Participant Characteristics
Participants ranged in age from 20–31 years (Table 1). Most (n = 16) had completed higher secondary school or above. Three had pursued diplomas and one participant was illiterate. All participants except one lived in multigenerational households including in-laws, brothers and sisters-in-law, and their children. All participants were married, except for one who was recently widowed. No participant lived in the same village as their parents. Husbands’ occupation varied (e.g., government job, car driver, plumber, auto driver, mechanic, farmer, etc.) Two women worked (lab technician, boutique owner); all others were homemakers.
Table 1
Sociodemographic characteristics of study participants (n = 20)
| Characteristic | N (%) |
| Agea | 25.5 (22.5–28) |
| Education | |
| None | 1(5%) |
| Primary School | 3 (15%) |
| Secondary School | 11 (55%) |
| Some Secondary School | 2 (10%) |
| Other | 3 (15%) |
| Able to read | |
| Cannot read | 1 (5%) |
| Can partially read | 3 (15%) |
| Able to read | 16 (80%) |
| Able to write | |
| Cannot write | 0 (0%) |
| Can partially write | 3 (15%) |
| Able to write | 17 (85%) |
| Relationship status | |
| Married | 20 (100%) |
| No. of childrena | 1 (1–1) |
| No. of children in the householda | 2 (1–3) |
| No. of adults in the householda | 6 (4.75-7) |
| Do the parents live in the same village? | |
| No | 20 (100%) |
| Monthly income husband,a Indian Rupees | 9,000 (0–16,000) |
| Monthly income woman,a Indian Rupees | 0 (0–0) |
| Not working | 19 (95%) |
| Ration Card category | |
| Orange (Below the poverty line) | 1 (5%) |
| Yellow (Above poverty line) | 2 (10%) |
| Do not know | 17 (85%) |
| Household phone ownership | |
| Yes – smart phone | 20 (100%) |
| Personal phone ownership | |
| Yes – smart phone | 11 (65%) |
| Yes – feature phone | 8 (40%) |
| No | 7 (35%) |
| Access to household phone | |
| Daily | 12 (60%) |
| Weekly | 0 (0%) |
| Less than weekly | 8 (40%) |
| aMedian (IQR). |
Social support resources and needs by perinatal phase
Participant narratives were analyzed for social support resources and needs during each phase of the perinatal period and themes were further organized by major social support domains; emotional, tangible, and informational.31 Fig. 1 presents the theme summary by social support domain and perinatal continuum of care stage.
Antenatal
Emotional Support
Women received emotional support from their neighbors, aunts, relatives, sisters-in-laws, friends, and especially from older women who already had a baby, largely focused on stress relief.
“All [family members] used to say don’t take tension (be afraid). In the first pregnancy, women get scared at the time of delivery, so they told me not to take tension, keep calm. Otherwise, there will be a problem with normal delivery.”- 25 years old, ‘other’ educational attainment, 1 child, C-Section
Tangible Support
Study participants described various tangible support received antenatally, including help with household chores, and medical and personal care facilitation. In most multigenerational Indian households, gender roles are starkly divided and the daughter-in-law bears a heavy housework burden. Most participants were responsible for most household work, e.g., washing clothes, cleaning, and cooking. During pregnancy, they were given some respite. Mothers-in-laws, and sometimes husbands, took over harder household chores given the perceived risk for pregnancy loss during the first trimester and women did light work (e.g., folding clothes, cutting vegetables, dusting) during this time. In the second trimester, women took on additional limited chores. In the third trimester, work such as mopping the floor was considered beneficial due to traditional beliefs that this activity widened the pelvis, increasing the likelihood of successful vaginal delivery.
