SUBMITTED 10 SEP 22 1

REVISION REQ. 26 OCT 22; REVISION RECD. 20 NOV 22 2

ACCEPTED 22 DEC 22 3

ONLINE-FIRST: JANUARY 2023 4

DOI: https://doi.org/10.18295/squmj.1.2023.003 5

Women’s Views on Factors that Influence Utilisation of Postnatal Follow-7

Up in Oman 8

A descriptive, qualitative study 9

*Amal Al Hadi,1 Jennifer Dawson,2 Michelle Paliwoda,1 Karen Walker,3 10

Karen New1 11

1School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, 13

Queensland, Australia; 2Newborn Research Centre, The Royal Women’s Hospital, Victoria, 14

Melbourne, Australia; 3Faculty of Medicine and Health, The University of Sydney, Sydney, 15

New South Wales, Australia 16

*Corresponding Author’s e-mail: a.alhadi@uq.net.au 17

Abstract 19

Objective: Postnatal follow-up care (PNFC) is important to promote maternal and newborn 20

health and wellbeing. In Oman, women’s utilisation of postnatal follow-up services has 21

declined with rates as low as 0.29 (mean visits) in some Governorates; well below the 22

recommended postnatal follow up visits at two- and six-weeks for assessment of mother and 23

newborn. The reasons for low utilisation are not well understood. The aim of this study is to 24

explore women’s views and identify factors that influence their utilisation of postnatal 25

follow-up services. Methods: Purposive sampling and semi-structured telephone interviews 26

with 15 women aged 20 to 39 years at six to eight weeks post childbirth between May 2021 27

to August 2022. Data were analysed using Erlingsson and Brysiewicz content analysis 28

approach. Results: Six categories were identified as influencing PNFC utilisation: 1) need for 29

information; 2) experiences and expectations; 3) family support, expectations and customs; 4) 30

sociocultural beliefs and practice; 5) impact of Covid-19 and 6) the healthcare environment. 31

Influencing factors within each category include the need to: empower women, provide 32

individualised care, address family and community expectations, offer alternatives to face-to-33

mailto:a.alhadi@uq.net.au

face clinic visits, provide organised, scheduled appointments. Conclusion: Women in Oman 34

identified the need for consistent information from health care providers (HCPs), a more 35

organised postnatal follow-up service including scheduled appointments and a woman-36

centred approach to PNFC. 37

Keywords: Postnatal care; postpartum period; qualitative research. 38

Advances in Knowledge 40

 To our knowledge, this is the first study to explore the views of women in Oman on 41

factors influencing their utilisation of PNFC. 42

 Obtaining the perspectives of the end-user of a service is an important step in 43

considering interventions to improve healthcare service utilisation. 44

Application to Patient Care 46

 The findings of this study will be used to inform the development of a survey that will 47

be sent to a large sample of postnatal women in Oman to confirm factors that 48

influence PNFC utilisation. 49

 The findings of this study intend to allow further clarification of influences that occur 50

at the individual, family, community, and institutional levels. 51

Introduction 53

Postnatal care is the latter part of the continuum of maternity care and is provided to women 54

and their newborns immediately following, and generally up to 42 days, after birth.1 The 42-55

day period (six weeks) post childbirth is based on universal agreement.1 However, in a 56

number of countries, this period extends to eight weeks post childbirth.2 The postnatal period 57

is classified into three stages: immediate (0–24 hours), early (2–7 days), and late (8–42 58

days).1 The immediate stage is usually spent at the birthing hospital, although with early 59

discharge becoming more common, the immediate care stage may last over only six hours.3 60

Early and late postnatal follow-up occurs in the community4 or at the hospital outpatient 61

level. Care during the postnatal period is equally important as that provided during the 62

antenatal period, as complications can result in adverse outcomes such as morbidities and 63

mortality for the mother, the newborn or both.1 In addition to physical complications, mental 64

health complications such as postnatal depression can occur in the mother5. These 65

complications can have a destructive impact on the whole family if not diagnosed and 66

managed early on and effectively.5 67

Newborn mortality is highest within the first week of life, caused by perinatal asphyxia, 69

prematurity and congenital malformations mostly.6 While approximately half of all infection-70

related deaths occur in the first week of life, a quarter of them occur between Weeks 2 and 4.6 71

