The role and attributes of social networks in the provision of support to women after stillbirth: experiences from Uganda

Introduction: Communities exert stigma on mothers after stillbirth despite their potential to offer social support to the grieving family. Maternal healthcare-seeking behaviors are socially reinforced rendering a social network approach vital in understanding support dynamics which when utilized can improve community response to mothers experiencing stillbirth. However, the form and direction of social support for women when in need is not clear. The study explored the role and attributes of women’s social networks in the provision of support to mothers who have experienced a stillbirth in Uganda. Methods: An exploratory cross-sectional study design adopting a social network approach was conducted. Data collection following established procedures was conducted on a convenient sample of 17 mothers who had experienced a stillbirth six months before the study. Frequencies and bivariate analysis were conducted to determine the factors influencing the provision of social support from 293 network members elicited during the alter generation. We then performed a Poisson regression on each of the social support forms and the explanatory variables. Network structure variables were calculated using UCINET version 6 while Netdraw facilitated the visualization of networks. Results: Overall, social support was available from all network relations mentioned by the respondents. No major variations were observed between the two time periods during pregnancy and following a stillbirth. The most common support received was in form of intangible support such as emotional and information support, mainly from females who were married and from the naturally occurring networks such as family and friends. We also observed that social support followed patterns of network relational characteristics including trust, frequency of contact and alters counted on for support more likely to provide the same. Conclusions: A great potential for social support exists within women’s social networks to help address stillbirth risk factors during pregnancy and cope after experiencing the same. Alter characteristics like being female, married, and from naturally occurring networks together with relational characteristics such as trust, frequency of contact, and count on alter for support were predictors of eventual social support. Interventions aiming at addressing stillbirth risks at the community level ought to harness these network characteristics for benefits to the mothers. This was an exploratory cross-sectional study adopting a social network approach as part of a larger mixed-methods study conducted in Mukono district located in central Uganda with a high fertility rate. It has characteristics of a pluralistic health system with the public, private not for profit and private for-profit health facilities offering maternal and child health services. There are a total of 51 health facilities of which only four are at Health Centre IV level and above offering Comprehensive Emergency Obstetric care services. Some mothers accessing maternal health services at the health facilities come from the neighboring districts due to central location, proximity to the city, and access to the great east Africa highway; a major transport route in the country and region. Details of the study setting have been described elsewhere [33]. Enrolled participants in this study included women in their reproductive age (18 years or older) with eligibility criteria of having experienced a stillbirth within six months before the study and consented to participate. They had delivered the index pregnancy in one of the health facilities in the district specifically focusing on Health center III and above because they offer emergency obstetric care services. Exclusion criteria included not being available for interview during the study period and those mothers who had delivered within one month prior to the study. The results reported here are from 17 respondents out of the 20 that were targeted and 23 who were approached. Data were collected between January and May 2019 where a convenient sampling technique was applied to access potential respondents who were identified from facility records and health worker’s recollections. They were approached by the health workers from the maternity unit who were first oriented about the study and supported to gain confidence and clarity while explaining the objectives and processes to potential respondents. Health workers would first speak to the potential participant and inform them about the study and thereafter would request them if they were willing to participate after elaborating the study objectives. A study team member verified information with health providers to ascertain eligibility before contacting the mothers. Those that agreed to participate were then approached by the study team member using the information provided via mobile telephone. Thereafter a convenient place and time for the interview would be agreed upon with the potential respondent. Interviews were face-to-face interviewer-administered whereby on the day of the interview, the objectives and procedures to be followed would be repeated for the participant and consent obtained. Although the study did not set out to collect data on refusal to participate, it later emerged that three of the potential respondents that had been approached declined to participate and at that point, no further contact was made. The tool used was developed by the first author based on literature and standard procedures for conducting social network interviews (attached here as Additional file 1). It contained five sections; section one elicited information on social demographics, household characteristics, maternal health, and obstetric history characteristics collected from each respondent through self-report. Section two included the name generator where an egocentric network approach was used to guide respondents to recall at least fifteen to twenty of their social network members. The criteria included giving names of those people they recall to have had contact or interacted with during pregnancy and after experiencing a stillbirth. This followed established processes for conducting social network interviews [34–36]. To assess network composition, section three asked respondents to provide information about each of the network members they had earlier listed which included demographic data such as age, education, gender, marital status, and relationship type. The level of trust, emotional closeness with network members, frequency of contact, and whether that particular network member could be relied on for support when in need. They were assessed on a three-point Likert scale including “Not at all, a little bit or Very much. The frequency of contact with a network member was assessed on a five-point Likert scale which reflected “1 = never, 2 = once a month, 3 = once a week, 4 = several times a week, and 5 = about every day”. Section four covered the different aspects of social support explored between the respondent and network members. Specifically, following guidance from literature [28, 37], social support was conceptualized as consisting of five types including; financial, information, material, emotional, and instrumental support. The questions were repeated for each of the categories asking if respondents had sought or received support from the network member during pregnancy and after experiencing a stillbirth. The responses were on a three-point Likert scale; [1] “Not at all, (2) A little bit, and (3) Very much”. The last section (five) assessed the network structure where participants reported if a particular network member knew the other alters mentioned with response options including “Yes, No or don’t know. They were also asked about the nature of the relationship with network members in terms of Trust and count on alter for support which was assessed on a three-point Likert scale; (1) “Not at all, (2) a little bit or (3) Very Much”. Emotional closeness was assessed on a three-point Likert scale with (1) Not at all, (2) somewhat, (3) very close. Frequency of contact was assessed on a five-point Likert scale with (1) once in six months, (2) once in three months, (3) Once in a month, (4) once a week and (5) about every day. Emotional support: behaviors that foster a feeling of comfort which leads to a person to believe that they are being admired, respected, loved, and that others are available to provide care and safety. Information support: Knowledge, advice, or information that helps an individual to understand their world and adapt to the change that comes with it. Instrumental support: the help from other people in terms of activities that the ego is unable to perform or for which others are required to help solve a problem.[help with household chores, accompany to the hospital] we separate instrumental from material as one refers to services while the other refers to tangible goods. Financial support: assistance in terms of money to a mother to help her buy a good or facilitate a service. Material support: This refers to tangible goods received by women to help solve a particular problem. Because the study adopted an exploratory approach, the results presented use descriptive statistics to characterize the study sample and network alters who were the primary providers of social support before and after experiencing a stillbirth. Descriptive analysis was conducted for the respondent and alters characteristics using frequencies and proportions. The prevalence of social support was calculated using frequencies, proportions, and chi-square tests with 95% confidence intervals. Alter characteristics and network relational characteristics reflecting qualities were considered explanatory variables. A bivariate analysis was conducted on both the alter and network characteristics to explore the association both during pregnancy and after experiencing a stillbirth. We then performed a Poisson regression on each of the social support types and the explanatory variables. Statistical analyses were conducted using Stata software with a significant level set at p < 0.005 while UCINET version 6 was used to calculate the social network structural measures for each of the respondents. Network graphs were produced using Netdraw.