Investigating the Relationship between the General Health of Mothers and their Maternal Performance following Vaginal Childbirth

1. INTRODUCTION

The performance of the birthing person in the postpartum period is an important indicator of the successful transition in their role as a parent and predicts behavior, self-efficacy, and infant care behavior [1]. Childbirth itself is one of the most significant life events [2]. Yet the postpartum period can be particularly stressful, with sudden and severe changes in one's roles and responsibilities following childbirth [3]. Applying the specialized skills that birthing parents need to strengthen their role as the first caregiver of the baby, ensuring their health, and managing household affairs is often referred to as ‘maternal performance’ [4], though we recognize the need for future language to be gender inclusive [5]. Such performance is an important variable affecting infant care during the 12 months following birth and throughout parental life [6]. Postpartum maternal performance is a complex and multidimensional concept that includes self-care, care of the baby, infant feeding, family care, and social and occupational activities [7]. As this performance presents as stressful, there is a need to explore how the health of the birthing parent may correlate with performance in this context.

The performance of the birthing person (often a mother) is influenced by several factors [8]. In the postpartum period, influencing factors may include mode of birth [9], infant mood and night waking [10], social support [11], depression [12], and anxiety [13]. Considering that depression and anxiety are both factors affecting maternal performance in this context, we hypothesized that general health and/or mental health may also be an influencing factor.

According to the World Health Organization, health is defined as being not only the absence of disease or disability but also the optimal state of physical, mental, and social well-being, where mental health is the relative ability of a person to perform physical, mental and social roles [14]. General health is also one of the important indicators of personal and social health [15]. It has four subscales, including physical function, social function, anxiety, and depression [16]. People experience significant changes in their general health status during and after pregnancy and childbirth [15]. As such, studying general health in this context will be vital, particularly in the prevention of adverse outcomes associated with pregnancy and childbirth [16].

Previous studies have identified significant relationships between maternal performance following childbirth and mental health (e.g., anxiety, depression, behavior control, and positive affect) [17-20]. Indeed, some child bearers with depression and clinical problems may experience lower performance [8] and functioning [7] when acting as primary carers for their newborn. Postpartum depression following childbirth can also have a negative effect on bonding with the infant at one- and four months post-childbirth [21]. Conversely, performance following childbirth can increase following a decrease in depression [22]. Yet, in one study, no significant relationship was found between postpartum depression symptoms and the quality of infant care [23]. Such inconsistencies require further examination in a variety of contexts, particularly in Iran, where limited studies exist and birthing people are reportedly less prepared for parenthood following childbirth [17, 24]. It is also not clear how general health (as opposed to mental health) may relate to maternal performance in this context. Considering the above, we aimed to determine the relationship between the general health of the birthing person (e.g., mother) and maternal performance following vaginal childbirth in the context of Iran.

2. METHODS

2.2. Sample Size

Where the standard deviation of maternal performance was equal to 0.24, taking into account an accuracy of 0.03 and with a confidence limit of 95%, the sample size calculated for a similar study based on estimating averages has been equal to 246, rising to 450 after additionally taking into account the possibility of incomplete cases [25].

n = [(1.96) ² × (0.24) ²] ÷ (0.03) ² = 246

3. RESULTS

The inclusion and exclusion criteria were examined in 765 potential participants. Many (n = 315) were subsequently excluded. Some because they were not Iranian (n = 85), some because they gave birth via cesarean section (n = 175), some because they declined to participate (n = 40), and others because they had known psychological conditions or underlying physical conditions (e.g., lupus, heart disease, kidney disease) (n = 15) (Response rate = 59%). Of all eligible participants included in this study (n = 450), most participants were aged between 26 and 35 years, with a frequency of 223 (49.6%). The highest level of education of participants (n=202) was university level (44.9 percent), and the majority (n=347) were unemployed (77.1%). Most (n=273) gave birth in a public hospital (60.7%), and the majority (n=258) had experienced one previous pregnancy (57.3%). Many (n=299) had a previous history of vaginal childbirth (66.4%), and even more (n=363) reported no history of abortion (80.7%). The average gestational age of participants at the time of vaginal childbirth was 38.75 weeks. The demographic characteristics and obstetric history of the participants are presented in Tables 1 and 2.

Table 3 below presents results highlighting an average general health status of 1.86±2.306 for participants based on scores from 0 to 100. In reference to the variable related to maternal performance, competence had the highest average score.

Table 4 presents our finding that performance had no significant relationship with either the favorable or unfavorable general health status of participants (P=0.486).

