Merrick_6992 Final Draft

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An Analysis of Preferred Maternal Education Topics among Prenatal and Postpartum

Women Employed in an Urban Corporate Setting in North Carolina

By Rebecca Merrick

May 2010

APPROVED BY:

PRIMARY PROFESSOR

Stephanie Jilcott, PhD Date

PROFESSIONAL PAPER CONTENT ADVISOR

April 1, 2010

Betsy LaForge, MPH Date

CHAIR, DEPARTMENT OF PUBLIC HEALTH

Lloyd Novick, MD, MPH Date

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Rebecca Merrick, MPH Candidate

East Carolina University Brody School of Medicine, Department of Public Health

Hardy Building, 1709 W. Sixth Street

Greenville, NC 27834

MPH 6992 – Professional Paper II

Primary Professor:

Stephanie Jilcott, PhD Brody School of Medicine

Department of Public Health

Content Advisor:

Betsy LaForge Director, Member Health Partnerships

Blue Cross Blue Shield of North Carolina

Spring 2010

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Rebecca Merrick, MPH1, Stephanie Jilcott, PhD1, Betsy LaForge, MPH2

1 Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC 27834

2 Blue Cross Blue Shield of North Carolina

Corresponding Author:

Rebecca Merrick, MPH, Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC 27834

Telephone: 252-555-1234

Fax: 252-744-4008

Email: [email protected]

Word Count: 8,559

Key Words: Maternal Education, Prenatal Care, Focus Groups, Social Cognitive Theory

Abstract Word Count: 229

Charts: 2

Tables: 6

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Abstract

Although preterm birth and infant mortality remain prominent public health issues in the

United States, little is known about the causes of these problems. To minimize preterm birth

risks for both mother and child, it is important for pregnant and postpartum mothers to receive

the appropriate prenatal care and education on healthy behaviors. The purpose of this study is to

examine knowledge gaps of prenatal and postpartum women employed in an urban corporate

setting in North Carolina and subsequently refine maternal education materials by

recommending appropriate topics for prenatal and postpartum education programs sponsored by

health insurance companies. Two focus groups of pregnant or postpartum (<6 months) women

were conducted at a major insurance company. Six educational booklets currently being

considered by the insurance company for its member pregnancy program were used to assess the

women’s’ perceptions, experiences, and knowledge base of common prenatal and postpartum

concerns. Focus group responses were organized using NVivo. Results indicate a number of

topics that should be considered when developing educational materials for pregnant and

postpartum women, particularly visual content, interactivity, father involvement, breast and

bottle feeding, booklet length, and mental health/post partum depression. Since a major

limitation for this study is its small unit of analysis (n=2) and number of participants (n=4, n=4),

these results should be used as preliminary research used to frame more in-depth focus groups

and shape future studies.

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Goal, Objectives, and Purpose of Research

The goal of this study is to increase adherence to prenatal care standards by improving

the information environment among women employed in an urban corporate setting in North

Carolina. In order to attain this goal, this study employs three outcome objectives as

investigatory tools: (1) Conduct focus groups with pregnant or recently delivered women in an

urban corporate setting in North Carolina, (2) Analyze responses from the focus groups to

determine differences and similarities in knowledge of pregnant or recently delivered women

from corporate urban settings, and (3) Recommend topics to include or exclude in education

materials and identify most economically feasible learning materials. These objectives will be

measured though attendance and participation during each focus group, using NVivo to analyze

participant responses, and the NVivo analysis results, respectively. Finally, the purpose of this

study is to examine knowledge gaps of prenatal and postpartum women employed in an urban

corporate setting in North Carolina and subsequently refine maternal education materials by

recommending appropriate topics for prenatal and postpartum education programs sponsored by

health insurance companies.

Introduction

The United States ranks 29th among industrialized nations in infant mortality rate.1 In

North Carolina, in 2005, the infant mortality rate was higher than the US average, reporting 8.53

deaths per live births in NC compared to 6.83 deaths per 100,000 live births nationwide, making

NC the 7th highest infant mortality rate among all the states.2

Short gestation and low birth weight are among the leading causes of premature infant

deaths. North Carolina exceeds the US preterm birth rate averages, with rates of 13.6 per

100,000 and 12.8 per 100,000, respectively.3 Among those premature babies who do survive,

low birth weight is associated with long-term disability such as cerebral palsy, mental

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retardation, vision and hearing impairments.4 Hence, the Centers for Disease Control (CDC) and

the Health Resources and Services Administration (HRSA) have set national public health goals

to improve maternal and child health care. For the public health community, Healthy People

2010 provides the most comprehensive national goals and objectives. Healthy People Objective

16 describes a number of areas to target in order to improve the health and well-being of women

and infants (Table 1). 5

Major cost drivers associated with pregnancy, in addition to premature deaths, are low

birth weight, premature birth, multiple gestations and elective Cesarean sections.6 Health plans

and employers struggle to manage these costs as the risk factors are either difficult to impact or

difficult to identify in a timely fashion. With today’s stagnant economy, most companies are

attempting to control costs and reduce expenses across the board. Even large private insurers and

managed care organizations need to reevaluate many of their programs and implement methods

to create efficiencies. A common approach to reaching members of such insurance companies is

mass mailings to members identified as having a certain condition, such as pregnancy. However,

large mailings can be expensive; reducing the volume and frequency of mailings is an effective

cost-reducing strategy. With economic restraints on pregnancy programs, health insurance

companies and physicians’ offices are looking to provide lower-cost yet high quality materials to

their members and patients.

Background and Literature Review

The prenatal and postpartum periods are critical times to influence the health of both

mother and child. Prenatal care potentially reduces rates of infant and maternal morbidity and

mortality.7 It is important that this population receives timely and accurate information

encouraging healthy behaviors to ensure a healthy pregnancy.

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Not receiving appropriate prenatal care can lead to a myriad of problems, which create

high costs during pregnancy, delivery, and the immediate postpartum period. A 2003 study by E.

Kathleen Adams8 attempted to quantify the cost discrepancy between normal and preterm births.

This study calculated a mean cost for a normal, full term infant to be $1,139, while the mean cost

for an infant with problems to be $15,772. In addition, Adams9 showed that while the majority of

births were normal (76%), they only accounted for 18% of the total delivery costs. These total

costs reflected only inpatient costs for room and board, physician, ancillary, and inpatients drugs.

The infants born prematurely or with problems accounted for 82% of the total delivery costs.

