Postpartum adjustment among women with heart disease in pregnancy: a qualitative study

Abstract

Background

Pregnancy with heart disease (PWHD) is a significant high-risk category, leading to adverse cardiovascular events and indirect maternal deaths. Despite advancements in perinatal care improving outcomes, the postpartum period remains high-risk for cardiovascular issues. Postpartum women face physical, psychological, and maternal role adjustments, with those having heart disease at higher risk for adjustment disorders. This study investigates the real experiences of postpartum adjustment in these patients.

Methods

Researchers conducted a qualitative study using reflexive thematic analysis. Semi-structured face-to-face interviews were conducted with 24 purposively sampled postpartum women with pregnancy-complicated heart disease recruited from a provincial tertiary hospital in Zhejiang Province, China, from May to September 2025. Interviews were audio-recorded, transcribed verbatim, and analysed using NVivo 15 to generate themes and subthemes.

Results

Five core themes and 16 sub-themes were identified: the dual burden of heart disease and postpartum challenges, psychological vulnerability and heightened emotional fluctuations, family support tension and intergenerational negotiation, gaps in disease understanding and health management skills, and the retreat from motherhood with a need for role repositioning.

Conclusions

These findings enhance the understanding of the complex challenges faced by women with pregnancy-related heart disease during postpartum adaptation. They emphasise the importance of care that goes beyond disease monitoring to include psychological, familial, and educational support. Implementing integrated, multidisciplinary postpartum care with family involvement and targeted support can foster better recovery and improve quality of life. This approach also contributes to developing comprehensive “fourth trimester” care models for sustained maternal and infant health.

Background

Pregnancy with heart disease (PWHD) encompasses a spectrum of congenital, acquired, and genetic cardiovascular conditions that are either pre-existing or newly diagnosed during pregnancy. It is associated with substantial maternal morbidity and mortality and includes structural heart disease, cardiomyopathy, arrhythmias, ischaemic heart disease, and aortic disorders [1, 2]. The incidence of PWHD ranges from 1% to 4% and has shown an increasing trend, partly attributable to delayed childbearing, rising cardiometabolic risk, and improved survival among women with congenital heart disease [3, 4].

The postpartum period represents a particularly vulnerable phase for women with PWHD. Rapid haemodynamic shifts following childbirth, together with persistent cardiac risk, increase the likelihood of clinical deterioration [5–7]. At the same time, women are required to adapt to new maternal roles while managing chronic illness, placing simultaneous physiological, psychological, and social demands on recovery [8–10]. This intersection of medical vulnerability and maternal transition renders postpartum adjustment especially complex.

Postpartum adjustment is increasingly recognised as a multidimensional and evolving process that extends beyond physical recovery to include emotional well-being, caregiving capacity, and transformations in identity and social roles [11]. For women with heart disease, this process is further complicated by persistent symptoms, incomplete cardiac recovery, and elevated long-term cardiovascular risk, underscoring the need for sustained follow-up and integrated care [12–17]. However, current postpartum care remains largely time-limited and medically oriented, often prioritising acute complications over longer-term adaptation [18]. Such approaches may be insufficient to address the complex interplay of physical, emotional, and social needs experienced by women with PWHD. In addition, fragmented follow-up services and limited integration of psychosocial support further widen the gap between clinical care and patients’ lived experiences [9, 19].

Despite growing recognition of postpartum vulnerability, existing research on pregnancy-complicated heart disease has largely prioritised perinatal risk assessment and clinical outcomes, with comparatively limited attention to women’s lived experiences during the postpartum period [20]. Qualitative studies in this field have tended to focus on specific dimensions, such as psychological distress or healthcare experiences, while offering less integrated accounts of how physical symptoms, maternal role transition, family interactions, and self-management practices intersect in shaping postpartum adjustment.

Moreover, postpartum adaptation in women with heart disease is not solely an individual process but unfolds within broader sociocultural contexts. In particular, within the Chinese setting, where intergenerational co-caregiving and family-centred decision-making are common, the ways in which family dynamics influence women’s recovery, autonomy, and role negotiation remain insufficiently explored [21–25]. The interaction between medical vulnerability and culturally embedded caregiving structures has yet to be fully understood.

