THE PSYCHOSOCIAL CONSEQUENCES FOR

PRIMIPARAS AND MULTIPARAS

Chich-Hsiu Hung
College of Nursing, Kaohsiung Medical University and Department of Nursing,
Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

The purpose of the study was to differentiate among various postpartum stressors and to com-
pare women’s postpartum stress, social support, and mental health status in relation to parity
differences. A non-experimental quantitative study with cross-sectional design was carried out.
A total of 435 primiparas and 426 multiparas from clinics and hospitals in southern Taiwan were
recruited for the study. The Hung Postpartum Stress Scale, the Social Support Scale, and the 12-item
Chinese Health Questionnaire were used to compare the postpartum stress, social support, and
mental health status of primiparous and multiparous women. Compared with multiparas, the
mean scores of primiparas were higher for postpartum stress, concerns about negative body
changes, concerns about maternal role attainment, as well as for measures of social support, family
support, and friend support. However, multiparas had higher scores than primiparas regarding
concerns about lack of social support. The mental health status of the two groups did not differ
significantly by parity. The primiparous women and multiparous women experienced unique
postpartum stressors. The results suggest that it is important to identify specific postpartum
stressors for primiparas and multiparas when providing supportive interventions. Specifically
tailored nursing interventions based on differences in parity may help reduce postpartum stress
and help prevent the development of more severe mental health problems among postpartum
women.

Key Words: mental health status, multiparas, postpartum stress, primiparas,

social support
(Kaohsiung J Med Sci 2007;23:352–60)

The postpartum period has been conceptualized in a themselves and their new infant(s), all of which
variety of cultures as a time of vulnerability to stress requires them to seek social support, especially from
for women. The new demands, structural constraints, significant others. For women going through this
and other characteristics of the postpartum period transition, it may be a uniquely stressful life experi-
bring about dramatic changes, adjustments, and there- ence, with adverse effects on their health [2]. As the
fore, difficulties that can lead to postpartum stress [1]. author’s previous research has indicated, the effects
After giving birth, mothers face multiple demands of of postpartum stress and social support on postpar-
adjusting to changes in the body, learning about their tum women’s health are significant [2]. In fact, three
new infant(s), and providing and arranging care for factors—”concerns about negative body changes”,
“concerns about maternal role attainment”, and “con-
cerns about lack of social support”—have been the
Received: September 28, 2006 Accepted: January 11, 2007 critical attributes for postpartum stress [3].
Address correspondence and reprint requests to: Dr Chich-
Researchers have found that women’s concerns
Hsiu Hung, School of Nursing, Kaohsiung Medical University,
100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. over body changes during the early postpartum period
E-mail: chhung@kmu.edu.tw are related to childbirth-related physiologic changes,

