**2. Postnatal challenges and coping strategies**

Mothers experience numerous changes which include physiological, psychological economic, and sociological changes, and without the necessary knowledge and support could affect their ability to care for the newborn and themselves.

#### **2.1 Physiologic challenges**

The human body witnesses several physiologic changes during pregnancy, some of which resolve or culminate in other conditions during the puerperium. There are increases in the activity of all organs from the cardiovascular to the respiratory, renal, endocrine, gastrointestinal, skeletal, and integumentary systems. These are characterized by increased cardiac output and heart rate (20–45%), 20% more oxygen demand, about 50% increased renal flow and function, delayed gastric emptying and reduced albumin level, 9–12 kg increase in body weight, relaxation of joints, reduced calcium, increased activity of the skin and mucus membranes [4].

These are normal changes during pregnancy, though may cause discomfort as the pregnancy advances. The woman must seek nursing and medical advice in cases of serious discomfort or interference with normal daily function. The advice comes in handy during antenatal sessions where the mother can ask pertinent questions and get clarifications as well as self-help advice from the midwife.

Physiologic challenges in puerperium may result from the reversal of some of the changes that occurred during pregnancy and cuts across all systems of the body as well. Firstly, the cardiovascular system experiences further increased cardiac volume from the contracting uterus which decreases within 24 hours and gradually returns to pre-pregnancy level in 4–6 weeks. There is increased body temperature from pain, fatigue, and increased blood flow, this also normalizes a few hours after birth. Pain on the episiotomy site and puerperal infection are notable causes of pyrexia [5].

Other physiologic challenges postpartum mothers experience include musculoskeletal disorder and or dysfunction. Pelvic floor dysfunction (PFD) and diastasis recti abdominis (DRA) are associated with pregnancy and childbirth. They have negative effects on the physical, psychological, and social life of the woman [6].

#### **2.2 Psychological challenges**

Pregnancy and puerperium come with multiple and numerous challenges for primipara and multiparous women. The task of caring for a new child, breastfeeding and combining it with work and family responsibilities can be enormous for women who are contending with drastic changes in their physics. Every woman

responds differently and must develop adaptive skills to navigate these phases of motherhood.

The pregnant woman faces mixed emotional changes and psychological support is important to pull through the mood changes, exhaustion and or alternating elation, and need for affection, sexual. Pregnancy is a stressor to some women; the anxiety and emotional instability can lead to preterm labour and preterm delivery in a quarter to two-thirds of women affected. Therefore, pregnant women require more support from partners and social and medical teams. The absence of psychological support during pregnancy and through the postpartum period could lead to postnatal depression and an inability to cope with childcare, self-care, and independent economic life [7].

Evidence shows adopting a positive psychological attitude during pregnancy supports psychological well-being in the puerperium. Women must develop elevated levels of resilience to cope with the added stress during puerperium for adequate self-care, coping with the infant and other social duties as a wife and mother [8, 9].

Women sometimes experience several negative and positive emotions, anxiety and psychological symptoms during pregnancy which often are associated with hormonal factors and the need for relationships. The emotional instability is more pronounced during the stress of labour, initiating breastfeeding and fitting into the motherhood role postpartum. Measuring into the motherhood role is therefore challenging necessitating the psychological support by the midwife. Midwives must create a tranquil environment to support the mothers' adjustments [10].

#### *2.2.1 Causes of unstable psychological state in the puerperium*

Many women are at risk of abnormal psychologic adjustment postnatally. Such women include mothers of babies diagnosed or born with birth defects [11], sociodemographic factors like low-income status, mode of delivery, and cultural practices with a preference for the male child [12], lack of social and psychologic support with bonding failures [13] positive history of prenatal psychologic symptoms and in clients with greater than one psychologic disorder [14] hereditary and family history of mental disorder [15].

Motherhood is a new role and can be challenging for multipara and first-time mothers. Social and societal norms are expected of new mothers. Childbirth is a social phenomenon; some women find it difficult to fit into these roles or function within acclaimed roles [16]. The ineffective social support during pregnancy affects the psychological state of mothers and could lead to failed bonding perinatally [13]. The inability to cope with the stress and challenges of breastfeeding affects mental health and adaptation to the new role. It may also result in delayed lactation, reduce the confidence to conduct breastfeeding and affect the newborn negatively [17].

