Study design and participants

This qualitative study was conducted at six research sites involved in the Pregnancy Risk, Infant Surveillance, and Measurement Alliance (PRISMA) Maternal and Newborn Health cohort study [14]. Sites were in Kintampo, Ghana; Kisumu, Kenya; Lusaka, Zambia; Karachi, Pakistan; Vellore, India (i.e., South India); and Hodal, India (i.e., North India). Data were collected between December 2023 and June 2024, during focus group discussions (FGDs) with pregnant and late postpartum women (6 months to 1 year postpartum) and in-depth interviews (IDIs) with early postpartum women (≤6 weeks postpartum). Eligible participants were women who were either currently pregnant or had delivered in the past 12 months, lived in the catchment area, met the minimum required age (Ghana, Zambia, and Pakistan: 15 years; Kenya and India: 18 years) and provided written informed consent. Recruitment start and end dates (dd-mm-yyyy) by site as follows: 21-12-2023–07-03-2024 in Hodal, India; 13-02-2024–12-06-2024 in Pakistan; 14-12-2023–04-04-2024 in Zambia; 12-03-2024–08-04-2024 in Kenya; 17-01-2024–20-04-2024 in Vellore, India; and 07-12-2023–23-02-2024 in Ghana.

Purposive sampling was used to identify potential participants. Recruitment leveraged existing household demographic surveillance systems and antenatal and postnatal care clinics. Sampling was largely conducted within the ongoing PRISMA study and therefore was not necessarily representative of the broader community makeup at a given site. Efforts were made to recruit evenly across age groups, trimesters, local languages (if multiple), and time since childbirth (“early postpartum” ≤ 6 weeks and “late postpartum” 6 months to 1 year). Pregnant and late postpartum women participated in FGDs at a healthcare facility or community location; early postpartum women completed an IDI at their home. It was not possible to conduct FGDs with early postpartum women because of cultural practices that discourage women from leaving the home in the early weeks following childbirth. FGDs were stratified by perinatal status (i.e., pregnant or late postpartum) and age group (conducted separately with women <25 years and ≥25 years of age); each FGD contained 8–10 women across all three trimesters (if pregnant). Recruitment continued until the target sample size was reached (determined a priori based on budgetary constraints).

Three or four FGDs and eight IDIs were conducted in Twi (Ghana), Swahili and Dholuo (Kenya), Bemba and Nyanja (Zambia), Tamil (South India), Hindi (North India), and Urdu (Pakistan). FGDs and IDIs were led by a female trained moderator/interviewer with postgraduate education and experience with qualitative research. The moderator/interviewer was assisted by a research assistant, also female, from the site country, and fluent in the local language and English. In most cases, either the moderator/interviewer and/or the assistant were involved with the PRISMA study and therefore may have been familiar to some participants. During the consent process, the following was stated: “The purpose of this study is to understand mothers’ experience during pregnancy and after childbirth”. Before starting the FGD or IDI, participants were asked to complete a brief sociodemographic and obstetric history questionnaire, which was administered verbally by a member of the research team.

Semi-structured guides for the FGDs and IDIs were developed collaboratively by the research team, with input from investigators at all six study sites and the coordinating site at the George Washington University (S1 File). The development of the guides was informed by existing conceptual frameworks of maternal morbidities [15,16]. The guides included questions about how women in the community care for themselves during pregnancy or postpartum, the main challenges that affect pregnant and/or postpartum women, how these challenges are viewed by family and community members, and how women could be better supported during pregnancy or postpartum. Postpartum women were also asked about their delivery and any challenges or complications experienced during the birth. If a participant indicated experiencing a complication, the interviewer asked an additional set of questions to obtain further details.

The FGD and IDI guides were forward translated and back translated by two translators fluent in both English and the local language. Back translations were reviewed by the study team and adjustments were made, as needed, to ensure conceptual equivalency. Minor revisions to some questions were made and additional probes (i.e., follow-up questions intended to encourage participants to elaborate on a prior response) were added after beginning data collection to enhance clarity and elicit meaningful responses. Specifically, the FGD guide was updated to include probes based on feedback from the sites about how family and community view physical, emotional, social, and economic challenges during pregnancy and how women seek healthcare while pregnant. The IDI guide was updated to include probes about women’s expectations regarding the birth of their child and how women care for their health postpartum.

