In total 28 primiparous mothers who were aged between 24 to 40 years (30.08 ) completed the study. Seventeen mothers had a bachelor’s degree or higher education level. The average age of the babies was approximately five months (5.56 ). Further characteristics of the participants are presented in Table 2. The duration of the interviews ranged from 20 to 86 minutes (mean=32 minutes). Data analysis resulted in the identification of three themes and seven sub-themes, which are shown in Table 3.
Table 2 Characteristics of the Mothers Interviewed (n = 28)
Characteristics
|
n (%)/
|
Age
|
|
(year)
|
30.08
|
BMI
|
|
<25 kg/m2
|
23 (82.1%)
|
≥25 kg/m2
|
5 (17.9%)
|
Residence
|
|
Urban
|
24 (85.7%)
|
Rural
|
4 (14.3%)
|
Education level
|
|
High school or below
|
4 (14.3%)
|
Junior college
|
7 (25.0%)
|
Bachelor degree or above
|
17 (60.7%)
|
Employment status
|
|
Full-time job
|
14 (50.0%)
|
Unemployed
|
14 (50.0%)
|
The way of delivery
|
|
Vaginal delivery
|
12 (42.9%)
|
Cesarean delivery
|
16 (57.1%)
|
Age of baby at interview
|
|
(month)
|
5.56
|
Gender of their baby
|
|
Boy
|
15 (53.6%)
|
Girl
|
13 (46.4%)
|
Infant illness within 4 weeks after childbirth
|
|
Yes
|
2 (7.1%)
|
No
|
26 (92.9%)
|
History of depression
|
|
Yes
|
8 (28.6%)
|
No
|
20 (71.4%)
|
Family per capita income
|
|
<4000 yuan
|
12 (43.9%)
|
≥4000 yuan
|
16 (57.1%)
|
Table 3 Themes and Sub-themes Identified in the Interviews
Themes and sub-themes
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1. Dissatisfaction with current professional services for postpartum mothers
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Being disappointed with current hospital maternal and child health care services.
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Distrusting services provided by community health centres, private institutes and commercial online platforms.
|
2. Likelihood of health care professional help- seeking behaviour
|
Preferring to not seek help from health care professionals as their first choice.
|
Hesitating to express their inner discourse to health care professionals.
|
Following confinement requirement and family burden prevents mothers from seeking professional help.
|
3. Highlighting demands for new health care services
|
Experiencing urgent needs for new baby-care-related health care services.
|
Determining the importance of mothers’ needs.
|
Dissatisfaction with current professional services for postpartum mothers
The vast majority of mothers in this study indicated a low level of acceptance and satisfaction with local maternal and child health care. Their comments regarding health care institutions for maternal and child health care can be categorized into two themes: (a) being disappointed with current hospital maternal and child health care services and (b) distrusting services provided by community health centres, private institutes and commercial online platforms.
Being disappointed with current hospital maternal and child health care services
Many mothers mentioned that the services provided in hospital maternity settings during the postpartum period were quite insufficient; they also claimed that health care professionals usually only focused on their current physical health issues, such as prolonged lochia and others. Health care professionals rarely considered the mothers’ long-term psychological, emotional and informational needs after discharge. Mother 28 emphasized her dissatisfaction with the hospital services.
“The service provided in hospitals is totally insufficient. I think the postpartum period is very important … We should have received some related education about postpartum problems before we gave birth, but we didn’t … Most of the time, the provided service was just superficial; they don’t take it seriously … what they did for us is not enough.” (Participant 28)
Furthermore, participants complained that the postpartum hospitalization time was very short and that follow-up checks after discharge were either absent or very simple. Some mothers noted that even though there was a follow-up, health care professionals often made a simple phone call without a home visit. Many mothers felt neglected and uncared for by health care professionals because they felt that they did not receive enough formal support from the hospitals. Mothers 5 and 27 both stressed the importance of follow-up visits by health care professionals. As mother 27 recounted,
“I had not received any service after discharge from the hospital, but I believe that follow-up visits are very important. For example, my brother’s wife had an episiotomy. Afterwards, the stiches were not taken out completely. But who knew that? The wound was infected with pus eventually. Then, she went to see the doctor by herself. There was no one who reminded her of such things that may occur after surgery.” (Participant 27)
Several mothers mentioned that the paediatric departments in their local government tertiary hospitals were very busy, and the doctors and nurses there were time-constrained and often impatient. Some mothers indicated that the health care professionals in the government tertiary hospitals did not even fully listen to their complaints and did not want to talk to them as those health care professionals did not have enough time. The mothers felt that they did not receive adequate respect. One mother felt upset when she took her baby to go to visit the paediatrician:
“After all, there are so many patients in big hospitals. When I have a little problem about my child, I really need to consult a family doctor or GP … but there was none, so I had to wait in a long line in the big hospital for a long, long time…when I eventually saw the doctor, the length of the conversation was no more than five minutes … I wish that health care professionals could be more patient and spend more time on every baby’s examination.” (Participant 13)
Some mothers also reported that they were treated with a lack of compassion and in these large hospitals, efficiency and profit were regarded as priorities over patients’ needs.
