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How women manage fatigue after childbirth
ARTICLE IN PRESS Midwifery (2010) 26, 367–375
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How women manage fatigue after childbirth Jan Taylor, RM, PhD (Senior Lecturer)a,, Maree Johnson, RN, PhD (Research Professor)b a
Disciplines of Nursing & Midwifery, Faculty of Health, University of Canberra, Canberra 2601, Australia School of Nursing, College of Health & Science, University of Western Sydney, Australia
b
Corresponding author.
E-mail address: [email protected] (J. Taylor).
Received 17 March 2008; received in revised form 7 July 2008; accepted 10 July 2008
Abstract Objective: to explore the strategies used by women to manage fatigue in the first six months following childbirth. Design: a qualitative study using an exploratory descriptive design. Data were collected using open-ended questions contained in surveys posted to participants six, 12 and 24 weeks after birth. Setting: Canberra, Australian Capital Territory, Australia. Participants: 59 well women, 27 primipara and 32 multipara, aged 20–40 years, who gave birth in the Australian Capital Territory. Findings: three themes emerged from the analysis:‘Looking after me’ or self-care practices; ‘Managing the load’ or balancing the work to be done with the aim of managing the woman’s fatigue; and ‘How it worked’, describing how useful the strategies had been in managing fatigue. From six weeks to six months, the women used self-care strategies (sleep/rest, relaxing, conserving energy) more often than strategies designed to manage the load (getting help, planning, lowering expectations). Most multiparas (24/32) conserved energy to manage fatigue, in contrast to primiparas (13/27). Women experiencing high fatigue conserved energy more often than women who were experiencing less fatigue. No differences in strategy choice were found between women who experienced a vaginal birth and those who had experienced a caesarean birth, or between those women who scored X13 on the Edinburgh Postnatal Depression Scale (EPDS) as opposed to those who scored o13. Overall, women rated their chosen strategies as very useful or useful. Womens’ comments also indicated that getting help from partners and family was sometimes difficult, reducing the usefulness of this strategy. Implications for practice: preparing women and their partners to manage postnatal fatigue more effectively is essential. Midwives should encourage women to identify sources of help and what particular help that individual could provide. Scenarios should be used in parenting classes to encourage women and their partners to negotiate issues surrounding the sharing of responsibilities after birth. After birth, ongoing assessment of fatigue and the strategies used to manage it is essential beyond the first six weeks. & 2008 Elsevier Ltd. All rights reserved. Keywords Women; Postnatal; Fatigue; Management strategies
Introduction For two decades, women from Western industrialised nations have ranked fatigue among their top
five concerns after birth (Troy, 2003). Experienced as a negative and unpleasant symptom, it is one of the most common symptoms reported by women following childbirth (Gjerdinger et al., 1993; Bick
0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2008.07.004
ARTICLE IN PRESS 368 and MacArthur, 1995; Killien, 1995; Brown and Lumley, 1998; Thompson et al., 2000, 2002; McGovern et al., 2006, 2007; Rychnovsky, 2007). Postnatal fatigue is defined as an overwhelming sense of exhaustion that is accompanied by a decreased capacity for physical and mental work at the individual’s usual level (Milligan et al., 1997; NANDA, 2005–2006). Beginning in the 1980s, the following research studies have contributed significantly to our understanding of the nature of postnatal fatigue and its effects on women, infants and families. Not only is postnatal fatigue a common health problem, but researchers highlight that it is progressive, rather than self-resolving, and continues past the traditional six-week period when women are considered to have recovered physically from giving birth (Bick and MacArthur, 1995; Parks et al., 1999). Ongoing postnatal fatigue has been associated with the development of maternal depression (Affonso et al., 1990; Bozoky and Corwin, 2002; Corwin et al., 2005), lower infant developmental performance (Parks et al., 1999), and delayed return of maternal functional status and early cessation of breast feeding (Tulman et al., 1990; Milligan et al., 1996; Parks et al., 1999; McVeigh, 2000). Few studies have described or tested interventions that reduce fatigue for childbearing women. This study aims to describe the strategies used by women within the first six months after childbirth, and outlines how useful women found such approaches. Several factors have been identified by researchers as contributing to or increasing levels of fatigue in women. Factors consistently associated with higher fatigue levels included: being a primipara (Milligan, 1989; MacArthur, 1999), experiencing a longer labour, caesarean birth, increased postpartum blood loss (Milligan, 1989; MacArthur et al., 1991), more depressive symptoms, perceiving the infant to be more difficult (Milligan, 1989; Wambach, 1998), less sleep (Elek et al., 1997) and less social support (Gottlieb and Mendelson, 1995). Combinations of factors also intensify fatigue. Milligan (1989) found that, together, having a difficult infant, breast feeding, and experiencing more depressive symptoms were significant predictors of women’s fatigue six weeks after birth. Additionally, the factors involved change over time. Birth-related factors (length of labour, assisted vaginal or caesarean birth) resulted in higher levels of fatigue two weeks after birth (Milligan, 1989; Troy, 1999). Having a more difficult infant (Milligan, 1989; Wambach, 1998), less sleep or more disturbed sleep (Wambach, 1998; Elek et al., 2002), and the presence of more depressive symptoms
J. Taylor, M. Johnson (Milligan, 1989; Wambach, 1998) were the major contributors to fatigue two to three months after birth. In healthy postnatal women, where serious physical and mental causes of fatigue have been excluded, management of fatigue is best decided by the individual. The severity of fatigue may influence what strategies individuals choose to manage fatigue, and how useful they perceive the strategies to be. Additionally, as fatigue intensity changes over time, the strategies used to manage it may also change. Midwives and maternal–child health nurses give anticipatory advice on how to manage fatigue; however, these strategies generally reflect a common sense approach. A better understanding of the strategies women use, and the usefulness of those strategies, may lead to better advice. In judging usefulness, it is imperative that the perspective of the individuals concerned is sought. Maushart (1997), and other feminist writers, have criticised what they consider to be the takeover of women’s knowledge of birth and mothering by professional experts. Knowledge of management strategies developed from women, for women, could provide support for the approaches currently recommended by midwives, other health professionals and women’s support groups such as La Leche and other not-for-profit groups. This knowledge may also suggest additional strategies. Few studies address the management of fatigue; however, some authors suggest that each woman should be assessed for the presence and causes of fatigue. Strategies to relieve the fatigue can then be chosen (Gardner and Campbell, 1991; Parks et al., 1999; Bick et al., 2002). Sleeping, resting, relaxing, decreasing energy consumption, and enlisting the help of family to decrease workloads are some of the strategies suggested in the literature (Bick et al., 2002; Troy and Dalgas-Pelish, 1995, 2003). Only two fatigue-reduction strategies have been specifically tested in postnatal women. Lying on the side to breast feed whilst in hospital (as opposed to sitting upright) was associated with less fatigue (po0.05) in women who gave birth vaginally (n ¼ 14) (Milligan et al., 1996). Troy and Dalgas-Pelish (2003) found the use of a tiredness management guide was associated with less morning fatigue (po0.01) in primiparas who had given birth vaginally (n ¼ 68) two to four weeks after birth. These intervention studies present a beginning in testing strategies for the self-care management of fatigue. Further evidence of the effectiveness of the strategies over longer periods of time with samples more representative of
ARTICLE IN PRESS How women manage fatigue after childbirth the general population of postnatal women is warranted. Given the high incidence of fatigue in women after birth, its impact on quality of life, and the lack of evidence-based interventions for managing the problem, there is a clear need to develop a better understanding of how childbearing women manage fatigue. The purpose of this research was to explore the strategies used by women to manage fatigue in the first six months following childbirth. The following research questions were explored: (1) How do women manage fatigue? (2) Are there differences/similarities in the strategies chosen by women with different characteristics (parity, type of birth, levels of fatigue and less/more depressive symptoms) (3) How do the strategies change over time? (4) From the woman’s perspective, how useful are the strategies they choose?