#### *2.2.2 Signs of altered postpartum psychologic state management*

There exists a chasm between actual and perceived altered postpartum psychological state. It is one syndrome that is underreported and undiagnosed due to the level of health provider knowledge, skill and competence stigma attached [18]. Signs of altered psychological state include increased anxiety and fear, and poor

maternal-infant bonding, poor maternal health and feeding [19, 20]. Low resilience and high stress perception are also associated with poor psychological coping [9].

Unidentified and untreated psychological concerns can interfere with the successful motherhood experience and social life of the woman [21]. Though midwives can identify and care for women with psychological disorders, they tend to refer such to other professionals. The psychological challenges encountered in puerperium could be managed effectively by maternity nurses [22].

Midwives play significant roles in screening, treating, and referring identified cases for expert management [23]. Other ways of managing postpartum psychologic challenges include hospital/facility-based care [24], and community and out-stationed care where networks and support groups are formed to help such clients [25]. The recent pandemic equally saw the introduction of mobile dyadic clinics to cater to the needs of such clients who would otherwise not assess care due to difficult social situations [26].

Another approach is by giving the client a voice, and an opportunity to express self and be heard. This will improve communication with the caregiver as the woman gains confidence, learns to trust, and relieves anxious feelings [27]. Moreover, providing both antenatal and postnatal counseling with reading/supportive literature, giving physical therapy like massage, and yoga, and through scheduled telephone calls from providers [28].

#### *2.2.3 Importance of psychologic support during the postpartum*

A stable maternal psychological state is a pre-requisite for effective coping, midwives must support and design/institute measures to enhance coping and prevent postpartum depression, anxiety, and stress. Some of the measures include providing information, creating opportunities to discuss fears and clarify doubts, and initiating breastfeeding early with support for women who do not lactate early. The midwife must explore the option of getting family presence and social support for women who demand it and for those without family presence.

It is also important to screen postpartum women to identify risk factors for psychological maladjustment and institute measures to mitigate them. There is also


#### **Table 1.**

*Psychological interventions for postpartum women.*

a need to encourage disclosures of untoward familial psychological states to enable early comprehensive assessment and treatment. **Table 1** shows some psychological assessments and interventions midwives can give to postpartum women.

#### *2.2.4 Strategies to overcome the postpartum psychological challenge*

Midwives contribute to the psychological well-being of new mothers by providing adequate care and partner support during labour and immediate puerperium. Encouraging mind and physical relaxation, early ambulation and exercise, socialization and interaction with family, peers, and colleagues to gain support and overcome stress [30].

Midwives can provide improved rapport and social support during pregnancy and encourage others to do the same. They can introduce the women to support groups online where they can interact and share thoughts as they transit through puerperium [13]. Another approach is to enable midwife-family-mediated support. The midwife here serves as the go-between the woman and her family, providing information and support to the woman and family as well as galvanizing family support for the mother. They also reduce the cost of care by enlightening mothers on how to take advantage of family support [29].

It is not enough to theoretically teach the breastfeeding method. A step further demonstration of breastfeeding interventions will further build their confidence and help mothers internalize the education [17]. A fourth strategy is adopting a systematic approach to the care of postpartum women. Using empathy and love, the wholistic midwifery framework leaves no system out, the mother must be assessed at each contact with the health practitioner, communicating care and providing a prompt referral to a higher level of care once any deviation is envisaged.

Moreover, maintaining standards of care and education of midwives is necessary for rapid identification, diagnosis, and treatment of psychological deviations in postpartum women. Also ensuring all postpartum women have access to follow-up care will enhance their performance of the women [31].

Postnatal care is an aspect of maternal and child health care that appears to have received minimal attention. Midwives, postnatal mothers, and their families tend to disregard postnatal visits, assuming that physical recovery is always guaranteed when a mother has had a normal pregnancy and childbirth. Unfortunately, preventable complications occurred during this period [32]. Encourage and ensure routine postnatal attendance and screening of mothers and their babies.

Other strategies to help women adjust to postnatal challenges include building their capacity through formal education and self-empowerment of midwives and other caregivers.

#### **2.3 Sociologic and economic challenge**

Women are revered for their role in procreation, however, different social, psychological, economic, and environmental factors with the status of these women and the demands of pregnancy pose a challenge to them. Pregnancy and the process of childbearing have social implication that affects a woman. The current wave of diseases and social unrest complicates the struggles of pregnant and breastfeeding women, reducing their coping ability and susceptibility to psychological and social stress [33].

Howbeit the presence of strong social and economic support increases the coping capacity of women.
