Advertisement

Joy, struggle and support: Postpartum experiences of first-time mothers in a Tanzanian suburb

      Abstract

      Objectives

      To explore and describe postpartum experiences of first-time mothers in a Tanzanian, multiethnic, low-income suburb.

      Methods

      Individual qualitative interviews with 10 first-time mothers, 4–10 weeks postpartum in Ilala suburb, Dar es Salaam, Tanzania.

      Results

      The first-time mothers enjoyed motherhood and the respectful status it implied. To understand and handle the infant's needs and own bodily changes were important during postpartum. The tradition of abstaining from sex up to 4 years during breastfeeding was a concern as male's faithfulness was questioned and with HIV a threat to family health. Partner relationship changed towards shared parental and household work and the man's active participation was appreciated. Support from family members and others in the neighbourhood were utilised as a resource by the mothers. In instances of uncertainties on how to handle things, their advice was typically followed. The new mothers generally had good experiences of health care during the childbearing period. However, they also experienced insufficiencies in knowledge transfer, disrespectful behaviour, and unofficial fees.

      Key conclusions and implication for practice

      The mothers’ perspective of postpartum revealed that they actively searched for ways to attain infants’ and own health needs, and family health in general. Prolonged sexual abstinence was considered a risk for the partner having other sexual partners and contracting HIV. The mothers relied heavily on the informal support network, which sometimes meant risking family health due to misinformation and harmful practices. Health care and informal support systems should complement each other to attain adequate support for the families postpartum.

      Keywords

      Introduction

      The postpartum period, defined as first 6 weeks after childbirth, is consistently described as challenging for the woman and her family.

      WHO. Postpartum care of mother and newborn: a practical guide. Geneva: World Health Organization; 1998. Report No. WHO/RHT/MSM/98.3.

      • Darvill R.
      • Skirton H.
      • Farrand P.
      Psychological factors that impact on women's experiences of first-time motherhood: a qualitative study of the transition.
      Postpartum involves health risks and complex interrelations between nurturing the baby and life changes
      • Christie J.
      • Poulton B.C.
      • Bunting B.P.
      An integrated mid-range theory of postpartum family development: a guide for research and practice.
      and is stressful.
      • Emmanuel E.
      • Creedy D.K.
      • St John W.
      • Gamble J.
      • Brown C.
      Maternal role development following childbirth among Australian women.
      • Kanotra S.
      • D’Angelo D.
      • Phares T.M.
      • Morrow B.
      • Barfield W.D.
      • Lansky A.
      Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) survey.
      Yet, compared to other maternity aspects, postpartum has received less attention globally, especially in low-income countries

      WHO. Postpartum care of mother and newborn: a practical guide. Geneva: World Health Organization; 1998. Report No. WHO/RHT/MSM/98.3.

      • Kerber K.J.
      • de Graft-Johnson J.E.
      • Bhutta Z.A.
      • Okong P.
      • Starrs A.
      • Lawn J.E.
      Continuum of care for maternal, newborn, and child health: from slogan to service delivery.
      such as Tanzania.
      Motherhood in Tanzania is highly valued and important for women's self-respect and womanhood. To prove fertility and become a mother is important, whereas, the number of children is less important.
      • Hollos M.
      • Larsen U.
      Motherhood in sub-Saharan Africa: the social consequences of infertility in an urban population in northern Tanzania.
      Being a new mother in low-income Tanzanian, urban and suburban areas, poses additional challenges due to poverty, poor housing and sanitation, high congestion, unemployment, and communicable diseases.
      • Obrist B.
      Strugling for health in the city: an anthropoligical inquiry of health, vulnerability and resilience in Dar es Salaam, Tanzania.
      Furthermore, postpartum support that is traditionally provided by extended family members might not be available, as many families in suburban areas are internal migrants.
      • Bamurange V.
      The dilemma of parenting.
      One area of mothers’ concern during postpartum includes the need for information on general health, baby behaviour, and baby care.
      • Eileen Greif F.
      • Elizabeth B.
      Early postpartum discharge: how are mothers managing?.
      • Kurth E.
      • Kennedy H.P.
      • Spichiger E.
      • Hosli I.
      • Zemp Stutz E.
      Crying babies, tired mothers: what do we know? A systematic review.
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      Infant crying is another problem described by Tanzanian mothers
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      and is associated with tiredness and fatigue.
      • Kurth E.
      • Kennedy H.P.
      • Spichiger E.
      • Hosli I.
      • Zemp Stutz E.
      Crying babies, tired mothers: what do we know? A systematic review.
      Exclusive breastfeeding is rarely practised by Tanzanian mothers
      • Shirima R.
      • Greiner T.
      • Kylberg E.
      • Gebre-Medhin M.
      Exclusive breast-feeding is rarely practised in rural and urban Morogoro, Tanzania.
      and combining breastfeeding with different motherhood roles and employment is complex and challenging.
      • Omer-Salim A.
      • Lars-Ake P.
      • Olsson P.
      Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.
      • Omer-Salim A.
      • Persson L.A.
      • Olsson P.
      How do health workers balance infant feeding and employment?.
      An increase in workload,
      • Christie J.
      • Poulton B.C.
      • Bunting B.P.
      An integrated mid-range theory of postpartum family development: a guide for research and practice.
      tiredness and fatigue
      • Eileen Greif F.
      • Elizabeth B.
      Early postpartum discharge: how are mothers managing?.
      • Kurth E.
      • Kennedy H.P.
      • Spichiger E.
      • Hosli I.
      • Zemp Stutz E.
      Crying babies, tired mothers: what do we know? A systematic review.
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      • Taylor J.
      • Johnson M.
      How women manage fatigue after childbirth.
      are reported. Sexual life after childbirth is another area of concern for new mothers,
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      fathers,