“My husband was a big support [throughout my pregnancy], he did all household chores like washing clothes, brooming and I used to cook only.” – 24 years old, secondary school or higher, 1 child, living with husband and father-in-law, Vaginal delivery
Medical care, diet, and rest were facilitated by family members including husbands, mothers, and mothers-in-laws. Women expressed a paramount importance of family members in facilitating their access to the medical care needed for a healthy pregnancy. All participants were from rural India, where transportation was limited. Social restrictions on women traveling to the hospital alone made transportation difficult thus most husbands drove women to their antenatal visits. Women also described how their husbands focused on their diet during pregnancy. Their husbands regularly brought fruits and ensured they ate frequently. One woman mentioned her husband’ guidance to avoid fried food. Another described her husband’s attention to her physical health throughout pregnancy, for example, giving her massages to alleviate pain. Mother-in-laws also provided home treatments for pregnancy-related discomforts, such as stomach aches, bodily pains, and morning sickness.
“Whenever the doctor would call us, we would go; whatever check-up they prescribed we did the same way. [My husband] supported me a lot [despite being a truck driver frequently away from home]. When I told him that this day is my test, he would rush back immediately. Because we don’t have any [personal] conveyance to go and in pregnancy a person can’t go alone." – 28 years old, secondary school or higher education, 1 child, Vaginal Delivery
“I don’t pay much heed about eating so [my husband] usually fed me. Sometimes he bought apple and sometimes other fruits. He used to cut and fed them to me. I wasn’t well at that time, I would keep lying on bed. He would wake me and feed me. I didn’t take as much care of myself as he took.” – 22 years old, secondary school of higher, 1 child, Vaginal delivery
Participants described highly supportive and readily accessible primary medical care in their villages including ASHAs, Auxiliary Nursing Midwives (ANM), Community Health Officers (CHOs), and physicians at a dispensary or private clinic. Most women had registered at the nearest public health facility during the first trimester. They were given a mother and child protection card to track pregnancy details. The card explains the required antenatal checkups, biomarkers to be monitored, pregnancy danger signs, etc. Throughout pregnancy, the women regularly accessed antenatal care. Medical professionals were considered approachable, and some women received their phone numbers to contact in case of an emergency. The widowed participant emphasized the importance of mobile phones for facilitating home-based pregnancy care due to the reduced support she had for physically accessing medical care as a widow. However, women without telephone accessibility to a medical professional had not perceived this to be a need; they had the support they needed for a healthy pregnancy regardless. Overall, participants were satisfied with the medical support provided by the sub-centers, private professionals, and tertiary health care system.
“Yes, I had bleeding in the 5th month, it wasn’t much, but I had bleeding. I was at my parental home, then I consulted doctor on the phone, and they gave me medicine for 5 days. They said it is normal, it happens, and there is nothing to fear. Whenever it happens, advise should be taken [from a doctor].” − 28, tenth standard, lives in a joint family
“I think it is essential to have a doctor’s contact number [during pregnancy]. Especially when your husband is no more because with a spouse it is much easier for a woman to manage during pregnancy. And one thinks that if we have phone in our life then we should make some use of it. We have to use our mind and have to depend on ourselves. When God makes you go through such situations in life then you have to do and learn many things. Life teaches you everything.” – 30 years, some secondary school education, 1 child, C-section
Informational Support
Advice seeking from family and others was prominent during respondents’ pregnancies. Participants sought day-to-day advice from mothers-in-law, sisters with children, and other elders. They regularly communicated with community health workers and providers for medical queries, and regularly used the internet and YouTube videos for information.
Informational needs voiced included how to have a healthy pregnancy, an appropriate diet, and how to solve problems. Mothers and mothers-in-law heavily influenced the food that women ate and avoided during pregnancy.
"Mostly, I would ask my sister and sisters-in-law. Since my husband has two elder sisters, I would ring them up and ask about my problems. Slowly-slowly I would collect all the information from everywhere and got to know what is right and what is wrong then I would apply accordingly. For example, if the thing matched between three people, I would do that." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal delivery
“I have a sister who has two kids. So, I used to ask her whenever I had any problem. She used to share everything that she went through in her pregnancies. We had many similarities. We used to discuss those. Her son is now three years old and her daughter is eight. The kids are big.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery
“During pregnancy my mother had told me not to eat anything that is hot in nature, especially in the beginning. In the initial months she used to give me healthy things like milk and curd, fruits like pomegranate, apples, etc. My mother used to ask me to eat these things more.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery
Two major areas of information sharing were managing pain, and concerns about delivery. Women’s relationships supported and empowered them during their pregnancy.
