Background
Methods
Design
Participants
FG | Area | Age | Ethnicity | Stage |
---|---|---|---|---|
1 | Urban | 25-30 yrs. = 1 31-35 yrs. = 2 36-40 yrs. = 3 | White British = 3 White New Zealander = 1 White European = 2 | Postpartum (primiparous) = 6 |
2 | Rural | 25-30 yrs. = 1 31-35 yrs. = 1 36-40 yrs. = 1 | White British = 2 White & Black African = 1 | Pregnant (multiparous) = 1 Postpartum (multiparous) = 2 |
3 | Rural | 31-35 yrs. = 1 36-40 yrs. = 1 | White British = 2 | Pregnant (multiparous) = 1 Postpartum (multiparous) = 1 |
4 | Urban | 25-30 yrs. = 1 31-35 yrs. = 4 36-40 yrs. = 1 | White British = 5 White European = 1 | Postpartum (primiparous) = 5 Postpartum (multiparous) = 1 |
5 | Urban | 31-35 yrs. = 1 36-40 yrs. = 4 41-45 yrs. = 1 | White British = 4 Black African = 1 White New Zealander = 1 | Postpartum (primiparous) = 6 |
Procedure
Data analysis
Results
Themes and Sub-Themes | Quotes |
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SOURCES OF ANXIETY | |
Unrealistic expectations of birth and motherhood | |
1. Expectations of childbirth | FG5.F3: she did this demonstration about epidurals… and she made it seem just really scary… I came away being absolutely terrified of any intervention… But I ended up being induced and having forceps, both of which were… well the induction wasn’t fine… but the forceps were. So I felt there was a lot of misinformation about what an intervention would be like… which made me unnecessarily anxious. |
FG5.F2: my community midwife refused to tell me about induction because she thought it would happen naturally. But my waters broke before labour started, so I had to be induced… and I had no idea what was happening… (which) made me really frightened. And I remember thinking, but I’m allowed to ask you and you’re meant to tell me… | |
2. Expectations of breastfeeding | FG5.F3 It’s crazy how people make breastfeeding out to be this magical experience, when it just couldn’t be more different than that really. |
FG4.F2: [antenatal classes] show you this video of a five month old baby breastfeeding quite happily in some sort of coffee morning, and it’s absolutely easy. But then the reality is so different. And I felt just a bit tricked by the whole lead up to having a baby… | |
3. Unrealistic guidelines and norms | FG4.F2: It worries me when things like the Babycentre say like at eight months your child should be doing this, especially sleep and feeding… you feel like you’re just doing everything wrong. |
FG1.F3 I don’t know any mum who was able to put their child in a moses basket on their back from day one, and it just causes you an enormous amount of anxiety. So what are you meant to do, what can you do? I still don’t know. | |
4. Unrealistic social comparison | FG2.F2: I just struggle with parenthood being completely honest. It’s like one of these things where there’s so much social media these days saying how you should be this and that. And for me that’s actually, like the biggest thing that really blocks me from thinking actually it’s OK, like this is normal. |
5. Societal pressure | FG1.F5: I think they put so much pressure on a mother by saying breast is best which means… yes it’s all positive. But… if you don’t succeed then… you’ve failed as a mother, you’ve failed your kids and it’s just not true because fed is the best isn’t it? |
FG1.F4: We’re still co-sleeping and everybody’s like… it’s so bad because SIDS and everything. Your babies will die if you co-sleep | |
Importance of Peer Support | |
6. Offline social support | FG1.F6: Being here and away from family… has been the hardest part for me… but the girls in the (antenatal) group have been great. I think they’ve been the biggest support through all of this. |
7. Online peer support (positive and negative) | FG5.F3: It definitely increases anxiety – those big forums definitely do. Because nobody wants to post when things go well. They just say terrible things…. which just made me really paranoid. |
FG4.F1: I found those (Facebook) groups just brilliantly good peer support, and more helpful than some of the breastfeeding groups I’ve been in. | |
8. Normalisation of experience | FG2, F1: So we just post whatever’s going on. So if you’re having a really naff day you’ll say Jesus Christ, the kids have done this, this and this. And someone goes oh tell me about it. And it’s just somebody, like, who’s feeling the same thing as you, so it’s not completely like… all the social media where it’s this perfect mum… it’s well I’m here with cereal stuck in my hair and it’s two o’clock in the afternoon. So at least with that it was other normal mums that were just like yeah, I’m doing the same thing as you. So you didn’t feel so alone. |
Uncertainty and Maternal Confidence | |
9. Unprepared for change | FG1.F1: I had absolutely no idea about any of motherhood I realised, y’know, the practical stuff. |
FG4.F2: That’s actually why people then struggle. I suppose we all go through our lives being good at a lot of things. You’ve established a career, you’ve established yourself, you’ve got qualifications. And then suddenly… this baby arrives and you’re not good at anything. | |
