i n h a l a t i o n anaes-t h e t i c were used to pr o v i d e a n a l g e s i a f o r one women (3 p e r c e n t ) . One woman d i d not r e c e i v e any form of a n a l g e s i a owing to a sh o r t l a b o u r and an in t a c t : p e r i n e u m . While i n the case-room a l l of the women were g i v e n an oxytocic drug to s t i m u l a t e u t e r i n e c o n t r a c t i o n s a f t e r d e l i v e r y of the baby i n order to prevent e x c e s s i v e blood l o s s . A l s o two women (7 p e r c e n t ) who planned not to b r e a s t f e e d were g i v e n an i n t r a m u s c u l a r i n j e c t i o n of L a c t o s t a t to suppress l a c t a t i o n and thereby reduce the p o s s i b i l i t y of b r e a s t engorgement. 50 F o l l o w i n g d e l i v e r y n i n e t e e n women (66 p e r c e n t ) accepted Seconal 100 m i l l i g r a m s o r a l l y to enhance s l e e p on t h e i r f i r s t postpartum n i g h t , while t e n women (34 p e r c e n t ) d e c l i n e d s e d a t i o n . S i x women (21 pe r c e n t ) took Seconal on t h e i r second postpartum n i g h t , f i v e women (17 p e r c e n t ) on t h e i r t h i r d n i g h t and one woman (3 pe r c e n t ) on her f o u r t h postpartum n i g h t i n h o s p i t a l . Other o r a l m edications g i v e n d u r i n g the postpartum h o s p i t a l s t a y were F r o s s t ' s 292's, Darvon Compound, T a n d e a r i l , Ergometrine, and S t i l b o e s t r o l . F r o s s t ' s 292's or Darvon Compound were ordered by most of the a t t e n d i n g p h y s i c i a n s , e i t h e r f o u r - h o u r l y o r s i x - h o u r l y as r e q u i r e d f o r the r e l i e f of p a i n from p e r i n e a l s utures, " a f t e r - p a i n s , " or b r e a s t engorgement. Twenty-one women (72 p e r c e n t ) took between one and f o u r t e e n doses of F r o s s t ' s 292 t a b l e t s and two women (7 p e r c e n t ) took one and t h i r t e e n doses of Darvon Compound ca p s u l e s r e s p e c t i v e l y . One woman (3 p e r c e n t ) r e c e i v e d Ergometrine t a b l e t s three times d a i l y f o r three days t o a i d i n v o l u t i o n of the u t e r u s . One woman (3 percent) r e c e i v e d ^ t i i b d e s t r o i ^ t a b l e t s three.times d a i l y f o r f o u r days to a i d s u p p r e s s i o n of l a c t a t i o n . F i n a l l y , one woman r e c e i v e d T a n d e a r i l three times d a i l y f o r f o u r days f o r j o i n t - p a i n r e l i e f . No s i g n i f i c a n t d i f f e r e n c e s i n r e l a t i o n to m e d i c a t i o n and i n c i d e n c e o f Postpartum Blues i n the study p o p u l a t i o n were found. Episiotomy Twenty-five women (86 p e r c e n t ) i n the study group had e p i s i o t o m i e s r e p a i r e d with s u t u r e s . The remaining f o u r women (14 pe r c e n t ) had i n t a c t perineums.. 51 Bir t h Weight The b i r t h weights of the infants ranged between si x pounds and nine pounds six ounces. Seven infants (24 percent) weighed between s i x and seven pounds, fourteen infants (49 percent) weighed between seven and eight pounds, seven infants (24 percent) weighed between eight and nine pounds, while one infant (3 percent) weighed between nine and ten pounds. Table 8 shows t h i s information compared with the incidence of Postpartum Blues. Table 8 Bir t h Weight of Infants by Incidence of Postpartum Blues i n the Study Population . Bir t h Weight Postpartum Blues No Postpartum Blues 6-7 pounds 4 3 7-8 pounds 10 4 8-9 pounds 6 1 9-10 pounds _0 1 TOTAL 20 9 Health Status The health status of each mother and infant was check-ed by the written medical record and by asking the mothers. I I . ASSESSMENT OF THE INCIDENCE OF POSTPARTUM BLUES Data provided by the Blues Questionnaire revealed t h a t a l l women had heard of Postpartum Blues and a l l had some idea s about-the phenomenon. E l e v e n o f the twenty women who l a t e r r e p o r t e d having experienced Postpartum Blues thought t h a t the episode was a d e p r e s s i o n s t a t e w h ile a l l o f the nine women who l a t e r r e p o r t e d not having experienced Postpartum Blues thought t h a t the episode was a d e p r e s s i o n s t a t e . T h e r e f o r e , the assumption t h a t women were capable of s e l f - r e p o r t i n g the i n c i d e n c e of Postpartum Blues was con-s i d e r e d a c c e p t a b l e f o r t h i s study. The i n f o r m a t i o n concerning Postpartum Blues c o l l e c -ted from the twenty women who experienced the episode was c l a s s i f i e d and examined. Reasdns^giveri-for the development of Postpartum Blues were predominantly f a t i g u e . Nine women c i t e d f a t i g u e , f o u r women c i t e d a n x i e t y , three women c i t e d body adjustments, one woman c i t e d hormones, and one woman c i t e d change i n l i f e s t y l e . The e f f e c t s o f Postpartum Blues were r e p o r t e d as f i f t e e n i n s t a n c e s of depression, f o u r i n -stances of i n t o l e r a n c e , f r u s t r a t i o n , or i r r i t a b i l i t y , one in s t a n c e of a n x i e t y , and one i n s t a n c e of o v e r s e n s i t i v i t y . Most o f these e f f e c t s were r e p o r t e d l y accompanied by s h o r t c r y i n g s p e l l s . However, f i v e women r e p o r t e d the e f f e c t s of Postpartum Blues as c r y i n g o n l y . The c r y i n g s p e l l s r e p o r t e d were b r i e f , l a s t i n g from two to f i f t e e n minutes, with the exc e p t i o n of two s p e l l s which l a s t e d t h i r t y and s i x t y minutes r e s p e c t i v e l y . These r e s u l t s are s i m i l a r to those r e p o r t e d 2 by Yalom and o t h e r s . I r v i n D. Yalom and Others,"^Postpartum i l u e s ' Syndrome/"Archives of General P s y c h i a t r y . XVIII (January, 1965), 16-27: The time of occurrence of Postpartum Blues was within two weeks of confinement i n a l l hut one case which extended into the t h i r d week. Ten women experienced Post-partum Blues while i n ho s p i t a l and seventeen women exper-ienced Postpartum Blues a f t e r returning home. Accordingly, seven women experienced the episode twice, three women once only i n hospita l , and ten women once only at home. Unfor-tunately, most of the women who experienced Postpartum Blues at home were unable to r e c a l l the exact date of occurrence. Therefore, inferences about whether or not the occurrence of Postpartum Blues was a continuation of the episode i n ho s p i t a l or a discrete episode i n seven women can only be speculative. The duration of Postpartum Blues experienced by the women while i n the ho s p i t a l d i f f e r e d from that experienced at home. The duration of Postpartum Blues reported while i n the hosp i t a l varied from less than one hour f o r two women to two days f o r two women. Four women reported the duration to be four to six hours and the remaining two women reported i t to be one day. However, the duration of Postpartum Blues at home was reported to be from one hour f o r three women to up to fourteen days intermittantly f o r one woman. Two women reported the episode to l a s t from four to six hours, one woman fo r one day, seven women fo r two to three days i n t e r -mittantly, and two women fo r four to seven days intermittantly. The difference i n the two duration times might be due to the fact that there were p o t e n t i a l l y more people a v a i l a b l e . f o r s o c i a l i n t e r a c t i o n and that there was only p a r t i a l respon-54 s i b i l i t y f o r the baby i n the h o s p i t a l . A l s o to be taken i n t o account i s the s o c i a l d e s i r a b i l i t y norm of b e i n g a "good p a t -i e n t " , as suggested by Baker. J With regard to a s s i s t a n c e i n overcoming Postpartum Blues, seven of the te n women who experienced the episode while i n h o s p i t a l r e p o r t e d t h a t no one helped them. One wo-man r e p o r t e d t h a t ,her husband and a nurse h e l p e d her, one woman r e p o r t e d t h a t the nurses helped her, and one woman re p o r t e d t h a t a r e l a t i v e helped her. T h i s f i n d i n g may w e l l i n d i c a t e postpartum women's need f o r emotional a s s i s t a n c e while i n the h o s p i t a l as claimed by Auerbach and a l s o by F i e l d i n g . Of the seventeen women who experienced Postpartum Blues a t home, ten r e p o r t e d s i g n i f i c a n t a s s i s t a n c e from t h e i r husbands, f o u r r e p o r t e d a s s i s t a n c e from a r e l a t i v e or f r i e n d and only three r e p o r t e d no a s s i s t a n c e . The d u r a t i o n o f Post-partum Blues f o r two of these three women was one hour, while t h a t of the t h i r d woman was one day. However, the f i n d i n g of the need f o r emotional support a t home i n the e a r l y puerperium i s c o n s i s t a n t with the c l a i m s o f Auerbach and Rice.-* Postpartum Blues was c o n s i d e r e d unpreventable JA.A. Baker, P s y c h i a t r i c D i s o r d e r s i n O b s t e t r i c s ( S a l i s b u r y : The S a l i s b u r y Press L t d . , 1967), p. 34. 4 A l i n e Auerbach, "Meeting the Needs of New Mothers," C h i l d & Family. VI (Winter, 1967) 13; Jane F i e l d i n g , , " S t u d y . , of S e l e c t e d Behaviours of P r i m i p a r o u s M o t h e r s During the F i r s t Three Post Partum Days," The Nursing Process, (New York: Teachers C o l l e g e P r e s s ) , 1972, p. 38. ^Auerbach, I b i d . ; E l i z a b e t h P. Rice, " A f t e r O f f i c e Hours," O b s t e t r i c s and Gynecology, XXIII (February, 1964), 313. by t h i r t e e n of the seventeen women who experienced the e p i -sode. Two women thought t h a t adequate r e s t and r e l a x a t i o n would p r e c l u d e the development of Postpartum Blues and two women were u n c e r t a i n but thought a " p o s i t i v e a t t i t u d e " may a f f e c t the outcome. Postpartum Blues was not con s i d e r e d t o be a bad experience by eleve n of the study group who developed the episode. Four women c o n s i d e r e d the episode to be unpleas-ant but s t a t e d t h a t i t was a l e a r n i n g experiences one woman con s i d e r e d i t t o be an unpleasant experience but f o r g e t t a b l e , and one woman co n s i d e r e d i t to be a bad experience because of g u i l t f e e l i n g s over her i n i t i a l disappointment w i t h the sex o f her i n f a n t . At the same time, t h i s woman s t a t e d t h a t she had r e s o l v e d her g u i l t f e e l i n g s and the Postpartum Blues d i d not have a l a s t i n g e f f e c t . These f i n d i n g s were some-what unexpected by the i n v e s t i g a t o r whose experience with postpartum women i n d i c a t e d t h a t the event of Postpartum Blues was o f t e n long-remembered with n e g a t i v e f e e l i n g s . A p o s s i b l e e x p l a n a t i o n might be t h a t the i n c i d e n c e o f Pos t -partum Blues a s s o c i a t e