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thesis entitled

The Effect Between Prenatal Infant Care Classes
And Primipara Mother's Level Of Self-Efficacy

presented by

Deborah Thar Nosotti

has been accepted towards fulfillment
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THE EFFECT BETWEEN PRENATAL INFANT CARE CLASSES
AND PRIMIPARA MOTHERS' LEVEL OF SELF -EFFICACY

By

Deborah Thar Nosotti

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1 996

ABSTRACT

THE EFFECT BETWEEN PRENATAL INFANT CARE CLASSES
AND PRIMIPARA MOTHERS' LEVEL OF SELF-EFFICACY

By

Deborah Thar Nosotti

Due to changes in health care, new mothers are being discharged early from the
hospital (around 24 hours after delivery). The time constraints of early discharge
compound the problem of infant care education for these mothers. The perceived level of
self-eficacy a primipara mother experiences 30 days after the birth of her infant was
explored using Bandura's Self-Efiicacy Theory. F ifiy-one primipara mothers (17 who
received prenatal infant care education, and 34 who did not) responded to a scaled-item
questionnaire on their perceived efficacy in caring for their infant. Instruction on infant
care prenatally yielded no statistical difi‘erence between the groups. However, results
fi‘om scoring shows that understanding infant behavior and mastering tasks associated with
infant care are still an unmet priority for new mothers, which lowers their overall

satisfaction with being a parent.

Cepyfight by
DEBORAH THAR NOSOTTI
1996

ACKNOWLEDGMENTS

I wish to acknowledge the chair of my thesis committee Linda Spence RN, PhD.
for all the time, support, and energy she has generously offered me this past year and one-
half. I also wish to thank the rest of my thesis committee, Cynthia Gibbons RN, Ph.D.,
Mary Sue Marz RN, Ph.D., and Jacqueline Wright RN, M.S.N. for their time and
support as well. I send my sincere gratitude to Expectant Parent Organization and The
Stork Club of Foote Hospital for their willingness to assist me with contacting mothers to
participate in this study. Finally, I wish to thank Karen Pridham RN, PhD for allowing
me the use of her WPL questionnaire and The March of Dimes who supported me
financially in this study, and who believes as much as I do in the health and well being of

mothers and their infants.

iv

 

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................ vii
LIST OF FIGURES .......................................................................................... viii
INTRODUCTION ............................................................................................. l
CONCEPTUAL FRAMEWORK ....................................................................... 4
Self-Eflicacy Theory ............................................................................... 4
REVIEW OF LITERATURE ........................................................................... 12
Maternal Self-efficacy ........................................................................... 12

Infant Care Education ........................................................................... 18
Readiness to learn ..................................................................... 19

Topics for infant care education ................................................. 20

Selection of infant care education program ................................. 22

Purpose of Study ................................................................................... 27
Definition of Terms ............................................................................... 28
METHODS .................................................................................................... 29
Sample Selection Procedures ................................................................ 29
Procedures ........................................................................................... 30
Instrument ............................................................................................ 3 1
Protection of Human Subjects .............................................................. 33

Data Analysis ....................................................................................... 34
FINDINGS/RESULTS ................................................................................... 36
Sample ................................................................................................ 36
Sociodemographic Characteristics ....................................................... 36
Evaluation Subscale Characteristics ..................................................... 43
Hypothesis results .............................................................................. 46
Reliability ............................................................................................ 47
DISCUSSION ................................................................................................ 48
Sample Characteristics ........................................................................ 48
Evaluation Subscale characteristics ..................................................... 50

Study Limitations ............................................................................... 52

Study Method Characteristics ............................................................. 52
Implications for APN and Further Research ........................................ 54
Conclusion ......................................................................................... 59
APPENDICES
Study Introduction Letter to Mothers ................................................ 61
Verbal Instructions for Nursing Instructors ........................................ 62
Contact Postcard ............................................................................... 63
Consent Form for study ..................................................................... 64
Cover letter for WPL ......................................................................... 65
Mother Demographic Form ............................................................... 66
WPL ................................................................................................. 68
Dr. Pridham's Consent to use WPL ................................................... 72
Comparison of EPO and SCFH Programs ......................................... 73
EPO's Written Consent ..................................................................... 74
SCFI-I's Written Consent .................................................................. 75
UCRIHS Approval Letter ................................................................ 76
LIST OF REFERENCES .......................................................................... 77

LIST OF TABLES

1. Maternal Age of Sample ...................................................................................... 37
2. Level of Education Characteristics ...................................................................... 39
3. Employment Characteristics ................................................................................ 4O
4. Type of Support Person, Income Characteristics of Sample ................................. 41
5. Evaluation Subscale Characteristics .................................................................... 44
6. t-Test Results ..................................................................................................... 47

vii

LIST OF FIGURES

1. Diagrammatic representation of the difference between eflicacy
expectations and outcome expectations .................................................................... 5

2. Major sources of eflicacy information and the principal sources through
which difl‘erent modes of treatment operate .............................................................. 7

3. Operationalization of Bandura's major sources of efficacy information in infant
care education classes ............................................................................................. 9

viii

INTRODUCTION

Is there a difference in perceived self-emcacy 30 days afier the birth of their infant
between primipara mothers who have received prenatal infant care education versus
primipara mothers who have not received prenatal infant care education? Basic infant care
information is vital for the first-time mother. Without it, the transition to parenthood can
be ”overwhelming” (Rothenberg, Hitchcock, Harrison, & Graham, 1981). Parenting skills
do not just occur - they need to be learned (Brown, 1982). When new mothers are faced
with postpartum physical discomfort and lack of sleep, coupled with the demands of their
lives and the new infant's needs, a perceived lack of parental knowledge can lead to
feelings of resentment, incompetence, anger, or depression. Power & Parke (1984) found
that lack of parental information on basic infant care was one of three major stresses in the
postpartum period.

The traditional way to ofi‘er infant care education to mothers was during the
immediate postpartum period while they were hospitalized. With changes occurring due to
health care reform, early discharge around 24 hours after vaginal delivery is now the norm.
The time constraint of early discharge severely compounds the problem of how to
efl‘ectively educate first-time mothers in basic infant care (Scherger et al., 1992; Ventura,
1987). Nurses, as primary providers of basic infant care education, must seek out new

ways to eficiently and effectively communicate this knowledge.

2

Three ways to offer infant care education to parents are prenatally, immediately
postpartum, or standard parenting classes after the birth of the infant. Prenatal education,
a highly regarded option to convey labor and delivery information, is seen as the most
promising way to ofi‘er mothers infant care education (Jefl‘ers, 1993; Nichols, 1988; Power
& Parke, 1984). However, only one study was discovered to assess the effect of prenatal
versus postpartum education of primipara mothers (Petrowski, 1981). Petrowski's study
covered umbilical care and burping for prenatal infant care education and the results
indicated no significant difi‘erence between the prenatal & postnatal groups.

For fixture research on prenatal infant care education, a more comprehensive
approach including areas other than just assessing umbilical care and burping nwd to be in
place in order to accurately determine the effectiveness of prenatal infant care education as
an intervention for primiparas. One way to determine efl‘ectiveness of infant care
education for mothers would be to determine the strength of a mother's self-efficacy in
caring for their infant at home. Self-efficacy is the perceived feeling of confidence in one's
ability to do a particular behavior (Bandura, 1977a;1982). The stronger one's sense of
self-eficacy, the more a person is likely to take on and feel comfortable in the role (i.e.
mother).

This study focused on prenatal infant care education as a viable option that could
increase a first-time mothers' self-efficacy in parenting. This increase in self-eficacy could
benefit the mother as well as the infant. This was done by comparing two groups of first-
time mothers. The first group was exposed to infant care education in their prenatal
classes, and the second group did not receive prenatal infant care education in their

classes. The purpose of this study was to compare perceived self-eficacy 30 days after

3

the birth of their infant between primipara mothers who had received prenatal infant care

education versus primipara mothers who had not received prenatal infant care education.

CONCEPTUAL FRAMEWORK
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White (1959) proposed that there is an inherent drive in humans to influence and
master their environment. White named this drive "efl‘ectance" and stated that the
efl‘ectance drive served to develop feelings of competence in dealing with the environment.
Bandura utilized White's efl‘ectance drive in the development of his theory of self-efficacy,
and Bandura's Self-Emcacy Theory is but one part of Bandura's Social Learning Theory.
Social Learning Theory (SLT) encompasses operant (reward and reinforcement as
necessary for learning), classical (non-voluntary responses) and vicarious (learning though
observing others) learning theories (Bandura, 1963). SLT is based on the interaction of
three areas on behavior: personal factors, environmental factors, and the behavior itself
(Bandura, 1986). Personal factors (thoughts, values, feelings, etc), influenced by
environmental factors (family, neighborhood, work, etc.) cause a change in the behavior
(i.e. smoking). These interactions build on the level of knowledge and comfort a person
has in an area. Outcomes of the behavior (positive or negative) cause a change in an
individual's personal factors which are again influenced by environmental factors and so
on.

If the outcomes are positive, a feeling of confidence grows in a person leading
him/her to believe that they are capable of performing the behavior and taking on the role
associated with that behavior. This feeling of perceived self-confidence is self-efficacy.
Self-emcacy beliefs act as cognitive mediators that influence a person's behavior in a given
situation (Figure ”(Bandura, 1977a; 1982). Self-efficacy has been used as a conceptual

framework for research in numerous areas of health concerns including weight control,

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smoking cessation, epilepsy, medication compliance, physician education, and maternal
depression (Chambliss & Murray, 1979; Condiotte, & Lichtenstein, 1981; Dilorio,
Faherty, & Manueufl‘el, 1994; Geest, Abraham, Gemoets, & Evers, 1994; Gross, Conrad,
F ogg, & Wothke, 1994; Mann, 1994). In this study, the person's (Mother) perceived self-
eficacy influences her behavior (parenting of her infant).

Perceived self-eflicacy is generated from four difl‘erent sources of information
(Figure 2): Performance accomplishments, vicarious experience, verbal persuasion, and ‘
emotional arousal (Bandura, 1977b; 1989). Performance accomplishments are learning
that is based on personal experiences in a particular or similar area. Performance
accomplishments are the most influential and powerful of the four sources because they
are based on the person's own experiences. Success in an area raises one's feelings of
mastery in that area while repeated failure lowers one's feelings of mastery, especially if
the failures occur early in the attempt at mastery. If strong self-efficacy is developed
through repeated successes, then even the negative effects of occasional failures is
lessened. In fact, mastery over failures by determination can strengthen one's coping
ability.

Vicarious experience is observing others performing the desired behavior/task,
which in turn creates expectations in the observer that he/ she can master the behavior/task
with continued and intensified efi‘ort. Vicarious experience is not as proficient in
producing long-term change due to the fact that the person is not doing the action but is
only seeing a model. Providing a competent model who can teach effective strategies for

dealing with changing situations is the key to affecting a long-term sense of self-efficacy.

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Verbal persuasion (persuading a person to do something by speaking with

authority on the subject) by one person to another is another way to develop perceived
self-eflicacy. Eficacy induced by these means is usually short-term since disconfirming
experiences will quickly extinguish whatever benefit was experienced. Having a credible,
trustworthy, and assured expert as the persuader usually adds to the amount of self-
eficacy developed however. Also, the use of verbal persuasion in a person who believes
he/she can produce an effect already, can give a person an added perception of cognitive
strength to attempt and be successful at the task/behavior (Bandura, 1977a; 1977b).

Emotional arousal, or physiological state (i.e. fear or anxiety), is the last way to
develop self-eficacy beliefs. A person analyzes the magnitude of visceral arousal they are
experiencing and based on the level of anxiety felt, determines their response. Since
extreme anxiety usually lowers performance, a person is most likely to be successful if
they are calm and without worry or only mildly anxious (Bandura, 1977a; 1977b; 1982;
Crnic, Greenberg, Ragozin, Robinson, & Basharn, 1983; Donovan & Leavitt, 1989).