Adams10 also showed that the use of cesarean delivery was a major cause of inflated costs for

premature delivery. Among normal infants, the cost of a vaginal delivery averaged $5,913.

Cesarean deliveries were markedly more expensive: uncomplicated cesarean deliveries averaged

$12,500 and complicated cesarean deliveries created costs averaging approximately $16,000.

These findings reflect the skewed nature of health care cost and the impact of preterm

complications.

Past studies have shown that prenatal care potentially improves birth outcomes11 and

disparities in outcomes due to socioeconomic factors.12 Parents need prenatal education,13 but no

studies (to our knowledge) have attempted to refine the topics presented to pregnant women in

materials originating from private insurance organizations. Privately insured pregnant women

typically receive education from physicians, laypersons, and their insurance plans. In contrast,

women without private insurance may not receive such education materials from physicians or

insurance programs due to access barriers associated with low socioeconomic status. A 2009

study by Jesse14 found that low-income African American women from a rural clinic in eastern

NC had a higher rate of preterm birth than African American women in the state of NC and the

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United States. The women in the Jesse15 study did not have private insurance and represented a

population characterized by high poverty, morbidity, and infant mortality.

The goal of this study is to increase adherence to prenatal care standards by improving

the information environment among women employed in an urban corporate setting in North

Carolina. Furthermore, this study examines the differences and similarities in knowledge women

from an urban corporate setting during prenatal and postpartum periods using focus groups. By

analyzing responses obtained during the focus groups, this study will recommend topics to

include or exclude in education materials and identify the most economically feasible learning

materials for private insurance companies to provide for pregnant or recently delivered women.

Specifically, this study uses materials potentially distributed by a major private insurance agency

in North Carolina.

Although low-socioeconomic populations are particularly in need of prenatal education,

this study focuses on women employed by large corporations in urban environments who receive

private insurance through their employer health plans. A high-income population was used for

this study because it provided a sample of pregnant and recently postpartum women receiving

prenatal education and to obtain a representative sample of urban women of childbearing age.

Since increased insurance coverage and receipt of early prenatal care are directly related,16 an

urban corporate population can be studied to determine which risk factors are not being

addressed in prenatal care education initiatives currently being applied to pregnant and

postpartum women. The findings of this pilot study can further offer preliminary research used to

frame more in-depth studies and create tools to help better target other populations in need of

preterm birth interventions. Since the high-income population in this study is characterized at a

lower risk for preterm birth than lower socioeconomic women in NC, 17 the results of this study

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may help identify other factors which may be contributing to the disparity in preterm birth rates.

Additionally, this study may identify characteristics of high-income populations that contribute

to healthier pregnancy outcomes and can potentially be used as points of intervention for the

lower income populations.

Applying the Social Cognitive Theory to Behaviors which Affect Prenatal Outcomes

The Social Cognitive Theory (SCT)18 is appropriate when describing factors and

behaviors that may affect prenatal outcomes, positing that self-efficacy, goals, and outcome

expectations determine the likelihood of a person changing a health behavior. This theory

operates at an interpersonal level, creating behavioral influences both within an individual and

from the external social environment (such as family, friends, and health professionals).

The six SCT constructs can be applied to programs that aim to improve prenatal

outcomes (Table 2). These constructs can help describe the relationship among factors that can

influence decision processes which lead to behaviors that ultimately affect prenatal outcomes.

The focus group data collected as a part of this study address all six of the constructs of the SCT.

In addition, a conceptual model can be used to depict the relationship between each of these

constructs and behaviors that impact prenatal outcomes. As an example, we will use the case of

maternal smoking during pregnancy since smoking is an established risk factor for abnormal

fetal development.19

Reciprocal determinism occurs as environmental and personal determinants interact with

a behavior such as smoking during the course of the expectant mother’s life. A woman may live

in a home where smoking during pregnancy is the norm or where she is exposed to secondhand

smoke from others (environmental determinants). Individual determinants, such as age and

education level, also contribute to a woman’s likelihood of smoking while pregnant. These

factors then influence the expectant mother’s decision to initiate, continue, or cease smoking.

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This relationship impacts the self-efficacy for tobacco-use cessation and behavioral

capability the mother has to cease tobacco use, to improve the birth outcome. Behavioral

Capability is the actual knowledge a person has to carry out a behavior. Pregnant women have

very specific needs that may not be common knowledge. In the case of maternal smoking, some

women have been taught the hazards of tobacco use on fetal development. Others, however, may

not have gained this knowledge and therefore unknowingly continue to expose the developing

child to the hazards of smoking. Self-efficacy is a person’s confidence to take action to

overcome barriers and perform the desired behavior change. Sometimes pregnant women must

drastically change their lifestyle choices if the baby’s health is to be maintained. Women who

smoke prior to pregnancy must make the decision to either continue smoking or cease the habit

once a pregnancy is confirmed. Some women may have high confidence in their ability to cease

smoking, but others may not be able to overcome the barriers (e.g., nicotine cravings) and create

a safer environment for pregnancy.

If the levels of self-efficacy and behavioral capability are enough to overcome barriers to

smoking cessation, the expectant mother can further the process though observational learning

and formulating goals and expectations. These expectations are often learned though modeling,

or observing other women’s behaviors and associated outcomes. For instance, one mother may

smoke during pregnancy and consequently give birth to a child with low birth weight.20 Another

woman may then extrapolate the cause-and-effect relationship between smoking and the low

birth weight infant, causing her to avoid smoking during her pregnancy with the expectation that

this avoidance will lead to a healthier child.

The mother’s decision to smoke or not smoke may be reinforced in a number of ways.

Examples of a positive reinforcement for not smoking may include praise from a health

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professional, feeling the baby’s activity as it moves within the womb, or support from family and

friends. Negative reinforcement can occur as the mother is observed smoking and criticized by a

health professional, family, friends, or others. Additionally, the mother may have feelings of

guilt as the smoking habit continues throughout the pregnancy.

These six constructs interact to influence the decision process to smoke or not during

pregnancy. By not smoking, the mother is adhering to prenatal care standards such as those

outlined by the American College of Obstetricians and Gynecologists (ACOG).21 Adherence to

these standards, particularly by not exposing the developing child to tobacco products, will

decrease her risk of preterm birth, and at the population level, lower the overall preterm birth

rate.