10. Maternal confidence and overwhelm | FG1, F4: I was overwhelmed with everything, the household running, and I only had to look after the baby. But it was so demanding. |
FG4, F1: (I have to know) when our daughter last fed, how much she’s fed and how much she’s vomited that day, how many wet nappies she’s had, and when her immunisation’s due… There’s this massive load that we’re carrying… And then you add to it just stupid things like the washing basket’s full…or I need to sterilise some things, and I need to do this and I need to do this. And I just find that there’s this constant like whir going on in my head. | |
11. Conflicting (or extreme) information | FG1, F1: I think (the internet) is a curse and a blessing. Because in the very early days you Google everything and there’s all these forums, there’s Netmums, there’s a blog, a Facebook thing that I was on Mummy’s Gin Fund… And the actual problem is there’s like too much advice and everyone’s – ‘do that’ and then there’ll be someone with complete opposite opinions saying do this, do that. And actually you get yourself into such a state because you almost read too much. And it made me very anxious, it didn’t really help that much… F2: …There’s just so much… F6: …and a lot of it’s extremes as well... F2: …Yeah… the last thing that I felt, or I feel that I need is like the polar opposite of opinions |
FG5, F2: What you read on the internet is quite extreme. And you always end up on message boards where one woman is like ‘I was induced and I was in labour for 72 h and then this happened to me’, and it just becomes really terrifying… | |
ISSUES AROUND SUPPORT | |
Stigma | |
12. Internal and external stigma | FG5.F4: I felt like I couldn’t talk to anyone about it, because I didn’t think it was normal and I felt like it was me not being a good mum F3: Me too. Yeah, exactly. I thought people might think I was an awful mother. |
13. Disclosure avoidance | FG2.F2: I fear that if I went to somebody saying look I really suffer from anxiety, I get worried on who’s going to get involved with my kids. F1: That was my fear, that social services would get involved if anyone found out. |
Lack of Mental Health Support and Knowledge | |
14. Lack of postnatal healthcare support | FG5.F4: You’re all geared up to give birth, and then you do it and you get home and you’re like, shit, now I have a baby… and there’s no support really. When I had her, I had really bad anxiety, like postnatal anxiety full on. Like I couldn’t leave the house, I couldn’t leave her to sleep, like I couldn’t let her be put down, I was sleeping in like 2 h shifts because I was just terrified that she was going to die… And it got to the point where I had like a complete melt down and I didn’t know why. But no one spotted it. I’d done, I’d had my initial appointment with the midwife or health visitor, whoever it was, but it was so rushed. They didn’t get it. I had to contact my GP myself to ask, y’know, to be put on the mental health service lists… but y’know, nobody contacted me. I waited for like 3 weeks… |
15. Mental health literacy | FG5.F2: I felt like I was going totally mad. I knew I didn’t have postnatal depression… and I did those questions with the health visitor, and she seemed to think I was ok. But then I couldn’t stop worrying about (the baby). I’d constantly check on her. And I didn’t want to go out in case something bad happened. And that’s not right. I didn’t know what it was, but I didn’t feel depressed. |
FG3, F2: I kept reading the books… and one page was on postnatal depression. I was like I haven’t got any of the symptoms, if anything I’m really happy but I’m not right. | |
FG2.F1: it definitely helps just knowing what it is. Because once I knew what it was I could, it was calmer in my mind a little bit. |
Unrealistic expectations of birth and motherhood
Expectations of childbirth
In addition, those actively pursuing natural childbirth felt that there was an absence of realistic information (or sometimes misinformation) available about what to expect during labour, with some women reporting that their midwives actively withheld information about commonly occurring interventions, which often made them feel anxious, out of control and infantilised.FG5.F2: By the end of the sessions, I was like maybe I want a natural birth, I don’t want any pain relief. And someone said to me, why do you want those things? Is it because you really want those things, or is it just because you’ve been sort of conditioned to think that. And I didn’t know.
FG5.F1: It’s almost like they treat you a bit like a child, like you can’t make your own decision so you can’t hear anything scary because you won’t be able to cope with it.
Expectations of breastfeeding
FG5.F4: Why is this kind of bias allowed in a place where you know, you’re actually working with people who are quite vulnerable… people should be able to provide unbiased information about childbirth and breastfeeding.
