Factors influencing Indonesian male partners’ support in the postpartum period

Background: Lack of male partners’ postpartum support can cause postpartum depression (PPD), a serious mood disorder, in women. Thus, to prevent PPD, it is important to clarify the factors influencing male partners’ postpartum support. Methods: In total, 62 male partners of postpartum women at 1 week–6 months after delivery, living in South Jakarta, were invited by assistance from community volunteers. Focus group interviews were employed; participants were grouped depending on their residences and asked about their behaviors in supporting postpartum women. Interviews were documented using two voice recorders and two video recorders. The content analysis method and Bertalanffy’s system theory of internal and external factors of health behaviors was utilized to develop units and codes. Results: The analysis identified five codes of individual-level factors: (1) knowledge; (2) belief; (3) social and life adaptation skills; (4) psychological disposition; and (5) physiological condition. Three codes of community-level factors included: (1) social support; (2) media; and (3) socio-cultural and economic. Two codes of social policy-level factors included (1) health care system and; (2) Indonesian societal laws and regulations. Conclusions: Various internal and external factors influence Indonesian male partners’ postpartum support. Different interventions for these factors might be impactful in preventing PPD.


Introduction
Postpartum depression (PPD) is a serious mood disorder that affects approximately 10%-15% of adult mothers anuually. 1 An Indonesian study showed that the national prevalence of PPD was 2.32%, and approximately 104,400 Indonesian postpartum women suffer from PPD annually. 2 PPD occurs because of various factors such as low economic status, 3,4 stressful life events (e.g. violence from parents in adolescence or from a partner 3,5,6 ), and alcohol consumption. 6 Additionally, previous studies revealed that lack of social support received by mothers, particularly from male partners, is the biggest factor causing PPD. 5,7,8 These findings deserve more attention because a recent study identified Indonesia as a fatherless country, not because of the huge number of orphans but owing to men's ignorance about raising children. 9 Along these lines, it can be speculated that the absence of male support due to lack of knowledge might contribute to PPD occurrence in Indonesia.
Several studies have identified internal and external factors influencing male partners' support during pregnancy and the postpartum period. Previous studies have identified internal or individual factors, including age, education level, lifestyle, race, beliefs and values, as the factors determining male partners' postpartum support. [10][11][12] However, few studies have discussed this topic in Indonesia, where the incidence of PPD is increasing and the involvement of male partners in supporting females during postpartum period is declining. To improve male partners' postpartum support, it is essential to clarify the factors that influence the support. Obtaining original perspectives from Indonesian male partners and exploring how patriarchal beliefs in the community affect their behavior in providing support will clarify this issue. Thus, the current study aimed to evaluate the factors that influence male partners' postpartum support.

Methods
The current research employed a focus group interview (FGI)-based and qualitative content analysis design.

Recruitment.
Purposive sampling method was used in this study to recruit participants. Community volunteers in Jagakarsa supported the recruitment process by distributing invitations to postpartum fathers who met the inclusion criteria: male partners with postpartum wives at 1 week-6 months after delivery, residing in South Jakarta, and with the ability to speak Indonesian. A total of 62 postpartum fathers were invited, but only 49 participants who were interested in voluntary participation gathered on the interview day and received a detailed explanation of the study aim.
Focus group interviews. Eight FGIs were conducted at community halls, and all participants were asked to complete the consent form before starting the interview. In total, 49 participants consented to participate and were divided into eight groups based on their residential area. Each group contained three to eight participants; the participants were provided snacks and drinks during the interview. During the 60-75-min interview, the entire process was documented using two voice recorders and two or three video recorders.
A moderator led the interview and asked participants three main questions: (1) What kind of support have you been providing to your wife during the postpartum period? (2) What kind of factors influence you to provide support during postpartum period? (3) From your own experience, what do Indonesian male partners need to improve in their support during the postpartum period? In the current study, two observers supported the interview documenting process by noting important points that arose. The observers are experts in qualitative research and have conducted several studies.
Ethical considerations. Ethical clearance and research permission were obtained from the University of Tsukuba (972) and the Indonesian Ministry of Home Affairs (440.02/772/Polpum).

