Journal of Obstetrics and Gynaecology, May 2015; 35: 336–340 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.960375
OBSTETRICS
Preparedness of pregnant women for childbirth and the postpartum period: Their knowledge and fear N. Tugut, D. Tirkes & G. Demirel
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Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey
The aim of the study was to identify knowledge and fear related to childbirth and the postpartum period in pregnant women. The sample consisted of 114 pregnant women. It was determined that pregnant women had insufficient levels of knowledge related to childbirth and the postpartum period. The Fear of Childbirth and Postpartum Anxiety Scale score for childbirth and the postpartum period related to ‘fear regarding the action of childbirth’, was found to be the highest. The highest causes for concern were determined to be ‘infant-related anxiety’ and ‘fear regarding infant and puerperal health’. No statistically significant correlation was observed between the perceived sufficiency of the knowledge of pregnant women in terms of maintaining their own health and care, and their mean childbirth and postpartum period concern score. These findings indicate that the level of concern among pregnant women with relation to the postpartum period and childbirth is rather high.
and lack of knowledge of pregnant women, and to determine the current content deficit in consultancy services in this field.
Keywords: Childbirth, fear, knowledge, pregnant women, postpartum period, preparedness
• A gestational age of ⱖ 13 weeks • Literacy • No diagnosed psychiatric/physical diseases.
Introduction
The mean age of the pregnant women in the present study was 26.76 ⫾ 5.86: 54.4% of the participants were elementary school graduates and 90.4% were living at the provincial centre. Pregnant woman who were not working comprised 88.6% of the sample and 85.1% were living with a nuclear family. The pregnant women who were at a middle-income level comprised 66.7% of the sample. From among the husbands of the pregnant women, it was established that 40.4% were elementary school graduates and 95.6% were working (Table I). Data for the study were collected through a Personal Information Form for Pregnant Women and Fear of Childbirth and Postpartum Anxiety Scale (FCPAS). The Personal Information Form was prepared with the aim of identifying certain individual and obstetric attributes of pregnant women, their knowledge and skills relevant to, and the information they needed in, childbirth and the postpartum period. Developed by Kitapçıoğlu et al. (2008), the FCPAS has high validity and reliability. The assessment was developed with the purpose of identifying women with fear of childbirth and the postpartum period. Each question has five response options. Post-standardisation scores are:
Prenatal care, healthy childbirth and postpartum care are among the reproductive health services that must be taken into consideration (Akış 2004). In fact, pregnancy and the postpartum period are significant times in a woman’s life in terms of biological, psychological and emotional changes (Kitapçıoğlu et al. 2008). Pregnancy and the postpartum period may lead to either joy, satisfaction, maturity, self-realisation and happiness, or give way to anxious and uneasy anticipation and various fears (Epstein and Leichtentritt 2009). The authors determined that women with a high level of prenatal adaptation are more prepared for childbirth, show greater control during childbirth and hold better spousal relations. Moreover, such women were also found to adapt well to the postpartum period, cope better with problems, exhibit a higher level of self-confidence and have a higher satisfaction with life and their role as a mother (Deave et al. 2008; Ho and Holroyd 2002; Kiehl and White 2003; Shin et al. 2006). The purpose of nursing care during pregnancy is to protect and improve family health, by enabling the pregnant woman and her family to adapt to the pregnancy in a healthy manner. Nurses assume significant roles in identifying the factors that may influence a woman’s process of adaptation to pregnancy, childbirth and the postpartum period: they also satisfy her needs during this adaptation process (Goto and Yasumura 2002). The present study was performed with the aim of providing guidance to enable nurses to be aware of the prenatal, childbirth and postpartum fear
Methods and materials This study was performed in a cross-sectional structure with the objective of addressing pregnant women that visited the outpatient polyclinics of gynaecology and obstetrics at a university hospital, to identify their preparedness for childbirth and the postpartum period. The study population was comprised of pregnant women that visited the gynaecological and obstetric services of a university hospital. The sample consisted of 114 pregnant women who visited the polyclinics of gynaecology for general health control purposes between 25 March and 30 April, 2013 and satisfied the following criteria:
• • • • •
0.00–2.00: Very low anxiety 2.01–4.00: Low anxiety 4.01–6.00: Moderate anxiety 6.01–8.00: High anxiety 8.01–10.00: Very high anxiety.
Correspondence: N. Tugut, Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, 58140 Sivas, Turkey. E-mail: [email protected]
Preparedness of pregnant women 337 Table I. Distribution of current pregnancy characteristics of pregnant women.
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Current pregnancy characteristics Pregnancy trimester 2nd trimester 3rd trimester Mean pregnancy week: 31.51; SD: 7.83; min: 13, max: 38 Planning status of pregnancy Planned Unplanned Intentionality of pregnancy Wanted Unwanted The 1st week of control for pregnant women Mean: 5.12; SD: 2.51; min: 1, max:16 Current number of controls 1–4 times 5–8 times ⱖ9 Planned mode of delivery Normal vaginal birth Caesarean section
n
(%)
17 97
14.9 85.1
78 36
68.4 31.6
95 19
83.3 16.7
21 38 55
18.4 33.3 48.2
88 26
77.2 22.8
Pregnant women that satisfied the criteria and volunteered to participate in the study were given information on the study and provided their verbal consent. A suitable environment (quiet, calm, etc.) was provided for the pregnant women and data collection tools were presented to the participants. Pregnant women were given the data collection tools and asked to fill in the forms and deliver them to the author after completion. Data collection forms were completed in 15–20 min. Data collected were evaluated using a database created on the SPSS 14.0 software. The evaluation demonstrated the data obtained through a count in the form of a frequency distribution and the data obtained through measurement in the form of means and standard deviations. Furthermore, groups of two were
analysed using a t-test, while groups of more than two were analysed with one-way analysis of variance and correlation. The study was carried out in accordance with the principles of the Helsinki Declaration. The necessary permissions were obtained from hospital management for the performance of the study. Pregnant women that had been invited to participate were given information on the study, and those that volunteered to participate verbally expressed consent.