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Data collection Data were collected using open-ended questions contained in questionnaires posted to all the participants in the larger study six, 12 and 24 weeks after birth. Women were asked the following questions:
Please list the things you have been doing to decrease your fatigue since the birth of your infant. Now, from this list, choose the thing you have used most often. Tell me more about one occasion when you used this to decrease your feelings of fatigue. Please tell me whether this way of dealing with your fatigue was useful or not.
Instruments Methods A qualitative descriptive design was used. Qualitative descriptive studies draw on the principles of naturalistic inquiry that aim to explore phenomena in their natural state, with no a priori commitment to one or another philosophical view (Lincoln and Guba, 1985; Sandelowski, 2000). Qualitative descriptive studies are the method of choice when the purpose is to know the ‘who’, ‘what’ and ‘where’ of events (Sandelowski, 2000).
Sample and sampling methodology A purposive sample of 59 well women, 27 primipara and 32 multipara, aged 20–40 years, was drawn from a larger study of postnatal fatigue (n ¼ 504) undertaken in the Australian Capital Territory (ACT). Due to the difficulty in translating questionnaires into other languages, women needed to be able to read and write English. A maximum variation sampling method was used which involved deciding the type of variations that were necessary to maximise the ability of a sample to answer the research question (Coyne, 1997). The researchers reviewed characteristics of the total sample thought to influence the type of strategies. Selected participants reflected a range of fatigue levels, less or more depressive symptoms, parity and type of birth experience. Ethical approval to conduct the study was granted by the Human Research Ethics Committees of ACT Health, Calvary Healthcare ACT, John James Memorial Hospital, and the University of Western Sydney, Australia.
Several psychometric scales were used to describe the characteristics of the sample and to allow for comparison of strategies between groups. The Postpartum Fatigue Scale (PFS) (Milligan et al., 1997) measured intensity of fatigue at each time point. The instrument consists of a total of 10 items measured on a four-point Likert scale, where one (not at all) to four (all the time) indicates the extent to which the particular symptom has been experienced during the past week. Possible scores range from 10 to 40, with higher scores reflecting higher levels of fatigue. Cronbach’s alpha for the scale ranged from 0.88 at six and 12 weeks to 0.89 at 24 weeks. Scores on the PFS were then further collapsed into three categories labelled ‘no/low’, ‘medium’ and ‘high’ based on the 25th, 50th and 75th percentiles, respectively, of the baseline PFS (one week after birth). This resulted in PFS scores of 10–14 being designated as the ‘no/low’ category, PFS scores of 15–20 as the ‘medium’ category and PFS scores of 21–40 as the ‘high’ category. The Edinburgh Postnatal Depression Scale (EPDS) was used to indicate the possible presence of depressive symptoms at each time point after birth (six, 12 and 24 weeks). The EPDS has been validated for use in Australia (Boyce et al., 1993) and is routinely used as a screening tool for postnatal depression in Australian primary care. EPDS scores alone do not represent a diagnosis of depression; however, a score of 13 or above on the EPDS is indicative of probable depression (Matthey et al., 2006).
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Data analysis Data were analysed using content analysis. Qualitative content analysis is a process of categorisation based on prominent themes and patterns expressed in the text (Polit and Beck, 2008). The concepts and principles outlined by Graneheim and Lundman (2004) were used to underpin the analysis. Participants’ responses were transcribed verbatim and formed the unit of analysis. Analysis included both manifest content (what the text said) as well as latent content (what the text meant) (Graneheim and Lundman, 2004). Each transcript was read several times by the lead researcher, and initial categories were developed based on the research questions. Next, a second in-depth review of the data was undertaken and the original clusters of categories were further refined by collapsing them into 10 categories. Once the final categories were determined, three themes, or threads of underlying meaning, emerged (Graneheim and Lundman, 2004). Names that reflected the meaning of the themes and their accompanying strategies were selected. Exemplars were then chosen to best reflect the features of each category and create a real-life picture of the strategy. As part of a process of confirmability, another researcher experienced in qualitative analysis and two experienced midwives independently reviewed the themes and categories, and agreed that the interpretations and conclusions were accurate reflections of the phenomenon. Finally, changes in the use of strategies were followed by retrieving and counting occurrences by time (six, 12 and 24 weeks) and characteristic (parity, type of birth, level of fatigue and less/more depressive symptoms). NVivo 2TM was used to manage the coding and retrieval of data.
J. Taylor, M. Johnson Forty-four per cent (n ¼ 26) of the women had completed tertiary studies. Eighty per cent of the women had birthed vaginally (n ¼ 47) and 46% (n ¼ 27) of the women were primiparas. The majority of women were fully breast feeding at each time point (86%, 69% and 63% at six, 12 and 24 weeks, respectively). The demographic characteristics of these women were similar to the characteristics of the majority of participants in the larger study with one exception. More women had completed tertiary education in this group than the number reaching this level in the total sample from which it was drawn [44% (26/59) as opposed to 38% (192/504)].
Levels of fatigue At each time point after birth (six, 12 and 24 weeks), the women were classified as experiencing no/low, medium, or high fatigue on the basis of their fatigue score (measured by PFS). Over the six months, women moved between these categories, with the majority of women moving from a higher fatigue category to a lower. Twelve women did not change their fatigue category over the period of the study; five remained in the no/low category, three remained in the medium category, and four remained in the high category (Table 1).
Depressive symptoms A score of 13 or above on the EPDS is indicative of probable depression (Matthey et al., 2006) and eight women scored 13 or above at six and 12 weeks, respectively (13.6%). By 24 weeks, the number of women scoring 13 or above had decreased to six (10.2%). The rates of probable depression were slightly higher than the rates in the total sample (10.1%, 8.6% and 7.2% at six,
Findings Participant profile Fifty-nine women were chosen for inclusion in this phase of the study. The women’s ages ranged from 20 to 44 years (M ¼ 30.49, SD ¼ 4.86). The majority were married or in a de facto relationship (98%) and were born in Australia (76%). Twenty-four per cent of women (n ¼ 14) were born in another country, including New Zealand, Europe, Africa, Asia and the Americas. The ACT has a low number of indigenous birthing women and, despite active recruiting, no woman who identified herself as indigenous participated.
