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Postpartum concerns of mothers Smith, Mary Patricia 1987

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POSTPARTUM CONCERNS OF MOTHERS By Mary PATRICIA SMITH B.S.N., The University of British Columbia, 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1987 © Mary Patricia Smith, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date Oohke.r /H.fff? DE-6(3/81) ii Abstract Using a questionnaire developed by M. Gruis in 1974, this study determines (a) the major concerns of primiparous and multiparous mothers one month postpartum, and (b) the resources used in meeting identified concerns. The sample was composed of 19 primiparas and 22 multiparas who delivered their babies in a large tertiary care maternity centre in Vancouver, B. C, in January and February of 1987. The most frequently identified major concerns of primiparas were feeding, fatigue, breast soreness, infant behavior, and return of the figure. The most frequently identified major concerns of multiparas were fatigue, regulating demands, emotional tension, jealousy of other children, and the labor and delivery experience. The vast majority of major concerns were dealt with effectively. The women used a variety of resources, and their partners were particularly helpful. However, for 64% of the multiparas in this study, the hospital stay did not provide preparation for the first weeks at home with their new babies. It is recommended that hospital nurses assess the learning needs of postpartum mothers individually, and place more attention on (a) the rest and recuperation of mothers from the birthing process, and (b) ensuring that mothers are able to thoroughly review their labor and delivery experiences. Public health or community health nurses should see their postpartum clients as soon as possible after discharge from hospital. Teaching sessions can occur in the home, and in accordance with individual concerns. i i i TABLE OF CONTENTS ABSTRACT ii LIST OF TABLES vi ACKNOWLEDGEMENTS vii CHAPTER ONE 1 The Research Problem 4 Purpose and Objectives 5 Definition of Terms 5 Assumption of the Study 6 Limitations of the Study 6 CHAPTER TWO: Conceptual Framework and Literature Review 7 Overview 7 Conceptual Framework 7 Physical Restoration 8 Learning to Care for and Meet the Needs of a Dependent Infant '. 9 Establishment of a Relationship with the Infant 10 Alteration of Lifestyle and Relationships to Accommodate a New Family Member 11 Literature Related to the Conceptual Framework 12 Gruis' Conceptualization of Tasks in Relation to the Other Theorists 15 Literature Review 17 Overview of the Findings of Gruis 17 Overview of the Findings of Harrison and Hicks 18 Overview of the Findings of Tobert 19 Foremost Concerns in Gruis' Study 23 1. Return of the figure 23 2. Regulating demands of husband/partner, housework, children 26 iv 3. Emotional tension 28 4. Fatigue 31 5. Infant behavior 33 Postpartum Resource Utilization 36 Summary 39 CHAPTER THREE: Research Methodology 41 Overview 41 Validity and Reliability of the Tool 42 Sample and Setting 43 Data Collection 43 Ethical Considerations and Human Rights 44 Data Analysis 45 CHAPTER FOUR: Presentation and Discussion of Findings 46 Overview 46 Section 1: The Sample 46 Age and Education 47 Community Resources Utilized 47 Section 2: Postpartum Concerns 48 Major Concerns of Primiparas 49 Infant feeding 49 Fatigue 51 Breast soreness 52 Infant behavior 53 Return of the figure 54 Other major concerns 54 Major Concerns of Multiparas 55 Fatigue 55 Regulating demands 55 Emotional tension 57 Other major concerns 58 Comparison of the Major Concerns of Primiparas and Multiparas 60 Expressed Concerns Not Covered in the Questionnaire 61 V Section 3: Relationship of Expectations of Labor and Delivery, Past Weeks at Home, and Attendance at Prenatal Classes to Expressed Concerns 62 Labor and Delivery Experience 62 Past Weeks at Home 63 Attendance at Prenatal Classes 64 Section 4: Sources of Help 65 Concerns for which No Help was Sought 67 Prenatal Classes, the Hospital Stay, and Public Health Nurse visits 68 Desire for Additional Support and Guidance 69 Summary 70 CHAPTER FIVE: Summary, Conclusions, Implications, and Recommendations 72 Summary 72 Conclusions 74 Implications for Nursing Practice 75 Recommendations for Further Study 78 References 80 Appendix A: Information Sheet for Nurses 84 Appendix B: Consent Letter: Postpartum Concerns Study 85 Appendix C: Letter Informing Physicians 86 Appendix D: Cover Letter, Questionnaire, and Background Information 88 Appendix E: Degree of Concern for All Items on the Questionnaire 98 vi LIST OF TABLES Table 1: Priority Ranking of Concerns at Two Days Postpartum (Toberfs Study) 21 Table 2: Priority Ranking of Concerns at One Month Postpartum (Toberfs Study) 22 Table 3: Number of Major Concerns and Parity 49 Table 4: Most Frequently Identified Major Concerns of Primiparas 50 Table 5: Most Frequently Identified Major Concerns of Multiparas 56 Table 6: Expectations of Labor and Delivery and Major Concerns Expressed ....62 Table 7: Expectations of Past Weeks at Home and Major Concerns Expressed 64 TAble 8: Number of Resources Used and Adequacy of Help for Major Concerns 66 vii ACKNOWLEDGEMENTS I wish to extend a special thanks to the members of my committee Elaine Carty and Sheila Stanton for their standards of academic excellence. In addition, I would like to thank my colleagues in the M.S.N, program, 1987, for their tremendous support and encouragement. Finally, I wish to thank the mothers who participated in this study, without whom this work would have been impossible. 1 CHAPTER ONE The postpartum period or puerperium has been the most neglected aspect of modern maternity care (Bowes, 1980; Boyer, 1983; Rubin, 1975; Sherwen & Toussie-Weingarten, 1983). It is a time of remarkable physiological and psychosocial changes, and consequently, is a dramatic and challenging time for mothers and their families. The investigator has observed that many mothers experience stress and discomfort during the postpartum period. Both the transition to parenthood for new mothers, and the incorporation of a new baby into the existing family structure for mothers with other children, generate concerns that must be dealt with. Nurses are in an ideal position to assist families as they cope with these concerns. Studies conducted by LeMasters (1957), Dyer (1963), and Sheehan (1981) concluded that the addition of the first child to the family constitutes a crisis, or potential crisis, for many couples because of the major reorganization of roles, relationships, and lifestyle patterns that parenting demands. In addition, many new mothers have had little or no experience caring for newborns. Our educational system prepares young people for jobs or careers, not for parenting. The extended family of grandparents, aunts, uncles, and cousins is frequently not available to provide the advice, support, and assistance to mothers that it once did, and the availability and effectiveness of other postpartum resources is 2 not well documented. The investigator also queries whether the concerns of mothers having their second or subsequent child are being adequately addressed by nurses. It appears that postpartum nurses in hospitals often overestimate the knowledge level and capabilities of mothers who have already had a child. Information given tends to be on the same topics as that given to new mothers, and the investigator queries whether this is appropriate. The concerns of the multiparous mother may be quite different from those of a new mother, and if so, the learning opportunities should be different. Tobert (1986) found that the foremost concerns of primiparas (N=31) two days post discharge from hospital were recognizing signs of baby illness, and being a good mother. Foremost concerns for multiparas (N=36) were fatigue and return of the figure. Prenatal classes do provide some postpartum teaching or anticipatory guidance to those mothers who attend them—generally mothers expecting their first child (Gruis, 1974; Tobert, 1986). However, they do not necessarily decrease postpartum concerns which are unidentified and sti l l in the future. Both Gruis (1974) and Harrison and Hicks (1983) found that women who attended prenatal classes had significantly more (not fewer) concerns than women who did not attend classes. Postpartum nurses in hospitals recognize the importance of postpartum education, and indeed, there tends to be a general feeling 3 that the hospital should provide as much information to mothers as is possible. This becomes more difficult as hospital stays become shorter. The investigator also queries how well such information is retained by mothers in the first few postpartum days. Perhaps mothers needs for rest, and for the opportunity to thoroughly review their labor and delivery experiences, require more attention in the hospital setting (Rubin, 1961; Mercer, 1981; Ziegel & Cranley, 1984). In a survey of twenty-seven postnatal educational programs in British Columbia, Alberta, and Saskatchewan, Glover and associates found that "the present system of in-hospital postnatal education seems to be addressing the physical aspects of maternal and infant care but not the emotional aspects and expectations surrounding this time" (Glover, Houston, Hardy, & Clyne, 1985, p. 54). These researchers believed that "this gap may have implications for mothers' satisfaction with the teaching received and for their overall adjustment to the postpartum period" (1985, p. 54). Their study found no consensus as to what was important in postnatal education, and there appeared to be no agreement as to the methods of assessing postpartum needs or of imparting information. Much is sti l l unknown about the postpartum period, and basic facts or building blocks continue to be discovered (Sherwen & Toussie-Weingarten, 1983). Although there have been some experimental studies cited in the postpartum literature, many more 4 studies have been designed as surveys to uncover fundamental information relevant to postpartum nursing care. The Research Problem Although Gruis" survey was conducted over thirteen years ago, it is receiving considerable attention in recent postpartum nursing literature (Boyer, 1983; Brooten, Brown, Hollingsworth, Tanis, & Donlen, 1983; Bull & Lawrence, 1985; Chapman, Macey, Keegan, Borum, & Bennett, 1985; Glover el al.,1985; Gruis, 1977; Harrison & Hicks, 1983; Mercer, 1981; Sherwen & Toussie-Weingarten, 1983; Tobert, 1986). Given such attention, it was felt by this author that Gruis' study should be replicated using a sample of contemporary mothers. The social changes of the 1980s such as (a) the women's movement, with mothers returning to jobs or careers in the fourth trimester, (b) the increasing types of family structures other than that of biological parents living with their offspring, (c) the growing network of self-help support groups in communities, and (d) hospitals promoting early postpartum discharge, may have changed the concerns and the resource utilization of mothers today. Postpartum nurses, both in hospitals and in the community, must be cognizant of the concerns of those to whom nursing care is delivered. Without this knowledge, it is impossible for nurses to (a) make effective use of the brief time available to them for postpartum care, 5 and (b) plan for appropriate changes In the delivery of postpartum nursing care In the future. Purpose and Objectives The purpose of this study was to determine, using Gruis' questionnaire, the concerns of postpartum mothers, as well as their resource utilization. The objectives of this study were to: 1. Identify the concerns of primiparous and multiparous women using Gruis' questionnaire. 2. Identify the resources used by the participants in meeting the identified concerns. 3. Discern whether the resources utilized were helpful in meeting concerns. 4 Identify areas where resources were not helpful and further assistance was needed. Definition of Terms Two key words, central to the operation of this study, have been defined with reference to Ziegel and Cranley (1984, p. 182). They are: Primipara: a woman who has given birth to one child of viable age (20 weeks or more) regardless of the condition of the infant. Multipara: (para II, para III, para IV) a woman who has given birth to two or more children of viable age (20 weeks or more) regardless of 6 the condition of the infant. Two additional terms require definition: Concern: a problem, question, misconception, or worry, with regard to the tasks of the postpartum period. Resource: those persons or sources of information that the mother utilized to determine (a) what to do, or (b) the appropriateness of her thoughts, feelings, or actions. For this study, the terms resources and sources of help are used interchangeably. Assumption of the Study The assumption of this study was that: 1. Knowledge of the concerns of postpartum mothers is important in planning educational programs for them. Limitations of the Study The limitations of this study were: 1. The results were limited primarily to the concerns that Gruis identified in the questionnaire, even though the questionnaire provided space for mothers to write "other" concerns not acknowledged. 2. Although mothers were asked to recall concerns experienced over the previous month, results may have more accurately reflected concerns at one month postpartum. 7 CHAPTER TWO Conceptual Framework and Literature Review Overview In this chapter, the conceptual framework chosen to structure this study will be described, and the rationale for its appropriateness will be given. Subsequently, literature supportive of the conceptual framework will be presented. The five concerns that were foremost in Gruis' study, and resource utilization in the postpartum period, will also be addressed. Conceptual Framework The conceptual framework used for the purpose of this study was the task framework developed by Gruis (1974). This framework was appropriate (a) because all the concerns outlined in Gruis' questionnaire (see Appendix D) related to the four tasks of the framework, and (b) because the literature was supportive of task frameworks similar to Gruis' (Hawkins & Gorvine, 1985; Mercer, 1981; Rubin, 1984; Ziegel & Cranley, 1984). The work of these authors is examined more closely in the literature review that follows discussion of the conceptual framework. The four tasks that comprise the conceptual framework for this 8 study, and which Gruis (1974, p. 4) believed all mothers must accomplish during the postpartum period are: 1. Physical restoration. 