Results The mean gestational week of the pregnant women was 31.51 ⫾ 7.83, with 68.4% of the pregnancies being planned and 83.3% being intentional. Of the pregnant women, 85.1% were determined to be in the 3rd trimester, and 77.2% were planning to have a vaginal childbirth. It was also established that the first pregnancy control took place within the 5th week on average, and 48.2% of pregnant women underwent control nine or more times (Table I). Of the participants, 21.1% stated that they had received information on the action of childbirth during pregnancy, with 13.2% receiving such information from a midwife or nurse; 31.6% of the pregnant women were determined to have received information on the postpartum process, and 22.8% of information sources were midwives or nurses (Table II). The mean score of the perceived sufficiency of the knowledge of pregnant women to maintain their own health and care during the action of childbirth was found to be 5.54 ⫾ 2.09. The mean score of the perceived sufficiency of their knowledge to maintain their health and care during the postpartum period was 6.55 ⫾ 1.95. Finally, the mean score of the perceived sufficiency of their knowledge to maintain health and care of the newborn during the postpartum period was 6.47 ⫾ 2.08. The mean score for the perceived preparedness of pregnant women for infant care in the postpartum period was 6.99 ⫾ 1.88 (Table III).
Table II. The distribution of received information of pregnant women on the action of childbirth and postpartum period and information sources. Status of received information and source of information Status of received information on the action of childbirth during pregnancy Received information Did not receive information Source of information on the action of childbirth∗ Midwife/nurse Doctor Family members Friend/neighbour Internet Books/magazines Television Status of received information on the postpartum period during pregnancy Received information Did not receive information Source of information on the postpartum period∗ Midwife/nurse Doctor Family members Internet Books/magazines Friend/neighbour Television ∗More than one option was marked.
n
(%)
24 90
21.1 78.9
15 10 4 1 4 3 1
13.2 8.8 3.5 0.9 3.5 2.6 0.9
36 78
31.6 68.4
26 7 6 6 4 3 1
22.8 6.1 5.3 5.3 3.5 2.6 0.9
338
N. Tugut et al.
Table III. Mean scores for pregnant women’s perceived sufficiency of knowledge and preparedness to maintain their own and infant health and care in the childbirth and postpartum periods. Pregnant women’s perceived sufficiency of information and preparedness
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Pregnant women’s perceived sufficiency of the knowledge to maintain their own health and care during the action of childbirth Pregnant women’s perceived sufficiency of their knowledge to maintain their own health and care during postpartum period Pregnant women’s perceived sufficiency of knowledge to maintain infant health and care during postpartum period Pregnant women’s perceived preparedness for infant care in postpartum period
X ⫾ SD 5.54 ⫾ 2.09 6.55 ⫾ 1.95 6.47 ⫾ 2.08 6.99 ⫾ 1.88
Table IV indicates the FCPAS and its sub-dimensions for pregnant women. The score of pregnant women in ‘fear regarding the action of childbirth’ was found to be the highest, at 7.99. The second highest cause for fear was determined to be ‘infant-related anxiety’ (5.55 ⫾ 1.90) and the third highest cause for fear was ‘fear regarding infant and puerperal health’ (4.57 ⫾ 1.35). The difference among pregnant women in terms of their FCPAS score per sociodemographic and obstetric attribute was not statistically significant (p ⬎ 0.05). No statistically significant correlation was observed between the perceived sufficiency of the knowledge of pregnant women to maintain their own health and care and their mean FCPAS score (p ⬎ 0.05). However, a statistically significant correlation existed among the sub-dimensions of the scale with relation to fear about postpartum breast-feeding, fear of not being supported by their spouse in the postpartum period and fear pertaining to the behaviour of healthcare personnel during childbirth (p ⬍ 0.05). No statistically significant correlation was established between the perceived sufficiency of the knowledge of pregnant women to maintain postpartum infant health and care and their mean FCPAS score (p ⬎ 0.05). The evaluation of the sub-dimensions of the scale revealed a statistically significant correlation between the sub-dimension pertaining to postpartum breast-feeding and the mean scale score (p ⬍ 0.05). No statistically significant correlation was established between the perceived sufficiency of the knowledge of pregnant women to maintain their postpartum health and care, their perceived preparedness for infant care and their mean FCPAS score (p ⬎ 0.05) (Table V). Table IV. Mean scores of natal and postnatal anxiety scale for pregnant women. Scale sub-dimensions Infant-related anxiety Fear regarding the action of childbirth Fear about breast-feeding Anxiety of inadequacy in postnatal infant care Fear regarding postnatal social life Fear regarding infant and puerperal health Fear of not being supported by their spouse in the postpartum period Pre-labour fear Fear pertaining to the behaviour of healthcare personnel during childbirth Anxiety of the possibility of a caesarean section Mean scale score
X ⫾ SD 5.55 ⫾ 1.90 7.99 ⫾ 2.26 3.22 ⫾ 1.06 3.62 ⫾ 1.19 2.33 ⫾ 0.89 4.57 ⫾ 1.35 2.51 ⫾ 0.98 1.77 ⫾ 0.65 2.95 ⫾ 0.86 1.32 ⫾ 0.51 34.70 ⫾ 8.04
Table V. Correlation between the pregnant women’s perceived sufficiency of the knowledge to maintain their own and infant health and care during the action of birth and postnatal period and their NPAS score means. Pregnant women’s perceived sufficiency of information and preparedness Pregnant women’s perceived sufficiency of the knowledge to maintain their own health and care during the action of childbirth Pregnant women’s perceived sufficiency of their knowledge to maintain their own health and care during the postpartum period Pregnant women’s perceived sufficiency of knowledge to maintain infant health and care during the postpartum period Pregnant women’s perceived preparedness for infant care in the postpartum period
