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thesis entitled

Prenatal Education: Examining Issues of
Maternal Knowledge and Preparedness
for Infant Care

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Alyne R. McCann

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il l I I

MSU leAn Atflrmetlve Action/Ewe! Oppommny Inetitwon
Walla-0.1

PRENATAL EDUCATION: EXAMINING ISSUES OF MATERNAL
KNOWLEDGE AND PREPAREDNESS FOR INFANT CARE

BY

Alyne R. McCann

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

MASTER OF SCIENCE

College of Nursing

1997

ABSTRACT

PRENATAL EDUCATION: EXAMINING ISSUES OF MATERNAL
KNOWLEDGE AND PREPAREDNESS FOR INFANT CARE

BY
Alyne R. McCann

The purpose of this study was to examine the issues of
maternal preparation for infant care and maternal knowledge
of jaundice and dehydration, factors which can result in
significant morbidity and possible mortality to the newborn
in the postpartum period. A convenience sample of 2 groups
of primiparous mothers was used; 50 who had completed a
prenatal education program and 45 who had not. The study
found that primiparous mothers who attended prenatal
education classes did not demonstrate a higher level of
preparedness for infant care. The study supported the
findings that primiparous women who attended childbirth
education classes were more likely to recognize signs of
infant jaundice, were more competent in the ability to
assess health related problems in the newborn and were less
likely to seek emergency services inappropriately for
matters related to the health of their infant. Implications
for advanced practice nursing and future research are also

discussed, based on the results of the study.

This manuscript is dedicated with love to my
husband Tom and my dear children Stephanie
and B. J. whose support and concern have
been my strength.

iii

ACKNOWLEDGMENTS

My deepest appreciation to my thesis chairperson, Linda
Beth Tiedje for her patience, countless hours of reading,
and unfailing encouragement. I will strive always to live
by her example of kindness and integrity.

My thanks, also, to the members of my thesis committee,
Mildred Omar and Rachel Schiffman for their support
throughout this project and to Carol Buzzitta and members of
the Expectant Parents Organization of the Greater Lansing
Area. Thank you for sharing a small part of the valuable
work you do with me and for always sharing with a smile!

Finally, my thanks to Sandy Metzger and Jackie Wright

for their insight and encouragement.

iv

 

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . . . .
LIST OF FIGURES . . . . . . . . . . . .
INTRODUCTION . . . . . . . . . . . . .
Statement of the Problem . . . . . . .
Research Questions . . . . . . . . . .

Review of the Literature . . . . . .
Introduction . . . . . . . . . .
Infant Care . . . . . . . . . .
Knowledge of Danger . . . . . .
Summary . . . . . . . .
Critique of the Literature . . .
Conceptual Definitions . . . . .
Theoretical Basis . . . . . . .

Methods . . . . . . . . . . . .
Description of Sample . . . . . .
Operational Definitions . . . . .
Instrumentation . . . . . . . . .
Procedures . . . . . . . . . . .
Data Collection . . . . . . . .
Protection of Subjects . . . .
Scoring/Data Summary Procedures .
Research Design . . . . . . . . .
Data Analysis . . . . . . . . . .

Results/Findings . . . . . . . . .
Demographic Characteristics .
Infant Care . . . . . . .
Danger Signs . . . . . . . .
Additional Data Analysis . . .

Discussion . . . . . . . . . . . . . .
Assumptions/Limitations . . . . . . . .

Implications for Existing Science . . .

V

TABLE OF CONTENTS (Cont.)

Page
Recommendations for Further Research . . . . . . . . . . 46
LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . 49
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . 54

vi

LIST OF TABLES

Page
Table 1: Demographic Characteristics of Primiparous
Mothers who Participated in Prenatal Classes
and Those Who Did Not . . . . . . . . . . . . 30

Table 2: Comparison of Responses to the Baby Care/First
Week Scale by Primiparous Mothers who Attended
Prenatal Classes and Those Who Did Not . . . . 32
Table 3: Responses to Primiparous Mothers who took
Prenatal Classes and those who did not
Related to Jaundice and Dehydration

scenarios 0 O I O O O O O O O O O O O O O O O 34

vii

LIST OF FIGURES

Page
FIGURE 1: Conceptualization of Orem's Self Care Deficit
Nursing Theory (Orem, 1995) . . . . . . . . . 18
FIGURE 2: Conceptualization of Orem's Self-Care
Deficit Nursing Theory as applied to
Primiparous Mothers in meeting the
Dependent Care Demands of Newborn Infants

(Adapted from Orem, 1995) . . . . . . . . . . 20

viii

INTRODUCTION

Childbearing and childrearing are processes marked by
transition. Traditionally, prenatal education programs have
been designed to prepare mothers for the transitions unique
to pregnancy and labor with the underlying belief that a
woman can utilize her mind and body to maintain self-control
during childbirth (Lindell, 1988). Recently, many prenatal
programs have expanded their educational focus to include
information on the transition that follows the birth of a
child; that of becoming a parent (Simkin & Enkin, 1989).

The purpose of this study was to determine whether there was
a difference between women who received prenatal education
and those who did not about their perceptions of being
prepared to perform infant care and recognize potential
dangers to their infant.

Statement of the Problem

Maternal preparedness for infant care and knowledge of
potential dangers to the infant are important for the care
and safety of newborns. Examining these factors can help
clarify appropriate content for prenatal classes and assist
nurses and other health educators in designing innovative
methods to provide solid preparation for new mothers. New

parents desire information related to infant care; they want

1

2

to be prepared (Omar & Schiffman, 1995). Shortened
postpartum hospitalization has greatly reduced the new
mother's exposure to infant care education which was
traditionally provided in the period between delivery and
discharge, a time when nurses could not only instruct and
demonstrate, but counsel and observe mothers providing care
to their newborns (Beck, 1991; Young, 1995). Between 1970
and 1992, the length of postpartum hospitalization in the
United States dropped from 3.9 to 2.1 days for uncomplicated
vaginal deliveries (Young, 1995). This critical time period
between the second and fourth postpartum days is now, in
most cases, a memory. When mothers today receive infant
care instructions very shortly following the birth of their
child, they may not fully comprehend these instructions due
to their strong personal needs for healing, rest, and
psychological adaptation (Handfield, 1995; Lemmer, 1986).

Research indicates that primiparous mothers are known
to have many more questions about infant care than
multiparous mothers (Freda, Anderson, Damus, & Merkatz,
1993). In addition, new mothers often don't know what to
expect about parenthood or what questions to ask (Freda et
al., 1993). While many forms of information on all aspects
of pregnancy, childbirth, and infant care abounds, what
mothers want are clear, personal, attentive explanations
from providers (Omar & Schiffman, 1995).

It is important to meet the new mother's need for

information related to caring for her infant and being able

3
to recognize potential dangers. Optimal outcomes related to
infant morbidity and mortality are strongly correlated with
the caregiving abilities of the mother (Salam, 1995). When
a new mother's need for knowledge regarding infant care is
not met by health care providers she seeks that information
from significant others such as family, friends, and
neighbors. Social networks may supply valuable psychosocial
benefits to new mothers, however, in light of current
scientific information, specific health-related information
passed from one lay person to another may not always be
correct. In one study, 33 percent of new mothers received
advice about infant care and nutrition from members of their
social network rather than their health care providers (St.
Clair & Anderson, 1989). Interviews showed such advice was
often in conflict with generally accepted medical
recommendations and when the advice was sound, mothers often
did not understand the rationale behind it. Therefore,
examining the primiparous mother's level of preparedness for
infant care and ability to recognize potential dangers to
the infant is important.

Potential dangers that are inherent to every newborn
are those of jaundice and dehydration. These physiologic
events may be life threatening to the newborn (Andres, 1992;
Dietz, 1992). Approximately 60 percent of full term
newborns in the United States are estimated to become
clinically jaundiced at some time in the postpartum period

(Cornell, 1997). Jaundice, a yellowing of the skin, sclera,

4

and mucous membranes, occurs when bilirubin accumulates in
the subcutaneous tissues (Jones, 1989). Jaundice
may have a variety of etiologies and may appear in the
infant anywhere from within the first 24 hours to 2-3 months
after birth (Silverman & Sokol, 1993). There is grave
importance in its recognition. Lack of recognition may
preclude appropriate treatment and result in kernicterus, a
type of permanent brain damage caused from deposits of
unconjugated bilirubin in brain tissue (Jones, 1989; Lustig,
1993). Dehydration, also one of the most common problems in
infants, presents a similarly serious dilemma. Due to
immature thermoregulation, newborn infants may easily become
dehydrated in response to a variety of conditions
(Charsha, 1997; Lustig, 1993). Dehydration carries with it
a high potential for morbidity (Dietz, 1992). These
conditions, therefore, become significant dangers to the
health of the infant in the postpartum period. Because new
mothers and infants are discharged from hospitals much
earlier than in the past, recognition of these conditions
becomes of paramount importance (Beck, 1991; Cornell, 1997).