Unrealistic guidelines and norms
Many women also felt childcare guidelines were often “unrealistic” (particularly on the topics of sleep and feeding) and offered no alternative suggestions for situations when their babies did not adhere to the guidance advice.FG1.F5: (milestones) put pressure on you. Because you want to know, ok…why is my baby not doing this? … And then you start to Google if he doesn’t sit by this month what’s wrong with him?
Unrealistic social comparison
Societal pressure
Throughout the quotes associated with this first theme was a sense that the women in this study felt they lacked agency, power and control in the perinatal period, often positioning themselves as novices in the situation and others as experts. For example, HCPs and antenatal class leaders were often characterised as gatekeepers to antenatal information, representing a lack of control or ability for the women themselves to make informed decisions about childbirth. Furthermore, discussions around milestones, guidelines and social comparisons often contained an implicit sense of powerlessness, as women both acknowledged that they were unrealistic, at the same time as aspiring to them. Societal scripts also gave way to a sense of helplessness and failure, with many women feeling that they did not live up to social expectations of what a good mother should be.FG4.F3: you do get a bit of rhetoric of this is the way that you should look after your baby, and then when it does deviate from that then you feel like you’re not meeting that standard.
Importance of peer support
Offline social support
However, many of the FG participants did not take part in antenatal classes, primarily “because it’s so expensive...” (FG3.F1), which often led to feelings of isolation. Interestingly, this arose as an issue more in the rural FGs than the urban groups, and may be indicative of social-economic differences between the groups. In contrast to antenatal groups and breastfeeding groups, postnatal ‘mum and baby’ classes were not identified as an important source of support and were often experienced as isolating, as they do not encourage adult peer interaction (due to their primary focus on the babies).FG5.F3: I would say this (antenatal group) has been the most important thing terms of support really.
Furthermore, discussions suggested there were fewer mum-and-baby classes available in rural (compared to urban) settings. (FG1.F5: if you live maybe in a small village, then I think you don’t have that much possibility to have these baby events.) And some mothers reported being “denied access to postnatal groups” (FG2.F2) because they already had older children.FG2.F1: I’d go to these classes… (but) people wouldn’t go by themselves, they’d all go in twos. And I’d sort of sit there and I’d be going I haven’t spoken to anyone.
Online social support
FG3.F2: Mumsnet gives me a little bit of anger…
FG3.F1: …Yeah, sometimes it makes you worry more.
FG2.F1: I would use (the Facebook group) for support there because I found, I tried the midwife, I tried the health visitor, I tried family and I tried the GP and I didn’t really get anywhere. So for me I used that because I don’t really… leave the house all that often... But actually I think the biggest support and the biggest help people get is other mums that are going through exactly the same thing.
Normalisation of experience
FG1.F1: it was one mum… it was so refreshing, she said I didn’t really enjoy it until he was six months old. And something clicked in my brain then where I was like finally somebody… And suddenly just having someone say it took the pressure off and I could start to enjoy it (and) give myself a bit of a break
Uncertainty and maternal confidence
Unprepared for change
FG4.F3: There’s a gap where I didn’t know anything about children until I was 35… and I think that was really too late. And I think all of these issues around y’know… how does breastfeeding work… or how to deal with different labour scenarios. For me coming into that being new at 35 was really too late I think… I don’t know why we don’t talk about it from school onwards.
Maternal confidence and overwhelm
Women often described feeling “overwhelmed” (FG3.F2) and found it difficult to balance the demands of motherhood with those of everyday life. Conversations often fell into ‘before/after’ childbirth narratives, with mothers often feeling that they were no longer able to do the things they used to, including finding the time to look after themselves.FG1.F6: People always just say just trust your instincts, you’re the mother you know best. But I don’t know. I don’t have any instincts because I don’t know about this situation. So I actually find that… to be really anxiety inducing.
FG3.F1: I never prioritise (looking after myself) anymore but I should… I just can’t stop enough… to do it.
Conflicting (or extreme) information
Interestingly, while women felt under pressure to live up to socially constructed ideals of motherhood, the presence of conflicting advice reveals how there is not really one true ideal. Not only is this confusing (and inherently contradictory), but also has the propensity to position women as always being wrong, regardless of what they do and what advice they follow.FG5.F3 “The midwife said one thing, the doctor said another, the two antenatal classes (I went to) gave exact opposite advice, and don’t even get me started on the internet. That just seemed to be one extreme or the other… So I was like, I don’t know what to do…. I don’t know who to listen to.”
