Title of manuscript

A Qualitative Study Exploring Pregnant Women Perceptions Regarding Their

Husbands and In-laws’ Support during Pregnancy
Abstract
Introduction: Pregnancy is not a disease but a psychologically challenging period
where a woman passes through several social, physical and psychological challenges
in life. This study is aimed at exploring pregnant women perceptions regarding their
husbands and in-laws’ support during pregnancy.
Methods: A qualitative exploratory design was used. Ten pregnant women in third
trimester of pregnancy and living in joint family system were recruited through
purposive sampling technique in a village of district Nowshehra. Permission was
taken from concerned departments as well as from participants before data
collection. Interview topic guide was used as tool. Face to face individual In-depth
interviews were conducted, audio recorded, transcribed and analyzed through
thematic analysis.
Results: 100 open codes were found out from the data. In the process of axial
coding extra and unnecessary codes were omitted and then 11 categories were
identified from open codes. The identified categories were kept under three major
themes of lack of comprehensive support mechanism, physical and mental strain,
barriers to antenatal services. Perceived support of husbands and in-laws and needs
and barriers to maternal and child health were discussed by the participants.
Conclusion: Findings suggested that family relationship quality might not be
improved by taking interventions i.e. making policies, but the incorporation of health
professionals’ support with family member’s behavior can improve maternal health.

