Subsequently, the findings are bundled into the operationalisation of an intervention which aims to enhance resilience.
Phase 1: identifying relevant COM-B components
The first phase aimed to identify resources mothers use and/or need to cope with stress and promote resilience during pregnancy and after childbirth. The COM-B components were explored by thirteen face-to-face individual semi-structured interviews. All mothers were Caucasian, born in Belgium and their mean (SD) age at the time of the interview was 33.6 (4.6) years. Ten mothers lived with a partner, three mothers were divorced or no longer living with the father of their child. The majority of mothers had at least a bachelor’s degree (N = 11) and were employed (N = 8). The infant’s mean age (SD) at the time of admission was 10.9 (5.2) months. The mean duration of admission was almost 6 (5.9, SD 2.0) months. Based on the qualitative analyses, following COM-B components were identified: capability (psychological), opportunity (physical and social), and motivation (reflective and automatic) (Fig. 1). Physical capability was not identified.
Capability
The first component of the COM-B model is capability, which states that people must have the physical or psychological strength to perform the behaviour. Based on the interviews with mothers, we could distinguish two factors in relation to psychological capability: knowledge and psychological skills.
A first factor is knowledge about perinatal mental well-being. Mothers thought that pregnancy and childbirth were perceived by society as moments of happiness with no space for negative feelings. Participants described this as being on a ‘pink cloud’ (also known as cloud nine, a state of perfect happiness), which was sustained in part by general opinions in society, social media, and television channels. Many mothers had a contrary experience to what they had expected and experienced negative feelings. Improved understanding of the impact of perinatal mental health problems on family functioning, resilience and stress(systems) may help to counter the perception of a ‘plink cloud’.
“The fact that there is increased knowledge. Nowadays, you often hear women say, “Yes, it’s not a pink cloud, it’s a grey one. But I always had the feeling that when I gave birth to [my son], there were only mothers with pink clouds around me”. (interview I)
A second factor is psychological skills containing coping resources and emotion regulation. The psychological toll of becoming a parent can be tough. Participants experienced negative feelings contradicting the anticipated feelings of happiness. To cope with their feelings, some mothers held up a facade and presented themselves in a way they thought others were expecting them to behave. Another coping strategy mentioned by some mothers was an escape into work or sleep medication.
“But I always pretended to be fine when they (cfr. midwife and maternity nurse) came to visit […] You shouldn’t feel bad because you just brought a child into the world” (Interview I).
Mothers felt like they could no longer control the situation and they experienced a lack of connection with their own and their infant’s emotions. Mothers got stuck in a vicious cycle, inhibiting their own feelings and desires. This led to difficulties within the mother-infant interaction from not understanding the child’s signals to not feeling like a loving parent.
“You let yourself get carried away so quickly by an emotion that you don’t longer see it anymore.” (Interview J).
Participants emphasised the importance of their own emotion regulation as a significant component of perinatal resilience. Being able to be aware of their emotions, to recognise them and to put them into perspective, enhances their sense of resilience. However, mothers expressed the need to develop the skills, which allow them to be aware, recognise and put their emotions into perspective, such as mindfulness and relaxation to enhance their emotion regulation capabilities.
“I was introduced to mindfulness there. While the first time I thought ‘what am I doing sitting here with my eyes closed’. And then I began to experience how that helped me to put my mind at rest.” (Interview F).
Mothers mentioned self-care, looking after themselves, as an important coping strategy in times of stress. For example, trying to relax, practising hobbies (e.g., sports) as well as getting enough sleep appeared to be important. A lack of sleep was mentioned as an important factor that negatively influenced the well-being of mothers.
“I think that that [sleep deprivation] took away a lot of my resilience, because I was so exhausted” (Interview M).
Opportunity
The second component is opportunity, which represents the physical and social opportunity for behaviour change to occur. Based on the interviews with mothers, we could distinguish two factors in relation to physical opportunity: accessibility and affordability of resources. Social opportunity involves interpersonal influences, social cues, and cultural norms that influence the way we think.
Mothers attach great weight to an easy accessibility of support programs. An extra support program needs to fit within the numerous consultations within the standard care pathway, their work commitments, and the busy schedule if they already have children. Time and place are important factors to consider in the development of a support program. If the burden is too high, this is an important reason to reject or stop attendance at a support program.
