Providing mental healthcare for postpartum women in Indonesia: a qualitative phenomenological study

Globally, it is estimated that around 13% of postpartum mothers experience mental health disorders, especially postpartum depression (World Health Organization, 2015). This prevalence is increasing in developing countries, which have a prevalence of almost 20% (Fisher et al, 2012; World Health Organization, 2015). In Indonesia, an estimated 26% of postpartum mothers experience depression (Nurbaeti et al, 2018). Postpartum depression, as an example of postpartum mental health disorders, can be caused by negative experiences of childbirth, but women without birth trauma may also experience it, even up to 2 years after birth (Slomian et al, 2019; Hutchens and Kearney, 2020).

Studies have identifed some causative factors, including pre-existing trauma, personality, medical conditions, birth outcomes, social support and environment (Lopez et al, 2017; MacKinnon et al, 2017; Dekel et al, 2020; Delgadillo and Gonzalez Salas Dugne, 2020). Additionally, postpartum mental health disorders can affect women of different parity, education and employment status (Knight et al, 2018). These issues can trigger lifelong negative effects for mothers, babies and families (Bradley and Slade, 2011; Knight et al, 2018; Dekel et al, 2020).

The adverse effects of postpartum trauma for both mother and baby include disrupting the ‘sacred hour’ between a mother and baby (Phillips, 2013) and can interfere with early breastfeeding initiation (Phillips, 2013; Koopman et al, 2016). If an initial mental health disorder is not identified early and appropriate interventions are not applied, this can affect the physical and psychological wellbeing of a mother. The effects of postpartum mental health disorders can also impact subsequent pregnancies and births, potentially causing more negative effects than in previous births (Holopainen et al, 2020). Therefore, it is important that every postpartum mother is given adequate mental healthcare (Royal College of Midwives, 2015).

Midwives provide vital care to postpartum mothers, especially mental healthcare (Ministry of Health Indonesia, 2007; International Confederation of Midwives, 2018). Unfortunately, even after mental health was identified as a strategic planning need by the Indonesian Ministry of Health (2015) in 2015, no specific regulations were passed to promote maternal mental health services in Indonesia. A lack of knowledge about maternal mental health services is an area of underdeveloped study in low- and middle-income countries, including Indonesia, and has been included in global research priorities (Edwards et al, 2006; Kennedy et al, 2018).

The present study's aims were to understand the implementation of postnatal mental healthcare provided by midwives, by exploring their views of their role and experiences. In addition, differences in midwives’ authority when providing care in different facilities, such as hospitals, health centres and places of independent practice, were considered when evaluating midwives’ experiences in providing mental health care for postpartum mothers.

Methods

The research design was descriptive phenomenology, drawing on principles from Edmund Husserl's philosophy (Johnson, 2000), which focuses on the concept of ‘life-world’ or ‘lived experience’. The study was conducted in Surabaya because it is the second largest urban area in Indonesia, and mothers living in an urban area are 1.4 times more likely to develop postpartum depression than those living in rural areas (Andajani-Sutjahjo et al, 2007; Idaiani and Basuki, 2012).

The population for the study was clinical midwives working in Surabaya. Participants were sampled purposively, a non-random method that uses eligibility criteria (Andajani-Sutjahjo et al, 2007; Idaiani and Basuki, 2012). The criteria were midwives actively working in hospitals, health centres or midwife-led care units, who had at least 3 years of clinical experience providing services to postpartum mothers.

Recruitment, data collection and analysis were done concurrently from November 2020 to January 2021. Midwives were recruited through the socialisation process, conducted by all researchers, using flyers uploaded on social media. A contact number for the researchers was provided if there were further questions from potential participants. Those who were interested could register via the online form with a link. After registration, potential participants were directed to the online informed consent sheet and options for the interview schedule.

A total of 20 midwives participated in this study, representing each region in Surabaya (north, south, east, west and central), with four mixed midwives from different healthcare facilities in each region. Different facilities (hospitals, primary healthcare centres and midwife-led care units) were used to understand experiences at different levels and environments of healthcare. Some participants knew the researchers, so the interview and data transcription processes were conducted by three research assistants to avoid bias. The assistants and researchers had coordinated before the interview and data transcription to ensure they had the same understanding of the research aims and processes.