A Conceptual Model: The Social Cognitive Theory Influences Behaviors Affecting Prenatal

Outcomes

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Methods

The target population for this study was urban women in North Carolina who were

currently pregnant or have delivered a child within the previous six months. Data were collected

during focus group discussions and examined using qualitative content analysis. For the purposes

of this study, the focus group was the unit of analysis. This study was approved by the East

Carolina University and Medical Center Institutional Review Board (ECU UMC IRB).

At the beginning of each session, the moderators explained the purpose of this study.

Both verbal and written consent were obtained from each participant. Participants also signed a

statement describing the study, showing their consent for responses to be audio-recorded and

used for this research project.

Methods of Data Collection in an Urban Corporate Environment

This study was conducted in a corporate environment at a major insurance company

located in Durham, NC. Two focus groups were conducted at different locations on the

company’s campus. These two locations were chosen a priori since they were the largest

employee centers for the company, and to minimize travel time for volunteers between their

offices and the focus group locations. The first focus group was conducted at the company

headquarters building. The second was conducted two days later at the customer service

building.

In order to recruit employees from the company to participate, a short article was posted

on the company’s intranet homepage. The article was posted five days before the first session

and seven days prior to the second session. Eligibility criteria included currently pregnant or had

delivered within the past six months and a current employee of the company. As an incentive,

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lunch was provided at no cost to those who participated. All volunteers met eligibility criteria

and were included in the focus group discussions.

Both groups were composed of three pregnant women and one participant who had

recently delivered her child. All participants had at least some college-level education, and all

but one participant was married and living with her husband at the time (Table 3). These women

participating in both focus groups were assumed to have employer-based health insurance, as

their employer granted this reward.

When a volunteer signed up for a focus group, the materials and instructions were

immediately intra-office mailed to her, which helped ensure the participant had adequate time to

review the materials before the focus group session As part of the registration, volunteers chose

which focus group location they planned to attend (either the headquarters building or customer

service building). Six different booklets from patient education companies were included in the

packets (Table 4). Attached to each booklet was short questionnaire to aid participants in their

reviews. Additionally, a seven-question survey was included to attain a general overview of the

participants’ demographic background (Table 5). These surveys were collected at the end of each

focus group.

Each focus group took one hour. Two moderators assisted with prompting discussion

using prepared questions for the participants (Table 6). Each group included four women. In each

session, participants were assigned a number (1-4) to ensure confidentiality. Notes were taken

during the session to help assign each response to the correct participant. The sessions were

audio-recorded and later transcribed verbatim by one of the session moderators. This moderator

was able to minimize transcription error since she was familiar with the participants’ voices and

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could correctly assign responses to each respective participant as opposed to a third-party

transcriptionist.

Data Analysis

Once both focus group sessions were transcribed, one of the moderators created a

codebook using both deductive and inductive codes. The deductive codes were established from

the Focus Group Discussion Guide based on questions asked during the focus groups.

Additionally, inductive codes were selected from the major themes and topics discussed during

the focus group sessions which were not originally anticipated. Each code and subcode were

defined and assigned criteria as to when a code would be used for a particular segment of text.

The transcripts and codes were then uploaded into Qualitative Solutions and Research

International NVivo software program (NVivo 8).22

This study used a double coding method to analyze data, with one of the moderators and

a second individual familiar with the study design independently coding both of the focus group

transcripts. The moderator and second coder met initially to review the codebook to ensure each

code was clearly defined and understood by each coder. Each coder then independently coded

the first transcript according to the codebook criteria. The coders reconvened to compare coding

assignments and discussed discrepancies between each coded transcript. After reaching an

agreement with respect to coding discrepancies, the codebook was refined with more exact codes

to better reflect the data and applied to the first transcript. Using the refined codebook, both

coders independently coded the second transcript then met to resolve coding discrepancies. The

final codes are listed in Appendix A: Codebook.

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Results

This study utilized two focus groups of pregnant or recently postpartum (<6 months)

women. Each focus group had four participants. Three women in each focus group were

currently pregnant and one participant in each group had recently delivered a child. Additionally,

three women in each focus group had one previous child. Only one participant was not married

at the time of this study; the other married participants were currently living with their husbands.

Participants’ ages ranged from 25-40 with a median age of 33 years. Four women were African

American, three were Caucasian, and one was Asian. Three participants had some college

education, three had completed a college degree, and two had completed a graduate degree.

Using NVivo to organize the data, the most common codes were identified and used as a

guide to identifying themes. The researcher used the NVivo coding frequencies as a guide to

select major themes present in the focus group data. The NVivo figures informed the researcher

of patterns in the data and the most prevalent codes; the researcher then determined which codes

represented major themes and topics that can be applied to future educational materials.

Chart 1 depicts the number of coding references for each node for both focus groups.

Chart 2 represents the percent of the total coding area each of the summed nodes covers. The

codes most often referenced were Quality Positive and Visual Positive, each with 23 references.

In other words, the participants most frequently mentioned what they liked about the educational

materials, specifically the visual aspects and quality of information, through constructive

criticism.

Visual Content

The visual layout and content of the booklets was a major discussion point in both focus

group sessions. A number of themes emerged using the codes relating to visual content, such as

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the use of real people, color, and number of pictures in educational materials. The participants

noted positive and negative attributes of the colors, pictures, layout, and the usefulness of these

features. The codes Visual Negative (a negative statement about the visual content) and Visual

Specific Desire (any statement concerning a desire for some specific visual component),

although both only coded 12 times, were still ranked 3rd in the overall number coding references.

“I don’t like the layout, I don’t like the color, I don’t like the texture, and I

think the pictures aren’t as nice as the other one… color always beats black and

white”. (32-year old Caucasian woman, currently pregnant, one previous child)

Often, the specific desire for a visual component was related to the inclusion of pictures to

help participants understand the material presented.

“I mean you can read the descriptions and everything, but I think if you

had like a small picture I know it’s not a whole lot of space but if you had a little

you know example of what it might look like you know that would be a lot of

help”. (33-year old African American woman, currently pregnant, with one

previous child)

In addition to the inclusion of pictures, some participants asserted that a written description

was still necessary to convey the material clearly.

“I wish they had more pictures of the exercises. Here they tell you what to

do but when you’re pregnant you’re afraid that well I, think here, ok, I might be

doing this, this exercise and doing something, doing it in an adverse way not like

the pictures. You’re gonna suggest exercises, and give some descriptions or a

picture”. (33-year old African American woman currently pregnant with her first

child)

The participants felt that who was featured in pictures also impacted their views on a topic.

One participant felt that the use of female models or drawings generated a negative impression of

a booklet. Instead, she preferred “normal” looking women to which she could relate.

