The impact of family social support on postpartum quality of life: the structural equation modeling

doi:10.21203/rs.3.rs-1672633/v1

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The impact of family social support on postpartum quality of life: the structural equation modeling

https://doi.org/10.21203/rs.3.rs-1672633/v1

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Background: The postpartum period is one of the most important stressful situations in women's lives that affects their quality of life (QOL). The important factor affecting the QOL in the postpartum period is social support, especially family social support (FSS). The present study has been designed to assess the impact of FSS on postpartum quality of life (PQOL).

Methods: In this analytical cross-sectional study, 240 postpartum women completed the PQOL questionnaire, and FSS questionnaire (FSSQ). The Pearson correlation and multivariate regression were used to determine the relationship between variables. A structural equation model (SEM) was used for path mapping of the impact of FSS on PQOL.

Results: The mean scores of PQOL and FSS were 61.63±9.59 and 69.80±11.19 respectively. The fit indices of the SEM were GFI: 1.00 and NFI: 1.00 that demonstrated, the fit of the SEM can be acceptable. The family support seeking (0.16), emotional support seeking (-0.13) and FSS (0.12) were three factors that influenced PQOL.

Conclusion: Our findings showed a picture of the association between FSS and the QOL of women in the postpartum period. The support from the family as the first people around the women who gave birth can improve their QOL by improving their physical, mental, and childcare performance and can be very effective in overcoming this challenging situation.

Family social support

Postpartum quality of life

Structure equation model

Postpartum

One of the most important stressful situations in the life of women is the postpartum period (1). The existence of a baby and acceptance of a new role as a mother with the occurrence of special physical, physiological, and psychological changes, challenging conditions and stressors causes women to lack adequate care for themselves and other family members, as a result of various aspects of women's lives and their quality of life changes (2,3). Nevertheless, biomedical indicators are still used in routine prenatal and postnatal care in obstetrics and gynecology clinics (4,5). While the use of holistic health indicators such as quality of life (QOL) in this period not only helps in planning holistic care but also in evaluating the effectiveness of care and treatment interventions in this period (6,7). The World Health Organization (WHO) defines the QOL as an individual's perception of his or her living situation in terms of culture, value system, and based on his or her ideals, expectations, standards, and interests. Knows the environment (8). Understanding the determinants of QOL is a prerequisite for planning to improve and enhance it (9). Most studies have focused on biomedical, demographic, or socioeconomic determinants (10–16). One of the factors of care and intervention affecting the QOL in the postpartum period is social support (17); A person's perception of the types and amount of potential and actual support he can receive from the social environment (18). In this regard, it has been stated that social support can be defined, measured, and presented from four dimensions emotional (empathy, love), instrumental (tangible assistance), informational (Consulting), and evaluation (constructive feedback) (19). Postpartum social support promotes a healthy lifestyle with buffering effects on stress, healthier nutrition for women, improving their quality of life and a higher rate of breastfeeding (20–23). Accordingly, social support is a key and essential for the physical and mental-emotional health of women, their infants and family and subsequently promotes society and social norms (19,24,25). Therefore, there is an urgent need to evaluate the routine and family social support (FSS)for women in the postpartum period to promote their mental health and familiarize health workers with this concept. Others empower women to mobilize social support from others, especially their families (26–29).

In general, shortcomings in current knowledge and practice in women's health care, the need for research on the QOL and its determinants in the postpartum period, especially the amount and dimensions of FSS, and providing evidence for change in implies health care approaches. In addition, the QOL in this period has not been studied much exclusively and the studies of postpartum FSS associated with QOL concurrently are low. Therefore, the present study has been designed to assess the status of postpartum FSS and QOL and the relationship between them.

The present study was conducted with an analytical cross-sectional design. In this research, sampling is done in a convenient and Continuous method. Sampling was done from 16 October to 9 February 2021 in 3 urban health centers of Shiraz. To determine the required sample size at a confidence interval of 99% ( = 2.58) with an acceptable error (\(d\)) of 1.45 (2.5% Mean: 58.11) and a standard deviation (\(\sigma )\) of 7.90 for postpartum quality of life in Iran (30), 198 people were estimated by quantifying in the following formula (31). The researchers included 240 women in the study because of the sample size was suitable for performing structural equation modeling (SEM) (32).

Women are selected who; 1) no mental retardation, 2) no physical disability, 3) literacy for reading and writing, 4) had a live birth at least 1 month and up to 18 months ago. After stating the objectives of the study for women, obtaining a written informed consent form from women, and explaining how to complete the questionnaires, asked them to complete the questionnaires within 30 minutes.

