Social support during the postpartum period: Mothers’ views on needs, expectations, and mobilization of support

Abstract

Objectives

Research has indicated that social support is a major buffer of postpartum depression. Yet little is known concerning women’s perceptions on social support during the postpartum period. The objective of this study was to explore postpartum women’s views and experiences with social support following childbirth.

Methods

Four focus groups were conducted with an ethnically diverse sample of women (n=33) in a large urban teaching hospital in New York City. Participants had completed participation in a postpartum depression randomized trial and were 6 to 12 months postpartum. Data transcripts were reviewed and analyzed for themes.

Results

The main themes identified in the focus group discussions were mother’s major needs and challenges postpartum, social support expectations and providers of support, how mothers mobilize support, and barriers to mobilizing support. Women across all groups identified receipt of instrumental support as essential to their physical and emotional recovery. Support from partners and families was expected and many women believed this support should be provided without asking. Racial/ethnic differences existed in the way women from different groups mobilized support from their support networks.

Conclusions

Instrumental support plays a significant role in meeting women’s basic needs during the postpartum period. In addition, women’s expectations surrounding support can have an impact on their ability to mobilize support among their social networks. The results of this study suggest that identifying support needs and expectations of new mothers is important for mothers’ recovery after childbirth. Future postpartum depression prevention efforts should integrate a strong focus on social support.

Background

Women experience a range of psychological stressors in the postpartum period (1–3). Social support has been shown to be effective in helping women cope with these stressors (2, 4). Moreover, low levels or inconsistent social support have been found to be a strong predictor of postpartum depression (5–7) and dissatisfaction with social support may increase the risk for clinical and subclinical depression during the postpartum period (8–10). Although some depression prevention efforts have focused on social support (11), little attention has been paid to how social support is perceived and mobilized by mothers during the postpartum period, particularly in underserved communities. Through survey and anecdotal data collected during a randomized controlled study that followed mothers for six-months after childbirth, we noted differences with how mothers viewed and mobilized support after childbirth (12). The primary objective in this study was to conduct focus groups to explore barriers and facilitators to receipt of social support among a diverse group of mothers.

Methods

The study was approved by the Program for the Protection of Human Subjects at the Mount Sinai School of Medicine. We used purposive sampling to recruit postpartum mothers into four focus groups in the fall of 2010. All women who had completed participation in a postpartum depression randomized trial and who had agreed to be contacted within the next year for future studies were eligible to participate, irrespective of randomization arm (treatment vs. usual care) and presence or absence of depressive symptoms during the randomized trial. During the randomized trial, postnatal depressive symptoms were assessed using the 10-item Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9) (13, 14).

The research team contacted eligible women and briefly discussed the content of the focus group discussions. Women were offered a $50 money order for compensation for their time. Each group was designed to be homogenous by race/ethnicity as homogeneity within each group is recommended in order to capitalize on people’s shared experiences (15). Race/ethnicity concordance with moderators was also used.

The moderator reviewed the informed consent document and participants gave written informed consent prior to participating in each focus group. Focus groups were arranged in a circular pattern to encourage discussion (16). A moderator guide containing open-ended questions was used by the moderators to insure consistency among focus groups and techniques such as reflection (e.g., “Let me repeat what you said”) were used to clarify statements. At the end of each focus group, participants completed a brief demographic questionnaire (Table 1). The focus group sessions were professionally audio-recorded and transcribed in their entirety. The Spanish focus group transcript was professionally translated into English and bilingual members of the research team verified the accuracy of the translation. Iterative review of the transcripts and coder triangulation were used to thematically analyze the data. Members of the research team individually reviewed the transcripts and then met to create an inclusive master themes list. Two independent readers then coded the transcripts and a third reader reviewed the coded transcripts for inter-rater agreement. Disagreements were then discussed and resolved. Atlas.Ti6 software was also used to facilitate data management and retrieval.

Table 1.

