1 Introduction

This chapter describes the need of health promotion strategies among families having a newborn baby. The focus of the utilization of the Salutogenesis theory in health promotion and future directions in health promotion research has been discussed. The following discussions are based on the research on perinatal mental health, trends in childbirth, health promotion, and, particularly, the integration of the Salutogenesis theory in health promotion during the perinatal period. The extensive discussions constitute a basis for development of future policies or initiatives to promote health promotion among families having a newborn that meet the standards for health care education and research.

2 Perinatal Mental Health

The perinatal period spans from the start of one’s pregnancy to the first 12 months after childbirth [1]. This period is a stressful and remarkably dynamic period of growth that poses significant challenges for both pregnant women and their partners [2]. Right from pregnancy till after child birth, the perinatal period is a complex phenomenon that consists of a myriad of adjustments to physical, social, and emotional lifestyles, that influence the overall well-being of the parents [3].

There is increasing research on parental perinatal mental health, in which systematic reviews revealed that 6.5% to 12.9% of pregnant and postpartum mothers experienced depression and anxiety [4, 5]. Likewise, depression and anxiety have been reported to be the most common mental health issues faced by fathers during the perinatal period [6, 7]. Existing meta-analyses have reported that the prevalence rate for paternal depression during the perinatal period was approximately 8.4% [8] and the prevalence of anxiety in fathers ranged between 3.4% and 25% during the prenatal period, to 2.4% and 51% during the postnatal period [9]. The striking prevalence of mental health issues among both mothers and fathers urge the need for a focus shift toward familial health promotion throughout the perinatal period.

In recent years, the experiences and needs of both mothers and fathers during the perinatal period have been explored. During pregnancy, mothers reported that it was an emotional roller-coaster ride that made them feel overwhelmed with the evolving pregnancy needs [10]. During postpartum, mothers felt varied emotional issues and many of them felt neglected to seek any help [10]. Mothers also experienced unpreparedness, anxiety, stress over infant care, breast-feeding concerns, and physical discomfort [11]. Existing barriers such as stigma, shame, and the lack of time and interactions with health care professionals prevented mothers from disclosing their feelings and needs [10, 12]. Hence, mothers expressed their need for (1) continuity of care, (2) mental health enquiries to include less common disorders on top of depression and anxiety, (3) culturally appropriate postnatal practices in infant care and upbringing, and (4) professional support needs, i.e. more information with regard to health care services [10, 11, 13]. Similarly, fathers exhibited negative feelings and psychological difficulties during the perinatal period. They expressed feelings of insecurity and inadequacy, felt isolated and excluded from the events that happened throughout the perinatal period [14,15,16,17,18]. Fathers also expressed stress, anxiety, depression, and role strain and conflict while they tried to cope with other role demands such as their jobs, parental stress from their children (e.g., fear of developmental problems), and conflict with in-laws and partners [14, 19, 20]. Therefore, fathers reported their needs: (1) including more educational information about pregnancy and parenting (during antenatal classes), (2) engaging them with other experienced fathers through small groups and focused group discussions [14, 17, 18], (3) having topics of discussion beyond the infant and partner care such as to include mental health topics [14, 20], (4) ensuring continuity of care after hospital discharge after the childbirth to seek timely help from health care professionals, and (5) incorporating technology (e.g., mobile health applications) to receive information covering mental health [21]. These evidences highlight the need to explore health promotion strategies among parents with a newborn to ensure smooth transition to parenthood and overall well-being of new parents and eventually their entire families.

3 Trends in Childbirth

Before the twentieth century, childbirth was considered a natural, normal, female-centred event, and hospital birth was uncommon [22, 23]. Female midwives predominantly helped with the childbirth, whereas men were rarely involved, and if they did, it was mainly during difficult deliveries [22]. In the nineteenth and twentieth centuries, medical influence on childbirth exaggerated with the development of medical procedures such as anesthesia and caesarean section [22]. Presently, the increased use of ultrasounds, fetal heart monitors, and increasing caesarean delivery rates illustrate multiple ways that women’s pregnancy and childbirth experiences have been heavily medicalized [22,23,24].

