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Differences in the evaluation of postnatal midwifery support by multiparous and primiparous women in the first two weeks after birth
Aust J Midwifery, 2003 16: 3:18
Differences in the evaluation of postnatal midwifery support by multiparous and primiparous women in the first two weeks after birth Margaret Cooke and Tomasina Stacey
ABSTRACT The aim of this study was to describe the differences in midwifery support required by women having their first and subsequent babies in the first week after birth. The sample group was all women in a one-month period who gave birth in three urban hospitals in Sydney. The sample size was 365 with a 78% response rate at the twoweek follow up. Self-report questionnaires were used to collect the data antenatally (28-36 weeks) and two weeks after birth. Analysis was simple descriptive statistics, t-tests and chi-square analyses were used where appropriate. The results show a high proportion of primiparous women (85-100%) required the 17 items of postnatal support examined. Although experienced mothers required less baby care support
Introduction The aim of this study is to examine the difference between experienced mothers and first time mothers in regard to postnatal support typically provided by midwives. Midwifery support is defined as giving practical assistance, provision of information and advice, emotional support, the identification and treatment of health problems and providing an environment that facilitates adjustment and recovery from childbirth. This study will examine the proportion of primiparous and multiparous women who reported requiring different forms of postnatal support. Further the study will also examine the proportion of women who perceived they received Correspondence to Margaret Cooke RN, CM, BA (Psych), PhD Senior researcher Centre Family Health & Midwifery, University of Technology, Sydney PO Box 123 Broadway NSW 2007 tel +61 2 9514 2977 fax +61 2 9514 1678 email [email protected] Tomasina Stacey RN CM MPH Midwife specialist: Quality and Research Waitakere Hospital,Auckland
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AustralianMidwifery Journal September2003
and less health support than first time mothers, between 57-72% of experienced mothers reported that they required midwifery support when caring for their infants. At least one-fifth of women (regardless of parity) did not have their needs met for 13/17 of the items of postnatal support examined. A large proportion of all women (> 40%) did not have their health needs met. The only significant difference in the postnatal support provided to women was that first time mothers were less likely, than multiparous women, to have their emotional needs met. The study demonstrated that midwifery support during the postnatal period needs to be improved for both primiparous and multiparous women. The majority of multiparous women would like to have support from midwives related to baby care, physical and emotional health. postnatal support when they needed it. Anecdotally, some midwives believe that multiparous women require less support than primiparous women. There is some indirect evidence to support this. Multiparous women have been found to be more confident than primiparous women about their own physical care, infant feeding and infant behaviour (Fairclough 1992, Lapadat & Lindsay 1999). Berger & Cook (1998) also found that during the initial postnatal period, first time mothers rate more areas of advice and information as important to know about compared to experienced mothers. The assumption, that experienced mothers require less support than first time mothers, may systematically decrease the level of support provided to multiparous women by midwives during the postnatal period. This research will examine whether multiparous women have different and/or fewer support needs than primiparous women. It will also examine how frequently these needs are addressed compared to primiparous women.
Method This paper analyses some of the data collected two weeks after birth from a cohort of women who birthed in three urban public hospitals in Sydney in 2000. Hospital and university ethics committees approved the study.
Margaret Cooke and Tomasina Stacey
Table I Characteristics of the sample Variable
Age Marital status
Total sample
Mean 30 (sd 5)
Primiparous w o m e n
Mean 28 (sd 5)
n (%)
n (%)
Multiparous w o m e n
Statistical test (dr)
Mean 31 (sd 5)
t (328) - 5.07
(%)
Chi Square (3) + 11.85
n
Single
20/334 (20)
13/ 182
Unmarried with partner
67/334 (20)
47/ 182 (26)
40/ 152 (I 3)
Married with partner
224/334 (73)
I 18/ 182 (65)
123/ 152 (81)
Divorced/separated
3/334 (I)
2/182 (t)
English first language
284/334 (85)
156/ 182 (86)
126/ 152 (86)
Chi Square (I) = 47
Secondary education
166/334 (40)
93/ 182 (5 I)
70/ 152 (46)
Chi Square (I) = 47
Pension
30/334 (9)
t 3/t 82 (7)
17/ 152 (I I)
Chi square (I) = I.I 9
Employed antenatally
207/334 (62)
127/ 182 (70)
79/ 152 (52)
Chi Square (I) = 11.84
< $20,000
30/334 (9)
18/182 0o)
t2/t 52 (8)
$20,00040,000
87/334 (26)
42/ 182 (23)
44/ 152 (29)
$40,00~60,000
77/334 (21)
38/ 182 (22)
38/152 (20)
$60,000-80,000
70/334 (21)
40/ 182 (22)
30/ 152 (20)
$$80,000
70/334 (21)
44/ 182 (24)
27/ 152 (I 8)
Parity (primiparous)
182/334 (52)
Antenatal classes
I01/289 (35)
89/ 151 959)
ii/138 (8)
Chi square (I) = 92.71
Midwifery led antenatal care
154/334 (46)
80/182 (44)
79/ 152 (52)
Chi Square (I) = 2.02
Normal preg and birth
176/289 (6 I)
80/ 151 (53)
97/ 138 (70)
Chi Square (I) = 7.83
Initiated breastfeeding
280/289 (97)
146/ 151 (97)
134/ 138 (95)
Chi Square (I) = 2.1
Early pstnatal discharge
96/289 (33)
38/15 t (25)
59/138 (43)
Chi Square (I) = 8.96
(7)
8/t52 (5)
t(t)
Family income per annum
Chi Square (4) = 3.36
Participants
Questionnaires
All women who were registered to deliver at three Sydney public hospitals within one area health service, during a onemonth period in 1999, were screened for eligibility. Data collection was completed in 2001. A list of women with an estimated date of confinement (EDC) within the designated month for recruitment in each hospital were identified upon registration with the hospital (n = 601). Of the women, 152 were excluded based on criteria of: miscarriage/birthed elsewhere (n = 39), non-English speaking (n = 29), obstetrician refused to take part in the research (privately insured women only (n = 11), unable to be contacted during the antenatal visit (unknown reason) (n = 52), and date of delivery greater than + 6 weeks from EDC at registration (this included women whose EDC was inaccurately recorded at registration or who birthed prematurely (n = 21).