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      and midwives providing health education and counselling to new parents.
      • Lugina H.I.
      • Lindmark G.
      • Johansson E.
      • Christensson K.
      Tanzanian midwives’ views on becoming a good resource and support person for postpartum women.
      Antenatal care (ANC) is attended at least once by 94% of pregnant women in Tanzania, but 43% deliver out of health facilities, of which only 13% have a postnatal check up.
      • NBS [Tanzania], ORC Macro
      Tanzania demographic and health survey 2004–2005.
      In Dar es Salaam, around 82% of deliveries are at public health institutions.
      • NBS [Tanzania], ORC Macro
      Tanzania demographic and health survey 2004–2005.
      Four to six weeks after childbirth, the mothers typically take their infants to the Reproductive and Child Health (RCH) clinics
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      where little attention is given to the health of the mothers. The national postpartum care policy
      • Ministry of Health
      National package of essential reproductive and child health interventions in Tanzania.
      prescribes the follow-up of both mothers’ and infants’ well being for early detection and management of complications. It also should provide information on contraceptive use and health promoting behaviours at family and community levels. However, there is low usage of services, discontinuity between maternal and child health programmes, and the lack of postpartum care guide.

      WHO. Postpartum care of mother and newborn: a practical guide. Geneva: World Health Organization; 1998. Report No. WHO/RHT/MSM/98.3.

      • Kerber K.J.
      • de Graft-Johnson J.E.
      • Bhutta Z.A.
      • Okong P.
      • Starrs A.
      • Lawn J.E.
      Continuum of care for maternal, newborn, and child health: from slogan to service delivery.
      • Mrisho M.
      • Obrist B.
      • Schellenberg J.
      • Haws R.
      • Mushi A.
      • Mshinda H.
      • et al.
      The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania.
      This implies that many postpartum problems for mothers and their families are unattended.
      Research knowledge on family health during postpartum in Tanzania, including mothers’,
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      • Omer-Salim A.
      • Lars-Ake P.
      • Olsson P.
      Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.
      • Mrisho M.
      • Obrist B.
      • Schellenberg J.
      • Haws R.
      • Mushi A.
      • Mshinda H.
      • et al.
      The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania.
      fathers’

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      and care providers’
      • Lugina H.I.
      • Lindmark G.
      • Johansson E.
      • Christensson K.
      Tanzanian midwives’ views on becoming a good resource and support person for postpartum women.
      • Mrisho M.
      • Obrist B.
      • Schellenberg J.
      • Haws R.
      • Mushi A.
      • Mshinda H.
      • et al.
      The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania.
      • Lugina H.I.
      • Johansson E.
      • Lindmark G.
      • Christensson K.
      Developing a theoretical framework on postpartum care from Tanzanian midwives’ views on their role.
      perspectives is increasing. Methodologically, though most of these studies were qualitative, they focused on specific aspects of postnatal care that limited an in-depth understanding of the mothers’ experiences with a holistic approach. This paper argues that, a deeper understanding of first-time mothers’ perspectives on health-related issues during the postpartum period would provide the basis for postpartum support that responds to the needs of women and their families. Thus, this study was designed to explore and describe postpartum experiences of first-time mothers in a Tanzanian, multiethnic, low-income suburb.

      Methods

      A qualitative study design was employed as it has an inductive approach
      • Dahlgren L.
      • Emmelin M.
      • Winkvist A.
      Qualitative methodology for international public health.
      and allows in-depth exploration of the under-researched area of the perspectives of the first-time mothers.

      Setting

      This study was conducted in the lower-income areas of Ilala municipality, one of the three municipalities of Dar es Salaam city, Tanzania. Dar es Salaam, the largest city in Tanzania has a population of about 2.5 million
      • NBS [Tanzania], ORC Macro
      2002 population and housing census: regional profiles, Dar es Salaam: Government of Tanzania.
      with most of its low-income people living under poor conditions and with high unemployment, especially among young people.
      • IFPR
      Dar es Salaam: urban livelihood challenges.
      The population of Ilala is estimated at around 635,000.
      • NBS [Tanzania], ORC Macro
      2002 population and housing census: regional profiles, Dar es Salaam: Government of Tanzania.
      Most inhabitants are migrants from rural parts of Tanzania looking for employment or greener pastures.
      • Obrist B.
      Strugling for health in the city: an anthropoligical inquiry of health, vulnerability and resilience in Dar es Salaam, Tanzania.
      Eighteen percent of the people in Ilala live below the poverty line,

      MoH. Tanzania district health service website; 2006. Available from: http://www.districthealthservice.com/district_page.php?id=95&year=2005 [cited 2009 11/2/2009].

      and it can be assumed a higher proportion of the population living under the poverty line live in the lower-income areas.
      Ilala has one district hospital and the affiliated RCH services functioning as a referral centre. There are two public health centres providing partial second level services and 14 dispensaries providing first level health services. Services included in RCH clinics are antenatal, intrapartum and postnatal care, voluntary counselling and testing (VCT) for HIV, prevention of mother to child transmission (PMTCT) of HIV, child health, and contraceptives. Tanzania health policy requires cost sharing or user fees for users of public health facilities, however maternal and child health services are exempted these charges.
      • Ministry of Health and Social Welfare
      Sera ya Afya.

      Ethical clearance

      Ethical clearance was granted by the ethical board of the Muhimbili University College of Health Sciences (MUCHS), now known as Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania. The Regional Ethical Review Board in Uppsala, Sweden, conducted a consultative review. Permission to conduct the study was obtained from the Municipal Director, Ilala Municipality, Dar es Salaam, Tanzania.