3.1 Medicalization of Childbirth

Medicalization is defined as the tendency to pathologize normal bodily processes and states, resulting in unnecessary medical management [25]. Some factors influencing childbirth medicalization include the complexity of maternal health care, culture of medical dominance, submissive culture in nursing and midwifery [26], technological advancement (e.g. emergence of biomedicine) [27, 28], and focus on risks involved with natural childbirth [29]. Childbirth medicalization is apparent in the widespread and increasing rates of medical interventions (i.e. caesarean and instrumental deliveries). In Western countries (e.g. the United States, Italy, and the United Kingdom), caesarean births account for approximately 20% of childbirth procedures [22, 30]. In Spain, the extent of medicalization is demonstrated in some of the highest caesarean delivery rates in Europe (e.g. 40% increase of the procedure in Catalonia over 5 years) and obstetricians are held accountable for not allowing women to be involved in childbirth decision-making [22, 31]. Furthermore, Eastern countries such as China and Singapore have one of the highest caesarean delivery rates in the world and South East Asia, respectively [32, 33]. In China, caesarean rates in the 90s rose from below 5% to above 10%, with urban rates as high as 20% by 1996. In 2010, of the 16 million babies born in China, approximately 50% were born by caesarean delivery [32]. In Singapore, the overall caesarean delivery rate increased from 32.2% (Year 2005) to 37.4% in year 2014 [34]. Some contributing factors to the alarming rates of caesarean delivery in China and Singapore include the obstetric care system (i.e. urbanization, medicalization of childbirth, and financial incentives), provider factors (i.e. obstetric training and staffing), and patient factors (i.e. parity where primiparas prefer caesarean delivery as it is deemed as more effective, and education level where university-educated women prefer caesarean births) [32].

The potential impacts of medicalization of childbirth and pregnancy include (1) dependence on medicine and the medical field [35], (2) hampering the embodiment process that neglects the body as somato-psychic [36, 37], and (3) hindering the gift dynamic at play during natural childbirth [38]. The medicalization of childbirth, at times can be a life-saving and effective procedure, but if done unnecessarily it may put women and their babies at increased susceptibility to mortality and morbidity and has aversive effects on maternal health and pregnancy outcomes [39, 40]. Hence, it should be limited to instances of medical emergencies. Finally, the medicalization of childbirth and pregnancy is coupled with a negative connotation, in which natural pregnancy and childbirth are now conceptualized as illnesses or diseases that require medical technologies and interventions [23, 41].

3.2 Latest Move Toward Natural Physiological Birth

In response to the increasing rates of medical intervention and medicalization of childbirth and pregnancy, there has been increasing efforts in promoting natural childbirth [42]. The World Health Organization (1997) highlighted the need to eliminate unnecessary medical interventions in childbirth [43] and countries have passed policies, initiatives, and guidelines to promote and protect natural childbirth. In Australia, the current maternity care reform (National Maternity Services Plan) is grounded on the underlying philosophy of childbirth as a natural physiological process [44]. Guidelines to protect, promote, and support natural childbirth were established and published in Queensland [45]. A policy in New South Wales (Towards Normal Birth in New South Wales) required all birthing facilities and institutions in the Australian state to have a written policy for natural childbirth by 2015 [46]. In the United Kingdom (UK), the Royal College of Midwives established the Campaign for Normal Birth that is now integrated as part of the Better Births Initiative [47]. Health care providers in Canada published a Joint Policy Statement on Normal Birth to protect the practice of natural birth [48]. In the Netherlands, the maternity care system is grounded on the principle that childbirth and pregnancy are natural physiological processes and community-based midwifery continue to play an important role [49] facilitating natural birth and continuity of care after childbirth. Hence, home birth remains a widely accepted and well-integrated part of the health care system [50].

