This article was downloaded by: [130.108.121.217]On: 06 October 2014, At: 09:07Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Women & HealthPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wwah20

Exploring the Roles of Family Membersin Women’s Decision to Use PostpartumHealthcare Services from thePerspectives of Women and Health CareProvidersLubna Abushaikha RN, PhDa & Inaam Khalaf RN, PhDb

a Department of Maternal-Child Health, Faculty of Nursing, TheUniversity of Jordan, Amman, Jordanb Department of Nursing, Faculty of Nursing, Al-Ahliyya AmmanUniversity, Amman, JordanAccepted author version posted online: 09 Jun 2014.Publishedonline: 01 Aug 2014.

To cite this article: Lubna Abushaikha RN, PhD & Inaam Khalaf RN, PhD (2014) Exploring theRoles of Family Members in Women’s Decision to Use Postpartum Healthcare Services fromthe Perspectives of Women and Health Care Providers, Women & Health, 54:6, 502-512, DOI:10.1080/03630242.2014.900526

To link to this article: http://dx.doi.org/10.1080/03630242.2014.900526

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Women & Health, 54:502–512, 2014Copyright © Taylor & Francis Group, LLCISSN: 0363-0242 print/1541-0331 onlineDOI: 10.1080/03630242.2014.900526

Exploring the Roles of Family Membersin Women’s Decision to Use Postpartum

Healthcare Services from the Perspectivesof Women and Health Care Providers

LUBNA ABUSHAIKHA, RN, PhDDepartment of Maternal-Child Health, Faculty of Nursing,

The University of Jordan, Amman, Jordan

INAAM KHALAF, RN, PhDDepartment of Nursing, Faculty of Nursing, Al-Ahliyya Amman University, Amman, Jordan

Although the postpartum period is a significant time in a family’slife, few studies have addressed the lack of continuity of care andservice use during the postpartum period. The aim of this study wasto explore the roles of family members in Jordanian women’s deci-sion to use postpartum health care services. An exploratory quali-tative design was employed to elicit the perspectives of 24 womenand 30 health care providers through six focus groups discussionsconducted in April 2006. Interviews were transcribed verbatim,translated to English, and analyzed using an inductive contentanalysis approach. In our study, three roles of family membersinfluencing Jordanian women’s decision to use postpartum healthcare services emerged: supporter role, opponent role, and activeparticipant in care role. Findings supported the need for a fami-ly-centered approach when providing postpartum care to enhancepositive family roles and limit negative ones to promote continuityof healthcare services use during the postpartum period.

KEYWORDS family members, roles, postpartum, health careservices use, qualitative research

Received March 14, 2013; revised February 20, 2014; accepted February 26, 2014.Address correspondence to Lubna Abushaikha, RN, PhD, Department of Maternal-

Child Health, Faculty of Nursing, The University of Jordan, Amman 11942, Jordan. E-mail:lubahmad@yahoo.com

502

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Roles of Family Members for Women with Postpartum 503

INTRODUCTION

The postpartum period is considered a momentous time for families (Cheng,Fowles, & Walker, 2006; Christie, Poulton, & Bunting 2007; Dhaher et al.,2008; Foulkes, 2011; Gjerdingen, Froberg, & Fontaine 1991; Kabakian-Khasholian & Campbell, 2005; Kabakian-Khasholian et al., 2006; Thomas,Boner, & Hildingsson, 2011). During the postpartum period, couples andfamily members reconnect together to redefine, restructure and renew thefamily unit as well as revive family roles and functions. In Jordan, as well asother Arab countries, the postpartum period can truly be described as “familytime.” During the postpartum, the roles and influence of the family membersbecome more visible compared to during pregnancy and childbirth when,typically, major roles are not assumed, and influences are not apparent.

