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Assessing Postpartum Adjustment A Pilot Study
research and studies
Assessing Postpartum Adjustment A Pilot Study FRANCI SHEEHAN, RN, MS Utilizing crisis theory, the stages of growth and development, and a theory of role transition and enactment, a series of questionnaires w a s developed as a clinical tool to study women’s adaptation to motherhood during six weeks postpartum. The tool was tested on six women. Results suggest that the postpartum is indeed a critical period of identity reformation and role transition. Theories are developedfor a framework, and a timetable for nursing intervention is given.
Relatively little systematic research has been done on the psychodynamics of the woman in the postnatal period. Existing studies usually concern the effects of mothers on children, rather than the effects of children on mothers. However, the integration of “motherliness” in a woman’s life is a developmental crisis that is a complex and, as yet, inadequately investigated process. Rubin has stated that nursing’s big failure today is the postpartum period.’ The continuity of care that is available prenatally and throughout the birth process often comes to an abrupt halt when the mother and infant are discharged. Maternity nursing must be concerned with the woman’s successful adaptation to the mother role. Emotional changes during the postnatal period are so common as to be termed popularly the “baby blues”, yet psychological requirements for good mental health during this time are not well understood. T h e postpartum period is a time when a woman’s identity and selfconfidence are in crisis. Becoming a mother is a rite of transition and involves a reordering of all the roles that are integrated into a woman’s self-concept. A woman must come to January/February 198 1 JOGN Nursing 009O-0311/81/0115-0019$0100
terms with society’s expectations of her and the expectations she has for herself, the father of the child, and the child itself. The outcome of this process will affect the future mental health of the woman and her family. Postpartum psychological responses, therefore, should not be regarded as isolated events but as part of the dynamic continuum of a woman’s life. For this reason, it is important to go beyond studies that view the new mother just in relation to her new baby. The woman deserves to be understood as a person undergoing the impact of a major life change. Mothering is a complex of culturally determined and learned behavior into which each woman brings a n integration of personality organizations a n d ego functions. T h e achievement of the maternal role further defines the woman’s identity in terms of role and social demands. Thus, when considering the task of becoming a mother, the outer demands of role perception and expectation, coupled with an inner demand for maintenance of self-image and the need to fit both into a newly arranged sense of identity, must be taken into account. The greater the conflict between role perception and self-image, the greater the extent of
identity confusion, which complicates the crisis state. Measurements of role perception and role expectation, levels of identity formation, an extent of crisis situation are therefore essential in studying a woman’s adaptation to motherhood. The purpose of this study was to identify variables which enable women to adjust successfully to motherhood in the six weeks following childbirth. The results were used to develop a framework and timetable for nursing intervention. Materials and Methods Three questionnaires, or survey sheets, composed of statements of thoughts, feelings, or beliefs were developed (see Appendix). Responses ranged from never to always. The statements assessed the woman’s perception of motherhood as a crisis in h e r life, a n d also assessed the woman’s validity of role perception and expectation, skill in role enactment, and current organization of the self. The questionnaires were administered during a series of four interviews. The interviews took place during the last month of pregnancy and at three days, two weeks, and six weeks postpartum. The third questionnaire was used for the last two interviews. Informal interviews were conducted at each of these times. These were non-directive, focusing on the woman’s concerns at that particular time. These subjective findings were recorded after each session. The prenatal interview and questionnaire provided baseline data for comparing role perception and expectations with the reality of role enactment. Six women were chosen from prepared childbirth classes on the basis of age (20-30 years of age), marital status (married, living with spouse), health (low-risk pregnancy), expected delivery date, and parity (primigravidas). These restrictions con-
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trolled t h e n u m b e r of variables which could bias the results. No other statistical data were known at the time of selection. The terms of participation in the study were explained to, and accepted by, each woman. Background information formed the following profile: average age, 26.5 years; average education, 16.4 years; and average length of marriage, 3.2 years. All subjects were employed until the last trimester of pregnancy. This was a small, self-selected sample, and no statistical analysis was done; the results cannot be generalized to a greater population. Nevertheless, the findings substantiate the use of the framework for data collection and assessment and support some hypotheses which have implications for nursing practice.
