As one of the leading causes of maternal morbidity and a potential contributor to maternal mortality, postnatal depression (PND) has garnered much attention from researchers studying women’s health over the years [1]. Apart from affecting the psychological well-being of mothers [2-4], maternal PND can potentially increase risks of depression in their partners [5] and severely hinder their children’s neurocognitive, psychological, and social development [6-8]. In consideration of long-term adverse societal consequences, various preventive measures have been implemented to battle PND, but targeting the root cause remains a challenge due to its complex multifactorial etiology (ie, biological, psychological, and social). The contribution of psychosocial factors to PND outweighs that of biological factors, with chronic social adversity in women playing a substantial role [9,10]. This is especially so in Asian countries, where polygamous marriages, conflicting influences of culture, and conflict between mothers- and daughters-in-law are unique risk factors of PND [11-13]. According to a review by Evagorou and colleagues [14], Asian and Western mothers share similar PND risk factors and have similar manifestations of physical symptoms. Differences lie in prevalence rates and cultural factors (beliefs, values, and environment). A local study has revealed a prevalence of 6.8% for PND in Singapore, which is much lower than the global average of 16% [15]. This corresponds with findings from another review [16], but the prevalence of PND varies across Asia itself as well, and South Asia collectively has higher PND rates than Western countries [17-18]. These reviews [16-18] have also highlighted cultural differences that contributed to differences in regional prevalence rates, such as Asian’s higher emphasis on family and social relationships, hence mothers’ higher dependency on their partners, their own mothers, and extended family. The lack of female empowerment, the Asian view of women as the weaker sex, and other traditional rituals such as practicing the confinement period are additional stressors for Asian mothers. Due to the collective nature of Asian societies, social support from mothers’ family members and partners plays a crucial role in mitigating PND. Therefore, positive social relationships and increased social support are exceptionally important in ensuring the healthy psychological well-being of Asian mothers [18].

Defined as an interpersonal process whereby the provider communicates to the recipient that he or she is cared for in this reciprocal relationship [19], social support is multidimensional and varies in terms of range of support network, type, source, and quality [20]. Types of support typically include (1) emotional support, involving expressions of trust, care, and empathy; (2) instrumental support, involving tangible aid; (3) informational support, such as advice, suggestions, and information; and (4) appraisal support, including advice that allows self-evaluation [21]. Additionally, preferred types of support are largely influenced by cultural differences. In an individualistic Western culture, direct forms of support involving verbal and emotional expressions are often sought explicitly from others, whereas in a collectivistic Asian culture, indirect support through companionship and attentiveness from others is preferred [22]. Given that the impact of social support on health and recovery highly depends on the match between support provided and needed, it is necessary to consider cultural contexts when providing postpartum support to mothers in need [23].

Social support from family and partners is known to be an effective stress buffer that reduces risks of maternal PND and maintains quality of life of mothers in the postpartum period [19]. The practice of a 1-month confinement period in the Asian culture also provides most mothers with additional instrumental support in terms of infant care and household chores from confinement nannies or in-laws [24,25]. However, mothers are often dissatisfied with social support, especially due to the lack of emotional support received [24,26,27]. This can be attributed to the conservative nature of Asian societies in which direct emotional expressions are often discouraged [28,29] and the availability of emotion-focused support is rare, even from those close [22]. This highlights an unspoken need for more emotional support for Asian mothers. Mothers often mentioned a need for a close, nonjudgmental confidante to initiate support and empathize with them [4,30]. Hence, peer support is a viable option as it creates a sense of belonging, boosts parenting confidence and self-esteem among mothers, and is effective in preventing PND [3,31]. Moreover, peer support provided by peer volunteers is found to ensure continuity of support during the postpartum period and fill in for health care professionals in between clinical follow-ups [32]. Although most mothers still prioritize the need for informational support from health care professionals [33], Sjoberg and colleagues [34] revealed that new-generation mothers preferred online peer support over face-to-face or online consultations with health care professionals. Using technology to support mothers will not only increase the accessibility, availability, and affordability of maternal health care but will also remove help-seeking barriers in conservative cultures [35-37]. Additionally, Singapore has been undergoing the Smart Nation initiative since 2014 [38], which encourages health care sectors to shift to telehealth in order to optimize resources and overcome manpower constraints. Previous local studies have also seen successful results with supportive technology-based interventions involving the use of online forums and mobile apps [39,40]. Therefore, technology-based supportive interventions in this context are not considered foreign and may be more ideally suited to the needs of new-generation mothers.