Stigma
Internal and external stigma
Disclosure avoidance
Lack of mental Health support and knowledge
Lack of HCP support
Several women felt they had “slipped through the net” and missed out on support, because they were not explicitly picked up as having an issue by their HCPs. Many felt that this was due to postnatal mental health screening procedures that are primarily focused on PND, and are not in-depth or maternally focused enough to pick up other mental health problems or indicative nuances in individual experience. This was likely compounded by aspects of stigma, which led some mothers to actively avoid disclosure.FG1.F1: there hasn’t been a lot of help. Even if you go to the doctor about things like that… there doesn’t seem to be any groups or much information or resources.
Mental health literacy
And many mentioned that knowing what was wrong acted as a facilitator for access to support. However, even when it was recognised, some women felt there was a lack of information about how to cope with PNA, and what they could do to relieve symptoms.FG5.F1: Once I knew that was happening it was easier… because I knew what to expect.
Overall, several common sources of anxiety were identified by the participants, and a number of issues around current support were highlighted.FG2.F1: For me I just haven’t found… coping strategies. As in if you’re having an anxiety attack it’s quite hard to have that when you’re looking after children… What’s the best thing to do when you have an anxiety attack?
Categories | Quotes |
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Better preparation and management of expectations of birth and motherhood | |
1. Unbiased, balanced information | FG5.F4: So maybe just like more information about what happens after you have the baby… like a little factsheet… you know, like there is clusterfeeding, things about sleep, because I think that’s why you get the anxiety isn’t it. Because you’re all geared up to give birth, and then you do it and you get home and you’re like, shit… now I have a baby… and you don’t know what’s normal or not. |
FG5.F1: Impartial advice. Which I know is really difficult, but just having facts for me would be really helpful. Like the reason people tell you to do stuff, rather than them just telling you to do it. So like the reason that we would tell you to do this is X, Y and Z… but if you didn’t want to do it then fine. I think it’s the way you use the language as well… | |
2. Realistic information | F5.F5: I just think that they need to give you realistic information for when your baby doesn’t fit into the guideline… like when they won’t sleep on their backs or whatever. Realistically, are you supposed to stand over them all night and turn them back over each time? That’s impossible. F2: So maybe some realistic advice would be good. Instead of it all being so black and white. |
FG1.F3: I think just balanced views and like also some realistic, I can’t think of what the word is but realistic experience or something. | |
3. Evidenced-based information | FG1.F3: KellyMom was quite good… because it’s not just everyone giving you their opinion. It’s hugely like y’know researched articles that they’ve got… In my experience that’s more balanced… |
4. Expert advice | FG1.F2: If there would be a specialist… you can ask questions and that you can get support. I think that could, I think maybe allay a little bit of the anxiety because then you know that you can trust the expert’s advice and then you can relax because you feel like you’re on the right track. |
FG3.F2: If you could get like a list of all these worries that are quite common for mums, and then like some sort of answer to them. That would be really helpful wouldn’t it? | |
Peer support | |
5. Moderated peer input | FG5.F1: There’s an app I use where people pose questions, and people answer them. But the answers are moderated and I think they pick like 5 or 6 answers that you see… You get like the expert answer and then you get like real mum’s answers. But the real mums answers, I think they pick them… ummm… moderate them. They’re generally quite like ummm… helpful. They’re not just like, ‘oh my god this happened to me and it was so awful…’ Which is good, because I don’t want to read someone’s nightmare story… that’s going to make me feel so much worse. |
FG5.F5: For breastfeeding, uhhh… there’s a UK Facebook support group. And that’s quite good, because the admins will turn off commenting. Or they will come in and say… you’re giving inappropriate advice here, this is what we would suggest. And I find that a bit more balanced. | |
6. Limited peer input | FG4.F5: One of my main sources of support is my NCT group because there’s eight of us, and that’s a nice number. It’s not too many voices and you feel like you can share and be open… so I don’t know if there is any scope to have an online version of that for people who can’t afford the NCT. |
7. Relevant adjunctive face-to-face support | FG2.F2: When you go in a baby group it’s not like this… it’s not focused on the parents. I think it would be nice if you go to a baby group like this, where it’s focused on the whole idea of getting you all to talk to one another and something like that would be really helpful for someone like me. |
FG2.F1: If there was a postnatal depression or anxiety group where you could bring your kids but you could also chat to other people… that’d be good. | |
FG3.F1: it would be good to have something where you could have a chat with the other mums…where the babies are happy but you can actually have a conversation as well with other… because sometimes you pay for those groups, and then you arrive. And the whole session is really busy, you don’t really talk to anyone else, and then you all go… even having 20 min after groups where people can get their bags together slowly, or there’s toys out where the babies can slowly leave, rather than everyone out the door. Because then you can actually make other contacts with people. | |