2. Learning to care for and meet the needs of a dependent infant. 3. Establishment of a relationship with the infant. 4. Alteration of lifestyle and relationships to accommodate a new family member. Physical Restoration The postpartum period is a time of rapid and dramatic physiologic changes. Rubin (1975) described them in the following way: What is the physical condition of a newly delivered mother when she arrives home "normally" today? Massive loss in circulating blood volume. We would admit any other person to the hospital for such a condition and prepare for cardiac arrest. Profuse diaphoresis. We would start I.V.'s and worry about chemistries in anyone else with so much diaphoresis. Profound weight loss. We would admit and protect any other patient who lost one-fifth of the body weight in a matter of hours. Massive displacement of internal organs suddenly and precipitously with a consequent loss in function. We would admit any other person for evaluation, bed rest, and careful observation with the same condition. Each symptom is severe, an emergency situation for anyone else, an accident perhaps. But not by accident in the maternity experience. 9 On the contrary, very "normal" for a woman who is postpartum. But surely not a situation for neglect and indifference? (p. 168) Physical restoration involves the process of uterine involution and the healing of the endometrium. Organs displaced by the enlarged uterus return to a nonpregnant position, and the blood volume decreases by approximately 30%. The abdominal walls, stretched to accommodate the growing uterus, remain soft and lax for at least six weeks after delivery. The cervix contracts to an almost closed state within the first postpartum week, while the vagina and vaginal inlet diminish in size more gradually. Mothers describe concerns about their figures, and often seek exercise programs to strengthen the abdominal and pelvic floor muscles. The puerperium can also be a time of discomfort (e.g., of the breasts and episiotomy site) and fatigue. Discomfort may inhibit comfortable handling of the baby, sexual relations, and effective elimination. Fatigue makes the postpartum woman vulnerable to emotional lability (Varney, 1980). Gruis (1977) believed that although the most obvious of tasks, physical restoration has drawn less attention than the other three. Her findings indicated "a need for health professionals to reexamine this task as well as to continue considering the others" (p. 182). Learning to Care for and Meet the Needs of a Dependent Infant "Fatigue and tension in the puerperium is also caused in part by 10 the incessant care demanded by an infant" (Gruis, 1977, p. 184). New mothers often begin to care for their babies when their own energies are low and physical discomforts are acute. In addition, many primiparous mothers have had little experience with infant care. Considerable energy may be spent performing basic mothering activities such as feeding and comforting the baby. No matter how well prepared a woman may feel before delivery, the continual demands of a new infant are almost always a shock. In the most basic sense, a woman's life changes, and this essential concept is not readily accepted by most women (Lynch-Fraser, 1983). The ability to care for one's infant may be equated with success as a mother, and consequently, this task may generate major concerns for mothers. Mercer (1981) recognized the pre-eminent concern of all mothers to know that they are capable of caring for their infants. Establishment of a Relationship with the Infant In addition to caring for her infant, the mother must establish a relationship with the infant that is one of the most important relationships in her infant's life (Gruis, 1977). It is through the mother-child relationship that the child learns to relate to the environment, and to others. Little by little, mothers begin to identify with their babies as whole, separate individuals. "A mother needs to learn about and understand her infant. She needs information about normal growth and 11 development of Infants and knowledge of her child's unique patterns of crying, sleeping, feeding, and motor and other behavior" (Gruis, 1977, p. 184). The mother's self-concept is influential in determining the ease in which she will relate to the infant (Rubin, 1961b). Rubin (1984) claimed that the unpredictability of infant behaviors and feeding patterns during the first postpartum week result in the mother's dependence on nursing expertise. "Without help or with too little help in interpretation and understanding, the irrationality of the neonate's behaviors can be overwhelming, producing rigid, and inflexible maternal behaviors, or producing premature and antipathetic polarization between mother and infant" ( p. 105). Alteration of Lifestyle and Relationships to Accommodate a New Family  Member As a mother gains control of her bodily functions, and becomes more comfortable caring for her infant, she begins the task of incorporating the infant into her life style and reconstructing her family to include the new member (Rubin, 1961a). Parents are seldom prepared for the changes in life style required by the integration of a baby into the existing family structure. "Stress occurs when there is an attempt to add the responsibilities of the newborn to family life as it exists rather than incorporating the child into the system" (Gruis, 1974, p. 10). Some mothers experience a sense of loss due to the necessary reductions in social activities, 12 jobs/careers, and/or other Interests. Marital relationships may suffer from neglect. The period of adjustment is not necessarily easier for the multiparous woman than it is for the primiparous woman. Although she may have more confidence in her ability to care for her infant, she has a more complex family system to reconstruct. Siblings may be jealous of the attention demanded by the new baby, and if so, their need for reassurance and affection increases. Some women fare better than others in the reorganization of their time and energies that the postpartum period demands (Shereshefsky & Yarrow, 1973). Nevertheless, major concerns appear inevitable. Literature Related to the Conceptual Framework Various authors have conceptualized the postpartum period in terms of tasks. Hawkins and Gorvine (1985, pp. 43-44) identified biophysical and psychosocial tasks. Biophysical tasks included involution of the reproductive organs, establishment of lactation or return of the breasts to a nonpregnant, nonlactating state, return to prepregnancy weight and body contours, restoration of muscle tone of the abdomen and pelvic soft tissues, and resumption of regular patterns of elimination. Psychosocial tasks included role realignment, acquisition of a new role, and integration of a new member into the family constellation. 13 Mercer (1981) identified five tasks to be resolved by a mother in the postpartum period. They were: 1. To review the events of the childbirth experience and to integrate the actual experience with the expected experience. 2. Identifying and then claiming the infant as hers. This includes reconciling the real baby with the fantasized baby. 3. Learning to care for the infant. For the primiparous woman with no experience with a newborn infant, much energy is spent acquiring and testing her performance of simple mothering tasks, For the multiparous woman, concerns relate to how to mother this particular infant during the early postpartum period, and how the infant will fit into the family. 4. Redefining or renewing her relationship with the infant's father. While caring for her infant, the new mother seeks to maintain a mutually satisfying relationship with her mate. Marital adjustments and disappointment with the postpartum body image are of concern. 5. Resuming responsibilities at home. Ziegel and Cranley (1984, p. 467) identified six tasks which women are confronted with during the first five to seven days postpartum, and with which they continue to work during the whole of the fourth trimester and perhaps, for some women and for some tasks, even beyond. The tasks identified were: 1. Achieving some closure or resolution of pregnancy, labor, and delivery. 14 2. Reconciling the real infant with one of antepartal fantasy. 3. Continuing the acquaintance - attachment to the infant. 4. Replenishing physical and psychic energy. 5. Learning infant care skills. 6. Reestablishing family life and relationships to include the new family member. Rubin (1984) also used the terminology of maternal tasks. She said, "Maternal tasks address three interpenetrating systems: the self-system, the maternal-child subsystem, and the larger family system" (p. 54). Physical restoration (within the self-system) was very strongly emphasized by Rubin (1984). She said: "Once childbirth occurs, a woman fully experts that all the growth in size and weight added to her body during pregnancy will be shed with delivery. Any residual weight or size after childbirth is rejected as fat, flabby, or useless" (pp. 70-71). Rubin addressed the many physical discomforts and concerns of the postpartum period. Low back pain, the feelings of congestion and pressure in the pelvic area, increased vaginal discharge with standing, fatigue, and anemia all impact on the mother's freedom of movement and her self-concept. Rubin (1984, p. 96) described the first three weeks of the postpartum period as a "taking-in" phase. It is a time for sleep and food; for the restoration of body functions, the self-concept, and 15 self-esteem. The events of pregnancy, labor, and delivery are reviewed to provide a debriefing for an intensive experience. In the receptivity of the "taking-in" phase, the mother begins to take-in her child and to establish the mother-child subsystem. "There is a cognitive imprinting, the formation of a cognitive map to know everything about this child. There is an eager, appetitive quality to this taking-in behavior" (Rubin, 1984, p. 96). Rubin also addressed concerns related to the integration of the neonate into the existing family structure. The maternal-child subsystem takes time with the mother away from other family members. Rubin (1984) said, "The resentment of the displacement is experienced by every member of the family, including the woman as wife and mother of other children. It is often hard to see the trade-off benefits of change that involves loss" (p. 101). Gruis' Conceptualization of Tasks in Relation to the Other Theorists The biophysical and psychosocial tasks identified by Hawkins and Gorvine (1985) are very similar to Gruis' four tasks, and consequently, lend support to Gruis' conceptualization. Mercer's tasks numbers 1 and 2 are part of the process of identifying with the new baby as a whole, separate individual. They are incorporated under Gruis" task "Establishment of a Relationship with the Infant". Mercer's tasks numbers 3, 4, and 5 are acknowledged by Gruis under the tasks "Learning to Care for and Meet the Needs of a Dependent Infant", and "Alteration of 16 Lifestyle and Relationships to Accommodate a New Family Member". Mercer recognized postpartum body image as a concern of mothers, but did not include other aspects of physical restoration as part of her conceptualization. The tasks identified by Ziegel and Cranley (1984), as well as those identified by Rubin (1984), are subsumed by Gruis* conceptualization of four tasks. The postpartum literature has lent considerable support to Gruis' conceptualization of four tasks, as well as to the concerns Gruis identified as relating to the tasks. In addition, Gruis' conceptualization has been cited by various contemporary authors. The American Journal of Maternal Child Nursing (1977) published Gruis' article "Beyond Maternity: Postpartum Concerns of Mothers" in which her conceptualization of four tasks, as well as the research findings of her masters thesis (1974) were presented. This article was reprinted and critiqued by Sherwen and Toussie-Weingarten (1983). Gruis' four tasks have been quoted by Boyer (1983), and her research findings have been referenced by Broom (1984), Brooten et al., (1983), Brouse, (1985), Bull (1981), Bull and Lawrence (1985) Chapman et al., (1985), Glover et al, (1985), and Mercer (1981). The study has been replicated with minor modification by Harrison and Hicks (1983), and with substantial modification by Tobert (1986). 17 Literature Review The review of the literature presents an overview of the findings of (a) Gruis, (b) Harrison and Hicks, and (c) Tobert. The five concerns that were foremost in Gruis' study and resource utilization in the postpartum period will subsequently be addressed. Overview of the Findings of Gruis Gruis' questionnaire, comprised of 32 items of concern, was completed and returned by 17 primiparous, and 23 multiparous mothers (N=40) in 1974 The concerns presented on the questionnaire related to the four tasks of the conceptual framework, but were grouped into three areas: (a) concerns related to self, (b) concerns related to the family, and (c) concerns related to the baby. The most frequently identified concern for both primiparas and multiparas was return of the figure to normal—a concern related to self, and encompassed by the task of physical restoration. This item caused concern to 95% (N=38) of the mothers. It was of major concern to 65%. Additional areas of concern (related to self) to 75% or more of the forty mothers were emotional tension (N=35), fatigue (N=33), and finding time for personal interests and recreation (N=31). More than 40% of the mothers rated diet and exercise as major concerns. The least frequently identified concern related to self was the return of the menstrual period. It was the only item that presented concern to less than one-third of the respondents. 