Social support refers to the assistance people receive from others, and it is divided into four types of support. Given the increasing mortality and morbidity rates of mothers and neonates postpartum, this study intended to determine whether the social support needs of the first-time mothers were met after early discharge from health care facilities.
The objective of the study was to explore the lived experiences and social support needs of the first-time mothers after an early discharge from health care facilities in the City of Tshwane, Gauteng.
A qualitative explorative study was conducted to explore the lived experiences and social support needs of the first-time mothers. The population were first-time mothers who had a vaginal delivery and were discharged within 6–12 hours of delivery from health care facilities. Purposive sampling was performed and 14 semi-structured interviews were conducted, with those mothers who came for the prescribed three postnatal check-ups at the three health care facilities identified according to maternity services provided. Saturation of data for the three health care facilities was reached at the 14th interview. Data analysis was performed using the hermeneutic interpretive approach.
Almost all participants had completed grades 11 or 12, but most were unemployed. The needs identified included the need for social support, lack of confidence, knowledge and skill to care for themselves and their newborn babies after early discharge.
There is need to identify alternative types of social support for the first-time mothers, to ensure a normal adjustment to motherhood.
The postpartum period is defined as the first six weeks after birth, and a critical period of health and survival of the mother and of the newborn baby (World Health Organization [WHO]
Becoming a mother for the first time is a life-changing experience and major life adjustments have to be made (Deave, Johnson & Ingram
The current practice of early discharge postpartum at 6–12 hours after a normal vaginal delivery minimises the opportunity for first-time mothers to master the skills and knowledge of caring for themselves and their newborn babies when at home. Anecdotal evidence shows that mothers expressed lack of confidence when caring for themselves and their babies.
The objective of the study was to explore and describe the lived experiences and the social support needs of the first-time mothers after early discharge from health care facilities in the City of Tshwane, Gauteng, from the immediate postpartum period to 6 weeks postnatally.
Challenges that contemporary mothers face because of changes in family structure, maternal role development and early post-partum discharge from health care facilities put added demands on these mothers’ emotional and physical adjustments during the postnatal period (Emmanuel et al.
Early discharge of new mothers and their babies from maternity units and health care facilities further creates a lack of professional support during the first 6 weeks postpartum (Barimani et al.
The WHO (
In response to the increasing number of postpartum deaths and complications, the WHO (
The Strategic Plan for Maternal, Newborn, Child and Women’s Health and Nutrition in South Africa 2012–2016 (Department of Health
Early discharge: It is the practice of discharging mothers and their babies within 6–12 hours post-delivery of a normal vaginal delivery and within 72 hours of a low-risk caesarean section.
Low-risk caesarean section: This is a caesarean section which was performed for foetal reasons or indications, for example foetal distress, and the caesarean section was performed on a healthy pregnant woman who had no chronic medical conditions.
Health care facilities
First-time mothers: Women who are becoming mothers for the first time; women who had given birth to their first newborn babies.
Postpartum period: Sometimes referred to as postnatal period is the period after the birth of a baby and commences from the first hour after delivery of a baby and ends at 6 weeks thereafter.
Postpartum care: Sometimes referred to as postnatal care or post-delivery care includes the assessments and care provided to mothers and babies after birth, and end at 6 weeks thereafter.
Immediate postpartum care
Social support: This is defined as the hopefulness, caring and reliance that the postpartum first-time mothers expect from midwives, families and communities up to 6 weeks after their discharge from health care facilities.
The findings of the study added information about some of the possible effects of early discharge on the first-time mothers. The needs for social support during the postpartum were highlighted by the study. These findings also indicated a need for an alternative measure such as a social support programme for the first-time mothers that could provide social support in the absence of an extended family structure. There is a need to relook at the practice of early discharge, especially for the first-time mothers and to search for alternative forms of social support.
A qualitative, descriptive and exploratory design was adopted. The motivation for using an exploratory design was to understand the meaning that the participants attributed to their everyday lives about early discharge and their postpartum social support needs (Creswell
This study was conducted at three health care facilities in the City of Tshwane, a metropolitan municipality in Gauteng Province, with a population of about 2 million people. The health care facilities comprise academic hospitals which are level two and three, while level one are PHC facilities. The PHC facilities, providing maternal and child health care service, fall within level one. Out of the three health care facilities identified for the study, two were open only during the day for 5 days a week. The remaining health care facility was open for 24 hours and operated as a midwifery obstetric unit (MOU), a PHC facility and was open for 7 days a week.
The area surrounding the participating health care facilities comprised mostly Setswana-speaking people residing with six other languages and cultural groups namely the BaPedi, Basotho, BaVhenda, Zulus, Xhosas and Tsongas. The justification for using the three health care facilities was that they offered maternal and child health services to most postpartum mothers and their babies residing in the area, during their postnatal clinic visits for a check-up. According to the interim report of the National Committee for Confidential Enquiry into Maternal Deaths of 2011–2013, the average childbearing age of mothers in South Africa ranged from less than 20 years to more than 45 years of age (Department of Health
The accessible population comprised the postpartum first-time mothers who were discharged within 6–12 hours from health care facilities in the City of Tshwane. The first-time mothers were asked about their experiences of early discharge, social support needs and taking care of themselves and their babies at home. A non-probability purposive sampling method was used to recruit participants at the three health care facilities in the chosen community. The three health care facilities were chosen as they provided postnatal care services to women who had given birth at those facilities while some had given birth at a level-two hospital and some at the tertiary hospital. All the postpartum first-time mothers who attended one of the three health care facilities, and were residing in these health care facilities’ surrounding areas, were invited to participate in the study during their postnatal visits at the facility for a check-up.
The inclusion criteria were postpartum first-time mothers who visited one of the three participating health care facilities for their postnatal check-ups, resided in the chosen communities, whose babies were born normally or through low-risk caesarean sections, were discharged within 6–12 hours after giving birth, and could communicate either in English or Setswana.
The exclusion criteria were mothers who were discharged after 12 hours of delivery, were more than 6 weeks postpartum, who were not first-time mothers, did not reside within the chosen community or had a complicated caesarean section.
Arrangements were made with the managers of the three identified health care facilities to visit these facilities once a week to gather dense data. On the day of data collection, the first author approached all postpartum first-time mothers who were attending the PHC facility, who complied with the inclusion criteria, invited them to participate in the study, and all indicated their availability and willingness to participate. The first author explained the type of research and supplied leaflets with information and consent forms. The women who were willing to be interviewed were requested to sign consent forms.
An interview schedule consisting of two sections was formulated. Section A gathered demographic data required to describe the sample. This included aspects of age, level of education, occupation and level of income. Section B comprised open-ended questions and a few probes which the researcher followed during the interview. The interview schedule was translated into Setswana to facilitate interviewing those who could not communicate in English.
The interview schedule was pre-tested by conducting interviews with two postpartum first-time mothers at the health care facility who were not included in the study. The biographical information section required re-numbering and two questions had to be rephrased after the data obtained during the pre-test had been analysed.
At the health care facility, after introducing herself and the field worker to all postpartum women and explaining the reason for the visit, the first author conducted individual interviews in a private room. Permission to interview the participants and the use of the audio tape recorder was requested from them and they signed a consent form to indicate their willingness to participate. The use of the audio tape recorder was to ensure that the data transcribed were a true reflection of what was shared by the participants.
Interviews were conducted by using an interview schedule (Greeff
During the interviews, the participants unfolded their experiences of being discharged from health care facilities within 6–12 hours after their babies’ birth and their social support needs. For this purpose, open-ended questions were asked, which read: ‘Please tell me about your experience of being discharged early from the health care facility, your social support needs and your experience of taking care of yourself and the newborn baby at home, and tell me how you recognised whether your baby was well or not.’ (Authors’ own phrase)
The questions were followed by probes, reflections and paraphrasing. The interview sessions lasted approximately 45 minutes.
Data saturation was reached at the 14th interview as no new information emerged from subsequent interviews.
A hermeneutic interpretive approach was used to analyse the data. Speziale and Carpenter (
The biographical data were analysed quantitatively by using descriptive statistics indicating the frequency and percentage distributions of variables (Brink, Van Der Walt & Van Rensburg
The study received approval from the University’s Ethics Committee (FCRE 2011/03/004), the Tshwane Research Committee and the managers of the three health care facilities where the study was conducted. Each participant signed a consent form before being interviewed. Respect of persons, beneficence, confidentiality, anonymity and autonomy were adhered to (Brink, Van Der Walt & Van Rensburg
The results are presented as the demographic profile of the participants and the themes which emerged during data analysis.
The demographic profile of the participants is shown in
Demographic characteristics of the participants (
Characteristics | % | |
---|---|---|
18–20 | 8 | 57.1 |
21–30 | 2 | 14.3 |
31–40 | 4 | 28.6 |
> 41 | 0 | - |
Married | 3 | 21.4 |
Single | 11 | 78.6 |
Widowed | 0 | - |
Divorced | 0 | - |
Tertiary | 1 | 7.1 |
Grades 11–12 | 12 | 85.7 |
Grades 8–10 | 1 | 7.1 |
Up to Grade 7 | 0 | - |
Never attended school | 0 | - |
Formal worker | 6 | 42.9 |
Unemployed | 7 | 50.0 |
Self-employed | 1 | 7.1 |
> R5000 | 2 | 14.5 |
R4999–R3001 | 2 | 14.5 |
R3000–R2500 | 1 | 7.1 |
R2499–R1100 | 1 | 7.1 |
< R1000 | 1 | 7.1 |
None | 7 | 50.0 |
Breastfeeding | 13 | 92.9 |
Bottle feeding | 0 | - |
Mixed feeding | 1 | 7.1 |
As much as 57.1% (
Lived experiences and social support needs of first-time postpartum mothers.
Themes | Categories | Subcategories |
---|---|---|
The need for support | Lack of confidence in mothering | Feelings of doubt, fear and anxiety |
Desperation to become a ‘picture-perfect mother’ | ||
Knowledge and skills deficit related to baby care | Baby care | Bathing and holding the baby |
Breastfeeding as a challenge | Concerns about breastfeeding | |
Cultural belief | Cultural beliefs and myths | The relationship between the umbilical cord, passing stools and urination |
The postpartum first-time mothers repeatedly expressed that they lacked confidence and needed social support. They had doubts about how they would care for themselves and the babies. These experiences were discussed under lack of confidence in mothering as expressed by feelings of doubt, anxiety and desperation to be a perfect mother.
Lack of confidence in mothering was revealed by participants who experienced uncertainty and lacked confidence to care for their babies which they related to their early discharge from the health facilities. Some women said that they felt guilty to have a meal when their babies sucked nothing from their empty breasts during the immediate postpartum period. In one incident the baby was separated for 24 hours from the mother because of ill health and was observed in the neonatal intensive care unit. The mother and baby were united for the first time when they were discharged from hospital. No assessment was performed on the woman to determine whether her milk supply would be sufficient, as the baby had never been breastfed prior to discharge. Feelings of doubt and anxiety evoked further strong emotions such as frustration and confusion. Most of the first-time mothers stated that they were holding a newborn baby for the first time in their entire lives, and expressed the lack of confidence as follows:
‘I worry a lot about what type of a mother I will be. I sometimes stress, feel down and, depressed, as I’m worried about how to bring up the baby.’ (Participant M, 18 years, Grade 11) ‘My sister encourages me to continue. She says it will become better with time. Because I love my baby too much, I believe her.’ (Participant G, 18 years, Grade 12) ‘My family helped me and taught me how to hold the baby.’ (Participant K, 20 years, Grade 12) ‘My partner asks things about the baby, why is the baby changing colour, why the cord is not falling off, and I don’t have answers for him. I am blank … I know nothing about the baby.’ (Participant C, 18 years, Grade 9)
The participants indicated that they were concerned about the type of mothers they would be and most of them expressed their wishes to be good and perfect mothers. Because of these aspirations some participants could not sleep as they were unsure about the safety of their babies while they slept. Some mothers reportedly spent most of the night checking that their babies were breathing while some were wary of leaving their babies with wet or soiled nappies at night, requiring them to stay awake at night. All these expressions indicated that the postnatal women were overly concerned to keep their babies safe. The participants wished to be the ‘perfect mothers’ or else they might be blamed later if something went wrong with themselves or their babies. As a result, the participants continued to deprive themselves of sleep and rest required for their postpartum recovery. This is what participants said:
‘What if something goes wrong, affecting me or my baby? What if my baby stops breathing, what will I do?’ (Participant D, 32 years, Grade 12) ‘I check her every time, throughout the night. I am worried about the safety of me, and I worry a lot about this.’ (Participant E, 30 years, Grade 11) ‘The baby slept here and there. But I kept awake most of the time to make sure that she is well, … is breathing, is warm and nappy is dry.’ (Participant K, 20 years, Grade 12)
‘I was afraid to hold the baby; I thought the baby will break. I did not know how to hold the baby.’ (Participant A, 19 years, Grade 11) ‘I am scared that I might drop the baby. It is too slippery.’ (Participant G, 18 years, Grade 12) ‘How does one test if the temperature is alright for the baby? Why don’t I know all these?’ (Participant G, 18 years, Grade 12) ‘If she does not wake up, after how long, must I remind her by waking her up for feeding?’ (Participant I, 19 years, Grade 12)
It dawned on most participants during the interviews that they would be unable to identify a baby who is unwell. However, a few could explain some of the signs which could indicate that the baby was sick if the baby refused to feed, ‘felt hot to touch’ or passed loose stools.
When asked about the signs of a baby who is not well, some participants stated:
‘I don’t know. I have never thought about that, now I realise I don’t know.’ (Participant E, 30 years, Grade 11) ‘Never thought about this … [ ‘If the baby does not do what I am used to, or if he wakes up earlier than usual, or when he is not feeding well.’ (Participant J, 22 years, Grade 12)
Umbilical cord care was a problem. Some first-time mothers were afraid of touching or cleaning the umbilical cord and mentioned that they hated the crying of their babies when the umbilical cord was cleaned or touched. They believed that the baby felt pain when the cord was touched. Some participants mentioned that they walked away as soon as a support person started cleaning the umbilical cord, stating:
‘The way the baby cries and screams when the cord is cleaned, it scares me.’ (Participant E, 30 years, Grade 11) ‘I literally go out when my sister attends and cleans the umbilical cord.I did not know that the cord must be kept exposed at all times to encourage drying off.’ (Participant A, 19 years, Grade 11) ‘I was afraid of the stump of the cord.’ (Participant K, 20 years, Grade 12)
Some participants mentioned that it always seemed easy when they read books about breastfeeding, but it was difficult when it came to applying what they had ‘learned’ in real life. Most of the first-time mothers complained about painful nipples, especially when breastfeeding for the first time. They mentioned that the pain on the breast felt like the ‘baby was biting the nipple’. Some of the participants alluded:
‘We have been taught how to breastfeed and hold the breast for the baby at the clinic, I thought this will be easy. The challenge is when coming to the practical part of it, reality strikes … and I realised I don’t know how.’ (Participant F, 21 years, Grade 11) ‘My body was painful. On the first day, no milk came out and the baby was crying. It only came out from the second day, and the baby is no more crying a lot.’ (Participant E, 30 years, Grade 11) ‘The baby was continuously sucking and I don’t know for how long the baby should continue. What will show me that the baby is full? I don’t know.’ (Participant F, 21 years, Grade 11)
Cultural practices and beliefs related to the umbilical cord, breastfeeding and passing of stools. They stated that they were worried that the babies did not pass urine, and the babies were crying when passing stools.
Some participants believed that the umbilical cord was related to other systems of the baby’s body. For instance, the baby might not pass urine or might have difficulty passing stools as long as the umbilical cord had not fallen off. Some participants mentioned that their babies cried when passing stools and some stated that their babies did not pass stools every day, and all these aspects were related to the umbilical cord which had not fallen off. The participants mentioned:
‘Because they told me he will not pass stools normally until the cord falls off. They told me I must not worry; he will not pass stools every day until the cord falls of. After the cord has fallen off, he will pass stools normally, that is every day.’ (Participant E, 30 years, Grade 11) ‘As long as the umbilical cord is on I know my baby will not pass urine.’ (Participant A, 19 years, Grade 11)
Credibility and transferability were enhanced by the fact that the first author had more than 20 years’ experience as a midwife while the second author is a recognised researcher. Consistency was maintained by ensuring that the first author conducted all the interviews using the same interview schedule.
Validity was ensured by the fact that the study’s proposal was approved by the Ethics Committee of the university. The scientific processes of sampling, data collection and analysis were followed and all the steps were supervised by the two researchers who were the supervisors of the study. The first author was a doctoral candidate, supervised by researchers with vast experience in community nursing and research. The environment and context of the study were described. Content validation of the tool was attended to by using relevant literature.
Reliability is the extent to which an experiment, test or any measuring procedure yields the same result on repeated trials (Burns & Grove
The women in the current study identified the need for social support, as they lacked knowledge and practical skills to provide baby care. Cultural practices and expectations were identified, which could guide the women’s care and social support needs. The current South African system of early postnatal discharge does not meet the needs of the first-time mothers, resulting in high anxiety levels.
First-time mothers expressed a lack of confidence characterised by feelings of doubt, anxiety and fears while caring for themselves and their newborn babies in the current study. These first-time mothers did not know about which signs and symptoms could indicate that the baby might be sick. Danbjorg and Clemensen (
In the current study, some mothers believed that a baby cried while passing a stool because the umbilical cord was still on. Although there is no direct danger about such beliefs, these myths should be clarified by a health professional. Most cultures have rituals connected to the postpartum period. There has been the practice of confining the postpartum mother to the house for 40 days in Norway as the woman was considered to be unclean (Eberhard et al.
The first-time mothers in the current study experienced a lack of knowledge and skills to care for themselves and their babies. The first-time mothers indicated their lack of basic skills and knowledge on how to hold the baby during breastfeeding and how to bathe their babies. The first-time mothers in the current study only realised when they arrived at home that they lacked information about simple tasks like how to recognise that the baby was not well and how to determine whether the baby was satisfied after a feed. Umbilical cord care and breastfeeding were viewed as being challenges. Although they were taught about breastfeeding during the antenatal period, the reality of breastfeeding their own babies had its own difficulties. This was also shown in a study about postnatal depression among first-time mothers, indicating that they had to learn new skills and roles which would help them to adjust to the new mothering role (Leahy-Warren, Mccarthy & Corcoran
Only first-time mothers were interviewed. Perhaps the findings might have been different if all mothers within the 6-week postpartum were interviewed. The findings cannot be generalised to all first-time mothers in other areas in Tshwane unless the study has been repeated in other areas.
There is a need to reconsider the practice of early discharge as the practice does not meet the social support needs of first-time mothers. Alternative social support structures should be identified within the community to cater for the first-time mothers during the postpartum period. There is a need to develop social support groups for first-time mothers in the community. In addition, the available community health care workers who are performing door-to-door follow-up visits for patients with chronic medical conditions within the community could be trained to provide social support to the first-time mothers.
The strength of this study is that it has provided an in-depth exploration of the experiences and social support needs of 14 first-time mothers in the City of Tshwane which has provided important insights into the current provision of post partum care.
Acknowledgement is made to the Adelaide Tambo School of Nursing Science and Tshwane University of Technology for support given to the first author during the carrying out of the study. The health care services that enabled the first author to contact the first-time postnatal mothers, and all the mothers who agreed to be interviewed are acknowledged. Appreciation is further given to Prof. “X” who did language editing of the manuscript. We wish to express our thanks to Tshwane University of Technology and Adelaide Tambo School of Nursing Science for funding the study.
The authors declare that they have no financial or personal relationships that might have inappropriately influenced them in writing this article.
M.E.T.M.-C. conceptualised the study, collected data, analysed and interpreted the findings. T.S.R. supervised the work, assisted with interpretation of the findings and critiqued the manuscript.