      Participants and recruitment

      Ten first-time mothers were recruited at two RCH clinics in Ilala, where they had brought their infants for routine examination and vaccination 4–10 weeks after childbirth. Purposive sampling
      • Dahlgren L.
      • Emmelin M.
      • Winkvist A.
      Qualitative methodology for international public health.
      ensured credibility by selecting participants with individual fresh experiences of postpartum. The inclusion criteria were: first-time mothers, willing to participate, perceiving themselves and their infants to be healthy, and living with the father of the infant. Midwives and nurses at the clinics helped to identify eligible participants. Oral and written informed consent was obtained and the mothers were ensured of confidentiality and freedom to withdraw at any time. Fourteen mothers were approached and 10 were recruited as participants. All participants had attended ANC and delivered in health facilities. Age ranged from 20 to 27 years and level of schooling from 7 to 11 years. Three women were employed outside home, five were self-employed outside the home, and two were housewives. None of the women had started working outside home during the interview period. All women were Tanzanians from different ethnic groups and seven out of 10 were married to Tanzanian men from ethnic groups other than their own.

      Data collection

      Individual semi-structured qualitative interviews
      • Kvale S.
      Interviews: an introduction to qualitative research interviewing.
      were conducted with 10 first-time mothers between 2006 and 2008. The interviewer was the first author (CKM), a Tanzanian nurse, university teacher, and native Swahili speaker. Audio-recorded interviews, lasting 45–90 min, were held in privacy at the RCH clinics, participant's homes, or interviewer's office, depending on the participant's preference. They were conducted in Kiswahili and field notes were taken. A broad question, “How would you describe your experience of being a mother for the first time?” initiated the discussion, followed by probing questions to encourage reflection. Thereafter, a piloted interview guide was used that included the topics: mother and family support; childcare; breastfeeding and nutrition; sexuality, marital relationship and contraceptives; parenting; and, health system support.

      Analysis

      The recordings were transcribed verbatim and translated to English to enable non-Swahili speaking co-researchers to participate in the analyses. The first author (CKM) and two research assistants did transcription and translation. The first author did the final editing and ensured the correct translation. The English transcripts were used for analysis; however the original transcripts were cross checked to ensure right interpretation throughout the process. The analysis was guided by the qualitative content analysis approach, inspired by Graneheim and Lundman,
      • Graneheim U.H.
      • Lundman B.
      Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
      with focus on both manifest and latent messages in the data. First, the entire text was read to obtain a sense of the whole. The text was later divided into meaning units, that is, paragraphs revealing specific mothers’ experiences. These were further condensed while preserving their core content. The condensed meaning units were further shortened and abstracted to codes, and then organised according to similarities and differences to form categories. An example of the analysis is given in Table 1. To ensure confirmability, all authors reflected, discussed in case of differences in interpretation of data, and agreed on the final categorisation.
      • Graneheim U.H.
      • Lundman B.
      Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
      The use of a systematic method for analysis, and using both the English and Kiswahili versions of the transcripts added to credibility of the findings. Further, the influence on our pre-understanding was regularly discussed within the research team. The researchers had vast and varied experiences and knowledge on the topic and had been exposed to postpartum care as mothers and as professionals with experience of caring, teaching and researching postpartum health in Tanzania and/or Sweden and other African countries.
      Table 1An example of an analysis process.
      Meaning unit in the interview textCondensed meaning unitCode
      When you ask they can tell you should start giving water after three months, you ask another person and say after one week. So I don’t understand, I am left in a dilemma. I mean, whoever you ask will give you different answers.Instructed to give the infant water after 3 months, others say after one week, doesn’t understand, left in dilemma.Confused with conflicting messages.
      This code was later included in the category ‘Responding to infants’ needs and managing daily life’.
      a This code was later included in the category ‘Responding to infants’ needs and managing daily life’.

      Results

      Six categories emerged as mothers’ postpartum experiences (Table 2), which are presented below. The mothers have been allocated pseudonyms for the purposes of reporting in the illustrating quotes.
      Table 2First-time mothers’ postpartum experiences.
      1. Enjoying motherhood and the implied respectful status
      2. Responding to infant's needs and managing daily life
      3. Learning about and recovering from bodily changes
      4. Abstaining from sex, doubting partner's faithfulness, and contraceptives
      5. Maintaining partner relationship and sharing responsibilities
      6. Seeing deficiencies in the public health care

      Enjoying motherhood and the implied respectful status

      Having their first babies brought not only happiness but also respect to the mothers from their immediate families and general community. Having delivered safely was something to rejoice as mothers had heard stories or witnessed fellow women losing their own or babies’ lives or both during labour. The joy expressed was also associated with proven womanhood and the maturity status it embodied:“Because for us women, where I live, I have seen my fellow women dying while pregnant, or they may deliver but the child dies, or the mother dies but the child survive, so I was so much worried” (Anna)“Being a mother for first time is good and it's also respectful … when you are a mother you are an adult … you are respected by the family. But, when you are a girl, people don’t respect you” (Joyce)

      Responding to infant's needs and managing daily life

      The mothers experienced an increase in household chores, tiredness, expenditure, and responsibilities after the birth of their babies, although for some it was not as much of a concern as this was expected. Life had to be reorganised such as leaving their jobs, waking up early in the morning, or limiting outings, to be able to cope:“I have a lot more to do than before. Because if you were used to wake up at 6:00 am, now you should wake up earlier around 4:30 am to start washing clothes, doing in-house cleaning and prepare breakfast for your husband so that he gets to work earlier and you remain home continuing with other activities. Yes specifically, to prepare the child, bath her and let her rest” (Irene)
      Mothers expressed concerns in relation to infant feeding, bathing, cord care, behaviour, and vaccination. Maternal mothers and sisters, in-laws, grandmothers, neighbours and friends provided guidance, reassurance, and company. These support people also assisted with bathing, cord care, and infant feeding, and household chores such as cooking, washing, house cleaning, and shopping:“I am with my mother in-law … She used to help me with household chores like cooking, washing clothes and much more to look after the child” (Rehema)“There is one woman at home she is an adult, now she has grandchildren. So when we have problems, we tell her, she gives us advice” (Joyce)
      Insufficient breast milk and infant crying were reasons for early initiation of supplementary infant feeding. Commonly, porridge and water was given after advice from support people, despite mothers recalling health workers advocating exclusive breastfeeding:“What troubles me is food, that a baby should be exclusively breastfed up to the said months, so for how many months so that I can start giving her solid food, because if you listen to others, some would tell you to give her water” (Neema)
      Bathing the infant was difficult for some mothers. For some, babies were not supposed to be bathed with water until the cord stump had healed. In hospital, it was advised to use spirit for cord cleaning while at home, support people said this is harmful. Apart from spirit, coconut oil was used.“I could not bath him, really. I was afraid of the umbilicus. Therefore it was my sister in-law who was giving him a bath. My job was to breastfeed him.” (Joyce)“I would like them to give education on how to treat the cord stump after delivery. I would like them to tell us every vaccine our children are given, what are they for?” (Rehema)