Therefore, this study aimed to explore, through qualitative interviews, how women with pregnancy-complicated heart disease experience and interpret postpartum adjustment within the Chinese sociocultural context. By capturing the interplay between physical symptoms, emotional responses, family dynamics, and self-management, this study seeks to provide a more holistic understanding of postpartum adaptation and to inform the development of personalised, context-sensitive postpartum care strategies.

Methods

The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [26].

Study design and setting

This qualitative study used reflexive thematic analysis, as described by Braun and Clarke. Semi-structured interviews were conducted to explore postpartum adjustment among women with pregnancy-complicated heart disease. The study was carried out in the obstetric department of a provincial tertiary grade A hospital in Zhejiang Province, China, which manages approximately 4,000 deliveries annually, including a substantial proportion of high-risk pregnancies.

Participants

Participants were purposively recruited from the study site. Eligible women were aged ≥ 20 years, had a confirmed diagnosis of congenital, acquired, or inherited heart disease before or during pregnancy, were between 6 weeks and 12 months postpartum, were clinically stable, and able to communicate in Mandarin. Women were excluded if they had severe psychiatric illness, cognitive impairment, had experienced medically indicated pregnancy termination, or were participating in other clinical studies. Recruitment continued until data saturation was reached. Saturation was defined as the point at which no new themes emerged, and was considered achieved when the final three interviews generated no new codes. A total of 24 women participated.

Data collection

Semi-structured interviews were conducted by the first author in a provincial tertiary hospital interview room. Relevant clinical information was reviewed beforehand to support rapport. Interviews lasted approximately 30–45 min. All interviews were audio-recorded with consent and supplemented by field notes. Open-ended questions with flexible probes were used to encourage detailed accounts. Follow-up contact was undertaken where clarification was needed. The interview guide is provided in Supplementary File 1. Participant recruitment and interviews were conducted between May and September 2025 until data saturation was achieved.

Data analysis

Data were analysed using reflexive thematic analysis following Braun and Clarke. Transcripts were read repeatedly for familiarisation. Initial codes were generated inductively to capture key features of the data. Codes were then reviewed and grouped into candidate themes. Themes were refined through comparison across transcripts to ensure coherence and consistency. Theme development was interpretive and focused on patterns of meaning rather than simple categorisation. NVivo (version 15) was used to support data management.

Reflexivity was maintained throughout analysis. The research team engaged in regular discussions to examine assumptions and interpretations, ensuring that findings remained grounded in participants’ accounts while recognising the active role of the researchers. To enhance rigour, a subset of transcripts was independently coded by two researchers, with discrepancies resolved through discussion. An audit trail documenting analytic decisions was maintained. All interviews were conducted, transcribed and analysed in Chinese. Quotations presented in the manuscript were translated into English by bilingual members of the research team and cross-checked to preserve semantic and conceptual equivalence.

Researcher reflexivity

Interviews were carried out by the first author, who is a senior obstetric nurse skilled in qualitative research and experienced in managing high-risk pregnancies. The interviewer had no prior clinical relationship with the participants and was not involved in their direct care. To minimise potential bias and enhance reflexivity, the interviewer maintained reflective field notes after each interview, documenting personal assumptions, emotional responses, and emerging interpretations. Regular discussions were held within the research team to examine preconceptions and ensure that data interpretation remained grounded in participants’ accounts.

Trustworthiness

Credibility was enhanced through prolonged engagement, iterative questioning, and member checking, with preliminary findings confirmed by participants. Dependability was supported by an audit trail of coding decisions and team discussions. Two researchers independently coded a subset of transcripts, resolved discrepancies, and applied the agreed framework to the remaining data. Confirmability was ensured through reflexive memoing and peer debriefing, while transferability was supported by detailed descriptions of the study context and participants.

Results

Participant characteristics

We interviewed 24 postpartum women with pregnancy-complicated heart disease. All interviews were conducted face-to-face and lasted a mean of 37 min (range 30–45).

All participants were between 6 weeks and 12 months postpartum at the time of the interview. The median age of participants was 32 years (range 22–44 years). Sixteen women (66.7%) had completed college or vocational education or above. Eighteen participants (75.0%) were delivered by caesarean section. Structural heart disease accounted for 54.2% (13/24) of cases, while the remaining participants had functional cardiac conditions. Nine women (37.5%) reported a history of cardiac surgery. Detailed participant characteristics are presented in Table 1.

