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Title:
Women's perceptions of postpartum stress : a narrative analysis
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Crist, Nancy
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Balancing Factors
Content Analysis
Coping
Crisis Theory
Fatigue
Lack of Support
Role Strain
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non-fiction   ( marcgt )

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Abstract:
ABSTRACT: The impact of stress on the health of postpartum mothers is poorly understood. Although the postpartum period increases risk for stress related diseases such as depression and autoimmune disorders, little qualitative research has focused on women's perceptions of postpartum stressors. A constant comparative content analysis using Atlas.Ti was done on data collected by Groer (NIH R01 NR05000"Influence of Lactation on Postpartum Stress & Immunity) from 2001 to 2005. Women (n=127) answered the prompt, "Think of any one incident, thought, or feeling that stands out as very stressful to you and describe in as much detail as you choose." Researcher triangulation was provided by independent coding of data by two qualitative researchers. The women were predominantly white (91%), married (72%), and not yet working following the baby's birth (70%). Only 28% had family incomes greater than $40,000 per year. Vaginal births were experienced by 66%, 83% without complications. Forty-seven percent were breastfeeding exclusively with 43% bottle feeding. Slightly less than half (48%) were first time mothers. Eighty-nine percent claimed no recent major life event, such as a death in the family. Twenty-seven postpartum stressors were identified that were grouped into five themes: 1) environmental stressors, 2) symptoms of depression, 3) infant health and safety issues, 4) maternal role strain, and 5) lack of support. Seventeen women identified fatigue or lack of sleep as stressful and each questioned her ability to parent a newborn. Though these women would seem low risk for stress (having had an uncomplicated birth, being married and not yet back at work postpartum), 27 different postpartum stressors were identified. Stressors such as lack of sleep may be known by maternal-child nurses, but women are unprepared for them. Interventions need to be designed to provide anticipatory guidance for new mothers regarding postpartum stressors. Tools should be developed for use by clinicians to assess maternal stress in the postpartum period. Prenatal preparation anticipating stressors and postpartum vigilance in assessing stressors could ease the transition into motherhood.
Thesis:
Dissertation (PHD)--University of South Florida, 2010.
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Includes bibliographical references.
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by Nancy Crist.
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Womens Perceptions of Postpartum Stress: A Narrative Analysis b y Nancy Gilbert Crist A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Prof essor: Cecilia M. Jevitt. Ph.D. Adri enne Berarducci, Ph.D. Lois O. Gonzalez, Ph.D. M aureen E. Groer, Ph.D. Date of Approval: May 26, 2010 Keywords: Balancing Factors, Content Analysis, Coping, Crisis Theory, Fatigue, Lack of Support, R ole Strain Copyright 2010, Nancy Gilbert Crist

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DEDICATION To my patient husband, Milford (Mo) friend and soul mate To my chi ldren, Sean and Bryan the amazing duo who continue to inspire me and bring joy to my life. To my father, Franklin Eugene Gilbert and my mother, Betty Louise McClatchey Gilbert who lovingly raised me, encouraging the pursuit of education and service to others. To my mentor and friend, Dr. Marie Visscher

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ACKNOWLEDGEMENTS I extend heartfelt appreciation to my Dissertation Committee Chair, Dr. Cec ilia Jevitt, CNM, and m embers, Dr. Adrienne Berarducci, ARNP, BC, FAANP, Dr. Lois Gonzalez, ARNP, CNS BC, and Dr. Maureen Groer RN, FAAN, for their expertise, guidance, encouragement, and inspiration during the development of this dissertation. I especially thank Dr. Maureen Groer for encouraging me to do the secondary analysis of her data and Dr. Lois Gonzalez for her invaluable contributions during the preliminary stages of this dissertation. Technical assistanc e provided by personnel at the Graduate School and USF Health IS is much appreciated. I am forever grateful to Dr. Mary Ev ans, College of Nursing Associate Dean for Research and Doctoral Programs, for her support and guidance during the extent of my doctor al studies.

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i TABLE OF CONTENTS L IST OF TABLES i v LIST OF FIGURES v ABSTRACT vi CHAPTER ONE: INTRODUCTION 1 Background and Significance 1 Problem Statement 2 Purpose of the Study 3 Research Questions 3 Conceptual Fr amework 3 Methodology 3 Summary 5 CHAPTER TWO: REVIEW OF THE LITERATURE 6 Literature Search Methodology 6 Conceptual Framework 7 Introduction to the Literature Review 10 Postpartum Stressors 10 Postpartum Stressors First Time Mothers 13 Postpartum Stressors Women Living Outside of Their Country of Origin 14 Postpartum Stressors Depression 15 Postpartum Stressors Other Sample Variations 16 Postpartum Stressors Summary 20 Perception of Postpartum Str ess 20 Perception of Postpartum Stress First Time Mothers 21 Perception of Postpartum Stress Women Living Outside of Their Country of Origin 21 Perception of Postpartum Stress Depression 22 Perception of Postpartum Stress Other Sampl e Variations 23 Perception of Postpartum Stress Summary 24 Postpartum Support 24 Postpartum Support First Time Mothers 25 Postpartum Support Women Living Outside of Their Country of O rigin 26 Postpartum Support Depression 27 Postpartum Support Other Sample Variations 27

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ii Postpartum Support Summary 29 Postpartum Coping 29 Postpartum Coping First Time Mothers 29 Postpartum Coping Women Living Outside of Their Country of Origin 30 Postpartum Coping O ther Sample Variations 32 Postpartum Coping Summary 33 Discussion and Conclusions 34 Summary 35 CHAPTER THREE: METHODS 36 Study Design 36 Study Sample 36 Sampling Procedure and Data Collection 37 Institutional Approval 37 Data Analysi s 38 Rigor 39 Summary 41 CHAPTER FOUR: FINDINGS 42 Description of the Sample 42 Research Questions 45 Most Stressful Events 45 Multiple Roles/Tasks/Children 47 Health and Safety of Children 48 Lack of Sleep 49 Tired/Fatigue 49 Significant Other Issues 50 Finances 51 Crying Newborn 52 Emergent Themes 53 Environmental Stressors 53 Symptoms of Depression 55 Health and Safety Issues 56 Roles Strain 57 Lack of Support 57 Connections or Associations 58 Summa ry 58 CHAPTER FIVE: DISCUSSION 59 Summary of the Study 59 Discussion of Study Findings 60 Theme Environment Stressors 60 Theme Symptoms of Depression 60 Theme Health and Safety Issues 61 Theme Rose Strain 62

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iii Theme Lack of Support 62 Strengths and Limitations of the Study 64 Dissemination 64 Implications for Nursing Practice 65 Recommendations for Future Studies 67 Conclusions 68 LIST OF REFERENCES 70 APPENDICES 75 Appendix A: Permission for Use of Original Study Data 76 Appendix B: Informed Consent for Original Study 77 Appendix C: Institutional Approval 78 Appendix D: Narratives and Codings Example 79 Appendix E: Themes, Categories, Events Example 81 Appendix F: Permission For Use of Figure 84 Appendix G: Original Narrative Transcript Example 86 ABOUT THE AUTHOR END PAGE

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iv LIST OF TABLES TABLE 1: Reviewed Qualitative Studies on the Postpartum Experience 11 TABLE 2: Components of Crisis Theory Paradigm and Reviewed Qualitative Studies on the Postpartum Experience 12 TABLE 3: Study Sample Demographic Characteristics 43 TABLE 4: Postpartum Stressful Events Categories 46 TABLE 5: Emergent Themes of Postpartum Stress 54

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v LIST OF FIGURES FIGURE 1: Crisis Theory Paradigm 9

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vi Womens Perceptions of Postpartum Stress: A Narrative Analysis Nancy Gilbert Crist ABSTRACT The impact of stress on the health of postpartum mothers is poorly understood. Although the postpartum period increa ses risk for stress related diseases such as depression and autoimmune disorders, little qualitative research has focused on womens perceptions of postpartum stressors. A constant comparative content analysis using Atlas.Ti was done on data collected by Groer (NIH R01 NR05000Influence of Lactation on Postpartum Stress & Immunity) from 2001 to 2005. Women (n=127) answered the prompt, Think of any one incident, thought, or feeling that stands out as very stressful to you and describe in as much detail as you choose. Researcher triangulation was provided by independent coding of data by two qualitative researchers. The women were predominantly white (91%), married (72%), and not yet working following the babys birth (70%). Only 28% had family incomes gre ater than $40,000 per year. Vaginal births were experienced by 66%, 83% without complications. Forty seven percent were breastfeeding exclusively with 43% bottle feeding. Slightly less than half (48%) were first time mothers. Eighty nine percent claimed no recent major life event, such as a death in the family. Twenty seven postpartum stressors were identified that were grouped into five themes: 1) environmental stressors, 2) symptoms of

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vii depression, 3) infant health and safety issues, 4) maternal role strai n, and 5) lack of support. Seventeen women identified fatigue or lack of sleep as stressful and each questioned her ability to parent a newborn. Though these women would seem low risk for stress (having had an uncomplicated birth, being married and not yet back at work postpartum), 27 different postpartum stressors were identified. Stressors such as lack of sleep may be known by maternal child nurses, but women are unprepared for them. Interventions need to be designed to provide anticipatory guidance for new mothers regarding postpartum stressors. Tools should be developed for use by clinicians to assess maternal stress in the postpartum period. Prenatal preparation anticipating stressors and postpartum vigilance in assessing stressors could ease the transi tion into motherhood.

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1 CHAPTER ONE INTRODUCTION Background and Significance The birth of a baby is a normal life event. As Groer, Davis, and Hemphill (2002) state, the postpartum period is a time of joy and satisfaction and also a time of vulnerabil ity or even crisis. Mothers may experience numerous stressors after giving birth. Excessive stress may be a threat to maternal well being. A classic study (N= 95) by Horowitz & Damato (1999) on postpartum stress identified four categories: roles, tasks, re sources, and relationships. Stress by itself does not constitute a crisis, however, an actual or perceived stressful event may precipitate a crisis. The literature suggests that new mothers perception of stressors, degree of social support and other factors related to coping, such as cultural and socioeconomic factors, influence the postpartum experience (Chan, Levy, Chung, & Lee 2002; Duong, Lee, & Binns, 2005). It is important to examine what specific stressors are identified by postpartum women in orde r to facilitate prevention or elimination of the stressors and their effects. Published qualitative studies suggest that postpartum stressors are present in all cultures, although perception of stress and coping may vary (Chan, et.al. 2002; Duong, & Binns 2005; Edge, Baker, & Rogers, 2004; Hildingsson, & Thomas, 2007; Leung, Arthur, Martinson, 2005; Rodrigues, Patel, Jaswal, & de Souza, 2003; Tammentie, Paavilainen, Astedt Kurki, & Tarkka, 2004; Templeton, Velleman, Persaud, & Milner,

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2 2003). Relationships are affected after childbirth, and marital problems and in law confl ict can be issues (Chan, et al. 2002; Rodriques, et al. 2003; Templeton, et al. 2003). Expectations of life after childbirth are frequently not consistent with reality (Leung, et al. 2005; Tammentie, et al. 2004). Postpartum women express feelings of entrapment, loss of control, being tied down, being bound to their environment, aloneness, confusion, nervousness, tearfulness, worry, and ambivalent feelings t oward the newborn (Chan, et al. 2002; Fooladi, 2006; Leung, et al, 2005; Tammentie, et al. 2004). Lack of practical help and emotional support are frequently cited issues (Rodrigues, et al. 2003). Husbands who are uncarin g and disengaged from newborn care and support of the mother ha ve been indicated as causal factors in pos tpartum depression (Chan, et al. 2002; Rodrigues, et al. 2003). The multitude of problems that many postpartum women endure also include violence, financial difficulties, helplessness, hopelessness, and a feeling of being trapped in a situation in which the only way out seems to be by violent means (Chan, et al. 2002; Templeton, et al. 2003). Women who breastfeed described a positive impact on the postpar tum experience, including improved mental health and sense of empowerment as young mother s (Fooladi, 2006; Duong, et al. 2005). In a study of women who did not breastfeed (N=9) lactation suppression by medication was associated with significant experiences of postpartum blues compared with women who used breast bi nders to suppress milk production (Fooladi, 2006). Problem Statement There is paucity of research addressing the impact of stress on the experience of postpartum women. In order to increase awareness of and sensitivity to the impact of

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3 stress during the postpartum period, specific postpartum stressors need to be identified and described. Purpose of the Study The purpose of this study was twofold. First a narrative analysis of written text was used to identify events which postpartum women consider the most stressful experience since the birth of their babies. Second was to identify and describe common themes regarding stressful events in the experience of postpartum women. Research Questions Two research questions were addressed : 1) What are the mos t stressful events experienced postpartum women? 2) What are common themes regarding stressful events experienced by postpartum women? Conceptual Framework The researcher acknowledges that qualitative research is not undertaken with a preconceived conc eptual framework. However, Aguileras C risis T heory model was used to guide and organize the literature review St ress is the central concept of C risis T heory and the balancing factors are perception of the stress, support, and coping mechanisms, all of wh ich are components found in the qualitative postpartum research. Methodology This qualitative study wa s a secondary data analysis of a larger study funded by the National Institutes of Health (R01 NR05000) focusing on the influence of lactation on postpa r tum stress and immunity (Groer, Davis, Casey, Smith, Kramer, & Bukovsky 2005). The purpose of the original study was to examine demographic, immune,

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4 endocrine, stress mood and health characteristics of formula feeding compared to breastfeeding mothers me asured between four and six weeks postpartum The qualitative component was intended to gather more data about postpartum stress in part to help refine the Tennessee Postpartum Stress Scale which the authors developed. Qualitative analysis was used to capt ure the rich description of postpartum stressors not expressed by aggregate statistical data. Content analysis, a qualitative research method, was conducted on written narrative responses to the question, Think of any one incident, thought, or feeling tha t stands out as very stressful to you and describe in as much deta il as you choose. The subset (n=127) from the larger study (N=200) consisted of women, four to six weeks postpartum, who answered this question in writing on the questionnaire. The purpos e of data analysis in qualitative research is to impose some order on the large volume of data collected. Analysis facilitates clarification of the essential interpretations of the raw data (Mi les & Huberman, 1994; Speziale & Carpenter, 2007). The verbatim transcripts were analyzed using content analysis, a method of descriptive analysis of text. It is performed step by step in order to descr ibe prominent themes (Speziale, & Carpenter, 2007 ). The transcripts of the written text were imported into the softwa re program ATLAS ti (Muhr, 1997). Initial coding of text fragments based on content was done b y the investigator and compared with independent coding by two doctoral committee members proficient in ATLAS ti. The coding framework was discussed by the invest igators and modified until agreement was reached. All text units belonging to a code of the coding framework were sorted according to the themes of the thematic framework. Text units were then re read to be sure that no emerging themes

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5 had been overlooke d. Illustrative quotes were selected, translated, and, when necessary, edited to improve clarity without changing meaning. Summary Though childbirth and assuming the role of mother are usually thought of as characterizing a time of excitement and joy, ther e is significant stress experienced by many postpartum women. Postpartum stress is a problem and needs to be looked at in greater depth. This chapter provided an introduction to the study by addressing the background and significance of the study, the prob lem statement, the purpose of the study, the research questions, the conceptual framework and the methodology The following chapter summarizes the review of extant liter ature on qualitative studies addressing the experience of postpartum women.