“Yes, my mother-in-law, sister-in-law, and other relatives used to guide me. Do like this, eat what you crave. If I had any problem, they told me to tell them, not hesitate.” – 22 years old, secondary school or higher education, 1 child, vaginal delivery
Elders provided considerable informational support to women living in multi-generational households. Women took this advice very seriously. The advice included conventional practices, e.g., ways to channel positive energy, specific foods for a healthy pregnancy, postures, and activities to increase the likelihood of a normal delivery. As previously described, one recommendation was to mop the floor to facilitate vaginal delivery. Foods were customarily categorically divided into ‘hot’ and ‘cold’ by the elders. Women were guided not to eat papaya, pineapple, eggplant, dry fruits, and other ‘hot’ foods in the first three months of pregnancy due to miscarriage fears.
"Typically, I would listen to religious hymns only and would listen to Bhajans (religious songs). Also, the elders would say the more you listen to religious things, the more it will give positive effects on the baby."- 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery
“[My mother-in-law] just told me not to sit too much as the baby’s head will grow big due to sitting. She didn’t allow me to work and asked me to rest only. The doctor also told me the same. I would do a little bit of work while standing, like making food.“ − 27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery
Community-based ASHA workers were the first point of contact for pregnant women in case of any health emergencies, or if they needed any health advice. ASHA workers informed women about available medical care, provided pregnancy-related information including on immunization, healthy diet, and supplements. Women mentioned calling their ASHA workers with questions, and particularly appreciated them during the COVID-19 lockdown because clinics were closed and doctors were not available.
“[I was in touch with my] ASHA worker only because due to COVID, clinics were not open. Some tests were done and some were not able to be done. This happened all the time due to COVID. And sometimes I visited Mohali Hospital. All my tests were done there…. [My ASHA] explained very nicely and told me to contact her in case of any problem. She lives nearby [my house], and is very supportive. She explained medicines to me…. I used to get sick at that time. She would counsel on eating healthy, and staying fit.” – 22 years old, secondary school or higher education, 1 child, Vaginal Delivery
“Yes, whenever I had a problem, I asked. Like in the 3rd month, I had bleeding. The ASHA suggested that I visit PGI (local referral hospital). I went to PGI, and the doctor gave me an injection. Afterwards, my bleeding stopped.” – 24 years old, secondary school or higher education, 1 child, C-Section
Some women contacted doctors over the phone. Women who had registered in private clinics would receive reminder calls from the doctors for check-ups. Women also visited doctors for medical care including routine checkups, scans, and to discuss other health issues.
“I used to phone call my brother, and he used to ask the doctor about the problems I had. Sometimes I had pain in the lower abdomen; they suggested avoiding lifting weight.”- 28, tenth standard, lives in a joint family, C-section
“[During the third trimester], Doctors used to call and we used to go every week. The baby keeps moving and we get to know that the baby is fine. They also used to come to check the heartbeat to see if it is fine or not.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery
Women mentioned different maternal and fetal health queries for which they sought advice from doctors, ASHAs, and other medical professionals. ASHA workers educated women on healthy everyday practices, such as diet. Doctors were a constant support in case of complicated pregnancies, for example, a twin pregnancy. Other queries focused on medication to be taken during pregnancy.
