INTRODUCTION

The psychological wellbeing of women in the perinatal period is poorly understood compared to that experienced by the general population. Subjective wellbeing is a multidimensional concept broadly considered to have cognitive (life satisfaction and positive functioning) and emotional (positive and negative affect) components that are subjective for the individual and relative to social norms and values¹. The term subjective wellbeing has been used interchangeably with happiness and flourishing and as a concept is not always well defined. There is no overall consensus as to all the components of subjective wellbeing; within the context of this paper a detailed model of wellbeing is used that was developed for use in the 7th round of the European Social Survey and highlights seven core components of wellbeing at the individual (emotional wellbeing, satisfying life, vitality, resilience and self-esteem, positive functioning) and social level (supportive relationships, trust, and belonging)².

It has been recognised for some time that subjective wellbeing and health are closely related. Diener and Chan³ conducted a review of the relationship between wellbeing, health and longevity and concluded that the effect of wellbeing, while variable, is substantial and comparable to other health behaviours targeted in public health policies for healthy diet and exercise. The link to health is now acknowledged in health policy, for example the World Health Organization¹ highlighted the need to set wellbeing targets as part of European Health 2020 policy and the Department of Health England have stated that wellbeing is a shared government objective⁴. Maternity care policy recognises that most women are well and that promoting emotional wellbeing is as important as supporting physical health⁵. While mental health problems are increasingly screened, it is important to broaden the assessment of psychological status during pregnancy in order to take action to optimize wellbeing at this time⁶.

The term ‘wellbeing’ in policy and practice, however, is often loosely defined and is not linked to research that explores the psychological construct of subjective wellbeing as outlined in this paper. Our limited knowledge comes predominantly from population-based studies using a single question on happiness and from literature on negative emotions particularly depression. Myrskylä and Margolis⁷ studied parental happiness trajectories before and after the birth of a child, using large British and German longitudinal data sets and found that happiness increased in the year before birth and through the year after birth but then decreased to before-child levels. Parity, age and education were associated with happiness responses with older or more educated parents having a particularly positive happiness response to a first birth. The first two children increased happiness response, whereas a third child did not⁷. Aassve et al.⁸ found, in a large European sample, that partners were overall happier than non-parents, however happiness was strictly related to a partner being present⁸. These cohort studies used simple one item questions to explore happiness and it is likely that parental wellbeing around the time of childbirth is complex and needs further investigation⁹.

Subjective wellbeing is a spectrum and includes an evaluation of both positive (e.g. happiness) and negative (e.g. depression) emotions. As we noted, our knowledge about wellbeing in the perinatal period comes primarily from studies of negative affect and mental illness. From this negative perspective, research has consistently highlighted the importance of subjective wellbeing in the perinatal period. For example, it is estimated that depression and anxiety affect 15–20% of women in the first year after childbirth¹⁰. While there are less data on fathers, the Paulson and Bazemore¹¹ review of depression in fathers estimated that 10% of fathers experienced depression in the perinatal period rising to 25% between 3 and 6 months after birth. Thus, while having a baby is widely assumed to be a happy time for parents these figures highlight the need to know more about the spectrum of wellbeing during this time and how we can best promote subjective wellbeing in the perinatal period for all women and their families.

Alderdice et al.⁹ compared a newly developed Wellbeing in Pregnancy Scale with general wellbeing measures in a sample of 312 pregnant women and found that the mean Satisfaction With Life Scale score was higher than those reported in other studies involving a range of non-pregnant populations¹². However, the complexity of wellbeing during this time was also evident by how women scored on the WHO5 Wellbeing measure, as the mean score was lower than that found in other studies in the general population¹³. This was mainly related to lower positive responses to two items in five questions, those of ‘I felt active and vigorous’ and ‘I woke up feeling fresh and rested’, which could reflect the physical impact of pregnancy rather than general wellbeing. This also demonstrates the importance of considering the appropriateness of using the above measure in perinatal populations and the importance of further research on the potential impact of the perinatal period on wellbeing, taking into consideration the physical, psychological and social aspects of childbirth and transition to parenthood.

The two focus groups described here where conducted as part of a larger study to develop a pregnancy specific wellbeing measure⁹. This paper aims to describe women’s experiences of subjective wellbeing in the postpartum, using the questions from the European Social Survey Wellbeing module to facilitate discussion, as a first step in exploring appropriate measures of wellbeing for use during this time.

METHODS

RESULTS

The sample characteristics of women who participated in the focus groups are given in Table 1. All the women were born in the UK. The majority of women were married and there was a good spread in age and educational qualifications.

Overall the response to the questionnaire was positive. Women did not comment on its length despite being a long questionnaire, but in relation to the questions one participant commented: ‘were kind of important questions I thought’ [Focus group 1].

Overall, there was also a recognition that many aspects of wellbeing were compromised after having a baby and so key concepts like autonomy and vitality were difficult to interpret. Women felt that their wellbeing was very much related to their current circumstances and women recognized that the experience of having a baby impacted on their wellbeing but they felt it was important to emphasize this and that it did not mean they had a significant problem or that they were depressed.