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6 CHAP T E R TWO REVIEW OF THE LITERATURE This chapter focuses on conceptualization of the research problem and a review of literature as it pertains to the postpartum experience. First, there is an elaboration of the conceptual framework guiding this review. Second the literature search methodology is defined. Finally a synthesis of published qualitative studies structured according to the crisis theory paradigm is presented. Specifically, studies that relate to 1) stressors experienced by postpartum women, 2) per ception of stressors experienced by postpartum women, 3) sources of support for postpartum women, and 4) methods of coping utilized by women during the postpartum period. Literature Search Methodology The literature search focused on qualitative studies in postpartum health. Qualitative research was specifically targeted in order to ascertain a richness of data often not captured in reports of aggregate statistics. The following key search terms were used in database searches: qualitative studies in postpar tum health, qualitative studies in postpartum care, qualitative postpartum experience, and qualitative postpartum stress. Computerized databases, including PubMed, CINAHL and PsycInfo, as well as reference lists from articles, were used to identify qualita tive studies in postpartum womens experiences. Inclusion criteria were studies published from 2002 through 2010, in peer reviewed journals in the English language.

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7 Conceptual Framework The C risis T heory conceptual model was used to examine the phenomena of stress and coping in the postpartum period. This conceptual framework was chosen because the dynamics of the postpartum experience as revealed in the literature are consistent with the components of the conceptual model. Crisis T heory provides a way to view the impact of stressors on womens postpartum experience. Stress, a complex psychological and interpersonal phenomenon, is the central concept in crisis theory as explained by Aguilera (1998). The C risis T heory paradigm is depicted in Figure 1. Psych ological cr isis refers to the inability of an individual to solve a problem. Individuals exist in a state of emotional equilibrium, which is a state of balance or homeostasis. The goal is always to return to or to maintain that state of balance or homeosta sis. Individuals are regularly faced with a need to solve problems in order to maintain equilibrium. When something occurs that is different, whether positive or negative, or a change, or a loss that creates a state of disequilibrium, people endeavor to re gain and maintain the previous level of equilibrium. Depending on past experience related to the immediate problem, some people are more proficient at finding solutions than others. When an individual is in crisis, that individual is at a turning point. Af ter many attempts at solution are made, the coping mechanisms that have worked before are ineffective in readily solving the problem. This results in increased inner tension and signs of anxiety with disorganization of function and the decreased ability to find a solution. The individual feels helpless, caught in a state of immense emotional distress, and feeling unable to act on her own to resolve the problem. Crisis is dangerous in that it

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8 threatens to overwhelm the individual or family, which may ultimately result in suicide or a psychotic break with reality (Aguilera, 1998). Crisis has four developmental phases (Aguilera, 1998). First, an initial rise in tension exists as the stimulus/stress continues and more discomfort is felt. During the second phase, the stimulus/stress continues and more discomfort is felt due to a lack of success in coping. With the third phase, tension increases further and acts as a powerful internal stimulus; internal and external resources are mobilized. Emergency problem solving mechanisms are tried. In this stage, a) the problem may be redefined, or b) resignation may occur as selected aspects of the goal may be given up as unattainable. In the fourth phase, a major disorganization occurs if the problem continues without resolu tion or avoidance. When a stressful event occurs, recognized balancing factors may determine the state of equilibrium. Strengths or weaknesses of any of these factors can be directly related to the onset of crisis or to its resolution. These balancing fac tors are perception of the event, available situational support, and coping strategies. Aguileras (1998) paradigm illustrates the effect of balancing factors in a stressful event (Figure 1). The individuals usual initial reaction to a stressful event is demonstrated in the upper portion of the paradigm. The role of the balancing factors is shown in the lower portion of the paradigm. This literature review is structured according to Aguileras (1998) Crisis T heory paradigm.

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9 Figure 1 Crisis Theory Paradigm: the effect of b alancing factors in a stressful event (Aguilera, 1998) State of equilibrium Human organism State of disequilibrium Need to restore equilibrium Realistic perception of the event Stressf ul event Stressful event Balancing factors present One or more balancing factors absent Adequate situational supports No adequate situational supports Adequate coping mechanisms No adequate coping mechanisms Problem unresolved Resolution of th e problem Equilibrium regained Disequilibrium continues AND PLUS AND RESULT IN RESULT IN PLUS Distorted perception of the event No crisis CRISIS

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10 Introduction to the Literature Review The time frame for postpart um or postpartum period described in these studies ranged from several months to 12 plus months. This differs from the conventional American medical definition of the postpartum period being the first six to eight weeks post delivery (Gorrie, McKinney & Murray, 1998; Scott, Gills, Karlan & H aney, 2003). The summary of the retrieved published qualitative literature is depicted in Table 1. This literature review is structured according to Aguileras (1998) C risis T heory paradigm and is presented in four sections: 1) postpartum stressors, 2) per ception of postpartum stress, 3) postpartum support, and 4) methods of postpartum coping. As depicted in Table 2, most of the studies reviewed addressed multiple components of the phenomenon of stress in the experience of postpartum women; therefore, most of the studies are cited in more than one of the following sections. Postpartum Stressors Both physiological and psychological stress can be produced by a variety of dissimilar situations. Horowitz and Damato (1999) suggest that maternal stressors may be events, situations, or demands that women identify as sources of mental, emotional, or physical discomfort, anguish, or difficulty during the postpartum period. Groer, et al. (2002) indicate that specific postpartum stressors consist of overlapping catego ries of physical, intrapersonal, and interpersonal phe nomena. According to the crisis theory model stress stimuli, or stressors, are conditions of threa t or loss (Aguilera, 1998). The next section explore s stressors reported by postpartum women. Qualitative studies are included that identify postpartum stressors. Eighty percent of the retrieved studies address postpartum stressors.

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11 Table 1: Reviewed Qualitative Studies on the Postpartum Experience Study N Location Sample Method Comments Amankwaa, 2003 1 2 USA African American Interview PPD diagnosed Chan, et.al., 2002 35 HK, China Interview Phenomenologic PPD diagnosed Deave, et.al, 2008 24 UK 1 st Interview; Content Analysis time moms Edge, et.al., 2004 101 UK Black Caribbean im migrants Mixed metho d; Narratives Fooladi, 2006 9 USA Focus groups, Interview; Ethnographic Forster, et.al., 2008 42 Australia Focus groups, Interviews George, 2005 10 USA 1 st Interview Grounded Theory time moms Hanley, & Long 2006 10 UK Interview PPD diagnosed Hildingsson & Thomas, 2007 827 Sweden Mailed questionnaire; Content Analysis Hoang, et.al., 2009 10 Australia Asian im migrants Interview Grounded Theory Kanotra, et.al., 2007 324 USA PRAMS Survey and Comment data Kiernan,2002 5 USA Audiotaped Therapeutic touch Kurtz Landy, et.al., 2009 24 Canada Interview; Descriptive Design SED Leung, et.al., 2005 20 HK, China Interview Doing the Month Nelson, 2004 7 USA 1 st Phenomenologic/Hermeneutic time moms, 36 45 y.o. Parvin, et.al., 2004 25 UK B angladeshi im migrants Focus groups Razurel, et.al., 2009 60 Switzerland 1 st Interview time moms Rodrigues, et.al., 2003 39 India Interview 19 identified with PPD during study Ross, et al., 2005 17 Canada LGBQ Focus Groups Shakespeare, et.al., 2004 39 UK Interview PPD EPDS (Edinburgh Postnatal Depression Scale) Spear, 2006 53 USA Adolescents Descriptive telephone survey Tammentie, et.al., 2004 9 Finland Interviews Grounded Theory PPD diagnosed Taniguchi & Baruffi, 2007 45 USA Japanese im mig rants Mixed Method; Telephone Interview Ugarriza, et al., 2007 20 USA Anglo American. Interview Prevention activities for PPD Wilkins, 2006 8 UK 1 st Interview Grounded Theory time moms Legend: HK Hong Kong PPD Postpartum Depression UK United Kingdom LGBQ Lesbian, Gay, Bisexual & Queer SED Socioeconomically Deprived USA United States of America

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12 Table 2: Components of Crisis Theory Paradigm and Reviewed Qualitative Studies on the Postpartum Experience Study Stressors Percept ion of Stressors Support Coping Total Components Addressed Amankwaa, 2003 X X X X 4 Deave, et.al., 2008 X X X X 4 Hanley & Long.,2006 X X X X 4 Kurz Landy et..al., 2009 X X X X 4 Parvin, et al., 2004 X X X X 4 Razurel, et.al., 2009 X X X X 4 Shakespeare, et al., 2004 X X X X 4 Taniguchi, et al., 2007 X X X X 4 Wilkins, 2006 X X X X 4 Chan, et al., 2002 X X X 3 Forster, et.al., 2008 X X X 3 George, 2005 X X X 3 Leung et al., 2005 X X X 3 Rodrigues, et al., 2003 X X X 3 Tammentie, et al., 2004 X X X 3 Nelson 2004 X X X 3 Spear, 2006 X X X 3 Hildingsson, et al., 2007 X X 2 Kanotra, et.al., 2007 X X 2 Ross, et al., 20 05 X X 2 Kiernan, 2002 X X 2 Edge, et al., 2004 X X 2 Hoang, et.al., 2009 X 1 Fooladi, 2006 X 1 Ugarriza, et al., 2007 X 1 TOTAL 21 (84%) 17 (68%) 20 (80%) 15 (60%)

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13 Postpartum Stressors First Time Mothers In this literature review, five qualitative studies on the postpartum experience of women addressed stressors in samples of first time mothers. George (2005) examine d the experiences of first time mothers (N=10) following discharge from the hospital after vaginal delivery. Change in priorities was stressful. There was the ne ed to reorganize everything because the newborn became the priority. Multiple tasks were found to be difficult. There was frustration with the role transition process and confusion about role expectations, a phenomenon that called for definition of the rol es. The discomfort and pain from the birthing experience was not anticipated, and interfered with womens ability to care for both themselves and their babies. Lack of sleep and fatigue was of significant concern of the women. A study conducted in the Uni ted States ( US ) had the purpose of creating a phenomenologic text explicating the experience of older, first time mothers (N=7) during the first year following childbirth (Nelson, 2004). These women found it a struggle to blend lifestyles. Reconciling thei r previously formed adult lifestyle and multiple priorities with a very time consuming new priority, that of motherhood, was often emotionally and physically exhausting. Deave, Johnson, and Ingram (2008) conducted a study in the United Kingdom ( UK) and as ked first time mothers (N=24) and their partners about their transition to parenthood. Breastfeeding was reported as stressful, as well as the pressure from health professionals to continue breastfeeding. The new parent relationships were strained. They w ere surprised at the demands that had been placed on their relationships, and how having a baby affected them as a couple creating negative interactions, such as snapping

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14 at each other. Wilkins (2006) interviewed first time mothers (N=8) in another UK stu dy in order to gain an understanding of their postpartum experiences. Primary stressors identified were an unsettled baby, a crying baby, and having little contact outside of the home and the baby. Postpartum stressful events, social support and coping str ategies of primiparous women (N=60) were explored in Geneva, Switzerland, by Razurel, BruchonSchweitzer, Dupanloup, Irion, and Epine y (2009). Interaction with care givers during hospitalization was considered a significant stressful event, primarily becaus e difficulties encountered by mothers were seen as minimized, or there was contradictory information provided. Issues related to breastfeeding, such as pain and difficulties in bre astfeeding were stressful events identified in both the hospital and at home for these postpartum women. Other frequently noted postpartum events indicated as stress producing were the logistics of organization, crying and rhythm of the baby, and concern for the health and care of the baby. Postpartum Stressors Women Living Outs ide Their Country of Origin In this literature review, three qualitative studies on the postpartum experience addressed stressors in samples of women experiencing postpartum living outside their country of origin. Japanese women in Hawaii (N=45) were eval uated by Taniguchi and Baruffi (2007) to assess the stress women experience during childbirth in a foreign country. Findings of postpartum stressors included language barrier, distance from family and friends, different culture, healthcare attitude about childbirth, crying babies, lack of breast milk during the first night after hospital discharge, always staying with their baby at home, and weakening of memory and cognitive skills. At the same time, they worried

