Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore s22

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and ACQUINO MARY ALIAS address I YEAR M. Sc. NURSING (in block letters) ATHENA COLLEGE OF NURSING FALNIR ROAD MANGALORE – 575 001.

2. Name of the Institution ATHENA COLLEGE OF NURSING FALNIR ROAD MANGALORE – 575 001.

3. Course of Study, M. Sc. NURSING Subject OBSTETRICS AND GYNAECOLOGICAL NURSING

4. Date of Admission to the 01.06.2012 course

5. Title of the Topic

A STUDY TO EVALUATE THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME (STP) ON

KNOWLEDGE OF POSTNATAL DIET AMONG

POSTNATAL MOTHERS IN A SELECTED HOSPITAL AT

MANGALORE

1 6 Brief Resume of the Intended Work . Introduction

“There is emerging evidence that maternal nutrition is key to the future health of not only mother but also her children…”

From time immemorial it has been recognized that the pregnant and lactating women are one of the most vulnerable segments of population: the ill effects of maternal under nutrition affect not only the mother but also her offspring.

The nutrient intake of lactating women is one of the most important determinants of woman’s health, well-being and the ability for long-term successful breast feeding. The nutrient intake of lactating women affects the nutrient content of breast milk and maternal health. Perinatal health of the infants are closely linked to the well-being of mothers.1

Postpartum diet is important in ensuring the mother can heal and reach back to her optimal potential. Postpartum knowledge is an important factor that drives behaviour, and might be one of the key factors that improve diet. Eating healthy during pregnancy is important, but a well balanced diet is equally important in postpartum.2

6.1 Need for the Study

Nutrition is a key factor in national development. The term ‘maternal nutrition’ focuses on women as mothers, on their nutritional status as it relates to the bearing and nurturing of children. Lactation makes considerable nutritional demands on the mother. The success of lactation as well as the health status of the infants depends entirely on the type of diet consumed by women during pregnancy and lactation period. The maternal diet is important during lactation. The quality and quantity of milk secretion depends upon maternal diet.2

The postpartum period, or puerperium, begins as soon as the placenta expelled and lasts for approximately 6 weeks when the uterus becomes

2 regressed almost to the non-pregnant state. By six weeks after delivery, most of the changes of pregnancy, labour, and delivery have resolved and the body has reverted to the non-pregnant state. A good postpartum care and well balanced diet during puerperal period can influence her health for rest of her life . After vaginal birth, there are no dietary restrictions for woman without underlying medical conditions or pregnancy induced complications. Woman should be encouraged to drink 3.000 ml of water and other liquids every 24 hours to restore the fluid balance altered by fluid loss during labour and birth process.3

Unfortunately, many women consume less than the recommended amounts of calcium, magnesium, zinc, vitamins B6, and folate. New mothers are likely to stop taking prenatal vitamins which result in nutritional deficiency during their postpartum period and necessitate a restitution of prenatal nutritional supplementation. Prenatal supplements generally do not include a significant amount of calcium, in addition during lactation; 250 – 350 mg of calcium is transferred daily from the mother to the neonate through breast feeding. Woman should be appraised of the need for additional supplementation to meet requirement for this key mineral.4

Nutritional needs increase during lactation for producing sufficient breast milk for the infant, for providing enough nutrients for the growing infant for the mother to recover her body’s strength and for the mother’s daily requirement. While there is no special diet for nursing mothers, some dietary considerations for breast feeding mother include attention to caloric intake and a commitment to adhering to a well balanced diet. In Asia, postpartum maternal food restrictions (food avoidances) are common practices, which may have important health consequences in reducing the nutritional content of breast milk, inadequate breastfeeding and weaning. Postpartum nutritional counselling can be tailored to the individual woman based on risk factors for poor nutrition such as extremes of maternal age, excessive weight gain during pregnancy, deviation from ideal body weight, multiple gestation, and history of eating disorders, close inter conceptional period and highly restrictive diet

3 due to traditional and religious practices.5

A wide range of studies shows that, maternal diet is important during the postnatal period. Knowledge of the mothers on postnatal diet is important as mothers future health as well as the baby’s health depend on the largely on the type of diet the mothers consumed.