However, postpartum maternal healthcare is a neglected aspect ofwomen’s healthcare (Cheng et al., 2006; Dhaher et al., 2008; Dhakalet al., 2007; Galaa & Daare, 2008; Kabakian-Khasholian & Campbell, 2005;Kabakian-Khasholian et al., 2006; Khalaf et al., 2007; Mrisho et al., 2009).This neglect is evident in the limited national health objectives and datarelated to maternal health, especially in developing countries, such as Jordan.Missed opportunities for enhancing the health care of postpartum womenoccur in the scope of routine postpartum care in which differing perceptionsof maternal needs between nurses and new mothers contribute to inade-quate health care. Furthermore, the postpartum period can be describedas the period that may lack follow-up and continuity of care (Kabakian-Khasholian & Campbell, 2005; Kabakian-Khasholian et al., 2006). Globally,current postpartum health services mainly focus on breastfeeding, familyplanning, and infant care, but rarely focus on assessing continuity of careand use of services, particularly in developing countries (Cheng et al., 2006;Galaa & Daare, 2008; Kabakian-Khasholian & Campbell, 2005; Kabakian-Khasholian et al., 2006; Mrisho et al., 2009). Therefore, seeking healthcareservices becomes a personal decision for the mother and her family, whichpotentially puts both mother and child at risk for developing various com-plications including hemorrhage, infections, psychological disorders andpossibly death (Dhaher et al., 2008; Dhakal et al., 2007; Galaa & Daare,2008; Glavin, Smith, & Sorum, 2008; Jarrah & Bond, 2007; Khalaf et al.,2007). A report by the Higher Population Council on maternal morbidity inJordan showed that 18.7% of postpartum women experienced one or moremorbidities, mostly anemia and gynecological infections (Higher PopulationCouncil, 2009). Furthermore, a survey investigating the status of postpar-tum services and use among Jordanian women showed that 65% did notreceive postpartum care after being discharged from a health facility fol-lowing delivery (Khalaf et al., 2007). This alarming number is similar tothose reported in other Arab countries where it is 63% in Palestine, 61%in Lebanon, and 94% in Yemen (Dhakal et al., 2007; Kabakian-Khasholian

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

504 L. Abushaikha and I. Khalaf

& Campbell, 2005; Kabakian-Khasholian et al., 2006). Consequently, mater-nal deaths still occur during the first 48 hours postpartum, and maternalmortality in Jordan remains relatively high at 19.1 per 100.000 live births(Higher Population Council, 2011; Jordanian Department of Statistics, 2011)despite the fact that postpartum healthcare services are provided to Jordanianwomen and their families in a variety of settings. In the Jordanian healthcare system, services are provided by four sectors: government, military,The United Nations Relief AND Work Agency for Palestine Refugees in theNear East (UNRWA), and private. Health care services provided by the firstthree of these are free, while services rendered by the private sector are feefor service. During the postpartum, the majority of Jordanian women seekhealth care services provided by government-run facilities, offered through435 maternal-child (MCH) centers distributed throughout the 12 governorateswithin Jordan (Jordanian Department of Statistics, 2011). Additionally, dis-parity in health services offered to women and their families suggests anurgent need to improve postpartum services by adopting a family-centeredapproach that promotes active involvement of the family, enhances fam-ily roles, and encourages seeking healthcare services during the postpartumperiod (Kabakian-Khasholian & Campbell, 2005; Kabakian-Khasholian et al.,2006).

In the typical Arab family, active input and active roles from husbandsand other family members such as the mother and the mother-in-law dur-ing the postpartum period can significantly influence women’s decisions touse postpartum health services and may ultimately affect the health and wellbeing of the mother, her offspring, and the family as a whole (Dhaher et al.,2008; Khalaf et al., 2007). Although studies have investigated quality of care,provider attitudes and behaviors, and accessibility of postpartum health ser-vices (Cheng et al., 2006; Dhaher et al., 2008; Dhakal et al., 2007; Galaa &Daare, 2008; Jarrah & Bond, 2007; Kabakian-Khasholian & Campbell, 2005;Kabakian-Khasholian et al., 2006; Khalaf et al., 2007; Mrisho et al., 2009),few studies have investigated use of postpartum health services from clientand health care provider perspectives. Therefore, the purpose of this studywas to explore the roles of family members in women’s decisions to usepostpartum healthcare services in Jordan from the perspectives of womenduring the postpartum and health care providers.

