Foruzan Sharifipour,Mojgan Javadnoori,Zahra Beboodi Moghadam,Mahin Najafian,Bahman Cheraghian,Zahra Abbaspoor
Primiparous Mothers' Perception and Expectations Regarding Social Support during the Postpartum Period: A Qualitative Study
Perception,postpartum care,qualitative research,social support
Background: Social support has been found to positively influence the mothering experience. Yet little is known concerning primiparous mothers' perceptions of social support following childbirth. This qualitative study aims to explore primiparous mothers' perception and expectations regarding social support during the postpartum period. Materials and Methods: This qualitative study with content analysis approach was conducted on 11 postpartum mothers who had been routinely referring to comprehensive health service centers in Kermanshah, Iran, from October 2020 to January 2021 for receiving postpartum care within the first 6 months after birth. Also, to further enrich the study data, interviews were conducted with healthcare providers (n = 6) and husbands (n = 3). Twenty-two semi-structured interviews were conducted individually through a purposive sampling method. Two participants were interviewed twice. Interviews were recorded and transcribed verbatim in Persian and analyzed using conventional content analysis. Results: Three main categories and thirteen subcategories emerged. The main categories were: “comprehensive support”, “support barriers,” and “support promotion strategies.” The main perception and expectation of mothers regarding social support was the sense of not being alone and receiving comprehensive support, especially from the husband and increasing his awareness about this support. Conclusions: An understanding of a comprehensive support, support barriers, and support promotion strategies with respect to social support can help healthcare professionals to develop interventions and programs aimed at promoting mothers' social support in the postpartum period.
Primiparous Mothers' Perception and Expectations Regarding Social Support during the Postpartum Period: A Qualitative Study

Social support has been found to positively influence the mothering experience. Yet little is known concerning primiparous mothers' perceptions of social support following childbirth. This qualitative study aims to explore primiparous mothers' perception and expectations regarding social support during the postpartum period.

This qualitative study with content analysis approach was conducted on 11 postpartum mothers who had been routinely referring to comprehensive health service centers in Kermanshah, Iran, from October 2020 to January 2021 for receiving postpartum care within the first 6 months after birth. Also, to further enrich the study data, interviews were conducted with healthcare providers (n = 6) and husbands (n = 3). Twenty-two semi-structured interviews were conducted individually through a purposive sampling method. Two participants were interviewed twice. Interviews were recorded and transcribed verbatim in Persian and analyzed using conventional content analysis.

Three main categories and thirteen subcategories emerged. The main categories were: “comprehensive support”, “support barriers,” and “support promotion strategies.” The main perception and expectation of mothers regarding social support was the sense of not being alone and receiving comprehensive support, especially from the husband and increasing his awareness about this support.

An understanding of a comprehensive support, support barriers, and support promotion strategies with respect to social support can help healthcare professionals to develop interventions and programs aimed at promoting mothers' social support in the postpartum period.

The postpartum period is a stressful transition period lasting for about 9–12 months during which mothers face numerous physical and emotional challenges because they try to adapt to new changes and roles in their life.[1] The postpartum period is also associated with psychosocial adjustments such as changes in the role of parents, changes in family relationships, and changes in self-perception and body image.[2] According to international and national policy documents, social support for mothers during the postpartum period is essential for promoting the health of the mother and her newborn and assists the acceptance of motherhood.[3] Social support is defined as a sense of belonging and the feeling to be accepted and loved by others. The components of social support include emotional support (indicating trust and empathy); information support (indicating reception of useful information from others to adapt to personal problems); and instrumental support (indicating direct assistance to individuals). Supporting the mother not only improves and strengthens the mother–infant relationship and promotes the newborn's mental health, but also enhances the mother's caring skills for the care of the newborn baby and her self-confidence.[4] Psychosocial studies have shown that inadequate social support increases the psychological distress risk during pregnancy and after childbirth.[56] According to Negron et al.,[7] identifying mothers' views and expectations regarding social support in the postpartum period is important and necessary for mothers' physical and emotional improvement. Therefore, in order to prevent postpartum depression in the future, there should be a serious focus on promoting social support for mothers. Women's major needs and challenges in the postpartum period include personal care needs, doing household chores, getting sleep, caring for the newborn, dealing with the new changes, and emotional and informational needs. Also, family members, especially the husband, are the main sources of instrumental and emotional support. Obviously, the advantages of social support to promote maternal and newborn health are evident.[8] A clear understanding of mothers' social support in the postpartum period is an important step in designing interventions or strategies to enhance this support and thus to improve maternal health.[9] Yet little is known concerning the primiparous mother's perceptions of social support following childbirth.[7] To the best of our knowledge, no study has yet been conducted on the perception and expectations of social support during the postpartum period in Iran. Therefore, this study aimed to explore primiparous mothers' perception and expectations regarding social support during the postpartum period.