The antenatal survey primarily collected demographic information such as age, education, income, parity, marital status and occupation. It also asked women to rate how important they expected various forms of postnatal support were in the initial period after birth. The two-week postnatal survey collected information about birth outcomes, infant feeding outcomes and the type and quality of postnatal care. An expert group of eight midwives, early childhood nurses, maternity managers and researchers developed a scale to measure postnatal support. The scale consisted of 17 items measuring practical, emotional and information support provided to women in the initial postnatal period. Five areas of support were identified from the literature. The five areas were: baby care (4 items) (Hoddinott & Pill 1999; Hitchcock 1990; Marchant et al 2000; Fairclough 1992); health and well being of mother and infant (2 items) (Mathews 2000; Lapadat et al 1999); emotional support (4 items) (Mathews 2000; Grindley et al 2000); environmental support (4 items) (Tarkka et al 1999; Tarkka et al 2000; Schlomer et al 1999; Mathews 2000; Bondas-Salonen 1998; Yelland et al 1998; Emery et al 2000) and discharge support (3 items). 'Baby care' support consisted of items relating to the practical and information support sometimes required by women when caring for the baby (eg bathing, changing nappies, infant feeding, and settling crying babies). 'Health and wellbeing' items determined whether the mother's and infant's
Thus 449 women were invited to participate in the study, of which 81% (n = 365) accepted. Of those who agreed to participate 91% returned the antenatal survey and 78% (n = 284) returned the two-week survey. After informed consent was obtained, participants were asked to complete an antenatal survey at 28-36 weeks gestation and a postnatal survey was mailed out two weeks after the birth of their infant. If participants had not responded within two weeks of receiving the surveys, they had a reminder phone call or letter to return the survey.
Australian Midwifery Journal September 2003
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Australian Midwifery Journal
health problems had been identified and treated appropriately. 'Environmental' support items were concerned with the provision of a restful environment, adequate nourishment, accessible professional support and consistent advice. 'Emotional support' consisted of items related to the facilitation of women to express feelings and concerns about parenting and birthing, the recognition of the parenting skills and the acknowledgment of decisions made by women when caring for their infants. 'Discharge information' items related to information that was not immediately necessary during their stay in hospital but may be required on discharge from hospital (eg information on contraception, community services and immunisation). Factor analysis of the scale indicated an alpha of .91. The content validity of these items was supported by open-ended satisfaction surveys of postnatal women recently conducted by several members of the expert group who gave advice on the survey. All the items were also evaluated as very important or essential postnatal support by the majority of women in the antenatal survey regardless of parity. Further testing of the reliability and validity of the scale has not as yet been carried out. Women were asked to indicate whether they personally required the item of postnatal support or not. When women indicated that they required a postnatal support item, they
were asked whether they received this support from midwives.
Analysis Simple descriptive statistics (2 and independent t-tests) were used to determine if there are differences in the postnatal needs of primiparous and multiparous women. An alpha of .05 was used to determine differences in demographic characteristics of primiparous and multiparous women. A more conservative alpha < .005 was used to determine statistical significance of the variables of interest in an attempt to control for type 1 errors due to the number of statistical tests carried out.
Results The age range of the women was between 16-45 years of age. A majority of women were of English speaking background, married, and employed during the antenatal period, with only 9% of the sample requiring a government pension. The sample was also highly educated with 49% having tertiary level education, the sample 54% was having their first baby and 61% of the sample reported having a normal
Table 2 Women's ratings for different forms of postnatal support reported in the antenatal period by parity Variables
Primiparous (median)
Baby Practical assistance for infant feeding Essential Information about infant feeding Essential Practical assistance in baby care Very important Information about crying and settling Essential Health Identification andtreatment (mother) Essential Identification and treatment (baby) Essential Environment Restful setting Very important Meals available Very important Midwives accessible Very important Consistent advice and information Very important Maternal emotional support Express feeling re birth Very important Support decisions re care of baby Very important Recognition parenting skills Very important Allowed to express concerns re parenting Very important Discharge information Immunisation Essential Early childhood services Very important Contraception Somewhat important
Multiparous (median)
Chi Square
Very important
24.21
.0002
Very important
35.39
.000 I
Somewhat important
85.92
.000 I
Very important
39.56
.0001
Essential
4.14
.24
Very important
13.4
.003
Very important Very important Very important
1.66 5.13 .09
.64 .16 .99
Very important
6.47
.09
Very important
1.89
.59
Very important
2.10
.55
Very important
2.96
.39
Very important
4.49
.21
Very important
61.69
.0001
Very important Somewhat important
i7.7 16
.0005 .98
Note A 4-point Likert scal was used in the rating. Essential = 4,Very important = 3, Somewhat important = 2, Not important = I
20
AustralianMidwiferyJournalSeptember2003
p
Margaret C o o k e and Tomasina Stacey
Table 3 Women's need for and provision of postnatal support by parity Postnatal support items
Proportion of women who required postnatal support Primipn= 136%(n) Mutdpn= 128%(n) ChiSquare p
Women who did not receive support Frimipn=%(n) Muldpn=%(n) ChiSquare
Baby Assistance for feeding Information re feeding Assistance in baby care Info about crying
i00 (136) i00 (136) 97 (131) tO0 (136)
72 (92)
43.85
.0001
I0 (14)
12(11)
.36
.54
65 (83)
56.83
.0001
24 (33)
25 (21)
.03
.85
57 (73)
67.74
.0001
24 (3 I)
.31
.57
62 (79)
63.92
.0001
57 (78)
27 (20) 46 (36)
2.78
.09
90 (i22)
67 (86)
21.35
.0001
46 (56)
38 (33)
1.19
.27
85 (116)
69 (88)
10.85
.0009
45 (52)
34 (30)
2.8
.09
39 (48) 25 (30) 8 (1o) 2i (25)
.00
.99
Health Identification & treatment (mother) Identification and treatment (baby) Environment Restful setting
97 (131)
97 (124)
.02
.88
39 (51)
Meals available
97 (131)
94 (120)
1.10
.29
20 (26)
Midwives accessible
99 (135)
93 0 1 9 )
7.09
.007
7 (9)
Consistent advice
99 (135)
94 (120)
4.23
.03
34 (46)
1.08
.29
0.25
.61
5.3
.02
Maternal emotional support Express feeling re birth
90 (122)
79 (iOl)
6.10
.013
42 (51)
Support decisionsre babycare
93 (126)
5.88
.015
37 (47)
Recognition parenting skills
92 (125)
3.13
.07
45 (56)
Expressconcerns re parenting
91 (124)
83 (io6) 85 (io9) 80 (io2)
5.80
.01
39 (48)
99 (i35) ioo (136) 92 (125)
64 (82) 81 004) 75 (96)
53.21
.0001
48 (65)
29.9
.0001
17 (23)
13.65
.0001
31 (39)
20 (20) 16 (17) 23 (25) 27 (28)
12.53
.0004
12.46
.0004
12.46
.0004
3.89
.04
9.33
.002
2.07
.14
.77
.37
Discharge Information Immunisation Early childhood servies Contraception
27 (22) 1I (11) 26 (25)
Note To control the occurrence of type I errors due to the number of analyses the level for statistical significance was set at Chi Square = .005.The number of women who indicated that they required support was used as the denominator to calculate the proportion of women who did not receive support
pregnancy and childbirth. Almost all the sample initiated breastfeeding and about one-third of women chose to leave hospital within two days of their birth (ie had early discharge with community midwifery support (mean no days 3.1, sd = 1, range 1-6 days). The average length of stay in hospital was 3.4 days with a range of 6 hours to 10 days. The demographic and birth characteristics of women who had completed the surveys are provided in Table 1.