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“It does help that it has real people. And not all of them look like

supermodels. That’s pretty”. (33-year old African American woman currently

pregnant with her first child)

Interactivity

The focus group data showed that some participants favored interactive materials, such as

interactive sections of workbooks, CDs, and worksheets. There were also negative responses for

interactive materials. There was considerable debate about the helpfulness of interactive

materials during each focus group. While some participants felt interactivity was a great way to

promote learning, others felt that these sections were not practical given the time constraints

involved with preparing for the birth of a child.

“I like the work- the workbook format. It really I guess in all the books but

it’s nice because I think it makes things a little more interactive and it soon

becomes a reference guide down the road where you can always pick it up and go

back to it”. (33-year old Asian woman, currently pregnant, one previous child)

“I do have to say, these little things about filling stuff out, I don’t even

have time to fill out my baby book so I found these to be like useless”. (32-year

old Caucasian woman, currently pregnant, one previous child)

Father Involvement

The focus group participants felt that the father’s role in prenatal education, the

pregnancy period, and newborn care warranted more attention. The participants asserted they

wanted the information directed towards the father included in pregnancy and postpartum

educational materials.

“They really did place an importance on the dad’s role and I thought it

was really pleasant and nice” (33-year old African American woman currently

pregnant with her first child)

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Overall, the participants felt that the father’s role was often minimized, despite their

critical role in the child’s life.

“Pregnancy myth number one, father’s role does not begin until the birth

of the baby”. (A 33-year old Asian woman, currently pregnant with one previous

child)

Only one participant in the focus groups was not married. However, even she noted the

appeal of education materials for other family members:

“This book I think anybody can read, the dad, the mom, the grandma…

they can read it and see, you know they might know something the mom doesn’t

and you know vice versa”. (33-year old African American woman with one

previous child)

As part of their desire for more father involvement, the focus group participants said it

was their responsibility to inform the fathers of what information they needed to know. One way

mothers included the fathers in pregnancy education was to discuss what the mother had learned

after reading educational materials. Some participants felt that their husbands would not take

time to read comprehensive educational materials. Instead, the expectant mother can relay the

main points of the materials she has read to her husband.

“It’s not like my husband would look at the book. He always would just

goes ‘what did you read?’ and ‘just tell me that you did not see something’”. (32-

year old Caucasian women, currently pregnant, one previous child)

Breast and Bottle Feeding

A very prominent topic centered on the difficulties of feeding an infant. Using the NVivo

word frequency application, there were 53 references to breastfeeding (combining the words

“breastfeed”, “breast”, and “breastfeeding”), 23 references to bottle feeding, and 16 references to

feeding without specifying breast or bottle (“feed” or “feeding”).

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Many participants had concerns with the proper feeding techniques for both breastfeeding

and bottle feeding, such as appropriate feeding schedules, when to wean a child off a bottle, how

to store milk properly and potential benefits to mother and child. These issues generate anxiety

with new mothers.

“Because I mean I didn’t know how. Once I stopped breastfeeding it was

a month in and I’m like, I didn’t know how to sterilize nipples. I didn’t know how

to do all that stuff”. (32-year old Caucasian women, currently pregnant, one

previous child)

Another participant was fearful of breastfeeding because of her friends’ experiences and

anecdotal stories:

“I didn’t want to breastfeed. I was the campaign like no, no, don’t come

over here…because I’m so nervous about it because everyone has those horror

stories about how it hurts and you just want to knock them off and you know you

bleed”. (32 year old African American woman, currently pregnant with her first

child)

The participants noted overwhelming societal pressures surrounding feeding an infant. These

pressures can lead to feelings of guilt and inadequacy if a mother could not breastfeed her child.

They pointed out that some mothers may consciously choose to bottle feed instead of breastfeed,

but many women who desire to breastfeed are not physically able to do so. To add to their

frustrations, most educational materials focus on the benefits of breastfeeding and minimize

information presented about bottle feeding, if any is included at all. One participant was

particularly upset about not being able to breastfeed, saying,

“It talks about breastfeeding and it’s really positive and then there’s this

little on bottle feeding. But it’s like it’s your choice. But the thing is you feel so

bad when you can’t… it would be nice if they had that in there because I was

really traumatized I cried and cried and cried”. (32-year old Caucasian woman,

currently pregnant, one previous child)

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Notably, breastfeeding advocacy groups, particularly La Leche League, were generally

disliked due to their confrontational approaches. The participants felt that such advocacy groups

forced them to breastfeed without allowing them to make decisions for their own infants. One

participant who had recently delivered described her experience as she learned how to feed her

newborn:

“My baby just didn’t take to it. But, and it’s been the biggest struggle. And

so it’s very troubling to see ‘your baby was born to be breastfed. It wants to be

breastfed’. And LaLeche? No no no. Don’t. Don’t”. (40-year old Caucasian

woman, recently delivered)

Booklet Length

The length of each booklet was an issue for the women before even reading the content of the

materials. When combined, the code for Length and its associated subcodes accounted for 28

total nodes. Participants in both groups found a balance of information very important. While

some educational materials do not provide enough information to satisfy an expectant mother,

others present too much detail which overwhelms the reader.

“But honestly the choices are a really big thick book like this thing you’re

dispensing or this little thing from a doctor’s office that says nothing”. (40-year

old Caucasian woman, recently delivered her first child)

The popular book, “What to Expect When You’re Expecting” was cited in both focus groups

as being intimidating and scary due to its sheer size, exceeding 600 pages.

“I think though I would read What to Expect When Your Expecting, well

that’s the most depressing book you’ll ever read in your life… because you’ll

think that everything in the world is wrong with you if you read it. Because it’s

just hits everything”. (40-year old Caucasian woman, recently delivered her first

child)

Mental Health / Postpartum Depression

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A recurring subject of both focus group discussions revolved around the mental health of

new mothers, particularly in regards to postpartum depression. Seven codes specifically

highlighted the mental health of the mother after delivery as a point of concern for the

participants. Although both groups agreed on the general need for additional materials directed

at identifying and coping with emotional stress during this time, they did not directly identify

postpartum depression as a major issue. Participants referred to postpartum depression as “baby

blues” and did not recognize it as an illness, but instead simply as a period of sadness.