352 Kaohsiung J Med Sci July 2007 • Vol 23 • No 7

© 2007 Elsevier. All rights reserved.
 Primipara vs. multipara

which can be a source of physical discomfort. Post- successfully. Crnic et al [15] conducted a longitudinal
partum women may experience pain and discomfort study, which indicated that mothers with more sup-
due to episiotomy, breast engorgement, and nipple port reported significantly greater satisfaction both in
soreness [4–6]. Affonso et al [7] identified fatigue, their lives and with their parenting, as well as more
sleep disturbances, general body discomforts, and eat- positive specific child rearing attitudes. These results
ing disturbances as stressors for postpartum women. are consistent with findings on the relationship of social
Postpartum women not only have to begin recover- support with health status during the stressful peri-
ing from childbirth but also have to provide ongoing natal period [17]. Thus, women with greater support
care to a needy infant. The literature on this topic has resources appear to have a better health status [17,19].
suggested that mothers’ postpartum concerns include The issues related to postpartum women’s health
the infant’s appearance, feeding, crying, sleeping, phys- status have received a great deal of scholarly attention.
ical care, handling and dressing, safety, and elimina- The exploration of stressful events during the post-
tion [5,6,8–10]. partum period has typically focused on primiparous
When women face concerns over maternal tasks, women. Although it is important to identify specific
their feelings of not fulfilling their obligation satisfacto- postpartum stressors for primiparas and multiparas
rily can induce postpartum stress. Postpartum women when providing supportive nursing interventions, the
have to simultaneously begin recovering from child- unique challenges faced by multiparous women with
birth, provide ongoing care to a needy infant, and deal increased parity have been neglected. In fact, post-
with the burden of many competing concerns. The partum stress is a newly developed concept and its
results of a study by Bennett [8], for example, showed measure has been developed by Hung [3]. Several
that laundry, cleaning, personal hygiene, cooking, nursing studies explored postpartum women’s con-
financial problems, restricted social life, giving up cerns but few systematically investigated postpartum
work, and a lack of spare time for interests caused the stress related to women’s parity. Therefore, the pur-
most concern in the early puerperium. While the pose of this study was to differentiate among postpar-
stress induced by these changes may be heightened tum stressors based on parity and to compare women’s
by a lack of social support, an individual’s social net- postpartum stress, social support, and health status in
work and the support it provides can be a coping relation to parity differences.
resource against stress [11,12]. Research findings have
indicated that adaptive maternal behavior was influ-
enced favorably by the mother’s perception of the METHODS
amount of positive support she received [12–16].
A core network of family and friends is frequently Study design
cited as an important source of postpartum support This study focused on one aspect of a larger project.
and plays a statistically significant role for mothers in A non-experimental quantitative study with a cross-
predicting postpartum adjustment [14,16,17]. Moran sectional design was conducted to differentiate post-
et al [18] conducted a study related to postpartum partum stressors and compare women’s postpartum
women’s desire for more information on self-care and stress, social support, and health status in relation to
infant care and found that all women who reported parity differences.
high levels of support from family and friends asked
for significantly less information than those with fair Sample
or poor support. Eight hundred and seventy-seven postpartum women
Not only has social support been postulated to were recruited from 22 hospitals and clinics in south-
play an important role in stressful transition periods, ern Taiwan that had birth rates of 30 or more per
it has also been found to play a statistically signifi- month. However, at the time of the telephone inter-
cant role in predicting postpartum women’s health view, 16 women could not be involved due to diverse
status [14,17]. Support is likely to increase a mother’s reasons such as their inconvenience, lack of interest,
sense of self- and infant-care capability and success in and investigators’ lack of access to correct forwarding
relating to the infant, which will influence her ability telephone numbers and addresses. The criteria for
to execute personal, maternal, and household tasks inclusion in the sample were women who: (a) had had

Kaohsiung J Med Sci July 2007 • Vol 23 • No 7 353

C.H. Hung

a single, healthy, and full-term baby, without compli- 0.64, respectively [21], and Cronbach’s α was 0.86 [21].
cations; (b) had no major postnatal complications and Cronbach’s α for the SSS in this sample was 0.90.
no underlying medical problems; (c) were married
Taiwanese residents; and (d) could speak Mandarin The 12-item CHQ
Chinese. The postpartum women’s mental health status was
measured with the 12-item CHQ [22,23]. This culture-
Instruments specific questionnaire is designed to reflect Chinese
Three instruments were used for the study: the sociocultural preferences in the expression of distress,
Hung Postpartum Stress Scale (Hung PSS); the Social including anxiety, depression, sleep disturbance and
Support Scale (SSS); and the 12-item Chinese Health somatic symptoms, somatic concerns, and interper-
Questionnaire (CHQ). sonal difficulties [22,24]. Respondents rated how fre-
quently each symptom for these minor psychiatric
The Hung PSS morbidities was experienced during the previous
The 61-item Hung PSS is a valid and reliable tool for weeks on a 4-point scale rating from 1 (not at all) to
assessing women’s postpartum stress during the 42- 4 (most of the time). One and 2 ratings were recoded
day puerperium [3]. An exploratory factor analysis as 0, and 3 and 4 ratings were recoded as 1. All rat-
indicated that concerns about negative body changes, ings were summed, forming a summary score rating
maternal role attainment, and lack of social support from 0 to 12 [23]. The scores used as a cut-off point
are three components of postpartum stress. The gen- for the “case”/”non-case” judgment for minor psy-
eralizability of the Hung PSS has been shown to have chiatric morbidity in community samples were 3/2 and
high coefficients of congruence among postpartum the sensitivity and specificity were 91.9% and 66.7%,
women across type of delivery, level of education, respectively [22]. Cronbach’s α for the CHQ in this
and income status. The internal consistency reliabili- study was 0.70.
ties for its three dimensions across a full sample and
within pertinent sub-samples has also shown that the Procedure
Hung PSS is a reliable tool for measuring postpartum After approval from the institutional review board
stress, with the alpha for coefficients ranging from of each participating institution and from the research
0.84 to 0.92 [3]. ethics committee at the researcher’s institution, each
On a 5-point scale rating from 1 (not at all) to potential participant was visited during her post-
5 (always), the women in the study rated each item partum hospitalization if the selection criteria were
on how much stress was perceived during the post- met. The study and consent forms were explained to
partum period. The score for postpartum stress was them using standardized scripts. Once a signed con-
derived by summing all ratings, resulting in poten- sent form was obtained, a demographic questionnaire
tial scores from 61 to 305. Higher values indicated was completed by each woman. Moreover, an entire
higher stress. The Cronbach’s α for the Hung PSS in pre-interview questionnaire was filed in a plastic folder
this study was 0.94. and given to the participants. Each woman was ran-
domly assigned to participate in a telephonic inter-
The SSS view during one of the 6 weeks of her postpartum
The SSS is a 10-item, 5-point Likert-type scale and period and was contacted over telephone at the place
includes the Family APGAR (Adaptation, Partnership, where she was staying for her postpartum period.
Growth, Affection, and Resolve) [20] and Friend The interviewer read each question while the woman
APGAR [21]. Items were scored using a 1 (never) to followed her version to complete the Hung PSS, the
5 (always) scale, from which a summative score was SSS, and the 12-item CHQ.
derived. The total score represented the frequency
with which social support was accepted from either Data analysis
family or friends. High scores indicated high social Data were analyzed using percentage, frequency,
support during the postpartum period. The cor- χ2, and independent two-sample t test using SPSS
relations with the Pless-Satterwhite Family Function (Statistical Package for the Social Sciences) version 9.0
Index and Psychotherapist Estimate were 0.80 and (SPSS Inc., Chicago, IL, USA).