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15 that their partners did not share an unders tanding of their physical and psychological postpartum situation, their loneliness, and feelings of isolation. Hoang, Le, and Kilpatrick (2009) used interviews to investigate Asian migrant womens (N=10) childbirth experiences in rural Tasmania, Australia. Lack of support from extended family in the new country was stress producing for these women. As described by one woman, I did all the house work and looked after my two children by myself. Bangladeshi women in the UK (N=25) were studied by Parvin, Jones, and Hull (2004) to explore first generation Bangladeshi womens understandings of postpartal distress, and to describe postpartum coping strategies. The results revealed the presence of several stressors. Support at home was lacking as the women had no relatives in the UK. These women had little opportunity to rest, as they immediately resumed the roles of mother, wife and housewife after returning from the hospital, having to deal with everything by themselves. Postpartum Stressors Depression Thr ee qualitative studies in this literature review on the postpartum experience addressed stressors in samples of women diagnosed with postpartum depression. In a study (Amankwaa, 2003) designed to describe the nature of postpartum depression among A frican A merican women, the participants (N=12) reporte d three categories of stressors: physical, mental and external. Pain, surgery, infection, complications, and current health problems were examples of physical stressors. Mental stres sors included feelings of lo neliness, unmet expectations, birth plan disappointment, and abandonment. External stressors included situations such as colicky newborns, sibling care, lack of

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16 support, partner concerns, employment, and financial concerns. Participants stated that multip le physical, mental, and external stressors contributed to sleeplessness, fatigue, and irritability, subsequently resulting in declining physical health and energy. Moreover, participants expressed opinions, without elaborating, that having too much support, being alone without family, and not having their mothers available when they wanted them to be there, were explicated as significant postpartum stressors. Hanley and Long (2006) examined the experiences of Welsh mothers (N=10) diagnosed with postnatal depression. Economic pressures and financial restrictions necessitated the mothers returning to work, leaving little quality time for their babies and family. The demand of many roles left them feeling exhausted all the time. In Finland, Tammentie, et a l. (2004) conducted a study (N=9) to ascertain experiences of family dynamics when the mother suffers from postnatal depression. Circumstances such as little time for the parents to spend together, infants lack of rhythm infant discordance with family activity patterns, and marital discord were identified as postpartum stressors. Postpartum Stressors Other Sample Variations The following nine qualitative studies on womens postpartum experience addressed postpartum stressors in various other samples. A US study designed to identify challenges that women face two to nine months postpartum (N=324) found that staying home with the newborn and not going out were difficult to tolerate (Kanotra, EAngelo, Phares,Morrow, Barfield, & Lansky, 2007). Mothers w ere concerned about ho w to care for their newborn babies at home, particularly regarding activities such as holding, bathing, and clothing. These women also found that returning to work posed a problem

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17 because it was difficult to continue breastfeeding due to limited time, support, and facilities for pumping their milk. In a large city in the northeast US, Kiernan (2002) examined the experience of therapeutic touch in the lives of postpartum women (N=5). Stressors identified were struggling with the demands of newborns, and having little time for themselves. Spear (2006) used a descriptive telephone survey (N=53) in a US study to examine the breastfeeding experiences and related behaviors of adolescent mothers after discharge from the hospital. Stressful e vents related to breastfeeding included inadequate milk supply, sore nipples, responsibilities associated with school and employment, and inadequate postnatal breastfeeding support. In an Australian study (N=42), Forster, McLachlan, Raner, Yelland, & Gold (2008) conducted focus groups and interviews to gain a more indepth understanding of womens views, expectations and experiences of early postnatal care. These mothers described anxiety and/or fear in two areas: the health and wellbeing of the baby and tr ansition to motherhood and parenting. They were concerned that leaving the hospital too early would interfere with professional support needed while acquiring new skills, establishment of breastfeeding, and the opportunity to rest and be cared for. Rodrig ues and colleagues (2003) studied postpartum women in India (N=39) to describe attitudes and perceptions toward childbirth. They indicated that economic difficulties, poor marital relationship, gender preference, low involvement of husbands in child car e, and insufficient or lack of practical support at home were stressful postpartum experiences. It was noted that strained relationships with husbands and inlaws were centered around the desired gender of the baby.

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18 Hildingsson & Thomas (2007) conducted a study in Sweden (N=827), using a mailed questionnaire and content analysis, in order to solicit and describe womens opinions about what is important to them during pregnancy and birth. Breastfeeding the baby was found to be frustrating and stressful. Ther e was concern about the timing of discharge from the hospital to home. The women didnt want to go home before getting their strength back and having breastfeeding established. To explore and describe the experiences of socioeconomically disadvantaged (SED ) postpartum women (N=24) in the first 4 weeks after hospital discharge, Kurtz Landy, Sword, and Valaitis (2009) interviewed a purposive sample in two large cities in southern Ontario, Canada. One identified stressor was related to financial probl ems invol ving material deprivation, poor quality housing, struggling with food security, and difficult access to transportation. Participants described inadequate or lack of social support as being stress producing. The changes and challenges of having a new baby w hile recovering from childbirth, and at the same time, resuming their day to day responsibilities, were described as difficult. Subjects indicated surprise at the hardship of multiple demands placed on them with other children at home. Having their persona l information shared among the many community services was stress producing. Absence of help at home with the day to day activities and housework was a strain. A complex relationship with the babys father was noted to produce stress. These relationshi ps w ere unstable or nonexistent. Additionally, there were those fathers who refused acknowledgment of paternity. Little or no sleep and fatigue complicated all circumstances. Added to all this was the fear of getting pregnant related to difficulty in accessin g birth control.

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19 A Canadian study by Ross, Steele, and Sapiro (2005) looked at a sample (N=17) of lesbian, gay, bisexual, and queer (LGBQ) women to assess predisposing and protective factors for perinatal depression. Lack of social support from their fami ly of origin and from the lesbian and gay community was stressful for these women. Both partners were extensively involved with the baby, which resulted in strain at times. Negotiating the parenting roles to ensure equal opportunity for bonding with the ba by proved to be challenging. Hong Kong Chinese women (N=20) were interviewed to explore their perceptions of stress induced by doing the month and the support they received from participating in the traditional postpartum ritual (Leung et al. 2005). Doing the month refers to the traditional ritual for Chinese postpartum women which include 1) environmental constraints, 2) prohibitive rituals, and 3) a care provider for the newborn. Environmental constraints include living in a small area, being unfa miliar with the environment, the loss of privacy, and being in someone elses home. The living area, typically the inlaws small flat (apartment), is crowded with helpers and relatives and friends paying visits, and the woman is guarded by others from goi ng out. The prohibitive rituals call for specific behavioral restrictions with strict adherence to the ritual without allowing any flexibili ty. Included in these rituals are refraining from touching water or being exposed to wind, not being allowed to use air conditioning or a fan, and not being allowed to take a bath daily in order to avoid getting the wind into the joints. The newborn care provider made all decisions related to child care. Findings revealed sources of stress to be environment constraint s, difficulties in following the proscriptions of the rituals, and decreased access to the newborn. Conflict between the parties involved was another

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20 stress producing factor. The conflict may be between the new mother and the care provider, or between mother in law and the maternal mother. The conflicts usually centered around the method of child care, how strictly to follow the traditional ritual of doing the month, or the actual practice in doing the month. The new mother is caught between the mother in law and the maternal mother; the husband would agree only with his own mother. Postpartum Stressors Summary In summary, the review of published qualitative literature supports the presence of numerous postpartum stressors. These stressors are relate d to the needs of a new baby, as well as preexisting stressors in relationships with the babys father, in law expectations, cultural constraints, and issues related to ones self as a mother and as a woman. Perception of Postpartum Stress Perception, or subjective meaning, is the mental processes by which intellectual, sensory, or emotional data are organized logically or meaningfully (Varcarolis, 2006). Emotional and psychological reactions to a life event are influenced by an individuals percepti ons of this event. Perception influences both the meaning assigned as well as personal reaction to stressors (Figure 1) (Aguilera, 1998). What does it mean to the person? How is the event seen to influence the future? Maternal perception of stress is influ ential in shaping postpartum adaptation (Horowitz & Damato, 1999). This cognitive process, i.e., interpretation, is a primary factor in determining choices of coping behaviors engaged by an individual (Aguilera, 1998). According to the crisis theory model, perception of a stressful event is a recognized balancing factor that may determine the state of equilibrium (Aguilera, 1998). This section will address the affective and

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21 interpretive aspects of the perception of stress in the experience of postpartum wom en. The affective and interpretive components of perception of stress are interrelated and difficult to separate into concrete entities. Therefore, they are introduced jointly in this section. Included are qualitative studies related to the maternal percep tion of postpartum stressors. Sixty four percent of the retrieved studies addressed perception of stressors during womens postpartum experience (Table 2). Perception of Postpartum Stress First Time Mothers In this literature review, three qualitative s tudies on the postpartum experience addressed perception of postpartum stress in samples of first time mothers. George (2005) found that first time mothers (N=10) in the US felt overwhelmed by the responsibility and frustration with role transition. Firsttime mothers in the UK (N=8) expressed feelings of inadequacy related to their inability to recognize their babies needs without advice from others (Wilkins, 2006). They thought that they would automatically know what to do, that caring for their babies w ould be instinctual. In addition, primiparous Swiss women (N=60) perceived that their partners lacked understanding of their needs (Razurel, et al. 2009). Perception of Postpartum Stress Women Living Outside Their Country of Origin In this literature r eview, three qualitative studies on the postpartum experience addressed perception of postpartum stress in samples of women experiencing postpartum living outside their country of origin. Hoang and colleagues (2009), found that postpartum Asian migrant wom en (N=10) in Australia, were having to do all the work and look after the children with no assistance. This left them feeling lonely, isolated,

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22 tired, and miserable. They looked after their babies in an appropriate manner, but they were not happy and did n ot find it an enjoyable experience to do so. Bangladeshi women in the UK (N=25) described emotional responses to postpartum stressors as being 1) restless or without peace in their minds, 2) feeling sad, bad or angry, 3) being tearful, and 4) not getting any comfort from looking after their children (Parvin, et al. 2004). Japanese women in Hawaii (N=45) described having poor body image, feeling loneliness and isolation, and left behind because they always stayed with their baby at home (Taniguchi & Baruffi 2007). Perception of Postpartum Stress Depression Five qualitative studies in this literature review on the postpartum experience addressed perception of postpartum stress in samples of women diagnosed with postpartum depression. Amankwaa (2003) reported that African American women (N=12) felt lonely and abandoned. These women held the belief that multiple physical, mental, and external stressors contributed to sleeplessness, fatigue, and irritability, subsequently resulting in declining physical hea lth and energy. Chan and colleagues (2002) examined the lived experience of Hong Kong Chinese women diagnosed with postpartum depression (N=35). Women expressed feelings of hopelessness, helplessness and loss of control. They felt trapped in a situation wi th no way of escape except by violent means, such as homicide or suicide. Feelings towards the baby were ambivalent, including both hate and love. The unhappiness expressed by the women was attributed to noncaring husbands, and the controlling and powerfu l in laws.

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23 When Welsh women (N=10) (Hanley and Long, 2006) rested or attended to domestic chores, there was a sense that they were abandoning their children and they had feelings of guilt. Their many roles were perceived to be an excessive burden and too demanding thus leaving them feeling exhausted all the time. Among working women, there was resentment at giving up employment. They felt a loss of status, independence and finance. Shakespeare, Blake, and Garcia (2004) interviewed postpartum women diagnose d with postpartum depression (N=39) in the UK. They reported that breastfeeding difficulties were exhausting and time consuming. In Finland, Tammentie, et al., (2004) (N=9) found that women perceived that the infant tied the mother down. Home was felt to be like a prison, where the highpoint of the day was the postmans visit. There were feelings of inadequacy and that all of the mothers energy was drained by childcare. Perception of Postpartum Stress Other Sample Variations The following five quali tative studies on the womens postpartum experience addressed perception of stress in various other samples. A lack of confidence in themselves as new mothers and their ability to care for their babies was a finding by Forster and colleagues (2008) in a sa mple of Australian postpartum women (N=42). Postpartum women in India (N=39) described feelings of being overworked and unsupported (Rodrigues et al. 2003). These feelings were reportedly linked to tiredness and other symptoms, which in turn may have cont ributed to strained relationships. Some US adolescent mothers (N=53) perceived breastfeeding to have an empowering effect on them as young mothers (Spear, 2006). Socioeconomically disadvantaged (SED) postpartum women (N=24) in Canada, felt frustration and loss of

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24 dignity at having to rely, for all their needs, on their parents low incomes (Kurtz Landy, et al. 2009). Their feeling of being out of control was related to the multiple demands of postpartum and the sharing of their private, personal information by many community services agencies. Fatigue contributed to their perception that the first few weeks were overwhelming. As previously described, doing the month refers to the traditional ritual for Chinese postpartum women. Hong Kong Chinese women (N= 20) participating in the traditional ritual felt trapped in their environment (Leung, et al. 2005). They felt deprived of the chance to carry or have contact with the baby. The new mothers felt incompetent and worried that they would not be able to handle the baby when the care provider left at the end of the proscribed period. Perception of Postpartum Stress Summary In summary, despite the arrival of the awaited newborn, it is evident that the postpartum experience can be a stressful time as is revealed in descriptive perceptions of the stressors encountered. The effect of the stress on womens postpartum experience is related to percepti on of the stressors encountered, both the affective reaction and interpretation. Postpartum Support Social support an essential resource utilized in preventing or altering stressful life event responses, is described as evidence, tangible and intangible, that leads the individual to believe she is cared for, loved, and a valued member of her social and familial netwo rk (Aguilera,1998). According to the crisis theory model, available situational support is a recognized balancing factor that may determine the state of

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25 equilibrium (Figure 1) (Aguilera, 1998). This section elaborates on the role of support in the experien ce of postpartum women. Qualitative studies reviewed addressed maternal support during the postpartum experience. Fifty two percent of the retrieved studies addressed the concept of support reported by women during the postpartum experience (Table 2). Pos tpartum Support First Time Mothers In this literature review, three qualitative studies on the postpartum experience addressed sources of support in samples of first time mothers Deave and colleagues (2008) found that for first time mothers (N=24) in the UK, the main source of support was female relatives, primarily their mothers. The practical support their mothers provided ranged from baby care to housework. In addition, cooking and babysitting ma de it possible for some couple time out for the pare nts. Postnatal support groups were useful mainly for reassurance that, as new parents, they were all going through similar difficulties and experiences. Primiparous Swiss women (N=60) perceived that social support by health professionals was insufficient in the early postpartum (Razurel, et al. 2009). At the same time, these women felt emotional support to be the primary protective factor in the stressful event of breastfeeding. Social support from the maternal grandmother was positively received. On the other hand, women perceived that their partners lacked understanding of their needs during postpartum. First time mothers (N=8) in the UK reported that practical help received in the midwife led centers after delivery and peer support were found to be important during postpartum recovery and adjustment (Wilkins, 2006). All participants desired the

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26 availability of a handy reference guide, practical tips, a checklist, or prompts and cues at their deposal for reference support. Postpartum Support Women Living Outside Their Country of Origin In this literature review, three qualitative studies on the postpartum experience addressed sources of support in samples of women experiencing the postpartum period living outside their country of origin. Resul ts of an Australian study (Hoang, et.al., 2009) showed that family and community play an important role in supporting Asian migrant women through the postpartum. Four reported that in the month following birth their recovery went well. This was attributed to the great deal of support they experienced from husband, family, friends, and community. Six women reported very little support, as their husbands were the only source of help, while at the same time having work or study commitments. They described thei r postpartum experiences in contrast to those of women having received a great deal of support. Women receiving little support felt exhausted, tearful, miserable, isolated, and unhappy. Two women reported a lack of extended family support for this postpart um period, after having had previous birth(s) in their country of origin. They attributed their feeling lonely, isolated and tired to the lack of support. In Bangladesh, women experience a 40 day rest and recuperation period. During this time maternal tas ks are delegated to others such as servants or female extended family members. In contrast, the Bangladeshi women in the UK (N=25) did not have this support at home, as relatives were not available (Parvin, et al. 2004). Japanese women in Hawaii (N=45) fou nd that help after childbirth from the participants mothers decreased the incidence of postpartum depression (Taniguchi and Baruffi, 2007).

