Postpartum adjustment among women with heart disease in pregnancy: a qualitative study

Postpartum adjustment among women with heart disease in pregnancy: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postpartum adjustment among women with heart disease in pregnancy: a qualitative study Yuan Wang, Huiling Wu, Qing Wang, Lewen Shao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9255633/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Pregnancy with heart disease (PWHD) is a significant high-risk category, leading to adverse cardiovascular events and indirect maternal deaths. Despite advancements in perinatal care improving outcomes, the postpartum period remains high-risk for cardiovascular issues. Postpartum women face physical, psychological, and maternal role adjustments, with those having heart disease at higher risk for adjustment disorders. This study investigates the real experiences of postpartum adjustment in these patients. Methods Researchers conducted a qualitative study using reflexive thematic analysis. Semi-structured face-to-face interviews were conducted with 24 postpartum women with pregnancy-complicated heart disease at a provincial tertiary hospital in Zhejiang Province, China. Interviews were audio-recorded, transcribed verbatim, and analysed using NVivo 15 to generate themes and subthemes. Results Five core themes and 16 sub-themes were identified: the dual burden of heart disease and postpartum challenges, psychological vulnerability and heightened emotional fluctuations, family support tension and intergenerational negotiation, gaps in disease understanding and health management skills, and the retreat from motherhood with a need for role repositioning. Conclusions These findings enhance the understanding of the complex challenges faced by women with pregnancy-related heart disease during postpartum adaptation. They emphasize the importance of care that goes beyond disease monitoring to include psychological, familial, and educational support. Implementing integrated, multidisciplinary postpartum care with family involvement and targeted support can foster better recovery and improve quality of life. This approach also contributes to developing comprehensive "fourth trimester" care models for sustained maternal and infant health. Pregnancy heart disease Postpartum Adjustment Maternal Health Qualitative Research Background Pregnancy with heart disease (PWHD) encompasses a spectrum of congenital, acquired, and genetic cardiovascular conditions that are either pre-existing or newly diagnosed during pregnancy. It is associated with substantial maternal morbidity and mortality and includes structural heart disease, cardiomyopathy, arrhythmias, ischemic heart disease, and aortic disorders[ 1 , 2 ]. The incidence of PWHD ranges from 1% to 4% and has shown an increasing trend, partly attributable to delayed childbearing, rising cardiometabolic risk, and improved survival among women with congenital heart disease[ 3 , 4 ]. The postpartum period represents a particularly vulnerable phase for women with PWHD. Rapid haemodynamic shifts following childbirth, together with persistent cardiac risk, increase the likelihood of clinical deterioration[ 5 – 7 ]. At the same time, women are required to adapt to new maternal roles while managing chronic illness, placing simultaneous physiological, psychological, and social demands on recovery[ 8 – 10 ]. This intersection of medical vulnerability and maternal transition renders postpartum adjustment especially complex. Postpartum adjustment is increasingly recognised as a multidimensional and evolving process that extends beyond physical recovery to include emotional well-being, caregiving capacity, and transformations in identity and social roles[ 11 ]. For women with heart disease, this process is further complicated by persistent symptoms, incomplete cardiac recovery, and elevated long-term cardiovascular risk, underscoring the need for sustained follow-up and integrated care[ 12 – 17 ]. However, current postpartum care remains largely time-limited and medically oriented, often prioritising acute complications over longer-term adaptation[ 18 ]. Such approaches may be insufficient to address the complex interplay of physical, emotional, and social needs experienced by women with PWHD. In addition, fragmented follow-up services and limited integration of psychosocial support further widen the gap between clinical care and patients’ lived experiences[ 9 , 19 ]. Despite growing recognition of postpartum vulnerability, existing research on pregnancy-complicated heart disease has largely prioritised perinatal risk assessment and clinical outcomes, with comparatively limited attention to women’s lived experiences during the postpartum period[ 20 ]. Qualitative studies in this field have tended to focus on specific dimensions, such as psychological distress or healthcare experiences, while offering less integrated accounts of how physical symptoms, maternal role transition, family interactions, and self-management practices intersect in shaping postpartum adjustment. Moreover, postpartum adaptation in women with heart disease is not solely an individual process but unfolds within broader sociocultural contexts. In particular, within the Chinese setting, where intergenerational co-caregiving and family-centred decision-making are common, the ways in which family dynamics influence women’s recovery, autonomy, and role negotiation remain insufficiently explored[ 21 – 25 ]. The interaction between medical vulnerability and culturally embedded caregiving structures has yet to be fully understood. Therefore, this study aimed to explore, through qualitative interviews, how women with pregnancy-complicated heart disease experience and interpret postpartum adjustment within the Chinese sociocultural context. By capturing the interplay between physical symptoms, emotional responses, family dynamics, and self-management, this study seeks to provide a more holistic understanding of postpartum adaptation and to inform the development of personalised, context-sensitive postpartum care strategies. Methods The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[ 26 ]. Study design and setting This qualitative study used reflexive thematic analysis, as described by Braun and Clarke. Semi-structured interviews were conducted to explore postpartum adjustment among women with pregnancy-complicated heart disease. The study was carried out in the obstetric department of a provincial tertiary grade A hospital in Zhejiang Province, China, which manages approximately 4,000 deliveries annually, including a substantial proportion of high-risk pregnancies. Participants Participants were purposively recruited from the study site. Eligible women were aged ≥ 20 years, had a confirmed diagnosis of congenital, acquired, or inherited heart disease before or during pregnancy, were between 6 weeks and 12 months postpartum, were clinically stable, and able to communicate in Mandarin. Women were excluded if they had severe psychiatric illness, cognitive impairment, had experienced medically indicated pregnancy termination, or were participating in other clinical studies. Recruitment continued until data saturation was reached. Saturation was defined as the point at which no new themes emerged, and was considered achieved when the final three interviews generated no new codes. A total of 24 women participated. Data collection Semi-structured interviews were conducted by the first author in a private hospital interview room. Relevant clinical information was reviewed beforehand to support rapport. Interviews lasted approximately 30–45 minutes. All interviews were audio-recorded with consent and supplemented by field notes. Open-ended questions with flexible probes were used to encourage detailed accounts. Follow-up contact was undertaken where clarification was needed. The interview guide is provided in Supplementary File 1. Data analysis Data were analysed using reflexive thematic analysis following Braun and Clarke. Transcripts were read repeatedly for familiarisation. Initial codes were generated inductively to capture key features of the data. Codes were then reviewed and grouped into candidate themes. Themes were refined through comparison across transcripts to ensure coherence and consistency. Theme development was interpretive and focused on patterns of meaning rather than simple categorisation. NVivo (version 15) was used to support data management. Reflexivity was maintained throughout analysis. The research team engaged in regular discussions to examine assumptions and interpretations, ensuring that findings remained grounded in participants’ accounts while recognising the active role of the researchers. To enhance rigour, a subset of transcripts was independently coded by two researchers, with discrepancies resolved through discussion. An audit trail documenting analytic decisions was maintained. Researcher reflexivity Interviews were carried out by the first author, who is a senior obstetric nurse skilled in qualitative research and experienced in managing high-risk pregnancies. The interviewer had no prior clinical relationship with the participants and was not involved in their direct care. To minimise potential bias and enhance reflexivity, the interviewer maintained reflective field notes after each interview, documenting personal assumptions, emotional responses, and emerging interpretations. Regular discussions were held within the research team to examine preconceptions and ensure that data interpretation remained grounded in participants’ accounts. Trustworthiness Credibility was enhanced through prolonged engagement, iterative questioning, and member checking, with preliminary findings confirmed by participants. Dependability was supported by an audit trail of coding decisions and team discussions. Two researchers independently coded a subset of transcripts, resolved discrepancies, and applied the agreed framework to the remaining data. Confirmability was ensured through reflexive memoing and peer debriefing, while transferability was supported by detailed descriptions of the study context and participants. Results Participant characteristics We interviewed 24 postpartum women with pregnancy-complicated heart disease. All interviews were conducted face-to-face and lasted a mean of 37 minutes (range 30–45). All participants were between 6 weeks and 12 months postpartum at the time of the interview. The median age of participants was 32 years (range 22–44 years). Sixteen women (66.7%) had completed college or vocational education or above. Eighteen participants (75.0%) were delivered by caesarean section. Structural heart disease accounted for 54.2% (13/24) of cases, while the remaining participants had functional cardiac conditions. Nine women (37.5%) reported a history of cardiac surgery. Detailed participant characteristics are presented in Table 1 . Table 1 Characteristics of the study participants (n = 24) Characteristic n (%) or Median (range) Age (years) 32 (22–44) Education level Junior high school or below 3 (12.5) High school 5 (20.8) College / vocational 7 (29.2) Bachelor’s degree or above 9 (37.5) Mode of delivery Vaginal delivery 6 (25.0) Cesarean section 18 (75.0) Gestational age at delivery (weeks) 37 + 2 (30 + 6 —40 + 0 ) History of cardiac surgery Yes 9 (37.5) No 15 (62.5) Type of heart disease Structural heart disease 13 (54.2) Functional heart disease 11 (45.8) Primary cardiac diagnosis Congenital heart disease 11 (45.8) Arrhythmia 8 (33.3) Pulmonary hypertension 3 (12.5) Other 2 (8.4) Themes and subthemes Thematic analysis identified five main themes and multiple subthemes. The themes covered physical symptoms, emotional responses, family dynamics, illness understanding, and role adaptation in the postpartum period. Details of themes, subthemes, and codes are presented in Table 2 . Table 2 Findings presented according to themes, subthemes, and codes Themes Subthemes Codes Dual burden of heart disease and postpartum context Persistent fatigue and physical decline • Delayed postpartum recovery • Recurrent physical exhaustion • Limitations in daily functioning Recurrent cardiopulmonary symptoms • Chest tightness and palpitations • Persistent or postoperative cardiac symptoms Night-time feeding and sleep disruption • Fragmented sleep due to infant care • Self-reported sleep disturbances Psychological vulnerability and emotional fluctuations Persistent illness-related fear • Fear of symptom recurrence • Heightened vigilance toward bodily sensations Invisible depression • Emotional fluctuation and distress • Positive emotional reframing and coping Self-dissolution and role strain • Conflict between health recovery and family responsibilities Family support tension Intergenerational caregiving conflicts • Conflicting childcare beliefs with parents or in-laws Spousal involvement and companionship • Emotional support from partner • Practical caregiving assistance Insufficient support and solitary coping • Perceived lack of emotional support • Financial strain and household economic pressure Illness perception and self-management challenges Uncertainty in disease cognition and prognosis • Uncertainty regarding disease