Differences in SES and birth characteristics due to parity There was a mean difference of 3.1 years in the ages of primiparous and multiparous women. Primiparous women, compared to multiparous women, were more likely to have attended antenatal classes, to be employed, and to have higher obstetric intervention scores. Multiparous women were more likely than primiparous women to be married and to choose to have early discharge from hospital. Primiparous and multiparous women did not differ in language, education levels, income, type of antenatal care, or initiation of breastfeeding.
Women's requirements postnatal support
for
A similar high proportion of primiparous women (85-100%) reported they required all 17 items of postnatal support after birth. The proportion of multiparous women who required the different items of support varied, with a slightly higher
proportion requiring items on environmental support eg facilitation of a restful setting (93-97%) and emotional support (79-85%) than discharge information (64-81%), identification and treatment of health needs (67-69%) and support with baby care (57-72%). Nevertheless, a large proportion of multiparous women (between 57-97%) indicated they required the different items of postnatal support measured in the study. A significantly higher proportion of primiparous women compared to multiparous women required support in all the items for baby care, identification and treatment of health problems and discharge information (Table 2). More primiparous women also reported being less confident about caring for their infants in hospital than multiparous women (((3)2 = 50.59, p <.0001). There was no significant difference in the proportion of primiparous and multiparous women who required items on emotional support and environmental support with at least 80% of all women indicating they required support for these items.
Provision of postnatal support to women Primiparous women were less likely than multiparous women to report having their emotional needs met and were less likely to report that they were provided information about immunisation (Table 3). For the remaining items (baby care support, health support, environmental support and discharge information) a similar proportion of primiparous and multiparous women reported not having their postnatal needs met. Australian Midwifery JournalSeptember2003
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Australian Midwifery Journal
For 13 of the 17 support items at least one-fifth and up to one-half of women felt their postnatal needs had not been met. Although 92% of women reported that they had access to midwives when they required it, more than a quarter reported that midwives did not provide consistent information and advice. Areas of support which were poorly provided (ie. 40% or more of all women not receiving the support when required) were: information about crying and settling babies, identification and treatment of mothers and babies health problems and provision of a restful setting.
Discussion This research examined the postnatal support requirements of women in the initial postnatal period and examined whether multiparous and primiparous women differed in their requirements. The study also investigated whether women were provided with postnatal support when they needed it and whether parity influenced the provision of support. The items used to examine postnatal support have not been previously used or tested. While we cannot state that the items are the most important areas of support required by women in the postnatal period, previous findings from qualitative and quantitative research, open ended satisfaction surveys, expert group discussions, a pilot study and the antenatal survey all suggest that the postnatal support items were valid. Of the sample, 78% responded to the survey and nonresponders may have had different experiences to those who completed the survey. The sample characteristics were. however. similar to those found in the population who attended the three hospitals used in the research. However, generalisation of these results to other hospitals, which may have different population characteristics, models of care and standards of practice, may be difficult. The study attempted to overcome this limitation by recruiting from several hospitals. Analysis of the results indicated little difference in the results of the three hospitals. However, a detailed description of the care provided in one of the hospitals is provided elsewhere for those who are interested (Stacey, 2000).
Baby care support The items for 'baby care' support consisted of: practical assistance with infant feeding, information about infant feeding, practical assistance with baby care (eg. bathing and changing nappies) and information about handling and setfling babies. All primiparous women in the sample reported requiring this support in the postnatal period. While multiparous women were less likely to report that they required support with baby care compared to primiparous women, on average two-thirds of multiparous women reported that they also required this support. The results of this study and others (Fairclough, 1992), indicate that multiparous women are more likely than first time mothers to be prepared for the postnatal period, to be confident of caring for their infant in hospital and require less support when caring for their infant. However, Mercer (Creedy, 2000) suggests even experienced mothers need to learn to care for a new baby with its individual behaviors. 22
AustralianMidwiferyJournalSeptember2003
Multiparous women were as likely as primiparous women to report that they were provided with the 'baby care' support when it was required. This suggests that midwives do not discriminate due to parity when a need related to baby care is identified. Nevertheless, about a quarter of all women did not receive support for baby care when they required it. The literature on how midwives can best provide women with support for baby care is somewhat complex (Hoddinott et al 1999; Holmes et al 1997; Hughes 1984). Nevertheless, many authors conclude that appropriate support can only be provided to women when midwives listen to women and gain an understanding of their individual needs (Holmes et al 1997). Such support is difficult to achieve when midwives appear busy and rushed as described by women in this study.