18 The most frequently Identifed area of concern related to family was regulating demands of housework, husband, and children. This item was of concern (both minor and major concern) to 90% of the mothers, and of major concern to 48%. Additional items of concern to more than 50% of the respondents included sexual relations (N=29), family planning (N=27), and changes in their relationship with husband (N=24). The most frequently identified area of concern related to the baby was infant behavior. Thirty-three percent of the sample identified this item as a major concern, and for 47% it was a minor concern. Growth and development (of concern to 70% of the sample), and feeding (of concern to 68% of the sample) were in the top five concerns of the primiparas. The foremost concerns of multiparas reflected more the strain that a new child places on the rest of the family. Overview of the Findings of Harrison and Hicks Harrison and Hicks (1983) pretested Gruis" tool and subsequently, added finances to the questionnaire they used in their study. Their sample was comprised of 64 primiparas and 94 multiparas residing in Winnipeg, Manitoba, in 1978. The participants were randomly selected from 312 suitable candidates who had given birth notification to the Manitoba Department of Health and Community Services. Like Gruis' survey, the study was limited by its retrospective focus. Mothers were required to recall concerns experienced over the preceeding month. The findings of Harrison and Hicks (1983) were very similar to 19 those of Gruis' (1974). The foremost concern was regulating demands of husband, housework, children, followed by return of the figure to normal. Harrison and Hicks said: Seventy percent or more of the women had some concern about: regulating demands of husband, housework, and children, return of the figure to normal, fatigue, emotional tension, exercise, diet and finding time for personal interests. With a focus only on major concerns, we found that 30% or more of the respondents were concerned about return of the figure to normal, regulating demands of husband, housework, and children, diet, family planning and fatigue, (p. 326) Primiparas identified significantly more minor concerns than multiparas, but there was no significant difference in the number of major concerns. It was not stated whether there was a difference in the types of concerns identified by the two groups. Overview of the Findings of Tobert Tobert (1986) conducted a study in an area of Vancouver where services to postnatal mothers were a priority of the community health department. All of the participants resided within the boundaries of the health unit, in a primarily middle class area with some upper middle class homes as well as some subsidized housing. Tobert used a 51 item self-administered questionnaire "that addressed potential levels of concerns with regards to the categories of 20 self, baby, husband and family, developed by Bull (1981) from a checklist of concerns developed by Gruis (1974)" (p. 40). The main difference between Tobert's questionnaire and that of Gruis, was the division of the item "infant behavior" into specific concerns (e.g., weight gain, rashes, fussiness, crying, and breathing), and the inclusion of items such as recognizing illness, safety, and being a good mother. The questionnaires were completed by 31 primiparas and 36 multiparas at two days and again at one month, following discharge from a large teaching hospital. Criteria for participation in the study were similar to Gruis (1974). The study was designed to compare the concerns mothers experienced at these two periods in time. Priority ranking of highest total concerns for primiparas and multiparas at two days postpartum is presented in Table 1. Priority ranking of concerns at one month postpartum is presented in Table 2. Tobert (1986) found no significant difference between primiparas and multiparas (in terms of the frequency and intensity of overall concerns) at either two days or at one month post discharge from hospital, despite the differences in the priority of concerns noted above. However, there were items (e.g., in the baby category at 2 days and at 1 month) for which the difference between the two groups was significant. Tobert's results also showed a statistically significant difference (decline) in intensity of concerns between the early days at home, and one month post discharge for both primiparas and multiparas. Table 1 Priority Ranking of Concerns at Two Days Postpartum Primiparas Multiparas Recognizing illness Fatigue Being a good mother Return of figure Safety Reaction of siblings Fatigue Safety Growth & development Being a good mother Feeding baby Growth & development Baby's weight gain Baby's feeding Baby's behavior Recognizing illness Baby's crying Demands of household Travelling with baby Birth control Pain from stitches Labor and delivery exp. Dressing baby Baby's weight gain 22 Table 2 Priority Ranking of Concerns at One Month Postpartum Primiparas Multiparas Recognizing illness Being a good mother Return of figure Fatigue Baby's behavior Safety Growth and development Baby's sleeping Exercise Baby's feeding Baby's crying Diet Return of figure Birth control Reaction of siblings Fatigue Personal interests Finances Household demands Being a good mother Exercise Emotional tension Safety Recognizing illness 23 She claimed that this may have been partially due to the fact that all of the mothers had made use of professional resources during this time. Toberfs findings indicated (a) a need for professional support soon after discharge, with the primiparas receiving additional assistance and support in areas of infant care, (b) consideration of the differences in priority of concerns when planning services for primiparous and multiparous mothers, and (c) the importance of individual assessment for professionals providing educative services to individual clients. Foremost Concerns in Gruis' Study 1. Return of the figure. Return of the figure is a concern encompassed by the task of physical restoration. In addition to being the most frequently identified concern for primiparas and multiparas, return of the figure to normal was most often listed as a major concern (N=26) in Gruis' study. Other authors in the postpartum literature (Chapman et al., 1985; Fishman, Rankin, Solkin, & Lenz, 1986; Gorrie, 1986; Lynch-Fraser, 1983; Mercer, 1981; and Rubin, 1984) have acknowledged the concern, frustration, and discouragement that many women experience in trying to regain their prepregnant figures. Harrison and Hicks (1983), found return of the figure the second most frequent concern (after regulating demands) in their study. For Tobert (1986), this item ranked the most frequent concern for multiparas and the 3rd concern of primiparas at one month post discharge from hospital. 24 Varney (1980) described the physical dynamics of regaining the prepregnant figure. She claimed that all puerperal women have some degree of diastasis recti. The severity of the diastasis depends on a number of factors including: the woman's general condition and muscle tone, if the woman exercised faithfully to regain her abdominal muscle tone and close the diastasis after each pregnancy, her parity (regaining complete muscle tone becomes increasingly difficult with increasing parity), the rapidity of her pregnancies (whether or not there was time for her to regain her muscle tone before being into another pregnancy), and pregnancies that have over-distended her abdomen (e.g., multiple gestations). These factors also determine how long it wil l take a mother to regain her muscle tone. pp. 252-253. If the abdominal muscle tone is not regained, the space between the recti muscles f i l ls in with peritoneum, fashia, and fat. Subsequent pregnancies will not have the muscle support of the first pregnancy, and the abdomen becomes increasingly pendulous. The back may become painful—even extremely painful, and/or difficulties with fetal engagement at the time of the next labor and delivery may be experienced. As part of a study of 68 middle-class couples at four months postpartum, and 126 couples at twelve months postpartum to determine changes in sexual relationships postpartum, (Fishman et al., 1986) 25 mothers were asked to indicate their feelings about their bodily appearance since delivery. "This question elicited the largest number of anecdotal comments and highlighted the frustration and discouragement many of the women were experiencing in trying to regain their prepregnancy figures" (p. 61). At four months postpartum, 70% of the mothers were less or much less than satisfied with their bodily appearance. One year later, 39% were sti l l dissatisfied. Whether or not these women had been satisfied with their bodily appearance before becoming pregnant was not addressed in the study. Dissatisfaction with appearance was not found to be associated with a decreased frequency of sexual intercourse. Broom (1984) investigated anticipated and actual postpartum concerns about the marital relationship during the transition to parenthood, for 22 couples expecting their first child. Interviews were conducted in the second or third postpartum week, and both husbands and wives were asked to rank a stack of 35 cards (each with a concern related to the marital relationship) from most to least important. Return of the figure was ranked 16th by the wives, and 26th by the husbands. From these last two studies it appeared that return of the figure to normal was not a major concern affecting the sexual and marital relationships of couples in the postpartum period. Consequently, it remains a concern encompassed primarily by the task of physical 26 restoration. 2. Regulating demands of husband/partner, housework, children. For both primiparous and muciparous mothers, this concern ranked second in frequency (following that of return of the figure to normal) in Gruis' study, and most frequent in the study by Harrison and Hicks (1983). Regulating demands of husband/partner, housework, and children is a concern incorporated by task of alteration of lifestyle and relationships to accommodate a new family member—the fourth task in the conceptual framework. It requires rearrangement of roles, finances, housekeeping duties, and social activities. It also demands careful reorganization of maternal time, energies, and priorities. Depending upon the availability of resources to assist the mother, this concern can generate other concerns—most notably those of fatigue and emotional tension. In the study by Broom (1984) investigating the marital relationship during the transition to parenthood, the foremost concerns identified by mothers at two to three weeks postpartum were: 1. Balancing demands of spouse, housework/job, and child. 2. Activities having to be worked around baby's schedule. 3. Economic responsibilities imposed by arrival of baby. 4. Feeling too busy, having too much to do. 5. Loss of income due to spouse's leave from work. 6. Little time/energy to devote to giving special attention to 27 spouse. 7. Less time for shared leisure activities with spouse. 8. Amount of time required to care for baby. (This was the number one concern identified by the husbands.) Most of these concerns related to the idea of having to balance demands of husband/partner, housework, and children. However, they also introduced the concern of finances, and the fact that many women today are balancing the demands created by jobs or careers in addition to the other demands. Tobert (1986) found that 54% of the mothers in her sample (when questioned two days post discharge from hospital) were planning to return to work. Lynch-Fraser (1983) claimed that "almost 40% of all new mothers return to their jobs before their baby is a year old, and that number is growing" (p. 181). In addition, "almost 70% of all working mothers in the United States are either the sole support for their children or have husbands who do not earn an income adequate to support the family's lifestyle" (pp. 185-186). Although mothers may not be considering the return to work in the first month postpartum, by the end of the fourth trimester, many will be (Brouse, 1985). Chapman et al. (1985) found that: almost 50% of the mothers in their study expressed concern, mainly in the form of ambivalence, about returning to work or school. Two mothers cited this during the first week. 28 This concern peaked during the 5th week and the third month, (p. 376) Sheehy (1974) in her popular book about the stages of adult development, used the word "integrators" to describe women choosing to merge marriage, career, and children simultaneously (rather than postponing a career until their families are raised, or postponing a family until their careers are established). Sheehy found that "integrating" was far more difficult for women in their early twenties, than it was for women at ages 28 to 30. The concern "Regulating demands of husband/partner, housework, and children" is receiving considerable attention in the postpartum literature. The researcher recommends though, that it be rewritten to say: "Regulating demands (or anticipated demands) of partner, housework, work/school, and children" the next time Gruis' study is replicated. 