Test X ⫾ SD
r
p
5.54 ⫾ 2.09 0.144 0.128 6.55 ⫾ 1.95 0.053 0.577
6.47 ⫾ 2.08 0.083 0.381 6.99 ⫾ 1.88 0.018 0.847
Discussion Preparedness for childbirth and the postpartum period is under the influence of various sociodemographic properties. The studies performed in this context specify that women’s sociodemographic properties (age, marital status, number of existing children, educational level, current trimester of pregnancy, etc. ) may lead to emotional fluctuations (fear, anxiety, etc.), especially during pregnancy and the postpartum period (Cornelius et al. 2007; Çalışkan et al. 2007; Gözüyeşil et al. 2008; Lee et al. 2007; Spinelli et al. 2003). The difference between pregnant women in terms of their FCPAS score per sociodemographic and obstetric attributes was not found to be statistically significant in our study. The role of antenatal education in the elimination of preexisting conditioning and fear pertaining to the action of childbirth is indisputable (Christiaens and Bracke 2007; Saisto et al. 2001). According to Gürel et al. (2006), with a rate of 32.4%, childbirth is one of the most prominent areas where the provision of information is necessitated with relation to pregnancy. On the other hand, the results showed that 21.1% of pregnant women had received information on the action of childbirth during pregnancy, and they represented a moderate level of perceived sufficiency of received information to maintain their own health and care during the action of childbirth (5.54 ⫾ 2.09). These findings indicate that pregnant women do not possess sufficient information on the action of childbirth. In our study, 13.2% and 8.8% of pregnant women stated that they received information on the action of childbirth most frequently from midwives or nurses and from doctors, respectively. The low percentage of pregnant women receiving information on the action of childbirth from healthcare personnel during pregnancy leads to the conception that antenatal education is not delivered at a sufficient level, and that pregnant women constitute a highrisk group in the childbirth and postpartum process. According to Şahin et al. (2009), women that pointed out midwives or nurses as the most frequent givers of prenatal care also stated that they received such service from doctors at the second highest frequency. The postpartum period is a time of developmental crisis, where the newborn is integrated into the family system and the woman is in the process of emotional, physical and social adaptation (Beydağ 2007; Karaçam and Ançel 2009). In this period, lack of information on the mother’s side with relation to their own care, infant care and normal characteristics of the infant may lead to anxiety in the mother, erosion of satisfaction with
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Preparedness of pregnant women 339 the role of motherhood and may negatively affect life changes (Sword and Watt 2005; Yıldız 2008). Our study established that only 31.6% of pregnant women had received information on the postpartum process. Furthermore, the perception of pregnant women with relation to the sufficiency of their knowledge about maintaining their own health and care (6.55 ⫾ 1.95), maintaining their infant’s health and care (6.47 ⫾ 2.08) and their perceived preparedness for infant care (6.99 ⫾ 1.88) were found to be at a moderate level in terms of mean scores. The study findings point out that women are not sufficiently informed about childbirth and the postpartum period. This conclusion may show that they will inadequately care for themselves and the infant. Dağ et al. (2013) also found the level of received information on the postpartum period to be rather low (33.6%). In the postpartum period, it is important for the mother to develop skills and confidence in infant care (Sword and Watt 2005; Yıldız 2008). A relevant study established that the most frequent sources of information for women that did receive such information on the postpartum period were nurses and undergraduate nurses (31.8%) (Dağ et al. 2013). In our study, on the other hand, the main source of information on the postpartum period for pregnant women was midwives or nurses (22.8%). However, the low percentage of midwives or nurses as a source of information is thought provoking. In pregnancy, receipt of not only clinical information on childbirth and the postpartum period, but also of other types of information, is of significance. Gürel et al. (2006) identified that, in addition to clinical information during pregnancy, the most frequent sources of information on pregnancy, childbirth and the postpartum period were books/magazines (54.0%), television (40.0%) and friends/acquaintances (22.4%); other sources, including radio, internet, newspapers and brochures were not utilised very frequently for this purpose. In contrast to this study, the findings of our study indicate the prominence of gathering information from family members, the internet and books/magazines (in that order) during childbirth and the postpartum period. During the postpartum period, the most prominent areas causing fear and a dire need for information among mothers included: postpartum care and complications (Christiaens et al. 2011); infant nutrition and care (Christie et al. 2008; Karataş 2001); postpartum exercises; adaptation to parenthood and family planning (Yıldız 2008). In Kitapçıoğlu et al. (2008), the three most prominent fears among pregnant women were regarding the behaviour of healthcare personnel during childbirth (7.2); fear about infant health (7.0); and fear about childbirth itself (6.92). However, in our study, the three most prominent areas of concern for pregnant women with relation to childbirth and the postpartum period were: fear regarding the action of childbirth (7.99 ⫾ 2.26); fear regarding the infant (5.55 ⫾ 1.90); and fear regarding infant and puerperal health (4.57 ⫾ 1.35). These findings indicate that the level of fear among pregnant women with relation to the postpartum period (and childbirth itself) is rather high. The cause of such high levels of fear is considered perhaps due to lack of information on childbirth and the postpartum period among pregnant women. According to our study findings, the other causes of fear, in descending order, are: self-inadequacy in postpartum infant care; postpartum breast-feeding; the behaviour of healthcare personnel during childbirth; not receiving postpartum social support; postpartum social life; pre-labour fear; and anxiety about the possibility of a caesarean section. Even although no significant correlation was revealed between the perceived sufficiency of the information received by pregnant