This qualitative study is part of a multi-stage mixed-methods study that aimed to develop an intervention for improving the social support of primiparous mothers in the postpartum period. This was a descriptive qualitative study using content analysis to elicit primiparous mothers' perception and expectations of social support in the postpartum period. Data collection started from October 2020 and finished in January 2021. The data collection site was comprehensive health service centers in Kermanshah, Iran. The participants of this study were 11 primiparous mothers who had given birth to a single full-term healthy baby and who had been routinely referring to comprehensive health service centers affiliated to Kermanshah University of Medical Sciences for receiving postpartum care within the first 6 months after delivery. Inclusion criteria were as follows: ability to speak Persian and provide appropriate and sufficient information on the subject matter, having favorable mental and physical conditions, acquiring the score <12 from Edinburgh postnatal depression questionnaire, and willingness to participate in research. In-depth semi-structured face-to-face or telephone interviews with open-ended questions were conducted to explore the detailed perception and expectations of participants regarding social support during the postpartum period. Interviews were conducted in Persian in a separate room at the health center where only the interviewer and the participant were present. Due to the COVID-19 pandemic and the quarantine and lockdown conditions in the city of Kermanshah, 12 interviews were conducted on telephone and 10 interviews were conducted face-to-face after coordination with the participants. The interviews were recorded by a telephone call recorder and were later transcribed. The main questions of the interview guide included the following: “Would you please explain how you feel about social support after your delivery?”, “Why and what made you feel this way?”, “How did you perceive social support?”, “What did you experience about support?”, “What do you think should have been done for you to get better support?”, and “Would you please suggest solutions to improve it?”. Husbands and healthcare providers were asked to describe one day of providing support for mothers in the postpartum period, as well as the challenges and facilities available to promote it. Then, the probing questions were asked to obtain a deeper and better understanding. The length of each interview ranged from 45 to 60 min. Also, to further enrich the study data, interviews were conducted with nine key informants (healthcare providers (n = 6) and husbands (n = 3)) in line with the purpose of the study. In addition to primiparous mothers as participants, the views of relevant healthcare providers and husbands as key informants were elicited. Key informants are knowledgeable individuals who offer a perspective on a research situation that the researchers themselves do not have. They are not usually participants in the research themselves, but they help to develop the researcher's accurate understanding and insight and help reduce potential bias.[10] Two participants were interviewed twice. Since in qualitative research, it is not possible to determine the sample size beforehand, sampling from the primiparous mothers, husbands, and healthcare providers continued until data saturation, i.e., until no new data or codes were obtained.[11] Data saturation was achieved after the twenty-second interview upon agreement among all researchers. Conventional content analysis method was used for data analysis as described by Graneheim and Ludman in the following five steps[12]: 1—Write down verbatim the entire interview immediately after each interview, 2—read and re-read several times the text of the interview to gain a general understanding of its content, 3—determine units of meaning and basic codes, 4—classify similar primary codes into more comprehensive categories (the codes were classified into subcategories, and then categories were derived from conceptual similarities), and 5—determine the content hidden in the data and extract the main theme. The coding process of the phrases was done by the first and the corresponding authors, and they were then compared to each other, and any disagreement was addressed. The other researchers discussed, checked, and verified the findings. Four criteria were used to evaluate the trustworthiness of qualitative data: 1) credibility, 2) dependability or compatibility, 3) transferability, and 4) confirm ability.[13] The participants' selection was done with a maximum variety in terms of the demographic characteristics to ensure the credibility of the data. Also, some of the coded interviews were shared with the participants at different sessions, and their opinions were sought to increase credibility. Accordingly, some of the draft interviews were returned to the participants to determine if the codes given by the researcher matched what the participants intended meaning. Three experts' opinions were also obtained to confirm the consistency between the coded data and the participants' statements to increase dependability. The study results were given to seven participants to judge the similarity of the results with their own experiences to increase the transferability. Finally, in order to increase confirm ability, at each stage of data analysis, experts and specialists in qualitative research were asked about the correctness of the semantic units and codes extracted and the obtained concept to confirm the relevance of the meanings of the data.

