“Do traditional customs brought support or obstacles during the first postpartum year?” : A qualitative investigation on perceived barriers of primiparas in the context of Chinese culture.

doi:10.21203/rs.3.rs-4995824/v1

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Research Article

“Do traditional customs brought support or obstacles during the first postpartum year?” : A qualitative investigation on perceived barriers of primiparas in the context of Chinese culture.

https://doi.org/10.21203/rs.3.rs-4995824/v1

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Background

Primiparas experience a series of physiological and emotional changes during the postpartum period. However, most studies have focused only on universal depressive symptoms and have neglected to interpret the possible mental health risk factors that primiparas may face in the context of specific cultures. This study sought to explore the experiences of Chinese primiparas, with the key point of understanding their barriers and correlated distress under the influence of cultural factors in the first postpartum year.

Methods

A descriptive phenomenological study design was used in this study. Unstructured interviews were conducted with 25 primiparas within one year of delivery during July and September 2022. Each conversation lasted between 32–56 min. Colaizzi’s seven-step phenomenological approach was utilized for data analysis.

Results

Six themes were identified, including (a) body weakness, pain and sleep deprivation are extremely common during the first confinement postpartum period; (b) struggling with much effort, sacrifice and obstacles to breastfeeding; (c) helplessness in childcare with insufficient or unreliable social support; (d) confusing difficult access to scientific maternal and child health knowledge; (e) frustrating increasing family conflicts centering on mother and mother-in-law relations; and (f) sticking to work or not bringing much entanglement to primiparas.

Conclusion

The results of this descriptive phenomenological study suggest that Chinese primiparas experienced a series of difficulties and distresses in the first postpartum year. Understanding the perceptions of specific problems with the combination of Chinese traditions, particularly in the first-month confinement in this context, is important for extending more practical and efficient interventions.

Primiparas

postpartum experience

barriers

challenges

cultural factors

Chinese traditions

customs

Primiparas often experience dramatic physiological and psychological changes after childbirth [1, 2]. Generally, these changes mark positive, worthwhile experiences [3, 4]. However, faced with many changes in various aspects of life, many mothers feel shocked and overwhelmed by their new responsibility and obligation for their babies and often find the transition to motherhood to be a time of fatigue, frustration and emotional turmoil, especially for primiparas, who are particularly vulnerable to a variety of mental health problems, such as posttraumatic stress disorder, anxiety, and depression [5–8]. These findings demonstrate that the postpartum period is a significant time in the life course of women, with many difficulties and challenges for new mothers [9, 10].

Many previous quantitative studies have consistently identified various common problems that occur during the postpartum period, including birth trauma, pain, poor relationships with families, reduced household income, lower marriage quality, and deficient or inconsistent social support [11, 12]. These factors have also been shown to be potential risk factors for postpartum depression (PPD), which is a common and major public maternal health problem that affects women worldwide [13, 14]. However, PPD is a multifactorial phenomenon that is usually explained by both environmental and genetic risk factors. Nevertheless, although many risk factors have been reported, many factors remain unexplained due to the limitations of quantitative measurements. These studies are also incapable of clarifying the process of occurrence and development of PPD. Although several qualitative studies have focused on the experience of depressed women and identified important experiential aspects of PPD [15, 16], more common women who are troubled with negative emotions and are at risk for developing depression are usually neglected [17]. There is evidence that distress after childbirth is more universal than PPD and quite common, affecting 50%-80% of postpartum women, which is considered a normal phenomenon [18, 19]. Thus, it is important to pay attention to this vulnerable population, which does not meet the clinical diagnostic criteria for mental disorders.

