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he transition from pregnancy to parenthood is one ing on financial need. All hospital care during labor, birth,
of life’s major events, and it can be a stressful and and the postpartum period is covered by provincial health
vulnerable time for families. To better support insurance. Public health nurses call all postpartum women
Canadian families through the transition to parenthood, within 48 hours of arriving home from hospital to offer sup-
Health Canada (2000) developed multidisciplinary guide- port and a home visit if indicated by nurse assessment and
lines on family-centered maternity and newborn care client acceptance. In 2006, there were approximately
(FCMNC). The FCMNC guidelines state that a primary 118,449 births in Ontario, 98% of which took place in a
goal of postpartum care should be to “support and hospital. The mean age of women giving birth was 30 years
strengthen the mother’s confidence in herself and in her (Ontario Perinatal Partnership Program, 2006).
baby’s health and well-being, thus enabling her to fulfill her The FCMC study was a prospective longitudinal study, the
mothering role” (Health Canada, 2000, p. 6.5). main objective of which was to gain an understanding of the
Maternal confidence can be defined as a mother’s percep- pregnancy, birth, and postpartum care received by women
tion of her ability to care for and understand her infant within hospital and community settings. Trained interviewers
(Badr, 2005). For instance, research indicates that women collected data by telephone using a standardized script at 1
who are confident in their ability to breastfeed are generally and 6 weeks postpartum. An experienced Canadian re-
successful at initiating and maintaining breastfeeding (Blyth searcher developed the surveys, and local experts reviewed
et al., 2002); a Canadian study found that women who are content validity. Women were invited to participate if they
less confident tend to wean their infants from breastfeeding lived in Ottawa, a city of approximately 750, 000 in 2001,
earlier than women who are very confident (Dunn, Davies, gave birth in one of the four Ottawa hospitals between Octo-
McCleary, Edwards, & Gaboury, 2006). High levels of ma- ber, 2000 and March 2001, spoke English or French, and
ternal confidence in the postpartum period are also associat- were discharged home with their infant. The planned sample
ed with lower levels of anxiety, less depression, increased self- size was 600 women, which represented 80% of the 750
esteem and coping capacity, and stronger social relationships births per month in Ottawa. To reach a predesignated pro-
(Papinczak & Turner, 2000). Interactions with and support portionate quota for each hospital, researchers contacted 677
received from nurses during pregnancy, birth, and the post- eligible women. Fifty-two women declined to participate in
partum period may influence a mother’s level of confidence. the initial survey, and an additional 29 women did not com-
FCMNC is a complex process of providing holistic care plete the 6-week postpartum survey. The response rate was
and support that responds to the physical, emotional, and 88%; 596 women completed both postpartum surveys.
psychosocial needs of the woman and her family. Family The current study used a subsample of women from the
support, participation, and choice are central to FCMNC, FCMC study. As part of the 6-week postpartum survey,
and support offered by nurses is recognized as having a women were asked to comment on how the care they received
Interactions with and support received from nurses during pregnancy, birth, and
the postpartum period may influence a mother’s level of confidence.
Shannon Mantha, MScN, RN, Barbara Davies, PhD, RN, Alwyn Moyer, PhD, RN,
and Katherine Crowe, BScN, RN
powerful effect on women and their families (Health Cana- during pregnancy, birth, and the postpartum period could have
ABSTRACT da, 2000). Receiving adequate care and support from nurses been more responsive to their needs and their family’s needs.
during the transition to parenthood has been associated Women’s responses were recorded verbatim over the telephone.
Purpose: To describe new mothers’ experiences with family-centered maternity care in relation to their confidence
with decreased levels of stress during labor and birth (Chang The responses were two to three sentences (range, two to eight
level and to determine how care could have been more responsive to their needs.