Keywords: Support, Husbands, Pregnancy, Pregnant women, Perceptions, In-laws

Introduction
Pregnancy is not a disease but a psychologically challenging period where a woman
passes through several social, physical and psychological challenges in life [1]. This is
a period, women need significant support from health care services, however, in
patriarchal societies such as Pakistan, a lot of these decisions related to access to
health services etc are in the hands of husband and in-laws [2]. Women are often
considered inferior to man and have limited autonomy and power of expression due
to deeply rooted societal norms may lead pregnant women to depression and affect
their pregnancy and fetal weight [3-7]. Worldwide, 10% of pregnant women
experience stress and depression due to the autocratic style of their in-laws [8]. In
addition, family values and beliefs, religion, level of education or awareness of the
family members affect the psychological, physical and social wellbeing of pregnant
women[5]. Mostly traditional families with rigid belief system think that medical care
is not necessary in pregnancy and they don’t allow pregnant women to seek medical
care due to which care seeking gets delay [9]. Delay in care seeking leads to
undesirable health outcomes such as high fertility, undesirable and unwanted
pregnancies, and medical complications in women[10]. Health professionals suggest
that during antenatal period, husbands and family members’ support is necessary to
ensure healthy pregnancy outcomes[11]. Specially, husband’s presence at the time
of delivery is fruitful because partner’s support strengthens and helps in reducing
fear and anxiety during delivery [7]. A study reported that witnessing labor pain can
help in family planning in future [8].Social support in terms of emotional, cognitive
guidance, positive feedback, and social reinforcement to pregnant women from their
family members is associated with better mental health, buffering of risks and
promotion of well-being [12]. Psychological support in terms of family members’
behavior and communication is another important factor which affects maternal
mental health and boost up pregnancy outcomes. Lack of psychological support can
lead to pregnancy complications i.e. deprived neurodevelopment of fetus, low birth
weight of fetus, an increase in the rates of caesarean birth, prolonged and preterm
labor which indicates that poor psychological support during pregnancy is strongly
related to pregnancy complications [13].It is evident from the literature that a good
quality family relationship plays an important role in the pregnant women’s mental
health and physical well-being[14]. Though, Pakistan is the part of international
community, still most Pakistani cities as well as villages has a high level of gender
inequalities including literacy, nutrition, employment and health care[15]. The
current study is aimed at exploring the perceptions of pregnant women regarding
their husbands and in-laws’ support during pregnancy. Findings of the study may
help the health care professionals in understanding the pregnant women’s
psychosocial issues, community stake holders and policymakers to develop and
implement the strategies for those factors that could affect the health of pregnant
women.
Methods
A qualitative exploratory study was conducted to explore the perceptions of
pregnant women regarding their husbands and in-laws’ support during pregnancy.
Using purposive sampling technique, pregnant women who were in third trimester
of pregnancy, house wives, living in joint family in the village of district Nowshehra,
Pakistan were selected. Study completed in six months. Sample size was decided
upon the data saturation to produce sufficient in-depth information that can
highlight the blueprints, types and aspects of the phenomenon of interest.
Permission was taken from the University’s ethical review board before the
commencement of data collection. Rapport was built with the participants and
research purpose and author’s information was fully disclosed then consent was
taken for face to face individual in-depth interview as well as for audio recording.
Language convenient to the participants was used during the interview. Semi-
structured interviews were conducted individually. Interviews were audio recorded
and field notes were taken. Data was found saturated on tenth participant. Audio
recorded information was then translated into English language and transcribed
verbatim anonymously following each interview. Thematic analysis approach was
used to analyze the data and analysis of the data was proceeding step by step [16].
Audio recorded information was listened one time and then data read and re-read
and initial analytic induction was noted. Next, semantic and conceptual reading was
done; all the data were coded, and the relevant data were extracted from the codes.
Next, searching for the repetition or similarity in the initial codes was done. Next,
themes were discovered from the coded data. The codes were then arranged
relevant to each theme. Lastly, themes were reviewed and names were identified for
each theme concisely and all the themes wrote in details which provided the readers
a holistic view of the research.
Results
100 open codes were found out from the data. In the process of axial coding extra
and unnecessary codes were omitted and then 11 categories were identified from
open codes. The identified categories were kept under three major themes of lack of
comprehensive support mechanism, physical and mental strain, barriers to antenatal
services. Perceived support of husbands and in-laws and needs and barriers to
maternal and child health were discussed by the participants.
Lack of a comprehensive support mechanism
Overall, participants disclosed a lack of a comprehensive support mechanism in
terms of emotional support, Physical support , psychological support, housekeeping
support, and financial support during pregnancy from their husband and in-laws.
The participants in this study lived in joint families with complex family dynamics and
power hierarchies outside of their control. The behaviours of husbands and in-laws
were reported to be stress causing pregnant ladies which was affecting their health
during pregnancy. Interviewees explained that their husbands showed careless
behaviour towards them. In joint family system, their husbands, as reported by these
women, wouldn’t say on behalf of them when their in-laws scolded them and where
the husband’s support was direly need in household chores during pregnancy. They
felt helpless when no one listened to their health problems. Overall, these
experiences were reported to be painful for these ladies as they felt helpless when
they needed support the most. Participants complained of their husbands’
irresponsible behaviours like not doing any work or having education but not actively
searching for any job, as these housewives were financially dependent on their
husbands, this would leave their wives and children to suffer at home regarding their
healthcare, these women mentioned, for example, as:
“My husband does not ask me what the doctor said about me and baby’s
condition when I come back from the doctor’s clinic he is careless.” (Participant 5,
gravida 3)

“When I go to visit my doctor no one from in-laws go with me due to my

husband’s irresponsible behavior, he does not earn and give money to them to spend
at home and on my health, so his parents dislike me. They push me to force him to do
some work. I talk to him, but he does not listen to me.” (participant 4, gravida 4)

Lack of Physical support was explained in a sense of expectations by participants’ in-

laws. They said that their in-laws did not understand their feelings and pain and ask
for routine work at home which was stressful for them physically as well as mentally.
They added that their in-laws treated them like a maid they hired for themselves.
They also said that they feel they are in the open air when they go to their parents’
homes:
 “In-laws say we are not responsible for your pregnancy, do all the work at
home, we cannot give you rest if you are not able to do work so don’t bring more
kids.” (Participant 2 & 4, gravida 3, gravida 4)