Compared with Western countries, most Asian countries, including China, have some distinct cultural features, such as a greater emphasis on family and social relationships and sex discrimination [20, 21]. These Chinese cultural factors may further significantly influence postpartum women’s perspectives, attitudes, feelings and behaviors [22–24]. Some researchers have shown that the evidence obtained from studies in Western countries may not be appropriate for Chinese women [25]. However, the evidence concerning the postpartum experience of mainland Chinese women is insufficient, and the corresponding barriers and correlated distress during this period have not yet been identified specifically. Thus, it is important to explore the experiences of postpartum women in China. Therefore, considering the abovementioned gaps in the literature, it is necessary to identify postpartum women’s barriers and related distress to explore how those factors specifically affect women’s thoughts and feelings in the context of the Chinese cultural background. These findings will contribute to identifying risk factors, enhancing early intervention strategies and benefiting preventive efforts to detect depression or other mental health issues during the postpartum period [26, 27], and help with providing more expectant, effective and practical interventions for more populations at risk of developing depression. This research aims to provide a comprehensive understanding of the experiences of primiparas within 1 year of childbirth in the context of Chinese culture and to explore perceived barriers and related distress during this period, thereby guiding the development of preventative targeted strategies to increase primiparas’ well-being.

Design

A descriptive phenomenological approach was used in this study to explore Chinese primiparas’ experiences during the first year after childbirth. This approach was chosen because it is a useful method for providing an accurate description of phenomena [28]. Husserl’s descriptive phenomenology approach has been widely used in nursing and midwifery studies [29]. In this approach, researchers should concentrate on participants’ experience of a phenomenon and identify the essences behind the phenomenon rather than their own beliefs, attitudes, previous experience and assumptions [30]. Therefore, under the guidance of Husserl’s approach, the researchers aimed to maintain openness throughout the entire study process.

Setting

This qualitative study was conducted at two community health centers in Xi’an city, Shaanxi Province, Northwest China, between July and September 2022. Both centers have child care units used for vaccine injection and physical examinations of infants. All the postpartum women who were covered in these two areas would go there for regular check-ups of their babies. This makes it possible for community nurses to perform preliminary screenings and to recommend the research to potential participants.

Participants and sampling

The directors of two community health centers agreed to be the study sites. The community nurses recommended primiparas who met the criteria to participate in the research after their babies’ assessment. The inclusion criterion was that the woman gave birth to her first baby within one year. The potential participants who were screened gave their oral consent to the study were required to complete a demographic questionnaire. Then, the two researchers screened them again on the basis of the principle of maximizing the variation. Different age groups, education levels, economic statuses and postpartum periods were taken into consideration to achieve variation in the sampling. A purposive sample of 35 potential participants who met the criteria agreed to participate in the study was selected. The sample size was ultimately determined by information saturation.

Data collection procedures

All the face-to-face interviews were conducted by two researchers (YP, N & JJ, Z) privately and individually. The first researcher was the interviewer, and the second researcher recorded the interviews, took notes, summarized and supplemented the data as necessary. Researchers helped participants describe their experience without leading the interviews. One main open-ended interview question was used in this study.

Would you please describe what changes have you experienced since you have become a mother? How did these changes influence yourself and people and things around you? Please provide some examples.

The prompt questions were developed to be nonprescriptive and open-ended, and the sequence of prompt questions and wording of some terms were changed according to the responses of the participants.

Data analysis and reporting

Colaizzi’s seven-step phenomenological approach was applied for data analysis [31]. Each audio-recorded interview was transcribed into Chinese word by word within 24 hours after the interviews were conducted by the researchers who attended the interviews. All the transcripts were cross-checked against the original records of the two researchers above to verify the accuracy of the transcriptions. The seven steps were as follows: the two researchers mentioned above separately read all the transcripts carefully and took field notes into consideration to gain a deeper understanding of the experiences of the postpartum women and their meanings; meaningful statements related to the participants’ experiences, including various changes, difficulties, challenges, related influences, and negative emotions, were extracted; views and statements that appeared repeatedly were double-coded separately by the two researchers and named with the participants’ keywords and phrases to gain a more accurate description of the participants’ postpartum experiences; the first three steps were repeated and checked by the two researchers; then, they cross-checked and discussed all the codes together; all the codes were reviewed and debriefed within the research team to ensure the integrity of the data; and all the codes were confirmed, identified and condensed into multidimensional categories and further grouped into themes. The final themes were determined on the basis of continuous discussion, comparison, reintegration, and inspection among all team members. All the participants were invited to access their transcripts to ensure that their intended meaning was captured. The final findings were returned to the participants, and they had no further input on the themes. To achieve confirmability and credibility in the analysis of the data, frequent debriefing sessions were held within the research teams. Through debriefing, all the findings were discussed and checked together on the premise that the participants’ accounts were given priority to minimize the influence of researchers’ personal values, theoretical assumptions and cultural background. Any discrepancy was discussed and clarified within the research team until consensus was achieved [32]. A 32-item checklist (COREQ) was used as the consolidated criterion for reporting this qualitative study [33].