      Learning about and recovering from bodily changes

      The mothers experienced bodily changes they were unaware of, or for which they had other expectations such as vaginal flow and resumption of menses. This created uncertainty and they expressed the need for information on issues related to maternal nutrition, self-care, hygiene, and care of episiotomy wounds. Mothers seldom received postnatal health information before discharge from hospital, and at home, more experienced women provided advice:“I thought after delivery the bleeding will end right away … But when I went home, I was wondering why bleeding is still going on … I thought bleeding was just for that one day, but after three days I decided to ask whether I was sick or not?” (Amisa)“Sometimes, I used to ask them [elders] like if someone delivers, is it normal to have pus discharged? They said yes, they say all those are normal things” (Halima)
      Food restrictions and confinement for about 40 days was reported. Hot water massage was believed to accelerate healing and restore the mothers’ body organs (uterus, abdomen) in place and to stop bleeding. Hot water was put in a bucket, basin, or big pot and a piece of cloth was used as a compress on all parts of the body, including private parts. Whereas some mothers enjoyed the massage, for others, the use of very hot water made the exercise painful:“Like bathing me [applying hot water massage] … Ooh it was too painful! They say it is a medicine. They say it helps to restore body organs into its places” (Rehema)

      Abstaining from sex, doubting partner's faithfulness, and contraceptives

      With exception of one, the mothers intended to abstain from sex for up to 4 years, until they had stopped breastfeeding. There was a belief that sex during the breastfeeding period would cause illness and hamper the development of the infant:“Yes, he gets thinner. I always see such children, he get thinner and thinner, he becomes floppy, the legs become weak, and he never crawls. Days are numbered but the child doesn’t grow, doesn’t walk, or do anything [emphasising]” (Rehema)“We don’t have sex … until the baby has grown up … about three to four years” (Rahma)
      However, the mothers had doubts over their partners’ ability to abstain from sex for the intended period, and thought their partners might become unfaithful and risk HIV contraction:“Yes, I have a feeling that he won’t wait! [After two years] I would not allow any excuses like if he says ‘you had never seen me with any woman’, the first thing we shall have to go to ANGAZA* for checking our status” (Rehema)(*ANGAZA provides voluntary counselling and testing for HIV)
      These mothers had all undergone voluntary counselling and testing for HIV, as part of ANC, and had good knowledge of some HIV issues. There was little understanding of prevention of mother to child transmission of HIV. Contracting HIV was primarily regarded a result of irresponsible sexual behaviour. They revealed that not all men agreed to have voluntary counselling and testing for HIV:“Both of you [mother and partner] should come and test. … If you are infected you are given counselling and told the hospital where to get drugs. If you are not infected you are given counselling as well, so that you don’t pick the disease from outside” (Joyce)
      Family planning use after delivery was generally not considered important and many did not know where to find the services. Only one mother had been to the RCH clinic for family planning services at the time of interviewing. However, some expressed interest in contraceptive methods and their effects:“Like contraceptives; how, they should explain if you are supposed to start before or after a year” (Joyce)
      Although health workers promoted the use of modern contraceptive methods, the mothers, their partners, and support people considered them harmful to the health of the women as they may cause cancer, bleeding and HIV:“We had a discussion on that, and he [the husband] said, that some use contraceptive pills, some are using injection, and later on they get health problems” (Rahma)“Contraceptives; some say using pills is harmful, the injection is harmful, if you use condom they say it has [HIV] viruses [laughs]. So you fail to understand!” (Irene)

      Maintaining partner relationship and sharing responsibilities

      Although these mothers felt there had been no major changes in their relationships with their partners, increased closeness to the partner was mentioned. Occasionally, it was stated that, the mothers felt ignored by their partners because of the baby, and the fathers felt neglected as all the mothers’ attention was directed to the newborn:“He thinks that you are not listening to him; he says ‘when I talk you don’t listen. Since you had that child, you have been ignoring me, it's only about that child, nothing else.’ I cannot help him; I don’t know how I can do that! There is really no way to help him because most of the time I am with my child” (Rehema)
      Partners helped to relieve the workload at home by helping in domestic activities such as cooking, fetching water, shopping, and babysitting and changing nappies:“Sometimes when I am loaded with work and there is no water, he helps me to go and fetch, or he helps me with getting something from the shop. If he needs ‘chapatti’ he goes to bring it or if I am the one who needs it he brings it” (Irene)“Yes, if the baby is crying, his father helps me with washing clothes and calming her down” (Rahma)
      However, mothers also reported fathers had limited time for supporting them due to work and employment responsibilities as the family providers:“Now every time you tell him [to go to RCH clinic] he says ‘I am going to work, may be my opportunity is on Saturday and Sunday’ …” (Joyce)

