Positive postpartum well‐being: What works for women

Abstract Background Women's experiences of pregnancy, birth and motherhood extend beyond healthcare provision and the immediate postpartum. Women's social, cultural and political environments shape the positive or negative effects of their experiences through this transition. However, there is limited research concerning the factors that women identify as being protective or promotive of maternal well‐being in the perinatal period and motherhood transition. Objective To explore women's views on the factors within healthcare, social, cultural, organizational, environmental and political domains that do or can work well in creating positive perinatal experiences. Design, Setting and Participants A qualitative descriptive study with embedded public and participant involvement (PPI). Participants were 24 women who were maternity care service users giving birth in Ireland. Results Three themes were developed. The first theme, ‘tone of care’, related to women's interactions with and attitudes of healthcare professionals in setting the tone for the care they experienced. The second theme, ‘postpartum presence and support’, concerned the professional postpartum supports and services that women found beneficial in the motherhood transition. The final theme, ‘flexibility for new families’ addresses social and organizational issues around parents returning to paid employment. Discussion and Conclusion Women suggested multiple avenues for promoting positive perinatal experiences for women giving birth in Ireland, which may be implemented at healthcare and policy levels. Women identified that maternal health education focuses on supporting informed decision‐making processes as a positive and worry‐alleviating resource. Additionally, women valued being met by healthcare professionals who regard women as the decision makers in their care experience. Exchanges in which healthcare professionals validate and encourage women in their mothering role and actively involve their partners as caregivers left lasting positive impressions. Extended and professional postpartum support was a common issue, and phone lines or drop‐in clinics were suggested as invaluable and affirming assets where women could access personalized support with healthcare professionals who had the knowledge and skills to genuinely approach women's concerns. Social and organizational considerations involved supporting parents to balance their responsibilities as new or growing families in the return to work. Public or Patient Contribution Maternity care service users were involved in the interviews and manuscript preparation.

professionals who regard women as the decision makers in their care experience.
Exchanges in which healthcare professionals validate and encourage women in their mothering role and actively involve their partners as caregivers left lasting positive impressions. Extended and professional postpartum support was a common issue, and phone lines or drop-in clinics were suggested as invaluable and affirming assets where women could access personalized support with healthcare professionals who had the knowledge and skills to genuinely approach women's concerns. Social and organizational considerations involved supporting parents to balance their responsibilities as new or growing families in the return to work.
Public or Patient Contribution: Maternity care service users were involved in the interviews and manuscript preparation. continuity of emotional and practical support from birth partners, (iv) consistent reassurance and support from competent staff and (v) a resourced and flexible health system. [1][2][3] Postnatal care and services have been described as the neglected aspect of maternity care throughout the world for decades. Criticisms include level and scope of service provision, duration of care and quality of care. [4][5][6][7][8][9][10][11] However, some studies have identified positive aspects of care, including active practical guidance with infant care and feeding, 12 assistance-focused, nonjudgemental at-home postpartum visits from a healthcare worker 13 and home-based postpartum care. 7 Additionally, positive postnatal care was found to enable women to adapt to their new identity, become confident in mothering and know and understand the physical and emotional changes that accompany childbirth and motherhood. 14 Evidently, perinatal care and quality services play pivotal roles in supporting women's perinatal health; however, women's experiences of pregnancy, birth and motherhood extend beyond healthcare provision. Women's social, cultural and political environments shape the positive or negative effects of their experiences through this transition. [15][16][17] Strong social support is an often-cited buffer against negative outcomes in any context, and it appears that in relation to the perinatal period, social support is the predominant area of exploration for promotive and protective factors for mental wellbeing. 18 There is, however, limited research concerning the factors that women identify as being protective or promotive of maternal well-being. Specifically, the factors that are present within women's interpersonal, social, ecological and political contexts and the healthcare systems available to them that (i) soothe or allay women's fears, worries, concerns and anxieties in the transition to motherhood and (ii) help women to adapt into this transition, support their confidence and well-being and promote a positive experience of the perinatal period. 19

| Design
A qualitative study with embedded public and participant involvement (PPI) explored the maternal health-related issues that matter most to women in the transition to motherhood, based on their experiences of maternity care and services. 21 The study was a substudy of the MAMMI (Maternal health And Maternal Morbidity in Ireland) study, a longitudinal study investigating the health and health problems of 3047 first-time mothers in Ireland.
The current study is a secondary analysis of data from women who participated in the PPI qualitative substudy. 21 The substudy identified a central concept of the 'invisible woman', which encapsulated issues arising within the current Irish maternity care system that left women feeling unheard, unseen and uncared for. The purpose of the current study was to tease out what women said worked well and/or what could have worked well when their experiences were less than positive. To achieve this, we conducted a secondary analysis of the data from the original PPI data to identify what factors support/could support women, within and beyond the health and maternity care systems, and foster positive experiences of the transition to motherhood. Findings are presented with this aim in mind; indications of less than optimal care or experiences are contrasted with solution-based descriptions of what women said did or could have succeeded in making their experience a positive one. This approach was derived from the way that women often spoke about their experiences, which were often accompanied by a description of care, services or resources that they wished they received/had access to.