The Ethics Committee of Ahvaz Jundishapur University of Medical Sciences approved this study (Ref. ID: IR.AJUMS.REC.1399.401). The objectives and importance of the study as well as the confidentiality of the collected data were explained to the participants. Written informed consent form was signed by all participants. Also, participants were free to decline participation at any stage of the study process. After obtaining permission from the participants, all recorded interviews were saved as audio files in password-protected computers.

A total of 20 participants were interviewed, of whom 11 were primiparous mothers who had given birth within 6 months, six were healthcare providers, and three were husbands. Two participants were interviewed twice, so the findings are based on 22 interviews. The mean and standard deviation of the mothers' age was 30.36 ± 4.94, and most of them (54.50%) had a bachelor's degree. Further details of the demographic characteristics of the participants are shown in Table 1. The final analysis of the 152 initial and 46 condensed codes was presented in form of 13 subcategories and three main categories [Table 2]. The participants' comments are presented using direct quotations.

Due to its prevalence in the participants' statements, comprehensive support was the most important category in mothers' perceptions and experiences of social support during the postpartum period. Under this category, the participants talked about the importance and necessity of the comprehensive support. They explained how the support provided by the husband, the family, the healthcare provider, and the social media contributes to well-being. This category included four subcategories: husband support as the most important source, family support, healthcare provider support, and social media support.

This type of support was one of the commonly expressed supports cited by most of the participants. From the participants' point of view, husband support was one of the most important sources of support that led to promoting mothers' abilities to adapt to and deal with new stressors after childbirth. It was believed to improve and strengthen the mother–child relationship. Participants mentioned husband support in caring for the baby, doing household chores, having successful breastfeeding, paying attention to the health of the baby and mother, and maintaining peace in family. A participant noted: “Fortunately, I had a good experience and I was able to deal with things effortlessly because my husband also supported me emotionally and mentally. He tried to calm me down and treated me considerately.” (Participant No. 5) Another participant stated: “My husband helps me with breastfeeding, changing diapers and clothes, showering, and giving vitamin drops to my daughter, and he also does the necessary housework.” (Participant No. 1)

From the participants' point of view, family support which entails a warm, intimate, and constant relationship with the mother not only promotes the mother's mental health, but also increases her skills of caring for the baby and enhances her self-confidence. The most common experiences with family support the participants cited were related to the support from their mothers and sisters in child care, household chores, and breastfeeding. A respondent commented: “My mother helps me a lot, like in housework or when I am very tired; she keeps the baby so that I can rest, or sometimes when I go shopping or somewhere else for work, she keeps the baby.” (Participant No. 3)

From the participants' point of view, healthcare providers have a significant role in ensuring the health of the community by providing desirable and needed services. Giving the necessary advice and information, providing the necessary cares, and performing examinations were among the main tasks healthcare providers did during the postpartum period as cited by the participants of this study. A healthcare provider said: “We teach mothers about health tips, breastfeeding, taking supplements, going for the next visit, nutrition, thyroid test, and audiometry of their baby.” (Participant No. 15) Another participant noted: “Health personnel call and ask about me and the baby; for example, if I have a problem, they want to see whether it has been resolved or not.” (Participant No. 3)

According to the participants, the correct and careful use of social networks provides information and facilitates communication. Participants felt supported by the information provided via Instagram and Telegram, and by making telephone calls if they had any questions or ambiguities. They also acknowledged the support they received through WhatsApp during the corona pandemic. A participant recounted: “I read the medical tips that were available on Instagram pages and checked what helps to avoid problems and relax.” (Participant No. 1)

This category involves the participants' statements about the deterrent factors of support. They had insufficient support due to the presence of barriers or deterrents. In their view, support barriers play a very important role in increasing the mother's vulnerability. This category consisted of five subcategories of cultural barriers, stress caused by COVID-19 pandemic, healthcare providers' lack of commitment to their duties, lack of efficient supportive laws, and changes in the mother's condition in the postpartum period.