Ethical considerations

This study was approved by the Ethics Committee of Xi’an Jiaotong University. The researchers also provided detailed introductions to the study, including the study goals, objectives, procedures, benefits and potential risks. Every participant signed a written informed consent form before the interviews. The interview sites were determined by the participants and were generally quiet, private and convenient places. All the participants were assured of their autonomy and anonymity and were informed of their right to refuse to answer any questions or to withdraw from the study anytime during the interviews. Audio recordings and transcripts were stored in an encrypted database at the School of Nursing to assure the confidentiality of the information.

All 25 participants were primiparas with ages ranging from 24–35 years (29.36 ± 2.91). Most of the participants were urban residents (n = 23) with a bachelor’s degree or higher (n = 14). The average age of the babies was approximately five months (5.42 ± 2.83). The detailed characteristics of the participants are presented in Table 1. The duration of the interviews ranged from 32–56 minutes (mean = 38 minutes). The data analysis resulted in two major themes and six subthemes, as follows.

Table 1

Characteristics of the women interviewed (n = 25)
Characteristics	n (%)/
Age
(year)	29.36 ± 2.91
Residence
Urban	23 (92.0%)
Rural	2 (8.0%)
Education level
High school or below	4 (16.0%)
Junior college	7 (28.0%)
Bachelor degree or above	14 (56.0%)
Employment status
Full-time job	14 (56.0%)
Unemployed	11 (44.0%)
Family per capita income
< 4000 yuan	10 (40.0%)
≥ 4000 yuan	15 (60.0%)
Age of baby at interview
(month)	5.42 ± 2.83
Sex of baby
Boy	13 (52.0%)
Girl	12 (48.0%)
Living with parents during “yuezi”
Yes	19(76.0%)
No	6(24.0%)
History of depression
Yes	7 (28.0%)
No	18 (72.0%)

1. Body weakness, pain and sleep deprivation are extremely common during the first confinement postpartum period.

Several mothers reported their depression in terms of deterioration in physical health and apparently experienced general pain, weakness, less strength and puerperal fever after childbirth. Most of the participants reported that various traditional customs they had to follow, especially within the first month of confinement, sometimes aggravated their hardship. They described that they were afraid of receiving poor health recovery if they did not follow customs. One participant recalled her tough experience during confinement.

“It was in summer when I was in my confinement period … the house was truly hot. I truly wanted to under air conditioner … but my families persuaded me from doing this, even opening the window was not allowed, claiming for better health condition.… so almost of time, I drenched in sweat. The house even becomes …you know, very smells bad… I don’t want to recall that experience.” (Participant 1)

In addition, moderate-to-very severe pain, including postdelivery cesarean section incision pain, lateral vaginal incision pain and several types of chronic pain, such as wrist pain, hand joint pain, knee joint pain and waist pain, was mentioned by the participants in this study during the early postpartum period. Mothers who experienced pain reported that fatigue and cold increased pain. Most of them ascribed this chronic pain and related uncomfortableness to poor recovery during the first month of confinement and suggested that they were sequelae. However, some mothers emphasized that their deterioration in physical health should be attributed to insufficient instrumental support to help with their basic needs. As participant 8 recounted,

“It was truly hard to take care of my baby by myself without others’ help… I always held my baby in one arm, and the other one did the chores… The things effortlessly to finish by two hands were tough to me to do… for example, I could only use one of my hands to pour water from the pot; therefore, I got a bad recovery in my “yue zi” (doing the month) and often got an ache in my wrist joints.” (Participant 8)

Anxiety about negative sleep experiences was frequently reported by the mothers. The mothers noted that low-quality sleep was the main extremely negative experience during the first month postpartum. They suffer from sleep deprivation, extreme fatigue and biorhythm disorders during confinement. They often cannot sleep for a long time, either in the daytime or at night, because of the requirements of feeding or comforting babies. Some mothers stated that they could not even go into deep sleep when babies fell asleep because they could not help worry about their babies’ various needs. For Participant 20, such feelings were more pronounced.