Each of the four sources to gain self-eficacy information are operationalized by
modes of induction that act as influences on that source (Figure 2). In this study, the
following modes of induction are utilized (performance exposure, symbolic modeling,
suggestion, self-instruction and symbolic exposure) in the prenatal infant care education
classes of the Intervention prenatal education group to increase eficacy (Figure 3). In the
Performance Accomplishments source, performance exposure (offering opportunities for a
person to view behaviors before the person is expected to perform the behavior) is enacted
by video. Mothers are shown videos of basic infant care tasks (performance

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come up with a list of options in soothing the infant.

In the Vicarious Experience source, symbolic modeling (a non spontaneous
experience where one person overcomes an obstacle while another is observing in order to
learn how to handle the obstacle) is applied when the prenatal education instructor
models infant care skills on a doll for the class. In the Verbal Persuasion source,
suggestions (something put forward for consideration of others) and self-instruction
(learning by oneself) are used by the prenatal education instructor via lectures and
handouts. The mothers utilize these items to expand their knowledge base.

The last eflicacy expectation source, Emotional Arousal, is also applied in the
Symbolic Exposure mode of induction. Symbolic Exposure (being introduced to
something in a controlled environment) is enacted when a crying infant tape is played in
order to expose the mothers before the birth of their infant to the reality of dealing with
the normal insistent infant.

The modes of inductions being mentioned above set the mothers with prenatal
infant care education classes apart fi'om the comparison mothers' classes where no prenatal
infant care education is taught. However, since this study is done 30 days afier the birth
of the infant, it must be mentioned that all the mothers will have postnatal infant care
education (postnatally in the hospital), as well as thirty days of experience to also develop
strength in their self-eficacy through the four sources of eficacy expectations.

Bandura (1977a; 1977b) also identified three dimensions that can vary one's
eficacy performance: magnitude, generality and strength. Magnitude is the relative level
of difficulty of each task in a behavior. Generality is the extent that the perceived self-

eficacy belief can be generalized to other similar or difl'erent areas. Strength is the degree

11

that a person believes they can succeed when performing a certain behavior.

Bandura postulated that self-efficacy is a global extension in a person but distinct
to one area. This means a person could have a high level of self-emcacy in one area but
feel hopeless in another. A person could be able to perform the task/behavior without
difliculty (magnitude) but due to low level of strength never attempt it. However if the
perceived strength is strong, the person is more likely to continue attempts at mastery
(Bandura, 1977a).

This is where effective infant care education could be a powerful intervention by
supporting first-time mothers in caring for their infants. Efl‘ective infant care education
could help raise the strength of a mother's perceived self-efiicacy by helping the mother
gain greater mastery of new/diflicult tasks/behavior of parenting through operationalizing
modes of induction (providing information and tips on parenting). Based on Bandura's
model this increase in maternal self-eficacy could lead to greater perseverance by the

mothers when faced with new challenges.

REVIEW OF LITERATURE
Matmaljrlfzeficam

Self-eficacy, as defined previously, is the perceived feeling of confidence that a
person has in the ability to perform a certain behavior (Bandura, 1977a; 1982). Self-
eficacy has been utilized in nursing research for the maternal/child population and is felt
to be an area that needs more understanding and research in order to help both the mother
and her child achieve the highest outcomes (Bullock & Pridham, 1988; Froman & Owen,
1989; Gross & Rocissano, 1988; Teti & Gelfand, 1991). Maternal self-efficacy has been
studied in regards to mothers with preterm infants and with firllterm infants. Mothers with
fullterm infants have been studied immediately postpartum, early postpartum (within one
month after discharge), and throughout the first year. Mothers with toddlers have also
been researched. Zahr (1991) in her study of 49 low socioeconomic mothers assessed
mothers behaviors while the infants were still in the intensive care unit, and at 4 & 8
month home visits. Infant temperament was also assessed. Maternal confidence (eflicacy)
was related to education, income, parity, and severity of intraventicular bleed. However,
no relationship was found between the observed maternal behaviors/skills and eflicacy.
Eficacy was also related to temperament ratings of the infants.

Efficacy of Latina mothers with premature infants was also studied by Zahr (1993).
Fifty-four Latina mothers with premature infants were compared with 25 Latina mothers
who had fullterm infants. No significant difl‘erence in perceived self-eflicacy was found.
The strongest predictor of self-eficacy was parity, and a decrease in medical
complications. Since parity and better health only accounted for 25% of variance in

eficacy, Zahr calls for future research to discover other factors that contribute to efiicacy.

12

l3

Immediate postpartum studies include Rutledge & Pridham (1987), and Froman &
Owen (1990). One hundred and forty primiparous and multiparous mothers were
questioned before discharge from the hospital in Rutledge & Pridham's study in 1987.
Maternal method of feeding (breast, bottle, or breast and bottle) was discovered to have a
significant efl‘ect on perceived eficacy. Mothers who breast fed had the highest level of
eficacy, and breast/bottle feeding mothers had the lowest level of perceived efficacy. The
authors support assessment and support of eflicacy of bottle-feeding mothers
and provision of adequate rest for breast feeding mothers. Froman & Owen (1990)
found in their study of two hundred mothers (primiparous and multiparous) and their
nurses that perceptions of self-eficacy difl‘ered in two (diapering and feeding) of the five
ratings on infant care between the two groups. Nurses felt mothers did not do as well in
diapering, but felt they did better in feeding the infants. Burping, bathing, and holding did
not show statistical significance between the two groups. Since less than 8% of the
variation in maternal eficacy overlaps with the nurses' ratings on maternal skill, F roman &
Owen felt that performing tasks should not be the only criteria that nurses use when
determining how much teaching a mother needs. Self-eficacy perceptions must also be
taken into account. Since 14-28% of self-efiicacy perceptions were characteristics set
before delivery, the authors felt the large unexplained variance in eflicacy expectations
must be uncovered in order for effective nursing intervention to take place.

Postpartum studies have been done with and without interventions on both
primiparous/multiparous and primiparous mothers. In their 1986 study, Golas & Parks
studied the efl’ect of ofl‘ering primipara mothers information on infant behavior (17

mothers), no information but the chance to fill out a checklist on infant behavior

14

(16 mothers) or neither teaching or a checklist (13 mothers) two weeks postnatally. At
four weeks, the mothers receiving education on infant behavior had more knowledge than
the other two groups but no difference in self-efficacy when interpreting behavioral cues
of their infants. The authors maintained that many factors affect maternal self-eficacy -
some that may be unrelated to knowledge about infant behavior.

Donovan & Leavitt (1989) looked at maternal self-emcacy and infant attachment.
Forty-eight mothers of five-month-old infants were assigned a task to estimate their
perceived control over stopping a crying infant. Mothers who had an overestimated high
illusion of control exhibited a depression-prone attribution, a mood of depression,
perceived the father of the infant as being less helpfirl in child care, and responded to
imminent infant cries with an aversive conditioning characteristic. Difficult temperament
was also an influence in mothers but where lower control mothers compensated for
”dificulty" with more attention, high control mothers were inattentive. When the infants
were 16 months old, 40 of the mothers were retested with the previous high control
mothers (at five months) showing insecure infant attachment. Efiicacy is impeded by the
autonomic aversive response and therefore lowered in the high control mothers.

Donovan, Leavitt, and Walsh (1990) firrther developed the previous study. First,
66 primiparous/multiparous mothers with five-month-old infants were assigned a task to
estimate their perceived control over stopping a crying infant. The next week they were
assigned a task to assess the mother's ability to learn efl‘ective responses in stopping the
cry. Mothers with perceived high control differed fiom the other low or moderate control
mothers by having increased susceptibility to helplessness. The authors extrapolated that

perceived efficacy was decreased in high control mothers because high control with its

15

resultant aversive response is a maladaptive response to infant demands.

Depression, perceived infant temperamental dificulty, and social-marital supports
were examined in 48 clinically depressed, and 38 nondepressed mothers with 3-13 month-
old-infants (Teti & Gelfand, 1991). Self-efficacy related significantly to maternal
behavioral competence without the effects of the other variables. When self-eficacy
effects were controlled, efficacy was not significant for social-marital support or
depression. Depression and low self-efiicacy were related. Maternal self-efficacy
correlated significantly with perceived infant temperament difficulty when family
demographic variables were controlled.

Bullock & Pridham (1988) studied 49 mothers at 30 and 90 days after their infant's
birth to determine sources of problem-solving efiicacy in infant care decisions. Infant
mood was the most reported source of eficacy or uncertainty by the mothers. Most of
the sources of confidence for the mother pertained to the infant. However, properties of
the mother and infant were more evenly distributed as the sources of uncertainty.
Competence in problem-solving was not supported in this study as a source of eficacy,
except in the area of infant properties.

In their 1994 study, Pridham, Chang & Chiu studied 117 primiparous and
multiparous mothers to determine what effect infant temperament has on the mother’s
evaluation of her parenting and problem-solving competence (eficacy). Temperament
variables contributed to the variance for both groups at one and three months.

Hill and Aldag (1991) studied just one aspect of infant care - breastfeeding
(indicators of insufficient milk syndrome) in their study on 384 mothers with unknown

parity. The level of maternal confidence in insuficient milk supply mothers had a

16

significant correlation as potential determinant to breastfeeding. Paternal support,
maternal health, infant behavior, and mother-in-law disapproval were also factors.

Froman & Owen (1989) in their development of an infant are self-efiicacy tool
studied 142 primiparous/multiparous mothers. The greatest perceived self-eficacy was
shown in infant care tasks/behaviors that were the most frequently performed or
observed. Primipara mothers also demonstrated a lower perceived self-eficacy than
multipara mothers. The authors recommended that nursing interventions be directed to
finding an initial area of eficacy in each mother as an area to build on to increase maternal
self-eficacy.

The final area where maternal self-efficacy has been researched is the toddler
period. Gross & Rocissano (1988) developed a tool to measure maternal eficacy in
toddlerhood. Fifty-eight mothers were surveyed with 32 of the toddlers first-born, l7
second-born, and 1 third-born. Only depressed mothers scored lower on the eficacy
questionnaire. Birth order and previous childcare experience was not a factor in lower
self-eficacy. The authors suggested that quality of marital relationship and nature of
child's temperament may be more influential in maternal confidence than prior childcare
experience. Also mothers of second-bom toddlers may have their efficacy influenced just
by having two versus one child to raise at the same time. In this study, results fi'om
multiparous mothers indicated continued challenge into the toddler period. Nursing
interventions for primiparous and multiparous mothers were recommended.

Maternal self-eficacy, depression, and difficult temperament were studied by
Gross, Conrad, Fogg, & Wothke (1994) longitudinally. One-hundred and twenty-six

mothers of one-year-olds, and 126 mothers of two-year-olds completed questionnaires

 

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17

three times over one year. Findings supported a) the more depressed a mother is, the
more she perceives her toddler's temperament as dificult, b) the more difficult a toddler's
temperament is perceived, the lower the mother's self-eficacy in parenting, c) the lower
the mother‘s self-eficacy, the greater her depression, and d) the more depressed a mother
is, the greater the chance she will remain depressed six months later. Because the three
variables (maternal depression, perceived dimcult toddler temperament, and low parenting
self-eficacy) remained stable over time, the authors suggest that mothers develop their
perceptions of themselves and their children early in the parent-chfld relationship and these
remain persistent. Negative perceptions can be harmful to mother and child.

Comparing maternal and paternal eficacy during toddlerhood was the focus of
Gross & Tucker’s 1994 study. Forty-six married mothers and fathers (n=92) completed a
questionnaire on child behavior (temperament, behavior intensity, and problem behavior),
parental depression, and parenting eflicacy. Maternal efiicacy was related to depression
and all meaSures of child behavior. Paternal efiicacy was related only to behavior intensity
in the child behavior area. Among both parents, efiicacy was significantly related to
perception of dificult child behavior. This included overall temperament and engaging in
annoying/disrupting behaviors. However, paternal eficacy was not influenced by
problematic behaviors from their child. Paternal depression, unlike maternal, was
unrelated to perceived efficacy. The authors extrapolate that mothers felt more social
stress to raise competent children but that this stress is not felt by fathers. Therefore,
factors influencing paternal self-efficacy are different than maternal.