Table 1 Number of women reporting no/low, medium and high levels of fatigue at six, 12 and 24 weeks after birth (n ¼ 59). Category of fatigue
Six weeks n
No/lowa Mediumb Highc
10 30 19
a
12 weeks nd 30 19 9
24 weeks n 33 16 10
Score of 10–14 on Postpartum Fatigue Scale (PFS). Score of 15–20 on PFS. c Score of 21–40 on PFS. d One less fatigue score was recorded at 12 weeks. b
ARTICLE IN PRESS How women manage fatigue after childbirth 12 and 24 weeks, respectively). Differences in strategies based on EPDS scores are presented later in this paper.
Managing postnatal fatigue Themes that emerged from analysis of the responses were grouped into three categories: ‘Looking after me’, ‘Managing the load’ and ‘How it worked’. ‘Looking after me’ described the selfcare practices that the women used. ‘Managing the load’ described balancing the work to be done with the aim of preventing or decreasing the woman’s fatigue. Finally, ‘How it worked’ described how useful the strategies had been in managing fatigue (Table 2).
Themes and accompanying strategies ‘Looking after me’ described how the women looked after themselves with the overall aim of managing fatigue. Going to bed early, sleeping in where possible after the first feed of the day, napping during the day, and resting were the most commonly used tactics. Some women indicated that a sense of being ‘off duty’ enhanced this strategy: My mother was staying and I felt dizzy with tiredness. I asked her to mind the baby while I slept and to wake me if he woke. It was reassuring to know she was watching, and that she would wake me. This meant my subconscious was not listening out for the baby. I did not have to take the responsibility of waking up as my mother would do it for me.
Table 2
Themes and accompanying strategies.
Theme
Strategy
‘Looking after me’
Sleeping/taking a nap/resting Conserving energy Time out Relaxing Exercise
‘Managing the load’
Planning/balancing/ developing a routine Having realistic expectations of self Getting help from others
‘How it worked’
Very useful/useful Not useful
371 This response also illustrates the consistent interaction, evident in women’s responses, between getting help in ‘Managing the load’, and ‘sleep/rest’, with women often seeking help from partners and family to maximise sleep and rest. Women identified conserving energy as a selfcare strategy to deal with the constant demands of managing a family. Some women described how they conserved their energy by making choices they would otherwise not have made, such as eating take-away meals and using disposable nappies, to reduce the workload. Others conserved energy by restricting their activities. One woman wrote, ‘I do not go out, I do not get dressed and I go slowly with the housework.’ Another important self-care strategy, time out, reflected time away from the task of being a mother. Women took time out for themselves to do favourite activities. They wrote, ‘ydoing more things to please myself’ and ‘quilting rather than energy sapping housework’. Some women identified exercise as a self-care strategy for dealing with fatigue. Whilst the expression of exercise ranged from going for walks with the baby in a pram to joining aerobics classes, some form of physical activity resulting in positive improvement to fatigue or increased energy was the consistent theme. The responses seemed to indicate that exercise decreased symptoms of mental fatigue and increased energy levels. For example, women wrote, ‘Exercise. I have joined a gym and go for 1/2 an hour every couple of days. This gives me extra energy and just helps me stretch out and clear my mind’ and, ‘I love to walk early am for clearing my head and trying to put an order to the day coming—helps with the fatigue.’ Another way of dealing with fatigue was reflected in the theme ‘Managing the load’, which included strategies to balance the work to be done with the aim of preventing or decreasing fatigue. Women planned their days, balanced completing essential with non-essential tasks, and developed a routine. For example, they wrote about juggling tasks, ‘cooking evening meals in morning so can rest in afternoon’ and establishing some form of routine within which they could manage the multiple roles, ‘for example, I clean the bathroom Tuesdays, wash one or two loads of washing each day.’ A recurring theme in the ‘Managing the load’ category was the importance of having realistic expectations regarding the accomplishment of household and care-giving activities. One woman wrote, ‘not having too high expectations of myself as a new mother, i.e. I don’t have to be the perfect wife and mother.’
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J. Taylor, M. Johnson
Despite their efforts, it appeared that the superwoman ideal perpetuated in the media (look like a film star, have a house that might be featured in a magazine and perfect children) was present in this group of women. They wrote of the problem of trying to keep up with an unrealistic ideal. For example, ‘ytry not to be superwoman’ and, ‘yrealising that I could not be superwoman at this time’. A crucial part of ‘Managing the load’ was reflected in the getting help strategy. Women sought the co-operation of others to get the work of parenting done and keep fatigue under control and, at some stage during the six months, all the women used this strategy to manage fatigue. However, many women acknowledged the difficulties associated with negotiating the help they needed from others around them. Sometimes the difficulty was implicit. For example, ‘Enlisting the help of my teenage girls (although one wonders why sometimes y).’ Other times it was openly acknowledged and some women wrote of resorting to demanding assistance. For example, ‘Told my partner he has to help because I am not the maid and he was being unfair y’
Similarities and differences between women (parity, type of birth, PFS scores, EPDS scores) in choice of strategies One of the most important and unexpected findings was that, with a few exceptions and irrespective of fatigue levels, the women were using the same or similar strategies. Across all time points, irrespective of the level of fatigue they were experiencing, 24 of the 32 multiparas conserved energy to manage fatigue as opposed to 13 of the 27 primiparas. In addition, at each time point, slightly more women (X80%) in the high fatigue group used conserving energy as one of their strategies as opposed to women who were experiencing less fatigue (p70% of the women in the medium and no/low fatigue groups). There appeared to be no difference in choice of strategies between women who experienced a vaginal birth as opposed to women who experienced a caesarean birth. Finally, there appeared to be no substantive differences in the strategies used by the women who scored X13 on the EPDS as opposed to those who scored o13.
Usefulness of strategies Similarities and differences between women at six weeks to six months As their lives changed over the study period and fatigue levels fluctuated, the way women managed fatigue also changed (Table 3). Sleep and/or rest from the ‘Looking after me’ theme was the most frequently identified strategy for managing fatigue at all time points, followed by getting help from the ‘Managing the load’ theme. The use of strategies such as conserving energy, lowering expectations and planning decreased slightly over time.
Table 3
It was evident that fatigue was an integral part of the context of these women’s lives, and it was within that context that decisions about how to manage fatigue and evaluation of the effectiveness of those decisions were made. With few exceptions, the strategies reflected in the themes ‘Looking after me’ and ‘Managing the load’ were rated as very useful or useful. Occasionally, women commented that a particular strategy had not been as useful as it might have been, and here they indicated how much that larger context of their lives influenced the success or otherwise of a
Changes in the use of strategies between six, 12 and 24 weeks.