Results This study substantiated the theory that the maternal adjustment period during the first six weeks after delivery constitutes a potential crisis in women’s lives. It is a time when physical demands and the tasks of role transition and identity reformation make women vulnerable to selfconflict and insecurity. Valid and clear role perceptions and expectations seem to be critical in terms of completion of role transition without detouring energies to other tasks. Other situational factors, such as physical capabilities and availability of support systems, are also determinants in easing maternal adjust men t . In this study the validity of role perceptions and expectations was measured by means of questionnaires. T h e one subject who had very little deviation in responses to any of the four forms concerning perception and expectations of the mother role and percepticln of enactment of t h e role h a d t h e least amount of difficulty in postpartum adjustment. This subject’s ease of role transition was validated in interview sessions. She had always wanted to be a mother, had planned her pregnancy, and felt there was nothing to regret about this decision. Raising her child was her most im-
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portant priority and she planned not ing was their main concern. If the to work for at least four or five years. subjects had not had well-formed She had a secure and stable per- egos validated by success in most of ception of the maternal role which their previous undertakings, their was in conformity with the historical self-confidence would have been views of society. As the “degree of more vulnerable a n d in greater adjustment to roles varies directly crisis. Until the issue of competency with the clarity with which roles are is resolved, the woman’s energies defined”’ there was no role-role or cannot be directed toward role-takself-role conflict to inhibit adjust- ing and identity formation. Believing that one is capable of ment. Subjects planning to return to meeting the child’s needs also apwork within a year after the child’s pears to be a positive factor in adbirth had conflicting emotions re- justment. The two subjects who had garding this decision. The subject the least amount of role conflict both who had the most difficulty in meet- stated consistently that they felt they ing her expectations of “mother” always had empathy and insight was planning to return to work six to into the feelings and needs of their nine weeks postpartum. She felt un- child. Of these two subjects, one had prepared for the deep emotional at- constant rooming-in with her baby. tachment that she had for the baby She had allowed no visitors during and found that the reality of caring her hospitalization so that the baby for a child was much more demand- would not have to be kept in the ing than she had anticipated. “Role nursery a t a n y time. T h e other conflicts occur when a person oc- mother had a cesarean delivery and cupies two or more positions simul- had her infant with her as much as taneously a n d when the role ex- possible during her seven-day hospipectations of one are incompatible tal stay. These two women experiwith the role expectations of the enced no problems with breastfeedother.”’ This subject’s emotions re- i n g a n d expressed n o concerns garding her return to her career regarding the issue of competency. were interfering with the task of role One further variable was that the transition. two mothers were the only two in The role-role conflict of career the study who felt they had adeand mothering is but one aspect of quate and helpful nursing care durinvalid role perceptions. Maternal ing their postpartum hospital stay. role adjustment also appears to be adversely affected by the amount of Discussion A woman’s ability to achieve a change in lifestyle necessitated by an infant’s integration into the home. sense of being a mother is dependent Role enactment is facilitated by the on the valid and defined perception woman’s ability to adapt her baby of the role of mother and its ininto her lifestyle rather t h a n at- tegration into her self-identity. The tempting to adapt to the baby. The critical factor in role enactment durwomen who expected t h a t they ing the postpartum period appears would have to change their lifestyles to be dependent on the degree of appreciably had a more difficult role conflict between the woman’s transition than the women who per- perception of the maternal role and ceived motherhood as being an in- the perception of her feminine identegral part of their identity forma- tity. tion. Thus, less restructuring of their In our society, women are geared self-concepts was needed. The most for many roles. They are indoctridifficult adjustment was found in nated with the sense that being only the subject who felt the reality of the wife and mother is an invalid prec h i l d c r e a t e d m u c h more of a scription for a satisfying and meanchange than anticipated. Again this ingful life. Being the “total woman” seems to validate the importance of involves being able to integrate carole perceptions and expectations. reer, successful marriage, creative At two weeks postpartum, three of mothering, and personal growth into the subjects felt that becoming a a secure feminine identity. Women mother was a crisis in their lives and must be alluring, assertive, able to that attaining competency in mother- climb the corporate ladder, and play January/February 198 1 JOGN Nursing
the male power games; then return home, and totally meet the demands of a fussy infant, and have insight into the child’s feelings and needs. As if this were not already an overwhelming task, the woman is expected to do this in a society where extended families are often nonexistent or unavailable, where there is no formal preparation for mothering, little if any previous experience with infant care, and almost no recognition of the worth and dignity of motherhood. If the definition of role is understood as “a patterned sequence of learned actions or deeds performed by a person in an interaction situation,’” and if the actions that are patterned into roles are learned through intentional instruction and incidental learning, then it follows that, as there is no intentional training for motherhood and much of our incidental learning is invalid due to the changing status of woman, role expectations that are the residue of prior experience will be ambiguous. These unclear expectations offer women no guidelines by which to model their actions. Role performance is based on hit-and-miss types of activities. Well-defined identities may be able to weather these insecurities; however, weaker egos will need to use coping skills to assure self-maintenance or a crisis situation will exist. T h e lack of knowledge and skills concerning infant care will increase i d e n t i t y confusion a s energies will be directed toward reestablishing self-control and competency. Empathy for the child’s needs will also be impossible t o achieve until competency issues are resolved. Any physical disabilities or lack of support systems will further potentiate this crisis situation.