3. Emotional tension. The term emotional tension was not defined on the postpartum questionnaire developed by Gruis. Consequently, the investigator can only hypothesize as to what specifically was intended by the mothers who responded to this item. Furthermore, although the term emotional tension has been used, not infrequently, in the postpartum literature, it has remained operationally undefined. Ludington-Hoe (1977) conceptualized the motherhood role as being 29 comprised of two components: emotional factors (maternicity) and physical caretaking (mothering). She said: Maternicity is the characteristic quality of a woman's personality that supplies her with the emotional energy for feeling that her infant occupies an essential part of her life as determined by bonds of affection. These bonds include feelings of warmth, devotion, protectiveness, concern for the infant's well-being, and pleasant anticipation of continuing contact, (p. 1171) Unfortunately, maternicity does not automatically accompany the birth of a child. It develops slowly as the mother and child learn to respond to each other. Until the infant can participate with the mother, the mother-child relationship may be particularly stressful (Ludington-Hoe, 1977). Ludington-Hoe stated that: "The mother can confidently move toward a rewarding relationship with her infant during the postpartum period provided she is taught how to interact with her infant" (p. 1171). Ludington-Hoe's conceptualization of the motherhood role as being comprised of two components: maternicity and mothering, is a useful reminder for nurses to not neglect the affective or emotional component in postpartum teaching sessions. However, Ludington-Hoe's belief that maternicity is directly related to a mother being "taught" how to interact with her baby, seems a superficial, and unrealistically simple answer to the mystery of the mother-child bond. Was maternicity 30 impossible before the times of nurses teaching mothers how to interact with their babies? Will natural instincts in a supportive environment (perhaps including nurses) foster maternicity as much as nurses can, or more so? Is there any "right" way for a mother to interact with her baby? These are some questions that come to mind in response to Ludington-Hoe's assertion. Bull (1981) studied the changes in concerns of primiparous mothers from three days postpartum in hospital, to one week postpartum at home. She found that the concerns regarding self care and infant care persisted, and that the concerns related to emotional self increased significantly. In another study (Bull, 1985), 49 multiparous, and 29 primiparous mothers returned a questionnaire to determine mothers* use of knowledge (acquired in hospital) during the first postpartum weeks. Information regarding emotional tension (one of six items in the social interaction category) was reported useful by approximately half of the mothers. Lynch-Fraser (1983) offered a different insight. She said: Many sociologists and psychologists believe that Western society's glorification of motherhood [the image of the mother as all-loving, all-giving, whose purpose is to guide, comfort, and nurture] sets up insecurity and guilt in women who may not feel adequate to fulfill the requirements of motherhood ( p. 27). Though there are unequaled joys to be experienced in mothering, most of what the 31 media has [sicl presented to us is, at the least, an exaggeration and, at the most, a lie. Yet women continue to compete with a dream of motherhood that doesn't exist, (p. 29) The concern of emotional tension may have significant impact on all four of the tasks of the postpartum period. Consequently, it requires further consideration and study. 4. Fatigue. Many authors (Burke, 1985; Chapman et al., 1985; Gruis, 1977; Hans, 1986; Rubin, 1961, 1975, and 1984; Shereshef sky & Yarrow, 1973; & Sumner & Fritsch, 1983) have acknowledged the significance of fatigue as a concern in the postpartum period. Fatigue can drain a mother's energies such that all of the tasks of the postpartum period become more difficult to accomplish. In the study conducted by Brouse (1985) at three weeks postpartum, "one-third of the mothers stated that they felt tired, disorganized, and frustrated" (p. 65). The process of physical restoration in the postpartum period begins after a deep, refreshing sleep that lasts for several hours (Rubin, 1961). Rubin claimed that when this deep sleep is disrupted, "the restorative processes are delayed, and the parturient experiences what can be best described as sleep-hunger for several days" (p. 754). The first phase of Rubin's restorative period is called the "taking-in" phase—taking in sleep and food. It is a dependent stage that lasts two to three days. The second phase, the "taking-hold" phase (it 32 ends approximately 2 weeks after delivery) sees the development of autonomy in the mother's body, and an extension of her energies and concerns towards her baby, and subsequently, towards her family. Rubin (1961) said that the "taking-hold" phase is one in which the consistency, the presence, and the faith of someone the mother can trust can help to reduce some of her exhaustion. "Despite the parturient's fond wishes, 'going home to rest' is not possible; postpartum fatigue stems from her own inner drive for excellence" (p. 755). In 1984 Rubin revised her conceptualization of the "taking-in" phase. Instead of lasting three days, it was viewed as comprising the first three weeks of the postpartum period. Rubin described this phase as a time for sleep and food, for the restoration of body functions, the self-concept, and self-esteem. Martel and Mitchell (1984) conducted a descriptive study of 20 healthy new mothers receiving hospital postpartal care to answer two questions: (1) Do the subjects show "taking-in" and "taking-hold" behaviors and attitudes as described by Rubin in 1961 ? and (2) Do these behaviors and attitudes change during the course of hospitalization? The investigators were concerned that "reliance on observations made under different social and economic conditions, such as those 20 years ago, can interfere with making new observations and drawing new conclusions today" (p. 149) 33 The results of the study supported Rubin's (1961) notion of mothers showing decreasing amounts of "taking-in" and increasing amounts of "taking-hold" during their hospitalizations. But "attitudes during the first of two postpartal days did not indicate a strong "taking-in" phase and the "taking hold" phase seemed to peak on the 2nd postpartal day, earlier than described by Rubin" (p. 148). The authors recognized that their study was a very limited test of Rubin's concept, and recommended further research in the area. One cannot deny that "intuitively, peoples throughout the ages have recognized the unique complexity of the puerperium by providing for the parturient the sanctuary of the lying-in period during which social or worldly tasks were barred" (Rubin, 1961, p. 754). 5. Infant behavior. Previous research (Reisch, 1979) has indicated that mothers do not receive sufficient information related to infant behavior during their hospitalizations. Reisch recommended that "nurses assess and demonstrate infants' interactive behaviors to mothers to facilitate meaningful interaction between mother and infant...[and perhaps} strengthen the maternal-infant bond" (p. 245). Ludington-Hoe (1977) and Rubin (1984) also believed that nurses could enhance the mother-child relationship by teaching appropriate interactive behaviors in the postpartum period. Without such instruction or guidance, the unpredictability and uniqueness of each 34 infant's behaviors may prove confusing or distressing (Rubin, 1984). In the study by Brouse (1985) a nursing intervention designed to teach primiparas about their infant's behaviors (performed in hospital before discharge) did not significantly alter the maternal anxiety measured three weeks postpartum. Perhaps the timing of such an intervention deserves further consideration and research. Approximately two-thirds of the 83 mothers studied by Bull and Lawrence (1985) reported that the information they received in hospital concerning infant behavior was useful during their first weeks at home. Twelve comments (the most frequent request) indicated the need for additional information concerning infant behavior—the infant's mood, normal activity, how to deal with fussy times, and normal sleep-wake patterns. Chapman et al. (1985) studied (a) breast concerns, (b) infant concerns, and (c) postpartum concerns of 44 breastfeeding mothers in the first four months postpartum. Data were collected from nursing notes taken at each interaction with the mother. The authors said that concerns about infant behaviors (fussy, sleepy, day-night mixed) were stated frequently and throughout the four months. A peak in the concern over day-night mixed behaviors (i.e., asleep during the day, awake at night) occurred during the third week. Sumner and Fritsch (1983) surveyed the spontaneous requests of parents for information and support, as evidenced by their telephone 35 calls to a health care facility. The highest percentage of questions was about feeding (31%)—especially breastfeeding. Mothers were also concerned about gastrointestinal problems in their infants (21% of the questions), rashes and cord care (16%), and sleep/cry behaviors (8%). Primiparas called in to the facility approximately three and a half times more frequently than multiparas, and multiparas asked slightly more questions per call. Twenty-five percent of the muciparous mothers eligible to call, did so. The study by Sumner and Fritsch (1983) used the survey technique to document the need for postnatal programs that included specific content areas as identified by the in-coming telephone calls. The study was able to use the resources already present in the institution studied, and could be easily replicated by other facilities. There were, however, several obvious limitations to this study. Only one facility was studied, and there is no guarantee that other facilities in different locations, and at different points in time, would report the same findings. Furthermore, one may query how appropriate the telephone is in conveying postpartum concerns of a personal nature—e.g., labor and delivery experiences, emotional tension, sexual relations, or role changes. Perhaps mothers felt comfortable in asking for help in relation to infant concerns, but not for concerns about themselves. Sumner and Fritsch (1983) did not examine other sources of help that mothers may have utilized concurrently with the facility 36 studied. The literature review presented here is somewhat confusing and conflicting in its findings regarding the concern of infant behavior. Infant behavior is a concern related to the tasks of learning to care for and meet the needs of a dependent infant, establishment of a relationship with the infant, and alteration of lifestyle and relationships to accommodate a new family member. Postpartum Resource Ulilization Both Gruis (1974) and Harrison and Hicks (1983) found husbands to be the most frequently utilized resource, followed by physicians, and books and pamphlets. Other relatives and nurses were least frequently utilized by respondents in Gruis' study. For Harrison and Hicks, nurses were the least frequently utilized resource. All of the resources used in Gruis' study were very helpful to the postpartum mothers. Harrison and Hicks (1983) did not examine helpfulness of resources in their study. For Tobert (1986), 81 % of the respondents in her study found their husbands to be their most helpful resource at two days post discharge from hospital. Tobert did not assess this resource at one month postpartum. Respondents in Gruis' study ranked the husband as the primary resource for concerns about self and family, but used the physician most frequently for concerns related to the baby. Books and pamphlets were used often for all concerns, and were consistently the most helpful 37 resource. Nurses were utilized to meet concerns about self and about the baby, but generally were not used to meet family related concerns. For Harrison and Hicks (1983), mothers used nursing assistance for their labor and delivery experiences, their physical care postpartum, and for concerns about the physical care and feeding of their infants. Of the 20 respondents attending prenatal classes in Gruis* study, (13 primiparas, and 7 multiparas), 85% found the classes a helpful preparation for the postpartum period. However, mothers attending prenatal classes did not experience fewer concerns than mothers who did not attend prenatal classes. Nineteen mothers reported the hospital stay as helpful, 21 mothers stated that it was not. For Harrison and Hicks (1983), 80% of the primiparas, and 37% of the multiparas had chosen to attend prenatal classes. As with Gruis' findings, women attending prenatal classes had significantly more concerns postpartum than women who did not attend classes. Perhaps prenatal classes reduce concerns related to labor and delivery, but not those concerns related to the postpartum period. Further nursing research is needed in this area. Seventy-two percent of the respondents in the study by Harrison and Hicks (1983), and 90% of the respondents in the study by Tobert (1986), were visited by community health nurses. All but one of the mothers in Tobert's study had had at least one contact with a physician. Gruis (1977) claimed that existing postpartum resources were 38 inadequate in meeting the needs of the postpartum mother. Rubin (1975) believed that "we provide less care to mothers and to babies than any other civilized nation because we stop too soon" (p. 1684). She said: today our big failure is the postpartum period. The postpartum period is at least six weeks long. Hospitalization—and third party payment for it where it exists at all—is only three to five days and drifting towards even less. Neither obstetrical or pediatric medicine is concerned or knowledgeable about postpartal problems, (p. 1684) Sumner and Fritsch (1983) noted an obvious gap in health service for the new mother from the date of her hospital discharge to the traditional four to six week medical visit (*this study was undertaken in 1977). They said: Generally, in today's family there is not the extended family close by, and there are few places where the mother can get information about both mothering and newborn behavior. Although there are places available in her community, it is frequently difficult to get to these sources of information because she lacks previous contact with them. (p. 194) Brouse (1985) found the situation in Vancouver, B. C. quite different for the 31 primiparas she studied. Most of the new mothers had support from other family members, usually their mothers. About one-half of the participants had lived 39 in Vancouver all of their lives and had a wide network of friends and family to call upon when needed. Of the mothers not born in Vancouver, many had lived here long enough to have established an informal support network. In addition, all of the new mothers emphasized the positive support given to them by the infants' fathers, (pp. 70-71) The health care system also provided more support to Brouse's sample. "Most doctors saw the mother and infant at two weeks postpartum and were readily available to answer questions at other times" (p. 71). Community health nurses visited between the first and second postpartum weeks, and would visit again if requested. These visits were seen by the mothers as helpful because the nurses were knowledgeable and supportive. Watts (1984) compiled a comprehensive and informative guide to resources for parents and prospective parents, in the Vancouver area and Lower Mainland. She found that there were a large number of support groups, well baby clinics, drop-in centres, family service societies, associations to help children develop, and day care facilities to assist the postpartum mother with her concerns. Summary The conceptualization of four tasks developed by Gruis (1974) has 40 provided a useful framework (supported by the literature) from which to view postpartum maternal concerns. The concerns of return of the figure, regulating demands, emotional tension, fatigue, and infant behavior are (a) well supported by research findings, and (b) concerns with which nurses have the education and experience to provide assistance and guidance. The use of nurses as a resource for these concerns has not been well documented, despite the fact that nurses appear to be a particularly appropriate resource for mothers experiencing these and other postpartum concerns. 