Theme
Strategy
Six weeks
12 weeks
24 weeks
Looking after me
Sleep/rest Conserving energy Relaxing Time out Exercise
67 30 22 11 10
54 21 21 12 11
51 16 19 13 9
Managing the load
Getting help Planning/balancing/developing a routine Lowering expectations
55 23 16
32 18 6
30 13 10
Note: The number of times a strategy was used is greater than the sample size, because women were encouraged to list all the strategies they had been using.
ARTICLE IN PRESS How women manage fatigue after childbirth strategy. One woman described the difficulties she experienced getting help from a partner: Having my husband do the school runyInitially yes (it worked) as it allowed me to grab another 30–60 min of sleep as he also readied our daughter for school. After a few weeks it stopped being useful as my daughter and husband constantly argued/battled. Giving up the sleep was the only acceptable solution as it was too difficult to hear my other child crying and arguing.
Discussion This study outlined the strategies used to manage fatigue by a group of Australian women who were predominately older, well educated, and married or in a de facto relationship at the time of the birth of their child. The findings represent their experiences and may not be representative of the experiences of all women, particularly those from culturally and linguistically diverse backgrounds such as migrant and indigenous populations. Frequently used strategies The strategies used by the women were similar to strategies suggested in the literature (Troy and Dalgas-Pelish, 1995, 2003; Bick et al., 2002). From six weeks to six months, the women in this study identified that they used self-care strategies (sleep/rest, relaxing, conserving energy) more often than strategies designed to manage the load (getting help, planning, lowering expectations). This is important, given suggestions by Troy (1999) that postnatal women may place their own needs below the needs of their children and partners. One suggestion for this finding may be that the women looked after themselves so that they could look after others. The women’s expectations of themselves were high. They felt that they should be able to cope with care for the new baby and other family members, as well as take the major share of domestic tasks. This finding reflects today’s cultural representations of mothers as ‘superwomen’, able to cope with multiple demands, and is consistent with sociological and feminist literature on the topic (Maushart, 1997; Choi et al., 2005). Less frequently used strategies The small number of women who used exercise as a management strategy indicated that exercise gave them extra energy and decreased feelings of fatigue. In addition, the concept of exercise as time out, suggested by some responses in the
373 present study, is congruent with a proposition that exercise improves mood state or mental wellbeing. It has been hypothesised that exercise distracts those participating in it from everyday worries and feelings, therefore providing time out (Koltyn and Schultes, 1997). There is growing evidence to support the effectiveness of exercise in reducing fatigue levels in women experiencing postnatal depression (Armstrong and Edwards, 2004; Daley et al., 2007), and the feasibility of using exercise as a strategy for managing fatigue generally in the postnatal period should be investigated. Support from others It is evident that support from a partner and others was an important strategy for managing fatigue; however, the difficulties that some of the women experienced in negotiating their desired level of support may have reduced the effectiveness of this strategy. Stemp et al. (1986) found that merely counting the number of people available to provide support was a poor indicator of the amount of support received. They suggested that it was the perception of being supported that was crucial in determining the adequacy of support. For some of the women, there was a discrepancy between the support they desired and the support they felt they received. Previous research has highlighted that good communication skills are necessary to negotiate issues such as sharing the care of infants and children, and household tasks (Matthey et al., 2002; Tulman and Fawcett, 2003). Evaluation of strategies It appeared that, for the individuals in this study, the strategies used sometimes worked and sometimes did not. This finding raises the question of whether or not there are strategies not commonly used (such as exercise) that might better manage fatigue. If the strategies used were similar and mostly perceived as useful, why were some women still experiencing medium and high levels of fatigue three to six months after birth? Although the numbers of women experiencing higher levels of fatigue reduced over time, why were the strategies not more successful in reducing the fatigue experienced by women in these groups? More information is obviously needed about the context in which fatigue occurs, and the decision-making processes that women engage in when they choose a strategy. The use of focus groups of postnatal women from the early postnatal period to the later postnatal period (six months) could improve our understanding of the decision-making processes surrounding the choice of strategies and their
ARTICLE IN PRESS 374 effectiveness, the ‘when’ and the ‘why’ of managing fatigue. Future research should examine how women decide on what specific strategies are used in particular situations, and include trials comparing specific interventions and their effectiveness.
Implications for practice These findings can assist midwives and antenatal educators to better understand how they might help women and their partners to prepare for and manage postnatal fatigue. Just as educators attempt to equip women and their partners with the skills to deal with the pain of labour, so can we attempt to equip them with skills to deal with fatigue. The content of such educational sessions could use the fatigue management strategies and exemplars identified in this study as a starting point for the discussion. Some partners were reluctant to become involved in household tasks and child care; as a consequence, women felt tired, resentful and angry. Women may find it hard to ask for help and may need to learn how to ask for assistance from their wider social network. Midwives and maternal– child health nurses could encourage women to identify who might help and what particular help that individual could provide. Considering these issues in advance may facilitate better use of these resources during peak times of fatigue.
Conclusions Fatigue was a significant problem for these Australian women, and the experience of fatigue had a greater impact than had been anticipated. The strategies women used (sleep, asking for help with tasks) were general and could be applied to any situation in which an individual was fatigued. Women rated their chosen strategies as very useful or useful, although getting help from partners and family was sometimes difficult. Further research is required on how women decide on specific strategies in a particular situation and why. These findings can assist midwives and antenatal educators to prepare women and their partners to manage postnatal fatigue during the first six months after childbirth.
Acknowledgements This study was funded by a PhD scholarship from the University of Western Sydney where the first author
J. Taylor, M. Johnson was a PhD candidate. We acknowledge the contribution of Dr Carol McVeigh to this study, and thank the midwives who assisted with the recruitment and the women who shared their stories.
