Introduction

The postnatal period is a significant phase in the lives of mothers and babies. It is a time of adaptation to parenthood, of the development of secure attachment for the neonate and young infant, and a time where bonds can develop within the family and with the community [1]. For some mothers and babies it includes ill-health [1,2]. Specific maternal mortality/morbidity data relating to the postnatal phase is limited; however, recent figures indicate there are an estimated 303 000 maternal deaths annually resulting from complications related to pregnancy, childbirth or the postnatal period [2]. The majority of these deaths occur postnatally, with post-partum haemorrhage (PPH) the most common cause of maternal death [3]. Neonatal data are more widely available and recent estimates indicate there are almost three million neonatal deaths (deaths in the first 28 days after birth) each year, most of which are preventable [4]. The Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030 highlights the importance of postnatal care for mothers and babies in ending preventable deaths and ensuring health and wellbeing [5]. Strategies designed to reduce the rates of maternal and neonatal mortality are also endorsed by the World Health Organization and emphasize the importance of the postnatal period in achieving this goal [6,7].

By definition the postnatal period is the phase of life immediately following childbirth. Its duration is culturally variable, but the first six weeks after childbirth is common cross-culturally, and the WHO defines the postnatal phase as beginning immediately after the birth of the baby and extending for up to six weeks (42 days) after birth [1]. In terms of care provision, the postnatal period tends to be divided into the immediate (first 24h), early (days 2–7) and late (days 8–42) periods. Postnatal care in the immediate phase is likely to be facility based in many settings, and focused on key clinical indicators for the baby and monitoring of general well-being for the mother [8,9]. Early and late postnatal care is more likely to be community based and focused on maximizing maternal and newborn health and wellbeing. Postnatal contacts provide an opportunity for healthcare providers to facilitate healthy breastfeeding practices, screen for postpartum depression, monitor the baby’s growth and overall health status, treat childbirth-related complications, counsel women about their family planning options and refer the mother and baby for specialized care if necessary [8,9].

To achieve the aim of both thriving and flourishing, as well as surviving, it is important that mothers and families are supported and enabled to experience the optimal start in life with their newborn [1]. However, the postnatal period is a neglected phase of maternity care with more emphasis and resources placed on antenatal and intrapartum care [10]. According to the recent ‘Countdown to 2030’ report postnatal services have the lowest median national coverage of interventions on the continuum of maternal and child healthcare [11]. In addition, utilization of postnatal services varies widely, particularly in low and middle-income countries (LMICs), where barriers to access based largely on socio-economic circumstances and rurality limit engagement [12]. Innovative approaches like m-health have shown some promise in raising awareness and increasing coverage in some LMIC settings [13] and giving birth in a recognized health facility may enhance further engagement with postnatal services [14]. However, the situation in many under resourced LMICs is hugely variable and, even in hospital settings, many women fail to receive the most basic pre-discharge check-up [15,16].

Existing literature focusses predominately on the effectiveness of specific postnatal interventions, or around women’s experiences of postnatal care services (see for example, [17–19]). This has resulted in limited information about what women themselves value during this period. The aim of the review is, therefore, to identify what matters to women in the postnatal period, in order to better understand how postnatal services can be optimally designed to deliver a positive experience to meet the needs of women, their families and their neonates.

Methods

We conducted a thematic synthesis of qualitative studies in accordance with the PRISMA guidelines (See S1 Table). We included studies where the focus was on healthy women and neonates, irrespective of parity, mode of birth or place of birth. Study assessment included the use of a validated quality appraisal tool [20]. Thematic synthesis techniques [21] were used for analysis and synthesis, and GRADE-CERQual [22] was applied to the resulting review findings.

Results

Included studies

Systematic searches yielded 2920 records. Ninety-five duplicate records were removed. Of the remaining records, 2473 were excluded by title and a further 213 excluded by abstract, leaving 139 full-text papers to be screened. Thirty-seven full-text papers were quality appraised and one [24] was excluded following translation because it focused on women’s experiences of postnatal care rather than their needs and expectations, meaning that 36 were included. No papers were excluded on quality grounds, and after our quality appraisal checks 8 included papers were rated A, 16 were rated B, and 12 were rated C. Thirty-six papers were therefore included in the data analysis [25–60]. A PRISMA flow chart illustrating the selection process is shown in Fig 1.