      Seeing deficiencies in the public health care

      The mothers were generally satisfied with the service provided at the public health care:“For sure, they took very good care of me [in labour room] … For example she responded well all the time I needed her, she was listening to what I say … Really the services are good, since antenatal” (Rehema)
      However, they also highlighted deficiencies such as limited number of staff, poor communication, and health workers demanding unofficial payments:“You know the language of these nurses is sometimes not good. Some have a nice language to the mothers, they counsel them, but others become very harsh. Sometimes you become afraid of saying what you have in mind” (Asha)“Because one mother after being helped to deliver was told, ‘Okay, call your relative to bring the money, I have finished the work” (Irene)
      According to these new mothers, there was insufficient health education provided at the RCH clinics. Conversely, they considered that too much information was provided all at once at ANC, which obstructed the assimilation of the messages. The mothers also suggested including fathers in the RCH clinics, as they could benefit from the session, however, the long waiting hours challenged fathers’ attendance:“You may find a lot of people but very few health workers, so we have to wait for a long time, something men cannot afford …” (Asha)

      Discussion

      Joy, struggle and support

      These first-time mothers experienced joy from their newly acquired status as mothers. They struggled to meet the infant's health needs and to manage daily family life. The mothers worry about the risk of contracting HIV due to their partners’ infidelity during the breastfeeding, where they claimed to be practicing sexual abstinence. Despite this, the informal social support provided at home was more influential than formal support from health care services, while balancing the two support systems was challenging because they often had conflicting perspectives.
      A limitation of this study was that the group studied did not include single mothers, mothers with more than one child, or professionally employed mothers, which could have resulted in different perspectives of postpartum care experience. Further, the transferability of study findings should be made with caution since all participants had attended ANC and had delivered at a health care facility, which is unusual in low-income countries. To enable the readers’ judgement of transferability to other settings, descriptions of participants, the setting and categories with illustrative quotes are presented in the findings.

      The vital role of social support

      To the mothers in this study, the informal network is the most trusted form of support and plays a more important role in deciding health-related issues than does the formal support offered from health professionals. This finding corroborates results from other Tanzanian studies,
      • Omer-Salim A.
      • Lars-Ake P.
      • Olsson P.
      Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      and could in part be explained by traditions, accessibility (to the informal support network), and a lack of formal postpartum follow-up. It is also worth noting that, as in these previous reportings, mothers in the present study experienced support from their male partners when they engaged with women's traditional work, such as infant care and household chores. This supports results from previous Tanzanian studies.
      • Omer-Salim A.
      • Lars-Ake P.
      • Olsson P.
      Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      Notwithstanding, given the methodology we used, we are unable to claim that our participants represent typical Tanzanians. However, this finding challenges gender stereotypes, and suggests that they are not always true and cannot be generalised. Further research is needed to investigate whether or not this represents a new trend within this setting.
      Social support is recognised as playing an important role in health and maternity care,
      • Christie J.
      • Poulton B.C.
      • Bunting B.P.
      An integrated mid-range theory of postpartum family development: a guide for research and practice.
      • Bogossian F.E.
      Social support: proposing a conceptual model for application to midwifery practice.
      and is categorised as emotional, tangible, informational and comparison support.
      • Bogossian F.E.
      Social support: proposing a conceptual model for application to midwifery practice.
      While the mothers in the present study utilises all four categories, they primarily express need and appreciation for the tangible support offered by their informal support networks. In our findings, the formal network provides informational support, but this sometimes contradicts the ‘norms’ expressed via the informal networks. Social networks, both formal and informal, have been described as a core element of the ‘social capital’ concept, other elements being norms of reciprocity and trust.
      • Ferlander S.
      The importance of different forms of social capital for health.
      Social capital is where an individual utilises resources from own social network(s) to obtain the desired support.
      • Campbell C.
      • Mzaidume Z.
      Grassroots participation, peer education, and HIV prevention by sex workers in South Africa.
      Moreover, Nyqvist
      • Nyqvist F.
      Social capital and health: variations, associations and challenges.
      claims that social capital enables individuals to gain access to resources, such as ideas, information, services and support that would otherwise not be accessible.
      This concept has been associated with both positive and negative health effects.
      • Ferlander S.
      The importance of different forms of social capital for health.
      • Campbell C.
      • Mzaidume Z.
      Grassroots participation, peer education, and HIV prevention by sex workers in South Africa.
      • Ware N.C.
      • Idoko J.
      • Kaaya S.
      • Biraro I.A.
      • Wyatt M.A.
      • Agbaji O.
      • et al.
      Explaining adherence success in sub-Saharan Africa: an ethnographic study.
      For example, “high” social capital explained the high adherence to antiretroviral therapy (ART) programmes in some sub-Saharan African populations, where suboptimal formal support was also reported.
      • Ware N.C.
      • Idoko J.
      • Kaaya S.
      • Biraro I.A.
      • Wyatt M.A.
      • Agbaji O.
      • et al.
      Explaining adherence success in sub-Saharan Africa: an ethnographic study.
      In the present study, the positive merit of trust is exhibited openly towards the informal support network. However, since some of the formal and informal information relayed to our participants is discordant, a risk is created in that what we perceive as “high social capital” might actually result into negative health consequences. Some of the informal information our participants received is imbedded in norms that promote harmful practices, as in infant feeding and postpartum sexual life. Such norms demonstrate the impact that the informal social network has at the community level and the potential that these networks influence health within communities. The informal support group should be targeted when designing interventions to raise awareness on postpartum health care issues. On the other hand, health services and other formal support agents should also be made aware of the importance of trust and norms of reciprocity as found within the postpartum families’ network. The norms of reciprocity exhibited are likely to enhance the tendency of mothers listening to advice from the informal support network, ensuring support beyond the postpartum period. Constructive interaction with families and the community in the provision of formal evidence-based health information could contribute to social capital that improves health in families during this time.