Anticipatory guidance, in the form of prenatal
education, is pivotal to achieving optimal health for
newborns (Foye, 1992). As postpartum hospitalization time
has decreased, prenatal education programs have increased
their inclusion of information deemed necessary to promote
optimal health for the infant in the initial postpartum

weeks (Enkin, 1990). The therapeutic alliance formed

5
between new mothers, prenatal educators and healthcare
providers contributes to optimal learning about such matters
as infant care, jaundice, and dehydration.

Nurses in advanced practice are appropriate providers
of health related information and anticipatory guidance.
While many nurses have a component of education in their
role, APNs have a greater ability to synthesize knowledge
and empower others (Benner, 1984). APNs, therefore, should
have a fundamental concern for providing information about
infant health and evaluating the effectiveness of health
education programs such as prenatal education programs.
Through the mechanisms of assessment, research, and program
design, APN's can help to ensure optimal health related
outcomes for infants, successful role adaptation for new
parents, appropriate use of health care resources, and
access to programs which support all new mothers. This
study is significant, not only because it examines reported
levels of knowledge and preparedness for new mothers, but
because it examines these issues for primiparous mothers
only, therefore eliminating the possible experiential bias
of multiparous mothers and enriching understanding of what
educational components first time mothers need. The study
examines differences between new mothers who have attended
prenatal education and new mothers who have not and seeks to
clarify understanding of the differences between these two
groups. All mothers included in this study who attended

prenatal education classes were involved with only one

6
program administered in the Greater Lansing Area, Lansing,
Michigan. The lack of standardized program content is,
therefore, minimized. Incorporating education related to
infant care is a relatively new phenomenon in prenatal
education. The prenatal education program utilized for this
study included specific content related to infant care and
recognizing potential dangers to the infant's health. The
proposed study also aimed to clarify whether delivering
infant care information during the prenatal period was
helpful to the new mother postnatally.
Research Questions

The following questions were examined by this study:
1) Are there differences in perceptions of preparedness to
perform infant care in women who receive prenatal classes
and those who do not? 2) Are there differences in knowledge
related to infant jaundice between women who receive
prenatal classes and those who do not? 3) Are there
differences in knowledge related to infant dehydration
between women who receive prenatal classes and those who do
not?

Review of the Literature

Introduction

A review of the literature revealed accumulated
scientific knowledge related to three areas of prenatal
education: Pain relief and intrapartal factors, non-
intrapartal factors, and infant related factors. Several

studies postulated that the primary benefit of prenatal

7

education was in improving the mother's ability to maintain
control and manage pain associated with the childbirth
process (Crowe 8 von Baeyer, 1989; Green, Coupland &
Kitzinger, 1990; Lowe, 1991; Mackey, 1995; Walker & Erdman,
1984). Prenatal education has also been linked with
decreased obstetrical complications and healthy birth
outcomes for infants (Libbus & Sable, 1991; Slager-Earnest,
Hoffman a Beckman, 1987). Other authors supported certain
psychosocial benefits of prenatal education, such as
increased social support, decreased anxiety in the mother
about the childbirth process, improved perception of support
between the partners, and increased self-efficacy of the
mother related to the birthing process (Bryce, Stanley &
Enkin, 1988; Coffman, Levitt & Brown, 1994; Cronenwett,
1985; Hiser, 1986; Libbus & Sable, 1991; Lowe, 1991; Lowe,
1993). For purposes of this review, issues related to
maternal preparation for infant care and knowledge of danger
to the infant were examined more fully.
Infant_£are

Understanding the interrelationships of findings
concerning infant care is vital to providing direction for
further study and synthesis of new knowledge. From the
research, it is apparent that new mothers have the greatest
number of questions related to infant care in the initial
postpartum period (Bull, 1981; Walker, Crain & Thompson,
1986). Primiparous mothers' concerns have been shown to

differ from those of multiparous mothers (Bull & Lawrence,

8
1985; Walker et al., 1986). Primiparous mothers today may
not know what questions to ask of health care providers or
other support persons and have demonstrated decreased
perceptions of maternal self-confidence in the postpartum
period (Freda et al., 1993; Salam, 1995; Walker et al.,
1986). Overwhelmingly, concerns primiparous mothers have
for their infants focus on areas of feeding, physical care,
infant behaviors, infant growth and development, and signs
of illness (Bull & Lawrence, 1985; Lemmer, 1987).

A recent study examined the effect of shortened
hospital stays and maternal perceptions of ability to
perform infant-care (Salam, 1995). Primiparous mothers
consistently perceived themselves as less prepared than
multiparous mothers for feeding (both breastfeeding and
bottlefeeding) and for infant care. Perceptions of
competence were higher in primiparous mothers who had the
advantage of prior experience with infants less than 3
months of age.

In light of the current trend toward postpartum stays
of 2 days or less, it is important to evaluate maternal
preparation for infant care and ensure that maternal needs
are being met.

Knowledge_of_nanger

Both jaundice and dehydration are potentially dangerous
to the newborn's health (Andres, 1992; Dietz, 1992; Harris,
1993; Muchmore, 1993; Zukowsky, Smith & Christoff, 1993).

Because of concern over shortened postpartum hospital stays

9
and the implications these problems may have for'the newborn
in the first days and weeks of life, prenatal education
programs have adjusted their curricula to include
information on infant health issues such as jaundice and
dehydration which were previously addressed as part of
hospital based postpartum education programs (Beck, 1991).

Research currently indicates that a significant
increase in the number of infants requiring outpatient serum
bilirubin determinations and phototherapy has been noted for
newborns involved in early discharge programs (Lemmer,
1987). An overall lack of knowledge by new mothers related
to care and appropriate follow-up for infant jaundice has
also been demonstrated (Salam, 1995).

Less is known about maternal knowledge of the signs,
symptoms, and treatment of infant dehydration. This may be
because dehydration is included broadly within the context
of infant illnesses. Little information exists in the
literature which specifically examines the frequency of
infant dehydration related to early discharge.

Currently the literature indicates that recognizing
illness in the baby is a high concern for new mothers and
that primiparous mothers involved in short postpartum stay
programs contact their infants' care providers more often
than multiparous mothers with concerns related to the
infant's health (Sheil et al., 1995; Lemmer, 1987). Other
research has shown that adolescent mothers who do not

participate in prenatal education programs may have more

lO
difficulty recognizing and seeking appropriate treatment for
conditions which may predispose the infant to dehydration
such as infection, temperature disturbance and other
complications (Slager-Earnest et al., 1987). Therefore,
although more research is necessary to evaluate the
frequency and impact of infant dehydration in light of
shortened postpartum stays, there is evidence to indicate
that it is a component of the health related problems
infants experience in the postpartum, that mothers have
documented concerns related to those health problems, and
that prenatal education programs may influence the mother's
ability to recognize and seek treatment for infant illnesses
such as dehydration.

Currently, teaching methods exist that enable parents
to learn how to recognize dangers to their infant's health,
report illnesses appropriately, and provide suitable infant
care (Delgado & Lutzker, 1988; Owens, 1996). In one study
(Delgado & Lutzker, 1988) strategies such as modeling, role-
playing, and practice sessions increased parental success in
being able to recognize and correctly report their
children's illnesses.

Summarx

Based on the findings of the literature and the fact
that many primiparous mothers rely on prenatal education
classes as their primary source of education for both
childbirth and the early transition to parenting (Simkin &

Enkin, 1989), that hospital stays for both vaginal and

11
cesarean deliveries have decreased dramatically in the last
few years (Enkin, 1990; Young, 1995), and that dehydration
and jaundice are grave threats to the infant's health in the
initial postpartum period (Foye, 1992; Muchmore, 1993;
Salam, 1995; Zukowsky et al., 1993), this author believes
that the proposed study to examine whether there is a
difference between primiparous women who receive prenatal
education and those who do not related to their perceptions
of being prepared to perform infant care and their ability
to recognize potential dangers to the infant's health is of
grave importance.
: 'l' E I] 1.! I

Two primary areas of concern present themselves from
the review of the literature; concern with the age of the
studies, and concern with the research methods incorporated
in the studies.

Many of the studies related to infant care are over a
decade old and deal with identifying maternal concerns
related to infant care (Bull, 1981; Bull 5 Lawrence, 1985;
Walker et al., 1986). In light of changes in medical
technology, communications technology, the health care
environment, decreasing lengths of postpartum
hospitalization, and the impact these entities may have on
new mothers, it is difficult to generalize the conclusions
reached years ago to today's primiparous mothers.

