T
he transition from pregnancy to parenthood is one ing on financial need. All hospital care during labor, birth,
of life’s major events, and it can be a stressful and
vulnerable time for families. To better support
Canadian families through the transition to parenthood,
Health Canada (2000) developed multidisciplinary guide-
lines on family-centered maternity and newborn care
(FCMNC). The FCMNC guidelines state that a primary
goal of postpartum care should be to “support and
strengthen the mother’s confidence in herself and in her
baby’s health and well-being, thus enabling her to fulfill her
mothering role” (Health Canada, 2000, p. 6.5).
Maternal confidence can be defined as a mother’s percep-
tion of her ability to care for and understand her infant
(Badr, 2005). For instance, research indicates that women
who are confident in their ability to breastfeed are generally
successful at initiating and maintaining breastfeeding (Blyth
et al., 2002); a Canadian study found that women who are
less confident tend to wean their infants from breastfeeding
earlier than women who are very confident (Dunn, Davies,
McCleary, Edwards, & Gaboury, 2006). High levels of ma-
ternal confidence in the postpartum period are also associat-
ed with lower levels of anxiety, less depression, increased self-
esteem and coping capacity, and stronger social relationships
(Papinczak & Turner, 2000). Interactions with and support
received from nurses during pregnancy, birth, and the post-
partum period may influence a mother’s level of confidence.
FCMNC is a complex process of providing holistic care
and support that responds to the physical, emotional, and
psychosocial needs of the woman and her family. Family
support, participation, and choice are central to FCMNC,
and support offered by nurses is recognized as having a
Interactions with and support received from nurses during pregnancy, birth, and
the postpartum period may influence a mother’s level of confidence.
Shannon Mantha, MScN, RN, Barbara Davies, PhD, RN, Alwyn Moyer, PhD, RN,
and Katherine Crowe, BScN, RN
powerful effect on women and their families (Health Cana-
ABSTRACT da, 2000). Receiving adequate care and support from nurses
during the transition to parenthood has been associated
Purpose: To describe new mothers’ experiences with family-centered maternity care in relation to their confidence
with decreased levels of stress during labor and birth (Chang
level and to determine how care could have been more responsive to their needs.
& Chen, 2000) and increased duration of breastfeeding
Study Design and Methods: Using data from a prospective Canadian survey of 596 postpartum women, a sub-
(Britton, McCormick, Renfrew, Wade, & King, 2007). In
sample of women with low and high confidence (N = 74) was selected. Data were analyzed using descriptive sta- summary, literature confirms the importance of nursing sup-
tistics and content analysis. port and maternal confidence for pregnant and parenting
Results: Women with both high and low confidence expressed negative experiences with similar frequency (n = women. However, little is known about the characteristics
47/74, 64%). Women wanted more nursing support for breastfeeding and postpartum teaching and education. and experiences of mothers with high and low confidence.
Women who reported a language other than English or French as their first language were significantly less confi-
dent than English- and French-speaking women (p < .05). Study Design and Methods
Clinical Implications: A multilevel framework about family-centered care is presented for healthcare providers in prenatal, Secondary analyses of data from the family-centred maternity
labor and birth, and postpartum care. It is recommended that nurses ask new mothers about their confidence level and care (FCMC) study, which was coordinated by the Ottawa-
give special consideration to cultural background in order to provide supportive care in hospital and community settings. Carleton Health Department in Ontario, Canada, were
conducted. In Ottawa, the health department offers prenatal
Key Words: Family nursing; Postpartum period; Maternal-child nursing; Breastfeeding.
education for a nominal fee, which can be waived depend-
September/October 2008 MCN 307 308 VOLUME 33 | NUMBER 5
and the postpartum period is covered by provincial health
insurance. Public health nurses call all postpartum women
within 48 hours of arriving home from hospital to offer sup-
port and a home visit if indicated by nurse assessment and
client acceptance. In 2006, there were approximately
118,449 births in Ontario, 98% of which took place in a
hospital. The mean age of women giving birth was 30 years
(Ontario Perinatal Partnership Program, 2006).