Therefore, the World Health Organization (WHO) emphasises that postnatal follow-up 72

contacts with health professionals play an important role in reducing deaths of newborns, 73

through early detection, referral and management of complications.7 74

The number and time of postnatal vary globally. The WHO8 recommends four postnatal 76

contacts9, while the American College of Obstetricians and Gynecologists recommend the 77

number and timing of contact be more individualised depending on the need.10 Whereas, the 78

Sultanate of Oman Ministry of Health guideline recommends postnatal follow-up health 79

centre visits at two and six weeks for both the mother and the newborn.11 80

In Oman, the number of postnatal follow-up visits has decreased from 1.3 in 2000 to 0.73 in 82

2019.12 In comparison, attendance is high for antenatal visits, with 74% of women attending 83

four or more appointments.12 There are clear differences between antenatal and postnatal 84

care. For example, women are given antenatal appointments to attend the clinic on a specific 85

date and time, with appointment reminders sent via the short message service (SMS). In 86

contrast, for PNFC, no formal appointment is arranged, with only HCPs informing women 87

that they should visit the health centre when they reach the 14- and 42-day mark post birth. 88

Low utilisation of postnatal follow-up means there are lost opportunities for health promotion 89

and health monitoring of mothers and their newborns, which may be reflected in the poor 90

exclusive breastfeeding rate at 6 months of only 8.9%12. 91

A literature review was undertaken with factors identified that impeded utilisation of 93

postnatal follow-up, including women’s lack of knowledge of postnatal services, beliefs that 94

there is no need for postnatal follow-up and the impact of long queues (waiting time) at 95

health centres.13 Of the 17 studies eligible for inclusion in the review, one was conducted in 96

the Middle East (Jordan), which has cultural similarities to Oman but a different healthcare 97

system and delivery of postnatal care. This study reported concerns regarding the unmet 98

learning needs of women in terms of postnatal care, including danger signs post caesarean 99

section, breastfeeding and newborn care at the two postnatal contacts, that is, at Day 1 and 6–100

8 weeks following birth.14 However, it did not explore the factors contributing to the low 101

utilisation of postnatal service. As no published studies have explored women’s experiences 102

and utilisation of PNFC in Oman, this study was undertaken as the first step toward 103

ascertaining why PNFC is poorly utilised in Oman. The objective of the study was to explore 104

the factors that influence utilisation of PNFC in Oman from the perspective of postnatal 105

women. 106

107

Methods 108

Design 109

This descriptive qualitative study is a part of a larger exploratory mixed methods project 110

designed to gain more insight into PNFC from women, hospitals and health centre HCPs 111

through qualitative interviews. The results from the HCPs will be reported elsewhere. The 112

results of Study One will inform the development of quantitative measures (survey) of the 113

mixed method study. This will enable an investigation of the PNFC with a larger sample size, 114

thereby facilitating policy change to improve the quality of care.15 Purposive sampling was 115

used and semi-structured telephone interviews were conducted in Arabic between May and 116

August 2021 by the primary investigator, an Omani registered nurse-midwife experienced in 117

conducting interviews. The interview guide (Table 3) developed by the researchers was 118

guided by the findings from the literature review.13 Ethical approval was granted by the 119

Research and Ethical Review and Approval Committee, Oman Ministry of Health 120

[MoH/CSR/20/23647], and the University of Queensland 121

[2020002085/MoH/CSR/20/23647]. 122

123

Setting and participants 124

Postnatal women were recruited at Khoula and Ibra Hospitals. The sites were selected 125

because of their differences in terms of population density and social, educational and 126

healthcare services.12 Women who gave birth at the study site and were fluent in Arabic or 127

English were eligible to participate, regardless of nationality. Women with any pregnancy 128

complications or history of newborn admission to a neonatal nursery were ineligible. Women 129

were recruited by the primary investigator in collaboration with the clinical hospital HCPs to 130

identify eligible women. Informed consent was obtained from the women following a 131

detailed explanation of the study and participation requirements. The date and time for the 132

telephone interview were scheduled between 6–8 weeks based on mutual agreement. 133

Data collection 134

Interviews were conducted between 6–8 weeks postnatally via telephone due to the Covid-19 135

pandemic. Further, this allowed women to be interviewed in their home environment. 136

Interviewing participants in their own environment in which they are comfortable and 137

familiar can result in more openly expressed opinions.16 The interviews were digitally 138

recorded and lasted on average for 25 min. Data collection ended with concept saturation.17 139

140

Data analysis 141

Interviews were de-identified and transcribed verbatim in Arabic and then translated into 142