No investigation considers the current extent of

prenatal information available at places other than prenatal

12
classes (i.e. video stores, magazines and books) to new
mothers in terms of controlling for bias. Subjects were
exposed to various types and amounts of information
depending on what was provided by their primary care
providers, obstetricians, various prenatal classes,
hospitals, and overall community environment. Methods of
presentation, format, timing, individual instructor
variables, and reinforcement techniques may all impact how
new mothers value and retain information. Attempts to
control these variables have been limited.

Recent investigations have been performed related to
the effects of decreased lengths of postpartum
hospitalization on maternal concerns and perceptions of
competence to perform infant care (Lemmer, 1987; Salam,
1995). Competence and preparedness for infant care may
share similar attributes which bear further conceptual
clarification and investigation. Further research is
necessary before findings related to shortened lengths of
postpartum hospitalization can be generalized.

Several methodological concerns exist related to the
samples included in the studies. All of the investigations
had small sample sizes. Larger samples tend to be more
likely to represent a given population (Polit & Hungler,
1995). Therefore, these small samples limit the
generalizability of the results. In addition, studies
mention the loss of a considerable number of participants

(25 to 40 percent) primarily due to postpartum

13
complications. Loss of respondents could have significantly
skewed the outcomes of the research (Bull & Lawrence, 1985;
Salam, 1995). All of the studies included in the review of
the literature were based on convenience samples. It is
impossible to know whether mothers who chose not to
participate in the research may have had particular
demographic traits or trends in their responses which were
different from those who did participate. This fact along
with specific inclusion criteria related to race, marital
status, education, and language may have contributed to
samples with an inherent bias (Bull & Lawrence, 1985; Salam,
1995). Of the literature reviewed, no studies attempted to
control for sampling bias by using probability sampling
techniques to ensure an adequate cross section of subjects
from the general population. Lack of control for possible
sampling bias also limits the generalizability of the
findings.

Also of concern is the fact that samples were often
inherently dissimilar in terms of age of the participants
(Bull & Lawrence, 1985; Salam, 1995). Ages of the subjects
varied by almost 20 years. Developmentally these women may
have been at very different points in their lives (Erikson,
1980; Mercer, 1985). Different developmental stages may
have impacted the participant's perceptions of themselves,
their infants, and issues related to infant care.

In some studies both primiparas and multiparas were

included (Bull 8 Lawrence, 1985; Salam, 1995). Although

l4

findings were, at times, extracted for mothers by parity,
conclusions based on the collective results of the responses
in these studies may actually have distorted differences
unique to primiparous and multiparous women.
Conceptual_nefinitiens

Three concepts are fundamental to this study. 1)
Prenatal Education - A form of anticipatory guidance given
in a structured setting and provided for individuals
expecting the birth of a child with the goal of improving
the knowledge of parents or significant others related to
aspects of pregnancy, labor and delivery, maternal self-
care, infant-care, and recognizing potential dangers to
maternal and newborn health (Enkin, 1990; Handfield & Bell,
1995; Maloney, 1985); 2) Maternal Perceptions of
Preparedness to Perform Infant Care - The mother's self-
assessment related to feelings of being ready to provide
suitable care for her infant in the first postpartum week in
order to promote the infant's optimal health (Bull 8
Lawrence, 1985; Maloney, 1985; Salam, 1995); 3) Knowledge of
Danger Signs Related to the Infant's Health - An ability to
recognize and understand signs and symptoms of illness in
the newborn which may indicate a potential threat to
extrauterine adaptation and result in significant morbidity
or mortality (Andres, 1992; Dietz, 1992; Harris, 1993;

Lustig, 1993; Muchmore, 1993).

15
II I' J E .

Orem's Self-Care Deficit Nursing Theory provides the
theoretical basis for this research. In this model, Orem
describes the components of nursing's paradigm in the
following way: 1) Person - The proper object or recipient of
nursing activities (Orem, 1995, p.8); 2) Environment -
Physical, chemical, biologic and social features
continuously or periodically interactive with men, women,
and children (Orem, 1995, p.51); 3) Health - A condition of
integrated human functioning. A state characterized by
soundness or wholeness of developed human structures,
bodily, and mental functioning (Orem, 1995, p.97, 101); 4)
Nursing - A practical and didactic art and human service
through which the practitioner gives specialized assistance
to persons with disabilities that require more than ordinary
assistance to meet daily self-care needs (Orem, 1995, p.7,
47).

Orem views the individual as needing continuous self-
maintenance and self-regulation which is termed "self-care".
To participate in self-care activities one must have certain
requisite abilities or "agency" to take action in one's own
behalf. Self-care is a learned activity which may be
affected by individual factors such as age, developmental
stage, health state, environment, and medical care (Orem,
1995).

Orem proposes that certain needs are present for all

living human beings. These needs include materials to

16
support life processes and structural/functional integrity
and are based on one's ability to manage within the
environment. Needs that are necessary to maintain life are
termed ”self-care requisites". These requisites fall into
three categories; "Universal Self-Care Requisites",
"Developmental Self-Care Requisites”, and "Health-Deviation
Self-Care Requisites" (Orem, 1995).

Just as the provider of self-care is termed "self-care
agent", so the provider of care to those who are not able to
optimally care for themselves is called the "dependent-care
agent". A need for dependent-care may result from immature
physical, psychological or psychosocial systems or from
significant insults to those systems resulting from age,
infirmity, or disease (Orem, 1995).

Nurses, according to Orem's theory, possess "nursing
agency", a power developed through specialized education and
training to provide for the needs of others or help others
meet a need for action. Nursing agency is employed in
dependent-care situations through the provision of direct
care or the provision of education and support which enables
the individual to ultimately care for one's self or another.

Dependent-care situations involving newborns often
require nursing agency. Legitimate use of nursing agency
occurs when a nurse provides education, role modeling, or
practice situations for a new mother that assist her in
meeting the needs of her infant. These dependent-care needs

are present as universal self care requisites such as:

17
Maintenance of sufficient air, water and food; prevention of
hazards to life and well—being; maintenance of balance
between activity and rest; and provision of care associated
with elimination processes. They are present as
developmental self care requisites which include: Provision
of a physical and psychosocial environment that ensures
feelings of safety and comfort; maintenance of conditions
that promote and sustain affective and cognitive
development; regulation of the environment to prevent states
of fear, anger or anxiety; and providing conditions that
prevent sensory deprivation or overload. Finally, nursing
agency can be utilized to help new mothers meet the health—
deviation self care requisites of the infant by teaching
them prenatally when it is appropriate to seek and secure
medical assistance; ways to assess and attend to jaundice
and dehydration, and ways to deal with discomforts or
negative effects associated with medical care.

Figure 1 illustrates the conceptualization of Orem's
theory as it relates to the effects of nursing agency on an
individual who would fall into ordinary parameters in terms
of physical and mental health, cognitive function, and
social support. The nurse can directly affect the patient's
ability to successfully meet personal self-care requisites
as well as the dependent-care requisites of others in their
environment. Self-care and dependent-care demands are
illustrated by interrupted lines as there is a changeable

quality to these demands based on the overall status of the

(Self Care)

Self Care Demand

111

Self Care Agency
A

 

18

Nurse
(Nursing Agency)

(Dependent Care)

Dependent Care Demand

III

Dependent Care Agency
A

 

 

 

 

 

 

Developmental Self-Care Requisites
4 Health-Deviation Self-Care Requisites ‘

Patient
Universal Self-Care Requisites

 

 

Eiml. Conceptualization of Orem's Self-Care Deficit Nursing Theory (Orem, 1995).

19

individual or dependent others. After accepting the
benefits of nursing agency the patient becomes
strengthened in knowledge and ability to meet self-care
and/or dependent-care demands that are depicted by the solid
lines from the patient to the agency.

Figure 2 illustrates the application of Orem's Self-
Care Deficit Nursing Theory to the situation of a,
primiparous mother who provides for the dependent-care needs
of her infant. This diagram integrates the concept of
prenatal education. The nurse's direct impact is on the
mother who must possess ability to understand and meet the
requisites of the newborn. Figure 2 depicts the mother as
the infant's primary dependent-care agent with the support
of the nurse through the function of prenatal education.
With the education and assistance offered through nursing
agency the mother becomes capable of providing for the
infant's dependent-care needs and meeting the requisite
areas of universal self-care for adequate nutrition and
daily care including skin, circumcision and umbilical cord
care. The mother is also capable of providing for
developmental self-care requisites by using measures that
promote psychosocial adaptation such as comforting and
soothing. With the nurse's guidance the new mother can
recognize significant threats to the infant's health such as
dehydration and jaundice thereby addressing the infant's
health-deviation requisites. Because the newborn is unable

to provide its own care due to immaturity, dependent-care

20

Nurse
(Nursing Agency)
Assists the primiparous mother in compensating
for health and developmental limitations
of the infant.