The FCMC study was a prospective longitudinal study, the
main objective of which was to gain an understanding of the
pregnancy, birth, and postpartum care received by women
within hospital and community settings. Trained interviewers
collected data by telephone using a standardized script at 1
and 6 weeks postpartum. An experienced Canadian re-
searcher developed the surveys, and local experts reviewed
content validity. Women were invited to participate if they
lived in Ottawa, a city of approximately 750, 000 in 2001,
gave birth in one of the four Ottawa hospitals between Octo-
ber, 2000 and March 2001, spoke English or French, and
were discharged home with their infant. The planned sample
size was 600 women, which represented 80% of the 750
births per month in Ottawa. To reach a predesignated pro-
portionate quota for each hospital, researchers contacted 677
eligible women. Fifty-two women declined to participate in
the initial survey, and an additional 29 women did not com-
plete the 6-week postpartum survey. The response rate was
88%; 596 women completed both postpartum surveys.
The current study used a subsample of women from the
FCMC study. As part of the 6-week postpartum survey,
women were asked to comment on how the care they received
during pregnancy, birth, and the postpartum period could have
been more responsive to their needs and their family’s needs.
Women’s responses were recorded verbatim over the telephone.
The responses were two to three sentences (range, two to eight
sentences) and provided the qualitative data for content analy-
sis. Both the 1- and 6-week surveys asked women to report
their level of confidence on a 5-point Likert scale for caring for
themselves and their baby upon discharge and during their
time at home. In the 1-week survey, confidence in caring for
self and baby upon discharge was a single measure, whereas
the 6-week survey used separate questions to measure confi-
dence about caring for self and baby. To create one confidence
score at 6 weeks postpartum for each woman, the two scores
were added to create a composite score that could range from
2 to 10. Scores of 6 or less on the composite score were catego-
rized as low maternal confidence, and scores of 10 were cate-
gorized as high maternal confidence.
September/October 2008
Table 1. Significant Differences Between Demographic Factors and Confidence Levels
WOMEN WITH WOMEN WITH The overwhelming message
ENTIRE SAMPLE
(N = 74)
LOW CONFIDENCE
(n = 37)
HIGH CONFIDENCE
(n = 37)
ed to provide a basis for quantitative embedded within mothers’
comparison. Descriptive statistics
!2 were used to describe women’s comments surrounded interactions
CHARACTERISTICS % % (n) % (n) p value
(by Fisher’s exact test)
characteristics, and chi-square tests with nurses. Mothers reported
were used to describe the relationship
Parity between women’s characteristics that they needed more support
and confidence level. When cell fre-
Primiparas 67.6 62.2 (23) 73.0 (27) 0.99 quencies were small, Fisher’s exact test from nurses regarding infant
Multiparas 32.4 37.8 (14) 27.0 (10) p = .320, ns was used. Statistics were computed feeding, postpartum teaching,
using the Statistical Package for the
Language
Social Sciences (SPSS) (version 12.0 and education.
for Windows). The University of
English 52.7 37.8 (14) 67.6 (25) Ottawa Research and Ethics Board
8.09 provided ethics approval.
French 24.3 27.1 (10) 21.6 (8)
p < .05 nurses regarding infant feeding, postpartum teaching, and
Other 23.0 35.1 (13) 10.8 (4) Results education. This finding is not surprising, because a recent re-
Characteristics of the entire sample and of women with low view of 18 studies on postpartum learning needs found that
Education and high confidence are displayed in Table 1. A significant the learning needs of new mothers are not always met with-
difference was found between maternal confidence level in the early postpartum period (Bowman, 2005).
High school/some
32.5 35.2 (13) 29.7 (11) and two demographic factors: language and age. Specifical- Women’s dissatisfaction with nursing support for infant
college/ university 0.25
ly, in the low-confidence group, more than one third feeding, specifically breastfeeding, had multiple reasons.