When reviewing research on maternal self-efficacy it can be noted that both

primiparous and multiparous mothers with preterm and fullterm infants have been studied.

18

Information has been gathered on immediate postpartum, postpartum, and toddler periods.
Most self-efiicacy research is measurement of self-efficacy with only one study measuring
self-eficacy after an intervention compared to a control (Golas & Parks, 1986). This
intervention study did not show a significant increase in maternal self-efficacy. However,
no studies were found that looked at self-eficacy with prenatal infant care education.

Self-efi'rcacy was significantly related most often with depression levels, and
temperament of the child. Marital support was also a factor though much less. Maternal
depression was often related to perception of dimcult temperament and led to decreased
maternal self-eficacy even through the toddler period (Donovan & Leavitt, 1989; Gross,
Conrad, F ogg & Wothke, 1994; Gross & Rocissano, 1988; Gross & Tucker, 1994).

W

Fine (1980) defines parent education as a "systematic and conceptually based
program, intended to impart information, awareness, or skills to the participants on the
aspects of parenting"(p. 5). Bromwich (1981) defines parent education as an intervention
that leads parents to not just enjoy their children, but strengthens the sensitivity,
responsiveness, and skills of the parent towards the child. This improved bond between
the mother and child leads to parental success and maximum potential for the child. Infant
care education is one type of parent education. Nurses can assist first-time mothers by
ofl'ering education in basic infant care tasks which could help impact the development of a
positive perception of self-eficacy. These feelings of maternal self—efiicacy play a vital
role in adaptation to the maternal role (Williams, Joy, Travis, Gotowiec, Blum-Steele,
Aiken, Painter, & Davison, 1987). If a first-time mother perceives herself as ineffective in

her role, her feelings of self-worth can be lowered and she feels incompetent, dissatisfied,

l9

and even more serious - depressed (Gross, et al., 1994). Infant care education ofl‘ers a
mother not only the opportunity for developing efi'ective parenting skills, but serves as a
solid base to which she can add knowledge.

In order for a mother to gain the maximum benefit fiom infant care education,
three areas - readiness to learn, topics for infant care education, and the selection of a
infant care program should be considered. The first two areas will be reviewed briefly.
The third area will be examined in more depth due to the focus of this study on prenatal
versus no prenatal classes.
Readincsatnlcam

Readiness to learn impacts infant care education. In order to teach first-time
mothers about basic infant care, readiness to learn must be taken into account (Petrowski,
1981). ”The task for nurses and other health professionals is to make available relevant,
comprehensible and useful information at the time and place where it is more likely to
motivate, enable, or reinforce behavior" (Lepczyk, Raleigh, & Rowley, 1990, p. 301 ).
Even with the proper amount of information available, the desire to learn is extremely
important or else the information will likely be forgotten or never integrated into the
person's knowledge base (Petrowski, 1981; Woldrum, Ryan-Morrell, Towson, Bower, &
lander, 1985). McCraw & Abplanalp (1982) in their study of 77 primipara mothers found
that desire to learn/gain information was the number one reason given to attend prenatal
childbirth classes.

Maloney (1985) in her study of 57 mothers found that information gathering was
an important component of attending prenatal classes. In her 1992 study, Koehn found

that of 57 postpartum women, 47.4% recommend prenatal classes due to the information

20

provided, 29.8% stated they would tell others to attend prenatal classes for it's
”informative" information, and 15.8% would recommend classes to others due to the
”what to expect" information of prenatal classes. Sumner and Fritsch (1977) in their study
of 270 telephone calls from postpartum mothers maintain that desire for information not
only is prenatal but continues into the postpartum period (after discharge to home) as well.

Other factors that influence the readiness to learn in prenatal or postnatal classes
are physical discomforts (i.e. advanced pregnancy, postpartum incision pain, etc.) and
anxiety. Physical and psychological comfort must be addressed to enhance an individual's
ability and motivation to learn (F alvo, 1985). Petrowski(l98l) noted that physical
discomforts of maternity patients needed further research since new mothers are "a class
of subjects required to learn under the handicap of pain and drug effects" (p.388). If
desire to learn is assessed, then readiness to learn must also be present along with the
reduction or alleviation of physical/psychological barriers for efi‘ective education. Since
prenatal classes must already deal with both physical and psychological barriers (advanced
pregnancy and anxiety) to learning, the addition of an infant care class should not greatly
influence these barriers.

Not only is readiness to learn important to assess in first-time mothers, but the
amount of information and what information is taught is also of great importance. Too
much information is confusing and results in overload to the mother, whereas not enough
information results in fiustration. Both situations might lead to fi'equent phone calls or
visits to the infant's health care provider which decreases the mother’s view of herself as a

competent parent and wrongly utilizes health care dollars (Sumner & Fritsch, 1977).

21

Polling mothers for information that they deem important is the primary option for
obtaining topic ideas (Ewy & Youmans, 1988; Harrison-Woernke & Graydon, 1993;
Koehn, 1993; and Lindell, 1988). Verbal, written, or small group input could individually
or collectively be utilized to determine what information is desired. Koehn (1993) clarifies
the issue even firrther by utilizing the psychoeducational model to design a prenatal class
that fits the needs of the mother, not the instructor. The task of the instructor is to
structure a class that ofi‘ers not just essential information along with support measures and
alternatives, but to also meet the needs of the mothers participating in the class. The
psychoeducational model has been extremely popular in designing childbirth classes since
it uses information, skill-building and support, all of which reduce anxiety and increase
feelings of confidence and self-eficacy. This model could be easily modified to ofi'er
relevant infant care information.

The topics listed below are suggested areas to be covered in basic infant care
education. The list is a summation of lists ofi‘ered by Ewy & Youmans (1988) and Hames

& Phillips (1987) for postnatal infant care education (fiom their experience with mothers),

butcanbeutilizedinanyclass.

S l I . E E E l . I t] C
Feeding (breast vs. bottle) Diapering and peri care . Bathing
Newbom characteristics Signs/symptoms of illness Safety
Normal bowel/bladder habits Sleep and activity pattern Newborn Senses
Umbilical cord care Crying and soothing behavior
Care of eyes and ears Handling and holding

Circumcision care Temperature taking

22
SI. [.5 l.

When a primiparous mother is selecting a infant care education class, there are
three options for her to choose. The three choices are: a) infant care education as a part
of parenting classes held after the birth of the child, b) infant care as part of postpartum
teaching in the hospital, and c) infant care education as part of prenatal childbirth classes.
For this study, only the last two areas will be discussed. The goal of infant care education
is two fold: positive maternal outcomes and positive infant outcomes. Positive maternal
outcomes do not rely on knowledge alone but rely on the mother's perception of the
knowledge, especially in the areas of retention/usefirllness of the knowledge. Also
important is if the mother feels the information is important enough to incorporate the
knowledge in practice. Knowledge is not the only area to be evaluated. Teaching
methods/style also should be assessed in relation to a mother's perceived satisfaction, and
most importantly for prudent health care expenditures, education given should be
appraised to see if it decreases mothers' phone calls/return visits to a health care provider.

Besides maternal outcomes, infant outcomes are also important. Areas that need
evaluation are if infants act and appear healthy, and if neglect/abuse decreases.
Monitoring if developmental milestones are being met is also important.

I E C l . l .

One option that covers infant care education is in the postpartum period. This
entails teaching done in the hospital before discharge (Aukamp, et al., 1988; Brown, 1982;
Barnes & Phillips, 1987; Ventura, 1987). Ventura (1987) expands her position on
postnatal hospital education by stating that initial teaching should start prenatally, with

follow-up postpartally, since hospital stays are now reduced to less than two days.

23

Information ofl‘ered in hospitals by nurses may not be able to firlfill the entire range of
needs a first-time mother experiences. This inability to meet a primipara's needs could be
related to the overwhelming emotions, and physical discomforts a new mother
experiences. The time constraints of early discharge (24 hour hospital stay) are an
additional barrier to retaining and categorizing teaching material (Martell, Irnle, Horwitz,
& Wheeler, 1989; Sumner & Fritsch, 1977). Nursing research advocates supplementing
postpartum education with prenatal (Gordon & Gordon, 1967) or parenting classes (Bull
& Lawrence, 1985; Mercer, 1985; Sumner & Fritsch, 1977; Wandersman et al., 1980)
because research done on mothers after discharge showed gaps in what information was
presented postnatally and what was still needed. Bull & Lawrence (1985) in their study of
78 hospitalized postpartum mothers, who only had postpartum hospital education, found
that 94% needed information on infant care/behavior and 70% needed information on
maternal health needs. Based on their findings Bull & Lawrence suggested parenting
classes along with preprinted educational booklets and community health nurse visits to
meet mothers' needs.

Mercer (1985) in her study of 294 mothers (over the first year after birth) in three
age groups (66 aged 15-19 years, 138 aged 20-29 years, and 90 aged 30—42 years), who
only received postpartum hospital infant care education, found that perceived maternal
incompetency in role skills was 49-50% at one month(except 15-19 year olds which was
33%). To combat these feelings of incompetency, Mercer states that parenting groups
could provide ”extensive help” during the first 30 days and beyond.

Martel] et al., 1989 fi'om their study of 42 postpartum mothers (within/at 72 hours

postpartum) state that topics covered for mothers should be limited to only the essential

24
health and safety issues since time before discharge is limited, mothers are preoccupied
and postpartum follow-up is usually within 72 hours.

Sumner & Fritsch (1977) based on their study of 270 postpartum mothers and
their calls to the infant's physician for the first month after birth found that ”postpartum
needs ...remain largely unmet” (p.27) Of the 270 mothers, 85% of eligible primiparous
mothers, and 25% of multiparous mothers called. The largest numbers of calls were in the
first three weeks after birth. The most common questions were about feeding,
gastrointestinal problems, and the infant's skin. Based on their results, Sumner & Fritsch
suggest that traditional teaching ”methods, content, and timing" all need to be re-examined
(p.31). They propose that mothers attend postpartum classes with the same mothers fi'om
their prenatal classes as well as experienced mothers to provide factual and emotional
support.

Adams (1963) in her study of 40 primigravida mothers (interviewed in the
hospital, and at one and four weeks) found that feeding, bathing, crying, and care of
naval/circumcision were the most common concerns that mothers had in the first 30 days
of the postpartum period.

Bull (1981) stated in her study of 30 first-time mothers (at three and seven days
postpartum) that infant behaviors and physical care of the infant did not change
significantly and remained ”moderate to much concern" to the mothers. Physical care
issues did decrease over the week.

Hanison & Hicks (1983) study on postpartum concerns of 158 mothers (64
primipara and 94 multipara) determined infant behavior, infant feeding, physical care of

infant, safety, infant's appearance, and handling of the infant to be the most common

25

concerns of mothers at one month.

Pridham's (1987) study of 83 mothers (48 primipara, 35 multipara) at 7, 30, and 90
days postpartum found that infant care tasks were identified as the most difficult factor of
having an infant at 7 and 30 days and the second most difficult factor at 90 days.

As noted above, the inefi‘ectiveness of postpartum education is supported in
research done after discharge to home. Postpartum teaching in the hospital was
determined to be inadequate as evidenced by both mothers and physicians stating basic
infant care remained a top issue for mothers up to thirty days after birth.

IE 1.. ll°lll'll

Prenatal infant care education is a viable option for teaching the primiparous
mother. The option of infant care education before childbirth is increasingly being
recommended in the literature (Ewy & Youman, 1988;1efl‘ers, 1993, Koehn, 1993; Power
& Parke, 1984; and Ventura, 1987). Three options for early infant care classes (if not able
to fit the education in the traditional six-week prenatal childbirth course) are: a)
information can be given during the second trimester when the pregnancy feels real,
interest is sparked and before the third trimester when labor fears are present, b) increase
the number of prenatal classes, and c) ofl‘er infant care classes concurrently with prenatal
classes (Ewy & Youmans,. 1988).