d w i t h prolonged n e g a t i v e f e e l i n g s i s low and th a t a much l a r g e r p o p u l a t i o n would be needed to r e v e a l i t . Or i t might be t h a t the s e l e c t i o n c r i t e r i a e l i m i n a t e d those women most l i k e l y to be l e f t with s t r o n g n e g a t i v e f e e l i n g s a f t e r the event of Postpartum Blues. Yet another e x p l a n a t i o n might be t h a t the postpartum women pre -v i o u s l y r e p o r t i n g t o the i n v e s t i g a t o r l o n g - l a s t i n g n e g a t i v e f e e l i n g s subsequent to Postpartum Blues had indeed not ex-pe r i e n c e d Postpartum Blues, but had s u f f e r e d an undetected Postpartum Depression. On the other hand, the findings are consistent with those of two other studies. The Beck Depression Inventory did not prove to be a useful measure i n pred i c t i n g the development of Postpartum Blues i n the women at home on the basis of t h e i r t o t a l score on the inventory administered at the hospital interview. A l l but one of the women's t o t a l scores on the inventory adminis-tered while i n ho s p i t a l were between zero and thirteen, the non-depressed category. The t o t a l scores of the twenty-six women were divided into two groups;™—those below seven and those from seven to fourteen. The scores were then compared to the incidence of Postpartum Blues, both i n the ho s p i t a l and at home. The ch i square t e s t showed no s i g n i f i c a n t differences. One woman had a t o t a l score of seventeen i n the ho s p i t a l and she experienced Postpartum Blues both i n the hosp i t a l and at home. The Beck Depression Inventory scores provided by the home interview were not r e f l e c t i v e of the incidence of Post-partum Blues i n the women at home. When compared to the inventory scores provided at the hospital interview the home inventory scores exceeded the ho s p i t a l inventory scores i n nine instances. None of the scores on the home inventory was greater than nine. In view of these findings the Beck Depression In-ventory did not prove useful i n pre d i c t i n g mild, 'transitory states of depression. Regarding moderately depressed states B r i c e . P i t t , '"Maternity Blues. *" B r i t i s h Journal of Psychiatry, CXX (1973);;433l. Yaldm an^;0^hers; 1 6 c : r c i t . . ;_> 57 there was only one woman whose ho s p i t a l inventory score was in t h i s category. This woman developed Postpartum Blues i n the ho s p i t a l and at home. Furthermore, the duration of Post-partum Blues f o r t h i s woman was three to four days, i n t e r -mittantly. Also t h i s woman reported that feelings consequent to the Postpartum Blues experience were that i t was a "thor-oughly unpleasant" experience. It might well be that the Beck Depression Inventory would consistently d i f f e r e n t i a t e between postpartum women who are; moderately or highly depressed and those who are non-depressed or mildly depressed. I I I . INCIDENCE OF STRESS ITEMS RELATED TO MATERNAL ROLE CONFLICT Data provided by the interview schedules showed that a l l of the study population reported some stress items related to maternal r o l e c o n f l i c t . The frequencies of each item were categorized according to the incidence of Postpartum Blues. The ch i square test was then used f o r each item to determine the significance of the difference between the group who experienced Postpartum Blues and the group who did not experience Postpartum Blues. The items were tabulated i n the manner described and under the headings oft inadequate pre-paration f o r maternal roles anxiety about maternal roles con-f l i c t with other roles and di s t r e s s i n g events during the puerperiumj inadequate help or support from s i g n i f i c a n t other persons; and emotional and cognitive changes. 7 'Richard Gordon and Katherine Gordon, "Social Factors i n Prevention of Postpartum Emotional Problems,"Obstetrics and  Gynecology XV, 4 ( A p r i l , I960), 433} Francis J . Kane, Jnr., "Emotional and Cognitive Disturbance i n the Early Puerperium," B r i t i s h Journal of Psychiatry, 114 (1968), 99. y 58 There was no s i g n i f i c a n t difference at the .05 l e v e l f o r any of the items. Further to t h i s , each stress item related to mater-nal role c o n f l i c t was assigned a value of one and t o t a l s were made f o r every woman i n each of the f i v e groups under the headings described above. These scores .were then tabulated according to the incidence of Postpartum Blues, f o r examples Number of emotional and cognitive changes 0 1 2 3 4 number of woman who developed Postpartum Blues 3 7 5 2 3 number of women who did not de-velop Postpartum Blues k 1 0 0 The chi square test was used to test for s i g n i f i -cant differences i n each of the f i v e groups. There were no s i g n i f i c a n t differences at the .05 l e v e l . F i n a l l y , a l l of the stress items of the f i v e groups were t o t a l l e d for each woman, then divided into three cate-gories of 1-5 items, 6-10 items, and 11-15 items. The cate-gories were then c l a s s i f i e d .into Postpartum Blues and no Postpartum Blues and the chi square test was used to test f o r s i g n i f i c a n t differences. Again, there were no s i g n i f i c a n t differences at the .05 l e v e l . Inadequate Preparation f o r Maternal Role The mothers of a l l the women i n the study group were a l i v e . Two women were raised by adoptive parents who, 59 f o r the purposes of t h i s study, were regarded f o r most items as t h e i r own pa r e n t s . S i x women had parents who l i v e d i n d e -pendently o f each other. Four o f these women experienced Postpartum Blues while two d i d not experience Postpartum B l u e s . Ten of the women had husbands whose f a t h e r s were dead. Seven of these women developed Postpartum Blues compared with three who d i d not. One woman's husband had parents who were l i v i n g s e p a r a t e l y . Table 9 i l l u s t r a t e s t h i s i n f o r m a t i o n . With r e g a r d to education, f i v e women had l e s s than a h i g h s c h o o l g r a d u a t i o n and a l l f i v e women experienced Postpartum Blues. T h i s f i n d i n g , although not s i g n i f i c a n t , was perhaps due to the s m a l l s i z e of the p o p u l a t i o n . The f a c t t h a t a l l of the women whose e d u c a t i o n a l attainment was l e s s than h i g h s c h o o l completion developed Postpartum Blues might support f i n d i n g s r e p o r t e d i n two s t u d i e s . The f i n d i n g s of those two s t u d i e s were t h a t l e s s than completion o f hig h s c h o o l e d u c a t i o n 8 r e p r e s e n t s a s t r e s s f a c t o r i n postpartum emotional adjustment. Fourteen women had a hi g h e r e d u c a t i o n than t h e i r parents and ten of these women experienced Postpartum Blues while f o u r d i d not experience Postpartum Blues. The husbands o f t h i r t e e n women had .a hi g h e r e d u c a t i o n than h i s p a r e n t s . Of these t h i r t e e n -wo- v ;men,eleven experienced Postpartum Blues and f o u r d i d not exper-ience Postpartum Blues. The husbands of e l e v e n women had a ! h i g h e r e d u c a t i o n than t h e i r wive's parents,,- nine o f these women Ri c h a r d E. Gordon, E l i E. Kapostins and Ka t h e r i n e K. Gordon, " F a c t o r s i n Postpartum Admustment," O b s t e t r i c s and  Gynecology, XXV (February, 1965), 159. : 60 experienced Postpartum Blues while two d i d not experience Postpartum Blues. T h i s i n f o r m a t i o n i s shown i n Table 9. In r e l a t i o n to occu p a t i o n s i x women's husbands had a h i g h e r occupation than . t h e i r "parents and a l l of -'-these women experienced Postpartum Blues. While t h i s f i n d i n g was not s i g n i f i c a n t the l a c k of s i g n i f i c a n c e may be due to the sm a l l s i z e of the p o p u l a t i o n . C e r t a i n l y the f i n d i n g 1 i s s u g g e s t i v e of support f o r the f i n d i n g s of a study r e p o r t e d Q by Gordon, Kapostins, and Gordon. That study showed t h a t when the husband's occ u p a t i o n was h i g h e r than t h a t o f h i s parents i t c o n s t i t u t e d a s t r e s s f a c t o r i n postpartum emotion-a l adjustment. ^However, the f i n d i n g of a l l s i x women develop-i n g Postpartum Blues may be e n t i r e l y by chance. Four women's husbands had a h i g h e r o c c u p a t i o n than the women's p a r e n t s . Three of these women experienced Postpartum Blues while one d i d not experience the episode. Table 9 shows t h i s i n f o r -mation. Regarding r e l i g i o n there were f i v e women who had an i n t e r r e l i g i o u s marriage. A l l of these women experienced Postpartum Blues. In f o u r i n s t a n c e s one p a r t n e r was r e a r e d i n the Roman C a t h o l i c Church and one i n the P r o t e s t a n t f a i t h . Although t h i s f i n d i n g was not s i g n i f i c a n t i t i s p o s s i b l e t h a t the s m a l l s i z e o f the p o p u l a t i o n may account f o r t h i s . That a l l f i v e women developed Postpartum Blues might w e l l be a c o i n c i d e n c e . On the other hand, i t might support the f i n d -Gordon, Kapostins, and Gordon, op. c i t . , p. 162. 6i i n g s i n a study r e p o r t by L a n d i s . 