Identification and treatment of health problems Fewer multiparous women, compared to primiparous women, reported that they actually required support for health problems. There may have been several reasons for this difference. Multiparous women may have been more aware of normal healthy behaviours of infants and the signs of normal recovery from childbirth and were therefore, less likely to require this type of support (Fairclough 1992; Hughes 1984). Alternatively, primiparous women were more likely than muttiparous women to have obstetric intervention and may have had more health problems during recovery and therefore required greater support in this area. Of great concern, is that more than 40% of all women who reported they required the identification and treatment of health problems did not have their health needs met. This supports the findings of previous research which suggests that women's health needs are not being met (Hitchcock 1990; Holmes et al 1997; Shearman 1989; Emery et al 2000; Glazener et al 1995).
Environmental support This area of support consisted of four items: a restful environment, meals available when required, midwives accessible 24 hours a day, and consistent advice and information provided. More than 93% of women reported requiring this type of support in hospital. Most women reported that midwives were accessible, but about a quarter indicated that their advice was not consistent. While women reported that midwives were accessible they also indicated in open-ended questions that midwives often seem rushed or busy. Similar findings have been found by others (Bondas-Salonen 1998; Tarkka et al 1999; Schlomer et al 1999). The item of environmental support least likely to be provided was a restful environment, with 40% of women reporting that the hospital environment was not restful. Other research has similar findings (Schlomer et al 1999; Mathews 2000; Yelland et al 1998). This result is a concern as the literature suggests that rest and recovery from childbirth is a primary goal of postnatal care (Stacey 2000; Emery et al 2000). Observations conducted at the same time as the survey
Margaret Cooke and Tomasina Stacey
(Stacey 2000) indicated that women had frequent interruptions from clinical and ancillary staff in hospital, including midwives. Also, several women complained in the survey that when they were exhausted and asked midwives to care for their baby the midwives refused, as one women stated "because of hospital policy". Methods of improving rest for women in hospital need to be explored.
Emotional support Four items were examined for emotional support. These were: able to express feelings about the birth, support provided for maternal decisions about care of self and baby, recognition of parenting skills, able to express concerns and feelings about parenting. Between 80-93% of women required emotional support regardless of parity. This supports other research which suggests that emotional support is an important characteristic of high quality postnatal care (Jain 1996; Woollett & Parr 1997; Grindley et al 2000; Beech 1999). Tarrka (2000) reports that women perceive characteristics such as empathy, friendliness, tenderness, calmness, and lack of hurry to be important to their experience of postnatal care. However, multiparous women compared to primiparous women were approximately twice as likely to have their needs met in this area (ie on average 41% of primiparous women did not have there emotional needs met compared to on average 21% of multiparous women). A combination of factors may explain this finding. Multiparous women may have more parenting skills and confidence and therefore their emotional needs may be more easily met compared to primiparous women's emotional needs. Multiparous women, because they have previous experience in hospital, may also feel more comfortable expressing feelings in this setting. Also midwives are more likely to acknowledge multiparous women's previous experience and expect them to be more skilled and therefore more readily concur with their parenting decisions. The level of obstetric intervention identified in primiparous women and their increased likelihood of being unmarried compared to multiparous women may also have influenced primiparous women's need for emotional support. An alternative explanation is that time constraints on care meant that midwives focused on primiparous women's need for baby care support rather than their emotional needs (Haggerty-Davis et al 1988; Morrow 1996; Grindley et al 2000). Midwives' priorities appear to be teaching women how to care for their infant (Martell et al 1989). While women also report that support for baby care is important, they are more likely to rate the importance of emotional support and support for their own physical health higher than do midwives (Martell et al 1989).
Discharge information Discharge support consisted of three items: information about immunisation, early childhood services and contraception. During the postnatal period, although a higher proportion of primiparous women compared to multiparous women reported requiring contraceptive advice, surprisingly high rates of both primiparous (92%) and multiparous women
(75%) required information about contraception. Furthermore, similarly high rates of primiparous (31%) and multiparous women (26%) reported they did not receive information about contraception when they required it. While it has not been established that providing routine education on contraception is effective (Hiller & Griffith 2001) participants did appear to want such advice. More research on the content and timing of contraceptive advice is required.
Conclusion Multiparous women do vary from primiparous women in some of their postnatal needs (eg support for baby care and discharge information) but have similar needs in other areas of support eg emotional support and environmental support. Nevertheless, the type and degree of support required by multiparous women should not be underestimated as the majority of experienced mothers required support in all areas investigated in this research. There is room for improvement in all areas of midwifery support but particular emphasis should be made on improving the health and well being of mothers, the provision of emotional support and the provision of an environment that is conducive to rest. Women also appear to want more information about the range of normal infant behaviour and techniques for settling crying babies.