women to maintain their own and their infant’s health and care in the postpartum period and their FCPAS scores, a significant correlation was observed among the sub-dimensions of fear relating to postpartum breast-feeding; not being able to receive postpartum support from their spouses; and the behaviours of healthcare personnel during childbirth. This indicates that such fear arose from insufficient levels of knowledge and lack of preparedness for these processes among pregnant women with relation to childbirth and postpartum processes. In terms of maternal and infant health, pregnant women can be defined as a high-risk group due to their limited knowledge about childbirth, the postpartum period and the anxiety they experience due to this fact. Study findings show that education of pregnant women on fear regarding childbirth and the postpartum period is of great importance. Antenatal education classes should be made widely available for the education for pregnant women. Nurses and midwives should identify and consult with pregnant women about their fears, and pregnant women should be motivated to alleviate their anxiety through the use of information technologies (telephone calls, short messages and e-mails). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Akış N. 2004. Bursa Nilüfer Halk Sağlığı Eğitim ve Araştırma bölgesindeki gebelerde risk etmenlerinin saptanması ve doğum öncesi bakım hizmetlerinin değerlendirilmesi. [In Turkish] Sağlık ve Toplum Dergisi 14:66–72. Beydağ KD. 2007. Adaptation to motherhood in the postpartum period and the nurse’s role. TSK Koruyucu Hekimlik Bülteni 6:479–484. Christiaens W, Bracke P. 2007. Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective. BMC Pregnancy and Childbirth 7:1–12. Christiaens W, Velde SVD, Bracke P. 2011. Pregnant women’s fear of childbirth in midwife and obstetrician led care in Belgium and the Netherlands: test of the medicalization hypothesis. Women and Health 51:220–239. Christie J, Poulton BC, Bunting BP. 2008. An integrated mid-range theory of postpartum family development: a guide for research and practice. Journal of Advanced Nursing 61:38–50. Cornelius MD, Goldschmidt L, DeGenna N, Day NL. 2007. Smoking during teenage pregnancies: effects on behavioral problems in offspring. Nicotine and Tobacco Research 9:739–750. Çalışkan D, Oncu B, Kose K, Ocaktan ME, Ozdemir O. 2007. Depression scores and associated factors in pregnant and non-pregnant women: a community based study in Turkey. Journal of Psychosomatic Obstetrics and Gynaecology 28:195–200. Dağ H, Dönmez S, Şen E, Şirin A. 2013. Postpartum discharge readiness situation of women who had vaginal deliveries. [In Turkish] Gaziantep Tıp Dergisi 19:65–70. Deave T, Johnson D, Ingram J. 2008. Transition to parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy Childbirth 8:30. Epstein P, Leichtentritt R. 2009. The experience of miscarriage in first pregnancy: the women’s voices. Death Studies 33:1–29. Goto A, Yasumura S. 2002. Factors associated with unintended pregnancy in Yamagata. Japan Social Science and Medicine 54:1065–1079. Gözüyeşil EY, Şirin A, Çetinkaya Ş. 2008. Depression of the pregnancy and the analysis of the factors which affect the depression. [In Turkish] Fırat Sağlık Hizmetleri Dergisi 3:39–66. Gürel SA, Gürel H, Balcan E. 2006. Antenatal education about pregnancy, delivery and puerperium during antenatal care. [In Turkish] Perinatoloji Dergisi 14:90–95. Ho I, Holroyd E. 2002. Chinese women’s perceptions of the effectiveness of antenatal education in the preparation for motherhood. Journal of Advanced Nursing 38:74–85. Karaçam Z, Ançel G. 2009. Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population. Midwifery 25:344–356.
340
N. Tugut et al.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/31/15 For personal use only.
Karataş B. 2001. Hemşire tarafından verilen doğum öncesi bakım hizmeti ve eğitiminin etkinliğinin incelenmesi. [In Turkish]. Optimal Tıp Dergisi 14:47–50. Kiehl EM, White MA. 2003. Maternal adaptation during childbearing in Norway, Sweden and United States. Scandinavian Journal of Caring Sciences 17:96–103. Kitapçıoğlu G, Yanıkkerem E, Sevil Ü, Yüksel D. 2008. Fear of childbirth and the postpartum period: a scale development and validation study. [In Turkish] ADÜ Tıp Fakültesi Dergisi 9:47–54. Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstetrics and Gynecology 110:1102–1112. Saisto T, Salmela-Aro K, Nurmi JE, Halmesmaki E. 2001. Psychosocial predictors of disappointment with delivery and puerperal depression: a
longitudinal study. Acta Obstetricia et Gynecologica Scandinavica 80: 39–45. Shin H, Park YJ, Kim MJ. 2006. Predictors of maternal sensitivity during the early postpartum period. Journal of Advanced Nursing 55:425–434. Spinelli A, Baglio G, Donati S, Grandolfo ME, Osborn J. 2003. Do antenatal classes benefit the mother and her baby? Journal of Maternal-Fetal and Neonatal Medicine 13:94–101. Sword W, Watt S. 2005. Learning needs of postpartum women: does socioeconomic status matter? Childbirth 32:86–92. Şahin N, Dinç H, Dişsiz M. 2009. Pregnant women’s fear of childbirth and related factors. [In Turkish] Zeynep Kamil Tıp Bülteni 40:57–63. Yıldız D. 2008. Counselling needs and interventions of mothers about infant care during postpartum period. [In Turkish] Gülhane Tıp Derg 50: 294–298.