Demographic Characteristics of the Study Participants by Race/Ethnicity (N=33)^*

	Black/African American	Hispanic/Latina	White/Other
Demographics	N (%)	N (%)	N (%)
Study participants	9	13	10
Mean Age	28	28	36
Birthplace
US Born	9 (100)	9 (69)	8 (80)
Foreign Born	0	4 (31)	2 (20)
Education**
Less than high school (8th–11th grade)	0	2 (17)	0
High school graduate or GED	3 (33)	6 (50)	0
Some college/trade or technical school	3 (33)	0	0
College graduate/professional training	3 (33)	4 (33)	10 (100)
Marital Status
Married/Living with a partner	7 (78)	8 (62)	10 (100)
Divorced/Separated	0	1 (8)	0
Never married	2 (22)	4 (31)	0
Parity
1	5 (56)	8 (62)	5 (50)
2	1 (11)	2 (15)	4 (40)
3	3 (33)	1 (8)	1 (10)
>3	0	2 (15)	0
Insurance
Medicaid/Medicaid Managed Care	6 (66)	6 (46)	0
Private health insurance/HMO	3 (33)	4 (31)	9 (90)
None	0	3 (23)	1 (10)
Currently Employed
Yes	5 (56)	4 (31)	9 (90)
No	4 (44)	9 (69)	1 (10)
Income
<$5,000	2 (22)	3 (23)	0
$5,000–$15,000	1 (11)	4 (31)	0
$15,001–$30,000	3 (33)	1 (8)	0
$30,001–$45,000		2 (15)	0
>$45,000	3 (33)	3 (23)	10 (100)

^*Based on 32 responses. Fourteen (14) Hispanic/Latina women participated in the focus groups, one missing demographic information.

^**Based on 12 responses for Hispanic/Latina

Results

Thirty three mothers participated in one of four focus groups (Table 1). The average age was 30 (range 22–43) and participants were between 6 and 12 months postpartum. Two groups were comprised of self-identified Hispanic/Latina women, one of which was English-speaking (n=11) and the other, Spanish-speaking (n=3). The third group included black/African American women (n=9) and a fourth group included white and other non-black, non-Hispanic women (n=10).

Four major themes were identified from the focus group discussions describing social support in the postpartum period: 1) mother’s major needs and challenges postpartum, 2) social support expectations and providers of support, 3) how mothers mobilized support, and 4) barriers to mobilizing support. The data analysis revealed several similarities as well as differences in the postpartum support experiences between racial/ethnic groups. Each theme is discussed below.

Major support needs and challenges

Mothers across all racial/ethnic groups identified fulfilling basic personal care needs, household chores, and getting sleep as the major challenges during the postpartum period. They discussed additional challenges with caring for other children and work-related stress.

“I actually lost my job because of my situation. My daughter got sick and my mom actually was sick as well….So I had to leave work to go take care of [my daughter]. And my boss told me ‘Well, if you leave, then you can go and find another job.’ And he told me that my priority was to be at work, not my child.” [Latina, English-speaking group]

Mothers mentioned physical symptoms such as post-delivery c-section pain or breastfeeding discomfort as obstacles to their postpartum recovery.

“My third was a Cesarean. And I was in more pain this time than I was the last time. Besides that, the breastfeeding was harder for me as well. My breasts had just engorged so badly and so much…. Like, it was just that bad.” [African American group]

Personal care needs such as bathing, eating, and sleeping were the most common needs mentioned and mothers also placed cleaning and cooking in the same category of importance. Fulfilling these basic needs was essential for women to feel they were more capable of dealing with the physical and emotional stressors inherent to the postpartum period.

“It’s like tiny victories every day. At first, getting out of bed is a big victory, and then getting to take a shower is a big victory. So I feel like you’re getting sort of the basic needs met and a little bit more each day, it feels like you’re getting somewhere. ‘Let me be clean, let me be fed, let me get some sleep’ and then you start building on top of that and it feels like you’re coming out of the darkness a little bit.” [White/other group]

Lack of the instrumental support to help with these basic needs was seen as the cause for depressive symptoms.