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27 Postpartum Support Depression Two qualitative studies in this literature review on the postpartum experience ad dressed sources of support in samples of women diagnosed with postpartum depression. AfricanAmerican women (N=12) expressed opinions, without elaborating, being alone without family, and not having their mothers available when they wanted them to be there were significant postpartum stressors (Amankwaa, 2003). On the other hand, having too much support was also perceived as stressful. Hanley and Long (2006) found that Welsh mothers (N=10) relied on social services and voluntary support groups. The help and guidance of grandmothers, which was the prime support network in previous generations, was not available. A Finnish study (N=9) found that the fathers physical presence was significant to the woman (Tammentie, et.al., 2004). With the concrete support of the fathers physical presence, the infant became the couples mutual responsibility. Other important sources of support were the grandparents and peer groups. Postpartum Support Other Sample Variations The following five qualitative studies on wome ns postpartum experiences addressed sources of support in various other samples. In a US study (N=324), 32% of the comments on postpartum concerns related to perceived need for social support following hospital discharge (Kanotra, et al. 2007). Women expr essed interest in postpartum support groups, such as new mother support, breastfeeding support, and couples support. Some stated that lack of support contributed to difficulty in continuing to breastfeed when returning to work. General public attitudes ups et some women and discouraged others from breastfeeding. Social stigma attached to breastfeeding in public

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28 and general lack of support for breastfeeding were perceived as prohibitive attitudes. In addition, a desire for additional support in newborn care w as expressed by multiparas as w ell as first time mothers. These mothers wanted more education and advice on holding, bathing, and clothing the baby. In a Florida study (N=20), Ugarriza, Brown, and Chang Martinez (2007) assessed postpartum depression prevention activities of Anglo American mothers. Results revealed that support from family and friends make it possible for the woman to achieve mandated rest, some degree of needed social seclusion, and assistance with tasks. Support is also given by social rec ognition of the womans new social status as a mother, such as a baby shower, and behavior that indicates special recognition by the husband. A majority of socioeconomically disadvantaged (SED) postpartum women (N=24) in Canada (Kurtz Landy et al. 2009) r eported inadequate or a lack of social support. This was related to being raised in SED families. For many, family and friends were not a support as they were too stressed themselves to be able to provide help. Some received material or financial assistanc e from family members, the babys father, or friends; however, it had to be untraceable, to avoid losing government assistance. In general, there was an absence of practical help with the day to day activities and housework, as well as traditional social support. Among lesbian, gay, bisexual, and queer (LGBQ) women (N=17) in Canada, the lack of social support from the family of origin, as well as the lesbian and gay community was reported as stress producing. In contrast, participants were very satisfie d with their partners support (Ross, et al. 2005).

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29 Hong Kong Chinese women (N=20) as aforementioned, participating in the traditional postpartum ritual of doing the month , reported that this tr adition provided abundant material support (Leung et al. 2005). Rest and early recovery of physical health was enhanced. However, psychological support was lacking to facilitate adjustment to the mother role. The care provider was responsible for child care and the new mother was not included. Postpartum Suppor t Summary In summary, the literature provides examples of appropriate support. However, there is evidence that lack of or inadequate practical and emotional support can contribute to distress in the experience of postpartum women. Postpartum Coping Co ping is described as reactive adjustments, conscious and unconscious, to environmental stress in order to maintain psychological integrity (Aguilera, 1998). According to the crisis theory model, coping is a recognized balancing factor that may determine th e state of equilibrium (Figure 1) (Aguilera, 1998). This section will examine coping in the experience of postpartum stress management. Qualitative studies will be addressed related to maternal coping in the postpartum experience. Sixty percent of the re trieved studies addressed coping methods reported by women during the postpartum experience (Table 2). Postpartum Coping First Time Mothers In this literature review, five qualitative studies on womens postpartum experience addressed methods of coping with stress in samples of first time mothers. Deave and colleagues (2008) studied first time mothers (N=24) in the UK. Having been

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30 surprised at the demands placed on their relationship, and how having a baby affected them as a couple, such as snapping at each other, these mothers and their partners found that relationship tension was reduced by spending time together and by making time to talk. George (2005) found that first time mothers in the US (N=10) were motivated to information seeking behavior by their perception of overwhelming responsibility and not knowing what to do. Older fir st time mothers in the US (N=7) used intense organization and planning as coping strategies (Nelson, 2004). Razurel, et al. (2009) identified strategies that Swiss women (N=60) used for coping with postpartum stressors as social support and mobilization of internal resources. Emotional support was seen as the primary protective factor related to the second most stressful event identified, breastfeeding. Avoidance or minimi zation was used for stressful events related to their own health, such as urinary incontinence. One sample of women (N=7) in the UK handled postpartum stressors through skill development, organization, and postpartal support groups (Wilkins, 2006). Avoida nce was another coping strategy. Because they did not want to reveal mothering inadequacies or they feared the perceived criticism of others, some mothers did not venture into the outside world. Postpartum Coping Women Living Outside Their Country of Or igin In this literature review, three qualitative studies on the postpartum experience addressed methods of coping with stress in samples of women experiencing postpartum living outside their country of origin. For Japanes e women in Hawaii (N=45) the me ans of coping with postpartum stresses emphasized social support (Taniguchi and Baruffi,

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31 2007). Some made the journey to Japan to seek support. Others communicated frequently by telephone and email with mothers, sisters, and friends who had experienced chi ldbirth. Still others found social support when their mothers came from Japan to help. In a mixed method study to compare the prevalence of depressive symptoms during and after pregnancy f or black Caribbean women and white British women, Edge, and colleagu es (2004) also explored black Caribbean womens help seeking attitudes (N=101) A powerful counter to depression as described by these women is their self concept as strong, black women, suggesting that they shared a common bond with women who not only e ndured but overcame adversity, disadvantage, and discrimination. As one woman put it, It all relates to slavery. There was great emphasis placed on autonomy, personal action and means, and mas tery over their lives. They felt the need to plan their way out of adversity, and to achieve financial independence, both of which are often linked. Additionally, spirituality was seen as a means to manage adversity. Black led churches and faith communities were sources from which a majority of these women drew neede d spiritual, emotional and practical support. This was true even when the women had no religious affiliation. The general feeling about coping with the stressors of postpartum for Bangladeshi women (N=25) in the UK was reported as Y ou do it, not giving thought about how you would do it (Parvin et al. 2004). This could include the woman relying on her own ability to manage problems and emotional distress, keeping yourself happy, or praying to Allah.

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32 Postpartum Coping Other Sample Variations The following seven qualitative studies on womens postpartum experience addressed methods of coping with postpartum stress in various other samples. Using focus groups, a study by Fooladi (2006) of women in Texas (N=9) explored personal experiences with postp artum blues in relation to crying, breastfeeding, lactation suppression, and prior pregnancy loss. Findings revealed that postpartum mental health was improved by the calming effect of breastfeeding. Women who reported breastfeeding for more than six weeks although they were tired, described feeling happy, thrilled, content, lucky, and blessed. In addition, women who used medications and breast binding to suppress prolactin hormone experienced more emotional turmoil compared with women who chose to brea stfeed. I n the UK postpartum women (N=39) described three strategies in dealing with the difficulties of breastfeeding (Shakespeare, et al. 2004). The first was total commitment to learning the skill of breastfeeding, at the exclusion of all else. The se cond strategy used by some was to stop breastfeeding altogether. And the third w as to adopt a flexible approach by mixing breastfeeding with bottle feeding. Women in a US study (N=324) expressed interest in support groups to facilitate adjustment during the postpartum, such as, new mother support, breastfeeding support, couples support, and grieving support (Kanotra, et al. 2007). Kiernan (2002) found Therapeutic Touch (TT) to be helpful to postpartum women. Therapeutic Touch (TT) is a reciprocal healing modality involving a mutual process of care and concern between two or more individuals. During the process the practitioner quiets, centers, and focuses his or her attention, then moves his or her hands carefully and intentionally in the two threeinch space around the other persons body

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33 searching for subtle differences in feeling tone. The hands are then used to intervene in a purposeful way to promote well being and change (p. 47). This US study (N=5) revealed that mothers found therapeutic touch to be a valuable asset in coping with the demands of a newborn and having little time for themselves. It helped them to stop, refocus, calm, and relax. In an Australian study, postpartum women (N=42) reported a lack of confidence in themselves as new mothers regarding their ability to care for their baby (Forster, et al. 2008) Coping with this stressor was facilitated by the physical presence and the availability of professional support, which helped alleviate their concerns. Rodrigues, et al. (2003) studied postpartum women (N=39) in India and found two strategies helpful in coping with postpartum stressors. Distraction from their worries was one, such as involving themselves in household work, caring for the children, watching television, or seeking out the company of others. The other strategy was described as just sit at a table and cry for Gods help. Socioeconomically disadvantaged (SED) postpartum wom en in Canada (N=24) described their coping strategies as the use of antidepressants, smoking cigarettes and receiving limited support from their families (Kurtz Landy, et al. 2009). Postpartum Coping Summary In summary, the literature reveals a variety of maternal postpartum coping methods. Coping methods differ in relation to specific populations. Org anization and planning, developing and integrating new routines, maintaining supportive relationships, accessing religion/spirituality beliefs and practices, having an attitude of resilience such as strong black woman, breastfeeding, rest, and social rit uals are examples of coping factors used by postpartum women.

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34 Discussion and Conclusions In the 25 retrieved qualitative studies on womens postpartum experience, various population groups were the focus: American, AfricanAmerican, Anglo American, Austral ian, Canadian, Chinese, Finnish, Indian, Swedish, Swiss, Welsh, Bangladeshi in the UK, black Caribbean in the UK, British, Japanese in the US, Asian in Australia, adolescent mothers, first time mothers, lesbian mothers and women diagnosed with postpartum depression. The overall summary of the retrieved published literature is found in Table 1. Eighty four percent of the 25 studies address postpartum stressors, while 68% speak to perception of postpartum stressors. Eighty percent discuss maternal support during postpartum, and 60% address methods of coping with postpartum stress. Each of the four components of the crisis theory paradigm (Figure1) stressors, perception of stressors, support, and coping is spoken to by 36 % of the studies, while 32% talk about three of the four components. Two components are addressed by 20%, and 12% discuss one of the four. Table 2 shows the distribution of the components within the retrieved studies. Numerous postpartum stressors have been identified in the literature re view of qualitative studies on the postpartum experience. It is evident that the postpartum experience can be a stressful time as is revealed in descriptive perceptions of the stressors encountered. The literature provides examples of appropriate support. However, there is evidence that lack of practical and emotional support varies in the experience of the postpartum woman. The literature reveals that maternal postpartum coping experiences differ in relation to the specific populations.

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35 This review of literature on qualitative research of womens postpartum experience is consistent with the use of the C risis T heory model as a framework by which to view the postpartum period (Figure 1) (Aguilera, 1998). Literature reviewed supports the presence of numerous stressors related to coping with the needs of a new baby, as well as preexisting and coexisting stressors in relationships with the babys father, in law expectations, cultural constraints, and issues related to ones self as a mother and as a woman. The review findings support the notion that a negative environment, spanning a continuum of nonsupportive to oppressive in nature, disrupts womens connection to community and can produce feelings of isolation, helplessness, and powerlessness. Summary This chapter provided a review of the literature in the areas of stressors experienced by postpartum women, perceptions of stressors experienced by postpartum women, support experienced by postpartum women, and coping mechanisms utilized by postpartum women from qualitative studies. The following chapter addresses methods utilized in this qualitative study.

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36 CHAPTER THREE METHODS The purpose of this study was to identify events which postpartum women consider the most stressful experience since the birth of their babies and to identify and describe common themes regarding these stressful events. This chapter describes the research methodology and analytical processes that were used in this study. Included sections address study design, study population, sa mpling procedure, data collection, data analysis, and rigor. Study Design Qualitative research is appropriate to discover, describe, interpret and understand human experience (Streubert Speziale and Carpenter, 2007), and can provide ideas and hypotheses for future study (Robson, 2002). Based on current published research, it is apparent that qualitative research captures some of the postpartum health issues not captured by aggregate statistics. An advantage of qualitative descriptive studies is a comprehens ive summary of an event in the everyday terms of those events (Sandelowski, 2000). This qualita tive descriptive study utilized the process of content analysis. Study Sample Demographic data assessed included several elements. These include d age, race, m arital status, income, employment status, method of newborn delivery, pregnancy or childbirth complications, major life events, and whether the participant breastfed or formula fed her baby.