‘I know this is a wellbeing quiz so… … To me, it seems like you’re trying to find out if you have a lot of time for yourself and to sort of nurture yourself, and I don’t basically because I have small children and they get all my time. …I know I can’t be unique in this, so just to be able to be given the opportunity to say, yes, I don’t have “me” time, but it’s not because I’m depressed or…do you know? It’s just because I have too much of a draw on my time. I am a happy enough person, …’ [Focus group 2].

DISCUSSION

Overall women were open to the concept of subjective wellbeing and could relate to the many aspects that were explored. However, they also felt that their wellbeing was impacted on by their current circumstances and that variations from how they usually felt and thought should not necessarily be considered a sign of a problem. This is in keeping with WHO-5 wellbeing scores for women during pregnancy that have been found to be reduced in certain aspects of wellbeing, e.g. vitality, that may be related to symptoms of pregnancy rather than a perceived reduction in wellbeing⁹.

Subjective wellbeing is a particularly attractive concept within the context of maternity care because the majority of women are well and the priority is to maximize the benefits for each woman and her family during this important time rather than simply aiming to prevent ill health. The concept of wellbeing fits well with the ethos of maternity care and provides a valuable framework for professional discussions around what women need physically, psychologically and socially after the birth of their baby. The underlying concepts of subjective wellbeing go beyond an assessment of mood, for example recognizing the changes in different relationships and identifying the sources of isolation that can be challenging.

In terms of the concepts that make up subjective wellbeing, satisfaction with life is perceived to be relatively stable over one’s lifetime but is thought to be sensitive to major life events such as childbearing¹⁷. In our study the satisfaction with the life component of wellbeing was reported by some women to be a positive consequence of having a baby, although women were generally not interested in discussing this in detail. Positive perspectives on satisfaction with life are in keeping with other studies on pregnancy and postpartum that suggest that women have a high satisfaction with their life at this time^9,18,19.

Women in the focus groups struggled with the questions related to trust and belonging to their local community with women reporting that they did not feel engaged with their local community and neighbours. They did, however, value meeting up with women in their local community who had babies. The value of informal community support for women is also reflected in research on the general population that suggests that informal community socializing is strongly associated with higher life satisfaction in women, irrespective of parenting status²⁰. These finding suggest that providing women with opportunities to meet other women in their local community, either through support groups or activity-based groups such as baby yoga or walking groups, are appropriate mechanisms to help manage the often-reported experiences of social isolation after birth¹⁸.

A key category for women in the focus groups was supportive relationships, particularly with partners. In the general population women’s wellbeing has been found to be more reliant on positive inter-personal relations than for men²¹. Within the perinatal period, Gebuza et al.¹⁸ found that social support after birth, particularly instrumental support, predicted a woman’s satisfaction with life. A large cohort study in Norway found that the relationship with the partner was particularly important for optimizing wellbeing around the time of birth¹⁹. Our study findings are in keeping with these findings. In addition to support in the immediate postpartum period, women expressed concerns about going back to work, the changes they would face and the impact it would have on them and their family. Mistry et al.²² suggest that emotional or functional support, spending time with their children, and difficulty paying for childcare, were all significantly associated with reduced wellbeing.

This is a vulnerable time for women and it is important that we have a better understanding about the spectrum of wellbeing and what support women need. While women in this study did not want the reported lowering in their wellbeing to be interpreted as ‘being depressed’, they equally recognized that women could experience mental illness particularly if unsupported. There was also an acknowledgement by women that their partners may also have problems adapting after the birth. As with current literature on depression, this highlights the need to identify and support women and their partners who are struggling psychologically^10,11.

In this study we used the European Social Survey Wellbeing module questionnaire to explore subjective wellbeing, however there are a number of standardized wellbeing measures that have been developed for use in the general population that could be used in the perinatal period^13,23. Our findings suggest that caution is necessary in interpreting some aspects of subjective wellbeing, such as vitality, which will be reduced because of the normal consequences of pregnancy and having a baby. Also consideration should be given to developing a perinatal specific measure as there was evidence of challenges in supportive relationships and positive functioning, that may not be reflected in general measures.

The comprehensive framework of subjective wellbeing used in the present study will allow assessment of a number of domains that women have highlighted as important to them. Although women in this study related to the underlying concepts of subjective wellbeing they perceived their wellbeing to be different after birth and it is important that psychometric data are developed for general measures during the postnatal period to identify variations in wellbeing from the general population.

The use of questionnaires and validated wellbeing scales may provide an alternative approach to current approaches in identifying perinatal psychological problems. Comparison with measures currently used in practice, such as the Edinburgh Postnatal Depression Scale, would further elucidate the relationship between positive and negative aspects of wellbeing. Measuring wellbeing at this time would help women to discuss mental health in a broader spectrum of positive and negative emotions that may help to destigmatize mental illness. However, the benefits of these measures require more research before implementation in practice. In addition to instrument development, further qualitative research that follows women through the first year postpartum would provide important insights into changes in subjective wellbeing at key transitions, including infant feeding, returning to work and planning future pregnancies.

CONCLUSIONS

Women perceive their subjective wellbeing to be different after birth with social relationships and positive functioning potential challenges. Assessment of subjective wellbeing after birth could provide a better understanding of the aspects of challenged wellbeing and facilitate the provision of tailored support for women and their families to maximize their ongoing better health and wellbeing.