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Settling Your Baby the book and video cost $5.50 and $22.00 respectively, (including GST) plus postage and handling. Available from Child and Youth Health, an organisation with more than 90 years experience in th~ health and well being of babies and good parenting at 295 South Terrace, Adelaide 5000 phone (08) 8303 1551 or our website www.cyh.com B 24
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Differences in the evaluation of postnatal midwifery support by multiparous and primiparous women in the first two weeks after birth Margaret Cooke and Tomasina Stacey
ABSTRACT The aim of this study was to describe the differences in midwifery support required by women having their first and subsequent babies in the first week after birth. The sample group was all women in a one-month period who gave birth in three urban hospitals in Sydney. The sample size was 365 with a 78% response rate at the twoweek follow up. Self-report questionnaires were used to collect the data antenatally (28-36 weeks) and two weeks after birth. Analysis was simple descriptive statistics, t-tests and chi-square analyses were used where appropriate. The results show a high proportion of primiparous women (85-100%) required the 17 items of postnatal support examined. Although experienced mothers required less baby care support
Introduction The aim of this study is to examine the difference between experienced mothers and first time mothers in regard to postnatal support typically provided by midwives. Midwifery support is defined as giving practical assistance, provision of information and advice, emotional support, the identification and treatment of health problems and providing an environment that facilitates adjustment and recovery from childbirth. This study will examine the proportion of primiparous and multiparous women who reported requiring different forms of postnatal support. Further the study will also examine the proportion of women who perceived they received Correspondence to Margaret Cooke RN, CM, BA (Psych), PhD Senior researcher Centre Family Health & Midwifery, University of Technology, Sydney PO Box 123 Broadway NSW 2007 tel +61 2 9514 2977 fax +61 2 9514 1678 email [email protected] Tomasina Stacey RN CM MPH Midwife specialist: Quality and Research Waitakere Hospital,Auckland
18
AustralianMidwifery Journal September2003
and less health support than first time mothers, between 57-72% of experienced mothers reported that they required midwifery support when caring for their infants. At least one-fifth of women (regardless of parity) did not have their needs met for 13/17 of the items of postnatal support examined. A large proportion of all women (> 40%) did not have their health needs met. The only significant difference in the postnatal support provided to women was that first time mothers were less likely, than multiparous women, to have their emotional needs met. The study demonstrated that midwifery support during the postnatal period needs to be improved for both primiparous and multiparous women. The majority of multiparous women would like to have support from midwives related to baby care, physical and emotional health. postnatal support when they needed it. Anecdotally, some midwives believe that multiparous women require less support than primiparous women. There is some indirect evidence to support this. Multiparous women have been found to be more confident than primiparous women about their own physical care, infant feeding and infant behaviour (Fairclough 1992, Lapadat & Lindsay 1999). Berger & Cook (1998) also found that during the initial postnatal period, first time mothers rate more areas of advice and information as important to know about compared to experienced mothers. The assumption, that experienced mothers require less support than first time mothers, may systematically decrease the level of support provided to multiparous women by midwives during the postnatal period. This research will examine whether multiparous women have different and/or fewer support needs than primiparous women. It will also examine how frequently these needs are addressed compared to primiparous women.
Method This paper analyses some of the data collected two weeks after birth from a cohort of women who birthed in three urban public hospitals in Sydney in 2000. Hospital and university ethics committees approved the study.
Margaret Cooke and Tomasina Stacey
Table I Characteristics of the sample Variable
Age Marital status
Total sample
Mean 30 (sd 5)
Primiparous w o m e n
Mean 28 (sd 5)
n (%)
n (%)
Multiparous w o m e n
Statistical test (dr)
Mean 31 (sd 5)
t (328) - 5.07
(%)
Chi Square (3) + 11.85
n
Single
20/334 (20)
13/ 182
Unmarried with partner
67/334 (20)
47/ 182 (26)
40/ 152 (I 3)
Married with partner
224/334 (73)
I 18/ 182 (65)
123/ 152 (81)
Divorced/separated
3/334 (I)
2/182 (t)
English first language
284/334 (85)
156/ 182 (86)
126/ 152 (86)
Chi Square (I) = 47
Secondary education
166/334 (40)
93/ 182 (5 I)
70/ 152 (46)
Chi Square (I) = 47
Pension
30/334 (9)
t 3/t 82 (7)
17/ 152 (I I)
Chi square (I) = I.I 9
Employed antenatally
207/334 (62)
127/ 182 (70)
79/ 152 (52)
Chi Square (I) = 11.84
< $20,000
30/334 (9)
18/182 0o)
t2/t 52 (8)
$20,00040,000
87/334 (26)
42/ 182 (23)
44/ 152 (29)
$40,00~60,000
77/334 (21)
38/ 182 (22)
38/152 (20)
$60,000-80,000
70/334 (21)
40/ 182 (22)
30/ 152 (20)
$$80,000
70/334 (21)
44/ 182 (24)
27/ 152 (I 8)
Parity (primiparous)
182/334 (52)
Antenatal classes
I01/289 (35)
89/ 151 959)
ii/138 (8)
Chi square (I) = 92.71
Midwifery led antenatal care
154/334 (46)
80/182 (44)
79/ 152 (52)
Chi Square (I) = 2.02
Normal preg and birth
176/289 (6 I)
80/ 151 (53)
97/ 138 (70)
Chi Square (I) = 7.83
Initiated breastfeeding
280/289 (97)
146/ 151 (97)
134/ 138 (95)
Chi Square (I) = 2.1
Early pstnatal discharge
96/289 (33)
38/15 t (25)
59/138 (43)
Chi Square (I) = 8.96
(7)
8/t52 (5)
t(t)
Family income per annum
Chi Square (4) = 3.36
Participants
Questionnaires
All women who were registered to deliver at three Sydney public hospitals within one area health service, during a onemonth period in 1999, were screened for eligibility. Data collection was completed in 2001. A list of women with an estimated date of confinement (EDC) within the designated month for recruitment in each hospital were identified upon registration with the hospital (n = 601). Of the women, 152 were excluded based on criteria of: miscarriage/birthed elsewhere (n = 39), non-English speaking (n = 29), obstetrician refused to take part in the research (privately insured women only (n = 11), unable to be contacted during the antenatal visit (unknown reason) (n = 52), and date of delivery greater than + 6 weeks from EDC at registration (this included women whose EDC was inaccurately recorded at registration or who birthed prematurely (n = 21).
The antenatal survey primarily collected demographic information such as age, education, income, parity, marital status and occupation. It also asked women to rate how important they expected various forms of postnatal support were in the initial period after birth. The two-week postnatal survey collected information about birth outcomes, infant feeding outcomes and the type and quality of postnatal care. An expert group of eight midwives, early childhood nurses, maternity managers and researchers developed a scale to measure postnatal support. The scale consisted of 17 items measuring practical, emotional and information support provided to women in the initial postnatal period. Five areas of support were identified from the literature. The five areas were: baby care (4 items) (Hoddinott & Pill 1999; Hitchcock 1990; Marchant et al 2000; Fairclough 1992); health and well being of mother and infant (2 items) (Mathews 2000; Lapadat et al 1999); emotional support (4 items) (Mathews 2000; Grindley et al 2000); environmental support (4 items) (Tarkka et al 1999; Tarkka et al 2000; Schlomer et al 1999; Mathews 2000; Bondas-Salonen 1998; Yelland et al 1998; Emery et al 2000) and discharge support (3 items). 'Baby care' support consisted of items relating to the practical and information support sometimes required by women when caring for the baby (eg bathing, changing nappies, infant feeding, and settling crying babies). 'Health and wellbeing' items determined whether the mother's and infant's
Thus 449 women were invited to participate in the study, of which 81% (n = 365) accepted. Of those who agreed to participate 91% returned the antenatal survey and 78% (n = 284) returned the two-week survey. After informed consent was obtained, participants were asked to complete an antenatal survey at 28-36 weeks gestation and a postnatal survey was mailed out two weeks after the birth of their infant. If participants had not responded within two weeks of receiving the surveys, they had a reminder phone call or letter to return the survey.