Normalisation | |
8. Normalisation of feelings through exposure to other mums | F1.FG1: I saw something really good… it was so simple, they had three women sat around with a cup of tea in a kitchen and they just spoke to each other like in a conversation about their postnatal anxiety problems. And it was just really lovely because you just felt like you weren’t alone... So something like that where there’s a bit of video content, and again like, you know, for someone who hasn’t had a lot of sleep and can’t read a lot, that would be really good I think. |
FG2.F2: I think maybe if you had somewhere you could watch little video clips of people just talking openly with the kids in the background, or doing whatever. Maybe just little things like that… | |
9. Humour as medicine | FG1.F5: I ended up following a public figure who was writing a book The Unmumsy Mum and they just said like very silly things. So I just ended up reading a lot of silly things that she’s been doing with her kids that makes it OK not to be the perfect mum. And that helped me to let go of other stuff as well. So I think just making things funny, maybe sometimes a good laugh can release some of the negative energy as well. |
Information about PNA symptoms and management | |
10. Information about PNA | FG3.F2: On this internet programme I have to do (questionnaires) every single week… and yeah they’re quite helpful. Because the first time I did them… I was like oh so other people think that too. |
FG2.F1: Yeah, and also understanding what is actually wrong with you… And then I guess then once you know you’ve got something, or that something’s building up, you can, I read a lot about it and I understood a lot about it and it helped me, so maybe some information (about PNA) on a website. | |
11. Anxiety management | FG2.F1: Coping strategies… I’d find that quite useful... just how to manage it almost. |
Increasing maternal confidence and wellbeing | |
12. General wellbeing support | FG1.F1: Could it be about helping mums with their wellbeing as well…So maybe that wellbeing as well as factual like about breastfeeding advice and that. I would love to have some more information about things that you can do to look after yourself. |
FG1.F6: People always just say just trust your instincts, you’re the mother you know best. But I don’t know. I don’t have any instincts because I don’t know about this situation. So I actually find that… to be really anxiety inducing. | |
FG3.F2: If somebody actually text me and say ‘think about you for 5 min… I might actually do it… you know’ | |
Accessible to audience | |
13. Video and audio content | FG1.F1: I don’t have a lot of time to read as well, so I don’t know if there could be elements where it’s audio. So I listened to a lot of podcasts and that was really helpful in the early days… I just think when you’re so sleep deprived. I don’t know about anyone else but completing a form or reading, like, a website full of paragraphs I couldn’t do it. So thinking about how you translate that information would be really helpful. |
FG3.F2: The only thing I can suggest is like… on You Tube, there’s some videos that you can watch… I could say to myself I’m going to have 10 min to watch this video, and it’ll be, I don’t know, just nice nature images and reaffirming things… something like that for mums postnatally to watch, that might be the way to just sit down and watch something. It would be nice when you can’t, you just haven’t got the energy to do it yourself. | |
14. Easy to navigate | FG1.F2: spend a lot of time on how the website looks, and how you navigate through it. And that will mean that people have the time and the inclination to use the resource, rather than it just to be too difficult, because when you’re sleep deprived and you don’t have time… y’know… I mean like easily structured and with headings and click routes on different categories of things. |
15. Easy to find | FG1.F1: Make sure you make yourself visible because that is the hardest thing, is finding. |
Privacy | |
16. Discreet | FG2.F1: The only thing I find off putting… is if (websites) can post on my Facebook page… that’s the only thing that would annoy me, is that I don’t want posts on Facebook page about my (problems). |
Better preparation/management of expectations of birth and motherhood (subthemes 1–5)
Peer support (subthemes 5–7)
FG5.F4: If there is going to be a forum, what is the purpose of the forum? And how… what role does it play in addition to what you want to offer. And if you are trying to offer you know, evidence-based information then I’m not sure it’s that helpful because it…
FG5.F3: …it muddies it…
Instead, women said they would prefer to hear from peers in a more moderated manner. And while the study aimed to elicit suggestions for supporting PNA online, all FGs suggested that internet-based support would greatly benefit from a face-to-face component. Interestingly, most women spontaneously commented on how supportive and useful they found the FGs themselves, with some women explicitly suggesting that the mum-focused nature of the interviews would be a useful model of support for future mum-and-baby classes:FG5.F4: …yeah, yeah it does. And also I think Mumsnet… already does that job.
FG2.F2: When you go in a baby group it’s not like this… it’s not focused on the parents. I think it would be nice if you go to a baby group like this, where it’s focused on the whole idea of getting you all to talk to one another and something like that would be really helpful for someone like me.