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Understanding and Meeting the Needs of Women in the Postpartum Period:

The Perinatal Maternal Health Promotion Model

Article  in  Journal of midwifery & women's health · December 2013

DOI: 10.1111/jmwh.12139 · Source: PubMed

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Journal of Midwifery & Women’s Health www.jmwh.org
Original Review

Understanding and Meeting the Needs of Women in

the Postpartum Period: The Perinatal Maternal Health
CEU
Promotion Model
Jenifer O. Fahey, CNM, MSN MPH, Edmond Shenassa, ScD

A new model for the care of women in the postpartum focuses on the development of life skills that promote complete well-being. The year
following childbirth is a time of significant transition for women. In addition to the physiologic changes associated with the postpartum period,
a woman undergoes marked psychosocial changes as she transitions into a motherhood role, reestablishes relationships, and works to meet the
physical and emotional needs of her infant and other family members. It is a time when women are vulnerable to health problems directly related to
childbirth and to compromised self-care, which can manifest in the development or reestablishment of unhealthy behaviors such as smoking and
a sedentary lifestyle. In addition to long-term implications for women, compromised maternal health in the postpartum period is associated with
suboptimal health and developmental outcomes for infants. Maternal health experts have called for a change in how care is provided for women
in the postpartum period. This article presents the rationale for a health promotion approach to meeting the needs of women in the postpartum
period and introduces the Perinatal Maternal Health Promotion Model. This conceptual framework is built around a definition of maternal well-
being that asserts that health goes beyond merely the absence of medical complications. In the model, the core elements of a healthy postpartum are
identified and include not only physical recovery but also the ability to meet individual needs and successfully transition into motherhood. These
goals can best be achieved by helping women develop or strengthen 4 key individual health-promoting skills: the ability to mobilize social support,
self-efficacy, positive coping strategies, and realistic expectations. While the model focuses on the woman, the health promotion approach takes
into account that maternal health in this critical period affects and is affected by her family, social network, and community. Clinical implications
of the model are addressed, including specific health promotion strategies that clinicians can readily incorporate into antepartum and postpartum
care.
J Midwifery Womens Health 2013;58:613–621  c 2013 by the American College of Nurse-Midwives.

Keywords: patient education, postpartum care, postpartum depression, preventive health care, public health

INTRODUCTION AND BACKGROUND
The postpartum period, as defined in the biomedical litera-
ture, is the 6- to 8-week time period beginning an hour fol-
lowing the birth of the fetus and expulsion of the placenta
and reflects the approximate time required for uterine invo-
lution and return of most maternal body systems to a non-
pregnant state. However, reproductive system involution and
the reestablishing of nonpregnant physiology are not the only
critical events occurring in the months following childbirth.
The postpartum period is also characterized by psychosocial
adaptations, including changes in parental role,1, 2 changes in
family relationships,3, 4 and alterations in self-perception and
body image,1, 4, 5 many of which take significantly longer than
6 to 8 weeks to resolve. These transitions, coupled with the
physical recovery from childbirth and the work that is re-
quired to meet the needs of an infant, make the year that
follows the birth of a child a time of heightened vulnerabil-
ity to health problems for women. Evidence suggests that, if
unmitigated, the stressors of the postpartum period can lead
to anxiety,6 fatigue,7 and decreased self-care,8 which are fac-
tors associated with an increased risk of physical and mental
illness—including postpartum depression.9, 10 Maternal men-
Address correspondence to Jenifer O. Fahey, CNM, MSN, MPH, Depart-
ment of Obstetrics, Gynecology and Reproductive Sciences, University of
Maryland, School of Medicine, 250 W. Pratt Street, Suite 880, Baltimore,
MD 21201. E-mail: jfahey@fpi.umaryland.edu
tal and physical health problems are in turn associated with an
increased risk of a multitude of poor health outcomes for the
entire household, including early breastfeeding discontinua-
tion, negative maternal perception of her infant, delayed child
language acquisition, compromised maternal–child attach-
ment, decreased childhood immunizations, and increased
child behavioral problems.11–13
Given the potential long-term impact of compromised
maternal health for the long-term well-being of the woman
and her family, it is not a surprise that maternal health experts
have called for optimizing women’s health in the year follow-
ing childbirth.14–16 Despite these calls, the health of women
during the postpartum period remains a neglected aspect of
health care that has been the subject of comparatively little re-
search, policy, and clinical attention. Therefore, it is not sur-
prising that many women report that their health concerns are
not adequately addressed in the course of their routine post-
partum care.17 In the United States, this care typically con-
sists of 2 to 3 days in the hospital following the birth, fol-
lowed by a postpartum visit 3 to 8 weeks later that focuses on
screening for and managing complications, assessing for re-
productive organ involution, and the initiation of contracep-
tion. In the last few years, there has been increased scrutiny
regarding the effectiveness of this care in terms of a holistic
approach to addressing the needs of women during this criti-
cal period.11, 15, 18, 19
The prevention, detection, and management of medical
complications of the postpartum period are, and should con-