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375 Parks, P., Lentz, E., Milligan, R., et al., 1999. What happens when fatigue lingers for 18 months after delivery. Journal of Obstetric, Gynecologic, and Neonatal Nursing 28, 87–93. Polit, D.F., Beck, C.T., 2008. Nursing Research. Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, Philadelphia. Rychnovsky, J.D., 2007. Postpartum fatigue in the active-duty military woman. Journal of Obstetric, Gynecologic, and Neonatal Nursing 36, 38–46. Sandelowski, M., 2000. Whatever happened to qualitative descriptive? Research in Nursing and Health 23, 334–340. Stemp, P., Turner, R., Noh, S., 1986. Psychological distress in the postpartum period: the significance of social support. Journal of Marriage and the Family 48, 271–277. Thompson, J., Roberts, C., Currie, M., et al., 2000. Maternal health problems after childbirth: a prospective study. In: Society for Paediatric and Perinatal Epidemiology Research. Paediatric and Perinatal Epidemiology. Thompson, J., Roberts, C., Currie, M., et al., 2002. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth 29, 83–94. Troy, N., 1999. A comparison of fatigue and energy levels at 6 weeks and 14–19 months postpartum. Clinical Nursing Research 8, 135–153. Troy, N., 2003. Is the significance of postpartum fatigue being overlooked in the lives of women? American Journal of Maternal/Child Nursing 28, 252–257. Troy, N., Dalgas-Pelish, P., 1995. The development of a self-care guide for the management of postpartum fatigue. Applied Nursing Research 8, 92–96. Troy, N., Dalgas-Pelish, P., 2003. The effectiveness of a self-care intervention for the management of postpartum fatigue. Applied Nursing Research 16, 38–45. Tulman, L., Fawcett, J., 2003. Women’s health during and after pregnancy: A theory-based study of adaptation to change. Springer Publishing Company, New York. Tulman, L., Fawcett, J., Groblewski, L., et al., 1990. Changes in functional status after childbirth. Nursing Research 39, 70–75. Wambach, K., 1998. Maternal fatigue in breastfeeding primiparae during the first nine weeks postpartum. Journal of Human Lactation 14, 219–229.
www.elsevier.com/midw
How women manage fatigue after childbirth Jan Taylor, RM, PhD (Senior Lecturer)a,, Maree Johnson, RN, PhD (Research Professor)b a
Disciplines of Nursing & Midwifery, Faculty of Health, University of Canberra, Canberra 2601, Australia School of Nursing, College of Health & Science, University of Western Sydney, Australia
b
Corresponding author.
E-mail address: [email protected] (J. Taylor).
Received 17 March 2008; received in revised form 7 July 2008; accepted 10 July 2008
Abstract Objective: to explore the strategies used by women to manage fatigue in the first six months following childbirth. Design: a qualitative study using an exploratory descriptive design. Data were collected using open-ended questions contained in surveys posted to participants six, 12 and 24 weeks after birth. Setting: Canberra, Australian Capital Territory, Australia. Participants: 59 well women, 27 primipara and 32 multipara, aged 20–40 years, who gave birth in the Australian Capital Territory. Findings: three themes emerged from the analysis:‘Looking after me’ or self-care practices; ‘Managing the load’ or balancing the work to be done with the aim of managing the woman’s fatigue; and ‘How it worked’, describing how useful the strategies had been in managing fatigue. From six weeks to six months, the women used self-care strategies (sleep/rest, relaxing, conserving energy) more often than strategies designed to manage the load (getting help, planning, lowering expectations). Most multiparas (24/32) conserved energy to manage fatigue, in contrast to primiparas (13/27). Women experiencing high fatigue conserved energy more often than women who were experiencing less fatigue. No differences in strategy choice were found between women who experienced a vaginal birth and those who had experienced a caesarean birth, or between those women who scored X13 on the Edinburgh Postnatal Depression Scale (EPDS) as opposed to those who scored o13. Overall, women rated their chosen strategies as very useful or useful. Womens’ comments also indicated that getting help from partners and family was sometimes difficult, reducing the usefulness of this strategy. Implications for practice: preparing women and their partners to manage postnatal fatigue more effectively is essential. Midwives should encourage women to identify sources of help and what particular help that individual could provide. Scenarios should be used in parenting classes to encourage women and their partners to negotiate issues surrounding the sharing of responsibilities after birth. After birth, ongoing assessment of fatigue and the strategies used to manage it is essential beyond the first six weeks. & 2008 Elsevier Ltd. All rights reserved. Keywords Women; Postnatal; Fatigue; Management strategies
Introduction For two decades, women from Western industrialised nations have ranked fatigue among their top
five concerns after birth (Troy, 2003). Experienced as a negative and unpleasant symptom, it is one of the most common symptoms reported by women following childbirth (Gjerdinger et al., 1993; Bick
0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2008.07.004
ARTICLE IN PRESS 368 and MacArthur, 1995; Killien, 1995; Brown and Lumley, 1998; Thompson et al., 2000, 2002; McGovern et al., 2006, 2007; Rychnovsky, 2007). Postnatal fatigue is defined as an overwhelming sense of exhaustion that is accompanied by a decreased capacity for physical and mental work at the individual’s usual level (Milligan et al., 1997; NANDA, 2005–2006). Beginning in the 1980s, the following research studies have contributed significantly to our understanding of the nature of postnatal fatigue and its effects on women, infants and families. Not only is postnatal fatigue a common health problem, but researchers highlight that it is progressive, rather than self-resolving, and continues past the traditional six-week period when women are considered to have recovered physically from giving birth (Bick and MacArthur, 1995; Parks et al., 1999). Ongoing postnatal fatigue has been associated with the development of maternal depression (Affonso et al., 1990; Bozoky and Corwin, 2002; Corwin et al., 2005), lower infant developmental performance (Parks et al., 1999), and delayed return of maternal functional status and early cessation of breast feeding (Tulman et al., 1990; Milligan et al., 1996; Parks et al., 1999; McVeigh, 2000). Few studies have described or tested interventions that reduce fatigue for childbearing women. This study aims to describe the strategies used by women within the first six months after childbirth, and outlines how useful women found such approaches. Several factors have been identified by researchers as contributing to or increasing levels of fatigue in women. Factors consistently associated with higher fatigue levels included: being a primipara (Milligan, 1989; MacArthur, 1999), experiencing a longer labour, caesarean birth, increased postpartum blood loss (Milligan, 1989; MacArthur et al., 1991), more depressive symptoms, perceiving the infant to be more difficult (Milligan, 1989; Wambach, 1998), less sleep (Elek et al., 1997) and less social support (Gottlieb and Mendelson, 1995). Combinations of factors also intensify fatigue. Milligan (1989) found that, together, having a difficult infant, breast feeding, and experiencing more depressive symptoms were significant predictors of women’s fatigue six weeks after birth. Additionally, the factors involved change over time. Birth-related factors (length of labour, assisted vaginal or caesarean birth) resulted in higher levels of fatigue two weeks after birth (Milligan, 1989; Troy, 1999). Having a more difficult infant (Milligan, 1989; Wambach, 1998), less sleep or more disturbed sleep (Wambach, 1998; Elek et al., 2002), and the presence of more depressive symptoms