Australian Midwifery Journal September 2003
19
Australian Midwifery Journal
health problems had been identified and treated appropriately. 'Environmental' support items were concerned with the provision of a restful environment, adequate nourishment, accessible professional support and consistent advice. 'Emotional support' consisted of items related to the facilitation of women to express feelings and concerns about parenting and birthing, the recognition of the parenting skills and the acknowledgment of decisions made by women when caring for their infants. 'Discharge information' items related to information that was not immediately necessary during their stay in hospital but may be required on discharge from hospital (eg information on contraception, community services and immunisation). Factor analysis of the scale indicated an alpha of .91. The content validity of these items was supported by open-ended satisfaction surveys of postnatal women recently conducted by several members of the expert group who gave advice on the survey. All the items were also evaluated as very important or essential postnatal support by the majority of women in the antenatal survey regardless of parity. Further testing of the reliability and validity of the scale has not as yet been carried out. Women were asked to indicate whether they personally required the item of postnatal support or not. When women indicated that they required a postnatal support item, they
were asked whether they received this support from midwives.
Analysis Simple descriptive statistics (2 and independent t-tests) were used to determine if there are differences in the postnatal needs of primiparous and multiparous women. An alpha of .05 was used to determine differences in demographic characteristics of primiparous and multiparous women. A more conservative alpha < .005 was used to determine statistical significance of the variables of interest in an attempt to control for type 1 errors due to the number of statistical tests carried out.
Results The age range of the women was between 16-45 years of age. A majority of women were of English speaking background, married, and employed during the antenatal period, with only 9% of the sample requiring a government pension. The sample was also highly educated with 49% having tertiary level education, the sample 54% was having their first baby and 61% of the sample reported having a normal
Table 2 Women's ratings for different forms of postnatal support reported in the antenatal period by parity Variables
Primiparous (median)
Baby Practical assistance for infant feeding Essential Information about infant feeding Essential Practical assistance in baby care Very important Information about crying and settling Essential Health Identification andtreatment (mother) Essential Identification and treatment (baby) Essential Environment Restful setting Very important Meals available Very important Midwives accessible Very important Consistent advice and information Very important Maternal emotional support Express feeling re birth Very important Support decisions re care of baby Very important Recognition parenting skills Very important Allowed to express concerns re parenting Very important Discharge information Immunisation Essential Early childhood services Very important Contraception Somewhat important
Multiparous (median)
Chi Square
Very important
24.21
.0002
Very important
35.39
.000 I
Somewhat important
85.92
.000 I
Very important
39.56
.0001
Essential
4.14
.24
Very important
13.4
.003
Very important Very important Very important
1.66 5.13 .09
.64 .16 .99
Very important
6.47
.09
Very important
1.89
.59
Very important
2.10
.55
Very important
2.96
.39
Very important
4.49
.21
Very important
61.69
.0001
Very important Somewhat important
i7.7 16
.0005 .98
Note A 4-point Likert scal was used in the rating. Essential = 4,Very important = 3, Somewhat important = 2, Not important = I
20
AustralianMidwiferyJournalSeptember2003
p
Margaret C o o k e and Tomasina Stacey
Table 3 Women's need for and provision of postnatal support by parity Postnatal support items
Proportion of women who required postnatal support Primipn= 136%(n) Mutdpn= 128%(n) ChiSquare p
Women who did not receive support Frimipn=%(n) Muldpn=%(n) ChiSquare
Baby Assistance for feeding Information re feeding Assistance in baby care Info about crying
i00 (136) i00 (136) 97 (131) tO0 (136)
72 (92)
43.85
.0001
I0 (14)
12(11)
.36
.54
65 (83)
56.83
.0001
24 (33)
25 (21)
.03
.85
57 (73)
67.74
.0001
24 (3 I)
.31
.57
62 (79)
63.92
.0001
57 (78)
27 (20) 46 (36)
2.78
.09
90 (i22)
67 (86)
21.35
.0001
46 (56)
38 (33)
1.19
.27
85 (116)
69 (88)
10.85
.0009
45 (52)
34 (30)
2.8
.09
39 (48) 25 (30) 8 (1o) 2i (25)
.00
.99
Health Identification & treatment (mother) Identification and treatment (baby) Environment Restful setting
97 (131)
97 (124)
.02
.88
39 (51)
Meals available
97 (131)
94 (120)
1.10
.29
20 (26)
Midwives accessible
99 (135)
93 0 1 9 )
7.09
.007
7 (9)
Consistent advice
99 (135)
94 (120)
4.23
.03
34 (46)
1.08
.29
0.25
.61
5.3
.02
Maternal emotional support Express feeling re birth
90 (122)
79 (iOl)
6.10
.013
42 (51)
Support decisionsre babycare
93 (126)
5.88
.015
37 (47)
Recognition parenting skills
92 (125)
3.13
.07
45 (56)
Expressconcerns re parenting
91 (124)
83 (io6) 85 (io9) 80 (io2)
5.80
.01
39 (48)
99 (i35) ioo (136) 92 (125)
64 (82) 81 004) 75 (96)
53.21
.0001
48 (65)
29.9
.0001
17 (23)
13.65
.0001
31 (39)
20 (20) 16 (17) 23 (25) 27 (28)
12.53
.0004
12.46
.0004
12.46
.0004
3.89
.04
9.33
.002
2.07
.14
.77
.37
Discharge Information Immunisation Early childhood servies Contraception
27 (22) 1I (11) 26 (25)
Note To control the occurrence of type I errors due to the number of analyses the level for statistical significance was set at Chi Square = .005.The number of women who indicated that they required support was used as the denominator to calculate the proportion of women who did not receive support
pregnancy and childbirth. Almost all the sample initiated breastfeeding and about one-third of women chose to leave hospital within two days of their birth (ie had early discharge with community midwifery support (mean no days 3.1, sd = 1, range 1-6 days). The average length of stay in hospital was 3.4 days with a range of 6 hours to 10 days. The demographic and birth characteristics of women who had completed the surveys are provided in Table 1.