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37 Sampling Procedure and Data Collection This qualitative study w as a secondary data analysis of a larger study funded by the National Institutes of Health (R01 NR05000) focusing on the influence of lactation on postpartum stress and immunity (Groer, et al. 2005). The purpose of the original study, conducted from 2001 t o 2005, was to examine demographic, immune, endocrine, stress and health characteristics of postpartum mothers, either exclusively lactating or formula feeding, measured between four and six weeks postpartum. The aim of this study was to classify and summa rize, via secondary data analysis, the most stressful events in a population of postpartum women in the southeastern United States, utilizing the data from the qualitative component of the larger study (N=200). This subset (n=127) from the larger study ans wered the stressful event question in writing on the questionnaire. Institutional Approval Based on the Code of Federal Regulations, Part 46: Protection of Human Subjects this study was granted an exempt status by the University of South Florida Institutional Review Board (IRB). This exemption was granted based on the published exempt criteria that 1) the study consist of existing data, 2) the information is recorded so that subjects cannot be identified, and 3) that data exists before the project begins. Th e data were numerically coded without identifiers in order to provide anonymity. The subjects consented to participation in the original study. A letter from the original investigator granting permission to use the data and a copy of the consent form use d are included in Appendix A and B Approval to conduct the study was obtained from the Institutional Review Board of the University of South Florida (Appendix C ).

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38 Data Analysis The purpose of data analysis in qualitative research is to impose some orde r on the large volume of data that are collected. Analysis facilitates clarification of the essential interpretations of the raw data (Mile s & Huberman, 1994; Speziale & Carpenter, 2007). Analysis was conducted on written responses to the question, Think of any one incident, thought, or feeling that stands out as very stressful to you and describe in as much detail as you choose in order to identify events which postpartum women consider the most stressful experience since the birth of their babies and t o identify and describe common themes regarding these stressful events. The qua litative data were transcribed by the original research team. The verbatim transcripts were analyzed using content analysis, the preferred strategy in qualitative studies for descriptive analysis of text. Content analysis is oriented toward summarizing the data by informational content, and is performed step by step in ord er to describe prominent themes (Sandelowski, 2000; Speziale & Carpenter, 2007 ). The data were analyzed ut ilizing six steps based on Giorgi (1985) for describing psychological meanings: 1. The transcripts were read in entirety to get a sense of the whole. 2. The same descriptions were read again, and meaning units were identified. 3. Meaning units were coded. 4. The meaning units were compared and contrasted in order to eliminate redundancies and to identify essential characteristics. 5. The essential characteristics were reviewed and classified by subject into emerging themes.

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39 6. An attempt was made to integr ate and synthesize connected events/themes of the phenomenon. Transcripts were read and meaning units were marked directly on the transcript. Identified meaning units were then coded. Coding involved summarizing the essence of the meaning unit in the lan guage of the informant. An example of a coded transcript is included as Appendix D In addition, the transcripts of the written text were imported into the software program ATLAS ti, which analyzes qualitative data electronically (Muhr, 1997). Initial codi ng of text fragments based on content was done by the researcher by hand and compared with the independent coding of two qualitative researchers Lois Gonzalez, Ph.D., and Cecilia Jevitt, Ph.D., proficient in ATLAS ti. The coding framework was discussed an d modified until agreement was reached. The transcripts were reread and modifications in the coding were established in accordance with the agreed coding framework. In the same way agreement was reached on a thematic framework, consisting of main themes a nd sub themes. All text units belonging to a code of the coding framework were sorted according to the themes of the thematic framework. Text units were reread to be sure that no emerging themes had been overlooked. Illustrative quotes were selected, tr anslated, and, when necessary, edited to improve clarity without changing meaning. Therefore, dynamics underlying the postpartum experience were examined by identifying, across all informants, stressful postpartum events, categories of stressful events, an d emergent themes (Appendix E) Permission was obtained from Elsevier to reproduce Aguileras Crisis Theory Paradigm (Figure 1) (Appendix F). This was used as the framework for the final literature review.

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40 Rigor The goal of rigor in qualitative research is to accurately represent study participants experience (Speziale &Carpenter, 2007 p. 38). Rigor in this study was facilitated using the method appropriate strategy of triangulation the qualitative evaluative criteria of auditability. Triangulation is an approach to research that uses a combination of more than one research strategy in a single investigation (Speziale & Carpenter, p.379). Triangulation is further explained by Speziale and Carpenter (2007). The purpose in qualitative research is to inc rease the credibility and validity of the results. Applying the principles of triangulation in a study design facilitates confirmation of findings and conclusions by cross checking data from multiple sources and decreasing potential for bias. There are fou r basic types of triangulation: data, investigator, theory, and methodological. Investigator triangulation was used in this study. This is when two or more researchers work together on the same study, each having divergent backgrounds yet possessing areas of expertise that are complementary. The process in this study was previously addressed in analysis of the data. The areas of expertise are distinct yet complementary: maternal child nursing and mental health nursing. Auditability refers to whether anot her researcher can follow the thought process of the research as the data were being analyzed (Nelson, 2004, p. 286). This was previously addressed by outlining the steps taken in analysis of the data. Speziale and Carpenter (2007) refer to the establishm ent of rigor through an audit trail by the term dependability. The researcher is responsible for providing enough information so that another researcher reading the study would come up with similar conclusions (Speziale

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41 & Carpenter, 2007, p. 38). A method of determining dependability outlined by Lincoln and Guba is the dependability audit. This entails an outside person examining both the process and the product to determine if the former is dependable and that the latter is internally coherent. In this s tudy, an outside researcher, Lois Gonzalez, Ph.D., reviewed the whole data set to confirm that the process was dependable. The outside researcher was provided with the data set in the form of an audit trail. This audit trail included: raw data in the form of transcriptions (Appendix G), coded transcriptions (Appendix D), and an outline of the eme rgent themes and essential characteristics (Table 5). Summary This chapter described the research methodology and analytical processes that were used in this study There was discussion of the study design, study population, sampling procedure, data collection, da ta analysis, and rigor. The following chapter will discuss the findings of the study.

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42 CHAPTER FOUR FINDINGS This chapter reports the study findings. Sections address the description of the study sample, frequently occurring postpartum stressors, and salient themes of postpartum stressors that emerged during the analysis. Description of the Sample The sample for this investigation (N=127), which is the subset from the larger study (N=200) (Groer, et.al., 2005), consisted of women four to six weeks postpartum who answered the qualitative question in writing on the questionnaire: Think of any one incident, thought, or feeling that stands out as very stre ssful to you and describe in as much detail as you choose. Ninety one percent of participants were Caucasian, 72% were married, 70% were not employed, and 40% had an incom e of less than $20,000 annually. The annual income for 28% of participants was great er than $40,000. Vaginal delivery was experienced by 66%, complications of delivery were rare at 14 %, and method of infant feeding was almost equally divided at 47% breast feeding exclusively and 43% formula feeding. Fifty two percent of the participants were 20 to 29 years of age, 89% reported experiencing no major life event prior to the study and 45% did not routinely exercise. Regarding parity, 43% had one child, 39% had two children, and 14% reported having three or more children. Demographic charact eristics are summarized in Table 3.

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43 Table 3: Study Sample Demographic Characteristics Characteristic n % of N Race/Ethnicity White 116 91% Asian 1 1% African American 4 3% Hispanic 3 2% Nat ive American 0 Other 1 1% No Response 2 2% Marital Status Single 31 24% Married 91 72% Divorced 1 <1% Widowed 1 <1% No Response 2 <2% Response Undeterminable 1 <1% Employment Status None 89 70% Part Time 11 9% Full Time 25 20% No Response 2 1% Annual Income Less than $10,000 27 21% $10,000 $20,000 24 19% $20,000 $30,000 21 17% $30,000 $40,000 11 9% Greater than $40,000 36 28% No Response 8 6% Type of Delivery Vaginal 84 66% Cesarean 42 33% No Response 1 <1% Delivery Complications No 106 83% Yes 18 14% No Response 2 <2% Response Undeterminable 1 <1%

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44 Table 3: Study Sample Demographic Characteristics (continued) Characteristic n % of N Method of Infant Feeding Breast 60 47% Formula 55 43% No Response 12 10% Age Less than 20 19 15% 20 29 65 51% 30 39 39 31% No Response 4 3% Experience Major Life Event No 113 89% Yes 9 7% No Response 3 2% Response Undeterminable 2 2% Exercise Routinely (minutes per week) None 57 45% 0 30 25 20% 30 60 19 15% 60 90 9 7% 90 120 13 10% No Response 4 3% Number of Children Zero 4 3% One 54 42% Two 49 39% Three 13 10% Four 4 3% Five 0 Six 1 <1% No Response 2 < 2%

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45 Research Questions Narrative responses to the question Think of any one incident, thought, or feeling that stands out as very stressful to you and describe in as much detail as you choose were obtained to better understand womens postpartum experience. Two research questions guided the study. First, what are the most stressful events experienced by postpartum women? Second, what are common themes regarding stressful events expe rienced by postpartum women? Most Stressful Events The first research question was What are the most stressful events in the experience of postpartum women? From the 127 informants, 171 stressful events were indicated. Multiple events were reported by some participants. In some instances, an individual event could have more than one coding. The coded text fragments were categorized. Categories of stressors reported by the population sample are shown in Table 4. Seven categories were salient, containing 114 (67%) of the 171 coded events. These most frequently occurring stress experience categories include multiple roles/tasks/children, health and safety of children, lack of sleep, significant other issues, finances, fatigue, and crying newborn.

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46 Table 4 : Postpartum Stressful Events Categories Category Coded Events % of Total Events Multiple Roles/Tasks/Children 32 (19%) Health & Safety of Children 24 (14%) Significant Other Issues 14 (8%) Lack of Sleep 14 (8%) Finances 10 (6%) Tired 10 (6%) Crying Newborn 10 114 67% (6%) **************************************************************** School or Work 7 (4%) Breastfeeding 7 (4%) Misc ellaneous Incidents 7 (4%) Alone 5 (3%) Housing 5 (3%) Car Problems 5 (3%) Child Care 4 (2%) Parent/In Law Intrusion 4 (2%) Own Illness 3 (2%) Away from Family 3 (2%) Newborn Contact with Dad 2 (1%) Extra People Around 2 (1%) Self Image 2 (1%) Depressed 1 57 33% (1%) Total 171 100%

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47 Multiple Roles/Tasks/Children The stress experience category of multiple roles/tasks/children includes 32 (19%) of the 171 coded events. To illustrate, several examples of narrative follow. My 3 year old and new baby crying and husband wanting lunch all at one time (three people wanting one person me) thats hard on me but I seem to do it. Mothers have to be strong for their family no matter what. Going to store with all three of my kids. Worrying if there is enough buggy room. If I got enough food. Getting kids and food in van. Get ting kids and food in house. Putting stuff up. Trying to clean house, take a shower, and watch the baby all at the same time. Supermom. I have a two year old and five year old twins. Everyone thinks that I can do everything all by myself. I cant and I cant get anything done with two needing bottles and two others needing things, too. It seems never ending. Currently, the most stressful part of my life is trying to care for a newborn, clean the house, cook, getting my two older children to mind me and cook meals.

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48 Health and Safety of Children The stress experience category of health and safety of children includes 24 (14%) of the 171 coded events. For illustration, s everal examples of narrative follow. The baby had awful diarrhea for about fiv e days right after birth. It caused a terrible diaper rash that made her miserable. Evenings are stressful due to babys colic. Wish I could make her better. Parents are stressed and tired. One thing that causes a great deal of stress is my older son who has been diagnosed as ADHA. He ignores me when told/asked to do/not do something. He teases his younger cousin when I sit down to feed the baby. He wants to pick up the baby and carry him and bounce around with him. The baby wasnt gaining weight lik e her doctor wanted her to and I had to keep taking her for infant weight checks and paying for them. The stressful thing is that she is eating but just not gaining weight. I spilled the baby out of the car seat (the handle wasnt locked right) as I he ad outside to go gardening. He only fell onto the bench he was sitting on, but onto his face and was screaming for a short while. Not even a mark on him, but I had to call my husband to tell him and calm down (the baby stopped crying right away but I took a bit longer). Felt so guilty but thankful he hadnt fallen all the way to the floor.

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49 Lack of Sleep The stress experience category of lack of sleep includes 14 (8%) of the 171 coded events. Several examples of narrative are as follow s: How can I get sl eep when baby is up all night and day? Some days I am so tired that I stress out not knowing when I will be able to sleep more than two hours at a time. At times I am very sleepy which becomes very stressful for me to get some sleep since I have to foc us on the baby and her needs. I try to sleep a little while she sleeps but I just cannot fall asleep thinking she might wake up any moment. I dont hardly get any sleep because of my baby. But its okay. Just very, very tired due to lack of sleep. Ti red/Fatigue The stress experience category of tired/fatigue includes 10 (6%) of the 171 coded events. Following are s everal examples of narrative illustrating this category Being tired makes me more irritable and I get upset or frustrated easily. On my second and third nights home I was exhausted and my baby cried all night and wanted to eat constantly. I didnt know if he was getting enough milk and my husband thought he was starving. We almost gave him formula but I wouldnt. My nipples were raw an d I was so tired. If I had any energy I could have been more patient. Instead I cried and doubted my abilities as a mother.