Data collection

Data were collected using individual in-depth interviews conducted in the Indonesian language with open-ended questions. The two main questions asked about midwives’ perceptions of and experiences with giving mental healthcare for postpartum mothers, with probes used to elicit further data. To avoid personal bias, researchers ensured they gave non-judgmental reactions to participants’ responses, encouraging participants to share in a safe and secure conversation and allowing for detailed descriptions of participants’ experiences without interruption. The interview was conducted through an online platform for approximately 60 minutes.

Data analysis

Data transcription and analysis were conducted manually because Indonesian is a language that cannot be transcribed and analysed by a computer program such as NVIVO. All researchers had training in qualitative methodology and the principal investigator received education on qualitative research while undertaking a master's degree in the UK.

The data were analysed using thematic analysis (Braun and Clarke, 2006) using the following steps:

• Familiarising with the data by repeated active reading (searching for meaning and patterns) through the entire dataset to gain a deeper understanding of the content along with marking ideas for coding
• Generating initial codes by organising data into meaningful groups
• Searching for themes by analyzing the developed codes and considering how different codes may combine to form themes
• Defining and reviewing themes
• Reporting data concisely, coherently and non-repetitively within and across themes.

Data analyisis was done manually, after receiving the data transcription from the research assistants, through intensive discussion. To ensure rigour and trustworthiness, the researchers’ assumptions were bracketed during the study process.

Ethical considerations

This study was approved by the Health Research Ethics Committee Universitas Airlangga School of Medicine Surabaya, Indonesia (No. 163/EC/KEPK/FKUA/2020). Before the interview began, participants were reminded that the interview would be recorded, that pseudonyms would be used for anonymity and that the participant may stop or withdraw from the interview without consequence. Databases of audio recordings, online consent documents and interview schedules were saved in a password-protected email.

The interviewer ensured participants felt secure to share their experiences before conducting the interview. During the interview, participants were free to stop the interview if they recalled something negative and become upset. After the interview, participants were asked to disclose their feelings and, if necessary, the interviewer referred the participant to the mental health and wellbeing unit at the Universitas Airlangga Hospital. All participants were informed of this before the interview.

Results

The participants’ characteristics are shown in Table 1. Of the 20 participants, most were between 30 and 35 years old, had more than 10 years of clinical experience and cared for less than 30 postpartum mothers per month. Half worked in hospitals as clinical midwives, and the remaining participants worked in primary healthcare centres and midwife-led care units. Almost half of the participants held a bachelor's degree.

Midwives’ views of implementing postpartum mental healthcare

There were four sub-themes related to midwives’ views of implementing postpartum mental healthcare: ‘a midwife's role as a companion and supporter’, ‘mental health needs to be addressed during pregnancy’, ‘the important role of providing mental healthcare for postpartum mothers’, and ‘providing holistic care, not just physical’.

A midwife's role as a companion and supporter

The midwives reported the belief that their role when provising mental healthcare to postpartum mothers was that of a companion and supporter.

‘The role of a midwife is as a companion.’ Sari

‘The midwife, as a partner of the patient, functions to support the postpartum process so that it normally runs.’ Putri

‘A midwife psychologically…provides support.’Ahha

Mental health needs to be addressed during pregnancy

Midwives stated that mental healthcare is complex and must be brought up with mothers early during pregnancy.

‘Taking care, providing counselling, providing intense communication about how to prepare and so on.’Asa

‘Starting from antenatal care, the feeling of starting to accept the pregnancy, accepting childbirth, so that the mother is calmer.’ Isti

The important role of providing mental healthcare for postpartum mothers

The participants believed that their role was important to providing mental healthcare for postpartum mothers.

‘It should be a series, and it is important to provide psychological care for the postpartum mother.’ Lova

‘This is very important, crucial about our role in mental healthcare. This is because if there is no clear information, there is not enough knowledge for the patient, and that is also quite a lot of difficulties.’ Isti

Providing holistic care, not just physical

The participants reported that when providing mental healthcare, their role needed to include holistic care, not just a physical approach.

