Maternal morbidity can be defined as ‘any health condition attributed to and/or complicating pregnancy and childbirth that has a negative impact on the woman's wellbeing and/or functioning’ (Chou et al, 2016). The prevalence of maternal morbidities varies from 70–90% during the first 8 weeks and 12 months after childbirth, respectively (Rouhi et al, 2020). Maternal morbidities remain a challenge to define, interpret and measure, and the prevalence of both general and specific morbidities has been inadequately addressed in the literature (Abdollahpour et al, 2019). Reduction of maternal morbidity post-childbirth is the United Nations' sustainable development goal 3, of ensuring healthy lives and promoting wellbeing for all at all ages (Taylor, 2020).
Many women worldwide experience morbidities that they may ignore, or that healthcare providers neglect (Maher and Souter, 2006; Cassiano et al, 2015; Finlayson et al, 2020). Cassiano et al (2015) and Finlayson et al (2020) found that after childbirth, women are less concerned about their physical and mental health problems, as they focus on caring for their newborn and responsibilities at home. Consequently, their health has been ignored and marginalised.
Addressing maternal morbidities is a relatively new area of practice, having gained increasing attention since the late 1980s. For example, Albers (2000) and MacArthur et al (1991) assessed health morbidities for the first time in a qualitative study. While various aspects of maternal morbidities have been explored, relatively little attention has focused on barriers to women seeking professional help for maternal health problems (Cornally and McCarthy, 2011; Brown et al, 2015). Therefore, there is limited evidence about how women manage post-childbirth morbidities. The first author of the present study has conducted comprehensive research on maternal morbidities, aiming to delve into the prevalence and enduring nature of health postpartum (Rouhi, 2001; Rouhi et al, 2011; Rouhi et al, 2012; Rouhi et al, 2016; Rouhi et al, 2017; Rouhi et al, 2018).
Help-seeking behaviour is a ‘problem-solving strategy’ (Cornally and McCarthy, 2011), manifested in an ability to find help, support, information, guidance or treatment (Fonseca and Canavarro, 2017). It is the action of actively seeking help after recognising a physical or mental health problem (Cornally and McCarthy, 2011). Factors that are known to influence women when seeking help after childbirth include knowledge about post-childbirth morbidities, culturally informed shame or stigma, accessibility of healthcare providers and awareness of available treatments (Bina, 2014; Brown et al, 2015). To further understand the barriers to help seeking for women with maternal morbidities, the present study was underpinned by the behavioural model of health service use as a lens through which to view the relevant factors (Andersen et al, 2011).
In this model, contextual and individual characteristics shape women's health behaviour. A systematic review by Magaard et al (2017) investigated factors associated with help-seeking behaviour among individuals with major depression using the behavioural model of health service use model. Their results showed that sociodemographic and need factors appeared most influential on help-seeking behaviour.
The behavioural model of health service use (Figure 1) proposes that health outcomes originate from a mix of contextual and individual characteristics and health behaviours (Andersen et al, 2011). The contextual and individual characteristics are categorised into predisposing variables, enabling factors and need variables (Andersen et al, 2011). Family, society and the healthcare system are contextual characteristics; while personal beliefs about healthcare services, education and demographic features such as age are classed as individual characteristics (Andersen, 2008). The health behaviours that are influenced by personal practices and the process of medical care shape the use of personal health services (Andersen et al, 2011). The present study considered the contextual and individual characteristic elements of the behavioural model of health service use model as barriers and facilitators to women's health behaviours and outcomes.
Feminist pragmatism as theoretical background
The theoretical background selected for this study was feminist pragmatism. First appearing in the 1990s (Rooney, 1993), the combination of pragmatism and feminism covers the strengths and weaknesses of both theories. Feminist philosophers adopted the core concepts of pragmatism, creating a framework combining ‘pluralism, lived experience and public philosophy, with feminist theory and practice in order to engage in social issues about women’ (Whipps and Lake, 2004). Feminists argue that sex is determined biologically, but that gender is a set of socially constructed expectations placed on men and women (Alston et al, 2006). These social expectations shape the roles of women and men, in a society where the physical strength of men (used in doing agricultural work, for example) marginalised women to home-based tasks (Liepins, 2000). In health, pregnancy has been accepted as the biological role of women, and Alston et al (2006) argue that gender construction has forced women to take care of their family members at the expense of ignoring their own health. Gender is thus a determining factor in health.
Creswell (2013) argued that there are ‘different forms of the pragmatism philosophy, but for many pragmatisms as a worldview arises out of actions, situations, and consequences rather than antecedent conditions’. Pragmatists believe that the priority is the research problem rather than the methodology. Researchers are not restricted to using special methods and techniques to collect and analyse data. Both feminism and pragmatism emphasise experience; the aim is solving problems, and the researcher's experience helps to form the knowledge about the area of research (Rooney, 1993). Accordingly, feminist pragmatism underpinned this study.
