Sociodemographic characteristics
Seven married pregnant women were included in the study. The ages ranged between 22 and 32 years, with an average of 26 years. Nearly half of the patients were primigravida. Many women had educational backgrounds from primary school to postgraduate; however, their male partners had educational backgrounds from middle school to postgraduate. Some women also held prestigious positions in both the public and private sectors. Most of the women shared a joint family system with their in-laws, including mother-in-law, father-in-law, sister-in-law, younger brother-in-law, and older brother-in-law, while few lived in the nuclear family (Table 1).
Pre-intervention phase
In the pre-intervention phase of the study, three main themes emerged from the collected data: (1) Impact of adverse life events on the mental health of pregnant women, (2) adverse effects of marital relationship issues on pregnant women’s health, and (3) depression-causing factors due to the joint family system. Figure 2 illustrates the emerged themes, subthemes/categories, and the codes from which the themes are derived.
Pre-intervention themes, subthemes, and codes
Impact of adverse life events on the mental health of pregnant women
For many women with depression, pregnancy has proven to be difficult due to their history of traumatic life events. In addition, life events included the death of a child, a divorce from the partner, and a mother’s serious illness, to name a few. The negative thoughts brought about by a negative experience were among the potential AD aggravators. Pregnant women who are in the middle or late stages of pregnancy are more likely to experience depression than postpartum women. Antenatal depression is a devastating condition that can cause a wide range of issues and aftereffects. For instance, depressed pregnant women may deal with a variety of conflicting roles, a lack of social support, uncertainty about the future, emotional instability, and issues with body image. Preterm birth and obstetric complications are additional potential risks.
Additionally, depression in mothers and wives can endanger the mental and physical well-being of newborns as well as their husbands. Different participants shared the adverse life events of their lives that impact their mental health:
“My greatest fear is losing another child. As five years ago, I delivered an abnormal child who could not survive afterwards; I am petrified that it might happen again.” (M1).
“This is my second pregnancy. Last year, I had a miscarriage, and I had a blood pressure problem during pregnancy. That is why I lost my baby.” (M6).
In addition, one participant shared the poor experience of her mentally dysfunctional child:
“I have a 7-year-old mentally disabled child. He cannot eat or urinate himself. He beats his siblings very brutally, which is why I must tie him with a chain. I felt great pain from seeing him in this condition. Many times, the environment of our home gets too stressed.” (M5).
Adverse effects of marital relationship issues on women’s health
Another significant factor identified as contributing to depression in pregnant women was difficulty in relationships. It seems that relationship problems caused by the husband’s or family member’s rudeness and lack of cooperation resulted in symptoms of depression in pregnant women. Due to the emotional highs and lows that pregnancy hormones can cause, many women may feel more vulnerable or anxious. Some women may struggle to manage their symptoms or even experience complications during pregnancy, which can add to extra stress. If pregnant women have a positive relationship with their partners, women who feel loved and supported will better cope with these situations. However, the majority of pregnant women may experience anxiety, depression, or self-doubt due to unhealthy relationships. The majority of the mothers reported that they had to suffer from domestic violence while they were pregnant. Pregnancy could be experienced for the first-time during pregnancy, or preexisting abuse might worsen one’s mental health and pregnancy.
“My husband does not like me and beats me very brutally, even during my pregnancy. When he shouts at me, I tremble with fear, and I cry. He scolds and misbehaves with me all the time.” (M5).
“My husband is very short-tempered and dislikes talking or discussing routine matters. I feel that we lack a friendly relationship. I could not share my problems with him due to fear. He criticises me on different issues and taunts me, blaming my parental family.” (M1).
“I had primary education, and my husband did a master’s degree and had a good Government job. There is a significant difference in education between me and my husband. He does not like me and is not happy with me. I always feel an inferiority complex. He says you are dumb and dull and make dramas; whenever I complain about my bad health and pain, he does not believe me.” (M7).