From the participants' point of view, mental perceptions, beliefs, and values that prevail among the public have a great impact on the way support is provided. They noted that cultural challenges such as negative attitudes toward women, demeaning women, negative prejudices, men's lack of understanding of the postpartum mother's condition, and patriarchal views lead to failure in providing support for women. In this regard, a participant stated: “In our family, all the housework is done by women and men do not do the housework and child care at all, and this is not good at all.” (Participant No. 9).

According to the participants, the social distancing plan, traffic restrictions, and quarantine are among the reasons for insufficient support and the increased level of anxiety and worry of women in the postpartum period. The stress of being infected or carrying the coronavirus reduces face-to-face communication and leads to the loss of social interactions, which is an important factor in the barriers to providing support. A participant noted: “In the hospital, because it was during the Corona days, I was always scared and stressed lest the baby or I get Corona. When I came home, I did not let anyone see me at all because I was afraid I would get it from the others, and it was very difficult for me because I was alone.” (Participant No. 4)

Commitment to work or work commitment is the degree to which employees are faithful and enthusiastic about doing their duties. Some participants expressed the healthcare providers' non-compliance with ethical standards and their failure to provide the necessary care. A participant recounted: “My baby had a problem. His testicles were inside his abdomen. The staff started mumbling once my baby was born. It was a very bad situation.” (Participant No. 6) One of the healthcare providers stated that due to the crowds and the large number of clients, negligence in care may occur. This statement is an example of this condition: ”We don't have enough time; we don't do many tasks while we know it should be done. For example, we do not wash hands while we know it is important.” (Participant No-19)

Based on the statements of the participants, laws have been passed in this regard in Iran. For example, there is a law on reducing the number of working hours of employed women with special conditions, and another on the promotion of breastfeeding and supporting mothers during breastfeeding period. However, these laws are neither sufficient nor efficient. Based on their experience, the participants reported high hospital costs, insufficient insurance coverage, reduced staffing in care centers, high cost of Internet calls to patients, and lack of any understanding of working mothers' conditions and their multi-tasking responsibilities. A participant complained: “My hospital costs were almost 80 million IRR of which only 25 million was covered by supplementary insurance, and the government did not support me appropriately in this regard.” (Participant No. 5) One of the healthcare providers stated that deficiency of manpower in health centers is one of the main reasons for the support barriers. “The number of manpower of the centers is very low, and at least every health center wants a statistician because it takes a long time to get statistics and we cannot take good care of mothers.” (Participant No. 18)

Based on the participants' experiences and statements, most mothers had various physical and mental problems during the postpartum period that prevented them from caring appropriately for their babies. The participants mentioned the following issues: hormonal changes in the body, body pain and disfigurement of the mother's body in the postpartum period, the need for family love, fatigue, the mother's stress and anxiety after childbirth, reduced tolerance and endurance of the mother, the priority of mental and emotional support over physical support, and the mother's need for a backup. A participant noted: “After I was discharged from the hospital and came home, the quarantine started. Because of the hormonal changes that occur after childbirth, as well as the limitations of social distancing, I was sort of irritable and very upset.” (Participant No. 2) One of the husbands stated that women are in a certain condition in the postpartum period that stops them from seeing any support. “During this period, the women's spirits become softer. Due to stress, anxiety and fatigue, they become less tolerant and need more sleep. All these factors cause the woman not to feel the support.” (Participant No. 13)

Based on their experiences, the participants proposed a number of strategies to improve maternal social support in the postpartum period. The category of “Support promotion strategies” is one of the important categories of mothers' perceptions and experiences because it has a great impact on reducing the negative effects of stressors, promoting maternal health, and improving motherhood on the whole. This category had four subcategories, namely raising the couples' awareness about their rights and responsibilities in family, holding childbirth preparation classes for husbands, and teaching support skills using media and social networks, and the need to increase government support.