J. Taylor, M. Johnson (Milligan, 1989; Wambach, 1998) were the major contributors to fatigue two to three months after birth. In healthy postnatal women, where serious physical and mental causes of fatigue have been excluded, management of fatigue is best decided by the individual. The severity of fatigue may influence what strategies individuals choose to manage fatigue, and how useful they perceive the strategies to be. Additionally, as fatigue intensity changes over time, the strategies used to manage it may also change. Midwives and maternal–child health nurses give anticipatory advice on how to manage fatigue; however, these strategies generally reflect a common sense approach. A better understanding of the strategies women use, and the usefulness of those strategies, may lead to better advice. In judging usefulness, it is imperative that the perspective of the individuals concerned is sought. Maushart (1997), and other feminist writers, have criticised what they consider to be the takeover of women’s knowledge of birth and mothering by professional experts. Knowledge of management strategies developed from women, for women, could provide support for the approaches currently recommended by midwives, other health professionals and women’s support groups such as La Leche and other not-for-profit groups. This knowledge may also suggest additional strategies. Few studies address the management of fatigue; however, some authors suggest that each woman should be assessed for the presence and causes of fatigue. Strategies to relieve the fatigue can then be chosen (Gardner and Campbell, 1991; Parks et al., 1999; Bick et al., 2002). Sleeping, resting, relaxing, decreasing energy consumption, and enlisting the help of family to decrease workloads are some of the strategies suggested in the literature (Bick et al., 2002; Troy and Dalgas-Pelish, 1995, 2003). Only two fatigue-reduction strategies have been specifically tested in postnatal women. Lying on the side to breast feed whilst in hospital (as opposed to sitting upright) was associated with less fatigue (po0.05) in women who gave birth vaginally (n ¼ 14) (Milligan et al., 1996). Troy and Dalgas-Pelish (2003) found the use of a tiredness management guide was associated with less morning fatigue (po0.01) in primiparas who had given birth vaginally (n ¼ 68) two to four weeks after birth. These intervention studies present a beginning in testing strategies for the self-care management of fatigue. Further evidence of the effectiveness of the strategies over longer periods of time with samples more representative of
ARTICLE IN PRESS How women manage fatigue after childbirth the general population of postnatal women is warranted. Given the high incidence of fatigue in women after birth, its impact on quality of life, and the lack of evidence-based interventions for managing the problem, there is a clear need to develop a better understanding of how childbearing women manage fatigue. The purpose of this research was to explore the strategies used by women to manage fatigue in the first six months following childbirth. The following research questions were explored: (1) How do women manage fatigue? (2) Are there differences/similarities in the strategies chosen by women with different characteristics (parity, type of birth, levels of fatigue and less/more depressive symptoms) (3) How do the strategies change over time? (4) From the woman’s perspective, how useful are the strategies they choose?
369
Data collection Data were collected using open-ended questions contained in questionnaires posted to all the participants in the larger study six, 12 and 24 weeks after birth. Women were asked the following questions:
Please list the things you have been doing to decrease your fatigue since the birth of your infant. Now, from this list, choose the thing you have used most often. Tell me more about one occasion when you used this to decrease your feelings of fatigue. Please tell me whether this way of dealing with your fatigue was useful or not.
Instruments Methods A qualitative descriptive design was used. Qualitative descriptive studies draw on the principles of naturalistic inquiry that aim to explore phenomena in their natural state, with no a priori commitment to one or another philosophical view (Lincoln and Guba, 1985; Sandelowski, 2000). Qualitative descriptive studies are the method of choice when the purpose is to know the ‘who’, ‘what’ and ‘where’ of events (Sandelowski, 2000).
Sample and sampling methodology A purposive sample of 59 well women, 27 primipara and 32 multipara, aged 20–40 years, was drawn from a larger study of postnatal fatigue (n ¼ 504) undertaken in the Australian Capital Territory (ACT). Due to the difficulty in translating questionnaires into other languages, women needed to be able to read and write English. A maximum variation sampling method was used which involved deciding the type of variations that were necessary to maximise the ability of a sample to answer the research question (Coyne, 1997). The researchers reviewed characteristics of the total sample thought to influence the type of strategies. Selected participants reflected a range of fatigue levels, less or more depressive symptoms, parity and type of birth experience. Ethical approval to conduct the study was granted by the Human Research Ethics Committees of ACT Health, Calvary Healthcare ACT, John James Memorial Hospital, and the University of Western Sydney, Australia.
Several psychometric scales were used to describe the characteristics of the sample and to allow for comparison of strategies between groups. The Postpartum Fatigue Scale (PFS) (Milligan et al., 1997) measured intensity of fatigue at each time point. The instrument consists of a total of 10 items measured on a four-point Likert scale, where one (not at all) to four (all the time) indicates the extent to which the particular symptom has been experienced during the past week. Possible scores range from 10 to 40, with higher scores reflecting higher levels of fatigue. Cronbach’s alpha for the scale ranged from 0.88 at six and 12 weeks to 0.89 at 24 weeks. Scores on the PFS were then further collapsed into three categories labelled ‘no/low’, ‘medium’ and ‘high’ based on the 25th, 50th and 75th percentiles, respectively, of the baseline PFS (one week after birth). This resulted in PFS scores of 10–14 being designated as the ‘no/low’ category, PFS scores of 15–20 as the ‘medium’ category and PFS scores of 21–40 as the ‘high’ category. The Edinburgh Postnatal Depression Scale (EPDS) was used to indicate the possible presence of depressive symptoms at each time point after birth (six, 12 and 24 weeks). The EPDS has been validated for use in Australia (Boyce et al., 1993) and is routinely used as a screening tool for postnatal depression in Australian primary care. EPDS scores alone do not represent a diagnosis of depression; however, a score of 13 or above on the EPDS is indicative of probable depression (Matthey et al., 2006).
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Data analysis Data were analysed using content analysis. Qualitative content analysis is a process of categorisation based on prominent themes and patterns expressed in the text (Polit and Beck, 2008). The concepts and principles outlined by Graneheim and Lundman (2004) were used to underpin the analysis. Participants’ responses were transcribed verbatim and formed the unit of analysis. Analysis included both manifest content (what the text said) as well as latent content (what the text meant) (Graneheim and Lundman, 2004). Each transcript was read several times by the lead researcher, and initial categories were developed based on the research questions. Next, a second in-depth review of the data was undertaken and the original clusters of categories were further refined by collapsing them into 10 categories. Once the final categories were determined, three themes, or threads of underlying meaning, emerged (Graneheim and Lundman, 2004). Names that reflected the meaning of the themes and their accompanying strategies were selected. Exemplars were then chosen to best reflect the features of each category and create a real-life picture of the strategy. As part of a process of confirmability, another researcher experienced in qualitative analysis and two experienced midwives independently reviewed the themes and categories, and agreed that the interpretations and conclusions were accurate reflections of the phenomenon. Finally, changes in the use of strategies were followed by retrieving and counting occurrences by time (six, 12 and 24 weeks) and characteristic (parity, type of birth, level of fatigue and less/more depressive symptoms). NVivo 2TM was used to manage the coding and retrieval of data.
J. Taylor, M. Johnson Forty-four per cent (n ¼ 26) of the women had completed tertiary studies. Eighty per cent of the women had birthed vaginally (n ¼ 47) and 46% (n ¼ 27) of the women were primiparas. The majority of women were fully breast feeding at each time point (86%, 69% and 63% at six, 12 and 24 weeks, respectively). The demographic characteristics of these women were similar to the characteristics of the majority of participants in the larger study with one exception. More women had completed tertiary education in this group than the number reaching this level in the total sample from which it was drawn [44% (26/59) as opposed to 38% (192/504)].
