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September/October 2008
Shannon Mantha, MScN, RN, Barbara Davies, PhD, RN, Alwyn Moyer, PhD, RN,and Katherine Crowe, BScN, RN
Todescribe new mothers’ experiences with family-centered maternity carein relation to their confidencelevel and to determine how care could have been more responsive to their needs.
Study Design and Methods:
Using data from a prospective Canadian survey of 596 postpartum women, a sub-sample of women with low and high confidence (N = 74) was selected. Data were analyzed using descriptive sta-tistics and content analysis.
Women with both high and low confidence expressed negative experiences with similar frequency (
=47/74, 64%). Women wanted more nursing support for breastfeeding and postpartum teaching and education.Women who reported a language other than English or French as their first language were significantly less confi-dent than English- and French-speaking women (
Clinical Implications:
Amultilevel framework about family-centered careis presented for healthcareproviders in prenatal,labor and birth, and postpartum care. It is recommended that nurses ask new mothers about their confidence level andgive special consideration to cultural background in order to provide supportive care in hospital and community settings.
Key Words:
Family nursing; Postpartum period; Maternal-child nursing; Breastfeeding.
September/October 2008
he transition from pregnancy to parenthood is oneof life’s major events, and it can be a stressful andvulnerable time for families. To better supportCanadian families through the transition to parenthood,Health Canada (2000) developed multidisciplinary guide-lines on family-centered maternity and newborn care(FCMNC). The FCMNC guidelines state that a primarygoal of postpartum care should be to “support andstrengthen the mother’s confidence in herself and in herbaby’s health and well-being, thus enabling her to fulfill hermothering role” (Health Canada, 2000, p. 6.5).Maternal confidence can be defined as a mother’s percep-tion of her ability to care for and understand her infant(Badr, 2005). For instance, research indicates that womenwho are confident in their ability to breastfeed are generallysuccessful at initiating and maintaining breastfeeding (Blythet al., 2002); a Canadian study found that women who areless confident tend to wean their infants from breastfeedingearlier than women who are very confident (Dunn, Davies,McCleary, Edwards, & Gaboury, 2006). High levels of ma-ternal confidence in the postpartum period are also associat-ed with lower levels of anxiety, less depression, increased self-esteem and coping capacity, and stronger social relationships(Papinczak & Turner, 2000). Interactions with and supportreceived from nurses during pregnancy, birth, and the post-partum period may influence a mother’s level of confidence.FCMNC is a complex process of providing holistic careand supportthat responds to the physical, emotional, andpsychosocial needs of the woman and her family.Familysupport, participation, and choice arecentral to FCMNC,and supportoffered by nurses is recognized as having apowerful effect on women and their families (Health Cana-da, 2000). Receiving adequate care and support from nursesduring the transition to parenthood has been associatedwith decreased levels of stress during labor and birth (Chang&Chen, 2000) and increased duration of breastfeeding(Britton, McCormick, Renfrew, Wade, & King, 2007). Insummary, literature confirms the importance of nursing sup-port and maternal confidence for pregnant and parentingwomen. However, little is known about the characteristicsand experiences of mothers with high and low confidence.
Study Design and Methods
Secondary analyses of data from the family-centred maternitycare(FCMC) study, which was coordinated by the Ottawa-Carleton Health Department in Ontario, Canada, wereconducted. In Ottawa, the health department offers prenataleducation for a nominal fee, which can be waived depend-ing on financial need. All hospital care during labor, birth,and the postpartum period is covered by provincial healthinsurance. Public health nurses call all postpartum womenwithin 48 hours of arriving home from hospital to offer sup-port and a home visit if indicated by nurse assessment andclient acceptance. In 2006, there were approximately118,449 births in Ontario, 98% of which took place in ahospital. The mean age of women giving birth was 30 years(Ontario Perinatal Partnership Program, 2006).The FCMC study was a prospective longitudinal study, themain objective of which was to gain an understanding of thepregnancy, birth, and postpartum care received by womenwithin hospital and community settings. Trained interviewerscollected data by telephone using a standardized script at 1and 6 weeks postpartum. An experienced Canadian re-searcher developed the surveys, and local experts reviewedcontent validity. Women were invited to participate if theylived in Ottawa, a city of approximately 750, 000 in 2001,gave birth in one of the four Ottawa hospitals between Octo-ber, 2000 and March 2001, spoke English or French, andweredischarged home with their infant. The planned samplesize was 600 women, which represented 80% of the 750births per month in Ottawa. To reach a predesignated pro-portionate quota for each hospital, researchers contacted 677eligible women. Fifty-two women declined to participate inthe initial survey, and an additional 29 women did not com-plete the 6-week postpartum survey.The response rate was88%; 596 women completed both postpartum surveys.The current study used a subsample of women from theFCMC study.As partof the 6-week postpartum survey,women wereasked to comment on how the carethey receivedduring pregnancy, birth, and the postpartum period could havebeen more responsive to their needs and their family’s needs.Women’s responses were recorded verbatim over the telephone.The responses were two to three sentences (range, two to eightsentences) and provided the qualitative data for content analy-sis. Both the 1- and 6-week surveys asked women to reporttheir level of confidence on a 5-point Likert scale for caring forthemselves and their baby upon discharge and during theirtime at home. In the 1-week survey, confidence in caring forself and baby upon discharge was a single measure, whereasthe 6-week survey used separate questions to measure confi-dence about caring for self and baby. To create one confidencescore at 6 weeks postpartum for each woman, the two scoreswereadded to create a composite score that could range from2to 10. Scores of 6 or less on the composite score were catego-rized as low maternal confidence, and scores of 10 were cate-gorized as high maternal confidence.