1 0 The Landis study showed t h a t marriages between C a t h o l i c s and P r o t e s t a n t s i n v o l v e more hazards t h a t do those between members of one f a i t h . Table 9 Incidence o f S t r e s s Items Re l a t e d to Maternal C o n f l i c t — I n a d e q u a t e Pre-p a r a t i o n f o r Maternal R o l e — B y Incidence of Postpartum Blues i n the Study P o p u l a t i o n Item Postpartum Blues No Postpartum Blues Husband's f a t h e r dead 7 3 Parents separated k 2 Husband's parents separated 1 0 E d u c a t i o n l e s s t h a t h i g h s c h o o l 5 0 E d u c a t i o n h i g h e r than parents 10 Husband's e d u c a t i o n h i g h e r than h i s parents i l 2 Husband's e d u c a t i o n h i g h e r than w i f e ' s p a r e n t s 9 2 Husband's occupation h i g h e r than h i s parents 6 0 Husband's occupation h i g h e r than w i f e ' s parents 3 1 I n t e r r e l i g i o u s marriage 5 0 Judson T. Landis, "Marriages of Mixed and Non-mixed R e l i g i o u s F a i t h , " American S o c i o l o g i c a l Review, XIV (June, 19 k9), k06. (, 62 -A n x i e t y about Maternal Role Only two women had not always expected to become mothers. Both of these women experienced Postpartum B l u e s . A l l but one of the women claimed to have a very good r e l a t i o n s h i p with t h e i r mothers. The excepted woman, who responded t h a t she d i d not get a l o n g with her mother very w e l l , experienced Postpartum Blues. Because o f the value t h a t s o c i e t y p l a c e s on having a good r e l a t i o n s h i p w i t h one's mother t h i s f i n d i n g can not be c o n v i n c i n g without a measure-ment o f s o c i a l d e s i r a b i l i t y . I t c o u l d be t h a t more than one woman had a l e s s than adequate r e l a t i o n s h i p w i t h t h e i r moth-e r s . On the other hand, i t c o u l d be t h a t d u r i n g the r e c e n t pregnancy,or a p r e v i o u s pregnancy the women had r e m i n i s c e d and r e s o l v e d any past c o n f l i c t s i n t h e i r r e l a t i o n s h i p s w i t h t h e i r mothers i n the process of maternal r o l e attainment 11 d e s c r i b e d by Rubin. A l l but two women claimed to have a very c l o s e r e l a t i o n s h i p with t h e i r husbands. The excepted two women, who responded t h a t t h e i r r e l a t i o n s h i p with t h e i r husbands was a l r i g h t , both experienced Postpartum Blues. Again, t h i s f i n d i n g may i n p a r t r e p r e s e n t s o c i a l d e s i r a b i l i t y r a t h e r than a c t u a l i t y . However, the f a c t t h a t twenty-eight women r e p o r t e d t h a t t h e i r husbands gave c o n s i d e r a b l e a s s i s t a n c e w i t h baby care and household d u t i e s does support t h i s f i n d i n g . Reva Rubin, "Attainment o f Maternal Role, Part I I , Models and R e f e r r a n t s , " Nursing Research, XVI ( F a l l , 1 9 6 ? ) , 343-46. — In the study population there were fourteen primiparas and three multiparas who had given birth to one infant but who had no infant care experience in relat ion to that infant. Of these seventeen women, eleven experienced Postpartum Blues while six did not experience the episode. The six women who did not experience Postpartum Blues were a l l primiparas. Therefore, the number of primiparas who experienced Postpartum Blues was lower than that expected. Even including the three - multiparas' mentioned, fewer of the women engaged in their f i r s t own baby-caring experience developed Postpartum Blues^than did the multiparas with other chi ldren. Table 10 shows this information. This f inding, then, i s in contradiction to the findings of other studies which show that more primiparas than miltiparas experienced d i f f i cu l ty in postpartum adjust-12 ment. Perhaps this i s by chance, in view of the small study population. On the other hand, this population may have had fewer stress factors than had the populations of the other studies. Those study populations were larger, were more heterogeneous in nature, and were residents of c i t i e s in the United States of America. Then again, in this study a l l but one of the seventeen women engaged in their f i r s t own baby-care experience had attended prenatal classes. Only one woman had experienced a previous physical problem with childbearing and this was a threatened immature delivery at twenty-four weeks gestation. This woman exper-t-Gordon and Gordon, op. c i t . , p. 4 3 4 : Yalom and Others, op. c i t . , p. 2 4 . ienced Postpartum Blues. Excepting the two women with adoptive parents for whom there was no information available, seven women had mothers or s i s t e r s who had experienced problems i n c h i l d -bearing. Five of these women developed Postpartum Blues while two did not develop Postpartum Blues. This i s shown in Table 10. Again, i n view of the small numbers, t h i s f i n d -ing i s hard to interpret. However, the fin d i n g i s not incon-s i s t e n t with the fin d i n g of twenty percent reported by Larsen and Others. J Of the seventeen primiparas and multiparas with no previous own baby-care experience, three primiparas had no previous experience with baby care. These three women de-veloped Postpartum Blues. Once again, t h i s f inding cannot be interpreted because of the small size of the study popu-l a t i o n . However, the fin d i n g does suggest that no previous experience with baby care i s a factor i n Postpartum.Blues. Larsen and others reported that l i t t l e or no previous c h i l d -care experience occurred i n sixteen percent of those with postpartum emotional d i f f i c u l t i e s i n a study i n 1968. A l l but one of the seventeen women with f i r s t bab-ies attended prenatal classes. The excepted woman experienced Postpartum Blues. Of the f i f t e e n multiparas, eight attended prenatal classes while carrying the present infant and the remaining seven women attended prenatal classes with t h e i r 13 -'Larsen, op. c i t . , p. 25. l k I b i d . , p. 23. -65 l a s t pregnancy. Of these seven women, f i v e experienced Postpartum Blues w h i l e two d i d not experience the epi s o d e . Inferences cannot he made from these f i n d i n g s because o f the sm a l l numbers and because of i n s u f f i c i e n t data about the amount of i n f o r m a t i o n the m u l t i p a r a s remembered from p r e v i o u s p r e n a t a l c l a s s e s . Regarding a n x i e t y d u r i n g pregnancy about l a b o u r and d e l i v e r y e l e v e n women r e p o r t e d a l i t t l e concern and f o u r women r e p o r t e d a l o t of concern. Seven of the el e v e n women who were s l i g h t l y concerned experienced Postpartum Blues while f o u r d i d not experience the episode. A l l f o u r women who were h i g h l y concerned d u r i n g pregnancy about l a b o u r and d e l i v e r y experienced Postpartum B l u e s . Table 10 shows t h i s i n f o r m a t i o n . These f i n d i n g s , w h ile s u g g e s t i v e of a r e l a t i o n -s h i p between Postpartum Blues and concern about l a b o u r and d e l i v e r y were not s i g n i f i c a n t . N e v e r t h e l e s s , the d i r e c t i o n of the tendency i s i n c o n t r a s t to the f i n d i n g s o f the study by Larsen i n which s t r e s s e s d u r i n g pregnancy showed l i t t l e or no p r e d i c t i v e value f o r postpartum s t r e s s . ^ In r e l a t i o n to e x p e c t a t i o n s about l a b o u r and de-l i v e r y , e l e v e n women expected t h e i r l a b o u r and d e l i v e r i e s to be e a s i e r than they were. Of these e l e v e n women, e i g h t experienced Postpartum Blues and three d i d not experience the episode. F i v e women expected t h e i r l a b o u r s and d e l i v e r -i e s to be about the same as they were and none o f these 1 ^ V i r g i n i a L. Larsen, " S t r e s s e s of the C h i l d b e a r i n g Year," American J o u r n a l o f P u b l i c H e a l t h , LVI (January, 1966), 36. 66 women experienced Postpartum Blues. The remaining t h i r t e e n women expected t h e i r l a b o u r s to be harder than they were. Seven of the t h i r t e e n women experienced Postpartum Blues while s i x d i d not experience the episode. Table 10 i l l u s -t r a t e s t h i s i n f o r m a t i o n . Table 10 Incidence o f Stress- -I;tems Related..to Maternal Role C o n f l i c t s r - A n x i e t y About Maternal ' ,Role--by Incidence of Postpartum * Blues i n the Study P o p u l a t i o n Item Postpartum Blues No Postpartum Blues P r i m i p a r a or m u l t i -para with no c h i l d -r e n 11 Mother or s i s t e r had problems with c h i l d -b e a r i n g 5 No p r e v i o u s experience with babies 3 A few concerns d u r i n g pregnancy about l a b o u r and d e l i v e r y 7 A l o t o f concerns d u r i n g pregnancy about l a b o u r and d e l i v e r y 4 Expected l a b o u r to be e a s i e r than i t was 8 Changed i n f a n t from b r e a s t to b o t t l e f e e d i n g 7 2 0 0 3 3 Only two women had a few concerns about baby care d u r i n g t h e i r pregnancies and both women experienced Postpartum Blues. However, twelve women had a few concerns and one woman a l o t of concerns about baby care a f t e r confinement and while s t i l l i n the h o s p i t a l . E i g h t of the twelve women with a few concerns developed Postpartum Blues while f o u r d i d not develop Postpartum Blues. The one woman with a l o t of concerns developed Postpartum Blues. Of the s i x t e e n r e -maining women who r e p o r t e d no concerns 'whilst i n h o s p i t a l e l e v e n women developed Postpartum Blues while f i v e d i d not develop;Postpartum Blues. E l e v e n o f the t h i r t e e n p u e r p e r a l women i n h o s p i t a l who had concerns about baby care were p r i m i p a r a s or m u l t i p a r a s with no c h i l d r e n a t home. The f a c t , then, 'that more of these women d i d not experience Postpartum 1 Blues might i n d i c a t e t h a t the concerns were p r e p a r a t o r y to the forthcoming maternal r o l e a t home r a t h e r than c o n f l i c t w ith maternal r o l e . Only f o u r women had s l i g h t concern about t h e i r babies a t home and i n each case the concern was r e g a r d i n g the baby's "wind" p a i n s . Three o f these women experienced Postpartum Blues a t home while one d i d riot. T h i r t e e n women began b r e a s t f e e d i n g t h e i r babies i n i t i a l l y w h i l e i n the h o s p i t a l and were c o n t i n u i n g one month l a t e r . E i g h t of these women experienced Postpartum Blues while f i v e d i d not. S i x women began b o t t l e f e e d i n g t h e i r i n f a n t s i n i t i a l l y w h i l e i n the. h o s p i t a l , f i v e of whom experienced Postpartum Blues while one d i d not experience the episode. The remaining ten women began b r e a s t f e e d i n g i n i t i a l l y w hile i n the h o s p i t a l but changed to b o t t l e f e e d -i n g w i t h i n one month. Seven of these women developed Post-partum Blues while three d i d not develop Postpartum B l u e s . 