Data analysis.
This study employed the content analysis technique for making inferences by systematically and objectively identifying specified characters within the text. 13 Content analysis consists of the following necessary steps that were applied in this study 14 : (1) initial preparation of data, (2) constructing a coding scheme, (3) preparing the data units, and (4) coding the data. First, data transcriptions were performed by two independent professional transcribers without any omissions. The transcription included the full answers of participants, as well as participants' nicknames. Important notes made by observers in the interview were also prepared during this period. During analysis, participants' answers were shortened into items and then developed into concepts without omitting the phenomenological essence. 15 The codes in the current study were defined as categories of words reflecting the concepts, and codes were justified from Cole et al. 16 about internal and external factors that encourage or discourage health-relevant behaviors. The internal factors included (1) knowledge; (2) attitudes, beliefs, and core values; (3) social and life adaptation skills; (4) psychological disposition; (5) and physiology. External factors included (1) social support; (2) media; (3) socio-cultural, economic, and political factors; (4) biological factors; (5) health care system; (6) environmental stressors; and (7) societal laws and regulations.
The units were developed from codes by employing general system theory 17 to define source levels of influencing factors for male partners and consisted of individual, community, and social policy levels. This theory helped develop a systematic framework and explain how multiple elements interacting at an individual level represent the internal factors; these factors consisted of knowledge level, beliefs and core values, life adaptation skills, psychological disposition, and physiological condition. While the external factors are built into community and social policy. After completing the analysis, the coding process required other professionals' opinions about the coding scheme and grouping. The current study obtained inter-coder agreement from other professionals on this study theme.

Validity and reliability.
In the current study, the researchers followed several steps to maintain validity: (1) moderator joined an FGI training and workshop to acquire certain skills in managing FGI dynamics; (2) the moderator and observers held a briefing just before the FGI to minimize any misconception; (3) the questions were arranged systematically; (4) data triangulation was performed by employing transcription and memos made by observers; and (5) peer debriefing was used to enhance the accuracy of the data; the last step involved including opinions from professionals on this theme who have conducted FGIs several times. Last, as the leader, the main researcher independently took all decisions regarding the study, beginning from obtaining ethical clearance, the recruitment process, interviewing, analysis, and writing the report; all these were done systematically. The researcher followed all the written rules on ethical clearance to implement the study and treat the data during the analysis. The different results were discussed and arranged together until a high-level agreement was achieved.
Several steps were also taken to maintain reliability. The transcriptions were checked many times to ensure they contained no obvious mistakes. The codes were developed by adapting a theory of factors influencing people's behavior; then the researcher had discussions with observers and professionals involved in the current study until agreement was achieved. The establishment of theories in the development of codes contributed to maintaining consistent reliability.

Results
Participants' demographic data. Participants came from various backgrounds, and their experiences were heterogeneous (Table 1).

Factors influencing Indonesian male partners' support 84
Makara J Health Res.

Individual factors influence Indonesian male partners' postpartum support
Knowledge level related to providing postpartum support. Participants considered knowledge level about the postpartum period as a factor that influenced them in providing support. As found in the concept, once the participants had more knowledge about the importance of their roles in providing support and about the type of postpartum support that can be provided, they provided greater support. Attitudes, beliefs, and core values. Attitudes, beliefs, and core values of participants were believed to be important variables that influenced the development of their attitude in providing support for postpartum women. Aging was also considered to be a physiological factor that keeps changing and influences male partners' postpartum support. A participant stated that when he was younger and still had one baby, he was still fresh and could do more things to provide support. "Regarding postpartum, the thing that influences is our age itself for sure. Maybe we were younger on our first child" (25S. PB). However, in the current situation it became difficult for him to provide support owing to his changing body.