In order to ofi‘er infant care education prenatally, the typical agenda of prenatal
classes would need to be altered. Many prenatal classes discuss only minimally the realm
of basic infant care. Lamaze classes deal only with breast versus bottle feeding (Koehn,
1993). Prenatal classes ofl‘ering infant care education are an improvement that

cannot occur without proper planning (Power & Parke, 1984). Since first-time mothers

26

recognize the need for education in learning to care for their infants, prenatal classes can
ofi‘er an added dimension to present infant care education.

Not all research results agree that prenatal infant care education is needed. Adams'
study found that pregnancy was not a time of interest in infant care for her mothers
(1963). Maloney (1985) in her study of 100 (43 fathers and 57 mothers - 50 prenatal and
50 postrnatal) clients that prenatal and postnatal goups both ageed that early infant care
was of geat importance but could not agee when it should be ofl‘ered. Prenatal mothers
reported a need for prenatal infarnt care education. However, postnatal mothers preferred
an early infarnt care class postnatally even when infant care education was given prenatally.
Maloney states prenatal infant care education is needed but recogrizes the dilemma in
ofl‘ering prenatal infant care education: "When is the appropriate time to teach infant care?
At the beginning of classes, the subject is too remote; at the end, the parent is too
preoccupied with labor and delivery” (p.247).

Education on basic infant care for the first-time mother is a necessity. Mothers
who can utilize krnowledge of skills and problem-solving methods when caring
for their infarnts will feel more confident in their ability to parent efi‘ectively (self-efficacy),
and satisfied with their role as parent (Bullock & Pridhann, 1988; Froman & Owen, 1990;
Rutledge & Pridhann, 1987). The traditional way to educate mothers has been postpartum
teaching while still in the hospital. Nurses who ofl‘er education to mothers are caught in a
dilemma on how to ofl‘er the most emcient and effective method of teaching. This
dilemma is due to the time constraints of early discharge brought on by health care reform.
Recent literature calls for education to be offered by prenatal classes since prenatal

childbirth classes have proven to be extremely efl‘ective for those who attend (Hughey, Mc

27

Elin, & Young, 1978, Jefl‘ers, 1993; Koehn, 1993; Lindell, 1987, and Maloney, 1985).
While there are prenatal progams available that do ofl‘er infant care education, many do
not. Research done on prenatal infant care education is sparse - only one empirical study
was discovered that has been done in this area (Petrowski, 1981).

Petrowski studied 40 primipara mothers in two areas of infant care (burping and
umbilical care). Half of the clients had prenatal and postnatal instruction and halfhad only
postnatal. No statistical sigiificant results were obtained between the two goups. Further
research is nwded to determine the efi‘ectiveness of prenatal teachirng if it is to be
embraced or determined as inadequate for the first-time mothers. Therefore, the present
study explored if receiving prenatal infant care education compared to no prenatal infant
care education afi‘ected the strength of parenting self-eficacy prinnipara mothers
experienced 30 days after the birth of their infant.

W

The purpose of this study was to answer the question, ”Is there a difl‘erence in
perceived self-eficacy 30 days after the birth of their infant between prinnipara mothers
who have received prenatal infant care education versus primipara mothers who have not
received prenatal infant care education?"

It was hypothesized that:

Primipara mothers who received prenatal infant care education will perceive a

higher strength of self-emcacy in being a parent of a new infant than prinnipara

mothers who had not received prenatal infant care education.

28

Definitinnnflm
Self-efficacy is the perceived strength of one's ability to perform whatever infant care
tasks need to be done for parenting and was measured by mother's written responses to
the self-eficacy subscale (Evaluation) in the tool "What Being The Parent of A Baby is
Like" (WPL).
Infant care education is the instruction of basic infant care irnforrnation to first-time
mothers. This was measured by first-time mothers who either received prenatal irnfarnt care

education or did not receive prenatal infant care education.

METHODS
A nonexperimental, descriptive, ex-post facto design was utilized to exarrnine the
efi‘ect between the two variables - education received at a prenatal infant care education
class and first-time mothers' sense of self-efficacy in their role as parents. This desigr was
utilized to help determine if self-efficacy increased with the addition of prenatal infant care
education.
SamaleSelectiaancedntes
A nonprobability convenience sample of primigavida mothers was obtained from
mothers who attended prenatal classes at two locations within an 80 mile radius of
Lansing, Michigan during a 6-month period. One site included infant education in the
prenatal classes and one site did not. Exact age, educational and socioeconomic data was
collected when volunteers consented to participate in the study. Criteria utilized in
selection of mothers included:
1. Informed consent by mother
2. Mothers who were older than 18 and less than 39 years of age.
3. Mothers who were either pregrant for the first time or had been pregnant
before but had not had a live birth that survived discharge fi'om hospital
to home.
4. Mothers who could read and write in english.
5. Mothers who were married or had at least one support person who resided in
the same household.
6. Mothers who had a working telephone in her home.

7. Mothers were considered ineligible for study if their infant was admitted to a

29

30

neonatal intensive care unit and was not discharged home when the
mother was released.

The prinnipara mothers selected for the sample were based on the number of
interested mothers who met the above criteria. A sample size of 17 intervention (had
prenatal infant care education) mothers and 34 control (no prenatal infant care education)
mothers was obtained.

mums

The nurse researcher sent letters explaining the study to the nurse instructors of
the prenatal childbirth classes that were held at the two locations in the Mid-Michigan
area. Written authorization to use the above classes for this study was obtained fiom the
Executive Directors of the two organizations (Appendices J & K). Classes that had infant
care education, and those that did not were solicited in order to elicit both goups for the
study (Appendix I).

The nurse instructor distributed a letter (Appendix A), that explained the study and
the request for volunteers. Verbatim instructions for the nurse instructor to read to the
mothers in the classes were provided (Appendix B). Interested mothers were able to
contact the nurse researcher by a stamped-addressed postcard available fiom the nurse
instructor (Appendix C). Once the postcard was returned to the nurse researcher, the
mother was contacted by telephone, and any questions the mother had about the study
were answered. If the mother was willing to participate in the study, the nurse researcher
asked the mother her address, mother‘s date of birth, g'avida/para status, and at which
location the mother attended prenatal childbirth classes (to help determine eligibility). If

the Intervention mother attended the prenatal classes and was through with the classes, the

31

mother was polled to see if she attended the last two sessions (the 6th and 7th classes)
which were the classes devoted to infant care. Any potential Intervention mother who
attended the prenatal classes but did not attend the infant care classes was reclassified as a
Control mother (no prenatal infant care education). If the mother met the study's
eligibility criteria, two copies of the consent form (one copy that the mother retained and
one copy that was sent back to the nurse researcher) were sent to the mother for her
signature (Appendix D).

After the written consent was received by the nurse researcher, the mothers were
contacted by phone 14-21 days after their EDC. Once birth date was established, a packet
containing the Mother Demogaphic Form (Appendix F), the "What Being the Parent of a
New Baby Is Like” (WPL) questionnaire (to measure the mother's self-eficacy), a cover
letter (Appendix E) that contained the instructions for filling out the WPL, a contact
phone number to reach the nurse researcher for questions, and a stamped addressed
envelope for the return of the forms was sent to the mother. Due to the irnitial
stressfirlness of adjusting to a newborn, the mothers were not asked to fill out the
questionnaire until the infant was 30 days old. When the questionnaire was not returned
within ten days after the infant's one month birthday, the nurse researcher recontacted the
mother by phone.

Instnnmcnt

"What Being the Parent of a New Baby Is Like" (WPL) was developed by Dr.
Karen Pridham (Pridham & Chang, 1985; revised Pridham & Chang, 1989). It is a 25 item
instrument which uses a 9-point (1-9) rating scale (Appendix G). The scale is graphed

with equal intervals with bipolar descriptors at the end points. The WPL instrument

32

measures three constructs: Evaluation, Centrality, and Life change. Pridham measures
self-efiicacy under the evaluation section of her tool. Evaluation is assessed by 11 items
(questions 1, 5, 7, 8, 13, 14, 17, 18, 19, 20, 23) that cover perceived self-eficacy on being
a new parernt and completing infant care tasks, the degee to which the mother feels she
knows the baby, and if the mother feels she is living up to her self-expectations of what a
parent should be.

Centrality is assessed by 8 items (questions 3, 4, 6, 12, 15, 16, 22, 25) in the
instrument that measure the mothers regard for the infant and the irnfant's care and physical
health, the mother's difficulty in leaving the infant in another’s care, and how easily the
mother is distracted fiom thinking about the infant.

Life change is addressed by 6 items (questions 2, 9, 10, l 1, 21, 24) in the
instrument that measure the perceived changes in the mother's life and self-image since
becoming a parent, changes noted in her relationship with her family, and overall
stressfinlness of the mother's life. Permission to use the WPL was obtained fi'om Dr.
Pridham (Appendix H).

Internal consistency (Cronbach's alpha) for the subscales of the WPL at one week,
one month, and three month adrrninistrations were .87, .90, and .87 for Evaluation; .87,
.80, .88 for Centrality; .77, .81, .81 for Life change. Average inter-item correlations
ranged from .39 -.40 for Evaluatiorn, .34 -.45 for Centrality, and .36 -.42 for Life
change. Item-subscale correlations with the three admirnistrations were .29 to .81 for

Evaluatiorn, .04 to .78 for Centrality, and .41 to .77 for Life change.

33

Stability of the WPL was determined by high coeflicients of intracorrelation of the
subscales across time. Intracorrelations of the three subscales at one week and one month
were .72, .73, and .72; and .61, .70, and .78 between one and three months. Stability at
one week and three months were .46, .57, and .69. The low (< .30)
intercorrelations among subscale scores shows that the three subscales were measuring
difl’erent constructs (Pridham & Chang, 1989).

C I! l' I'

To determine the construct validity of the WPL, a factor analysis using principal
components and orthogonal rotation was used to examine the factor structure.
Irnterpretable factors that made up at least 50% of the variance were determined from the
three-factor solution of the factor analysis.

Evaluation was positively related to Competence in the one (r = .65, p < .001, n =
82,) and three month (r = .60, p < .001, n = 63) testing. Centrality and Competence did
not have a significant relationship at one (r = -.12, p > .05, n = 82) and three months (r = -
.13, p > .05, n = 63) which was in line with the authors' beliefs that centrality would have
an afi‘ective rather than a cognitive basis. Life Change and Competence demonstrated a
negative relationship at one (r = -.39, p < .001, n = 83) and three months (r = -.26, p <
.05, n = 64). This negative relationship was also anticipated due to the authors' beliefs
that life changes may distract a parernt's attention from infant-care issues (Pridham &
Chang, 1989).

Watts
All mothers who participated in this study did so on a voluntary basis. The

mothers were given a letter explaining the study and the need for volunteers. The letter

34

the mother received informed her that the study was about the effect between prenatal
infarnt care education and the strength of self-efficacy one feels about parenting and that
no known risk was involved. Mothers indicated their interest in joirning the study by
sending back the contact postcard. Once the contact card was received, the nurse
researcher telephoned each mother to verbally go over the purpose of the study and the
contribution it could make for the area of prenatal infant care education, and answered any
questions she (the mother) nnight have had about the study. Besides the letter, two copies
of the informed consent form were also sent to the mother for her signature (one for her to
keep) (Appendix D).

All information was held in strict confidence. No names were written on the WPL
instrument or demogaphic form. A coded numbering system was used to identify
information on each mother and a copy of the master sheet with the mother’s name and
corresponding code was kept in a locked filing cabinet separate fi'om the data. Contact
postcards (Appendix C) returned to the nurse researcher were attached to the master sheet
and placed in the locked filing cabinet. Only the nurse researcher had access to the locked
filing cabinet. This study was reviewed and approved by the University Comnnittee on
Research Involving Human Subjects at Michigan State University (Appendix L).