trajectory • Lack of clear consultation pathways Transition toward active health management • Difficulty maintaining medication routines • Hesitation toward seeking medical care • Self-monitoring behaviors Variability in health information acquisition • Reliance on peer support • Unmet disease-related consultation needs • Challenges managing postpartum daily life Maternal role withdrawal and reintegration Breastfeeding-related pressure • Conflicts and compromises in breastfeeding decisions Maternal identity and responsibility • Perceived maternal responsibility Parenting stress and competence • Parenting burden and caregiving stress Role reintegration and employment concerns • Concerns about returning to work and role functioning Theme 1: Dual burden of heart disease and postpartum context This theme reflects the dual challenges of postpartum recovery and ongoing cardiac symptoms. Fatigue, sleep disruption, and cardiopulmonary symptoms were commonly reported and often limited daily functioning. These challenges were experienced as cumulative rather than isolated, reinforcing difficulties in early postpartum adjustment. Persistent fatigue and physical decline Persistent fatigue was widely reported, with variation in severity and manageability. For some, infant care, household tasks, and early return to work led to pronounced exhaustion with little opportunity for rest. Others experienced partial relief when family support allowed recovery. A smaller group reported smoother recovery and used self-regulation to maintain balance. “I returned to work two months after delivery. There is no time to rest during the day, and my sleep at night is disrupted. I often wake up feeling dizzy and exhausted” (P2). “In the early postpartum period, I had to go to the hospital frequently. Caring for the baby was very demanding, and I felt completely drained” (P8). “My husband sometimes helps with night-time feeding. It is still tiring, but I feel less overwhelmed” (P10). “Sometimes I am so tired that I do not want to move. But during the day, my mother helps with the baby, which allows me to rest. I feel much better physically” (P12). “My body has recovered well after childbirth. I still feel tired at times, but it is not as severe as in the early postpartum period” (P19). Night-time feeding and sleep disruption Disrupted sleep was a persistent burden, driven by night-time feeding and infant crying. Fragmented sleep hindered recovery and increased fatigue. Some women reported partial relief with family support, while others noted gradual improvement as infants developed more regular sleep patterns. “I have had insufficient sleep since pregnancy, and it did not improve after delivery. Even as my baby grows older, I still feel weak and fatigued” (P4). “The baby feeds every two hours, and my sleep is almost completely interrupted throughout the night” (P6). “My husband helps occasionally, but I still have to wake up for night feedings. In any case, my sleep is not as good as before” (P10). “When the baby cries at night, my mother-in-law sometimes comforts the baby first, so I can sleep a bit longer” (P13). “At the beginning, I slept poorly, but as the baby grew, things gradually improved. Now I can usually sleep through the night” (P17). “Waking up once or twice at night is acceptable for me. I can rest during the day, and that helps” (P20). Recurrent cardiopulmonary symptoms In addition to fatigue and sleep disruption, recurrent cardiopulmonary symptoms such as chest tightness, palpitations, and shortness of breath remained a source of distress for many participants. These symptoms often intensified during infant care and heightened concerns about disease recurrence or deterioration. While some women reported reassurance following regular follow-up and medical explanations, others prioritized caregiving responsibilities over symptom monitoring, delaying attention to their own health. “Sometimes I feel a sense of pressure in my chest. When I hold the baby against my chest, I become short of breath” (P5). “I still experience chest tightness and shortness of breath. The doctor advised me to return for follow-up” (P6). “My atrial fibrillation still occurs occasionally. During episodes, I feel chest tightness and breathlessness” (P9). “Sometimes I notice my heart beating faster, but the doctor said it is temporary, so I am not too worried” (P11). “My condition has mostly recovered. The doctor also said everything looks good, so I am not very concerned” (P21). Theme 2: Psychological vulnerability and emotional fluctuations This theme captures the heightened emotional sensitivity experienced by participants as they navigated uncertainty related to illness, caregiving demands, and shifting self-identity in the postpartum period. Psychological responses were shaped by concerns about disease recurrence, emotional suppression, and the tension between maternal responsibilities and personal well-being. Persistent illness-related fear Fear of disease recurrence was common among participants, though its intensity and focus differed. Some women described heightened vigilance, interpreting minor physical sensations as signs of serious cardiac problems, which contributed to ongoing anxiety and avoidance of physical exertion. Others concentrated their worries on pregnancy or infant-related risks, while a subset reported managing fear through adherence to follow-up care and trust in medical guidance. “Whenever my chest feels uncomfortable, I immediately think something is wrong with my heart.” (P2) “As long as I follow the doctor’s advice and go for check-ups, I don’t let myself worry too much.” (P21) Invisible depression Participants commonly reported emotional fluctuations during the postpartum period; however, the expression, intensity, and coping strategies varied considerably. For some women, emotional distress was pronounced and persistent, often triggered by infant care demands, sleep deprivation, and delayed physical recovery. These experiences were sometimes accompanied by irritability, anxiety, and even negative thoughts about motherhood. Some participants reported pronounced emotional distress, often triggered by infant crying and sleep disruption. “The baby is so difficult to care for. I regret it almost every day. The constant crying at night drives me to the edge” (P2). Even when recognising such behaviours as normal, some women still felt overwhelmed: “The doctor said it was normal for babies to cry at night, but those days were still very hard for me to cope with” (P8). For some, emotional distress was alleviated through family support and gradual adjustment. “At first I felt very tired and emotionally low, but my mother helped with the baby, and I gradually felt better” (P11). Others maintained relatively stable emotional states and expressed positive reframing: “Sometimes I feel tired, but being with my baby makes me happy. I feel it is all worth it” (P18). “Taking care of the baby is demanding, but I feel fulfilled” (P24). Self-dissolution and role strain Assuming the maternal role significantly reshaped participants’ sense of self. Many women described placing their own needs secondary to those of their infants, even when experiencing health limitations. Some gradually recognized the tension between caregiving obligations and personal recovery, attempting to renegotiate balance. Others derived meaning and value from motherhood, reframing sacrifice as responsibility and personal growth. “Everything has to revolve around the baby now. I often forget about myself.” (P2) “Being a mother has changed my priorities, but I feel it’s a responsibility, not just a sacrifice.” (P20) “The baby cried all night, and I felt like I was about to break down. I became so irritable.” (P4) “It’s tiring, but being with my baby makes me feel happy. I think it’s all worth it.” (P18) Theme 3: Family support tension This theme reflects the complex and sometimes conflicting experiences of family support during the postpartum period. Participants described varying levels of emotional and practical assistance from partners and extended family members, which shaped their capacity to cope with recovery demands and caregiving responsibilities. Intergenerational caregiving conflicts Conflict ing childcare beliefs between participants and their parents or in-laws were frequently reported. Traditional caregiving practices sometimes contradicted medical advice, leading to tension and emotional distress despite the availability of practical assistance. While some women felt misunderstood, others described learning to negotiate differences in order to maintain household stability. “My parents-in-law help with childcare and provide financial support, but there is still an emotional gap. For example, they think there is no need to respond when the baby cries, while I worry the baby might be hungry or uncomfortable, which often leads to conflict” (P2). “My parents-in-law help take care of the baby when I go for follow-up visits, otherwise it would be difficult to manage. Although their caregiving approach sometimes differs from mine, such as not responding immediately when the baby cries, having their support makes me feel reassured” (P10). “My mother-in-law helps with cooking and childcare every day, which allows me to rest. Although there are occasional disagreements, she is willing to follow medical advice rather than insisting on traditional practices, which makes me feel fortunate” (P19). “My parents help take care of the baby so I can attend follow-up appointments with peace of mind. They also remind me to take medication and rest, sometimes even more attentively than I would myself” (P20). Spousal involvement and companionship Participants reported substantial variation in spousal involvement. Emotional reassurance and practical caregiving assistance from partners were described as crucial sources of security. In contrast, limited engagement intensified exhaustion and feelings of isolation, particularly during nighttime caregiving. “Sometimes I feel that no one can really help me, and I become very anxious. Even when my husband is at home, he feels tired from work and rarely helps” (P1). “Although we hired a maternity caregiver, there is no one who truly understands me emotionally. My husband thinks that paying for help is enough and is rarely involved himself” (P8). “My husband is somewhat supportive emotionally. When the baby cries intensely, he will hold the baby for a while. Even though he is not always present, having someone there when I feel overwhelmed is important” (P12). “My husband occasionally helps with night feeding. It is still tiring, but it feels different. He will prepare the formula and soothe the baby, so I can rest briefly” (P17). “Doctors and nurses offered reassurance, but what mattered most was my husband’s constant presence. He accompanied me throughout pregnancy and after delivery, attended follow-up visits with me.” (P18). Insufficient support and solitary coping Some participants experienced inadequate emotional or practical support, leading to solitary coping with postpartum recovery and childcare. Financial strain and household economic pressure further compounded stress. Conversely, women who received consistent support reported greater opportunities for rest and medical follow-up. “Most of the time I am on my own. It feels very lonely. When the baby cries, there is no one to help, and I have to soothe the baby while crying myself” (P6). “My family helps, but they do not always understand my views. For example, I wanted to take the baby outside, but they thought the baby was too young, which led to disagreements” (P13). “When the baby cries at night, my parents-in-law sometimes get up first so I can sleep a little longer. I know it is not easy for them, so I feel very grateful” (P18). “My parents help a lot, which makes things much easier. They take on household tasks and childcare, so I have time for follow-up and can get a full night’s sleep” (P24). Theme 4: Illness perception and self-management challenges This theme illustrates disparities in disease understanding, uncertainty regarding prognosis, and differences in engagement with postpartum health management. Uncertainty in disease cognition and prognosis Participants demonstrated varying awareness of their cardiac condition. Some struggled to distinguish pathological symptoms from normal postpartum changes, leading to uncertainty and anxiety. Others relied on follow-up assessments to interpret disease trajectory and gain reassurance. “I wasn’t sure whether my symptoms were normal after childbirth or heart-related.” (P2) “Even though the doctor said it was stable, I still worried about the future.” (P8) “Follow-up results have been normal, so I feel there are no major problems” (P18). “It is hard to predict the future, but as long as I attend follow-up regularly, it should be fine” (P23). Transition toward active health management Postpartum self-management behaviors ranged from passive to proactive. Some participants reported difficulty maintaining medication routines or delayed medical visits due to caregiving demands. Others gradually adopted active strategies, including scheduled follow-ups and symptom monitoring. “Sometimes I forget, and I only