If mothers are educated, the maternal health can be improved. There is a chance for the welfare of the baby only when the diet of lactating mother improves. There fore, the investigator decided to give structured teaching programme to postnatal mothers on postnatal diet in a selected hospital at Mangalore.

6.2 Review of literature

A retrospective study was conducted on early postpartum dietary practices among a group of Saudi women. A convenient sampling technique was used to select 300 postpartum women. An interview questionnaire and a dietary scale of King and Jakobson were used for data collection. The results showed that 73.3% of the study subjects had incomplete knowledge about post-partum nutrition and an equal proportion of them (28.3%) had either excellent or borderline dietary practices during their early post-partum period and about one-fifth of them (19.3%) had dangerous dietary practices. The study concluded that Saudi women’s post-partum dietary practices were significantly associated with their general characteristics such as age, education, employment and number of family member as well as with their obstetrical characteristics including their gravidity and parity.6

A prospective study was conducted to evaluate postpartum thiamine deficiency among Karen women in Thailand. Fifty samples were recruited for the study. 25 in supplemented group and 25 in the un-supplemented group. Women were enrolled prospectively at 30 week of gestation and were followed up weekly until delivery and at 3 months postpartum. On admission, an antenatal and neurological examination carried out weekly until delivery. Maternal blood samples were collected at 30 weeks, at delivery and 3 months

4 postpartum (p<0.05). The results were found as, at 3 months postpartum, thiamine deficiency reflected by an erythrocyte transketolase activity (ETKA) > 1.20% was found in 57.7% of mothers, 26.9% of whom had severe deficiency. The study concluded that thiamine deficiency is still common in Karen women and the situation can be improved by educating lactating women and by implementing an effective thiamine supplementation programme.7

A descriptive study was conducted to evaluate the dietary intake of lactating women in China. Samples selected were 199 healthy lactating women. Personal interviews were conducted to collect a 24 hour diet recall questionnaire. Results showed that the mean daily energy and carbohydrate intake was lower than that of Chinese Recommended Nutrient Intake (RNI), the fat intake increases from 3% to 13% , protein intake exceeded the RNI of 85g by 53% and the intake of vitamin C, B, folate, zinc, dietary fibre and calcium was 5% lower than RNI. This study states that the lactating women on a self-selected diet did not meet the Chinese RNI for many important micronutrients, which may influence the nutritional composition of breast milk and thus impact the potential health of mother and Infants.8

A cross-sectional survey was conducted on prevalence of anaemia in pregnancy and lactating women in India. A total of 1751 women (1148 pregnant and 603 lactating – exclusively breast feeding up to 3 months of age), from 7 states were selected. Data collected by a structured questionnaire and Haemoglobin was estimated by Cyan methaemoglobin method (p<0.001). The results showed that a total of 84% pregnant and 92.2% lactating women were anaemic. The study states that the prevalence as well as severity of anaemia was significantly higher in the study.9

A descriptive survey was conducted to assess traditional pre- and postnatal dietary practices prevalent among rural women in Kangra district of

Himachal Pradesh. 50 samples were selected and data collected through questionnaire based survey. The results revealed that all ladies used one or the other decoction i.e. decoction of dates, sesame and fenugreek by 14%, mixture of dill seeds and fennel by 10% and mixture of dill seeds and dates by 13%

5 ladies. Postnatally, nearly 70-80% had consumed Sund and Kharani where as 32% had taken moong dal halwa. The study concluded that in Kangara district, rural women use traditional knowledge to a considerable extent for mother care at pre and postnatal stage since time immemorial.10

6.3 Problem Statement

A study to evaluate the effectiveness of structured teaching programme (STP) on knowledge of postnatal diet among postnatal mothers in a selected hospital at Mangalore.