English by an external experienced bilingual translator. This enabled the native English-143

speaking research team to review the transcripts, thus increasing reliability and minimising 144

inaccuracies when translating between the source language to the target language.18 The 145

primary investigator compared the English transcripts with the Arabic transcripts, checking 146

for accuracy, including transliteration where necessary in cases where English counterparts 147

for certain Arabic terms and names did not exist. Conventional content analysis was 148

performed manually and was guided by the process described by Erlingsson and 149

Brysiewicz19: familiarisation with the data; dividing the text into meaning units; condensing 150

meaning units; formulating codes; developing categories. Conventional content analysis was 151

performed, as no study has been conducted in Oman about PNFC. This approach enabled the 152

flow of categories without the restriction of preconceived ideas/categories.20 All condensed 153

meaning units, codes, sub-categories and categories were manually added to Microsoft Excel 154

version 16.54 to enhance data management. 155

156

The development of meaning units, codes and categories was undertaken by the primary 157

investigator and agreed upon by two co-authors. The categories reflected factors that 158

influenced women’s views, decisions or experiences of utilisation of PNFC. 159

160

Results 161

No new information was identified from the 14th interview, and this was empirically 162

confirmed following the completion of the 15th interview. The demographic data of the 163

participants is presented in Table 1. 164

165

During the content analysis, initially 246 meaning units were extracted. After reviewing, the 166

units were condensed into 166 units. Then the meaning units were coded into 46 codes. The 167

codes were further clustered into 18 sub-categories. Finally, six clear categories emerged 168

from the data: 1) need for information; 2) experiences and expectations; 3) family support, 169

expectations and customs; 4) sociocultural beliefs and practice; 5) impact of Covid-19; 6) the 170

healthcare environment. 171

172

Need for information 173

The utilisation of early PNFC at health centres appears to be dependent on HCPs providing 174

information to women about the need for PNFC for both themselves and their newborns. The 175

participants reported that appointments were not given or explained well to them: “No one 176

told me about appointments about me, they just gave me an appointment for my child 177

vaccination after two months and it is written in my baby card” (P7) (Table 2, Quote 1), or 178

that they were told they would be seen by a doctor but not specifically informed why (Table 179

2, Quote 2). The women felt strongly that they should be informed and empowered by being 180

given information with an explanation of why they should attend (Table 2, Quote 3). 181

182

The participants reported not visiting for PNFC because they were told by the HCPs at the 183

hospitals and health centres that they only needed to attend if they experienced complications 184

(Table 2, Quote 4). Thus, women who did not have any complications did not visit any health 185

centres. 186

187

Many women expressed a desire for more information around newborn care (e.g. bathing, 188

feeding, cord care), signs of danger to themselves or their newborns, managing complications 189

for themselves women and their newborns and, in particular, their own mental health (Table 190

2, Quote 5). Additionally, women who had a caesarian section birth or had perineal wounds 191

expressed the need for more information on wound care (Table 2, Quote 6), and this was 192

highlighted by a postnatal woman who was also a nurse. She stated that she knew how to take 193

care of her wound because of her experience, not because she was given any information by 194

the HCPs (Table 2, Quote 7). Women who delivered by caesearean felt they needed an 195

appointment 1 week postnatally for reassurance about their health and well-being (Table 2, 196

Quote 8). 197

198

The need for increased and more comprehensive breastfeeding information and support was 199

raised by most women, as many reported breastfeeding challenges that they had to try and 200

solve by themselves: “I faced a huge problem with breastfeeding I did not know how to 201

breastfeed, maybe the technique was wrong, or I did not have enough milk” (P3) (Table 2, 202

quotes 9). Otherwise, they opted to artificially feed, as it was easier (Table 2, Quotes 10 and 203

11). Additionally, women reported that the information given to them was not helpful or did 204

not solve their problems (Table 2, Quotes 12 and 13). 205

206

Experiences and expectations 207

Previous experience with PNFC influenced the participants’ decisions to attend or not with 208

their newborn. Many women reported that the care was not woman-focused or beneficial, nor 209

did it meet their individual needs: “I feel every time I go to the doctor, I only get a verbal 210

advice, which does not benefit me much, it is not practical, they give us their opinion, but the 211

reality is different” (P6) (Table 2, Quote 14). They also reported that PNFC was focused on 212

the newborn, with little attention to the mothers’ health (Table 2, Quotes 15 and 16). 213