| Ethics
The research ethics application was drafted by the researchers and reviewed by five women in the PPI study. Ethical approval was granted by the Faculty of Health Sciences' Research Ethics Committee of Trinity College Dublin. All participants completed written informed consent. Participants' identities have been anonymized for publication and all names are pseudonyms.

| Recruitment and participants
Following ethical approval, a letter of invitation was emailed to all MAMMI study participants who consented to receive research information and invitations. Women interested in taking part contacted the researchers directly by email or text; they then received a study information pack. Recruitment took place in June 2018.
Interviews with 24 women were conducted between June and September 2018 by one interviewer (Table 1). Details on recruitment and data collection were described previously. 21

| Data analysis
Data were reflexively thematically analysed using Braun and Clarke's six-step framework 22 : familiarization; transcribing, reading and rereading the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes and writing the report. Data were managed using Microsoft Excel. Illustrative quotes are presented using pseudonyms.

| Rigor
This study is underpinned by a critical realist ontology and a constructionist epistemology and takes a participatory/advocacy approach. It is part of a PPI initiative and a wider study examining Irish women's experiences of motherhood. The researchers are maternal health researchers (midwives, psychologists, sociologists and chiropractors), advocates of women's health and agency, who coconceived/co-designed the study with women in the PPI. This approach influenced the way that data were analysed, and themes were produced. This reflexivity and transparency aid in qualitative research rigour and we present raw data to demonstrate each theme.
Co-authorship with one to two self-nominating women from the PPI study was planned from the outset.
For the current study, three researchers (S. H., E. N. and D. D.) refamiliarized themselves with the complete interview data set and then analysed eight transcripts each in which they identified new codes related to the secondary research focus. We met to discuss our initial codes and findings and to ensure that there was no overlap with the findings of the previous study. Following the agreement of codes and themes, the final themes and a selection of anonymized illustrative quotations were returned to participants for confirmation and comments. Participants were asked if they recognized their views or the views of others that they may have heard of, even if they did not hold or agree with those views themselves. Four participants responded, and all stated that the findings and themes were very or fairly true of their own views and that they recognized the views of others even if they did not hold those views themselves. Two PPI members (L. J. and E. M.) who were also participants of the original study were involved in refining the final themes and manuscript preparation.

| FINDINGS
Participants' characteristics are presented in Table 1. And I was able to decide … between us, we were able to sit down and have a chat about it, in our own time.
And I felt like, right 'Now I'm going into having a section, because I know that's the safest thing to do'. and what to bring to the hospital and all that sort of thing. Whereas the other one … was more empowering, about understanding the whole medical side of things, so that you were more in charge of your own labour and delivery. Rather than just feeling like you were … I was going to say, prey for the consultants but you know? That you were secondary, you were just, everybody else was in charge and you were just … The external course also clearly recognized the role, importance and involvement of the partner. As one participant identified, it empowered her partner to take an active role in the labour process. Women viewed paternity leave as a societal recognition that a partner (in this study, all partners were male) is as equal a parent as the mother.
The woman gets six months off, like why can't the husband get half of that time off? I know they've changed the law in that. Again, it's just a cultural thing like (…). Like, they're just not, they're secondary. (Sarah) Women also acknowledged certain perceptions, barriers and career consequences to partners availing of paternity leave.
He would love to have the opportunity to be able to Research with fathers consistently reports a lack of father-specific support within the maternity care systems. This can range from poor communication with HCPs, to being ignored and side-lined in maternity settings where they feel treated as visitors. 27 Our findings align with previous research, which shows that women value partner inclusion as an acknowledgement of their partner's vital supportive role, 28 and extend beyond this by demonstrating that women perceive the inclusion of their partners as a comforting evolution from out-dated perceptions that mothers are solely responsible for childcare within the family unit.
The positive involvement of fathers by HCPs can also help in the preparation of parents. 29 However, midwives and key HCPs acknowledged their lack of training and confidence in addressing fathers' needs and the numerous individual, social, cultural and health service factors that can present barriers to engaging fathers in perinatal care. 30 The recognition of a partner as a parent to the child and support to the woman was echoed in women's views.
With regard to the postpartum period, similar to previous research in which mothers expressed dissatisfaction and disappointment in insufficient postpartum services and information, 31 34 One Irish study with employed women revealed the complex inequalities experienced by mothers in paid employment, 35 whilst another study showed the influence that these costs have on women's participation in the workplace. 36

| Limitations
Women's experiences are influenced by culturally based expectations. Women in this study were predominately White-Irish. Women of diverse ethnic and cultural backgrounds may offer different perspectives on factors that lead to positive maternal well-being and experiences. Additionally, the data lacked perspectives from single mothers or women in same-sex relationships as all participants were married or living with male partners.

| CONCLUSION
Although there has been increasing interest in understanding the factors involved in cultivating a positive perinatal experience, research largely remains focused on risk, barriers and illness. The