1526-9523/09/$36.00 doi:10.1111/jmwh.12139 
c 2013 by the American College of Nurse-Midwives 613
 ✦ The year that follows childbirth is a time of immense physical and psychosocial transition for women during which women
are vulnerable to compromised health not only from causes directly related to childbirth but also from decreased self-care
related to the demands of new motherhood.
✦ Optimizing the health of women in the year following childbirth requires a shift from a disease screening and treatment
approach to a health promotion approach that focuses on strengthening 4 life skills that have been demonstrated to promote
health: mobilization of social support, positive coping skills, self-efficacy, and realistic expectations.
✦ These life skills promote health directly by leading to improved health-seeking behaviors and indirectly by serving as buffers
from the stressors of this time period.
✦ Clinicians can help women enhance these life skills through targeted educational messages, activities, and referrals during
the antepartum and perinatal period.

tinue to be, key components of maternal perinatal health. A
summary of recommendations related to these is included
in Table 1. However, interventions that promote health in all
women during the postpartum period have been identified as
a critical gap in the care provided to women during this pe-
riod of transition. This article presents the key concepts that
characterize a health promotion approach, followed by the in-
troduction of a health promotion model for the postpartum
period to help guide providers and researchers in work to fill
this gap. This perinatal maternal health promotion model is
based on findings of studies on the needs of women in the
postpartum period, as well as on factors that are determinants
of maternal health.
HEALTH PROMOTION
Three core concepts distinguish a health promotion approach.
The first tenet is the perspective of health as a state of well-
being, which is the capability to engage in developmentally
appropriate physical, psychological, and social tasks to one’s
fullest potential.20 Within this perspective, well-being is dif-
ferent than simply the absence of disease or disorder.21 From
a health promotion perspective, individuals are not healthy
unless they are living to their fullest potential. Well-being is
in part predicated on the learning and adoption of skills and
traits that buffer the individual from disease-inducing events
and situations. For example, a key protective factor is the com-
petence by which individuals navigate stressful life events, re-
lationships, and experiences.22, 23
The second tenet of health promotion is universal appli-
cation. The premise of this approach is that every individual
can benefit from improved functioning, and thus from pro-
motion of well-being in all people. This approach circum-
vents problems associated with inaccuracies in classification
of women’s risk status and errors in prognosticating women’s
future health status based on these risk factors. For example,
not every woman who is diagnosed as depressed is truly de-
pressed and not every woman who is correctly diagnosed with
depression has a poor prognosis. Similarly, some women with-
out risk factors will develop postpartum depression (PPD),
while others will have some signs of depression but will not
cross the threshold by which an intervention may be trig-
gered, such as a particular score on the Edinburgh Post-
partum Depression Scale. By undertaking health promotion
efforts to help all women to achieve effective coping skills and
activation of a woman’s social network, clinicians have the po-
tential to reduce the overall incidence of maternal depression,
including among those who may not have any observable risk
for depression or who are below the diagnostic thresholds.
Moreover, where a large population is experiencing height-
ened vulnerability, such as the 4.1 million women who give
birth in the United States each year, even a low prevalence of
a condition will lead to a large number of affected women. An
intervention that lowers the prevalence of postpartum depres-
sion in the United States from 13% to 10%, for example, would
prevent 123,000 cases of PPD annually.
The third tenet of health promotion is the importance
of contextual influences. Within this perspective, individu-
als’ well-being is best viewed within the context of the fam-
ily, and the family within the context of its community. Con-
textual factors, such as family members’ misunderstanding
of psychological issues and the social milieu (eg, the social
stigma of suffering from depression), have long been recog-
nized as deterrents for seeking treatment. Health can thus
be promoted by amplifying the positive contextual influences
and reducing the social barriers to help-seeking. Individual-
level efforts do not address the contextual issues that, in addi-
tion to decreasing the probability that such efforts will be suc-
cessful, leave future generations vulnerable to the same risks
facing the present generation.24 To the extent that changes in
the social milieu are lasting, programs that work to change
these contextual influences also promote the health of future
generations.
PERINATAL MATERNAL HEALTH PROMOTION
MODEL
The model introduced here and presented visually in Figure 1
was created in response to calls for a change in the approach
to the postpartum period.11, 15, 16 It applies health promotion
concepts and provides a framework for understanding both
the factors that correlate with a successful maternal transition
and how to translate this understanding into practice.
At the center of the model are key components of a healthy
postpartum period: 1) physical recovery from pregnancy and
childbirth; 2) meeting the needs of the mother (including so-
cial needs), infant, and other family members; and 3) suc-
cessful attainment of the maternal role. The next layer of the