I

Prenatal Education

I

 

Primiparous Mother
(Dependent Care Agent)
Infant
A
(Self Care) Universal Self-Care Requisites
Developmental Self-Care
(Self Care Agency) Requisites
- Maternal preparedness to perform infant
care.

 

Health-Deviati on Self Care
Requisites

- Knowledge and recognition of signs of
danger to the infant's health

Figure; Conceptualization of Orem's Self-Care Deficit Nursing Theory as applied to
Primiparous Mothers in meeting the Dependent Care Demands of Newborn Infants
(Adapted from Orem, 1995).

21

becomes the mechanism by which the infant's needs are met.
Self-care agency becomes an entity of the diagram
unconnected to the infant in the postpartum period as the
infant is not physically or cognitively mature enough to
care for itself.

Methods
We

The sample consisted of 95 self-selected women
delivering their first baby and considered primiparous by
their own definition. Fifty participants receiving prenatal
classes were recruited from one prenatal education program
in a midwestern community. A registered nurse affiliated
with the study presented a five minute talk about the
purpose of the research and types of information that would
be solicited. By recruiting all mothers who had received
prenatal classes from one program, the problem of
standardized program content was addressed. Forty-five
participants who had not received prenatal education were
recruited by postpartum nurses after delivery at one
hospital in the same community. Identical information was
given to these participants by the postpartum nurses.

: ll 1 E E' 'l'

Operational terms relative to this research were
defined as follows: 1) Maternal Perceptions of Preparedness
to Perform Infant Care - For purposes of this study,
maternal perceptions of preparedness to perform infant care

were measured by the Baby Care/First Week Scale. This four

22
item Likert type scale was designed to measure perceptions
of preparedness for infant care in the first postpartum
week. Questions included how well prepared mothers felt to
do baby care, soothe the infant, adjust to parenting changes
and feed the infant. Responses were measured on a scale of
1 to 5 with 1 meaning not at all prepared and 5 meaning very
well prepared. Responses to the “Baby Care/First Week
Scale” were summed individually and for the collective
scale. Mean scores were compared for mothers who
participated in prenatal education and those who did not
both for individual items and for the scale in its entirety.
Lower scores indicated that mothers felt less prepared for
infant care. Higher scores indicated that mothers felt more
prepared for infant care (see Appendix A); 2) Knowledge of
Danger Signs Related to the Infant's Health - For purposes
of this study, knowledge of danger signs related to the
infant's health were measured by two separate scenarios
included under the title Able to Identify Danger Signs.
Mothers were asked two questions in relation to each
scenario: 1) What would you do? and 2) What do you think
might be wrong? Scenarios were based on current literature
summarizing signs and symptoms of jaundice (scenario 1) and
dehydration (scenario 2). Mother's responses were recorded
narratively by the investigators for qualitative analysis

(see Appendix B for complete content).

23
Instrumentation

.For purposes of this study four questions were asked of
the mothers related to infant care during the first
postpartum week. Questions on infant care were developed
based on the 4 areas which the literature indicated were
most important to new mothers in terms of being prepared to
perform infant care. The questions were reviewed by a panel
of 7 nursing experts (3 doctorally prepared, 1 masters
prepared, 2 graduate students and 1 bachelors prepared
childbirth educator) for content validity. The questions
were scored on a 5 point Likert type scale with 1 being not
prepared and 5 being very well prepared.

Since the infant care questions had not been
statistically evaluated prior to this study, no information
was available on the reliability or validity of the tool.
Analysis of the compiled infant care questions produced a
Cronbach's alpha reliability of 0.69 for this research which
was considered a measure high enough to demonstrate
consistency while establishing that all items on the scale
were not exploring identical dimensions of maternal
preparation for infant care (Marks & MacDermid, 1996).

The instrument also evaluated responses to two open
ended questions for each of the two scenarios designed to
elicit the mother's understanding of danger signs of
impending illness in the newborn, specifically, dehydration
and jaundice. These questions were asked in a contextual

manner and based on a review of the literature pertaining to

24
infant jaundice and dehydration. Responses were recorded in
a narrative manner. Scenarios involving an infant with
symptoms of hyperbilirubinemia were presented in the first
question and those with symptoms of dehydration were
presented in the second question. Again, the scenarios were
developed by the seven nursing experts described previously
to substantiate content validity .
Procedures

Only primiparas whose anticipated date of delivery was
from March 1, 1996 to August 1, 1996 were recruited for the
study. This was done in order to ensure that mothers would
be in approximately their sixth postpartum week during the
data collection period of April 15, 1996 to September 15,
1996. All participants were given a written consent form
outlining the content, possible risks and discomforts,
ability to withdraw from the study at any time, and
procedures to protect confidentiality. Participants were
informed that they would be contacted within 2 weeks
following their anticipated due date to confirm the success
of the birth, their continued willingness to participate in
the study, and to schedule an interview.

Mothers were asked to reflect back to the first week at
home with their new baby to answer the infant care
questions. Competence in infant care is a process which
occurs over time. Research indicates that the first week at
home is a time when mothers express the highest number of

questions about infant care (Bull, 1981; Bull & Lawrence,

25

1985; Davis, Brucker & Macmullen, 1988). Therefore, the
intent of these questions was to capture how prepared the
new mother felt before gaining experiential knowledge in the
ensuing postpartum weeks. This study asked mothers to
retrospectively recall information related to their first
week at home. Administration of the questionnaire at 6
weeks postpartum was considered an optimal time for
evaluation as mothers are generally feeling well, have
resumed their prebirth activities, and generally have taken
on most responsibilities for infant care. Research has
shown that mothers accurately recall birth information with
little change in their responses for up to years following
the birth event (Githens, Glass, Sloan & Entman, 1993;
Fawcett et al., 1993) (See subject consent in Appendix C).

In order to familiarize mothers with the questions to
be asked and improve the effectiveness of the interview
process, participants were mailed a copy of the study
questionnaire approximately one week before the scheduled
interview. The scheduled date and time of the interview
were placed at the top of the form as a reminder. Questions
related to recognizing signs of dehydration and jaundice
were not included in the mailed questionnaire in order to
prevent the participants from investigating these areas
simply to answer the questions.

At six weeks postpartum, telephone interviews were
conducted by a group of 6 registered nurses. Each

interviewer had six hours of specialized training related to

26
the interview process in order to ensure consistency in
conducting the survey and, ultimately, the reliability of
the results. Interviewers were provided with a list of
resources including community agencies and health care
providers to which the mother could be referred if concerns
arose during the interview process related to herself, her
infant, or her family.
mus-29m

Data were collected by one of six registered nurses
affiliated with the study during scheduled telephone
interviews at 6 weeks postpartum. Each interview took
between 30 and 60 minutes.

Mothers were offered the option of receiving a second
call from the interviewer if circumstances made it difficult
to finish the interview at the scheduled time. This was
done in an attempt to optimize comfort with the interview
process and allow the mother to stop if the infant became
fussy or needed attention. Mothers were given permission to
not answer any question they did not feel comfortable with.
Subjects' responses were recorded by each interviewer
utilizing a questionnaire. Responses that required an
explanation by the subject were recorded verbatim by the
interviewer. At completion of the investigation, all
responses were coded by a graduate assistant from Michigan
State University with a background in statistics and entered
into a computer data system. Responses which could not be

coded were entered in narrative form for qualitative

27
analysis. Subjects received a $10.00 gift certificate for
their participation in the study.
2 l l' E 5] . l

Approval for the research was obtained from the
University Committee on Research Involving Human subjects of
Michigan State University, East Lansing, Michigan, and from
the Institutional Research and Review Committee of Sparrow
Hospital, Lansing, Michigan. Code numbers were used to
ensure confidentiality of the subjects' responses; no
information was retrieved by respondent name. Furthermore,
all data used for this research was kept in a locked file
cabinet by the investigator to ensure continued
confidentiality (see Appendix D for approval forms).
WW

Likert responses to the Baby Care/First Week scale were
summed for comparison between the two groups. Higher scores
indicated a higher level of maternal preparedness.