OBSTETRICS
Preparedness of pregnant women for childbirth and the postpartum period: Their knowledge and fear N. Tugut, D. Tirkes & G. Demirel
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/31/15 For personal use only.
Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey
The aim of the study was to identify knowledge and fear related to childbirth and the postpartum period in pregnant women. The sample consisted of 114 pregnant women. It was determined that pregnant women had insufficient levels of knowledge related to childbirth and the postpartum period. The Fear of Childbirth and Postpartum Anxiety Scale score for childbirth and the postpartum period related to ‘fear regarding the action of childbirth’, was found to be the highest. The highest causes for concern were determined to be ‘infant-related anxiety’ and ‘fear regarding infant and puerperal health’. No statistically significant correlation was observed between the perceived sufficiency of the knowledge of pregnant women in terms of maintaining their own health and care, and their mean childbirth and postpartum period concern score. These findings indicate that the level of concern among pregnant women with relation to the postpartum period and childbirth is rather high.
and lack of knowledge of pregnant women, and to determine the current content deficit in consultancy services in this field.
Keywords: Childbirth, fear, knowledge, pregnant women, postpartum period, preparedness
• A gestational age of ⱖ 13 weeks • Literacy • No diagnosed psychiatric/physical diseases.
Introduction
The mean age of the pregnant women in the present study was 26.76 ⫾ 5.86: 54.4% of the participants were elementary school graduates and 90.4% were living at the provincial centre. Pregnant woman who were not working comprised 88.6% of the sample and 85.1% were living with a nuclear family. The pregnant women who were at a middle-income level comprised 66.7% of the sample. From among the husbands of the pregnant women, it was established that 40.4% were elementary school graduates and 95.6% were working (Table I). Data for the study were collected through a Personal Information Form for Pregnant Women and Fear of Childbirth and Postpartum Anxiety Scale (FCPAS). The Personal Information Form was prepared with the aim of identifying certain individual and obstetric attributes of pregnant women, their knowledge and skills relevant to, and the information they needed in, childbirth and the postpartum period. Developed by Kitapçıoğlu et al. (2008), the FCPAS has high validity and reliability. The assessment was developed with the purpose of identifying women with fear of childbirth and the postpartum period. Each question has five response options. Post-standardisation scores are:
Prenatal care, healthy childbirth and postpartum care are among the reproductive health services that must be taken into consideration (Akış 2004). In fact, pregnancy and the postpartum period are significant times in a woman’s life in terms of biological, psychological and emotional changes (Kitapçıoğlu et al. 2008). Pregnancy and the postpartum period may lead to either joy, satisfaction, maturity, self-realisation and happiness, or give way to anxious and uneasy anticipation and various fears (Epstein and Leichtentritt 2009). The authors determined that women with a high level of prenatal adaptation are more prepared for childbirth, show greater control during childbirth and hold better spousal relations. Moreover, such women were also found to adapt well to the postpartum period, cope better with problems, exhibit a higher level of self-confidence and have a higher satisfaction with life and their role as a mother (Deave et al. 2008; Ho and Holroyd 2002; Kiehl and White 2003; Shin et al. 2006). The purpose of nursing care during pregnancy is to protect and improve family health, by enabling the pregnant woman and her family to adapt to the pregnancy in a healthy manner. Nurses assume significant roles in identifying the factors that may influence a woman’s process of adaptation to pregnancy, childbirth and the postpartum period: they also satisfy her needs during this adaptation process (Goto and Yasumura 2002). The present study was performed with the aim of providing guidance to enable nurses to be aware of the prenatal, childbirth and postpartum fear
Methods and materials This study was performed in a cross-sectional structure with the objective of addressing pregnant women that visited the outpatient polyclinics of gynaecology and obstetrics at a university hospital, to identify their preparedness for childbirth and the postpartum period. The study population was comprised of pregnant women that visited the gynaecological and obstetric services of a university hospital. The sample consisted of 114 pregnant women who visited the polyclinics of gynaecology for general health control purposes between 25 March and 30 April, 2013 and satisfied the following criteria:
• • • • •
0.00–2.00: Very low anxiety 2.01–4.00: Low anxiety 4.01–6.00: Moderate anxiety 6.01–8.00: High anxiety 8.01–10.00: Very high anxiety.
Correspondence: N. Tugut, Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, 58140 Sivas, Turkey. E-mail: [email protected]
Preparedness of pregnant women 337 Table I. Distribution of current pregnancy characteristics of pregnant women.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/31/15 For personal use only.
Current pregnancy characteristics Pregnancy trimester 2nd trimester 3rd trimester Mean pregnancy week: 31.51; SD: 7.83; min: 13, max: 38 Planning status of pregnancy Planned Unplanned Intentionality of pregnancy Wanted Unwanted The 1st week of control for pregnant women Mean: 5.12; SD: 2.51; min: 1, max:16 Current number of controls 1–4 times 5–8 times ⱖ9 Planned mode of delivery Normal vaginal birth Caesarean section
n
(%)
17 97
14.9 85.1
78 36
68.4 31.6
95 19
83.3 16.7
21 38 55
18.4 33.3 48.2
88 26
77.2 22.8
Pregnant women that satisfied the criteria and volunteered to participate in the study were given information on the study and provided their verbal consent. A suitable environment (quiet, calm, etc.) was provided for the pregnant women and data collection tools were presented to the participants. Pregnant women were given the data collection tools and asked to fill in the forms and deliver them to the author after completion. Data collection forms were completed in 15–20 min. Data collected were evaluated using a database created on the SPSS 14.0 software. The evaluation demonstrated the data obtained through a count in the form of a frequency distribution and the data obtained through measurement in the form of means and standard deviations. Furthermore, groups of two were
analysed using a t-test, while groups of more than two were analysed with one-way analysis of variance and correlation. The study was carried out in accordance with the principles of the Helsinki Declaration. The necessary permissions were obtained from hospital management for the performance of the study. Pregnant women that had been invited to participate were given information on the study, and those that volunteered to participate verbally expressed consent.