6.4 Objectives of the Study

1. To determine the pre-test level of knowledge of postnatal mothers regarding postnatal diet.

2. To evaluate the effectiveness of STP on postnatal diet among postnatal mothers in terms of gain in mean post-test knowledge.

3. To find out the association between knowledge score with selected baseline variables (age, age at marriage, education, occupation, family monthly income, type of family, dietary pattern, and years of married life).

6.5 Operational Definitions

 Effectiveness: In this study, it refers to the extent to which the structured teaching programme will achieve the desired effect in improving the knowledge of postnatal mothers on postnatal diet as evidenced by gain in mean post-test knowledge score.

 Structured teaching programme: In this study, it refers to the systematically planned teaching programme designed to provide information regarding postnatal diet to postnatal mothers which includes definition, importance, types of food, postnatal dietary tips, and foods to be avoided and will be given using lecture cum discussion method.

6  Knowledge: In this study, it refers to the correct written responses obtained from the postnatal mothers regarding postnatal diet as measured by a structured knowledge questionnaire.

 Postnatal diet: In this study, it refers to the type, variety and quantity of food that has to be consumed by the postnatal mothers.

 Postnatal mothers: In this study, it refers to the primipara mothers who are in the first postnatal day.

6.6 Assumptions

The study assumes that:

1. Postnatal mothers will have some knowledge regarding postnatal diet.

2. Structured teaching programme is an accepted teaching strategy in improving the knowledge.

6.7 Delimitations

The study is delimited to postnatal mothers who are:

 willing to participate.

 primipara in their first postnatal day.

 available during the period of data collection.

 able to read or write English/Kannada.

6.8 Projected outcome (Hypotheses)

All hypotheses will be tested at 0.05 level of significance.

H1: The mean post-test knowledge score of postnatal mothers on postnatal diet will be significantly higher than their mean pre-test knowledge.

H2: There will be significant association between the mean pre-test knowledge score of mothers with selected baseline variables (age, age

7 at marriage, education, occupation, family monthly income, type of family, dietary pattern, and years of married life).

6.9 Variables under study

Variables identified in this study are:

Dependent variable: In this study, it refers to knowledge level of postnatal mothers on postnatal diet.

Independent variable: In this study, it refers to structured teaching programme on postnatal diet.

Extraneous variable: In this study, it refers to the selected variables such as age, age at marriage, education, occupation, family monthly income, type of family, dietary pattern, years of married life, and parity.

7. MATERIAL AND METHODS

7.1 SOURCE OF DATA

The data will be collected from postnatal mothers those who are primipara and are in their first postnatal day.

7.1.1 Research Design

Pre-experimental one group pre-test post-test design will be used for the study.

O1 X O2

O1 - Pre-test

X - Structure teaching programme

8 O2 - Post-test

7.1.2 Setting

The study will be conducted in Lady Goschan hospital at Mangalore. It is a government hospital, which offers care during antenatal, intranatal, postnatal, gynaecological, and newborn care. It is a 260-bedded hospital with 100% occupancy and has got approximately 500 deliveries per month.

7.1.3 Population

Population of this study consists of postnatal mothers who are primipara and are in their first postnatal day.

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling Procedure

In this study, purposive sampling technique will be used to select the samples.

7.2.2 Sample Size

The sample for the current study consists of 30 postnatal mothers who will be fulfilling the inclusion criteria.

7.2.3 Inclusion criteria for sampling

Postnatal mothers who are:

 willing to participate in the study.

 able to read or write Kannada/English

 primipara and are in their first postnatal day.

7.2.4 Exclusion Criteria for sampling

Postnatal mothers who:

9  have medical or obstetrical complications.

 are nurses by profession.

7.2.5 Instrument intended to be Used

The tool would consist of two sections.

Section 1: Baseline proforma which includes age, age at marriage, education, occupation, family monthly income, type of family, dietary pattern, years of married life, and parity.

Section 2: A structured knowledge questionnaire to assess the knowledge of postnatal mothers on postnatal diet.