 Interactions with and support received from nurses during pregnancy, birth, andthe postpartum period may influence a mother’s level of confidence.
Extreme case sampling of the 596 participants was usedto create a subsample for the qualitative analysis. Extremecase sampling follows the underlying assumption that caseson either end of a spectrum are rich in information andmay provide important insight about the phenomenon of interest (Polit & Beck, 2004). Because maternal confidencewas the focus of the study, all women from the sample whoscored 6 or less on the composite score were selected (
=37) and categorized as the low-confidence group. An equalsample of women (
=37) with composite scores of 10wererandomly selected from the 283 women within thesample who had composite scores of 10 and were catego-rized as the high-confidence group. A final sample of 74women was obtained for the current study. There were nomissing data for confidence scores.Independent content analyses of the data wereperformedby two of the researchers (Caelli, Ray, & Mill, 2003). First,women’s comments were categorized for content under prena-tal, labor and birth, and postpartum. Items were then com-pared within and across categories to identify themes. Con-sensus agreement was used for categorizing comments andtheme identification. Comments under each stage werecount-
September/October 2008
(by Fisher’s exact test)
Primiparas67.662.2 (23)73.0 (27)0.99
Multiparas32.437.8 (14)27.0 (10)
English52.7 37.8 (14)67.6 (25)8.09
<.05French24.327.1 (10)21.6 (8)Other23.035.1 (13)10.8 (4)
High school/somecollege/ university32.535.2 (13)29.7 (11)0.25
Completed college/university/Postgraduate67.564.8 (24)70.3 (26)
Maternal Age
30 or older58.175.7 (28)40.6 (15)9.48
<.0525-2929.716.2 (6)43.2 (16)15-2412.28.1 (3)16.2 (6)
$59,999 or less31.533.3 (9)29.7 (8)0.09
$60,000 or greater68.566.7 (18)70.3 (19)Declined to answer(20)(10)(10)
Partner Status
Has a partner77.083.8 (31)70.3 (26)1.91
No partner23.016.2 (6)29.7 (11)
Table 1.
Significant Differences Between Demographic Factors and Confidence Levels
September/October 2008
ed to provide a basis for quantitativecomparison. Descriptive statisticswere used to describe women’scharacteristics, and chi-square testswere used to describe the relationshipbetween women’s characteristicsand confidence level. When cell fre-quencies were small, Fisher’s exact testwas used. Statistics were computedusing the Statistical Package for theSocial Sciences (SPSS) (version 12.0for Windows). The University of Ottawa Research and Ethics Boardprovided ethics approval.
Characteristics of the entire sample and of women with lowand high confidence are displayed in Table 1. A significantdifference was found between maternal confidence leveland two demographic factors: language and age. Specifical-ly,in the low-confidence group, more than one third(35.1%) of mothers indicated a language other than Englishor French as the language first learned, and only 10.8% of mothers in the high-confidence group indicated a languageother than English or French (
<.05).Asignificant difference was also noted for maternal age andconfidence level (
<.05), with 76% of older mothers (
30)reporting that they wereless confident. The number of mothers aged 15 to 24 is small, and caution in interpretingthese results is recommended.Figure1summarizes women’scomments by stage and ele-ment of care. Figures 2 and 3 provides an example of quotesfrom mothers with low and high confidence. Eighty-five per-cent of women in the study commented about how their carecould have been more responsive. More than one half of women (
=47/74, 64%) commented on negative experi-ences encountered. Women with high and low confidencecommented on negative experiences with similar frequency.Almost three fourths of the women who commented refer-enced the postpartum care they received, and nurses were re-ferred to three times as often as other members of the health-care team. Both groups of women commented on breastfeed-ing experiences with the same frequency, although their de-scriptions of why support was lacking differed. Women withlow confidence reported confusion about breastfeeding dueto conflicting advice given by nurses, whereas women withhigh confidence reported too much pressure to breastfeedfrom nurses. Women with low confidence commented twiceas often on postpartum teaching and educational needs whencompared to women with high confidence.