41 CHAPTER THREE Research Methodology Overview The purpose of this study was to identify the postpartum concerns, and corresponding resource utilization and resource helpfulness, of primiparous and multiparous women. Participants were recruited from a large tertiary care maternity hospital, and were mailed a postpartum concerns questionnaire and cover letter (see Appendix D) three and one half weeks after their delivery dates. Permission to use the questionnaire was obtained by telephone from its developer, Dr. M. Killien (formerly M. Gruis), associate professor at the University of Washington. The questionnaire was slightly modified in the following ways: 1. The category of "Nurse" was divided into "Hospital Nurse" and "Public Health Nurse" because both groups are involved in the delivery of postpartum nursing care. 2. The category "Husband" was changed to "Partner". 3. A category entitled "Other" was added for mothers to acknowledge resources that had not been accounted for in the questionnaire. 4. Respondents were asked whether their labor and delivery 42 experiences were easier, the same, or more difficult than expected to see if this information appeared to affect the number of concerns experienced postpartum. 5. Respondents were asked if they desired more support and guidance in the postpartum period, and were asked for an explanation if they answered in the affirmative. This addition to the questionnaire gave respondends an opportunity to express themselves outside the confines of the research tool. Demographic data (parity, age, and education) were solicited to determine whether certain concerns were specific to particular characteristics of the sample. Validity and Reliability of the Tool Gruis (1974) established content validity for the instrument by formulating the items for her checklist based on a study of needs during the postpartum period from seventeen literature sources (see Gruis, 1974, p. 20). The tool was pretested with five mothers who met the criteria for sample selection. These mothers were asked to comment on the clarity and pertinence of items on the questionnaire. "Their comments did not indicate [the necessity for] any changes in the questionnaire" (Gruis, 1974, p, 23). Similar findings to Gruis' were reported by Harrison and Hicks (1983) and Tobert (1986). Reliability of Gruis' tool has not been established. 43 Sample and Setting Participants for this study were recruited from five postpartum wards of a large tertiary care maternity hospital in Vancouver, B. C. Thirty primiparas and 30 multiparas who volunteered to participate composed the sample. To be a participant in this study, mothers were required to meet the criteria identified by Gruis (1974): 1. Delivered a normal infant who was discharged from the hospital with the mother. 2. No complications which required an extended hospital stay of more than four days. 3. Living with the father of the baby at the time of the study. In addition, a fourth criterion related to language was added: 4. Fluent in both spoken and written English. Data Collection At the beginning of this study, copies of the questionnaire and the "Information Sheet for Nurses" (see Appendix A) were posted on the postpartum wards. Each time the investigator visited the hospital, the charge nurses for each ward reviewed the "Information Sheet for Nurses" to help recruit appropriate participants. This sheet explained the investigator's desire to visit the mothers to discuss the study and request their participation, as well as the selection criteria for the 44 study. In addition, the charge nurses were asked if they believed there was any reason why any mother should not be approached. Subsequently, mothers recommended by the charge nurses were invited to participate in the study. To each mother was explained (a) the purpose and objectives of the study, (b) the selection criteria, and (c) the ethical considerations outlined below. Questions raised were answered verbally by the invesigator. Written consent (see Appendix B) was then obtained from the mothers who expressed interest in participating, and a copy of the consent form was retained by the participant. Physicians of the participants were sent a letter describing the nature of the study (see Appendix C). Over a period of 10 days (January 26, 1987 - February 4, 1987), 30 primiparous, and 30 multiparous mothers were recruited for participation in the study. Participants were mailed the questionnaire (which included a stamped return-addressed envelope) three and one half weeks after delivery. A cover letter attached to the questionnaire explained the purpose of the study, directions for completing the questionnaire, and indicated the voluntary nature of participation in the study. Ethical Considerations and Human Rights Permission to conduct this study was received from the Research Coordinating Committee of the large tertiary care maternity hospital in 45 Vancouver, B.C., and from the Behavioral Sciences Screening Committee For Research and Other Studies Involving Human Subjects of the University of British Columbia. Subsequent to a verbal explanation of the purpose of the study, subjects were asked to sign a letter of consent (see Appendix B) of which they retained a copy. All subjects were informed that their participation in the study was voluntary, that they were free to leave any questions they chose unanswered, and/or to withdraw from participation at any time. Subjects were also informed that their decision not to participate in the study would not, in any way, jeopardize the treatment they would receive in hospital. Subjects were told by the investigator that confidentiality would be strictly respected, and that individual anonymity would be protected through the use of an unsigned returned questionnaire and grouped data reporting. Data Analysis Using descriptive statistics, data from the questionnaires were analyzed to determine (a) the kinds and frequencies of concerns identified by mothers, (b) the types of resources utilized to meet major concerns, and (c) the adequacy of resources. In chapter four the data analysis is explicitly described. 46 CHAPTER FOUR Presentation and Discussion of Findings Overview The findings of this study are presented in four sections. In the first section a description of the two groups making up the sample, noting similarities and differences between primiparas and multiparas on demographic variables, is provided. In the second section the major postpartum concerns of primiparas and multiparas are identified and compared. Three selected perceptions and how they relate to expressed concerns are described in section three. Finally, in section four the resources used by the mothers in the study are identified and assessed in terms of their helpfulness in meeting postpartum concerns. Section 1: The Sample Sixty mothers, who met the study criteria and delivered at a large metropolitan tertiary care maternity centre, were recruited in January and February of 1987 to participate in the study. Three and one half weeks after their delivery dates, 59 mothers (one mother had lost her baby in this interval) were mailed the postpartum questionnaire. Forty-two completed questionnaires were returned; giving a return rate of 71%. One respondent had not been discharged with her baby, and was 47 eliminated from the study. Thus, the data producing sample was 41 postpartum mothers who met the study criteria—19 primiparas and 22 multiparas. Age and Education The ages of the primiparas in the sample (excluding one mother who did not provide data) ranged from 17-37 years, with a mean of 28.5 and a median of 28.5 years. Thirteen of the 19 primiparas (68%) had education beyond the high school level. The ages of the multiparas ranged from 22 to 39 years, with a mean of 30.2 and a median of 30.5 years. Twenty of the 22 multiparas (91%) had education beyond the high school level. In comparing the two groups, the primiparas in the sample were somewhat younger than the multiparas. Both groups were highly educated. Community Resources Utilized Information concerning attendance at prenatal classes and postpartum visits by public health nurses was sought from the mothers in the study. Sixteen of the primiparous mothers attended prenatal classes. Two mothers (ages 17 and 20) did not attend classes, and one mother attended 3 out of 8 classes. Six of the multiparous mothers attended prenatal classes for this baby. Sixteen did not attend. However, 20 multiparas had attended prenatal classes for a previous baby. Only two multiparous mothers had not attended any prenatal 48 classes. All of the primiparas were visited in the first weeks postpartum by a public health nurse. Ten multiparas (45%) were not visited. One multipara was asked if she desired a visit, but she declined. Three primiparas were visited twice. Two primiparas were visited three times. One muciparous mother stated that she received a visit every day (duration not specified) due to concerns about the baby's weight gain and bilirubin level. In comparing the two groups, the primiparas had attended prenatal classes more recently, and had more contact with public health nurses, than the multiparas. Section 2: Postpartum Concerns The presentation and discussion of findings is focused on the major concerns of the mothers in the sample. The investigator believes that mothers having to discriminate between minor and major concerns on the questionnaire, made the major concerns identified particularly noteworthy for nurses planning postpartum educational programs. The degree of concern (i.e., none, minor, and major) experienced by the mothers for all of the 32 items on the questionnaire can be found in Appendix E. The number of major concerns experienced by mothers in the two study groups is presented in Table 3. 49 Table 3 Number* of Major Concerns and Parity Major Concerns Primiparas (N) Multiparas (N) <6 6(31.5%) 10(46%) 6-10 6(31.5%) 6 (27%) 11-15 4(21%) 4(18%) 16-20 3(16%) 2(9%) *out of 32 possible concerns Major Concerns of Primiparas There were 11 items on the questionnaire which were of major concern to more than one third of the primiparas in the study. They are presented in Table 4. Infant feeding. Infant feeding was identified as a major concern by 12 of the 19 primiparas (63%). In addition, five of the primiparas (26.5%) found infant feeding to be of minor concern. Only two primiparas (10.5%) had no concern with this item. Infant feeding is a concern encompassed by the task of learning to care for and meet the demands of a dependent infant. Successful infant 50 Table 4 host Frequently Identified Major Concerns of Primiparas (N=19) Concern Major Minor No Concern (N) Concern (N) Concern (N) Feeding 12 5 2 Fatigue 10 7 2 Breast Soreness 10 4 5 Infant Behavior 9 9 1 Return of Figure 9 6 4 Limiting Visitors 8 7 4 Regulating Demands 7 10 2 Growth & Development 7 8 4 Interpreting Behavior 7 8 4 Physical Care of Baby 7 8 4 Labor & Delivery 7 6 6 51 feeding is basic to the establishment of maternal self confidence, and to the growth of the child. Mercer (1981) discussed the pre-eminent concern of all mothers to know they are capable of caring for their infants. Postpartum teaching in hospitals emphasizes the task of learning to care for and meet the needs of a dependent infant more so than any of the other tasks (Glover et al., 1985). Nevertheless, it could appear from the data that: (a) the information and assistance recieved by the majority of primiparas in the first postpartum month is not sufficient, or (b) for various reasons (e.g., fatigue, nervousness, euphoria) mothers have not been able to assimilate the information given, or (c) mothers have had ongoing concerns (despite the information and support received) as was reported by Chapman et al. (1985) in their study of the concern of breastfeeding mothers from birth to four months. Further research in this area is needed. Fatigue. Fatigue was identified as a major concern by 10 (52.5%) of the primiparas in this study. An additional seven (37%) identified fatigue as a minor concern. As with infant feeding, only two (10.5%) primiparas had no concern with this item. Fatigue is a concern which affects all four tasks of the conceptual framework, including the body's capacity to heal, to resume prepregnant physical functioning, and to establish lactation. If a mother is 52 breastfeeding, fatigue may be a major detriment to successful infant feeding—the number one major concern of the primiparas. Rubin (1961) believed that a deep refreshing sleep that lasted for several hours after delivery was necessary before the commencement of physical restoration. Unfortunately, this sleep is often not possible in the context of hospital routines that can be busy and noisy. Once discharged, opportunities to rest may become even fewer as other household demands and regular night wakenings encroach upon a mother's energies. Prenatal and postpartum nurses need to assist mothers by letting them know that they may experience fatigue, and provide mothers with possible strategies for acquiring additional rest both in hospital, and throughout the early weeks at home. Breast soreness. Breast soreness was the only other major concern for more than 10 of the primiparas in this study. It was a minor concern for four (21%) primiparas, and of no concern for five (26.5%) primiparas. Breast soreness is related to physical restoration, and to the task of learning to care for and meet the needs of a dependent infant if the mother is breastfeeding. It is a concern that may also affect the task of establishing a relationship with the infant. As a major concern reported more than three weeks after delivery, breast soreness is noteworthy. It would be anticipated that most 53 problems related to breast soreness would have occurred in the first postpartum week during the establishment of lactation. The data indicate that mothers have not "forgotten" the breast soreness experienced initially, or perhaps they continued to have discomfort and problems. Further research in this area is warranted. Infant behavior. A major concern for nine (47.5%) of the primiparas, and a minor concern for an additional nine primiparas in the sample was infant behavior. Only one primipara had no concern with this item. Various authors (Reisch, 1979; Ludington-Hoe, 1977; Rubin, 1984; Brouse, 1985; Chapman et al., 1985; Sumnner & Fritsch, 1983) have acknowledged the concern that mothers experience in relation to infant behavior. Rubin (1984) discussed how the unpredictability and uniqueness of each infant's behavior may prove overwhelming to mothers, and recommended that nurses assist mothers in interpreting and understanding the "irrationality of the neonate's behavior" (p. 105). Regardless of whether an infant is crying and irritable, or sleepy and unresponsive, infant behavior may be a concern that affects several tasks of the conceptual framework. It is also a concern that has the potential to generate many other maternal concerns including: fatigue, regulating demands, emotional tension, finding time for self, changes in relationship with husband/partner, and other children's behavior. 