Depression-causing factors due to the joint family system
Pakistan has a widespread trend of joining families where extended families live together, sharing a typical household environment, household chores, and many other family responsibilities. Usually, the mother-in-law or father-in-law is considered the head of the family, which restricts and interferes with the lives of their son and daughter-in-law. Ultimately, these circumstances create issues for daughters-in-law, for instance, a lack of social support from husbands and families, excessive interference from mothers-in-law, a lack of decision-making capacity from females, and mothers-in-law’s authoritative behaviour.
On the other hand, in a patriarchal society such as Pakistan, household chores are exclusively the domain of women, which also exacerbates the mental condition of pregnant women. This process becomes significantly more difficult for mothers during pregnancy and other difficult times. Some mothers identified stress-inducing factors as the burden of household work and the absence of support from husbands or in-laws. Additionally, women with greater responsibilities and less support from their husbands and families reported sleep problems and fatigue, which harmed their interactions with their husbands and children. Low rewards and lack of visibility in housework are also determining factors for pregnant women.
Therefore, this theme has three subthemes: lack of emotional support from family, mother-in-law’s authoritarian attitude toward a joint family, and lack of autonomy in making decisions.
Lack of emotional support from the family
Another factor that seemed to contribute to the mothers’ depression was a lack of emotional support; when they had nowhere to turn for help, this led to depression. When physical and emotional changes occur during pregnancy, family support and sympathy are crucial, and expectant mothers need kind and caring people close together to share their feelings and struggles. This can help halt the development of depression. An unstable marriage can prevent the wife from discussing her problems with her husband, other family members, or in-laws. Individuals may begin to lack maternal confidence if they do not trust others and do not share their problems with their immediate family. A healthy relationship between partners, family members, and pregnant women is essential for overcoming stress and mood disorders during the transition to parenthood. Women who move to far-off places and different cultures after marriage experience adjustment problems; in such a circumstance, a lack of emotional support results in sadness and depressive symptoms.
“I am unable to discuss my issues with my husband or my mother-in-law. It frustrates me and makes me feel unimportant in the family that I am not even allowed to discuss my problems with my mother because my husband does not like this.” (M2).
“I did not like to share anything with my husband. Whenever I share my mother-in-law’s attitude, my husband always supports his mother and considers me guilty, not in my home even in front of their relatives, which makes me more annoyed. Therefore, I stopped sharing anything with him and did not consider him trustworthy.” (M3).
“I belong to Karachi, and we are married in Lahore. We live in a joint family system. I do not have friends here. I miss my parents and family a lot. I could not visit my parents’ home because it was too far away and required a lot of money and time. I am not frank with my in-laws. Sometimes, I discuss my problems with my sister-in-law, but I cannot discuss many things with her; this makes me feel useless and helpless.” (M4).
Authoritative attitudes of mothers-in-law in joint families
The conflict between mothers-in-law and daughters-in-law seems to be a significant source of stress for married women in Pakistan, affecting their psychological health and ability to adjust to marriage and further their period of pregnancy.
The majority of the participants reported that in-laws are a significant cause of depression because of poor behaviour, poor treatment by mothers-in-law during the antepartum period, and lack of support from husbands and family. Increased household responsibilities and a lack of support from the husband and other family members are additional factors that contribute to maternal depression. The family environment significantly impacts the physical and mental health of mothers. More importantly, it appeared that mothers’ poor behaviour directly resulted from husbands’ and mothers’ negative behaviour. Social support was found to be an essential tool for resolving disputes with mothers-in-law. A daughter-in-law may require support from those close to her to deal with the conflict successfully. These support systems could include empathy, a sense of competence, or suggestions for potential resolutions. Positivity may be associated with a daughter-in-law based on how she is viewed by others, either directly or by attenuating the perceived intensity of conflict and psychological well-being.
“My husband is the eldest son of his family and works in a factory; he and I have a significant responsibility at home. We live in a joint family system in a rented house. I was the first daughter-in-law, and my mother-in-law and father-in-law put many restrictions on me; I had no permission to make decisions about my life and family.” (M1).
“My mother-in-law constantly criticises me for her little interest. She creates big issues with minor things. She brainwashes my husband against me, which makes him rude to me. Sometimes I feel I will get mad in such a suffocating environment.” (M2).