Community factors influence Indonesian male partners' postpartum support
Social support from others. Support from others was defined as help from other parties, such as parents, parents-in-law, relatives, neighbors, or coworkers. "In a way, parents help more. Sometimes when separated, parents certainly give their hand because they know more. The role of grandma and grandpa can't be denied" (10M. P3). Another participant added that this condition is related to Indonesian customs, which involve strong kinship or tendencies to be close to one another: "for Indonesian, parents always give full support, present, and be there, at least they come in a week" (13M. P1).
The availability of informational support from the environment was also considered an important factor to improve male partners' involvement. When postpartumrelated information from the environment is limited, male partners provide limited support.

Social policy factors influence Indonesian male partners' postpartum support
Health care system. Difficulty accessing the health care system in Indonesia hampers male partners from obtaining appropriate support from professionals. Especially, access to information from professionals about the postpartum period and their roles in it, or even some biases in information between communities and professionals, were concerns: "there is a difference in information between professional and parents. One side we're guided by the professional. The one hand, from parents" (4M. P6). Moreover, the Indonesian health system classifies people based on their economic status, which impacts which health services can be accessed. This kind of system hampers Indonesian male partners from obtaining optimal support or access from professionals, especially for those of low-economic status: "sometimes the midwives or nearby clinics would ask about our 'class,' please excuse me, the class refers to economic status level" (5M. PC).
Indonesian societal laws and regulations. Unsupportive policies for male partners in Indonesia during childbirth and postpartum period are a factor influencing male partners' quality and quantity of support. Unavailability of paternal leave limits male partners' time to attend and provide support for wife and baby. Thus, if the company provides paternity leave, male partners would have more time to spend with family and provide optimal support: "luckily, when my 2 nd baby was born I could get more days off, so I automatically spent more and more time at home helping my wife" (25S. P3).
Unfortunately, few companies have this policy, hence male partners' involvement is still limited in Indonesia. These conditions influence male partners' ability to provide support to their wives, particularly during the early postpartum period.

Discussion
Individual factors influencing Indonesian male partners' support. The current findings clarified that Indonesian male partners really wanted to help postpartum women, but they lacked knowledge regarding what needed to be done.  [18][19][20] reporting that knowledge-level influences male partners' involvement in helping postpartum women. The more knowledge they possess, the more support they can provide. Along with knowledge, the core values that generally originate from religion, culture, and affiliation with others were also identified as factors influencing Indonesian male partners' support. Core values are often defined as fundamental beliefs of a person to connect and relate to others and the beliefs determining the importance that an individual will place on having contact with and helping others. 22 The participants in this study stated that religion and culture determined their behavior in providing support to their wives. Particularly, values derived from religion and culture are still strongly believed in Indonesia.
Life adaptation skills are related to male partners' ability to cover family needs in terms of skill and expenses, as well as time management to deal with coming challenges. Social life adaptation skills, defined as the ability to adapt to the environment, and people with this skill tend to have positive outcomes. 22 The current results showed that postpartum experience level would help male partners to provide support in the present. This finding is consistent with a previous study 18 finding that first-time fathers would tend to feel "disconnected" in the early period because of having no previous experience, while "experienced" fathers were more like to give advice from their previous experience.
Because most participants had incomes higher than the city standard, they could cover family needs. However, the remaining participants with lower incomes considered their support was still not optimal because male partners are expected to provide financial support Optimally. 11,23 This finding differs from that of a previous study that distinguished between financial support and male involvement. 24 In addition, the availability of time to spend with family was a factor influencing support provision; hence, time management is an important skill for Indonesian male partners. This finding is supported by a previous study 11 reporting that fathers seek to spend more time with their children and to engage with them in caring and playful activities.
Male partners' expectations related to pregnancy were also considered as a factor influencing their postpartum support. Discrepancies between expectations and reality affected male partners' mood. Additionally, Wiemann 12 found that an unplanned pregnancy was significantly associated with low support by Mexican American male partners. In conclusion, expectations might differ across individuals and are difficult to change.
The next factor influencing male partners' support is the physiological condition of both postpartum parents, which consists of postpartum women's health status and sexual needs and male partners' age. Postpartum women's health status refers to both their mental and physical conditions. Participants confessed that their support likely improved when their wife's condition was not healthy or when she still needed time to recover after a cesarean procedure. In addition to their physical condition, when postpartum women felt anxious or nervous, male partners tried to provide more emotional support. However, when postpartum women's condition became healthier and more stable, participants tended to decrease their support.
Additionally, this study found that male partners' age was a factor influencing their postpartum support. One participant associated age with the physical ability to move. At the birth of the first child, he was younger and could perform many support activities easily, but when he grew older, everything became more difficult. Previous studies have found that male partners' age has significant associations with their ability to provide support, [10][11][12] however, these studies found that younger male partners tended to provide lower support owing to limited knowledge, experience, and income.