DataAnalxsis

Data from this study were analyzed using Statistical Package for the Social
Sciences (SPSS) software. The sociodemogaphic data from the sample and questions
fiom the Evaluation (self-efficacy) subscale of the instrumernt were analyzed using
descriptive statistics both as an entire goup and also as Intervention and Control goups.

Parametric tests were used since the WPL is an irnterval scale. The Independent Samples t

35

test was used to determine if there was a statistically significant difference irn self-efficacy
between the two goups, and the Pearson r test was utilized to determine correlations

between the variables (Brink & Wood, 1994).

FINDINGS/RE SULTS
Sample

Fifty-eight mothers sent back postcards indicating interest to participate in this
study. One mother was not eligible due to no working phone at that tirne. One mother
delivered a stillborn child and asked to be withdrawn from the study, and two mothers had
their infarnts adrrnitted to the neonatal intensive care unit due to prematurity and asked to
be withdrawn from the study. Also, two mothers were withdrawn due to having no live-in
support person, and one mother never returned her questionnaire. Three Intervention
mothers had to be converted to Control data because the mothers were not able to attend
the prenatal infant care classes. A total of 51 prinnipara mothers completed this study with
17 Intervention mothers, and 34 Control mothers.

5 . l l . Cl . .

The subjects in this study were comprised of two goups, 17 mothers in the
prenatal infant care education group, and 34 mothers in the prenatal with no infant care
education goup. The ages for the mothers ranged from 18-38 years with the mean age
for both goups combined 26.5 years, the mean age for the Intervention goup 28.3 years,
and the mean age for the Control goup 25.6 years (Table 1). The between goup
difference in Maternal age was statistically significant (p=.05).

Spontaneous vaginal deliveries (SVD) accounted for 70.6% of the overall
childbirth deliveries for this study, and caesarean sections (c/s) accounted for 29.4%.
However, the Irntervention mothers had a much higher level of c/s compared to the control

mothers (41.2% versus 23.5%). Difference in type of childbirth delivery was not

36

37

 

Table 1

Adamant-infirm]:

We Total Sample Irntervention Control
Age in % n % n %
18 years 1 2 1 5.9 0 0
19 years 1 2 O O l 2.9
20 years 3 5.9 O O 3 8.8
21 years 1 2 O 0 1 2.9
22 years 5 9.8 2 11.8 3 8.8
23 years 3 5.9 O 0 3 8.8
24 years 2 3.9 0 0 2 5.9
25 years 9 17.6 2 11.8 7 20.6
26 years 4 7.8 l 5.9 3 8.8
27 years 2 3.9 1 5.9 1 2.9
28 years 4 7.8 1 5.9 3 8.8
29 years 6 11.8 3 17.6 3 8.8
30 years 1 2.0 O 0 1 2.9
31 years 4 7.8 3 17.6 1 2.9
33 years 1 2.0 1 5.9 0 0
37 years 1 2.0 l 5.9 0 0
38 years 3 5.9 1 5.9 2 5.9

38
statistically significant (p=. 19).

The majority of mothers (80.4%) in this study were educated beyond high school,
having completed at least some college up to a professional degee. Three mothers had
not completed high school at the time of the study. Control mothers were more likely to
be high school gaduates, and two Control mothers had professional degrees. Mothers in
the Intervention goup had more college degees but no mothers with a
professional/gaduate degee (Table 2). However, Educational level was not significantly
difi‘erent (p=. 52). Considering employment, 74. 5% mothers were employed firll-time,
17.6% were part-time, and 7.8% were homemakers (for the entire goup). Full-time
employment for the Intervention mothers was 94.1%, and part-time was 5.9%. No
Intervention mother was employed strictly as a homemaker before giving birth. Of the
mothers in the Control goup, 64.7% were employed full-time, 23 .5% as part-time, and
11.8% as homemakers. Irntervention mothers worked almost exclusively full-time whereas
Control mothers only worked finll-tirne a little over half of the time. Difl‘erence in
employment was not found to be statistically significant (p=.07).

Mothers returning back to work after the birth of the infant included 82.4% of the
entire goup with 11.8% not returning and 5.9% indicating not applicable. For the
Intervention mothers, 76. 5% who worked before delivery were returning to work and
23.5% were not. Of the 31 Control mothers responding to this question, 85.3% who
worked before were returning to work, and 5 .9% were not. More Control mothers who
worked before delivery were returrning back to work than Intervention mothers (85.3% vs.
76.5%). However, more of these mothers worked part-time (see employment paragaph

above). Returrning to work after the birth of the infant was not statistically significant

Table 2

39

 

 

Total Sample Intervention Control
W n % n % n %
I-IighSchoolgaduate 10 19.6 2 11.8 8 23.5
or less .
Associatedegeeor 21 41.2 7 41.2 14 41.2
some college
Bachelordegeeor 20 39.2 8 47.1 12 35.3
Professional
(p=.09).

For the overall sample of mothers working outside the home, 11.8% were

professionals, 21.6% were blue collar workers, 29.4% were oflice workers, and 21.6%

were managerial. Intervention mothers were employed mostly as ofiice workers, and

Control mothers were more likely to be employed as blue collar workers. Both the

Intervention and the Control goup had the same percentage (11.8%) of professional

mothers, and the Control mothers had fewer managerial positions (Table 3). Type of

Employment was not found to be statistically significant (p=.45)

4O

 

Table 3
E 1 Cl . .
Total Sample Intervention Control

W n % n % rn %
Professional 6 11.8 2 11.8 4 11.8
Blue Collar 11 21.6 1 5.9 10 29.4
Ofiiee Worker 15 29.4 6 35.3 9 26.5
Managerial 11 21.6 5 29.4 6 17.6
N/A 7 13.7 3 17.6 4 11.8

 

All coded cases had a support person living with them since the delivery of their
child. Most mothers' support person was their spouse (70.6%). A relative was the
support person 9.8% of the time. The infant's maternal gandmother was the only non-
spouse relative reported. Spouses were the major support persons for the Intervention
mothers (88.2%). No Intervention support persons were relatives to the Intervention
mothers. The Control mothers also had a majority of their support persons as spouses
(61.8%), but also utilized relatives and fiiends as supports (whereas Intervention mothers

did not) (I able 4). There was not a significant difl‘erence in type of support person

(p=.20).

41

Table 4

 

Total Sample EPO SCFH

W n % n % n %
Relative 5 9.8 0 O S 14.7
Friend 1 2.0 0 0 1 2.9
Spouse 36 70.6 15 88.2 21 61.8
Sign. Other 9 17.6 2 11.8 7 20.6

Income

<34,999-24,999 12 23.5 1 5.9 11 32.3
$25,000-74,999 32 62.7 11 64.7 21 61.8

$75,000-lO0,000+ 6 11.7 4 23.5 2 5.8

 

When comparing household incomes, 64. 7% of Intervention mothers lived in
households with incomes of $25,000-75,000, while 61.8% of Control mothers lived in
households with incomes of 525,000-75,000. Therefore, geater than 50% of each goup
were fi'om middle income households. However, the other two income levels were
inverted - Intervention mothers had more afiluent (375,000+) and fewer lower income

(<$24,999) mothers and the Control mothers had more lower income mothers and fewer

42

afiluernt mothers (Table 4). Despite these differences, income was not found to be
significantly difl'erent betweern the two goups.

Infants were born at one of the following hospitals: Sparrow Hospital (37.3%),
Michigan Capital Medical Center (2.0%), or Foote Hospital (60.8%). Intervention
mothers delivered 100% at Sparrow Hospital. ' Control mothers delivered 5.9% of the
time at Sparrow Hospital, 2.9% of the time at Michigan Capital Medical Center, and
91.2% of the time at Foote Hospital.

In summary, the average age of the prirrnipara mothers in this study was 26.5 years.
Intervention mothers were slightly older. The overall sample and the Control mothers had
rouglnly two-thirds spontaneous vaginal deliveries. Intervention mothers were almost
evernly split between SVD and C/S delivery. All Irntervention mothers delivered at
Sparrow Hospital, and 90% of Control mothers delivered at Foote Hospital.

A majority of the mothers had education beyond high school. Both goups had
over half of their mothers living in middle class households based on household income.
However, the income levels of the Intervention mothers' households were higher overall.

The mq'ority of mothers for both goups were employed full-time with the majority
of mothers who worked before delivering, planning on returrning to work in the future.
Irntervention mothers' major employmernt was in ofiice and managerial roles. Control
mothers' major employment was as blue collar and office workers.

All mothers had a live-in support person. For both goups, the major support
person was a spouse. Control mothers also had mothers and fiiends as support persorn,
whereas Irntervention mothers only had a partner support person (either spouse or

significant other). Maternal age was the only statistically significant differences found

43

between the two goups.
E l . 5 l l Cl . .

Descriptive statistics were run on the 11 questions of the Evaluation subscale
(which measures self-eficacy strength) fi'om the WPL questionnaire (Table 5). All

answers were on a 1-9 scale with ”1" being the least and ”9" being the largest degee.

The first question, Satis (How satisfying has being the parent of a new baby been for you?)
had a mean score of 8.4 with a standard deviation (SD) of .84 for the entire sample. For
both goups, only 7, 8, or 9 (high satisfaction) was answered. Both goups chose
”completely satisfying" (number 9) a majority of the time (58.8%). However, Intervention
mothers were more likely to choose ”8" out of 9 (23.5% to 14.7%).

Posdev (How much do you think that you positively affect your baby's
development) had a total mean score of 8.5 with a SD of .70. This question also had high
ratings of 7, 8, or 9 (high sense of positive afl‘ect). However, more Intervention mothers
believed they had the geatest afi‘ect (number 9) possible on their infarnts (76.5% to
61.8%).

Satistas (How much have the tasks of taking care of a new baby been satisfying to
you?) had a goup mean score of 7.5 with a SD of 1.2. Answers to this question had the
overall second lowest mean. Intervention mothers had a total mean score that was .2
higher than the Control mothers. Satistas range of answers were 4-9 for entire goup
which brought the total mean down. However, most answers (84.3%) for both goups
were in the 79 range which indicated strong satisfaction.

Interact (How much do you think your baby enjoys his/her interactions with you?)

had a mean score of 8.3 with a SD of .83. Interact scores were all middle to high

 

Tables
E l . S] 1 Cl . .
Total Sample Intervention Control

Variable mean SD mean SD mean SD
Satis 8.4 .84 8.4 .80 8.3 .88
Posdev 8.5 .70 8.6 .70 8.5 .70
Satistas 7.5 1.2 7.6 1.3 7.4 1.2
Interact 8.3 .83 8.3 .85 8.3 .84
Babyneed 7.3 1.0 7.2 1.2 7.3 .91
Person 8.0 1.1 8.0 1.2 8.0 1.1
Knowbaby 7.9 .90 8.1 .82 7.8 .92
Parexpec 7.5 1.1 7.8 .95 7.3 1.1
Growdev 8.4 .86 8.4 .86 8.5 .86
Tune 7.7 1.1 7.9 1.1 7.6 1.1
Satrelat 7.8 1.0 7.9 1.1 7.7 .93

 

enjoyment from interactions with a range of 6-9 for each goup.
Babyneed (How much of the time can you tell what your baby needs?) had a total

goup mean of 7.3 with a SD of 1.0, which was the lowest total goup mean in the

45

Evaluation subscale. This question had a larger range (5-9) for each goup which brought
down the total mean.

Person (How much does the baby seem like a person, with his/her own personality,
to you?) had a total goup mean score of 8.0 with a SD of 1 . 1. Control mothers were
more likely to score that their infants had their own personality all the time.

Knowbaby (How well do you think you know your baby?) had a total mean score
of 7.9 with in SD of .90. Intervention mothers had a .2 higher mean score than Control
mothers. While the range of responses (6-9) were identical, more Control mothers
(32.4% vs. 17.7%) gaded less knowledge of baby.

Parexpec (How well are you meeting your expectations for yourself as a parent of
a new baby?) had a total mean score of7.5 with a SD of 1.1. This question had the
largest difi‘erence between the mearns (.5). Irntervention mothers on average scored how
well their expectations as parents were being met higher than Control mothers.