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Fig 1. PRISMA flowchart.

https://doi.org/10.1371/journal.pone.0231415.g001

The characteristics and quality appraisal ratings of the included papers are summarised in Table 1. Papers were published between 2003 and 2019 and 33/36 were from high or upper-middle income countries (according to World Bank, 2019). By country the papers were from Australia (n = 4), Belgium (n = 1), Brazil (n = 7), Canada (n = 3), Iran (n = 1), Ireland (n = 1), Kenya (n = 1), Malawi (n = 1), Norway (n = 1), Spain (n = 2), Switzerland (n = 4),Taiwan (n = 2), Tanzania (n = 1), UK (n = 4), USA (n = 3). Two papers from Switzerland [35,36] appeared to report findings from the same study, and three papers from Brazil [50–52] also appeared to report findings from the same study; all papers were included in the analysis as they reported on different themes. Two papers were translated from Portuguese into English [42,52] and one from Spanish to English [44] using a recognized software tool (‘Google Translate’). Nineteen of the thirty-six included studies were focused on the views of first-time mothers only and the remaining seventeen incorporated the views of women with a range of parities. Most data were collected by individual interviews and/or focus or discussion groups. The studies incorporated a variety of methodological approaches including phenomenological studies, studies based on grounded theory and ethnographic studies. They represent the views of more than 800 women, from a range of ethnic backgrounds and socio-demographic groups.

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Table 1. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0231415.t001

Findings

We generated 22 descriptive themes (review findings), most of which were graded as high or moderate confidence. From these, we generated five analytical themes: Riding the emotional rapids; Dancing around the baby–social and relational adaptation; It takes a community to raise a mother; Re-forming the birthing body; and Putting the mother into postnatal care. Our framework and associated CERQual gradings are shown in Table 2.

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Table 2. Framework of themes emerging from the data.

https://doi.org/10.1371/journal.pone.0231415.t002

From our analysis, we present the following summary statement;

The postnatal phase is a period of significant transition characterised by changes in self-identity, the redefinition of relationships, opportunities for personal growth and alterations to sexual behaviour as women adjust to the ‘new normal’ in their own cultural context. Women describe experiencing intense joy and happiness, and also low mood, anxiety and depression, often compounded by feelings of acute fatigue and exhaustion. Women often prioritise their relationship with the new baby and sacrifice their own practical and self-care needs in favour of the baby’s nutrition and safety. At the same time women may be struggling to come to terms with the physical and psychological impact of childbirth and the lack of opportunity to process associated feelings. This includes negative feelings associated with their post-birth body image. To cope with this period of adjustment women express the need for practical, emotional and psychological support from family members, peer groups and online sources, as well as from health providers. Women also want information and reassurance from health providers delivered in a consistent manner by authentic, familiar providers who recognise the mother’s as well as baby’s needs, within a well-resourced and flexible healthcare system that respects their cultural context.

Based on this statement we identified the key components of a positive postnatal experience to align with previous reviews of what matters to women during antenatal care [61] and intraprtum care [62] (see Box 2)

We now discuss each of the five analytical themes in more detail below.

Discussion

Based on a systematic qualitative review of findings from 36 studies from 15 countries published between 2003 and 2019 [25–60], the postnatal phase is a period of significant transition characterised by changes in self-identity, the redefinition of relationships, opportunities for personal growth, and alterations to sexual behaviour as women adjust to the ‘new normal’ within their own cultural context.

As Rubin has noted, becoming a mother, especially for the first time, involves ‘an exchange of a known self in a known world for an unknown self in an unknown world’ [63], p52. As Lanley et al comment, for this dynamic adaptive process to be successful, previous identities need to be remade [64], ‘the process of incorporating motherhood into women's identities can be conceptualized as a fracturing of identity wherein women lose or have compressed selves for a time. This fracturing creates space for women to incorporate their children's needs into their awareness’. In their phenomenological study of Australian women in the postnatal period, Rogan et al [65] cite Rubin, and describe the fluid nature of the adaptation to becoming a woman who is also a mother. While this shift is dramatic when it occurs for the first time, subsequent childbirth requires a new process of re-calibration as the identities of ‘woman’ and ‘mother’ once more shift. In line with Rogan, and with our prior expectations, our review notes the difficulties and challenges of this process. However, unlike the mostly negative accounts of Rogan’s cohort of Australian women [63], inclusion of studies from a wide range of social and cultural contexts in our review has also illuminated the life-enhancing, joyful aspects of the early postnatal period.

Based on our findings, for this transition to motherhood to be a positive experience, women need to balance both losses and gains. Losses encompass changed (often negative) body image, reduced capacity to be in control of one’s time and sleep, changes to previous sexual and romantic relationships with partners, and a loss of identity as an individual with inherent value (separate from the baby). Gains include intense feelings of joy and love for their new baby, and a new sense of triumph and self-esteem in overcoming the difficulties and stresses of pregnancy, birth, and the postnatal period, as well as the discovery of a previously unanticipated capacity to persevere, to love, to be selfless, to be compassionate and, for many, to feel more complete in their new integrated identity of ‘woman as mother’.