Responses to the section entitled Able to Identify
Danger Signs were evaluated by analyzing the narrative
responses for prevailing themes. Two nursing experts
separately reviewed the first 60 responses to the scenarios
involving jaundice and dehydration. Each expert examined
the content of the responses for themes related to maternal
knowledge about the meaning of the situation and maternal
knowledge about what would be the most appropriate response
to the situation. After complete agreement was reached

between the experts regarding content analysis of the first

28

60 responses, the remaining 40 were analyzed by one of the
experts using the themes extracted from the first 60
responses. These themes remained consistent throughout the
responses.
Reseamneeign

This descriptive research utilized a survey format.
The purpose was to ascertain whether there was a difference
between primiparous mothers who had received prenatal
classes with a component of infant care and those who had
received no prenatal classes related to their perceptions of
being prepared to perform infant care and recognize
potential dangers to their newborn's health in the
postpartum period. This study was based on analysis of data
collected for the larger work entitled thldbizth_£dugatigni
Qutggmes_3eseazgh (Tiedje, Omar, Schiffman, Buzzitta,
Wright, Metzger & McCann, 1996).
We

Information about the subjects' ages, education, total
household income, and marital status was evaluated using t-
test and Chi—Square tests for significance. Scores for the
Baby Care/First Week Scale were evaluated using t-tests.
This included both individual item scores and the mean score
for the total scale. Responses to the dehydration and
jaundice scenarios were evaluated qualitatively and
summarized by themes. These responses were then recorded by
number of responses in each thematic category and by

percentages in each category to facilitate interpretation.

29
A significance level of .05 was used for all statistical
tests.
Results/Findings

Demographic characteristics of the subjects from the
study are included in Table 1. Of the total sample of 95
participants, subjects ranged in age from 15 years to 40
years. Mean age for the entire population was 25.19 years
(SD 5.87). Mothers participating in prenatal education had
a mean age of 26.38 years (SD 5.76) and those not
participating in prenatal education had a mean age of 23.87
years (SD 5.77). Due to the fact that maternal age was not
well distributed in categories, i? analysis was not
reliable. Mean ages of participants across the two groups
were analyzed by t-test which revealed a significant
difference with mothers from the prenatal education group
being significantly older than those in the non-prenatal
education group (3(93) = 2.12, p = .036). Subjects also
differed significantly in areas of general education (X? 9,
11:95) = 124.68, p=.000), household income (x2 7, n=82) =
54.39, p=.000), marital status (x2 4, n=88) -- 130.86,
p=.000), and ethnicity (x2 5, n=95) = 253.82, p=.000).
Therefore, it can be concluded that the subjects in the two
groups differed significantly on each demographic variable
analyzed. Those subjects who participated in prenatal
classes were older, had a higher level of formal education,

had a greater household income, were more likely to be

30

Table 1.

WW ll' li' E Ill] iTl m 11.1”]

 

 

 

Characteristic Prenatal Education No Prenatal
Education
(n=50) (n=45)
No. % No. %
Age
15-19 yrs. 7 14 10 22
20-24 yrs. 14 28 20 44
25-29 yrs. 14 28 8 18
z 30 yrs. 15 3o 7 16
Education
= or < H.S. 16 32 24 53
College gassoc. 10 20 11 24
Bachelors 18 36 9 20
Masters 4 8 1 2
Ph.D. 2 4 0 0
Total Household Income
< 5,000 1 2 3 7
5,000-9,999 0 O 5 11
10,000 - 14,999 4 8 3 7
15,000 - 19,999 3 6 1 2
20,000 - 29,999 5 10 8 18
30,000 - 39,999 6 12 3 7
40,000 - 49,999 4 8 5 11
2 50,000 21 42 10 22
AFDC 2 4 0 0
Don't Know 2 4 3 6
Income not reported 2 4 4 9
Marital Status
Now Married 36 72 21 47
Never Married 7 14 17 38
Engaged l 2 0 0
Cohabitating 2 4 3 7
Separated 1 2 0 0
Ethnicity
European American 39 78 34 76
African American 6 12 7 16
Native American 1 2 1 2
Asian 1 2 1 2
Latino 2 4 2 4
Bi/Multi-racial 1 2 0 0

 

31

married, and differed in ethnic background from their
counterparts.
Infant_care

Items on the Infant Care Scale are summarized in Table
2. For the research question "Are there differences in
perceptions of preparedness to perform infant care in women
who receive prenatal classes and those who do not?" the
following findings resulted. There were no significant
differences between the responses of mothers taking prenatal
classes and those not taking prenatal classes on any of the
infant care items when analyzed by t-test. Neither were
there significant differences on the summed scores of the
responses for either group when evaluating the entire scale
using the t-test. From these results mothers in both groups
indicated a similar level of preparedness for infant care in
the first week. It is interesting to note that scores
showed a pattern of consistency from question to question
both within groups and between groups. Mothers who
participated in prenatal classes had highest scores for
feeling prepared to do daily infant care, indicating that
they felt fairly well prepared for this task. These same
mothers felt least prepared for understanding changes of
being a new parent, evaluating their level of preparedness
in this area at above somewhat prepared but below fairly
well prepared. Mothers who did not participate in prenatal
education classes also felt most prepared to do daily infant

care indicating they were slightly more than fairly well

32

 

 

Table 2.
eue. -e. e :‘eee. ‘- e .‘ ;.e . ‘ . - ‘--. - - e
ue‘. e 9e .‘ ‘ee ; ‘.O‘O ' ‘9- ; .1:- see gei-
flhQ_Did_NQ£
Had Classes Did Not Have Classes
Item M SD M SD
1. Daily
Care 4.06 .74 4.31 .92

(1(93) = - 1.45, p = .151)

2. Soothe
Baby 3.72 1.01 4.02 .99
(t(93) = -1.47, p = .144)

3. Understand
changes of
being a new

parent 3.40 .99 3.58 1.27
(1(93) = -.76, p = .446)
4. Infant
feeding 3.84 .96 3.91 1.04
(1(92) = -.36, p = .720)
Total Scale
mean 3.76 .275 3.95 .302
(t(6) = -.98, p = .365)

 

prepared but less than very well prepared. These mothers,

too, felt least prepared for understanding changes of being
a new parent, indicating a level of preparedness about half
way between somewhat prepared and fairly well prepared. T-
test results for perceptions of preparedness to both soothe
the baby and feed the baby were slightly higher for mothers

who did_not participate in prenatal education than for those

33

who did. Although the standard deviations of the responses
indicated slightly more variation in the responses of the
non-prenatal education group, scores, overall, were slightly
higher in this group for each question and for the total
scale mean. Again, no significant difference was found for
any individual question or for the total scale when
evaluated by t-test. Interestingly, neither group as a
whole scored in the very well prepared category for any of
the four items on the Baby Care/First Week Scale.
DanoeLSigne

Responses to the Danger Signs scenarios are summarized
in Table 3. In evaluating maternal responses to the
question "Are there differences in knowledge related to
infant jaundice between women who receive prenatal classes
and those who do not?" three themes emerged when mothers
were asked the question: "What would you do?" following a
description of a jaundiced infant. First, some mothers
responded with a sense of urgency as if the situation
required immediate emergency care. A second group of
mothers responded in a way that indicated the situation was
serious or important; requiring advice or direction from a
healthcare provider, hospital, clinic or other source.
Finally, a third group of mothers had responses indicating
that the situation would require either emergency assistance
or advice but these mothers felt that either response was

appropriate. It should be noted that the scenarios were

Table 3.

\':ee.1“ e

Sfifinflllflfi

34

 

Had Classes
N - SO
Jaundice Dehydration
n i. n .1

Did Not Have Classes
N - 4S

Jaundice. Dehydration

n 3. n. A

 

Responses to
scenarios.

(1) What would
you do?

Seek emergency
care

Contact health-
care provider

Either seek
emergency care/
contact health-
care provider

11 22 20 40

32 64 22 44

16 36 25 56

26 58 16 36

 

Response to
scenarios.

Correctly
identified
jaundice/
dehydration.

(2) What do you
think might
be wrong?

43 86 20 40

34 76 16 36

 

framed by the panel of experts so that the ideal response

would have been to seek assistance and evaluation from a

healthcare provider.

More mothers who did not participate

35
in prenatal education indicated that they would seek
emergency care for the infant in this situation.

When asked "What do you think might be wrong?” mothers
in both groups correctly identified infant jaundice the
majority of the time, however, mothers who participated in
prenatal education were able to identify jaundice more often
than those who did not participate in prenatal education.

In evaluating maternal responses to the question ”Are
there differences in knowledge related to infant dehydration
between women who receive prenatal classes and those who do
not?” a similar pattern of responses occurred. Mothers
again responded in a manner which indicated that the
situation was urgent and they would seek emergency care,
that the situation was serious or important, requiring
advice from a healthcare provider, or that the situation
could be either urgent or serious and that either emergency
assistance or advice from a healthcare provider would be an
acceptable course of action. Again, a higher number of
mothers who did not participate in prenatal education said
that they would seek emergency care, even more so for this
scenario involving dehydration than the one involving
jaundice. Again, more mothers who had been involved in
prenatal education verbalized that the first course of
action would be to seek advice from a healthcare provider.
Unlike jaundice, only a minority of the participants in both
groups were able to correctly identify dehydration. In

fact, for both groups of participants, the most prevalent

36
response for this scenario was "Don't know". Sixty percent
of the mothers participating in prenatal classes and 64% of
the mothers not participating in prenatal classes could not
label the danger as dehydration for the newborn as presented
in this scenario.
Eii°ll J E l E 1 .