According to the participants' views, one of the ways to strengthen maternal social support in the postpartum period is to increase the awareness of the couple about their mutual support and duties. According to the participants, it is better to inform the couple about changing the society's attitude about the wife's duties at home, division of duties at home between the couples, establishing mutual support between the couples, and providing support to the mother during pregnancy and after childbirth. A participant stated: “According to the society's conventions, raising children and cleaning the house and other chores are the responsibility of the mother. However, people should be informed on the Instagram or Telegram, and especially in the national media and radio and television, that this is not the case.” (Participant No. 2) One of the husbands noted: “There are psychological pressures on me as a father, and conflicts may start between the couple with the slightest things, and it is better to hold specialized psychology courses for men and women.” (Participant No. 14)

This was one of the most commonly discussed subjects raised by the majority of the participants. Women's social support has a protective role in her mental health, and the husband is the most important person who can be the source of this support. Most participants stated that husbands should be educated on how to promote maternal social support in the postpartum period. It was believed that a postpartum woman's husband will better understand and support his wife if he has more information about his wife's physical and mental condition. According to one participant: “In physiological delivery classes which husbands attend with their wives, the mother's mental and physical conditions and the need for maternal support in the postpartum period should be discussed.” (Participant No. 10) A healthcare provider believed: “The childbirth preparation class, which is held during pregnancy, includes 8 sessions. I think it is better to add two more sessions in the postpartum period and 10 sessions in total. In these two sessions, the husband must be present and talk about his care and support to the mother in the postpartum period.” (Participant No. 20)

From the participants' point of view, by making information available, media and cyberspace provide information support as well as psychosocial and emotional support, and high self-esteem. They mentioned that broadcasting can be used to educate the community about the role of husbands in postpartum support, and social networks can also be used to raise public awareness about the participation of men and women in household chores and to answer mothers' questions. One of the healthcare providers stated “I wish we could create a group with mothers in WhatsApp or any other social networks so that they could ask their question.” (Participant No. 16) A participant noted: “In addition to social networks, it is better to dedicate a program on the Health Channel on TV to the role of the husband in supporting the mother during and after pregnancy.” (Participant No. 11)

This subcategory reflects the participants' views on the need to increase government support. In fact, they regarded increasing government support as a key factor in enhancing maternal support. Participants felt the need for the government to extend the postpartum leave and reduce working hours for working mothers and fathers who have just had a baby, create jobs for unemployed new fathers, reduce hospital costs, increase staff salaries, monitor the performance of healthcare workers in order to improve maternal support, and increase the responsibility of physicians. They also pointed to the need to employ gynecologists, nutritionists, and mental health experts in all clinics and increase the number of staff. A healthcare provider commented: “Our salary is very low. Certainly, with a raise in salary, the motivation and interest for service and the quality of care will increase.” (Participant No. 17) Another participant noted: “I wish the government would reduce the costs of the hospital, monitor the work of the staff and the doctors in the hospital, and do not let them abuse the mother and shout at her.” (Participant No. 6)