Table 1.

Characteristics of the study participants (n = 24)

Characteristic	n (%) or Median (range)
Age (years)	32 (22–44)
Education level
Junior high school or below	3 (12.5)
High school	5 (20.8)
College / vocational	7 (29.2)
Bachelor’s degree or above	9 (37.5)
Mode of delivery
Vaginal delivery	6 (25.0)
Caesarean section	18 (75.0)
Gestational age at delivery (weeks)	37 + 2 (30+ 6—40+ 0)
History of cardiac surgery
Yes	9 (37.5)
No	15 (62.5)
Type of heart disease
Structural heart disease	13 (54.2)
Functional heart disease	11 (45.8)
Primary cardiac diagnosis
Congenital heart disease	11 (45.8)
Arrhythmia	8 (33.3)
Pulmonary hypertension	3 (12.5)
Other	2 (8.4)

Themes and subthemes

Thematic analysis identified five main themes and multiple subthemes. The themes covered physical symptoms, emotional responses, family dynamics, illness understanding, and role adaptation in the postpartum period. Details of themes, subthemes, and codes are presented in Table 2.

Table 2.

Findings presented according to themes, subthemes, and codes

Themes	Subthemes	Codes
Dual burden of heart disease and postpartum context	Persistent fatigue and physical decline	• Delayed postpartum recovery
		• Recurrent physical exhaustion
		• Limitations in daily functioning
	Recurrent cardiopulmonary symptoms	• Chest tightness and palpitations
		• Persistent or postoperative cardiac symptoms
	Night-time feeding and sleep disruption	• Fragmented sleep due to infant care
		• Self-reported sleep disturbances
Psychological vulnerability and emotional fluctuations	Persistent illness-related fear	• Fear of symptom recurrence
		• Heightened vigilance toward bodily sensations
	Invisible depression	• Emotional fluctuation and distress
		• Positive emotional reframing and coping
	Self-dissolution and role strain	• Conflict between health recovery and family responsibilities
Family support tension	Intergenerational caregiving conflicts	• Conflicting childcare beliefs with parents or in-laws
	Spousal involvement and companionship	• Emotional support from partner
		• Practical caregiving assistance
	Insufficient support and solitary coping	• Perceived lack of emotional support
		• Financial strain and household economic pressure
Illness perception and self-management challenges	Uncertainty in disease cognition and prognosis	• Uncertainty regarding disease trajectory
		• Lack of clear consultation pathways
	Transition toward active health management	• Difficulty maintaining medication routines
		• Hesitation toward seeking medical care
		• Self-monitoring behaviours
	Variability in health information acquisition	• Reliance on peer support
		• Unmet disease-related consultation needs
		• Challenges managing postpartum daily life
Maternal role withdrawal and reintegration	Breastfeeding-related pressure	• Conflicts and compromises in breastfeeding decisions
	Maternal identity and responsibility	• Perceived maternal responsibility
	Parenting stress and competence	• Parenting burden and caregiving stress
	Role reintegration and employment concerns	• Concerns about returning to work and role functioning

Theme 1: dual burden of heart disease and postpartum context

This theme reflects the dual challenges of postpartum recovery and ongoing cardiac symptoms. Fatigue, sleep disruption, and cardiopulmonary symptoms were commonly reported and often limited daily functioning. These challenges were experienced as cumulative rather than isolated, reinforcing difficulties in early postpartum adjustment.

Persistent fatigue and physical decline

Persistent fatigue was widely reported, with variation in severity and manageability. For some, infant care, household tasks, and early return to work led to pronounced exhaustion with little opportunity for rest. Others experienced partial relief when family support allowed recovery. A smaller group reported smoother recovery and used self-regulation to maintain balance.

“I returned to work two months after delivery. There is no time to rest during the day, and my sleep at night is disrupted. I often wake up feeling dizzy and exhausted” (P2, functional heart disease).

“In the early postpartum period, I had to go to the hospital frequently. Caring for the baby was very demanding, and I felt completely drained” (P8, structural heart disease).