54 Return of the figure. Return of the figure was also acknowledged as a major concern of nine (47.5%) of the primiparas. Return of the figure and exercise are major concerns identified in the postpartum literature by Gruis (1974), Harrison and Hicks (1983), and Tobert (1986). Rubin (1984) said that mothers often expect the weight gained in pregnancy to be shed at delivery. When this does not happen, negative feelings can be evoked. There are few apparent compensations for a thick waistline, an abdomen protruding with a two-pound uterus, sore perineum, or broad hips. Although her uterus shrinks to half that size within a week postpartum, her abdomen does not feel as 'empty' as the new mother expected. (Mercer, 1981, p. 342) In a study conducted by Brouse (1985), 31 primiparous mothers were interviewed informally in their homes three weeks postpartum. "Approximately one-third of the mothers were concerned about their weight gain and several stated that this was more upsetting than anything else" (p. 66). Other major concerns. More than one third of the primiparas identified major concerns related to the baby—growth and development, interpreting behavior, and physical care; regulating demands and limiting visitors; and the labor and delivery experience. 55 Major Concerns of Multiparas There were six items on the questionnaire that presented major concern to almost one third or more of the multiparas. There were 12 items that presented major concern to more than one fourth of the group. These findings are presented in Table 5. Fatigue. Fatigue, the number one major concern of the multiparas, was identified by 14(63.5%) mothers. An additional three (13.5%) multiparas identified fatigue as a minor concern. Fatigue can drain a mother's energies such that all the tasks of the postpartum period become more difficult to accomplish. Furthermore, fatigue has the potential to generate many other maternal concerns. The opportunities for postpartum multiparas to rest are perhaps even fewer than for primiparas, due to the fact that they have at least one other child in the family requiring their time and attention. Multiparas may benefit from teachings on time management and relaxation to help decrease the incidence of fatigue as a major postpartum concern. Regulating demands. Regulating demands was identified as a major concern by 13 (59%) of the multiparas. An additional six multiparas (27.5%) identified it as a minor concern. Regulating demands was of more major concern to the multiparas 56 Table 5 host Frequently Identified Major Concerns of Multiparas (N=22) Concern Major Minor No Concern (N) Concern (N) Concern (N) Fatigue 14 3 5 Regulating Demands 13 6 3 Emotional Tension 10 9 3 Other Children Jealous 7 11 4 Breast Soreness 7 7 8 Labor & Delivery 7 3 12 Exercise 6 14 2 Finding Time for Self 6 12 A Infant Behavior 6 10 6 Feeding 6 8 8 Growth & Development 6 5 11 Hemorrhoids 6 2 14 57 than to the primiparas in this study. This may be because multiparous mothers have more complex family structures to organize with the arrival of a newborn. The integration of a newborn into the existing family structure can be very stressful. Marital relationships may suffer from neglect, or other children may react with hostility. Chapman et al. (1985) found that 83% of the multiparas in their study (N=16) expressed concern about the adjustment of siblings. Regressive, attention-getting, and disruptive (i.e., temper tantrums) behaviors were reported in additon to avoidance of the newborn. Regulating demands is no doubt a skill that improves with practice. None-the-less, mothers can be encouraged to participate in postpartum groups where organizational techniques and time management skills are discussed. Mothers require guidance and support in setting priorities for themselves and their families, and in deciding what are reasonable expectations to have. Public health nurses can be an important resource in this area. Emotional tension. For almost one half of the multiparas (N=10) in the study emotional tension was a major concern. Emotional tension is a concern which may have considerable impact on all four tasks of the postpartum period. Burke (1985), Oakley (1980), Shereshefsky and Yarrow (1973), and Ziegel and Cranley (1984) have acknowledged the emotional tension of the postpartum period. Mothers are often isolated from previous 58 employment, activities, interests, and friends. Those mothers who do return to work may experience improvement in their maternal feelings (Heywood Jones, 1983), or they may feel an intensified conflict between their different roles. In addition to the labor and delivery experience, loss of a former lifestyle may need to be grieved and resolved before the mother can successfully establish a relationship with the infant, and/or accommodate the infant into the existing family structure. Addressing the postpartum woman, Lynch-Fraser (1983) said: The cumulative emotional effect of new parenthood probably represents the greatest single period of loss in your life. It seems as if everything has changed. If you worked, more than likely you have left your job, at least temporarily. Your baby has left the confines of your body. You've even lost the shape and strength of your body. Most significantly, though, you can feel as if you've lost yourself, (p. 26) Other major concerns. For almost one third of the multiparas, three additional items were of major concern: jealousy of other children, breast soreness, and the labor and delivery experience. The jealousy of other children is a concern encompassed by the task of alteration of lifestyle and relationships to accommodate a new family member. Public health nurses may be a particularly useful resource for assessing mothers 59 that require additional assistance in this area, and by providing appropriate information for helping mothers to meet the needs of jealous siblings. Breast soreness was a major concern for both the primiparas and the multiparas in this study. It is a concern that was not frequently identified by mothers in the studies of Gruis (1974), Harrison and Hicks (1983), or Tobert (1986). When recruiting mothers in the hospital for this study, the investigator had been impressed by the number of mothers mentioning concern about the filling and engorgement of their breasts close to the time of their discharge. For this reason, the discharge of mothers on what was generally their third postpartum day needs further consideration. The labor and delivery experience was of major concern to approximately one third of the primiparas and one third of the multiparas in this study. Mercer (1981) said that the first step in establishing a relationship with an infant is for a mother to achieve a sense of resolution of her labor and delivery experiences through a thorough review of the events which transpired. The actual experience of childbirth needs to be integrated with the expected experience. Some mothers begin the postpartum period experiencing a loss. The loss may have been due to disappointment/frustration with the labor and delivery experience, and/or with the sex of the child. A 60 mother whose expectations have not been met needs assistance from the nurse in understanding the experience and in working through the loss (Hans, 1986). Brouse (1985) found that many mothers in her study had an urgent need to describe their pregnancy and delivery experiences three weeks postpartum. It is essential that mothers be allowed the opportunity to thoroughly review their labor and delivery experience shortly after delivery. Postpartum nurses must be (a) cognizant of this necessity, and (b) supportive listeners. Furthermore, because approximately one third of the primiparas and multiparas indicated concern, both hospital and public health nurses need to carefully assess which mothers may not have been able to thoroughly review and resolve their labor and delivery experience, and then provide the appropriate support. Comparison of the Major Concerns of Primiparas and Multiparas In comparing the most frequently identified major concerns of primiparas and multiparas, six points were evident. 1. Fatigue was a major concern affecting both groups. 2. Primiparas were most concerned with items related to themselves, and to their babies. 3. Multiparas were most concerned with items related to themselves and to their families. These three findings were compatible with those of Gruis (1974) and Tobert (1986). 4. Breast soreness was a major concern affecting approximately 61 one half of the primiparas, and one third of the multiparas. This finding had not been reported in the studies by Gruis (1974), Harrison and Hicks (1983), or Tobert (1986). 5. Return of the figure was of major concern to the primiparas. Gruis (1974) and Tobert (1986) reported return of the figure as a major concern to both primiparas and multiparas in their studies. 6. For approximately one third of both groups, the labor and delivery experience was of major concern. This finding had not been reported in the other studies. Expressed Concerns Not Covered in the Questionnaire There were a number of concerns identified by the mothers that were not included on the questionnaire. Two mothers identified financial concerns. Each of the following concerns was reported once: urinary retention and bladder spasms; concern related to the respondent's mother; feelings of loss of status, resentment over loss of career, and work; own milk supply; nursery care and the attitude of nurses. Again, these data were supported by the literature findings that regulating demands includes work or career. 62 Section 3: Relationship of Expectations of Labor and Delivery.  Past Weeks at Home, and Attendance at Prenatal Classes  to Expressed Concerns  Labor and Delivery Experience Participants in the study were asked whether their labor and delivery experience was easier than expected, the same as expected, or more difficult than expected, so that these data could be examined in light of the number of major concerns experienced postpartum. The information obtained is summarized in Table 6. Table 6 Expectations of Labor and Delivery (L&D) and Major Concerns Expressed Characteristic Primiparas (N= 19) Multipararas (N=22) Respondents Number Respondents Number Major Major Concerns Concerns L&D Easier than Expected 6 54 8 40 L&D Same as Expected 18 8 57 L & D More Difficult than Expected 12 97 6 53 63 Twelve primiparas (63%) described their labor and delivery experience as more difficult than expected. Five of these mothers identified labor and delivery as a major concern on the questionnaire. Sixteen (73%) of the multiparas described their labor and delivery the same as or easier than expected. Six multiparas described their labor and delivery as more difficult than expected. Five of these mothers identified labor and delivery as a major concern on the questionnaire. The findings presented in Table 6 suggest that primiparas with labor and delivery experiences more difficult than expected on average (range = 4-18 major concerns), did not have more major concerns than did primiparas with labor and delivery experiences easier than expected. Multiparas with labor and delivery experiences more difficult than expected on average (range - 7-12 major concerns), had somewhat more major concerns than did multiparas with labor and delivery experiences easier or the same as expected. These findings must be considered in light of the small size of group providing data. The differences could be skewed due to the ratings of one or two respondents. Past Weeks at Home Respondents were also asked if their past weeks at home were easier, the same, or more difficult than expected. The data obtained are presented in Table 7. The data suggest that both primiparas and multiparas who experienced more difficulty at home than expected also 64 Table 7 Expectations of Past Weeks at Home and Major Concerns Expressed Characteristic Primiparas (N=19) Multipararas (N=22) Respondents Number Major Concerns Respondents Number Major Concerns Past Weeks at Home Easier than Expected 3 17 5 16 Past Weeks at Home Same as Expected 9 57 9 57 Past Weeks at Home More Difficult than Expected 7 95 8 77 experienced more major postpartum concerns. It seems likely that the reason mothers have more difficulties at home than expected, is because they are experiencing more unanticipated major postpartum concerns. Attendance at Prenatal Classes Two primiparas (ages 17 and 20) had not attended prenatal classes. These mothers experienced 14 and 11 major postpartum concerns. The two multiparas who had not attended any prenatal classes experienced 65 18 and 19 major concerns. As can be seen from Table 3 (page 49), this is a relatively large number of concerns. Gruis (1974) and Harrison and Hicks (1983) found that women who attended prenatal classes had significantly more (not less) concerns than women who did not attend classes. The findings in this study appear contrary to that. However, the data may be misleading due to the very small numbers who did not attend prenatal classes. Section 4: Sources of Help Mothers used a variety of both professional and non-professional resources in meeting their major postpartum concerns. The vast majority of these resources were found to be helpful. The resources used, and their adequacy of help, for the major concerns identified on the questionnaire are presented in Table 8. Partners, followed by pamphlets and books, were the major source of help identified by postpartum mothers. This finding is compatible with the studies of Gruis (1974), and Harrison and Hicks (1983). Other relatives and friends were the least frequently utilized resources in this study. Partners were used for concerns related to fatigue, regulating demands, emotional tension, labor and delivery experience, setting limits on visitors, and finding time for personal interests. Other relatives (including the respondent's mother), although used less 66 TableB number of Resources Used and Adequacy of Helo for ha lor Concerns Area of Major Concern Source of Help Partner H NH Your Mother H NH Other Relative H NH Friend H NH Public Health Hospital Nurse Nurse H NH H NH Doctor H NH Pamphlets/ Books H NH No Help Sought Other Diet <N-9> 2 1 2 1 2 1 2 1 2 - 1 2 3 Mtdwlves Program Exercise (N-12) 3 - 1 1 1 3 - - - 2 - 5 2 Community Centre Re tan of Figure to Normal (N-13) A 1 - - 2 1 3 1 3 1 1 - - - 3 A hospital physio Vaginal Discharge (H-7) 1 1 - - 1 1 2 - 1 - S 1 1 1 -Discomfort from Stitches (N-9) A - 3 - 1 1 2 - 6 1 3 - 2 -Hemorrhoids (N-9) 5 1 6 - 1 1 cream medication Constipation (N-5) 2 - - - 1 - " 1 I I 1 1 " -Breast Soreness (N-17) 2 - 1 - - 2 - 2 - 12 - A - 7 2 Care of the Breasts (N-8) - - 1 - - - - 2 - 7 - 2 - 5 - La Leche League Fatigue (N-24) 21 - II 1 A 1 . 