68 T h i s i n f o r m a t i o n i s shown i n Table 10. The reason f o r the changes and the time f o l l o w i n g b i r t h of the changes are as follows J f i v e women stopped b r e a s t f e e d i n g because of inadequate m i l k supply, f o u r be-tween s i x and t e n days and one a t twenty-eight days; one woman had i n v e r t e d n i p p l e s which became cracked and she changed the s t y l e of i n f a n t f e e d i n g a t f o u r days;; one woman d e s i r e d her husband to share i n the f e e d i n g and to g i v e her r e l i e f with f e e d i n g a t n i g h t , and she changed the f e e d i n g s t y l e a t nine days; one woman had a b r e a s t abscess and she changed the f e e d i n g s t y l e a t ten days;, one woman's i n f a n t was a l l e r g i c to b r e a s t - m i l k and was changed to formula a t nine days; and f i n a l l y one woman had c o m p l i c a t i o n s f o l l o w i n g the e p i d u r a l a n a e s t h e s i a g i v e n d u r i n g labour, and her baby was changed to formula a t s i x days. C o n f l i c t with Other Roles and D i s t r e s s i n g Events During  The Puerperium Seven women had :unplanned pregnancies. F i v e of these women experienced Postpartum Blues while two d i d not experience the episode. Although no c o n c l u s i o n s can be drawn from t h i s i n s i g n i f i c a n t f i n d i n g , i t i s i n t e r e s t i n g to note that two of these women who experienced Postpartum Blues r e p o r t e d a l o t of concerns about l a b o u r and d e l i v e r y d u r i n g t h e i r pregnancies and one woman r e p o r t e d a few concerns. Such a f i n d i n g on a l a r g e r s c a l e might l e n d support to the c l a i m by Rice t h a t "those with the more s e r i o u s problems about l a b o u r and d e l i v e r y were the ones who had poor p e r s o n a l and s o c i a l adjustments and who had not planned t h e i r p r e g -16 n a n c i e s . Of the e i g h t women who had p r e v i o u s l y experienced Postpartum Blues, s i x experienced the episode a g a i n while two d i d not experience i t . Three of the remaining f o u r m u l t i p a r a s who had not p r e v i o u s l y experienced Postpartum Blues developed Postpartum Blues f o l l o w i n g the b i r t h o f t h i s baby while one d i d not develop the episode. These f i n d -i n g s do not len d support to the f i n d i n g s of other s t u d i e s which showed t h a t the occurrence of p r e v i o u s Postpartum Blues was h i g h l y p r e d i s p o s i n g to postpartum p s y c h i a t r i c d i s o r d e r s . N e v e r t h e l e s s , the s m a l l sample s i z e and the r e s t r i c t i o n s o f the study may have p r e c l u d e d s i g n i f i c a n t f i n d i n g s . There were e l e v e n women i n the study p o p u l a t i o n who had i n f a n t s e x - p r e f e r e n c e s . Three o f these women had i n f a n t s of the p r e f e r r e d sex, none of whom experienced Postpartum Blues. E i g h t women had i n f a n t s of the n o t - p r e f e r r e d sex, s i x of whom experienced Postpartum Blues and two of whom d i d not experience the episode. Adjustment d i f f i c u l t i e s i n r e l a t i o n t o baby's needs, housework r o u t i n e , other c h i l d r e n ' s needs, i n t e r f e r e n c e from neighbours and r e l a t i o n s , and i n c r e a s e d company were not r e -por t e d as a problem by any of the study p o p u l a t i o n . T h i s • ^ E l i z a b e t h P. Rice, " A f t e r O f f i c e Hours," O b s t e t r i c s and Gynecology. XXIII (February, 1964), 311. — 17 F r e d e r i c k T. Melges, "Postpartum P s y c h i a t r i c Syn-dromes, Psychsomatic Medicine. XXX (January, 1968), 9 8 5 B r i c e P i t t , " ' A t y p i c a l ' , Depression F o l l o w i n g C h i l d b i r t h , " B r i t i s h J o u r n a l of P s y c h i a t r y . CXIV (1968), 1332? Yalom, op. c i t . , p. 26. 70 c o u l d w e l l be because o f the high attendance of the study-p o p u l a t i o n a t p r e n a t a l c l a s s e s where adjustment d i f f i c u l t i e s are discussed'. Table 11 Incidence of S t r e s s Items, R e l a t e d to Maternal Role C o n f l i c t — C o n f l i c t w i t h Other Roles and D i s t r i s s i n g Events During the Puerperium—by Incidence of Postpartum Blues i n the Study P o p u l a t i o n Item Postpartum Blues No Postpartum Blues Pregnancy unplanned 5 2 P r e v i o u s Postpartum Blues 6 2 P r e f e r e n c e f o r i n f a n t of opposite sex 6 2 D i s t r e s s i n g events i n the puerperium k 2 S i x women experienced d i s t r e s s i n g events d u r i n g t h e i r f i r s t week a t home a f t e r d i s c h a r g e from the h o s p i t a l . Four of these women developed Postpartum Blues while two d i d not experience the episode. The d i s t r e s s i n g events i n v o l v e d p h y s i c a l c o n d i t i o n s of e i t h e r the woman or her baby. One woman developed a b r e a s t abscess. A second woman had a lung i n f e c t i o n f o l l o w i n g i n f l u e n z a , and as w e l l as the pass-age o f some b l o o d c l o t s v a g i n a l l y , A t h i r d woman developed c o m p l i c a t i o n s f o l l o w i n g the e p i d u r a l a n a e s t h e s i a g i v e n d u r i n g l a b o u r . S i x hours a f t e r her r e t u r n home from the h o s p i t a l the woman developed severe headache, d i z z i n e s s , and v o m i t t i n g and was consequently t r e a t e d i n a g e n e r a l h o s p i t a l f o r f o u r 7 1 days. One i n f a n t developed j a u n d i c e as a r e s u l t of b r e a s t m i l k and was h o s p i t a l i z e d f o r f o u r days. A second i n f a n t had a p h y s i o l o g i c a l jaundice which i n c r e a s e d a f t e r he went homes t h e r e f o r e he was h o s p i t a l i z e d f o r f i v e days. L a s t l y , a t h i r d i n f a n t developed h y p e r a c t i v i t y a f t e r g o i ng home and he r e c e i v e d m edications f o r the c o n d i t i o n . Inadequate Help or Support from S i g n i f i c a n t Other Persons Only one of the husbands was not p r e s e n t throughout h i s w i f e ' s f i r s t stage of labour, but he was p r e s e n t f o r her d e l i v e r y . T h i s woman developed Postpartum Blues. Four o f the husbands were not presen t d u r i n g t h e i r wive's d e l i v e r i e s . Three o f these women developed Postpartum Blues while one d i d not experience the episode. A l l of the women responded t h a t they were helped dur-i n g labour, some by more than one a i d . The s i g n i f i c a n t h e l p a c c o r d i n g to the i n c i d e n c e of Postpartum Blues i s shown i n Table 1 2 . Table 12 S i g n i f i c a n t Help During Labour by Incidence of Postpartum Blues i n the Study P o p u l a t i o n S i g n i f i c a n t Help Postpartum Blues No Postpartum Blues S e l f 0 Husband 16 8 Nurse 5 0 B r e a t h i n g 3 k P r e n a t a l C l a s s 1 0 Demerol 2 1 ,- ?2 A l l of the women s t a t e d t h a t they were/helped d u r i n g d e l i v e r y , some by more than one a i d . The s i g n i f i c a n t h e l p a c c o r d i n g to the i n c i d e n c e of Postpartum Blues i s shown i n Table 13. Table 13 S i g n i f i c a n t Help During D e l i v e r y By Incidence of Postpartum Blues i n the Study P o p u l a t i o n S i g n i f i c a n t Help Postpartum Blues No Postpartum Blues S e l f 3 0 Husband 6 5 Nurse 3 2 Doctor 6 3 E p i d u r a l 3 B r e a t h i n g 1 M i r r o r 1 1 S i x t e e n women had an e x t r a person, mostly a mother or s i s t e r , s t ay to h e l p f o r the f i r s t f i v e to f o u r t e e n days a f t e r t h e i r r e t u r n home wit h t h e i r b a b i e s . Of these s i x t e e n women, eleve n developed Postpartum Blues while f i v e d i d not develop the episode. Of the women who d i d not have someone stay to help , nine developed Postpartum Blues and f o u r d i d not develop the episode. However, e x t r a help a t home was not measurable because of inadequate data and because most of the women's husbands had e x t r a time a t home over the Christmas p e r i o d . A l l but one of the husbands were r e p o r t e d to l e n d c o n s i d e r a b l e h e l p to t h e i r wives, both with baby care and household routines. None of the women had husbands who spent time away from home overnight. Emotional and Cognitive Changes Nine women reported some degree of mood l a b i l i t y i n that they experienced v a c i l l a t i n g feelings from happiness to sadness. Of these women, eight developed Postpartum Blues while one did not develop the episode. Of the remaining twenty women who reported no mood change, twelve developed Postpartum Blues while one did not develop the episode. Emo-t i o n a l and cognitive disturbances which occurred and t h e i r r e l a t i o n s h i p to the incidence of Postpartum Blues are shown in Table 14. Table 14 Incidence of Stress Items Related to Maternal Role C o n f l i c t — E m o t i o n a l and Cognitive Changes—by Incidence of Postpartum Blues i n the Study Population Item Postpartum Blues No Postpartum Blues Mood l a b i l i t y 8 1 S l i g h t reduction i n recent memory 6 2 S l i g h t increase i n d i s t r a c t a b i l i t y 4 1 Decrease i n concentration 8 0 Increased feelings of dependency 11 1 Because of t h e i r ins ignificance these findings were unable to shed any further l i g h t on the question of the association of diminished mental functioning and sub-1 Q jective d i s t r e s s as suggested by Kane and others. Increased feelings of dependency were experienced by twelve women, eleven of whom developed Postpartum Blues and one of whom did not developJthe episode. Of the remain-ing seventeen women who perceived no increase i n t h e i r de-pendency feelings nine developed Postpartum Blues while eight did not develop the episode. This finding, while below the s i g n i f i c a n t l e v e l of acceptance, indicated a ten-dency f o r Postpartum Blues to occur with increased feelings of dependency. This tendency would c e r t a i n l y support the viewpoint of both Auerbach and Riker that increased depen-19 dency needs are preparatory to maternal role attainment. None of the women reported any feelings of entrap-ment. None of the women reported that t h e i r goals had been blocked. Only one woman stated that her goals had been de-ferred because of the baby and t h i s woman experienced Post-partum Blues. Fif t e e n women stated that t h e i r goals were more d i f f i c u l t to a t t a i n because of the babies. Ten of these women developed Postpartum Blues and f i v e did not develop' the episode. Of the remaining thirteen women who stated t h e i r goals as unaffected by the babies nine developed Post-partum 31ues and four did not develop the episode. Kane, op. c i t . , p. 101. 7Audrey Riker, "New Parent Blues," Child and Family, VI (Spring, 196?), 11j Auerbach, op. c i t . , p. 12. 75 VI. INCIDENCE OF SPECIFIC ENDOCRINE FACTORS RELATED TO THE MENSTRUAL CYCLE Information p r o v i d e d by the i n t e r v i e w schedules showed t h a t only one woman had not experienced a t l e a s t one of the menstrual c y c l e d i f f i c u l t i e s c i t e d i n the l i t e r a t u r e . The one excepted woman developed Postpartum Blues. Nine women r e p o r t e d the f i r s t d i f f i c u l t y (age of menarche between nine and e l e v e n ) . F i v e o f these women developed Postpartum Blues while f o u r d i d not develop the episode. F i f t e e n of the remaining twenty who d i d not r e p o r t the d i f f i c u l t y d e v e l -oped Postpartum Blues while f i v e d i d not develop: the episode. Although not s i g n i f i c a n t , the d i r e c t i o n o f t h i s f i n d i n g i s i n c o n t r a s t to-the f i n d i n g s r e p o r t e d by Yalom and others which 20 c o r r e l a t e d e a r l y age of menarche with Postpartum Blues. Of the s i x women who r e p o r t e d the second d i f f i -c u l t y ( i r r e g u l a r p e r i o d s ) f i v e developed Postpartum Blues and one d i d not develop the episode. E i g h t women r e p o r t e d the t h i r d d i f f i c u l t y (dys-menorrhoea). S i x of these women experienced Postpartum Blues while two d i d not experience the episode. Therefore f o u r -teen of the women who d i d not r e p o r t dysmenorrhoea developed Postpartum Blues w h i l e seven d i d not develop the episode. Of the t h i r t e e n women who r e p o r t e d the f o u r t h Yalom and Others, op. c i t . , p. 24. d i f f i c u l t y (premenstrual d e p r e s s i o n ) ten developed P o s t -partum Blues and three d i d not develop the episode. Therefore, t e n of the women who d i d not r e p o r t premenstrual d e p r e s s i o n developed Postpartum Blues and s i x d i d not de-velop the episode. E i g h t e e n women r e p o r t e d the f i f t h d i f f i c u l t y (premenstrual i r r i t a b i l i t y ) . T h i r t e e n of these women ex-pe r i e n c e d Postpartum Blues while f i v e d i d not experience the episode. Therefore, of the remaining n i n e t e e n women who d i d not r e p o r t premenstrual i r r i t a b i l i t y , twelve de-veloped Postpartum Blues and seven d i d not develop the, episode. Table 15 i l l u s t r a t e s the i n c i d e n c e of each menstrual d i f f i c u l t y r e p o r t e d a c c o r d i n g t o the i n c i d e n c e of Postpartum Blues. The f i n d i n g s o f the second to the f i f t h d i f f i c u l t i e s r e p o r t e d by the study p o p u l a t i o n showed no tendencies s u p p o r t i v e of the f i n d i n g s r e p o r t e d i n the 21 study by Yalom and o t h e r s . The d i f f i c u l t y of s h o r t d u r a t i o n o f menstrual flow was not r e p o r t e d by any of the study p o p u l a t i o n . 