‘We provide holistic care, not just physical.’ Tyara

‘Yes, we must not only take care of patients physically, but also pay attention to the mother's psychological aspects.’Ahha

‘It would be better if the approach was not only from the physical aspect, but also from psychological matters.’ Ita

Midwives’ experiences of implementing postpartum mental healthcare

Identifying issues by examining attitude

The participants stated that a mother's attitude can be an early sign of potential mental health disorders. Identifying if a mother's behavious was unusual or abnormal helped in the detection of developing issues.

‘What I experienced at that time was that she didn't want to breastfeed her baby, so the term was…"the baby blues". Not only the baby blues, but she also kept wanting to hurt the baby. She…almost dropped the baby.’ Lova

‘When a mother feels sad after giving birth, it means that it is not as usual. If it is only the birth process, it is a happy thing for the mother, especially the first child…There is a husband, there is a family, [but] the mother is just silent, she does not respond to the baby.’ Mawar

‘If the mother does not want to see the baby's face… it already points to the mother's psychological problem.’ Putri

‘She does not want to eat. She does not want to drink, she does not want to do early ambulation or anything.’ Kenanga

An intensive approach to initial treatment

An intensive approach to caring for the mother and family was considered an essential and effective first step for managing suspected postpartum mental health disorders.

‘So we are trying to find out if, for example, the mother suddenly cries, we must ask why the mother is crying? So, trying to get closer…go into what the mother feels, then try to enter or dive into what the mother is feeling.’ Lova

‘I came to patient's house to be intense, until I realised that this is a situation… a destiny that cannot be changed…Finally, it could be resolved…We [midwives] are the ones who want to jump right in.’ Asa

Collaborative care or referrals for patients who need further treatment

If mental health problems persisted and independent approaches and efforts to resolve the issue were not successful, the participants felt a midwife should collaborate or refer for further treatment.

‘Because of such conditions, we cannot overcome it ourselves. So we will collaborate or consult with psychiatry.’ Lova

‘If there is something essential that we cannot do, we will consult a doctor. For example, a psychiatrist if there is a postpartum blues.’ Indah

Openness and a co-operative attitude determine success

The participants felt that when a mother had an open and co-operative attitude, this made it easier to identify and manage problems.

‘The most important thing is a co-operative patient. When we provide care and the patient is cooperative, of course, the care is maximised.’ Putri

‘The important thing is that the mother is co-operative with the supporting things. It is easy to identify a co-operative mother's problem.’ Sari

Physical and social aspects of successful healthcare

The physical aspects, including the environment and the care system affected the mental healthcare provided, as did social factors such as family, community and culture.

‘At that time, the condition of the room was quite supportive for me to invite her to the room…I also turned on a relaxation song.’Tyara

‘The most supportive thing is family. For example, if the family understands the needs of the postpartum mother, so maternal care can still run optimally.’ Indah

‘The environment of care is essential. I am working in a hospital ward that cares for all cases. When I need more time to take care of a mother with special issues, like mothers with postpartum blues, my colleagues from other health professions do not really support that. They rush me and it makes me uncomfortable giving care to the postpartum mother.’Ahha

Midwives need standard guidelines

All participants reported that they hoped for a standard postpartum mental healthcare guideline, to provide optimal care.

‘There is no guideline, I hope that after this research, there will be a specific guide for caring for the psychology of postpartum mothers so that midwives can provide optimal care.’ Putri

‘We don't have a standard operational procedure specifically about postpartum mental healthcare. Most guidelines are about basic midwifery care, such as how to educate mothers to breastfeed and midwifery care in emergency cases, and I feel that this is our main problem in giving care comprehensively.’ Ahha

‘To be honest, because we don't have a standard operating procedure for postpartum mental health care; how it's done depends on the midwife. If mothers have risk factors, then a midwife will assess them more comprehensively than mothers who look fine, and the mental healthcare given may be different among midwives. I feel that this is unfair to the mothers. Sometimes I've asked myself if my mental healthcare for the mothers is appropriate.’ Sari

Discussion

Midwives are essential to providing care for postpartum women. By examining midwives perceptions and experiences of providing mental healthcare to postpartum mothers, this study aimed to establish a cultural concept of mental healthcare for postpartum mothers, provided by midwives, and contribute evidence to improve midwifery care.

The midwives in this study felt that their role was as a companion and to provide support during the postpartum period. In the postpartum period, midwives can provide both physical and mental healthcare (Coates and Foureur, 2019; Goemaes et al, 2020), and most midwives in the present study recognised the proven negative impact that postpartum psychological disorders can have on a mother, her baby and her family (Bradley and Slade, 2011; Coates and Foureur, 2019). A midwife's role in postnatal mental health can start with making mothers aware that they may display clinical symptoms of mental health disorders after childbirth, even if they did not experience potential risk factors (Ionio and Di Blasio, 2014).

According to the participants’, postpartum mental healthcare needs to begin during pregnancy. Mental healthcare can only be successful if there is trust between a mother and midwife, and this must be developed from the start of antenatal care to support open discussion (Ford and Ayers, 2011; Anis et al, 2022). Building trust is essential as the evidence suggests that mothers experiencing postpartum mental health issues may feel insecure, helpless and unable to communicate with others, potentially exacerbating the negative effects of the issue (Taghizadeh et al, 2014). To prevent postnatal psychological problems, midwives should provide appropriate care through personalised support for each mother, involving her in decision making, giving consistent information and providing continuity of care, especially for vulnerable women. Proper education and holistic care beginning in pregnancy reduces the risk of postpartum maternal mental health disorders (Taghizadeh et al, 2014). These are essential to strengthen emotional wellbeing and positive emotional connections between midwives, mothers and their families.

Midwives who carried out care in the midwife-led care units seemed to be more manageable and flexible in providing maternal psychological care; for example, Tyara, who worked in a midwife-led unit, was able to turn on a relaxation song for the mother and noted that the room itself supported care. By contrast, midwives who worked in hospitals experienced limitations on providing care. Ahha, who worked in a hospital, found it uncomfortable as colleagues would rush care for mothers, even when they had concerns such as postpartum depression. According to Simpson and Catling (2016), it is essential to ensure the environment is conducive to postpartum psychological healthcare, as the environment is a determining factor for postpartum maternal psychological healthcare success.

According to the participants’ experiences, postpartum mental health disorders may be the result of both physical and social factors, including poor social relations. Social aspects, such as a mother's relationship with the father of the child, have previously been reported to impact psychological disorders after childbirth (Ayers et al, 2014). In addition, a woman's perception of and response to the birth, particularly the care they received, is a more critical determinant factor for mental health disorders after birth than the nature of the birth itself (Martin, 2012; Izzati et al, 2021). Midwives must carefully consider the necessity of interventions during intrapartum care, even when these interventions are routine or expected (Royal College of Midwives, 2015; MacKinnon et al, 2017).

Although there is no standardised screening tool for mental health disorders (Martin, 2012), almost all respondents reported that they would identify a postpartum psychological disorder by examining a mother's attitude. Behaviours such as not wanting to breastfeed their baby, looking sad and crying for no identifiable reason, losing focus, not wanting to take care of themselves and wanting to hurt themselves or their baby, could all indicate a postpartum mental health issue.

Theoretically, midwives can identify risk and wellbeing in a number of ways (Ionio and Di Blasio, 2014; Royal College of Midwives, 2015), including postnatal debriefing, involving a structured or unstructured discussion about the mother's perceptions after childbirth and coping mechanisms (Royal College of Midwives, 2012). A midwife should appraise a mother's feeling about their birth, particularly for those who have a traumatic birth and/or potential risk factors for mental health disorders (Ionio and Di Blasio, 2014) and a mother should be encouraged to share her feelings, thoughts or responses about childbirth with midwives, even seemingly minor concerns, such as sleep disturbance (Taghizadeh et al, 2014).

The ‘red flag’ guidance is recommended by Mothers and Babies: Reducing Risk through Audits and Confidential Inquiries across the UK (Knight et al, 2018) and the NHS (2017). The ‘red flag’ system points to significant changes in a mother's mental condition (NHS, 2017; Knight et al, 2018). These might include a persistent feeling of inability to take care of the baby, feeling like a stranger to the baby or thoughts or acts of self-harm, and indicate an increased risk of suicide (NHS, 2017; Knight et al, 2018).

In the present study's setting of Indonesia, although there have been efforts to include assessing postpartum mental health in maternity facilities, the participants felt that a standardised guideline on maternal mental healthcare was necessary. In the absence of standardised guidelines, the participants’ used an intensive approach to mental healthcare. The approach involved asking a mother how she felt, trying to get closer and diving into what the mother was feeling. This approach is similar to the concept of cognitive behavioural therapy (Delgadillo and Gonzalez Salas Duhne, 2020), which is used to change people's thoughts and behaviours to manage mental health problems through talking therapy (NHS, 2022). It has been shown to be an effective treatment for mental health disorders (Otte, 2011; Delgadillo and Gonzalez Salas Duhne, 2020).

If the symptoms of a mental health disorder persisted even after using this approach, or a mother was experiencing severe mental health problems, the participants would collaborate with other health professionals working in primary and secondary care to secure appropriate care for mother. This is in line with national regulations to encourage the early detection of risk and complications during pregnancy, childbirth, postpartum, and post-abortion care. These efforts are also in line with the essential competencies for midwifery practice (International Confederation of Midwives, 2018).

Although approaches and efforts have been made to improve mental healthcare for postpartum mothers in Indonesia, the participants reported feeling that the main obstacle to mental healthcare for postpartum mothers was the absence of standard operating procedures or guidelines for implementing mental healthcare, which made them hesitant about providing treatment. Consequently, there is variability in postpartum mental health management and a high incidence of postpartum maternal mental health disorders (Halbreich and Karkun, 2006).

Midwives need up-to-date education and training about perinatal mental health, which would be more effective if given to midwifery students (McCauley et al, 2011; Jarrett, 2015; Coates and Foureur, 2019). Midwives should be encouraged to participate in developing clinical guidelines related to postnatal mental health.

Limitations

As a result of language constraints, a computer programme could not be used to assist in transcribing and analysing the data. This may have allowed for bias from human error. Additionally, the sample size for this study was small, meaning the results may not be generalisable to midwives across Indonesia.

This study was conducted by researchers who were new to qualitative methodologies. Further qualitative research with larger and more varied samples is needed, as well as quantitative evidence of maternal mental healthcare.

Conclusions

A midwife's role was seen by this study's participants as that of a companion who provides support and holistic care for postpartum mothers, which should be begun during pregnancy. In the absence of national guidelines for providing mental healthcare for postpartum women, midwives diagnosed postpartum mental disorders by examining a mother's attitude. If their attitude was considered abnormal, most midwives made initial treatment efforts using an intensive approach. If necessary, further management of suspected mental health disorders was carried out through collaboration or referral.

Both social and physical factors were thought to determine the success of mental health management approaches, and the participants felt that they would benefit from the creation of standardised guidelines to assist in mental healthcare provision. Midwives have an essential role in managing postpartum mental health, and should keep up to date with education and training. Clinical guidelines related to postnatal mental health would benefit midwives in Indonesia. BJM

Key points

• This study examined midwives’ experiences of providing postpartum mental healthcare for mothers in Indonesia.
• Midwives were aware that it is essential to give mental healthcare to all postpartum mothers and there were efforts to provide mental healthcare in maternity services.
• Postpartum mental healthcare was given in diverse ways by the midwives.
• A standard guideline for postpartum mental healthcare is needed for midwives providing this care, as there is no current guideline.

CPD reflective questions

• To what extent do you regularly consider your role in providing maternal mental healthcare?
• Do you always consider mental health when assessing postpartum mothers?
• How do you implement mental healthcare for postpartum women?
• How does the presence of a standard guideline for providing mental healthcare for postpartum mothers influence your practice and the mothers in your care?