Analysis of the data generated 4 themes which are described below.
Theme 1: Cultural relevance and usefulness of the adapted THP
The majority of the women found the intervention material comprehensible, relatable and beneficial. They reported increase in their knowledge and felt better equipped for providing care to their babies.
“I would definitely want to be informed (about perinatal period, stress and feelings). My mother and grandmother have been through this period, but this is my first pregnancy. Yes, there are some books, but it is not possible to learn everything from books. Every day, we learned something new”. (28-year-old, pregnant woman).
“Although we talk about the mother-baby relationship in the lessons, pregnancy and postpartum period is very baby cantered in most of the families living nearby. Mother's feelings are left in the background. I believe that this program can be very effective in showing the importance of maternal mental health in pregnancy schools”. (23-year-old, nurse)
Problem-solving and stress management strategies were the most frequently reported beneficial techniques. They found problem-solving skills helpful to deal with their everyday issues and breathing exercise useful to manage their anxiety.
“Problem solving, and deep breathing exercises were a huge help because these exercises taught me to cope better with anxiety, and to think positively”. (29-year-old, pregnant woman)
Most women reported Mood Chart helpful to identify their mood. It also helped husbands to recognize their wives’ feelings and offer better support to them. However, Health Charts such as Diet and Rest Chart were not found useful. This might be explained by the fact that women were already receiving such information from their pregnancy schools.
Theme 2: Acceptability of the format of delivery
All the participants found the delivery of the programme in group setting acceptable and valuable. They reported positive experience of interacting with other participants and their facilitators and appreciated the friendly environment created in a group setting.
“I felt very comfortable interacting with other women in the group, and expressing my feelings. The group environment was very friendly which made me comfortable and safe in expressing my feeling”. (29-year-old, pregnant woman)
The group format helped the women to realize that they were not alone in their fears and anxieties. They valued the emotional support offered by the group and felt safe sharing their problems without fear of being judged. They appreciated suggestions offered to them.
“My favourite thing was sharing and listening to each other’s’ problems, and finding solutions”. (26-year-old, pregnant woman).
“In addition to the mother's physical health, I think it is very valuable to focus on the issues related to the mother's mental health. Role plays and to share in-group experiences were very demonstrative and helpful for pregnant women. They normalize their worries about their pregnancy period by the help of these.” (40-year-old, nurse)
While most participants were satisfied with the group, some wanted the sessions to be of shorter durations and more frequent during the week. Few participants also expressed their wish to have more sessions as they felt relaxed and suggested sessions to continue after the baby is born. One participant expressed her dissatisfaction with the timing of the session as it was falling during her lunch hour.
Theme 3: Improved wellbeing and interpersonal relationships
The majority of the women reported applying the skills and the knowledge, learned during the sessions, to improve their wellbeing. Breathing exercise was found particularly useful.
“There were not only theoretical discussions. There were also practice work such as exercises and breathing exercises. I really felt relieved, when I practiced them at home. I felt better and better every week”. (28-year-old, pregnant woman).
Some women reported the intervention not only benefitting them but also their family members. One woman during her interview stated how it helped her and her husband to change their unhelpful thinking patterns.
“The programme is helpful for my unborn baby, my husband, and my mother-in law. I was able to change not just my thoughts into healthier ones, but also my husband’s”. (28-year-old, pregnant woman)
Many participants reported improved relationship with their husbands and in-laws. They attributed this to their improved confidence and better communication. They were able to share their concerns and ask for help. A woman whose marriage was at the brink of breaking stated;
“I did not have a good communication with my husband, and I was even thinking of getting divorce, but it has changed. We are spending more time together, listening to each other, and have a more positive point of view”. (31-year-old, pregnant woman)
Not only were their relationship improved with their families, it also helped them to bond with their unborn baby. During the interviews they reported getting into the habit of talking and singing to their babies.
“I found it difficult to bond with the baby for the first 4 to 5 months. But with the support of the programme I communicate more, make her listen to songs, and tell her stories, which makes me feel better”. (30-year-old, pregnant woman).
Theme 4: Appropriate delivery agent
The majority of the participants, described their facilitators genuine, supportive, and understanding. They felt that the facilitators listened to them, made them feel valued, gave them the opportunity to ask questions and responded to their queries adequately. The facilitators positive attitude made them feel comfortable and encouraged them to express their feelings.
“The facilitator addressed each of us by our names, and listened eagerly by spending her time. She engaged all of us to the problem-solving process, asking what would you do if you are in her shoes? The facilitator encouraged us to feel included and valued within the group”. (31-year-old, pregnant woman)
Table 1
Adaptation of the THP for incorporating in the routine on-line pregnancy schools
Overall adaptations for the THP – Group version
|
Rational
|
Language
|
Translation of the manual into Turkish language.
The key messages were simplified and generalised to target all expectant women.
|
To make intervention universal instead of targeted for perinatal depression.
To allow generating discussions in the group.
|
Context
|
The illustrations were re-draw to depict Turkish women in everyday scenarios
|
To make illustrations relevant to its target population
|
Concept: the core strategies
|
The facilitators used; a) empathy to build rapport with the group members, b) illustrations for psychoeducation and to highlight the importance of thought challenging, c) mood charts for encouraging mood monitoring and behaviour activation and d) every day examples for enhancing problem solving skills.
|
Original THP core strategies were aimed to improve depression symptoms through delivery of individual sessions. The THP-group version used these strategies for psychoeducation in group setting and to prevent depression.
|
Content:
|
The introductory session was split into sessions 1 and 2.
Session 1: Engaging the participants and introducing THP-group version.
Session 2: Psychoeducation and problem managing skills
|
Splitting introductory session into 2 sessions will allow more time for:
1) rapport building,
2) group gelling,
3) introducing the programme, relaxation exercise and introducing 5 steps of problem-solving skills,
4) raising awareness and generating discussions on the importance of emotional wellbeing during pregnancy
|
Sessions 3: Personal Health
Diet chart and rest charts are removed
|
These topics are addressed during the routine pregnancy schools and therefore not needed
|
Session 4: Relationship with the baby
More information is added about the importance of 1000 days, maternal responsiveness to the baby’s need, breast feeding and colic babies.
|
These topics are considered important by a co-author PB, who is a paediatrician by professional
|
Session 5: Relationship with people around the mother
The ending of session 5 focuses on concluding the group
|
This will allow the participants to give closure to the group and give feedback on their experiences
|
The organisation
|
Marmara University hospital under the Turkish Ministry of Health
|
Incorporating the THP-group sessions at ‘pregnancy schools’ at public hospitals
|
The individuals
|
Delivery agent: Nurses
|
Antenatal nurses to deliver THP- group sessions during the routine pregnancy schools to all expectant women
|
The format
|
Mode of delivery: On-line delivery of sessions
|
The COVID pandemic poses a risk for the face-to-face delivery of the sessions.
|
Duration: 1 hour except the introductory session of 90 minutes with break in-between the routine program
|
Shorter duration and breaks to allow pregnant women to rest during sessions.
|
Time of sessions’ delivery: Noon
|
Daily housework is already done and school-aged children were off line and to facilitate working mothers’ attendance
|
Accessibility: Smart phone ownership and internet availability
|
Providing internet packages will allow the participants to receive on-line sessions
|