Results The mean gestational week of the pregnant women was 31.51 ⫾ 7.83, with 68.4% of the pregnancies being planned and 83.3% being intentional. Of the pregnant women, 85.1% were determined to be in the 3rd trimester, and 77.2% were planning to have a vaginal childbirth. It was also established that the first pregnancy control took place within the 5th week on average, and 48.2% of pregnant women underwent control nine or more times (Table I). Of the participants, 21.1% stated that they had received information on the action of childbirth during pregnancy, with 13.2% receiving such information from a midwife or nurse; 31.6% of the pregnant women were determined to have received information on the postpartum process, and 22.8% of information sources were midwives or nurses (Table II). The mean score of the perceived sufficiency of the knowledge of pregnant women to maintain their own health and care during the action of childbirth was found to be 5.54 ⫾ 2.09. The mean score of the perceived sufficiency of their knowledge to maintain their health and care during the postpartum period was 6.55 ⫾ 1.95. Finally, the mean score of the perceived sufficiency of their knowledge to maintain health and care of the newborn during the postpartum period was 6.47 ⫾ 2.08. The mean score for the perceived preparedness of pregnant women for infant care in the postpartum period was 6.99 ⫾ 1.88 (Table III).
Table II. The distribution of received information of pregnant women on the action of childbirth and postpartum period and information sources. Status of received information and source of information Status of received information on the action of childbirth during pregnancy Received information Did not receive information Source of information on the action of childbirth∗ Midwife/nurse Doctor Family members Friend/neighbour Internet Books/magazines Television Status of received information on the postpartum period during pregnancy Received information Did not receive information Source of information on the postpartum period∗ Midwife/nurse Doctor Family members Internet Books/magazines Friend/neighbour Television ∗More than one option was marked.
n
(%)
24 90
21.1 78.9
15 10 4 1 4 3 1
13.2 8.8 3.5 0.9 3.5 2.6 0.9
36 78
31.6 68.4
26 7 6 6 4 3 1
22.8 6.1 5.3 5.3 3.5 2.6 0.9
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Table III. Mean scores for pregnant women’s perceived sufficiency of knowledge and preparedness to maintain their own and infant health and care in the childbirth and postpartum periods. Pregnant women’s perceived sufficiency of information and preparedness
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Pregnant women’s perceived sufficiency of the knowledge to maintain their own health and care during the action of childbirth Pregnant women’s perceived sufficiency of their knowledge to maintain their own health and care during postpartum period Pregnant women’s perceived sufficiency of knowledge to maintain infant health and care during postpartum period Pregnant women’s perceived preparedness for infant care in postpartum period
X ⫾ SD 5.54 ⫾ 2.09 6.55 ⫾ 1.95 6.47 ⫾ 2.08 6.99 ⫾ 1.88
Table IV indicates the FCPAS and its sub-dimensions for pregnant women. The score of pregnant women in ‘fear regarding the action of childbirth’ was found to be the highest, at 7.99. The second highest cause for fear was determined to be ‘infant-related anxiety’ (5.55 ⫾ 1.90) and the third highest cause for fear was ‘fear regarding infant and puerperal health’ (4.57 ⫾ 1.35). The difference among pregnant women in terms of their FCPAS score per sociodemographic and obstetric attribute was not statistically significant (p ⬎ 0.05). No statistically significant correlation was observed between the perceived sufficiency of the knowledge of pregnant women to maintain their own health and care and their mean FCPAS score (p ⬎ 0.05). However, a statistically significant correlation existed among the sub-dimensions of the scale with relation to fear about postpartum breast-feeding, fear of not being supported by their spouse in the postpartum period and fear pertaining to the behaviour of healthcare personnel during childbirth (p ⬍ 0.05). No statistically significant correlation was established between the perceived sufficiency of the knowledge of pregnant women to maintain postpartum infant health and care and their mean FCPAS score (p ⬎ 0.05). The evaluation of the sub-dimensions of the scale revealed a statistically significant correlation between the sub-dimension pertaining to postpartum breast-feeding and the mean scale score (p ⬍ 0.05). No statistically significant correlation was established between the perceived sufficiency of the knowledge of pregnant women to maintain their postpartum health and care, their perceived preparedness for infant care and their mean FCPAS score (p ⬎ 0.05) (Table V). Table IV. Mean scores of natal and postnatal anxiety scale for pregnant women. Scale sub-dimensions Infant-related anxiety Fear regarding the action of childbirth Fear about breast-feeding Anxiety of inadequacy in postnatal infant care Fear regarding postnatal social life Fear regarding infant and puerperal health Fear of not being supported by their spouse in the postpartum period Pre-labour fear Fear pertaining to the behaviour of healthcare personnel during childbirth Anxiety of the possibility of a caesarean section Mean scale score
X ⫾ SD 5.55 ⫾ 1.90 7.99 ⫾ 2.26 3.22 ⫾ 1.06 3.62 ⫾ 1.19 2.33 ⫾ 0.89 4.57 ⫾ 1.35 2.51 ⫾ 0.98 1.77 ⫾ 0.65 2.95 ⫾ 0.86 1.32 ⫾ 0.51 34.70 ⫾ 8.04
Table V. Correlation between the pregnant women’s perceived sufficiency of the knowledge to maintain their own and infant health and care during the action of birth and postnatal period and their NPAS score means. Pregnant women’s perceived sufficiency of information and preparedness Pregnant women’s perceived sufficiency of the knowledge to maintain their own health and care during the action of childbirth Pregnant women’s perceived sufficiency of their knowledge to maintain their own health and care during the postpartum period Pregnant women’s perceived sufficiency of knowledge to maintain infant health and care during the postpartum period Pregnant women’s perceived preparedness for infant care in the postpartum period