Levels of fatigue At each time point after birth (six, 12 and 24 weeks), the women were classified as experiencing no/low, medium, or high fatigue on the basis of their fatigue score (measured by PFS). Over the six months, women moved between these categories, with the majority of women moving from a higher fatigue category to a lower. Twelve women did not change their fatigue category over the period of the study; five remained in the no/low category, three remained in the medium category, and four remained in the high category (Table 1).
Depressive symptoms A score of 13 or above on the EPDS is indicative of probable depression (Matthey et al., 2006) and eight women scored 13 or above at six and 12 weeks, respectively (13.6%). By 24 weeks, the number of women scoring 13 or above had decreased to six (10.2%). The rates of probable depression were slightly higher than the rates in the total sample (10.1%, 8.6% and 7.2% at six,
Findings Participant profile Fifty-nine women were chosen for inclusion in this phase of the study. The women’s ages ranged from 20 to 44 years (M ¼ 30.49, SD ¼ 4.86). The majority were married or in a de facto relationship (98%) and were born in Australia (76%). Twenty-four per cent of women (n ¼ 14) were born in another country, including New Zealand, Europe, Africa, Asia and the Americas. The ACT has a low number of indigenous birthing women and, despite active recruiting, no woman who identified herself as indigenous participated.
Table 1 Number of women reporting no/low, medium and high levels of fatigue at six, 12 and 24 weeks after birth (n ¼ 59). Category of fatigue
Six weeks n
No/lowa Mediumb Highc
10 30 19
a
12 weeks nd 30 19 9
24 weeks n 33 16 10
Score of 10–14 on Postpartum Fatigue Scale (PFS). Score of 15–20 on PFS. c Score of 21–40 on PFS. d One less fatigue score was recorded at 12 weeks. b
ARTICLE IN PRESS How women manage fatigue after childbirth 12 and 24 weeks, respectively). Differences in strategies based on EPDS scores are presented later in this paper.
Managing postnatal fatigue Themes that emerged from analysis of the responses were grouped into three categories: ‘Looking after me’, ‘Managing the load’ and ‘How it worked’. ‘Looking after me’ described the selfcare practices that the women used. ‘Managing the load’ described balancing the work to be done with the aim of preventing or decreasing the woman’s fatigue. Finally, ‘How it worked’ described how useful the strategies had been in managing fatigue (Table 2).
Themes and accompanying strategies ‘Looking after me’ described how the women looked after themselves with the overall aim of managing fatigue. Going to bed early, sleeping in where possible after the first feed of the day, napping during the day, and resting were the most commonly used tactics. Some women indicated that a sense of being ‘off duty’ enhanced this strategy: My mother was staying and I felt dizzy with tiredness. I asked her to mind the baby while I slept and to wake me if he woke. It was reassuring to know she was watching, and that she would wake me. This meant my subconscious was not listening out for the baby. I did not have to take the responsibility of waking up as my mother would do it for me.
Table 2
Themes and accompanying strategies.
Theme
Strategy
‘Looking after me’
Sleeping/taking a nap/resting Conserving energy Time out Relaxing Exercise
‘Managing the load’
Planning/balancing/ developing a routine Having realistic expectations of self Getting help from others
‘How it worked’
Very useful/useful Not useful
371 This response also illustrates the consistent interaction, evident in women’s responses, between getting help in ‘Managing the load’, and ‘sleep/rest’, with women often seeking help from partners and family to maximise sleep and rest. Women identified conserving energy as a selfcare strategy to deal with the constant demands of managing a family. Some women described how they conserved their energy by making choices they would otherwise not have made, such as eating take-away meals and using disposable nappies, to reduce the workload. Others conserved energy by restricting their activities. One woman wrote, ‘I do not go out, I do not get dressed and I go slowly with the housework.’ Another important self-care strategy, time out, reflected time away from the task of being a mother. Women took time out for themselves to do favourite activities. They wrote, ‘ydoing more things to please myself’ and ‘quilting rather than energy sapping housework’. Some women identified exercise as a self-care strategy for dealing with fatigue. Whilst the expression of exercise ranged from going for walks with the baby in a pram to joining aerobics classes, some form of physical activity resulting in positive improvement to fatigue or increased energy was the consistent theme. The responses seemed to indicate that exercise decreased symptoms of mental fatigue and increased energy levels. For example, women wrote, ‘Exercise. I have joined a gym and go for 1/2 an hour every couple of days. This gives me extra energy and just helps me stretch out and clear my mind’ and, ‘I love to walk early am for clearing my head and trying to put an order to the day coming—helps with the fatigue.’ Another way of dealing with fatigue was reflected in the theme ‘Managing the load’, which included strategies to balance the work to be done with the aim of preventing or decreasing fatigue. Women planned their days, balanced completing essential with non-essential tasks, and developed a routine. For example, they wrote about juggling tasks, ‘cooking evening meals in morning so can rest in afternoon’ and establishing some form of routine within which they could manage the multiple roles, ‘for example, I clean the bathroom Tuesdays, wash one or two loads of washing each day.’ A recurring theme in the ‘Managing the load’ category was the importance of having realistic expectations regarding the accomplishment of household and care-giving activities. One woman wrote, ‘not having too high expectations of myself as a new mother, i.e. I don’t have to be the perfect wife and mother.’
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Despite their efforts, it appeared that the superwoman ideal perpetuated in the media (look like a film star, have a house that might be featured in a magazine and perfect children) was present in this group of women. They wrote of the problem of trying to keep up with an unrealistic ideal. For example, ‘ytry not to be superwoman’ and, ‘yrealising that I could not be superwoman at this time’. A crucial part of ‘Managing the load’ was reflected in the getting help strategy. Women sought the co-operation of others to get the work of parenting done and keep fatigue under control and, at some stage during the six months, all the women used this strategy to manage fatigue. However, many women acknowledged the difficulties associated with negotiating the help they needed from others around them. Sometimes the difficulty was implicit. For example, ‘Enlisting the help of my teenage girls (although one wonders why sometimes y).’ Other times it was openly acknowledged and some women wrote of resorting to demanding assistance. For example, ‘Told my partner he has to help because I am not the maid and he was being unfair y’
Similarities and differences between women (parity, type of birth, PFS scores, EPDS scores) in choice of strategies One of the most important and unexpected findings was that, with a few exceptions and irrespective of fatigue levels, the women were using the same or similar strategies. Across all time points, irrespective of the level of fatigue they were experiencing, 24 of the 32 multiparas conserved energy to manage fatigue as opposed to 13 of the 27 primiparas. In addition, at each time point, slightly more women (X80%) in the high fatigue group used conserving energy as one of their strategies as opposed to women who were experiencing less fatigue (p70% of the women in the medium and no/low fatigue groups). There appeared to be no difference in choice of strategies between women who experienced a vaginal birth as opposed to women who experienced a caesarean birth. Finally, there appeared to be no substantive differences in the strategies used by the women who scored X13 on the EPDS as opposed to those who scored o13.