Completed college/ p = .619, ns
67.5 64.8 (24) 70.3 (26) (35.1%) of mothers indicated a language other than English Women with low confidence reported confusion about
university/Postgraduate
or French as the language first learned, and only 10.8% of breastfeeding due to conflicting nursing advice, whereas
mothers in the high-confidence group indicated a language women with high confidence reported too much pressure to
Maternal Age other than English or French (χ2(2, N = 74) = 8.09, p < .05). breastfeed from nurses. Although conclusions cannot be
30 or older 58.1 75.7 (28) 40.6 (15) A significant difference was also noted for maternal age and drawn, this finding raises the question of whether nursing
9.48 confidence level (p < .05), with 76% of older mothers (≥ 30) care actually differed between the two groups of women or
25-29 29.7 16.2 (6) 43.2 (16) reporting that they were less confident. The number of if care was perceived differently. Nurses have the ability to
p < .05
15-24 12.2 8.1 (3) 16.2 (6) mothers aged 15 to 24 is small, and caution in interpreting significantly impact a mother’s breastfeeding experience
these results is recommended. through offering supportive or nonsupportive care (Lauwer
Income Figure 1 summarizes women’s comments by stage and ele- & Shinskie, 2000). Having low confidence increases risk of
ment of care. Figures 2 and 3 provides an example of quotes early weaning and introduction of formula (Blyth et al.,
$59,999 or less 31.5 33.3 (9) 29.7 (8) from mothers with low and high confidence. Eighty-five per- 2002), and if nursing support for breastfeeding is inade-
0.09 cent of women in the study commented about how their care quate, these women may be at increased risk for early
$60,000 or greater 68.5 66.7 (18) 70.3 (19)
p = .354, ns could have been more responsive. More than one half of weaning or not breastfeeding at all. Inadequate nursing
Declined to answer (20) (10) (10) women (n = 47/74, 64%) commented on negative experi- support for infant feeding has been documented in the liter-
ences encountered. Women with high and low confidence ature and has been thought to be due to a lack of knowl-
Partner Status commented on negative experiences with similar frequency. edge among nurses regarding current best practices (Hong,
Has a partner 77.0 83.8 (31) 70.3 (26) Almost three fourths of the women who commented refer- Callister, & Schwartz, 2003). Further research is required
1.91
enced the postpartum care they received, and nurses were re- to explore the relationship between confidence level and
No partner 23.0 16.2 (6) 29.7 (11) p = .167, ns
ferred to three times as often as other members of the health- perceptions about nursing support.
care team. Both groups of women commented on breastfeed- In addition to providing correct information that is
ing experiences with the same frequency, although their de- based on current best practice and protocols for infant feed-
Extreme case sampling of the 596 participants was used sample who had composite scores of 10 and were catego- scriptions of why support was lacking differed. Women with ing, nurses need to provide advice and support that women
to create a subsample for the qualitative analysis. Extreme rized as the high-confidence group. A final sample of 74 low confidence reported confusion about breastfeeding due perceive as beneficial to them. In recognition of personal
case sampling follows the underlying assumption that cases women was obtained for the current study. There were no to conflicting advice given by nurses, whereas women with variables that affect breastfeeding, individualized breast-
on either end of a spectrum are rich in information and missing data for confidence scores. high confidence reported too much pressure to breastfeed feeding support offered through tailored care plans is rec-
may provide important insight about the phenomenon of Independent content analyses of the data were performed from nurses. Women with low confidence commented twice ommended as best practice when caring for breastfeeding
interest (Polit & Beck, 2004). Because maternal confidence by two of the researchers (Caelli, Ray, & Mill, 2003). First, as often on postpartum teaching and educational needs when mothers (Registered Nurses’ Association of Ontario,
was the focus of the study, all women from the sample who women’s comments were categorized for content under prena- compared to women with high confidence. 2007a). Care plans for breastfeeding mothers also should
scored 6 or less on the composite score were selected (n = tal, labor and birth, and postpartum. Items were then com- incorporate assessment of women’s confidence level for
37) and categorized as the low-confidence group. An equal pared within and across categories to identify themes. Con- Clinical Implications breastfeeding as a potential predictor of future problems
sample of women (n = 37) with composite scores of 10 sensus agreement was used for categorizing comments and Mothers’ comments often mentioned interactions with nurs- (Dunn et al., 2006) and as a method of gaining insight for
were randomly selected from the 283 women within the theme identification. Comments under each stage were count- es. Mothers reported that they needed more support from tailoring nursing support interventions. Policies, care plans,

September/October 2008 MCN 309 310 VOLUME 33 | NUMBER 5 September/October 2008


Figure 1. Women’s Comments About What Would Have Improved Their Care
Stage Element of Care
• Healthcare provider
Prenatal
• Community services
Labor & Birth
• Healthcare provider
• Hospital environment
• Healthcare provider
Postpartum (up to 6 weeks)
• Hospital environment
and critical pathways used for breastfeeding mothers
should include evaluation measures for breastfeeding sup-
port. In addition to promoting reflective nursing practice,
evaluation enables continual improvement of nursing care
and the identification of systemic problems.