“In-laws does not help me in household chores, sister-in-law eats a meal

with us and does not collects utensils and does not help me in washing clothes
conversely mother-in-law says to do household chores facilitates the delivery of the
baby.” (Participant 9, gravida 4)

“Our routine is that son’s wife will do all of the work at home and their own
daughter will not do anything. They treat their son’s wife like a maid they hire for
themselves. I feel suffocated in my husband’s home when I go to my parents’ house I
feel I am in the open air.” (Participant 10, gravida 2)

The participants experienced a lack of support from both their husbands and in-laws.
In-laws did not support them when their husbands do not earn. They added that if
their husbands’ financial condition was poor so the in-laws were also did not ask
them whether they were in need for their health or they need any diet.
“My husband plays with his phone and laptop and I try to talk to him, I try
to spend time with him but he does not reply to my words, my mother-in-law says
that although he is careless but it is the power of your prayers that you remain
healthy before after delivery of the baby.”(Participant 5, gravida 3)
“My in-laws have the poor financial condition and they know that their
son also does not do any job, but they even do not ask me if I need something like
food or medicine.”(Participant 4, gravida 4)

Others highlighted that family marriages are not good as their aunts were so loving
and caring before their marriage but when they turn into mothers in-law their
behaviors got changed which was also painful. They expressed that they might not
need medical care if they have stress free environment:
“Mother In-law is my aunt; she liked me for her son but now she blames
me for my bad luck. She says you have bad luck there is no money in your luck, so he
cannot do any job. Money is in wife’s luck and kids are in husband’s luck.”
(Participant 4, gravida 4)
 “She is my aunt; she was very loving when I was not married to her son but
she is so harsh to me, my husband to see everything, but he does not say anything
because he says environment gets tough if he says any single word to them on my
behalf. Husband’s support makes you stress free during pregnancy and throughout in
life.”(I think the doctor is not needed if you are mentally relax at your husband’s
home. Participant 10, gravida 2)
One of the participants’ views was against the views of all other participants; she told
that her husband as well as in-laws was fine. Her husband was caring; he brought
milk for her daily when she got pregnant. She added that whenever she felt any
problem with her pregnancy her in-laws carried her to the doctor for check up
though they were financially poor. She said that she was satisfied with her married
life.
“My husband is so loving and caring; he takes care for my diet, he brings me
½ kg milk and fruits on daily basis, though my in-laws are poor financially but they
bring me medicine if I need and they take me to the doctor if need check up.”
(Participant 7, Primi gravida)
Physical and mental strain
One of the challenges faced by women was “physical and mental strain” which was
due to fatigue and natural mood swinging and frustration, mothering and violence
and abuse during pregnancy.
Mood swinging and frustration was the most common cause of mental strain in
participants. They highlighted that they feel mood changes when they get pregnant.
Sometimes they do not want to hear and talk to anyone. They want mental peace
during pregnancy, but their husbands do not understand them:
“Woman gets frustrated during pregnancy, it is common. I also get frustrated,
I want no one makes noise no one talk loudly, when children make noise I use abusive
language to them because I dislike noise during this period. Everything returns to
normal after delivery of the baby.” (Participant 8, gravida 4)

“Woman gets frustrated during pregnancy, but husbands don’t care for their
mood.” (Participant 1, 2, 5, 9 & 10)
Mothering is also an issue during pregnancy. Participants expressed that they need
help in handling other children because they cannot manage feeding and cleaning of
their young children during pregnancy but their husbands and in-laws do not help
them beyond watching everything.
“To manage other children with a full term pregnancy is exhausting. My son
wants to play all the time and I cannot walk easily with heavy abdomen but instead
of helping my mother-in-law says not to bring other children if you are unable to
control them.” (Participant 2 gravida 3)

“It is very difficult to clean and feed other children with heavy abdomen but
mother in-law says that she is not responsible for my children.” (Participant 4 gravida
4)