Usefulness of strategies Similarities and differences between women at six weeks to six months As their lives changed over the study period and fatigue levels fluctuated, the way women managed fatigue also changed (Table 3). Sleep and/or rest from the ‘Looking after me’ theme was the most frequently identified strategy for managing fatigue at all time points, followed by getting help from the ‘Managing the load’ theme. The use of strategies such as conserving energy, lowering expectations and planning decreased slightly over time.
Table 3
It was evident that fatigue was an integral part of the context of these women’s lives, and it was within that context that decisions about how to manage fatigue and evaluation of the effectiveness of those decisions were made. With few exceptions, the strategies reflected in the themes ‘Looking after me’ and ‘Managing the load’ were rated as very useful or useful. Occasionally, women commented that a particular strategy had not been as useful as it might have been, and here they indicated how much that larger context of their lives influenced the success or otherwise of a
Changes in the use of strategies between six, 12 and 24 weeks.
Theme
Strategy
Six weeks
12 weeks
24 weeks
Looking after me
Sleep/rest Conserving energy Relaxing Time out Exercise
67 30 22 11 10
54 21 21 12 11
51 16 19 13 9
Managing the load
Getting help Planning/balancing/developing a routine Lowering expectations
55 23 16
32 18 6
30 13 10
Note: The number of times a strategy was used is greater than the sample size, because women were encouraged to list all the strategies they had been using.
ARTICLE IN PRESS How women manage fatigue after childbirth strategy. One woman described the difficulties she experienced getting help from a partner: Having my husband do the school runyInitially yes (it worked) as it allowed me to grab another 30–60 min of sleep as he also readied our daughter for school. After a few weeks it stopped being useful as my daughter and husband constantly argued/battled. Giving up the sleep was the only acceptable solution as it was too difficult to hear my other child crying and arguing.
Discussion This study outlined the strategies used to manage fatigue by a group of Australian women who were predominately older, well educated, and married or in a de facto relationship at the time of the birth of their child. The findings represent their experiences and may not be representative of the experiences of all women, particularly those from culturally and linguistically diverse backgrounds such as migrant and indigenous populations. Frequently used strategies The strategies used by the women were similar to strategies suggested in the literature (Troy and Dalgas-Pelish, 1995, 2003; Bick et al., 2002). From six weeks to six months, the women in this study identified that they used self-care strategies (sleep/rest, relaxing, conserving energy) more often than strategies designed to manage the load (getting help, planning, lowering expectations). This is important, given suggestions by Troy (1999) that postnatal women may place their own needs below the needs of their children and partners. One suggestion for this finding may be that the women looked after themselves so that they could look after others. The women’s expectations of themselves were high. They felt that they should be able to cope with care for the new baby and other family members, as well as take the major share of domestic tasks. This finding reflects today’s cultural representations of mothers as ‘superwomen’, able to cope with multiple demands, and is consistent with sociological and feminist literature on the topic (Maushart, 1997; Choi et al., 2005). Less frequently used strategies The small number of women who used exercise as a management strategy indicated that exercise gave them extra energy and decreased feelings of fatigue. In addition, the concept of exercise as time out, suggested by some responses in the
373 present study, is congruent with a proposition that exercise improves mood state or mental wellbeing. It has been hypothesised that exercise distracts those participating in it from everyday worries and feelings, therefore providing time out (Koltyn and Schultes, 1997). There is growing evidence to support the effectiveness of exercise in reducing fatigue levels in women experiencing postnatal depression (Armstrong and Edwards, 2004; Daley et al., 2007), and the feasibility of using exercise as a strategy for managing fatigue generally in the postnatal period should be investigated. Support from others It is evident that support from a partner and others was an important strategy for managing fatigue; however, the difficulties that some of the women experienced in negotiating their desired level of support may have reduced the effectiveness of this strategy. Stemp et al. (1986) found that merely counting the number of people available to provide support was a poor indicator of the amount of support received. They suggested that it was the perception of being supported that was crucial in determining the adequacy of support. For some of the women, there was a discrepancy between the support they desired and the support they felt they received. Previous research has highlighted that good communication skills are necessary to negotiate issues such as sharing the care of infants and children, and household tasks (Matthey et al., 2002; Tulman and Fawcett, 2003). Evaluation of strategies It appeared that, for the individuals in this study, the strategies used sometimes worked and sometimes did not. This finding raises the question of whether or not there are strategies not commonly used (such as exercise) that might better manage fatigue. If the strategies used were similar and mostly perceived as useful, why were some women still experiencing medium and high levels of fatigue three to six months after birth? Although the numbers of women experiencing higher levels of fatigue reduced over time, why were the strategies not more successful in reducing the fatigue experienced by women in these groups? More information is obviously needed about the context in which fatigue occurs, and the decision-making processes that women engage in when they choose a strategy. The use of focus groups of postnatal women from the early postnatal period to the later postnatal period (six months) could improve our understanding of the decision-making processes surrounding the choice of strategies and their
ARTICLE IN PRESS 374 effectiveness, the ‘when’ and the ‘why’ of managing fatigue. Future research should examine how women decide on what specific strategies are used in particular situations, and include trials comparing specific interventions and their effectiveness.
Implications for practice These findings can assist midwives and antenatal educators to better understand how they might help women and their partners to prepare for and manage postnatal fatigue. Just as educators attempt to equip women and their partners with the skills to deal with the pain of labour, so can we attempt to equip them with skills to deal with fatigue. The content of such educational sessions could use the fatigue management strategies and exemplars identified in this study as a starting point for the discussion. Some partners were reluctant to become involved in household tasks and child care; as a consequence, women felt tired, resentful and angry. Women may find it hard to ask for help and may need to learn how to ask for assistance from their wider social network. Midwives and maternal– child health nurses could encourage women to identify who might help and what particular help that individual could provide. Considering these issues in advance may facilitate better use of these resources during peak times of fatigue.
Conclusions Fatigue was a significant problem for these Australian women, and the experience of fatigue had a greater impact than had been anticipated. The strategies women used (sleep, asking for help with tasks) were general and could be applied to any situation in which an individual was fatigued. Women rated their chosen strategies as very useful or useful, although getting help from partners and family was sometimes difficult. Further research is required on how women decide on specific strategies in a particular situation and why. These findings can assist midwives and antenatal educators to prepare women and their partners to manage postnatal fatigue during the first six months after childbirth.
Acknowledgements This study was funded by a PhD scholarship from the University of Western Sydney where the first author
J. Taylor, M. Johnson was a PhD candidate. We acknowledge the contribution of Dr Carol McVeigh to this study, and thank the midwives who assisted with the recruitment and the women who shared their stories.
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