1 1 2 1 3 1 2 - 1 1 1 nanny, baby sit ter Emotional Tension (N- M ) 11 1 A 2 2 2 1 1 Feelings of Isolation, being tied down (N-8) 3 1 2 - 2 - 1 - - - 1 2 Parent-Infant group Finding time for Personal Interests & Recreation (N - l l ) S 2 A - 1 2 - - 1 hired help, neighbours tabor and Delivery experience (N-1A) 11 - 2 - 1 1 1 1 1 9 1 9 2 1 - student doctor Changes tn Relationship with Partner <H-S) 3 Sexual Relations (N-6) 1 - - - 2 3 Family Planning (N-9) 3 1 - - . " - - 1 - - - 5 - 2 -Regulating Demands of housework, partner, other children (N-20) IS 2 9 - A 2 s - 2 - - - - 2 hired help, nanny Other Children jealous of Baby (N-7) A 2 - 1 2 - 1 - - 1 3 -Father's Role with Baby (N-5) 3 3 Setting Limits on Visitors t, Relatives (N-9) 7 2 - 1 2 _ - " 1 2 Feeling Comfortable Handling Baby (N-6) 3 3 - 1 A 3 - 2 - 1 -Growth 1 Development of Baby <N-13) 6 - 1 1 6 2 8 -Infant Behavior (N- IS) 5 1 4 1 2 1 1 S - 2 - 7 10 1 Interpreting Infants Behavior (N-IO) 2 2 - 1 - 3 - 2 - 1 6 -Feeding (N-18) A 1 1 3 1 A 10 2 5 2 6 2 7 1 - television shows Physical Care (N-IO) 3 - 3 5 - 5 1 7 - 3 1 Travelling with Baby (N-4) 2 - - 1 - 1 - - 1 -Safety (N-6) 3 I I - - - 3 3 Clothing for Baby <N-3) - 2 - 1 2 - - - - 1 mt H - Helpful; NH - Not Helpful 67 frequently, were used for similar concerns with the exception of the labor and delivery experience. Hospital nurses were the most frequently identified resource for breast soreness. They were also utilized for the labor and delivery experience, care of the breasts, and discomfort from stitches. To a lesser extent, they were used for concerns related to infant feeding and physical care. These findings are compatible with the role of postpartum hospital nurses. Public health nurses were used for concerns related to the baby: feeding, growth and development, behavior, and physical care. These findings are also compatible with the role of public health nurses visiting postpartum women. Doctors were used for concerns related to labor and delivery, feeding, infant behavior, and physical care. Health professionals were used more frequently by primiparas than by multiparas. Pamphlets and books were used for many infant concerns-behavior, growth and development, feeding, interpreting behavior, and for breast soreness. Pamphlets and books were used primarily by the primiparas in this study. Concerns for which No Help was Sought Return of the figure (N=3) and regulating demands (N=2) were the two most frequently identified major concerns of primiparas for which no help was sought. For the multiparas, there were no foremost concerns where help was not sought. Consequently, It would appear 68 from these data that most postpartum concerns were dealt with adequately. Prenatal Classes, the Hospital Stay, and Public Health Nurse Visits Eleven of the primiparas (73%) and 10 multiparas (56%) who had attended attended prenatal classes found the classes helpful in preparing them for the first weeks at home with their babies. Four primiparas and eight multiparas stated that the classes were not helpful. For the multiparas, the classes referred to may have been some time in the past. Three mothers did not answer this item. Fourteen primiparas (74%) found their time in the hospital prepared them for the first weeks at home with their new babies. Only eight multiparas (36%) found the hospital stay prepared them for the first weeks at home with their new babies. These data suggest that the care given during the hospital stay for the muciparous mother requires careful scrutiny. The most frequently identified major concerns of the multiparas in this study included fatigue, regulating demands, emotional tension, and the jealousy of other children. It is not known how much emphasis is placed on these concerns during a hospital stay. Priorities for nursing the postpartum muciparous mother must be set. One priority is providing the multipara with opportunities to rest, and practice with relaxation techniques. Another priority could be for nurses to explore with muciparous mothers strategies to help regulate the demands at home (e.g., acquiring help, time management, providing 69 information to help siblings with the integration of the new baby into the family). Thirty-one mothers were visited by a public health nurse at least once. Ten mothers (all multiparas) were not visited. Of these ten, three expressed a desire for additional support and guidance. All the public health nurse visits were reported as helpful. Desire for Additional Support and Guidance Seven primiparas (37%) (one of which had not attended prenatal classes) and eight multiparas (36%) (not including the 2 multiparas who had not attended any prenatal classes) wished more support and guidance had been available to them during the postpartum period. Primiparas wanted more information (one mother suggested films or classes) about what to expect in the postpartum period. For example, several mothers requested more information about breast feeding (how to know if the baby is getting enough milk, what to do if you have to leave for 4-6 hours, if and when to supplement, foods to avoid), cord care, alleviation of constipation and swollen sutures, and infant behavior. They also expressed a desire for earlier professional advice (most public health nurse visits were after the first week), more contact with other mothers, and more family help in the home. How to say "no" to well meaning visitors was a major concern for one mother. Muciparous mothers also desired more information and emotional support in the postpartum period. Problems with nursing were common 70 to several mothers, as were the dynamics of coping with other children, other demands, and fatigue. One mother felt that someone available to help in the home for the first ten days would have allowed her to recover from labor and delivery, and to become familiar with her newborn. Another mother felt that if discharges from hospital were to occur within three days, mothers should be eligible for some initial homemaker assistance. Summary Fatigue was a major concern for both the primiparas and the multiparas in this study. In addition, primiparas identified major concerns related to learning to care for and meet the demands of a dependent infant. Multiparas had concerns relative to the alteration of lifestyle and relationships required to accommodate a new family member. Breast soreness and the labor and delivery experience were of major concern to both primiparas and multiparas. It was not evident that mothers with more difficult labor and delivery experiences had more postpartum concerns. However, mothers experiencing more difficulty at home (than expected), also experienced more major postpartum concerns. Partners were the major source of help identified by postpartum mothers. They were utilized for concerns related to fatigue, regulating demands, emotional tension, labor and delivery experience, setting 71 limits on visitors, and finding time for personal interests. Hospital nurses were used for breast soreness, labor and delivery, care of the breasts, and discomfort from stitches. Public health nurses were used for concerns related to the baby. The vast majority of resources used were helpful. Five primiparas (26%) and 14 multiparas (64% ) found that their time in hospital did not prepare them for the first weeks at home with their new babies. Furthermore, seven primiparas (37%) and eight multiparas (36%) wished more support and guidance had been available to them during the postpartum period. Several mothers expressed the desire for earlier professional advice post discharge from hospital. Most public health nurse visits were made after the first week. 72 CHAPTER FIVE Summary, Conclusions, Implications, and Recommendations Summary The purpose of this study was to identify the concerns and resource utilization of postpartum mothers using a questionnaire developed in 1974 The investigator queried whether the social changes of the 1980s such as (a) the women's movement, with mothers returning to jobs or careers in the fourth trimester, (b) the increasing numbers of family structures other than that of biological parents living with their offspring, (c) the growing network of self-help support groups in communities, and (d) hospitals promoting early postpartum discharge, had changed the concerns and/or the resource utilization of contemporary mothers. The study was descriptive in nature, and was carried out using a mail-back questionnaire as the data collecting tool. The tool was developed by Gruis (1974) and was used with her permission. The sample consisted of 19 primiparas and 22 multiparas approximately four weeks after the spontaneous vaginal deliveries of their healthy babies. The sample was recruited from a large tertiary care maternity hospital in Vancouver, British Columbia. The findings in this study were analyzed to identify and compare 73 the major concerns of primiparas and multiparas. The use of resources in the postpartum period was also examined. Gruis's survey had been replicated with minor adjustment by Harrison and Hicks in 1978, and with major adjustment by Tobert in 1986. Consequently, the results of this study were compared with these three other studies. The most frequently identified major concerns of primiparas were feeding, fatigue, breast soreness, infant behavior, and return of the figure. The most frequently identified major concerns of multiparas were fatigue, regulating demands, emotional tension, jealousy of other children, breast soreness, and the labor and delivery experience. Breast soreness was a major concern affecting approximately one half of the primiparas, and one third of the multiparas. The labor and delivery experience was a concern affecting approximately one third of both groups. These findings had not been reported in the studies of Gruis (1974), Harrison and Hicks (1983), or Tobert (1986). Partners (followed by pamphlets and books) were the major source of help identified by postpartum mothers. They were utilized for concerns related to: fatigue, regulating demands, emotional tension, labor and delivery experience, setting limits on visitors, and finding time for personal interests. Hospital nurses were utilized for concerns related to breast soreness, labor and delivery, care of the breasts, and discomfort from stitches. Public health nurses were used for concerns 74 related to the baby. The vast majority of resources used were helpful in meeting postpartum concerns. Five primiparas (26%) and 14 multiparas (64%) found that their time in hospital did not prepare them for the first weeks at home with their new babies. Furthermore, seven primiparas (37%) and eight multiparas (36%) wished more support and guidance had been available to them during the postpartum period. Conclusions The findings of this study were compatible with those of Gruis (1974), Harrison and Hicks (1983), and Tobert (1986). Consequently, it appeared that the social changes of the 1980s have not substantially altered the postpartum concerns of mothers. There were, however, two items of major concern to both the primiparas and multiparas in this study, that were not noted in the other studies. These items were breast soreness and the labor and delivery experience. In addition, return of the figure was a major concern to the primiparas in this study, and not to both primiparas and multiparas as was reported by Gruis (1974) and Tobert (1986). This study suggested that the vast majority of major.concerns were dealt with effectively given a variety of resources to assist the postpartum mothers. However, for 14 multiparas (64%) the hospital stay did not prepare them for the first weeks at home with their new 75 babies. Furthermore, almost one third of both groups wished more support and guidance had been available to help them during the postpartum period. Replication of Gruis' survey has allowed for validation of the postpartum concerns of mothers today. Further replication of the survey does not appear warranted—at least not from a sample meeting the same criteria for participation, or using the same methodology. Implications for Nursing Practice 1. The Conceptual Framework The task framework used in this study provided a useful conceptualization of the postpartum period, and was well supported by the literature. Both (a) the four tasks: physical restoration, learning to care for and meet the needs of a dependent infant, establishment of a relationship with the infant, and alteration of lifestyle and relationships to accommodate a new family member, and (b) the major concerns identified in this study, could be the framework for a data collecting form for use by postpartum nurses in either the home or hospital setting. 