While there are a substantial amount of randomized controlled trials (RCTs) that adopted a technology-based supportive approach, the effectiveness of these RCTs is usually determined by a quantitative analysis of maternal outcomes [41-45]. In-depth qualitative analyses of user experiences and feedback are limited. Technology-based supportive interventions are effective in reducing PND in women, and study designs primarily involved weekly telephone calls or video calls by paraprofessionals or peer volunteers [41-43]. A qualitative analysis provides a descriptive and exploratory insight of user needs that can inform the further refinement and tailoring process of an intervention program to better meet user needs. The limited number of qualitative studies and the heterogeneity of available studies in terms of support source, delivery method, and frequency warrant a need to perform a qualitative study on a technology-based peer support program in an Asian setting [46-50].

Therefore, this study aimed to evaluate the postnatal experiences of mothers at risk of PND and their perceptions of a technology-based peer support intervention program (PIP). Feedback from peer volunteers was also examined in order to gain a well-rounded perspective from both recipients and administrators.

This descriptive qualitative study is a follow-up of an RCT [51] that examined the effectiveness of a technology-based PIP on maternal outcomes including PND, postnatal anxiety, loneliness, and perceived social support received. The original study was conducted at a tertiary hospital in Singapore where 136 mothers at risk of PND were recruited through purposive sampling and randomized into either the intervention (n=69) or control (n=69) group. Mothers at risk were identified through an initial screening using the Edinburgh Postnatal Depression Scale. Only those who scored 9 and above were recruited for the RCT. Twenty peer volunteers, mothers who had recovered from PND, were recruited through a blasting of emails to the study venue’s working community and by word of mouth to facilitate the support program. Peer volunteers then underwent a training session by a psychiatrist to learn required skills (via role play and discussions) for successful administration of technology-based peer support, which covered topics on alleviating depression, anxiety, loneliness, and how to conduct appropriate referrals to a health care professional when necessary. Details on peer volunteer training can be found in the published protocol [52]. Each peer volunteer was matched with at least three mothers. The fidelity of the PIP intervention was maintained using the strategies proposed by Bellg et al [53] and Eaton et al [54]: (1) the protocol for intervention was developed and has been published [52]; (2) to confirm dosage of the intervention, log sheets were maintained on the time and duration of contacts made with peer volunteers; (3) to ensure consistency, peer volunteers were trained by the same psychiatrist; and (4) a peer volunteer manual was developed for a standardized delivery of information.

Participants in the control and intervention groups received standard hospital postnatal care such as lactation support, parent craft teaching, and postpartum follow-up appointments with an obstetrician. In addition, participants in the intervention group had support from peer volunteers for at least 1 month postpartum involving a minimum of once-a-week correspondence between the mothers and the volunteers through any technology-based means (ie, phone calls, text messages, and WhatsApp). Frequency and duration were tailored to maternal needs. Further details have been published elsewhere [52]. The experiences of mothers in the control group were included in this follow-up to provide different perspectives and form a basis of comparison of needs and received support during the perinatal period. Prior to this, all participants were informed of this optional extended qualitative component of the study. Qualitative feedback from peer volunteers on delivery of the intervention was made mandatory upon the initial consent for the original study.

Purposive sampling was used to achieve an equal number of participants from the control and intervention groups. Recruitment was conducted at 1-month postpartum through the blasting of emails to the 136 participants in the original study until data saturation was reached. Thirty-six mothers volunteered for the interviews. However, data saturation was reached at the eighth participant for both groups when no new findings emerged. Two additional mothers from each group were interviewed to confirm the findings, resulting in a total of 20 interviewed mothers (10 from the control group and 10 from the intervention group). The remaining 16 mothers consented to be excluded from the interviews. One peer volunteer had withdrawn from the original study due to time commitment issues, leaving nineteen peer volunteers in this study. Mothers and peer volunteers were informed of the approximate duration of each interview (30 to 60 minutes) and that all interviews would be audio-recorded for research purposes only.