“For baby blues, they say ok well you know you’re going to be moody

and whatever and it-it will pass in a week or two…And well I mean it does and

then it goes away… Well you don’t realize. I was like crying for a month you

know” (32-year old Caucasian woman with one previous child)

Interestingly, the participants revealed that their child’s pediatrician, not their OBGYN or

primary care doctors, are asking about the mother’s emotional well-being.

“I just took my daughter in for uh her checkup and the doctor was like,

‘how are you feeling? Are you having a good day?’ I was like, ‘Oh my gosh’”.

(33-year old Asian woman currently pregnant, one previous child)

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Chart 1: Number of Coding Referenced for Each Node Transcriptions 1 and 2

Chart 2: Percent Coverage for Each Node, Transcriptions 1 and 2

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Discussion

The three objectives of this study were achieved: The project conducted focus groups

consisting of pregnant or recently delivered women in an urban corporate setting in North

Carolina, the focus group responses were analyzed to assess knowledge gaps of pregnant and

postpartum women, and a number of topics were identified to refine education materials and

therefore create more cost-effective options. The results of this study can be used to promote the

overall goal of increasing adherence to prenatal standards by improving the information

environment, particularly when designing future studies to further investigate knowledge gaps

for pregnant and postpartum women.

It is important to recognize the third objective, identifying cost-effective materials, was

more in the interest of BlueCross BlueShield than the focus of this paper. BlueCross BlueShield

did utilize the recommendations of the focus group participants, eventually using one of the

favored booklets for their state-wide pregnancy program. At the same time, the data provided

valuable insight into potential knowledge gaps of pregnant and recently delivered women,

providing research to support potential points of intervention for educational programs.

Recommendations for Developing New Educational Materials

Results of this study reveal a number of issues and topics that should be considered when

developing educational materials for pregnant and postpartum women.

The use of pictures can also help the reader better understand the educational material,

but should not replace written information. This is an important consideration, since different

people have different learning styles. Some women may want a detailed description, but others

may depend more on illustrations to understand the materials. Prenatal exercises and infant

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feeding positions were two instances that the participants felt that pictures were particularly

helpful.

Furthermore, prenatal and postpartum education materials should be culturally competent

with the pictures presented for their respective audiences. These images should depict people to

which the audience can relate instead of models or illustrations; those directed towards the

majority population should have different pictures than one directed towards a minority

population.

Prenatal and postpartum educational materials directed to a general audience should

include but limit the amount of space dedicated to interactive sections, such as places for the

mothers to create lists, take notes, and record reminders. While some of the focus group

participants felt interactivity was a great way to promote learning, other felt that these sections

were impractical due to time constraints. An expecting mother has many items to attend to before

the baby’s arrival; creating a day-by-day scrapbook, for example, may not be a priority. Instead,

these mothers looked for more content-oriented materials.

Pregnant mothers have a significant number of educational materials available to them,

but the information environment for expectant fathers is severely lacking. The participants

agreed that the father plays a critical role during and after pregnancy. This discrepancy reveals a

possible point of intervention to bolster the knowledge of expectant fathers. One method to

encourage fathers to participate in the educational process is to provide the fathers with a

compact, to-the-point booklet directed at their role. New educational materials need to

acknowledge the father’s role and allow them to take part in the educational process of

pregnancy and childbirth.

25

Educational materials should contain information for both breastfeeding and bottle

feeding. Many of the current resources solely focus on breastfeeding as the primary means of

feeding and do not address the needs mothers who choose to bottle feed or who cannot

breastfeed due to physical problems. The data indicated significant feelings of guilt, anger and

anxiety for these mothers. The participants wanted to have a choice in the method of feeding

their child and did not want to feel pressured to breastfeed to satisfy societal norms.

Additionally, many women may have negative impressions of breastfeeding advocacy groups

due to their aggressive approaches. These feelings suggest that an alternative, less forceful,

means of promoting breastfeeding may be more acceptable for new mothers. Feeding technique,

frequency, milk storage, and hygiene are all important topics to include in educational materials,

for both breastfeeding and bottle-feeding methods.

The length of a booklet is also a consideration in the development of new materials.

Educational resources should try to find a balance of information to address major issues in

adequate detail but not overwhelm the reader. Many participants found that educational materials

currently available are either too long or too short. A mid-sized educational booklet would serve

as a practical resource for many mothers, as it would be a guide that can refer mothers to more

detailed sources if they desire to further investigate a topic.

The focus group data results suggested a lack of recognition of postpartum depression, an

affliction that often goes undiagnosed in new mothers. The results acknowledged the presence

of depressive episodes commonly occurring after birth and the need for additional materials

directed at this period.

The period between birth and the initial follow up appointment with the mother’s

physician normally is 6-8 weeks, during which postpartum depression can potentially occur. The

26

focus group results indicate that the mothers were being asked about their emotional state by

their child’s pediatrician, not the mother’s physician. This interaction can provide a point of

early identification for postpartum depression symptoms, since the pediatric visits occur before

the mother’s follow-up appointments.

Mental health issues are still poorly understood compared to physical disease; it is important

to evaluate emotional well-being to ensure a healthy mental status of a new mother, which

inevitably impacts the child. New materials should dedicate resources to directly addressing

postpartum depression, as this illness can have devastating effects on both mother and child if

undiagnosed.

Strengths and Limitations

Using focus groups as a qualitative research strategy has both strengths and weaknesses.

This method allows for participants to discuss their attitudes, feelings, and opinions about a topic

with a group of peers who may share similar experiences. It also provides a setting for group

interaction which can facilitate the discovery of unexpected data and provide more insight than

individual interviews. Focus groups are a reasonable method to explore a topic in a low-cost,

flexible setting, and generate data with high face validity.

A limitation for this study was the small unit of analysis (n=2). Focus groups are usually

conducted until the responses to questions have been saturated, or similar responses are

continuously reported from different focus groups. In addition, the number of participants in

each focus group was small (n=4, n=4). Having 8-10 participants in each focus group may have

provided for better conversation and varied perspectives. The participants in this study were a

convenience sample of volunteers from the urban corporation. The views expressed by these

women cannot be generalized to other women in North Carolina, particularly those located in

27

rural environments or who are unemployed. The results of this study are only truly able to be

generalized to pregnant or recently delivered women working at BlueCross BlueShield of North

Carolina. While additional focus groups would have been beneficial to this study, we were

unable to conduct additional sessions due to time constraints for the research study.

Another limitation is that some of the participants did not have adequate time to review

the materials before the focus group session. Although the recruitment advertisement was posted

five to seven days before the sessions, some participants did not immediately enroll. Materials

were intra-office mailed to participants only after enrolling, giving several participants only one

or two days to review the six booklets.