614 Volume 58, No. 6, November/December 2013

 Table 1. Common Postpartum Complications: Prevention and Management
Complication Preventive Strategies
Excessive bleeding Conduct active management of the third stage of labor;
avoid traction on cord in third stage until signs of
placental detachment; minimize operative birth and
episiotomy; monitor anticoagulation therapy closely.
Infection Endometritis: Minimize number of vaginal examinations
during labor; provide prophylactic antibiotics 20-30
minutes prior to cesarean; avoid manual removal of
placenta and manual exploration of uterus.
Urinary tract infection: Avoid/minimize catheterization;
promote voiding following birth.
Episiotomy/laceration infection: Avoid episiotomy; utilize
appropriate repair techniques; promote sitz baths.
Mastitis: Promote frequent and regular
breastfeeding/pumping (8-12 times per day); provide
assistance with latch-on techniques.
Depression Promote social support; screen for and treat antepartum
depression.
Thyroid dysfunction Promote euthyroid state in pregnancy for women with
preexisting thyroid disease.
Venous Avoid prolonged immobilization; compression boots if
thromboembolic indicated; early postpartum ambulation; prophylactic
event anticoagulation if indicated; delay of combined hormonal
contraception until ⬎ 21 days postpartum (⬎ 42 if other
risks of VTE).
Urinary Promote pelvic floor exercises; avoid operative birth; avoid
incontinence episiotomy.
Management
Evaluate to find cause (eg, uterine atony, retained
products of conception, lacerations, hematoma,
coagulation disorder/anticoagulation treatment)
and treat accordingly.
Obtain a culture and sensitivity if indicated;
prescribe antibiotic therapy as indicated;
recommend antiinflammatories and other pain
relief measures as needed. If mastitis occurs,
instruct woman to continue to breastfeed/pump.
Screen all women using a validated tool; initiate
antidepressants if indicated; contract for safety;
provide referral to psychiatric care.
Screen/test symptomatic women; treat accordingly.
Anticoagulation therapy; screening for
thrombophilia.
Rule out UTI; evaluate for cystocele and uterine
prolapse; pelvic floor exercises; referral to
urogynecology if problem persists.

Abbreviations: UTI, urinary tract infection; VTE, venous thromboembolic event.

Adapted from Thung and Norwitz.15

model contains the key individual skills associated with the
improved ability of women to achieve the goals of the post-
partum. These four distinct but interrelated skills are 1) effec-
tive mobilization of social support, 2) self-efficacy, 3) positive
coping, and 4) realistic expectations and goal setting. Finally,
on the outside layer of the model are external resources that
may be necessary for a healthy postpartum period. These in-
clude access to clinical services, social and other support ser-
vices, information, and material resources such as food and
housing.
Each of the model components is explained in more detail
below.
Core Elements of a Healthy Postpartum
The key components of a healthy postpartum have been
grouped into 3 categories in the model. These categories have
important distinguishing characteristics, but they are intri-
cately interrelated and overlap. The ability to meet the goals in
one area can determine whether or not goals in another area
can be achieved.
Physical Recovery From Pregnancy and Childbirth
Assessing for normal reproductive system involution (eg, re-
turn of the uterus to nonpregnant size, complete shedding of
the pregnant decidua) and the reestablishing of the nonpreg-
nant physiology (eg, normalization of glucose metabolism, re-
turn to baseline blood pressure) is the traditional focus of the
routine postpartum visit with health care providers. There is
some variation among women in how long most body sys-
tems take in returning to a nonpregnant state, but for most
women this will have taken place by 6 to 8 weeks postpar-
tum. However, while most women’s bodies return to what
is considered nonpregnant anatomy and physiology within 2
months, results of population-based surveys of women in the