When participants were between 4 and 12 weeks postpartum, a female research assistant trained in qualitative interviewing techniques conducted individual face-to-face interviews at a time and location to each mother’s convenience, typically at the mother’s home. Participants were given pseudonyms during the interviews to protect their actual identities. Peer volunteers were only interviewed after the conclusion of the intervention for all 69 mothers, and the Peer Volunteer Activity Logs, which were used by peer volunteers to record the frequency, duration, and key points of the correspondences, were submitted to the research assistant during the interviews. Three versions of a semistructured interview guide specifically tailored to the control group, the intervention group, and peer volunteers were developed and piloted to attain a comprehensive view of the delivery and recipient of the PIP and the postnatal experiences of mothers (Multimedia Appendix 1). The interviews lasted an average 40 minutes and were subsequently transcribed verbatim. Field notes were taken during the interviews to note nonverbal cues that were used to supplement the transcripts.

A thematic analysis was conducted according to the six phases of analysis described in the research of Braun and Clark [55]. The authors read the 39 transcribed interviews multiple times to gain familiarity with the data and subsequently adopted a manual color-coding method to highlight different concepts and generate the initial codes independently. These excerpts were then extracted and put into a tabular format, entailing themes and subthemes within a new document. Data source triangulation from all three groups of participants (intervention and control groups and peer volunteers) was performed to look for common themes [56]. The themes were reviewed comprehensively for homogeneity by both authors before overarching themes were decided. To achieve confirmability and objectivity in the analysis of data, the various themes and subthemes were discussed extensively in several meetings between the two authors. Any discrepancies were discussed and clarified between the two authors until a consensus was achieved. Field notes were also constantly referred to as supplementary materials, and constant comparative analyses were performed. Themes constituting frequently reported overlapping data were selected from the authors’ independent analyses, renamed, and included in the final analysis.

Ethics approval was obtained from the National Health Group Domain Specific Review Board (reference number: NHG DSRB 2017/00185) of the participating hospital. Prior to obtaining the participants’ written informed consents, the participants were briefed thoroughly on the purpose of the research and were informed of their rights to withdraw at any time during the study. Study participation was strictly voluntary, and confidentiality was adhered to.

Study findings were reported according to the Consolidated Criteria for Reporting Qualitative Research checklist (COREQ, Multimedia Appendix 2) [57]. According to our RCT results [51], the PIP was successful in significantly reducing PND symptoms at the end of three months postpartum. Although not statistically significant, there were also observable decreases in postnatal anxiety and loneliness and an increase in perceived social support at the end of three months.

A total of 39 interviews were completed with 20 Asian mothers (10 from the control group and 10 from the intervention group) and 19 peer volunteers. Mothers had an age range of 25 to 40 years while peer volunteers had an age range of 25 to 54 years. The majority of the mothers were Chinese (n=10), followed by Malay (n=9) and Indian (n=1), which was likewise for the peer volunteers (Chinese, n=17; Malay, n=1; Indian, n=1). All 10 of the mother-volunteer dyads corresponded (regarding emotional needs and available resources) through WhatsApp messages at least once a week; only five dyads attempted to schedule a weekly phone call. Further details of the participants and peer volunteers can be found in Table 1.

Two overarching themes comprising five subthemes were generated: postnatal experience (a bouncy ride, a way forward) and evaluation of the PIP (valuable, flexible, and supportive program; building blocks of a good relationship; and lessons learned and the road ahead). A detailed breakdown of the themes and subthemes is shown in Figure 1. Exact quotes from the participants were used to represent their emic views, and their identities were coded to allow for anonymity, with mothers in the control group labeled with C, mothers in the intervention group labeled with T, and peer volunteers labeled with P.

This theme describes the bumpy postnatal experiences of mothers including the challenges of breastfeeding, their physical and emotional states, and the types of support received.

In general, mothers indicated a need for more informed decisions and social support to improve their birth experiences.

This theme summarizes the feedback of peer volunteers and mothers who received support (the intervention group only) on the usefulness of the PIP. Overall, the peer volunteers were satisfied with the informative training session. The flexibility of the program was also mentioned by both mothers and peer volunteers, which made them feel supported.

This theme describes the essential traits of a befriender and the basic underlying foundation of a good relationship.