354 Kaohsiung J Med Sci July 2007 • Vol 23 • No 7

 Primipara vs. multipara

RESULTS belly”, “interrupted sleep”, and “not sleeping enough”;

for the multiparas, it was “the flabby flesh of my belly”,
Characteristics of the primiparas and “interrupted sleep”, “not sleeping enough”, “the un-
multiparas predictability of the baby’s schedule”, and “the baby
A total of 435 primiparas and 426 multiparas completed getting sick suddenly” (Table 2).
the study. The average age was 28.1 years (standard
deviation [SD] = 4.1) for the primiparas and 30.6 years Ranking of postpartum women’s social
(SD = 4.4) for the multiparas; 238 (44.7%) and 168 support
(39.4%) of the women, respectively, had a junior col- The mean scores for the items indicating social sup-
lege diploma or above; 231 (53.1%) and 192 (45.1%), port, family support, and friends’ support all reached
respectively, were employed full-time. Most had a total 3.0 or above, showing that the use of social support,
monthly household income of 50,000 New Taiwan family support, and friend support by the postpar-
Dollars or above. The mean length of marriage was tum women was between “sometimes” and “fre-
19.8 months (SD = 20.9) for the primiparas and 62.0 quently”. The item “I am satisfied with the way my
months (SD = 34.8) for the multiparas. Regarding the family and I share time together” received the highest
most recent pregnancy, 130 (29.9%) and 105 (24.6%) social support score from both the primiparas and
of the women, respectively, had a planned pregnancy. the multiparas.
Among the respondents, 183 (42.1%) of the primi-
paras and 196 (46.0%) of the multiparas had a vaginal Postpartum women’s mental health status
delivery, and most of the women expressed satis- The CHQ score ranged from 0 to 9 for the primiparas
faction with their childbirth experience. The baby’s and from 0 to 12 for the multiparas. Three hundred
average birth weight was 3,175.9 g (SD = 384.0) and and three of the primiparas and 271 of the multiparas
3,210.1 g (SD = 376.0), respectively, and 216 (49.7%) were in the non-minor psychiatric morbidity cate-
and 227 (53.3%) of the babies were boys. There was gory, whereas 132 of the primiparas and 155 of the
no infant gender preference for 320 (73.6%) and 196 multiparas were in the minor psychiatric morbidity
(46.0%) of the women, respectively. Most of the women category (CHQ scores ≥ 3).
(56.1% and 56.8%) fed their babies by a combination
of formula and breast feedings. The women’s demo- Mean scores of postpartum stress and
graphic characteristics showed no significant differ- social support, and percentage of women’s
ences between primiparas and multiparas, with the mental health status for primiparas and
exception of the women’s age, education level, current multiparas
employment status, length of marriage, the planning The mean scores for postpartum stress and its three
status for this pregnancy, this childbirth experience, dimensions—concerns about negative body changes,
and preferred sex of this baby, which differed signifi- concerns about maternal role attainment, and concerns
cantly (Table 1). about lack of social support—and the mean scores for
social support and its two dimensions—family support
Ranking of postpartum stress and friend support—are listed in Table 3 for both the
The mean scores reached up to 2.0 or above for 35 primiparas and the multiparas. Of the 435 primiparas
items in the case of the primiparas, and 28 items in and 426 multiparas, 132 (30.3%) and 155 (36.4%),
the case of the multiparas. This indicates that the post- respectively, had CHQ scores in the “case” category
partum women perceived these items to be “seldom” in terms of having minor psychiatric morbidity.
to “frequently” stressful; 25 items among the items for Differences in the mean scores of the women’s post-
both groups were consistent postpartum stressors. partum stress, concerns about negative body changes,
Five items were consistently the most highly ranked concerns about maternal role attainment, concerns
postpartum stressors among the women regardless about lack of social support, social support, family
of their parity, but the order of their rankings differed. support, and friend support between the primiparas
In a descending order, the ranking for the primiparas and the multiparas were determined by an independ-
was “the baby getting sick suddenly”, “the unpredict- ent samples t test. The results showed that women’s
ability of the baby’s schedule”, “the flabby flesh of my mean scores for postpartum stress, concerns about