2 1 I b i d . 77 Table 1 5 Incidence of Menstrual C y c l e D i f f i c u l t i e s A c c o r d i n g to Incidence of Postpartum Blues i n the Study P o p u l a t i o n D i f f i c u l t y Number Who Number Who Did Reported Developed Not Develop Post-Postpartum Blues partum Blues Age of Menarch 9 - 1 1 y e a r s 5 I r r e g u l a r p e r i o d s 5 1 Dysmenorrhoea 6 2 Premenstrual Depression 1 0 3 Premenstrual I r r i t a b i l i t y 1 3 5 V. INCIDENCE OF SLEEP DEFICIENCY Information c o n c e r n i n g s l e e p was c o l l e c t e d by the i n t e r v i e w schedules. With r e g a r d to the p a t t e r n of s l e e p a t home d u r i n g the f i r s t week, no c o n c l u s i o n s other than i t was r e p o r t e d l y b e t t e r than when i n h o s p i t a l , c o u l d be drawn due to i n s u f f i c i e n t data. Therefore, only the data from the h o s p i t a l i n t e r v i e w schedule were used. The amount of u n i n t e r -rupted s l e e p obtained from the day p r i o r to the. onset of l a b o u r and f o r the three days f o l l o w i n g confinement were examined. Of n e c e s s i t y , any s l e e p which may have been obtained d u r i n g l a b o u r was not accounted f o r . I t was f e l t t h a t the women co u l d not estimate any s l e e p t h a t they may have had and i t was beyond the scope of t h i s study to make o b s e r v a t i o n s on sleep. Also, i t was improbable that even one sleep cycle could have been completed during labour i n the hos p i t a l be-cause of pa i n f u l contractions and because of nursing care procedures. Therefore, the four-day period referred to i n t h i s section i s a c t u a l l y four twenty-four hour days plus the duration of labour which was between one hour and t h i r t y minutes and fourteen hours and ten minutes. The number of sleep cycles possible during each period of uninterrupted sleep reported by the women fo r each of the four days was estimated. A minimum of eighty-five 2 2 minutes was counted as equal to one sleep cycle. The num-ber of sleep cycles f o r each woman was then t o t a l l e d f o r the four-day period. Next, the data were tabulated i n the following way: Thirteen sleep cycles Twelve sleep cycles or more i n four days or less i n four days Postpartum Blues 3 1 7 No Postpartum Blues 6 3 The chi square test showed a s i g n i f i c a n t difference between the two groups. The r e s u l t was ?.? L at the .05 l e v e l . The number of sleep cycles were t o t a l l e d f o r two days and fo r three days of the four-day period under examina-tion and were s i m i l a r l y tested. However, the findings were i n s i g n i f i c a n t . It would appear, then, that i f the deficiency of sleep persisted beyond three days, the development of Post-Nathaniel Kleitman, Sleep and Wakefulness (Chicago.-University of Chicago Press, 1 9 ^ 3 ) p. 1 1 2 . partum Blues resulted. Perhaps th i s explains the fa c t noted i n the l i t e r a t u r e that Postpartum Blues rarely occurs be-23 fore the t h i r d postpartum day. In accordance with sleep theory four or more sleep cycles i n twenty-four hours was regarded as adequate sleep, two or three cycles as inadequate and zero or one cycle as oh a sleep deprivation. Therefore, twelve or less sleep cyc-les i n four days consistuted inadequate sleep or sleep de-pr i v a t i o n i n the study population. In view of the exertion of labour the sleep needs are generally considered to be increased i n the early puerperium. Consequently, sleep de-f i c i e n c i e s imposed an even greater hardship on the recently-confined women. It i s not surprising, then, that t h i s f i n d -ing was s i g n i f i c a n t . This f i n d i n g i s s i m i l a r to a fi n d i n g 2 *5 reported i n the study by Yalom and others. J The fi n d i n g i s also supportive of the l i t e r a t u r e i n that the lack of sleep 26 may lead to exhaustion that precedes depression. In fact, of the seventeen women who experienced Postpartum Blues at home seven thought that the episode had been caused by fatigue due to d e f i c i e n t sleep. Therefore the perceptions of the study population which implicated a 2 3 P i t t , "Maternity Blues," op. c i t . p. k31? Yalom and Others, op. c i t . , p. 16. oh Susanna Lee Garner and Pamela M i t c h e l l , "Com-f o r t and Sleep," Concepts Basic to Nursing, (McGraw H i l l Book Company, 1973), p. k 3 8 . 2 < -. ^Yalom, op. c i t . , p. 20! 26 Riker, op. cit.VvCp. ^ 14.' 80 r e d u c t i o n i n s l e e p as a cause of Postpartum Blues a l s o supports t h i s f i n d i n g of the study. VI..' SUMMARY Data c o l l e c t e d by the i n t e r v i e w instruments were d e s c r i b e d . S e l e c t e d c h a r a c t e r i s t i c s of the study p o p u l a t i o n were presented. The i n c i d e n c e of Postpartum Blues as d e r i v e d from the data was d e s c r i b e d . Data obtained to answer the three q u e s t i o n s asked by the study n e g a t i v e l y answered the f i r s t and second q u e s t i o n s and a f f i r m a t i v e l y answered the t h i r d q u e s t i o n when s t a t i s t i c a l l y a n a l y z e d . For the f i r s t q u e s t i o n the data showed t h a t the items of maternal r o l e c o n f l i c t examined d i d not s i g -n i f i c a n t l y i n f l u e n c e the development of Postpartum Blues. For the second q u e s t i o n the data showed t h a t spe-c i f i c endocrine f a c t o r s r e l a t e d to the menstrual c y c l e d i d not s i g n i f i c a n t l y i n f l u e n c e the development of Post-partum Blues. For the t h i r d q u e s t i o n the data'showed t h a t s l e e p d e f i c i e n c y , i n terms of the number of s l e e p c y c l e s over a four-day p e r i o d , s i g n i f i c a n t l y i n f l u e n c e d the development of Postpartum Blues. Of the twenty women who experienced s l e e p d e f i c i e n c i e s , seventeen (85 p e r c e n t ) developed Post-partum Blues whereas of the nine women who d i d not exper-ience s l e e p d e f i c i e n c i e s only three (33 p e r c e n t ) developed Postpartum Blues. CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS I. SUMMARY The purpose of t h i s d e s c r i p t i v e study was to d e t e r -mine the i n f l u e n c e o f c e r t a i n v a r i a b l e s ; upon the development of Postpartum Blues. The study was planned t o answer the f o l l o w i n g q u e s t i o n s : (1) Do f a c t o r s r e l a t e d to maternal r o l e c o n f l i c t i n f l u e n c e the development of Postpartum Blues? (2) Do s p e c i f i c endocrine f a c t o r s r e l a t e d t o the menstrual c y c l e i n f l u e n c e the development of Postpartum Blues? (3) Does a r e d u c t i o n i n the number of s l e e p c y c l e s i n f l u e n c e the,develop ment of Postpartum Blues? A review of the l i t e r a t u r e presented r e l e v a n t theory and r e s e a r c h p e r t i n e n t to Postpartum Blues i n f i v e s e c t i o n s . The f i r s t s e c t i o n viewed the puerperium as a developmental c r i s i s . The second s e c t i o n viewed the changes o c c u r r i n g i n the puerperium. The t h i r d s e c t i o n viewed some concepts of r o l e theory. The f o u r t h s e c t i o n viewed s l e e p needs. L a s t l y , the f i f t h s e c t i o n viewed the Postpartum Blues syndrome. The l i t e r a t u r e review showed t h a t the Post-partum Blues syndrome has a r e p o r t e d occurrence o f anywhere between f i v e and e i g h t y p e r c e n t . A v a r i e t y of f a c t o r s were r e p o r t e d as i m p l i c a t e d i n the development of the syn-81 82/ drome. The most commonly suggested factors were maternal role c o n f l i c t items, endocrine factors, and sleep deficiency. The l i t e r a t u r e emphasized the importance of a s s i s t i n g women to meet t h e i r emotional needs i n the puerperium. Research studies on Postpartum Blues were limited both i n number and scope. Instruments used to obtain data relevant to the questions asked by the study were two semi-structured i n t e r -view schedules and one semi-structured questionnaire. These were developed following the l i t e r a t u r e review. In addition, the Beck Depression Inventory was used to measure the degree of depression present at the time of the interview. The study population consisted of twenty-nine postpartum women who delivered full-term, apparently healthy infants, i n one obstetrics and gynecology h o s p i t a l i n the Greater Vancouver area. Other c r i t e r i a of e l i g i b i l i t y to the study were willingness to pa r t i c i p a t e and ce r t a i n lang-uage, demographic, health, and o b s t e t r i c a l requirements. Two interviews were conducted, one i n ho s p i t a l on the t h i r d or fourth day, and one i n each woman's home at around four weeks a f t e r confinement. The data:, c o l l e c t e d by. the interview instruments were d e s c r i p t i v e l y analyzed. Charac t e r i s t i c s of the study population were described and shown i n frequency d i s t r i b u t i o n tables. The incidence of Postpartum Blues was assessed by information provided by the Blues Questionnaire. The Beck Depression Inventory did not prove to be a useful measure i n predi c t i n g the development of Postpartum Blues i n the women a t home on the b a s i s of t h e i r t o t a l score on the i n v e n t o r y a d m i n i s t e r e d a t the h o s p i t a l i n t e r v i e w . Data p e r t i n e n t t o maternal r o l e c o n f l i c t , s p e c i f i c endocrine f a c t o r s r e l a t e d to the menstrual c y c l e , and s l e e p d e f i c i e n c i e s were des-c r i b e d i n terms o f t h e i r c o i n c i d e n c e with the development o f Postpartum Blues. Tables c o n t a i n i n g t h i s i n f o r m a t i o n were i n c l u d e d . The c h i square t e s t was used to determine any s i g n i f i c a n t d i f f e r e n c e s between the women who experienced Postpartum Blues and the women who d i d not experience the episode i n r e l a t i o n to each of the items c o n s t i t u t i n g the three f a c t o r s under examination. The r e s u l t s showed t h a t there were no s i g n i f i c a n t d i f f e r e n c e s f o r items l e a d i n g to maternal r o l e c o n f l i c t or f o r items of s p e c i f i c endocrine f a c t o r s r e l a t e d t o the menstrual c y c l e . However, there was a s i g n i f i c a n t d i f f e r e n c e f o r s l e e p d e f i c i e n c y . I t was shown t h a t s l e e p d e f i c i e n c y i n terms of the number o f s l e e p c y c l e s over a four-day p e r i o d , s i g n i f i c a n t l y i n f l u e n c e d the development of Postpartum Blues. The m a j o r i t y of the women (85 p e r -cent) who experienced s l e e p d e f i c i e n c i e s developed Post-partum Blues whereas the m i n o r i t y o f those who d i d not experience s l e e p d e f i c i e n c i e s developed Postpartum Blues. I I . CONCLUSIONS On the b a s i s of the f i n d i n g s of t h i s study, the f o l l o w i n g c o n c l u s i o n s were made: 1. Postpartum Blues may w e l l be the t r i v i a l ' 84 and f l e e t i n g phenomenon as d e s c r i b e d by P i t t . 