Mothers with low confidence scores reported postpartum
teaching and education to be areas in which nursing support
was lacking. Shorter postpartum hospital stays translate into
decreased contact with nurses for teaching, and parents may
leave the hospital with unmet learning needs. George (2005)
studied a group of new mothers, and the major theme that
emerged was lack of preparedness upon returning home. To
facilitate postpartum learning in busy work environments,
nurses need access to current information and simple tools
that can guide teaching and education. The FCMNC guide-
lines outline five principles to facilitate postpartum learning:
• Set a comfortable climate for learning
• Share control of the content and the process
• Work at building the mother’s self-esteem
• Ensure that learning applies to the family’s home situation
• Encourage self-responsibility of the mother (Health
Canada, 2000)
September/October 2008
What Would Have Improved My Care
• Physician taking time to listen and answer questions
• Not feeling rushed during prenatal appointments (by physician and nurse)
• Prenatal education
a) Standardizing what is taught to provide consistent and accurate information
b) Emphasizing the positive aspects of labor & birth during prenatal classes
• Having the nurse present more often to provide more personalized care and support
• Having physician present more often to ask questions
• Nursing staff being supportive of family’s presence
• Policy and procedures that aim to include partner/family in the labor & birth
experience (access is not restricted)
• An environment that respects cultural and religious beliefs and values
• More support from physicians and nurses (i.e., taking time to listen and explain things)
• More personalized care and support from nurses to offer teaching and education
related to learning needs
• Consistent advice from nurses regarding breastfeeding
• Breastfeeding support offered by nurses that is nonjudgmental, nonpatronizing, and
aimed at increasing sense of control and ability to problem solve
• A lactation consultant available in-hospital
• More awareness among healthcare providers in community to recognize postpartum
depression (PPD)
• More support and follow-up from physicians and public health nurses for postpartum
issues such as breastfeeding and PPD
• More nurses available in-hospital to provide care and support in the early
postpartum period
• Hospital environment that is more supportive to mothers and babies rooming-in
• Warmer room temperatures
These principles could be incorporated into policy docu-
ments on maternal teaching and education and adapted to
suit practice at the bedside and within the community.
Staffing shortages and increasing demands on nurses
may contribute to altered levels of support, and comments
about nurses being too busy, overworked, and short staffed
were concerning. Some mothers described nurses’ behaviors
as “blunt” and “forceful.” When mothers perceive nurses
to be rushing or too busy to help them, they may feel intim-
idated and be reluctant to ask for much needed support
(Hong et al., 2003). Nurses should actively solicit feedback
from women and their families regarding their nursing care.
This feedback enables nurses to reflect on their practice and
increase awareness regarding how specific behaviors are
perceived by families. In busy work environments, it is rec-
ommended that nurses teach content that mothers and fam-
ilies are most in need of knowing (Ruchala, 2000); this con-
tent may differ from generic postpartum checklists and
teaching tools. Freda (2002) suggests starting each postpar-
tum teaching session by asking new mothers about their ex-
isting knowledge base, what they need to know, and what
they want to know. Within practice settings, individualized
MCN 311
Figure 2. Quotes From Mothers With Low Confidence
Stage Element of Care What Would Have Improved My Care
• Community services PRENATAL
“ Lengthening the prenatal course and standardizing what is taught at the different
Prenatal
courses. [I] attended a couple of classes at other prenatal courses and learned things
that were not covered in the primary course.”“…during my pregnancy I was
depressed and found that there was a lack of support for this.” “Moms should be
aware of public health services that are available before the baby is born. Postpartum
depression should be explained to moms before birth and they should be taught to
recognize the signs and symptoms.”
• Healthcare provider LACK OF NURSING SUPPORT AND NEED FOR MORE
PERSONALIZED CARE FROM NURSES
• Hospital environment
“ …nurses are overworked and made mistakes due to this, we need more nurses.”
“The nurses were overworked and not too happy…” “…nurses should spend more
Labor & Birth
time explaining, rather than just giving pamphlets…they expect moms to automatically
know how to breastfeed or bottle feed.”
INCLUSION OF PARTNER & FAMILY, RESPECTFUL OF
CULTURAL/RELIGIOUS BELIEFS AND VALUES
“…husbands should be in hospital room right away [following cesarean birth]. The
hospital restricted my husband’s time. This was stressful for a mother who wanted
support…”“My husband felt totally unwelcome during labor and birth” “I asked my
doctor to have a female during delivery. When I arrived I told the nurse that I had to
have a female doctor because of religious beliefs. The female resident had to get a
male doctor. This was very upsetting to my husband and myself…very embarrassing.”