Data collection tools included two questionnaires: The Persian version of the postpartum quality of life questionnaire (PQOL) (30), and the family social support questionnaire (FSSQ) (33). The Persian version of PQOL has validity of 0.88 through Cronbach's alpha calculation and validity of 0.77 through KMO and Bartlett's test at the level of p < 0.001(30). This questionnaire has 4 dimensions and 40 questions, the dimensions of which are: 1- Child care dimension with 8 questions, 2- Physical function dimension with 12 questions, 3- Psychological function dimension has 8 questions, 4- Social support dimension has 12 questions. The answering to the questions of the questionnaire was on the 5-point Likert scale in the form of intensity ([1] not at all, [2] slightly, [3] moderately, [4] very, [5] extremely); frequency ([1] never, [2] rarely, [3] sometimes, [4] often, [5] always); and evaluation ([1] very dissatisfied, [2] dissatisfied, [3] neither satisfied nor dissatisfied, [4] satisfied, [5] very satisfied) which were scored by the method of the original version between 0-100 that lowest score indicates the unfavorable situation and the highest score indicates the favorable situation. First, the score of each item was transformed from 0 to 100 (0–100 scale) by using the formula of transformed scale = \(\frac{\text{a}\text{c}\text{t}\text{u}\text{a}\text{l} \text{r}\text{a}\text{w} \text{s}\text{c}\text{o}\text{r}\text{e}-\text{l}\text{o}\text{w}\text{e}\text{r} \text{p}\text{o}\text{s}\text{s}\text{i}\text{b}\text{l}\text{e} \text{s}\text{c}\text{o}\text{r}\text{e}}{\text{p}\text{o}\text{s}\text{s}\text{i}\text{b}\text{l}\text{e} \text{r}\text{a}\text{w} \text{s}\text{c}\text{o}\text{r}\text{e} \text{r}\text{a}\text{n}\text{g}\text{e}} \times\)100, then the score of each domain and the total score of the questionnaire was obtained from the mean scores of the items and domains respectively (15).

The social support questionnaire with a validity of 97. 0 through Cronbach's alpha calculation and validity of 0.921 through KMO and Bartlett's test at the level of p < 0.0001 (33). This is a researcher-made questionnaire retrieved from SSQ, BSSS, and PFUK questionnaire called "Family Social Support Questionnaire" (FSSQ) with 79 questions in 4 dimensions, which are: 1- Emotional support, including 25 questions about perceived, received and needed support, 2- Instrumental support, including 9 questions about including needed support, 3- Informational support, including 16 questions about perceived and received support. 4- Family support seeking including 29 questions about emotional, instrumental and informational support. The questions are answered in the form of Likert scores and four grades. The four degrees of the "strongly disagree" [1], "disagree" [2], "agree" [3], "strongly agree" [4] were included, which in the present study for better analysis and understanding transformed to the score of 0 to 100 (15).

Answering all the questions of the questionnaires is self-reporting. After extracting the data, descriptive statistics such as frequency, mean, median, and standard deviation were used for demographic data. Analytical statistical tests including the Pearson correlation and multivariate regression were used to determine the relationship between variables. The SEM was used to path mapping and measurement accuracy of impact of FSS on PQOL as latent variables. All calculations were performed with SPSS software version 25 and Amos software version 24 (34,35).

The mean ages of the participant were 31.34 ± 5.52 years (range: 16–47 years). The mean score of PQOL was 61.63 ± 9.59 (range: 40.00- 87.5). The mean and range scores of child care, physical function, psychological function, and social support dimensions showed in Table 1. The mean score of women's FSS was 69.80 ± 11.19 (range: 39.24–100). The mean and range scores of emotional, instrumental, informational and seeking support dimensions and sub-dimensions showed in Table 1. Result of Pearson’s correlation test showed in Table 2. According to the results of multivariate regression; perceived emotional support (p = 0.01), received emotional support (p = 0.03), emotional support seeking (p = 0.00) and informational support seeking (p = 0.00) and family support seeking (p = 0.00) affects the PQOL (see Table 3). In addition, by using SEM, the impact of variables on each other was evaluated and Fit indices of the model were Goodness of fit index (GFI): 1.00 and Normed fit index (NFI): 1.00 that demonstrated, fit of the SEM can be acceptable. The factor load between PQOL and family support seeking and emotional support seeking were 0.16 and − 0.13 respectively, which were higher than the load between FSS (0.12) and PQOL. The relationships between FSS and PQOL are depicted in Fig. 1.