go for follow-up when my mother reminds me” (P11). “The doctor recommended monthly follow-up. I went once or twice, but I could not maintain it regularly” (P13). “I now attend follow-up visits regularly and also record my blood pressure and heart rate” (P20). “I always cooperate with the hospital’s telephone follow-up. It makes me feel reassured that someone is checking on me” (P24). “I attend every follow-up visit and also monitor my heart rate and blood pressure at home” (P21). Variability in health information acquisition Participants obtained health information through diverse channels, including healthcare providers, peers, and online sources. While some relied heavily on experiential or peer advice, others expressed unmet consultation needs or difficulties translating information into daily management. “I often asked other mothers first because it was more convenient.” (P7) “Sometimes I still don’t know who to consult when new problems arise.” (P11) “I often seek advice online by posting questions on different platforms. People with similar conditions sometimes share their experiences, and occasionally I also consult AI-based tools” (P18). Theme 5: Maternal role withdrawal and reintegration This theme captures women’s evolving maternal identity as they navigated feeding decisions, caregiving confidence, and competing role expectations during the postpartum period. Breastfeeding-related pressure Participants described considerable stress surrounding breastfeeding decisions. Conflicts between physical capacity, infant needs, and family expectations often resulted in emotional burden. While some women experienced guilt when breastfeeding goals were unmet, others reached a compromise through professional guidance and flexible feeding strategies. “My milk supply was insufficient, and my family kept urging me, which created a lot of pressure” (P5). “When the baby cried, my family said it was due to insufficient milk, which made me feel anxious and inadequate” (P8). “My milk supply was low at first, but after the doctor suggested formula, I gradually accepted it” (P10). “When breast milk is not enough, I use formula. The most important thing is that the baby is well fed” (P19). “I wanted to exclusively breastfeed at first, but later I chose to take things as they come. The baby’s health matters most” (P18). “I am not concerned about breastfeeding or formula, as long as the baby is growing well” (P20). Maternal identity and responsibility The assumption of maternal responsibility reshaped participants’ self-perception. Many women described prioritizing infant needs over personal health, while others gradually integrated maternal duties into daily life. Maternal identity was often framed as both an obligation and personal growth. “I prioritise the baby and often neglect my own needs” (P2). “Caring for the baby conflicts with my recovery, and I usually prioritise the baby” (P6). “It is demanding, but I see it as part of being a mother” (P10). “Most decisions now revolve around the baby, and I have adapted” (P11). “Becoming a mother has helped me grow” (P23). Parenting stress and competence Participants expressed varying levels of parenting confidence. First-time mothers frequently reported stress and uncertainty, whereas others gained competence through experience. Increasing caregiving skills contributed to improved emotional stability and perceived self-efficacy. “I didn’t know how to soothe the baby and felt very frustrated.” (P9) “When the baby keeps crying and I cannot soothe them, I feel very frustrated” (P2). “As I gained experience, I became much more confident.” (P18) Role reintegration and employment concerns Concerns about returning to work reflected tensions between caregiving responsibilities and personal identity. Participants described balancing employment expectations with physical recovery and childcare demands, viewing work as both an economic necessity and an avenue for self-restoration. “I hope to return to work soon to reduce financial pressure.” (P1) “I am considering returning to work, depending on family arrangements” (P13) “Work helps me feel like myself again, not just a mother.” (P21) “I plan to return to work when the baby is older; I do not want my life to revolve only around the family” (P24). Discussion Principal findings This qualitative study investigated the postpartum experiences of women with heart disease and found that adaptation during this period is marked by persistent physical challenges, emotional vulnerability, intergenerational family tensions, variations in disease understanding, and the need to balance maternal responsibilities with personal health. Rather than a brief transition, the postpartum period appeared as a prolonged and unstable phase shaped by the interaction between chronic cardiac conditions and the demands of intensive infant care[ 27 – 29 ]. Physical and emotional challenges A key finding was the persistence of physiological burden after childbirth. Many participants reported fatigue, chest tightness, palpitations, and reduced exercise tolerance lasting beyond six weeks postpartum and, in some cases, up to one year. Night-time breastfeeding and frequent infant care disrupted sleep and often worsened these symptoms. Recovery was rarely linear. Fluctuating symptoms and sustained fatigue created an ongoing sense of physical vulnerability. Similar patterns have been reported in women with congenital or acquired heart disease, suggesting that postpartum symptoms may persist for months and affect daily functioning[ 27 , 29 – 31 ]. Importantly, participants described their cardiac symptoms as closely intertwined with caregiving responsibilities. When physical discomfort coincided with infant care demands, many felt caught in a cycle of exhaustion and incomplete recovery. These findings indicate that postpartum care should address maternal recovery and infant care as interconnected rather than separate domains. Emotional vulnerability was also prominent. Many women described heightened anxiety about disease progression, symptom recurrence, and long-term health uncertainty. Minor physical discomfort was often interpreted as a warning sign, leading to constant vigilance[ 9 ]. Some participants avoided physical activity due to fear of cardiac complications, sometimes reinforced by traditional postpartum confinement practices that limited mobility[ 9 , 10 ]. Depressive symptoms were common, particularly in the context of sleep deprivation and unexplained discomfort. Consistent with earlier qualitative studies, emotional distress extended beyond clinical depression to include persistent worry, emotional exhaustion, irritability, and feelings of helplessness. The dual identity of being both a new mother and a patient with chronic disease intensified emotional strain. Several women reported gradually neglecting their own emotional and health needs while prioritising infant care[ 32 ]. Family dynamics and sociocultural context Family support functioned as both a protective factor and a potential source of tension. Participants described greater reliance on family members to manage childcare, cardiac monitoring, and rehabilitation. Support from spouses and shared parenting responsibilities were often beneficial and helped reduce stress[ 33 – 35 ]. Previous research similarly shows that adequate family support improves psychological well-being and health-related quality of life[ 33 , 36 ]. However, involvement of older family members sometimes generated intergenerational disagreements regarding infant care and maternal health management. When support did not align with women’s preferences or medical needs, it occasionally increased emotional burden and strained relationships. This coexistence of support and tension reflects the complex role of family dynamics in postpartum adaptation[ 37 ]. These findings also highlight the influence of the Chinese family context, in which intensive intergenerational involvement in postpartum and infant care can inadvertently generate conflict when elders’ practices or beliefs do not align with mothers’ needs, preferences, or medical advice[ 38 , 39 ]. Differences in disease knowledge further shaped postpartum experiences. Some women had a limited understanding of heart disease mechanisms and prognosis, and occasionally misinterpreted warning symptoms as normal postpartum changes. This sometimes delayed help-seeking or disrupted follow-up care. In contrast, women with higher health literacy were more proactive in monitoring symptoms and seeking professional advice. Postpartum health behaviours, therefore, appear closely linked to women’s ability to interpret symptoms and assess risk, underscoring the importance of tailored health education. Role transition and identity reconstruction Under the pressures of motherhood, personal recovery needs were often marginalised. Many women expressed a strong desire to return to work, resume social roles, and rebuild a sense of self. However, caregiving demands and cardiac vulnerability frequently limited physical capacity and delayed return-to-work plans. In the absence of sufficient support and professional guidance, some prioritised infant care over their own recovery. While caregiving responsibilities were widely accepted as necessary, they also created internal conflict. Employment was viewed not only as an economic need but also as a means of restoring identity and normalcy[ 34 , 40 ]. Strengths and Limitations This study was conducted in a single provincial tertiary hospital in China, which may limit the transferability of the findings. Future longitudinal studies are needed to examine changes in postpartum adaptation and to inform the development of long-term follow-up and supportive interventions. Nevertheless, based on the rich data obtained from semi-structured face-to-face interviews, this study conducted in-depth qualitative analysis and achieved data saturation. Conclusion Collectively, these findings indicate that postpartum adaptation among women with pregnancy-complicated heart disease is a prolonged and multifaceted process shaped by interacting physical, emotional, familial, and informational factors. Rather than a brief recovery stage, the postpartum period reflects an ongoing negotiation between illness vulnerability, caregiving demands, and identity reconstruction. Clinical and research implications These findings highlight the need to shift postpartum care from a time-limited, medically focused model to a more continuous and context-sensitive approach. Follow-up should extend beyond routine obstetric time points and include monitoring of symptoms, functional recovery, and psychological well-being. Discharge education should incorporate guidance on symptom recognition, fatigue management, and breastfeeding in the context of cardiac medication use. Given the central role of family, partners and primary caregivers should be actively involved in follow-up care. Family-based education may help align medical recommendations with caregiving practices, particularly in intergenerational contexts. In addition, accessible consultation pathways (eg, nurse-led or digital support) are needed to reduce reliance on fragmented online information. Future research should adopt more integrative and longitudinal approaches to capture the dynamic interplay between symptoms, emotional responses, family context, and self-management over time. Developing and evaluating family-inclusive and digitally supported care models may further improve continuity and patient-centred outcomes in this population. Declarations Funding Statement This research received no external funding. Data Sharing Statement The datasets generated and analyzed during the current study are not publicly available due to the need to protect participants’ privacy and confidentiality, but are available from the corresponding author on reasonable request. Ethics Approval and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was granted by the Research Ethics Committee of the First Affiliated Hospital of Zhejiang University School of Medicine (Ethical Approval Number: IIT-EA-2025-0609). Written informed consent was obtained from all participants prior to participation. Consent for Publication All participants provided consent for the anonymised data to be used in research publications. Author Contributions Yuan Wang contributed to the conception and design of the study, data collection, data analysis, and drafting of the manuscript. Huiling Wu contributed to study supervision, methodological guidance, and critical revision of the manuscript. Qing Wang contributed to data collation. Lewen Shao contributed to the study design and critical revision of the manuscript. All authors read and approved the final manuscript. Competing Interests The authors declare that they have no competing interests. References Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165-3241. DOI:10.5603/KP.2019.0049. Liu JL, Wang Q, Qu DY. Postpartum quality of life and mental health in women with heart disease: integrated clinical communication and treatment. World J Psychiatry. 2024;14(1):63-75. DOI:10.5498/wjp.v14.i1.63. Rex S, Devroe S. Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol. 2022;36(1):191-208. DOI:10.1016/j.bpa.2022.02.004. Wu L, Li N, Liu Y. Association between maternal factors and risk of congenital heart disease in offspring: a systematic review and meta-analysis. Matern Child Health J. 2022;27:29-48. DOI:10.1007/s10995-022-03538-8. Davis MB, Arendt K, Bello NA, Brown H, Briller J, Epps K, et al. Team-based care of women with cardiovascular disease from pre-conception through pregnancy and postpartum. J Am Coll Cardiol. 2021;77(14):1763-1777.DOI:10.1016/j.jacc.2021.02.033. Shrestha P, Kuikel S, Bajracharya S, Ghimire A, Shrestha R, Mishra A, et al. Pregnancy with heart disease in South Asia: a systematic review and meta-analysis of prevalence and outcome. Ann Med Surg. 2022;80:104238. DOI:10.1016/j.amsu.2022.104293. Rosenfeld E, Brandt J, Fields J, Lee R, Graham H, Sharma R, et al. Chronic hypertension and the risk of readmission for postpartum cardiovascular complications. Obstet Gynecol. 2023;142:1431-1439.DOI:10.1097/AOG.0000000000005424. Lorén H, Weineland S, Rembeck G. Facing a new life—the healthy transition to motherhood: a phenomenological-hermeneutic study. Midwifery. 2024;130:103917. DOI:10.1016/j.midw.2024.103917. Hutchens J, Frawley J, Sullivan E. Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection. BMC Pregnancy Childbirth. 2022;22. DOI:10.1186/s12884-022-04614-1. Freiberger A, Beckmann J, Freilinger S, Kaemmerer H, Huber M, Nagdyman N, et al. Psychosocial well-being in postpartum women with congenital heart disease. Cardiovasc Diagn Ther. 2022;12:389-399. DOI:10.21037/cdt-22-213. Kılavuz M, Topaloğlu Sİ. Psychosocial and maternal care needs of recently delivered women during the postpartum period. BMC Pregnancy Childbirth. 2025;25. DOI:10.1186/s12884-025-07982-6. Sharma G, Gaffey A, Hameed A, Kasparian N, Mauricio R, Marsh E, et al. Optimizing psychological health across the perinatal period: an update on maternal cardiovascular health. J Am Heart Assoc. 2025;14.DOI:10.1161/JAHA.125.041369 Donofry S, Jouppi R, Call C, Conlon RK, Levine M. Improvements in maternal cardiovascular health over the perinatal period longitudinally predict lower postpartum psychological distress. J Am Heart Assoc. 2024;13. DOI:10.1161/JAHA.123.034153. Sharma R, Singh U, Kamal R, Kumar R. From pregnancy to postpartum: the cardiovascular risks associated with gestational diabetes. Curr Cardiol Rev. 2025. DOI:10.2174/011573403X354645250329171327. Martin T, Juarros M, Leinwand L. Regression of cardiac hypertrophy in health and disease: mechanisms and therapeutic potential. Nat Rev Cardiol. 2023;20:347-363. DOI:10.1038/s41569-022-00806-6. Lane-Cordova AD, Khan SS, Grobman WA, Greenland P, Shah SJ. Long-term cardiovascular risks associated with adverse pregnancy outcomes. J Am Coll Cardiol. 2019;73(16):2106-2116. DOI:10.1016/j.jacc.2018.12.092. Lewey J, Beckie T, Brown H, Brown S, Garovic V, Khan S, et al. Opportunities in the postpartum period to reduce cardiovascular disease risk after adverse pregnancy outcomes. Circulation. 2024;149. DOI:10.1161/CIR.0000000000001212. Lewey J, Levine LD, Yang L, Triebwasser JE, Groeneveld PW. Patterns of postpartum ambulatory follow-up care among women with hypertensive disorders of pregnancy. J Am Heart Assoc. 2020;9. DOI:10.1161/JAHA.120.016357. Countouris ME, Shapero K, Swabe G, Hauspurg A, Davis EF, Magnani JW. Association of race and ethnicity and social factors with postpartum follow-up visits among individuals with preeclampsia. J Am Heart Assoc. 2024;13. DOI:10.1161/JAHA.123.033188. Kiley J, Corlett A, Mitchell-Sparke E, Jasper B, Wishlade T, Bhagra C, et al. Postnatal experiences of women with cardiac conditions: a systematic review and meta-synthesis. AJOG Glob Rep. 2025;5. DOI:10.1016/j.xagr.2025.100564. Syed I, Sajjad R, Anwar S, Syed R, Naqvi SB, Syed I. Perinatal outcome in pregnancy complicated by maternal heart disease. Insights J Health Rehabil. 2025. Manthorpe T, Arstall M, Andraweera P, Aldridge E. Patient experiences of a postpartum cardiovascular disease intervention clinic for pregnancy complications. Matern Child Health J. 2025;29:310-321. DOI:10.1007/s10995-025-04047-0. Venkatesh KK, Grobman WA, Wu J, Shah N, Pencina MJ, Costantine MM, et al. Hypertensive disorders of pregnancy and gestational diabetes mellitus and predicted risk of maternal cardiovascular disease 10–14 years after delivery: a prospective cohort. Diabet Med. 2025;42. DOI:10.1111/dme.15516. Hutchens J, Frawley J, Sullivan E. The healthcare experiences of women with cardiac disease in pregnancy and postpartum: a qualitative study. Health Expect. 2022;25:1872-1881. DOI:10.1111/hex.13532 Arntzen EK, Jøsengdal R, Sandsæter HL, Horn J. Postpartum follow-up of women with preeclampsia: facilitators and barriers—a qualitative study. BMC Pregnancy Childbirth. 2023;23. DOI:10.1186/s12884-023-06146-8. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. DOI:10.1093/intqhc/mzm042 De Backer J, Haugaa KH, Hasselberg NE, de Hosson M, Brida M, Castelletti S, et al. 2025 ESC guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J. 2025;46(43):4462-4568. DOI:10.1093/eurheartj/ehaf193. Silversides CK, Grewal J, Mason J, Sermer M, Kiess M, Rychel V, et al. Pregnancy outcomes in women with heart disease: the CARPREG II study. J Am Coll Cardiol. 2018. Wallin N, Bergman L, Smith GN. Pregnancy-associated cardiovascular risks and postpartum care: an opportunity for interventions aiming at health preservation and disease prevention. Best Pract Res Clin Obstet Gynaecol. 2024;92:102435.DOI:10.1016/j.bpobgyn.2023.102435. Siu SC, Lee DS, Rashid M, Fang J, Austin PC, Silversides CK. Long-term cardiovascular outcomes after pregnancy in women with heart disease. J Am Heart Assoc. 2021;10(11):e020584. doi:10.1161/JAHA.120.020584 . ACOG Practice Bulletin No. 212: pregnancy and heart disease. Obstet Gynecol. 2019. Wu Y, Andescavage N, Lopez C, et al. Maternal mental distress and cortisol levels in pregnancies with congenital heart disease. Cardiol Young. 2022;32(6):975-979. DOI:10.1017/S1047951121003504 . Qi W, Liu Y, Lv H, et al. Effects of family relationship and social support on the mental health of Chinese postpartum women. BMC Pregnancy Childbirth. 2022;22(1):65. Published 2022 Jan 25. doi:10.1186/s12884-022-04392-w. Khademi K, Kaveh MH. Social support as a coping resource for psychosocial conditions in postpartum period: a systematic review and logic framework. BMC Psychol. 2024;12(1):301. Published 2024 May 28. doi:10.1186/s40359-024-01814-6. Şen H, Ay A. Predictors of parenting stress among mothers of Turkish children with congenital heart disease. J Pediatr Nurs. 2025;84:226-234. DOI:10.1016/j.pedn.2025.06.025. Khademi K, Kaveh M, Ghahremani L, Nazari M, Karimi M. The impact of family social support on postpartum quality of life among Iranian women: structural equation modelling. J Int Med Res. 2023;51. DOI:10.1177/03000605221147198. Xiao X, Ngai FW, Zhu SN, Loke AY. The experiences of early postpartum Shenzhen mothers and their need for home visit services: a qualitative exploratory study. BMC Pregnancy Childbirth. 2019;20. DOI:10.1186/s12884-019-2686-8. Xiao X, Loke AY. Experiences of intergenerational co-parenting during the postpartum period in modern China: A qualitative exploratory study. Nurs Inq.2021;28(3):e12403. DOI:10.1111/nin.12403. Hanser A, Zhang Y. Mothers and grandmothers: rethinking motherhood in the context of intergenerational caregiving. J Marriage Fam. 2025;87. doi:10.1111/jomf.13070. Fahey JO, Shenassa E. Understanding and meeting the needs of women in the postpartum period: the perinatal maternal health promotion model. J Midwifery Womens Health. 2013;58(6):613-621. DOI:10.1111/jmwh.12139. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviewers invited by journal 03 Apr, 2026 Editor invited by journal 01 Apr, 2026 Editor assigned by journal 01 Apr, 2026 Submission checks completed at journal 01 Apr, 2026 First submitted to journal 28 Mar, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-9255633","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619777924,"identity":"59a1d230-40ad-4b55-86c1-e781784355a3","order_by":0,"name":"Yuan Wang","email":"","orcid":"","institution":"The First Affiliated Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Wang","suffix":""},{"id":619777925,"identity":"d31cce2f-a6aa-40d1-ba44-8cacb0cdad73","order_by":1,"name":"Huiling Wu","email":"","orcid":"","institution":"The First Affiliated Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Huiling","middleName":"","lastName":"Wu","suffix":""},{"id":619777926,"identity":"7ffab531-cc33-49c9-85bb-c4bd22e02374","order_by":2,"name":"Qing Wang","email":"","orcid":"","institution":"The First Affiliated Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Wang","suffix":""},{"id":619777927,"identity":"553f6cd1-d9e3-4749-9310-24a827e3b7ae","order_by":3,"name":"Lewen Shao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBACfvmDDQcSKmwYGBuAPB5itEjOYG488OFMGglaDG6wNx+c2XYYwiNOy+3GhsO8beftmWckMD5428Ygb07QYXcONhzmOXebmXFGArPh3DYGw50NBLTwHUgEaim7zQbUwibN28aQYHCAkDVgLWzneIBa2H8TpUXgRmLDwRltByRAtjATpUWyBxgvH84kGzD2PGyWnHNOwnADIS387O2PPyRU2Nkbticf/PCmzEaesF9gwLABHJkSxKoHAnkS1I6CUTAKRsEIAwAVxEdkF4qQxgAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital, Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Lewen","middleName":"","lastName":"Shao","suffix":""}],"badges":[],"createdAt":"2026-03-29 00:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9255633/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9255633/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106724768,"identity":"afad1f59-8b22-49ec-8778-3b026fbd3d33","added_by":"auto","created_at":"2026-04-12 18:29:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1303353,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9255633/v1/8f3e1083-9d75-4f25-9a69-6e5f0214e880.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Postpartum adjustment among women with heart disease in pregnancy: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003ePregnancy with heart disease (PWHD) encompasses a spectrum of congenital, acquired, and genetic cardiovascular conditions that are either pre-existing or newly diagnosed during pregnancy. It is associated with substantial maternal morbidity and mortality and includes structural heart disease, cardiomyopathy, arrhythmias, ischemic heart disease, and aortic disorders[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The incidence of PWHD ranges from 1% to 4% and has shown an increasing trend, partly attributable to delayed childbearing, rising cardiometabolic risk, and improved survival among women with congenital heart disease[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe postpartum period represents a particularly vulnerable phase for women with PWHD. Rapid haemodynamic shifts following childbirth, together with persistent cardiac risk, increase the likelihood of clinical deterioration[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. At the same time, women are required to adapt to new maternal roles while managing chronic illness, placing simultaneous physiological, psychological, and social demands on recovery[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This intersection of medical vulnerability and maternal transition renders postpartum adjustment especially complex.\u003c/p\u003e \u003cp\u003ePostpartum adjustment is increasingly recognised as a multidimensional and evolving process that extends beyond physical recovery to include emotional well-being, caregiving capacity, and transformations in identity and social roles[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For women with heart disease, this process is further complicated by persistent symptoms, incomplete cardiac recovery, and elevated long-term cardiovascular risk, underscoring the need for sustained follow-up and integrated care[\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, current postpartum care remains largely time-limited and medically oriented, often prioritising acute complications over longer-term adaptation[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Such approaches may be insufficient to address the complex interplay of physical, emotional, and social needs experienced by women with PWHD. In addition, fragmented follow-up services and limited integration of psychosocial support further widen the gap between clinical care and patients\u0026rsquo; lived experiences[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite growing recognition of postpartum vulnerability, existing research on pregnancy-complicated heart disease has largely prioritised perinatal risk assessment and clinical outcomes, with comparatively limited attention to women\u0026rsquo;s lived experiences during the postpartum period[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Qualitative studies in this field have tended to focus on specific dimensions, such as psychological distress or healthcare experiences, while offering less integrated accounts of how physical symptoms, maternal role transition, family interactions, and self-management practices intersect in shaping postpartum adjustment.