• Healthcare provider LACK OF NURSING SUPPORT AND UNMET LEARNING NEEDS
• Hospital environment “ I had a breast reduction, and found no info on breastfeeding for this condition. I was
not encouraged or supported in any way regarding breastfeeding.” “How to care for
Postpartum (up to 6 weeks)
my vaginal area was not explained at the hospital. I was later informed about a sitz
bath through the family doctor [2 weeks after delivery]…still wasn’t healed and was
getting worse.” ”There should be more information about mother’s health after
labor…what to expect.”
INCONSISTENT NURSING ADVICE FOR BREASTFEEDING
“ Nurses were giving contradictory and confusing advice regarding breastfeeding,
more support expected. Felt completely on my own.” “…nurses tell you different
advice regarding breastfeeding—very confusing!” “Every nurse gave different advice,
they should be consistent with their advice, especially for first-time moms!”
ENVIRONMENT CONDUCIVE TO ROOMING-IN
“ Roommate had a restraining order from CAS [Children’s Aid Society] to see her baby.
Police had been to see her [roommate] the night before… I was very upset about this.”
“…night nurse was very regimented, she would wake us [mom and baby]…We could
not rest because she insisted the baby should nurse when she was not hungry.”
“Rooms were freezing cold! Baby would have stayed 24 hours [with me] if not so cold.”
care plans could be formatted to collect this type of infor- confident than women who spoke English or French. These
mation as part of routine nursing assessment. women may have experienced language and cultural barriers
Ottawa is a large urban city in which English and French are during their care, which increased anxiety and decreased confi-
the official languages. In 2006, approximately 21% of Ottawa dence. Alternatively, they are likely to be immigrant women,
residents spoke a language other than English or French as their who may perceive nursing care and support differently than
mother tongue, and slightly more than 82,000 individuals had Canadian-born women due to cultural beliefs and practices.
immigrated to the city within the previous 15 years (Statistics One study found that immigrant women were significantly
Canada, 2007). Women in this study who reported a language more likely than Canadian-born women to perceive experiences
other than English or French as their first language were less with breastfeeding support received as detrimental to their suc-
312 VOLUME 33 | NUMBER 5 September/October 2008
Figure 3. Quotes From Mothers With High Confidence
Stage Element of Care
Prenatal
• Community services
• Healthcare provider
• Hospital environment
Postpartum (up to 6 weeks)
cess (Loiselle, Semenic, Coté, Lapointe, & Gendron, 2001).
With increasing evidence that communication barriers con-
tribute to disparities in healthcare (Guthrie, 2005), cultural
assessment that includes asking the mother about language
should be included as routine practice within all FCMC en-
vironments. To provide ongoing support to nurses, cultural
competence education should be embedded within organi-
zational processes (Registered Nurses’ Association of On-
tario, 2007b). This can be accomplished by incorporating
questions about culture and language into routine forms
such as birthing plans. Assessing language fluency enables
nurses to arrange for additional resources, such as transla-
tors or translation of teaching materials.
The findings from this study should be evaluated with
the limitations in mind. Seven years have elapsed since da-
ta collection, and maternity care may have changed, al-
though the increasing trend of immigration to large Cana-
dian cities from other countries most likely makes study
findings relevant today. In the 1-week survey, confidence
in caring for self and baby was a combined question,
whereas in the 6-week survey this question was separated
into two questions. It would have been preferable to use
the same measure in both surveys. There was no baseline
measure of maternal confidence before the childbirth ex-
perience. Future research should build on our findings
and consider the use of validated scales with repeated
consistent measures using a time series design. Although
September/October 2008
What Would Have Improved My Care
PRENATAL
“ Prenatal classes were not helpful. The nurse spoke of tragic births and reiterated
pamphlets.” “Prenatal classes were very informative and excellent.”
LACK OF NURSING SUPPORT AND NEED FOR MORE
PERSONALIZED CARE FROM NURSES
“ …day nurses were too busy.” “Nurse during delivery was extremely blunt—rude with
the father of the baby.” “I expected more support [from nurses], I felt completely on
my own.” “… I had no help at all with baby [in hospital].”