Kaohsiung J Med Sci July 2007 • Vol 23 • No 7 355

C.H. Hung

Table 1. Demographic characteristics of primiparas and multiparas

Primiparas Multiparas
(n = 435) (n = 426)
Demographic characteristics Mean ± SD Mean ± SD t or χ2 p

n % n %
Age (yr) −8.50 0.000*
Mean ± SD 28.1 ± 4.1 100.0 30.6 ± 4.4 100.0

Education 20.16 0.000*

Senior high or below 197 45.3 258 60.5
Junior college or above 238 44.7 168 39.4

Current employment status 5.56 0.018†

Full time 231 53.1 192 45.1
Part time or housewife 204 46.9 234 54.9

Total household income per month 1.02 0.312

< NT 50,000 152 34.9 163 38.3
≥ NT 50,000 283 65.0 263 61.8

Length of marriage (mo) −21.53 0.000*

Mean ± SD 19.8 ± 20.9 100.0 62.0 ± 34.8 100.0

This pregnancy was 7.97 0.019†

Planned 130 29.9 105 24.6
Unplanned
No contraceptive used 214 49.2 198 46.5
Used contraceptives 91 20.9 123 28.9

Type of delivery 1.36 0.244

Vaginal delivery 183 42.1 196 46.0
Cesarean section 252 57.9 230 54.0

This childbirth experience 4.72 0.030†

Satisfied 387 89.0 397 93.2
Unsatisfied 48 11.0 29 6.8

Baby’s body weight (g) −1.32 0.190

Mean ± SD 3,175.9 ± 384.0 100.0 3,210.1 ± 376.0 100.0

Sex of this baby 1.14 0.286

Boy 216 49.7 227 53.3
Girl 219 50.3 199 46.7

Preferred sex of this baby 68.05 0.000*

Boy or girl 115 26.4 230 54.0
Did not matter 320 73.6 196 46.0

Method of this baby’s feeding 0.05 0.832

Breast or formula 191 43.9 184 43.2
Mixed 244 56.1 242 56.8
*p < 0.01; †p < 0.05. SD = standard deviation.

negative body changes, and concerns about maternal social support than the primiparas (Table 3). The
role attainment, social support, family support, and postpartum women with a CHQ score ≥ 3 were cate-
friend support were higher, respectively, for the gorized as having minor psychiatric disorders but
primiparas than for the multiparas. However, the they did not differ significantly by parity (χ2 = 3.53,
multiparas had greater concerns regarding lack of df = 1, p = 0.06).

356 Kaohsiung J Med Sci July 2007 • Vol 23 • No 7

 Primipara vs. multipara

Table 2. The top five postpartum stressors for primiparas and multiparas
Primiparas Multiparas
(n = 435) (n = 426)
Interrupted sleep 2.90 ± 1.24 2.97 ± 1.20
Unpredictability of the baby’s schedule 3.06 ± 1.11 2.76 ± 1.15
Baby getting sick suddenly 3.07 ± 1.09 2.73 ± 1.06
Flabby flesh of my belly 3.06 ± 1.25 2.98 ± 1.19
Not sleeping enough 2.84 ± 1.18 2.80 ± 1.19