Growdev (How much has the baby's gowth and development been a source of
satisfaction to you?) had a mean total score of 8.4 with a SD of .86. Both goups of
mothers were fairly consistent with their scores in this area with 50% or geater choosing
the highest score, and 30% or geater choosing the next highest score.

Tune (How in tune with your baby do you feel? (How much do you feel like you
and your baby are in harmony with each other?) had a mean total score of 7.7 with a SD
of 1.1. Intervention mothers scored higher in feeling in tune with their infant than Control
mothers. However, while the majority of answers were in the 7-9 range, enough mothers

in both categories were in the middle range of scores (4-6) to bring the total mean down.

46

Satrelat (How satisfied are you with the way that you relate to your baby and your
baby's needs?) had a mean total score of 7.8 with a SD of 1.0. Intervention mothers
believed they were the most satisfied (number 9) with how they related to their infant than
Control mothers (41.2% versus 20.6%).

In summary, the item total mean scores ranged from 7.3 to 8.5. The SD ranged
fi'om .70 to 1.2. Both goups were similar in their scores.
W

A t-Test for independent samples was performed (See Table 6). The Levene's Test
for Equality of Variances p value was .45. Therefore, the null hypothesis must be
accepted that there is no difi‘erence in self-efi'ncacy strength between the two prenatal
goups. The 2-tail significance was .47. Therefore, the hypothesis, primipara mothers
who receive prenatal infarnt care education will perceive a higher strength of self-efiicacy
in being a parernt of a new infant than primipara mothers who have not received prenatal
infant care education was rejected.

A reliability analysis of the 11 questions that make up the Evaluation (Self-
efficacy) Subscale of the WPL instrument was done. The Cronbach alpha for the

Evaluation subscale was .85 which indicated a strong internal consistency for the subscale.

47

Table 6

 

 

 

Efficacy
EPO 17 88.2353 8.105 1.966
SCFH 34 86.7647 6.248 1.071

 

Mean Difl‘erence = 1.4706

Levene's Test for Equality of Variances: F=.561 p=.457

t-Test for Equality of Means

Variances t-Value df 2-tail Sig SE of Diff 95% CI for Difl‘

 

Equal .72 49 .477 2.052 (-2.654 5.595)

 

DISCUSSION

This section will interpret the results of the study in several aspects. A discussion
of the sample characteristics and an interpretation of the results from the data analysis will
be presented. In addition, study limitations, implications of the study findings in terms of
the Self-eficacy conceptual fi'amework and the Advanced Practice Nurse's (APN) role in
the primary health care setting will be presented. Finally, topics for future research will be
suggested.

Samplafihatastm'sfics

A small convenience sample was utilized for this study. The target goal of 36
members for each goup was not realized. The reason for this is unkrnown. A total of 250
postcards were given out with only 58 responses. Additional contacts with the directors
of both organizations to increase recruitment by having the class instructors mail in the
completed postcards did not yield results. Previous research has suggested that primipara
mothers have little interest in infant care in the third trimester of pregnancy (Adams, 1963;
Bliss-Holtz, 1988). Lack of interest in infant care at this stage of pregnancy is one
possible reason for poor response rate. Another may be that a high number of mothers
were employed finll-time which may have limited their desire to participate.

The goups were fairly homogeneous with the majority of mothers working fitll-
time, planning to return to work after the birth, a spouse as a support persorn, at least
some college education, and middle class incomes. Significant difi‘erence was found only
in the sociodemogaphic variable maternal age for the two goups. The mean age of the
Intervention mothers was three years older than the Control mother. However, Roosa

(1988) in his study of older mothers, did not find a difference between older mothers and

48

49

younger mothers in responses to parenthood.

An additional area that efl‘ects prinniparas, while not found to be significantly
difi’erent in this study but should be taken into account, was the type of childbirth the
primipara experienced. In this study, the Intervention goup was almost evenly split
between vaginal and caesarean birth. Caesarean birth, because it is major surgery, could
efi‘ect the healing time of a primipara both in a physical and emotional way. This in turn
could impact her perception of her ability as a new mother.

The results of this study did not show a significant difference in perceived self-
eficacy between mothers who received prenatal infant care education and those mothers
who did not. Since maternal scores on tasks, needs, and maternal expectations (things
that pertain in some part to krnowledge deficit and inexperience) did not rate as highly, it is
possible that even though prenatal education did not show a significant difi‘erence,
education could help to increase knowledge and reduce the dissatisfaction experienced by
these mothers. It is also possible that even though enrolled in a prenatal class with infant
care education, the mothers were not as interested in the infant care aspect (decreased
readiness to learn) as the labor and delivery teaching and therefore did not retain much of
the teaching. This could explain the lack of interest in this study as well as why three
Intervention mothers attended all but the classes on infant care in their prenatal progarn.

Besides readiness to learn (mentioned above), types of childbirth progams and
topics offered in the infant care education must also be considered. While intervention as
well as control prenatal progams were available in the immediate vicinity for this study,
many areas do not offer prenatal infant care education. Inavailablity to attend or even hear

about local prenatal progams on infant care could be sending a message to mothers that

50

prenatal infant care is not needed or necessary since it cannot even be found in their
community.

In this study there was no researcher control over the topics on infant care offered.
No evaluation on how helpfinl the mothers found the prenatal infant care information was
done for this study, and no evaluation on what areas mothers would have preferred more
emphasis on was evaluated. Due to the mothers reporting lower scores on comfort in
doing infant tasks and reading infant cues, perhaps more emphasis should be placed on
these areas in prenatal classes.

E l . S l l Cl . .

The Evaluation subscale of the WPL instrument is designed to determine the
strength of self-eficacy a mother perceives in being a new parent. In this study, mothers
reported very strong positive relationships with their infants in the following areas: overall
satisfaction with being a parent, impacting the positive development of their infant,
believing the infant enjoys maternal irnteractions, and feeling that the infant's gowth and
development was a source of satisfaction for the mother. These findings were supported
in Bullock & Pridham's 1988 study on maternal problem-solving at one month that
reported sources of confidence as ”infant's mood, response to care, physical well-being,
and mother's success in dealing with a concern or managing care" (p.324). Pridham &
Chang (1985) also found that at one month gowth and development was a source of
satisfaction to mothers.

The mothers also reported less satisfaction in the areas of: tasks involved with
caring for a new infant, krnowing what the infant needs, meeting the mother's parental

expectations, feeling in tune with the infant, and feeling satisfied in the way the mother

51
relates to the infant and the infant's needs. Bullock & Pridham's 1988 study also covered

areas of less maternal satisfaction which included infant care tasks, the mother being
unsure ofwhat needs the infant had, and being unsure ofwhat was going on with'infant as
major concerns - the same as in this study. Infant care tasks were also identified as a
major concern, as well as satisfying irnfarnts needs in Pridham & Chang's 1985 study.

One extraneous variable not taken into consideration that could have affected the
strength of self-eficacy according to Bandura's theory was previous infant care
experience. Exposure to successful infant care experiences would classin as a positive
performance accomplishment which is the strongest builder of self-eficacy in a person.
Curry (1983) supported this concept in her study of prinnipara mothers and found that
previous experience with infants was the only variable difference between easy and
dificult adjustment to parenthood. Three mothers in this study were day care providers
and many more may have had recent infant care experience which could have influenced
this study's results.

Other variables not taken into consideration were the sex and perceived
temperament of the infant. Mothers of female infants were found to have geater
perceived self-efiicacy in Froman & Owens's 1990 study. Sex of infarnt was obtained for
this study but not studied as to it's efi‘ect on maternal selfieficacy. Temperament has been
recognized as an influence on maternal self-eflicacy and has been found to be significant in
a number of studies on infants (Bull, 1981; Donovan & Leavitt, 1989; Teti & Gelfand,
1991). Golas & Parks (1986) listed temperament as a variable that could influence
maternal eficacy. No infant temperament scale was utilized in this study to ascertain this

data and could have been usefinl in conjunction with the self-eficacy scale to help better

52

identify sources of eficacy building for mothers.

Although it is desirable to obtain a sample by a probability sampling technique, a
complete listing of all primipara mothers could not be obtained and there was no way to
randomize for attendance in a prenatal infant care class since not all primiparas attend
prenatal infant care classes. Also random assignment to either the intervention or control
goup was not possible. Therefore, a convenience sample was obtained fi'om mothers
who were attending either the prenatal class with infant care education or the prenatal
class without infant care education. This self selection of mothers to attend prenatal
classes as well as those mothers in the prenatal classes who self selected to participate in
this study are major limitations to the generalizability of the results to the population since
a diversity of first time mothers were not incorporated due to these factors.

Another linnitation was the fact that each prenatal class goup was taught by
difi'erent teachers and even though basic guidelines of educational information taught was
outlined, some variations were possible which could have influenced what education each
mother received. Small sample size and unequal sizes between the intervention and the
control goups are other limitations in this study.

5 l l l l 1 Cl . .

This study was an intervention-based study. A goup of mothers had prenatal
intervention, another goup did not and the two goups were compared. A limitation in
this study was the limited amount of previous intervention research in the area of maternal
self-efficacy for comparison. Only one intervention study on infants was found

(Petrowski, 1981). Most studies dealt with polling mothers on their educational needs but

 

We

inc

53

did not ofi‘er intervention. Petrowski's intervention study ofi‘ered prenatal education with
postnatal evaluation as well as a control goup who did not received any information.
However Petrowski's study only ofi‘ered two areas of infant care education and was
different fi'om this research study in that it also offered postpartum education as well as
prenatal. The results of Petrowski's study were also statistically insignificant (Petrowski,
1981)

Bandura's Self-eficacy Theory supports prenatal education for increased self-
efiicacy because areas of emcacy expectations could be utilized in the educational process.
In this study, each of Bandura's four areas of eficacy expectations (performance
accomplishments, vicarious experience, verbal persuasion, and emotional arousal) were
included in the prenatal infant care class offered. However, no measurement of how
effective the mothers perceived the classes was performed.

It should be noted however that while education could possibly help increase
perceived self-eficacy, eficacy is more than education (or lack of). While this study did
measure the perceived strength of self-eficacy of the mothers, other dimensions
(magnitude and generality) of self-eficacy were not taken irnto consideration. No
evaluation was done on how difficult the mothers felt the tasks associated with taking care
of an infant were in general. Perceived task dificulty could have lowered the overall self-
eficacy strength because the mothers did not feel comfortable doing or attempting the
tasks. Previous experiences with sirrniliar areas (i.e. other recent infant care), or generality
may have also influenced the results. All of the three mothers who were daycare workers
were with the Control goup of mothers. This extra recent experience could have

increased the Control mothers overall score in self-efiicacy and in turn, made the

54
intervention appear weaker than it was.
Il'liIEEHIEEl

Taking into consideration the limitations of this study, this next section will discuss
the implications this study has for the Advanced Practice Nurse (APN) in primary health
care, and the implications for future research.

I l' . E l 5211

The Advanced Practice Nurse (APN) can play an important role in self-care
education and self-eficacy in first-time mothers. Remaining current and up-to-date by
seeking new and improved ways to ofl‘er educational opportunities is just one way an APN
can offer advanced clinical practice in the primary care setting. The APN should utilize
the roles of practitioner, assessor, change agent educator, counselor, advocate, and
evaluator for the primipara mother and her partner/support person not only before the
delivery but after as well. In addition, utilizing Bandura's Self-emcacy Theory in the areas
of eficacy expectations, the APN can tailor his/her teaching methods to target individual
needs. As practitioner, the APN has the opportunity to impact the prinnipara's knowledge
level of infarnt care for the first 30 days after birth in prenatal visits, well-infant visits at the
3rd day, 10th day, and 1 month visits, phone follow-up after visits, and home visits as
needed.