PRESSURE FROM NURSES TO BREASTFEED
“ Too much pressure to breastfeed, result is feelings of worthlessness.” “…there was
too much support for breastfeeding…baby was losing weight and no one mentioned
bottle feeding until it was critical.” “Too much pressure on breastfeeding, I had to
argue about getting a supplement.” “Nurses were way too overzealous for breast-
feeding. Too much pressure, I had to justify reasons for pumping milk…felt like a
child.” “Nurse forced baby onto mom in the OR to breastfeed when she [baby] wasn’t
yet capable. The nurse refused to give bottle.”
ENVIRONMENT CONDUCIVE TO ROOMING-IN
“ When mothers get a caesarean section they should get a semi-private or private
room, there were too many visitors to be able to rest.” “…difficult to rest [with
rooming-in]. I just needed to adjust with a lack of sleep and having a new baby—it was
a shock to the system.”
not available at the time of survey design, the Breastfeed-
ing Self-Efficacy Scale by Dennis (2003) could be incorpo-
rated into data collection tools. This scale was developed
from a theoretical framework and translated and validat-
ed in Chinese and Spanish (Dai & Dennis, 2003; Torres,
Torres, Rodriguez, & Dennis, 2003).
Summary
This study examined the responses of women with low and
high confidence levels in order to describe how FCMC
could have been more responsive to their needs and how
their experiences related to confidence level. Findings indi-
cated that mothers with both low and high confidence
needed more nursing support for infant feeding. Findings
also indicated that mothers with low confidence who were
more likely to speak a language other than English or
French needed more support for postpartum teaching and
education. An increasing amount of international attention
is paid to women’s views about their childbearing experi-
ences, as demonstrated by recent large-scale surveys in the
United States (Declerq, Sakala, Corry & Applebaum, 2006)
and Canada (Chalmers, Dzakpasu, Heaman & Kaczorows-
ki, 2008). This study and others suggest that nurses can fa-
cilitate practice level changes that enable care to be more
responsive to families’ unique needs by going beyond rou-
tine nursing assessment to include maternal confidence level
and cultural background. ✜
MCN 313
SUGGESTED CLINICAL
IMPLICATIONS:
• Actively solicit feedback from mothers and families regarding
their experiences with nursing care and support. Evaluate
support received for infant feeding and general satisfaction
with family-centered care.
• Provide cultural assessment education and support to all
nurses working with families. Support may include having
access to translators or print resources in multiple languages.
• Advocate for culturally sensitive practice changes, such
as incorporating cultural and language assessment into
admission forms and birth plans.
• Utilize best practice guidelines and other evidence-based
resources to develop a consistent and individualized practice
approach for assessing and supporting breastfeeding mothers.
• Develop clinical assessment tools to guide postpartum teach-
ing and education of mothers and their families. Tools should
be easy to use and tailored for identified learning needs.
Acknowledgments
The Public Health Research Education and Development
Program funded the original Family-Centered Maternity
Care Survey.
Shannon Mantha is Program Manager, Early Years,
North Bay Parry Sound District Health Unit, Ontario,
Canada. She can be reached via e-mail at Shannon.man-
tha@sympatico.ca
Barbara Davies is an Associate Professor, University of
Ottawa, Ontario, Canada.
Alwyn Moyer is an Adjunct Professor, University of
Ottawa, Ontario, Canada.
Katherine Crowe is a Supervisor, Reproductive Health
Program, Ottawa Public Health, Ontario, Canada.
References
Badr, L. K. (2005). Further psychometric testing and use of the maternal
confidence questionnaire. Issues in Comprehensive Pediatric Nursing,
28, 163-174.
Blyth, R., Creedy, D. K., Dennis, C., Moyle, W., Pratt, J., & De Vries, S.
(2002). Effect of maternal confidence on breastfeeding duration: An
application of breastfeeding self-efficacy theory. Birth, 29, 278-284.
Bowman, K. G. (2005). Postpartum learning needs. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 34, 438-443.
Britton, C., McCormick, F. M., Renfrew, M. J., Wade, A., & King, S. E. (2007).
Support for breast feeding mothers. Cochrane Database of Systematic
Reviews, 4, CD001141. DOI:10.1002/14651858.CD001141.pub3
Caelli, K., Ray, L., & Mill, J. (2003). Clear as mud: Toward greater clarity in
generic qualitative research. International Journal of Qualitative Meth-
ods, 2(2), 1-23.
Chalmers, B., Dzakpasu, S., Heaman, M., & Kaczorowski, J. (2008). The
Canadian maternity experiences survey: An overview of findings.
Journal of Obstetrics and Gynaecology Canada, 30, 217-228.