Differences in SES and birth characteristics due to parity There was a mean difference of 3.1 years in the ages of primiparous and multiparous women. Primiparous women, compared to multiparous women, were more likely to have attended antenatal classes, to be employed, and to have higher obstetric intervention scores. Multiparous women were more likely than primiparous women to be married and to choose to have early discharge from hospital. Primiparous and multiparous women did not differ in language, education levels, income, type of antenatal care, or initiation of breastfeeding.
Women's requirements postnatal support
for
A similar high proportion of primiparous women (85-100%) reported they required all 17 items of postnatal support after birth. The proportion of multiparous women who required the different items of support varied, with a slightly higher
proportion requiring items on environmental support eg facilitation of a restful setting (93-97%) and emotional support (79-85%) than discharge information (64-81%), identification and treatment of health needs (67-69%) and support with baby care (57-72%). Nevertheless, a large proportion of multiparous women (between 57-97%) indicated they required the different items of postnatal support measured in the study. A significantly higher proportion of primiparous women compared to multiparous women required support in all the items for baby care, identification and treatment of health problems and discharge information (Table 2). More primiparous women also reported being less confident about caring for their infants in hospital than multiparous women (((3)2 = 50.59, p <.0001). There was no significant difference in the proportion of primiparous and multiparous women who required items on emotional support and environmental support with at least 80% of all women indicating they required support for these items.
Provision of postnatal support to women Primiparous women were less likely than multiparous women to report having their emotional needs met and were less likely to report that they were provided information about immunisation (Table 3). For the remaining items (baby care support, health support, environmental support and discharge information) a similar proportion of primiparous and multiparous women reported not having their postnatal needs met. Australian Midwifery JournalSeptember2003
21
Australian Midwifery Journal
For 13 of the 17 support items at least one-fifth and up to one-half of women felt their postnatal needs had not been met. Although 92% of women reported that they had access to midwives when they required it, more than a quarter reported that midwives did not provide consistent information and advice. Areas of support which were poorly provided (ie. 40% or more of all women not receiving the support when required) were: information about crying and settling babies, identification and treatment of mothers and babies health problems and provision of a restful setting.
Discussion This research examined the postnatal support requirements of women in the initial postnatal period and examined whether multiparous and primiparous women differed in their requirements. The study also investigated whether women were provided with postnatal support when they needed it and whether parity influenced the provision of support. The items used to examine postnatal support have not been previously used or tested. While we cannot state that the items are the most important areas of support required by women in the postnatal period, previous findings from qualitative and quantitative research, open ended satisfaction surveys, expert group discussions, a pilot study and the antenatal survey all suggest that the postnatal support items were valid. Of the sample, 78% responded to the survey and nonresponders may have had different experiences to those who completed the survey. The sample characteristics were. however. similar to those found in the population who attended the three hospitals used in the research. However, generalisation of these results to other hospitals, which may have different population characteristics, models of care and standards of practice, may be difficult. The study attempted to overcome this limitation by recruiting from several hospitals. Analysis of the results indicated little difference in the results of the three hospitals. However, a detailed description of the care provided in one of the hospitals is provided elsewhere for those who are interested (Stacey, 2000).
Baby care support The items for 'baby care' support consisted of: practical assistance with infant feeding, information about infant feeding, practical assistance with baby care (eg. bathing and changing nappies) and information about handling and setfling babies. All primiparous women in the sample reported requiring this support in the postnatal period. While multiparous women were less likely to report that they required support with baby care compared to primiparous women, on average two-thirds of multiparous women reported that they also required this support. The results of this study and others (Fairclough, 1992), indicate that multiparous women are more likely than first time mothers to be prepared for the postnatal period, to be confident of caring for their infant in hospital and require less support when caring for their infant. However, Mercer (Creedy, 2000) suggests even experienced mothers need to learn to care for a new baby with its individual behaviors. 22
AustralianMidwiferyJournalSeptember2003
Multiparous women were as likely as primiparous women to report that they were provided with the 'baby care' support when it was required. This suggests that midwives do not discriminate due to parity when a need related to baby care is identified. Nevertheless, about a quarter of all women did not receive support for baby care when they required it. The literature on how midwives can best provide women with support for baby care is somewhat complex (Hoddinott et al 1999; Holmes et al 1997; Hughes 1984). Nevertheless, many authors conclude that appropriate support can only be provided to women when midwives listen to women and gain an understanding of their individual needs (Holmes et al 1997). Such support is difficult to achieve when midwives appear busy and rushed as described by women in this study.
Identification and treatment of health problems Fewer multiparous women, compared to primiparous women, reported that they actually required support for health problems. There may have been several reasons for this difference. Multiparous women may have been more aware of normal healthy behaviours of infants and the signs of normal recovery from childbirth and were therefore, less likely to require this type of support (Fairclough 1992; Hughes 1984). Alternatively, primiparous women were more likely than muttiparous women to have obstetric intervention and may have had more health problems during recovery and therefore required greater support in this area. Of great concern, is that more than 40% of all women who reported they required the identification and treatment of health problems did not have their health needs met. This supports the findings of previous research which suggests that women's health needs are not being met (Hitchcock 1990; Holmes et al 1997; Shearman 1989; Emery et al 2000; Glazener et al 1995).