FGDs were 60–90 minutes in duration and IDIs were 30–45 minutes. All FGDs and IDIs were recorded and the recordings were transcribed verbatim in the local language. Transcripts were subsequently translated into English by translators fluent in both languages and reviewed by the interviewer/moderator to ensure that the essence was intact. All transcripts were reviewed for completeness, anonymity, and clarity prior to coding and analysis.

Data analysis

A collaborative, multi-step approach was used for data analysis. After reviewing the transcripts for familiarization with the data and confirming that saturation had been reached, a subset (2–3 FGDs and 1–2 IDIs) of transcripts from each site was coded independently by two coders (one from the local site and one from the coordinating site) using an inductive approach, to develop a site-specific codebook. The site-specific codebooks were then merged into a shared cross-site codebook and discussed with all site investigators. All transcripts were then coded independently by two coders in Dedoose using the shared cross-site codebook, which was iteratively refined by adding, merging, and reorganizing codes throughout the coding process [17]. After finalizing the shared cross-site codebook, all transcripts were independently reviewed and re-coded by the two coders to ensure alignment with a final shared cross-site codebook. Initial themes and subthemes were identified and subsequently discussed with investigators at all local sites. Participant input into the themes and subthemes identified was not solicited. The themes and subthemes were refined iteratively and collaboratively through discussion with investigators at all research sites, after which, representative quotations were selected.

Ethical considerations

All participants provided written informed consent or assent prior to participating. Study procedures were reviewed and approved or exempted by the Institutional Review Board (IRB) and Ethics Review Committee (ERC) at each participating institution, as follows: The George Washington University, United States (NCR235136); Kintampo Health Research Centre, Ghana (KHRCIEC/2023–32); Society for Applied Studies, India (SAS/ERC/MMS Study/2023); Kenya Medical Research Institute, Kenya (SERU 4882); Aga Khan University, Pakistan (2023-9286-26951); Christian Medical College Vellore, India (IRB Min. No. 15913); University of Zambia, Zambia (Ref No. 4442–2023); and the University of North Carolina at Chapel Hill, United States (Z32301). Participants who expressed severe psychological distress or disclosed circumstances of abuse or violence were referred for additional care at a health facility, as appropriate.

Theme 1. Pregnancy and postpartum challenges pose a barrier to daily activities

Physical morbidities, such as pain and fatigue, were a near-universal experience during pregnancy and postpartum and hindered women’s ability to carry out daily activities (Table 2). Pain associated with bending and lifting made it difficult for women to complete household work, particularly chores such as washing, sweeping, and fetching water. As one postpartum woman in Vellore, India said, “Because of my back pain, I can’t bend and do any work.” Feelings of weakness and fatigue were also commonly reported. For some, this made it impossible to complete tasks that involved heavy lifting, or any tasks at all without taking breaks. A pregnant woman in Lusaka, Zambia said, “I feel body weakness like I have just woken up. Sometimes I am very weak that I only manage to do laundry once in a week and just some light work. Most of the time I just want to sit and sleep.” Many women also indicated that they would have liked more help from family members to reduce their workload.

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Table 2. Physical and emotional symptoms pose a barrier to daily activities.

https://doi.org/10.1371/journal.pgph.0004229.t002

Emotional changes during pregnancy and postpartum also posed a challenge to daily functioning (Table 2). Women described a variety of emotional challenges, including mood swings, depression, anger, anxiety, brain fog, and feelings of helplessness. In some cases, this also manifested as physical morbidity. As one pregnant participant in Lusaka, Zambia said, “I have become very moody and high-tempered, sometimes I feel pain in my heart. I think this is not good for a pregnant woman.” Some women found it difficult to control their emotions, which made it hard for them to be productive and complete the tasks expected of them. For example, a postpartum woman in Karachi, Pakistan said, “When I get angry, then I just go outside. I start to lose consciousness from the anger.” The physical and emotional challenges women described experiencing during pregnancy and postpartum were similar across the different local contexts.