A closer examination of the narrative responses
revealed other, more subtle, differences between the two
groups of participants. Mothers who took prenatal classes
projected more confidence in their answers whereas mothers
who did not take prenatal classes seemed to be less
confident in their decisions overall. For example, a
typical response from a mother who took prenatal classes was
"I would call the doctor's office, explain symptoms, and do
what they suggest. I'd also check my medical child care
book. In fact, I would check the book first and the
doctor's notes on when to call." Mothers in the group not
participating in classes specifically used words and phrases
like "panic", "rush to the emergency room" and "I'd be
calling EMS (Emergency Medical Services), I would be in no
shape to drive." In response to the jaundice scenario, two
mothers who did not take prenatal classes mentioned starting
CPR for the infant. These responses contrast with one
mother who attended classes and responded she would "make
sure he was breathing O.K. before I called (the
pediatrician)." This shows a subtle difference between the

mother who attended prenatal classes when compared with the

37

mothers who did not. The mother who attended prenatal
classes would not begin CPR immediately but would assess her
infant before proceeding to call a healthcare provider.
Engaging in this type of systematic process indicates a
degree of knowledge and competence not seen in the mothers
who did not participate in prenatal education classes.

Another difference between mothers who participated in
prenatal classes and those who did not was apparent in
responses to the question: "What do you think might be
wrong?" A minority of subjects in both groups incorrectly
identified an illness other than dehydration or jaundice
from the scenarios. Mothers in both groups associated such
problems as fever, difficulties with digestion/formula, and
flu with the signs and symptoms presented for dehydration.
One mother who had participated in prenatal education
classes labeled the jaundice scenario as "some type of
anemia". However, only mothers who did not participate in
prenatal classes identified such problems as "a tumor in her
head", "someone put fingers in it" (related to the
description of a sunken anterior fontanelle), "cerebral or
circulatory problem", or "failure of her organs" with the
cues intended to describe dehydration. A similar pattern
was noted for responses to the jaundice scenario. Mothers
who did not participate in prenatal education associated
such things as "convulsing", "crib death", "temperature" and
"passed out" with the cues representing jaundice. From

these responses it appears that there were discrete

38

differences in knowledge of danger for the infant related to
jaundice and dehydration between the mothers in this sample
who participated in prenatal education and those who did
not. These differences indicated that the mothers who
participated in prenatal education reacted to situations
involving perceived threat to the infants' health in ways
that revealed a higher level of composure, an improved
ability to assess situations indicating possible danger to
the infant's health, and a more appropriate understanding of
the signs and symptoms of illness as presented in the
scenarios.

Discussion

The two most important results of this research were:
1. Prenatal education as measured by the Baby Care/First

Week Scale did not appear to improve the primiparous

mother's perceptions of preparedness for infant care.
2. Prenatal education did appear to prepare the

primiparous mother in ways which empowered her to rely
on healthcare providers as a primary source for
guidance when she perceived there was a danger to her
infant's health rather than relying on emergency
services.

The lack of difference in preparedness for infant care
corroborated some of the current literature on prenatal
education and infant care preparation (Hamilton-Dodd,
Kawamoto, Clark, Burke 8 Fanchiang, 1989; Nichols, 1995;

Salam, 1995). However, qualitative analysis of the scenario

39
involving the infant jaundice indicated that there were
differences involving tendency to use emergency services in
the two groups. Mothers who did not participate in prenatal
education were less likely to be able to identify infant
jaundice and were more likely to seek emergency care for
signs and symptoms of jaundice in the newborn.

Little difference existed between the groups related to
knowledge of infant dehydration when responses were
evaluated qualitatively. Neither mothers who participated
in prenatal classes or those who did not were able to
identify infant dehydration a majority of the time. The
ability to identify jaundice more readily may relate to: 1)
having more information available on infant jaundice; 2) it
may be visually easier to detect jaundice than dehydration;
and 3) jaundice has been a component of infant care
education for a number of years.

In this time of constantly changing technology and
advances in medical science it is important to ensure that
new mothers have the information and skills they need to be
optimal dependent-care agents for their newborn infants.
This is especially critical for primiparous mothers who do
not have the benefit of experience with babies. It is
especially important to ensure that new mothers are prepared
to provide infant care and recognize signs of danger to the
infant's health in light of the many changes which have
contributed to decreasing lengths of postpartum

hospitalization for both mothers and infants and reduced the

4O
opportunities for education and preparation for the critical
maternal role as dependent-care agent.
Assumptions/Limitations

Several possibilities exist that may have influenced
the findings. The investigator assumed that mothers had
similar life experiences to prepare them for infant care.
Mothers were assumed to have had limited experience with
newborns and were considered primiparous by their own
definition. Experience with newborns is a factor believed
to influence the perceptions of new mothers (Freda et al.,
1993; Gruis, 1977). It was assumed that self-reported data
was accurate and that the primiparous mothers in both groups
had limited prior experience with newborns.

The researcher assumed that mothers would be able to
accurately recall and assess their feelings of preparation
for infant care in the first week at six weeks postpartum.
Any experiential knowledge gained between the first
postpartum week and the time that the questionnaire was
administered at six weeks postpartum could have influenced
the study findings.

Other methods to measure maternal knowledge of infant
care may have been more sensitive than the survey method.
For example, use of videotaped mother/infant interactions
may have yielded a much richer variety of information which
could have altered the study findings. Although the mothers
participating in prenatal classes were all recruited from

one prenatal education program, classes were presented in

41
two different formats. Thirty-seven participants had the
traditional format of prenatal classes which consisted of
eight classes two hours in length. Thirteen participants
had Saturday classes sponsored by the same organization but
meeting for three and one-half hours on four separate
Saturdays. It can be noted that the total length of time in
class was different for these two groups and that the format
may well have been modified by the different time
constraints.

No controls were attempted for extraneous sources of
prenatal education materials. In today's society, media,
books, magazines, and a variety of other materials are
easily available. It is impossible to know whether exposure
to forms of information about infant care or danger signs
other than those in prenatal classes may have influenced the
study findings.

Subjects included in the research were from a
convenience sample. It is impossible to estimate the
potential for bias in such a sample (Brink 8 Wood, 1994).
Random sampling would have lended credibility to the
results. A few mothers agreed to participate but could not
be contacted by phone. It is also impossible to know what
influence the responses of this group would have been on the
study findings.

The two groups of mothers were different based on the
demographic variables of age, education, income, marital

status, and ethnicity. This may be an important limitation

42
of the study as younger, single mothers, with less
education, and less total household income were more
represented in the group of primiparas who did not take
prenatal education. These mothers may not fully understand
what preparation is needed for infant care. These mothers
may have a different perception of what it means to be
prepared than older, more educated mothers. Mothers in the
sample also ranged in age from 15-40 years. Again, due to
variations in cognitive and psychosocial development,
further analysis of differences in the groups should
statistically control for these demographic differences.
Implications for Existing Science

This research examined the effects of prenatal
education on primiparous mothers' perceptions of
preparedness for infant care and knowledge of danger signs
related to infants' health. One of the strengths of this
study is that the prenatal classes were provided by one
group with one core curriculum. Further study needs to
examine the outcomes of knowledge and preparedness for
infant care in light of what program variables are most
effective with parents. Particular program variables such
as teaching methods, environment, and ways in which newly
learned behaviors and skills are practiced and applied needs
to be examined.

Research needs to be expanded to examine maternal
groups in light of specific demographic variables such as

parity, age, education, income, social networks and cultural

43
influences. This could help to refine understanding of what
differences exist in preparedness between various groups.
These same factors could be examined in relationship to
maternal knowledge in order to optimize the effects of
educational programs designed to serve specific group needs.
In particular, research related to the ways in which younger
primiparous mothers learn how to care for infants and
recognize danger signs could be addressed. One way to do
this would be to compare primiparous mothers less than 20
years old who had no previous experience with infants less
than three months of age with primiparous mothers less than
20 years old who came from large families or extended
families where they had extensive exposure to infant care
practices. Another way to evaluate differences in infant
care and knowledge in groups of primiparous mothers less
than 20 years old would be to videotape interactions between
the mothers and their infants and compare the qualities of
these interactions for a group who had prenatal education
and one who did not.