“My daughter has a red spot on her face, I am very worried … I couldn’t figure out what happened. During her examination, my baby cried fiercely … I was very nervous, but the doctor didn’t care about our emotions at all, he gave no comfort to us, and didn’t explain my daughter’s condition in detail either.” (Participant 23)
Distrusting services provided by community health centres, private institutes and commercial online platforms.
Most of the participants indicated that they nevertheless trust the government tertiary hospitals rather than other institutions, because of the high professional skills levels and well-equipped facilities in those hospitals. Some mothers expressed their hesitation to seek help from health care professionals in community health centres because they felt that doctors and nurses in these settings had lower qualifications, professional titles and skill levels than in tertiary hospitals. Furthermore, some mothers also mentioned that the poorly equipped community health care centres could not guarantee the reliability of the examination results. Mother 2 expressed her feelings about the community health centres:
“I think the community health centres are not so good … their function is not specific enough. Only when my child needs to be vaccinated, would I go there … I am not confident in such settings because I think health workers there can’t be as professional as in the big hospitals… and the examination equipment there is less reassuring … I feel that community health centres should play a role in consulting and being the primary treatment provider. But in fact, I get little help from there.” (Participant 2)
Two mothers mentioned that private institutes did not have enough qualified health care professionals and were profit-driven. For example, some private clinics have lactation masseuses who help mother with lactation by using Chinese massage. The mothers indicated that they were sceptical about those professionals’ educational backgrounds and professional certificates. In addition, the costs of the services were often too expensive for mothers to afford. Mother 28 recalled her experience finding help for her difficulty breastfeeding:
“Low milk supply is a big problem for me; it troubled me a lot. I really needed a professional who could help me at that time. But it’s difficult to find a qualified lactation masseuse in a formal way; those in the private clinics are inexperienced and not well-trained most of time” (Participant 28)
Many participants had mentioned that online services brought a great convenience to their life and had advantages over traditional ways. However, some of the participants were doubtful of the accuracy and reliability of information provided on many profit-driven online platforms, and some mothers reported that ample educational information was tied to the sales of goods, which may confuse or mislead consumers. Furthermore, some mothers expressed their dislikes towards advertisements and promotions on such platforms. Moreover, these mothers also expressed concerns with the qualifications of the purported professionals who provided online services. Therefore, many participants expressed expectations for new non-profit online platforms which were officially operated by the government or government tertiary hospitals to which they could easily access.
“I often consulted doctors online on baby health issues. To be honest, I didn’t trust them (the doctors) so much … but I had no choice, so I often combined their advice with information from other sources.” (Participant 21)
Likelihood of health care professional help-seeking behavior
Some mothers expressed that their willingness to seek professional help is not very strong unless faced with acute or critical conditions of their own or their babies. The participants’ professional help seeking behaviour was summarized into three sub-themes: (a) preferring not to seek help from health care professionals as their first choice, (b) hesitating to express their inner discourse to health care professionals, and (c) following confinement requirement and family burden prevents mothers from seeking professional help.
Preferring not to seek help from health care professionals as their first choice
Several participants indicated that they were used to solve common problems by themselves instead of mobilizing support from health care professionals. Some mothers stressed independent values and thought that it was a sign of independence to deal with most of the problems by themselves. One mother mentioned that she felt embarrassed to discuss her private issues, especially emotional and mental issues with any other people, including health care professionals, because she neither wanted to be a burden to others and nor wanted to show any signs of vulnerability.
“I thought … It was irresponsible to expose my negative feelings to others … which may have a negative influence on their lives. It's just like throwing my own garbage to someone else … neither I nor anyone else will feel well from that.” (Participant 23)
In addition, most of the participants emphasized that their problems that occurred frequently in daily life were generally minor ones, so they usually gave priority to the most convenient and economic ways to solve such problems. Most of the participants mentioned that they had benefited from using professional online platforms, which were perceived as the most convenient way to obtain information. The standard forms of such services included apps, videos, online forums, and online counselling. Professional none-profit apps were the most appreciated form by the majority of participants, who preferred, trusted, and spoke highly of them because of their convenience, many functions, and lack of time and space constrains, which allowed mothers to access information anywhere or anytime. Most of the time, participants believed that almost all of their problems could be solved in that way.