The first author undertook this research into maternal morbidities to explore the prevalence and persistence of health problems. As part of a PhD, a multiphase mixed methods design was adopted to explore the key influences on women's help-seeking behaviour in the 12 months after childbirth. This article reports the final step of the project, which involved synthesising the three projects into a conceptual model of key influences on women's help-seeking for maternal morbidities. All three stages of the research have been reported separately (Rouhi et al, 2019a, b; 2021).
Methods
This study aimed to explore the key influences on women's help-seeking behaviour in the first 12 months post-childbirth. This study was conducted over three phases using a mixed-methods approach. Phase one involved a meta-aggregation systematic review to explore women's perceptions of the barriers and facilitators they experienced when seeking help from healthcare professionals in the first 12 months (Rouhi et al, 2019a).
In phase two, help-seeking behaviour among Australian women for health problems related to childbirth was investigated using an online platform. This phase aimed to identify physical and mental health problems that women felt required help and subsequent help-seeking behaviour 12 months after childbirth (Rouhi et al, 2019a).
Phase three involved using online support forums to explore women's online help-seeking behaviours in relation to post-childbirth problems. This phase had three objectives: identification of health problems by women shared online; identification of women's motivations for questions posted on the forum discussion board; and understanding the support given to women who posted questions about post-childbirth morbidities (Rouhi et al, 2021).
The messages posted on the forum were loaded into NVIVO 12 Pro and analysed using content and qualitative thematic analysis. Three research questions guided the qualitative content analysis of the data:
- Which health problems were women posting about?
- What were women's motivations for posting their health concerns?
- What support was given to women in response to their comments?
Content analysis identified major health problems, and thematic analysis was used to identify motivations and support offered. A directed qualitative content approach was used to analyse text or data gathered from audio, video, printed data (such as books, papers or pamphlets) and online sources to find themes or patterns (Hsieh and Shannon, 2005). This method has helped to answer midwifery research questions considering why participants use a service and the nature of their concerns (Vaismoradi et al, 2013).
The final step involved synthesising the three studies to generate a conceptual model of the key influences on women's help-seeking for maternal morbidities (Figure 1).
Ethical considerations
This study consisted of three phases, each adhering to the national ethics application format. Ethical approval was granted for phases two and three by the Tasmanian Human Research Ethics Committee (Social Sciences) on 21 April 2017 and 19 August 2019 respectively.
Results
The results of the three phases of the study highlighted that if women's need changed to an expressed need, they mostly sought help from trusted persons, or, in the case of embarrassing problems, approached strangers through online platforms. The three phases showed normalisation of health problems after childbirth; family, friends and other women only encouraged small numbers of women to seek professional help.
For those women who selected professional help as a last resort, the normalisation of their health problems was sometimes confirmed by healthcare providers. This pattern was visible in all three phases of this study, which enabled the development of a new conceptual model for understanding the key influences on women's help-seeking for maternal morbidities. Each of the three phases highlighted ‘normalisation’ as a key concept influencing women's help-seeking behaviour (Figure 2).
The results of the systematic review carried out in phase one of the study showed a dearth of research in post-childbirth maternal morbidities. The limited research presenting women's perspectives on help-seeking behaviours for post-childbirth morbidities is surprising, given the prevalence of morbidities, and suggests a hidden problem. Furthermore, it was found that women often did not recognise post-childbirth morbidities or were disinclined to reveal physical and mental post-childbirth morbidities in a primary care setting. The synthesised results indicated that women used interpersonal communication with trusted persons as a fundamental way to deal with post-childbirth morbidities.
Concept mapping of women's views of health problems 12 months after childbirth (completed in phase two) found that women had a much broader perception of post-childbirth problems than healthcare professionals. Women included social and chat support and fitness when asked about health problems that they felt required help during the 12 months after childbirth. It was identified in the data that not all women had access to good social support, suggesting a need to review the content and timing of post-childbirth care. Family and friends were the primary sources of support for women, and normalising health problems was supported in this phase. The data also found that health professionals did not facilitate discussions about post-childbirth morbidities.
Women frequently made use of online platforms to share post-childbirth concerns, as identified in the final phase of the study. Although women shared different health problems, pelvic issues, especially incontinence and prolapse, and mental health problems were key health issues motivating women to post on the online forum.
Discussion
This study adopted the term ‘fallacy of normalcy’, which conceptualised women's perception of their health problems after childbirth. All three phases (Rouhi et al, 2019a, b; 2021) showed that it was common for women to think that health problems after childbirth were part of the normal process of recovery, and would resolve on their own without the need to seek help from others. The fallacy of normalcy hinders women from seeking professional help, and family and friends contribute to this issue, often convincing women that it is normal to have mental health or pelvic problems (Wuytack et al, 2015).