METHOD

Study Design and Sample

An exploratory qualitative design was used in this study to elicit responsesfrom both mothers and health care providers to delineate the roles of thefamily members in Jordanian women’s use of postpartum healthcare ser-vices. Study participants were recruited from three health care centers inAmman (center), Al-Karak (south), and Irbid (north). These three health

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Roles of Family Members for Women with Postpartum 505

care centers were purposely chosen from 400 maternal-child health carecenters across the country to represent major populous cities covering thethree major geographic areas in Jordan. To recruit study participants, healthrecords of women were reviewed to ensure eligibility, which included hav-ing a normal birth without complications and a healthy baby. Women whohad delivered during the past 3 months and had current addresses and phonenumbers were approached to participate in the study. A purposive sample ofthese women was selected to provide diverse demographic characteristics inthe study sample, including age, educational level, and place of residence, toobtain as valid a representation of Jordanian women during the postpartumperiod as possible. Women were invited to participate in the focus group dis-cussions when they came for their children’s immunizations or postpartumcheckup visits. Eligibility of health care providers was determined through ascreening questionnaire used to recruit a diverse sample regarding specialty,clinical experience, and gender. Identifying eligible participants and orga-nizing the focus group discussions were done in coordination with officialpersonnel in the health care centers.

The majority of women and health care providers were found eligibleand agreed to participate in the study. However, 15% of women and 10% ofhealth care providers who were recruited could not attend the focus groupdiscussions and were not included in the final sample. Most of the attritionin participants was from the Al-Karak health care center (southern region)for women and the Amman health care center (central region) for healthcare providers. The study sample consisted of 24 women and 30 healthcare providers. The women were divided into three focus groups, rangingfrom 6–11 women; while health care providers were divided into three focusgroups, ranging between 9–11 providers.

Data Collection

This study was conducted as a part of a larger study on postpartum care inJordan during April 2006 by holding 6 focus group discussions that rangedfrom 90 to 120 minutes. The focus group discussions were conducted byone of the researchers (I.K.), who is an experienced qualitative researcher, inArabic using a semi-structured interview guide and audiotaped after obtain-ing verbal consent from participants. Written consent was not sought tomaintain participant anonymity. Through the use of semi-structured, open-ended questions, the facilitator was able to obtain in-depth data on issues,concerns and challenges facing women in the postnatal period from both thewomen and the health care providers’ perspectives, including an explorationof the roles of the family members in encouraging or discouraging womento seek postpartum healthcare. Additionally, three maternal-child health cen-ters (MCH) were the designated settings to represent all geographical regionsin Jordan (i.e., the northern, central, and southern regions) to obtain a

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

506 L. Abushaikha and I. Khalaf

representative sample. The purpose of the study, the benefits and the par-ticipants’ right to withdraw from the study at any time were explained indetail. The data in this study were treated confidentially to ensure protectionof participants’ rights. Participant’s verbal agreement to join the focus groupdiscussions was considered an indication of consent. Approval of the studyprotocol was obtained from the university research ethical committee andthe Jordanian Ministry of Health.

The tape recordings were transcribed verbatim and translated intoEnglish and back translated to ensure trustworthiness of the data. Duringthe focus group discussions, both women and health care providers wereasked to describe in detail their experiences regarding the role of the familymembers in women’s use of postpartum health services. Participants wereoffered complimentary snacks and beverages during the discussions andwere provided transportation fees.

Data Analysis

Data were analyzed through inductive content analysis in which recurrentmeanings and concepts were identified throughout the narratives, and finalthemes were inductively constructed (Elo & Kyngas, 2008; Smith & Firth,2011). Data analyses were undertaken by the two researchers, who inde-pendently coded the transcripts and identified the subthemes. After threemeetings of the two researchers, they reached a final consensus on thethemes of the study. Core concepts in the transcripts were identified and clas-sified into conceptually relevant categories, providing rich qualitative datafrom the subjective perspective of the women and the health care providers.The content analysis occurred concurrently with data collection and includedthe following steps: collecting and transcribing the focus group interviews;extracting significant statements from the original transcripts; identifyingrecurrent concepts and meanings; and, finally, forming the themes. The cat-egories were manually coded into two major codes: women’s perspectivesand health care providers’ perspectives. Then each part was analyzed andcoded with a focus on exploring and identifying words and phrases pertain-ing to the role of family members in encouraging or discouraging women toseek postpartum health services. Similarities and differences were comparedand common themes between the two parts were integrated in final themesthrough consensus by the two researchers. This yielded three themes codedas supportive (SR), opponent (OR), and active participation (APR).