214

The participants strongly felt that it was very important to have PNFC appointments, as 215

attending with a newborn in a crowded clinic and waiting for long periods without dedicated 216

breastfeeding areas was not ideal (Table 2, Quotes 17, 18 and 19). Not having scheduled 217

appointments led the women to perceive that PNFC is optional and not important. If 218

appointments had been scheduled, they would have attended (Table 2, Quotes 20 and 21). 219

The women further stressed that the COVID-19 pandemic highlighted the need and 220

importance of scheduled appointments: “Set scheduled appointments with specific date in an 221

organised manner, so women do not have to wait for long time with their babies especially 222

now corona is here” (P10). Also important to women was the need for alternative follow-up 223

options, which they suggested should be more accessible and practical, such as text 224

messaging, telephone calls and home visits. 225

226

Family support, expectations and customs 227

Some of the participants followed strict customs pertaining to the postnatal period, such as 228

staying in their family home for a few days: “They can ask about the woman by calling and 229

this is very useful way to ensure about her health and the health of the child, and they see 230

what she needs” (P9). Another custom is to receive support from their family, which is 231

viewed as an expectation and responsibility of the family (Table 2, Quotes 22 and 23). 232

However, several others received little support (Table 2, Quotes 24 and 25). The level of 233

support had an influence on attendance at PNFC, as when the mothers had no one to take 234

them to the health centre or to take care of their other children at home, then they did not visit 235

(Table 2, Quote 26). The influence of family and customs affecting women’s decisions and 236

choices were also revealed: “I gave all my children artificial milk immediately after hospital 237

discharge because of my in-laws’ influence. They told me that I have to give my baby 238

artificial milk or he will lose weight” (P4). 239

240

Sociocultural beliefs and practice 241

Various social and cultural practices are expected of women during the postnatal period, such 242

as ‘seclusion’, which appear to influence attendance at PNFC. The participants reported that 243

they are expected to stay indoors for 40 days, as seclusion is important to prevent maternal 244

and newborn sickness, to ensure normal growth for the newborn and to avoid embarrassment 245

among family and community members: “I did not leave the house in the 40 days because it 246

is a scandal and people will talk about me…this is our custom, even if we had a normal 247

vaginal birth, we do not go out, we must sit at home except for necessity” (P14) (Table 2, 248

Quote 27). 249

250

Several traditional practices related to food and medicine used after birth also appear to 251

influence women’s decision to visit a health centre. The participants indicated that they 252

believed traditional foods were effective in overcoming postnatal complications, such as 253

insufficient milk production and bleeding and to ‘cleanse the uterus’: “My family cooked for 254

me special food such as fresh meat, Omani chicken, fenugreek, and bread made of wheat 255

flour, which very helpful in increasing the milk production, prevent gases formation and 256

make my bones stronger as it was weakened due to pregnancy and delivery” (P15) (Table 2, 257

Quote 28). Similarly, women used and trusted traditional medicines to treat postnatal 258

complications such as wound pain, infection and the newborn’s abdominal cramps (Table 2, 259

Quotes 29 and 30). 260

261

Impact of Covid-19 262

The participants stated that they did not utilise PNFC because they were worried about both 263

themselves and their newborn being infected with Covid-19 when visiting health centres: “I 264

was afraid to go out during after birth because of Corona” (P6) (Table 2, Quote 31). 265

Moreover, these women’s decision to visit health centres was impacted by being discouraged 266

or turned away by HCPs due to Covid-19 (Table 2, Quote 32). 267

268

Healthcare environment 269

The women in this study were reluctant to attend PNFC, as they felt that the physical 270

environment for postnatal care in health centres was not comfortable or suitable for them or 271

for their newborn: “The environment in the health centre is not comfortable it is very cold 272

and the chairs are hard so it causes pain especially with perineal wound…there is no special 273

area for mothers to breastfeed their babies” (P5). With no appointment system, women are 274

expected to sit and wait for their turn. Depending on the number of women, some may not be 275

seen and have to return another day. Thus, a number of women stated that they chose to be 276

seen in private health facilities (Table 2, Quote 33). Furthermore, women cited the low 277

quality of PNFC provided as a reason for not visiting (Table 2, Quotes 34 and 35). 278

279

Discussion 280

This qualitative study highlights factors influencing postnatal women’s utilisation of PNFC in 281

Oman. These occur at four levels: individual, family, community and institutional levels. 282