Violence and abuse was also reported as a bad habit of the participant’s husband
which was risky for both mother and child. One of the participants highlighted that
her husband beat her without any specific reason and used abusive language with
her and children also.
“My husband beats me badly, sometimes bleeding starts from my nose.”
(Participant 6, gravida 3)
“My husband was good in the first year of marriage, but someone bewitched
him, and he started using abusive language to me and children. We have been
married for seven years.” (Participant 6, gravida 3)

Barriers to antenatal services

Participants discussed a few barriers to antenatal services in terms of socio-economic
status of the family and inappropriate behavior of husbands and in-laws.
Participants said that their husbands were not actively searching for a job so they
were not able to pay for their antenatal checkups. Another said that their in-laws did
not allow their husbands when they want to seek private health services as public
sectors were not satisfactory.
“I cannot afford maternal health services because my husband doesn’t do
any work he stays home all the time.”(Participant 4, 6, gravida 3, gravida 4)
 “I want to go to the private setup but my elder sister-in-law does not allow
my husband to take me to the private clinic and she goes to the private setup for
herself when she gets pregnant.” (Participant 10, gravida 2)

One of the participants gave her views that she was not allowed to go and seek
maternal health services if her husband was not home and they have emergency, but
they will not go alone to see the doctor.
“If my husband is not home I am not allowed to leave home to seek medical
care and my in-laws also do not go with me. Money is also a big problem for me to
seek maternal health services.” (Participant 2, gravida 3)