Journal of Midwifery & Women’s Health r www.jmwh.org 615

 Table 2. Common Concerns of Women in Postpartum Period
Physical
Fatigue and sleep disturbances
Pain (perineal, incisional, breast, nipple, head, and back)
Self-care (hygiene, nutrition, weight loss)
Psychosocial
Maternal role attainment and attachment to infant
Body self-image
Marital/intimate relationship disruption
Care of infant, house, and family
Infant needs (feeding, soothing, identification of signs and
symptoms of illness)
House maintenance (cooking, cleaning)
Needs of other children
Household logistics (transportation, childcare)
postpartum period reveal that many women have physical
concerns directly related to pregnancy or childbirth at 3, 6,
and even 12 months postpartum.25–28 The most common
concerns expressed by women in these surveys are summa-
rized in Table 2. For many women, these concerns are signif-
icant enough to interfere with activities of daily living and/or
with their relationships with others, yet many of them do not
seek help from providers.25–28 Because of this high prevalence
of unaddressed health concerns, the postpartum period has
been referred to as a time of “hidden morbidity.”27 From a
health promotion perspective, successful interventions to ad-
dress these health concerns would be aimed not at increas-
ing the frequency of contacts with the health care system for
all women, as has sometimes been proposed, but at helping
women acquire the knowledge and skills to mobilize available
resources to prevent or address health concerns, including the
ability to seek care when necessary.
Ability to Meet Individual Needs
Pregnancy and the peripartum are a time of transition in
which nearly every aspect of a woman’s life is disrupted. Dur-
ing the postpartum period, a woman faces the task of adjusting
to these transitions and reestablishing balance, routines, and
relationships. During the first few days to weeks following the
birth of a child, a key concern of women is the ability to take
care of their own basic needs for sleep, eating, and hygiene.29
It is common, however, for providers to focus their education,
assessment, and support during this time period on the new-
born’s needs and not the woman’s.16 Women also frequently
ignore concerns for their own well-being in order to focus
their attention on the needs of their infant and family. Neglect
by a woman of her needs during this period can lay the roots
for compromised health for herself and her family in the long-
term. Research shows that the postpartum period is a time of
heightened risk for compromised self-care and for the devel-
opment or resumption of unhealthy behaviors such as smok-
ing, inactivity, and poor diet.16 About one-third of mothers re-
port that during the first 2 months their postpartum physical
616
health or emotional health interfered at least “some” with their
ability to care for their infant, with 42% of all mothers report-
ing physical and/or emotional impairment.26 Unmitigated fa-
tigue and sleep disruption during the postpartum period is
associated with multiple morbidities, including PPD,30 which
in turn are associated with a disrupted transition to parenting
and compromised outcomes for the infant and other mem-
bers of a woman’s family.31 Providers should reassure women
that it is normal to be concerned with their own well-being,
and that addressing their own basic needs in the postpartum
period is essential to their long-term health and the health of
their families.
Maternal Role Attainment
A major goal of the postpartum period is for women to suc-
cessfully transition into their role as mothers. This devel-
opmental process that is alternately referred to as maternal
role attainment, maternal role development, or becoming a
mother is extensively described and discussed in the literature
on motherhood.1, 32 Becoming a mother requires a woman to
redefine her sense of self through a restructuring of goals, be-
haviors, and responsibilities. The ability of a woman to form
an attachment and care for each of her children depends on
her ability to meet the developmental tasks or stages of this
process. Various models have built on Rubin’s initial descrip-
tion of the progressive stages of the process of transitioning
into motherhood. A brief description of key tasks of postpar-
tum maternal role attainment as initially described by Rubin
is included in Table 3. Support of these psychosocial processes
should be an element of care of women during this important
life transition.
Individual Health-Enhancing Skills
Four skills consistently emerge in the literature as necessary
for women to successfully exercise control over their health
and the health of their infants and other family members in
the postpartum period: effective mobilization of social sup-
port, self-efficacy, positive coping, and the setting of realistic
expectations and goals.
Effective Mobilization of Social Support
Social support is the assistance that individuals provide and
receive from others. The role of social support in health behav-
iors and outcomes has been studied extensively. Social support
provided by close relations and professionals appears to have
a positive effect on physical health and psychological well-
being; a lack of social support is associated with unhealthy
behaviors such as smoking and a sedentary lifestyle.33–35 In
the postpartum period, social support can be broadly divided
into 2 categories: emotional support and instrumental sup-
port. Emotional support is what individuals do or say to make
other individuals feel loved, supported, or encouraged. In-
strumental support is when individuals provide needed ma-
terial resources or assist with or complete a task for another
individual. A third category of support, informational sup-
port, is sometimes mentioned in the literature. Informational
support is included in the model as an external or enabling
Volume 58, No. 6, November/December 2013
 Table 3. Rubin’s Phases of Maternal Role Attainment
Taking In: Mother focused on own needs and may need to tell and retell birth story; may take some time accepting newborn as “hers”;
may not feel maternal and may seem passive in maternal role; may not be very responsive to attempts by others to get her to take on
active role in newborn care; may not internalize educational messages.
Taking Hold: At about day 3, mother will become very interested in taking charge of newborn care; may seek perfection in her maternal
caregiver role and is vulnerable to feelings of inadequacy; may become anxious and preoccupied with ensuring that she is doing
everything right; will be open to education, but this needs to be provided in a way that does not erode her feelings of self-efficacy.
Letting Go: Mother may go through broad range of emotions from despondency to euphoria as she comes to accept the significance of her
new maternal role and lets go of her old self to accept this “new normal.”