“The doctor in 6 phase (hospital) was very nice. She used to talk to me very politely. Whatever she used to ask, I used to tell her. Like I used to feel pain in the lower region, I used to tell her. She used to say this much will happen. It should not be much, but little bit will happen. Just that. Overall, doctors were good there.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery
“I used to take calcium and iron supplements daily. And doctors told me not to take any other medicines. If I have pain, then just have paracetamol. So, I just used to have that if I felt pain. Like when I used to feel fever or tiredness, then I used to have that. But I didn’t take much medicines otherwise. As it is not good to take many medicines.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery
Most participants owned smartphones, and commonly used the internet for pregnancy-related queries, usually via YouTube videos. The most common searches focused on nutrition, sleeping postures, and baby’s sex. The educational videos were the only educational content mentioned. Women’s narratives demonstrated how crucial the internet was in supporting them antenatally, and it was used independent of professional guidance.
“I used to find out if its a girl or boy by watching the scans…(laughs). They used to show signs in the videos, if this sign, it is girl. That sign, it is boy…..(laughs)” – 31 years old, secondary school or higher, 2 children, Vaginal Delivery
“About the eating stuff. Like papaya is not good for the initial days of pregnancy, it is hot in nature. There is fear of miscarriage. One should have dry fruits, juice, and milk. We used to watch all this. We used to get to know what not to eat. Like in the initial days, not to eat warm things because there is fear of miscarriage if we eat it.” – 25 years old, ‘other’ educational attainment, 1 child, c-section
“Yes, I have used the phone to see how to sleep while pregnant… like when I will sleep, there should not be any problem to the baby. In fact, I have seen how to tell whether there is any problem or not on YouTube. I have seen how to sleep, how to sit, how to eat, and what to eat. Eat vegetables and fruits, and drink juice.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery
Childbirth
Emotional and Tangible Support
Participant narratives intertwined emotional and tangible support around childbirth. They discussed the main individuals providing both emotional and tangible support, and the tangible support provided to assist women’s birthing experiences.
When asked about their birthing experiences, most participants mentioned the people supporting them including husbands, brothers, mothers, and mothers-in-laws. These individuals provided emotional support and coordinated with hospital staff for prescribed essentials and medications. For the most part, family members kept the women calm as they endured labor. Mothers comforted the women, while male family members (not allowed in labor rooms) purchased medicines requested by the doctor and ran errands. All participants expressed relief with this support during their birth. One woman expressed how her husband’s communication with the nurse comforted her:
"Yes, [my husband] said nothing will happen. He kept on talking to the nurse that nothing should happen to both of us (baby and the participant). Both should be fine."- 22, 9th standard, lives in a joint family, child 1, C-Section
“[Family support during delivery] is very important. People get emotional at that time, so the family should be nearby for emotional support.” – 25 years old, ‘other’ educational attainment,1 child, C-Section
Women reported feeling comforted through medical staff support during childbirth. One woman shared her confidence in the staff: “If anything happens, then the nurse is there to look after you at the hospital, but at home there is no one to look after you.”-18, Primary School, lives with husband, child 1, vaginal delivery
Narratives revealed the key importance of tangible social support during labor and birth, particularly where participants’ lack of knowledge around emergency medical procedures challenged informed consent. For example, two participants were uncomfortable having to rapidly decide about cesarean surgery with no knowledge.
Sometimes, family members were not allowed with the women during birth and women reported feeling emotionally supported by nurses when making hard decisions. One participant undergoing cesarean surgery appreciated the comfort provided by supportive medical staff during the otherwise stressful situation. In one case, a nurse tried to calm the woman by cracking a joke.
“The doctors and nurses were nice. The doctor who operated was nice. They all talked with me during the operation, kept me calm all the time.” − 25 years old, ‘other’ educational attainment, 1 child, cesarean delivery
However, not all women had supportive experiences with hospital staff. One shared that they scolded her for not following instructions: “They were telling me to lay down so that I can get contractions, but I was restless. They kept scolding me because I wasn’t sitting. Then after some time, I delivered. It was very difficult. They kept pushing the baby. After delivery they gave me stitches.”-10
Informational Support
Most participants were pregnant for the first time and were anxious about giving birth so they looked for information to help them prepare. They were mostly unaware of what giving birth would be like yet were generally told by their mothers that they would be fine, without sharing critical details, to avoid scaring them. Women also sought knowledge from their mothers, friends, and sisters on practices to ease childbirth, such as eating certain foods or doing certain activities. Mothers informed them of ways to push during labor, and what foods would help in easing delivery pain. This support helped reduce women’s anxiety around labor and birth, although they were not evidence-based.
