768011
research-article2018
CNRXXX10.1177/1054773818768011Clinical Nursing ResearchNgai and Chan
Research Article
A Qualitative Evaluation
of Telephone-Based
Cognitive-Behavioral
Therapy for Postpartum
Mothers
Clinical Nursing Research
2019, Vol. 28(7) 852­–868
© The Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/1054773818768011
DOI: 10.1177/1054773818768011
journals.sagepub.com/home/cnr
Fei Wan Ngai, PhD1
and Pui Sze Chan, MN1
Abstract
The purpose of this study was to explore postpartum women’s perceptions of
a telephone-based cognitive-behavioral therapy (T-CBT). Using an exploratory
qualitative design, a purposeful sample of 39 first-time Chinese mothers who
had participated in the T-CBT was interviewed at 6 weeks postpartum. Data
were collected using semi-structured interviews and analyzed by content
analysis. The findings revealed that Chinese women perceived T-CBT to be
helpful in increasing their confidence in the maternal role, enhancing their
emotional control, and increasing their sense of support. The effectiveness
of T-CBT was enhanced by the delivery of the intervention by health care
professional and the flexibility of intervention to provide individualized and
timely information. The evidence suggests T-CBT is a feasible modality
with the potential to support mothers in managing the demands of parental
transition. T-CBT could be incorporated into perinatal services on an ongoing
and regular basis, and therefore readily accessible to all postpartum women.
Keywords
postpartum women, qualitative evaluation, telephone-based cognitivebehavioral therapy
1The
Hong Kong Polytechnic University, Hong Kong
Corresponding Author:
Fei Wan Ngai, Assistant Professor, School of Nursing, The Hong Kong Polytechnic University,
Hung Hom, Kowloon, Hong Kong.
Email: vivian.ngai@polyu.edu.hk
Ngai and Chan
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Introduction
Transition to motherhood is a time of intense physical and emotional demands
that pose critical adaptation challenges for new mothers (Ngai & Ngu, 2013).
Some women manage to integrate the developmental tasks of a mother and
are satisfied with their maternal roles. However, there are others whose abilities to cope are undermined by stressful demands of motherhood and become
depressed in the first month following childbirth (Ngai & Ngu, 2015).
Postnatal depression was found to be a worldwide health problem affecting
13% of women (Underwood, Waldie, D’Souza, Peterson, & Morton, 2016).
In a longitudinal study of 200 Hong Kong Chinese childbearing couples,
11.5% of women have been reported to suffer from depressive symptoms at
6 months after delivery (Ngai & Ngu, 2015). The impact of postnatal depression on the women can be long lasting and have serious consequences on the
psychosocial development of the child (Raposa, Hammen, Brennan, &
Najman, 2014). Thus, health promotion activities preparing women for the
stress of motherhood and empowering women with coping skills to manage
the complexity of maternal role are an urgent priority.
Telephone-based intervention has shown itself to be an effective treatment
modality for postnatal depression, which offers flexible and accessible individualized care for women in the immediate postpartum period (Logsdon,
Foltz, Stein, Usui, & Josephson, 2010; Ugarriza & Schmidt, 2006). In a randomized controlled trial of 325 primary care patients with major depressive
disorder in the United States, Mohr et al. (2012) found that telephone-based
cognitive-behavioral therapy (T-CBT) was as effective as traditional face-toface cognitive-behavioral therapy (CBT) in reducing depressive symptoms at
posttreatment. CBT focuses on changing dysfunctional cognitions and maladaptive behavior, as well as developing problem-solving and coping skills
that are believed to play a role in the prevention of postnatal depression
(Sockol, 2015). In a systematic review of 48 studies involving 4,937 mothers
and fathers, the results showed that parenting programs underpinned by cognitive, behavioral, or CBT produced statistically significant short-term
improvement in parental self-efficacy 4 weeks after the birth (Barlow,
Smailagic, Huband, Roloff, & Bennett, 2014). A recent systematic review of
36 trials of psychosocial intervention for perinatal depression also revealed
promising findings for CBT on parenting and child development (Letourneau,
Dennis, Cosic, & Linder, 2017).