“My husband and mother-in-law helped me in turn, yet I lost sleep for almost the first half a month after the baby was born. My sleep is easily interrupted, and I have concentrated all my energy on my baby. I couldn’t stop worrying about him.” (Participant 20)

Disturbed sleep-related emotional problems affect mothers. Some mothers mentioned that they could not be patient with the babies’ crying and were often easily angered due to exhaustion. Participant 22 did not feel like a good mother.

“Sometimes, the baby made me a fuss in the night, I didn’t sleep well, and I was easily angered about that. “Why are you crying? What’s the matter with you?” I was yelling to her… Obviously, I knew without any response… After that, I blamed myself a lot immediately… I just thought I was like a madman.” (Participant 22)

2. Struggling with much effort, sacrifice and obstacles to breastfeeding

Eighteen participants specifically mentioned their breastfeeding experience. Thirteen of them struggled to stimulate the secretion of milk. They paid for galactagogue divisions, took traditional Chinese medicine or folk prescriptions, drank plenty of broth, or had massages to increase the milk supply. However, most of the above measures have usually made little difference, which has led the majority of mothers into the shadow of failure and further led to a series of mental problems. Sometimes, women who fail to breastfeed are sensitive to their families’ support and even distort others’ words and motives.

“My husband got the folk prescription from his hometown, it’s Western medicine… it may have some side effects. However, he even persuaded me to take it. The more he pushed me, the more I resisted… I thought he only cared about his child but did not consider my feelings at all.” (Participant 12)

Eight participants reported that their wish for body shape contradicted the need to breastfeed the baby. Most mothers in this study agreed that the nutritional supply of their children was the most important thing, and they supposed that consuming many nutritious foods, especially broth, may help promote lactation and achieve this priority. Thus, they sacrificed their own desire to lose weight to meet the need to feed the babies.

“I never stopped eating and never minded how fat I was, for what? Of course, I did this for my children’s supply of nutrition… I didn’t lose weight until the day that I stopped to feed my baby.” (Participant 25)

Some mothers indicated that families’ unsupportive attitudes or behaviors sometimes aggravated their difficulty in breastfeeding and even restrained milk production. In particular, a few of the participants mentioned being unsatisfied with their mothers-in-law, who were often afraid of starving the babies, and continuously pushed them to feed the babies, even with little patience with the natural process of colostrum secretion. As a result, almost all of those mothers expressed anxiety and irritability about that experience during the interviews.

“I was very depressed because of my little breast milk… I truly wanted to breastfeed my baby, while my mother-in-law just couldn’t figure out why I must stick to doing so…she always doubted if the baby wasn’t full or my breast milk wasn’t enough; I couldn’t stomach her constant nagging… The more she pushed me, the more I hated to breastfeed.” (participant 8)

In addition, some women stressed that they had received little professional guidance in the hospital after giving birth. On the basis of the participants’ experience in this study, mothers who received little professional guidance had more difficulties breastfeeding. For example, participant 12 could not cooperate well with her baby, who rejected sucking the breast but preferred sucking nipples.

“After I left the delivery room and went back to my ward, there was no one to teach me how to feed my baby. I did not have any experience, so I followed my mother-in-law’s advice to give my baby a milk bottle. Then, he refused to suck my breast, so I gave up breastfeeding at that time.” (Participant 12)

3. Helplessness in childcare with insufficient or unreliable social support.

Many mothers mentioned that they could not obtain prompt professional guidance when they needed relevant support. Some of them emphasized that the stress was extraordinarily increased when the babies were crying due to the discomfort caused by an illness or for no reason. Mother 25 recalled her tough experience in the hospital with her sick baby.

“I felt very troubled when my baby was sick. She was too young to express herself… She just could not stop crying loudly… all my family was in a mess because of her… I couldn’t figure out what happened to her… whether she got a sick or not. I was very anxious… I truly need a professional to teach me how to deal with it at that time, but I didn’t know who I should turn to…” (Participant 25)

Some participants felt helpless and were overloaded by childcare-related chores due to the lack of instrumental support from family members. In addition, even when help was obtained, it was still insufficient or unsuitable.