Gaining the perspectives of postnatal women is essential since they are consumers of 283

healthcare services, and they should feel cared for, safe and confident in receiving quality 284

care.21 Many countries have developed Standards for Safe and Quality Health Care in which 285

the importance of involving consumers in their own care and providing clear communication 286

is advocated22 across the continuum of ‘planning, design, delivery, measurement and 287

evaluation of care’.21 Involvement of the consumer at the primary care level has the potential 288

to prevent illness before it begins. Thus, engaging postnatal women to improve utilisation of 289

PNFC service has the potential to shape and influence policy change for better outcomes.23 290

291

Need for information 292

Our findings reveal that postnatal women need more information regarding postnatal care. 293

Increasing health literacy, including knowledge and awareness, and thereby empowering 294

women in their own healthcare is not unique to Oman, having been reported in studies from 295

many countries.14, 24,25 Two studies found that postnatal women in Indonesia and Ethiopia 296

were not provided with adequate information and thus had poor knowledge and awareness of 297

the importance of postnatal care.24,25 Engaging and empowering consumers in health care and 298

health promotion appears to remain a challenge despite discussion and policy development 299

over the last few decades. Interestingly, the need for more information was not only reported 300

by first-time mothers but also multiparous women, who highlighted their need for more 301

educational support, especially regarding breastfeeding. The women in our study reported 302

using artificial formula very early in the postnatal period as a way of overcoming 303

breastfeeding challenges such as attachment or low milk supply, and few women maintained 304

exclusive breastfeeding to 6 months postnatally. Data from Oman shows that only around a 305

third (31.3%) of women breastfed exclusively at 6 months in 2005, and by 2019, the rate of 306

exclusive breastfeeding declined to just 8.9%.12 In contrast, over the same time period, the 307

use of artificial formula and other foods rather than breastmilk has increased considerably at 308

6 months, from 60.7% in 2005 to 90.7 % in 2019.12 This is a concern, as breastmilk is 309

important for the health and wellbeing of newborns, as it protects from malnutrition, common 310

childhood infections, allergies, metabolic disorders and obesity.1, 26 Thus, at the institutional 311

level, it is clear that there is potential for improvement of PNFC by addressing health literacy 312

through policies that support individualised care and making information resources accessible 313

to consumers. 314

315

Experiences and expectations 316

The women in this study believed that not having specific appointments for postnatal follow-317

up meant that PNFC was not important. In 2019, the rate of utilisation of postnatal care in 318

Oman was shown to be as low as 0.73 postnatal visits per woman.12 This is in contrast to 319

antenatal appointments which are scheduled and, therefore, considered important, with 73.9% 320

of women attending four or more visits in 2019.12 The American College of Obstetricians and 321

Gynecologists10 recommends scheduling postnatal visits during the prenatal period or prior to 322

hospital discharge as an imperative strategy to promote and ensure women’s utilisation of 323

postnatal follow-up. 324

325

In this study, women expressed that they would like options for postnatal follow-up, 326

including home visits and telephone calls, indicating that a more individualised postnatal 327

follow-up approach was of importance. De Sousa et al.27 reported that, to ensure the best 328

health outcomes, there is a need to promote attentive listening to women’s concerns, 329

encourage continuity of care and increase home-based services. Furthermore, a Cochrane 330

systematic review found that early discharge accompanied by a home visit resulted in reduced 331

newborn readmissions in the weeks following birth, encouraged women to continue exclusive 332

breastfeeding and increased maternal satisfaction with postnatal care. 28 The importance and 333

need for individualised care have been reported by several international organisations and 334

agencies.9, 29 Our study has demonstrated that alternative modes of postnatal follow-up are 335

wanted by women; thus, future studies should explore alternative options at community and 336

institutional levels. 337

338

Family support, expectations and customs 339

In Oman, the influence of the family, their expectations, customs and level of support to 340

women in the postnatal period plays a key role in utilisation of health services. This is 341

consistent with a study reporting the influence of families on women’s knowledge, attitudes 342

and practices during the postnatal period.24 Therefore, it is important that this is considered at 343

the individual level when designing interventions to improve utilisation of services. 344