This reflects that the family environment is vital to mothers’ physical and mental well-being.
Lack of autonomy in terms of decision
Women do not have the authority or complete freedom to make decisions that affect their own lives, families, or children. They do not receive respect from a family member and frequently rely on their husbands, mothers-in-law, and other relatives to make decisions about their matters. Even when they came to move freely to access medical care and meet basic needs for themselves and their children, women faced restrictions from their husbands and in-laws. Women are prevented from obtaining education and working due to the restrictive and controlled environment created by their in-laws, which causes stress, anxiety, and hopelessness. Mothers’ physical and mental health is impacted by their partners’ harsh and unsupportive attitudes toward their families and children. Females felt frustrated and stressed due to their domestic responsibilities, uncooperative family members, and abuse of power by in-laws, which resulted in antenatal depression.
“I was an MPhil student and had to freeze my semester due to family problems. I have no permission to move independently, even for my gynaecological check-ups. I must wait or request someone to take me to the hospital, which is why I missed some of my routine visits.” (M2).
“My father owns a school, and before marriage, I used to teach there. I still want to continue my job, but my husband does not allow me to teach or do any other job or further studies. I am unhappy with my married life because it greatly restricts me. I cannot continue my studies and teaching when I compare myself with my other sisters and friends; they live joyful lives at university.” (M1).
Post-intervention themes
The post-intervention phase focused on THP effectiveness and assessed the intervention’s contribution to reducing depression, as described by the participants. The THP’s objectives were to cure mothers with depression and encourage optimism. Following the postintervention interviews, the four main themes appeared: (1) Development of positivity in thinking and attitude, (2) gaining self-esteem to deal matters positively, (3) relationship improvement with unborn and family, and (4) learning about stress management through the provision of compassion and sharing avenues. Figure 3 represents the themes, subthemes and codes that emerged in the post-intervention phase.
Post-intervention themes, subthemes, and codes
Development of positivity in thinking and attitude
Positive thinking concentrates on good things in life and expects good things to occur. Women may find this difficult, particularly during pregnancy. A positive outlook is a way of thinking that does not easily give in and is unaffected by obstacles, problems, or delays. Through the THP intervention, women were inspired to adopt a positive outlook and improve their physical health. THP intervention also aids pregnant women in changing their thought patterns. A mother’s ability to improve her health more effectively will ultimately help to ensure the child’s healthy development. Mothers can be encouraged to stay active by a healthy diet and sufficient sleep. Mothers are unable to adopt healthy habits that are harmful to both the mother and the unborn child because of negative thoughts. Sessions with a psychologist helped pregnant women handle routine tasks or daily life more positively, which ultimately seemed beneficial for the mother. Positive thinking, which is related to the mother’s physical and mental well-being, appears crucial for a healthy baby’s sake.
“Before sessions with a psychologist, I used to find faults in my thinking behaviour, which made me irritable and angry. I realised that we can do everything when we prioritise things for ourselves and our children. I averted my negative for me and my unborn baby. I feel much better about myself. I stopped overthinking about my mother-in-law’s behaviour; it improved my irritating behaviour and anger.” (M2).
“My previous practices during pregnancy were not good. I was not eating three meals and never asked for help or discussed my needs with anyone. I used to take my breakfast with my husband and wait until night to have dinner with him or with family. However, now, I started to eat my diet correctly. After seven years, I conceived and tried my best to perform all the practices to get a healthy and normal child. That motivated me a lot to take care of myself and my baby.” (M1).
Learning about stress management through the provision of compassion and sharing avenue
Stress management is a psychological intervention technique that reduces how the body responds to demanding environmental circumstances. These troubling responses could be the result of negative emotions such as anxiety, depression, anger, pain, or illness. The intervention helped the mothers by directing ways of reducing discomfort, which may include directly addressing the source of the stress through relaxation, altering one’s perspective of the situation (reappraisal), or changing the environment (e.g., making greater use of available social support). THP sessions assisted pregnant women in managing stress and opening up to share their issues rather than enduring them silently. Women who have learned stress-coping techniques attempt to control their problems by looking for solutions rather than thinking negatively about them. The meetings also gave them a sense of community and gave them a place to talk about their issues. Pregnant women find relief and relaxation from negative thinking by spending time with someone, talking about the positive aspects of life, and exploring solutions to the issues and difficulties of parenthood.