Future Studies

The results of this pilot study can be used to frame future studies on identifying

knowledge gaps, educational preferences, and preferred topics for pregnancy programs. Future

studies can utilize the participants’ responses to create more specialized focus groups discussions

in order to encompass other populations. This can help assess knowledge gaps specific to

particular groups of women, characterized by race, geographic location, or cultural values. These

studies can help create educational materials unique to the needs and preferences of these women

and can identify which methods of outreach may work best for these populations.

Future studies can also assess how the self-efficacy for behaviors (such as adhering to the

ACOG recommendations) of pregnant women changes before and after education. Another study

can investigate how self-efficacy varies in response to different educational materials focusing

on the topics identified in this study. Additionally, future studies can assess how the timing of

educational intervention, related to the stage of pregnancy, affects the desired topics for mothers.

These findings can help build educational materials in a way to increase overall confidence and

28

decrease anxiety during pregnancy and the postpartum period related to inadequate educational

resources.

Conclusion

Overall, the results suggest that pregnant and recently postpartum women need mid-sized

educational materials that depict normal women, address the father’s role, present both breast

and bottle feeding recommendations, and include references for more in-depth information. The

findings of this qualitative study suggest the Social Cognitive Theory is a relevant framework for

understanding individual behaviors that contribute to pregnancy risks.

As a pilot study, the results can help form the basis of more in-depth, specific,

investigations into the knowledge gaps of pregnant and recently postpartum women. Particularly,

the results from this study can be used as a framework for investigations which address

disparities in birth outcomes for certain populations and how the information environment

impact’s a mother’s self-efficacy during pregnancy and the postpartum period. It is important to

ensure that educational materials for different populations address knowledge gaps unique to

each group that may lead to increased pregnancy risk. By having information presented in a way

that is culturally competent, easy to understand, and appealing, expectant mothers can better take

personal steps towards having a healthy pregnancy.

29

Table 1: Healthy People 2010 Objective 16: Maternal, Infant, and Child Health

Healthy People 2010 Objective Description

16-1 Reduce fetal and infant deaths.

16-5 Reduce maternal illness and complications due to pregnancy.

16-6 Increase the proportion of pregnant women who receive early

and adequate prenatal care.

16-9 Reduce cesarean births among low-risk (full term, singleton,

vertex presentation) women.

16-10 Reduce low birth weight (LBW) and very low birth weight

(VLBW).

16-11 Reduce preterm births.

16-12 Increase the proportion of mothers who achieve a recommended

weight gain during their pregnancies.

16-14 Reduce the occurrence of developmental disabilities.

16-15 Reduce the occurrence of spina bifida and other neural tube defects

(NTDs).

16-16 Increase the proportion of pregnancies begun with an

optimum folic acid level.

16-17 Increase abstinence from alcohol, cigarettes, and illicit drugs

among pregnant women.

16-18 (Developmental) Reduce the occurrence of fetal alcohol

syndrome (FAS).

16-19 Increase the proportion of mothers who breastfeed their

babies.

30

Table 2: The Six Constructs of the Social Cognitive Model

Construct How it applies to prenatal care and

preterm birth

Focus group question which

addresses construct

Reciprocal Determinism

This construct includes environmental, personal, and behavioral factors, such as

education level, socioeconomic status, and established habits. These

determinants can affect prenatal outcomes if they contribute to unhealthy behaviors.

Was the educational material easy to understand?

Where in your home would you keep this booklet?

How did you feel about this booklet overall?

Behavioral

Capability

A mother possesses a level of knowledge

about the prenatal period. If she is aware of certain healthy or unhealthy behaviors

prior to pregnancy, she can prevent poor birth outcomes by practicing the appropriate behavior.

Which sections of this book

would be most useful to a new parent?

Which sections of this booklet were not useful or difficult to

understand?

How helpful did you find the

content of the booklet?

Expectations By observing others and learning from educational resources, a mother can associate behaviors with birth outcomes.

This association can help her set goals to increase the likelihood of a healthy

infant.

What topics should be addressed in a pregnancy program?

What other topics should be included in this booklet?

Self-efficacy This construct encompasses a mother’s motivation and confidence to learn

healthy behaviors and comply with her provider’s recommendations, therefore decreasing the risk of preterm birth.

Would you use this booklet throughout your pregnancy?

How has reading this booklet changed your confidence to

manage your pregnancy or care for your infant

Observational learning

(Modeling)

Many behaviors unique to pregnancy are learned from family, friends, and other

resources during the pregnancy. By adopting these behaviors, a mother can

have a healthier pregnancy.

Are the pictures in this booklet

helpful to understanding the material?

Did you learn anything new or

useful from this booklet?

Reinforcements A behavior can generate positive or negative consequences which can

encourage or deter the mother from continuing that behavior. By learning

what consequences are associated with her own behaviors, a mother can build confidence to remain healthy during her

pregnancy.

Would you participate in a

pregnancy management program in order to receive this booklet?

31

Table 3: Characteristics of Urban Focus Group Participants

Headquarters Building

Assigned Number 1 2 3 4

Age 32 34 32 25

Race Caucasian African American African American Caucasian

Pregnant or Recently

Delivered

Pregnant Pregnant Pregnant Recently Delivered

Highest Level of

Education

College Graduate Graduate Degree Some College Some College

Relationship Status Married Married Married Married

Living Situation Husband Husband Husband Husband

Number of Children 1 1 0 1

Customer Service Building

Assigned Number 1 2 3 4

Age 40 33 33 33

Race Caucasian African American Asian African American

Pregnant or Recently

Delivered

Recently Delivered Pregnant Pregnant Pregnant

Highest Level of

Education

Masters Degree College Graduate Some College College Graduate

Relationship Status Married Single Married Married

Living Situation Husband Single Husband Husband

Number of Children 1 1 1 0

32

Table 4: Characteristics of Educational Booklets

Title Number

of Pages

Prenatal or

Postpartum

Period

Topics Covered

Nutrition and

Exercise

Common

Discomforts

Doctors Appointments

and Testing

Baby’s

Development

Complications and Preterm

Labor Risks

Labor and

Delivery

Breastfeeding Postpartum Depression

and Care

Immunizations Interactive

Sections

Great Expectations

64 Prenatal

Planning A Healthy

Pregnancy

31 Prenatal

Great

Beginnings

Start Before

Birth

23 Prenatal

The Joy of

Parenthood 104 Postpartum

A New

Beginning 45 Postpartum

Caring for

Your Baby 31 Postpartum

33

Table 5: Survey Questions, Urban Focus Group Sessions

In order for us to ensure the diversity of this focus group, we have included questions about your personal background. Your responses to these questions are CONFIDENTIAL and will be used

for comparison purposes only. Age:

Pregnant or Delivered within last 6 months:

Highest level of Education:

Race:

Relationship Status:

Living Situation (who lives in your household):

Number of Children:

Table 6: Interview Guide for Corporate Focus Group Sessions

1. What topics should be addressed in a pregnancy program?

2. What was your initial reaction to this booklet? 3. What did you think of the length of the booklet? 4. Approximately how long did you spend reviewing this booklet?

