Study on the effect of intervention on postpartum psychological improvement and body recovery of caesarean section women based on information‐motivation‐behavioural skills model

To explore the effect of information‐motivation‐behavioural skills (IMB) model on psychological and emotional state of caesarean section (CS) women.


| INTRODUC TI ON
Caesarean section (CS) is the most frequently performed obstetric surgery. In recent years, the rate of CS has been increasing (Antoine & Young, 2020). Compared with vaginal delivery, CS is associated with a stronger stress response in pregnant women, which can not only increase the operation risk, but also affect the postpartum recovery (Madsen et al., 2013;Molgora et al., 2020). Studies have suggested that the adverse psychological and emotional state of mothers during pregnancy and childbirth can affect the neurobiology and behaviour of the offspring, and this effect may continue until adulthood (Sandall et al., 2018). Therefore, in recent years, the emphasis has been placed on the psychological intervention during the perioperative period in women who are about to undergo CS (Che et al., 2020). On the basis of a comprehensive analysis of patients' psychological and emotional states, targeted psychological intervention measures can effectively improve the adverse psychological mood and further improve the safety of delivery (Hemanth Kumar et al., 2014). The IMB model was first proposed by Fisher and other scholars in 1992 in the process of studying high-risk behaviours associated with AIDS. The model suggests that the occurrence of the disease-prevention behaviour is affected by whether the patient has obtained sufficient information, motivation, and skills. Based on the IMB model, intervention can promote self-motivation and healthy behaviour, and encourage active cooperation with clinical intervention (Ali et al., 2020;Chu et al., 2019). The IMB model not only provides a framework for analysing the influencing factors of the behaviour, but also outlines the impact of various factors on the behaviour of patients, helping to predict it (Ntoumanis et al., 2021). At present, the IMB mode of intervention is mainly applied to patients with AIDS and diabetes, while the reports of applying it to mothers undergoing CS are limited (Bakır et al., 2021;Dubov et al., 2018).
Therefore, this study evaluated the efficiency of the IMB model intervention in the perioperative period of CS and discussed its effect on the improvement of postpartum psychological and emotional state and postpartum recovery.

| MATERIAL S AND ME THODS
One hundred and two pregnant women who underwent caesarean section in Hangzhou Women's Hospital from January 2020 to June 2021 were randomly divided into Control-group and Observationgroup, with 51 cases in each group. Two patients in the Observationgroup withdrew halfway. All pregnant women met the indications of caesarean section or the requirements of pregnant women for caesarean section.

| Control-group
All the patients in the Control-group received routine nursing, and the routine nursing was as follows.
• Preoperative and intraoperative care: The nurses introduced the basic procedure of CS, the environment of the operating room and the ward to the puerperae, and informed them of precautions and cooperation points, calmed their anxiety, encouraged them, patiently listened and responded to maternal complaints. Close interaction was maintained during the operation, through limb and eye contact, which helped to build a trusting relationship between the surgeons, nurses and the puerperae.
• Postoperative care: Patients were immediately informed of the successful operation after the surgery. Mother-infant contact was established as soon as possible. The blood pressure, heart rate, pulse, vital signs, uterine contraction and vaginal bleeding of the puerperae should be closely observed, and the doctors should be notified in time if there is any abnormality. The puerperae should adopt a semi-recumbent position 24 h after CS, which can promote the discharge of lochia. The urinary catheter was indwelled for 24 h after CS, and the puerperae were instructed to urinate as soon as possible after extubation. The puerperae were encouraged to turn over frequently and get out of bed as soon as possible.

| Observation-group
Patients in the Observation-group received the same routine nursing as the Control-group (see above). In addition, a special IMB mode intervention team was set up and included one doctor and three nurses. The team carried out IMB mode intervention on the Observation-group for 2 months. All team members have been trained by IMB professionals. The key points of the IMB mode intervention include the following: • Information intervention: After the patients were admitted to the hospital, the pain questionnaire and face-to-face communication were used to understand the cognition level of the patients, and health education was carried out based on these data. In addition to introducing the basic knowledge of routine nursing to patients (operation-related knowledge, the environment of the operating room and the ward, precautions and cooperation points), nurses also informed the patients about the prevalence of CS, CS procedure, CS-related complications, as well as the key points of rehabilitation after CS, which allowed patients to have a more comprehensive understanding of CS. Relevant knowledge was compiled into a health education brochure, which was distributed to the parturients for independent reading. The key points of the health education brochure were listed in Table 1. • Behavioural intervention: (A) Before the operation, patients were informed in detail of the discomfort and complications that may occur during the operation, and operation safety and prognosis were discussed to make them cooperate actively. (B) After CS, in addition to the postoperative care mentioned in the routine nursing, the women were given behavioural skills training on how to rapidly recover from CS, enlisted social support from family members and received self-regulation strategies. (1) Rapid recovery behavioural skills: 6 h after CS, the puerpera performed straight leg lifting exercises to enhance abdominal muscle tension, six times per minute. Three days after delivery, they performed sit-ups, four times per minute; waist rotation exercises were performed to exercise the muscles of the lower back, six times per minute; squat upright exercise to strengthen leg muscles were done 10 times per minute. Women were guided to walk slowly to exercise the muscle strength of lower limbs, 4-5 min each time. Moreover, the puerperae were taught to exercise the pelvic floor muscles and fascia through the anal contraction exercise: the puerperae took a free position, lifted the anus, urethra and perineum as much as possible, contracted once every 5-10 s, rested for 5-10 s and then repeated the training for 5 min, three times a day, until the end of puerperium. (2) Social support from family members: ① Family members were guided to massage the lower abdomen of the puerpera after CS, with even force in a clockwise direction, from light to heavy massage, which can help to promote uterine contraction. ② Six hours after CS, the responsible nurse evaluated the situation of the women, provided semi-liquid food rich in protein, vitamins, minerals and cellulose according to the personal situation of the women, and formulated a special and reasonable healthy diet plan for women with special needs, to adequately supplement the nutrition and energy. Family members were encouraged to strictly follow the nurse's requirements to give a nutritional supplement to the puerpera. ③ Family members received guidance on breastfeeding and helped mothers breastfeed for the first time.
(3) Self-regulation strategies: ① Self-body management: Puerpera should pay close attention to their physical condition and timely report any discomfort after CS, and perform the rapid recovery behavioural tasks accordingly. ② Caesarean incision care: since it takes about 5 weeks for the incision to heal after CS, the mothers were provided with guidelines for incision health management and were encouraged to pay attention to exudate, infection and cleanliness of the incision. ③ Timely contraceptive measures: women were provided with the information that sexual intercourse should not be started until 42 days after the delivery and after the lochia has completely cleared. points and above are severe anxiety (Grigoriadis et al., 2018). There are 20 items in the SDS, the rough score is obtained by adding the scores of the 20 items using the 4-level scoring method. The rough score is multiplied by 1.25 and the integer part is taken to get the standard score; the higher the standard score, the more serious the degree of depression. According to the results of the Chinese norm, the SDS standard was divided into 53 points, 53-62 points for mild depression, 63-72 points for moderate depression, and ≥73 points for severe depression (Zung, 1965). The general self-efficacy scale (GSE) (Schwarzer & Jerusalem, 1995)