\u003c/p\u003e \u003cp\u003eMoreover, postpartum adaptation in women with heart disease is not solely an individual process but unfolds within broader sociocultural contexts. In particular, within the Chinese setting, where intergenerational co-caregiving and family-centred decision-making are common, the ways in which family dynamics influence women\u0026rsquo;s recovery, autonomy, and role negotiation remain insufficiently explored[\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The interaction between medical vulnerability and culturally embedded caregiving structures has yet to be fully understood.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to explore, through qualitative interviews, how women with pregnancy-complicated heart disease experience and interpret postpartum adjustment within the Chinese sociocultural context. By capturing the interplay between physical symptoms, emotional responses, family dynamics, and self-management, this study seeks to provide a more holistic understanding of postpartum adaptation and to inform the development of personalised, context-sensitive postpartum care strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis qualitative study used reflexive thematic analysis, as described by Braun and Clarke. Semi-structured interviews were conducted to explore postpartum adjustment among women with pregnancy-complicated heart disease. The study was carried out in the obstetric department of a provincial tertiary grade A hospital in Zhejiang Province, China, which manages approximately 4,000 deliveries annually, including a substantial proportion of high-risk pregnancies.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants were purposively recruited from the study site. Eligible women were aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years, had a confirmed diagnosis of congenital, acquired, or inherited heart disease before or during pregnancy, were between 6 weeks and 12 months postpartum, were clinically stable, and able to communicate in Mandarin. Women were excluded if they had severe psychiatric illness, cognitive impairment, had experienced medically indicated pregnancy termination, or were participating in other clinical studies. Recruitment continued until data saturation was reached. Saturation was defined as the point at which no new themes emerged, and was considered achieved when the final three interviews generated no new codes. A total of 24 women participated.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted by the first author in a private hospital interview room. Relevant clinical information was reviewed beforehand to support rapport. Interviews lasted approximately 30\u0026ndash;45 minutes. All interviews were audio-recorded with consent and supplemented by field notes. Open-ended questions with flexible probes were used to encourage detailed accounts. Follow-up contact was undertaken where clarification was needed. The interview guide is provided in Supplementary File 1.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analysed using reflexive thematic analysis following Braun and Clarke. Transcripts were read repeatedly for familiarisation. Initial codes were generated inductively to capture key features of the data. Codes were then reviewed and grouped into candidate themes. Themes were refined through comparison across transcripts to ensure coherence and consistency. Theme development was interpretive and focused on patterns of meaning rather than simple categorisation. NVivo (version 15) was used to support data management.\u003c/p\u003e \u003cp\u003eReflexivity was maintained throughout analysis. The research team engaged in regular discussions to examine assumptions and interpretations, ensuring that findings remained grounded in participants\u0026rsquo; accounts while recognising the active role of the researchers. To enhance rigour, a subset of transcripts was independently coded by two researchers, with discrepancies resolved through discussion. An audit trail documenting analytic decisions was maintained.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearcher reflexivity\u003c/h3\u003e\n\u003cp\u003eInterviews were carried out by the first author, who is a senior obstetric nurse skilled in qualitative research and experienced in managing high-risk pregnancies. The interviewer had no prior clinical relationship with the participants and was not involved in their direct care. To minimise potential bias and enhance reflexivity, the interviewer maintained reflective field notes after each interview, documenting personal assumptions, emotional responses, and emerging interpretations. Regular discussions were held within the research team to examine preconceptions and ensure that data interpretation remained grounded in participants\u0026rsquo; accounts.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTrustworthiness\u003c/h2\u003e \u003cp\u003eCredibility was enhanced through prolonged engagement, iterative questioning, and member checking, with preliminary findings confirmed by participants. Dependability was supported by an audit trail of coding decisions and team discussions. Two researchers independently coded a subset of transcripts, resolved discrepancies, and applied the agreed framework to the remaining data. Confirmability was ensured through reflexive memoing and peer debriefing, while transferability was supported by detailed descriptions of the study context and participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eWe interviewed 24 postpartum women with pregnancy-complicated heart disease. All interviews were conducted face-to-face and lasted a mean of 37 minutes (range 30\u0026ndash;45).\u003c/p\u003e \u003cp\u003eAll participants were between 6 weeks and 12 months postpartum at the time of the interview. The median age of participants was 32 years (range 22\u0026ndash;44 years). Sixteen women (66.7%) had completed college or vocational education or above. Eighteen participants (75.0%) were delivered by caesarean section. Structural heart disease accounted for 54.2% (13/24) of cases, while the remaining participants had functional cardiac conditions. Nine women (37.5%) reported a history of cardiac surgery. Detailed participant characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eCharacteristics of the study participants (n\u0026thinsp;=\u0026thinsp;24)\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 (%) or Median (range)\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 (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (22\u0026ndash;44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\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\u003eJunior high school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege / vocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (29.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of delivery\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\u003eVaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age at delivery (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u0026thinsp;\u003csup\u003e+\u0026thinsp;2\u003c/sup\u003e (30\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e\u0026mdash;40\u003csup\u003e+\u0026thinsp;0\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of cardiac surgery\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\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (37.5)\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\u003e15 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of heart disease\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\u003eStructural heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (54.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary cardiac diagnosis\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\u003eCongenital heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.5)\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\u003e2 (8.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThemes and subthemes\u003c/h2\u003e \u003cp\u003eThematic analysis identified five main themes and multiple subthemes. The themes covered physical symptoms, emotional responses, family dynamics, illness understanding, and role adaptation in the postpartum period. Details of themes, subthemes, and codes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFindings presented according to themes, subthemes, and codes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eDual burden of heart disease and postpartum context\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePersistent fatigue and physical decline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Delayed postpartum recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Recurrent physical exhaustion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Limitations in daily functioning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRecurrent cardiopulmonary symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Chest tightness and palpitations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Persistent or postoperative cardiac symptoms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNight-time feeding and sleep disruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Fragmented sleep due to infant care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Self-reported sleep disturbances\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003ePsychological vulnerability and emotional fluctuations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePersistent illness-related fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Fear of symptom recurrence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Heightened vigilance toward bodily sensations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInvisible depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Emotional fluctuation and distress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Positive emotional reframing and coping\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-dissolution and role strain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Conflict between health recovery and family responsibilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFamily support tension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntergenerational caregiving conflicts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Conflicting childcare beliefs with parents or in-laws\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSpousal involvement and companionship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Emotional support from partner\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Practical caregiving assistance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInsufficient support and solitary coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Perceived lack of emotional support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Financial strain and household economic pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eIllness perception and self-management challenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUncertainty in disease cognition and prognosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Uncertainty regarding disease trajectory\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Lack of clear consultation pathways\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTransition toward active health management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Difficulty maintaining medication routines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Hesitation toward seeking medical care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Self-monitoring behaviors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eVariability in health information acquisition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Reliance on peer support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Unmet disease-related consultation needs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Challenges managing postpartum daily life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMaternal role withdrawal and reintegration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreastfeeding-related pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Conflicts and compromises in breastfeeding decisions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaternal identity and responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Perceived maternal responsibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParenting stress and competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Parenting burden and caregiving stress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRole reintegration and employment concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Concerns about returning to work and role functioning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Dual burden of heart disease and postpartum context\u003c/h2\u003e \u003cp\u003eThis theme reflects the dual challenges of postpartum recovery and ongoing cardiac symptoms. Fatigue, sleep disruption, and cardiopulmonary symptoms were commonly reported and often limited daily functioning. These challenges were experienced as cumulative rather than isolated, reinforcing difficulties in early postpartum adjustment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePersistent fatigue and physical decline\u003c/h2\u003e \u003cp\u003ePersistent fatigue was widely reported, with variation in severity and manageability. For some, infant care, household tasks, and early return to work led to pronounced exhaustion with little opportunity for rest. Others experienced partial relief when family support allowed recovery. A smaller group reported smoother recovery and used self-regulation to maintain balance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I returned to work two months after delivery. There is no time to rest during the day, and my sleep at night is disrupted. I often wake up feeling dizzy and exhausted\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In the early postpartum period, I had to go to the hospital frequently. Caring for the baby was very demanding, and I felt completely drained\u0026rdquo; (P8).