Women and Birth
Volume 20, Issue 4 , Pages 169-173, December 2007

Social support: Proposing a conceptual model for application to midwifery practice

School of Nursing and Midwifery, Faculty of Health Sciences, The University of Queensland, Edith Cavell Building, Royal Brisbane & Women's Hospital Road, Herston, Qld 4029, Australia

Received 8 May 2006; received in revised form 27 July 2007; accepted 23 August 2007.

Article Outline

Summary 

The notion of social support is one which midwives often intuit rather than clearly articulate or conceptualise. Increasingly social support is being touted as an area of midwifery assessment and potential intervention which may improve birthing outcomes for mothers and their infants. This paper is the first of three to address social support within the discipline of midwifery. It aims to review the fundamental theoretical constructs relating to social support and proposes a conceptual model to assist midwives in applying social support theory to their practice. Further papers will address social support-related research assumptions and the validation of measurement instruments in midwifery research.

Keywords: Social support, Social networks, Psycho-neuroimmunology, Perceived support, Buffer hypothesis, Social exchange theory, Self-esteem theory

 

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Introduction 

Historically, social support has been an important component of pregnancy and birth in most cultures.1 In recent times, there has been increasing recognition of the role of social support in relation to health in general and to maternity care in particular. Changes in family structure, the contemporaneous development of models of maternity care, reductions in length of postnatal stays and the resultant pressures on limited community postnatal services and resources may have resulted in a vicarious undermining of the level of social support experienced by women and their families. Midwives need to be able to assess social support resources available to mothers and infants in their care and further enhance these resources where needs exist.

Research on social support and pregnancy outcomes2 and reviews of social support in childbirth1, 3, 4 demonstrate an increasing interest in the concept of social support as an area of assessment and intervention within midwifery. However, social support, if assessed at all in practice, is often explored informally, somewhat intuitively and perhaps haphazardly by midwives. This may reflect a lack of conceptual understanding of social support constructs. This paper, the first of three to explore the concept, aims to provide an overview of the fundamental theoretical constructs of social support which underpin contemporary midwifery scholarship. The concept will be defined and its pathways of influence explored. To enable midwives to apply it to their practice, a generic conceptual model of social support is proposed.

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Social support defined 

An ecological view of health supports the concept that it is not exclusively a function of disease or illness but rather the result of complex interactions of physical, psychological and social factors. Similarly, social support is a multifaceted concept and many authors point to imprecision in its definitions and the consequences these have had on the quality of related research.5, 6, 7 It is therefore important to untangle the various components of social relationships8 and, in the process, add conceptual clarity to notions of social support.

Social support can be pragmatically defined as “…any social resource provided by another person…the degree to which a person's basic social needs are gratified through interaction with others”(Ref. 9, p. 5). Social support is a notion rooted in the individual's social network or the web of relationships of which the person is a part.10 However, an extensive social network does not guarantee an individual will have their needs met.9 Having a social network is the first step towards enjoying social support and is dependent on the quality of relationships one finds in the network11: adequate support may be derived from one very good relationship but not necessarily from multiple superficial relationships.12 Schaefer et al.5 clearly demonstrated social support and social networks are “…empirically separate variables which have different relationships to psychological functioning” (p. 340).

Social networks are an illumination of ties and relationships that an individual enjoys. The concept of social network analysis arose in response to methodological issues related to measuring social support. Specifically, if individuals who enjoy good health are asked to rate their social support they are more likely to do this positively than those suffering poor health.1, 13 Social network analysis may be used to objectively measure the nature of social support and utilises various means to assess the extent, density, quality, type, frequency, duration/durability and direction or symmetry of social networks. While this may have some predictive value in relation to the individual's opportunity to access social support and social support may be one function of a social network, the two concepts can be measured separately.5

A shortcoming of social network analysis is that while the quantity of relationships may have some bearing on health outcomes, it is the quality of relationships that seem more important. Although originally aiming to address a lack of objectivity in social support measurement, social network analysis could not overcome the tendency that an individual's perception of social support provided may impact on health outcomes. As Baker, Taylor and the Survey Team of the Avon Longitudinal Study of Pregnancy and Childhood14 clearly articulate:

…the construct of social support is concerned more with feelings about being supported and it is this that is closely associated with good health or poor health. Validity would thus not necessarily be established by objective measurement such as the number and intensity of social contacts, since people may feel supported by only one family member or friend, or the same person may be supportive at one time point, but not at another (p. 1334).