314 VOLUME 33 | NUMBER 5
Chang, S., & Chen, C. (2000). A correlational study of nursing support in
labor and women’s birth experience. Journal of Nursing Research, 8,
663-672.
Dai, X., & Dennis, C. (2003). Translation and validation of the breastfeed-
ing self-efficacy scale into Chinese. Journal of Midwifery & Women’s
Health, 48, 350-356.
Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening
to mothers II: Report of the second national U.S. survey of women’s
childbearing experiences. New York: Childbirth Connection.
Dennis, C. (2003). The Breastfeeding Self-Efficacy Scale: Psychometric as-
sessment of the short form. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 32, 734-744.
Dunn, S., Davies, B., McCleary, L., Edwards, N., & Gaboury, I. (2006). The
relationship between vulnerability factors and breastfeeding outcome.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 1-11.
Freda, M. C. (2002). Perinatal patient education: A practical guide with educa-
tion handouts for patients. Philadelphia, PA: Lippincott Williams & Wilkins.
George, L. (2005). Lack of preparedness experiences of first-time mothers.
MCN The American Journal of Maternal Child Nursing, 30, 251-255.
Guthrie, B. J. (2005). Health disparities: Why communication matters.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 504.
Health Canada. (2000). Family-centered maternity and newborn care: Na-
tional guidelines. Ottawa, Ontario, Canada: Minister of Public Works
and Government Services.
Hong, T., Callister, L., & Schwartz, R. (2003). First-time mothers’ views of
breastfeeding support from nurses. MCN The American Journal of
Maternal Child Nursing, 28, 11-15.
Lauwer, J., & Shinskie, D. (Eds.). (2000). Counseling the nursing mother.
In Empowering women through your attitude and approach (pp. 25-
42). Boston, MA: Jones and Bartlett.
Loiselle, C. G., Semenic, S. E., Coté, B., Lapointe, M., & Gendron, R.
(2001). Impressions of breastfeeding information and support among
first-time mothers within a multiethnic community. Canadian Journal
of Nursing Research, 33(3), 31-46.
Ontario Perinatal Partnership Program. (2006). Tailoring services to preg-
nant women and their babies in Ontario. 2006 provincial perinatal re-
port. Ottawa, Canada: Provincial Perinatal Surveillance System.
Papinczak, T. A., & Turner, C.T. (2000). An analysis of personal and social
factors influencing initiation and duration of breastfeeding in a large
Queensland maternity hospital. Breastfeeding Review, 8, 25-33.
Polit, D. F., & Beck, C. T. (2004). Sampling designs. In Nursing research:
Principles and methods (7th ed., pp. 307-308). Philadelphia: Lippincott
Williams & Wilkins.
Registered Nurses’ Association of Ontario. (2007a). Breastfeeding best
practice guidelines for nurses (Revision Supplement). Toronto, On-
tario, Canada: Registered Nurses’ Association of Ontario.
Registered Nurses’ Association of Ontario. (2007b). Embracing cultural di-
versity in health care: Developing cultural competence. Toronto, On-
tario, Canada: Registered Nurses’ Association of Ontario.
Ruchala, P. L. (2000). Teaching new mothers: Priorities of nurses and post-
partum women. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 29, 265-273.
Statistics Canada. (2007). 2006 Community Profiles, Ottawa, Ontario
(City). 2006 Census. Statistics Canada. Retrieved March 31, 2008, from
www.12.statcan.ca/english/profil01/CP01/Index.cfm?Lang=E
Torres, M. M., Torres, R. R. D., Rodriguez, A. M. P., & Dennis, C. (2003).
Translation and validation of the Breastfeeding Self-Efficacy Scale into
Spanish: Data from a Puerto Rican population. Journal of Human Lac-
tation, 19, 35-42.
ONLINE
Public Health Agency of Canada, Family-
Centered Maternity and Newborn Care:
National Guidelines
www.phac-aspc.gc.ca/dca-dea/publications/
bkgrdcon_e.html
Registered Nurses Association of Ontario: Best
Practice Guidelines
www.rnao.org/Storage/30/2457_Breastfeeding_Supplement.pdf
www.rnao.org/Storage/29/2336_BPG_Embracing_Cultural_Diversity.pdf
Perinatal Partnership Program of Eastern and Southeastern Ontario
www.pppeso.on.ca/english/home.html
Childbirth Connection
www.childbirthconnection.org
September/October 2008