The views of women, as well as their family, friends and healthcare providers, closely adhere to ‘the fallacy of normalcy’. However, some family and friends successfully encouraged women to seek professional help (Rouhi et al, 2019a). When seeking professional help, the availability and source of help is important to encourage them to seek help. Although, some health care providers contribute to ‘the fallacy of normalcy’, and decrease the number of women who would access to help (Rouhi et al, 2021).
The results of the fallacy of normalcy are supported by other evidence, which suggests that many women initially ignore their health problems, considering them to be normal post-childbirth trauma (Buurman and Lagro-Janssen, 2013; Wagg et al, 2017). For example, a seminal integrative literature review by Koch (2006) explored help-seeking behaviour for urinary incontinence symptoms among women of all ages, and found that fewer than 38% sought help for their symptoms, and that women normalised their problems as a part of aging or childbirth.
Normalisation of post-childbirth issues by family and friends is concerning, as there is a long history of research showing that family and friends are an important source of help for women experiencing health problems, beginning with seminal studies by Guillot (1964) and McIntosh (1993), who highlighted the role of family and friends for women with depression who seek help. These results have been confirmed in a more recent study (Mousa et al, 2023). McIntosh (1993) reported that families expected women to only share their problems within the family, not with outsiders. Once women decided that they required help, informal support by family and friends became the most important factor in encouraging or impeding seeking professional help (Fonseca and Canavarro, 2017). According to Jacobs (2017), postpartum women in Canada eschewed professional help for pelvic floor problems because their relatives normalised the problem. Fisher (2005) established a community picture of help-seeking behaviour among rural women experiencing post-childbirth depression, and confirmed that family and friends influenced women's decisions by providing informal support.
Society's perception of post-childbirth health problems plays a significant role in influencing women's attitudes and decisions. Trusted individuals often encourage women to seek professional medical assistance, which is essential for addressing these health concerns effectively. In this context, two distinct aspects are intertwined: society's perspectives on post-childbirth health issues and their impact on women, as well as encouragement from trusted sources for women to seek appropriate medical help. This encouragement encompasses normative needs, which healthcare providers can address by either normalising post-childbirth health problems or administering treatments based on well-established evidence-based practices.
Normalisation of women's post-childbirth health problems as feminist praxis
This study found that feminist perspectives on the normalisation of health problems after childbirth are embedded in society, rather than the medicalisation of health problems. Feminist theory states that pregnancy and childbirth have been regarded as a biological and gender role for women. This idea makes these two processes ‘normal’. Consequently, health problems arising from them must also be considered normal. Beliefs about what is normal for women are rooted in how society views normality more broadly (Aston et al, 2015). In a society where postpartum morbidities are seen as normal, it is logical that women in that society normalise their own health problems too. Additionally, it must be remembered that for many years, inequity in women's health and a lack of research has led to the normalisation of problems related to pregnancy and menopause (Klima, 2001).
Conclusions
This study achieved its main aim to find the key influences on women's help-seeking behaviour in the 12 months after childbirth. The key factor is ‘the fallacy of normalcy’. Although presaged by the term ‘normalisation’, the rest of the three phases clearly showed ‘the fallacy of normalcy’ to be more suitable. The justification of normalisation of post-childbirth health problem is rooted in sociocultural matters, about which feminist theory conceptualises the myth of the ‘good mother’ as accepting all post-childbirth health problems as normal. It leads to women, family and friends normalising post-childbirth health problems and, consequently, to women ignoring those problems despite needing help.
Key points
- Many women worldwide experience post-childbirth morbidities, which they may ignore or which healthcare providers may neglect.
- Help-seeking behaviour is a ‘problem-solving strategy’ and is manifested in an ability to find help, support, information, guidance or treatment.
- Feminism and pragmatism emphasise experience; the aim is solving problems, and the researcher's experience helps to form knowledge about the area of research.
- Feminist theory conceptualises the myth of the ‘good mother’ as accepting all post-childbirth health problems as normal.
- In the three phases of this study, the process of normalisation was found to be a common reason to overlook or accept post-childbirth health problems among family and friends, healthcare providers, online forums and among women themselves.
CPD reflective questions
- How does society's perception of ‘normal’ impact the way that women view and address their post-childbirth health problems in the framework of feminist principles?
- How does the concept of the ‘fallacy of normalcy’ shed light on the intricate interplay between societal expectations, feminist viewpoints and women's reluctance to seek help for post-childbirth health issues?
- How does the notion of help-seeking behaviour as a ‘problem-solving strategy’ reflect the complex interplay between individual characteristics, societal influences and the accessibility of healthcare services in the context of maternal morbidities?
- What role do online platforms play in influencing women's willingness to discuss and seek help for post-childbirth health problems, and how does the potential normalisation of abnormal issues affect this dynamic?