Researchers have explored the role of midwives in encouraging natural birth as midwifery-led models of care are associated with the reduced use of medical interventions and mothers’ increased satisfaction with the natural birthing experience [51]. Thompson et al.’s (2016) qualitative study explored Dutch midwives’ attitudes and motivations toward the promotion of natural childbirth, and identified factors associated with these attitudes and motivations [52]. Findings revealed that midwives perceive the safeguarding and promotion of natural physiological childbirth as the focus of their role, and hospital culture is deemed as a barrier to practices that promote natural childbirth [52]. To overcome this barrier, midwives expressed the need to be aware of factors that inhibit and encourage natural childbirth practices, and to employ strategies that promote natural childbirth in home and hospital settings [52]. A recent UK evaluation study examined the effectiveness of an educational training package designed for midwives and maternity support workers [53]. The training package included a core workshop entitled “Keeping Birth Normal” (KBM), workshops that focused on antenatal education, communication skills, and baby massage [53]. Findings revealed that midwives were appreciative of the educational materials (e.g. videos and lectures) and expressed that small group discussions helped to facilitate learning [53]. They described two barriers to the implementation of training: (1) cultural focus on risk and (2) hospital culture of low prioritization of natural childbirth [29, 52, 53]. Despite the barriers, the training provided opportunities (1) to build a community of practice around natural childbirth that helped in overcoming the existing risk-focused culture and (2) created awareness within the midwifery unit that the promotion of natural physiological childbirth is central to their role [53]. These evidences urge the need for future midwifery education and research to focus on developing and testing strategies that support midwives in delivery health-promoting care and services [52, 53].

Moreover, a recent qualitative study that aimed to clarify how primiparous women in Turkey experience childbirth and intrapartum care revealed that the women wanted a natural birth without interventions [54]. Grounded theory guided interviews with 12 women were conducted and they reported wanting vaginal birth without interventions, which required empowerment and social support from others (i.e. health care professionals, family, and friends) [54]. Also, they expressed that routine medical interventions during the birth process cause their anxiety and frustration [54]. These interventions become obstructions to women’s natural position during birth, interrupt the birth process, and compromise their dignity and sense of autonomy [54]. This is an exceptionally important finding as Turkey has one of the highest caesarean rates, in which care during labor often entails the overuse of medicalized interventions such as episiotomy (i.e. experienced by 93.3% of primiparous women in Turkey) and augmentation with oxytocin and caesarean section [55]. With women who voiced their “want” for natural birth without interventions due to the negative consequences of medicalized interventions, it is a “need” to work toward a less- or non-medicalized childbirth process through positive health promotion.

With the progression toward less-medicalized models of birth through promotion of natural childbirth, existing barriers such as hospital and risk-focused culture are still apparent in many parts of the health care system. Therefore, it is imperative to adopt an appropriate approach of health promotion that will provide the necessary shift of focus from the risks and complications associated with childbirth to one that provides a positive and health-promoting experience for families with a newborn [56].

4 Health Promotion: Use of Salutogenesis Theory

Health promotion is purported to enable individuals with increased control over their own health [57]. One such approach is to integrate the Salutogenesis theory that was coined by the medical sociologist Antonovsky (1979) who focused on the origin of good health rather than the origin of illness [58]. Salutogenesis illustrates that the state of health lies on a spectrum—from complete absence of health to absolute state of health on the other extreme [58]. This theory implies that one has the ability and control to move toward better health with available resources around them. Salutogenesis consists of two: (1) generalized resistance resources (GRR), i.e. characteristics of an individual, family, or community that are resources to aid the individual in coping with stressors and (2) sense of coherence (SOC), i.e. one’s ability to use available resources for stress-coping and health promotion ( [59]. In recent years, the salutogenic framework has been explored and expanded, in which more concepts were included within the framework. It is known as the Salutogenesis umbrella (Fig. 14.1) that constitutes concepts (e.g. Gratitude, Self-efficacy, Connectedness, Coping, and Well-Being [60,61,62,63,64] with the positive view of health as a resource for life and executing behaviors to restore and maintain good health even when one is not ill [65]. Hence, Salutogenesis is a potential school of thought that urges health care professionals to adopt positive and health-promoting care to assist families during the perinatal period.