“I feel very bad about that, I had to drive all the way from here to there, in the traffic jam for an hour and a half each time.” (Interview E).
Another pitfall is the affordability of resources. Psychological support is associated with high costs, making it for some mothers not affordable.
“Because it costs so much money, I stopped doing it, however I still feel the need for it [emotional].” (Interview L).
A factor of social opportunity is the availability of a supportive social network. Mothers emphasize the importance of social support as part of resilience and as a protective factor that buffers the negative influences of stress. Important sources of support are the partner, family members, and the broader network (e.g., friends, colleagues). They can support (future) parents at various levels such as practical, informative and emotional support. Despite the importance of social support, mothers reported barriers in engaging their social support network regarding childcare or household duties. They viewed a potential request for help as indicator of not being able to handle parental responsibilities.
“In retrospect, that was stupid of me too because I was just way too proud to ask for help.“ (Interview I).
Mothers therefore mentioned that they needed to be actively encouraged to reach out to their network for help.
“Who is around you, who is there to rely on […] and then they also said that I should really make use of my support network. (Interview D)
An important need regarding social support is the need to be heard without judgment. Mothers indicated that the desired support consisted mostly of the recognition and confirmation of their feelings.
“We felt heard, and at ease and reassured about ‘it’s not abnormal, you’re not the only one” (Interview E).
“Social support is very important I think but it should not be judgmental.” (Interview G).
The support of health care professionals was highly valued, where mothers appreciated continuity of care, consistent advice, and attention to the psychological aspects of becoming a parent such as the shift in the couple relationship. The absence of professional support caused feelings of despair. Also, the lack of attention to the mental health of pregnant women or new mothers frustrated participants.
“If you don’t get help and you don’t get support, there comes a moment when you feel so desperate” (Interview G).
The support of peers was highlighted by mothers in the interviews. Peers go through similar experiences, which may lead to feelings of understanding and acknowledgement. Understanding that other new mothers have similar experiences can be empowering and can strengthen the confidence of mothers to seek out solutions in the knowledge that she is not alone. One way to access peer support is through participating in mother groups.
“Yes, I have noticed that I had a lot of support just by chatting with other moms, who also experienced similar situations (…)” (Interview K).
Motivation
The third component is motivation, which is divided into reflective and automatic motivation [17]. Based on the interviews with mothers, we could distinguish two factors in relation to reflective motivation: self-efficacy and stigma. Automatic motivation involves emotional reactions, desires, and reflex responses.
Self-efficacy can be categorized under reflective motivation since it is the mother’s ability to evaluate and reflect on their skills and if they are sufficient to perform the necessary behaviour [30]. Mothers frequently experienced feelings of doubt and uncertainties regarding their early parenthood, putting their resilience under pressure.
“But there is also a moment when you start to doubt yourself. That you think ‘I am not doing it right…’. Yes, maybe you feel you have failed, or ‘Why am I acting like this?‘, ‘I can’t handle this [motherhood]’’ (Interview H).
Mothers indicated that they had to learn to trust themselves and their own competence. Being confirmed in their role as a mother by their support network and being encouraged by others was considered important.
Another component of reflective motivation is the pre-existing stigma regarding perinatal mental health problems. Mothers recognised it in themselves and in the caregivers. As a result, they doubted whether psychological support was appropriate because they linked this kind of support to being ‘crazy’.
“There is still such a taboo around psychiatry in general.” (Interview C).
In case of automatic motivation, mothers emphasized the importance of their gut feeling.
“You keep on doing what you think you have to do, because you are so far from your own gut feeling.” (Interview E).
To conclude from the interviews, knowledge, psychological skills, social support, and self-efficacy have been identified as important resources for mothers in case of perinatal resilience. Barriers to take into account refer to the accessibility and affordability of resources and the pre-existing stigma regarding perinatal mental health problems. In the following phases, the COM-B components were linked to the intervention functions and behaviour change techniques.