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My husband sometimes helps with night-time feeding. It is still tiring, but I feel less overwhelmed\u0026rdquo; (P10).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I am so tired that I do not want to move. But during the day, my mother helps with the baby, which allows me to rest. I feel much better physically\u0026rdquo; (P12).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My body has recovered well after childbirth. I still feel tired at times, but it is not as severe as in the early postpartum period\u0026rdquo; (P19).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eNight-time feeding and sleep disruption\u003c/h2\u003e \u003cp\u003eDisrupted sleep was a persistent burden, driven by night-time feeding and infant crying. Fragmented sleep hindered recovery and increased fatigue. Some women reported partial relief with family support, while others noted gradual improvement as infants developed more regular sleep patterns.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have had insufficient sleep since pregnancy, and it did not improve after delivery. Even as my baby grows older, I still feel weak and fatigued\u0026rdquo; (P4).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The baby feeds every two hours, and my sleep is almost completely interrupted throughout the night\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My husband helps occasionally, but I still have to wake up for night feedings. In any case, my sleep is not as good as before\u0026rdquo; (P10).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the baby cries at night, my mother-in-law sometimes comforts the baby first, so I can sleep a bit longer\u0026rdquo; (P13).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At the beginning, I slept poorly, but as the baby grew, things gradually improved. Now I can usually sleep through the night\u0026rdquo; (P17).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Waking up once or twice at night is acceptable for me. I can rest during the day, and that helps\u0026rdquo; (P20).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecurrent cardiopulmonary symptoms\u003c/h2\u003e \u003cp\u003eIn addition to fatigue and sleep disruption, recurrent cardiopulmonary symptoms such as chest tightness, palpitations, and shortness of breath remained a source of distress for many participants. These symptoms often intensified during infant care and heightened concerns about disease recurrence or deterioration. While some women reported reassurance following regular follow-up and medical explanations, others prioritized caregiving responsibilities over symptom monitoring, delaying attention to their own health.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I feel a sense of pressure in my chest. When I hold the baby against my chest, I become short of breath\u0026rdquo; (P5).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I still experience chest tightness and shortness of breath. The doctor advised me to return for follow-up\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My atrial fibrillation still occurs occasionally. During episodes, I feel chest tightness and breathlessness\u0026rdquo; (P9).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I notice my heart beating faster, but the doctor said it is temporary, so I am not too worried\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My condition has mostly recovered. The doctor also said everything looks good, so I am not very concerned\u0026rdquo; (P21).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Psychological vulnerability and emotional fluctuations\u003c/h2\u003e \u003cp\u003eThis theme captures the heightened emotional sensitivity experienced by participants as they navigated uncertainty related to illness, caregiving demands, and shifting self-identity in the postpartum period. Psychological responses were shaped by concerns about disease recurrence, emotional suppression, and the tension between maternal responsibilities and personal well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePersistent illness-related fear\u003c/h2\u003e \u003cp\u003eFear of disease recurrence was common among participants, though its intensity and focus differed. Some women described heightened vigilance, interpreting minor physical sensations as signs of serious cardiac problems, which contributed to ongoing anxiety and avoidance of physical exertion. Others concentrated their worries on pregnancy or infant-related risks, while a subset reported managing fear through adherence to follow-up care and trust in medical guidance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Whenever my chest feels uncomfortable, I immediately think something is wrong with my heart.\u0026rdquo; (P2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As long as I follow the doctor\u0026rsquo;s advice and go for check-ups, I don\u0026rsquo;t let myself worry too much.\u0026rdquo; (P21)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInvisible depression\u003c/h2\u003e \u003cp\u003eParticipants commonly reported emotional fluctuations during the postpartum period; however, the expression, intensity, and coping strategies varied considerably. For some women, emotional distress was pronounced and persistent, often triggered by infant care demands, sleep deprivation, and delayed physical recovery. These experiences were sometimes accompanied by irritability, anxiety, and even negative thoughts about motherhood.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSome participants reported pronounced emotional distress, often triggered by infant crying and sleep disruption. \u0026ldquo;The baby is so difficult to care for. I regret it almost every day. The constant crying at night drives me to the edge\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eEven when recognising such behaviours as normal, some women still felt overwhelmed: \u0026ldquo;The doctor said it was normal for babies to cry at night, but those days were still very hard for me to cope with\u0026rdquo; (P8).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eFor some, emotional distress was alleviated through family support and gradual adjustment. \u0026ldquo;At first I felt very tired and emotionally low, but my mother helped with the baby, and I gradually felt better\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eOthers maintained relatively stable emotional states and expressed positive reframing: \u0026ldquo;Sometimes I feel tired, but being with my baby makes me happy. I feel it is all worth it\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Taking care of the baby is demanding, but I feel fulfilled\u0026rdquo; (P24).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSelf-dissolution and role strain\u003c/h2\u003e \u003cp\u003eAssuming the maternal role significantly reshaped participants\u0026rsquo; sense of self. Many women described placing their own needs secondary to those of their infants, even when experiencing health limitations. Some gradually recognized the tension between caregiving obligations and personal recovery, attempting to renegotiate balance. Others derived meaning and value from motherhood, reframing sacrifice as responsibility and personal growth.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Everything has to revolve around the baby now. I often forget about myself.\u0026rdquo; (P2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Being a mother has changed my priorities, but I feel it\u0026rsquo;s a responsibility, not just a sacrifice.\u0026rdquo; (P20)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The baby cried all night, and I felt like I was about to break down. I became so irritable.\u0026rdquo; (P4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s tiring, but being with my baby makes me feel happy. I think it\u0026rsquo;s all worth it.\u0026rdquo; (P18)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Family support tension\u003c/h2\u003e \u003cp\u003eThis theme reflects the complex and sometimes conflicting experiences of family support during the postpartum period. Participants described varying levels of emotional and practical assistance from partners and extended family members, which shaped their capacity to cope with recovery demands and caregiving responsibilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eIntergenerational caregiving conflicts\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eConflict\u003c/strong\u003e \u003cp\u003eing childcare beliefs between participants and their parents or in-laws were frequently reported. Traditional caregiving practices sometimes contradicted medical advice, leading to tension and emotional distress despite the availability of practical assistance. While some women felt misunderstood, others described learning to negotiate differences in order to maintain household stability.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My parents-in-law help with childcare and provide financial support, but there is still an emotional gap. For example, they think there is no need to respond when the baby cries, while I worry the baby might be hungry or uncomfortable, which often leads to conflict\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My parents-in-law help take care of the baby when I go for follow-up visits, otherwise it would be difficult to manage. Although their caregiving approach sometimes differs from mine, such as not responding immediately when the baby cries, having their support makes me feel reassured\u0026rdquo; (P10).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My mother-in-law helps with cooking and childcare every day, which allows me to rest. Although there are occasional disagreements, she is willing to follow medical advice rather than insisting on traditional practices, which makes me feel fortunate\u0026rdquo; (P19).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;My parents help take care of the baby so I can attend follow-up appointments with peace of mind. They also remind me to take medication and rest, sometimes even more attentively than I would myself\u0026rdquo; (P20).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSpousal involvement and companionship\u003c/h2\u003e \u003cp\u003eParticipants reported substantial variation in spousal involvement. Emotional reassurance and practical caregiving assistance from partners were described as crucial sources of security. In contrast, limited engagement intensified exhaustion and feelings of isolation, particularly during nighttime caregiving.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I feel that no one can really help me, and I become very anxious. Even when my husband is at home, he feels tired from work and rarely helps\u0026rdquo; (P1).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Although we hired a maternity caregiver, there is no one who truly understands me emotionally. My husband thinks that paying for help is enough and is rarely involved himself\u0026rdquo; (P8).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My husband is somewhat supportive emotionally. When the baby cries intensely, he will hold the baby for a while. Even though he is not always present, having someone there when I feel overwhelmed is important\u0026rdquo; (P12).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My husband occasionally helps with night feeding. It is still tiring, but it feels different. He will prepare the formula and soothe the baby, so I can rest briefly\u0026rdquo; (P17).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Doctors and nurses offered reassurance, but what mattered most was my husband\u0026rsquo;s constant presence. He accompanied me throughout pregnancy and after delivery, attended follow-up visits with me.\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eInsufficient support and solitary coping\u003c/h2\u003e \u003cp\u003eSome participants experienced inadequate emotional or practical support, leading to solitary coping with postpartum recovery and childcare. Financial strain and household economic pressure further compounded stress. Conversely, women who received consistent support reported greater opportunities for rest and medical follow-up.