Test X ⫾ SD
r
p
5.54 ⫾ 2.09 0.144 0.128 6.55 ⫾ 1.95 0.053 0.577
6.47 ⫾ 2.08 0.083 0.381 6.99 ⫾ 1.88 0.018 0.847
Discussion Preparedness for childbirth and the postpartum period is under the influence of various sociodemographic properties. The studies performed in this context specify that women’s sociodemographic properties (age, marital status, number of existing children, educational level, current trimester of pregnancy, etc. ) may lead to emotional fluctuations (fear, anxiety, etc.), especially during pregnancy and the postpartum period (Cornelius et al. 2007; Çalışkan et al. 2007; Gözüyeşil et al. 2008; Lee et al. 2007; Spinelli et al. 2003). The difference between pregnant women in terms of their FCPAS score per sociodemographic and obstetric attributes was not found to be statistically significant in our study. The role of antenatal education in the elimination of preexisting conditioning and fear pertaining to the action of childbirth is indisputable (Christiaens and Bracke 2007; Saisto et al. 2001). According to Gürel et al. (2006), with a rate of 32.4%, childbirth is one of the most prominent areas where the provision of information is necessitated with relation to pregnancy. On the other hand, the results showed that 21.1% of pregnant women had received information on the action of childbirth during pregnancy, and they represented a moderate level of perceived sufficiency of received information to maintain their own health and care during the action of childbirth (5.54 ⫾ 2.09). These findings indicate that pregnant women do not possess sufficient information on the action of childbirth. In our study, 13.2% and 8.8% of pregnant women stated that they received information on the action of childbirth most frequently from midwives or nurses and from doctors, respectively. The low percentage of pregnant women receiving information on the action of childbirth from healthcare personnel during pregnancy leads to the conception that antenatal education is not delivered at a sufficient level, and that pregnant women constitute a highrisk group in the childbirth and postpartum process. According to Şahin et al. (2009), women that pointed out midwives or nurses as the most frequent givers of prenatal care also stated that they received such service from doctors at the second highest frequency. The postpartum period is a time of developmental crisis, where the newborn is integrated into the family system and the woman is in the process of emotional, physical and social adaptation (Beydağ 2007; Karaçam and Ançel 2009). In this period, lack of information on the mother’s side with relation to their own care, infant care and normal characteristics of the infant may lead to anxiety in the mother, erosion of satisfaction with
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Preparedness of pregnant women 339 the role of motherhood and may negatively affect life changes (Sword and Watt 2005; Yıldız 2008). Our study established that only 31.6% of pregnant women had received information on the postpartum process. Furthermore, the perception of pregnant women with relation to the sufficiency of their knowledge about maintaining their own health and care (6.55 ⫾ 1.95), maintaining their infant’s health and care (6.47 ⫾ 2.08) and their perceived preparedness for infant care (6.99 ⫾ 1.88) were found to be at a moderate level in terms of mean scores. The study findings point out that women are not sufficiently informed about childbirth and the postpartum period. This conclusion may show that they will inadequately care for themselves and the infant. Dağ et al. (2013) also found the level of received information on the postpartum period to be rather low (33.6%). In the postpartum period, it is important for the mother to develop skills and confidence in infant care (Sword and Watt 2005; Yıldız 2008). A relevant study established that the most frequent sources of information for women that did receive such information on the postpartum period were nurses and undergraduate nurses (31.8%) (Dağ et al. 2013). In our study, on the other hand, the main source of information on the postpartum period for pregnant women was midwives or nurses (22.8%). However, the low percentage of midwives or nurses as a source of information is thought provoking. In pregnancy, receipt of not only clinical information on childbirth and the postpartum period, but also of other types of information, is of significance. Gürel et al. (2006) identified that, in addition to clinical information during pregnancy, the most frequent sources of information on pregnancy, childbirth and the postpartum period were books/magazines (54.0%), television (40.0%) and friends/acquaintances (22.4%); other sources, including radio, internet, newspapers and brochures were not utilised very frequently for this purpose. In contrast to this study, the findings of our study indicate the prominence of gathering information from family members, the internet and books/magazines (in that order) during childbirth and the postpartum period. During the postpartum period, the most prominent areas causing fear and a dire need for information among mothers included: postpartum care and complications (Christiaens et al. 2011); infant nutrition and care (Christie et al. 2008; Karataş 2001); postpartum exercises; adaptation to parenthood and family planning (Yıldız 2008). In Kitapçıoğlu et al. (2008), the three most prominent fears among pregnant women were regarding the behaviour of healthcare personnel during childbirth (7.2); fear about infant health (7.0); and fear about childbirth itself (6.92). However, in our study, the three most prominent areas of concern for pregnant women with relation to childbirth and the postpartum period were: fear regarding the action of childbirth (7.99 ⫾ 2.26); fear regarding the infant (5.55 ⫾ 1.90); and fear regarding infant and puerperal health (4.57 ⫾ 1.35). These findings indicate that the level of fear among pregnant women with relation to the postpartum period (and childbirth itself) is rather high. The cause of such high levels of fear is considered perhaps due to lack of information on childbirth and the postpartum period among pregnant women. According to our study findings, the other causes of fear, in descending order, are: self-inadequacy in postpartum infant care; postpartum breast-feeding; the behaviour of healthcare personnel during childbirth; not receiving postpartum social support; postpartum social life; pre-labour fear; and anxiety about the possibility of a caesarean section. Even although no significant correlation was revealed between the perceived sufficiency of the information received by pregnant