Overall, postnatal experiences were highly similar in both groups of mothers, such as common breastfeeding issues and physical fatigue. A large-scale review of the effectiveness of various types of breastfeeding support concluded that regularly scheduled face-to-face support by health care professionals has a higher success rate in teaching mothers to breastfeed [58]. Findings from another local study that used educational parenting videos emphasized mothers’ need for both theory and hands-on learning through visual means [55]. As the PIP did not focus on the physical or breastfeeding needs of mothers, this could be the reason that mothers from the intervention group were equally distressed about their physical and breastfeeding needs.

In terms of emotional experience, mothers who received the PIP had reduced negative feelings and better understanding and acceptability of their emotional situations; hence, they were better able to enjoy their birth experiences. Mothers without additional support felt lost, anxious, and alone, which has been commonly reported in other studies [55-60]. The perceived effectiveness of the PIP in providing adequate emotional support for mothers is also supported by the study findings of Dennis et al [46], in which mothers benefitted from the emotional support received from peer volunteers.

Although mothers in both groups were highly satisfied with the quality and competency of health care providers during their hospitalization stays, they were disappointed with the lack of transparency and insufficient information from health care professionals, which hindered their informed decision making processes. Being involved and making well-informed child care decisions gives mothers a sense of empowerment, responsibility, and preparedness, which promotes better health outcomes and healthier physical and psychological well-being and even affects the long-term health and well-being of their children [61]. Mothers also voiced the need for more hospital follow-ups and continuity of care in terms of phone calls and home visits. Studies have shown that continuity of care is often lacking due to resource constraints, such as a lack of manpower [62], but patients who received continuity after hospital discharge had better health care outcomes, higher satisfaction rates, and more cost-effective health care [59,63]. Therefore, in order to promote positive postpartum experiences, a multidimensional approach to improve current hospital care in the form of follow-up multimodal educational programs needs to be considered.

Interestingly, when describing the support received from family and their partners, mothers from both groups only mentioned their satisfaction with the instrumental support received from their parents, in-laws, and partners. This is supported in a study by Chen and colleagues [64] that revealed that Asians tend to provide more problem-focused support than European Americans who tend to provide more emotion-focused support. This is mainly due to the conservative, collectivist Asian culture whereby indirect support, which avoids mention of the stressor, is preferred and includes displays of attentiveness and companionship from their loved ones [22]. However, conflicts with in-laws in terms of parenting styles and differences in opinions due to generation gaps were commonly reported, adding emotional stress for mothers. As respect for elders is highly observed in the Asian culture, new mothers often have to suppress their emotions, and having a poor relationship with one’s mother-in-law potentially jeopardizes her marital relationship and increases risks of PND [11,26,27,65]. Chen and colleagues [64] concluded that the most effective type of social support is a delicate balance between autonomy and dependence. Considering that negative childbirth experiences can cause partner and family strain, an external support in the form of peer-volunteers might be more ideal when providing a nonjudgmental listening ear [66].

Similar to other peer support studies [47,67,68], our peer volunteers underwent mandatory training to learn adequate support provision for at-risk mothers, which most found useful in setting personal expectations and gaining confidence and preparedness. Additionally, since peer volunteers were mothers with a history of PND, training sessions also served as a platform for mothers with similar pasts to connect and form a community of support [47].

In an effort to increase the accessibility and flexibility of support with minimal disruption to the mothers’ lives, communication through technology-based platforms was adopted. This aspect was praised by both recipients and peer volunteers as correspondence was flexible and suited to their own levels of comfort, whether it was through text messages or phone calls. Due to unpredictability and difficulty in arranging fixed calling times, most mothers and volunteers preferred correspondence through text messages. However, a few reported the lack of a personal touch and difficulty in gauging mothers’ responses over text messages, with some mothers also suggesting at least one home visit or face-to-face meet-up. A review by Shaw [60] acknowledged the effectiveness of peer-support in reducing PND, but maternal satisfaction was higher for home visits. Videoconferencing was not used in this study, but it has been shown to improve mental health outcomes [69] and increase confidence and was deemed to be almost equivalent to the physical presence of a peer volunteer [43]. Parents in a study by Linberg [43] also felt that the midwife understood their situations better with added nonverbal communication through videoconferencing. Hence, the option of using videoconferencing can be considered in future local studies to support mothers at risk of PND.