Source: Attrill.31

Figure 1. The Perinatal Maternal Health Promotion Model

Note: The 3 inner circles are the key maternal tasks of a healthy postpartum period. The ring around these tasks includes the core individual skills that are needed to ensure that
the tasks are successfully accomplished. The outer ring represents resources that a woman may need in order to successfully acquire or employ her individual skills in order to
accomplish the tasks of the postpartum, which include access to clinical services, social and other support services, information, and material resources.

factor rather than an individual skill. In addition to the direct
effects of receiving instrumental assistance with tasks, social
support is also thought to impact health positively by reducing
the degree to which life events are perceived as stressful by an
individual and by enhancing feelings of self-esteem and self-
efficacy.36 The ameliorating effect of social support on per-
ceptions of stressful events is often referred to as a “buffering
effect.”37
Social support emerges as a key need of women during
the postpartum period. Women express a need for both emo-
tional and instrumental support; however, they may priori-
tize the need for instrumental assistance, especially during the
first few postpartum weeks following the postpartum period.
Throughout this time period, women report a need for as-
sistance with infant, child, and household care so that they
can complete basic tasks of self-care such as bathing, eating,
and sleeping.29 Assistance with cleaning and cooking are also
given high priority. Women report anger, stress, and anxiety
when they perceive that others are failing to meet their need
for support.35 Particularly stressful to women appears to be a
dissonance between the support she expects to receive and the
amount of support she perceives to receive.35, 38 This finding
that the perceptions of the support received can be as impor-
tant as the actual support received is consistent with findings
by researchers in other fields of health.33 How social support
is mobilized, the perception of who should provide this sup-
port, and the degree of support that is expected may vary by
race and ethnicity.29
Women from some ethnic or racial groups may be more
likely to rely on their social network for assistance in the post-
partum period. These women may be more likely to feel frus-
trated when their social network fails to meet their needs,
whereas other groups of women may be less likely to involve
anyone in their social network other than their partner in the