women to maintain their own and their infant’s health and care in the postpartum period and their FCPAS scores, a significant correlation was observed among the sub-dimensions of fear relating to postpartum breast-feeding; not being able to receive postpartum support from their spouses; and the behaviours of healthcare personnel during childbirth. This indicates that such fear arose from insufficient levels of knowledge and lack of preparedness for these processes among pregnant women with relation to childbirth and postpartum processes. In terms of maternal and infant health, pregnant women can be defined as a high-risk group due to their limited knowledge about childbirth, the postpartum period and the anxiety they experience due to this fact. Study findings show that education of pregnant women on fear regarding childbirth and the postpartum period is of great importance. Antenatal education classes should be made widely available for the education for pregnant women. Nurses and midwives should identify and consult with pregnant women about their fears, and pregnant women should be motivated to alleviate their anxiety through the use of information technologies (telephone calls, short messages and e-mails). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Akış N. 2004. Bursa Nilüfer Halk Sağlığı Eğitim ve Araştırma bölgesindeki gebelerde risk etmenlerinin saptanması ve doğum öncesi bakım hizmetlerinin değerlendirilmesi. [In Turkish] Sağlık ve Toplum Dergisi 14:66–72. Beydağ KD. 2007. Adaptation to motherhood in the postpartum period and the nurse’s role. TSK Koruyucu Hekimlik Bülteni 6:479–484. Christiaens W, Bracke P. 2007. Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective. BMC Pregnancy and Childbirth 7:1–12. Christiaens W, Velde SVD, Bracke P. 2011. Pregnant women’s fear of childbirth in midwife and obstetrician led care in Belgium and the Netherlands: test of the medicalization hypothesis. Women and Health 51:220–239. Christie J, Poulton BC, Bunting BP. 2008. An integrated mid-range theory of postpartum family development: a guide for research and practice. Journal of Advanced Nursing 61:38–50. Cornelius MD, Goldschmidt L, DeGenna N, Day NL. 2007. Smoking during teenage pregnancies: effects on behavioral problems in offspring. Nicotine and Tobacco Research 9:739–750. Çalışkan D, Oncu B, Kose K, Ocaktan ME, Ozdemir O. 2007. Depression scores and associated factors in pregnant and non-pregnant women: a community based study in Turkey. Journal of Psychosomatic Obstetrics and Gynaecology 28:195–200. Dağ H, Dönmez S, Şen E, Şirin A. 2013. Postpartum discharge readiness situation of women who had vaginal deliveries. [In Turkish] Gaziantep Tıp Dergisi 19:65–70. Deave T, Johnson D, Ingram J. 2008. Transition to parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy Childbirth 8:30. Epstein P, Leichtentritt R. 2009. The experience of miscarriage in first pregnancy: the women’s voices. Death Studies 33:1–29. Goto A, Yasumura S. 2002. Factors associated with unintended pregnancy in Yamagata. Japan Social Science and Medicine 54:1065–1079. Gözüyeşil EY, Şirin A, Çetinkaya Ş. 2008. Depression of the pregnancy and the analysis of the factors which affect the depression. [In Turkish] Fırat Sağlık Hizmetleri Dergisi 3:39–66. Gürel SA, Gürel H, Balcan E. 2006. Antenatal education about pregnancy, delivery and puerperium during antenatal care. [In Turkish] Perinatoloji Dergisi 14:90–95. Ho I, Holroyd E. 2002. Chinese women’s perceptions of the effectiveness of antenatal education in the preparation for motherhood. Journal of Advanced Nursing 38:74–85. Karaçam Z, Ançel G. 2009. Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population. Midwifery 25:344–356.
340
N. Tugut et al.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/31/15 For personal use only.
Karataş B. 2001. Hemşire tarafından verilen doğum öncesi bakım hizmeti ve eğitiminin etkinliğinin incelenmesi. [In Turkish]. Optimal Tıp Dergisi 14:47–50. Kiehl EM, White MA. 2003. Maternal adaptation during childbearing in Norway, Sweden and United States. Scandinavian Journal of Caring Sciences 17:96–103. Kitapçıoğlu G, Yanıkkerem E, Sevil Ü, Yüksel D. 2008. Fear of childbirth and the postpartum period: a scale development and validation study. [In Turkish] ADÜ Tıp Fakültesi Dergisi 9:47–54. Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstetrics and Gynecology 110:1102–1112. Saisto T, Salmela-Aro K, Nurmi JE, Halmesmaki E. 2001. Psychosocial predictors of disappointment with delivery and puerperal depression: a
longitudinal study. Acta Obstetricia et Gynecologica Scandinavica 80: 39–45. Shin H, Park YJ, Kim MJ. 2006. Predictors of maternal sensitivity during the early postpartum period. Journal of Advanced Nursing 55:425–434. Spinelli A, Baglio G, Donati S, Grandolfo ME, Osborn J. 2003. Do antenatal classes benefit the mother and her baby? Journal of Maternal-Fetal and Neonatal Medicine 13:94–101. Sword W, Watt S. 2005. Learning needs of postpartum women: does socioeconomic status matter? Childbirth 32:86–92. Şahin N, Dinç H, Dişsiz M. 2009. Pregnant women’s fear of childbirth and related factors. [In Turkish] Zeynep Kamil Tıp Bülteni 40:57–63. Yıldız D. 2008. Counselling needs and interventions of mothers about infant care during postpartum period. [In Turkish] Gülhane Tıp Derg 50: 294–298.