The APN has a vital role in assessing not only areas of knowledge limitations in the
prinnipara mother, but also in determining areas in which the primipara has an irnterest for
additional learrning. It is in the prenatal visits that the APN should encourage prenatal
education courses not only for a smoother labor but infant care education as well (verbal

persuasion). Since 24 hour discharge after delivery is now the standard, the APN should

55

direct the client's plan of care to ensure the best educational opportunities for infant care
education and labor/delivery preparation.

The APN can also act as change agent for the first-time mother. Ifthe research is
accurate and prinniparas are uninterested in infant care prenatally because they believe all
the education they need to have will be given in the the postpartum period, the APN, as
change agernt, should present the history of childbirth hospital stays so that the prinnipara
can see how prenatal infant care education has become more important as the length of
hospital stays have decreased.

As client advocate, the APN should explore with the primipara what early hospital
discharge means to that client on an individual basis. Ifthe client chooses to attend a
prenatal class, the APN should empower the client to choose what prenatal classes are
most appropriate for her. Other sources of support should also be ofi‘ered (i.e. a new
mother support goup, LaLeche League, etc.) as well (vicarious experience). To
efi‘ectively advocate for the client, the APN is required to stay current in what community
resources are available for referral potential. The APN can also positively identify and
reinforce to the new mother what skills/tasks the new mother has mastered at each well-
infant check (performance accomplishment,verbal persuasion), and praise progess up to
that poirnt (emotional arrousal).

Besides offering commurnity resources, the APN can be effective as an educator
and counselor as well. As an educator, the APN could teach and have return
demonstration by the mother on some aspects of infant care both before and after the
delivery at the well-infant checks (vicarious experinence and performance

accomplishments). By serving as a role model, the APN could serve as a ”safe" resource

56

for the mother to bring her concerns and questions. The APN could also offer education
by other means (i.e. handouts, books, videos). The APN as a counselor could also ofl‘er
anticipatory guidance both before and after delivery on risk factors, concerns, and safety
topics (i.e. colic/feeding issues or developing a house evacuation plan in case of fire).

Finally as an evaluator, the APN could assess the effectiveness of interventions
instituted by the APN or mother and change the plan of care with the mother as needed.
By receiving feedback fi'om the mother on what issues/educational material/classes were
most helpful, the APN could also change his/her interventions to other new mothers in the
future.

As part of a collaborative team, the APN should institute protocols for the office
to follow for education of prinniparas and delegate if necessary the investigation of
written/taped educational material or else be willing to help draft material for the ofice.
The APN should educate the ofi'nce team on the importance of these issues so all members
of the team advocate for the client wherever the entry into the system.

Education of other community health care professionals by the APN should also
occur. These opportunities can occur by interventions such as speaking at workshops,
peer goups and research presentation. Sharing the results of this research can also be
helpful to other health care providers to re-emphasize the need to assess, educate, and
assist prinnipara mothers in infant care.

While the APN can utilize the roles of the APN to assist the primipara in infant
care education, full interpretation of the benefits of prenatal education remains incomplete
due to the limited amount of previous research available and the predicted increase in self-

eflicacy strength not recognized statistically in this study. However, as was discussed

57

above, the APN in primary care can offer individualized interventions to clients (and their
infants) that can work within the four areas of eficacy expectation to increase the
perceived self-efficacy in being a new mother.

I l . E E l E l

Future studies regarding the effects of prenatal education on prirrnipara mothers
should have three focuses. First, future studies should focus on the same research
question, but be replicated without the limitations found in this study. Second, additional
investigation should be done on the interest of primipara mothers in infant care education.
Third, investigation of the support person's role in efficacy should be examined.

This study was limited by its small sample size that does not represent the
population of prinniparas as a whole. Future research should address a more generalizable
population representation as well as larger sample sizes. Additional sociodemogaphic
variables should also be taken into consideration including race/ethnic backgound of
mothers, and sex of infant. Since the goups were mostly homogeneous in the variables of
income, education, and employment status, it becomes difficult to generalize these results
to other populations. Future studies should examine difi‘erent goups, especially low-
income, lower education, unemployed, or inner-city populations.

Another limitation of this study was no measurement of infant's temperament for
consideration with self-efficacy. While considerable research has been done on
temperament and depression, none is found in an intervention study dealing with prenatal
education and self-eflicacy. This is a serious impediment to determining what efl‘ects

other than task education are irnportarnt to examine.

be
Vii.

bes

58

Future studies may also evaluate the use of Pridham's What Being The Parent Of A
Baby Is Like instrument (WPL) in intervention studies. No previous research has been
found utilizing intervention (prenatal or postnatal) with the WPL and it is not krnown if the
WPL is best used alone or should be used in combination with other scales to get the best
measurement of self-efficacy and the variables that afl‘ect it.

Since maternal ernrollment in this study was lower than anticipated and previous
research has found that primipara mothers have a decreased interest in prenatal infant care
education, another area of future research should be on what factors influernce a mother's
interest or lack of interest in prenatal infant care. This is important due to the fact that the
effectiveness of intervention studies will not be able to be evaluated if the mothers have a
lowered readiness to learrn, and therefore it is not the intervention that is faulty but the
irntervention is never retained to analyze the efl‘ect. Besides Adarns's 1963 study (which is
too out-dated to apply at this time), the only other study which examined maternal
readiness to learn was done by Bliss-Holtz in 1988. Given the changes in postpartum
discharges over even the last five years, even this information is outdated.

Additional efi‘ort must be put forth to deternnine how ready primiparas are for prenatal
infarnt care education intervention before finther intervention studies are implemented.
Nursing research should attempt to determine which goups of mothers would respond
best to prenatal information and offer it to them. An additional focus should be placed on
when to ofi‘er the infant care education prenatally-early, midway or late in classes for the
best possible readiness to learn.

The third area for future research is the support person's role in maternal self-

efiicacy development. Little research has been done on fathers and none was found on

In

59

what effect fathers have on maternal self-efficacy. Besides paternal support, since many
mothers are without a significant other/partner, the role of other support persons (i.e. the
mother's mother, fi'iends, sisters, etc.) should be examined. Having a support person that
lives with the mother was deliberately chosen as a control variable in this study. However,
depending on the relationship of the support person to the mother, different types of
support persons may ofl‘er difi‘erent support to the new mother (i.e. the mother's mother
may be able to offer more assistance in learning infant care tasks, where fathers may give
more emotional support). These relationships should be examined in order for the health
care professional to tailor the information given to new mothers to "shore up” areas in
which the support person may be unable to offer help for the new mother.
Conclusion

This study has presented the serious lack of current literature regarding effective
educational interventions for first-time mothers. The limited literature that is available
emphasizes polling mothers about their needs, but no new research is being done with all
the health care changes on how health care professionals should intervene to help new
mothers and their infants in the first month after the birth of the infant. Even though the
statistical significance of prenatal education on maternal self-eficacy was not supported in
this study, results from scoring show that understanding behavior of their infant, and
mastering tasks associated with caring for their infant is still a priority for new mothers.
Studies of intervention options are usefirl for the APN and other health care providers in
the primary care setting where prinnipara mothers and their infants can both benefit from
the holistic, continuous, and individualized care provided. Effective educational

interventions in infant care could increase the perceived feeling of maternal self-efficacy in

6O

primipara mothers which could impact the overall satisfaction of being a parent. These

positive feelings can benefit both mother and infant.

APPENDICES

APPENDIX A

Appendix A
Study Introduction Letter to Mothers
Parent education and confidence of first-time mothers

Investigator:

Deborah Nosotti, RN, BSN

Graduate Student, College of Nursing
Michigan State University

East Lansing, Michigan

Telephone: (517)669-1 789

Dear First-time mother,

I am a gaduate student in Nursing at Michigan State University and I am
conducting a study on the effect of parent education on first-time mothers' level of
confidence in taking care of their infant. I have been involved with parent education for
the past five years and am very interested in researching if the way infant-care information
is taught to mothers (either before the birth of their baby, or after) effects the level of
confidence a new mother experiences. I feel this is especially important now because new
mothers are being sent home from the hospital within 1-2 days after the birth of their baby
and the best way possible to teach mothers may need to be reconsidered. The results of
this study could help childbirth instructors provide the best possible information at
childbirth classes.

Please consider joining me in this study. Ifyou decide to participate you will be
mailed a 25 item questionnaire that takes about 10 minutes to complete, 30 days after the
birth of your baby. Your name will not appear on the questionnaire and all personal
information provided by you will be treated confidentially . Ifyou desire, I would also be
happy to share the results of the study with you.

Please take a moment to fill out the stamped-addressed postcard, attached to this
letter, if you are interested in helping me with this study. If you have any finrther questions
about the study, please feel flee to call me collect at (517) 669-1789.

Thank you for your consideration.

Deborah Nosotti

61

APPENDIX B

Appendix B
Verbal Instructions for Nursing Instructors

Hi! I‘m Deb Nosotti a gaduate student in Nursing at MSU. I am conducting a
study to see if prenatal parent education increases the level of parenting confidence (self-
eficacy) in prinnipara mothers. Could you please take a few moments after your class to
read the following instructions to your class? I am also including letters with attached
stamped-addressed postcards that the mothers can fill out to notify me of their interest.
Thanks!

PLEASE READ VERBATIM TO HELP ME CONTROL THE STUDY

I am handing out a letter and postcard from a gaduate student in Nursing asking
for your help in a study she is undertaking on parent education for first-time mothers. If
you are irnterested and willing to have her to contact you, please fill out the stamped
postcard attached and mail it.

62

APPENDIX C

Appendix C

Contact postcard

Prenatal Education and Confidence
in First-time Mothers

Yes I am interested in hearing
more about this study. You may
call me at the number below.

Name:
(Please Print)

Signature:
Phonet:

Date the baby is due:

 

63

APPENDIX D

Appendix D
Consent Fornn for study

Prenatal education and Confidence in First-time Mothers
Nurse Researcher:
Deborah Nosotti, RN,BSN
Graduate Student, College of Nursing
Michigan State University
East Lansing, Michigan
Telephone: (5 17)669—1789

The purpose of this study is to determine the effect of prenatal parent education on
first-time mothers' feelings of confidence in taking care of their infant. The nurse
researcher will call your home 14-21 days after your due date to determine when your
infant was born. She will then send a packet of information to you that contains
instructions on how to fill out the questionnaire, the questionnaire, and a stamped-
addressed envelope to return the questionnaire. You are to complete the questionnaire
when your infant is one month old. The questionnaire is 25 questions and should take
approximately 10 minutes to fill out.

The information you provide will not have your name on it, just a code number.
The list of mothers names and their assigned number will be kept separately in a locked
filing cabinet. The nurse researcher and her faculty thesis committee will be the only ones
to have access to the information. The results of the study will be reported for
the goup as a whole in the researchers thesis in partial fulfillment of the requirements for
a Master of Science in Nursing degee. When the findings of the study are reported in this
thesis, at meetings, or in articles, neither your name nor any identifying information will be
gven.

There are no known risks or direct benefits to you if you participate in this study.
The results of the study may help nurses provide the best possible information at prenatal
classes. You are flee to refuse to participate in this study or withdraw fi'om the study at
any time by telling the nurse researcher you do not want to continue. You have the right
to refuse to answer any of the study questions. Participation in this study will not cost you
anything nor will you be paid for your participation. Ifyou have any questions, you may
contact the nurse researcher, Deborah Nosotti at (517) 669-1789. Linda Spence PhD,
RN, Assistant Professor and Thesis Chairperson, College of Nursing, Michigan State
University can also be reached for questions at (517) 353-8684. A summary of the results
of the study will be made available upon request.

I understand the information given above and agee to participate in this study. I
have been given a copy of this consent form.

 

 

Mother Date

 

 

Researcher Date

APPENDIX E

Appendix E
Cover letter for WPL

Dear ,

Thank you for ageeing to participate in this study. Enclosed is a demogaphic
sheet and the 25 item questionnaire called "What Being The Parent Of A Baby Is Like”. It
is a 1-9 scale and to answer the questions just circle the number that most pertains to you
as a new mother. Your name is not to be written on the form and a stamped-addressed
envelope has been provided for you to send the questionnaire back.