Fig. 14.1
figure 1

Salutogenesis Umbrella (Reproduced with permission from Folkhälsan Research Center, Lindstrom & Eriksson, 2010) [65] According to Monica Eriksson, there is a revised version of the Salutogenesis umbrella which is used now)

Presently, there is an increasing trend in the utility of Salutogenesis for guiding health promotion under various disciplines. For instance, García-Moya and Morgan (2016) assessed the theoretical status of Salutogenesis and the utility of SOC to advance health promotion practices for young people’s well-being [66]. SOC has been shown to be associated with well-being, in which it can be an asset that operates by increasing one’s ability to mobilize both internal and external resources for well-being [66, 67]. More recently, Johansson et al. (2018) developed and implemented a salutogenic treatment model in a clinical setting of emergency child and adolescent psychiatry in Sweden [68]. Eight GRRs (e.g. clear language, daily information, and participation in decision-making) were developed and implemented in the emergency unit, and parents reported increased satisfaction with the treatment and care provided [68]. Mental health of children improved during their stay at the hospital, and results revealed reduced treatment length and readmission rates [68]. Therefore, the salutogenic framework can be applied as a strong and effective theoretical basis to direct the development and implementation of health care services.

Multiple studies have adopted the salutogenic framework to highlight important qualities of health care providers and areas of improvements to promote SOC in new mothers [69,70,71]. Findings revealed that midwives should stay calm in tight time-constraint environments while targeting positive wellness topics rather than risk factors and provide mothers constant reassurances to encourage SOC [69]. Dahlberg et al. (2016) interviewed new mothers and they expressed the need to be cared for exclusively and highlighted the importance of a midwife for emotional support, coaching, and parenting guidance [70]. In Kelly et al. (2016) study, Salutogenesis was adopted, and a framework was proposed to promote families’ SOC and well-being to better facilitate their transition into parenthood [71]. To promote SOC, the health care sector should (1) improve on the continuity of care and support for parents in the postpartum period, (2) improve the method of information delivery, and (3) increase parental involvement in decision-making, while balancing relationships among parents and health care professionals [71]. Altogether, these salutogenically focused studies highlighted the need for health care providers to possess more humane qualities (i.e. midwives to stay calm and provide emotional support), as opposed to just the delivery of tangible materials (e.g. provision of educational booklets) to provide positive and health-promoting services.

4.1 Salutogenesis Theory in Perinatal Health Care

The salutogenic framework has been applied in perinatal health care, specifically for families having a newborn. Existing salutogenically focused studies addressed several phenomena across the perinatal period. Greer et al. (2014) explored mothers’ fear of childbirth and its impact on birth choices among women and their partners through interviews carried out within the SOC theoretical framework [72]. The findings (i.e. riskiness, ways of coping, and being a good parent) were related to the three dimensions of SOC (i.e. comprehensibility, manageability, and meaningfulness) [72]. For instance, pregnant couples feared the repercussions of natural childbirth and preferred medical interventions over natural childbirth to cope with uncertainties and to ensure a smooth and safe transition to parenthood [72]. The three dimensions of SOC were utilized to demonstrate parental and professional perspectives on neonatal care [73]. The concepts of comprehensibility, manageability, and meaningfulness provided a theoretical foundation to develop and integrate meaningful care that complemented existing services for optimal care [73]. Similarly, Kelly et al. (2016) applied the salutogenic framework to discuss ways in maintaining parental mental well-being during the perinatal period [71]. It was reported that the framework shaped parental mental well-being in two ways: (1) through helping parents to make sense of parenting stressors by examining psychosocial protective factors such as optimism, self-esteem, and stressor identification as well as how these factors fit into their lives, and they can use them to cope with the parenting stressors, and (2) strengthening parents’ sense of coherence [71]. As such the salutogenic framework could be used as a perinatal parent education framework to promote overall parental well-being during the perinatal period [71]. There are only two existing reviews that consolidated existing studies that examined Salutogenesis in perinatal health care. Smith et al. (2014) identified salutogenically focused outcomes (n = 16; e.g. maternal satisfaction and breastfeeding) and non-salutogenically focused outcomes (n = 49; e.g. measures of neonatal morbidity) during the intrapartum period (Smith et al. 2014). The review implied a lack of salutogenically focused outcomes reported in intrapartum intervention-based research [74]. Perez-Botella et al. (2015) examined how the Salutogenesis theory can be utilized to address several parenting outcomes across the perinatal period, and implied that the theory is rarely used in maternity care research and urged future research to measure salutogenitcally oriented outcomes to provide a balance in maternity care design [75]. Though there are increasing but limited perinatal studies that adopted the salutogenic framework with majority of studies focussing on only SOC, there is a crucial need to expand the utilization of the salutogenic framework and concepts in the salutogenic umbrella (other than SOC) to ensure a holistic application of the theory to encourage health promotion during the perinatal period.