Participants talked about their in-laws authoritarian behavior. They stated that if
their husbands give the whole salary to their mothers and if their husbands asked for
money for antenatal check up of their wives but their mother in-law did not allow
them to spend money on their pregnancy. They added that they were in need to ask
for money from their own parents instead of husbands or in laws because they were
aware of pregnancy complications.
“My husband wish to give me doctor’s fees but his mother did not allow him
to spend on my pregnancy; he asks for money from his mother for everything he
needs because he puts his full salary in his mother’s hands. I bring money from my
parents for my checkups because I know complications may occur during pregnancy
as I have experienced them in previous pregnancy.” (Participant 1, gravida 2)
Discussion
In the current study it was observed that good support from husbands and family
members positively and poor support from them was negatively affecting maternal
and child health. It was suggested by the study participants that husband’s support
provided emotional security, mental peace and improved physical health of the
pregnant women. A study from Nigeria showed similar results that 86% of the
women who were supported by their husbands showed less stress during pregnancy
and they felt emotionally secure and physically healthy [17]. Another study in Brazil
also showed that husbands supports and participation in women’ reproductive
health produced feelings of confidence and safety in women [18]. Expectant mothers
want to do rest in their last trimester but they have to do household chores without
the help of any member from in-laws. The in-laws believed that routines tasks would
facilitate the delivery of the baby. In-laws shared their experiences with their
daughter in-laws that when they were young they would have to do their routine
household chores without anyone’s help. The participants’ husbands also supported
their parent's views. Findings were supported by a study in South Africa that
daughters in-laws were expected to do harder and longer works in the fields and at
their homes and in other days also during pregnancy[19]. In Pakistani culture it is
found that decision making whether it is financial or about the health of expected
mothers is on the basis of hierarchy and age but a study in Nepal showed that
financial decision making was mostly in the hands of husbands in the nuclear family
system[20]. Multiple challenges faced by expecting mothers were the cause of
physical and mental strain in them e.g. incomplete bed rest and household chores,
inadequate food, use of the abusive language of family members and husbands,
violent behavior of husbands i.e. beating and verbal abuse, mothering tasks like
feeding and cleaning kids. They felt tired due to services they were providing to their
in-laws and managing their kids without the help of anyone. Mood swing was
another big issue found in many pregnant women which was frustrating for them
when no one cared for their mood. Literature showed multiple findings concordant
to this study [21, 22]. They also expressed that fatigue during pregnancy was
physical, psychological and emotional [21, 22]. Studies also showed that women
relied financially and emotionally on their husbands and family. Poor financial
support from a partner did not meet the adequate food requirements for pregnant
women and affected their physical health during pregnancy[23]. Barriers that were
found in accessing antenatal services were poor financial condition and husbands
and in-law’s inappropriate behavior. Husbands and in-laws took pregnancy as a
natural process and didn’t feel the need to go for antenatal checkups until unless
complications occurred. Some risks were also understood by the participants due to
overlooking behavior of husband and in-laws i.e. miscarriage in the first three
months and development of high blood pressure during pregnancy. Participants
understood that delay in seeking medical care may arise problems like anemia and
fetal anomaly during pregnancy, but they were unable to seek medical care due to
lack of financial support from husbands. Participants who were aware of the risks
depended on their parents for money to prevent those risks but others who couldn’t
depend on their parents and in-laws were also not supporting them, were more
prone to develop such complications during pregnancy and at the time of delivery.
The findings were concordant with the study in Nepal in which role of mother-in-law
was highlighted as the resource person of the family and husband had to ask money
from his mother which was resulted in delayed seeking care [24]. Findings were also
consistent with a systematic review which reviewed 131 studies and found all the
characteristics discussed in the present study around the world in which 16% of the
studies were from Africa, 29% were from Asia and others were from Latin America,
Middle East [25].
The strength of the study was that it provided a richer insight of pregnant women
regarding their husbands and in-laws’ support during pregnancy. Participants who
were willing to participate enjoyed to give their insights and participated actively.
Researcher did not feel bore or exhausted at any stage of the study. The topic was
very interesting and researcher felt joy when conducting interviews. The weakness of
the study was that the topic of the study was sensitive. Researcher faced resistance
in conducting interviews because whenever the title was explained to the participant
they felt uneasy to provide information about their husbands and in-laws’ behavior.
Only highly educated participants were convinced easily, rest of the participants
needed much struggle to be taken into confidence for providing their private
information. Six participants provided data only about health professionals and
health services access and refused to give information about their in-laws so their
recorded interviews were discarded due to insufficient data.
Conclusion
Study findings showed that support of husbands and in-laws could affect maternal
and child health both positively and negatively. The current study helps the nurses to
explore pregnant women’s feelings regarding their husbands and in-laws and can
treat the patient accordingly when they come to the antenatal clinics. By
incorporating, support of husbands, in-laws and health professionals the
comprehensive and effective support can provide optimum level of health to the
expected mothers and their upcoming children to achieve the third goal in
sustainable development goals. Study also suggests that nurse should provide
culturally sensitive care to pregnant women.
What is already know on this topic
 Pregnancy complications are due to delay in seeking care.
 Mother in-law and husband are the key persons that if take care for pregnant
lady could lead to a healthy pregnancy outcomes.
What this study adds
All pregnant women should be screened for depressive symptoms regardless of age,
socio-economic status, and race or education level. Thorough history and physical
exam could highlight pregnancy complications i.e. anemia, pregnancy induced
hypertension etc. which may be because of delayed in seeking care. Other pregnancy
related complications e.g. preterm delivery or low birth weight babies may also be
assessed for poor support from husbands and In-laws during pregnancy. Case
management approach could be used for pregnant women who are severely
affected by their families’ behavior. Family centered approach should be used by
health professionals. Multiple studies could be conducted on the basis of the current
study e.g. future cross-sectional studies could be conducted on physical and mental
strain among pregnant women in joint family system, family dynamics, barriers to
accessing maternal health services etc.
Competing interests
The authors declare no competing interest.
Authors’ contributions
All the authors were equally involved in conceptualization and the design of the
work, searched literature, data collection, analysis and interpretation and wrote
report.
Acknowledgements
All the participants and hospitals administrators are equally acknowledged for their
help and cooperation in completing this study.
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