Theme 2. Lack of social support detracts from well-being during pregnancy and postpartum

Women described receiving inadequate support from the baby’s father, as well as from their families and communities (Table 3). With regard to the baby’s father, participants explained that they received a lack of support in several areas, which included practical support (e.g., household chores or childcare), emotional support, and financial support. While a lack of support from the baby’s father emerged as a theme in both sub-Saharan Africa and South Asia, this was a particularly salient theme in the African countries. For example, a postpartum woman in Lusaka, Zambia said, “After delivery, every woman expects their husband to be happy and support them, but this doesn’t happen to everyone, so many women go into postnatal depression because of lack of care from their spouses.” Participants also expressed that the baby’s father did not recognize or acknowledge their feelings or need for rest when they were physically and or mentally exhausted, which contributed to feeling isolated. As explained by a pregnant woman in Kintampo, Ghana, “If I say I am tired and cannot work anymore, he will not understand and will not give me the needed attention.”

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Table 3. Lack of social support detracts from well-being during pregnancy and postpartum.

https://doi.org/10.1371/journal.pgph.0004229.t003

Insufficient financial support was also widely identified as a key challenge, with the baby’s father sometimes unable or unwilling to contribute to expenses for food, medical care, or basic supplies. As a participant in Kisumu, Kenya said, “Sometimes when you get pregnant and realize, as a woman, you will go to your husband and tell him that you should start saving and buy the baby’s necessities; but he won’t be even interested in even giving out the support that you would need.” Women explained that the absence of financial assistance from the baby’s father forced women to return to work earlier than expected after childbirth, which exacerbated physical challenges such as back pain and delayed or precluded their recovery.

Some participants described mistreatment from the baby’s father, including being subjected to physical violence, psychological abuse, and withholding of necessities, such as food. While mistreatment from the baby’s father was described in both sub-Saharan Africa and South Asia, this was particularly salient in Zambia. As a postpartum woman in Lusaka, Zambia said, “I was being beaten by my husband, claiming that I didn’t have respect for him. He would torture me by not providing me with food, and I would just drink water.” Participants’ also described experiences of infidelity and rejection from their baby’s father, which was also particularly salient at the Zambia site.

Outside of the home, some women described feeling judged by their community as being lazy when they were weak or unwell, as well as being compared to other pregnant women who did not suffer such symptoms. One pregnant woman in Kintampo, Ghana said, “I am currently not feeling well but another pregnant woman might be okay so if I show any signs of weakness, people might say I am being lazy.” Participants expressed a desire for more empathy and/or assistance from their community. As a pregnant woman in Vellore, India explained “There’s no one to offer help or even ask if [pregnant women] are tired. No one is there to inquire if they need assistance. Even if there are many people around them, no one cares enough to ask how they feel personally.”

A subtheme specific to India and Pakistan, was that participants perceived the medical care they received as inadequate. Women reported that hospital staff were not attentive to their physical and emotional needs during pregnancy or during labor and delivery. In some cases, participants spoke of broader systemic challenges, including lack of nearby clinics and insufficient health care professionals. However, lack of support from the medical system and healthcare providers was not commonly described among women at the sites in sub-Saharan Africa.

A lack of support from family members further detracted from participants’ well-being. For example, participants explained that their family members did not offer to help with household chores. One pregnant woman in Hodal, India said “We have no choice but to do all the work. Like living alone with my husband, father-in-law, and one and a half-year-old daughter, I have to take care of all of them, clean my house, and make food and I have no one for help. Even if I am on a ventilator, I will be the only one who will do all the work [joked and smiled].” Participants shared that their family members had unreasonable expectations and pressured them to complete tasks they were unable to do. Specifically in India and Pakistan, this criticism and pressure was described as being commonly inflicted by the mother-in-law. As a postpartum woman in Karachi, Pakistan said “I have to complete my tasks before resting otherwise the family...I can’t just tell them I’m resting now and will serve food later, can I? If I say that, my mother-in-law would take it badly, thinking I’m being lazy or neglectful.”