In a systematic review of 40 qualitative studies on women’s experience of
postnatal depression, Dennis and Chung-Lee (2006) found that women did
not proactively seek help and they prefer to talk with someone who was nonjudgmental rather than receive pharmacological interventions. The delivery
of CBT via telephone has the potential to support mothers by providing
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Clinical Nursing Research 28(7)
proactive, flexible, and accessible individualized care. Such support is vital
during the early postpartum when vulnerable women may become stressed
by child care demands and develop depressive symptoms (Wisner et al.,
2013). A randomized controlled trial was designed to evaluate the effectiveness of a T-CBT for first-time mothers who were at risk of postnatal depression (Ngai, Wong, Leung, Chau, & Chung, 2015). The primary outcome was
postnatal depression and the secondary outcomes were parental competence,
parenting stress, quality of life, and social support. A 5-week telephoneadministered manual-based CBT of 30 min each time was delivered weekly
from 1-week to 5-week postpartum by a trained midwife. The T-CBT was
associated with significant improvements in postnatal depression, parental
competence, parenting stress, and quality of life compared with standard care
at 6 weeks and 6 months postpartum (Ngai et al., 2015). Although the results
from the quantitative evaluation of the T-CBT intervention are encouraging,
it has been recommended that complex interventions should be evaluated
with both quantitative and qualitative methods to understand the context in
which the individual and multiple components of a complex intervention
affect the outcome (Campbell et al., 2007). A qualitative evaluation was conducted to offer additional insight into the success and benefits of T-CBT for
first-time mothers.
Purpose of Study
The aim of this study was to have an in-depth understanding on specific components of the T-CBT intervention that women considered helpful in their
preparation for early motherhood.
Method
Design and Participants
Participants of the randomized controlled trial were recruited from the postnatal units of three regional hospitals in Hong Kong between 2012 and 2014,
which included primipara with singleton full-term healthy baby (gestation:
37-41 weeks; body weight > 2.5 kg, 5-min Apgar score > 7), aged 18 years or
above, married, Hong Kong Chinese residents, able to speak and read Chinese
language, and scored ≥10 on Edinburgh Postnatal Depression Scale (EPDS).
Women were excluded if they had complications after delivery, had regular
psychiatric follow-up, or were currently taking antidepressant or antipsychotic drugs. Participants were randomly assigned to the T-CBT or the control group. The intervention group received usual care and T-CBT, whereas
the control group only received usual postnatal care (Ngai et al., 2015).
Ngai and Chan
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Among the 197 women who had completed all five sessions of T-CBT, a
purposeful sample of 39 women was invited for an in-depth, semi-structured,
telephone interview at 6 weeks postpartum. Purposeful sampling involves
interviewing people who have had experience with or are part of the phenomenon of interest, to develop a rich description of the phenomenon (Speziale &
Carpenter, 2011). Participants were recruited until data saturation was
achieved when additional participants did not uncover new ideas.
Main elements of T-CBT included exploring stress and emotional changes
during the postpartum period, discussing signs and symptoms of postnatal
depression, identifying negative thoughts and techniques for modifying those
thoughts, facilitating effective problem solving and decision making to cope
with common neonatal problems, and improving communication skills to
resolve interpersonal conflict.
Data Collection
A semi-structured interview guide was developed to facilitate the interview.
Examples of questions were “What’s your experience of early motherhood?”
“How did T-CBT help you cope with the experience of new motherhood?”
“What did you like or dislike most about T-CBT?” “Did you have any suggestions for improvements of T-CBT?” “Would you recommend T-CBT to a
friend?” The semi-structured interview guide was reviewed by a panel of
experts including two academics in midwifery and mental health nursing,
two experienced midwives, and two mothers. The interviews were conducted
by a trained independent research assistant.