“Everybody used to tell me to eat well, and also to keep working so that I have a normal delivery. Sometimes the private doctors suggest bed rest, as they suggested to me when I had pain. So, I used to rest. But everyone used to suggest working to have a normal delivery. I used to go for a walk in the evenings as much as possible, because this will help in normal delivery.”- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery
“I used to take a lot of care so that the health of the baby is good, especially regarding eating. By the end, my mother used to ask me to eat foods that are hot in nature. Like almonds, she used to put almonds in milk for me. Also, they used to tell me to eat ghee in milk because it helps with normal delivery.“ − 26 years old, primary school, 1 child, living in a joint family, vaginal delivery My mother-in-law would tell me that at the time of delivery, I should push with all the force, and not take too many deep breaths… like this [enacts the action] … this can move the baby backwards.”-41, vaginal delivery
In the study sample, six women had c-sections, and 12 had vaginal deliveries. Women’s narratives evidenced a lack of education on cesarean section. In many cases, women only learned of the possibility of a cesarean section on the day they were admitted to the hospital which made emergency decision-making difficult.
“When I was in the 9th month, I was scared about what will happen. They would tell me that in normal delivery, there is a lot of pain and the person can’t handle it. That there is a lot of difficulty during that time. In the last part, I had difficulties… that’s it.” – 31 years old, secondary school education, 1 child, C-Section
Postpartum
Emotional Support
Narratives around postpartum emotional support centered largely around recovering from childbirth. Some participants reported moving to their natal homes during the third trimester of pregnancy, whereas others did so after giving birth. In their natal homes, women had added support from their parents, and comfort from familiarity with their surroundings. They explained that they were relieved of all household responsibilities and could physically rest as desired while their mothers cared for their babies.
“At my mother’s place, there was no such work to do. Your mother does the work, and so does your sister-in-law. For one month, one aunt came to bathe the baby… we had hired her. After that I started doing it myself... for the baby and for myself too. Clothes and all, mother used to wash.” – 30 years old, some secondary education, 1 child, Vaginal Delivery
Tangible Support
During the postpartum period, mothers dealt with their own bodily changes in addition to new responsibility caring for a child. Families provided assistance in caring for both women and their babies. Women mentioned movement restrictions for the initial few weeks due to stitches; nearly all participants had some intervention (six underwent cesarean section and 12 underwent episiotomy). Most women were first time mothers, and therefore were nervous with baby care. In most cases, responsibility for the child was taken by their mother-in-law or mother. This included bathing, cutting nails, giving massages, etc. Watching their mothers or mothers-in-law care for the baby helped them learn infant care and gain confidence. Women staying at their natal home appreciated this caring environment. Respondents appreciated having husbands and other family members care for their child from time to time.
“This is my first child, so I don’t know much about caring. My mother-in-law does everything. I usually do what she suggests. I keep asking her. She would make me sit and teach me how to give a massage to baby.” – 22 years old, secondary school or higher education, 1 child, Vaginal Delivery
"During the night [my husband] keeps the baby with him when I get tired. In the evening, he also keeps holding her, and goes around the house with her. He also plays with her during the night when I get tired. I cannot sit for a long time."- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery
Culturally, women are prescribed substantial rest and nutritious diet to support postpartum recovery. Women who gave birth vaginally were asked to eat panjiri, a high-calorie snack made of ghee, nuts, dried fruits, sugar, and herbal gums, to improve lactation and warm the body. Both mothers-in-law and mothers prepared panjiri for respondents. Doctors asked women who had cesarean section to avoid panjiri, as consumption of high calorie foods is believed to reduce wound healing.