A specific source of stress described by women in both sub-Saharan African and South Asian countries stemmed from societal pressure to have a male child (Table 3). Participants described being looked down upon and resented for having a female child and feeling upset as a result. This was especially present in India, where it is illegal to determine the sex of the fetus and female feticide remains a major concern. As one woman in Hodal, India said, “Her husband drinks and beats her up because she gave birth to 5 girls.”

Theme 3. Receipt of social support mitigates pregnancy and postpartum challenges

Participants, across all study contexts, shared that receiving support from their families and communities made managing pregnancy and postpartum challenges easier (Table 4). For example, women were able to rest and recover when family members helped with household chores and were appreciative of emotional support such as extra care, attention, and pampering. One postpartum woman in Kintampo, Ghana said, “I live peacefully with the people in my house so I get people to bathe the baby and even if I want, they will want to bathe and massage me. For the baby, they will take very good care of him. They will cook and bathe the baby until you ask them to stop.” Some family members also provided financial assistance for expenses such as medical costs during pregnancy and buying food and supplies for her recovery after childbirth, which alleviated economic pressures.

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Table 4. Receipt of social support mitigates pregnancy and postpartum challenges.

https://doi.org/10.1371/journal.pgph.0004229.t004

Community support further mitigated challenges during pregnancy and postpartum across all study contexts, and in some cases, was described as eliciting feelings of belonging. For example, participants explained that their neighbors helped with physical tasks during pregnancy, such as fetching water, and assisted with transportation to the hospital at the time of delivery. As a postpartum woman in Karachi, Pakistan said, “In my case, my neighbor, although she is not closely related, took care of me just as my sisters would have. She didn’t leave anything lacking.” Friends also provided support by preparing meals and washing clothes, especially when women did not have that support from their families. One woman in Kintampo, Ghana said, “When you give birth in the community your loved ones and friends can come and help with cooking, washing clothing, and fetching water for you.” Women explained that they felt valued by their community when their needs were recognized and prioritized. For example, receiving priority seating on public transportation or at community gatherings provided participants with a sense of comfort and belonging within the community.

Theme 4. Economic challenges detract from health/well-being in pregnancy and postpartum

Economic hardship was described by participants across all study sites (Table 5). Participants explained that they struggled to afford prenatal and postnatal care, including the transportation costs to travel to and from the healthcare facility. A woman in Lusaka, Zambia said, “…a pregnant woman is required to carry out some tests, but they don’t have money.” In some cases, participants explained that the baby’s father or their family had to spend more than they could afford to cover the prenatal and delivery expenses, which compromised their financial situation. Food insecurity was also a widespread concern. Participants spoke about not having food at home and relying on the baby’s father to bring them something to eat, with some women forced to resort to begging. The subtheme lack of food was particularly salient in sub-Saharan African countries. As a participant in Lusaka, Zambia described, “I have seen some women who have not fully recovered from childbirth, going round in the community begging for food with a very small baby, because they had no food at home.”

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Table 5. Economic challenges exacerbate declines in women’s health/well-being during pregnancy and postpartum.

https://doi.org/10.1371/journal.pgph.0004229.t005

While financially necessary, returning to work or seeking employment after childbirth was complicated by physical challenges and lack of childcare. Many women described being physically exhausted and not having the strength to work. One woman in Vellore, India said, “I wanted to return to the office and thought I could work, but since I can’t sit for more than a few hours, I don’t know how I would manage in the office.” Even among mothers who were physically capable, a lack of caretakers or financial ability to pay for childcare precluded them from seeking employment. Those who did return to work often did so prematurely, compromising their health to support themselves and their baby, and often against the wishes of their families. As described by a woman in Hodal, India: “After having a baby, women often leave their job. Their family tells them that they are incapable of taking care of the baby. Therefore, they tell women to choose one between their home and career. I have seen many cases in our village like this.”