Table 3. Mean scores of postpartum stress and social support, and percentage of health status between primiparas and
multiparas
Primiparas Multiparas
t or χ2 df p
(n = 435) (n = 426)
Postpartum stress 125.92 ± 30.21 121.26 ± 30.60 2.25 859 0.03*
Negative body changes 29.49 ± 8.46 28.35 ± 8.33 2.00 825.99 0.05*
Maternal role attainment 65.98 ± 17.50 57.48 ± 16.19 7.40 859 0.00†
Lack of social support 30.45 ± 8.60 35.44 ± 10.30 −7.71 859 0.00†
Social support 35.26 ± 7.32 33.21 ± 6.93 4.22 859 0.00†
Family support 17.61 ± 4.32 16.45 ± 4.18 4.00 859 0.00†
Friend support 17.65 ± 4.13 16.76 ± 4.16 3.16 859 0.00†
Health status 3.53 1 0.06
Non-case 303 (69.6%) 271 (63.6%)
Case 132 (30.4%) 155 (36.3%)
*p < 0.05; †p < 0.01.

DISCUSSION about their pre-pregnant bodies. That study, moreover,

reported that primiparas felt more negative about their
The study demonstrates that compared with the mul- postpartum bodies than did multiparas. Flagler [30]
tiparas, the mean scores for the primiparas were found that postpartum women’s negative physical
higher for postpartum stress, concerns about negative feelings resulted in decreased maternal capability.
body changes, concerns about maternal role attain- Maternal role attainment always requires knowl-
ment, as well as for measures of social support, family edge, skill, and motivation. A lack of knowledge, abil-
support, and friend support. However, the multiparas ity, or motivation could produce a deficit in mothering
had higher scores than the primiparas regarding con- capability and become stressful for women [30]. At
cerns about lack of social support. The mental health 1-month postpartum, a mother’s priority is the capa-
status of the two groups did not differ significantly bility to care for her baby [4,31]. A mother needs infor-
by parity. mation about the normal growth and development of
The primiparas reported greater concerns than did infants and knowledge regarding her child’s unique
the multiparas over negative body changes. Fitness is patterns of crying, sleeping, feeding, and other behav-
a major focus in today’s society, and most women are iors. Compared with the multiparas in this study, who
disappointed with their postpartum bodies [25–27]. were experienced in these matters, the inexperienced
Russell [28] found that worries about personal appear- primiparas reported greater concerns about maternal
ance, distress over the changes in their bodies, and attainment.
complaints of physical tiredness and fatigue were the The primiparas reported not only higher post-
foremost issues expressed by new mothers. Strang partum stress but also higher social support than the
and Sullivan’s [29] study indicated that women felt multiparas. This finding is congruent with the findings
more negative about their postpartum bodies than of other research [16,32]. Although the primiparas

Kaohsiung J Med Sci July 2007 • Vol 23 • No 7 357

C.H. Hung

were naïve about childbearing and parenting and were are specific to primiparas and multiparas is necessary
concerned about negative body changes and maternal in order to provide stressor-specific supportive nurs-
role attainment, they received more attention and help ing interventions. Specifically tailored nursing inter-
from their families and friends than did the multi- ventions based on differences in parity may lead to the
paras [7]. Social support has been found to be impor- reduction in postpartum stress and prevention of more
tant to postpartum women in helping them adapt to severe health problems among postpartum women.
a new role, helping them be more responsive to their In this study, there was a homogeneous sample
babies, and facilitating their intimate relationships. of low-risk postpartum women, who had a single,
Hung et al’s study documented that the supporting role healthy, and full-term baby without complications,
of family is significantly associated with a low occur- had no major postnatal complications or underlying
rence of stress during the postpartum period [32]. medical problems, and were married Taiwanese resi-
The woman’s partner, in particular, is a key source dents. The results can only be generalized to low-risk
of validation and assistance during the early weeks Taiwanese postpartum women. Future research should
of motherhood [5–7,33,34]. also include those high-risk women who have twins or
Family and friends provide instrumental and emo- multiple babies, have ill babies, or babies with com-
tional support in daily life, as well as assistance dur- plications during the perinatal period, and who have
ing the postpartum period or times of need. The results major postnatal complications or underlying medical
of the present study indicate that the multiparas had problems themselves, or are single mothers.
higher concerns than the primiparas about lack of
social support. Compared with primiparas, multiparas
appear to have special needs due to more complex ACKNOWLEDGMENTS
family dynamics and being overwhelmed by insuffi-
cient time to meet the new baby’s needs amidst the This research project was supported partly by a grant
care of family and household; thus, they frequently from the National Science Council, Taiwan, Republic
deprive themselves of time to meet their own needs. of China (NSC90-2314-B-037-076).
In short, multiparous women need relatively greater
assistance with time management to achieve a sense
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360 Kaohsiung J Med Sci July 2007 • Vol 23 • No 7