Data analysis took into consideration within group variations and inter-group similarities or differences. A general statement about a group wasmade if most of women and/or the health care providers had similarexperience and/or opinion with regard to the theme under considera-tion. Otherwise statements such as one woman/health care provider or allwomen/health care providers were used. Trustworthiness and credibility of

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Roles of Family Members for Women with Postpartum 507

data was established through disclosing study findings to women and healthcare providers. Results were presented to women and health care providerswho worked with women in the postnatal period separately; in each groupdata were presented for all regions together unless they had different find-ings. Additionally, to ensure the rigor of the data analysis, three qualitativeresearchers who were not involved in the data analysis process verified thestudy findings and study themes.

RESULTS

In our study, the women’s ages ranged from 18 to 45 years, while theages of health care providers ranged from 21 to 45 years, with a majoritybeing 31–40 years of age and the mean age of all study participants being29.3 years. All of the women were married with an average of four children.The majority of women was not employed outside the home and had anelementary educational level (1st to 6th grade level). The majority of healthcare providers had a diploma or associate degrees in nursing/midwifery andbachelor degrees in medicine and a minimum of five years experience inpostpartum care. The health care provider group consisted of 9 physicians,12 midwives, and 9 nurses/nurse associates.

Supporter Role

All the women from the central and northern regions and most of the womenfrom the southern region indicated that they viewed their husbands andrelatives as supporters who encouraged them to go for postpartum visitsand continue to seek health services. Positive roles and encouragement fromfamily members resulted in continued postpartum visits, especially if mothershad a certain health need and if the services were deemed beneficial to them,such as family planning methods and immunization. Comments included:

My husband encourages me to go for the postpartum visit, especially ifI am sick. (mother, center region)

He does not object. I can go wherever I want. (mother, north region)

For me he [her husband] had a positive role. He did not mind. (mother,south region)

All of the health providers from all three regions also emphasized the influ-ence and potential positive role of the family members in seeking postpartumhealthcare services, especially in the context of a “family visit” in which

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

508 L. Abushaikha and I. Khalaf

family needs are met not just the women’s needs. Comments from healthcare providers included:

Sometimes they [husbands] come with them [women]. They tell them didyou ask her about this? When we immunize them I hear “Did you ask thenurse about the pills”? Did you ask her? Of course they encourage them.(nurse, center region)

Depending on his personality, he [the husband] could be a helpful factoror a hindering factor. (midwife, south region)

Opponent Role

Some women from the central and southern regions commented on theopposing negative attitudes and roles that family members had towardpostpartum visits. Participants explained that many husbands and familymembers, such as mothers-in-law, did not encourage or support women togo out of their homes and seek postpartum health services in the maternal-child health centers, especially during the first 40 days after childbirth. Onewoman commented:

They [husbands] don’t encourage us to visit the center. Some of them saythere is no need. (mother, south region)

Furthermore, all of the health care providers in the northern region andsome in the central region confirmed the ideas communicated by womenregarding postpartum visits by restricting them to women with complica-tions and illnesses, thus reflecting a disease-oriented mindset in dealingwith healthcare services. These opposing attitudes and roles are rootedand shaped by sociocultural beliefs and restrictions in Jordanian societyin which the roles of family members, particularly husbands, were por-trayed as being minimal. Examples of comments from health care providersincluded:

For example, her mother-in-law prevented her [from visiting the center].The traditions also have a role. Some women cannot go out before40 days. (midwife, south region)

No, they are not used to it. There is no awareness that the husband comesto the MCH center with his wife. They were not used to that. In the past,men were forbidden from entering the center. From my experience, nohusband has come with his wife to the MCH center. (midwife, northregion)

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Roles of Family Members for Women with Postpartum 509

Active Participant in Care Role

Some mother in the central and northern regions discussed the changes anddevelopments that have occurred in Jordanian society regarding reproductivehealth issues, especially clients’ attitudes in seeking postpartum healthcareservices. Women commented on the changing dynamics between Jordaniancouples in which husbands and fathers were assuming more active roles andbecoming more involved in receiving and sharing reproductive healthcareservices with their wives, while acknowledging the differences in practicesin various regions. An example of a comment came from one woman:

My husband goes with me to carry the baby, and even my family and myhusband’s family encourage me to visit the health center. (mother, northregion)

Most of the health care providers in the central region also reiteratedthe ideas conveyed by women regarding the changing dynamics betweenJordanian family members. Examples of comments included:

It is hard to give a judgment. I see both sides. I see some [husbands]who care a lot and I see ones who do not allow her [the wife] to gooutside the door unless she has his permission or is with him or with hermother-in-law or with the family. (physician, center region)