5. Where in your home would you keep this booklet? 6. Was the educational material easy to understand?

7. Are the pictures in this booklet helpful to understanding the material? 8. How helpful did you find the content of the booklet? 9. Which sections of this book would be most useful to a new parent?

10. Which sections of this booklet were not useful or difficult to understand? 11. Would you participate in a pregnancy management program in order to receive this

booklet? 12. Would you use this booklet throughout your pregnancy? 13. What did you like the most about this booklet?

14. What other topics should be included in this booklet? 15. Did you learn anything new or useful from this booklet?

16. How do you feel about this booklet overall? 17. How has reading this booklet changed your confidence to manage your pregnancy or care

for your infant?

34

References

1 NCHS Data Brief. No. 9. Oct 2008. Recent Trends in Infant Mortality in the United States National Center for

Health Statistics. Accessed 9/1/09. <http://www.cdc.gov/nchs/data/databriefs/db09.htm>. 2 National Center for Health Statistics. State Profile: North Carolina. Accessed 9/1/09.

<http://www.cdc.gov/nchs/pressroom/data/state_profile_NC.htm>. 3 National Center for Health Statistics. State Profile: North Carolina. Accessed 9/1/09.

<http://www.cdc.gov/nchs/pressroom/data/state_profile_NC.htm>. 4 The Mayo Clinic. Complications. Accessed 9/1/09. < http://www.mayoclinic.com/health/premature-

birth/DS00137/DSECTION=complications>. 5 Healthy People 2010. Objective 16:Maternal, Infant, and Child Health. Accessed 9/1/09.

<http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm>.

6 Washington, AE. Ectopic pregnancy in the United States: Economic Consequences and Payment Source Trends.

Obstetrics and Gynecology. 1993 Feb;81(2):287-92. 7 Centers for Disease Control and Prevention. Safe Motherhood: Promoting health for women before, during, and

after pregnancy. Accessed 9/3/09. <http://www.cdc.gov/nccdphp/publications/aag/pdf/drh.pdf>. 8 Adams, E. K., et al. "Costs of Poor Birth Outcomes among Privately Insured." Journal of Health Care Finance

29.3 (2003): 11-27. 9 Adams, E. K., et al. "Costs of Poor Birth Outcomes among Privately Insured." Journal of Health Care Finance

29.3 (2003): 11-27. 10 Adams, E. K., et al. "Costs of Poor Birth Outcomes among Privately Insured." Journal of Health Care Finance

29.3 (2003): 11-27. 11 Williams, K.J. Williams, K. J., A. Zolotor, and L. Kaufmann. "Clinical Inquiries: Does Group Prenatal Care

Improve Pregnancy Outcomes?" The Journal of Family Practice 58.7 (2009): 384a-c. 12 Beard, J. R., et al. "Socioeconomic and Maternal Determinants of Small-for-Gestational Age Births: Patterns of

Increasing Disparity." Acta Obstetricia et Gynecologica Scandinavica 88.5 (2009): 575-83. 13 Dumas, L. "Focus Groups to Reveal Parents' Needs for Prenatal Education." The Journal of Perinatal Education:

An ASPO/Lamaze Publication 11.3 (2002): 1-9. 14 Jesse, D. E., et al. "Racial Disparities in Biopsychosocial Factors and Spontaneous Preterm Birth among Rural

Low-Income Women." Journal of Midwifery & Women's Health 54.1 (2009): 35-42. 15 Jesse, D. E., et al. "Racial Disparities in Biopsychosocial Factors and Spontaneous Preterm Birth among Rural

Low-Income Women." Journal of Midwifery & Women's Health 54.1 (2009): 35-42. 16 Long SH, Marquis MS. 1998. “The Effects of Florida’s Medicaid Eligibility Expansion for Pregnant Women.”

American Journal of Public Health 88(3):371-376. 17 Jesse, D. E., et al. "Racial Disparities in Biopsychosocial Factors and Spontaneous Preterm Birth among Rural

Low-Income Women." Journal of Midwifery & Women's Health 54.1 (2009): 35-42. 18 National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice . US Department of

Health and Human Services. Pages 12-15. Sept. 2005 19 March of Dimes. Quick Reference Facts Sheets: Smoking During Pregnancy. Accessed 9/8/09.

<http://www.marchofdimes.com/professionals/14332_1171.asp> 20 March of Dimes. Quick Reference Facts Sheets: Smoking During Pregnancy. Accessed 9/8/09.

<http://www.marchofdimes.com/professionals/14332_1171.asp> 21 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for

Perinatal Care. 6th Ed. Chapter 4: Antepartum Care. 22 NVivo 8. Qualitative Solutions and Research International. January 2010.