Journal of Midwifery & Women’s Health r www.jmwh.org 617

care of the infant or household, and they are also less likely to
express frustration at a lack of support.29
Barriers to effective mobilization of social support in the
postpartum include maternal perceptions that asking for help
will reflect poorly on her parenting abilities, fears of being per-
ceived as a burden, fear of hurting people’s feelings (eg, by
asking for instrumental assistance different than what is being
offered), and a perception that others would not be able to re-
late to her experience and thus not be able to offer adequate
support.29 Helping women overcome these barriers can be a
key intervention by health care providers that helps promote
postpartum health.
Self-Efficacy
In Bandura’s classic definition, self-efficacy is a person’s beliefs
in their ability to perform a particular behavior successfully.39
An expanded definition of self-efficacy as an individual’s
ability to achieve goals has been proposed by others and is
used here. In the postpartum period, self-efficacy is posi-
tively related to health-seeking behaviors and inversely re-
lated to maternal stress and depression.40, 41 Self-efficacy is
also a key skill in maternal role attainment and a woman’s
ability to competently perform infant care and other parent-
ing tasks that depend on her confidence in her mothering
abilities.1, 42, 43 Maternal self-efficacy is also closely linked to
child development.43
Direct experience with a task or similar tasks strongly in-
fluences self-efficacy.39 This is reflected in findings that mul-
tiparas have a higher level of self-efficacy than primiparas and
that maternal self-efficacy increases as the postpartum pe-
riod progresses.2 While direct experience with a task has the
strongest correlation with ratings of self-efficacy, vicarious ex-
periences (seeing others perform the task) are also associated
with increased self-efficacy.39
Another important determinant of maternal self-efficacy
in the postpartum period is infant temperament.44 Women
with infants who are difficult to soothe lose confidence in their
ability to take care of their infants’ needs and are more likely
to report fewer efforts to soothe their infant.45 This highlights
an important snowball effect of self-efficacy: when confronted
with a difficult task, individuals with lower self-efficacy will
avoid or give up more easily, which in turn further decreases
their self-efficacy. Alternately, success at a task that is impor-
tant or difficult enhances self-efficacy and improves the prob-
ability that an individual will persist at a task, even when it
becomes difficult.39
Positive Coping
Although sometimes defined as an adaptive response by an
organism to adverse circumstances, from a human behavioral
perspective, coping can best be defined as an effort to manage
and overcome demands or experiences that pose a challenge
or a threat of harm, loss, or benefit to a person.46 Coping can
occur in response to (reactive) or in anticipation of (proactive)
demands or problems. Coping strategies can be divided into 3
broad categories: appraisal-focused coping, problem-focused
coping, and emotion-focused coping. Individuals can mod-
ify the way that they think about the problem/stressor, such
as by redefining or accepting the stressful situation. These are
appraisal-focused strategies. Individuals can also cope by tak-
ing direct action to change the situation by reducing or elimi-
618
nating the stressor. This is known as problem-focused coping.
Individuals may also purposefully change the way in which
they react to a stressor, using strategies such as meditation,
relaxation, or prayer. These are examples of emotion-focused
coping strategies.46, 47
Coping seems to be a highly individualized response de-
pendent on the nature of the situation and disposition of the
people involved. Women use a variety of coping strategies
to deal with the stressors of the postpartum period. How-
ever, several common themes emerge regarding coping in the
time following childbirth. Reaching out for social support is a
positive coping strategy, particularly in the early postpartum
period.35 Unfortunately, women also tend to use negative cop-
ing strategies such as avoidance or minimization to deal with
issues related to their own health in the postpartum period.
This is consistent with findings that many maternal health
problems in the postpartum period go unaddressed.26, 27
Realistic Expectations
The development of expectations is a normal adaptive hu-
man response that helps modulate individual behavior and
allow for efficient and effective interpersonal interactions.48
However, when expectations are based on incomplete or in-
correct information and conflict with the reality of a situa-
tion, the dissonance that results can be disruptive to the in-
dividual and to relationships. Whether or not expectations
are met in the postpartum period affects a woman’s ability
to adjust to motherhood and to other transitions following
childbirth.48, 49 Similarly, women who report feeling unpre-
pared for the postpartum period may be at increased risk
for postpartum depressive symptoms, physical ailments, and
functional limitations.50 In addition, postpartum adjustment
is rated as more difficult by women whose experiences are
worse than what they expected.51 Unmet expectations regard-