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most of the time I am on my own. It feels very lonely. When the baby cries, there is no one to help, and I have to soothe the baby while crying myself\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My family helps, but they do not always understand my views. For example, I wanted to take the baby outside, but they thought the baby was too young, which led to disagreements\u0026rdquo; (P13).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the baby cries at night, my parents-in-law sometimes get up first so I can sleep a little longer. I know it is not easy for them, so I feel very grateful\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My parents help a lot, which makes things much easier. They take on household tasks and childcare, so I have time for follow-up and can get a full night\u0026rsquo;s sleep\u0026rdquo; (P24).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Illness perception and self-management challenges\u003c/h2\u003e \u003cp\u003eThis theme illustrates disparities in disease understanding, uncertainty regarding prognosis, and differences in engagement with postpartum health management.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eUncertainty in disease cognition and prognosis\u003c/h2\u003e \u003cp\u003eParticipants demonstrated varying awareness of their cardiac condition. Some struggled to distinguish pathological symptoms from normal postpartum changes, leading to uncertainty and anxiety. Others relied on follow-up assessments to interpret disease trajectory and gain reassurance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I wasn\u0026rsquo;t sure whether my symptoms were normal after childbirth or heart-related.\u0026rdquo; (P2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Even though the doctor said it was stable, I still worried about the future.\u0026rdquo; (P8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Follow-up results have been normal, so I feel there are no major problems\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is hard to predict the future, but as long as I attend follow-up regularly, it should be fine\u0026rdquo; (P23).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eTransition toward active health management\u003c/h2\u003e \u003cp\u003ePostpartum self-management behaviors ranged from passive to proactive. Some participants reported difficulty maintaining medication routines or delayed medical visits due to caregiving demands. Others gradually adopted active strategies, including scheduled follow-ups and symptom monitoring.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I forget, and I only go for follow-up when my mother reminds me\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The doctor recommended monthly follow-up. I went once or twice, but I could not maintain it regularly\u0026rdquo; (P13).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I now attend follow-up visits regularly and also record my blood pressure and heart rate\u0026rdquo; (P20).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I always cooperate with the hospital\u0026rsquo;s telephone follow-up. It makes me feel reassured that someone is checking on me\u0026rdquo; (P24).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I attend every follow-up visit and also monitor my heart rate and blood pressure at home\u0026rdquo; (P21).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eVariability in health information acquisition\u003c/h2\u003e \u003cp\u003e Participants obtained health information through diverse channels, including healthcare providers, peers, and online sources. While some relied heavily on experiential or peer advice, others expressed unmet consultation needs or difficulties translating information into daily management.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I often asked other mothers first because it was more convenient.\u0026rdquo; (P7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I still don\u0026rsquo;t know who to consult when new problems arise.\u0026rdquo; (P11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I often seek advice online by posting questions on different platforms. People with similar conditions sometimes share their experiences, and occasionally I also consult AI-based tools\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Maternal role withdrawal and reintegration\u003c/h2\u003e \u003cp\u003eThis theme captures women\u0026rsquo;s evolving maternal identity as they navigated feeding decisions, caregiving confidence, and competing role expectations during the postpartum period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eBreastfeeding-related pressure\u003c/h2\u003e \u003cp\u003eParticipants described considerable stress surrounding breastfeeding decisions. Conflicts between physical capacity, infant needs, and family expectations often resulted in emotional burden. While some women experienced guilt when breastfeeding goals were unmet, others reached a compromise through professional guidance and flexible feeding strategies.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My milk supply was insufficient, and my family kept urging me, which created a lot of pressure\u0026rdquo; (P5).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the baby cried, my family said it was due to insufficient milk, which made me feel anxious and inadequate\u0026rdquo; (P8).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My milk supply was low at first, but after the doctor suggested formula, I gradually accepted it\u0026rdquo; (P10).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When breast milk is not enough, I use formula. The most important thing is that the baby is well fed\u0026rdquo; (P19).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I wanted to exclusively breastfeed at first, but later I chose to take things as they come. The baby\u0026rsquo;s health matters most\u0026rdquo; (P18).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am not concerned about breastfeeding or formula, as long as the baby is growing well\u0026rdquo; (P20).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMaternal identity and responsibility\u003c/h3\u003e\n\u003cp\u003eThe assumption of maternal responsibility reshaped participants\u0026rsquo; self-perception. Many women described prioritizing infant needs over personal health, while others gradually integrated maternal duties into daily life. Maternal identity was often framed as both an obligation and personal growth.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I prioritise the baby and often neglect my own needs\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Caring for the baby conflicts with my recovery, and I usually prioritise the baby\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is demanding, but I see it as part of being a mother\u0026rdquo; (P10).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most decisions now revolve around the baby, and I have adapted\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Becoming a mother has helped me grow\u0026rdquo; (P23).\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eParenting stress and competence\u003c/h2\u003e \u003cp\u003eParticipants expressed varying levels of parenting confidence. First-time mothers frequently reported stress and uncertainty, whereas others gained competence through experience. Increasing caregiving skills contributed to improved emotional stability and perceived self-efficacy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t know how to soothe the baby and felt very frustrated.\u0026rdquo; (P9)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the baby keeps crying and I cannot soothe them, I feel very frustrated\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As I gained experience, I became much more confident.\u0026rdquo; (P18)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eRole reintegration and employment concerns\u003c/h2\u003e \u003cp\u003eConcerns about returning to work reflected tensions between caregiving responsibilities and personal identity. Participants described balancing employment expectations with physical recovery and childcare demands, viewing work as both an economic necessity and an avenue for self-restoration.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I hope to return to work soon to reduce financial pressure.\u0026rdquo; (P1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am considering returning to work, depending on family arrangements\u0026rdquo; (P13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Work helps me feel like myself again, not just a mother.\u0026rdquo; (P21)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I plan to return to work when the baby is older; I do not want my life to revolve only around the family\u0026rdquo; (P24).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal findings\u003c/h2\u003e \u003cp\u003eThis qualitative study investigated the postpartum experiences of women with heart disease and found that adaptation during this period is marked by persistent physical challenges, emotional vulnerability, intergenerational family tensions, variations in disease understanding, and the need to balance maternal responsibilities with personal health. Rather than a brief transition, the postpartum period appeared as a prolonged and unstable phase shaped by the interaction between chronic cardiac conditions and the demands of intensive infant care[\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhysical and emotional challenges\u003c/h3\u003e\n\u003cp\u003eA key finding was the persistence of physiological burden after childbirth. Many participants reported fatigue, chest tightness, palpitations, and reduced exercise tolerance lasting beyond six weeks postpartum and, in some cases, up to one year. Night-time breastfeeding and frequent infant care disrupted sleep and often worsened these symptoms. Recovery was rarely linear. Fluctuating symptoms and sustained fatigue created an ongoing sense of physical vulnerability. Similar patterns have been reported in women with congenital or acquired heart disease, suggesting that postpartum symptoms may persist for months and affect daily functioning[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Importantly, participants described their cardiac symptoms as closely intertwined with caregiving responsibilities. When physical discomfort coincided with infant care demands, many felt caught in a cycle of exhaustion and incomplete recovery. These findings indicate that postpartum care should address maternal recovery and infant care as interconnected rather than separate domains.\u003c/p\u003e \u003cp\u003eEmotional vulnerability was also prominent. Many women described heightened anxiety about disease progression, symptom recurrence, and long-term health uncertainty. Minor physical discomfort was often interpreted as a warning sign, leading to constant vigilance[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Some participants avoided physical activity due to fear of cardiac complications, sometimes reinforced by traditional postpartum confinement practices that limited mobility[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Depressive symptoms were common, particularly in the context of sleep deprivation and unexplained discomfort. Consistent with earlier qualitative studies, emotional distress extended beyond clinical depression to include persistent worry, emotional exhaustion, irritability, and feelings of helplessness. The dual identity of being both a new mother and a patient with chronic disease intensified emotional strain. Several women reported gradually neglecting their own emotional and health needs while prioritising infant care[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eFamily dynamics and sociocultural context\u003c/h3\u003e\n\u003cp\u003eFamily support functioned as both a protective factor and a potential source of tension. Participants described greater reliance on family members to manage childcare, cardiac monitoring, and rehabilitation. Support from spouses and shared parenting responsibilities were often beneficial and helped reduce stress[\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Previous research similarly shows that adequate family support improves psychological well-being and health-related quality of life[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, involvement of older family members sometimes generated intergenerational disagreements regarding infant care and maternal health management. When support did not align with women\u0026rsquo;s preferences or medical needs, it occasionally increased emotional burden and strained relationships. This coexistence of support and tension reflects the complex role of family dynamics in postpartum adaptation[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings also highlight the influence of the Chinese family context, in which intensive intergenerational involvement in postpartum and infant care can inadvertently generate conflict when elders\u0026rsquo; practices or beliefs do not align with mothers\u0026rsquo; needs, preferences, or medical advice[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Differences in disease knowledge further shaped postpartum experiences. Some women had a limited understanding of heart disease mechanisms and prognosis, and occasionally misinterpreted warning symptoms as normal postpartum changes. This sometimes delayed help-seeking or disrupted follow-up care. In contrast, women with higher health literacy were more proactive in monitoring symptoms and seeking professional advice. Postpartum health behaviours, therefore, appear closely linked to women\u0026rsquo;s ability to interpret symptoms and assess risk, underscoring the importance of tailored health education.