The present study was conducted to explore primiparous mothers' perceptions and experiences of social support during the postpartum period. “Comprehensive support,” “support barriers,” and “support promotion strategies” were emerged as the three main categories. In the first category, the findings showed that comprehensive support from the husband, family, healthcare staff, and social networks leads to maternal comfort and increases maternal self-efficacy. This is in line with previous studies which have shown that comprehensive support for a woman who has just given birth reduces perceived stress facilitates the mother's coping with postpartum problems and strengthens the mother–child bond.[414] Husband support is one of the most important sources of support that increases maternal self-confidence and facilitates the acceptance of a new maternal role and successful breastfeeding, which are among the important findings of our study. Various studies have introduced the husband as the most important source of support in stressful life situations of women.[1516] Previous studies have also shown that husband support facilitates coping with stress in mothers[17] and is associated with increased self-efficacy in breastfeeding.[18] In the second category, our findings revealed that there are barriers to understanding, receiving, and providing support in the postpartum period that play an important role in increasing postpartum stress. These include several factors such as maternal mood swings, cultural barriers, the stress caused by COVID-19 pandemic, lack of staff commitment, and lack of efficient supportive laws. According to one study, patriarchal culture is the biggest barrier to enjoying social rights and access to family justice.[19] Another study found that one of the most common stressors after childbirth is women's concern about lack of social support. This is because women experience various physical and psychological changes during this period that may prevent them from perceiving social support.[20] To promote the health of the mother and baby, health professionals should be educated on the relationship between lack of social support for women in childbirth and the increased risk of postpartum depression, and how to support and establish relationships with these women. Most women are willing to contact a professional for help in the postpartum period.[21] The stress and anxiety caused by the COVID-19 pandemic must be controlled. Some postpartum mothers worry about conditions such as breastfeeding and baby care, vaccination, and screening. In this regard, it is recommended to increase mothers' awareness about the disease and to provide remote counseling to care for them and help them reduce their anxiety and worry.[22] The findings of a study showed that the rate of burnout among nursing staff is significantly high, which is inversely related to emotional commitment. In addition, establishing support and justice in the workplace increases the emotional commitment of the nursing staff.[23] Participants in the present study also stated that they need financial support due to the increase in costs of the postpartum period. According to Barkin et al.,[9] the most important barriers to women's social support in the postpartum period are the cost and demand for infant care and changing priorities. A qualitative study reported the following as obstacles to providing social support: fear of being judged, a sense of responsibility, fear of being criticized, and a sense of non-attachment, which is inconsistent with the results of the present study. This inconsistency can be due to the type and purpose of study, as well as the number of the participants. In addition, the participants in that study were postpartum women who had given birth 6–12 months prior to the study, while the participants in the present study included not only primiparous mothers in their first 6 months after birth but also their husbands and healthcare providers.[11] In the third category, the participants pointed to supportive strategies and believed that these strategies would increase maternal support which will in turn lead to promoting maternal health and improving their role as a mother. These strategies included raising the couples' awareness about their rights and responsibilities in the family, educating husbands in childbirth preparation classes, and teaching supportive skills using media and social networks. This is in line with the findings of Mohammadpour et al.[24] who showed that four 60-minute sessions of consultation with fathers significantly increased the mean score of social support 4 weeks after the intervention. Web-based postpartum education and psychological interventions both reduced postpartum depression and improved social support for mothers in all postintervention tests.[25] Family education is one of the most important ways to improve marital adjustment, resilience, and quality of life of couples.[26] Using the principles of family therapy, couples can stand up against unnecessary judgments.[27] Due to the advent of information and communication technology into everyday life, we are witnessing the formation of a new generation of Internet tools that have provided more opportunities for interaction, negotiation, and dialogue. Internet social networks are one of the most important cases in point.[28] Heydari et al.[29] reported that education through social networks increases self-efficacy and self-confidence of mothers in the postpartum period. According to previous studies, fathers who do not attend perinatal care classes often feel that they do not play a significant role in the birth of their child and have been neglected by midwives and other members of the treatment team. These negative feelings and experiences cause problems such as unfamiliarity of couples with pregnancy, childbirth, and the postpartum period, as well as limiting the supportive role of the father after birth.[3031] In addition, men's lack of participation affects the educational, behavioral, and developmental status of children by reducing the father–child relationship, reducing social support, and increasing levels of maternal stress hormones.[32] One of the main limitations of the present study was the COVID-19 pandemic at the time of data gathering, which required us to interview approximately half of the participants on telephone. Thus, in addition to the lack of face-to-face communication, their perception of social support may have been affected by the pandemic status of the disease. Also, this study focused on primiparous mothers' experiences of support, and we had no information about the actual support received. Apart from these shortcomings, interviewing postpartum mothers provided a unique opportunity to explore the role of social support in postpartum women's lives. One of the most important strengths of the study was the participation of healthcare providers and the postpartum women's husbands, which shed light on the research topic from different perspectives.

The findings of this study suggest that identifying support perception and expectations of new mothers is important for their recovery after birth. The mothers' main perception of social support was the sense of not being alone, and the main expectation of primiparous mothers from social support was to receive comprehensive support, especially from the husband, and to increase the awareness of the husband about this support. By recognizing the aspects related to comprehensive support, support barriers, and support promotion strategies, healthcare professionals can design and implement supportive programs to promote social support of mothers. Future studies are recommended to benefit from the results obtained from this study in doing the design and psychometrics of social support of women during the postpartum period. Assessment tools need to be used to evaluate the effectiveness of educational-supportive programs in promoting social support.

Ahvaz Jundishapur University of Medical Sciences in Iran

Nothing to declare.