4. DISCUSSION

This study has determined no relationship between general health and maternal performance in those referring to comprehensive health centers affiliated with the University of Medical Sciences in Tehran, Iran. The mean and standard deviation of general health scores were 1.86 and 2.306, respectively. Considering that the general health score varies between 0 (favorable) and 12 (unfavorable), our results demonstrate that many participants have favorable general health overall. In a previous study, the average rating scores of participants at 34 and 36 weeks of pregnancy and 6 weeks after vaginal childbirth were reported as 3.36 (SD = 2.69), 3.11 (SD = 2.58), and 3.12 (SD = 2.89), respectively [30]. Yet in Molly et al.'s (2013) study, the average score of the general health of those with children who had hearing impairments was 29.82 compared to those who did not (20.24). These averages indicate that the general health of those with children who had hearing impairments is somewhat favorable, and the general health of those who did not is favorable [31]. Considering these results are inconsistent with those presented in the present study, large meta-analyses may be indicated in the future.

The average general health score identified in a previous study conducted by Omidi et al. (2019) was 33.81 ± 16.27. The highest percentage of those studied (40%) had mild health disorders, and only a small percentage (3.7%) had severe health disorders [32]. Based on results reported by Mohajeri et al. (2015), the mean general health of participants in physical functioning areas (65.81 ± 24.12), social performance (61.62± 27.01), pain (62.12±27.01), mental Health (61.94 ± 20.14) was higher than other areas, and the lowest general health average was related to the impact of the role affected by emotional problems (44.38 ± 44.49). However, 23.2% in this area had a maximum general health score, and 32.1% had the lowest general health score. General health in those birthing with special educational needs was reported at a low level [33]. Moreover, birthing parents of children with disabilities also reportedly had low health levels [34]. Considering these inconsistencies with the results of the present study, it may be useful to take an intersectional approach in the future to account for how the characteristics of different birthing people intersect in this context.

5. MATERNAL PERFORMANCE

The mean and standard deviation of scores relating to maternal performance, maternal needs, and maternal competence were 91.04 ± 12.418, 30.58 ± 6.272, and 60.46 ± 7.383, respectively. A separate study conducted in Tabriz, Iran, reported an average maternal performance score of 97.4 [17]. Elsewhere, performance scores have been reported at 93.3 [35], 97.4 [36]. All the above studies used the same questionnaire, and the results aligned with those presented here. As such, this research contributes to a growing body of evidence in this regard. This is particularly interesting given that performance has been reported with an average score of 80 (range: 0-120) elsewhere, where participants screened positive for depression and other mental ill health conditions [37]. As in the present study, the highest scores related to competence have also been reported elsewhere more recently [38]. This further suggests that the field must now act on the growing body of evidence in this regard. Nevertheless, future studies may more usefully draw from alternate data collection tools such as the IFSAC tool [25, 39, 40] in order to make meta-analyses more feasible.

6. GENERAL HEALTH AND MATERNAL PERFORMANCE

We have identified no statistically significant difference in performance scores for those with favorable and unfavorable general health status following childbirth. This is somewhat surprising given that there is often a significant relationship reported between performance following childbirth alongside mental health and all its subscales (anxiety, depression, behavior control, and positive affect) [4, 17, 37, 38]. Yet our study excluded participants who did not self-report good mental health, and performance is known to increase in the absence of poor mental health [4, 6, 7, 8, 22]. Yet, considering the importance of family and the role of birthing parents in Iranian culture, some may attempt to maintain their role, strengthen family relationships, and maintain their performance despite ill health. Future studies could usefully explore these phenomena by employing more qualitative methodologies.

The implications of the findings presented suggest that those childbearing with poor general health may be overcompensating in caring for their newborns early on. The consequences of this may unfold later in parenthood, when maternal performance can no longer be sustained in the face of ill health. As such, it will be important that parental support continues to sustain childhood development in the long term, particularly as parental burnout may have detrimental consequences to both childhood development and parental well-being in the long term.

7. STRENGTHS, LIMITATIONS, AND SUGGESTIONS FOR FUTURE RESEARCH

The current study was rigorously conducted, and multi-stage sampling was used to reduce sampling errors and enhance representation. Nevertheless, a clear limitation is that only participants from the west and northwest regions of Tehran were included. Moreover, due to the design of this study, those who experienced birth via cesarean section were also excluded. Considering that not all participants with a high-risk pregnancy and/or birth were able to participate, results cannot be generalized to all high-risk pregnancies and births. Future research is required in other geographical areas of Tehran, examining maternal performance in those who have given birth via cesarean section and those who experience high-risk pregnancy and childbirth. It will also be important to compare scores with participants in other parts of the world and conduct more qualitative research to understand how people adapt to parenthood following childbirth in a variety of cultures and contexts.

CONCLUSION

No statistically significant difference in maternal performance score was identified for those with favorable and unfavorable general health status following vaginal childbirth. This builds upon a growing body of evidence in the context of Iran. Despite this sample having high performance scores, it will be important to enhance and maintain good mental health in all childbearing people, particularly following childbirth, as this will enhance care and outcomes overall.

REFERENCES