Environmental support This area of support consisted of four items: a restful environment, meals available when required, midwives accessible 24 hours a day, and consistent advice and information provided. More than 93% of women reported requiring this type of support in hospital. Most women reported that midwives were accessible, but about a quarter indicated that their advice was not consistent. While women reported that midwives were accessible they also indicated in open-ended questions that midwives often seem rushed or busy. Similar findings have been found by others (Bondas-Salonen 1998; Tarkka et al 1999; Schlomer et al 1999). The item of environmental support least likely to be provided was a restful environment, with 40% of women reporting that the hospital environment was not restful. Other research has similar findings (Schlomer et al 1999; Mathews 2000; Yelland et al 1998). This result is a concern as the literature suggests that rest and recovery from childbirth is a primary goal of postnatal care (Stacey 2000; Emery et al 2000). Observations conducted at the same time as the survey
Margaret Cooke and Tomasina Stacey
(Stacey 2000) indicated that women had frequent interruptions from clinical and ancillary staff in hospital, including midwives. Also, several women complained in the survey that when they were exhausted and asked midwives to care for their baby the midwives refused, as one women stated "because of hospital policy". Methods of improving rest for women in hospital need to be explored.
Emotional support Four items were examined for emotional support. These were: able to express feelings about the birth, support provided for maternal decisions about care of self and baby, recognition of parenting skills, able to express concerns and feelings about parenting. Between 80-93% of women required emotional support regardless of parity. This supports other research which suggests that emotional support is an important characteristic of high quality postnatal care (Jain 1996; Woollett & Parr 1997; Grindley et al 2000; Beech 1999). Tarrka (2000) reports that women perceive characteristics such as empathy, friendliness, tenderness, calmness, and lack of hurry to be important to their experience of postnatal care. However, multiparous women compared to primiparous women were approximately twice as likely to have their needs met in this area (ie on average 41% of primiparous women did not have there emotional needs met compared to on average 21% of multiparous women). A combination of factors may explain this finding. Multiparous women may have more parenting skills and confidence and therefore their emotional needs may be more easily met compared to primiparous women's emotional needs. Multiparous women, because they have previous experience in hospital, may also feel more comfortable expressing feelings in this setting. Also midwives are more likely to acknowledge multiparous women's previous experience and expect them to be more skilled and therefore more readily concur with their parenting decisions. The level of obstetric intervention identified in primiparous women and their increased likelihood of being unmarried compared to multiparous women may also have influenced primiparous women's need for emotional support. An alternative explanation is that time constraints on care meant that midwives focused on primiparous women's need for baby care support rather than their emotional needs (Haggerty-Davis et al 1988; Morrow 1996; Grindley et al 2000). Midwives' priorities appear to be teaching women how to care for their infant (Martell et al 1989). While women also report that support for baby care is important, they are more likely to rate the importance of emotional support and support for their own physical health higher than do midwives (Martell et al 1989).
Discharge information Discharge support consisted of three items: information about immunisation, early childhood services and contraception. During the postnatal period, although a higher proportion of primiparous women compared to multiparous women reported requiring contraceptive advice, surprisingly high rates of both primiparous (92%) and multiparous women
(75%) required information about contraception. Furthermore, similarly high rates of primiparous (31%) and multiparous women (26%) reported they did not receive information about contraception when they required it. While it has not been established that providing routine education on contraception is effective (Hiller & Griffith 2001) participants did appear to want such advice. More research on the content and timing of contraceptive advice is required.
Conclusion Multiparous women do vary from primiparous women in some of their postnatal needs (eg support for baby care and discharge information) but have similar needs in other areas of support eg emotional support and environmental support. Nevertheless, the type and degree of support required by multiparous women should not be underestimated as the majority of experienced mothers required support in all areas investigated in this research. There is room for improvement in all areas of midwifery support but particular emphasis should be made on improving the health and well being of mothers, the provision of emotional support and the provision of an environment that is conducive to rest. Women also appear to want more information about the range of normal infant behaviour and techniques for settling crying babies.
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Marchent S, Alexandra, J, Garcia J (2000). Research and review. How does it feel for you? Uterine palpation and lochia loss as guides to postnatal recovery. Practicing Midwife. 3; 8: 23-24. MarteI L, Imle M, Horwirz S, Wheeler L (1989). Information priorities of new mothers in a short stay program. WesternJournal Of Nursing Research. 11: 320-327. Morrow M (1996). Breastfeeding in Vietnam: Poverty, tradition, and economic transition. Journal of Human Lactation, 12; 2: 97-103. Schlomer J, Kemmerer J, Twiss J (1999). Evaluating the association of two breastfeeding assessment tools with breastfeeding problems and breastfeeding satisfaction. Journal of Human Lactation, 15; 1: 35. Stacey T (2000). Describing Postnatal Care: a qualitative study. Masters thesis, School of Public Health, University of NSW, Sydney. Tarkka M, Paunanen M, Laippala P (2000). Importance of the midwife in the first time mother's experience of childbirth. Scandinavian Journal of Caring Sciences, 14; 3: 184-190. Tarkka MP, Paunonen M, Laippala P (1999). Factors related to successful breast feeding by first-time mothers when the child is 3 months old. Journal of Advanced Nursing,.29; 1: 113-118. Woollett A, Parr M (1997)9 Psychological tasks for women and men in the post-partum. Journal of Reproductive and Infant Psychology, 15; 2: 159-183. Yelland J, Small R, Lutrdey J, Rice P, Cotonei V, Warren R. Support, sensitivity, satisfaction:Fillipino, Turkish and Vietnamese women's views of postnatal stay. Midwifeo, 14; 3: 144-154.
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SettlingYour Babg
SefflingYourBabg
A video based on the book - Settling Your Baby... t h e first 6 m o n t h s covers such topics as Feed - Play - Sleep patterns, settling techniques, wrapping a baby, safe sleeping, sharing the care, breast and bottle feeding and play options for baby, all helpful information for parents in the first 6 months. A "one on one" class with Dr Robyn Leeson. Appropriate for use in parent education groups.
Are the new mothers you are seeing feeling frustrated and tired and having lots of sleepless nights? Then this book may be their survival guide with helpful information and tips on
9 feed-play-steep patterns
9 crying and colic 9 looking after yourself and much more.
9 playtime 9 settling baby to sleep
Settling Your Baby the book and video cost $5.50 and $22.00 respectively, (including GST) plus postage and handling. Available from Child and Youth Health, an organisation with more than 90 years experience in th~ health and well being of babies and good parenting at 295 South Terrace, Adelaide 5000 phone (08) 8303 1551 or our website www.cyh.com B 24
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