At 6 weeks postpartum, the research assistant telephoned the participants
who had completed T-CBT and invited them to participate in a semi-structured interview. The nature and purpose of the study were explained. Once
consent was obtained, the interview was conducted via telephone. The participants were encouraged to express their perceived impact of T-CBT in
Cantonese. Each interview lasted for about 30 min and all the interviews
were audio-recorded.
Ethical Consideration
Ethics approval for the study was granted by the Clinical Research Ethics
Committee of the University and the participating hospital. The nature and
purpose of the study were explained. Participants were assured of confidentiality and their right to withdraw from the study at any time with no adverse
consequences to their treatment and care. Informed consent was obtained
from those who agreed to voluntarily participate in the study.
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Data Analysis and Trustworthiness
Data were analyzed using content analysis which was conducted simultaneously with data collection (Speziale & Carpenter, 2011). Interview data were
transcribed and analyzed in its original language. This was done to maintain
the subtlety and meaning of the women’s voices as accurately as possible.
Data were reviewed and coded independently by the researchers. The initial
coding was done by noting key meaning of the data in the margin of the transcribed text. Each term, sentence, and phrase representing an idea was identified and grouped into a category for analysis of emerging themes. The two
researchers then compared the emerging themes for commonalities and variations, and identified the overall themes that best described the participants’
perceptions of T-CBT. Quotations that are presented in this article were translated into English. The translations retained what the women said with some
syntactical corrections. The first author translated the quotations, which were
then cross checked by the second author.
Trustworthiness is often a concern in qualitative content analysis
(Graneheim & Lundman, 2004). The data in the current study were reviewed
and coded independently by two researchers. Themes were identified and
compared with ongoing and regular communication to ensure consensus and
accurate interpretation of the data, thus, enhancing both the credibility and
dependability of the findings. All interviews were conducted by the same
research assistant using the semi-structure interview guide to ensure consistency in the process of data collection. All interviews were tape-recorded and
transcribed by the same research assistant to ensure dependability of the findings. Field notes were taken to document observations and describe the interviewer’s personal experience with a particular encounter, which may facilitate
data analysis and interpretation.
Results
Thirty-nine women were interviewed. The mean age of the participants was
32 years (SD = 3.3). All participants had a secondary school education and
were employed, which is representative of the general population of postpartum women in Hong Kong (Ngai et al., 2015). The median monthly household
income was HK$33,203 (US$4,257). The majority of participants had vaginal
birth (76.9%). The characteristics of the participants are presented in Table 1.
Four main themes emerged from the women’s perception of the T-CBT:
(a) benefits of T-CBT, (b) facilitators to T-CBT, (c) barriers to the effectiveness of T-CBT, and (d) suggestions for improving T-CBT. All themes and
subthemes are summarized in Table 2.
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Ngai and Chan
Table 1. Characteristics of Participants (n = 39).
Characteristics
Age, M (SD)
Education
Secondary
Tertiary or university
Employment status
Unemployed
Employed
Monthly household income
<HK$20,000
HK$20,000-HK$30,000
HK$30,001-HK$40,000
>HK$40,000
Mode of delivery
Vaginal delivery
Cesarean section
%
n
32.0 (3.3)
15
24
38.5
61.5
0
39
0
100
7
8
14
10
17.9
20.5
35.9
25.7
30
9
76.9
23.1
Table 2. Themes and Subthemes of the Findings.
Themes
Benefits of T-CBT
Facilitators to T-CBT
Barriers to the effectiveness
of T-CBT
Suggestions for improving
T-CBT
Subthemes
Increased confidence in the maternal role
Enhanced emotional control
Increased sense of support
Delivery of T-CBT by a health care professional
Accessibility and flexibility of T-CBT
Difficult to meet individual learning needs
Busy schedule of mothers
Extending T-CBT over a longer postnatal period
Note. T-CBT = telephone-based cognitive-behavioral therapy.
Theme 1: Benefits of T-CBT
Within the theme of benefits of T-CBT, three subthemes were identified,
including increased confidence in maternal role, enhanced emotional control,
and increased sense of support.