Nursing Implications How do these considerations influence nursing practice? How can maternal adjustment be facilitated, a n d at which time in the childbearing process are women most receptive to intervention? If we consider that postpartum adjustment is facilitated by lack of conflict between role perceptions, expectations, and role enactment, the first step in intervention must occur before the child is conceived. Nurses January/February 198 1 JOGN Nursing
who are involved in our educational system, especially at the high school level, should work toward adapting curricula which will include information on child care and mothering. We prepare young women for career roles but preparation for the role of mother, which is an irreversible role and certainly an important one in regards to future generations, is neglected. We cannot expect, or even wish, that society return to a time when women were prepared at home to be mothers. These skills should now be an intrinsic part of every woman’s education. Such training, however, is a long-range goal and cannot be reached overnight. More immediate is the need of childbirth educators and nurses in obstetrical practices to become involved in focusing on the crisis of maternal adaptation, not just on labor and delivery. It might be advisable to ask ourselves which emphasis will be most helpful to parents in the long run. Maternal expectations could be defined during childbirth classes or during office visits. Couples should be made active participants in discussion of their perceptions and previous experiences. Expected physical discomforts, the demands of a new baby, emotions, the depth of attachment, conflicts with career a n d other roles should all be described and discussed. If the childbirth instructor is comfortable with role playing, she might ask a couple to enact their responses to a baby who has not slept in the last 12 hours. Discussion should also focus on how the family will integrate the child into their lifestyle. If prospective parents have friends with young children, they could be encouraged to practice a few child care skills. Postpartum couples could return for a class to discuss their adaptation to parenthood. Preparation should be given for cesarean deliveries, not only for the delivery itself but also for the postoperative condition. Emphasis should be put on the importance of available support systems, not only family and friends, but also applicable community resources. The merits of rooming-in and the importance of early contact with the infant should also be considered. Postpartum classes may be helpful for later parenting experiences but
no new mother who is physically exhausted and having difficulties with her infant is going to travel out to a class in the first few weeks after delivery. Women in this study complained a b o u t t h e lack of support from nurses during the postpartum hospital stay. T h r e e women who had problems breastfeeding had received either little or inaccurate counseling from their nurses. Nurses who work on postpartum units should receive in-service education in childcare skills, breastfeeding, and the psychological needs of t h e postpartum woman. The new mother does not need the nurse to whisk in and take the baby back to the nursery when it is crying. She needs guidance in how to handle these situations. Most of all she needs to be encouraged that she is doing the right thing. The new mother has an acute desire to learn and to succeed. The findings of this study are in concurrence with Rubin’s observation that these first few days are a time of optimal readiness for learning.3 Classes on the postpartum unit should not be on breastfeeding and baby care alone, but s h o u l d also i n c l u d e ,discussion groups with mothers to help clarify their expectations and perceptions, discuss their emotions and concerns, and answer their questions. These groups could be available every day. Information could be given regarding physical recovery and normal discomforts. Cesarean mothers could be given an opportunity to discuss their feelings concerning their cesarean deliveries. The use of a maternity clinical specialist on the postpartum unit could be invaluable in terms of inservice education, program development, group leadership, counseling, and discharge planning. Since many postpartum problems occur after discharge, a telephone service set up to provide mothers with information and answers to questions during the first few weeks at home would be helpful. Pediatricians should be encouraged to make their first assessment visit at two weeks rather than the usual four- to six-week visit. Pediatric clinical specialists could be utilized at this time to make a well family assessment.
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As we move into the use of maternity centers where new mothers stay only six to 24 hours, the health care delivery system is going to have to provide home c a r e services for mothers and their babies. Instruction for care during the postpartum period is too often colored with an attitude of normalcy that provides routine care bordering on neglect. If nurses would understand the new mother in terms of her crisis of role transition and identity reformation, they would discover that the postpartum period is a time for creative and invaluable nursing intervention. It is a time when a small amount of support and guidance can have lasting effects. Intervention must focus on a plan of care that will provide each woman with the individual strengths and skills needed to complete successfully role enactment and identity reformation.