& Chen, 2000) and increased duration of breastfeeding sentences) and provided the qualitative data for content analy-
Study Design and Methods: Using data from a prospective Canadian survey of 596 postpartum women, a sub-
(Britton, McCormick, Renfrew, Wade, & King, 2007). In sis. Both the 1- and 6-week surveys asked women to report
sample of women with low and high confidence (N = 74) was selected. Data were analyzed using descriptive sta- summary, literature confirms the importance of nursing sup- their level of confidence on a 5-point Likert scale for caring for
tistics and content analysis. port and maternal confidence for pregnant and parenting themselves and their baby upon discharge and during their
Results: Women with both high and low confidence expressed negative experiences with similar frequency (n = women. However, little is known about the characteristics time at home. In the 1-week survey, confidence in caring for
47/74, 64%). Women wanted more nursing support for breastfeeding and postpartum teaching and education. and experiences of mothers with high and low confidence. self and baby upon discharge was a single measure, whereas
Women who reported a language other than English or French as their first language were significantly less confi- the 6-week survey used separate questions to measure confi-
dent than English- and French-speaking women (p < .05). Study Design and Methods dence about caring for self and baby. To create one confidence
Clinical Implications: A multilevel framework about family-centered care is presented for healthcare providers in prenatal, Secondary analyses of data from the family-centred maternity score at 6 weeks postpartum for each woman, the two scores
labor and birth, and postpartum care. It is recommended that nurses ask new mothers about their confidence level and care (FCMC) study, which was coordinated by the Ottawa- were added to create a composite score that could range from
give special consideration to cultural background in order to provide supportive care in hospital and community settings. Carleton Health Department in Ontario, Canada, were 2 to 10. Scores of 6 or less on the composite score were catego-
conducted. In Ottawa, the health department offers prenatal rized as low maternal confidence, and scores of 10 were cate-
Key Words: Family nursing; Postpartum period; Maternal-child nursing; Breastfeeding.
education for a nominal fee, which can be waived depend- gorized as high maternal confidence.
Prenatal
• Community services • Not feeling rushed during prenatal appointments (by physician and nurse) courses. [I] attended a couple of classes at other prenatal courses and learned things
• Prenatal education that were not covered in the primary course.”“…during my pregnancy I was
depressed and found that there was a lack of support for this.” “Moms should be
a) Standardizing what is taught to provide consistent and accurate information
aware of public health services that are available before the baby is born. Postpartum
b) Emphasizing the positive aspects of labor & birth during prenatal classes
depression should be explained to moms before birth and they should be taught to
recognize the signs and symptoms.”
Labor & Birth
• Healthcare provider • Having the nurse present more often to provide more personalized care and support
• Hospital environment • Having physician present more often to ask questions
• Healthcare provider LACK OF NURSING SUPPORT AND NEED FOR MORE
• Nursing staff being supportive of family’s presence PERSONALIZED CARE FROM NURSES
• Hospital environment
• Policy and procedures that aim to include partner/family in the labor & birth “ …nurses are overworked and made mistakes due to this, we need more nurses.”
experience (access is not restricted) “The nurses were overworked and not too happy…” “…nurses should spend more
• Healthcare provider • More support from physicians and nurses (i.e., taking time to listen and explain things) INCLUSION OF PARTNER & FAMILY, RESPECTFUL OF
Postpartum (up to 6 weeks)
• Hospital environment • More personalized care and support from nurses to offer teaching and education CULTURAL/RELIGIOUS BELIEFS AND VALUES
related to learning needs “…husbands should be in hospital room right away [following cesarean birth]. The
• Consistent advice from nurses regarding breastfeeding hospital restricted my husband’s time. This was stressful for a mother who wanted
• Breastfeeding support offered by nurses that is nonjudgmental, nonpatronizing, and support…”“My husband felt totally unwelcome during labor and birth” “I asked my
aimed at increasing sense of control and ability to problem solve doctor to have a female during delivery. When I arrived I told the nurse that I had to
• A lactation consultant available in-hospital have a female doctor because of religious beliefs. The female resident had to get a
• More awareness among healthcare providers in community to recognize postpartum male doctor. This was very upsetting to my husband and myself…very embarrassing.”
depression (PPD)
• More support and follow-up from physicians and public health nurses for postpartum • Healthcare provider LACK OF NURSING SUPPORT AND UNMET LEARNING NEEDS
issues such as breastfeeding and PPD
• Hospital environment “ I had a breast reduction, and found no info on breastfeeding for this condition. I was
• More nurses available in-hospital to provide care and support in the early
not encouraged or supported in any way regarding breastfeeding.” “How to care for
postpartum period
and critical pathways used for breastfeeding mothers These principles could be incorporated into policy docu- INCONSISTENT NURSING ADVICE FOR BREASTFEEDING
should include evaluation measures for breastfeeding sup- ments on maternal teaching and education and adapted to “ Nurses were giving contradictory and confusing advice regarding breastfeeding,
port. In addition to promoting reflective nursing practice, suit practice at the bedside and within the community. more support expected. Felt completely on my own.” “…nurses tell you different
advice regarding breastfeeding—very confusing!” “Every nurse gave different advice,
evaluation enables continual improvement of nursing care Staffing shortages and increasing demands on nurses
they should be consistent with their advice, especially for first-time moms!”