ing parenting tasks are associated with compromised ability
to cope, increased maternal distress, increased marital dis-
ruption, and decreased ability to effectively mobilize social
support.29, 34 Previous experience with a task or a similar situ-
ation and accurate and timely information are associated with
a better match between expectations and reality.48, 49 Find-
ing ways for women, particularly those expecting their first
child, to practice some of the tasks of new parenthood, such
as soothing a fussy infant, may help ameliorate some of the
stress of this time period. Additional ways to promote the set-
ting of realistic expectations and to support the other individ-
ual health-enhancing skills are described later in this article.
External Resources
In the outer layer of the model are the external resources
that a woman may need for a healthy postpartum period,
which include access to clinical services, social and other sup-
port services, information, and material resources (eg, food,
shelter, medications, health insurance, infant care supplies).
Many current interventions and policies aimed at increas-
ing access to these resources were designed to focus on preg-
nancy and often only extend 6 to 8 weeks into the postpartum
period, after which they disappear or become available only
for the infant (eg, case management, home visitation, public
Volume 58, No. 6, November/December 2013
 Table 4. Examples of Health Promotion Strategies for Clinicians
Effectively Mobilize Social Support
Helping the woman create and communicate concrete plans for the support she will need in the postpartum period may help the woman
achieve the support she needs and make it more likely that she will have a positive perception of this support.
Ask the woman to identify specific tasks she will need support for, the members of her social support network, and what type of support
she expects from her support network.
Let her (and support people if possible) know that she will need both emotional support (encouragement, positive feedback) and
instrumental support (help with infant care and housekeeping).
Let her know that others may not be able to anticipate her needs and that if others fail to meet her needs this can cause anger or sadness.
To avoid this, encourage her to share her specific concrete requests with those to whom she has identified as her source of support.
Self-Efficacy
Key in this domain is to promote in the woman a sense of herself as capable of meeting demands of parenting.
Ask the woman about tasks that she foresees will be difficult for her in taking care of a newborn or herself in the postpartum period, and
engage her in a quick troubleshooting session where she can create solutions to obstacles and challenges.
Give her permission to “fail.” Remind her that her ability to accomplish tasks of parenting will not always be a reflection of her skills as a
mother, but rather a variety of factors (such as infant temperament), only some of which she may be able to control.
Let her know that it is normal in the postpartum period to not feel immediately maternal toward her newborn. Providers do need to be
aware, however, that a lack of maternal feelings that persists past 1-2 weeks may signal a problem such as depression.
Videos or demonstrations of others successfully completing tasks can be helpful as long as it seems feasible to the woman. The more the
women in the video resembles the woman, the more she will be able to feel a sense that she too can achieve the skills or activities being
demonstrated.
Positive Coping
The goal is to help the woman grow her positive coping skill armamentarium and minimize the use of negative coping skills.
Help the woman conduct a coping skills assessment by asking questions such as, “What sort of things do you do to cope or to manage a
difficult problem?” “What are you going to do when you are so tired that you do not feel you can take care of your baby?” “Newborns
cry a lot and that can be very stressful for new mothers. What are you going to do when your baby starts crying and you cannot get
your baby to stop?”
Help her identify positive versus negative coping skills and what leads her to resort to one or the other.
Stress and anger management classes (even if they are not focused on pregnancy) may be a useful resource to refer a woman for.
Teach the woman about safe stepping-away techniques (eg, put infant in crib and walk away to catch her breath, time-outs for toddlers,
10 deep breaths). Have her identify some of these that she can use if she needs them.
Realistic Expectations
The main goal as providers in this arena is to better prepare the mother for the demands of the postpartum period. “A proactive, honest,
reality-based approach aimed at altering maternal expectations of the postpartum could be directed at counteracting the feelings of
inadequacy often experienced by new mothers.”19
Normalize the experience of feeling overwhelmed and uncertain by letting her know that these are feelings that are almost universally
expressed by women in this time period.
Provide information on wide variations of normal infant temperament including feeding, crying, and sleeping patterns.
Provide information on the fact that it is normal for it to take months, if not a year or more, for a woman to feel back to herself.