| Statistical analysis
The data of this study were processed by SPSS22.0. [n (%)] representing the counting data, the test methods used were χ 2 or Fisher's exact test. The measurement data were tested for normality by Shapiro-Wilk test, and ( ± s) was used to represent the measurement data that conformed to normal distribution and homogeneity of variance test. Paired t-test was used for intra-group comparison, and án independent sample t-test was used for inter-group comparison for measurement data. The significance level was set at 0.05.

| RE SULTS
In total, 102 women were included in the study and randomly divided into two equal groups (n + 51 in each group). The average age of the Control-group was 28.17 ± 3.79 years old. the two groups increased after intervention, the GSEs scores of the Observation-group was significantly higher than the Controlgroup (p < 0.05) ( Table 3); The incidence of complications in the Observation-group was 3.70%, lower than 14.81% in the Controlgroup (p < 0.05) ( Table 4). There were no women with more than one complication in our study; Before the intervention, there was no significant difference in the scores of FSS and EPDS between the two groups (p > 0.05), but on the 14th day after delivery, the scores of FSS and EPDS decreased in both groups, and patients in the Observation-group showed significantly lower FSS and EPDS scores than the Control-group (p < 0.05) ( Table 5).

| DISCUSS ION
It has been reported that the prevalence of maternal postnatal anxious symptomatology was 34.5% at 1-24 weeks postpartum, and 30.8% at >24 weeks postpartum, which seriously affects maternal mental health and postpartum quality of life (Cena et al., 2021).
Our results showed that the SAS and SDS scores of patients that received the IMB model of nursing were significantly lower than those who received routine nursing. We considered the reasons In addition, our study also found that the GSEs score of the Observation-group was higher than that of the Control-group.
Previous study by Wang et al. (2019) (Burke & Allen, 2020;Woodd et al., 2019). Postpartum complications following CS not only affect the physical and mental health of women, but also directly reduce the efficiency of postpartum recovery (Hung et al., 2016).
In this study, the incidence of complications in the Observationgroup was lower than that in the Control-group (p < 0.05), suggesting that the self-care behaviours applied by the IMB model in the perioperative intervention of CS women can reduce the incidence of complications.
Moreover, our study also found that the postpartum FSS and EPDS of the Observation-group were lower than those of the Control-group (p < 0.05), suggesting that the implementation of  This study has several limitations, such as a small sample size, few observation indicators and no long-term postpartum follow-up, which may make the conclusion one-sided and limited. Additionally, the study was performed during the period of the COVID-19 pandemic which had an impact on the perinatal care system and on the mental health of pregnant women, which may affect the results.
Therefore, the follow-up multi-center and large-scale studies are needed to comprehensively analyse the perioperative psychological and emotional state and psychological intervention effect on women undergoing CS.

| CON CLUS ION
Compared with routine nursing, nursing intervention based on the IMB model can more effectively improve the postpartum psychological and emotional state of women that are undergoing CS, enhance self-efficacy, reduce the incidence of complications, and help to promote postpartum recovery.

AUTH O R CO NTR I B UTI O N S
LX conceptualized and designed the study; LX and LF did literature search and data collection; QX and DS analysed the data; LX and LF wrote the paper; QX and DS reviewed and edited the manuscript. All authors read and approved the final manuscript.

ACK N O WLE D G E M ENTS
None.

FU N D I N G I N FO R M ATI O N
The current study was funded by Zhejiang Medicine and Health Science and Technology Plan Project (Grant number: 2019322760).  *Indicates the comparison with that before the intervention, p < 0.05.

TA B L E 5
Comparison of postpartum recovery between the two groups ( ± s, score).

TA B L E 3
Comparison of SAS, SDS and GSEs scores between the two groups before and after the intervention ( ± s, score).

Before intervention
After intervention

Before intervention
After intervention Abbreviations: SAS, self-rating anxiety scale; SDS, self-rating depression scale.

After intervention
*Indicates the comparison with that before the intervention, p < 0.05.

CO N FLI C T O F I NTE R E S T S TATE M E NT
No conflict of interest has been declared by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

R E S E A RCH E TH I C S CO M M IT TE E A PPROVA L
The medical ethics Association of Hangzhou Women's Hospital has approved the study (Approval number: 2021-K-10-09, date: 2021-10-19).