Please fill out the questionnaire when your infarnt is one month old. Please feel free
to call the researcher at
(517)669-1789 collect if you have any questions.

Thank you again for participating.

Deborah Nosotti

65

 

APPENDIX F

 

Appendix F

 

 

 

 

 

 

Mother Demogaphic Form
PLEASE FILL OUT OR CIRCLE THE CORRECT RESPONSE
BELOW THE DO'I'I‘ED LINE
Code#: Phone#:( ) G P
Address:
City: State: Zip
Mother's DOB: EDC: SVD or C/S

 

Attended EPO or SCFH

Attended EPO's NB Care and Feeding Classes (6th & 7th)
Yes or No

1. What is the highest gade of school you completed

Less than 5th gade

5th to 8th gade

9th to 12th gade (no diploma)

High School gaduate—

Some college, no degee

Associate degee

Bachelor degee

Graduate or professional degee

2. Prior to delivery, were you employed as a:
Full-time worker: Homemaker:
Part-time worker:

3. Ifyou were employed outside the home prior to delivery, do you plan to go back to
work? YES NO

4. If employed outside of the home, what is your job title and description of your job?
Title
Things you do

5. Do you have a support person(s) in your home? YES NO

 

6. What relationship(s) do you have with your support person(s)? (Circle all that apply)
Relative Friend Spouse Significant other

66

7. If your support person is a relative, of what nature
(i.e. Husband, mother, sister, gandmother, aunt, etc.) ?

 

8. Yearly household income:
a) less than $4,999 e) 835,000-849,999
b) $5,000-S9,999 f) 550,000—574,999
c) 810,000-824,999 g) 575,000-599,999
d) 325,000-534,999 h) $100,000 and over

9. What hospital did you deliver your infant at?
Sparrow Hospital

Foote Hospital
St.Lawrence Hospital Michigan Capital Medical Center

67

APPENDIX G

Appendix G

 

 

 

 

WPL
10L
Child's Btrrnoare_
Date Completed
Visit Number

FOR EACH QUESTION. PLEASE ME THE NUMBER THAT BEST SHOWS YOUR
ANSWER. FOR EXAMPLE:

 

 

n 2 ,. 3 4 G) a 7 a a
J— l l l l I l 1_
mm:
Imam:
t. _ 1. How satisfying has being the parent of a new baby been for you?
1 2 3 4 s e 7 I 9
L I l l l l l l 1
Not at all Completely
umMm umMm

I
2. _ 2. How much has your life changed since you hid IN “by?

1 2 3 4 S I 7 I I

 

 

 

 

#4 l l l l l l l
Hardly at all A great deal
3 _ 3. Howmuchiathebabyonyourmindwhenyeuaraathomewlth
him/her?
1 2 3 4 8 0 7 I 9
l l l l l l l L l
Verylittla Allotthetlme
4._ 4. Overall.howeaay1eittoryeutobadietractedtromttinltingabetntha
baby?
1 2 3 4 8 0 7 8 O
L l l l l l l l l
Noteaeyatall Veryeaey
5 _ b. Hownnnchdoyouminkmatyoupoanivelyaflactmba'by'e
development?
1 2 3 4 8 0 7 I I
l l J l l l l l J-
Notatall Agreatdeal
nnnoavs
'KarenF.Pridhem
imam

68

10.

11.

12.

13.

10.

11.

12.

13.

How moth is the baby or the baby's care on your rnrnd’

1 2 3 4 S 6 7 8 9

Very little of All of. the time

 

How much have the tasks of taking care of anew baby been satisfying to
you?

12: 4 s s 7_a 9

l 1 I I I
j e

-—
b-
-

-

Not at all Completely
satisfying satisfying

How much do you think your baby enjoys his/her interactions with you?

1 2 3 4 8 s 7 8 a
l l 1 l l . l l l #1
Not at all A great deal

How much do you relate to family members in a different way since you
have had the blby?

1 2 3 4 s s 7 I 8
l J 4 l l l l l I
Not at all A great deal

On the whole. how stressful is your life; being the parent of a young
baby and ”than: having other things to deal with?

t 2 3 4 5 e 7 a I

l l l l l l l l A
Not at all Very stressful
stressful

How much do you look at yourself differently since you have had the
baby? '

1 2 3 4 5 0 7 I S
l

l l l l l l l #1
Not at all A great deal

When you go out and leave the baby with someone else. how much do
you have the baby on your mind during the time that you are away?

1 2 3 4 8 8 7 I S

 

l l l l L l l l 1
Very little of All of one time
the time

How much of the time can you tell what your baby needs?
1 2 3 4 8 s 7 a 3

 

l l l l l l J l 4
Hardly every Almost all of one
time

69

1s.

16.

17.

1I.

19.

20.

21.

14.

13.

16.

17.

13.

19.

20.

21.

 

How 'huch does the any seem like a person. WIth hisrhIr own
personality. to you?

t 2 3 4 s d 7 8 9

L I l 1 l 1 L l l
Very_little of All-‘of the time
the time
How much is the baby's physical health on your mind?

1 2 3 4 5 I 7 I I

l l l l 4 2 2 ° l !
Very little of All of the time
the time

How easy would it be for you to leave the baby with your spouse/partner
when you go out?

1 2 3 4 5 I 7 I I
l l l l l J l I

Not easy at all Very easy

b-

_Not applicable. l99l
How well do you think that you know your baby?

1 2 3 4 5 I 7 I I
g l l l l l l J l
Hardly at all Very well

How well are you meeting your expectations for yourqu as a parent of a
new baby?

1 2 3 4 I I 7 I I
L l l l l l l 1
Not at all Completely

—

How much has the baby's growth and development been a source of
satisfaction to you?

1 2 3 4 I I 7 I I

l l L l l l l J 1
Not at all A great deal

How in tune with your baby do you feel? (How much do you feel lilte
you and your baby are in harmony with each other?)

1 2 3 4 I I 7 I I

 

l l J l L l l l I
Not stall Completelylntune
intune

How much has your life with members of you family changed?
1 2 3 4 I I 7 I I

L l l l l l l l l
Hardly at all A great deel

7O

22

23.

24.

25.

26.

Date Completed:

22.

23.

24.

25.

26.

How nay would it be for you to leave the «by WIth :gmggng gxhgv m..-
m! “(nanny when you go out?

 

1 2 3 4 s 6 7 8 9
L l l l : r 9 . 3
Not easy stall Very easy

How sstisfied are you with the way that you relate to YOuf baby and
your baby's needs?

1 2 3 4 5 6 7 '8 I
L l l l 2 . L ' 2
Not at all Completely

satisfied satisfied

1

How much do you feel that having a baby affects what you do and
when?

1 2 s 4 s s' 7 s s
l_ l l i l f l l I
Not at all A great deal

How much does the baby or the baby's cars come first in your thoughts.
taking precedence over things you would otherwise spend time thinking

 

about?
1 2 3 4 3 e 7 I I
Lg l l l l l l l _l
Not at all A great deal

Please use this space to write anything that you think is important to
help us understand what being the parent of a baby is like for you.

 

 

 

 

 

 

 

 

71

APPENDIX H

L‘

Appendix H

Dr. Pridham‘s Consent to use WPL

School of Nursing
University of Wisconsin-Madison

Cemerl‘orl-iedthSdenocs
Chaisaenceamr
WWW
Myriam-isomer»
unnamed-5332

34qu ~

March 13, 1995

Ms. Deborah Nosotti, RN
12710 Ontonagon Drive
DcWitt Michigan 48820

Dear Deborah:

Thank you for your inquiry concerning the instrument, What Being the Parent of A Baby is
Like. I have sent you a copy of the instrument as well as a copy with scoring instructions
Also attached is a copy of our most recent article using the instrument.

I will be very happy to get your input concerning the usefulness of the instrument to assess the
self-efficacy of women who take prenatal classes. Please do not hesitate to call me if you have
any questions. Best wishes to you in your research.

Sincerely,

wafiumea.

Karen F. Pridham, RN, PhD, FAAN
Helen Denne Schulte Professor of Nursing
School of Nursing
Professor

ent of Family Medicine and Practice
Medical School

KFPzdh

Enclosures

72

APPENDIX I

WW

1021!: EEO .SCEH
Normal Pregnancy YES YES
Breathing & Relaxation Techniques YES YES
Labor & Delivery, Cesarean Birth YES YES
After Delivery Care Of Mother YES YES
Breast & Bottle Feeding YES YES
Hospital Tour YES YES
Newborn Characteristics & Care YES NO

Appendix I

73

APPENDIX J

Appendix J

EPO's Written Consent

EXPECTANT PARENTS
ORGANIZATION

2620 MONTEGO DRIVE 0 LANSING. MICHIGAN 48912 O PHONE (517) 337-7365

 

October 4. 1995

Deborah Nosotti. R.N.. B.S.N.
Graduate Student

12710 Dntonagon Drive

DeUitt. n1 48820

Dear Deborah.
You have my permission to utilize Expeciant Parents Organization to
hand out information on your study of prenatal infant care
education and self-efficacy. I understand that you uill provide
the necessary literature and post cards for any interested mother
from our classes.
Sincerely.

a J’A‘L Cit/'13 ’ \Jfl‘;
Carol Buzzitta

Executive Director
Expectant Parents Organization

74

APPENDIX K

 

Appendix K

SCFH's Written Consent

September 20, 1995

Deborah Nosotti RN,BSN.
Graduate Student

12710 Ontonagon Drive
DeWrtt. Michigan 48820

Dear Deborah,

You have my permission to utilize the Stork Club of Foote Hospital to hand out
information on your study of prenatal infant care education and self-efficacy. I understand that
you will provide the necessary literature and post cards for any interested mother from our
classes.

 

Stork Club of Foote Hospital

75

APPENDIX L

 

Appendix L

UCRIHS Approval Letter

MICHIGAN STATE

UNIVERSITY
July 12, 1995

 

To: Deborah Nosotti
12710 Ontona on Drive
Dewitt, HI 8820

RE: IRII: 95-346
TITLE: THE RELATIONSHIP BETHEEN PRENATAL PARENTING
CLASSES AND PRIHIPARA HOTflERS' LEVEL 0!
REVISION REQUESTED SELF-EE’ICACY
3
CATEGORY: -C
APPROVAL DATEs 07/12/95

The University Committee on Research Involving Human Sub ects'(UCRInS)
review of this project is complete. I am pleased to adv se that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.
herefore, the UCRIHS approved this project and any rev sions listed
above.

Illllhbt DCRIhS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be ond one year must use the green renewal
form (enclosed with t e original approval letter or when a
proi:ct is renewed) to seek u ate certification. There is a
max um of four such expedit renewals ssible. Investigators
wishing to continue a roject beyond tha time need to submit it
again or complete rev ew.

llVIIIOlIt ocatns must review any changes in rocedures involving human
subjects, rior to in tiation of t e change. If this is done at
the t o renewal. please use the green renewal form. To
revise an approved protocol at ena other time during the year
send your written request to the CRIRS Chair, requesting revised
gpproval and referencing the project's IRS i and title. Include
in your request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

elAlIlIt Should either of the followin arise during the course of the
work, investi ators must noti y UCRIHS romptly: {1) problems
(unexpected e de effects comp aints, e c.) involv ng uman
subjects or 2 changes in the research environment or new
information n icating greater risk to the human sub ects than
existed when the protocol was previously reviewed a approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517)432- lll.

Sincerel .

       

517355.21” cc 2 Linda Spence
FAX:517%I32-li?1

"incurs-ummmq
anon—nmeaumm
enumerate

“38m

76

LIST OF REFERENCES

 

LIST OF REFERENCES

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/ Bandura, A. (1982). Self-eficacy mechanisms in human agency._Amerigan
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Bandura,A. (1986). . = ' .
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/ Bandura, A. (1989). Regulation of cognitive processes through perceived self-
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Bull, M., & Lawrence, D. (1985). Mothers' use of knowledge during the first

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/ Zahr, L. (1993). The confidence of latina mothers in the care of their low birth
weight infants WMO) 335-342

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