“My mother had made panjiri (high fat snack) and she used to give me milk. She used to ask me to eat warm foods more like panjiri, dal, chapatti, and porridge.“- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery
“My mother gave me panjiri, which is rich in desi ghee and dry fruits. This is so that the baby’s health improves. It will benefit the baby.” – 24 years old, secondary school or higher education, 1 child, vaginal delivery
Women mentioned physical discomforts which included pain with stitches, weakness, and leg pain. Mothers and mothers-in-law helped the women sit, assisted with breastfeeding, washing, massages, and other needs to increase comfort. Participants felt this support helped them recover more quickly. One woman who lived alone with her husband had a sister stay with her to care for her post-delivery.
“I was good, my mother would help me in sitting and standing. My younger brother helped my mother in taking care of me.”- 28, tenth standard, lives in a joint family, C-Section
“I take rest, or [my sister-in-law] massages my legs and arm, as massage cannot be done on abdomen because of stiches.” – 25 years old, ‘other’ educational attainment, 1 child, C-Section
Informational Support
Informational support needs paralleled the infant and self-care described within emotional support. In addition, as the women recovered and resumed sexual intercourse, they considered contraceptives.
Women sought advice from their mothers, sisters, neighbors, ASHA workers, and other family members regarding childcare. Main questions involved baby massage, foods to eat to promote baby health, and superstitious practices to ward off evil. Some mothers firmly believed the information shared with them, and religiously followed the advice. They were certain that those who had handled children before would provide helpful information to take care of their child. Additionally, the women sought informational support from ASHA workers about child vaccination.
"I felt satisfied from my sisters’ advice because they themselves have 2 children each. That’s why I seek consultation from them, as they know how to handle kids who are 1–2 years old now." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery
"Actually, I feel happy if somebody guides me, tells me what is right and wrong, and advises me as I am new to this. I feel happy if somebody informs and I don’t feel that somebody is interrupting me. I feel happy that before a mishappening, I have caught the problem and have taken preventive measures. Like somebody told me if I ate too hot food, it would affect the health of the baby; likewise, if I ate sweet food then the baby will have saliva leaking, and if I consumed spicy food then the baby might suffer from stomach pain. I want somebody to tell me what is good or bad for my baby and me." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery
Women needed informational support around self-care for which other mothers were of most help to them. For example, one mother was finding it hard to breastfeed, and a new mother in the hospital advised her when to formula feed. Similarly, women with perineal and abdominal stitch discomfort or other body pain sought advice from doctors and other mothers to find a cure.
“There was another [mother] who had delivered her baby there. She was also having pain in the breast, and she told me that she also feed the baby with that powder...she said that she bought it from here. Then we fed it one day only, then never gave that again. I am giving [breastmilk] only, despite the pain.”- 27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery
Postpartum contraception
Most respondents targeted a specific gap between pregnancies. Some had consulted doctors or family members for family planning education; one woman also mentioned undergoing contraceptive counseling at the hospital regarding intrauterine devices, oral contraceptive pills, and condoms. A few women were unaware of contraceptive methods but intended to delay pregnancy. Overall, family planning is an area for which women need informational support. Husbands’ narratives were missing in the interviews, although they also play a crucial part in making these decisions.
Effects Of The Coronavirus Pandemic On Seeking Care
LImitations faced by respondents due to the coronavirus pandemic impacted their perinatal experiences. Women were unable to visit their maternal homes due to movement restrictions, potentially influencing their mental health. Women were also unable to access other small things due to lack of mobility and transportation. Participants also mentioned missing some check-ups due to closures in response to the pandemic.
“I went every month for check-up…. I was scared because it was corona time and nothing should go here and there. After that, I would go for regular check-ups, like blood tests and BP check-ups.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery
“Yes. It happened only once, and then it didn’t happen because of corona. Everything was closed because of that. Check-ups were not done.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery