Maternal health education and social support needs across the perinatal continuum of care in India: A thematic analysis

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Understanding deficits among support and educational resources can contribute to improved public health decision-making and maternal and child healthcare and wellbeing. Methods We conducted a qualitative study among 20 postpartum North Indian women to better understand current resources and identify gaps in support across the perinatal continuum of care. Data was analyzed thematically. Results Participants in this study have considerably low maternal knowledge surrounding delivery, in addition to low levels of maternal knowledge and social support around postpartum care and practices. Participants received the most social and educational support during the antenatal phase of pregnancy, which is consistent with the implementation of government and community program goals to increase antenatal care among pregnant women. Notable issues among women during these phases involved consent, and satisfaction and comfort with childbirth care. Participant narratives described the important role of both formal and informal support structures in addressing maternal health needs. Formal structures of support include health systems at the community and facility levels whereas informal structures include family, friends, and the community. Participants also relied heavily on advice from formal modes of support including community health workers (ASHAs), midwives, and doctors. While many participants’ support needs were met by their support networks, our study identified certain areas where support needs remained unmet such as post cesarean section diet and care, institutional delivery, support of ASHA etc., in addition to areas of discrepancy between the advice provided compared to evidence-based practices. Conclusion This study identified a major lack of informational support during the delivery and postpartum phases of pregnancy, which may lead to complications for pregnant women. Programs targeting improved maternal health and wellbeing throughout the continuum of care need to educate pregnant women more about the institutional delivery process. Additionally, programs need to further supply women with support and education with regard to the postpartum phase, which remains neglected. Trial registration: This research is part of the formative phase of a larger intervention trial prospectively registered with Clinical trial registry of India. (CTRI/2020/12/029800 [Registered on: 15/12/2020] and clinicaltrials.gov (phase 1: NCT04636398, phase 2: NCT04693585) social support health education pregnancy childbirth postpartum postnatal India Figures Figure 1 Background Recent data estimates India’s maternal mortality ratio at 103 per 100,000 live births in 2017–2019, representing an 81% percent decline from 556 per 100,000 live births in 1990. 1 – 3 Although there has been substantial improvement in maternal mortality rates over the last three decades, there are still existing maternal health needs that are not being met. An analysis of India’s nationally-representative National Family Health Survey identified a significant increase in the prevalence of self-reported maternal complications between 2005–06 and 2015–16, from 43.6–53.7%. 4 While this increase may be due to both increases in occurrence and reporting (due to more awareness), as a patient-reported outcome it emphasizes a need for broader attention to be paid to the quality of maternal health care. High quality postnatal care and social support is associated with reduced maternal and neonatal mortality, 6 , 7 and increased maternal engagement in behaviors promoting newborn (e.g., exclusive breastfeeding and child immunization) and maternal health (e.g., postnatal adoption of family planning). 8 , 9 Access to high quality care across the perinatal continuum is essential to prevent maternal and neonatal complications and deaths; however, important gaps exist and are patterned by socioeconomic status, raising equity concerns. A little over half (59.0%) of women achieve the Indian guidelines of four or more antenatal care (ANC) visits, with a noticeable difference between rural (55.0%) and urban populations (69.0%). 10 Most births country-wide occur in health facilities (89.0%), though only 61.0% of mothers and 82.0% of newborns received a postnatal health check within 48 hours of birth. 10 By wealth quintile, receipt of a postnatal care visit within 48 hours of giving birth ranged from 58–63%. 10 India’s cash assistance schemes and programs to improve maternal health have broadly removed financial barriers, increased institutional deliveries, and increased the use of antenatal services. The National Rural Health Mission (NRHM) was launched for the period of 2005–2012 to improve equitable access to quality healthcare through a robust community-based health workforce. 11 , 12 Additionally, the Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK) government programs were launched to promote institutional delivery in addition to antenatal checkups by offering cash incentives to women giving birth at a government hospital, with free antenatal care, delivery, postnatal care and neonatal care. 11 Another initiative running under the name SUMAN (The Surakshit Matritva Aashwasan) is being implemented to achieve zero preventable newborn deaths and provide essential newborn care services. 13 The Government of India programs were found to have increased institutional delivery across all socioeconomic groups, and increased ANC usage across most states, reducing inequities. ASHA workers have also played a key role in the success of these programs. 12 , 14 Still, inequalities in access to perinatal care persist, patterned by social gradients. 15 , 16 Finally, the prevalence of gender inequitable norms including child marriage, restricted mobility, and low decision-making control has been found to influence the success of programs targeting maternal and newborn health continuum of care, with greater gender inequity limiting program impact. 17 These findings suggest the demand for programs to address these limitations in access to care. 17 India also has an extensive Community Health Worker Program, consisting of over two million trained Accredited Social Health Activist workers (ASHAs) who assist with accessibility to community-based services for pregnant women throughout pregnancy, and link families and health systems in rural India. 18 – 20 Assessment of India’s Community Health Worker Program found ASHA workers to be effective in increasing antenatal care, immunization coverage, and hospital deliveries. 16 However, ASHA worker performance was found to be less effective at increasing postpartum care, including counseling on maternal danger signs and neonatal care. 16 ASHAs provided appropriate care for chronic diarrhea or child acute respiratory illness in only about half of the cases. 16 These reports indicate a lack of neonatal support and the gap in maternal knowledge and counseling on preventative methods for common neonatal and child illnesses. This includes knowledge on nutritional health, and danger signs of common morbidities, such as pneumonia in newborns. 16 Beyond care provision, ensuring the accessibility of high-quality perinatal care is facilitated by health knowledge and social support. 21 – 24 Studies exploring knowledge of pregnancy-related danger signs have identified low awareness among Indian women. 22 , 23 , 25 Other research has identified misperceptions about the cause of infant illnesses OBJ as a major OBJ barrier to appropriate care-seeking. 26 , 27 Social support across emotional, informational, and tangible domains has been associated with improved health knowledge and care seeking, as well as improved postpartum mental health. 28 – 30 The presence of key individual types in a social support network (e.g., educated females or health care providers) is predictive of high-level maternal knowledge of child health among mothers with low educational attainment. 30 Given the important role of health education and social support for optimizing perinatal health, we conducted a qualitative study to understand resources and gaps across the perinatal continuum of care in northern Indian women, providing a baseline understanding of maternal experiences and needs from the antenatal period through postpartum. Methods We conducted a qualitative study among 20 postpartum North Indian women from Boothgarh block, Mohali district, Punjab, to understand perinatal care perspectives and experiences, barriers to access, social support systems and informational resources, and needs for pregnancy and childbirth. Inclusion criteria were: primiparous and within 3 months postpartum. In-depth interviews were conducted from October 2020 through December 2020. India’s first major COVID-19 surge peaked in September 2020; data collection began as cases decreased and research restrictions allowed for in-person data collection with COVID safety protocols. Due to our inclusion criteria, participants experienced some varied COVID-19 pandemic and pandemic mitigation severity during pregnancy and postpartum. Data Collection Potential participants were identified from antenatal care (ANC) registers maintained at Boothgarh’s 17 healthcare sub-centers. They were introduced to the study via telephone to ascertain interest in participating. Interested individuals were scheduled for an in-person interview. Research staff (qualitative interviewer and a note-taker) visited participants at their home, conducted the informed consent process including obtaining written confirmation, and conducted the interview face-to-face. The research team prioritized a quiet and private location; however, a few interviews had a family member present. In some cases, mothers-in-law came to check but were politely requested to allow privacy to the interviewee. Interviews followed a semi-structured format. The interviewer was well versed with the interview guide to keep the environment of the interview as informal as possible. The note-taker recorded important observations such as attitude and behavior of the participant, important quotes, timing of the interview, location details, etc. The interview guide focused on women’s experiences during their recent pregnancy and postpartum. Interviewees were asked to share their views on perinatal care, pregnancy and postnatal care in the community, barriers to accessing postnatal care, existing social support systems after childbirth, and information needs in the postnatal period. We also sought information to inform a mobile health education intervention to improve maternal health outcomes. The interviews lasted approximately 30–90 minutes, were conducted in Hindi or Punjabi, and transcribed to English, and were audio-recorded upon participant permission. Data Analysis We employed thematic analysis using both deductive and inductive approaches. Transcripts were coded using Dedoose qualitative analysis software following a codebook developed from the in-depth interview guide and supplemented by unexpected findings in the data. After jointly coding 4 transcripts together to standardize analysis, our analysis team of 4 Indian and 4 American researchers coded the transcripts independently, addressing queries and discrepancies through group discussion. The current analysis focused on social support and health education across the perinatal period, employing Berkman and Glass’ social support framework. 31 Emotional support refers to empathetic interactions, offering reassurance, comfort, or acceptance. Tangible support refers to contributing resources, finances, or assistance. Informational support refers to knowledge, facts, and advice or feedback on actions. Data were analyzed within broad perinatal timeframes (i.e., antenatal, delivery, and postnatal). Results Participant Characteristics Participants ranged in age from 20–31 years (Table 1 ). Most (n = 16) had completed higher secondary school or above. Three had pursued diplomas and one participant was illiterate. All participants except one lived in multigenerational households including in-laws, brothers and sisters-in-law, and their children. All participants were married, except for one who was recently widowed. No participant lived in the same village as their parents. Husbands’ occupation varied (e.g., government job, car driver, plumber, auto driver, mechanic, farmer, etc.) Two women worked (lab technician, boutique owner); all others were homemakers. Table 1 Sociodemographic characteristics of study participants (n = 20) Characteristic N (%) Age a 25.5 (22.5–28) Education None 1(5%) Primary School 3 (15%) Secondary School 11 (55%) Some Secondary School 2 (10%) Other 3 (15%) Able to read Cannot read 1 (5%) Can partially read 3 (15%) Able to read 16 (80%) Able to write Cannot write 0 (0%) Can partially write 3 (15%) Able to write 17 (85%) Relationship status Married 20 (100%) No. of children a 1 (1–1) No. of children in the household a 2 (1–3) No. of adults in the household a 6 (4.75-7) Do the parents live in the same village? No 20 (100%) Monthly income husband , a Indian Rupees 9,000 (0–16,000) Monthly income woman , a Indian Rupees 0 (0–0) Not working 19 (95%) Ration Card category Orange (Below the poverty line) 1 (5%) Yellow (Above poverty line) 2 (10%) Do not know 17 (85%) Household phone ownership Yes – smart phone 20 (100%) Personal phone ownership Yes – smart phone 11 (65%) Yes – feature phone 8 (40%) No 7 (35%) Access to household phone Daily 12 (60%) Weekly 0 (0%) Less than weekly 8 (40%) a Median (IQR). Social support resources and needs by perinatal phase Participant narratives were analyzed for social support resources and needs during each phase of the perinatal period and themes were further organized by major social support domains; emotional, tangible, and informational. 31 Fig. 1 presents the theme summary by social support domain and perinatal continuum of care stage. Antenatal Emotional Support Women received emotional support from their neighbors, aunts, relatives, sisters-in-laws, friends, and especially from older women who already had a baby, largely focused on stress relief. “All [family members] used to say don’t take tension (be afraid). In the first pregnancy, women get scared at the time of delivery, so they told me not to take tension, keep calm. Otherwise, there will be a problem with normal delivery.”- 25 years old, ‘other’ educational attainment, 1 child, C-Section Tangible Support Study participants described various tangible support received antenatally, including help with household chores, and medical and personal care facilitation. In most multigenerational Indian households, gender roles are starkly divided and the daughter-in-law bears a heavy housework burden. Most participants were responsible for most household work, e.g., washing clothes, cleaning, and cooking. During pregnancy, they were given some respite. Mothers-in-laws, and sometimes husbands, took over harder household chores given the perceived risk for pregnancy loss during the first trimester and women did light work (e.g., folding clothes, cutting vegetables, dusting) during this time. In the second trimester, women took on additional limited chores. In the third trimester, work such as mopping the floor was considered beneficial due to traditional beliefs that this activity widened the pelvis, increasing the likelihood of successful vaginal delivery. “My husband was a big support [throughout my pregnancy], he did all household chores like washing clothes, brooming and I used to cook only.” – 24 years old, secondary school or higher, 1 child, living with husband and father-in-law, Vaginal delivery Medical care, diet, and rest were facilitated by family members including husbands, mothers, and mothers-in-laws. Women expressed a paramount importance of family members in facilitating their access to the medical care needed for a healthy pregnancy. All participants were from rural India, where transportation was limited. Social restrictions on women traveling to the hospital alone made transportation difficult thus most husbands drove women to their antenatal visits. Women also described how their husbands focused on their diet during pregnancy. Their husbands regularly brought fruits and ensured they ate frequently. One woman mentioned her husband’ guidance to avoid fried food. Another described her husband’s attention to her physical health throughout pregnancy, for example, giving her massages to alleviate pain. Mother-in-laws also provided home treatments for pregnancy-related discomforts, such as stomach aches, bodily pains, and morning sickness. “Whenever the doctor would call us, we would go; whatever check-up they prescribed we did the same way. [My husband] supported me a lot [despite being a truck driver frequently away from home]. When I told him that this day is my test, he would rush back immediately. Because we don’t have any [personal] conveyance to go and in pregnancy a person can’t go alone." – 28 years old, secondary school or higher education, 1 child, Vaginal Delivery “I don’t pay much heed about eating so [my husband] usually fed me. Sometimes he bought apple and sometimes other fruits. He used to cut and fed them to me. I wasn’t well at that time, I would keep lying on bed. He would wake me and feed me. I didn’t take as much care of myself as he took.” – 22 years old, secondary school of higher, 1 child, Vaginal delivery Participants described highly supportive and readily accessible primary medical care in their villages including ASHAs, Auxiliary Nursing Midwives (ANM), Community Health Officers (CHOs), and physicians at a dispensary or private clinic. Most women had registered at the nearest public health facility during the first trimester. They were given a mother and child protection card to track pregnancy details. The card explains the required antenatal checkups, biomarkers to be monitored, pregnancy danger signs, etc. Throughout pregnancy, the women regularly accessed antenatal care. Medical professionals were considered approachable, and some women received their phone numbers to contact in case of an emergency. The widowed participant emphasized the importance of mobile phones for facilitating home-based pregnancy care due to the reduced support she had for physically accessing medical care as a widow. However, women without telephone accessibility to a medical professional had not perceived this to be a need; they had the support they needed for a healthy pregnancy regardless. Overall, participants were satisfied with the medical support provided by the sub-centers, private professionals, and tertiary health care system. “Yes, I had bleeding in the 5th month, it wasn’t much, but I had bleeding. I was at my parental home, then I consulted doctor on the phone, and they gave me medicine for 5 days. They said it is normal, it happens, and there is nothing to fear. Whenever it happens, advise should be taken [from a doctor].” − 28, tenth standard, lives in a joint family “I think it is essential to have a doctor’s contact number [during pregnancy]. Especially when your husband is no more because with a spouse it is much easier for a woman to manage during pregnancy. And one thinks that if we have phone in our life then we should make some use of it. We have to use our mind and have to depend on ourselves. When God makes you go through such situations in life then you have to do and learn many things. Life teaches you everything.” – 30 years, some secondary school education, 1 child, C-section Informational Support Advice seeking from family and others was prominent during respondents’ pregnancies. Participants sought day-to-day advice from mothers-in-law, sisters with children, and other elders. They regularly communicated with community health workers and providers for medical queries, and regularly used the internet and YouTube videos for information. Informational needs voiced included how to have a healthy pregnancy, an appropriate diet, and how to solve problems. Mothers and mothers-in-law heavily influenced the food that women ate and avoided during pregnancy. "Mostly, I would ask my sister and sisters-in-law. Since my husband has two elder sisters, I would ring them up and ask about my problems. Slowly-slowly I would collect all the information from everywhere and got to know what is right and what is wrong then I would apply accordingly. For example, if the thing matched between three people, I would do that." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal delivery “I have a sister who has two kids. So, I used to ask her whenever I had any problem. She used to share everything that she went through in her pregnancies. We had many similarities. We used to discuss those. Her son is now three years old and her daughter is eight. The kids are big.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery “During pregnancy my mother had told me not to eat anything that is hot in nature, especially in the beginning. In the initial months she used to give me healthy things like milk and curd, fruits like pomegranate, apples, etc. My mother used to ask me to eat these things more.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery Two major areas of information sharing were managing pain, and concerns about delivery. Women’s relationships supported and empowered them during their pregnancy. “Yes, my mother-in-law, sister-in-law, and other relatives used to guide me. Do like this, eat what you crave. If I had any problem, they told me to tell them, not hesitate.” – 22 years old, secondary school or higher education, 1 child, vaginal delivery Elders provided considerable informational support to women living in multi-generational households. Women took this advice very seriously. The advice included conventional practices, e.g., ways to channel positive energy, specific foods for a healthy pregnancy, postures, and activities to increase the likelihood of a normal delivery. As previously described, one recommendation was to mop the floor to facilitate vaginal delivery. Foods were customarily categorically divided into ‘hot’ and ‘cold’ by the elders. Women were guided not to eat papaya, pineapple, eggplant, dry fruits, and other ‘hot’ foods in the first three months of pregnancy due to miscarriage fears. "Typically, I would listen to religious hymns only and would listen to Bhajans (religious songs). Also, the elders would say the more you listen to religious things, the more it will give positive effects on the baby."- 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery “[My mother-in-law] just told me not to sit too much as the baby’s head will grow big due to sitting. She didn’t allow me to work and asked me to rest only. The doctor also told me the same. I would do a little bit of work while standing, like making food.“ − 27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery Community-based ASHA workers were the first point of contact for pregnant women in case of any health emergencies, or if they needed any health advice. ASHA workers informed women about available medical care, provided pregnancy-related information including on immunization, healthy diet, and supplements. Women mentioned calling their ASHA workers with questions, and particularly appreciated them during the COVID-19 lockdown because clinics were closed and doctors were not available. “[I was in touch with my] ASHA worker only because due to COVID, clinics were not open. Some tests were done and some were not able to be done. This happened all the time due to COVID. And sometimes I visited Mohali Hospital. All my tests were done there…. [My ASHA] explained very nicely and told me to contact her in case of any problem. She lives nearby [my house], and is very supportive. She explained medicines to me…. I used to get sick at that time. She would counsel on eating healthy, and staying fit.” – 22 years old, secondary school or higher education, 1 child, Vaginal Delivery “Yes, whenever I had a problem, I asked. Like in the 3rd month, I had bleeding. The ASHA suggested that I visit PGI (local referral hospital). I went to PGI, and the doctor gave me an injection. Afterwards, my bleeding stopped.” – 24 years old, secondary school or higher education, 1 child, C-Section Some women contacted doctors over the phone. Women who had registered in private clinics would receive reminder calls from the doctors for check-ups. Women also visited doctors for medical care including routine checkups, scans, and to discuss other health issues. “I used to phone call my brother, and he used to ask the doctor about the problems I had. Sometimes I had pain in the lower abdomen; they suggested avoiding lifting weight.”- 28, tenth standard, lives in a joint family, C-section “[During the third trimester], Doctors used to call and we used to go every week. The baby keeps moving and we get to know that the baby is fine. They also used to come to check the heartbeat to see if it is fine or not.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery Women mentioned different maternal and fetal health queries for which they sought advice from doctors, ASHAs, and other medical professionals. ASHA workers educated women on healthy everyday practices, such as diet. Doctors were a constant support in case of complicated pregnancies, for example, a twin pregnancy. Other queries focused on medication to be taken during pregnancy. “The doctor in 6 phase (hospital) was very nice. She used to talk to me very politely. Whatever she used to ask, I used to tell her. Like I used to feel pain in the lower region, I used to tell her. She used to say this much will happen. It should not be much, but little bit will happen. Just that. Overall, doctors were good there.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery “I used to take calcium and iron supplements daily. And doctors told me not to take any other medicines. If I have pain, then just have paracetamol. So, I just used to have that if I felt pain. Like when I used to feel fever or tiredness, then I used to have that. But I didn’t take much medicines otherwise. As it is not good to take many medicines.”- 26 years old, primary school, 1 child, living in a joint family, normal delivery Most participants owned smartphones, and commonly used the internet for pregnancy-related queries, usually via YouTube videos. The most common searches focused on nutrition, sleeping postures, and baby’s sex. The educational videos were the only educational content mentioned. Women’s narratives demonstrated how crucial the internet was in supporting them antenatally, and it was used independent of professional guidance. “I used to find out if its a girl or boy by watching the scans…(laughs). They used to show signs in the videos, if this sign, it is girl. That sign, it is boy…..(laughs)” – 31 years old, secondary school or higher, 2 children, Vaginal Delivery “About the eating stuff. Like papaya is not good for the initial days of pregnancy, it is hot in nature. There is fear of miscarriage. One should have dry fruits, juice, and milk. We used to watch all this. We used to get to know what not to eat. Like in the initial days, not to eat warm things because there is fear of miscarriage if we eat it.” – 25 years old, ‘other’ educational attainment, 1 child, c-section “Yes, I have used the phone to see how to sleep while pregnant… like when I will sleep, there should not be any problem to the baby. In fact, I have seen how to tell whether there is any problem or not on YouTube. I have seen how to sleep, how to sit, how to eat, and what to eat. Eat vegetables and fruits, and drink juice.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery Childbirth Emotional and Tangible Support Participant narratives intertwined emotional and tangible support around childbirth. They discussed the main individuals providing both emotional and tangible support, and the tangible support provided to assist women’s birthing experiences. When asked about their birthing experiences, most participants mentioned the people supporting them including husbands, brothers, mothers, and mothers-in-laws. These individuals provided emotional support and coordinated with hospital staff for prescribed essentials and medications. For the most part, family members kept the women calm as they endured labor. Mothers comforted the women, while male family members (not allowed in labor rooms) purchased medicines requested by the doctor and ran errands. All participants expressed relief with this support during their birth. One woman expressed how her husband’s communication with the nurse comforted her: "Yes, [my husband] said nothing will happen. He kept on talking to the nurse that nothing should happen to both of us (baby and the participant). Both should be fine."- 22, 9th standard, lives in a joint family, child 1, C-Section “[Family support during delivery] is very important. People get emotional at that time, so the family should be nearby for emotional support.” – 25 years old, ‘other’ educational attainment,1 child, C-Section Women reported feeling comforted through medical staff support during childbirth. One woman shared her confidence in the staff: “ If anything happens, then the nurse is there to look after you at the hospital, but at home there is no one to look after you.”-18, Primary School, lives with husband, child 1, vaginal delivery Narratives revealed the key importance of tangible social support during labor and birth, particularly where participants’ lack of knowledge around emergency medical procedures challenged informed consent. For example, two participants were uncomfortable having to rapidly decide about cesarean surgery with no knowledge. Sometimes, family members were not allowed with the women during birth and women reported feeling emotionally supported by nurses when making hard decisions. One participant undergoing cesarean surgery appreciated the comfort provided by supportive medical staff during the otherwise stressful situation. In one case, a nurse tried to calm the woman by cracking a joke. “The doctors and nurses were nice. The doctor who operated was nice. They all talked with me during the operation, kept me calm all the time.” − 25 years old, ‘other’ educational attainment, 1 child, cesarean delivery However, not all women had supportive experiences with hospital staff. One shared that they scolded her for not following instructions: “They were telling me to lay down so that I can get contractions, but I was restless. They kept scolding me because I wasn’t sitting. Then after some time, I delivered. It was very difficult. They kept pushing the baby. After delivery they gave me stitches.”-10 Informational Support Most participants were pregnant for the first time and were anxious about giving birth so they looked for information to help them prepare. They were mostly unaware of what giving birth would be like yet were generally told by their mothers that they would be fine, without sharing critical details, to avoid scaring them. Women also sought knowledge from their mothers, friends, and sisters on practices to ease childbirth, such as eating certain foods or doing certain activities. Mothers informed them of ways to push during labor, and what foods would help in easing delivery pain. This support helped reduce women’s anxiety around labor and birth, although they were not evidence-based. “Everybody used to tell me to eat well, and also to keep working so that I have a normal delivery. Sometimes the private doctors suggest bed rest, as they suggested to me when I had pain. So, I used to rest. But everyone used to suggest working to have a normal delivery. I used to go for a walk in the evenings as much as possible, because this will help in normal delivery.”- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery “I used to take a lot of care so that the health of the baby is good, especially regarding eating. By the end, my mother used to ask me to eat foods that are hot in nature. Like almonds, she used to put almonds in milk for me. Also, they used to tell me to eat ghee in milk because it helps with normal delivery.“ − 26 years old, primary school, 1 child, living in a joint family, vaginal delivery My mother-in-law would tell me that at the time of delivery, I should push with all the force, and not take too many deep breaths… like this [enacts the action] … this can move the baby backwards.”-41, vaginal delivery In the study sample, six women had c-sections, and 12 had vaginal deliveries. Women’s narratives evidenced a lack of education on cesarean section. In many cases, women only learned of the possibility of a cesarean section on the day they were admitted to the hospital which made emergency decision-making difficult. “When I was in the 9th month, I was scared about what will happen. They would tell me that in normal delivery, there is a lot of pain and the person can’t handle it. That there is a lot of difficulty during that time. In the last part, I had difficulties… that’s it.” – 31 years old, secondary school education, 1 child, C-Section Postpartum Emotional Support Narratives around postpartum emotional support centered largely around recovering from childbirth. Some participants reported moving to their natal homes during the third trimester of pregnancy, whereas others did so after giving birth. In their natal homes, women had added support from their parents, and comfort from familiarity with their surroundings. They explained that they were relieved of all household responsibilities and could physically rest as desired while their mothers cared for their babies. “At my mother’s place, there was no such work to do. Your mother does the work, and so does your sister-in-law. For one month, one aunt came to bathe the baby… we had hired her. After that I started doing it myself... for the baby and for myself too. Clothes and all, mother used to wash.” – 30 years old, some secondary education, 1 child, Vaginal Delivery Tangible Support During the postpartum period, mothers dealt with their own bodily changes in addition to new responsibility caring for a child. Families provided assistance in caring for both women and their babies. Women mentioned movement restrictions for the initial few weeks due to stitches; nearly all participants had some intervention (six underwent cesarean section and 12 underwent episiotomy). Most women were first time mothers, and therefore were nervous with baby care. In most cases, responsibility for the child was taken by their mother-in-law or mother. This included bathing, cutting nails, giving massages, etc. Watching their mothers or mothers-in-law care for the baby helped them learn infant care and gain confidence. Women staying at their natal home appreciated this caring environment. Respondents appreciated having husbands and other family members care for their child from time to time. “This is my first child, so I don’t know much about caring. My mother-in-law does everything. I usually do what she suggests. I keep asking her. She would make me sit and teach me how to give a massage to baby.” – 22 years old, secondary school or higher education, 1 child, Vaginal Delivery "During the night [my husband] keeps the baby with him when I get tired. In the evening, he also keeps holding her, and goes around the house with her. He also plays with her during the night when I get tired. I cannot sit for a long time."- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery Culturally, women are prescribed substantial rest and nutritious diet to support postpartum recovery. Women who gave birth vaginally were asked to eat panjiri, a high-calorie snack made of ghee, nuts, dried fruits, sugar, and herbal gums, to improve lactation and warm the body. Both mothers-in-law and mothers prepared panjiri for respondents. Doctors asked women who had cesarean section to avoid panjiri, as consumption of high calorie foods is believed to reduce wound healing. “My mother had made panjiri (high fat snack) and she used to give me milk. She used to ask me to eat warm foods more like panjiri, dal, chapatti, and porridge.“- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery “My mother gave me panjiri, which is rich in desi ghee and dry fruits. This is so that the baby’s health improves. It will benefit the baby.” – 24 years old, secondary school or higher education, 1 child, vaginal delivery Women mentioned physical discomforts which included pain with stitches, weakness, and leg pain. Mothers and mothers-in-law helped the women sit, assisted with breastfeeding, washing, massages, and other needs to increase comfort. Participants felt this support helped them recover more quickly. One woman who lived alone with her husband had a sister stay with her to care for her post-delivery. “I was good, my mother would help me in sitting and standing. My younger brother helped my mother in taking care of me.”- 28, tenth standard, lives in a joint family, C-Section “I take rest, or [my sister-in-law] massages my legs and arm, as massage cannot be done on abdomen because of stiches.” – 25 years old, ‘other’ educational attainment, 1 child, C-Section Informational Support Informational support needs paralleled the infant and self-care described within emotional support. In addition, as the women recovered and resumed sexual intercourse, they considered contraceptives. Women sought advice from their mothers, sisters, neighbors, ASHA workers, and other family members regarding childcare. Main questions involved baby massage, foods to eat to promote baby health, and superstitious practices to ward off evil. Some mothers firmly believed the information shared with them, and religiously followed the advice. They were certain that those who had handled children before would provide helpful information to take care of their child. Additionally, the women sought informational support from ASHA workers about child vaccination. "I felt satisfied from my sisters’ advice because they themselves have 2 children each. That’s why I seek consultation from them, as they know how to handle kids who are 1–2 years old now." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery "Actually, I feel happy if somebody guides me, tells me what is right and wrong, and advises me as I am new to this. I feel happy if somebody informs and I don’t feel that somebody is interrupting me. I feel happy that before a mishappening, I have caught the problem and have taken preventive measures. Like somebody told me if I ate too hot food, it would affect the health of the baby; likewise, if I ate sweet food then the baby will have saliva leaking, and if I consumed spicy food then the baby might suffer from stomach pain. I want somebody to tell me what is good or bad for my baby and me." – 25 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery Women needed informational support around self-care for which other mothers were of most help to them. For example, one mother was finding it hard to breastfeed, and a new mother in the hospital advised her when to formula feed. Similarly, women with perineal and abdominal stitch discomfort or other body pain sought advice from doctors and other mothers to find a cure. “There was another [mother] who had delivered her baby there. She was also having pain in the breast, and she told me that she also feed the baby with that powder...she said that she bought it from here. Then we fed it one day only, then never gave that again. I am giving [breastmilk] only, despite the pain.”- 27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery Postpartum contraception Most respondents targeted a specific gap between pregnancies. Some had consulted doctors or family members for family planning education; one woman also mentioned undergoing contraceptive counseling at the hospital regarding intrauterine devices, oral contraceptive pills, and condoms. A few women were unaware of contraceptive methods but intended to delay pregnancy. Overall, family planning is an area for which women need informational support. Husbands’ narratives were missing in the interviews, although they also play a crucial part in making these decisions. Effects Of The Coronavirus Pandemic On Seeking Care LImitations faced by respondents due to the coronavirus pandemic impacted their perinatal experiences. Women were unable to visit their maternal homes due to movement restrictions, potentially influencing their mental health. Women were also unable to access other small things due to lack of mobility and transportation. Participants also mentioned missing some check-ups due to closures in response to the pandemic. “I went every month for check-up…. I was scared because it was corona time and nothing should go here and there. After that, I would go for regular check-ups, like blood tests and BP check-ups.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery “Yes. It happened only once, and then it didn’t happen because of corona. Everything was closed because of that. Check-ups were not done.” – 20 years old, ‘other’ educational attainment, 1 child, Vaginal Delivery Discussion Interpretation of major findings Participant narratives describe the important role of formal and informal support structures in addressing maternal health needs. Participants had strong informal support systems consisting of husbands, family members, friends, and neighbors. Most participants reported adequate access to health providers. Women also sought formal health supporter in their community including ASHA workers, midwives, and doctors. While many of the participants’ support needs were met by their support networks, our study identified certain areas where support needs remained unmet, in addition to discrepancies between the content provided and evidence-based care. Participants’ narratives show that for the most part, their emotional, tangible, and informational support needs during the antenatal period were met but larger gaps existed during childbirth and postpartum. Study participants were generally equipped with a strong emotional support system antenatally which was essential in meeting major antenatal support needs, as a large amount of informational support came from family members, both marital and natal. Participants followed traditional advice from their support network closely, though not all was evidence-based maternal care. Previous literature confirms that informal support systems may not be adequately educated on antenatal maternal care and danger signs. For example, husband knowledge of maternal danger signs is low. 32 Additionally, information sought by our study participants about traditional practices to help ease pregnancy-related problems is in line with other literature on illness perceptions and cultural beliefs which prevented care-seeking. This includes traditional beliefs on nutrition and food consumption, herbal medicines, the role of family and husbands, and antenatal rituals. 4 , 26 Similar beliefs were prevalent in our study, signifying the importance of healthcare providers and other resources in overcoming prevalent yet incorrect practices. This is especially important considering they are highly dependent on informational support from medical professionals for medical needs. ASHA workers and doctors played a significant role in supplying pregnant women with informational support regarding sickness and pregnancy-related complications. These results were expected, as a rather large role of ASHA workers and providers is to assist women antenatally. 18 – 20 Emotional support at childbirth was provided by family members to instill confidence, and medical staff to help women give birth easily. Women’s fear of labor pains and information-seeking from both informal and formal networks on ways to ease pain was similar to previous literature where women obtained the most childbirth information from family and friends. 33 While government-funded programs have successfully increased facility birth to 80% nationally, 34 these formal networks have been less successful in educating women about childbirth, as noted by our study participants’ lack of knowledge. While this is not inconsistent with other research from India which reports only 27.7% of participants had knowledge of labor and 21.2% of sufficient knowledge of childbirth, 35 this led to our participants having to make emergency decisions during childbirth that they were not previously informed of, presenting challenges for informed consent. The lack of knowledge during the delivery and postpartum phases may ultimately contribute to adverse maternal health outcomes, as 66% of maternal mortality occurs around this time. 2 This lack of knowledge with regards to delivery must be targeted to provide pregnant women with the information they need to make informed decisions during childbirth. During the postpartum period, women had significant emotional and tangible support needs for caring for themselves and their infants, and they relied heavily on their family members. Additionally, lack of proper support for neonatal and postpartum health issues by ASHA workers in comparison to antenatal care indicates more postpartum support from formal networks is needed that can provide clear evidence-based information. 16 During the postpartum phase, women were confused by contradicting dietary advice between doctors and their elders. Previous studies have also identified misconceptions regarding the c-section diet and wound healing among providers, families, and women. Many misconceptions are not aligned with evidence-based guidance on diet, which consists of postpartum women intaking an extra 500 kilocalories, encouraging food intake within two hours after cesarean section, and a complete calorie dense diet within eight hours of surgery, thereby improving recovery. 36 Recommendations for formal and informal support networks The knowledge gaps found among our study participants suggests disparities in accessibility to maternal health knowledge in rural areas. This aligns with previous studies, as significant variations have been found in the level of continuum of care across states and socioeconomic groups of India, indicating an more limited care accessibility among less economically advanced regions. 15 Additionally, government funded programs such as the JSY and ASHA workers were found to improve institutional delivery and antenatal check-ups, 11 , 12 , 16 though may not have been as effective in increasing maternal knowledge, consistent with their healthcare access goals. Given these findings, government-funded programs should further maternal knowledge. Although formal care networks have substantially improved perinatal care, our results indicate major gaps in informational support. Across the perinatal continuum, women relied more heavily on informal networks consisting of husbands, family, and neighbors which is consistent with nationally-representative studies which found that 62.5% of women make healthcare decisions in conjunction with their husbands, and 15.3% of women did not receive antenatal care due to husbands not feeling it was necessary. 10 , 32 Previous studies showed better spousal relationship quality was linked to antenatal care and facility birth, and similarly where women in joint families had better relationships with their in-laws. 37 National Indian data also identified gaps in antenatal counseling of partners, with only 63.9% of men who attended ANC visits counseled on what to do if their wife had pregnancy complications. Programs related to maternal care should account for the familial networks that women have, as this heavily influences their decision-making with regards to health concerns. Interventions for husbands and other familial support can be designed to better support the needs of pregnant women. Implications For Future Studies The government of India has installed multiple programs to assist with pregnancy for women. A couple of these programs include Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), which consists of free antenatal care once per month, and the Janani Shishu Suraksha Karyakaram (JSSK), which consists of free maternal health services. Independent of such interventions, gaps in accessibility and knowledge preventing the overall quality and continuum of maternal health care in India 11 can be addressed through targeted social programs equipped with evidence-based guidance. Pregnant and postpartum women may also benefit from educational programs designed for their informal networks, including family and neighbors, to better deal with pregnancy and postpartum issues. Furthermore, women would benefit from communicating with one another on pregnancy-related issues, as important information can be exchanged through social network. Programs could build in-person or mHealth groups relying on digital devices for support. A focus on the improvement of both informal and formal networks of support through means of education is essential for assisting pregnant women with the perinatal continuum. Strengths and limitations This qualitative study provided nuanced information on health education and social support among a select group of rural Indian women. While the results may not be generalizable, these findings can inform broader research studies with the broad goal of improving maternal health. Our study was strengthened by the use of a social support framework which allowed for a robust theoretical classification of support needs. Our study’s attention to both informal and formal sources of support provides a comprehensive analysis of the support resources that currently exist. Finally, to improve interpretation of qualitative findings, the analysis and interpretation of these data employed a team approach. Conclusion The results from this study suggest that ongoing efforts to reduce maternal morbidity and mortality in India must not neglect important gaps in informational support needs among pregnant women and their households, particularly for childbirth and postpartum. Accessibility to care and quality of informational support across the continuum of care need to be addressed to further reduce maternal morbidity. Abbreviations ANC Antenatal care ASHAs Accredited Social Health Activist workers JSY Janani Suraksha Yojana JSSK Janani Shishu Suraksha Karyakram NRHM National Rural Health Mission The Surakshit Matritva Aashwasan SUMAN Declarations Ethics approval and consent to participate : This study received ethical approval from Institute Ethics committee of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh and the University of California, San Francisco. Informed consent was obtained from all the participants. All the experiments in this study were conducted in accordance to the relevant guidelines and regulations. Consent for publication: Not Applicable Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : No potential competing interest was reported by the authors. Funding: This research was funded by UCSF’s Research Evaluation & Allocation Committee and the Government of India Ministry of Education’s Scheme for Promotion of Academic and Research Collaboration (SPARC; Project ID 66). The funders held no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript. Authors' contributions : PS: Conceptualization, Investigation, Formal analysis, Writing – Original Draft RB: Conceptualization, Supervision, Funding acquisition, Writing – Review & Editing MK: Formal analysis, Writing – Original Draft MD: Conceptualization, Supervision, Project administration, Funding acquisition, Writing – Review & Editing DH: Investigation, Writing – Review & Editing AA: Investigation, Writing – Review & Editing AK: Writing – Review & Editing ND: Conceptualization, Supervision, Funding acquisition, Writing – Review & Editing VK: Writing – Review & Editing MK: Investigation, Writing – Review & Editing PS: Funding acquisition, Writing – Review & Editing JK: Writing – Review & Editing AE: Conceptualization, Supervision, Funding acquisition, Formal analysis, Writing – Review & Editing Acknowledgements: We greatly appreciate our research participants who shared their time and experiences with us. 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Nithya R, Dorairajan G, Chinnakali P. Do pregnant women know about danger signs of pregnancy and childbirth? – A study of the level of knowledge and its associated factors from a tertiary care hospital in Southern India. Int J Adv Med Health Res. 2017;4:11. Macones GA, Caughey AB, Wood SL et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019; 221: 247.e1-247.e9. Allendorf K. The quality of family relationships and use of maternal health-care services in India. Stud Fam Plann. 2010;41:263–76. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2721467","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":192400294,"identity":"6fed9f18-250a-4830-820d-10cc16200d8f","order_by":0,"name":"Preetika Sharma","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Preetika","middleName":"","lastName":"Sharma","suffix":""},{"id":192400295,"identity":"5e57ca08-2745-45f0-a103-0f67489d028a","order_by":1,"name":"Rashmi 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1","display":"","copyAsset":false,"role":"figure","size":607076,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSummary of themes by social support domain and perinatal continuum of care stage\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2721467/v1/c9955836b93a2874818a803c.jpeg"},{"id":52674221,"identity":"6e49918e-3ffa-4e08-8c7d-1f548434b02b","added_by":"auto","created_at":"2024-03-14 10:54:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670495,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2721467/v1/eef700b4-1891-4d5a-8b77-2cd0d5a45970.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Maternal health education and social support needs across the perinatal continuum of care in India: A thematic analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eRecent data estimates India\u0026rsquo;s maternal mortality ratio at 103 per 100,000 live births in 2017\u0026ndash;2019, representing an 81% percent decline from 556 per 100,000 live births in 1990.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Although there has been substantial improvement in maternal mortality rates over the last three decades, there are still existing maternal health needs that are not being met. An analysis of India\u0026rsquo;s nationally-representative National Family Health Survey identified a significant increase in the prevalence of self-reported maternal complications between 2005\u0026ndash;06 and 2015\u0026ndash;16, from 43.6\u0026ndash;53.7%.\u003csup\u003e4\u003c/sup\u003e While this increase may be due to both increases in occurrence and reporting (due to more awareness), as a patient-reported outcome it emphasizes a need for broader attention to be paid to the quality of maternal health care. High quality postnatal care and social support is associated with reduced maternal and neonatal mortality,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and increased maternal engagement in behaviors promoting newborn (e.g., exclusive breastfeeding and child immunization) and maternal health (e.g., postnatal adoption of family planning).\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccess to high quality care across the perinatal continuum is essential to prevent maternal and neonatal complications and deaths; however, important gaps exist and are patterned by socioeconomic status, raising equity concerns. A little over half (59.0%) of women achieve the Indian guidelines of four or more antenatal care (ANC) visits, with a noticeable difference between rural (55.0%) and urban populations (69.0%).\u003csup\u003e10\u003c/sup\u003e Most births country-wide occur in health facilities (89.0%), though only 61.0% of mothers and 82.0% of newborns received a postnatal health check within 48 hours of birth.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e By wealth quintile, receipt of a postnatal care visit within 48 hours of giving birth ranged from 58\u0026ndash;63%.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIndia\u0026rsquo;s cash assistance schemes and programs to improve maternal health have broadly removed financial barriers, increased institutional deliveries, and increased the use of antenatal services. The National Rural Health Mission (NRHM) was launched for the period of 2005\u0026ndash;2012 to improve equitable access to quality healthcare through a robust community-based health workforce.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Additionally, the Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK) government programs were launched to promote institutional delivery in addition to antenatal checkups by offering cash incentives to women giving birth at a government hospital, with free antenatal care, delivery, postnatal care and neonatal care.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Another initiative running under the name SUMAN (The Surakshit Matritva Aashwasan) is being implemented to achieve zero preventable newborn deaths and provide essential newborn care services.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The Government of India programs were found to have increased institutional delivery across all socioeconomic groups, and increased ANC usage across most states, reducing inequities. ASHA workers have also played a key role in the success of these programs.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Still, inequalities in access to perinatal care persist, patterned by social gradients.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Finally, the prevalence of gender inequitable norms including child marriage, restricted mobility, and low decision-making control has been found to influence the success of programs targeting maternal and newborn health continuum of care, with greater gender inequity limiting program impact.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These findings suggest the demand for programs to address these limitations in access to care.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIndia also has an extensive Community Health Worker Program, consisting of over two million trained Accredited Social Health Activist workers (ASHAs) who assist with accessibility to community-based services for pregnant women throughout pregnancy, and link families and health systems in rural India. \u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Assessment of India\u0026rsquo;s Community Health Worker Program found ASHA workers to be effective in increasing antenatal care, immunization coverage, and hospital deliveries.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e However, ASHA worker performance was found to be less effective at increasing postpartum care, including counseling on maternal danger signs and neonatal care.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e ASHAs provided appropriate care for chronic diarrhea or child acute respiratory illness in only about half of the cases.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e These reports indicate a lack of neonatal support and the gap in maternal knowledge and counseling on preventative methods for common neonatal and child illnesses. This includes knowledge on nutritional health, and danger signs of common morbidities, such as pneumonia in newborns.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBeyond care provision, ensuring the accessibility of high-quality perinatal care is facilitated by health knowledge and social support.\u003csup\u003e\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Studies exploring knowledge of pregnancy-related danger signs have identified low awareness among Indian women.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Other research has identified misperceptions about the cause of infant illnesses\u003csup\u003eOBJ\u003c/sup\u003e as a major \u003csup\u003eOBJ\u003c/sup\u003ebarrier to appropriate care-seeking.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Social support across emotional, informational, and tangible domains has been associated with improved health knowledge and care seeking, as well as improved postpartum mental health.\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e The presence of key individual types in a social support network (e.g., educated females or health care providers) is predictive of high-level maternal knowledge of child health among mothers with low educational attainment.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the important role of health education and social support for optimizing perinatal health, we conducted a qualitative study to understand resources and gaps across the perinatal continuum of care in northern Indian women, providing a baseline understanding of maternal experiences and needs from the antenatal period through postpartum.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We conducted a qualitative study among 20 postpartum North Indian women from Boothgarh block, Mohali district, Punjab, to understand perinatal care perspectives and experiences, barriers to access, social support systems and informational resources, and needs for pregnancy and childbirth. Inclusion criteria were: primiparous and within 3 months postpartum. In-depth interviews were conducted from October 2020 through December 2020. India\u0026rsquo;s first major COVID-19 surge peaked in September 2020; data collection began as cases decreased and research restrictions allowed for in-person data collection with COVID safety protocols. Due to our inclusion criteria, participants experienced some varied COVID-19 pandemic and pandemic mitigation severity during pregnancy and postpartum.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003ePotential participants were identified from antenatal care (ANC) registers maintained at Boothgarh\u0026rsquo;s 17 healthcare sub-centers. They were introduced to the study via telephone to ascertain interest in participating. Interested individuals were scheduled for an in-person interview. Research staff (qualitative interviewer and a note-taker) visited participants at their home, conducted the informed consent process including obtaining written confirmation, and conducted the interview face-to-face. The research team prioritized a quiet and private location; however, a few interviews had a family member present. In some cases, mothers-in-law came to check but were politely requested to allow privacy to the interviewee.\u003c/p\u003e \u003cp\u003eInterviews followed a semi-structured format. The interviewer was well versed with the interview guide to keep the environment of the interview as informal as possible. The note-taker recorded important observations such as attitude and behavior of the participant, important quotes, timing of the interview, location details, etc. The interview guide focused on women\u0026rsquo;s experiences during their recent pregnancy and postpartum. Interviewees were asked to share their views on perinatal care, pregnancy and postnatal care in the community, barriers to accessing postnatal care, existing social support systems after childbirth, and information needs in the postnatal period. We also sought information to inform a mobile health education intervention to improve maternal health outcomes. The interviews lasted approximately 30\u0026ndash;90 minutes, were conducted in Hindi or Punjabi, and transcribed to English, and were audio-recorded upon participant permission.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe employed thematic analysis using both deductive and inductive approaches. Transcripts were coded using Dedoose qualitative analysis software following a codebook developed from the in-depth interview guide and supplemented by unexpected findings in the data. After jointly coding 4 transcripts together to standardize analysis, our analysis team of 4 Indian and 4 American researchers coded the transcripts independently, addressing queries and discrepancies through group discussion. The current analysis focused on social support and health education across the perinatal period, employing Berkman and Glass\u0026rsquo; social support framework.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Emotional support refers to empathetic interactions, offering reassurance, comfort, or acceptance. Tangible support refers to contributing resources, finances, or assistance. Informational support refers to knowledge, facts, and advice or feedback on actions. Data were analyzed within broad perinatal timeframes (i.e., antenatal, delivery, and postnatal).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eParticipants ranged in age from 20\u0026ndash;31 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most (n\u0026thinsp;=\u0026thinsp;16) had completed higher secondary school or above. Three had pursued diplomas and one participant was illiterate. All participants except one lived in multigenerational households including in-laws, brothers and sisters-in-law, and their children. All participants were married, except for one who was recently widowed. No participant lived in the same village as their parents. Husbands\u0026rsquo; occupation varied (e.g., government job, car driver, plumber, auto driver, mechanic, farmer, etc.) Two women worked (lab technician, boutique owner); all others were homemakers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of study participants (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.5 (22.5\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome Secondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAble to read\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannot read\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCan partially read\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAble to read\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (80%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAble to write\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannot write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCan partially write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAble to write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. of children\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. of children in the household\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. of adults in the household\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.75-7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo the parents live in the same village?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly income husband\u003c/b\u003e,\u003csup\u003ea\u003c/sup\u003e \u003cb\u003eIndian Rupees\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,000 (0\u0026ndash;16,000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly income woman\u003c/b\u003e,\u003csup\u003ea\u003c/sup\u003e \u003cb\u003eIndian Rupees\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (95%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRation Card category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrange (Below the poverty line)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYellow (Above poverty line)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold phone ownership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes \u0026ndash; smart phone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePersonal phone ownership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes \u0026ndash; smart phone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (65%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes \u0026ndash; feature phone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccess to household phone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than weekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eMedian (IQR).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSocial support resources and needs by perinatal phase\u003c/h2\u003e \u003cp\u003eParticipant narratives were analyzed for social support resources and needs during each phase of the perinatal period and themes were further organized by major social support domains; emotional, tangible, and informational.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the theme summary by social support domain and perinatal continuum of care stage.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAntenatal\u003c/h3\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEmotional Support\u003c/h2\u003e \u003cp\u003eWomen received emotional support from their neighbors, aunts, relatives, sisters-in-laws, friends, and especially from older women who already had a baby, largely focused on stress relief.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;All [family members] used to say don\u0026rsquo;t take tension (be afraid). In the first pregnancy, women get scared at the time of delivery, so they told me not to take tension, keep calm. Otherwise, there will be a problem with normal delivery.\u0026rdquo;- 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, C-Section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTangible Support\u003c/h2\u003e \u003cp\u003eStudy participants described various tangible support received antenatally, including help with household chores, and medical and personal care facilitation. In most multigenerational Indian households, gender roles are starkly divided and the daughter-in-law bears a heavy housework burden. Most participants were responsible for most household work, e.g., washing clothes, cleaning, and cooking. During pregnancy, they were given some respite. Mothers-in-laws, and sometimes husbands, took over harder household chores given the perceived risk for pregnancy loss during the first trimester and women did light work (e.g., folding clothes, cutting vegetables, dusting) during this time. In the second trimester, women took on additional limited chores. In the third trimester, work such as mopping the floor was considered beneficial due to traditional beliefs that this activity widened the pelvis, increasing the likelihood of successful vaginal delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My husband was a big support [throughout my pregnancy], he did all household chores like washing clothes, brooming and I used to cook only.\u0026rdquo; \u0026ndash; 24 years old, secondary school or higher, 1 child, living with husband and father-in-law, Vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMedical care, diet, and rest were facilitated by family members including husbands, mothers, and mothers-in-laws. Women expressed a paramount importance of family members in facilitating their access to the medical care needed for a healthy pregnancy. All participants were from rural India, where transportation was limited. Social restrictions on women traveling to the hospital alone made transportation difficult thus most husbands drove women to their antenatal visits. Women also described how their husbands focused on their diet during pregnancy. Their husbands regularly brought fruits and ensured they ate frequently. One woman mentioned her husband\u0026rsquo; guidance to avoid fried food. Another described her husband\u0026rsquo;s attention to her physical health throughout pregnancy, for example, giving her massages to alleviate pain. Mother-in-laws also provided home treatments for pregnancy-related discomforts, such as stomach aches, bodily pains, and morning sickness.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Whenever the doctor would call us, we would go; whatever check-up they prescribed we did the same way. [My husband] supported me a lot [despite being a truck driver frequently away from home]. When I told him that this day is my test, he would rush back immediately. Because we don\u0026rsquo;t have any [personal] conveyance to go and in pregnancy a person can\u0026rsquo;t go alone.\" \u0026ndash; 28 years old, secondary school or higher education, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t pay much heed about eating so [my husband] usually fed me. Sometimes he bought apple and sometimes other fruits. He used to cut and fed them to me. I wasn\u0026rsquo;t well at that time, I would keep lying on bed. He would wake me and feed me. I didn\u0026rsquo;t take as much care of myself as he took.\u0026rdquo; \u0026ndash; 22 years old, secondary school of higher, 1 child, Vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants described highly supportive and readily accessible primary medical care in their villages including ASHAs, Auxiliary Nursing Midwives (ANM), Community Health Officers (CHOs), and physicians at a dispensary or private clinic. Most women had registered at the nearest public health facility during the first trimester. They were given a mother and child protection card to track pregnancy details. The card explains the required antenatal checkups, biomarkers to be monitored, pregnancy danger signs, etc. Throughout pregnancy, the women regularly accessed antenatal care. Medical professionals were considered approachable, and some women received their phone numbers to contact in case of an emergency. The widowed participant emphasized the importance of mobile phones for facilitating home-based pregnancy care due to the reduced support she had for physically accessing medical care as a widow. However, women without telephone accessibility to a medical professional had not perceived this to be a need; they had the support they needed for a healthy pregnancy regardless. Overall, participants were satisfied with the medical support provided by the sub-centers, private professionals, and tertiary health care system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I had bleeding in the 5th month, it wasn\u0026rsquo;t much, but I had bleeding. I was at my parental home, then I consulted doctor on the phone, and they gave me medicine for 5 days. They said it is normal, it happens, and there is nothing to fear. Whenever it happens, advise should be taken [from a doctor].\u0026rdquo; \u0026minus;\u0026thinsp;28, tenth standard, lives in a joint family\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it is essential to have a doctor\u0026rsquo;s contact number [during pregnancy]. Especially when your husband is no more because with a spouse it is much easier for a woman to manage during pregnancy. And one thinks that if we have phone in our life then we should make some use of it. We have to use our mind and have to depend on ourselves. When God makes you go through such situations in life then you have to do and learn many things. Life teaches you everything.\u0026rdquo; \u0026ndash; 30 years, some secondary school education, 1 child, C-section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInformational Support\u003c/h2\u003e \u003cp\u003eAdvice seeking from family and others was prominent during respondents\u0026rsquo; pregnancies. Participants sought day-to-day advice from mothers-in-law, sisters with children, and other elders. They regularly communicated with community health workers and providers for medical queries, and regularly used the internet and YouTube videos for information.\u003c/p\u003e \u003cp\u003eInformational needs voiced included how to have a healthy pregnancy, an appropriate diet, and how to solve problems. Mothers and mothers-in-law heavily influenced the food that women ate and avoided during pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"Mostly, I would ask my sister and sisters-in-law. Since my husband has two elder sisters, I would ring them up and ask about my problems. Slowly-slowly I would collect all the information from everywhere and got to know what is right and what is wrong then I would apply accordingly. For example, if the thing matched between three people, I would do that.\" \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have a sister who has two kids. So, I used to ask her whenever I had any problem. She used to share everything that she went through in her pregnancies. We had many similarities. We used to discuss those. Her son is now three years old and her daughter is eight. The kids are big.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, normal delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;During pregnancy my mother had told me not to eat anything that is hot in nature, especially in the beginning. In the initial months she used to give me healthy things like milk and curd, fruits like pomegranate, apples, etc. My mother used to ask me to eat these things more.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, normal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTwo major areas of information sharing were managing pain, and concerns about delivery. Women\u0026rsquo;s relationships supported and empowered them during their pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, my mother-in-law, sister-in-law, and other relatives used to guide me. Do like this, eat what you crave. If I had any problem, they told me to tell them, not hesitate.\u0026rdquo; \u0026ndash; 22 years old, secondary school or higher education, 1 child, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eElders provided considerable informational support to women living in multi-generational households. Women took this advice very seriously. The advice included conventional practices, e.g., ways to channel positive energy, specific foods for a healthy pregnancy, postures, and activities to increase the likelihood of a normal delivery. As previously described, one recommendation was to mop the floor to facilitate vaginal delivery. Foods were customarily categorically divided into \u0026lsquo;hot\u0026rsquo; and \u0026lsquo;cold\u0026rsquo; by the elders. Women were guided not to eat papaya, pineapple, eggplant, dry fruits, and other \u0026lsquo;hot\u0026rsquo; foods in the first three months of pregnancy due to miscarriage fears.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"Typically, I would listen to religious hymns only and would listen to Bhajans (religious songs). Also, the elders would say the more you listen to religious things, the more it will give positive effects on the baby.\"- 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[My mother-in-law] just told me not to sit too much as the baby\u0026rsquo;s head will grow big due to sitting. She didn\u0026rsquo;t allow me to work and asked me to rest only. The doctor also told me the same. I would do a little bit of work while standing, like making food.\u0026ldquo; \u0026minus;\u0026thinsp;27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCommunity-based ASHA workers were the first point of contact for pregnant women in case of any health emergencies, or if they needed any health advice. ASHA workers informed women about available medical care, provided pregnancy-related information including on immunization, healthy diet, and supplements. Women mentioned calling their ASHA workers with questions, and particularly appreciated them during the COVID-19 lockdown because clinics were closed and doctors were not available.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[I was in touch with my] ASHA worker only because due to COVID, clinics were not open. Some tests were done and some were not able to be done. This happened all the time due to COVID. And sometimes I visited Mohali Hospital. All my tests were done there\u0026hellip;. [My ASHA] explained very nicely and told me to contact her in case of any problem. She lives nearby [my house], and is very supportive. She explained medicines to me\u0026hellip;. I used to get sick at that time. She would counsel on eating healthy, and staying fit.\u0026rdquo; \u0026ndash; 22 years old, secondary school or higher education, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, whenever I had a problem, I asked. Like in the 3rd month, I had bleeding. The ASHA suggested that I visit PGI (local referral hospital). I went to PGI, and the doctor gave me an injection. Afterwards, my bleeding stopped.\u0026rdquo; \u0026ndash; 24 years old, secondary school or higher education, 1 child, C-Section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome women contacted doctors over the phone. Women who had registered in private clinics would receive reminder calls from the doctors for check-ups. Women also visited doctors for medical care including routine checkups, scans, and to discuss other health issues.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to phone call my brother, and he used to ask the doctor about the problems I had. Sometimes I had pain in the lower abdomen; they suggested avoiding lifting weight.\u0026rdquo;- 28, tenth standard, lives in a joint family, C-section\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[During the third trimester], Doctors used to call and we used to go every week. The baby keeps moving and we get to know that the baby is fine. They also used to come to check the heartbeat to see if it is fine or not.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, normal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen mentioned different maternal and fetal health queries for which they sought advice from doctors, ASHAs, and other medical professionals. ASHA workers educated women on healthy everyday practices, such as diet. Doctors were a constant support in case of complicated pregnancies, for example, a twin pregnancy. Other queries focused on medication to be taken during pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor in 6 phase (hospital) was very nice. She used to talk to me very politely. Whatever she used to ask, I used to tell her. Like I used to feel pain in the lower region, I used to tell her. She used to say this much will happen. It should not be much, but little bit will happen. Just that. Overall, doctors were good there.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, normal delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to take calcium and iron supplements daily. And doctors told me not to take any other medicines. If I have pain, then just have paracetamol. So, I just used to have that if I felt pain. Like when I used to feel fever or tiredness, then I used to have that. But I didn\u0026rsquo;t take much medicines otherwise. As it is not good to take many medicines.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, normal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants owned smartphones, and commonly used the internet for pregnancy-related queries, usually via YouTube videos. The most common searches focused on nutrition, sleeping postures, and baby\u0026rsquo;s sex. The educational videos were the only educational content mentioned. Women\u0026rsquo;s narratives demonstrated how crucial the internet was in supporting them antenatally, and it was used independent of professional guidance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to find out if its a girl or boy by watching the scans\u0026hellip;(laughs). They used to show signs in the videos, if this sign, it is girl. That sign, it is boy\u0026hellip;..(laughs)\u0026rdquo; \u0026ndash; 31 years old, secondary school or higher, 2 children, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;About the eating stuff. Like papaya is not good for the initial days of pregnancy, it is hot in nature. There is fear of miscarriage. One should have dry fruits, juice, and milk. We used to watch all this. We used to get to know what not to eat. Like in the initial days, not to eat warm things because there is fear of miscarriage if we eat it.\u0026rdquo; \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, c-section\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I have used the phone to see how to sleep while pregnant\u0026hellip; like when I will sleep, there should not be any problem to the baby. In fact, I have seen how to tell whether there is any problem or not on YouTube. I have seen how to sleep, how to sit, how to eat, and what to eat. Eat vegetables and fruits, and drink juice.\u0026rdquo; \u0026ndash; 20 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eChildbirth\u003c/h3\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEmotional and Tangible Support\u003c/h2\u003e \u003cp\u003eParticipant narratives intertwined emotional and tangible support around childbirth. They discussed the main individuals providing both emotional and tangible support, and the tangible support provided to assist women\u0026rsquo;s birthing experiences.\u003c/p\u003e \u003cp\u003eWhen asked about their birthing experiences, most participants mentioned the people supporting them including husbands, brothers, mothers, and mothers-in-laws. These individuals provided emotional support and coordinated with hospital staff for prescribed essentials and medications. For the most part, family members kept the women calm as they endured labor. Mothers comforted the women, while male family members (not allowed in labor rooms) purchased medicines requested by the doctor and ran errands. All participants expressed relief with this support during their birth. One woman expressed how her husband\u0026rsquo;s communication with the nurse comforted her:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"Yes, [my husband] said nothing will happen. He kept on talking to the nurse that nothing should happen to both of us (baby and the participant). Both should be fine.\"- 22, 9th standard, lives in a joint family, child 1, C-Section\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[Family support during delivery] is very important. People get emotional at that time, so the family should be nearby for emotional support.\u0026rdquo; \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment,1 child, C-Section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen reported feeling comforted through medical staff support during childbirth. One woman shared her confidence in the staff: \u0026ldquo;\u003cem\u003eIf anything happens, then the nurse is there to look after you at the hospital, but at home there is no one to look after you.\u0026rdquo;-18, Primary School, lives with husband, child 1, vaginal delivery\u003c/em\u003e\u003c/p\u003e \u003cp\u003eNarratives revealed the key importance of tangible social support during labor and birth, particularly where participants\u0026rsquo; lack of knowledge around emergency medical procedures challenged informed consent. For example, two participants were uncomfortable having to rapidly decide about cesarean surgery with no knowledge.\u003c/p\u003e \u003cp\u003eSometimes, family members were not allowed with the women during birth and women reported feeling emotionally supported by nurses when making hard decisions. One participant undergoing cesarean surgery appreciated the comfort provided by supportive medical staff during the otherwise stressful situation. In one case, a nurse tried to calm the woman by cracking a joke.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctors and nurses were nice. The doctor who operated was nice. They all talked with me during the operation, kept me calm all the time.\u0026rdquo; \u0026minus;\u0026thinsp;25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, cesarean delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, not all women had supportive experiences with hospital staff. One shared that they scolded her for not following instructions: \u003cem\u003e\u0026ldquo;They were telling me to lay down so that I can get contractions, but I was restless. They kept scolding me because I wasn\u0026rsquo;t sitting. Then after some time, I delivered. It was very difficult. They kept pushing the baby. After delivery they gave me stitches.\u0026rdquo;-10\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInformational Support\u003c/h2\u003e \u003cp\u003eMost participants were pregnant for the first time and were anxious about giving birth so they looked for information to help them prepare. They were mostly unaware of what giving birth would be like yet were generally told by their mothers that they would be fine, without sharing critical details, to avoid scaring them. Women also sought knowledge from their mothers, friends, and sisters on practices to ease childbirth, such as eating certain foods or doing certain activities. Mothers informed them of ways to push during labor, and what foods would help in easing delivery pain. This support helped reduce women\u0026rsquo;s anxiety around labor and birth, although they were not evidence-based.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Everybody used to tell me to eat well, and also to keep working so that I have a normal delivery. Sometimes the private doctors suggest bed rest, as they suggested to me when I had pain. So, I used to rest. But everyone used to suggest working to have a normal delivery. I used to go for a walk in the evenings as much as possible, because this will help in normal delivery.\u0026rdquo;- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to take a lot of care so that the health of the baby is good, especially regarding eating. By the end, my mother used to ask me to eat foods that are hot in nature. Like almonds, she used to put almonds in milk for me. Also, they used to tell me to eat ghee in milk because it helps with normal delivery.\u0026ldquo; \u0026minus;\u0026thinsp;26 years old, primary school, 1 child, living in a joint family, vaginal delivery My mother-in-law would tell me that at the time of delivery, I should push with all the force, and not take too many deep breaths\u0026hellip; like this [enacts the action] \u0026hellip; this can move the baby backwards.\u0026rdquo;-41, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the study sample, six women had c-sections, and 12 had vaginal deliveries. Women\u0026rsquo;s narratives evidenced a lack of education on cesarean section. In many cases, women only learned of the possibility of a cesarean section on the day they were admitted to the hospital which made emergency decision-making difficult.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I was in the 9th month, I was scared about what will happen. They would tell me that in normal delivery, there is a lot of pain and the person can\u0026rsquo;t handle it. That there is a lot of difficulty during that time. In the last part, I had difficulties\u0026hellip; that\u0026rsquo;s it.\u0026rdquo; \u0026ndash; 31 years old, secondary school education, 1 child, C-Section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostpartum\u003c/h3\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEmotional Support\u003c/h2\u003e \u003cp\u003eNarratives around postpartum emotional support centered largely around recovering from childbirth. Some participants reported moving to their natal homes during the third trimester of pregnancy, whereas others did so after giving birth. In their natal homes, women had added support from their parents, and comfort from familiarity with their surroundings. They explained that they were relieved of all household responsibilities and could physically rest as desired while their mothers cared for their babies.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At my mother\u0026rsquo;s place, there was no such work to do. Your mother does the work, and so does your sister-in-law. For one month, one aunt came to bathe the baby\u0026hellip; we had hired her. After that I started doing it myself... for the baby and for myself too. Clothes and all, mother used to wash.\u0026rdquo; \u0026ndash; 30 years old, some secondary education, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTangible Support\u003c/h2\u003e \u003cp\u003eDuring the postpartum period, mothers dealt with their own bodily changes in addition to new responsibility caring for a child. Families provided assistance in caring for both women and their babies. Women mentioned movement restrictions for the initial few weeks due to stitches; nearly all participants had some intervention (six underwent cesarean section and 12 underwent episiotomy). Most women were first time mothers, and therefore were nervous with baby care. In most cases, responsibility for the child was taken by their mother-in-law or mother. This included bathing, cutting nails, giving massages, etc. Watching their mothers or mothers-in-law care for the baby helped them learn infant care and gain confidence. Women staying at their natal home appreciated this caring environment. Respondents appreciated having husbands and other family members care for their child from time to time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This is my first child, so I don\u0026rsquo;t know much about caring. My mother-in-law does everything. I usually do what she suggests. I keep asking her. She would make me sit and teach me how to give a massage to baby.\u0026rdquo; \u0026ndash; 22 years old, secondary school or higher education, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"During the night [my husband] keeps the baby with him when I get tired. In the evening, he also keeps holding her, and goes around the house with her. He also plays with her during the night when I get tired. I cannot sit for a long time.\"- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCulturally, women are prescribed substantial rest and nutritious diet to support postpartum recovery. Women who gave birth vaginally were asked to eat panjiri, a high-calorie snack made of ghee, nuts, dried fruits, sugar, and herbal gums, to improve lactation and warm the body. Both mothers-in-law and mothers prepared panjiri for respondents. Doctors asked women who had cesarean section to avoid panjiri, as consumption of high calorie foods is believed to reduce wound healing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My mother had made panjiri (high fat snack) and she used to give me milk. She used to ask me to eat warm foods more like panjiri, dal, chapatti, and porridge.\u0026ldquo;- 26 years old, primary school, 1 child, living in a joint family, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My mother gave me panjiri, which is rich in desi ghee and dry fruits. This is so that the baby\u0026rsquo;s health improves. It will benefit the baby.\u0026rdquo; \u0026ndash; 24 years old, secondary school or higher education, 1 child, vaginal delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen mentioned physical discomforts which included pain with stitches, weakness, and leg pain. Mothers and mothers-in-law helped the women sit, assisted with breastfeeding, washing, massages, and other needs to increase comfort. Participants felt this support helped them recover more quickly. One woman who lived alone with her husband had a sister stay with her to care for her post-delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was good, my mother would help me in sitting and standing. My younger brother helped my mother in taking care of me.\u0026rdquo;- 28, tenth standard, lives in a joint family, C-Section\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I take rest, or [my sister-in-law] massages my legs and arm, as massage cannot be done on abdomen because of stiches.\u0026rdquo; \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, C-Section\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInformational Support\u003c/h2\u003e \u003cp\u003eInformational support needs paralleled the infant and self-care described within emotional support. In addition, as the women recovered and resumed sexual intercourse, they considered contraceptives.\u003c/p\u003e \u003cp\u003eWomen sought advice from their mothers, sisters, neighbors, ASHA workers, and other family members regarding childcare. Main questions involved baby massage, foods to eat to promote baby health, and superstitious practices to ward off evil. Some mothers firmly believed the information shared with them, and religiously followed the advice. They were certain that those who had handled children before would provide helpful information to take care of their child. Additionally, the women sought informational support from ASHA workers about child vaccination.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"I felt satisfied from my sisters\u0026rsquo; advice because they themselves have 2 children each. That\u0026rsquo;s why I seek consultation from them, as they know how to handle kids who are 1\u0026ndash;2 years old now.\" \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Actually, I feel happy if somebody guides me, tells me what is right and wrong, and advises me as I am new to this. I feel happy if somebody informs and I don\u0026rsquo;t feel that somebody is interrupting me. I feel happy that before a mishappening, I have caught the problem and have taken preventive measures. Like somebody told me if I ate too hot food, it would affect the health of the baby; likewise, if I ate sweet food then the baby will have saliva leaking, and if I consumed spicy food then the baby might suffer from stomach pain. I want somebody to tell me what is good or bad for my baby and me.\" \u0026ndash; 25 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen needed informational support around self-care for which other mothers were of most help to them. For example, one mother was finding it hard to breastfeed, and a new mother in the hospital advised her when to formula feed. Similarly, women with perineal and abdominal stitch discomfort or other body pain sought advice from doctors and other mothers to find a cure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was another [mother] who had delivered her baby there. She was also having pain in the breast, and she told me that she also feed the baby with that powder...she said that she bought it from here. Then we fed it one day only, then never gave that again. I am giving [breastmilk] only, despite the pain.\u0026rdquo;- 27, 10th Standard, lives in a joint family, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003ePostpartum contraception\u003c/h2\u003e \u003cp\u003eMost respondents targeted a specific gap between pregnancies. Some had consulted doctors or family members for family planning education; one woman also mentioned undergoing contraceptive counseling at the hospital regarding intrauterine devices, oral contraceptive pills, and condoms. A few women were unaware of contraceptive methods but intended to delay pregnancy. Overall, family planning is an area for which women need informational support. Husbands\u0026rsquo; narratives were missing in the interviews, although they also play a crucial part in making these decisions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eEffects Of The Coronavirus Pandemic On Seeking Care\u003c/h3\u003e\n\u003cp\u003eLImitations faced by respondents due to the coronavirus pandemic impacted their perinatal experiences. Women were unable to visit their maternal homes due to movement restrictions, potentially influencing their mental health. Women were also unable to access other small things due to lack of mobility and transportation. Participants also mentioned missing some check-ups due to closures in response to the pandemic.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I went every month for check-up\u0026hellip;. I was scared because it was corona time and nothing should go here and there. After that, I would go for regular check-ups, like blood tests and BP check-ups.\u0026rdquo; \u0026ndash; 20 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes. It happened only once, and then it didn\u0026rsquo;t happen because of corona. Everything was closed because of that. Check-ups were not done.\u0026rdquo; \u0026ndash; 20 years old, \u0026lsquo;other\u0026rsquo; educational attainment, 1 child, Vaginal Delivery\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation of major findings\u003c/h2\u003e \u003cp\u003eParticipant narratives describe the important role of formal and informal support structures in addressing maternal health needs. Participants had strong informal support systems consisting of husbands, family members, friends, and neighbors. Most participants reported adequate access to health providers. Women also sought formal health supporter in their community including ASHA workers, midwives, and doctors. While many of the participants\u0026rsquo; support needs were met by their support networks, our study identified certain areas where support needs remained unmet, in addition to discrepancies between the content provided and evidence-based care. Participants\u0026rsquo; narratives show that for the most part, their emotional, tangible, and informational support needs during the antenatal period were met but larger gaps existed during childbirth and postpartum.\u003c/p\u003e \u003cp\u003e Study participants were generally equipped with a strong emotional support system antenatally which was essential in meeting major antenatal support needs, as a large amount of informational support came from family members, both marital and natal. Participants followed traditional advice from their support network closely, though not all was evidence-based maternal care. Previous literature confirms that informal support systems may not be adequately educated on antenatal maternal care and danger signs. For example, husband knowledge of maternal danger signs is low.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Additionally, information sought by our study participants about traditional practices to help ease pregnancy-related problems is in line with other literature on illness perceptions and cultural beliefs which prevented care-seeking. This includes traditional beliefs on nutrition and food consumption, herbal medicines, the role of family and husbands, and antenatal rituals.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Similar beliefs were prevalent in our study, signifying the importance of healthcare providers and other resources in overcoming prevalent yet incorrect practices. This is especially important considering they are highly dependent on informational support from medical professionals for medical needs. ASHA workers and doctors played a significant role in supplying pregnant women with informational support regarding sickness and pregnancy-related complications. These results were expected, as a rather large role of ASHA workers and providers is to assist women antenatally.\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEmotional support at childbirth was provided by family members to instill confidence, and medical staff to help women give birth easily. Women\u0026rsquo;s fear of labor pains and information-seeking from both informal and formal networks on ways to ease pain was similar to previous literature where women obtained the most childbirth information from family and friends.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e While government-funded programs have successfully increased facility birth to 80% nationally,\u003csup\u003e34\u003c/sup\u003e these formal networks have been less successful in educating women about childbirth, as noted by our study participants\u0026rsquo; lack of knowledge. While this is not inconsistent with other research from India which reports only 27.7% of participants had knowledge of labor and 21.2% of sufficient knowledge of childbirth,\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e this led to our participants having to make emergency decisions during childbirth that they were not previously informed of, presenting challenges for informed consent. The lack of knowledge during the delivery and postpartum phases may ultimately contribute to adverse maternal health outcomes, as 66% of maternal mortality occurs around this time.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e This lack of knowledge with regards to delivery must be targeted to provide pregnant women with the information they need to make informed decisions during childbirth.\u003c/p\u003e \u003cp\u003eDuring the postpartum period, women had significant emotional and tangible support needs for caring for themselves and their infants, and they relied heavily on their family members. Additionally, lack of proper support for neonatal and postpartum health issues by ASHA workers in comparison to antenatal care indicates more postpartum support from formal networks is needed that can provide clear evidence-based information.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e During the postpartum phase, women were confused by contradicting dietary advice between doctors and their elders. Previous studies have also identified misconceptions regarding the c-section diet and wound healing among providers, families, and women. Many misconceptions are not aligned with evidence-based guidance on diet, which consists of postpartum women intaking an extra 500 kilocalories, encouraging food intake within two hours after cesarean section, and a complete calorie dense diet within eight hours of surgery, thereby improving recovery.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for formal and informal support networks\u003c/h2\u003e \u003cp\u003eThe knowledge gaps found among our study participants suggests disparities in accessibility to maternal health knowledge in rural areas. This aligns with previous studies, as significant variations have been found in the level of continuum of care across states and socioeconomic groups of India, indicating an more limited care accessibility among less economically advanced regions.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Additionally, government funded programs such as the JSY and ASHA workers were found to improve institutional delivery and antenatal check-ups,\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e though may not have been as effective in increasing maternal knowledge, consistent with their healthcare access goals. Given these findings, government-funded programs should further maternal knowledge.\u003c/p\u003e \u003cp\u003eAlthough formal care networks have substantially improved perinatal care, our results indicate major gaps in informational support. Across the perinatal continuum, women relied more heavily on informal networks consisting of husbands, family, and neighbors which is consistent with nationally-representative studies which found that 62.5% of women make healthcare decisions in conjunction with their husbands, and 15.3% of women did not receive antenatal care due to husbands not feeling it was necessary.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Previous studies showed better spousal relationship quality was linked to antenatal care and facility birth, and similarly where women in joint families had better relationships with their in-laws.