This study focuses on women who h a d planned pregnancies, strong self-concepts, and available support systems. Assessing t h e role perceptions, expectations, degree of identity formaton, a n d potential crisis situations for women who are not in such advantageous positions is even more crucial in providing nursing care which will aid maternal adjustment a n d thereby foster improved health.
References 1. Rubin R: Maternity nursing stops too soon. Am J Nurs 75:1680-1684, 1975 2. Sarbin TR: Role theory, Handbook of Social Psychology, Edited by: G. Lindzey Reading, Massachusetts, Addison-Wesley, 1964, 223-258 3. Rubin R: Puerperal changes. Nurs Outlook 3:753-755, 1961 4. Rubin R: Attainment of the maternal role, Part 1: Processes. Nurs Res 16:237-245, 1967
Bibliography Anthony EJ, Benedek T (eds): Parenthood. Boston, Little, Brown & Co, 1970 Caplan G: An Approach to Community Mental Health. New York, Grune & Stratton, 1961 Erikson E: Identity and the life cycle, Psychological Issues. New York, International Univeristies Press, 1959 Address for correspondence: Franci A. Sheehan, RN, Box 198, Trapelo Road, Lincoln, MA 01773. Franci Sheehan is an ob/gyn nurse practitioner at East Boston Health Center. She has worked as a clinical instructor on a postpartum unit, a prepared childbirth instructor, and a community health nurse. Ms. Sheehan's undergraduate degree is from the University of Kentucky in Lexington, and her M S degree is from Boston College-Harvard Medical School. She is a member of NAACOG.
Appendix: Description of Clinical Tool for Assessing Adaptation to Motherhood through Six Weeks Postpartum Presented below are the basic questions used in three questionnaires: one for the prenatal interview, one for the interview at three days postpartum, and one for the interviews at two and six weeks postpartum. Words in parentheses are changes or additions made in the second and third questionnaires. Words in brackets indicate words in the first questionnaire that were deleted for the second and third questionnaires. Italics are explanatory. On each questionnaire, the following directions were given: "The following statements are thoughts, feelings, or beliefs that people may have. After reading each statement please indicate how much you either agree with the statement or how frequently you think or feel the way the statement describes". The respondents then had the choice of checking Never, Sometimes, Often, or Always. The first 10 statements assess the woman's preception of pregnancy or motherhood as a potential crisis in her life, her ability to adapt and cope with this event, and her situational supports and coping mechanisms. The next 15 statements employ a series of either I-sentences or statements in which adjectives are the significant terms (qualities. traits, habits) which enable inferences to be made about the woman's level of identity.2 They measure the level of ego development along Erikson's series of psychosocial crises and critical areas in the organization of the self as defined by Sar-
bin.2 Sarbin's view of self-determination ends with the establishment of the social self during the stage of initiative versus guilt; however, these qualities can be reinforced and redefined throughout life. These ego traits that influence role transition are timebinding (trust and autonomy), flexibility (autonomy and initiative), empathy or "as if" behavior (initiative), and self-perception versus the perception of others (autonomy through identity). The last 20 statements assess the woman's ability to perceive and enact roles and record her role expectations regarding motherhood. Validity of role perception can be measured by availability of role models and concurrence with societal views. Skill in role enactment is related to the use of "as if" behavior, degree to which expectations mesh with reality, and areas of potential conflict.* The timing of these assessment periods is based on Rubin's study of "Attainment of Maternal-R~le".~ During the last month of pregnancy, the woman begins to view her child as a separate individual. The first phase of the postpartum period ends on the third day. At this point, Rubin says that the new mother begins to take hold, assert her independence and focus on what must be done. This phase lasts until approximately two weeks when the woman begins to focus outside her immeditate family. By six weeks, the postpartum period should be over and the role-taking phase completed.
1. Becoming pregnant (a mother) was (is) a crisis in my life. 2. My husband has been (is being) supportive and understanding (during my pregnancy). 3.I have enjoyed (am enjoying) being pregnant (a mother). 4. My own mother has been (is being) very helpful to me during my pregnancy (in adjusting to motherhood). 5. I feel that I am at a point in my life where I am ready for motherhood. (Ifeel ready for motherhood at this point in my life.) 6. I have difficulty handling problems. (I feel that I am handling problems without difficulty.) 7. Most of the time I feel I act appropriately. 8. I find it easy to overcome frustration. 9. I do not feel that I will have to change my lifestyle appreciably after (now that) the baby is born. 10. I feel that I will adjust (am adjusting) easily to motherhood.