In light of this study's findings related to a
potential for increased utilization of emergency services
among primiparous women who did not attend prenatal classes,
further research is warranted examining the variables of
prenatal education programs that may be responsible for
empowering new mothers to confidently use healthcare
providers as primary resources and to examine the potential

cost savings which may result. One way to do this would be

44
to audit emergency room records in order to establish how
often mothers seek care in the emergency room which may be
better handled in a primary care office or clinic.

‘Timing of the infant care component of prenatal classes
warrants critical evaluation. Some of the current
literature indicates that prenatal delivery of information
specifically related to the infant may not be as effective
as delivering that information in the postnatal period
(Hall, 1983; Maloney, 1985). In light of this study's
finding that neither mothers who participated in prenatal
education or mothers who did not felt optimally prepared for
infant care, programs which involve postpartum follow-up
with new mothers and infants in home environments bear
further examination. Current methods of lecture and
demonstration used in prenatal classes also bear examination
in light of information which supports effective behavior
change when role-modeled behavior is taught and practiced
(Delgado 8 Lutzker, 1988; Owens, 1996).

Implications for Advanced Practice Nursing

Advanced Practice Nurses have a crucial role, not only
in facilitating maternal-newborn interactions, but also in
assessing educational programs which impact the mother's
ability to be an effective dependent-care agent and
supplementing the information provided by these programs.
Ensuring and providing effective health related education is

an appropriate function of nursing agency (Orem, 1995).

45

More and more, APNs are seeing mothers and infants in a
variety of arenas; clinics, office based practices,
agencies, and client homes. APNs caring for infants and
families need to ensure that the primary caretakers of these
newborns have adequate and accurate information presented in
a way that promotes understanding and ensures a safe
transition to extrauterine life for the infant. Currently,
information related to pregnancy, childbirth and infant care
is available from a variety of sources. APNs need to assess
new mothers' level of knowledge related to jaundice and
dehydration as well as infant care in order to ensure that
the information each mother has is not only appropriate but
clearly understood. By making thorough assessments of
maternal knowledge and presenting clear information, the APN
can minimize the mothers' fears about the safety and care of
her infant, strengthen her affiliation with the healthcare
system, and decrease isolation.

Through assessment and referral the APN can refine
practice to meet specific needs of various client groups.
For example, mothers whose demographic profile indicates
that they are young, with limited social support, education,
or finances, may benefit from weekly follow—up phone
conversations with the APN in the first postpartum weeks to
discuss infant care and health related issues. By either
contacting the new mother or having a scheduled time when
the mother can call the APN, the APN can assist the mother

in strengthening her caregiving and assessment skills and

46
provide a valuable link to community resources this mother
may not otherwise have. The APN can also refer the new
mother to social agencies she may not be aware of, thereby
facilitating a connection to a wider system of social
support to benefit both mother and baby.

The APN can engage in research to further examine where
maternal strengths and weaknesses may lie in providing
infant care. For example, randomized studies of mothers
receiving prenatal education and those not receiving
prenatal education could further refine understanding of the
impact prenatal education programs have on maternal
knowledge and preparedness. Randomized studies comparing
mothers who receive prenatal infant care education and those
who receive postnatal infant care education in the home
environment could assist us in understanding whether
differences in the timing or environment in which infant
care is taught makes a difference in terms of maternal
knowledge and perceptions of preparedness to perform infant
care.

Recommendations for Further Research

Evidence from this study supports the conclusions that
primiparous mothers who participated in prenatal classes
were able to demonstrate a higher level of recognition for
danger signs which may indicate a potential threat of
jaundice in the newborn. Primiparous mothers who attended
prenatal classes were less likely to utilize emergency

services in response to these potential threats and more

47

likely to contact a healthcare provider. These mothers also
indicated a more competent demeanor and less panic in their
responses to situations which might indicate danger to the
infant's health. Further study is warranted in view of the
potential cost savings which may be realized with decreased
utilization of emergency services. This may be done by
retrospective chart audits to see if emergency rooms are
being inappropriately over utilized by non-CBE primiparous
mothers, and if so, whether there are specific demographic
characteristics which would allow the APN to provide focused
educational support or referral to other programs.

Primiparous mothers in this study did not show a
significantly higher level of preparedness for infant care
related to whether or not they had CBE. They also did not
show different levels of knowledge related to infant
dehydration based on whether or not they had classes.
Further research is necessary to clarify the concept of
preparedness and clarify the optimal timing and delivery
methods for infant care education. Clarity of the concept
of preparedness for infant care may be better examined by
the use of videotaping actual episodes of care. Based on
the study findings this author found Orem's Self- Care
Deficit Nursing Theory an appropriate framework for the
investigation. This theory provided clarity to the concepts
of maternal preparedness and knowledge while allowing for

integration of the role of nursing agency in the form of the

48

nurse/prenatal educator and the impact of that role on the
primiparous mother as a dependent-care agent for the infant.

Findings of this study corroborated some of the current
literature on prenatal education in concluding that while
concerns related to infant care are high among primiparas,
prenatal classes do not necessarily produce significantly
greater perceptions of levels of maternal preparedness for
infant care (Hamilton-Dodd, Kawamoto, Clark, Burke 8
Fanchiang, 1989; Nichols, 1995; Salam, 1995). The study
found a higher level of maternal knowledge related to infant
jaundice, and a decreased tendency for inappropriate
utilization of emergency services among primiparous mothers
who attended prenatal education classes. The study also
found evidence to support the conclusions that primiparous
mothers who participate in prenatal classes demonstrate an
higher level of composure and improved ability to assess
potential dangers concerning the health of infants. Further

investigation is warranted in light of these findings.

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49

50

Crowe, K., 8 von Baeyer, C. (1989). Predictors of a
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Nureinu_leurnall_11(1). 41- 50-

Delgado, L., 8 Lutzker, J. (1988). Training young
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Dietz, H. (1992). Dehydration. In R. A. Hoekelman, S.

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Enkin, M. (1990). Commentary: Are the correct outcomes
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Erikson. E. (1980)- Identit¥_and_the_life_e¥ele (2nd

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Fawcett, J., Pollio, N., Tully, A., Baron, M.,
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adaptation to cesarean birth. ans1ng_Reseazch1_12(l), 49-
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Foye, H. (1992). Anticipatory guidance. In R. A.
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Erimaz¥_nedietrie_eere (pp- 162-180)- St. LouiS. M0: Most-

Freda, M. C., Anderson, H., Damus, K., 8 Merkatz, I.
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client and provider perceptions. lguznal_gfi_gb§;gtz1g1
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Githens, P., Glass, C., Sloan, F., 8 Entman, S. (1993).
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Birth1_ZQ(3): 135-141-

Green, J., Coupland, V., 8 Kitzinger, J. (1990).
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Gruis, M. (1983). Beyond maternity: Postpartum concerns

of mothers. Heternal_9hild_Nureinui_2(3). 182- -188-

Hall, L. (1983). Effect of teaching on primiparas'
perceptions of their newborn. In L. Sherwen 8 C. Toussie-
Weingarten (Eds. ), ° ' '
research (pp. 201— 208). Monterey, CA: Wadsworth.

51

Hamilton-Dodd, C., Kawamoto, T., Clark, F., Burke, J.,
8 Fanchiang, S. (1989). The effect of a maternal preparation
program on mother-infant pairs: A pilot study. The_Amez1gan_
Jeurnal_ef_Qeeunatienal_Theren¥1_11(8). 513- 521.

Handfield, B., 8 Bell, R. (1995). Do childbirth classes
influence decision making about labor and postpartum issues?

Birth1_22(3). 153-150-

Harris, M. (1993). Breastfeeding. In S. Mattson 8 J.
Smith (Eds.), ' - -
(p. 350-358). Philadelphia: Saunders.

Hickey, J., Ouimette, R., 8 Venegoni, S. (1996).

innlicaligns1 Philadelphia: Lippincott.

Hiser, P. (1987). Concerns of multiparas during the
second postpartum week. ' '

and_Neenatal_Nureingi_15(3). 195-203-

Humenick, S., 8 Bugen, L. (1987). Parenting roles:

Expectation versus reality Hater.nal:£h11d_Nureing_.Ieurnal1
12, 36-39.

Jones, M. (1989). A physiologic approach to identifying
neonates at risk for kernicterus.

fixneeelegie_and_ueenatal_Nursinu1_1§(4). 230-236-

Lemmer, C. (1987). Early discharge: Outcomes of

primiparas and their infants. Journa1_gf_Qh§tetz1g1
GYneeeleuie_and_Neenatal_Nursin§1_1§(4). 230-236-

Libbus, M., 8 Sable, M. (1991). Prenatal education in a
high risk population: The effect on birth outcomes. B1zth1
18(2). 78-82.