Educational interventions need to be targeted towards the family and community and not just 345

the women concerned.24 This is particularly important in our study setting, where there is an 346

expectation that the family provides information and physical support and influences 347

decision-making. The impact of family-related factors has been reported to negatively 348

influence postnatal women’s compliance to health advice provided by HCPs.24 However, 349

having family support can also impact utilisation positively. For example, family members 350

can assist women to attend postnatal follow-up appointments by caring for other children to 351

allow women time to visit the health centre for appointments. Without this type of support, it 352

is often too difficult for women to focus on their health. The women in our study indicated 353

that lack of family assistance with their other children prevented them from utilising postnatal 354

follow-up, which is consistent with the findings from studies conducted in Ethiopia.25, 30 355

356

Sociocultural beliefs and practice 357

In Oman, similar to many Arab countries, the postnatal period is culturally perceived as a 358

unique time during which mothers are expected to practice seclusion, eat a special diet and 359

receive congratulatory visits and gifts from family members and friends.31 The practice of 360

seclusion for 40 days is common in Middle Eastern countries, where the women and their 361

newborns are viewed as being weak and at increased risk of morbidities, mortality and the 362

‘evil eye’.31 Although seclusion did not appear to directly impede the study participants’ 363

utilisation of postnatal follow-up, they still reported that they favoured staying indoors for 40 364

days, with many mentioning that they would only attend the health centre at 40 days for 365

information about birth spacing. Thus, offering alternative methods of follow-up could be 366

useful to provide support on breastfeeding and mental health well-being in the early postnatal 367

period. In our study, the women trusted the cultural practices of traditional food and medicine 368

consumption to overcome postnatal complications and were more likely to try these than go 369

to a health centre, as reported in previous studies.25, 32 Therefore, it is crucial for 370

policymakers, community leaders and HCPs to work collaboratively toward increasing 371

community awareness regarding the importance of postnatal follow-up. 372

373

Impact of Covid-19 374

Not surprisingly, concerns were raised regarding the inability to utilise postnatal follow-up 375

due to the Covid-19 pandemic. This occurred at the individual level, with many women 376

indicating that they were reluctant to leave the house and go to a health centre where they 377

would be required to sit and wait for an extended period of time because appointments were 378

not scheduled. At the institutional level, women spoke about being discouraged from visiting 379

clinics in person. Non-face-to-face methods for providing postnatal follow-up were not 380

initiated by institutions in response to the pandemic. An unintended result of not attending 381

postnatal clinics has been the isolation of new mothers, impacting further their ability to 382

obtain information and support. Women raised concerns regarding their mental, physical and 383

emotional well-being, including the risk of postnatal depression. This is concerning, as the 384

findings from a cross-sectional survey indicated that the risk of postpartum depression at one 385

month was higher in women with low support compared to those with higher support.33 386

Recommendations have been made regarding the importance of continued care for postnatal 387

women and newborns during the pandemic and the use of different accessible modalities to 388

provide breastfeeding, mental health and parenting support.34 Unlike in other countries, 389

institutions in Oman have not reviewed or adapted services or policies in response to the 390

pandemic, as women were not offered alternative postnatal follow-up approaches. 391

392

The healthcare environment 393

Several environmental factors that played a key role in impeding women’s utilisation of 394

postnatal follow-up have been highlighted in this study. These factors included crowded 395

health centres and long waiting times. The impact of the environment and long waiting 396

queues at health facilities on postnatal follow-up utilisation has previously been reported in 397

the literature.35 Thus, for Oman, a solution to address these factors may be as simple as 398

scheduling appointments, as it can help to reduce both overcrowding and long waiting times. 399

Providing women with alternatives to face-to-face visits, such as phone calls and home visits, 400

might also be successful in improving utilisation. 401

402

Strengths and limitations of the study 403

To our knowledge, this is the first study exploring the utilisation of PNFC in Oman from the 404

perspective of postnatal women. This is important to inform quality care improvements, make 405

PNFC women-centred and amend the National Guideline to increase the uptake of PNFC. A 406

limitation of this study is that it was conducted during the COVID-19 pandemic, which may 407

have influenced the women’s decision to attend the PNFC visit, although it did not inhibit 408

policymakers from providing alternative ways of contact, such as via telephone calls, text 409

messages and videoconferencing via platforms such as Zoom. 410

411

Conclusion 412

The women in this study identified key factors that both facilitated and impeded utilisation of 413

PNFC. These are important in the development and implementation of effective strategies to 414

increase utilisation of PNFC, which can provide opportunities for health promotion, support 415

and optimal care of women and newborns. Policymakers, community leaders and HCPs must 416

work collaboratively to promote the utilisation of PNFC by scheduling appointments, 417

increasing awareness among women, families and the community on the importance of 418