“For our office staff, face-to-face services are out of date; the internet platform is faster… I could take advantage of the short time of a bathroom break or other break to read messages and communicate with somebody through apps.” (Participant 13)
Compared to ask for health care professional help, many mothers in this study were more likely to discuss current issues with reliable people around them, such as their own parents, significant others or peers. The mother’s parents, especially their mothers, were mentioned as a trustworthy source of emotional support; the participants noted that their mothers made great efforts for their daughters’ families and often expressed understanding and sympathy of their daughters’ suffering and distress. Some of the participants believed that sharing with peers was also effective and that peers could be trusted; sharing with peers was described as powerful and as imparting cognitive empathy for the roles of different mothers. Mother 5 showed her appreciation for support from peers:
“I benefited from peer groups a lot because everyone can obtain limited information, but by exchanging messages and sharing experiences, and I could view one issue from various perspectives … If I was lucky enough, I could find the information that just matched my requirements.” (Participant 5)
Hesitating to express their inner discourse to health care professionals
With the influence of “saving face” culture in China (saving face, refers to the social confidence in individuals’ moral character in society and that people cannot properly function in society if the integrity of this character is broken [48]), mothers stated that seeking help from mental health professionals for inconsequential matters in daily life was unnecessary. The mothers worried that if they sought professionals help for their family conflicts, the prejudices or stigma of making family life public would harm themselves and their family members. One participant even preferred discussing matters with a stranger rather than a health care professional:
“When I was upset, I hadn’t considered turning to health care professionals yet … I think it would make more sense and be safer to discuss my story with a stranger.” (Participant 23)
Family conflicts were sensitive topics for almost all the mothers in the study, and the conflicts between them and their mothers-in-law were mentioned as the main reason for their distress. However, most of the mothers believed in the old Chinese adage that domestic shame should not be made public no matter what happens, and it should be solved within the family. If others knew about the conflicts in their families, it would have made the mothers feel ashamed and would have also demonstrated their incompetence at becoming good mothers. Thus, most of the time when the mothers experienced difficulties, turning to health care professionals was not their first choice. As Mother 4 said,
“Actually, I just let bad emotions blow over, and I would feel better… after all, the fact is that we are family … and no matter how many conflicts happen, they can be settled down eventually … It is not necessary to seriously take them into consideration.” (Participant 4)
Additionally, even some mothers suffered substantially from family conflicts, they supposed that such conflicts were universal phenomena and therefore followed social norms of keeping family conflicts inside without any effort to solve it. Mother 23 related her point of view:
“There is an old saying in China, “even an upright official finds it hard to settle family quarrels”. I think that even my mother-in-law has many problems with me, but we are one family… I believe conflicts happen in every family… I think I could endure that.” (Participant 23)
Some mothers decided to hide their own feelings from others because of their previous unsuccessful experiences of help-seeking. These mothers felt disappointed because their closest family members could not fully understand them. They also felt frustrated with the ineffective communication by the people around them, including health care professionals. The participants tended to believe that without the same experience, it is impossible for others to understand their feelings, or show sympathy for them, let alone professionals who were not familiar with them at all.
“Unlike other young mothers, I was very old when I gave birth … I suffered a lot from the birth and felt very uncomfortable after that … But when I shared my feelings with peers, they just told me it was a kind of neurosis … the doctors didn’t treat my complaints seriously either and thought my body was alright … they couldn’t understand me at all. It was useless to discuss my feelings with them.” (Participant 5)
Following confinement requirement and family burden prevent mothers from seeking professional help
Because of the mothers’ weakened physical condition during the first month of confinement “yue zi” (which is a postpartum tradition among Chinese mothers in which new mothers are required to strictly comply with specific regulations for 30 or 40 days postpartum [12]), it was inconvenient for mothers to leave the house. As Mother 27 said:
“He (the baby) is too small to go to crowded places, especially hospitals, due to fears that he will get sick… It was also inconvenient for me to go outside with him. I was still in confinement at that time (in “yue zi”). I was not allowed to go outside” (Participant 27)
In addition, many mothers expressed that they often tried to mobilize support from health care professionals, but several mothers showed their hesitation towards the cost of money and time on seeking professional support. In addition, some of the mothers expressed that they had been overburdened with baby care and housework after confinement, which caused that they were too tired to go outside most of the time. These mothers also felt there was no time at all to consider their own feelings. If they experienced negative emotions, they would put them aside to do housework or to play with their babies. Mother 6 recounted,
“My life was filled with various household chores… I was too tired to think too much about my distress… I hung out with my baby in the morning, had a nap at noon, and played with my baby in the afternoon. When the day finished, I had forgotten my distress, especially when faced with my baby’s smile.” (Participant 6)
Highlighting demands for new health care services
Twenty-one mothers emphasized that professional support was urgently needed and that they had high expectations for new health care services. Their demands were classified into two aspects: (a) experiencing urgent needs for new baby-care-related health care services and (b) determining the importance of mothers’ needs.