Increased confidence in maternal role. Acquisition of knowledge and parenting
skills appeared to be the most important aspect of T-CBT, because it elicited
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the greatest number of responses from the participants. Most mothers (89.7%,
n = 35) found the T-CBT helpful because of the advice and guidance provided
by the nurse on the practical care of their child, such as feeding, bathing,
nappy changing, and the ways of dealing with common neonatal problems.
One mother said,
I encountered difficulties in breastfeeding . . . my child seemed to have nasal
congestion and breathing difficulties . . . the nurse [who delivered T-CBT]
taught me how to position my child . . . the correct technique of breastfeeding
. . . which was really helpful. (Informant 11)
Another mother said,
As a first-time mother, T-CBT was really helpful . . . I learnt how to feed my
child, burping, how to take good care of my child, how to make him feel more
comfortable . . . When my child had hiccups, the nurse taught me different
methods to stop the hiccups . . . I tried them and they worked, my child stopped
the hiccups. (Informant 22)
Knowledge about infant care also enhanced a new mother’s confidence in
taking up the maternal role. Some women (46.2%, n = 18) stated that T-CBT
provided them with different strategies for handling problems associated
with infant care, and this increased their confidence in dealing with difficult
situations. A mother said,
I felt painful [on my nipple] because of my child’s sucking . . . so I had to
supplement with bottle feeding . . . I tried to use the breast pump, but I was not
sure whether I was doing it right. The nurse [who delivered T-CBT] reassured
me that it was just normal and it would be all right . . . which increased my
confidence. (Informant 3)
Another mother said,
Everything about newborn care was new to me. When I encountered things I
could not manage, they were all seemed to be problems to me. When I had
gained more experiences or after the guidance and advice from the nurse [who
delivered T-CBT], I could handle the problem, and I started to feel less stressed
and more confident. (Informant 34)
Enhanced emotional control. Participants in this study commented that the
skills they learnt in T-CBT, such as positive thinking and problem-solving
help them control their emotions when faced with the stress of motherhood.
For example, one mother said,
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I tried to make myself happy by stopping negative thoughts . . . actually every
problem could be solved . . . I was happy just looking at my baby. (Informant 5)
Another woman said,
When I was upset by my child’s crying, I reminded myself to think more
positively that every child cries . . . (Informant 16)
Others also shared their experiences in using problem-solving skills to
help them cope with the negative emotion. One said,
I tried different strategies and tips provided by the nurse [who delivered T-CBT],
such as how to breastfeed my child and whether my child had enough milk or not,
which helped me solve the problem and improve my emotion. (Informant 28)
Another woman said,
During the time when I was “doing-the-month,” I was frustrated every time my
child cried, not hating my child, but frustrated . . . then I learnt to control
myself, when I started to have the feeling of frustration, I would take a break
and ask the domestic maid to help take care of my child. (Informant 7)
Increased sense of support. Emotional support was identified for the majority
of mothers as an important aspect of the T-CBT. Most mothers (87.1%, n =
34) were very grateful for the support they received from the nurse who
delivered T-CBT, as one remembered,
I was very worried at the beginning . . . the nurse [who delivered T-CBT] taught
me the correct skills in breastfeeding . . . I felt being supported . . . emotional
support . . . I felt much better after talking to her. (Informant 9)
Talking about feelings and being listened to were appreciated by the mothers, in particular during the first month after delivery. A woman said,
T-CBT was very helpful . . . because there was no one that I could really talk to
. . . I did not know where to seek help . . . I could not go out because I was
“doing-the-month.” (Informant 10)
Another woman echoed,
T-CBT was very helpful . . . in particular during the first month when I could
not go out [because of “doing-the-month”]. When I received the phone call
from the nurse [who delivered T-CBT], it was just nice to have someone you
could talk to . . . I felt good . . . being supported. (Informant 3)
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Clinical Nursing Research 28(7)
Theme 2: Facilitators to T-CBT
Facilitators to the T-CBT were identified by the participants. These included
the delivery of the T-CBT by a health care professional and the accessibility
and flexibility of the T-CBT.
Delivery of T-CBT by health care professional. The majority of mothers (64.1%,
n = 25) appreciated the delivery of T-CBT by an experienced nurse who could
provide professional knowledge, which gave them a feeling of security. A
mother said,
Ms. Ho [who delivered T-CBT] is a nurse. I had trust in what she taught me
. . . she also got a university degree . . . I felt more confidence . . . better than
listened to my friends or others . . . I felt a sense of security . . . because she
got midwifery experiences. (Informant 9)
Another mother shared,
My child had a fever up to 40 degrees, and she was admitted to the hospital and
received the antibiotics . . . she had urinary tract infection . . . the nurse [who
delivered T-CBT] taught me how to take care of my child, and reminded me of
the things I should pay attention to . . . the nurse got the professional knowledge
. . . if others reminded me, I might not believe them . . . but a nurse, I felt a sense
of security . . . more relieved. (Informant 5)
Accessibility and flexibility of T-CBT. Some mothers (38.5%) found the T-CBT
helpful because of its flexibility and accessibility to provide individualized
and timely information. A mother said,
It happened several times when I encountered problems in child care, I received
phone calls from the nurse [who delivered T-CBT]. I immediately sough her
advice . . . because it was not possible to go to the maternal and child center to
ask the doctor . . . she could give me the professional advice which was helpful
. . . I could also call back when I missed the call from the nurse. (Informant 21)
Another mother echoed,
I did not need to go out . . . I could ask the nurse on the phone about problems
I encountered in childcare and my own recovery. (Informant 32)
Theme 3: Barriers to T-CBT Effectiveness
Barriers to the effectiveness of T-CBT were identified by the participants. These
included difficult to meet individual needs and busy schedule of the mothers.
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Difficult to meet individual needs. Although the majority of women (92.3%, n = 36)
stated that the T-CBT was helpful, a few expressed that the information provided
by the nurse at T-CBT could not satisfy their needs. A mother said,
When I started to have breastfeeding, I asked the nurse [who delivered T-CBT]
if I wanted to supplement with bottle feeding, how could I do it? . . . I also
asked her other questions, but it seemed that she could not address my questions.
(Informant 33)
Busy schedule of mothers. Several mothers mentioned about their busy schedule and had missed the phone calls from the nurse who delivered T-CBT. A
mother said,
It was quite busy in particular for a first-time mother. The nurse had called me
several times, but I was not able to listen to the phone calls. The nurse needed
to keep calling me, and sometimes I had missed her calls. I knew it was the
nurse’s call, but I was busy and unable to listen to her call. (Informant 14)
Another mother said,
I was really busy, sometimes I missed the nurse’s phone call and did not have
the chance to talk to the nurse . . . when I tried to call back, the nurse was not
on the phone or the line was busy. (Informant 28)
Theme 4: Suggestions for Improving T-CBT
Although one third of the mothers felt that the frequency and duration of
T-CBT was sufficient, the majority of mothers suggested extending the
T-CBT over a longer postnatal period. One woman said,
Extending T-CBT over a longer period . . . 2-3 more weeks, eight sessions
would be more appropriate in particular for first-time mothers, I looked forward
to the nurse’s phone calls every week, and I would write down all my concerns
. . . because when the nurse called me, I might not be able to remember all of
them . . . so three more weeks would be better. (Informant 32)
Some mothers suggested extending the T-CBT beyond the time when they
returned to work. For example, a mother said,
If the duration of T-CBT was longer, it could focus on more parenting issues
which would be better . . . T-CBT was finished before I returned to my work.
There might be many changes in childcare when I returned to work . . . how to
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continue breastfeeding . . . how to use the breast pump . . . what’s the effect of
decreased sucking from my child . . . and the emotional change . . . it would be
better if T-CBT was longer, so that it could provide more support. (Informant 9)
Another mother said,
The frequency of T-CBT could be increased in the first two weeks because it was
the most stressful time . . . 1-2 phone calls in the first two weeks, if there were not
many problems, weekly at 4-6 weeks, then monthly up to six months . . . because
the child might not be well developed at 3-month-old, the child might start to
have the solid food at five months . . . learning to sit up. (Informant 3)
Despite these suggestions, more than 92% (n = 36) of the participants
expressed that they would recommend the T-CBT to other women, in particular the first-time mothers, because the T-CBT was useful in helping them
cope with the demands of new parenthood.
Discussion
The findings of the qualitative data revealed that the majority of mothers
found T-CBT helpful and enabled them to feel more skilled and confident in
taking care of their child, less stressed, better emotional control, and more
supported in taking up the maternal role. Existing literature suggested that
new parents felt they had inadequate knowledge and skills in child care and
experienced feelings of insecurity and incompetence in their parental role
(Nilsson et al., 2015; Ong et al., 2014). Many mothers in this study found that
it was the advice provided by the T-CBT nurse on the practical care of their
child and dealing with common neonatal problems, that enabled them to feel
more capable to cope and boosted their confidence in the maternal role. The
findings concur with previous studies that the more a mother felt prepared for
caring for her infant and equipped with the parenting skills, the greater her
feelings of competence and fulfillment in the maternal role (Fowler et al.,
2012; Gagnon & Sandall, 2011).
Furthermore, new mothers in this study expressed that encouragement and
verbal support from the T-CBT nurse helped reassure them and reinforced
their confidence in their ability to perform parenting tasks. Verbal reassurance has been identified as an important source of building a woman’s competence for successful parenting (Bandura, 1989; de Montigny & Lacharite,
2004). In contemporary Hong Kong society, the breakdown of the extended
family as a result of the rapid growth of the nuclear family, and the pressure
of household tasks and employment have left many women feeling isolated
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863
and incompetent in the maternal role (Ngai & Chan, 2012). In addition, with
the decreasing length of stay in the hospital after childbirth, new mothers may
not have enough time to learn parenting skills and acquire the experience
necessary to develop competence with an infant (Nilsson et al., 2015). Thus,
the T-CBT seems to provide new mothers with a valuable platform to acquire
the knowledge and skills, and the professional support necessary to be competent mothers. The findings concur with previous studies that women
expressed a need to be confirmed as competent mothers by health care professionals. This can be achieved by encouragement and confirmation that
they are “doing it right” in caring for their child (Kynø et al., 2013; Persson,
Fridlund, Kvist, & Dykes, 2011).
The immediate postpartum period is often characterized by the mother’s
great emotional lability and thus more vulnerable to the development of postnatal depression (Ngai & Ngu, 2015; Paulson & Bazemore, 2010). The skills
taught at T-CBT including cognitive reframing and problem-solving strategies were identified as constructive and useful to the mothers in this study.
Participants quoted examples of application of positive thinking and problem-solving skills to help them control their emotions when faced with the
demands of infant care; thus, they tended to feel less stressed and have better
emotions in the early postpartum weeks. The use of positive thinking and
problem-solving skills may have helped mothers moderate their thoughts,
feelings, and sensations that affect their daily activities and improve their
effectiveness in managing negative emotions when faced with the demands
of new parenthood. Findings from this study confirm the theoretical underpinning of T-CBT, which helps prevent postpartum depression through modifying negative thoughts and developing problem-solving skills (Sockol,
2015). Previous study has found that a telecare therapy teaching problemsolving and cognitive strategies was effective in reducing depressive symptoms in women suffering from postnatal depression (Ugarriza & Schmidt,
2006). This supports telephone-based intervention as a therapeutic option for
promoting mental health during the postnatal period.
Furthermore, emotional support through the T-CBT nurse was appreciated
by the mothers in this study and regarded as an important positive component
of T-CBT. It was observed that new mothers looked forwarded to the T-CBT
nurse’s phone calls. Having the opportunity to talk about their feelings and
being listened to seemed to make the new mothers less vulnerable to stress
and more secure, in particular during the first month after delivery when they
are confined to their homes due to the cultural practice of “doing-the-month.”
Traditionally, Chinese mothers are recommended to practice the ritual of
“doing-the-month” in which they are engaged in a series of month-long prescriptive and restrictive practices to restore their health, such as stay in the
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Clinical Nursing Research 28(7)
house for a full month, do not wash hair and take shower to avoid exposure
to cold wind (Holroyd, Lopez, & Chan, 2011). It was observed that the postpartum traditional custom of “doing-the-month” was still commonly practiced by contemporary Hong Kong Chinese women (Holroyd et al., 2011).
Such practices may deter women from seeking perinatal services when they
need help in child care or experience emotional distress. Thus, many mothers
in this study appreciated the accessibility and flexibility of T-CBT to provide
individualized and timely information.
The effectiveness of T-CBT was further enhanced by the delivery of intervention with a nurse who could provide professional knowledge and expert
advice on the parenting issues that new mothers encountered in the immediate postpartum period. Today, it is more easy and convenient for new parents
to access parenting information with the availability of new media technologies. However, the exposure to profound information often creates confusion
especially when it contradicts another. Porter and Ispa (2013) found that conflicting messages about childrearing could lead to confusion and stress. Thus,
new mothers in this study appreciated the expert advice from a professional
nurse who they could trust. The ability of T-CBT nurse to help new mothers
solve the immediate problems they faced in parenting seemed to increase
their sense of security. This was in line with previous studies that a mother’s
sense of security during the early postpartum weeks depended on the level of
support provided by the health care professionals and knowing where to seek
help when needed (Persson et al., 2011).
However, the busy schedule of new mothers and their individual needs
seem to hinder the effectiveness of T-CBT. The early postpartum weeks
are particularly stressful and busy for first-time mothers because of the
daily demands of child care, such as breastfeeding (Ngai & Chan, 2012).
Remedial measures, such as leaving T-CBT nurse’s contact number to call
back when they were available and making more frequent calls at different
time during the day, were introduced to enhance the accessibility and flexibility of T-CBT. However, some mothers still could not be reached.
Alternative approaches of providing postnatal care, such as the instant
mobile messaging or online forums, could be considered in addition to the
telephone-based intervention to provide the new mothers with individualized information. Furthermore, many mothers expressed the concerns
about continuing breastfeed after returning to work and needed more
information about weaning and their child’s developmental needs.
Extending the T-CBT for a longer postnatal period could be considered in
the future development of perinatal care to provide ongoing support and
information appropriate for the breastfeeding mothers and the changing
developmental needs of the child.
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Ngai and Chan
Limitations
This study was conducted with a small sample of Chinese first-time mothers
participated in a randomized controlled trial to test the effectiveness of
T-CBT, which might limit the transferability of the results. The sample comprised women who had completed all five sessions of the T-CBT, which may
not be transferable to those who completed fewer sessions. Despite the limitation, it does provide in-depth and contextual data for a better understanding
of the strengths and weaknesses of T-CBT, which is essential to improve the
quality of care for first-time mothers.
Conclusion
The evidence suggests T-CBT as a feasible treatment modality with the
potential to support mothers in managing the demands of the postpartum
period. It is important to incorporate T-CBT into maternal and child health
services on an ongoing basis, so that it can become part of the regular service
and, therefore, readily accessible to all postpartum women to improve their
perinatal well-being.
Acknowledgments
The authors would like to thank the research team in data collection and management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was supported by the Health
and Medical Research Fund of the Hong Kong SAR Government.
ORCID iD
Fei Wan Ngai
https://orcid.org/0000-0003-1760-5105
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Clinical Nursing Research 28(7)
Author Biographies
Fei Wan Ngai, Phd, is a registered midwife and received her PhD from the Chinese
University of Hong Kong. Her research interest is in the area of maternal health care,
with special focus on the prevention of perinatal depression.
Pui Sze Chan, MN, is a nurse midwife and has been working in obstetric nursing and
prenatal diagnosis for over 10 years. Now she is a nurse educator and a clinical mentor
of undergraduate students. She is interested in maternity nursing, especially on teenage pregnancy and related care; also on nursing education.