1 None of the women r e p o r t e d Postpartum Blues t o be a s s o c i a t e d with p r o -longed n e g a t i v e f e e l i n g s . Most o f the women r e p o r t e d viewing the episode as unpleasant while i t l a s t e d but not as over-whelming. Therefore,, i t was--concluded t h a t , f o r t h i s popular tion,Postpartum Blues was of no g r e a t importance. Furthermore, f o u r women viewed the episode as a l e a r n i n g e xperience. Accord-i n g l y Postpartum Blues may, i n f a c t , be b e n e f i c i a l to some wo-2 men as the l i t e r a t u r e suggested. The l o n g e s t d u r a t i o n of Postpartum Blues o c c u r r e d i n -t e r m i t t a n t l y over a p e r i o d of between f o u r and seven days with the e x c e p t i o n of one which l a s t e d i n t e r m i t t a n t l y over two weeks. Th i s f i n d i n g i s i n agreement with the assumption of the study, d e r i v e d from the l i t e r a t u r e , t h a t Postpartum Blues can be d i s -t i n g u i s h e d from other forms o f d e p r e s s i o n by i t s d u r a t i o n . The assumption t h a t the degree of s e v e r i t y of Postpartum Blues c o u l d be measured by the s e l f - r e p o r t e d s t a t e -ments of the women was supported i n p a r t by the study. Be-cause none of the women i n the study i n d i c a t e d symptoms or e x h i b i t e d behaviour c o n s i s t e n t w i t h d e p r e s s i o n of a more se-vere nature than the Postpartum Blues experienced, t h i s con-c l u s i o n was not d e f i n i t i v e . N e v e rtheless, the degree o f sev-e r i t y of the episode was i n d i c a t e d by the women as not severe. 1 B r i c e . P i t t , "Maternity B l u e s , " B r i t i s h J o u r n a l o f  P s y c h i a t r y . GXX (1973), 432-433. 2 P a u l e t t e Robischon and Diane S c o t t , "Role Theory and i t s A p p l i c a t i o n i n Family Nursing," Nursing Outlook XXVII ( J u l y , 1967), 54. 8 5 That the Beck Depression Inventory c o u l d measure the degree of s e v e r i t y of Postpartum Blues was not born out by the f i n d i n g s . Therefore, i t was concluded t h a t the i n -ventory was not a u s e f u l measure i n p r e d i c t i n g the develop-ment of Postpartum Blues on the b a s i s of the i n v e n t o r y score on the t h i r d or f o u r t h day postpartum. Conversely, i t c o u l d be concluded t h a t the i n v e n t o r y , by p l a c i n g a l l but one woman i n the non-depressed category, determined t h a t Postpartum Blues was a non-depressed s t a t e . However, such a c o n c l u s i o n would be i n c o n t r a d i c t i o n t o the r e p o r t e d f e e l i n g s of depres-s i o n experienced by the women i n c o n j u n c t i o n w i t h Postpartum Blues. 2 . The items of maternal r o l e c o n f l i c t examined i n t h i s study were not of s u f f i c i e n t magnitude or number to i n f l u e n c e the development o f Postpartum Blues. A l t e r n a t i v e l y , the items of maternal r o l e c o n f l i c t were counter-balanced by p o s i t i v e f o r c e s such ,that t h e i r e f f e c t was not s u f f i c i e n t t o i n f l u e n c e the development o f Postpartum B l u e s . Then again, the items of maternal r o l e c o n f l i c t alorie\ may not be i n f l u e n -t i a l , but must be i n combination with items not pr e s e n t i n t h i s p o p u l a t i o n . On the other hand, equal w e i g h t i n g o f the items of maternal r o l e c o n f l i c t may have been a f a u l t y method i n the data a n a l y s i s , thereby masking the tr u e weight of each item. 3. The endocrine f a c t o r s r e l a t e d to the menstrual c y c l e which were examined were not, alone or i n combination, i n f l u e n t i a l i n the development of Postpartum B l u e s . T h i s i s i n c o n t r a d i c t i o n o f the f i n d i n g s of a study with a p o p u l a t i o n of thirty-nine.-^ S ociocultural differences between the two populations may account f o r the discrepant findings. 4. Sleep deficiency i s detrimental to the emo-t i o n a l well-being of postpartum women. The majority of the women perceived fatigue due to sleep deficiency as the under-l y i n g cause of the development of Postpartum Blues. However, there was l i t t l e the women could do i n the hos p i t a l , and sometimes at home, about increasing the amount of uninterrup-ted sleep. 5. The h o s p i t a l environment and routines are not conducive to adequate sleep f o r most postpartum women. The majority of the women reported h o s p i t a l noises and routines including the 5 a.m. infant-feeding as disruptive of t h e i r sleep. 6. Public Health Nurses should play a greater role i n education and support of postpartum women at home. A num-ber of women had some questions on s e l f or baby care that a Public Health Nurse could have answered. Further information on what i s normal f o r infants with regard to suoh things as eating, sleeping, and elimination habits, and skin condition would have benefitted most primiparas. Other women could have been helped by more s p e c i f i c advice ox*, just from reassurance that they were good mothers. J I r v i n D. Yalom and Others, "'Postpartum Blues' Syndrome," Archives of General Psychiatry. XVIII (January. 1968), 24. 87 I I I . RECOMMENDATIONS The r e s u l t s of t h i s study i n d i c a t e t h a t ; (1) postpartum women .fre q u e n t l y encounter s l e e p d e f i c i e n c y ! (2) s l e e p d e f i c i e n c y i s an i n f l u e n t i a l f a c t o r i n the development of Postpartum Blues; (3) women who attended p r e n a t a l c l a s s e s have an understanding o f the puerperium and i t s i n h e r e n t problems, judged by the r e f l e c t i o n of content l e a r n e d a t c l a s s e s : (4) husbands who attended p r e n a t a l c l a s s e s and a t t h e i r wives' l a b o u r and d e l i v e r y were very s u p p o r t i v e of t h e i r wives a t home; (5) postpartum women a t home have q u e s t i o n s about baby care, p a r t i c u l a r l y about f e e d i n g and about what i s normal f o r a baby of t h a t age; (6) postpartum women common-l y view h o s p i t a l n u r s i n g s t a f f , p u b l i c h e a l t h nurses, and p h y s i c i a n s as very busy people and consequently, the women are r e t i c e n t t o c a l l upon them f o r a d v i c e . In view o f these r e s u l t s the f o l l o w i n g recommenda-t i o n s are made: 1. Regarding f u r t h e r r e s e a r c h , t h a t : (a) a--study of a l a r g e r and more d i v e r s e p o p u l a t i o n a t a time other than December-January be conducted; (b) a b e t t e r method of c o l l e c t i n g s l e e p data be used; (c) i n t e r v i e w s be conducted d u r i n g the episode of Postpartum Blues, and (d) a s o c i a l d e s i r a b i l i t y measure be used; (e) /instruments f o r data c o l l e c t i o n be p r e t e s t e d •oh a l a r g e r s c a l e . r : ' \ * 88 2 . Regarding education, t h a t (a) a h i g h e r a t t e n -dance a t p r e n a t a l c l a s s e s of expectant p a r e n t couples of a l l socio-economic groups be a c t i v e l y sought; (b) more educa t i o n w i t h i n the h o s p i t a l be made a v a i l a b l e , p o s s i b l e to i n c l u d e audio-v i s u a l s e l f - u s e k i t s ; (e) p r a c t i c e s e s s i o n s which i n c l u d e d i s c u s s i o n s and r e h e a r s a l o f l i k e -l y problems t o be encountered by the mother be encouraged; (d) a "handout" sheet c o n t a i n i n g i n f o r m a t i o n on t i p s toward p r e v e n t i n g Post-partum Blues and toward f a c i l i t a t i n g the moth-e r ' s c o n f i d e n c e i n her new r o l e . b e p r o v i d e d . 3. Regarding n u r s i n g p r a c t i c e , t h a t h o s p i t a l s : (a) review c u r r e n t r o u t i n e s and n u r s i n g care pro-cedures to reduce d i s t u r b a n c e s i n s l e e p and permit a l o n g e r p e r i o d of time to be a v a i l a b l e f o r s l e e p ; (b) c o n s i d e r moving women a f t e r t h e i r f i r s t postpartum day to a u n i t e n v i r o n -m e n t a l l y more conducive t o r e s t and comfort where there are few n o i s e s and i n t e r r u p t i o n s . 4. Regarding r e s o u r c e s t h a t (a) c l a s s i f i c a t i o n s be made among h e a l t h resource persons as to who a d v i s e s on matters of i n f a n t care, such as f e e d i n g . A l t e r n a t i v e l y , t h a t h e a l t h p r o f e s s i o n -a l s e s t a b l i s h common r o u t i n e s f o r a d v i s i n g mothers on such matters; (b) g r e a t e r l i a -son between the h o s p i t a l and p u b l i c h e a l t h agencies be established to ensure consistent and immediate feedback of information regarding c l i e n t s to both p a r t i e s . Further to resources, that a l i a s o n nurse em-ployed by hospitals could: (a) i n t e r a c t with postpartum women i n h o s p i t a l to determine t h e i r needsj (b) f a c i l i t a t e i n d i v i d u a l or group learn-ing; (c) coordinate two-way r e f e r r a l s and ex-change of information with other health or health-related personnel i n the community. ,90 BIBLIOGRAPHY BOOKS Abdellah, Faye G., and Eugene Levine. Better Patient Care  Through Nursing Research. New York: The Macmillan C ompany, 196 5. Baker, A.A. Psychiatric Disorders i n Obstetrics. Salisbury: The Salisbury Press Ltd., 1967. Biddle, Bruce, and Edwin J. Thomas (eds.). Role Theory: Concepts and Research. New York: John Wiley & Sons, Inc., 1966. Caplan, Gerald. An Approach to Community Mental Health. New York: Grune & Stratton, Inc., 1961. Fielding, Jane. "Study of Selected Behaviours of Primi-parous Mothers During the F i r s t Three Post Partum Days," The Nursing Process, ed. Marie Seedor. New York: Teacher's College Press, 1972. Fowler, Mary M. "Psychological Needs of the Puerperium," Maturational C r i s i s of Childbearing, ed. Ann Clark. Honolulu: University of Hawaii, 1971. Garner, Susanna Lee, and Pamela M i t c h e l l . "Comfort and Sleep Status," Concepts Basic to Nursing, ed. Pamela M i t c h e l l . New York: McGraw-Hill Book Company, 1973. Hamilton, James Alexander. Postpartum Psychiatric Problems. Saint Louis: The C.V. Mosby Company, 1962. Hardyck, Curtis D., and Lewis F. Petrinovich. Introduction  to S t a t i s t i c s for the Behavioural Sciences. P h i l a -delphia: W.B. Saunders Company, 1969. Kleitman, Nathaniel. Sleep and Wakefulness. Chicago: Uni-v e r s i t y of Chicago Presi^ 1963. Myles, Margaret F. A Textbook for Midwives. Edinburgh: E.