PNFC and providing alternative modes of contact. 419

420

Acknowledgements 421

Our sincere thanks and appreciation to women for their participation in this study. We also 422

extend our gratitude to the Directorates General of Khoula Hospital and the Directorate 423

General of Health Services at North Ash Sharqiyah Governorate for facilitating the 424

recruitment process. 425

426

Authors’ Contribution 427

AAH contributed to the conceptualization, methodology, formal analysis, project 428

administration, visualisation and writing (original draft). JD contributed to the 429

conceptualization, methodology, visualisation, supervision and writing (review and editing). 430

MP contributed to the conceptualization, methodology, formal analysis, visualisation, 431

supervision and writing (review and editing). KW contributed to the conceptualization, 432

methodology, visualisation, supervision and writing (review and editing). KN contributed to 433

the conceptualization, methodology, formal analysis, visualisation, supervision and writing 434

(review and editing). 435

436

Conflicts of Interest 437

The authors declare no conflict of interests. 438

439

Funding 440

Funding for AAH via a scholarship was provided by the Omani 441

government through the Omani Ministry of Higher Education, Research and Innovation 442

(Grant number: D.P.S/699/201). 443

444

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549

Table 1: Participants’ demographic data 550

Participa

nt and

Hospital

Age

group

(years

)

Educational

level

Birth

(num

ber)

Living arrangements

P1-KH 25-29 Advanced* 2 Living with extended family**

P2-KH 30–34 Advanced* 1 Living with extended family**

P3-KH 30-34 Advanced* 1 Living with husband and children

P4-KH 35 -39 Secondary*** 4 Living with husband and children

P5-KH 30-34 Secondary*** 3 Living with husband and children

P6-KH 35-39 Advanced* 2 Living with husband and children

P7-IH 25-29 Secondary*** 5 Living with husband and children

P8-IH 25-29 Advanced* 2 Living with husband and children

P9-IH 20-24 Advanced* 1
Living with husband, child/children, and

one set of parents

P10-KH 25-29 Advanced* 1 Living with husband and children

P11-KH 25-29 Advanced* 3 Living with husband and children

P12-KH 20-24 Primary**** 5 Living with extended family**

P13-IH 30-34 Preparatory***

3 Living with husband and children

P14-IH 25-29 Advanced* 2 Living with extended family**

P15-IH 25-29 Secondary*** 5
Living with husband, child/children, and

one set of parents

*Advanced: completed diploma bachelor, master’s, or PhD. **Extended family includes 551

others in addition to parents, such as grandparents, brothers, sisters, uncles, aunts and 552

cousins. ***Secondary: completed Grade 12; ****Primary: Grade 1–6. *****Preparatory: 553

Grade 7–9. 554

555

Table 2: Quotes from participants 556

Categories Verbatim quotation from participants

Need for information

1. “Appointments need to be clearly explained to us, whether
they are for mother only or we have to bring our baby with

us.” (P1)

2. “They told me that after two weeks, my baby is having
appointment and it is written in the pink card, and I should

go with baby because the doctor will see me as well.” (P6)

3. “Before we [are] discharged from the hospital, they must
explain to us in detail about the appointments and give us

the numbers of the people we can contact if we need

information about postpartum care in general, not only

about breastfeeding.” (P6)

4. “I was informed from health centre that no need to follow-
up after birth unless you or newborn have complication.”

(P1)

5. “I need someone to teach me about mental health, as
sometimes I was feeling bad, depressed and tired,

especially when the baby was crying despite that I have

fed him and changed his diaper.” (P1)

6. “I wish to know more about how to take care of the wound
because I still suffer from pain and infection.” (P5)

7. “From my experience as a nurse, I know how to take care
of the wound and know if the wound bleeds or smells or

the wound opens, I go to the health center, but no one

explained this to me after the birth.” (P14)

8. “Women should return to health centre after a week,
especially if delivered by is operation, because we want to

be reassured our health and wellbeing and to have chance

to discuss with them about our concerns on this

appointment.” (P8)

9. “I learned everything by myself and through searching the
Internet. (P6)

10. “I started with artificial milk with all my three children
because it was the easiest solution to solve breastfeeding

problems.” (P4)

11. “My first and second child, I did not breastfeed them
naturally because I did not know how to breastfeed them.