“My mother-in-law came to look after me during my confinement. However, she was neither capable of taking care of the baby and me nor good at cooking… actually, I have little breast milk, I need lots of nutrition supply, but she just cooked simple meals with a little vegetable and fruit. I sometimes got angry with her.” (participant 17)

Several mothers mentioned that most maternal child social service institutions could provide limited help to them. They noted that it was difficult to find a qualified and experienced babysitter from there, and they were always worried that the babysitters were not reliable enough to look after the babies alone without other families’ surveillance. Some of them even doubted that babysitters did not treat their babies well or even do something harmful to the babies when they were absent.

“To be honest, I worry about the babysitters… I don’t trust them… because the cases of child abuse were frequently reported. I could not truly put a monitor in my house, right? That is too crazy.” (participant 22)

4. Confusing difficult access to scientific maternal and child health knowledge.

In addition to the direct support obtained from professional support, most of the participants reported their desire for easy access to scientific maternal and child health knowledge so that they could solve common problems by themselves. They particularly expressed their urgent demands for knowledge about maternal child health maintenance and promotion. However, many mothers reported that the information and knowledge obtained from books, the internet, and peers’ parental sharing were sometimes inaccurate and unhelpful, which often caused feelings of insecurity, confusion and helplessness and brought many difficulties to them in making appropriate health decisions. Therefore, many mothers indicated that they tend to trust multichannel access information through the process of frequent comparison and integration. Participant 5 described her puzzled experience with knowledge acquisition.

“Most mothers around me were guessing, no matter what questions (about baby care) you asked them, the answer was “I guess… maybe…” that made me truly confused, and I didn’t know whether to believe them or not … The basic knowledge of baby care should have been public … I hope that such simple but meaningful knowledge will be spread more widely and be more helpful without any charge.” (Participant 5)

The importance of maternal self-recovery in terms of physical and mental health was noted by some participants in this study. Nonetheless, many mothers mentioned that much attention was given only to infants’ health and development, while maternal mental and physical health was seldom considered, and the related information and knowledge support were usually neglected, especially when they were discharged from hospitals. Mother 10 said that she was unable to deal with mental recovery without professional informational support.

“I just did some sport or yoga in my house. As for internal recovery, my mind was totally blank; there was a teacher who helped me perform mental exercises, but when I left there (confinement service center), I did not know how to do it anymore.” (Participant 10)

5. Frustrating increasing family conflicts centering on mother and mother-in-law relations.

Most of the participants mentioned that they felt it stressful to get along with their parents-in-law during the postpartum period. Because of the custom that mothers-in-law take care of babies after childbirth, the majority of participants had to live with their mothers-in-law. Therefore, they noted that the different lifestyles, habits, values and visions among the two generations were reflected in various aspects of daily life and became the main reasons for family conflicts. However, the major trigger of family conflicts was related to caring for the babies. Many mothers indicated that they were often in conflict with their mothers-in-law due to different parenting philosophies and ways of caring. Mother 16 felt depressed that she could only make concessions on the matter.

“My mother-in-law was very aggressive; she did not accept my advice at all; she insisted on her old traditional method of caring, even regardless of the doctor’s recommendation. She often said that if I wanted to get help from her, I must follow her, or she would leave.” (Participant 16)

Several mothers indicated that the conflicts became increasingly intense sometimes because their partners were incapable or unwilling to mediate the relationship between them and mothers-in-law. Mother 21 recalled her conflicts with her mother-in-law and described how she felt disappointed with her husband.

“Once, my mother-in-law called me to lunch, I felt not very comfortable, so I told her I would eat later… To my surprise, she directly complained to my husband that I wasn’t satisfied with her…then, he just believed her and recklessly yelled at me on the phone… I just wanted to die.” (Participant 21)

Nonetheless, many mothers comforted themselves that conflicts were common in many other families and that the differences in parenting philosophies between two generations were unavoidable. Some of them mentioned that they should learn to bear conflicts for Chinese tradition: a peaceful family will prosper. Most of the participants were reluctant to talk about conflicts within their family and treated them as private during the interviews. Mother 22, who suffered a lot in family conflict, said,

“Every time we have different opinions, my mother-in-law said I should listen to her because she was helping me. Therefore, I had to compromise and comfort myself that she did that all out of kindness… but in fact… I could still not accept it…and just was bearing her.” (Participant 22)

6. Sticking to work or not bringing much entanglement to primiparas

Many mothers changed their work intentions after childbirth. They paid more attention to their family, particularly their babies, while they paid less personal consideration to their future careers. Mother 1 spoke of her obvious changes in work choice.