Lindell, S. (1988). Education for childbirth: A time
for change. ' '

Nureinu1_11(2). 103'112-

Lowe, N. (1993). Maternal confidence for labor:
Development of the childbirth self-efficacy inventory.

Reeeareh_in_Nureinu_8_Health1_1§ 141- -149.

Lowe, N. (1991). Maternal confidence in coping with

labor: A self-efficacy concept. Journal_gfi_gb§tetz1g1
fixneeeleeiei_and_Neenatal_Nursinei_ZQ(6). 457- 463.

Lustig, J. (1993). Fluid and electrolyte therapy. In W.
Hathaway, W. Hay, J. Groothus, 8 J. Paisley (Eds. ), current

2ediatrie_Diagneeie_and;mreatment (pp 1129-1140). Norwalk:
Appleton 8 Lange.

52

Mackey, M. (1995). Women's evaluation of their

Childbirth Performance. Haternal:Child_Nursino_leurna11
23(2), 57-72.

Maloney, R. (1985). Childbirth education classes:
Expectant parents expectations.

G¥neeeleuie1_and_Neenatal_Nursinei_11(3). 245- 248-

Mercer, R. (1985L The process of maternal role

attainment over the first year. Nuzs1ng_Research1_14(4),
198-204.

Muchmore, P. (1993). Sepsis in the newborn. In S.
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Nichols, M. (1995). Adjustment to new parenthood:
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Birth1_22(1), 21-26.

Omar, M. 8 Schiffman, R. (1995). Pregnant women's

perceptions of prenatal care. Md;eznel:£hild_Nurs1ng
Jeurnali_12(4), 132-142.

Orem. D- (1995) Nursinu1_£eneents_ef_nraetiee (5th
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Owens, C. (1996). Incorporating parenting information
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Educatien1_11(1). 14-15-

Polit, D. 8 Hungler, B. (1995). Nuns1ng_zeseazgn1
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St. Clair, P. 8 Anderson, N. (1989). Social network
advice during pregnancy: Myths, misrepresentation, and sound

counsel. B1zth1_1§(3), 103-107.

Salam, C. (1995). Mother's perception of infant care
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Internatienal_Ieurnal_ef_Childbirth_Edueatien1_In(2). 30- 39-

Sheil, E., Bull. M., Moxon, B., Muehl, P., Kroening,
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current_nediatrie_diegnesis_and_treatment (pp 610- -640)
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53

Simkin, P., 8 Enkin, M. (1989). Antenatal classes. In

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Effects of a specialized prenatal adolescent program on

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Tiedje, L. B., Omar, M., Schiffman, R., Buzzitta, C.,
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Walker, B. 8 Erdman, A. (1984). Childbirth education
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Birth1_11(2). 103'108-

Walker, L., Crain, H., 8 Thompson, E. (1986). Mothering
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Young, D. (1995). Changing childbirth: For better and
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Curr1euIum_fer_naternal:Neubern_Nursing (pp. 702 711)
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Appendix A

Baby Care/First Week Scale

54

Appendix A
Baby Care/First Week Scale

Caring for your baby and yourself after delivery is

something new that you needed to learn. Please indicate how

prepared you felt in caring for your baby within the first

week home.

Think back to your first week at home, how well

prepared did you feel to:

1.

Do Daily
care:
Bathing,
Cord care,
Circumcision
care, etc.

Soothe your
crying baby

Understand
the changes
you are going
through as a
new parent

. Feed your

baby

Very Well. Fairly Well Somewhat Not very' Not at

well all
prepared prepared prepared prepared prepared
5 4 3 2 l
S 4 3 2 1
5 4 3 2 1
5 4 3 2 l

 

Appendix B

Danger Signs Scenarios

55

Appendix B
Danger Signs Scenarios

I will read you two situations about life at home with
babies. I will then ask you what you would do in these
situations. You do not have a copy of these situations, so
just listen as I read them.

1.

You and baby have been home form the hospital for 24
hours. You notice your baby's skin or whites of their
eyes is the color of a banana. Although she/he is
awake, her/his body feels limp when you pick her/him

up.
What would you do?
What do you think might be wrong?

Your baby has had 8 liquid green stools in the last
day. Although fussy yesterday, today she/he seems very
sleepy. You have not been able to keep her/him awake
long enough to feed her/him in the last eight hours.
Her/his soft spot is sunken in. Her/his temperature is
102.

What would you do?

What do you think might be wrong?

Appendix C

Subject Consent Form

56

Respondent number:
Informed Consent Form

I understand 1 am being asked to participate in a telephone interview at six
weeks following the delivery of my first child. This interview will be
conducted by Dr. Linda Beth Tiedjc, RN, PhD, Associate Professor in the
College of Nursing at Michigan State University or a nurse from her research
staff. If I agree to participate, I will be called on the telephone and asked
questions about my birth, my feelings of the help I received from peOple who
were with me during labor, the pain I experienced, outcomes for my baby,
resources I have used since delivery, and (ifI had childbirth classes) any
thoughts I have about what I heard in my classes before the baby was born.
The telephone interview will take about 30 minutes. After the interview I
will be mailed a $10 gift certificate.

No risls or discomforts are expected to result from this study, although it is
possible that some of the questions may make me uncomfortable. If this
happens I can let the telephone interviewer know, and since she is a nurse
she will talk with me and refer me for needed help if necessary.

I understand that participation in this study is voluntary and refusing to
participate will not affect my future health care. I also understand that 1 can
stop participating at any time during the telephone interviews; all I have to
say is "I want to st0p". I also understand I am free to only answer the
questions I want to. I know I may benefit by discussing my labor and delivery
with a nurse. In addition, I know this study may help nurses to better plan
childbirth education for other mothers like me.

All information I give will be identified by a code number only. After all the
information has been collected for this study, any information identifying
names with code numbers will be destroyed. The telephone interviews will
be kept in a locked file cabinet with the signed consent forms. My responses
will be anonymous in any report of these research findings.

If I should have any questions concerning this study, or wish to withdraw my
consent to participate, 1 may contact Linda Beth Tiedje, RN at 353-8685.

Signing this consent indicates that I understand and am willing to participate
in the study.

Study participant __________ Date

Phone number WllCl’C you can be reached
cc: Participant

 

Appendix D

UCRIHS Approval Form and
Approval from Sparrow Hospital

 

onmtm
RESEARCH
AND
GRADUATE
STUDIES

University Committee 0
Researchlnvolnng
HumanSuMeds
(UCRIHS)

MdupnflacUmmun
232 Administration Building
DSUMquawm
4M34M6

SUHSSZIN
FAX‘ 517M324!“

m- uo-gan Sm mam
lXAnhmMaWOann
Imminent

M50 is M mum anon
WW mum

57

MICHIGAN STATE

U lfl l \’ E ll 5 l 1' Y

 

March 20, 1996

T0: Linda Beth Tiedje _ '
A—230 Lite Seiences Building

RE: IRE“: 96-183
TITLE: CHILDBIRTH EDUCATION: OUTCOMES RESEARCR
REVISION REQUESTED: N/A
CATEGORY: l-C
APPROVAL DATE: 03/19/96

The University Committee on Research Involving Human Subjects'lUCRIRSl
review of this project is complete.. I am pleased to adVise 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 reVisions listed
above.

RENEHAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a pr03ect beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u te certification. There is a
maximum of four_such expedite renewals ssible. Investigators
wishing to continue a pro3ect beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year
send your written request to the_ CRIHS Chair, requesting reVised
approval and referenCing the progect's IRE I and title. Include
in our request a description of the change and any revised
ins ruments. consent forms or advertisements that are applicable.

PROBLEMS/

CHANGES: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: t1) roblems
(unexpected Side effects, comp aints, e c.) involVing uman
subjects or $2).changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2- 171.

\it‘

Sincerel

  
 
    
 

d s. wright, Ph.D.
RIHS Chair

58

SPARROW

HOSPITAL

 

April 15, 1996

Linda Beth Tiedje

Michigan State University
A-230 Life Sciences Buliding
College of Nursing

East Lansing, MI 48824

RE: Childbirth Education: Outcomes Research

Dear MS. Tiedje:

I am in receipt of your research application requesting review and approval for the above
mentioned protocol by the Sparrow Hospital Institutional Research & Review Committee.

This letter is to inform you that the protocol has been approved under the Sparrow Hospital

Institutional Research 8. Review Committee Policy on Expedited Status Protocol.

Sincerely,

G orge S. Abela, MD, Chairperson
Institutional Research 8. Review Committee

 

lZlS E. Michigan. P.O. Box 30480. Lansing, MI 48909-7980 ' (5W) 483-2700

”Illllllllllllllll