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eRole transition and identity reconstruction\u003c/h2\u003e \u003cp\u003eUnder the pressures of motherhood, personal recovery needs were often marginalised. Many women expressed a strong desire to return to work, resume social roles, and rebuild a sense of self. However, caregiving demands and cardiac vulnerability frequently limited physical capacity and delayed return-to-work plans. In the absence of sufficient support and professional guidance, some prioritised infant care over their own recovery. While caregiving responsibilities were widely accepted as necessary, they also created internal conflict. Employment was viewed not only as an economic need but also as a means of restoring identity and normalcy[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study was conducted in a single provincial tertiary hospital in China, which may limit the transferability of the findings. Future longitudinal studies are needed to examine changes in postpartum adaptation and to inform the development of long-term follow-up and supportive interventions. Nevertheless, based on the rich data obtained from semi-structured face-to-face interviews, this study conducted in-depth qualitative analysis and achieved data saturation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCollectively, these findings indicate that postpartum adaptation among women with pregnancy-complicated heart disease is a prolonged and multifaceted process shaped by interacting physical, emotional, familial, and informational factors. Rather than a brief recovery stage, the postpartum period reflects an ongoing negotiation between illness vulnerability, caregiving demands, and identity reconstruction.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section2\"\u003e \u003ch2\u003eClinical and research implications\u003c/h2\u003e \u003cp\u003eThese findings highlight the need to shift postpartum care from a time-limited, medically focused model to a more continuous and context-sensitive approach. Follow-up should extend beyond routine obstetric time points and include monitoring of symptoms, functional recovery, and psychological well-being. Discharge education should incorporate guidance on symptom recognition, fatigue management, and breastfeeding in the context of cardiac medication use.\u003c/p\u003e \u003cp\u003eGiven the central role of family, partners and primary caregivers should be actively involved in follow-up care. Family-based education may help align medical recommendations with caregiving practices, particularly in intergenerational contexts. In addition, accessible consultation pathways (eg, nurse-led or digital support) are needed to reduce reliance on fragmented online information.\u003c/p\u003e \u003cp\u003eFuture research should adopt more integrative and longitudinal approaches to capture the dynamic interplay between symptoms, emotional responses, family context, and self-management over time. Developing and evaluating family-inclusive and digitally supported care models may further improve continuity and patient-centred outcomes in this population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to the need to protect participants’ privacy and confidentiality, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was granted by the Research Ethics Committee of the First Affiliated Hospital of Zhejiang University School of Medicine (Ethical Approval Number: IIT-EA-2025-0609). Written informed consent was obtained from all participants prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided consent for the anonymised data to be used in research publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYuan Wang contributed to the conception and design of the study, data collection, data analysis, and drafting of the manuscript.\u003c/p\u003e\n\u003cp\u003eHuiling Wu contributed to study supervision, methodological guidance, and critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eQing Wang contributed to data collation.\u003c/p\u003e\n\u003cp\u003eLewen Shao contributed to the study design and critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRegitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstr\u0026ouml;m-Lundqvist C, C\u0026iacute;fkov\u0026aacute; R, De Bonis M, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. 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Improvements in maternal cardiovascular health over the perinatal period longitudinally predict lower postpartum psychological distress. J Am Heart Assoc. 2024;13. DOI:10.1161/JAHA.123.034153.\u003c/li\u003e\n \u003cli\u003eSharma R, Singh U, Kamal R, Kumar R. From pregnancy to postpartum: the cardiovascular\u003c/li\u003e\n \u003cli\u003erisks associated with gestational diabetes. Curr Cardiol Rev. 2025. DOI:10.2174/011573403X354645250329171327.\u003c/li\u003e\n \u003cli\u003eMartin T, Juarros M, Leinwand L. Regression of cardiac hypertrophy in health and disease: mechanisms and therapeutic potential. Nat Rev Cardiol. 2023;20:347-363. DOI:10.1038/s41569-022-00806-6.\u003c/li\u003e\n \u003cli\u003eLane-Cordova AD, Khan SS, Grobman WA, Greenland P, Shah SJ. Long-term cardiovascular risks associated with adverse pregnancy outcomes. J Am Coll Cardiol. 2019;73(16):2106-2116. DOI:10.1016/j.jacc.2018.12.092.\u003c/li\u003e\n \u003cli\u003eLewey J, Beckie T, Brown H, Brown S, Garovic V, Khan S, et al. Opportunities in the postpartum period to reduce cardiovascular disease risk after adverse pregnancy outcomes. Circulation. 2024;149. DOI:10.1161/CIR.0000000000001212.\u003c/li\u003e\n \u003cli\u003eLewey J, Levine LD, Yang L, Triebwasser JE, Groeneveld PW. Patterns of postpartum ambulatory follow-up care among women with hypertensive disorders of pregnancy. J Am Heart Assoc. 2020;9. DOI:10.1161/JAHA.120.016357.\u003c/li\u003e\n \u003cli\u003eCountouris ME, Shapero K, Swabe G, Hauspurg A, Davis EF, Magnani JW. Association of race and ethnicity and social factors with postpartum follow-up visits among individuals with preeclampsia. J Am Heart Assoc. 2024;13. DOI:10.1161/JAHA.123.033188.\u003c/li\u003e\n \u003cli\u003eKiley J, Corlett A, Mitchell-Sparke E, Jasper B, Wishlade T, Bhagra C, et al. Postnatal experiences of women with cardiac conditions: a systematic review and meta-synthesis. AJOG Glob Rep. 2025;5. DOI:10.1016/j.xagr.2025.100564.\u003c/li\u003e\n \u003cli\u003eSyed I, Sajjad R, Anwar S, Syed R, Naqvi SB, Syed I. Perinatal outcome in pregnancy complicated by maternal heart disease. Insights J Health Rehabil. 2025.\u003c/li\u003e\n \u003cli\u003eManthorpe T, Arstall M, Andraweera P, Aldridge E. Patient experiences of a postpartum cardiovascular disease intervention clinic for pregnancy complications. Matern Child Health J. 2025;29:310-321. DOI:10.1007/s10995-025-04047-0.\u003c/li\u003e\n \u003cli\u003eVenkatesh KK, Grobman WA, Wu J, Shah N, Pencina MJ, Costantine MM, et al. Hypertensive disorders of pregnancy and gestational diabetes mellitus and predicted risk of maternal cardiovascular disease 10\u0026ndash;14 years after delivery: a prospective cohort. Diabet Med. 2025;42. DOI:10.1111/dme.15516.\u003c/li\u003e\n \u003cli\u003eHutchens J, Frawley J, Sullivan E. 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Maternal mental distress and cortisol levels in pregnancies with congenital heart disease. Cardiol Young. 2022;32(6):975-979. DOI:10.1017/S1047951121003504 .\u003c/li\u003e\n \u003cli\u003eQi W, Liu Y, Lv H, et al. Effects of family relationship and social support on the mental health of Chinese postpartum women. BMC Pregnancy Childbirth. 2022;22(1):65. Published 2022 Jan 25. doi:10.1186/s12884-022-04392-w.\u003c/li\u003e\n \u003cli\u003eKhademi K, Kaveh MH. Social support as a coping resource for psychosocial conditions in postpartum period: a systematic review and logic framework. BMC Psychol. 2024;12(1):301. Published 2024 May 28. doi:10.1186/s40359-024-01814-6.\u003c/li\u003e\n \u003cli\u003eŞen H, Ay A. Predictors of parenting stress among mothers of Turkish children with congenital heart disease. J Pediatr Nurs. 2025;84:226-234. DOI:10.1016/j.pedn.2025.06.025.\u003c/li\u003e\n \u003cli\u003eKhademi K, Kaveh M, Ghahremani L, Nazari M, Karimi M. The impact of family social support on postpartum quality of life among Iranian women: structural equation modelling. J Int Med Res. 2023;51. DOI:10.1177/03000605221147198.\u003c/li\u003e\n \u003cli\u003eXiao X, Ngai FW, Zhu SN, Loke AY. The experiences of early postpartum Shenzhen mothers and their need for home visit services: a qualitative exploratory study. BMC Pregnancy Childbirth. 2019;20. DOI:10.1186/s12884-019-2686-8.\u003c/li\u003e\n \u003cli\u003eXiao X, Loke AY. Experiences of intergenerational co-parenting during the postpartum period in modern China: A qualitative exploratory study. Nurs Inq.2021;28(3):e12403.\u003c/li\u003e\n \u003cli\u003eDOI:10.1111/nin.12403.\u003c/li\u003e\n \u003cli\u003eHanser A, Zhang Y. Mothers and grandmothers: rethinking motherhood in the context of intergenerational caregiving. J Marriage Fam. 2025;87. doi:10.1111/jomf.13070.\u003c/li\u003e\n \u003cli\u003eFahey JO, Shenassa E. Understanding and meeting the needs of women in the postpartum period: the perinatal maternal health promotion model. J Midwifery Womens Health. 2013;58(6):613-621. DOI:10.1111/jmwh.12139.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, heart disease, Postpartum Adjustment, Maternal Health, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-9255633/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9255633/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePregnancy with heart disease (PWHD) is a significant high-risk category, leading to adverse cardiovascular events and indirect maternal deaths. Despite advancements in perinatal care improving outcomes, the postpartum period remains high-risk for cardiovascular issues. Postpartum women face physical, psychological, and maternal role adjustments, with those having heart disease at higher risk for adjustment disorders. This study investigates the real experiences of postpartum adjustment in these patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eResearchers conducted a qualitative study using reflexive thematic analysis. Semi-structured face-to-face interviews were conducted with 24 postpartum women with pregnancy-complicated heart disease at a provincial tertiary hospital in Zhejiang Province, China. Interviews were audio-recorded, transcribed verbatim, and analysed using NVivo 15 to generate themes and subthemes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFive core themes and 16 sub-themes were identified: the dual burden of heart disease and postpartum challenges, psychological vulnerability and heightened emotional fluctuations, family support tension and intergenerational negotiation, gaps in disease understanding and health management skills, and the retreat from motherhood with a need for role repositioning.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThese findings enhance the understanding of the complex challenges faced by women with pregnancy-related heart disease during postpartum adaptation. They emphasize the importance of care that goes beyond disease monitoring to include psychological, familial, and educational support. Implementing integrated, multidisciplinary postpartum care with family involvement and targeted support can foster better recovery and improve quality of life. This approach also contributes to developing comprehensive \"fourth trimester\" care models for sustained maternal and infant health.\u003c/p\u003e","manuscriptTitle":"Postpartum adjustment among women with heart disease in pregnancy: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 10:01:18","doi":"10.21203/rs.3.rs-9255633/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-07T15:57:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53709808166419205288276314113642903091","date":"2026-04-03T14:10:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21003225464142982447460459894687496043","date":"2026-04-03T12:14:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T10:15:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-01T09:57:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T09:30:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-01T09:29:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-29T00:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5fbd0e1f-a40b-40cf-8d38-098c09280bc7","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T10:01:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 10:01:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9255633","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9255633","identity":"rs-9255633","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}