“Well, I feel like if you’re not getting help with [the everyday tasks], it’s like – just, you know, you’re setting yourself up for postpartum [depression]….I can’t imagine not having help with anything like that and dealing with your emotions on top of it.” [White/other group]

Social support expectations and providers of support

Women in all groups identified immediate family members, particularly their partners and mothers as principal sources of instrumental support and emotional support. Friends and other family members including fathers, godmothers and sisters-in-laws were also mentioned. One woman noted her disappointment with her partner:

“I guess I felt depressed more so with this one ‘cause I didn’t have the help from the father as much as I expected I was going to get. So I cried a lot. I felt like I didn’t want to be bothered with the baby even though I knew he had to eat, I knew he had to be washed, I knew he had to be changed. So I knew I had to do it, like I felt I was being forced to do it.” [African American group]

The majority of women in the African American and Latina groups also felt that support should come naturally and that they should not have to ask for help. One mother expressed:

“The one person I resent is their father because I’m like, you see what I have to do I shouldn’t have to tell you what to do. That should come automatically. I shouldn’t have to be like, okay the baby’s clothes need to be washed and things like that. Those things as a parent, you share those responsibilities.” [African American group]

Women spoke about emotional support as being able to talk to someone about what they were going through, receiving words of encouragement, and pampering. Partners were identified as the primary resource for emotional support, but some women also sought girlfriends, cousins, godmothers, and other mothers from mother support groups to talk about their feelings and experiences.

Counseling was mentioned as a trustworthy source for emotional support especially among African American mothers. In addition, African American and Latina-Spanish speaking mothers identified the use of prayer and self-reflection as ways of coping with feelings in the absence of people they could talk to. One woman said that prayer “was like medicine” and another said that she would “only talk to the Man above” since she did not feel her partner would understand how she felt.

How mothers mobilize support

Differences existed in the way women from the different racial/ethnic groups asked for help from their support networks. The Latina English-speaking mothers and African American mothers educated partners with the use of direct instructions and also made manuals or lists on how to care for the baby as well as how to perform household chores. One Latina mother read information aloud to her partner:

“I would say, ‘Here, read this.’ Just slide it over to him. ‘Just read it.’ He be like, ‘Oh, I don’t want to read it.’ And sometimes I would just open it and I’ll read it out loud. Just make sure you open your ears and you listen.” [Latina, English speaking group]

Latina and African American mothers mentioned dividing the tasks with baby care as well as household chores. One mother mentioned the use of a feeding chart as a visual aid to inform everyone on the baby’s feeding times. One Latina mother also mentioned:

“When I asked him, ‘Can you make the baby’s milk?’, he was like-he looked at me like, what do you mean? I said, ‘You go into the kitchen, you take a bottle, four ounces of water—you see four, you put it right there, you have two cups. Then he said ’Oh, that’s it? I said ‘Yeah, and you shake it.’ And then I told him that if I cook, I give her a bath, I make her milk, you feed her and you put her to sleep. I told him that that’s his job.” [Latina, English-speaking group]

Mothers in the African American and Latina groups went to greater lengths to secure the instrumental support provided by family members. A few mothers reported simply asking, crying, begging, cursing, or “catching an instant attitude” to make their needs and expectations known to those around them.

“I had to beg for it. Actually, to get [help] from my mother, like, to take the other two, or my father – actually, I really cried….that’s what I had to do – I had to cry on the phone. ‘Please, I need this help.” [African American group]

The Spanish-speaking women mentioned that their support networks were very limited, sometimes only receiving help from their partners. This group was very vocal in asking for help and communicated specific needs to partners, “I am one of those people that demands it. I demand that they give me affection. I tell him ‘I need this to feel good.” At times, they had to resort to asking acquaintances or providing compensation to relatives that lived far away to receive their help.

These women also mentioned the help of visiting nurses, who visited them periodically after the delivery. The Spanish-speaking women expressed “no other option” but to actively mobilize support from partners, parents, or other close family members.

In contrast, mothers in the white/other group did not express concrete mobilization techniques to secure support. In the white group, family members seemed to be less involved in the direct care and mothers did not mention feeling frustrated with any provision or lack of provision of support from relatives. Many women in this group previously arranged for baby nurses or other caregivers to provide help following childbirth. The decision to hire baby nurses or other caregivers was made primarily to prevent disagreements with mothers and mothers-in-law over the baby’s care.