It is according to the region, and this has to do with the culture of thehusband and the culture of the wife. Some of them [husbands] comecarrying their children at two weeks and he is happy. (physician, northregion)

Additionally, some health care providers in the central and southern regionsalso talked about the changing dynamics between health care providers andclients, reflecting more positive attitudes and more acceptance of a father’sparticipation in postpartum care services, including the following comments:

It seems to me that talking with men is easier that talking with women.When you talk with a man he is convinced, and when he is convinced,he can convince his wife . . . that’s it. If you come at 10 am, you will seemore men than women waiting in the hall. In the past, we used to tellhusbands to get out. Now, we don’t throw them out . . . they want to sithere. (nurse, south region)

I am against throwing the husband out. The husband should participate.(nurse, center region)

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

510 L. Abushaikha and I. Khalaf

DISCUSSION

In our study, we sought to explore the experiences of women and healthcare providers regarding the roles of family members in decisions to usehealth services in the postpartum period. The participants in this studydescribed both positive and negative roles and influences of husbands andfamily members. In this study, a positive role and influence was repre-sented by encouragement, support, and positive attitudes that were displayedby Jordanian husbands, mothers-in-law, and mothers to Jordanian women,which propelled them to seek postpartum care and use health services.Women felt that when they received the necessary approval and were metwith positive attitudes toward seeking postpartum care, the likelihood ofdeciding to seek postpartum health services was heightened. This result wassimilar to findings by Cheng et al. (2006), who reported that encouragingthe husband or partner’s participation in maternal and childcare needs isrecommended.

Conversely, a negative role and influence was represented in this studyby preventing women from going out of the home during the first 40 dayspostpartum to seek health services, which is considered an enduring tradi-tion in the Arab culture. This result was congruent with the finding reportedby Dhaher et al. (2008) that was conducted to investigate the postnatal careamong Palestinian women, in which it was indicated that some women whobelieve in the importance of postnatal care cannot obtain it due to barri-ers, such as a lack of available services or cultural norms, including thetraditional custom of not going out during the first 6 weeks after delivery.Moreover, many husbands and family members displayed negative roles andattitudes regarding postpartum health services by not appreciating its valueand its importance to the health and well-being of the mother and her child.Consequently, although postpartum health services are provided with mini-mal fees to Jordanian women, the majority of women succumbed to negativeinfluences and opposing negative attitudes from their husbands and familymembers, especially their mothers-in-law, and decided to not seek neededcare. This problem needs to be addressed to provide better health care forJordanian childbearing women.

Pregnancy, birth, and becoming a mother collectively represent criticalperiods of physical and emotional upheaval in a woman’s life. The need for aholistic care approach that supports the emotional and physical health of thedyad is imperative (Dhaher et al., 2008; Gjerdingen et al., 1991; Kabakian-Khasholian & Campbell, 2005; Kabakian-Khasholian et al., 2006). Our resultsindicated that mostly positive roles for family members were reported regard-ing use of postpartum services. However, the problem of devaluing andopposing postpartum healthcare services still remains a challenge in provid-ing holistic family-centered quality care for Jordanian women. A suggestedsolution for this problem in a culturally sensitive fashion would be to revive

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

Roles of Family Members for Women with Postpartum 511

postpartum health visits by nurses and midwives, especially during the first40 days postpartum that are missing from the Jordanian healthcare systemdue to national shortages in nurses and midwives to meet the needs ofwomen who do not engage in postpartum visits. Although this policy is notexpected to directly reduce maternal morbidity and mortality rate per se, itwould be significant to the continuity of needed postpartum care for women.

Our study had several limitations, including the potential for social desir-ability bias in terms of the participants’ responses in focus group discussions.Another limitation was restricting participants to women and health careproviders, because thoughts and opinions of other family members, suchas mothers, mothers-in-law and husbands, could have been different thatthose portrayed in this study and should be considered in future research.A final limitation was selecting women and providers from only three out of400 health care centers in Jordan, which may have resulted in participants notbeing representative of Jordanian postpartum women and their health careproviders, although the purposive sampling used was designed to providediversity in both groups, which should have enhanced the generalizability ofthe findings.