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50 My three year old son has been having a hard time adjusting to the new schedule lifestyle of having a new baby and summer schedule changes. He also got a cold. All of this has caused him to have more temper tantrums and night terrors than usual. This has caused stress for me as a parent and my husband as arents/spouses. Are we handling it right? How long will this last? We are so tir ed and are we reacting correctly or not because we are so tired? Always being tired. Many times I feel I cant take care of the baby. I have to wake up several times in the night and she does not sleep unless I hold her. I am so tired and frustrated. I feel like I am not a good mother. Significant Other Issues The stress experience category issues with significant other includes 14 (8%) of the 171 coded events. Several examples of narrative illustrate this category Getting into arguments with spou se then having the fear of losing him. My babys dad is not with me any more. Seeing him when he comes to visit the baby is stressful. My husband decided to stay home with the baby and our thirteen year old. He considers weekends as his days off. When asked to come with me and the kids to a little event, he answer s

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51 no with a hurtful comment: Why would I wa ste my days off with you guys!? This comment bothered me and still hurts a lot. Just having a baby and my husband never really helps me. And on top of that having to cook and eat, clean and waking up every hour or two to feed. I am happy he is here, but he wears me out and I have been so tired since the first day that I always fall asleep feeding him. Im feeling sad in a way because things have changed between me and my spouse for the better but we dont have any time to ourselves anymore. My husband and me fighting cause I was not spending a lot of time with him, so he was going to leave. But we talked and its fine now. Im finding more time for him. Finances The stress experience category of finances includes 10 (6%) of the 171 coded events. For illustration, several examples of narrative follow. I have been extremely worried about finance. My husband only makes $16,000 a year and that sc ares me. I have been worried about him getting a new job. Lack of finances. Finances cause a lot of stress as far as frequency but a lot of stress regarding to the amount. This stress leads to feelings of not being able to provide for our child, losing

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52 w hat things we currently have, keeping a roof over our head, food on the table, clothes on our backs, etc. BILLS. Going back to work. I desperately want to stay home with my baby but we cant afford it. My husband came in at three oclock a.m. and w hen I complained about it he packed his stuff and left me and my kids with all the bills. Crying Newborn The stress experience category crying newborn includes 10 (6%) of the 171 coded events. Several examples of narrative illustrating this category fol low. The baby seems to cry often and for no reason that I can tell. I find that I count down the time until my husband comes home from work so that I can get things done at home. When the baby cries, I feel like I need to just run away. Because my husba nd sleeps during the day and works at night, the baby does not want his father, just me. My baby crying non stop when nothing I do helps. When my son wakes up and screams, it is like he is in excruciating pain and it is difficult for me to console hi m. I worry that he will get no relief. I just have to try anything to get him as comfortable as possible.

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53 Babys crying at night for hours, after being fed, changed, etc. Sometimes it seems like it will never stop. Emergent Themes The second research question was What are common themes regarding stressful events in the experience of postpartum women? Categories of coded stressful events emerged from the content analysis of text fragments using the agreed upon coding framework. Emergent themes were id entified based on content and logical reasoning From the responses of the 127 informants, five salient themes emerged from the data across informants:1) Environmental Stressors, 2) Symptoms of Depression, 3) Health and Safety Issues, 4) Role Strain and 5) Lack of Support (Table 5). Environmental Stressors Environmental stressors is the predominant theme of this study. Of the 171 coded stressful events in this study, 52 (30%) fit in the Environmental Stressors theme. Three categories accounted for 53% of the events in this theme: 1) crying newborn, 2) finances, and 3) school or work. Other categories include newborn contact with dad, extra people around, child care, housing, car problems, and miscellaneous incidents (Table 5). Mothers sp oke of t he newborn crying as occurring all night, fo r hours, often, long term, three days, and seems like it will never stop . The crying newborn was difficult to console. Mothers reported that nothing I do seems to help, or they had no ide a what was going on, or that they didnt know what was wrong; the baby was crying for no reason that I can tell. One mother expressed that when her baby cries, she feels the need to run away. Of concern was the comment that the baby was

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54 Table 5: Emerg ent Themes of Postpartum Stressful Events Theme Coded Events Stressful Events Categories Environmental Stressors 51 Crying Newborn Finances School or Work Newborn Contact with Dad Extra People Around Child Care Housing Car Problems Miscellaneous Incidents Symptoms of Depression 35 Lack of Sleep Tired Alone Poor Self Image Own Illness Depressed Health and Safety Issues 31 Childrens Health/Safety Breastfeeding Role Strain 32 Multiple Roles/Tasks/Children Lack of Support 21 Significant Other Issues Parent/In Law Intrusion Away from Family crying pur posefully. Another category in the Environmental Stres s ors theme was finances. Concerns ranged from needing a better paying job, to the husband walking out and leaving his wife and the children with all the bills. Other elaborations on financial concern s were that the husband was out of work, or the husbands income was $16,000, or that the state of the economy was such that the mother couldnt afford not to work. One woman spoke of the lack of finances to continue providing the basic necessities for he r children food, clothing, and a home and the fear of lo sing what they had.

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55 Other notable environmental stressful events reported in this study were returning to work and returning to school. Some women expressed the stress as 1) having to leave the newborn and other children, 2) not being around them, or 3) leaving them in the care of others. Symptoms of Depression Of the 171 coded stressful events in this study, 35 (20%) fit in the Symptoms of Depression theme. Three categories account for 83% of th e events in this theme: 1) lack of sleep, 2) tired, and 3) alone. Other categories are poor self image, own illness, and depressed (Table 5). Participants reported a lack of sleep, being tired and alone. These categories accounted for 83% of the events in this theme. Some women said they were tired all the time. With others, dealing with newborn colic left them stressed and tired. For some, frequent newborn feedings, every one to two hours, left little opportunity for sleep. One woman stated tha t she has been so tired since the first day that I always fall asleep feeding him. Another woman asked, How can I get sleep when the baby is up all night and day? As another put it, Some days I am so tired that I stress out not knowing when I will be able to sleep more than two hours at a time. One woman explained her sleepiness as I do not like being so tired that I feel like I am going to pass out. Some described the effects of lack of sleep and being tired as irritability, getting upset or frustrated easily, not having the nerves to stay calm, crying, and headaches. One woman had to explain to her friend that sleep deprivation was the reason for her behavior; she was not avoiding her or being aloof. Still others were so tired and frustrated

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56 that they doubted their abilities as a mother. Women spoke of being alone, feeling lonely and forgotten, and having no one to turn to. Health and Safety Issues Of the 171 coded stressful events in this study, 31 (18%) fit in the H ealth and Safety Issues the me. Childrens health and safety accounted for 78% of the event s in this theme. Breastfeeding is the other cat egory (Table 5). Stressful events regarding newborn safety were 1) aggressive four year old sibling who hits the baby, 2) older sibling with ADHD who wants to pick up the baby and carry and bounce him around, 3) newborn fell out of the car seat, 4) newborn in a life jacket, sleeping soundly, feared strangled, 5) newborn safety in dads care he used drugs and his live in girlfriend could be violent, and 6) day care will newborn be well cared for? One woman felt lack of control over the total safety of her children, worrying about her children getting hurt in an accident of some kind. Stressful events regarding newborn health were 1) a possib le problem with the spine, 2) diarrhea and diaper rash, 3) lack of weight gain, 4) colic, 5) not taking newborn out in public to avoid illness, 6) avoiding illness when newborn has five older siblings, and 7) needed blood work drawn at four days of age. For one woman, an older child had surgery soon after her babys birth. Another woman didnt want her brother, who had obsessive compulsive disorder (OCD), around her children. He was aggressive, emotionally abusive, and had frequent and unpredictable outburs ts. Several women questioned their mothering abilities, usually related to times when they were tired, frustrated, or didnt understand what was going on with the newborns behavior. Issues related to breastfeeding were reported by the women

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57 as stressful e vents. These issues were primarily clustered around the establishment of breastfeeding in the early postpartum. Role Strain Multiple roles /tasks/children is the one category of stressful events in the Role Strain theme. Of the 171 coded stressful events in this study, 32 (19%) are accounted for in this theme (Table 5). Onehalf of the events in this theme mentioned being the mother of multiple children. In addition, there are the attention demands of older children, conventional schooling or home school ing, sibling adjustment and jealousy, and dealing with older children difficulties such as truancy or ADHD. There are multiple roles and multiple tasks mother, wife, domestic tasks, MD appointments, and chauffeur which complicate these postpartum women s lives. Lack of Support Of the 171 coded stressful events in this study, 21 (12%) fit in the Lack of Support theme. Significant other is the category that accounts for 67% of the events in the theme. Other categories include away from family, and parent/in law intrusion (Table 5). Almost one half of the e vents reported were arguing or fighting with the husband or boyfriend. One woman reported fight ing with her husband because he wanted more of her time or he was going to leave. Again, almos t one half of the reported events revealed that the husband would not help with the children or the home. In addition, one woman shared that her husband made her choose between his help and her mothers help with the newborn. Another woman stated she had s ustained a significant

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58 emotional hurt by her husband that resulted in her feeling depressed and having trouble focusing. She describes being so stressed that she wrecked her car and then was even more stressed. Also, little or no parent together time was a stress factor. Connections and Associations Another analysis was undertaken to look at the events and themes to determine whether there were any connections among them. No findings seemed to be connected except that all those who expressed that they w ere tired or lacked sleep, also questioned their ability to parent. Seventeen of the 127 participants (13.3%) expressed a connection between tiredness or not enough sleep with either direct statements (overt) or implied (covert) questioning of their abilit y to parent. Summary In addition to a demographic description of the sample, this chapter presented the results obtained in this qualitative secondary data analysis. Findings identified 1) the most stressful events in the postpartum experience of these wom en since the birth of their babies and, 2) common themes regarding stressful events in the experience of these postpartum women. Among the findings, one association was found. The following chapter will summarize the study including discussion of the findi ngs, implications, strengths and limitations of the study, recommendations, and conclusions.

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59 CHAPTER FIVE DISCUSSION The purpose of this final chapter is to provide a summary of the study and a discussion of the research findings presented in Chapter F our. In addition, strengths and limitations of the study, plans for dissemination, implications for nursing practice, and recommendations for future studies are included. Summary of the Study This was a qualitative descriptive study of postpartum women ( N=127) undertaken to identify their stress producing events. A secondary analysis was conducted on qualitative data collected (2001 to 2005) in a larger study (Groer, et a l. 2005). The study sample consisted of women, four to six weeks postpartum, from the southeast United States. Content analysis included identification and coding of text fragments based on content, elimination of redundancy to identify stressful events, and examination of these stressful events to identify emergent themes across informant s. Five salient themes emerged. These themes are a) External Stressors, b) Symptoms of Depression, c) Health and Safety Issues d) Role Strain, and e) Lack of Support. Lack of sleep / fatigue and questioning ability to parent was the one connection between themes that emerged from the findings.

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60 Discussion of Study Findings Theme Environmental Stressors This prominent theme primarily dealt with the stressors of crying newborns, financial concerns, and returning to school or work. The comment that t he baby was crying purposefully i s a concern. This could suggest that there is a lack of maternal knowl edge about newborn development, possibly putting babies at risk for abuse. Literature reviewed reported that a crying baby ( Razurel, et al. 2009; Tani guchi & Baruffi, 2007; Wilkins, 2006), an unsettled baby or a babys lack of rhythm (Razurel, et.al., 2009; Tammentie, et al. 2004; Wilkins, 2006) were found to be postpartum stressors. Similarly, Amankwaa (2003) indicated newborn colic, which is accom panied by crying, to be a stress factor. These findings of financial concerns and restrictions as postpartum stressors are also documented (Amankwaa, 2003; Hanley & Long, 2006; Kurtz Landy, et al. 2009; Rodigues et al. 2003). As with the study sample, returning to work due to financial constraints (Hanley & Long, 2006), was a significant stress factor. In contrast to the findings of this study, Hanley and Long (2006) found that some postpartum women resented giving up employment, due to loss of status, inde pendence, and income. Theme Symptoms of Depression Lack of sleep, being tired / fatigued and feeling alone were stressors identified by the study sample. Lack of sleep and being tired were coded separately, however, in this discussion they will be considered together, as one is closely associated with the other. A great deal of energy is required for the postpartum restorative period. Fatigue impacts the health and parenting ability of the mother, interfering with self care as well as newborn

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61 care. Wom en questioned their mothering abilities, usually related to times when they were tired, frustrated, or didnt understand what was going on with the newborns behavior. The one connection between themes that emerged from the findings, being tired / fatigued and questioning parental abilities, was also found by Killien (1998), who reported that fatigue and depression were associated with greater parenting stress and anxiety and a decreased sense of gratification from parenting. Similar findings of lack of sleep, being tired, fatigued, and exhausted during postpartum are well documented in the literature (Ge orge, 2005; Kurtz Landy, et al. 2009; Hanley & Long, 2006; Hoang, et al. 2009; Nelson, 2004; Parvin, et al. 2004; Rodigues, et al. 2003; Tammentie, et al. 2004). As with the findings, feelings of loneliness and/or isolation during postpartum were reported by Taniguchi and Baruffi (2007), Hoang, et al. (2009), and Amankwaa (2003). Theme Health and Safety Issues In this study, childrens safety and child rens health were the predominant categories in this theme. Of these, safety and health of the newborn was the primary factor. One study reviewed found that breastfeeding was the second most stressful event immediately after delivery, and the primary stre ssful event after going home ( Razurel, et al. 2009). Yet, in this study, stress related to breastfeeding was not a prominent issue. In contrast to study findings, Spear (2006) found that breastfeeding empowered adolescent mothers as women and as mothers. W hile concerned for the health and wellbeing of their babies, postpartum women lacked confidence in their parenting skills and their ability to care for their newborns, thus the stress factor (Forster, et al. 2008; Kanotra, et al. 2007).