“I did not want my mother-in-law to come stay with us. That was a conscious choice on my behalf. I have a great mother-in-law but that’s two different things. So we chose to have a baby nurse and my husband was very supportive of that.” [White and Other group]

Similarly, several of the African American mothers voiced that they assigned their partners the role to deal with unwanted help from family members.

Barriers to mobilizing support

Barriers to mobilizing support were present across all racial/ethnic groups. Some women felt that asking for help reflected negatively on their capacity to take care of their household and their children. Fear of judgment by family and friends if they asked for help was reported by many of the mothers.

“You know, they come from a place wanting to help, of wanting to reach out—with their own experience, be mother, sister, friend, aunt, grandmother. But I was just embarrassed to ask for help, reach out, because I felt ‘Are they going to judge me?”[Latina, English-speaking group]

Asking for help was a perceived criticism of parenting skills among Latina, English-speaking and white mothers. Several Spanish-speaking women mentioned difficulty in asking for instrumental help because they did not want to feel like a burden, especially if they had a small social support network. Other women decided not talk to their families about their frustration or disappointment with their lack of instrumental support because they thought they could hurt their family’s feelings. Pride and independence were two barriers to mobilizing support among African American mothers. One woman mentioned that she did not want to seem “ungrateful” since the delivery of her baby was meant to be a happy experience for everyone. Some women, however, mentioned that “having everyone on the same page” regarding expectations and responsibilities positively impacted interactions with support networks. One participant said that voicing expectations was necessary to fulfill instrumental support needs.

“I mean, the expectations were one thing, but they’re not verbalized, the other person does not necessarily share your expectations. So I have to know what your expectations are and they’re going to be whole different than mine, and we have to go through a list. And so we had a list of all those items over there [household chores] and we had a breakdown of what we needed to do.” [African American group]

Lastly, women also decided not to make their needs known to others if they felt the people around them could not offer the kind of support they needed. Some women rarely talked about their feelings with others, due to thoughts that their peers could not relate to their postpartum experiences:

“Sometimes things would just get to a point where I would just break down and start crying. And sometimes, I could talk to my husband or my mom, but I don’t have peers who have kids at this point. And so I didn’t have any--I really wanted to talk to people and I didn’t know who to call, who to ask for advice, to share experiences with.” [White and other group]

Barriers, including fear of judgment, feeling like a burden, perceived criticism, and independence, inhibited the mobilization of social support.

Discussion

The findings of this study reinforce the notion that social support is an essential component for the physical and emotional well-being of mothers following childbirth. We found that mothers have similar support needs and challenges postpartum, identify partners and family members as major providers of support, and while some mothers are able to find ways to actively mobilize support, barriers exist that prevent others from receiving the support they need or want.

Our findings mirror results from other studies examining the needs of postpartum mothers where mothers found it challenging to balance the various competing demands of early motherhood (17, 18). Additionally, our study reveals that women consider instrumental support an essential component for physical and emotional well-being. It is possible that women find completing concrete tasks as markers for their progress and ability to adapt and deal with new life stressors after childbirth. Moreover, meeting basic needs and completing routine chores may normalize their experience, helping women retain their identity during a time where everything around them has changed (16).

Partner instrumental support has been found to be important to women’s postpartum health and closeness with partner has been inversely related to risk for postpartum depression (6, 20, 21). Consistent with other studies, we found that mothers identified partners and family as main providers of both instrumental and emotional support. Our findings suggest that interventions focused on bolstering partner and family support should also be considered. Norbeck et al found this approach useful in preventing low-birthweight babies in African American women (22). Others also recommend encouraging education among patients, spouses and their families to increase support quality and availability (23, 24).

Few studies have focused on techniques for mobilizing support among social networks. Our study found that women utilized specific tactics, such as making lists or role play, in order to mobilize support. These results suggest that interventions aimed at improving skills needed to actively mobilize support can be beneficial in meeting the needs of postpartum women. Some studies have developed interventions that include training components in building communication and problem-solving skills, with the objective of enhancing quality of support and support satisfaction (25–27).