To enable optimum adaptation and wellbeing, women’s accounts suggest that they value practical, emotional and psychological support from family members, peer groups and online sources. Our findings here are in accord with a range of studies from different contexts and cultural settings where social support is seen as a vital component in effective transition to motherhood [66–68]. In adapting the often-cited phrase ‘it takes a village to raise a child,’ into ‘it takes a community to raise a mother’ we have tried to capture the essence of the data that showed that the primary source of support and growth in this period is the family and the local community in which new mothers are embedded. This suggests that, to ensure that all women experience a positive postnatal experience, families and communities should be informed, educated and mobilised so that women receive realistic information, appropriate reassurance, and culturally appropriate validation. Where women do not have access to supportive families and communities, or where there is conflict between the woman and her family/community, or, more generally, with the norms and expectations of being mother and of childcare that are held by her family/community, her capacity to cope and to successfully integrate the identities of both woman and mother could be more difficult and problematic. This may be a time when good quality professional input is especially valuable and effective.

In our previous review of what matters to women at the beginning of the maternity episode, in the antenatal period, adaptation to motherhood was seen as the critical endpoint of the pregnancy and labour experience. This was the case even though the actual nature of motherhood wasn’t clear, especially to those who were having their first baby [61]. This current review of women’s accounts at the end of the postnatal period reinforces the sense that, for childbearing women around the world, maternity care is not perceived as three distinct stages (antenatal, intrapartum, postnatal) as defined by most maternity care systems, but as an adaptive process that dynamically and continuously builds and reframes women physically, psychologically, socially and emotionally through birth and motherhood.

It is unsurprising that the hallmarks of good quality professional postnatal care are the same as those for good antenatal and intrapartum care–support, communication, and effective clinical input, based on what each mother and baby and family need, when they need it, and how they need it [61, 62]. This finding is so prevalent across studies of pregnancy, childbirth, and the postnatal period, in all contexts and cultures, that there could be an argument that health systems that do not provide this kind of integrated maternity care are malfunctioning. These components are especially important for women who do not have community and family support for whatever reason.

Whilst we didn’t seek to explore the specific requirements of first-time mothers our review does include nineteen studies of this specific population and our findings indicate that the theme related to support and information (‘it takes a community to raise a mother’) is likely to be particularly relevant to this group, regardless of setting or context. Our findings represent the views of more than 800 women from a wide variety of settings and contexts including Europe, Africa, North and South America, Australasia and the Middle East. As such, they bring together the perspectives of numerous, disparate, individuals and, given the relatively high CERQual gradings (16/22 were graded high or moderate), we can be reasonably confident they accurately portray shared understandings relating to what matters to women during the postnatal period. Although this is a major strength, we could only find three studies from LICs. This is a limitation, as there are likely to be particular cultural insights relating to postnatal care practices in these contexts. Most of our included studies were done in urban settings and we cannot rule out that women in rural settings may have different experiences. In addition, our searches were carried out in health and medical databases and it is possible that the inclusion of social science databases may have identified more papers relating to women’s needs during the postnatal period.

Although our aim was to understand what women value during the postnatal period as opposed to their experiences of current provision, participant’s values were occasionally conflated with their perceptions of the care they received. We therefore have some findings that relate to what matters about formal postnatal care provision, as well as about what women value in relation to experiencing the state of being postnatal. We were also unable to disentangle women’s views and priorities relating to defined postnatal stages, i.e. early, intermediate and late, since most study authors didn’t ask women to consider these specific time periods. Further qualitative research with women during these distinct phases may generate additional insights relating to the needs and priorities of mothers at different stages of the postnatal period.

Finally, we recognize that our review focuses on the values of healthy women from the general population and does not incorporate the views of women with identified clinical complications (e.g. cardiovascular disease, infection, diabetes, urinary problems) or mental health concerns (e.g. postnatal depression) that may require specific postnatal interventions.

Conclusion

Our systematic scoping review of findings from 36 studies from 15 countries published between 2003 and 2019 demonstrates that a positive postnatal experience is one in which women are able to adapt to their new self-identity and develop a sense of confidence and competence as mothers, adjust to changes in their intimate and family relationships, including their relationship to their baby, navigate ordinary physical and emotional challenges, and experience the dynamic achievement of personal growth as they adjust to the ‘new normal’ of motherhood and parenting in their own cultural context. Effective, culturally appropriate family, community and professional support and activities can help women to overcome the exhaustion, and physical, emotional and psychological stress of the early postnatal period. As anticipated by a previous review of what matters to women in pregnancy, what matters to women in the postnatal period is achieving positive motherhood (including maternal self‐esteem, competence, and autonomy). This review provides evidence that, where this process is positive, it also results in joy, self-confidence, and an enhanced capacity to persevere and to succeed in the new integrated identity of ‘woman and mother’.

Supporting information

Acknowledgments

We would like to thank all members of the WHO technical working group for their support and advice during the development of this review. This paper reflects the views of the named authors only, and not the views of their institutions.