2. The Hospital Stay Twenty-six percent of the primiparas, and 64% of the multiparas in this study found that their time in hospital did not provide preparation for the first weeks at home with their new babies. There may be a 76 variety of reasons for this finding. Effective establishment of lactation requires an atmosphere of relaxation and patience. Hospital routines are busy and noisy both during the day and night, and opportunities for mothers to rest and to recuperate from the birthing process may be few. The findings from this study indicated that primiparas have more major concerns related to learning to care for and meet the needs of a dependent infant, and multiparas are more concerned with the alteration of lifestyle and relationships required to accommodate a new family member. Consequently, the teaching emphasis should be different for the two groups. A need for individualized assessment of mothers prior to commencing teaching sesssions is apparent. 3. Fatigue Fatigue was the major concern of multiparas, while breast soreness and fatigue were the major concerns of the primiparas in this study. Both prenatal and postpartum nurses need to inform mothers that fatigue may be a major concern for them, and help them to find strategies to acquire additional rest in the early weeks at home. Nurses could also focus more attention on the rest and recuperation (physical restoration) of mothers from the birthing process during the hospital stay. Practice sessions in relaxation could be conducted. 4. The Labor and Delivery Experience The hospital nurse should be encouraged to talk through the labor and delivery experience with each newly delivered mother. Mercer 77 (1981) believed that a sense of resolution of the labor and delivery experience through a thorough review of the events which transpired was the first step in establishing a relationship with the infant—the third task in the conceptual framework of this study. 5. Resources Mothers should be visited in their home by a public health nurse as soon as possible following discharge from hospital. Individual assessments should be done, and information should be provided according to identified concerns. For example, some mothers may not have adequately reviewed their labor and delivery experiences, and require the opportunity to do so. The home setting also allows nurses the opportunity to teach baby care using the resources in the mother's own environment. Relaxation techniques may be reviewed, and exercise plans implemented as needed. The public health nurse should clarify realistic expectations for mothers as regards their body image postpartum, and provide information about the appropriate time to begin exercising, and what types of exercise are most manageable with a new baby in the family. In addition, information regarding community resources to assist the postpartum mother should be made available. Pamphlets and books were the second most frequently identified postpartum resource. They were used for many infant concerns—behavior, growth and development, feeding, interpreting 78 behavior, and for breast soreness. These are all concerns that the professional nurse has been educated to assist with. It would seem important, therefore, that nurses be involved with the production, monitoring, and dissemination of postpartum literature. Partners were the most frequently identified postpartum resource. Consequently, it is important for nurses to work with a family-centered approach to maternity care that involves partners in teaching sessions, and provides information and literature appropriate for the growing family. Recommendations for Further Study Further nursing research is recommended in the following areas: 1. A qualitative study to "uncover" postpartum concerns without the limitations imposed by mothers having to respond to a set questionnaire. Qualitative study could also identify the major concerns of different sample groups (e.g., single mothers, mothers who have had cesarean sections, mothers of different cultural backgrounds) prior to the development of other research tools. 2. Further exploration of the major concerns identified in this study (e.g., feeding, fatigue, breast soreness, labor and delivery experience) in order for health professionals to intervene effectively. 3. 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K., & Mitchell, S. K. (1984). Rubin's "puerperal change reconsidered. JOGNN. 13(3). 145-149. Mercer, R. T. (1981). The nurse and maternal tasks of the early postpartum. American Journal of Maternal Child Nursing. 6. 341-345. Oakley, A. (1980). Women confined. Towards a sociology of childbirth. Oxford: Robertson. Reisch, S. (1979). Enhancement of mother-infant social interaction. JOGNN 8(4), 213-217. Rubin, R. (1961). Puerperal change. Nursing Outlook. 9( 12), 753-755. Rubin, R. (1975). Maternity nursing stops too soon. American Journal of Nursing. 75(10). 1680-1684 Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer. Sheehan, F. (1981). Assessing postpartum adjustment. JOGNN. K)( 1), 19-23. 83 Sheehy 6. (1974). Passages. New York: Dutton. Shereshefsky, P. Ii., & Yarrow, L. J. (1973). Psychological aspects of a first pregnancy and early postnatal adaptation. New York: Raven. Sherwen, L. N., & Toussie-Weingarten, C. (Eds.). (1983). Analysis and application of nursing research: Parent-neonate studies. Belmont, CA: Wadsworth. Sumner, G., & Fritsch, J. (1983). Postnatal concerns: The first six weeks of life. In L. N. Sherwen, & C. Toussie-Weingarten (Eds.), Analysis and application of nursing research: Parent-neonate  studies. Belmont, CA: Wadsworth. Tobert, S. R. (1986). Concerns of mothers in the first month  postpartum. Unpublished master's thesis, University of British Columbia, Vancouver, B.C. Varney, H. (1980). Nurse-midwifery. Boston: Blackwell. Watts, Ii, T. (1984). The Vancouver babv book. North Vancouver, B. C: Whitecap. Ziegel, E. E., & Cranley, Ii. S. (1984). Obstetric nursing (8th ed.). New York: rlacmillan. 84 Appendix A Information Sheet for Nurses Dear Nurses, I wish to ask mothers on their second postpartum day, to participate in a postpartum concerns study at one month (see attached). Because I don't want to disturb mothers who might not be suitable, I will be asking your advice on which women to approach. The women that I study must meet the criteria of: 1. Delivering a normal infant who will be discharged from the hospital with the mother. 2. Having no complications that will require an extended hospital stay (more than four days) for the mother. 3. Living with the father of the baby at the time of the study. 4 Fluent in both written and spoken English. I have received permission, from Grace Hospital and from the nursing department, to "collect" participants for my study and hope that it will prove of use to both mothers and nurses. I will be on the modules starting on Thank-you and sincerely, Ii. Pat Smith, M.S.N. Student 89 available in the library of the University of British Columbia. If you would like a summary of the results, please indicate so on the questionnaire (including your address). Thank-you for your co-operation. Sincerely, M. Pat Smith li.S.N. Student, U.B.C. School of Nursing Postpartum Questionnaire - Developed by M. Gruis - Reproduced with permission Direct i o n s . Listed below are ccncems experienced by other matters during the first weeks at heme with a new baby. Please indicate wti> an X the degree of concern each of the items presented to you. Then indicate with an H (helpful) or NH (not helpful) wfiat sources of help >ai utilized to meet these cencerns, and whether those sources were helpful or not helpful. Example: AREA Of CONCERN DEGREE OF CONCERN SOURCE OF HELP None Minor Major Partner Your Mother Other Relative Friend Public Health torse Hospital Nurse Doctor Pamphlets Books No Help Sougrrt Other (describe) Fatigje X H H - Helpful NH - Not Helpful . AREA'Of CONCERN 0E6REE OF CONCERN SOURCE OF HELP None Minor Major Partner Your Mather Other Relative Friend Public Health Njrse Hospital Njrse Doctor Pamphlets Books to Help Sought Other (describe) Concerns Related to Self Diet Exercise Postpartum Questionnaire (p. 2) H - Helpful W - tot Helpful AfiEA Of CONCERN DEGREE OF CONCERN SOURCE OF HELP tone Minor Major Partner Your (•other Other Relative friend Public Health Nurse Hospital Nurse Ooctor Pamphlets Books to Help Sought Other (describe) Concerns Related to Self ftetum of figure to normal Vaginal discharge (lochia) ftetum of menstrual period Oisccnrort firm stitches Herorrhoids Constipation Breast Soreness > Care of the Breasts Fatigue Emotional tension Feelings of isolation, being tied dcwi Finding tine for personal interests I recreation labor and delivery experiences Postpartum Questionnaire (p. 3) H - Helpful m - Not Helpful Afi£A OF CONCERN OEtfiEE Of CONCERN SOURCE Of HELP None Minor Major Partner Your Mother Other Relative friend Puolic Health Nurse Hospital Nurse Doctor Panphlets Books No Help Sought Other (describe) Concerns relating to fami ly Changes in relationship with partner Sexual relations Family planning Regulating demands of house-wort, partner, other children Other children jealous of baby Father's role with baby Setting limits on visitors & relatives Concerns relating to baby Feeling carfbrtable handling baty Growth & development of baby Infant's appearance Postpartum Questionnaire (p. 4) H - Helpful NH - Not Helpful AREA OF CONCERN DEGREE OF CONCERN SOURCE OF HELP None Minor Major Partner Your Mother Other Relative Friend Public Health Njrse Hospital Nurse Doctor Pamphlets Bocks No Help Sought Other (o s^cribe) Concerns Related to baby Behavior (i.e., crying sleeping, breathing) Interpret log infant's behavior Feeding (i.e., amount, how often, adding foods, burping) Physical care (i.e., cord care, cirancision, bathing baby, skin care) Travelling with baby Safety Clothing for baby Other Ccrcerns 94 Background Information (Primiparous Mothers) 1. What is your present age? 2. How many days were you in the hospital for this baby? Circle the Appropriate Response 3. What was the last level of education that you completed? Some High School High School Some University or University Degree Post Secondary or Other 4. Did you attend prenatal classes? Yes No If yes, were the classes helpful in preparing you for the first weeks at home with the baby? Yes No 5. Did you find your time in the hospital prepared you for the first weeks at home with this baby? Yes No 6. Was your baby discharged from the hospital with you? Yes No 7. Were you visited at home by a public health nurse? Yes No If yes, when (in terms of the baby's age)? Was the visit(s) helpful? Yes No 8. Which of the following best describes your experience of labor and delivery? Easier than expected Same as expected More difficult than expected 95 9. Which of the following best describes your experience during the past weeks at home with your new baby? Easier than expected Same as expected More difficult than expected 10. Do you wish more guidance and support had been available to you during the past weeks? Yes No If yes, please explain. 96 Background Information (Muciparous Mothers) 1. What is your present age? 2. Including this baby, how many children do you have? 3. How many days were you in hospital for this baby? Circle the appropriate response 4 What was the highest level of education that you completed? Some High School High School Some University or University Degree Post Secondary or Other 5. Did you attend prenatal classes for this baby? Yes No For a previous baby? Yes No If yes, were the classes helpful in preparing you for the first weeks at home with this baby? Yes No 6. Did you find your time in the hospital prepared you for the first weeks at home with this baby? Yes No 7. Was your baby discharged from the hospital with you? Yes No 8. Were you visited at home by a public health nurse? Yes No If yes, when (in terms of the baby's age)? Was the visit(s) helpful? Yes No 97 9. Which of the following best describes your experience during labor and delivery? Easier than expected Same as expected More difficult than expected 10. Which of the following best describes your experience during the past weeks at home with your new baby? Easier than expected Same as expected More difficult than expected 11. Do you wish more guidance and support had been available to you during the past weeks? Yes No If yes, please explain. 98 Appendix E Degree of Concern for All items on the Questionnaire Area of Concern Degree of Concern None Minor Major (N) (N) (N) Concerns Related to Self: Diet Primiparas 3 Multiparas 8 Exercise Primiparas 2 Multiparas 2 Return of Figure to Normal Primiparas 4 Multiparas 1 Vaginal Discharge Primiparas 8 Multiparas 10 12 4 9 5 11 6 14 6 6 9 17 4 9 2 7 5 Return of Menstrual Period Primiparas 14 Multiparas 22 5 0 0 0 (table continues) 99 Area of Concern Degree of Concern None (N) Minor (N) Major (N) Discomfort from Stitches Primiparas 6 Multiparas 8 9 9 4 5 Hemorrhoids Primiparas Multiparas Constipation Primiparas Multiparas 10 14 9 14 6 2 7 6 3 6 3 2 Breast Soreness Primiparas Multiparas 5 8 4 7 10 7 Care of the Breasts Primiparas Multiparas Fatigue Primiparas Multiparas Emotional Tension Primiparas Multiparas 5 12 2 5 3 3 11 5 7 3 12 9 3 5 10 14 4 10 (table continues) 100 Area of Concern Degree of Concern None (N) Minor (N) Major (N) Feelings of Isolation, being tied down Primiparas Multiparas 7 9 Finding Time for Personal Interests & Recreation Primiparas 4 Multiparas 4 Labor & Delivery Experience Primiparas 6 Multiparas 12 Concerns Related to Family: Change in Relationship with Partner Primiparas 5 Multiparas 12 Sexual Relations Primiparas Multiparas 9 10 6 11 10 12 6 3 10 9 7 9 6 2 5 6 7 7 4 1 3 3 (table continues) 101 Area of Concern Degree of Concern None (N) Minor (N) Major (N) Family Planning Primiparas 5 Multiparas 9 Regulating Demands Primiparas 2 Multiparas 3 10 8 10 6 4 5 7 13 Other Children Jealous Multiparas Father's Role with Baby Primiparas Multiparas 9 16 11 7 4 3 2 Setting Limits on Visitors Primiparas 4 Multiparas 12 Concerns Related to Baby: Feeling Comfortable Handling Baby Primiparas 9 Multiparas 16 7 9 4 6 8 1 6 0 (table continues) 102 Area of Concern Degree of Concern None Minor Major (N) (N) (N) Growth and Development of Baby Primiparas 4 8 7 Multiparas 11 5 6 Infant Appearance Primiparas 10 8 1 Multiparas 15 6 1 Infant Behavior Primiparas 1 9 9 Multiparas 6 10 6 Interpreting Infant Behavior Primiparas 4 8 7 Multiparas 11 8 3 Feeding Primiparas 2 5 12 Multiparas 8 8 6 Physical Care Primiparas 4 8 7 Multiparas 7 12 3 (table continues) Area of Concern Degree of Concern None Minor Major (N) (N) (N) Travel Primiparas 5 10 4 Multiparas 16 6 0 Safety Primiparas 4 11 4 Multiparas 14 4 4 Clothing Primiparas 7 10 2 Multiparas 17 4 1 

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