“My husband sometimes helps with night-time feeding. It is still tiring, but I feel less overwhelmed” (P10, structural heart disease).

“Sometimes I am so tired that I do not want to move. But during the day, my mother helps with the baby, which allows me to rest. I feel much better physically” (P12, structural heart disease).

“My body has recovered well after childbirth. I still feel tired at times, but it is not as severe as in the early postpartum period” (P19, functional heart disease).

Night-time feeding and sleep disruption

Disrupted sleep was a persistent burden, driven by night-time feeding and infant crying. Fragmented sleep hindered recovery and increased fatigue. Some women reported partial relief with family support, while others noted gradual improvement as infants developed more regular sleep patterns.

“I have had insufficient sleep since pregnancy, and it did not improve after delivery. Even as my baby grows older, I still feel weak and fatigued” (P4, structural heart disease).

“The baby feeds every two hours, and my sleep is almost completely interrupted throughout the night” (P6, structural heart disease).

“My husband helps occasionally, but I still have to wake up for night feedings. In any case, my sleep is not as good as before” (P10, structural heart disease).

“When the baby cries at night, my mother-in-law sometimes comforts the baby first, so I can sleep a bit longer” (P13, structural heart disease).

“At the beginning, I slept poorly, but as the baby grew, things gradually improved. Now I can usually sleep through the night” (P17, structural heart disease).

“Waking up once or twice at night is acceptable for me. I can rest during the day, and that helps” (P20, structural heart disease).

Recurrent cardiopulmonary symptoms

In addition to fatigue and sleep disruption, recurrent cardiopulmonary symptoms such as chest tightness, palpitations, and shortness of breath remained a source of distress for many participants. These symptoms often intensified during infant care and heightened concerns about disease recurrence or deterioration. While some women reported reassurance following regular follow-up and medical explanations, others prioritised caregiving responsibilities over symptom monitoring, delaying attention to their own health.

“Sometimes I feel a sense of pressure in my chest. When I hold the baby against my chest, I become short of breath” (P5, functional heart disease).

“I still experience chest tightness and shortness of breath. The doctor advised me to return for follow-up” (P6, structural heart disease).

“My atrial fibrillation still occurs occasionally. During episodes, I feel chest tightness and breathlessness” (P9, structural heart disease).

“Sometimes I notice my heart beating faster, but the doctor said it is temporary, so I am not too worried” (P11, structural heart disease).

“My condition has mostly recovered. The doctor also said everything looks good, so I am not very concerned” (P21, functional heart disease).

Theme 2: psychological vulnerability and emotional fluctuations

This theme captures the heightened emotional sensitivity experienced by participants as they navigated uncertainty related to illness, caregiving demands, and shifting self-identity in the postpartum period. Psychological responses were shaped by concerns about disease recurrence, emotional suppression, and the tension between maternal responsibilities and personal well-being.

Persistent illness-related fear

Fear of disease recurrence was common among participants, though its intensity and focus differed. Some women described heightened vigilance, interpreting minor physical sensations as signs of serious cardiac problems, which contributed to ongoing anxiety and avoidance of physical exertion. Others concentrated their worries on pregnancy or infant-related risks, while a subset reported managing fear through adherence to follow-up care and trust in medical guidance.

“Whenever my chest feels uncomfortable, I immediately think something is wrong with my heart” (P2, functional heart disease).

“As long as I follow the doctor’s advice and go for check-ups, I don’t let myself worry too much” (P21, functional heart disease).

Invisible depression

Participants commonly reported emotional fluctuations during the postpartum period; however, the expression, intensity, and coping strategies varied considerably. For some women, emotional distress was pronounced and persistent, often triggered by infant care demands, sleep deprivation, and delayed physical recovery. These experiences were sometimes accompanied by irritability, anxiety, and even negative thoughts about motherhood.

Some participants reported pronounced emotional distress, often triggered by infant crying and sleep disruption. “The baby is so difficult to care for. I regret it almost every day. The constant crying at night drives me to the edge” (P2, functional heart disease).

Even when recognising such behaviours as normal, some women still felt overwhelmed: “The doctor said it was normal for babies to cry at night, but those days were still very hard for me to cope with” (P8, structural heart disease).

For some, emotional distress was alleviated through family support and gradual adjustment. “At first I felt very tired and emotionally low, but my mother helped with the baby, and I gradually felt better” (P11, structural heart disease).

Others maintained relatively stable emotional states and expressed positive reframing: “Sometimes I feel tired, but being with my baby makes me happy. I feel it is all worth it” (P18, structural heart disease).

“Taking care of the baby is demanding, but I feel fulfilled” (P24, functional heart disease).

Self-dissolution and role strain

Assuming the maternal role significantly reshaped participants’ sense of self. Many women described placing their own needs secondary to those of their infants, even when experiencing health limitations. Some gradually recognised the tension between caregiving obligations and personal recovery, attempting to renegotiate balance. Others derived meaning and value from motherhood, reframing sacrifice as responsibility and personal growth.

“Everything has to revolve around the baby now. I often forget about myself” (P2, functional heart disease).

“Being a mother has changed my priorities, but I feel it’s a responsibility, not just a sacrifice” (P20, structural heart disease).

“The baby cried all night, and I felt like I was about to break down. I became so irritable” (P4, structural heart disease) .

“It’s tiring, but being with my baby makes me feel happy. I think it’s all worth it” (P18, structural heart disease).

Theme 3: family support tension

This theme reflects the complex and sometimes conflicting experiences of family support during the postpartum period. Participants described varying levels of emotional and practical assistance from partners and extended family members, which shaped their capacity to cope with recovery demands and caregiving responsibilities.

Intergenerational caregiving conflicts

Conflicting childcare beliefs between participants and their parents or in-laws were frequently reported. Traditional postpartum and caregiving practices sometimes contradicted medical advice, leading to tension and emotional distress despite the availability of practical assistance. While some women felt misunderstood, others described learning to negotiate differences in order to maintain household stability.

“My parents-in-law help with childcare and provide financial support, but there is still an emotional gap. For example, they think there is no need to respond when the baby cries, while I worry the baby might be hungry or uncomfortable, which often leads to conflict” (P2, functional heart disease).

“My parents-in-law help take care of the baby when I go for follow-up visits, otherwise it would be difficult to manage. Although their caregiving approach sometimes differs from mine, such as not responding immediately when the baby cries, having their support makes me feel reassured” (P10, structural heart disease).

“My mother-in-law helps with cooking and childcare every day, which allows me to rest. Although there are occasional disagreements, she is willing to follow medical advice rather than insisting on traditional practices, which makes me feel fortunate” (P19, functional heart disease).

“My parents help take care of the baby so I can attend follow-up appointments with peace of mind. They also remind me to take medication and rest, sometimes even more attentively than I would myself” (P20, structural heart disease).

Spousal involvement and companionship

Participants reported substantial variation in spousal involvement. Emotional reassurance and practical caregiving assistance from partners were described as crucial sources of security. In contrast, limited engagement intensified exhaustion and feelings of isolation, particularly during nighttime caregiving.

“Sometimes I feel that no one can really help me, and I become very anxious. Even when my husband is at home, he feels tired from work and rarely helps” (P1, functional heart disease).

“Although we hired a maternity caregiver, there is no one who truly understands me emotionally. My husband thinks that paying for help is enough and is rarely involved himself” (P8, structural heart disease).

“My husband is somewhat supportive emotionally. When the baby cries intensely, he will hold the baby for a while. Even though he is not always present, having someone there when I feel overwhelmed is important” (P12, structural heart disease).

“My husband occasionally helps with night feeding. It is still tiring, but it feels different. He will prepare the formula and soothe the baby, so I can rest briefly” (P17, structural heart disease).

“Doctors and nurses offered reassurance, but what mattered most was my husband’s constant presence. He accompanied me throughout pregnancy and after delivery, attended follow-up visits with me” (P18, structural heart disease).

Insufficient support and solitary coping

Some participants experienced inadequate emotional or practical support, leading to solitary coping with postpartum recovery and childcare. Financial strain and household economic pressure further compounded stress. Conversely, women who received consistent support reported greater opportunities for rest and medical follow-up.

“Most of the time I am on my own. It feels very lonely. When the baby cries, there is no one to help, and I have to soothe the baby while crying myself” (P6, structural heart disease).

“My family helps, but they do not always understand my views. For example, I wanted to take the baby outside, but they thought the baby was too young, which led to disagreements” (P13, structural heart disease).

“When the baby cries at night, my parents-in-law sometimes get up first so I can sleep a little longer. I know it is not easy for them, so I feel very grateful” (P18, structural heart disease).

“My parents help a lot, which makes things much easier. They take on household tasks and childcare, so I have time for follow-up and can get a full night’s sleep” (P24, functional heart disease).

Theme 4: illness perception and self-management challenges

This theme illustrates disparities in disease understanding, uncertainty regarding prognosis, and differences in engagement with postpartum health management.

Uncertainty in disease cognition and prognosis

Participants demonstrated varying awareness of their cardiac condition. Some struggled to distinguish pathological symptoms from normal postpartum changes, leading to uncertainty and anxiety. Others relied on follow-up assessments to interpret disease trajectory and gain reassurance.

“I wasn’t sure whether my symptoms were normal after childbirth or heart-related” (P2, functional heart disease).

“Even though the doctor said it was stable, I still worried about the future” (P8, structural heart disease).

“Follow-up results have been normal, so I feel there are no major problems” (P18, structural heart disease).

“It is hard to predict the future, but as long as I attend follow-up regularly, it should be fine” (P23, functional heart disease).

Transition toward active health management

Postpartum self-management behaviours ranged from passive to proactive. Some participants reported difficulty maintaining medication routines or delayed medical visits due to caregiving demands. Others gradually adopted active strategies, including scheduled follow-ups and symptom monitoring.

“Sometimes I forget, and I only go for follow-up when my mother reminds me” (P11, structural heart disease).

“The doctor recommended monthly follow-up. I went once or twice, but I could not maintain it regularly” (P13, structural heart disease).

“I now attend follow-up visits regularly and also record my blood pressure and heart rate” (P20, structural heart disease).

“I always cooperate with the hospital’s telephone follow-up. It makes me feel reassured that someone is checking on me” (P24, functional heart disease).

“I attend every follow-up visit and also monitor my heart rate and blood pressure at home” (P21, functional heart disease).

Variability in health information acquisition

Participants obtained health information through diverse channels, including healthcare providers, peers, and online sources. While some relied heavily on experiential or peer advice, others expressed unmet consultation needs or difficulties translating information into daily management.

“I often asked other mothers first because it was more convenient” (P7, functional heart disease).

“Sometimes I still don’t know who to consult when new problems arise” (P11, structural heart disease).

“I often seek advice online by posting questions on different platforms. People with similar conditions sometimes share their experiences, and occasionally I also consult AI-based tools” (P18, structural heart disease).

Theme 5: Maternal role withdrawal and reintegration

This theme captures women’s evolving maternal identity as they navigated feeding decisions, caregiving confidence, and competing role expectations during the postpartum period.

Breastfeeding-related pressure

Participants described considerable stress surrounding breastfeeding decisions. Conflicts between physical capacity, infant needs, and family expectations often resulted in emotional burden. While some women experienced guilt when breastfeeding goals were unmet, others reached a compromise through professional guidance and flexible feeding strategies.

“My milk supply was insufficient, and my family kept urging me, which created a lot of pressure” (P5, functional heart disease).

“When the baby cried, my family said it was due to insufficient milk, which made me feel anxious and inadequate” (P8, structural heart disease).

“My milk supply was low at first, but after the doctor suggested formula, I gradually accepted it” (P10, structural heart disease).

“When breast milk is not enough, I use formula. The most important thing is that the baby is well fed” (P19, functional heart disease).

“I wanted to exclusively breastfeed at first, but later I chose to take things as they come. The baby’s health matters most” (P18, structural heart disease).

“I am not concerned about breastfeeding or formula, as long as the baby is growing well” (P20, structural heart disease).

Maternal identity and responsibility

The assumption of maternal responsibility reshaped participants’ self-perception. Many women described prioritising infant needs over personal health, while others gradually integrated maternal duties into daily life. Maternal identity was often framed as both an obligation and personal growth.