McCourt and Percival1 also suggest that it is helpful to distinguish between ‘perceived’ and ‘received’ support. Perceived support – what the mother recognises as support – may differ from what a midwife viewing or participating in the same interaction regards as the support given to and received by the mother. Support provided but not perceived as such by the recipient may be ineffective. Therefore, social support is considered as a resource provided by another and perceived as effective by the recipient. It can be categorised into specific types according to function.1, 5, 15, 16

Emotional support 

Emotional support consists of intimacy and attachment, reassurance and confiding in and relying on one another. It implies a caring relationship or membership of a group and may be as simple as a willingness to listen or companionship. Conveying this type of support is seen as having a positive influence on esteem. Emotional support is also referred to as affection: the midwife places a comforting arm around a distressed mother whose baby has just been transferred to a neonatal unit for monitoring.

Informational support 

Informational support involves the provision of information or advice to assist the person to solve a problem and providing feedback on how the person is doing. Feedback assists the person to maintain social identity, provides a sense of social integration and control, and increases confidence and security. Informational support is also referred to as Affirmation Support: the midwife provides advice and feedback to a mother who is trying to successfully attach her baby to the breast.

Tangible support 

Tangible support addresses the provision of practical help and encompasses a broad range of activities. It focuses on direct aid or services which can include loans, gifts, taking care of a needy person or assistance with chores and other types of more general aid. While some of these examples exceed the ethical boundaries of the midwife, physical comfort measures provided during labour and birth are regarded as forms of tangible support to the mother.1

Comparison support 

Comparison support relates to encouragement, advice or information given by someone in a similar situation or who has had similar experiences. People providing this type of support are perceived by the recipient to have credible feelings or information to share.15, 17, 18 Comparison support is also referred to as appraisal support or affiliation. The midwife who provides opportunities for groups of mothers to meet is fostering comparison support in a general sense. More specifically, a midwife might arrange for a multiple birth support group member to visit a mother with twins.

Therefore, social support can be defined as any emotional, informational, tangible and/or comparison social resource provided to and perceived as effective by the recipient. The midwife can utilise this definition to assist mothers by exploring potential social resources in response to challenges or problems which draw on one or a combination of these categories. Consider a relatively common challenge faced by the midwife and mother. A mother who, after many hours in established labour and whose contractions have diminished in frequency and intensity, is very disheartened when she is assessed by the midwife as only four centimetres dilated. The midwife's response demonstrates how social support resources can be used to assist this mother. The midwife removes her gloves, assists the mother to a position of comfort and says:

“…I can understand your disappointment after all this time you felt you might be further dilated, but you really have coped very well up until now (emotional support). In my experience it is not uncommon for mothers to arrive at the birth suite and have their labour slow down (comparison support). You seem very tired, so what I suggest is that you have a short rest, here is the heating pad and I’ll get you another blanket (tangible support)”. The midwife strokes the mother's hair away from her face and makes eye contact. “After you rest for a while we can discuss the options in detail (informational support)”.

The midwife's caring response to the situation may be almost intuitive and it is perhaps only the reflective midwife who could identify the social resources she or he used to support the mother. However, midwives can further their understanding of social support and its potential in practice by exploring the mechanisms of action – or “pathways of influence”(Ref. 7, p. 133), – which provides its hypothetical foundation.

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Social support: pathways of influence 

Social support hypotheses have their origins in the areas of psychology and sociology and studies by Selye19 and Durkheim20 paved the way for the development of related concepts. Over the intervening years, several hypotheses regarding pathways of influence have emerged and these may be grouped according to their foundations as follows. Each is conceptually represented and interrelated in the proposed conceptual model Figure 1.