Initiating a socially meaningful relationship of trust involves certain key characteristics of peer volunteers: positivity, determination, openness, proactiveness, sincerity, and respect. These qualities are critical to successful program delivery and enable peer volunteers to overcome challenges and stress and establish effective functional relationships [68]. Mothers and volunteers shared that the mutual understanding and identification that drew on the shared experiences of parenthood and social circumstances increased feelings of connectedness and ease of sharing. Despite the differences in personality, the sharing of experiences with someone of similar backgrounds, attitudes, and experiences facilitates trust-building and easier communication [68,70]. The matching of peer volunteers to mothers is an important component of successful peer-mentoring as the provision of support should be targeted to fit the nature and situation of the family [46,50,71].

This PIP was also seen as a two-way support system. While most mothers were appreciative of the extra listening ear and support provided that improved their overall emotional well-being, peer volunteers were also glad for the opportunity to impact other lives with their experiences and felt happier after volunteering. Expressing satisfaction with their roles, many volunteers felt empowered and took this chance to learn new things to enhance their personal growth and self-discovery. Similarly, in other studies peer volunteers felt emotionally rewarded and enriched by their interpersonal relationships; given the chance, they would volunteer again [47,66].

However, challenges and stressful moments arose for some peer volunteers when communication was only one-sided. Mothers and volunteers attributed it to insufficient rapport-building and the discomfort of sharing with a stranger. A few volunteers perceived some relationships as superficial and obligatory, while some mothers felt that they did not need the additional support. This is common in the Asian culture as the stigma of mental illness is related to the loss of face beyond the individual level [72,73]. In a culture that emphasizes emotional restraint, avoidance of shame, and saving face, it may take a longer time for mothers to warm up and share their problems with volunteers [74].

Given the easy accessibility and wide availability of technological devices today, technology-based peer support is a potentially time-saving and cost-effective way to extend social support to mothers in need. Being able to provide mothers with a personalized continuity of care post–hospital discharge should incentivize health care sectors to dedicate more resources to train peer volunteers and implement the technology-based peer support to a wider population.

In consideration of the collectivistic culture and strong interdependence on family, future studies on technology-based peer support in Asia can involve partners and family members, which might reduce the emotional strain between mothers and family members during the stressful postpartum period. Future research can also consider including videoconferencing or developing a peer volunteer mobile app with detailed profiles to provide more targeted forms of support. Given that breastfeeding remains a key stressor to mothers, future interventions can adopt a holistic approach of providing both instrumental and emotional support to new mothers. Additionally, the introduction of peer volunteers to mothers should ideally take place during the third trimester, when mothers still have the time to build rapport. Last, the practice of the confinement period may see mothers receiving more help from family, in-laws, or confinement nannies during the immediate postpartum period for one month [24]. Instead, the second month postpartum, when all added help is depleted, may be more crucial as mothers resume work and the full responsibility of infant care. Therefore, the extension of the PIP’s duration will be beneficial to mothers during this period.

Unique to this study is the valuable insight of cultural influences on preferred types of social support and the help-seeking behaviors of Asian mothers in the postpartum period. The inclusion of both mothers’ and peer volunteers’ perspectives also provided a well-rounded overview of the PIP. To our knowledge, this is the first technology-based peer support intervention in Asia. Therefore, the study findings are vital in informing future research on PND prevention using technology-based peer support, especially in an Asian context.

However, the cross-sectional nature of this study disallows the comparison of the pretest and posttest perceptions of mothers, making it difficult to determine the effectiveness of the intervention. Additionally, due to previous childbirth experiences, the sample inclusion of non–first-time mothers may bias the findings positively and provide inaccurate information on the usefulness of the PIP. Hence, future interviews should consider interviewing an equal number of first-time and experienced mothers and analyzing if there is any uniqueness in their individual experiences of receiving the PIP.

This study not only provided insight into the postnatal experiences and needs of at-risk Asian mothers but also evaluated the perceptions of both recipients and administrators of the technology-based PIP. The positive endorsement by mothers and volunteers suggests the PIP’s success and usefulness in meeting mothers’ postpartum needs. The technology-based PIP has the potential to connect with and give support to vulnerable mothers and enable them to access services in ways that complement the work of health professionals. However, given the suggestions for improvement by stakeholders, more research and rigorous testing are needed to further refine this approach before its implementation to a wider community.