Table 1

Dimensions of family social support and postpartum quality of life (N = 240)
Variables	Mean ± Std.Deviation	Minimum-Maximum
Postpartum quality of life (PQOL)	61.63 ± 9.59	40.00- 87.5
Child care	56.54 ± 15.08	15.63–96.88
Physical function	55.83 ± 12.84	20.83–87.50
Psychological function	83.34 ± 11.76	37.50–100
Social support	56.36 ± 13.20	16.67–87.50
Family social support (FSS)	69.80 ± 11.19	40.00- 100
Family emotional support	70.21 ± 11.32	40.00- 100
Perceived emotional support	69.75 ± 12.50	29.17–100
Received emotional support	70.55 ± 12.81	33.33–100
Needed emotional support	70.11 ± 11.53	33.33–100
Family instrumental support [Needed instrumental support]	70.38 ± 10.51	37.04–100
Family informational support	69.53 ± 12.85	33.33–100
Perceived informational support	69.63 ± 12.81	33.33–100
Received informational support	69.44 ± 13.24	33.33–100
Family support seeking	69.03 ± 11.80	20.37–100
Emotional support seeking	67.87 ± 12.67	22.22–100
Instrumental support seeking	69.50 ± 13.78	16.67–100
Informational support seeking	69.73 ± 13.31	22.22–100

Table 2

Results of the Pearson correlation between variables
Variables	PQOL	CC	PhyF	PsyF	SS	FSS	FES	PES	RES	NES	NInsS	FInfS	PInfS	RInfS	FSSe	ESSe	InsSSe	InfSSe
PQOL	1	.64^**	.82^**	.61^**	.76^**	.15^*	. 12	.17^**	.15^*	.09-	− .02	.16^*	17^**.	15^*.	.21^**	.21^**	.21^**	.14^*
CC		1	.39^**	.27^**	.24^**	.03	.00	.04	.05	− .19^**	-08	.04	.04	.03	.05	.02	.08	.03
PhyF			1	.39^**	.49^**	.09	.08	.13^*	.10	− .08	− .04	.10	.11	.09	.14^*	.17^**	.12^*	.07
PsyF				1	30^**	.07	.05	.06	.08	− .05	− .00	.07	.06	.07	.13^*	.20^**	.07	.07
SS					1	.21^**	.17^**	.21^**	.17^**	.02	.05	.22^**	.23^**	.20^**	.26^**	.22^**	.27^**	.19^**
FSS						1	.95^**	.91^**	.93^**	.60^**	.64^**	.96^**	.94^**	.94^**	.96^**	.70^**	.91^**	.95^**
FES							1	.95^**	.97^**	.65^**	.66^**	.87^**	.85^**	.86^**	.88^**	.68^**	.80^**	.86^**
PES								1	.92^**	.48^**	.49^**	.85^**	.85^**	.84^**	.85^**	.62^**	.80^**	.84^**
RES									1	.52^**	.57^**	.87^**	.84^**	.87^**	.87^**	.64^**	.80^**	.86^**
NES										1	.88^**	.45^**	.44^**	.45^**	.53^**	.57^**	.41^**	.44^**
NInsS											1	.50^**	.49^**	.49^**	.58^**	.62^**	.43^**	.50^**
FInfS												1	.98^**	.98^**	.93^**	.61^**	.89^**	.96^**
PInfS													1	.94^**	.92^**	.60^**	.89^**	.94^**
RInfS														1	.91^**	.60^**	.87^**	.96^**
FSSe															1	.81^**	.91^**	.94^**
ESSe																1	.55^**	.63^**
InsSSe																	1	.86^**
InfSSe																		1

^**. Correlation is significant at the 0.01 level (2-tailed).

*. Correlation is significant at the 0.05 level (2-tailed).

PQOL: Postpartum quality of life, CC: Child care, PhyF: Physical function, PsyF: Psychological function, SS: Social support, FSS: Family social support, FES: Family emotional support, PES: Perceived emotional support, RES: Received emotional support, NES: Needed emotional support, NInsS: Needed instrumental support, FInfS: Family informational support, PInfS: Perceived informational support, RInfS: Received informational support, FSSe: Family support seeking, ESSe: Emotional support seeking, InsSSe: Instrumental support seeking, InfSSe: Informational support seeking.

Table 3

Results of the multivariate regression for postpartum quality of life
Model	B	Std.Error	Beta	t	Sig.	95.0%Confidence Interval for B
Constant	57.18	4.02		14.19	.00	49.25–65.12
Perceived emotional support	.34	.14	.45	2.44	.01	.06- .62
Received emotional support	.35	.16	.47	2.18	.03	.03- .67
Perceived informational support	.10	.17	.14	.61	.54	− .23- .45
Received informational support	.03	.18	.05	.20	.83	− .31-.39
Family support seeking	− .92	.19	1.03	4.27	.00	.45- 1.22
Emotional support seeking	− .06	.19	-1.03	-4.86	.00	-1.29- .-.55
Instrumental support seeking	− .62	.11	− .09	− .54	.58	− .29- .16
Informational support seeking	− .26	.19	− .86	-3.21	.00	-1.00- − .24