Experiencing urgent needs for new baby-care-related health care services
Baby-care-related professionals, such as lactation masseuses, nutritionists, paediatricians, and nurses, were mentioned repeatedly by many mothers, in order to help them with breastfeeding, complementary food supplements, preliminary diagnosis of their babies’ diseases, and training of skills for baby care.
“When I added complementary food for my boy, I really didn’t know which kind of food was suitable for him and whether the nutrition was right or reasonable. I always worried, not only about if he had indigestion but also about malnutrition. I really needed some professional advice.” (Participant 26)
Considering their reliance on large tertiary hospitals, several mothers indicated their desire for hospital hotlines that would provide round-the-clock counselling for when their babies got sick. In addition, some mothers wanted to have regular appointments with experienced doctors or nurses about their babies’ existing problems at a convenient place near their home. Mother 15 had the following expectations for health care professionals:
“In fact, it is too troublesome to take children to the hospital all the time. The community health centre is very convenient but not reliable, the most important parts are the health care professionals who provide services. Rich clinical experience and knowledge and proficient caring skills are the key points for professionals.” (Participant 15)
The majority of mothers also mentioned their requirements for baby-care-related knowledge and information because they believed that acquiring more knowledge in advance would help them have a better understanding of their babies’ needs and would be good for the health of their babies. This knowledge would also allow greater anticipation of possible risks and the establishment of adequate preparations for the risks. The requirements for knowledge could be divided into several aspects as follows: instructions regarding the growth, development and care of babies; methods to promote babies’ growth and development; and possible events that might occur during babies’ growth.
“I really confused on her (my daughter’s) mental development. I have little knowledge on the psychological development of children, but I know there must be some meaning in her emotions and actions. I just try to understand her by relying on my intuition. I need professional guidance.” (Participant 22)
The early identification of symptoms of diseases and the management of minor problems were also strongly emphasized by many mothers. Finally, four mothers emphasized the importance of targeted guidance through the provision of information and knowledge according to their baby’s different stages of the growth. These mothers wished that they could receive reminders and cautionary messages for several key periods during their babies’ growth. As Mother 20 said,
“I wish there were some tips from health care professionals to regularly remind me of important things, for example, vaccinations and examinations. What’s more, I would like to receive basic information about growth and development standards that is matched with my baby’s growth stage. For example, at what age can the baby crawl or sit?” (Participant 20)
Determining the importance of mothers’ needs
Several mothers reported their personal needs for physical and mental recovery during the postpartum period, including guidance for achieving physical fitness, having a healthy diet, and regulating their emotions. Therefore, related professionals, such as weight management doctors, nutritionists, and psychologists, were mentioned by the mothers as necessary to meet their postpartum requirements. However, some mothers stressed the shortage of the professionals in those areas. One mother demonstrated her keen expectations for professional help:
“I just want to say that it doesn’t matter if professionals couldn’t offer perfect services; it is also acceptable if there is someone who just provides the information about how to get access to the professionals above. Most of the time when I needed help, my mind went blank; I didn’t know who I should turn to, who could be trusted.” (Participant 28)
The provision of professional support during “yue zi” was emphasized by many mothers. Due to this widely accepted social custom, mothers were restricted from leaving the house after giving birth. Therefore, mothers expressed their urgent needs for obstetricians and nurses to help them identify abnormal postpartum symptoms, specifically related to lochia and wounds, and to teach them interventions to prevent infection and reduce wound pain.
“I had a vaginal incision while giving birth; there were doctors and nurses who checked and nursed my incision and lochia on time when I was in the hospital, but when I left to come home, there was nobody who could help me with that anymore. For example, I was not sure whether the incision was infected or not when I felt unwell, but I couldn’t check it by myself.” (Participant 28)
In addition, some mothers stressed the necessity of receiving health education. These mothers hoped to have access to reliable scientific knowledge to help them achieve a better recovery. The delivery of instructions via various methods was also needed to remind them of appointments after delivery.
“I was in a confinement (yue zi) service centre for a month; I indeed received much service in my own recovery, but when I left there, there was no one to guide me anymore. I didn’t know how to go on recovering and needed relevant knowledge at least.” (Participant 10)
Although psychological consultants were mentioned by some individuals, it seemed that most mothers were sensitive regarding that topic. Some participants explained that they just needed to find somebody to talk to or to receive mental health guidance from professionals rather than psychologists. Mother 13 felt it was not necessary to see a psychologist:
“I think chatting with health professionals like nurse is enough; I feel much better after I talked with you in so much detail. In fact, those things were unworthy to mention to psychologists; that’s too exaggerated.” (Participant 13) Finally, support from professionals to improve family relationships was mentioned by three mothers.