“I prioritise the baby and often neglect my own needs” (P2, functional heart disease).

“Caring for the baby conflicts with my recovery, and I usually prioritise the baby” (P6, structural heart disease).

“It is demanding, but I see it as part of being a mother” (P10, structural heart disease).

“Most decisions now revolve around the baby, and I have adapted” (P11, structural heart disease).

“Becoming a mother has helped me grow” (P23, functional heart disease).

Parenting stress and competence

Participants expressed varying levels of parenting confidence. First-time mothers frequently reported stress and uncertainty, whereas others gained competence through experience. Increasing caregiving skills contributed to improved emotional stability and perceived self-efficacy.

“When the baby keeps crying and I cannot soothe them, I feel very frustrated” (P2, functional heart disease).

“I didn’t know how to soothe the baby and felt very frustrated” (P9, structural heart disease).

“As I gained experience, I became much more confident” (P18, structural heart disease).

Role reintegration and employment concerns

Concerns about returning to work reflected tensions between caregiving responsibilities and personal identity. Participants described balancing employment expectations with physical recovery and childcare demands, viewing work as both an economic necessity and an avenue for self-restoration.

“I hope to return to work soon to reduce financial pressure” (P1, functional heart disease).

“I am considering returning to work, depending on family arrangements” (P13, structural heart disease).

“Work helps me feel like myself again, not just a mother” (P21, functional heart disease).

“I plan to return to work when the baby is older; I do not want my life to revolve only around the family” (P24, functional heart disease).

Discussion

Principal findings

This qualitative study investigated the postpartum experiences of women with heart disease and found that adaptation during this period is marked by persistent physical challenges, emotional vulnerability, intergenerational family tensions, variations in disease understanding, and the need to balance maternal responsibilities with personal health. Rather than a brief transition, the postpartum period appeared as a prolonged and unstable phase shaped by the interaction between chronic cardiac conditions and the demands of intensive infant care [27–29].

Physical and emotional challenges

A key finding was the persistence of physiological burden after childbirth. Many participants reported fatigue, chest tightness, palpitations, and reduced exercise tolerance lasting beyond six weeks postpartum and, in some cases, up to one year. Night-time breastfeeding and frequent infant care disrupted sleep and often worsened these symptoms. Recovery was rarely linear. Fluctuating symptoms and sustained fatigue created an ongoing sense of physical vulnerability. Similar patterns have been reported in women with congenital or acquired heart disease, suggesting that postpartum symptoms may persist for months and affect daily functioning [27, 29–31]. Importantly, participants described their cardiac symptoms as closely intertwined with caregiving responsibilities. When physical discomfort coincided with infant care demands, many felt caught in a cycle of exhaustion and incomplete recovery. These findings indicate that postpartum care should address maternal recovery and infant care as interconnected rather than separate domains.

Emotional vulnerability was also prominent. Many women described heightened anxiety about disease progression, symptom recurrence, and long-term health uncertainty. Minor physical discomfort was often interpreted as a warning sign, leading to constant vigilance [9]. Some participants avoided physical activity due to fear of cardiac complications, sometimes reinforced by traditional postpartum confinement practices that limited mobility [9, 10]. Depressive symptoms were common, particularly in the context of sleep deprivation and unexplained discomfort. Consistent with earlier qualitative studies, emotional distress extended beyond clinical depression to include persistent worry, emotional exhaustion, irritability, and feelings of helplessness. The dual identity of being both a new mother and a patient with chronic disease intensified emotional strain. Several women reported gradually neglecting their own emotional and health needs while prioritising infant care [32].

Family dynamics and sociocultural context

Family support functioned as both a protective factor and a potential source of tension. Participants described greater reliance on family members to manage childcare, cardiac monitoring, and rehabilitation. Support from spouses and shared parenting responsibilities were often beneficial and helped reduce stress [33–35]. Previous research similarly shows that adequate family support improves psychological well-being and health-related quality of life [33, 36]. However, involvement of older family members sometimes generated intergenerational disagreements regarding infant care and maternal health management. When support did not align with women’s preferences or medical needs, it occasionally increased emotional burden and strained relationships. This coexistence of support and tension reflects the complex role of family dynamics in postpartum adaptation [37]. In the Chinese context, traditional postpartum confinement practices (“zuo yuezi”) may further shape family interactions during the postpartum period. Although these practices can provide practical support and opportunities for rest, differing expectations regarding infant care, maternal recovery and health management may contribute to intergenerational tensions, particularly when traditional beliefs do not align with women’s preferences or professional medical advice.

These findings also highlight the influence of the Chinese family context, in which intensive intergenerational involvement in postpartum and infant care can inadvertently generate conflict when elders’ practices or beliefs do not align with mothers’ needs, preferences, or medical advice [38, 39]. Differences in disease knowledge further shaped postpartum experiences. Some women had a limited understanding of heart disease mechanisms and prognosis, and occasionally misinterpreted warning symptoms as normal postpartum changes. This sometimes delayed help-seeking or disrupted follow-up care. In contrast, women with higher health literacy were more proactive in monitoring symptoms and seeking professional advice. Postpartum health behaviours, therefore, appear closely linked to women’s ability to interpret symptoms and assess risk, underscoring the importance of tailored health education.

Role transition and identity reconstruction

Under the pressures of motherhood, personal recovery needs were often marginalised. Many women expressed a strong desire to return to work, resume social roles, and rebuild a sense of self. However, caregiving demands and cardiac vulnerability frequently limited physical capacity and delayed return-to-work plans. In the absence of sufficient support and professional guidance, some prioritised infant care over their own recovery. While caregiving responsibilities were widely accepted as necessary, they also created internal conflict. Employment was vie normalitywed not only as an economic need but also as a means of restoring identity and normalcy [34, 40].

Strengths and limitations

This study was conducted in a single provincial tertiary hospital in China, which may limit the transferability of the findings. In addition, participants were interviewed across a relatively broad postpartum period (6 weeks to 12 months postpartum). As women’s physical, emotional and social recovery experiences may evolve over time, future longitudinal studies are needed to explore changes in postpartum adaptation and to inform the development of long-term follow-up and supportive interventions. Nevertheless, this study drew on rich accounts generated through semi-structured face-to-face interviews with women representing diverse cardiac conditions and postpartum experiences. The iterative process of data collection and analysis, together with the achievement of data saturation, enhanced the depth, credibility and contextual richness of the findings.

Conclusion

Collectively, these findings indicate that postpartum adaptation among women with pregnancy-complicated heart disease is a prolonged and multifaceted process shaped by interacting physical, emotional, familial, and informational factors. Rather than a brief recovery stage, the postpartum period reflects an ongoing negotiation between illness vulnerability, caregiving demands, and identity reconstruction.

Clinical and research implications

These findings highlight the need to shift postpartum care from a time-limited, medically focused model to a more continuous and context-sensitive approach. Follow-up should extend beyond routine obstetric time points and include monitoring of symptoms, functional recovery, and psychological well-being. Discharge education should incorporate guidance on symptom recognition, fatigue management, and breastfeeding in the context of cardiac medication use.

Given the central role of family, partners and primary caregivers should be actively involved in follow-up care. Family-based education may help align medical recommendations with caregiving practices, particularly in intergenerational contexts. In addition, accessible consultation pathways (e.g., nurse-led or digital support) are needed to reduce reliance on fragmented online information.

Future research should adopt more integrative and longitudinal approaches to capture the dynamic interplay between symptoms, emotional responses, family context, and self-management over time. Developing and evaluating family-inclusive and digitally supported care models may further improve continuity and patient-centred outcomes in this population.

Authors’ contributions

Yuan Wang contributed to the conception and design of the study, data collection, data analysis, and drafting of the manuscript.Huiling Wu contributed to study supervision, methodological guidance, and critical revision of the manuscript.Qing Wang contributed to data collation.Lewen Shao contributed to the study design and critical revision of the manuscript.All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to the need to protect participants’ privacy and confidentiality, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was granted by the Research Ethics Committee of the First Affiliated Hospital of Zhejiang University School of Medicine (Ethical Approval Number: IIT-EA-2025-0609). Written informed consent was obtained from all participants prior to participation.

Consent for publication

All participants provided consent for the anonymised data to be used in research publications.

Competing interests

The authors declare no competing interests.