and the identification of systemic problems. may contribute to altered levels of support, and comments
Mothers with low confidence scores reported postpartum about nurses being too busy, overworked, and short staffed ENVIRONMENT CONDUCIVE TO ROOMING-IN
teaching and education to be areas in which nursing support were concerning. Some mothers described nurses’ behaviors “ Roommate had a restraining order from CAS [Children’s Aid Society] to see her baby.
was lacking. Shorter postpartum hospital stays translate into as “blunt” and “forceful.” When mothers perceive nurses Police had been to see her [roommate] the night before… I was very upset about this.”
decreased contact with nurses for teaching, and parents may to be rushing or too busy to help them, they may feel intim- “…night nurse was very regimented, she would wake us [mom and baby]…We could
leave the hospital with unmet learning needs. George (2005) idated and be reluctant to ask for much needed support not rest because she insisted the baby should nurse when she was not hungry.”
studied a group of new mothers, and the major theme that (Hong et al., 2003). Nurses should actively solicit feedback “Rooms were freezing cold! Baby would have stayed 24 hours [with me] if not so cold.”
emerged was lack of preparedness upon returning home. To from women and their families regarding their nursing care.
facilitate postpartum learning in busy work environments, This feedback enables nurses to reflect on their practice and
nurses need access to current information and simple tools increase awareness regarding how specific behaviors are care plans could be formatted to collect this type of infor- confident than women who spoke English or French. These
that can guide teaching and education. The FCMNC guide- perceived by families. In busy work environments, it is rec- mation as part of routine nursing assessment. women may have experienced language and cultural barriers
lines outline five principles to facilitate postpartum learning: ommended that nurses teach content that mothers and fam- Ottawa is a large urban city in which English and French are during their care, which increased anxiety and decreased confi-
• Set a comfortable climate for learning ilies are most in need of knowing (Ruchala, 2000); this con- the official languages. In 2006, approximately 21% of Ottawa dence. Alternatively, they are likely to be immigrant women,
• Share control of the content and the process tent may differ from generic postpartum checklists and residents spoke a language other than English or French as their who may perceive nursing care and support differently than
• Work at building the mother’s self-esteem teaching tools. Freda (2002) suggests starting each postpar- mother tongue, and slightly more than 82,000 individuals had Canadian-born women due to cultural beliefs and practices.
• Ensure that learning applies to the family’s home situation tum teaching session by asking new mothers about their ex- immigrated to the city within the previous 15 years (Statistics One study found that immigrant women were significantly
• Encourage self-responsibility of the mother (Health isting knowledge base, what they need to know, and what Canada, 2007). Women in this study who reported a language more likely than Canadian-born women to perceive experiences
Canada, 2000) they want to know. Within practice settings, individualized other than English or French as their first language were less with breastfeeding support received as detrimental to their suc-
the father of the baby.” “I expected more support [from nurses], I felt completely on nurses working with families. Support may include having Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 1-11.
my own.” “… I had no help at all with baby [in hospital].” Freda, M. C. (2002). Perinatal patient education: A practical guide with educa-
access to translators or print resources in multiple languages. tion handouts for patients. Philadelphia, PA: Lippincott Williams & Wilkins.
George, L. (2005). Lack of preparedness experiences of first-time mothers.
PRESSURE FROM NURSES TO BREASTFEED MCN The American Journal of Maternal Child Nursing, 30, 251-255.
“ Too much pressure to breastfeed, result is feelings of worthlessness.” “…there was
• Advocate for culturally sensitive practice changes, such Guthrie, B. J. (2005). Health disparities: Why communication matters.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 504.
too much support for breastfeeding…baby was losing weight and no one mentioned as incorporating cultural and language assessment into Health Canada. (2000). Family-centered maternity and newborn care: Na-
bottle feeding until it was critical.” “Too much pressure on breastfeeding, I had to admission forms and birth plans. tional guidelines. Ottawa, Ontario, Canada: Minister of Public Works
and Government Services.
argue about getting a supplement.” “Nurses were way too overzealous for breast- Hong, T., Callister, L., & Schwartz, R. (2003). First-time mothers’ views of
feeding. Too much pressure, I had to justify reasons for pumping milk…felt like a • Utilize best practice guidelines and other evidence-based breastfeeding support from nurses. MCN The American Journal of
child.” “Nurse forced baby onto mom in the OR to breastfeed when she [baby] wasn’t Maternal Child Nursing, 28, 11-15.
resources to develop a consistent and individualized practice Lauwer, J., & Shinskie, D. (Eds.). (2000). Counseling the nursing mother.
yet capable. The nurse refused to give bottle.” approach for assessing and supporting breastfeeding mothers. In Empowering women through your attitude and approach (pp. 25-
42). Boston, MA: Jones and Bartlett.