&S. Livingstone Ltd., 1961. Parad, Howard J . (ed.). C r i s i s Intervention: Selected Readings. New York: Family Services Association of America, 1965. Peck, Sharon S., and Rana L. Peck. "Postpartum Needs of the Family," Maternity Nursing Today, ed. Joy P. Clausen. New York: McGraw H i l l Book Company, 1973. 92. Wiedenbach, Ernestine. Family-Centred Maternity Nursing. New York: G.P. Putnam's Sons, 1967. Wrightsman, Lawrence S. S o c i a l Psychology In the Seventies. Monterey: Brooks/Cole Publishing Company, 1972. Yoshioka, Ruth. "Maturational C r i s i s of Pregnancy," Maturational C r i s i s of Childbearing, ed. Ann Clark. Honolulu: University of Hawaii, 1971, 15-22. PERIODICALS Aitken, R.C.B., and A.K. Zeally. "Measurement of Moods," B r i t i s h Journal of Hospital Medicine, IV, (August, 1970), 215-224. Auerbach, Aline B. "Meeting the Needs of New Mothers," Child and Family. VI (Winter, 196?), 9-17. Beck, A.T., and Others. "An Inventory f o r Measuring De-pression, " Archives of General Psychiatry, IV (June, 1968), 561-571. Bibring, Grete L. "Recognition of Psychological Stress Often Neglected i n 0 B Care," Hospital Topics, XLIV (September, 1966), 100-103. Caplan, Gerald. "Psychological Aspects of Maternity Care," American Journal of Public Health, XLVII (January, 1957), 25-31. earner, Charles. "After-Baby Blues," Today's Health. VC (December, 1967), 33-35. Davidson, J.R.T. "Postpartum Mood Change i n Jamaican Women: A Description and Discussion on i t s S i g n i f i -canae," B r i t i s h Journal of Psychiatry. XCCI (1972), 659-663. E i s l e r , Jeanne, John A. Wolfer, and Donna Diers. "Relation-ships Between Need f o r S o c i a l Approval and Postoperative Recovery and Welfare," Nursing Research, XXI (November-December, 1972), 520-525. Gordon, Richard E., and Katherine Gordon. "Social Factors i n Prevention of Postpartum Emotional Factors," Ob-s t e t r i c s and Gynecology, XV ( A p r i l , i960), pp. 433-Gordon, Richard E., E l i Kapostins, and Katherine Gordon, "Factors i n Postpartum Adjustment," Obstetrics and Gynecology, XXV (February, 1965), 158-166. Grimm, E l a i n e R., and Wanda R. Venet. "The R e l a t i o n s h i p of Emotional Adjustment and A t t i t u d e s to the Course and Outcome of Pregnancy," Psychosomatic Medicine, XXXVIII (January, 1966), 34-49. Highley, B e t t y . "Maternal Role I d e n t i t y , " D e f i n i n g C l i n i c a l  Content, V o l . 1. Boulders Western I n t e r s t a t e Commis-s i o n f o r Higher Education, 196?, pp. 33-4-3. J a r r a h i - Z a d e h , A l i , and Others. "Emotional and C o g n i t i v e Changes i n Pregnancy and E a r l y Puerperium," B r i t i s h  J o u r n a l of P s y c h i a t r y . CXV (1969), 797-805. Kane, F r a n c i s J . J n r . , and Others. "Emotional and Cog-n i t i v e Disturbance i n the E a r l y P u e r p e r i u m , " - B r i t i s h  J o u r n a l of P s y c h i a t r y , GXIV (January, 1968), 99-102. Landis, Judson T. "Marriages of Mixed and Non-mixed R e l i g i o u s F a i t h , " American S o c i o l o g i c a l Review, XIV (june, 1949), 401-407T Larsen, V i r g i n i a L. " S t r e s s e s of the C h i l d b e a r i n g Year," American J o u r n a l of P u b l i c H e a l t h . LVI (January, 1966), 32-36. L i t t l e , Crawford, and N e i l I. McPhail. "Measures of De-p r e s s i v e Mood a t Monthly I n t e r v a l s , " B r i t i s h J o u r n a l  of P s y c h i a t r y . XCCII (1973), 447-452. Melges, F r e d e r i c k T. "Postpartum P s y c h i a t r i c Syndromes," Psychosomatic Medicine. XXX (January-Februarym 1968), pp. 95-108. Murphy, George E., and Others. " ' L i f e S t r e s s ' i n a Normal Populations A Study of 101 Women H o s p i t a l i z e d f o r Normal D e l i v e r y , " J o u r n a l of Nervous and Mental D i s - ease, CXXXV (February, 1962), 150-161. Paffenbarger, R. "The P i c t u r e Puzzle of the Postpartum Psychoses," J o u r n a l of Chronic Diseases. X I I I (1961), 161-173. P i t t , B r i c e . "'Maternity B l u e s ' , " B r i t i s h J o u r n a l of Psy- c h i a t r y , CXX (1973), 431-433. Rice, E l i z a b e t h P. " A f t e r O f f i c e Hours," O b s t e t r i c s and  Gynecology, XXIII (February, 1964), 307-315. Riker, Audrey. "New Parent B l u e s , " C h i l d and Family. VI (Spring, .1967), 10-17. Robin, A.A. "The. P s y c h o l o g i c a l Changes of Normal P a r t u r i t i o n P s y c h i a t r i c Q u a r t e r l y , XXXVI (January, 1962), 129-150. Robischon, P a u l e t t , and Diane S c o t t . "Role Theory and I t s A p p l i c a t i o n i n Family N u r s i n g , " Nursing Outlook, XXXVI ( J u l y , 1969), 52-57. Rubin, Reva. "Puerperal Change," Nursing Outlook, IX (Dec-ember, 1961), 753-755. Rubin, Reva. "Attainment of the Maternal Role. P a r t Is Processes," Nursing Research, XVI (Summer, 1967), 237-245. Rubin, Reva, "Attainment of Maternal Role. P a r t I I . Models and R e f e r e n t s , " Nursing Research. XVI ( F a l l , I967), 3 4 2 - 3 4 7 . Rubin, Reva. " C o g n i t i v e S t y l e i n Pregnancy," American  J o u r n a l of Nursing. LXX (March, 1970), 502-508. Tod, E.M. "Puerperal D e p r e s s i o n , " The Lancet, XI (December, 1964), 1 2 6 4 - 1 2 6 6 . W i l l i a m s , Barbara. "Sleep Needs During the M a t e r n i t y C y c l e , " Nursing Outlook. XV (February, I967), 53-55. Yalom, I r v i n D., and Others. "Postpartum B l u e s ' Syndrome," A r c h i v e s of General P s y c h i a t r y , XVIII (January, 1968), 16-27. OTHER F u r n e l l , Margary D. "Adolescent Depression and I n t e r p e r s o n a l Behaviour." Unpublished Master's T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973. Jordan, A. Dorreen. "An E v a l u a t i o n of a Family-Centred M a t e r n i t y Care H o s p i t a l Program." Unpublished Re-search P r o j e c t , Calgary, 1971. Larsen, V i r g i n i a L. " P r e d i c t i o n and Improvement of Post-partum Adjustment." Unpublished Research Report, Washington, 1968. APPENDIX A ..95 r96 A # I, , agree t o p a r t i c i p a t e i n a study a t H o s p i t a l M a t e r n i t y U n i t . The study i s of mother's f e e l i n g s i n the f i r s t s i x weeks a f t e r t h e i r babies are born. I understand that? - 2 i n t e r v i e w s w i l l be h e l d , one a t the h o s p i t a l on the f o u r t h day a f t e r the b i r t h of the baby, and one a t about f o u r weeks a f t e r the b i r t h of the baby, when I am a t home. The i n t e r v i e w s w i l l be h e l d a t my convenience, and w i l l each take about h a l f o f one hour. - no r i s k s are i n v o l v e d and no names w i l l be used. - I am f r e e to withdraw from the study a t any time. - On request I w i l l be g i v e n knowledge of the r e s u l t s . i - . Signature of P a r t i c i p a n t S i g n a ture of Researcher Date 98 B HOSPITAL INTERVIEW Code No. Address Phone Date of Interview Age Gravida Parity-E stimated date of Confinement Confinement Date: T.imej .-Outcome: M P Apgar Score of Baby (1) (2) B i r t h Weight of Baby Length of Labour - 1 s t stage 2nd stage 3rd stage TOTAL Drugs Ad m i n i s t e r e d - 1 s t stage 2nd stage 3rd stage Postpartum Episiotomy or L a c e r a t i o n Sutures I f not Canadian, what country are you from How l o n g have you l i v e d i n Canada Have you had any major i l l n e s s d u r i n g or a p a r t from t h i s pregnancy Have you ever had a p s y c h i a t r i c d i s o r d e r Are you and the baby w e l l a t p r e s e n t What i s your m a r i t a l s t a t u s : M S W D C/L No. years l i v i n g with husband or partner Are your parents a l i v e : M. F. Where are they l i v i n g : M. F. Are your husband's parents a l i v e : M. F. Where are they l i v i n g : M. F. What i s your r e l i g i o n What i s your husband's r e l i g i o n ; Were you brought with a r e l i g i o u s background: Yes No Was your husband: Yes No Do you follow your r e l i g i o n Does your husband follow h i s r e l i g i o n What was the highest education completed: - s e l f - husband your mother, - your father. - your husband's mother, - your husband's father" What i s your occupation: Are you planning to work If yes, when do you.begin work Had you always expected some day to become a mother: - Yes - No What i s your husband's occupation: Is he working: No "Part-time '•- Full-time^ ^ S h i f t - w o r k What i s the occupation of: your mother your father • • your husband's mother your husband's father How many children do you have at home: How old i s your youngest c h i l d 100 Did you have any physical problems with any previous pregnancy: No A l i t t l e A l o t - labour No A l i t t l e A l o t - b i r t h No A l i t t l e A lot_ Did you have any emotional problems with any - previous pregnancy i No, A l i t t l e A lot_ - labour No A l i t t l e A lot_ - b i r t h No A l i t t l e Avlot V -Did your mother or s i s t e r s have any problems with pregnancy, labour, or b i r t h : No A l i t t l e A l o t Who What At what age did your periods s t a r t : How many days do your periods l a s t Are your periods regular Have you had trouble with p a i n f u l periods: No A l i t t l e A l o t How long f o r When did i t stop What did you do f o r i t : take medicine go to bed apply heat miss work Have you f e l t depressed or i r r i t a b l e before your periods: - o f f the p i l l No A l i t t l e A l o t - on the p i l l No A l i t t l e A l o t For how long were you tr y i n g to become pregnant: Did you attend prenatal classes: No A few A l l Where To learn more about pregnancy, labour, b i r t h , and baby care, did you: - read books No A l i t t l e A l o t - t a l k with f r i e n d s or r e l a t i v e s who are not profession-a l s No A l i t t l e A l o t - 1 0 1 t a l k with your d o c t o r or nurse No_ Who A l i t t l e A l o t With t h i s pregnancy, d i d you have concerns about: - l a