Perspectives and challenges of mothers in the care of newborns delivered in a non-profit tertiary care institution in South India: a qualitative study

INTRODUCTION

Newborn care is closely intertwined with the wellbeing of mothers in the postnatal period. Early newborn care during the first week is facility based with a focus on clinical indicators of weight gain. Beyond the first week, postnatal care of mother and newborn is primarily community-based through the health workers and accredited social health activists (ASHA) who visit mothers at their homes.¹ Postnatal care is highly influenced by cultural and societal beliefs on maternal nutrition, breastfeeding and child rearing.²

The transitional postnatal phase involves a delicate balance between the demands of newborn’s biological needs with the mother’s physical and psychological changes of pregnancy and delivery. Postnatal care should aim to understand the perspectives of mothers and caretakers in the regular care of newborn. Newborn care involves unmet clinical needs and priorities of the new mothers. Literature report that mothers are oblivious to the range of medical specialties and the first contact person of the health care team for concerns related to newborn care.³

Approximately three million preventable neonatal deaths occur annually.⁴ India’s neonatal mortality has declined from 26 per 1000 live births in 2014 to 17.29 in 2023.⁵ The National Health Mission has implemented facility based newborn care services 4224ocusing on immediate resuscitation, prevention of infection, early breastfeeding, care of sick newborn in newborn stabilization units and special newborn care units.⁶ Kangaroo mother care and family care are promoted within the newborn units to yield maximum benefits to the newborn.

In our setting of a non-profit tertiary referral centre for obstetrics and neonatal care, access to health care professionals for minor illnesses and concerns related to care of the newborn is to be explored. The study results will provide insights into the knowledge of mothers on newborn care. Based on the study results, comprehensive health education can be planned to address maternal concerns on newborn care and to improve the quality of newborn care in the community.

This qualitative study was undertaken with the following objectives:

To explore the perspectives and challenges of mothers and caretakers of neonates, who presented to a hospital for an unscheduled neonatal visit after discharge.

To explore the perspectives and challenges of mothers of neonates who did not come for a scheduled neonatal visit, either for a special or routine visit after discharge and of mothers of neonates who came for a scheduled neonatal visit.

To explore the perspectives and challenges of mothers of neonates for optimal breast feeding.

METHODS

This study was part of a large cohort study of postnatal events done at the department of obstetrics and gynecology in a not-for-profit referral centre in Vellore, South India.⁷

Study design

A hospital-based qualitative study was conducted with in-depth telephonic interviews of purposively selected postnatal mothers who delivered in our centre in the last quarter of 2022.

Inclusion criteria

Mothers and care takers if any, of babies with unscheduled and scheduled neonatal visits with a medical problem or for a routine checkup and mothers who did not come for a scheduled neonatal visit in the last quarter of the year 2022.

Data collection

A structured questionnaire with open ended questions on neonatal care, breast-feeding, knowledge, attitude, practices and challenges of mothers during the neonatal period was pretested using pilot interviews. The questionnaire was translated into regional language (Tamil) and back translated to English. In-depth telephonic interview of the eligible participants was done by the co-investigators and research assistants who are well versed in the regional language. The interviews were conducted with the informed consent of the participants at their convenience, audio-recorded and transcribed. A total of 27 interviews were conducted till saturation of the content of interviews was reached.

Data analysis

The transcripts were independently reviewed by the co-investigators and interpreted based on the individual understanding of the textual data. The selected quotes of the data that correspond to a pattern of viewpoints were grouped under a common code. According to the objectives of the study the codes were grouped together to form major themes.⁸

RESULTS

About 80% of the participants had more than 12 years of education and 48% belonged to the upper lower socioeconomic group of modified Kuppuswamy scale. About 60% of the mothers were primi and 44% had undergone caesarean section. Majority of the newborns weighed more than 2.5 kg. Most participants were between 26-30 years of age (Tables 1-4; Figure 1).

The major themes that emerged from the data were related to: 1) Feeding of the newborn; 2) Handling illness in the baby; 3) Health and recovery of the mother during the postpartum period; 4) Support system; 5) Financial challenges; 6) Health education at discharge.

DISCUSSION

Based on the thematic analysis of the textual data from the in-depth interviews of 27 mothers who delivered in a tertiary care set-up, postnatal mothers felt challenged in implementing exclusive breastfeeding practices, managing common illnesses of the newborn and acceptance of the new self. In culturally bound situations, mother’s family members were perceived to be the most supportive during the postnatal period. Costs of hospitalization for acute care and access to the health care system for minor illnesses of the newborn were the other prominent challenges of postnatal mothers.

Challenges in breast feeding were either related to medical (less milk, surgery, preterm baby, inverted nipple) and or social causes (like bottle-feeding, giving cow’s milk, or pressure from family). Participants were aware of the benefits of exclusive breastfeeding for six months, yet supplementary feeds were substituted in complex real-life situations of excessive crying of the infant or sickness in mothers. Mother’s commitment to breastfeeding needs moral support, encouragement and appreciation within the family and the healthcare system. Recent literature on ways to encourage breastfeeding concluded that morally neutral and realistic goals on breastfeeding should be set with active involvement of the family.⁹

Common illnesses including fever, cold, vomiting, and poor weight gain in the first three months was a major concern for many mothers who felt supported by the reassurance of the hospital staff. Mothers and families of babies who required hospitalization, surgery or intensive care admission were very stressed emotionally and financially. In addition to physiological changes, maternal medical morbidities, operative deliveries and postpartum complications directly affected their ability to feed and care for the baby. Empowering mothers for self care, enabling group sessions in the community to validate the experiences of mothers and culturally appropriate holistic care for families should be reinforced.⁶

Mothers who had a strong support network of husbands, parents, in-laws and other family members reported fewer problems and were less stressed. Those who lacked support or had only partial help felt more burdened and anxious, especially when babies cried continuously or when mothers experienced medical problems. Culturally, family systems in India influence and own newborn care as their primary responsibility. Preparing family members for a culturally sensitive role through health education during the antenatal period will emphasize family centered care of the newborn and empower the mothers in newborn care.¹⁰

Most mothers were supported for the expenses of a delivery and newborn care in a private institution through a stable income of the family and or private insurance. However few mothers who faced unexpected medical costs [neonatal intensive care unit (NICU), surgeries, or twins] suffered greatly. Financial hardship added to the emotional stress affecting family life and children’s education. A meta-analysis on the stress of parents of high-risk neonates admitted in NICU in India concluded that uncertainty related to high NICU costs and baby’s wellbeing along with barriers to bonding were the primary stressors for parents.¹¹

CONCLUSION

Our study adds to the evidence on the unmet maternal needs of newborn care related to breastfeeding, neonatal illnesses, financial supports, family systems and access to health care systems. Common symptoms, cultural role of family members, unexpected hospitalisation of the mother and or the newborn, undefined role of motherhood and costs of regular newborn care or hospitalisation contribute to the stress of newborn care. Implementing exclusive breastfeeding need non-judgemental support to the mother from family and health care professionals. Health care teams should anticipate, explore and identify the common challenges of mothers and plan a culturally sensitive communication to ensure holistic family-centred newborn care.

ACKNOWLEDGEMENTS

Authors would like to acknowledge and thank all research staff from the department of obstetrics and gynecology for helping with recruitment and participation in the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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