Clinical Implications
Mothers’ comments often mentioned interactions with nurs-es. Mothers reported that they needed more support fromnurses regarding infant feeding, postpartum teaching, andeducation. This finding is not surprising, because a recent re-view of 18 studies on postpartum learning needs found thatthe learning needs of new mothers are not always met with-in the early postpartum period (Bowman, 2005).Women’s dissatisfaction with nursing support for infantfeeding, specifically breastfeeding, had multiple reasons.Women with low confidence reported confusion aboutbreastfeeding due to conflicting nursing advice, whereaswomen with high confidence reported too much pressure tobreastfeed from nurses. Although conclusions cannot bedrawn, this finding raises the question of whether nursingcareactually differed between the two groups of women orif carewas perceived differently.Nurses have the ability tosignificantly impact a mother’s breastfeeding experiencethrough offering supportive or nonsupportive care(Lauwer&Shinskie, 2000). Having low confidence increases risk of early weaning and introduction of formula (Blyth et al.,2002), and if nursing supportfor breastfeeding is inade-quate, these women may be at increased risk for earlyweaning or not breastfeeding at all. Inadequate nursingsupport for infant feeding has been documented in the liter-ature and has been thought to be due to a lack of knowl-edge among nurses regarding current best practices (Hong,Callister, & Schwartz, 2003). Further research is requiredto explore the relationship between confidence level andperceptions about nursing support.In addition to providing correct information that isbased on current best practice and protocols for infant feed-ing, nurses need to provide advice and support that womenperceive as beneficial to them. In recognition of personalvariables that affect breastfeeding, individualized breast-feeding support offered through tailored care plans is rec-ommended as best practice when caring for breastfeedingmothers (Registered Nurses’ Association of Ontario,2007a). Care plans for breastfeeding mothers also shouldincorporate assessment of women’sconfidence level forbreastfeeding as a potential predictor of future problems(Dunn et al., 2006) and as a method of gaining insight fortailoring nursing supportinterventions. Policies, care plans,
The overwhelming message embedded within mothers’  comments surrounded interactionswith nurses. Mothers reportedthat they needed more support from nurses regarding infant feeding, postpartum teaching, and education.
and critical pathways used for breastfeeding mothersshould include evaluation measures for breastfeeding sup-port. In addition to promoting reflective nursing practice,evaluation enables continual improvement of nursing careand the identification of systemic problems.Mothers with low confidence scores reported postpartumteaching and education to be areas in which nursing supportwas lacking. Shorter postpartum hospital stays translate intodecreased contact with nurses for teaching, and parents mayleave the hospital with unmet learning needs. George (2005)studied a group of new mothers, and the major theme thatemerged was lack of preparedness upon returning home. Tofacilitate postpartum learning in busy work environments,nurses need access to current information and simple toolsthat can guide teaching and education. The FCMNC guide-lines outline five principles to facilitate postpartum learning:Set a comfortable climate for learningShare control of the content and the processWork at building the mother’s self-esteemEnsure that learning applies to the family’s home situationEncourage self-responsibility of the mother (HealthCanada, 2000)These principles could be incorporated into policy docu-ments on maternal teaching and education and adapted tosuit practice at the bedside and within the community.Staffing shortages and increasing demands on nursesmay contribute to altered levels of support, and commentsabout nurses being too busy, overworked, and short staffedwere concerning. Some mothers described nurses’ behaviorsas “blunt” and “forceful.” When mothers perceive nursesto be rushing or too busy to help them, they may feel intim-idated and be reluctant to ask for much needed support(Hong et al., 2003). Nurses should actively solicit feedbackfrom women and their families regarding their nursing care.This feedback enables nurses to reflect on their practice andincrease awareness regarding how specific behaviors areperceived by families. In busy work environments, it is rec-ommended that nurses teach content that mothers and fam-ilies are most in need of knowing (Ruchala, 2000); this con-tent may differ from generic postpartum checklists andteaching tools. Freda (2002) suggests starting each postpar-tum teaching session by asking new mothers about their ex-isting knowledge base, what they need to know, and whatthey want to know.Within practice settings, individualized
September/October 2008
 StageElement of CareWhat Would Have Improved My Care
    P  r  e  n  a   t  a    l
Healthcare providerCommunity servicesPhysician taking time to listen and answer questionsNot feeling rushed during prenatal appointments (by physician and nurse)Prenatal educationa)Standardizing what is taught to provide consistent and accurate informationb)Emphasizing the positive aspects of labor & birth during prenatal classes
    L  a    b  o  r    &    B    i  r   t    h
Healthcare providerHospital environmentHaving the nurse present more often to provide more personalized care and supportHaving physician present more often to ask questionsNursing staff being supportive of family’s presencePolicy and procedures that aim to include partner/family in the labor & birthexperience (access is not restricted)An environment that respects cultural and religious beliefs and values
    P  o   s   t  p  a  r   t  u  m    (  u  p   t  o    6  w  e  e    k   s    )
Healthcare providerHospital environmentMore support from physicians and nurses (i.e., taking time to listen and explain things)More personalized care and support from nurses to offer teaching and educationrelated to learning needsConsistent advice from nurses regarding breastfeedingBreastfeeding support offered by nurses that is nonjudgmental, nonpatronizing, andaimed at increasing sense of control and ability to problem solveA lactation consultant available in-hospitalMore awareness among healthcare providers in community to recognize postpartumdepression (PPD)More support and follow-up from physicians and public health nurses for postpartumissues such as breastfeeding and PPDMore nurses available in-hospital to provide care and support in the earlypostpartum periodHospital environment that is more supportive to mothers and babies rooming-inWarmer room temperatures
Figure 1.