Physiological pathways/psycho-neuroimmunology 

This hypothesis postulates that social support has an effect on emotional well-being and subsequently on the neuro-endocrine and psycho-immunologic pathways which affect physical health.9 Cassel21 identified the social environment as a contributor to the “chain of inference” in disease aetiology. He specifically identified that social support networks could be a preventive strategy for people at high risk of disease. The direct physiological mechanisms by which this occurs have been studied in various groups, particularly in the modification of cardiovascular responses.9 This hypothesis is alternately known as the Main or Direct Effect model of social support.12 However, it is postulated that alternate pathways exist by which physical health outcomes are influenced. Social support may effect emotional wellbeing which enhances equilibrium in neuro-endocrine and psycho-immunologic pathways and thus enhances positive health outcomes. Alternately, social support may act to effect mood state which contributes to health behaviours and thus also enhances positive health outcomes.

Consider the application of this hypothesis to midwifery practice. The midwife provides a birthing environment in which the mother's emotional wellbeing and mood state are supported. Social support is evidenced: tangibly by dim lighting, warmth and the provision of comfort measures; emotionally by the presence of people with whom the mother feels bonded; and informationally by providing feedback using gentle positive words of encouragement. These actions appear to support the Physiological Pathways/Psycho-neuroimmunology hypothesis and result in the reduction of neocortical activity required for birthing.22

The buffer hypothesis 

Research23 suggests social support may not contribute directly to health outcomes but acts as a “buffer” to protect the individual from harmful effects of one's environment in times of stress. This proposes that social support may intervene between the stressful event/s and the stress response by attenuating or preventing a stress appraisal response.12 Rather than protecting against the effects of a stressful event when it occurs (as outlined in the Physiological Pathways/Psycho-neuroimmunology hypothesis), the Buffer hypothesis suggests a protective effect is achieved by preventing or reducing the amount of psychological risk factors experienced.7, 11, 12, 24, 25

Application of this hypothesis to midwifery practice may be evidenced by interventions preventing unnecessary intrusion into the birthing room which could impact on the mother's sense of security and need for privacy. Feeling insecure or exposed are psychological risk factors which enhance neocortical stimulation which may in turn inhibit labour.22

The social exchange theory 

Cohen and Syme26 identified that another component of social support is the notion of reciprocity. The exchange of social support has two functions. First, when such exchanges occur repeatedly the person involved feels increasingly secure that they will be assisted again should the need arise. Secondly, participation in this exchange adds to the worth and dignity of those involved and consequently they may be more willing to accept assistance when it is needed. According to McCourt and Percival1 the effects of social support are therefore likely to be reinforcing and self-confirming.

This theory is inferred in the relationship between midwives and mothers who are involved with maternity service reform. The midwives advocate for the mother's right to choose care options and the mothers/families become involved in providing support for midwives in personal, professional and political senses.

Self-esteem theory 

The mutual exchange of social support is seen as reinforcing feelings of respect. Muhlenkamp and Sayles16 postulate that social support and self-esteem have an impact on health status. Not only does self-esteem impact directly on how one deals with major events it also affects whether the individual seeks and accepts assistance.9 Self-esteem may be a characteristic of the individual that is brought into a relationship and may function to reduce stress and create social support. Midwives who acknowledge and respect a mother's ability to birth and convey a sense of confidence about this process are utilising this pathway of influence.

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Conclusion 

Social support is a complex phenomenon for which there is no single unifying definition. While social support has links with the notion of social networks, these concepts should be untangled. Types of social support – emotional, informational, tangible and comparison – have been explored and the hypotheses relating to pathways of influence outlined. The types and hypothetical pathways of social support are not mutually exclusive and indeed each has something to contribute to the understanding of social support theory. The proposed conceptual model may enhance understanding, application to practice and research quality in midwifery, whether used as a guide to determine midwifery assessment and action, as a means to assist structured reflection on practice or to suggest further research direction. This is the first of three papers exploring social support within the context of midwifery practice. Other papers to follow will address social support-related research assumptions and the validation of measurement instruments in midwifery research.

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Acknowledgements 

Thanks to Dr. Fran Boyle, Associate Professor Peter O’Rourke and Professor Elizabeth Davies for scholarly advice,Susan Kellett for editorial support, and Penny Buntine for practice examples.

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References 

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PII: S1871-5192(07)00094-7

doi:10.1016/j.wombi.2007.08.003

Women and Birth
Volume 20, Issue 4 , Pages 169-173, December 2007

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