http://www.cdc.gov/nchs/pressroom/data/state_profile_NC.htm

35

Appendix A: Codebook

Code Subcode Description Inclusion Criteria Exclusion Criteria

Pregnanc

yManage

ment

A statement about the content

of a booklet which impacts the

mother’s ability to manage her

pregnancy or care for her infant

Any statement which regards

the content of the booklet with

respect to the mother’s ability

to manage her pregnancy or

care for her infant

Any statement which does not

describe the mother’s ability to

manage her pregnancy or care

for her infant

PM/Incre

ase


of a booklet which can

increase confidence in

managing pregnancy or caring for a child

Any statement which reveals an

increase in confidence for

managing pregnancy or caring

for an infant resulting from the information presented in a

booklet

Any statement which reveals a

decrease or no change in

confidence for managing

pregnancy or caring for an infant resulting from the

information presented in a

booklet

PM/Decr

ease


of a booklet which can

decrease confidence in


for an infant

Any statement which reveals a

decrease in confidence for


for an infant resulting from the

information presented in a booklet

Any statement which reveals an

increase or no change in


pregnancy or caring for an

infant resulting from the information presented in a

booklet

NoChange

A statement revealing no change in confidence to

manage pregnancy or care for

an infant

Any statement which reveals the content of the booklet did

not impact the mother’s

confidence in managing her

pregnancy or caring for her

infant

Any statement which reveals increase or decrease in


pregnancy or caring for an

infant resulting from the

information presented in a booklet

Length A statement which describes

the length of the booklet

Any statement which describes

the length, size, or time taken to review a booklet


describe the length, size, or time taken to review a booklet

Length/L

ong

A statement that the booklet is

too long or too large

Any statement which reveals

that the book is too large or

long to read

Any statement that the booklet

is too short, small, or of

appropriate size

Length/S

hort


too short or too small


the booklet is too small or too

short


is too long, large, or of

appropriate size

Length/A

ppropriat

e


of appropriate length size


the booklet is an appropriate

length for the reader and topic


is too long, large, short, or

small

Breastfee

ding

A reference to breastfeeding Any statement about

breastfeeding

Statement being described with

other types of feeding

techniques or does not

reference breastfeeding

Breastfee

ding

/Technique

A question or statement about

how to breastfeed correctly

Statement references proper

technique or frequency of

feedings

Statement does not reference

technique or frequency of

feedings

Breastfee

ding /PositiveP

ressure

A reference to the benefits of

breastfeeding instead of bottlefeeding

Statement encourages

individual to breastfeed

Statement discourages

individual from breastfeeding

Breastfee

ding /Negative

Pressure

A reference to societal or

personal pressure to breastfeed instead of bottlefeed and any

personal feelings of guilt for

not being able to breastfeed

Statement discourages

individual from breastfeeding

Statement encourages

individual to breastfeed

36

Breastvsb

ottle

A statement about deciding to

breastfeed or bottlefeed and the

benefits and drawbacks of each one

Any statement which references

both breast and bottlefeeding

Statements about each

breastfeeding or bottle feeding

without reference the other

Bottlefee

ding

A reference to bottlefeeding Any statement about

bottlefeeding

Statement being described with

other types of feeding

techniques

Bottlefee

ding

/Technique

A question or statement about

how to bottlefeed correctly


proper technique or frequency

of feedings


reference technique or

frequency of feedings

Visual

Content

A statement about the visual

content or appearance of a booklet

Any statement about the color,

layout, pictures, or appearance of a booklet


refer to color, layout, pictures, or appearance

Visual/Po

sitive

A positive statement about the

visual content

Any positive statement about

the visual content

Any negative statement about

the visual content

Visual/Ne

gative

A negative statement about the

visual content


the visual content


the visual content

Visual/Sp

ecific

Desires

Any statement concerning a

desire for some specific visual

component

Any statement concerning a

desire for some specific visual

component

Any statement that does not

refer to a desire for specific

visual components

Interactivity

Any statement about the usefulness of interactive

sections of a booklet

Any statement about the usefulness of interactive

sections of a booklet

Statement does not refer to interactive sections of a booklet

Interact/Positive

A positive statement about an interactive section

Any positive statement about an interactive section

Any negative statement about an interactive section

Interact/N

egative

A negative statement about an

interactive section


an interactive section


an interactive section

Quality

of

Information

A statement regarding the

quality or comprehensiveness

or the information presented in a booklet

Any statement regarding the

quality or comprehensiveness

or the information presented in a booklet


refer to the quality or

comprehensiveness presented in a booklet

Quality/R

einforcer

A statement which reveals

information presented in a

booklet that reinforces something previously known

Any statement which infers

information presented is known

but reinforces knowledge


information presented in

booklet is new or not useful

Quality/N

ew

A statement which references

new information learned from a booklet


information presented is novel


information presented is known or not useful

Quality/N

one

A statement which references t

information presented in a booklet which is regarded as

not useful


information presented is not useful


information presented is novel or reinforces knowledge

Quality/P

ositive

A statement which reveals

information presented in a booklet is useful


information presented is generally useful


information presented is not useful; Any statement that

infers information is useful and

either new or reinforcement

Father

Involvem

ent

A statement about the

father/husband/significant

other’s role in prenatal,

postpartum, and child care


father/husband/significant other


reference

father/husband/significant other

OBGYN A statement about OBGYNs,

issues pertaining to prenatal

visits or responsibilities of the

OBGYN

Any statement which pertains

to OBYGNs, prenatal visits or

responsibilities of the OBGYN


pertain to OBGYN, prenatal

visits, or OBYGN

responsibilities

Pediatrici

an

A statement pertaining to

pediatric visits or a

pediatrician’s responsibilities


to pediatric visits or a



pertain to pediatric visits or a


37

PrenatalC

are

A statement pertaining to the

prenatal period and prenatal

care issues

Any statement pertaining to the

prenatal period and prenatal

care issues


pertain to the prenatal period

and prenatal care issues

Prenatal/

Maternal

A statement pertaining to

maternal health issues during

the prenatal period

Any statement pertaining to

maternal health issues during

the prenatal period


pertain to maternal health

issues during the prenatal

period

Paternal/f

etal

A statement pertaining to fetal

health and development issues

during the prenatal period


to fetal health and development

issues during the prenatal period


pertain to fetal health and

development issues during the prenatal period

Postpartu

mCare


mother’s health during the postpartum period


to the mother’s health during the postpartum period


pertain to the mother’s health during the postpartum period

Postpartu

m/Mental


mother ’s mental health in the

postpartum period


to the mother’s mental health

during the postpartum period


pertain to the mother’s mental

health during the postpartum period

Postpartu

m/Physical


mother’s physical care and healing process during the

postpartum period


to the mother’s physical health during the postpartum period


pertain to the mother’s physical health during the postpartum

period

ChildDevelopment

A statement about the child’s development after birth

Any statement which pertains to the child’s development after

birth

Any statement which does not pertain to the child’s

development after birth

ChildDev

/Mental


child’s mental health and development after birth

Any statement pertaining to the

child’s mental health and development after birth


pertain to the child’s mental health and development after

birth

ChildDev/Physical

A statement pertaining to the child’s physical health and


Any statement pertaining to the child’s physical health and


Any statement which does not pertain to the child’s physical

health and development after

birth

Topics A statement which refers to

topics of interest

Any statement referring to

specific topics that respondents

would like information to

address


refer to specific topics of

interest

Documents

Merrick_6992 Final Draft