CONCLUSIONS

Postpartum maternal health care influences the health of both mothers andtheir children; however, it is not adequately provided for or emphasized innational policies or national health objectives. Investigating issues related tofactors that enhance women’s use of postpartum care is an imperative issueto provide postpartum care to the women at this important stage. Providing afamily-centered holistic approach to care, providing flexible maternal healthcare, encouraging family support and involvement of the woman familymembers in the care during the postpartum period are important factorsin helping women to use postpartum care services more effectively. In plan-ning postpartum services, we need to pay special attention to the status ofwomen, their available social supports, and the systems of time and powerwithin which they operate.

Recommendations to promote maternal health include establishing poli-cies regarding postpartum maternal health, reevaluating and reforming theprogram of routine postpartum health care to be based on a family-centeredholistic care, encouraging family support, involving husbands in the care,educating families about the importance of postpartum care and their rolein enhancing the mothers to adhere to the care are important issues thatneed to be promoted and encouraged. Additionally, conducting researchfocused on postpartum maternal health within a family context approach isrecommended.

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4

512 L. Abushaikha and I. Khalaf

REFERENCES

Cheng, C. Y., E. R. Fowles, and L. O. Walker. 2006. Postpartum maternal health carein the United States: A critical review. J Perinat Educ 15:34–42.

Christie, J., B. C. Poulton, and P. B. Bunting. 2007. An integrated mid-range theory ofpostpartum family development: A guide for research and practice. J Adv Nurs61:38–50.

Dhaher, E., R. T. Mikolajczyk, A. E. Maxwell, and A. Kramer. 2008. Factors associ-ated with lack of postnatal care among Palestinian women: A cross-sectionalstudy of three clinics in the West Bank. BMC Pregnancy Childbirth 8:26.doi:10.1186/1471-2393-8-26

Dhakal, S., G. N. Chapman, P. P. Simkhada, E. R. van Teijlingen, J. Stephens, and A.E. Raja. 2007. Utilisation of postnatal care among rural women in Nepal. BMCPregnancy Childbirth 7:19.

Elo, S., and H. Kyngas. 2008. The qualitative content analysis process. J Adv Nurs62:107–15.

Foulkes, M. 2011. Enablers and barriers to seeking help for a postpartum mooddisorder. JOGNN 40:450–7.

Galaa, S. Z., and K. Daare. 2008 Understanding barriers to maternal child healthservices utilisation in northern Ghana. J Soc Dev Af 23:127–55.

Gjerdingen, D. K, D. G. Froberg, and P. Fontaine. 1991. The effects of social supporton women’s health during pregnancy, labor and delivery, and the postpartumperiod. Fam Med 23:370–5.

Glavin, K., L. Smith, and R. Sorum. 2009. Prevalence of postpartum depression intwo municipalities in Norway. Scand J Caring Sci 23:705–10.

Higher Population Council. 2009. Maternal morbidity in Jordan 2007–2008. Amman,Jordan: Higher Population Council.

Higher Population Council. 2011. Annual report 2011. Amman, Jordan: HigherPopulation Council.

Jarrah, S., and A. E. Bond. 2007. Jordanian women’s postpartum beliefs: Anexploratory study. Int J Nurs Pract 13:289–95.

Jordanian Department of Statistics. 2011. Statistical yearbook 2011. Amman, Jordan:Department of Statistics (DOS).

Kabakian-Khasholian, T., and O. M. Campbell. 2005. A simple way to increase serviceuse: Triggers of women’s uptake of postpartum services. BJOG 112:1315–21.

Kabakian-Khasholian, T., R. Jurdi, F. El-Kak, and A. Kaddour. 2006. What ishappening during the postnatal visit? Health Care Women In 27:839–47.

Khalaf, I., F. Abu-Moghli, A. Mahadeen, L. C. Callister, and M. Al-Hadidi. 2007.Jordanian women’s perceptions of post-partum health care. Int Nurs Rev 54:288–94.

Mrisho, M., B. Obrist, J. A. Schellenberg, R. A. Haws, A. K. Mushi, H. Mshinda, et al.2009. The use of antenatal and postnatal care: perspectives and experiences ofwomen and health care providers in rural southern Tanzania. BMC PregnancyChildbirth 9:10.

Smith, J., and J. Firth. 2011. Qualitative data analysis: The framework approach. NursRes 18:52–62.

Thomas, J. E., A. Boner, and I. Hildingsson. 2011. Fathering in the first few months.Scand J Caring Sci 25:499–509.

Dow

nloa

ded

by [

130.

108.

121.

217]

at 0

9:07

06

Oct

ober

201

4