The role and attributes of social networks in the provision of support to women after stillbirth: experiences from Uganda

This was an exploratory cross-sectional study adopting a social network approach as part of a larger mixed-methods study conducted in Mukono district located in central Uganda with a high fertility rate. It has characteristics of a pluralistic health system with the public, private not for profit and private for-profit health facilities offering maternal and child health services. There are a total of 51 health facilities of which only four are at Health Centre IV level and above offering Comprehensive Emergency Obstetric care services. Some mothers accessing maternal health services at the health facilities come from the neighboring districts due to central location, proximity to the city, and access to the great east Africa highway; a major transport route in the country and region. Details of the study setting have been described elsewhere [33].

Enrolled participants in this study included women in their reproductive age (18 years or older) with eligibility criteria of having experienced a stillbirth within six months before the study and consented to participate. They had delivered the index pregnancy in one of the health facilities in the district specifically focusing on Health center III and above because they offer emergency obstetric care services. Exclusion criteria included not being available for interview during the study period and those mothers who had delivered within one month prior to the study. The results reported here are from 17 respondents out of the 20 that were targeted and 23 who were approached.

Data were collected between January and May 2019 where a convenient sampling technique was applied to access potential respondents who were identified from facility records and health worker’s recollections. They were approached by the health workers from the maternity unit who were first oriented about the study and supported to gain confidence and clarity while explaining the objectives and processes to potential respondents. Health workers would first speak to the potential participant and inform them about the study and thereafter would request them if they were willing to participate after elaborating the study objectives. A study team member verified information with health providers to ascertain eligibility before contacting the mothers. Those that agreed to participate were then approached by the study team member using the information provided via mobile telephone. Thereafter a convenient place and time for the interview would be agreed upon with the potential respondent. Interviews were face-to-face interviewer-administered whereby on the day of the interview, the objectives and procedures to be followed would be repeated for the participant and consent obtained. Although the study did not set out to collect data on refusal to participate, it later emerged that three of the potential respondents that had been approached declined to participate and at that point, no further contact was made.

The tool used was developed by the first author based on literature and standard procedures for conducting social network interviews (attached here as Additional file 1). It contained five sections; section one elicited information on social demographics, household characteristics, maternal health, and obstetric history characteristics collected from each respondent through self-report. Section two included the name generator where an egocentric network approach was used to guide respondents to recall at least fifteen to twenty of their social network members. The criteria included giving names of those people they recall to have had contact or interacted with during pregnancy and after experiencing a stillbirth. This followed established processes for conducting social network interviews [34‐36].

To assess network composition, section three asked respondents to provide information about each of the network members they had earlier listed which included demographic data such as age, education, gender, marital status, and relationship type. The level of trust, emotional closeness with network members, frequency of contact, and whether that particular network member could be relied on for support when in need. They were assessed on a three-point Likert scale including “Not at all, a little bit or Very much. The frequency of contact with a network member was assessed on a five-point Likert scale which reflected “1 = never, 2 = once a month, 3 = once a week, 4 = several times a week, and 5 = about every day”.

Section four covered the different aspects of social support explored between the respondent and network members. Specifically, following guidance from literature [28, 37], social support was conceptualized as consisting of five types including; financial, information, material, emotional, and instrumental support. The questions were repeated for each of the categories asking if respondents had sought or received support from the network member during pregnancy and after experiencing a stillbirth. The responses were on a three-point Likert scale; [1] “Not at all, (2) A little bit, and (3) Very much”. The last section (five) assessed the network structure where participants reported if a particular network member knew the other alters mentioned with response options including “Yes, No or don’t know. They were also asked about the nature of the relationship with network members in terms of Trust and count on alter for support which was assessed on a three-point Likert scale; (1) “Not at all, (2) a little bit or (3) Very Much”. Emotional closeness was assessed on a three-point Likert scale with (1) Not at all, (2) somewhat, (3) very close. Frequency of contact was assessed on a five-point Likert scale with (1) once in six months, (2) once in three months, (3) Once in a month, (4) once a week and (5) about every day.

Overall, respondents reported the mean age at first pregnancy as 20.5 years (range 14–30) with 65% reporting a parity of three or more at the time of the interview. Close to a quarter of the respondents (24%) indicated a history of a negative pregnancy outcome such as a stillbirth prior to the index pregnancy. Half of the index pregnancies (52%) that resulted in the stillbirth were referrals-in with the first point of care-seeking being mainly the lower-level public health facilities (44.4%) and private clinics (44.4%). Very few (16.7%) reported using any family planning method at the time with more than half (64.7%) reporting intentions to have another child within the next one to three years.

According to respondents’ demographics, the mean age was 29.4 years (range 21–41), the majority (41%) had some secondary level education with many of whom (88%) being Christians. The majority (83.3%) were married with more than half (59%) living with four members or less in the households and staying in a nuclear family arrangement (65%). Details are presented in Table 1.