7.2.6 Data collection method

Permission will be obtained from the concerned authority. The purpose of the study will be explained to the postnatal mothers and an informed consent will be obtained. Confidentiality of the information will be assured to gain co-operation of subjects. A pre-test will be conducted by administering a structured knowledge questionnaire followed by a structured teaching programme on postnatal diet to postnatal mothers. A post-test will be conducted after 5 days using the same structured knowledge questionnaire. The investigator will do follow-up and conduct the post test on 5th day as patients will be discharged from the hospital.

7.2.7 Data Analysis Plan

Based on objectives, data analysis will be done by using descriptive and inferential statistics. The findings will be presented in tables and figures.

1. Baseline proforma will be analysed using descriptive statistics such as mean, median, frequency, and standard deviation.

2. Effectiveness of structured teaching programme will be analysed using paired ‘t’ test.

10 3. Association between pre-test mean knowledge score and selected baseline proforma will be analysed using Chi-square test.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, please describe briefly.

No, however a STP will be offered to the postnatal mothers on postnatal diet.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, ethical clearance will be obtained from the ethical committee of the college of nursing prior to the conduction of the study. Administrative permission will be obtained from the concerned authorities. Consent will be obtained from the samples and confidentiality will be assured.

List of References 1. Skerrett PJ, Willett WC. Essentials of healthy eating. J Midwifery Womens Health 2010 Dec;55(6):492-508.

2. Bhide AS, Patki A, Levi M. A textbook of obstetrics for nurses and midwives, pregnancy and childbirth. New Delhi: Jaypee Publications; 2003.

3. Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New Central Book Agency; 2009.

4. Pillitteri A. Maternal and child health nursing. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2010.

5. Penney DS, Miller KG. Nutritional counselling for vegetarians during pregnancy and lactation. J Midwifery Womens Health 2008 Feb;53(1):98-100.

11 6. Hafez SK, Yakout SM. Early postpartum dietary practices among a group of Saudi women. J Am Sci 2010 Aug;6(11):990-8.

7. Gready R, Simpson J. Postpartum thiamine deficiency in a Karen displaced population. Am J Clin Nutr [Internet]. 2001 Jan [cited 2001May 22];74(3):808-13. Available from: URL:http://www.ajcn.org/

8. Koon PB, Peng WY, Karim NA. Postpartum dietary intakes and food taboos among Chinese women. Malays J Nutr [Internet]. 2005 Apr [cited 2005 Jun 10 ];11(1):1-21 Available from: URL:http://www.nutriweb.org.my/publications/mjn 0012_2/default.php

9. Agarwl KN, Agarwal DK, Sharma A, Sharma K, Prasad K, Kalita MC, et al. Prevalence of anaemia in pregnant and lactating women in India. Indian J Med Res. 2006 Aug; 26(5): 173-84.

10. Kanwar P, Sharma N. Traditional pre- and postnatal dietary practices prevalent in Kangara district of Himachal Pradesh. Indian J Traditional Knowledge. [Internet]. 2010 Apr [cited 2011 Apr 20];10(2):339-43. Available from: URL:http://www.niscair.res.in/jinfo/IJTK

12 8. Signature of the Candidate

9. Remarks of the Guide

10. Name and Designation of (in block letters)

10.1 Guide MRS. MERCIA REKHA D’SOUZA ASSISTANT PROFESSOR OBSTETRICS AND GYNAECOLOGICAL NURSING ATHENA COLLEGE OF NURSING FALNIR ROAD MANGALORE.

10.2 Signature

10.3 Co-guide (if any)

10.4 Signature

11.1 Head of the Department SR. SELINAMMA DEVASIA (DHANYA) ASSOCIATE PROFESSOR & HOD OBSTETRICS AND GYNAECOLOGICAL NURSING ATHENA COLLEGE OF NURSING FALNIR ROAD MANGALORE.

11.2 Signature

12.2 Remarks of the Chairman and Principal

12.3 Signature