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11. made the decision to become pregnant. [Not used in second questionnaire.] 12. have been (am) successful in most of my undertakings. 13. have (had) a good relationship with my own mother (most of my life). 14. feel that I have many goals for myself. 15. would feel guilty i f I had negative feelings about my child. 16. find it upsetting if my needs are not met. 17. I feel that I have a lot of patience. ‘ 18. Most of the time I think before acting. 19. I find it very unpleasant to fail at a task. 20. How other people view me is very important to me. (I am very concerned how other people view my abilities as a mother.) 21. I think a lot about who I am. 22. I am basically happy with my life. 23. I feel that I have a lot of self-control. 24. I feel that I expect the same things of myself that others expect of me. 25. I find that I am easily annoyed. 26. I am a creature of immediate gratification. 27. I find it easy to adapt to new situations. 28. Becoming a mother is the most important event in my life thus far. 29. My own mother is a role model for me. 30.I have spent a great deal of time imagining what kind of mother I will be. (Thus far I am the kind of mother that I imagined myself to be.) 31. I feel that I know the sex of my child. (Ipredicted the sex of my child accurately.) 32. I have a good idea of what my child will look like. (My child looks much like what I imagined him/her to be.) 33. I can picture what it will be like to have a child. (Having a child is much like what I pictured it.) 34. Becoming a mother is a learned role and is not instinctive. 35. I want to have a career that is meaningful to me aside from wife and mother. [Not used in second questionnaire.] 36. I intend to resume or begin a career within a year after the baby’s born. [Not used in second questionnaire.] 37. I find that I am (already) acting “as if” (like) I were a mother. 38. I feel that I have a lot of empathy and insight into the feelings of others (my child). 39. I feel I have a clear idea of how a mother should behave. 40. My views of motherhood seem in conformance with the views of society. 41. 1 have begun to view my child as separate from me (a separate individual). 42. My mother was pleased with her pregnancy and my birth. [Not used in second or third questionnaire.] 43. I have had a lot of experience caring for babies. (I am not having difficulty learning to take care of my baby.) 44. I feel that I have already started changing my life in preparation for motherhood. [No similar item in second questionnaire. Third questionnaire: I am already changing my life in order to adapt to motherhood.] 45. I will have to give (have given) up a lot of my present (past) activities after the baby is born (since the baby’s birth). [No similar item in second questionnaire.] 46. I feel (that I was) well prepared for labor and delivery. In addition, in the third and fourth interviews (third questionnaire), the woman was asked to respond to four open-ended questions to allow for more in-depth indications regarding degree of difference or sameness in expectations versus realization:
1. The greatest concern that I have at this point in time is? 2. I am most unprepared for? 3. My biggest disappointment in becoming a mother has been? 4. The thing which has pleased me the most about becoming a mother is?
NURSE MIDWIVES “Whole Woman Health Care” will be the theme of the 26th Annual Convention of the American College of Nurse-Midwives. The convention will be held April 26-30, 1981, at the Denver Hilton in Colorado. Continuing education workshops are planned for April 26 and 27. For further information contact the American College of Nurse-Midwives, 1012 14th Street, NW, Suite 801, Washington, DC 20005, (202) 347-5445.
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Assessing Postpartum Adjustment A Pilot Study FRANCI SHEEHAN, RN, MS Utilizing crisis theory, the stages of growth and development, and a theory of role transition and enactment, a series of questionnaires w a s developed as a clinical tool to study women’s adaptation to motherhood during six weeks postpartum. The tool was tested on six women. Results suggest that the postpartum is indeed a critical period of identity reformation and role transition. Theories are developedfor a framework, and a timetable for nursing intervention is given.