Network member characteristics reflected diversity where 70.6% were females, the majority (64.8%) with some secondary level education or more, and more than half (67.6%) being married. By composition, more than half (58.4%) were from naturally occurring network members of which 62.6% were family members. The majority (80.9%) of the alters were trusted by the respondents while 78.5% were in frequent contact with the respondent and 72% were emotionally close to the respondent. 66.6% of the alters would be counted on to offer support with 65.5% maintaining or improving their relationship with the respondent following a stillbirth. Details are presented in Table 2.

According to alter characteristics, material support was reported to come from alters who were female 63% (p = 0.05), married 80% (p = 0.003), and from naturally occurring network members such as family and friends 81% (p = 0.001) during pregnancy. After experiencing a stillbirth, material support was reported to mainly come from alters who were 26–45 years 68% (p = 0.078) and were married 77% (p = 0.008).

Financial support was reported to come from alters who were married 82% (p = 0.001) and from naturally occurring network members 75% (p = 0.001) during pregnancy. After experiencing a stillbirth, material support was reported to mainly come from alters who were female 62% (p = 0.018) married 82% (p = 0.001), and were from naturally occurring network members 68% (p = 0.014).

Emotional support was reported to come from alters who were male 72% (p = 0.05) and with a secondary level education, 36% (p = 0.03) during pregnancy and after experiencing a stillbirth emotional support was reported to come from respondents whose age ranged from 26–45 years 63% (p = 0.04).

During pregnancy, instrumental support was reported to come from alters aged 26–45 years 60% (p = 0.03) and from naturally occurring network members 67% (p = 0.02) while after experiencing a stillbirth instrumental support was reported to mainly come from alters who were aged 26–45 years 61% (p = 0.03), married 62% (p = 0.032) and from the naturally occurring network members 64% (p = 0.038).

Information support to respondents during pregnancy was reported to come from network members who were females 66% (p = 0.001), between ages 26–45 years 82% (p = 0.001), and with a tertiary level education 35% (p = 0.008). On the other hand, after experiencing a stillbirth, information support was reported to come from alters who were in age category of 26–45 years 68% (p = 0.001), females 80% (p = 0.001), and who were married 73% (p = 0.007). Details are reflected in Table 3.

The findings revealed that social support was available from all network relations mentioned by the respondents. No major variations were observed between the two time periods during pregnancy and after experiencing a stillbirth. During pregnancy only 10 (3.4%) relations (network member mentioned) were noted not to have provided any form of support while 9 (3.1%) were noted for the same after experiencing a stillbirth. All forms of support from network members increased slightly after experiencing a stillbirth compared to the same during pregnancy save for information support which reduced. This is expected since communities tend to empathize with grieving families and as a result will tend to offer any possible support available at that particular time. Another possible explanation could be that given the alters elicited during the study were perceived to have an already existing relationship with the respondent, provision of such support would be expected and forthcoming. Targeting mothers immediately to engage them in postnatal counseling is key to guide them in subsequent pregnancies since studies have long established that the desire for more children increases with a loss of a child and women tend to conceive immediately [54]. Purposing the support at that point to one which will help the mother recover from the situation empowered is important. Such support can range from information and emotional since many women would wish to be guided through their post-partum healthcare seeking and emotional recovery.

The most commonly available support that respondents received was in form of intangible support such as emotional and information support. It was reported from 96% of the alters throughout pregnancy and after experiencing a stillbirth. Similar results have been reported elsewhere [4, 39] where emotional support was found to be the most prevalent among network members. It provides a sense of empathy, accompaniment and understanding [40]. This demonstrates that the quality of information shared with a pregnant mother or even after experiencing a stillbirth through emotional support is crucial. Ensuring that quality information is offered in the context of averting stillbirth risk factors is key. One reason as to why emotional and information support was more prevalent could be that it is readily available unlike other forms of support such as material [41]. However, information support reduced slightly after experiencing a stillbirth most likely a reflection of a sense of loss and fear of causing more distress and stigma to the affected mother. It may also have been due to a lack of confidence on which information to provide then that would be beneficial to the grieving mother and her family. Mapping of network members likely to offer this kind of support and empower them through programs identifying community peer supporters is one way to achieve this.

Most of the social support reportedly received by the respondents came from females who were married. These variables highlight the importance of gender and social status such as marital status in predicting social support both during pregnancy and after experiencing a stillbirth. The results add to the existing body of knowledge that highlighted the importance of gender in provision of social support [42]. Elsewhere studies have also identified marital status as being key in predicting provision of social support [43]. Regarding the relationships between the ego and alter, our results show that much of the social support come from alters who were from the naturally occurring networks such as family and friends. This observation builds on the existing literature where studies have previously reported the important contribution of family and friends in the provision of social support whenever in need [44]. As previously reported, the higher proportion of family members within one’s network might be a reflection of the group orientation around family which is typical in many sub-Sahara African settings including Uganda [45]. Also this may serve to emphasize the role of family as a major factor in decision making dynamics surrounding maternal healthcare and overall health in general [46, 47]. For friends, they are an immediate point of reference whenever faced with life threatening challenges including negative maternal health outcomes. They serve to cushion pregnant women from adverse life events and also help uplift them after experiencing such [48]. Interventions aiming at addressing stillbirth reduction therefore ought not to view pregnant women in isolation of the surrounding environment especially their embedded relationships.