      Sexuality postpartum

      The intention to abstain from sex for several years after childbirth is reported in the present study, as well as in a previous interview study with new fathers in Ilala.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      Prolonged postpartum sexual abstinence has been described as an old fertility regulation practice in Tanzania
      • Ntukula M.
      Custodians of custom.
      • Mabilia M.
      Breast feeding and sexuality: behaviour, beliefs and taboos among Gogo mothers in Tanzania.
      and Cote d’Ivoire.
      • Desgrées-du-Loû A.
      • Brou H.
      Resumption of sexual relations following childbirth: norms, practices and reproductive health issues in Abidjan, Côte d’Ivoire.
      However, in the present study, the reason for abstention is to protect the infant's health, which was also the case in another study in Malawi.
      • Zulu E.M.
      Ethnic variations in observance and rationale for postpartum sexual abstinence in Malawi.
      This kind of attitude has no scientific basis, and mothers therefore have the right to proper information so as to be able to make informed decisions in relation to sexuality issues. Quantitative studies are needed to explore the prevalence of this kind of belief, and qualitative studies will help to understand the depth and diversity of the phenomenon.
      The mothers in Ilala doubt their partners’ ability to abstain, as did women in Cote d’Ivoire
      • Desgrées-du-Loû A.
      • Brou H.
      Resumption of sexual relations following childbirth: norms, practices and reproductive health issues in Abidjan, Côte d’Ivoire.
      and first-time fathers in Ilala.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      This provides some explanation to previous findings that primiparous mothers in Ilala worried about sexual resumption.
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      West African studies indicate that prolonged postpartum abstinence can be associated with increased risk for HIV.
      • Desgrées-du-Loû A.
      • Brou H.
      Resumption of sexual relations following childbirth: norms, practices and reproductive health issues in Abidjan, Côte d’Ivoire.
      • Cleland J.G.
      • Ali M.M.
      • Capo-Chichi V.
      Post-partum sexual abstinence in West Africa: implications for AIDS-control and family planning programmes.
      Evidence-based information for new mothers, sexual partners, families, and communities is needed to avoid confusion and to enable informed decisions on when to resume sex after childbirth. Abolishment of the tradition of prolonged sexual abstinence could contribute to the efforts against HIV transmission. This would be welcome, as the prevalence of HIV among women in reproductive age in urban Tanzania is 10% as compared 6% for the general population.
      • NBS [Tanzania], ORC Macro
      Tanzania HIV/AIDS and malaria indicator survey 2007–08.
      The mistrust of modern contraceptives was also described among first-time fathers in Ilala.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      The conflicting messages about contraceptive methods imply misinformation among new parents and community members and could have influenced the low prevalence of modern contraceptive (20%) use among married women in Tanzania.
      • NBS [Tanzania], ORC Macro
      Tanzania demographic and health survey 2004–2005.
      In Tanzania, the level of community approval of family planning has a large influence on contraceptive use.
      • Stephenson R.
      • Baschieri A.
      • Clements S.
      • Hennink M.
      • Madise N.
      Contextual influences on modern contraceptive use in sub-Saharan Africa.
      Raising community awareness through health educational programmes is important for changing these attitudes and the quality of the information provided in schools and health facilities need scrutinising.

      Infant care

      The women's concerns over infant care are pertinent and deserved attention. Consistent with previous studies in Tanzania, crying is mentioned as a concern
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
      and is closely related to early initiation of supplementary feeding.
      • Omer-Salim A.
      • Lars-Ake P.
      • Olsson P.
      Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.
      Perceived insufficient breast milk leading to frequent infant crying is the main reason for early initiation of supplementary feeding in the present study. The WHO recommends exclusive breastfeeding for 6 months.
      • WHO
      Global strategy for infant and young child feeding.
      However, without support and proper information on breastfeeding, it is difficult for the mothers to handle the conflicting advice from the formal and informal support networks. Evidence suggests support from both professionals and lay people were effective in initiation and continuation of breastfeeding
      • Britton C.
      • McCormick F.M.
      • Renfrew M.J.
      • Wade A.
      • King S.E.
      Support for breastfeeding mothers.
      and for the duration and promotion of exclusive breastfeeding.
      • Sikorski J.
      • Renfrew M.J.
      • Pindoria S.
      • Wade A.
      Support for breastfeeding mothers: a systematic review.
      Further, WHO
      • WHO
      Global strategy for infant and young child feeding.
      recommends targeting families and communities as resources in promoting breastfeeding, as this is where mothers live and the present study demonstrates the mothers’ heavy reliance on this group. Concerns related to baby care needs and behaviour, maternal nutrition, and hygiene were mentioned elsewhere.
      • Lugina H.I.
      • Christensson K.
      • Massawe S.
      • Nystrom L.
      • Lindmark G.
      Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.

      Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

      For all highlighted issues, postpartum care follow-ups would provide a platform for mothers to discuss their concerns and obtain the right information from the health care experts at the right time. As mothers in Tanzania routinely bring their children to the RCH clinics for growth monitoring and immunisation, this provides a valuable opportunity for nurses and midwives to meet the mothers and families for postpartum counselling. A postpartum care guide would help midwives and nurses consider all the important aspects of care during their encounters with new parents.

      Information provision

      In this setting, there is need for the provision of information that increases awareness and stimulates practices promoting family health postpartum. The mothers in the present study lack awareness of basic postpartum health issues despite having attended ANC, which raises questions on the quality and usefulness of antenatal health education. Difficulties in retaining postpartum information provided during ANC were also described in privileged Western settings.
      • Razurel C.
      • Bruchon-Schweitzer M.
      • Dupanloup A.
      • Irion O.
      • Epiney M.
      Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study.
      According to the health belief model, the individual's perceived susceptibility is important for behavioural change.
      • Janz N.K.
      • Becker M.H.
      The health belief model: a decade later.
      Thus, timing and the manner in which information is conveyed is crucial.
      There is no evidence for which is the best method between groups or individual approaches for antenatal health education.
      • Gagnon A.J.
      • Sandall J.
      Individual or group antenatal education for childbirth or parenthood, or both.
      In the present study setting, antenatal health education is provided in large groups and professional postpartum care after discharge from a health facility after childbirth is rare. In one Tanzanian study, it was found that the average time spent for counselling at the first ANC visit is 1.30 min and at the second visit, counselling hardily takes place.
      • von Both C.
      • Fleaa S.
      • Makuwani A.
      • Mpembeni R.
      • Jahn A.
      How much time do health services spend on antenatal care? Implications for the introduction of focused antenatal care model in Tanzania.
      Counselling under such circumstances would not sufficiently prepare women for postpartum health care. Women are more likely to be receptive and benefit from the postpartum information if it is provided when it is most needed.
      Mass media has been proved effective in positively affecting behaviour, attitude, and utilisation of health services.
      • Grilli R.
      • Ramsay C.
      • Minozzi S.
      Mass media interventions: effects on health services utilisation.
      • Vidanapathirana J.
      • Abramson M.J.
      • Forbes A.
      • Fairley C.
      Mass media interventions for promoting HIV testing.
      Women in the present study rely on an informal support network and reveal problems when health staffs convey alternative messages. Mass media has the potential to provide mothers, families, and community members at large with evidence-based information, thereby, diminishing misconceptions, promoting positive behaviours postpartum and facilitating the two support systems to complement each other.