The reference article to determine the sample size and express the validity and reliability of the PQOL questionnaire was the only study found by us that used this questionnaire in Iran. Similar to that study (PQOL = 58.11 ± 7.90), our results showed a moderate PQOL in Iranian women and the mean score of PQOL was 61.63 ± 9.59. Also, the results of the dimensions of Child care 53.83 ± 16.28, Physical function 52.16 ± 14.13, Psychological function 71.65 ± 9.26, and Social Support 57.90 ± 6.70 were similar to the results of this study (56.54 ± 15.08, 55.83 ± 12.84, 83.34 ± 11.76 and 56.36 ± 13.20, respectively) (30). It should be noted that in our study, the scores of all dimensions except social support were higher than the scores of that study, which could be the reason for the inclusion criteria. In our study, women with a history of childbirth were 1 to 18 months, while in their study, the history of childbirth was 60 to 67 days, which was the time of most attention to the mother and the least adaptation of the mother to new conditions. In another recent study in Iran, the mean postpartum quality of life of women by using the Short-Form Health Survey (SF-12) questionnaire was 74.18 ± 12.65 (36). The reason for the difference in the quality of life between their study and ours could be the use of a different and general questionnaire with a different number of questions in the extent of dimensions on the relevant topic. In other countries, the mean score of PQOL has been reported 45.15 ± 10.50 to 83.00 ± 8.13 (15,37,38). The reason for this range of differences can be due to the use of different questionnaires which has general questions or differences in the cultural, social, and economic context of the people of those countries which affect the quality of life.

In this study, the level of FSS for postpartum Iranian women was moderate and the mean score of women's FSSQ was 69.80 ± 11.19 (range: 39.24–100). We did not find a study in Iran that merely assessed FSS in the postpartum period, and most studies focused on this important issue as social support from family, friends, and significant others (39–42). It should be noted that the mean scores of the Family Support subscale in these studies were 21.52 and 22.39 from the range of 4–28 (39,42). The results show that family support is good, which is different from the result of our study due to the large differences in the number of questions that affect the extent to which different aspects of the issue and the transparency and accuracy of the results. In other countries, the family support subscale was good (43–45). What can be said about the reason for this discrepancy between these results and our study is the lack of questions and not seeing the various aspects of the issue, and as a result, the results are incorrect and unclear.

Our study showed the family support seeking (0.16), emotional support seeking (-0.13) and FSS (0.12) were three factor that influenced PQOL. Unfortunately, we did not find a study that exclusively examines the effects of FSS on PQOL. So, further studies are needed to discuss these results.

Limitations of this study include the data collection method, which was through self-reporting, which can be verified with further studies. In addition, the number of articles with our method was so limited that it is suggested to do a similar study to compare the results to achieve effective actions. Also, due to the study during the Covid-19 epidemic, women were not eager to participate in the study, which took a long time to attract their participation.

As you have seen, there are very few studies on the relationship between FSS and the QOL of women after childbirth, which requires the evaluation of this issue through further studies in Iran and around the world. However, our findings showed that PQOL was affected by three factors of family support seeking, emotional support seeking and FSS. This kind of comprehensive support from the family as the first people around the women who gave birth can improve their quality of life by improving their physical, mental, and childcare performance and can be very effective in overcoming this challenging situation.

Ethics approval and consent to participate:

Permission was obtained from the Research Ethics Committee (REC) of Shiraz University of Medical Sciences (SUMS) under approval ID: IR.SUMS.REC.1400.223, in 2021. all methods were performed in accordance with the relevant guidelines and regulations.

written Informed consent obtained from all the participants and participants of age 16 from their parents for completing questionnaires of study.

Consent for publication:

Not Applicable.

Availability of data and materials:

Availability of data and materials available on reasonable request to corresponding author ([email protected]).

Competing interests:

There was no competing interest for any of the authors.

Funding:

There was no funding for this study.

Authors' contributions:

MH. K as a supervisor, he supervised all the processes from the registration of the project proposal to the end of the final editing of the article.

KH. KH collected and analyzed the data and wrote the article.

L. GH participated in writing the proposal and expressing how to write the article.

M. K advised statistical analysis and how to report it.

M. N as an advisor, she participated in correcting the title of the project, choosing the instrument and how to conduct the study.

All authors read and approved the final manuscript.

Acknowledgments:

This study was supported by Shiraz University of Medical Sciences (SUMS) and we are grateful for this support. We would like to thank all the women who participated in this study and the staff of Mohsen Eftekhar, Haj Jafar Dalaki (Taleghani), and Imam Mehdi Health Centers, especially the person in charge of vaccination at Taleghani Center, for their cooperation with us.

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The impact of family social support on postpartum quality of life: the structural equation modeling

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