Our focus group study identified barriers to support mobilization related to personal attitudes and cultural norms, as well as perceived support expectations, support availability, and consequences on relationships with partners and family members. Attitudes such as pride, independence, embarrassment, and stigma associated with experiencing depressive symptoms have been recognized as barriers to emotional support seeking (28–33). Attitudinal barriers to instrumental support have not been well-studied, yet our findings show that instrumental support barriers may be similar to emotional support barriers. In addition, some women in our focus groups were concerned about how others would perceive their role as mothers if they had to ask for help.

Perceived consequences on existing relationships with members of support networks have also been noted to impact an individual’s ability to mobilize social support (34, 35). Results from this study indicate that the implications of this barrier may be of particular importance for postpartum women who only have very limited support networks available to them. Women with limited support may not ask for help if they feel they are a burden and do not want to risk straining relationships with those on whom they heavily depend. This may lead to challenges in meeting the needs of these women. As mentioned by women in our study, not receiving adequate support has led mothers to feel misunderstood, frustrated and at times, depressed (5, 7, 21).

Racial/ethnic differences in mobilization of support sources seemed to stem primarily from differing perceptions between groups on the kind of support they expected from their social networks. We also found that perceptions on support availability and expectations may inhibit support mobilization. Not knowing what is available or what the support source can provide may prevent mothers from asking for help, especially if mothers find asking shameful or inappropriate. In addition, having unrealistic expectations of their support networks may inhibit mothers from mobilizing the help they need. If mothers expect their support networks to know what they need without having to voice their needs, it may be difficult for the support providers to meet these expectations. These unfulfilled needs may lead to frustration as seen in our focus group discussions.

In contrast, some mothers were able to actively mobilize support and recognized that “lining up support beforehand” would be helpful in meeting postpartum needs and strongly advised other mothers to assess support sources before childbirth. Identification and preparation of support sources is a strategy that deserves further assessment. Posing questions to mothers that allow them to review their support networks and have appropriate expectations of the types of support around them could help women consider their postpartum needs and secure the appropriate support sources to meet those needs. Instruments that capture postpartum social support expectations have been developed and shown to be useful in medical care settings (36). Incorporating assessments like these into prenatal care settings could be helpful in facilitating resources for mothers who do not have easily available help. They could also be used to improve communication of needs between mothers and their partners and families.

While some women mentioned experiencing depression or depressive symptoms postpartum during this focus group study, it is not known whether these participants had received a formal psychiatric assessment and/or a postpartum depression diagnosis. The results of this study may help illustrate the needs or expectations of a diverse group of postpartum women regardless of the presence or absence of postpartum depressive symptoms. The identified themes may deserve further examination with a group of women known to have suffered from postpartum depression.

Women in this study were all adult women with an average age of mothers across all four participating groups of 30 years. It is also necessary to examine needs of very young mothers who may have different expectations surrounding support and whose stressors may be accentuated by their unique situation (37). However, similar to our group of adult mothers, being able to assess their support needs and expectations during pregnancy may be beneficial to help secure the support they need and want from their social networks.

Due to the qualitative nature of the study we cannot generalize the results to the population of postpartum women as whole. However, we did conduct focus groups with a racially/ethnically diverse group of postpartum mothers and many of the lessons learned are likely relevant for others. In addition, women who participated in these focus groups had been part of a postpartum depression trial where questions surrounding depression and social support were used. As a result, they could be more attuned to issues surrounding their emotional and physical health needs. Our discussions with postpartum mothers provided a unique opportunity to examine the role of social support in postpartum women’s lives.

Conclusion

Instrumental support postpartum is an important factor in the emotional and physical well being of mothers and their newborns. Our study gathered information on the techniques used to mobilize support and the barriers that hinder the mobilization of the support for a diverse sample of mothers. Our results suggest that helping women identify their own needs and expectations surrounding support could impact their ability to mobilize support. Further, interventions aimed at strengthening mothers’ ability to rally social support may not only reduce early postpartum depressive symptoms but may enhance a mother’s postpartum recovery. Our findings also highlight the importance of continued examination of social support in the postpartum period and the differences and similarities existing among women from different racial/ethnic backgrounds.