Phase 2: identifying intervention functions
In the second phase, the identified COM-B components were linked to the relevant intervention functions. Following Michie et al. (2014) [24], complex interventions could have multiple functions and the selection of the functions requires judgement of what is most appropriate for the context. Out of the nine proposed intervention functions by the BCW framework, five were considered suitable (Fig. 1) based on published BCW linkage matrices (Additional file 2), mothers’ report (phase 1), and an expert panel consensus meeting. Coercion, persuasion, and restriction were rejected as unsuitable, as these go against an approach focusing on resilience. Education, training, and enablement were considered as main functions of the intervention.
Matrix of COM-B components and intervention functions
Phase 3: prioritising BCTs and identify modes of intervention delivery
During the last phase, the content of the intervention was selected in terms of potential behaviour change techniques appropriate for each selected intervention function. A BCT is an active component of an intervention designed to change behaviour and is applicable to a range of different health behaviours. For each intervention function, the BCW guide lists the most and less frequently used BCTs according to the Behaviour Change Techniques Taxonomy version 1 (BCTTv1) [28]. This taxonomy consists of 93 items that can be divided into sixteen groups of techniques. This was used to facilitate the selection of relevant BCTs. In total, the research team selected 18 BCTs to be included in the intervention. These are associated with the following BCT grouping: goals and planning, feedback and monitoring, social support, shaping knowledge, natural consequences, comparison of behaviour, repetition and substitution, regulation, antecedents, identity, and self-belief. After a first selection by the research team (SVH, MB, AB), the selection was discussed within a follow-up expert panel consensus meeting. Following criteria; (1) affordability, (2) practicability, (3) acceptability, and (4) equity (Michie et al., 2014) were discussed, evaluated, and taken into account for the final selection of BCTs and their operationalisation. The chosen BCT groupings were linked to the selected COM-B components and intervention functions obtained in phase 2 (Fig. 2). Details about the individual BCTs and how they were operationalised in a resilience-enhancing intervention are presented in additional file 3.
Overview of the COM-B components, intervention functions and BCT groupings
Mode of intervention delivery
At last, the mode of intervention delivery was decided [17]. Modes of delivery can be broad, such as delivery at distance or face-to-face on individual, group or population level. Based on the interviews with the mothers (phase 1), physical and social opportunities seemed important to take into account. Physical opportunity relates to accessibility and affordability of the intervention. Pregnant women face barriers such as busy schedules, because of continued work and regular consultations with health care providers during pregnancy. Also, during the immediate postpartum, mothers find it often difficult to leave the house due to their recovery after childbirth, the lack of daily structure, and the demands of infant care. In response to this needs, an online format was selected as the primary mode of intervention delivery. Online interventions may be particularly appealing for mothers because of the flexibility and time efficiency, making it possible to follow and complete the program anytime and anywhere.
. Interactive online environments, such as Facebook, blogs, and smartphone applications (apps) are also popular among mothers [31]. Another important finding of phase 1 is the importance of social- and peer support (social opportunities). Therefore, it was proposed to deliver the intervention in a group format and to develop an online support platform. To enhance the effectiveness and adherence of the online intervention, human support by a psychologist, midwife and peers will be applied throughout the intervention.
Operationalisation
After a systematic intervention development process, a 28-week online perinatal program aimed to enhance resilience was constructed. The program consists of resilience-enhancing exercises, group sessions, and an online peer-support platform (Fig. 3). Through these components, the intervention aims to address the needs of mothers regarding perinatal resilience in terms of knowledge, psychological skill training, self-efficacy, and social support.
Operationalisation of the developed intervention
The program starts during pregnancy and continues up to twelve weeks postpartum, with two follow-ups at 6 months and one year postpartum. At enrolment, women will be grouped according to their gestational age. Group size was maximised to six participants plus two counsellors (clinical psychologist/midwife) trained in the content and the delivery of the program. Women will be invited for a first online group session at 28–32 weeks of pregnancy, after which they get access to resilience-enhancing exercises and an online peer-support platform in the format of confidential Facebook groups, where they can exchange experiences and support each other. This online intervention comprises different forms of human-support being: counselling by a psychologist and midwife during the online group sessions, an individual phone call to the participant around three weeks after childbirth and peer-support by the online platform. In addition, personalised online information with tailored messages depending their gestational age or postpartum duration were shared on the online platform.