      Conclusions

      The mothers’ perspective of postpartum revealed that they actively searched for ways to attain infants’ and own health needs, and family health in general. Prolonged sexual abstinence was considered a risk for the partner having other sexual partners and contracting HIV. In absence of quality formal postpartum support and evidence-based information, they relied heavily on the informal support network, which sometimes meant risking family health due to misinformation and harmful practices. The two support systems should complement each other to attain adequate support for the families postpartum.

      Acknowledgements

      We acknowledge the mothers for giving their time and reflections, nurses and midwives at RCH clinics for assisting in recruitment, Flora Kilapilo for helping with pilot interviews and, Sida/SAREC for financial support.

      References

      1. WHO. Postpartum care of mother and newborn: a practical guide. Geneva: World Health Organization; 1998. Report No. WHO/RHT/MSM/98.3.

        • Darvill R.
        • Skirton H.
        • Farrand P.
        Psychological factors that impact on women's experiences of first-time motherhood: a qualitative study of the transition.
        Midwifery. 2010; 26: 357-366
        • Christie J.
        • Poulton B.C.
        • Bunting B.P.
        An integrated mid-range theory of postpartum family development: a guide for research and practice.
        J Adv Nurs. 2008; 61: 38-50
        • Emmanuel E.
        • Creedy D.K.
        • St John W.
        • Gamble J.
        • Brown C.
        Maternal role development following childbirth among Australian women.
        J Adv Nurs. 2008; 64: 18-26
        • Kanotra S.
        • D’Angelo D.
        • Phares T.M.
        • Morrow B.
        • Barfield W.D.
        • Lansky A.
        Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) survey.
        Matern Child Health J. 2007; 11: 549-558
        • Kerber K.J.
        • de Graft-Johnson J.E.
        • Bhutta Z.A.
        • Okong P.
        • Starrs A.
        • Lawn J.E.
        Continuum of care for maternal, newborn, and child health: from slogan to service delivery.
        The Lancet. 2007; 370: 1358-1369
      2. Lawn J. Kerber K. Opportunities for the Africa's newborns: practical data, policy and programmatic support for newborn care in Africa. The Partnership for Maternal, Newborn and Child Health, Cape Town, South Africa2006
        • Hollos M.
        • Larsen U.
        Motherhood in sub-Saharan Africa: the social consequences of infertility in an urban population in northern Tanzania.
        Cult Health Sex. 2008; 10: 159-173
        • Obrist B.
        Strugling for health in the city: an anthropoligical inquiry of health, vulnerability and resilience in Dar es Salaam, Tanzania.
        European Academic Publishers, Bern2006
        • Bamurange V.
        The dilemma of parenting.
        in: Ntukula M. Liljestrom R. Umleavyo: the dilemma of parenting. Grafilur Artes Graficas, Spain2004
        • Eileen Greif F.
        • Elizabeth B.
        Early postpartum discharge: how are mothers managing?.
        J Obstet Gynecol Neonatal Nurs. 1998; 27: 142-148
        • Kurth E.
        • Kennedy H.P.
        • Spichiger E.
        • Hosli I.
        • Zemp Stutz E.
        Crying babies, tired mothers: what do we know? A systematic review.
        Midwifery. 2009; https://doi.org/10.1016/j.midw.2009.05.012
        • Lugina H.I.
        • Christensson K.
        • Massawe S.
        • Nystrom L.
        • Lindmark G.
        Change in maternal concerns during the 6 weeks postpartum period: a study of primaparous mothers in Dar es Salaam, Tanzania.
        J Midwifery Womens Health. 2001; 46: 248-257
        • Shirima R.
        • Greiner T.
        • Kylberg E.
        • Gebre-Medhin M.
        Exclusive breast-feeding is rarely practised in rural and urban Morogoro, Tanzania.
        Public Health Nutr. 2001; 4: 147-154
        • Omer-Salim A.
        • Lars-Ake P.
        • Olsson P.
        Whom can I rely on? Mothers’ approaches to support for feeding: an interview study in suburban Dar es Salaam, Tanzania.
        Midwifery. 2007; 23: 172-183
        • Omer-Salim A.
        • Persson L.A.
        • Olsson P.
        How do health workers balance infant feeding and employment?.
        Afr J Midwifery Women's Health. 2008; 1: 46-52
        • Taylor J.
        • Johnson M.
        How women manage fatigue after childbirth.
        Midwifery. 2010; 26: 367-375
      3. Mbekenga CK, Lugina HI, Christensson K, Olsson P. Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study. Midwifery; in press, doi:10.1016/j.midw.2009.03.002.