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62 Theme Role Strain The role strain theme includes the stress of occupying multiple roles, having the responsibility for multiple tasks and multiple children. An expectation of being all things to all people at al l times is unreasonable and may well lead to exhaustion. There were similar findings in reviewed literature, women spoke of the multiple roles of postpartum as 1) dealing with everything by themselves (Parvin et al. 2004), and 2) being burdensome and too demanding (Hanley & Long, 2006; Kurtz Landy, et al. 2009). The process of role transition, with the new priorities, is challenging, frustrating, and emotionally and physical ly exhausting (Forster, et al. 2008; George 2005; Nelson, 2004). Amankwaa (2003) and Kurtz Landy, et al. (2009) found multiple children to be stress producing for the postpartum woman. Theme Lack of Support This theme primarily included husbands that would not take mutual responsibility for the home or children, as well as overt discord in the parental relationship. There were similar findi ngs in the reviewed literature. Several studies reported partner relationship strain (Deave, et al. 2008; Razurel, et al. 2009; Ross et al. 2005). This ranged from tension on the relationship due to the demands of changes in the family composition, to perception that the partner lacked an understanding of the post partum womans experience. In Chinese traditions the husband always sides with his mot her whenever a conflict occurs between his wife and his mother (Leung et al. 2005). Lack of social and practical support during the postpartum is well documented, also. Women felt that lack of support contributed to difficulty in continuing breastfeed ing when returning to work (Kanotra, et al. 2007). Psy chological support was lacking for the adjustment of the

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63 woma n to the mother role in the traditional Chinese postpartum rituals (Leung et al. 2005). Yet, at the same time, there was plenty of practical support in the traditional postpartum rituals for rest and physical rec overy, unlike the study sample of s ame sex c ouples who found the lack of support from their families of origin and the gay and lesbian community to be stressful (Ross et al. 2005). Women living outside their country of origin reported lack of support at home from the extended family (Hoang, et al. 2009; Parvin et al. 2004). And socioeconomically deprived women experienced a lack of support from family and friends primarily because they were too stressed to help (Kurtz Landy, et al. 2009). Important sources of support were found to be grandparents, support groups, and peer groups (Deave, et al., 2008; Hanley & Long, 2006; Razurel et al. 2009). The physical presence of the father is significant to the woman (Tammentie et al. 2004). With the fathers physical presence, the newborn is the couples mutual responsibility. Support of family and friends enhance the possibility of getting needed rest and assistance with tasks, as well as important social recognition of the new status of mother (Ugarriza, 2002). Women in the UK shared that practical help after d elivery at the mid wife led centers and peer groups were important to their recovery and adjustment during postpartum (Wilkins, 2006). Hoang, et al. (2009) found that family and community have a significant support role in postpartum. With a great deal of s upport, recovery went well. When there was little support, the women were exhausted, fearful, miserable, and felt isolated and unhappy. With lack of extended family support, the women were lonely, isolated, and tired. A significant finding by Taniguchi and Baruffi (2007) was that help from the womans mother decreased the incidence of postpartum

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64 depression. The review of literature and the findings of this study highlight the basic principle of a womans need for a supportive environment during postpartum. Strengths and Limitations of the Study A major strength of this study was the use of a method appropriate to the nature of the phenomenon under investigation. The aim of this study was to identify the most stressful postpartum events and to identify theme s regarding stressful events in the experience of postpartum women. The qualitative description method of content analysis was used to fulfill the purpose of this study. A second strength of this study was the rigor of the method chosen, using investigator triangulation and providing an audit trail, establishing dependability. Limitations of the study include data that was already collected, thus making it impossible to clarify analytic findings with participants through the process of member checking to he lp improve accuracy, credibility, validity, and transferability. Also, it was not a diverse sample, and given the small sample size, it is unclear to what extent that findings generalize to a broader population. Another limitation of the study was that the sample did not include a significant number of nonCaucasian participants. Dissemination An abbreviated report of these findings is being prepared for submission to either the American Journal of Maternal Child Nursing or the Journal of Obstetric, Gynecologic, and Neonatal Nursing, peer reviewed nursing specialty journals. Dr. Maureen Groer, having conducted the original study yielding the qualitative data for this study, will use these data in future presentations and research.

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65 Implications for Nursi ng Practice Findings may contribute to increased awareness of and sensitivity to the impact of stress on the experience of postpartum women. It is important to examine what specific stressors are identified by postpartum women in order to facilitate preve ntion of stressors or to decrease the negative impact of stressors. Support groups may offer a sense of validation for postpartum wome n and a feeling of universality, that their experiences are shared by others. Community resource referrals should be made when appropriate and community health follow up for mothers identified to be at risk for failure to assume the maternal role, i.e., inadequate social support should be arranged. Practical support by health professionals should be standard, particularly in the early postpartum period, for breastfeeding, self care, newborn care skills, while making available quick reference materials, i.e. pocket guides, checklists, DVDs. The nurse is in a unique position to facilitate this process. Nursing education focuses on health promotion, patient education, and communication. Education related to car etaking skills and use of communication skills to assist the family in expressing their feelings and concerns so that the changes in redefining roles can be accomplished wit h a minimum of stress. Education could include a component for mothers about the need to access, recruit, and delegate to helpers for household activities. At the same time, the women could be helped to have more realistic expectations about life after chi ldbirth emphasizing the need for support and the use of coping mechanisms and offering anticipatory guidance about postpartum fatigue. Troy (2003) advises, Since we know that postpartum fatigue is progressive, and since nurses have so little physical time with the women in hospitals and birthing centers, it is important for women to be empowered

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66 with knowledge in order to manage postpartum fatigue Assessment of postpartum fatigue should be a part of postpartum care. Findings increase the body of knowled ge for nursing so that appropriate evidence based curricula can be developed to address the phenomenon of the postpartum experience. The nurse views a person from a holistic perspective, and uses developmental theory in providing appropriate care. The clas sic work of Rubin in the 1960s expanded developmental theory for postpartum by introducing the concepts of postpartal restorative phases and maternal role attainment (Gorrie, et al. 1998; Rubin, 1967; Rubin, 1984) She described the maternal role as a comp lex cognitive and social process which is learned, reciprocal, and interactive. In the postpartal restorative process, mothers progress thru fairly discrete phases of recovery following childbirth. The mother must go through these restorative phases to rep lenish the energy lost during labor and to attain comfort in the role of mother. These postpartal phases are called taking in, taking hold, and letting go. During the takingin phase, the mother is focused primarily on her own need for fluid, food, and dee p restorative sleep, the major task being to integrate her birth experience into reality. With the taking hold phase, the mother becomes more independent and teachable, exhibiting concern about managing her own body functions and assuming responsibility for her own self care. The letting go phase is a time of relinquishment for the mother. This may be acknowledging the loss of a carefree lifestyle, giving up idealized expectations of the birth experience, or relinquishing the newborn of her fantasies and accepting the real newborn. These losses may provoke feelings of grief, though subtle. The 3 phases may provide a useful method to plan and implement nursing

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67 care by observing progressive change in maternal behavior, anticipating maternal needs and interveni ng to meet the needs. Qualitative research is an accepted, meaningful, and important methodologic approach to the development of a substantive body of nursing knowledge (Speziale & Carpenter, 2007, p. 1). Stress is the central theme in C risis T heory and the balancing factors are perception of the stress, support, and coping mechanisms. These components were found in the qualitative research reviewed. This is consistent with the use of the Crisis T heory model (Aquilera, 1998) as a framework by which to vie w the postpartum period. Therefore, it may be useful as an assessment tool in postpartum care. Horowitz and Damato (1999) recommended that postpartum assessment of mental health status and adjustment should be a standard part of clinical care. The explorat ion and implementation of personal resources have the potential for expanding coping skills. Accessing prior and new methods of coping have the potential to facilitate a healing process (physically, emotionally, and cognitively) in the postpartum period. T he crisis theory model may also be useful as a decision making framework in womens health. Another implication would be to bring these findings to the attention of those making decisions regarding health policy. Given the current climate for health reform in the country, now would be an important time to seriously address the needs of postpart um women. Recommendations for Future Studies F uture research is warranted including replication of this study with d ifferent populations, i.e. different cultural backgrounds in other geographic locations These data could be used with the quantitative data (i.e., stress and immunity measures) from the

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68 original study. Further study is needed to evaluate postpartum womens response / adaptation to stress /crisis so that timely intervention can be initiated and evaluated. The C risis T heory model (Aguilera, 1998) is suggested as a method of structuring evidenced based clinical research. Intervention research is needed to identify and validate needs of postpartum women as w ell as to measure progression through a developmental growth process that, hopefully, will lead to an increased sense of competence and empowerment as a mother and as a woman. The connection between fatigue and feelings of inadequacy regarding parenting could be further examined by follow up with a new population, and a correlational study. More in depth phenomenological study could be undertaken to examine concepts of bonding, self identity, fatigue and lack of confidence in parenting, as well as suppor t from fathers. Conclusions This study identified stressful events in the experience of postpartum women from a qualitative perspective. In this study, for the most part, the factors associated with postpartum stress are not major life events, but rather daily hassles. It is evident that the postpartum experience can be a stressful time and is revealed in descriptive perceptions of the stressors encountered. Content analysis revealed five themes: Environmental Stressors, Symptoms of Depression, Lack of Self Confidence, Role Strain, and Lack of Support. Findings revealed a connection between lack of sleep / fatigue and questioning parenting ability. T he findings establish a base for further investigation to learn about the role of stress, perception of st ress, support, and coping during postpartum. Ideas for future research were suggested. It is hoped that the identified dimensions of the

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69 phenomenon of stress in the postpartum experience will provide a stimulus for further empirical research.

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70 LIST OF REFE RENCES Aguilera, D. (1998). Crisis intervention: Theory and methodology (8thMO : Mosby. ed.). St. Louis Amankwaa, L. (2003). Postpartum depression among African American women. Issues in Mental Health Nursing, 24(3), 297316. Chan, S., Levy, V., Chung, T., & Lee, D. (2002). A qualitative study of the experiences of a group of Hong Kong Chinese women diagnosed with postnatal depression. Journal of Advanced Nursing, 39(6), 571579. Deave, T., Johnson, D., & Ingram, J. (2008). Transition to parenthood: t he needs of parents in pregnancy and early parenthood. BMC Pregnancy and Childbirth, 2008(8), 30. Duong, D., Lee, A., & Binns, C. (2005). Determinants of breast feeding within the first 6 months post partum in rural Vietnam. Journal of Paediat ric Child Health, 42(7), 338343. Edge, D., Baker, D., & Rogers, A. (2004). Perinatal depression among black Caribbean women. Health and Social Care in the Community, 12(5), 430438. Fooladi, M. (2006). Therapeutic tears and postpartum blues. Holistic Nu rsing Practice, 20(4), 204211. Forster, D., McLachlan, H., Rayner, J., Yelland,J., Gold, L., & Rayner, S. (2008). The early postnatal period: exploring womens views, expectations and experiences of care using focus groups in Victoria, Australia. BMC P regnancy and Childbirth, 2008(8), 27.

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71 George, L. (2005). Lack of preparedness: Experiences of first time mothers. MCN. The American Journal of Maternal Child Nursing, 30(4), 251 255. Giorgi, A. (1985 ). Phenomenology and psychological research. Pittsbur gh, PA: Duquesne University Press. Gorrie, T., McKinney, E., & Murray, S. (1998). Foundations of maternal newborn nursing (2ndGroer, M. Davis, M., Casey, K., Smith, K. Kramer, V., Bukovsky, E., (2005). Immunity ed.). Philadelphia, PA: W. B. Saunders. A nd infection: differences between breastfeeders, formula feeders and controls. American Journal of Reproductive Immunology, 54, 222231. Groer, M, Davis, M., & Hemphill. J. (2002). Postpartum stress: Current concepts and the possible protective role of breastfeeding. Journal of Obstetrics Gynecology and Neonatal Nursing, 31(4), 411417. Hanley, J., & Long, B. (2006). A study of Welsh mothers experiences of postnatal depression. Midwifery, 22 (2), 147157. Hildingsson, I., & Thomas, J. (2007). Womens perspectives on maternity services in Sweden: Processes, problems, and solutions. Journal of Midwifery and Womens Health, 52(2), 126133. Hoang, H.T., Le, Q., & Kilpatrick, S. (2009). Having a baby in the new land: a qualitative exploration of the expe riences of Asian migrants in rural Tamania, Australia. Rural and Remote Health 9 (online), 1084. Horowitz, J. & Damato, E. (1999). Mothers perceptions of postpartum stress and satisfaction. Journal of Obstetrics Gynecology and Neonatal Nursing, 28(6), 595605.

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72 Kanotra, S., DAngelo, D., Phares, T., Morrow, B., Barfield, W., Lansky, A. (2007). Maternal Child Health Journal, 2007(11), 549 558. Kiernan, J. (2002). The experience of therapeutic touch in the lives of five postpartum women. MCN. The American Journal of Maternal Child Nursing, 27(1), 47 53. Kurtz Landy, C., Sword,W., & Valaitis, R. (2009). Qualitative Health Research,19(2), 194206. Leung, S., Arthur, D., & Martinson, I. (2005). Perceived stress and support of the Chinese post partum ritual doing the month. Health Care for Women International, 26(3), 212224. Miles, M. & Huberman, A. ( 1994) Qualitative data analysis (2ndCA : Sage Publications. ed.). Thousand Oaks Muhr, T. (1997) User's Manual for ATLAS.ti 5.2, ATLAS.ti: GmbH, Berlin:Scientific Software Development. Nelson, A. (2004). A qualitative study of older first time mothering in the first year. Journal of Pediatric Health Care, 18(6), 284291. Parvin, A., Jones, C., & Hull S. (2004). Experiences and understandings of social and emotional distress in the postnatal period among Bangladeshi women living in Tower Hamlets. Family Practice, 21 (3), 254 260. Razurel, C., BruchonSchweitzer, M., Dupanloup, A., Irion, O., & Epiney, M. (2009). Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study [Epub ahead of print]. Midwifery, 2009, Sept.22. http://www.sciencedirect.com/ezproxy.shc.usf.edu

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73 Robson, C. (2002). Real world research: A resource for social scientists and practitioner researchers (2ndRodrigues, M., Patel, V., Jaswal, S., & de Souza, N. (2003). Listening to mothers: ed.). Malden, MA: Blackwell Publishers. Qualitative studies on motherhood and depression from Goa, India. Social Science and Medicine, 57(10), 17971806. Ross, L., Steele, L., & Sapiro, B. (2005). Perceptions of predisposing and protective factors for perinatal depression in samesex parents. Journal of Midwifery and Wome ns Health, 50(6), e65e70. Rubin, R. (1967). Attainment of the maternal role. Part 1: Processess. Nursing Research, 16(3), 237245. Rubin, R. (1984). Maternal identity and the maternal experience. New York, NY: Springer. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23, 334340. Scott, J., Gills, R., Karlan, B., Haney, A. (Eds.). (2003). Danforths obstetrics and gynecology (9thShakespeare, J ., Blake, F., & Garcia, J. (2004). Breast feeding difficulties experienced by ed.). Philadelphia PA : Lippincott, William & Wilkins. women taking part in a qualitative interview study of postnatal depression. Midwifery, 20(3), 251260. Spear, H. (2006). Breastfeeding behaviors and experiences of adolescent mothers. MCN. The American Journal of Maternal Child Nursing, 31(2), 106113.