medical insurance). Helping to ensure availability of and ac-
cess to these resources is an important component of health
promotion for women.
In addition to clinical care and referrals for social and
other services, midwives and other clinicians provide infor-
mation and education to women. Timely and accurate in-
formation is often a critical resource in order for women to
effectively utilize their individual health-promoting skills in
the postpartum period. For example, a crying infant can be
a source of anxiety and stress for a woman, which, if unmiti-
gated, can increase the risk of depression or shaken-baby syn-
drome. In order to be able to effectively soothe her infant, a
woman needs to know what strategies work best to make an
infant stop crying, which is information that can be provided
by clinicians. Similarly, a woman is also less likely to experi-
ence a loss of self-efficacy related to the crying if she under-
stands the normal crying patterns for infants and the reasons
infants cry. If a woman believes the crying is not due to a lack
of skill on her part, but instead that it is an expected behavior,
she will be more likely to attempt to soothe her infant, which

Journal of Midwifery & Women’s Health r www.jmwh.org 619

is an important activity to build trust—a key developmental
milestone for infants.
While it is generally known that women want and need
information to successfully transition in the postpartum pe-
riod, the timing of when to deliver this information is not
clear. While new parents often state feeling like they did not re-
ceive enough information to prepare them for the first weeks
and months of parenthood, research also shows that parents
who receive abundant information during antenatal classes
have difficulties in assimilating information referring to the
postpartum period.51 Providers must find and test ways to
effectively transfer information regarding the postpartum to
parents.
CLINICAL IMPLICATIONS FOR MIDWIVES AND
OTHER HEALTH CARE PROVIDERS
A health promotion approach to maternal health in the post-
partum period is one that is consistent with the philosophy
of care of midwives that affirms “the power and strength of
women and the importance of their health in the well-being of
families, communities, and nations.”52 Philosophy, however,
can often be difficult to operationalize. The model presented
here is designed with the goal of helping transform philosophy
into action by describing those elements that are the source of
power and strength for women in the perinatal period and by
providing specifics of how they can translate into health out-
comes for herself and her family.
While this model can help guide the design of health
promotion interventions at the policy or program level, a
health promotion approach can also be implemented by the
individual clinician during routine encounters with women
during pregnancy and postpartum care. A health promotion
approach at the provider–client level requires an understand-
ing by the provider that the health needs of women in this time
period include, but also extend beyond, the physical recovery
from birth. Similarly, it means expanding the realm of inter-
ventions beyond those to increase contact with the health care
system or to improve identification and treatment of morbidi-
ties. Adopting a health promotion approach to care means im-
plementing strategies that enhance a woman’s internal skills
that protect her from disease-inducing events, thus promoting
her own ability to ensure her health, and in turn the health of
her infant and other family members. Table 4 includes exam-
ples of health promotion strategies within each internal skills’
component of the model that providers can utilize in the clin-
ical setting. The CenteringPregnancy model of care is an ex-
ample of a program that deliberately and successfully has in-
corporated a health promotion approach.53, 54 In the Center-
ingPregnancy model of group care, mobilization of social sup-
port, self-efficacy, and positive coping skills are all promoted
explicitly as session goals and implicitly through the essential
elements that guide its design.
The promotion of maternal health cannot end at the birth
of the newborn, nor at the 6-week postpartum visit. Women
have physical and emotional needs directly related to preg-
nancy and childbirth that take longer than 6 weeks to resolve.
Furthermore, the long-term health of infants and children is
extensively and intricately tied to the health of their mothers.
The research evidence overwhelmingly suggests that a healthy
620
postpartum period depends on the ability of a woman to effec-
tively employ her own skills to ensure that her needs and the
needs of her family are met. Midwives and other providers of
care to women during this critical life transition have a duty to
understand that the health needs of women during this time
period extend beyond physical recuperation from childbirth
and to find ways to incorporate strategies into care that will
help women build their individual skills to successfully meet
those needs.
AUTHORS
Jenifer O. Fahey, CNM, MSN, MPH, is an Assistant Profes-
sor in the Department of Obstetrics, Gynecology, and Repro-
ductive Sciences at the University of Maryland in Baltimore,
where she is in full-scope clinical practice. She is also a PhD
student in the Maternal and Child Health program at the Uni-
versity of Maryland School of Public Health, College Park.
Edmond D. Shenassa, ScD, is an Associate Professor and
founding director for the Maternal and Child Health program
at the University of Maryland School of Public Health in Col-
lege Park, and is an epidemiologist interested in the appli-
cation of epidemiologic thought and methods to the field of
midwifery.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
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