        • Lugina H.I.
        • Lindmark G.
        • Johansson E.
        • Christensson K.
        Tanzanian midwives’ views on becoming a good resource and support person for postpartum women.
        Midwifery. 2001; 17: 267-278
        • NBS [Tanzania], ORC Macro
        Tanzania demographic and health survey 2004–2005.
        National Bureau of Statistics [Tanzania] and ORC Macro, Dar es Salaam2005
        • Ministry of Health
        National package of essential reproductive and child health interventions in Tanzania.
        Reproductive and Child Health Section, Dar es Salaam, United Republic of Tanzania2000
        • Mrisho M.
        • Obrist B.
        • Schellenberg J.
        • Haws R.
        • Mushi A.
        • Mshinda H.
        • et al.
        The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania.
        BMC Pregnancy Childbirth. 2009; 9: 10
        • Lugina H.I.
        • Johansson E.
        • Lindmark G.
        • Christensson K.
        Developing a theoretical framework on postpartum care from Tanzanian midwives’ views on their role.
        Midwifery. 2002; 18: 12-20
        • Dahlgren L.
        • Emmelin M.
        • Winkvist A.
        Qualitative methodology for international public health.
        Umeå University Publications, Umeå2004
        • NBS [Tanzania], ORC Macro
        2002 population and housing census: regional profiles, Dar es Salaam: Government of Tanzania.
        National Bureau of Statistics [Tanzania] ORC Macro, Dar es Salaam2003
        • IFPR
        Dar es Salaam: urban livelihood challenges.
        International Food Policy Research Institute, Washington, DC2003
      4. MoH. Tanzania district health service website; 2006. Available from: http://www.districthealthservice.com/district_page.php?id=95&year=2005 [cited 2009 11/2/2009].

        • Ministry of Health and Social Welfare
        Sera ya Afya.
        Ministry of Health and Social Welfare, Dar es Salaam, Tanzania2007
        • Kvale S.
        Interviews: an introduction to qualitative research interviewing.
        SAGE Publications, Thousand Oaks, CA1996
        • Graneheim U.H.
        • Lundman B.
        Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
        Nurse Educ Today. 2004; 24: 105-112
        • Bogossian F.E.
        Social support: proposing a conceptual model for application to midwifery practice.
        Women Birth. 2007; 20: 169-173
        • Ferlander S.
        The importance of different forms of social capital for health.
        Acta Sociol. 2007; 50: 115-128
        • Campbell C.
        • Mzaidume Z.
        Grassroots participation, peer education, and HIV prevention by sex workers in South Africa.
        Am J Public Health. 2001; 91: 1978-1986
        • Nyqvist F.
        Social capital and health: variations, associations and challenges.
        Åbo Academi University, Finland, Vasa2009
        • Ware N.C.
        • Idoko J.
        • Kaaya S.
        • Biraro I.A.
        • Wyatt M.A.
        • Agbaji O.
        • et al.
        Explaining adherence success in sub-Saharan Africa: an ethnographic study.
        PLoS Med. 2009; 6: e11
        • Ntukula M.
        Custodians of custom.
        in: Ntukula M. Liljestrom R. Umleavyo: the dilemma of parenting. Grafilur artes Graicas, Spain2004
        • Mabilia M.
        Breast feeding and sexuality: behaviour, beliefs and taboos among Gogo mothers in Tanzania.
        Oxford Berghahn, New York2005
        • Desgrées-du-Loû A.
        • Brou H.
        Resumption of sexual relations following childbirth: norms, practices and reproductive health issues in Abidjan, Côte d’Ivoire.
        Reprod Health Matters. 2005; 13: 155-163
        • Zulu E.M.
        Ethnic variations in observance and rationale for postpartum sexual abstinence in Malawi.
        Demography. 2001; 38: 467-479
        • Cleland J.G.
        • Ali M.M.
        • Capo-Chichi V.
        Post-partum sexual abstinence in West Africa: implications for AIDS-control and family planning programmes.
        AIDS. 1999; 13: 125-131
        • NBS [Tanzania], ORC Macro
        Tanzania HIV/AIDS and malaria indicator survey 2007–08.
        National Bureau of Statistics and ORC Macro, Dar es Salaam, Tanzania2008
        • Stephenson R.
        • Baschieri A.
        • Clements S.
        • Hennink M.
        • Madise N.
        Contextual influences on modern contraceptive use in sub-Saharan Africa.
        Am J Public Health. 2007; 97: 1233-1240
        • WHO
        Global strategy for infant and young child feeding.
        World Health Organization, Geneva, Switzerland2003
        • Britton C.
        • McCormick F.M.
        • Renfrew M.J.
        • Wade A.
        • King S.E.
        Support for breastfeeding mothers.
        Cochrane Database Syst Rev. 2007; : CD001141
        • Sikorski J.
        • Renfrew M.J.
        • Pindoria S.
        • Wade A.
        Support for breastfeeding mothers: a systematic review.
        Paediatr Perinat Epidemiol. 2003; 17: 407-417
        • Razurel C.
        • Bruchon-Schweitzer M.
        • Dupanloup A.
        • Irion O.
        • Epiney M.
        Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study.
        Midwifery. 2009; https://doi.org/10.1016/j.midw.2009.06.005
        • Janz N.K.
        • Becker M.H.
        The health belief model: a decade later.
        Health Educ Behav. 1984; 11: 1-47
        • Gagnon A.J.
        • Sandall J.
        Individual or group antenatal education for childbirth or parenthood, or both.
        Cochrane Database Syst Rev. 2007; 18: CD002869
        • von Both C.
        • Fleaa S.
        • Makuwani A.
        • Mpembeni R.
        • Jahn A.
        How much time do health services spend on antenatal care? Implications for the introduction of focused antenatal care model in Tanzania.
        BMC Pregnancy Childbirth. 2006; 6: 22
        • Grilli R.
        • Ramsay C.
        • Minozzi S.
        Mass media interventions: effects on health services utilisation.
        Cochrane Database Syst Rev. 2002; : CD000389
        • Vidanapathirana J.
        • Abramson M.J.
        • Forbes A.
        • Fairley C.
        Mass media interventions for promoting HIV testing.
        Cochrane Database Syst Rev. 2005; 20: CD004775