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74 Spezial e, H. & Carpenter, D. (2007). Qualitative research in nursing: advancing the humanistic imperative (3rdWilkins. ed.). Philadelphia PA : Lippincott, William & Tamment ie, T., Paavilainen, E., Astedt Kurki, P., & Tarkka, M. (2004). Family dynamics of postnatally depressed mothers discrepancy between expectations and reality. Journal of Clinical Nursing, 13(1), 6574. Taniguchi, H., & Baruffi, G. (2007). Childbi rth overseas: The experience of Japanese women in Hawaii. Nursing and Health Sciences, 9(2), 9095. Templeton, L., Velleman, R., Persaud, A., & Milner, P. (2003). The experiences of postnatal depression in women from black and minority ethnic communities in W iltshire, UK. Ethnicity and Health, 8(3), 207221. Troy, N. (2003). Is the significance of postpartum fatigue being overlooked in the lives of women? MCN. The American Journal of Maternal Child Nursing, 28(4), 252259. Ugarriza, D. (2002). Postpartum depr essed womens explanation of depression. Journal of Nursing Scholarchip, 34(3), 227233. Ugarriza, D., Brown, S., & Chang Martinez, C. (2007). AngloAmerican mothers and the prevention of postpartum depression. Issues in Mental Health Nursing, 28(7), 781798. Varcarolis, E. (2006). Foundations of psychiatric mental health nursing (3rdPhiladelphia PA: W.B. Saunders ed.). Wilkins, C. (2006). A qualitative study exploring the support needs of first time mothers on their journey towards intuitive parenting Midwifery, 22(2), 169180.

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75 APPENDICES

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76 APPENDIX A PERMISSION FOR USE OF ORIGINAL STUDY DATA

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77 APPENDIX B INFORMED CONSENT FOR ORIGINAL STUDY

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78 APPENDIX C INSTITUTIONAL APPROVAL

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79 APPENDIX D NARRATIVES AND CODINGS EXAMPLE

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80 APPENDIX D (continued)

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81 APPENDIX E THEMES, CATEGORIES, EVENTS EXAMPLE Health and Safety Issues 31 coded events Childrens Health/Safety (24) 25 NB safety 36 NB safety in dads care 46 getting NB to sleep after eating 53 limited abilit y in helping child when NB upset/hurting 65 NB physical health 69 older child had surgery soon after birth of NB 71 maternal broth with OCD, dont want around her children, (words, aggressive behavior, emotionally abusive) 74 NB not sleep, colicky 85 questioning mothering, good mother? 94 wondering if good mother 103 lack of understanding of what was going on with NB 109 NB diarrhea with diaper rash 114 doubted abilities as a mother 116 NB safety, fell out of car seat onto bench 121 NB not gaining wt. 124 worry of childrens total safety, feeling lack of control over..) 128 NB in day care, take care of well? 146 NB colic 149 NB safety, older child with ADHD 164 NB safety, aggressive 4 y.o. 170 thot of tak ing NB out in public, sick again? 179 NB hospitalized 194 NB possible problem with spine 195 NB needed blood work redone at 4 days of age Breastfeeding (7) 30 not breastfeeding 78 breastfeeding in hospital, interruptions 80 not as eas y as thot, difficulty establishing, nipple shield, UT staff not helpful 96 breastfeeding, not latch on, painful at beginning 114 breastfeeding, enough?, nipples raw, constantly 128 breastmilk production enough? 158 breastfeeding, rough start

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82 APPENDIX E (continued) Role Strain 32 coded events Multiple Roles/Tasks/Children (32) 4 demands of 2 children 14 needs of multiple children 17 multiple children 24 meeting needs of children & spouse at a 1 time 40 not getting things d one at home, when by self with NB 41 2 very young children 50 arrangements for MD visit, d/t car problem 59 not spending time with older child (19 mos.) 65 multiple children 65(2) home schooling, organization 65(3) 5 y.o. bugging her 6 8 constantly on the run with MD appts, kids/moms 75 attention demands of older daughter 99 mother multiple children 102 never ending mothering of multiple children, super mom 101 truancy of an older child; Social Worker visit 117 multiple roles, multiple children, care of NB, clean, cook, older child not mind 126 multiple children, HS 2 y.o. to bed, NB crying, husband not there or asleep 129 both children crying at same time 138 sibling jealousy, 2 children different dads 138 (2) giving necessary attention to both children 143 3 y.o.s adjustment, not sure how to handle 144 meeting needs of 2 children at once; have enough to fulfill demands of m otherhood? 149 child with ADHD 153 not able to take care of everythin g multiple children need 170 store trip with multiple children 171 multi tasking with multiple children 181 watch NB while doing self care/household tasks 185 getting kindergartener to school 191 3 kids under 5 y.o. 196 regain children 1 98 2 y.o., big kid now

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83 APPENDIX E (continued) Lack of Support 21 coded events Significant Other (14) 31 spouse, arguing, fear of losing 36 NB dads visit 45 NB dads arguing 48 spouse left 52 me breaking it off with NB s dad 55 spouse, lack of sharing total care of children 58 spouse, lack of helping with NB & home 90 spouse, constantly fighting 97 boyfriend, fight a lot 135 spouse, hurt her emotionally 147 not time for spouses to themselves 157 spou se, made her choose between his help & her moms help with NB 168 spouse, not help with NB 175 spouse, fighting with, wanted more of her time, going to leave Parent/In Law Intrusion (4) 32 in laws take NB from mom 130 mother in law questioni ng her childcare 155 mother in law asking negative questions 182 her mom going on about having BTL (bilateral tubal ligation) Away from Family (3) 76 not able to see family at holiday 132 mom 10 hrs. away 176 missing family

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84 APPENDIX F PERMISSION FOR USE OF FIGURE

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85 APPENDIX F (continued)

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86 APPENDIX G ORIGINAL NARRATIVE TRANSCRIPT EXAMPLE SUBJECT NUMBER: 66 STRESSFUL EVENT:Going back to work and leaving my newborn and two year old at a day care.I hate the thought of other people taking care of my kids more than mebut financiallyi have no other choice. I worry that something would happen without me around or that they will not need me as much as they do SUBJECT NUMBER: 67 STRESSFUL EVENT:My best friend accused me of being aloof and said I didnt want to spend time with her.I explained that I was only sleep deprived and she understood and apologized. SUBJECT NUMBER: 68 FRIENDS POS:Friends commented on how good I looked. FRIENDS NEG: SPOUSE/PARTNER POS: SPOUSE/PARTNER NEG: FAMILY POS: FAMILY NEG: STRESSFUL EVENT:There are so many appointments;between me going to the doctor and my kids going to the doctor,I get very stressed out because I am nervous,tired,aggravated,irritable because I have to constantly stay on the run. HEALTH CHANGES: C section infection,red,pus filled sore. BABYS HEALTH:Perfect,eats very well. SUBJECT NUMBER: 69 : STRESSFUL EVENT:The most stressful event had been when my first daughter had surgery.We had Cal and then her surgery and I never thought we were going to g et to come home. SUBJECT NUMBER: 70 SUBJECT NUMBER: 71 : STRESSFUL EVENT:My younger brother has OCD he lives with my parents because he is unable to care for himself.He is a very difficult person to be around because of his aggressive behaviour.He can be emotionally abusive too.This is an extraordinarily stressful situation for everyone involved particularly when he uses these words in front of my children(especially the two year old).Even though he loves his nieces I have decided they cannot be around hi m since his outbursts are so frequent and unpredictable.

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87 APPENDIX G ORIGINAL NARRATIVE TRANSCRIPT EXAMPLE (continued) SUBJECT NUMBER: 73 FRIENDS POS: STRESSFUL EVENT:At times I am very sleepy which becomes very stressful for me to get some sleep since I have to focus on the baby and her needs.I try to sleep a little while she sleeps but I just cannot fall asleep thinking she might wake up any moment. SUBJECT NUMBER: 74 : STRESSFUL EVENT:The baby will not sleep.She is very colicy. SUBJECT NUMBER: 75 S TRESSFUL EVENT:My oldest daughter is very jealous of the new baby and shes all the time.I cant put her down at all without her crying. HEALTH CHANGES:Breast infection.Saw a health care practitioner.Treatment was to keep them in a very, SUBJECT NUMBER: 7 6 STRESSFUL EVENT:I was really upset and sad because I was not able to see my family for thanksgiving. SUBJECT NUMBER: 77 SUBJECT NUMBER: 78 STRESSFUL EVENT:The most stressful event was trying to breastfeed in the hospital.The baby was not staying latche d on well to begin with.There were too many interruptions from nurses,water changers,meal delivery pickup etc.Iwas exhausted and had pain and was worried about the baby eating.She caught on and everything worked out but it was a very stressful few days. S UBJECT NUMBER: 79 STRESSFUL EVENTS:The baby had a very restless nightand we were awake for a very long time.I was so tired and I couldnt make the baby happy.She was fighting her sleep.I had to remember she is just a baby and she will finally fall asleep a s she did and we both slept until 2pm that day. SUBJECT NUMBER: 80 STRESSFUL EVENT:I am very stressed with breastfeeding.It isnt as easy as I expected.My baby has been using a nipple shield to nurse and Im having extreme difficulty in weaning her from t his.I feel like somewhat of a failure when it comes to breastfeeding.Several times I felt like giving up.Also the UT hospital staff werent so helpful with feeding as I expected.

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88 APPENDIX G (continued) SUBJECT NUMBER: 81 STRESSFUL EVENT:My husband is s elf employed and we are worried about finances due to it being the holidays and him being out of work with me during the birth of our baby. SUBJECT NUMBER: 82 SUBJECT NUMBER: 83 STRESSFUL EVENT:My biggest issue is with my self image.I gained 80lb with pregnancy and obviously its going to take a while to get it off.I have become obsessed with my weight,looks,hair,nontanned skin etc and I can hardly stand to look at myself in the mirror.It has made me down in the dumps when rationally I realise it is goin g to take a while but I cant seem to shake tho depressed feelings.It is not affecting my interactions with my baby I adore and love every minute spent with him.It has not gotten in my way of everyday activity,I have just been down on myself. SUBJECT NUMB ER: 84 (SPANISH) SUBJECT NUMBER: 85 FRIENDS POS:My friends are helping by bringing dinner for us or helping with my oldest daughter. FRIENDS NEG: STRESSFUL EVENT:Many times I feel I cant take care of the baby.I have to wake up several times in the nigh t and she does not sleep unless I hold her.I am so tired and frustrated.I feel like I am not a good mother SUBJECT NUMBER: 86 SUBJECT NUMBER: 87 (SPANISH) SUBJECT NUMBER: 88 STRESSFUL EVENT:When my son wakes up and screams it is like he is in excruci ating pain and it is difficult for me to console him.I worry that he will get no relief.I just have to try any thing to get him as comfortable as possible. SUBJECT NUMBER: 89 STRESSFUL EVENT:I got a stomach virus and had to ask for someone to come and wat ch the baby for me.

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ABOUT THE AUTHOR Nancy Gilbert Crist received a B.S. degree in Nursing from Walla Walla College and a M.S.N. degree from the University of Florida. She holds a certification as Registered Nurse Certified in In Patient Obstetrics with the National Certification Corporation. In addition to the years of varied clinical experience with a focus on areas of maternal newborn nursing, Nancy has 19 years of experience in a cademia at the collegiate level primarily with maternalnewborn nur sing and mental health nursing concentrations. S he has overseen major nursing program curriculum changes as well as the process for National League for Nursing program accreditation.


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Women's perceptions of postpartum stress :
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ABSTRACT: The impact of stress on the health of postpartum mothers is poorly understood. Although the postpartum period increases risk for stress related diseases such as depression and autoimmune disorders, little qualitative research has focused on women's perceptions of postpartum stressors. A constant comparative content analysis using Atlas.Ti was done on data collected by Groer (NIH R01 NR05000"Influence of Lactation on Postpartum Stress & Immunity) from 2001 to 2005. Women (n=127) answered the prompt, "Think of any one incident, thought, or feeling that stands out as very stressful to you and describe in as much detail as you choose." Researcher triangulation was provided by independent coding of data by two qualitative researchers. The women were predominantly white (91%), married (72%), and not yet working following the baby's birth (70%). Only 28% had family incomes greater than $40,000 per year. Vaginal births were experienced by 66%, 83% without complications. Forty-seven percent were breastfeeding exclusively with 43% bottle feeding. Slightly less than half (48%) were first time mothers. Eighty-nine percent claimed no recent major life event, such as a death in the family. Twenty-seven postpartum stressors were identified that were grouped into five themes: 1) environmental stressors, 2) symptoms of depression, 3) infant health and safety issues, 4) maternal role strain, and 5) lack of support. Seventeen women identified fatigue or lack of sleep as stressful and each questioned her ability to parent a newborn. Though these women would seem low risk for stress (having had an uncomplicated birth, being married and not yet back at work postpartum), 27 different postpartum stressors were identified. Stressors such as lack of sleep may be known by maternal-child nurses, but women are unprepared for them. Interventions need to be designed to provide anticipatory guidance for new mothers regarding postpartum stressors. Tools should be developed for use by clinicians to assess maternal stress in the postpartum period. Prenatal preparation anticipating stressors and postpartum vigilance in assessing stressors could ease the transition into motherhood.
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Role Strain
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