My family tried with me, but it did not work, and I gave

them artificial milk.” (P7)

12. “The nurse gave me a paper and it was written on it how
to store the milk, but my milk flow was not enough for the

baby.” (P10)

13. “I was trying to breastfeed her but was having difficulty to
attach to the nipple and [she] refused to breastfeed as she

did not want me, so I contacted the lactation specialist

through Instagram, she advised me to stop giving my

baby’s pacifier. Her advice helped me a little, but the

problem did not stop.” (P6)

Experiences and

expectations

14. “For all my five births, I never went to the health centre,
neither for the two-week nor for the forty-day appointment

because they don’t do anything for me, only they measure

the baby weight.” (P12)

15. “I feel frankly that there is no care for me, they only ask
about the child if he passed urine, there was nothing else,

unless the person asks by himself in order to get

reassured.” (P7)

16. “The two-week appointment they do not give us much, they
only ask us how are you doing, and if you have any

problem, I feel they are more interested in the child than

the mother, at least they could do a comprehensive

examination for the mother like a child.” (P6)

17. “It is very important to have scheduled appointments with
date and time.” (P4)

18. “Health centres are crowded and we have a newborn with
us.” (P5)

19. “Especially women who have undergone surgeries or have
stitches, they should pay more attention to them because

they suffer from more pain and open wounds.” (P13)

20. “If we have scheduled appointment with date and time, we
will care more about it.” (P2)

21. “They must be on time, they are not optional … We don't
feel that postnatal care is important.” (P8)

22. “I went to my family’s house for forty days and got
psychological support from my mother and sisters who

raised my spirits to prevent me from getting postpartum

depression, they were also helping me with my first child,

since I had operational delivery and I could not move

much.” (P8)

23. “My aunt (mother-in-law) and my sisters helped me clean
the house and cook for us to eat while I stay in my house

because my parents passed away.” (P12)

24. “I was in my sisters’ house and I was sleeping alone with
my baby and I was holding her all the night no body

helped me.” (P3)

25. “My parents passed away and I have my sisters and
brothers, but they have other responsibilities.”(P4)

26. “I could not attend as my husband at work and I didn’t
have car and I have 3 more children at home.” (P4)

Sociocultural beliefs

and practices

27. “In our customs, women must stay for forty days in the
same place, and we are convinced that this custom is

beneficial for the mother and the child.” (P11)

28. “My mother and sisters helped me and they cooked me
rice and porridge with fenugreek. This food is useful

especially the fenugreek as it increases milk production

and cleans the uterus from traces of blood.” (P13)

29. “The operation wound was very painful and I got tired
from the pain so my mother advised me to apply Luqman

oil to it to heal fast.” (P13)

30. “My mother helped me to deal with my baby's abdominal
cramps and gave the baby traditional medicine and did

some massage to remove gasses from the baby's tummy.”

(P1)

Impact of Covid-19

31. “I will not go out because of corona; I am worried about
my child.” (P2)

32. “They [HCPs] told me, don't come, we don't receive the
two-week appointment, come only for vaccination date

after two months because of Corona, even they didn't

check the child, so, I had to go to another private hospital

recommended from my workplace to check my baby and to

be reassured that everything is fine with her.” (P6)

Health care

environment

33. “We follow-up in private because health centres are
overcrowded and only see postnatal women in specific

timings.” (P1)

34. “The quality of postnatal services provided for mothers
and babies need to be improved not only checking baby

weight and looking at our faces otherwise I will not waste

my time to attend.” (P3)

35. “There is no postnatal care, they only give the child an
injection and that’s all.” (P13)

557

558

Table 3: Interview guide 559

1. When you were getting ready to be discharged from hospital, can you tell me what

information the nurse/midwife/doctor gave you about visiting a health centre for

postnatal care?

2. When you got home from the hospital, can you tell me about the support your

family gave you?

3. Thinking about when you first arrived home from the hospital, what were the most

challenging things?

4. Have you had the opportunity to leave the house since your baby was born?

5. Since you were discharged from the hospital, have you visited any health centres

for you or your baby?

a. If attended – How many times did you visit? Who did you see when you

visited the health centre - a nurse/midwife/doctor? Can you tell me about

your experience of visiting the health centre? In your opinion are their

things that could be done better to improve the visit?

b. If did not attend – Can you tell me a little about why you did not visit? Did

anyone else give you information about looking after yourself/your baby?

What could be done differently to encourage you to visit? From your point

of view, can you think of any other reasons why women may/may not attend

postnatal follow-up care at a health centre?

6. In your opinion, what would you like to discuss or be told about at postnatal follow-