Women’s Comments About What Would Have Improved Their Care
care plans could be formatted to collect this type of infor-mation as part of routine nursing assessment.Ottawa is a large urban city in which English and French arethe official languages. In 2006, approximately 21% of Ottawaresidents spoke a language other than English or French as theirmother tongue, and slightly morethan 82,000 individuals hadimmigrated to the city within the previous 15 years (StatisticsCanada, 2007). Women in this study who reported a languageother than English or French as their first language were lessconfident than women who spoke English or French. Thesewomen may have experienced language and cultural barriersduring their care, which increased anxiety and decreased confi-dence. Alternatively, they are likely to be immigrant women,who may perceive nursing care and support differently thanCanadian-bornwomen due to cultural beliefs and practices.One study found that immigrant women were significantlymore likely than Canadian-born women to perceive experienceswith breastfeeding support received as detrimental to their suc-
September/October 2008
 StageElement of CareWhat Would Have Improved My Care
    P  r  e  n  a   t  a    l
Community services
Lengthening the prenatal course and standardizing what is taught at the differentcourses. [I] attended a couple of classes at other prenatal courses and learned things that were not covered in the primary course.”“…during my pregnancy I wasdepressed and found that there was a lack of support for this.” “Moms should beaware of public health services that are available before the baby is born. Postpartumdepression should be explained to moms before birth and they should be taught torecognize the signs and symptoms.”
    L  a    b  o  r    &    B    i  r   t    h
Healthcare providerHospital environment
…nurses are overworked and made mistakes due to this, we need more nurses.”“The nurses were overworked and not too happy…” “…nurses should spend more time explaining, rather than just giving pamphlets…they expect moms to automaticallyknow how to breastfeed or bottle feed.”
“…husbands should be in hospital room right away [following cesarean birth]. Thehospital restricted my husband’stime. This was stressful for a mother who wantedsupport…”“My husband felt totally unwelcome during labor and birth” “I asked mydoctor to have a female during delivery.When I arrived I told the nurse that I had tohave a female doctor because of religious beliefs. The female resident had to get amale doctor. This was very upsetting to my husband and myself…very embarrassing.”
    P  o   s   t  p  a  r   t  u  m    (  u  p   t  o    6  w  e  e    k   s    )
Healthcare providerHospital environment
I had a breast reduction, and found no info on breastfeeding for this condition. I wasnot encouraged or supported in any way regarding breastfeeding.” “How to care formy vaginal area was not explained at the hospital. I was later informed about a sitzbath through the family doctor [2 weeks after delivery]…still wasn’t healed and wasgetting worse.” ”There should be more information about mother’s health afterlabor…what to expect.”
Nurses were giving contradictory and confusing advice regarding breastfeeding,more support expected. Felt completely on my own.” “…nurses tell you differentadvice regarding breastfeeding—very confusing!” “Every nurse gave different advice, they should be consistent with their advice, especially for first-time moms!”
Roommate had a restraining order from CAS [Children’s Aid Society] to see her baby.Police had been to see her [roommate] the night before… I was very upset about this.”“…night nurse was very regimented, she would wake us [mom and baby]…We couldnot rest because she insisted the baby should nurse when she was not hungry.”“Rooms were freezing cold! Baby would have stayed 24 hours [with me] if not so cold.”
Figure 2.
Quotes From Mothers With Low Confidence
September/October 2008

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