Community factors influencing indonesian male partners' support.
This study found that kinship among Indonesians was a significant factor in male partners' support. The community support system includes family, neighbors, and relatives who are willing to provide help for postpartum women in the form of informational and tangible support. This support allows Indonesian postpartum parents to share their stressors and live a better life. Further, community is defined as membership with a sense of identity and belonging; the members influence and are influenced by one another. 25 Therefore, interactions among community members, particularly male partners, occur naturally and shape their belief systems, behaviors, values, and knowledge levels.
The current study clarified the social norms in the community, such as patriarchal beliefs and not expecting male partners to help, that influence male partners in helping their wives to deal with the postpartum period. Consistent results established in previous studies have shown negative social reactions to male partners' involvement. 11,18 Some urban areas of Indonesia still consider that men should not perform housework and infant care, consistent with patriarchal beliefs. Patriarchal beliefs decrease male partners' involvement and make them felt "left-out" regarding postpartum issues. 18 The norms that applied in the community regarding the postpartum period were shared by all members, and they developed as a common paradigm among them. Supportive values and norms would also help male partners to become more involved, and vice versa. a society because it is a government product that generally considers people's needs and problems. The goal of the policy is to influence people to take up ideas and change their behaviors. 26 According to the Alert-Husband program, Indonesian male partners are expected to be involved only during pregnancy and delivery, but their involvement is not required during the postpartum period. Difficulty accessing postpartum information from professionals also shaped male partners' assumption that they are not expected to be involved. These findings support Alio et al.'s 27 finding that unsupportive policy often discourages fathers' involvement. However, the development of new government programs like breastfeeding fathers encourages Indonesian male partners to improve their roles. This type of program is expected to develop more in the future to change both community and individual behaviors. As stated in previous study, 25 policy forces people to act as expected, therefore, it would be worth applying as an intervention.

Social policy factors influencing Indonesian male partners' support. Social policy is the greatest element in
Interaction between individual, community, and social policy factors. The government decides national goals that influence the establishment of roles in the community. The current study found limited government programs regarding the postpartum period and limited media coverage or information from others that could be accessed by Indonesian male partners. In this study, media was considered an important variable influencing people to change their behavior; this agrees with a previous finding that media coverage is significantly powerful in determining people's behavior. 27,29 The stressors that exist in the community, such as economic pressures, also influence people in making decisions and considering risks. This finding is consistent with those of a previous study 29 reporting that individual decisions and risk considerations are determined by the community because members are living in the same environment, and, therefore, their views influence each other.
Bertalanffy, 17 using general system theory, explained how multiple elements interact and develop into a system. This theory is also suitable to accurately explain Indonesian male partners' support that is influenced by the interaction among individuals, community, and social policy factors. This finding suggests that no single factor influences people's tendency to take an action, and it is strengthened by general system theory in connecting multiple elements to build a system. Therefore, several interventions can be applied to each element, but the impact would spread to all elements owing to the interaction.
The researchers have made their best efforts to conduct a good study and planned to collect the data from several areas. However, during the study period, the bureaucracy system of Indonesia was quite complicated and the study took longer than planned. The permission to conduct the study could be obtained from only one area, limiting the number of participants. Thus, the results might not be representative of the general Indonesian population. Last, randomization was not applied in the current study due to the participant number; this may influence the results. Yet, several steps have been followed to maintain the validity and reliability of the study.

Conclusions
The study results showed several internal and external factors classified into three levels of source factors: individual, community, and social policy.