4.2 Managing the Perinatal Period with Physical Activity: A Salutogenic Approach

Women during pregnancy are generally sedentary and could gain excessive weight due to physical limitations, increased appetite, and tiredness [76, 77]. As a result, majority of the pregnant women fail to meet the recommended level of physical activity and this increases their risk of negative pregnancy conditions such as gestational diabetes and pregnancy-induced hypertension [77, 78]. Also, the children of obese women during pregnancy are more likely to become obese adults [79]. Therefore, there is a need for health care professionals to inform pregnant couples about healthy lifestyle choices such as the engagement in physical activity for health promotion during the perinatal period [78]. Physical activity is recommended as a health promoting approach that aid pregnant couples to cope with the bodily changes throughout the perinatal period [80]. Also, physical activity has been found to be associated with increased overall well-being during pregnancy, self-esteem, shorter duration of labor, fewer depressive symptoms, higher prevalence of natural childbirth [77], and reduced occurrence of gestational diabetes [81] and pregnancy-induced hypertension [82].

The Salutogenesis theory has been found useful in directing families to engage in physical activity as a mean to cope with potential negative pregnancy conditions during the perinatal period [83]. Frequent physical activity has been shown to be associated with strong SOC [83]. In Hassmen et al.’s (2000) population study significant correlations were found between individuals, both men and women, who exercised more frequently with higher SOC than those who exercise less frequently [84]. Another study from the Netherlands revealed that individuals with a strong SOC engaged in sports more frequently and have better health outcomes such as lower average blood pressure [85]. The individuals with increased physical activity not only found to have stronger SOC but also higher self-esteem, stronger control over bad habits, and more positive attitudes toward changes in life [86]. A review conducted by Eriksson and Lindstrøm (2006) synthesized empirical findings on SOC and reported that stronger SOC is linked to better health outcomes [87]. Stronger SOC was found to be associated with lower mortality risk [85], delay onset of cancer [88], and lower rates of diabetes [89].

During the perinatal period, one of the main contributing factor that lead to physical inactivity is lack of social support [76, 78]. Women reported that due to lack of support from their partners to run errands at home and to care for older children, they often have limited time and tend to neglect their physical exercise. To promote a strong social support and to increase physical activity, the salutogenic framework can pave the path in encouraging families to engage in physical activities together. On top of the two main components (i.e. GRR and SOC) of the salutogenic theory, the other concepts from the salutogenic umbrella such as connectedness [61], coping [63], and well-being [62], can be included to form a conceptual framework in the development of family-focused interventions catered for the pregnant couples. For instance, during prenatal care, health care professionals (i.e. doctors and midwives) have the unique opportunity to inform pregnant couples about the benefits of healthy lifestyle choices such as walking and swimming and to recommend individualized exercise routines and nutritional plans for couples to follow through. At this stage, pregnant couples can be motivated to have a shared physical activity plan to enhance their connectedness [61] and thus supporting each other for a shared activity that will eventually benefit them both physically and mentally. These individualized couple-based exercise routines and nutritional plans can be then enhanced with other shared physical and mental changes with the addition of the newborn during the postpartum period.

During postpartum, shared physical activities and nutritional plans could continue to direct couples and their newborn through connecting and benefitting the overall familial well-being. Hence, health care professionals who recommend physical activities and nutritional plans (Coping) help to provide a common ground for both mothers and fathers (GRR) with a newborn (Connectedness) to manage the likelihood of negative pregnancy conditions. The adherence to exercise routines and nutritional plans could aid in parental overall physical and mental well-being (Well-being; SOC), improving their physical and mental health. With connectedness and appropriate coping to stressors throughout the perinatal period, the overall familial well-being and SOC could be maintained using the available resources, and thus, result in positive perinatal health outlooks and outcomes. Therefore, additional concepts in the salutogenic umbrella can be included on top of GRR and SOC in directing the development of family-focused services.