“My mind changed obviously after childbirth. It was impossible for me to choose such a common job in the past because I insisted that people should always be positive and ambitious. However, everything changed when I became a mother, the consideration about the time of keeping baby company became the dominant factor that influenced my choice.” (participant 1)

Almost half of the mothers had given up jobs temporarily for their families. The main reason is that taking care of babies full-time with little support from others. Most of the time, mothers felt that it was worth sacrificing their own career to take care of their babies, but sometimes, they were also deeply influenced by the side effects of quitting their jobs. A lower family income, less confidence and personal worth, social withdrawal and isolation made them feel depressed. Mother 4 expressed her concern about the future.

“Because I had no job now, so… self-worth is not good… thus far, all things going well…but sometimes I was wondering when my child grew up, he will never rely on me anymore, I can’t imagine what I would be like at that time.” (participant 4)

For working mothers, work-family conflicts were more obvious than they were for those without jobs. They were unwilling to give up their jobs, mainly because they wanted to shoulder the family’s financial burden with their husbands. Additionally, mothers who sought self-worth and fulfillment from work did not want to be isolated from society. Work–family conflicts confused mother 13 greatly.

“Out of long-term consideration, I couldn’t treat my job perfunctorily; I must be serious toward my job. However, my child needed me; I couldn’t accompany him most of the time, let alone pay more attention to his early education. I suffered in this conflict and always felt guilt.” (participant 13)

However, several mothers complained that it was almost impossible to concentrate on their jobs, as they were always worried about their babies during work time. In addition, some mothers reported that their babies were very dependent on them while rejecting others’ care, which aggravated their anxiety and guilt. Many mothers mentioned that they were stressed by poor work efficiency, often had difficulties finishing work on time and being despised by their supervisors. Most of them believed that more support and understanding from supervisors could relieve the pressure. Mother 24 represented the negative effects of caring for a baby on her job.

“I do some translation at home, since I had a baby, my workload had been decreasing. I could work for eight hours a day in the past, but that is impossible for me now to do so. Because I cost most of the time caring for the baby.” (participant 24)

Nonetheless, some mothers recognized working as a way of escaping the burdens of heavy chores and family conflicts. By working, their attention was switched, and their body and mind could relax for a while.

“After about three months, I felt much better because I went back to work, I could get rid of the stressful circumstance in family temporarily, even though I missed my baby when I worked, I could indeed take a deep breath!” (participant 18)

This descriptive phenomenological study has generated information regarding the experiences of primiparas during the first postpartum year to determine the difficulties and challenges they face, make sense of the profound influence of traditional Chinese cultural factors on maternal experience and determine the potential predictive factors of emotional disorders.

On the basis of the relevant literature review, postpartum health problems are universal around the world. Many quantitative studies have reported a high prevalence of poor self-rated health status among postpartum women in the early postpartum period. For example, a survey conducted in Australia reported that 94% of women had one or more health problems 6 to 7 months after birth [34]. Common health problems include general fatigue, headache, pelvic girdle pain, low back pain, urinary incontinence, fecal incontinence, anxiety, irritability and depression [35]. These findings generally echo the results of previous studies [36, 37]. However, it is worth noting that almost all of the participants in this study who had health problems considered poor recovery from first-month confinement to be the main cause in the context of Chinese culture. This may be because the zuo yuezi was a traditional postpartum ritual that was strictly adhered to by Chinese women and Chinese immigrant women overseas [38]. Most of the time, Chinese women believe that zuo yuezi is an important care model that can assist in the recovery of the wounded and the weak body after traumatizing childbirth [39]. Therefore, they treated this as a critical period to achieve better recovery. They strictly adhere to routines in the first month postpartum confinement; otherwise, they have poor recovery and experience discomfort or disease over their lifetime [18, 40]. Under the influence of this tradition, most of the mothers in this study specifically reported their experience in confinement and agreed that confinement was also the most difficult period after childbirth because of the high degree of discomfort and limits. In addition, mothers in this study mentioned that their suffering from insufficient instrumental support from family members or professionals during the confinement period resulted in their sequela. These results suggest that discomfort and a lack of instrumental support during the postpartum period, especially during the confinement period, may be important risk factors for emotional disorders in China. This finding also implies that more efforts should be made to improve the sense of comfort, relieve pain and provide more professional guidance for postnatal care, especially during the first month of confinement [38].

