Introduction

The quality of care and support received by pregnant women during pregnancy determines the quality of delivery and maternal/neonatal health (8). Perceived social support of a mother indicates her cognitive assessment of the environment and her certainty of the avail-ability of assistance when necessary. The importance of social support in coping with stress and mental/physical symptoms is well documented (9).

Empowerment of women is defined as the ability to make strategic life choices in contexts where they have been denied the chance to make decisions (10). This concept includes the process of change in which the person tends to make better decisions and thereby enjoy greater welfare (11). Concepts such as independence and power are classified under empowerment (11, 12).

The outcomes of women's empowerment include the individual’s independence, better decision-making, the ability to affect the satisfactory results of life (11, 13), attainment of reproductive health, and improvement of well-being during pregnancy (14). Moreover, if women have more access to financial and intellectual resources, they can improve their self-confidence, achieve independence, combat gender discrimination, and make autonomous decisions (11, 15).

In most counties, in order to empower women and eliminate gender inequalities, some measures have been taken (16). Health-related well-being refers to the individual’s mental evaluation of his/her current health status (17, 18). During pregnancy, women undergo various biological, chemical, physiological, and anato-mical changes which modify their quality of life and well-being (19). These changes occur in physical, psychological, and social health domains and can be measured through quality of life assessments. In addition, they can be used by health policy planners in health care planning and management (20).

The postpartum period is a critical transitional period in the lives of new mothers, marked by several physiological, emotional, and psychosocial changes, which start soon after delivery and result in the occurrence of new situations and needs (21). Since the empowerment of pregnant women improves their health and reduces maternal mortality (22), obtaining knowledge about postpartum complications and care is of fundamental importance. However, to the best of our knowledge, no studies have examined this issue in Iran yet. Likewise, the World Health Organization has emphasized on the empo-werment and well-being of women, as they can improve maternal and neonatal health (23).

Similarly, some studies suggest that pregnancy (24, 25) and postpartum problems (26) simultaneously impact females' quality of life and mental health. According to the literature, 40% of pregnant women experience physical health problems during pregnancy and after childbirth, and 15% of them suffer from long-term complications in their lifetime (27). Nevertheless, very little information is available on the impact of women's empowerment and perceived support from family on postpartum well-being, which is compromised in this sensitive and important period. Therefore, this study aimed to investigate the effect of perceived family support and women's postpartum empowerment on the well-being of mothers.

Materials and Methods

This descriptive, analytical, cross-sectional study was carried out on 358 women who had given birth at Fatemiyeh Hospital in Shahroud, Iran in the second half of 2015. After obtaining the necessary permission, the researcher (a midwife) referred to the postpartum ward within 24-48 h after delivery. After explaining the study objectives and obtaining written informed consent from the mothers, the social support, empowerment, and well-being questionnaires were completed.

The inclusion criteria were as follows: 1) Iranian nationality; 2) age range of 18-45 years; 3) lack of any known mental health problems; 4) lack of any underlying medical conditions; 5) no stressful events over the past nine months; and 6) minimum of reading and writing literacy. On the other hand, the exclusion criterion was unwillingness to continue participation in the study. The independent variables were perceived social support from family and empowerment.

For the purpose of data collection, four questionnaires were utilized. The first questionnaire entailed demographic charac-teristics and pregnancy information. The second questionnaire, including 20 questions, evaluated the perceived social support from family. The reliability and validity of the English and Persian versions of this questionnaire have been confirmed by Procidano (1983) and Sanaee et al., respectively (28).

The third questionnaire was Spreitzer’s psychological empowerment scale which entails 19 questions and has been translated and validated in various countries. In a previous study, Abdullahi and Navebrahim used three dimensions of this scale (29). Later, this scale was translated into Persian and then utilized in other studies in Iran (30). Scores ranges of 19-38, 38-57, and > 57 indicate poor, moderate, and good empowerment, respectively. By examining the criterion validity, Borghei revealed a strong positive correlation between the total score and subscale scores of Kameda's and Spritzer's empowerment scales (22).

The fourth questionnaire was the World Health Organization Well-Being Index, which has shown acceptable validity and reliability (31). This questionnaire has five items and is graded on a six-point Likert scale; scores below 13 indicate poor well-being, while scores above 13 indicate normal well-being. Economic situation was evaluated based on principal component analysis and household assets; it was divided into three groups of good, moderate, and poor.

Quantitative data were presented as mean and standard deviation, while qualitative data were presented as frequency and percentage. The relationship between variables was evaluated using t-test and chi-square test via SPSS version 18 at a significance level of less than 0.05. The relationship between health, social support, and empowerment as latent variables was also investigated, using structural equation modeling through Stata software (SEM).

By using SEM, the impact of variables on each other was evaluated in unidirectional and bidirectional forms. Additionally, this method was used to investigate the measurement accuracy of well-being, social support, and empowerment, as well as the relationship between the latent variables. This model also examined the effect of two latent variables of social support and female empowerment (independent variables) on the latent variable of well-being (dependent variable). Moreover, the relationship between social support and empowerment of women as independent variables was investigated in the model.

Results

This study examined postpartum women in terms of empowerment and perceived social support from family and measured the relationship of these variables with maternal well-being. Based on the findings, the mean age of mothers was 27.65±5.08 years (age range: 18-41 years). The results showed that the mean score of well-being was 12.9±5.8. In addition, 197 (55%) mothers were found to have normal well-being, whereas 161 (45%) cases showed poor well-being.

The mean score of perceived social support from family was 15±3.7 (range: 5-20). It was shown that 11 (3.1%), 100 (27.9%), and 247 (69%) mothers had poor, moderate, and good family support, respectively. The mean score of mothers’ postpartum empowerment was found to be 70.3±13.5 (range: 19-143). As a result, 3 (0.8%) mothers showed poor empowerment, 51 (14.2%) mothers had moderate empowerment, and 304 (84.9%) mothers showed good empowerment.

Demographic characteristics, i.e., mother’s occupation and body mass index (BMI), family’s economic status, mother’s and spouse’s education level, and their smoking status, are presented in Table 1. As Table 1 indicates, 38.8% of the mothers were overweight and obese, and the majority (89.1%) were housewives.

According to the findings, well-being had no significant relationship with the mother’s BMI,family’s economic status, and mother's occupation. Also, well-being was shown to have no significant relationship with mother’s smoking/substance abuse or education level of mother and husband. However, maternal well-being and spouse’s smoking were demonstrated to have a significant relationship; in other words, husband’s smoking/substance abuse was associated with lower well-being of mothers.

According to Table 2, there was a borderline significant relationship between the acceptance of pregnancy, type of pregnancy (wanted or unwanted), and mother's well-being in the postpartum period; therefore, women with unwanted pregnancies had lower well-being. However, no significant relationship was observed between the type of pregnancy, complications of pregnancy and delivery, birth weight, number of prenatal care sessions, and pregnancy order.

As can be seen in Figures 1 and 2, perceived social family support was found to have a direct impact on mother’s well-being. Moreover, there was a significant correlation (0.55) between postpartum empowerment and perceived support from family; however, postpartum empowerment did not affect mothers’ well-being and no relationship was observed between these two variables.