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e National Indian data also identified gaps in antenatal counseling of partners, with only 63.9% of men who attended ANC visits counseled on what to do if their wife had pregnancy complications. Programs related to maternal care should account for the familial networks that women have, as this heavily influences their decision-making with regards to health concerns. Interventions for husbands and other familial support can be designed to better support the needs of pregnant women.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplications For Future Studies\u003c/h3\u003e\n\u003cp\u003eThe government of India has installed multiple programs to assist with pregnancy for women. A couple of these programs include Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), which consists of free antenatal care once per month, and the Janani Shishu Suraksha Karyakaram (JSSK), which consists of free maternal health services. Independent of such interventions, gaps in accessibility and knowledge preventing the overall quality and continuum of maternal health care in India\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e can be addressed through targeted social programs equipped with evidence-based guidance. Pregnant and postpartum women may also benefit from educational programs designed for their informal networks, including family and neighbors, to better deal with pregnancy and postpartum issues. Furthermore, women would benefit from communicating with one another on pregnancy-related issues, as important information can be exchanged through social network. Programs could build in-person or mHealth groups relying on digital devices for support. A focus on the improvement of both informal and formal networks of support through means of education is essential for assisting pregnant women with the perinatal continuum.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis qualitative study provided nuanced information on health education and social support among a select group of rural Indian women. While the results may not be generalizable, these findings can inform broader research studies with the broad goal of improving maternal health. Our study was strengthened by the use of a social support framework which allowed for a robust theoretical classification of support needs. Our study\u0026rsquo;s attention to both informal and formal sources of support provides a comprehensive analysis of the support resources that currently exist. Finally, to improve interpretation of qualitative findings, the analysis and interpretation of these data employed a team approach.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results from this study suggest that ongoing efforts to reduce maternal morbidity and mortality in India must not neglect important gaps in informational support needs among pregnant women and their households, particularly for childbirth and postpartum. Accessibility to care and quality of informational support across the continuum of care need to be addressed to further reduce maternal morbidity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntenatal care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASHAs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccredited Social Health Activist workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJSY\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJanani Suraksha Yojana\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJSSK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJanani Shishu Suraksha Karyakram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNRHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Rural Health Mission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eThe Surakshit Matritva Aashwasan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSUMAN\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u0026nbsp;This study received ethical approval from Institute Ethics committee of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh and the University of California, San Francisco. Informed consent was obtained from all the participants. All the experiments in this study were conducted in accordance to the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: No potential competing interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;This research was funded by UCSF\u0026rsquo;s\u0026nbsp;Research Evaluation \u0026amp; Allocation Committee and the Government of India Ministry of Education\u0026rsquo;s Scheme for Promotion of Academic and Research Collaboration (SPARC; Project ID 66). The funders held no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePS: Conceptualization, Investigation, Formal analysis, Writing \u0026ndash; Original Draft\u003c/p\u003e\n\u003cp\u003eRB: Conceptualization, Supervision, Funding acquisition, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eMK: Formal analysis, Writing \u0026ndash; Original Draft\u003c/p\u003e\n\u003cp\u003eMD: Conceptualization, Supervision, Project administration, Funding acquisition, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eDH: Investigation, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eAA: Investigation, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eAK: Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eND: Conceptualization, Supervision, Funding acquisition, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eVK: Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eMK: Investigation, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003ePS: Funding acquisition, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eJK: Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eAE: Conceptualization, Supervision, Funding acquisition, Formal analysis, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We greatly appreciate our research participants who shared their time and experiences with us. We also appreciate members of the field team, Rupinder Kaur and Gurpreet Singh, for collecting data and assisting in field activities. We thank all the ASHAs who helped us reach the respondents\u0026apos; houses.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOffice of the Registrar General, India. Special Bulletin on Maternal Mortality in India 2016\u0026ndash;2018.Office of the Registrar General, India; Vital Statistics Division.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank Group, and United Nations Population Division. Trends in maternal mortality: 1990 to 2015. 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PLoS ONE. 2017;12:e0171002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra A. Trust and teamwork matter\u0026rsquo;: Community health workers\u0026rsquo; experiences in integrated service delivery in India. Glob Public Health. 2014;9:960\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health and Family Welfare. Accredited Social Health Activist (ASHA) Guidelines. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/index1.php?lang=1\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/index1.php?lang=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u0026amp;level=1\u0026amp;sublinkid=150\u0026amp;lid=226 (accessed May 17, 2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Rural Health Mission. ASHA-Which Way Forward? Evaluation of the ASHA Programme. New Delhi: National Health Systems Resource Centre (NHSRC)., 2011 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nipccd-earchive.wcd.nic.in/sites/default/files/PDF/Evaluation_of_ASHA_Program_2010-11_Report.pdf\u003c/span\u003e\u003cspan address=\"http://www.nipccd-earchive.wcd.nic.in/sites/default/files/PDF/Evaluation_of_ASHA_Program_2010-11_Report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (accessed May 17, 2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIyengar K. Early Postpartum Maternal Morbidity among Rural Women of Rajasthan, India: A Community-based Study. J Health Popul Nutr. 2012;30:213\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNithya R, Dorairajan G, Chinnakali P. Do pregnant women know about danger signs of pregnancy and childbirth? \u0026ndash; A study of the level of knowledge and its associated factors from a tertiary care hospital in Southern India. Int J Adv Med Health Res. 2017;4:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar G, Choudhary TS, Srivastava A, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019;19:327.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzbay F, Johnson DC, Dimoulas E, Morgan CA, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont). 2007;4:35\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaleema M, Raghuveer P, Kiran R, Mohammed I, Mohammed IA, Mohammed M. Assessment of knowledge of obstetric danger signs among pregnant women attending a teaching hospital. J Family Med Prim Care. 2019;8:1422.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAruldas K, Kant A, Mohanan PS. Care-seeking behaviors for maternal and newborn illnesses among self-help group households in Uttar Pradesh, India. J Health Popul Nutr. 2017;36:49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLegare CH, Akhauri S, Chaudhuri I, et al. Perinatal risk and the cultural ecology of health in Bihar, India. Phil Trans R Soc B. 2020;375:20190433.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUpadhyay RP, Chowdhury R, Aslyeh S, et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ. 2017;95:706\u0026ndash;717C.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBedaso A, Adams J, Peng W, Sibbritt D. The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reproductive Health. 2021;18:162.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRanjan Kumar P, Unisa S. Effect of social support networks on maternal knowledge of child health in rural Odisha, India. \u003cem\u003eJournal of Health and Social Sciences\u003c/em\u003e 2017; published online March 15. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.19204/2017/ffcr8\u003c/span\u003e\u003cspan address=\"10.19204/2017/ffcr8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkman L, Glass T. Social integration, social networks, social support and health. In: Berkman L, Kawachi I, editors. Social Epidemiology. New York: Oxford University Press; 2000. pp. 158\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences. National Family Health Survey-4 2015\u0026ndash;2016. New Delhi, India: Government of India, Ministry of Health and Family Welfare; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarghese S, Singh S, Kour G, Dhar T. Knowledge, attitude and preferences of pregnant women towards mode of delivery in a tertiary care center.Int J Res Med Sci2016;:4394\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad D, Mohanty I, Hazra A, Niyonsenga T. The knowledge of danger signs of obstetric complications among women in rural India: evaluating an integrated microfinance and health literacy program. BMC Pregnancy Childbirth. 2021;21:79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNithya R, Dorairajan G, Chinnakali P. Do pregnant women know about danger signs of pregnancy and childbirth? \u0026ndash; A study of the level of knowledge and its associated factors from a tertiary care hospital in Southern India. Int J Adv Med Health Res. 2017;4:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacones GA, Caughey AB, Wood SL et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e 2019; 221: 247.e1-247.e9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllendorf K. The quality of family relationships and use of maternal health-care services in India. Stud Fam Plann. 2010;41:263\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"social support, health education, pregnancy, childbirth, postpartum, postnatal, India","lastPublishedDoi":"10.21203/rs.3.rs-2721467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2721467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial support and maternal education throughout the antenatal, delivery, and postpartum phases contribute to the optimization of health and well-being of mothers and infants. Understanding deficits among support and educational resources can contribute to improved public health decision-making and maternal and child healthcare and wellbeing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a qualitative study among 20 postpartum North Indian women to better understand current resources and identify gaps in support across the perinatal continuum of care. Data was analyzed thematically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in this study have considerably low maternal knowledge surrounding delivery, in addition to low levels of maternal knowledge and social support around postpartum care and practices. Participants received the most social and educational support during the antenatal phase of pregnancy, which is consistent with the implementation of government and community program goals to increase antenatal care among pregnant women. Notable issues among women during these phases involved consent, and satisfaction and comfort with childbirth care. Participant narratives described the important role of both formal and informal support structures in addressing maternal health needs. Formal structures of support include health systems at the community and facility levels whereas informal structures include family, friends, and the community. Participants also relied heavily on advice from formal modes of support including community health workers (ASHAs), midwives, and doctors. While many participants’ support needs were met by their support networks, our study identified certain areas where support needs remained unmet such as post cesarean section diet and care, institutional delivery, support of ASHA etc., in addition to areas of discrepancy between the advice provided compared to evidence-based practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study identified a major lack of informational support during the delivery and postpartum phases of pregnancy, which may lead to complications for pregnant women. Programs targeting improved maternal health and wellbeing throughout the continuum of care need to educate pregnant women more about the institutional delivery process. Additionally, programs need to further supply women with support and education with regard to the postpartum phase, which remains neglected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e \u0026nbsp;This research is part of the formative phase of a larger intervention trial prospectively registered with Clinical trial registry of India. (CTRI/2020/12/029800 [Registered on: 15/12/2020] and clinicaltrials.gov (phase 1: NCT04636398, phase 2: NCT04693585)\u003c/p\u003e","manuscriptTitle":"Maternal health education and social support needs across the perinatal continuum of care in India: A thematic analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-18 22:49:57","doi":"10.21203/rs.3.rs-2721467/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"638de561-1ed3-4557-92a2-d37589373586","owner":[],"postedDate":"April 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-14T10:46:48+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-18 22:49:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2721467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2721467","identity":"rs-2721467","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}