In this study, many mothers experienced extremely low-quality sleep during the first month of the postpartum period. The participants also described their relevant emotional problems. These results are in line with those of a longitudinal study in which sleep maintenance parameters, such as sleep fragmentation, sleep efficiency, and wake time after sleep onset, were significantly correlated with postpartum depression [41]. This finding implies that improving the quality of sleep during the early postpartum period may be important for preventing PPD.

Additionally, the results revealed that breastfeeding-related difficulties were a challenge for new mothers and could also increase various passive emotions. The mothers in this study showed a strong willingness to breastfeed, but some of them struggled to establish and maintain breastfeeding. This result is highly consistent with another study conducted in China, which reported that only 59.4% of new mothers had begun breastfeeding early (i.e., within 1 hour of birth) and that only 28.7% of infants younger than 6 months had been exclusively breastfed [42]. Breastfeeding-related difficulties could also be observed in other previous qualitative studies. However, this study highlighted the significant point that mothers attributed their shortage in breast milk to family members’ unsupportive attitudes and behaviors. The custom of the intergenerational group living after childbirth and the lack of breastfeeding knowledge may influence the formation of this problem. These results suggest that relevant policies aimed at promoting the quantity and quality of professional guidance and raising the level of education on breastfeeding for new mothers and their family members may relieve the stress of primiparas and help with the adaptation of the mother role.

The helplessness caused by baby care was mentioned by the participants in this study. The participants’ complaints could be attributed to three aspects: less support from family members, little guidance from professionals, and limited help from social resources. These results echo many quantitative studies showing that social support is a vital factor that can influence mothers’ emotional well-being and that the level of support is inversely proportional to emotional difficulties [8, 43]. Interventions aimed at helping with basic needs and chores through improving primary care and social support may be helpful for primiparas.

The shortage of maternal–child health knowledge and information often contribute to mothers’ anxiety, which is highly consistent with the findings of previous studies [21]. This study also revealed high expectations for easier access to professional informational support for maternal self-recovery and childcare. The benefits of informational support and education delivery during the postpartum period have been demonstrated in other studies [44, 45]. These findings imply that interventions that provide plenty of professional informational support, increase access to them and pay more attention to providing the public awareness rate of those above may be important for decreasing the level of primiparas’ stress and may be effective strategies for enhancing mothers’ physical and mental well-being.

Additionally, this study specifically demonstrated postnatal family conflicts in the context of traditional customs and new living patterns during the postpartum period, which has also been reported in prior studies [46]. Many participants reported that they had to adapt to living with their parents-in-law, and the majority of the conflicts occurred between the two generations, mainly due to the different ways of taking care of babies, lack of understanding from mothers-in-law and less emotional support from partners who had poor ability to solve contradictions among family members. Therefore, new mothers may obtain limited emotional support from their husbands’ families when conflicts occur, which can cause much extra stress to mothers and may further contribute to emotional problems. This phenomenon is partially due to the traditional Chinese postpartum ritual that both newborn and maternal caregivers were mothers’ mothers-in-law or mothers, especially within the first confinement month [47]. However, this tradition may trigger intergenerational power struggle and cause more conflicts [21]. These results indicate that the relationships between family members may be a significant predictor of mental disorders. These findings are consistent with studies conducted in 11 countries around the world, and the results revealed that poor relationships with family members, especially husbands and mothers-in-law, were a source of unhappiness for new mothers during the postpartum period [48, 49]. Although several studies have focused on the correlation between social support and a series of emotional disorders, few studies have focused on interventions aimed at improving the quality of relationships and further enhancing family support, which implies that this topic should be investigated in further research [10, 43, 50]. Additionally, considering the traditions in China, it would be more practical and efficient to deliver interventions to multiple family members, especially the husbands and mothers-in-law of new mothers.