“I liked the way you counselled me about my mentally retorted child, and I felt relaxed knowing that there is someone who understands my difficulties and I am not facing them alone. These sessions motivated me to take care of myself and my unborn baby.” (M5).
“I decided to participate in the program for my mental relaxation. I did not share my problems with anyone. I was harming myself physically and mentally. You listened to all my concerns very carefully and made me very relaxed. I avoid overthinking useless things now. When I did not react to small things, my home environment automatically went well, and my mood also improved.” (M2).
Gaining self-esteem to deal life matters positively
People who are confident in themselves and their abilities appear at ease. They engender confidence and invite others to trust. All of these qualities are desirable to possess. However, it is not always simple to have self-confidence, especially if you tend to be critical of yourself or if other people criticise you. Almost all mothers asserted that every aspect of our lives requires self-confidence, but many people lack it. The THP intervention revived and boosted our self-confidence to address life matters positively and more efficiently.
“My mother is blind, and my elder sister also had a 3rd trimester of pregnancy. My mother-in-law also refused to take care of me. After delivery, I was alone in the hospital and had a C-section, and my husband was also not allowed to come there. I was terrified. I changed a lot. If I were my previous self, I would die, weeping and crying, and I could not manage the things that I could be able to do at this time.” (M2).
“In my opinion, I became brave now and gained some self-confidence in facing and handling the worst situation. I will be affectionate toward my children and develop a strong bond with them. I managed a helping hand to support me these days by discussing my situation with my husband and neighbourhood friend.” (M5).
“Can you believe I sold my gold set a couple of weeks ago? My husband tried to convince me to sell many times, but I refused. Through these sessions, I converted my thoughts from negative to positive and gave them to my husband without any bad behaviour. That was very unusual for my husband and my in-laws. This was very relaxing for me because it solved our problem, which can give me stress.” (M4).
Relationship improvement with the unborn child and family
One of the key focuses of these psychotherapy sessions, which were shared by some of the participants, was building relationships with the unborn individual and other family members that gave the mother a comforting feeling and a sense of connection. A woman’s life goes through a new stage with pregnancy, along with all the changes that may result from that new stage. People often discuss obvious factors, such as cravings, exhaustion, nausea, and body shape. Still, other circumstances, such as negotiating new employment terms and reorganising your finances, can make this a challenging time. Many women experience emotional, financial, physical, and social changes during pregnancy. A normal and important aspect of getting ready to have children is experiencing mixed emotions. Women’s relationships undergo significant changes because of their pregnancy, particularly if the pregnancy is the first child. While some women adjust to these changes without much difficulty, others struggle. It is quite typical for couples to argue while pregnant occasionally. It is crucial to understand that there are valid reasons for feeling closer and more in love during pregnancy and for occasional difficulty. The mother’s positive behaviour seemed to depend on her family’s ability to form a strong bond with her. Strengthening a mother’s bonds with her child and other family members can be facilitated by practising conflict resolution and problem-solving techniques.
“I am taking care of my diet all the time for my baby. I feel much better about myself and my well-being. I tried to develop a good relationship with my husband and in-laws. When I started practising developing a bond with the unborn child, it responded to me by giving me movements. My relationship with a 3-year-old child has also improved. I loved him more, tried to spend time with him, and enjoyed his playing activities, which relaxed me.” (M4).
“My husband was not cooperative, which made me so angry. However, now I have changed my thinking and found that he did so because he thought all these activities made me active and engaged with him. He made me realise I am not ill and I can do house chores. The development of relations with the unborn was fascinating for me. I feel my baby with love; I talk to him in my imagination, and he responds to me by making movements. This is my very pleasurable activity.” (M2).
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