b o u r No A l i t t l e A l o t _ - b i r t h No A l i t t l e A l o t _ - baby care No A l i t t l e A l o t _ Did you d i s c u s s these w i t h : - your husband No A l i t t l e A l o t . - your f a m i l y or f r i e n d s - your d o c t o r or nurses No No A l i t t l e , A l i t t l e A l o t _ A l o t Do you have any concerns now about: - baby care No A l i t t l e . ~ m o n e y No A l i t t l e . - housing Mo A l i t t l e . - o t h e r No A l i t t l e A l o t _ A l o t _ A l o t _ A l o t Have you had p r e v i o u s experience with babies and t h e i r c a r e : No A l i t t l e A l o t Is your husband away from home: No A l i t t l e A l o t Was your s l e e p i n t e r r u p t e d d u r i n g the l a s t week before your l a b o u r s t a r t e d due t o : - p i l e s - v a r i c o s e v e i n s -frequency of u r i n e - other No How many times each n i g h t No How many times each n i g h t No How many times each n i g h t No How many times each n i g h t 102 Average amount of sleep Did,you f e e l rested when you got up i n the morning How many hours of sleep did you have i n the 24 hours before your labour started Total How many hours of sleep have you had each day since the baby was born Straight sleep Interrupted C Total Day 1 \ r__ Day 2 ; ' Day 3 ;  Did you expect labour to be: - easier than i t was - about the same as i t was - harder than i t was Was your husband present during the labour and delivery: No How long Who or what helped you the most during labour: Who or what helped you the most during the b i r t h : Why did you come to t h i s h o s p i t a l to have your baby: - no reason - your doctor attends here - friends advised you - you decided i t was the best f o r you How are you feeding your baby: - bottle - breast How i s the feeding going Some mothers d e f i n i t e l y prefer a boy or g i r l ; do you have a preference: Yes No When i s a suitable time f o r me to v i s i t you at home Date Time 103 > BECK INVENTORY Case Number: NAME:. DATE: 1 2 3 5 5 6 7 ( ) A. <• - :• 0 I do not f e e l sad. 1 I f e e l sad. 2 I am sad a l l the time and I can't snap out of i t . 3 I am so sad or unhappy that I can't stand i t . 8 ( ) B. 0 I am not p a r t i c u l a r l y discouraged about the future. 1 I f e e l discouraged about the future. 2 I f e e l I have nothing to look forward to. 3 I f e e l that the future i s hopeless and that things cannot improve. 9 ( ) C 0 I do not f e e l l i k e a f a i l u r e . 1 I f e e l I have f a i l e d more than the average person 2 As I look back on my l i f e , a l l I can see i s a l o t of f a i l u r e s . 3 I f e c i as i f I am a complete f a i l u r e as a per-son. ' 10 (a) D . . „ 0,;I get as much s a t i s f a c t i o n out of things as I used to. 1 I don't enjoy things the way I used to. 2 I don't get r e a l s a t i s f a c t i o n out of anything anymore. 3 I am d i s s a t i s f i e d or bored with everything. 11 ( ) E. 0 I don't f e e l p a r t i c u l a r l y g u i l t y . 1 I f e e l g u i l t y a good part of the time. 2 I f e e l quite g u i l t y most of the time. 3 I f e e l g u i l t y a l l of the time. 12 ( ) F. . 0 I don't f e e l I am being punished. 1 I f e e l I may be punished. 2 I expect to be punished. 3 I f e e l I am being punished. 104 13 ( ) G- 0 I don't f e e l disappointed i n myself. 1 I am disappointed i n myself. 2 I am disgusted with myself. 3 I hate myself. 14 ( ) H. 0 I don't f e e l I am any worse than anybody else. 1 I am c r i t i c a l of myself f o r my weaknesses or mistakes. 2 I blame myself a l l the time f o r my f a u l t s . 3 I blame myself f o r everything bad that happens. 15 ( ) I. 0 I don"t have any thoughts of k i l l i n g myself. 1 I have thoughts of k i l l i n g myself, but I would not carry them out. 2 I would l i k e to k i l l myself. 3 I would k i l l myself i f I had the chance. 16 ( ) J . 0 I don't cry any more than usual. 1 I cry more now than I used to. 2 I cry a l l the time now. 3 I used to be able to cry, but now I can't cry even though I want to. 17 ( ) K. 0 I am no more i r r i t a t e d now that I ever am. 1 I get annoyed or i r r i t a t e d more e a s i l y than I used to. 2 I f e e l i r r i t a t e d a l l the time now. 3 I don't get i r r i t a t e d at a l l by the things that used to i r r i t a t e me. 18 ( ) L. _ . • r - -0 I have "not Tost i n t e r e s t i n other people. 1 I am les s interested i n other people than I used to be. 2 I have l o s t most of my int e r e s t i n other people. 3 I have l o s t a l l of my in t e r e s t i n other people. 19 ( ) M. 0 I make decisions about as well as I ever could, 1 I put of f making decisions more than I used to, 2 I have greater d i f f i c u l t y i n making decisions than before. 3 I can't make decisions at a l l any more. 105 20 ( ) N. 0 I don't f e e l I look any worse than I used to. 1 I am worried that I am looking old or un-a t t r a c t i v e . 2 I f e e l that there are permanent changes i n my appearance that make me look unattractive. 3 I believe that I look ugly. 21 ( ) 0. 0 I can work about as well as before. 1 It takes an extra e f f o r t to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at a l l . 22 ( ) P. 0 I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake up 1-2 hours e a r l i e r than usual and f i n d i t hard to get back to sleep. 3 I wake up several hours e a r l i e r than I used to and cannot get back to sleep. 23 ( ) Q. 0 I don't get more t i r e d than usual. 1 I get t i r e d more e a s i l y than I used to. 2 I get t i r e d from doing almost anything. 3 I am too t i r e d to do anything. 2k ( ) R. 0 My appetite i s no worse than usual. 1 My appetite i s not as good as i t used to be. 2 My appetite i s much worse now. 3 I have no appetite at a l l anymore. 25 ( ) S . 0 I am not l o s i n g as much weight as i s to be expected. 1 I f e e l I am not l o s i n g more weight than i s to be expected. 2 I am l o s i n g more weight than i s to be expected. 3 I am l o s i n g a l o t more weight than i s to be expected I am purposely try i n g to lose weight by eating l e s s . yesC no 26 ( ) T . 0 I am no more worried about my health than usual. 1 I am worried about physical problems such as aches and pains; or upset stomach; or con-s t i p a t i o n . 2 I am very worried about physical problems and i t s hard to think of much else. 3 I am so worried about my physical problems, that I cannot think about anything else. 106 27 ( ) U. 0 I have not n o t i c e d any r e c e n t change i n my i n t e r e s t i n sex. 1 I am l e s s i n t e r e s t e d i n sex than I used t o be. 2 I am much l e s s i n t e r e s t e d i n sex now. 3 I have l o s t i n t e r e s t i n sex completely. Time elapsed s i n c e c l i n i c a l i n t e r v i e w . IQ? "BLUES" QUESTIONNAIRE # Have you heard of the "baby b l u e s " ? What do you t h i n k they are? Have you had "the b l u e s " f o l l o w i n g the b i r t h of t h i s baby? When? How l o n g d i d they l a s t ? What e f f e c t d i d "the b l u e s ' have on you? Did you c r y ? I f so, f o r how long? how many times? What d i d you do to get back to normal? Did o t h ers h e l p ? Who helped? What d i d they do t h a t helped? What do you t h i n k caused "the b l u e s " ? Do you t h i n k "the b l u e s " can be prevented? How? HOME INTERVIEW 108 Since coming home, have you taken* Type and Dose Amount sleeping p i l l s or t r a n q u i l i z e r s pain k i l l e r s vitamins other How many hours sleep have you had i n the l a s t 3 days: straight sleep interrupted sleep Total Day 1 •  Day 2 Day 3 Do you have any concerns about the baby: No A few A l o t If yes, what are your concerns? Have you found i t d i f f i c u l t adjusting to the: - baby's needs No A l i t t l e A l o t - housework routine No - other c h i l d -ren's needs No A l i t t l e . A l i t t l e A l o t . A l o t -interference from neigh-bours and re-la t i o n s - increased company No A l i t t l e A l o t No A l i t t l e A l o t Did you have a r e l a t i v e or close f r i e n d stay with you to help you? If yes, f o r how long: 109 0 I get a l o n g with my mother v e r y w e l l 1 I do not get a l o n g w i t h my mother very w e l l 2 I get a l o n g w i t h my mother r a t h e r badly 3 I cannot stand my mother 0 My husband/partner and I are very c l o s e to each o t h e r 1 My husband/partner and I get a l o n g a l r i g h t 2 My husband/partner and I do not get a l o n g very w e l l 3 My husband/partner and I j u s t put up with each other 0 I f e e l v ery happy a l l of the time 1 I f e e l happy most of the time 2 Sometimes I f e e l happy and sometimes I f e e l sad 3 I do not f e e l happy any of the time 0 I can remember t h i n g s as w e l l as I c o u l d before 1 Recently, I cannot remember t h i n g s as w e l l as I c o u l d 2 Recently, I f o r g e t a l o t 3 Recently, I f o r g e t e v e r y t h i n g 0 I can c o n c e n t r a t e as w e l l as I c o u l d b e f o r e 1 I cannot co n c e n t r a t e as w e l l as I c o u l d before 2 I cannot co n c e n t r a t e on t h i n g s f o r l o n g a t a l l 3 I cannot c o n c e n t r a t e on a n y t h i n g a t a l l 0 I am not d i s t r a c t e d by t h i n g s any more than u s u a l 1 Recently, I am d i s t r a c t e d by t h i n g s more than u s u a l 2 Recently, I am d i s t r a c t e d by t h i n g s much more than u s u a l 3 Recently, I am d i s t r a c t e d by a n y t h i n g a t a l l 0 I f e e l t h a t I do not need to be cared f o r 1 I f e e l t h a t I need to be cared f o r a l i t t l e more than u s u a l 2 I f e e l t h a t I need to be cared f o r a l o t more than u s u a l 3 I f e e l t h a t I need to be cared f o r most of the time 0 I f e e l t h a t having the baby has not i n t e r f e r e d with my p l a n s 1 I f e e l t h a t having the baby makes i t harder f o r me to keep to my p l a n s 2 I f e e l t h a t having the baby makes me postpone my p l a n s 3 I f e e l t h a t having the baby f o r c e s me to g i v e up my p l a n s a l t o g e t h e r 0 I f e e l t h a t having the baby does not t r a p me 1 I f e e l t h a t having the baby c a s t s t h e " d i e so t h a t I s t a y where I am ' 2 I f e e l t h a t the baby has trapped me i n t o a s i t u a t i o n I would r a t h e r have l e f t 3 I f e e l t h a t the baby has trapped me i n t o an i m p o s s i b l e s i t u a t i o n "BLUES" QUESTIONNAIRE l i b Have you had "the blues" following the b i r t h of t h i s baby? When? How long ,<|id they l a s t ? What e f f e c t did "the blues" have on you? Did you cry? If so, f o r how long? how many times? What did you do to get back to normal? Did others help? Who helped? What did they do that helped? What do you think caused "the blues"? Do you think "the blues" can be prevented? How? Do you think having had the blues was a bad experience? 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0093378/manifest

Comment

Related Items