Perceived consequences for existing stress related to work, which influences the level of self-worth or self-esteem of mothers, were also noted in this study. The relationship between employment and mental health after delivery has also been explored in other studies [51]. For example, a study reported that worse depression scores were associated with greater total workload, lower job flexibility, and lower social support in the first 6 months after childbirth [52]. However, the difference found in this study is that doing work outside the home appropriately sometimes could relieve mothers’ stress. The reason for this may be that mothers could take the burden off baby-caring for a while and gain some relief. Moreover, mothers may gain more social support from colleagues and supervisors. Studies have shown that the more social support mothers receive from supervisors and colleagues, the better their mental health is [53, 54]. These results indicate that an appropriate workload may be a protective factor for the better mental health of mothers.

Limitations

This study has a few limitations. First, some of the data were collected through the participants’ retrospective experience, which may have resulted in recall bias. Second, the majority of participants came from cities that were selected from two community health centers, and the results may be subject to selection bias. This experience should be explored with women from different districts and ethnicities in future studies to supplement the findings of this study. Notably, the results emerged from the subjective perspectives of the participants. It is necessary to conduct a mixed-method study to fully understand primiparas’ difficulties and obstacles from both subjective and objective perspectives.

This research provides insights into primiparas’ experiences during the first postpartum year to determine the specific difficulties and challenges they face in the context of Chinese culture. The results imply that the first postpartum year, especially the first-month confinement during this period, is much more difficult for Chinese primiparas, which indicates that much more efforts should be made to improve the sense of comfort, promote the quality of sleep and provide more professional guidance on breastfeeding and self-recovery during this key period. In addition, the findings of this study also illustrate that instrumental support and emotional support, especially from families-in-law and colleagues, may be important protective factors for mothers’ well-being. The results shed light on common Chinese family problems and indicate that decreasing such problems through the delivery of interventions to multiple family members, which are aimed at improving the quality of relationships and further enhancing family support, would be more practical and efficient. This finding has implications for health care professionals to provide adequate informational support and more access to such information and knowledge, which may be an effective strategy to increase mothers’ physical and mental well-being.

In conclusion, the findings of this study provide a reference for future intervention studies that identify primiparas’ difficulties and challenges and interpret their causes in combination with specific cultural backgrounds, further providing interventions with cultural adaptability for resolving their target problems. This approach may be efficient in normalizing related emotional problems and reducing the risk for emotional disorders.

Acknowledgments

We are grateful to the directors of the two community health centers for supporting the data acquisition process. We would like to thank Lei Yang and Jingjun Zhang for transcribing the records and Xiaomei Li for guiding the data analysis process. Finally, we thank all mothers who participated in the study for their contribution to this project.

Author contributions

YN and YZ designed the study. YN wrote the first draft. XL and NA critically reviewed the article and provided their input. LY and JZ participated in the study design, data collection and analysis. FL, MZ, and YG coordinated and assisted in the data analysis. All the authors read and approved the final manuscript.

Funding

The authors received funds from the “Support Plan for Sanqin Scholars Innovation Team”. Fund No. [2020]45, Shaanxi Province.

Data availability

The datasets generated and analyzed in this study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the Health Science Centre at Xi’an Jiaotong University. Written informed consent was obtained from the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

¹School of Nursing and Rehabilitation, Xi’an Medical University, Xi’an, People’s Republic of China.

²School of Nursing, Health Science Centre, Xi’an Jiaotong University, Xi’an, People’s Republic of China.

³Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK.

⁴School of Nursing, Shaanxi University of Chinese Medicine, Xi’an, People’s Republic of China.

⁵Department of the Second Affiliated Hospital of Xi’an Medical University, Xi’an, People’s Republic of China.

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“Do traditional customs brought support or obstacles during the first postpartum year?” : A qualitative investigation on perceived barriers of primiparas in the context of Chinese culture.

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Methods

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2. Struggling with much effort, sacrifice and obstacles to breastfeeding

6. Sticking to work or not bringing much entanglement to primiparas

Discussion

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