5 Literature Gaps, Implications, and Future Research

With rising prevalence rates of negative parental mental health during the perinatal period, mothers and fathers reported negative feelings and expressed needs to assist them during this period. The medicalization of childbirth resulted in aversive effects on maternal health and pregnancy outcomes and is coupled with a negative connotation that pregnancy and childbirth are conceptualized as illnesses or diseases. Despite the increasing efforts to promote natural physiological childbirth, hospital and risk-focused cultures continue to pose as strong barriers to normalizing natural childbirth. Therefore, these pose as existing gaps in the literature that imply a necessary shift of focus to one that provides a positive and health-promoting experience for families with a newborn. To bridge these gaps, health promotion that integrates the Salutogenesis theory forms a foundational basis that directs health care professionals and providers to design and deliver well-being focused interventions and care services for the pregnant couples and the new parents. Existing salutogenically focused studies that adopted quantitative (i.e. correlational studies and randomized controlled trials) and/or qualitative approaches (i.e. in-depth interviews and grounded-theory studies), implied that the salutogenic framework is a potential school of thought that urges health care professionals to adopt in providing positive and health-promoting services and care to assist families during the perinatal period. Also, salutogenically focused qualitative studies that interviewed pregnant women and midwives during the perinatal period highlighted the need for health care providers to possess more humane qualities (e.g. emotional support) to deliver positive and health-promoting care. This implies the need to train health care professionals such as midwives to be prepared and proactive in delivering optimal positive perinatal care. Future research can consider the salutogenic framework in designing midwifery education that focuses on developing and testing strategies to support midwives in this endeavour. The salutogenic framework is well-positioned as a perinatal parent education framework and future research can aim to design salutogenically focused interventions (e.g. support groups and perinatal classes) to promote parental well-being during the perinatal period.

Existing quantitative and correlational studies have shown the benefits of being physically active during the perinatal period, but the majority remains physically inactive. This implies the need for health care professionals to inform pregnant couples about healthy lifestyle choices for health promotion and prevention of negative pregnancy conditions during the perinatal period. Future research can aim to adopt the salutogenic framework in developing family-focused care services (i.e. exercise routines and nutritional plans) catered to pregnant couples during the perinatal period. It is also important to conduct further research on pregnant couples and factors that promote physical activity.

6 Conclusion

There are increasing but limited perinatal studies that adopted the salutogenic framework, especially elements of SOC in isolation. Future research could expand the utilization of the framework and concepts in the salutogenic umbrella beyond SOC to ensure a holistic application of the theory to encourage health promoting outcomes during the perinatal period. As majority of the existing studies are from the West, more studies from geographically diverse backgrounds such as the Middle East and Asia are required to explore and garner a holistic view of salutogenic framework and health promotion across the perinatal period. In summary, salutogenic theory offers the potential to influence a shift away from negative health outlooks and outcomes, medicalization of childbirth, toward health promotion and positive well-being focus for maternity care services design and delivery in the future.

Take-Home Messages

  • It is imperative to enhance quality of care for families having a newborn to ensure optimal parental mental health and newborn health.

  • A fundamental step is to recognize and acknowledge the problem of medicalization interventions during the perinatal period, and to adopt an appropriate approach of health promotion that will provide a shift of focus from the risks and complications associated with childbirth to one that is positive and health-promoting for families with a newborn.

  • It is timely to evaluate and implement the up-and-coming salutogenic framework in health care services that focuses on positive well-being and health promotion, especially with its increasing but limited application in perinatal health care. The framework serves as a guide for health care professionals in developing health-promoting services to families with a newborn.

  • There is a crucial need to expand and integrate the salutogenic framework in promoting the engagement in physical activities as families tend to become sedentary during the perinatal period. The framework serves as a common ground for health care professionals and families to discuss individualized activity plans that can optimize their experience and positive well-being during the perinatal period.

  • Theory-based research is the way to describe and evaluate evidence-based quality care to families with a newborn. Health care professionals need to be equipped with relevant skills in conducting quality research that work toward the expansion of the framework and concepts in the salutogenic umbrella beyond SOC to ensure a holistic application of the theory to encourage health promoting outcomes during the perinatal period.