ENVIRONMENT CONDUCIVE TO ROOMING-IN Loiselle, C. G., Semenic, S. E., Coté, B., Lapointe, M., & Gendron, R.
• Develop clinical assessment tools to guide postpartum teach- (2001). Impressions of breastfeeding information and support among
“ When mothers get a caesarean section they should get a semi-private or private first-time mothers within a multiethnic community. Canadian Journal
ing and education of mothers and their families. Tools should of Nursing Research, 33(3), 31-46.
room, there were too many visitors to be able to rest.” “…difficult to rest [with
rooming-in]. I just needed to adjust with a lack of sleep and having a new baby—it was be easy to use and tailored for identified learning needs. Ontario Perinatal Partnership Program. (2006). Tailoring services to preg-
nant women and their babies in Ontario. 2006 provincial perinatal re-
a shock to the system.” port. Ottawa, Canada: Provincial Perinatal Surveillance System.
Papinczak, T. A., & Turner, C.T. (2000). An analysis of personal and social
Acknowledgments factors influencing initiation and duration of breastfeeding in a large
Queensland maternity hospital. Breastfeeding Review, 8, 25-33.
Polit, D. F., & Beck, C. T. (2004). Sampling designs. In Nursing research:
cess (Loiselle, Semenic, Coté, Lapointe, & Gendron, 2001). not available at the time of survey design, the Breastfeed- The Public Health Research Education and Development Principles and methods (7th ed., pp. 307-308). Philadelphia: Lippincott
With increasing evidence that communication barriers con- ing Self-Efficacy Scale by Dennis (2003) could be incorpo- Program funded the original Family-Centered Maternity Williams & Wilkins.
Registered Nurses’ Association of Ontario. (2007a). Breastfeeding best
tribute to disparities in healthcare (Guthrie, 2005), cultural rated into data collection tools. This scale was developed Care Survey. practice guidelines for nurses (Revision Supplement). Toronto, On-
assessment that includes asking the mother about language from a theoretical framework and translated and validat- tario, Canada: Registered Nurses’ Association of Ontario.
Registered Nurses’ Association of Ontario. (2007b). Embracing cultural di-
should be included as routine practice within all FCMC en- ed in Chinese and Spanish (Dai & Dennis, 2003; Torres, Shannon Mantha is Program Manager, Early Years, versity in health care: Developing cultural competence. Toronto, On-
vironments. To provide ongoing support to nurses, cultural Torres, Rodriguez, & Dennis, 2003). North Bay Parry Sound District Health Unit, Ontario, tario, Canada: Registered Nurses’ Association of Ontario.
Ruchala, P. L. (2000). Teaching new mothers: Priorities of nurses and post-
competence education should be embedded within organi- Canada. She can be reached via e-mail at Shannon.man-
zational processes (Registered Nurses’ Association of On- Summary tha@sympatico.ca
partum women. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 29, 265-273.
Statistics Canada. (2007). 2006 Community Profiles, Ottawa, Ontario
tario, 2007b). This can be accomplished by incorporating This study examined the responses of women with low and Barbara Davies is an Associate Professor, University of (City). 2006 Census. Statistics Canada. Retrieved March 31, 2008, from
questions about culture and language into routine forms high confidence levels in order to describe how FCMC Ottawa, Ontario, Canada. www.12.statcan.ca/english/profil01/CP01/Index.cfm?Lang=E
Torres, M. M., Torres, R. R. D., Rodriguez, A. M. P., & Dennis, C. (2003).
such as birthing plans. Assessing language fluency enables could have been more responsive to their needs and how Alwyn Moyer is an Adjunct Professor, University of Translation and validation of the Breastfeeding Self-Efficacy Scale into
nurses to arrange for additional resources, such as transla- their experiences related to confidence level. Findings indi- Ottawa, Ontario, Canada. Spanish: Data from a Puerto Rican population. Journal of Human Lac-
tation, 19, 35-42.
tors or translation of teaching materials. cated that mothers with both low and high confidence Katherine Crowe is a Supervisor, Reproductive Health
The findings from this study should be evaluated with needed more nursing support for infant feeding. Findings Program, Ottawa Public Health, Ontario, Canada.
the limitations in mind. Seven years have elapsed since da- also indicated that mothers with low confidence who were
ONLINE
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Childbirth Connection
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