Relatively little systematic research has been done on the psychodynamics of the woman in the postnatal period. Existing studies usually concern the effects of mothers on children, rather than the effects of children on mothers. However, the integration of “motherliness” in a woman’s life is a developmental crisis that is a complex and, as yet, inadequately investigated process. Rubin has stated that nursing’s big failure today is the postpartum period.’ The continuity of care that is available prenatally and throughout the birth process often comes to an abrupt halt when the mother and infant are discharged. Maternity nursing must be concerned with the woman’s successful adaptation to the mother role. Emotional changes during the postnatal period are so common as to be termed popularly the “baby blues”, yet psychological requirements for good mental health during this time are not well understood. T h e postpartum period is a time when a woman’s identity and selfconfidence are in crisis. Becoming a mother is a rite of transition and involves a reordering of all the roles that are integrated into a woman’s self-concept. A woman must come to January/February 198 1 JOGN Nursing 009O-0311/81/0115-0019$0100
terms with society’s expectations of her and the expectations she has for herself, the father of the child, and the child itself. The outcome of this process will affect the future mental health of the woman and her family. Postpartum psychological responses, therefore, should not be regarded as isolated events but as part of the dynamic continuum of a woman’s life. For this reason, it is important to go beyond studies that view the new mother just in relation to her new baby. The woman deserves to be understood as a person undergoing the impact of a major life change. Mothering is a complex of culturally determined and learned behavior into which each woman brings a n integration of personality organizations a n d ego functions. T h e achievement of the maternal role further defines the woman’s identity in terms of role and social demands. Thus, when considering the task of becoming a mother, the outer demands of role perception and expectation, coupled with an inner demand for maintenance of self-image and the need to fit both into a newly arranged sense of identity, must be taken into account. The greater the conflict between role perception and self-image, the greater the extent of
identity confusion, which complicates the crisis state. Measurements of role perception and role expectation, levels of identity formation, an extent of crisis situation are therefore essential in studying a woman’s adaptation to motherhood. The purpose of this study was to identify variables which enable women to adjust successfully to motherhood in the six weeks following childbirth. The results were used to develop a framework and timetable for nursing intervention. Materials and Methods Three questionnaires, or survey sheets, composed of statements of thoughts, feelings, or beliefs were developed (see Appendix). Responses ranged from never to always. The statements assessed the woman’s perception of motherhood as a crisis in h e r life, a n d also assessed the woman’s validity of role perception and expectation, skill in role enactment, and current organization of the self. The questionnaires were administered during a series of four interviews. The interviews took place during the last month of pregnancy and at three days, two weeks, and six weeks postpartum. The third questionnaire was used for the last two interviews. Informal interviews were conducted at each of these times. These were non-directive, focusing on the woman’s concerns at that particular time. These subjective findings were recorded after each session. The prenatal interview and questionnaire provided baseline data for comparing role perception and expectations with the reality of role enactment. Six women were chosen from prepared childbirth classes on the basis of age (20-30 years of age), marital status (married, living with spouse), health (low-risk pregnancy), expected delivery date, and parity (primigravidas). These restrictions con-
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trolled t h e n u m b e r of variables which could bias the results. No other statistical data were known at the time of selection. The terms of participation in the study were explained to, and accepted by, each woman. Background information formed the following profile: average age, 26.5 years; average education, 16.4 years; and average length of marriage, 3.2 years. All subjects were employed until the last trimester of pregnancy. This was a small, self-selected sample, and no statistical analysis was done; the results cannot be generalized to a greater population. Nevertheless, the findings substantiate the use of the framework for data collection and assessment and support some hypotheses which have implications for nursing practice.
Results This study substantiated the theory that the maternal adjustment period during the first six weeks after delivery constitutes a potential crisis in women’s lives. It is a time when physical demands and the tasks of role transition and identity reformation make women vulnerable to selfconflict and insecurity. Valid and clear role perceptions and expectations seem to be critical in terms of completion of role transition without detouring energies to other tasks. Other situational factors, such as physical capabilities and availability of support systems, are also determinants in easing maternal adjust men t . In this study the validity of role perceptions and expectations was measured by means of questionnaires. T h e one subject who had very little deviation in responses to any of the four forms concerning perception and expectations of the mother role and percepticln of enactment of t h e role h a d t h e least amount of difficulty in postpartum adjustment. This subject’s ease of role transition was validated in interview sessions. She had always wanted to be a mother, had planned her pregnancy, and felt there was nothing to regret about this decision. Raising her child was her most im-
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portant priority and she planned not ing was their main concern. If the to work for at least four or five years. subjects had not had well-formed She had a secure and stable per- egos validated by success in most of ception of the maternal role which their previous undertakings, their was in conformity with the historical self-confidence would have been views of society. As the “degree of more vulnerable a n d in greater adjustment to roles varies directly crisis. Until the issue of competency with the clarity with which roles are is resolved, the woman’s energies defined”’ there was no role-role or cannot be directed toward role-takself-role conflict to inhibit adjust- ing and identity formation. Believing that one is capable of ment. Subjects planning to return to meeting the child’s needs also apwork within a year after the child’s pears to be a positive factor in adbirth had conflicting emotions re- justment. The two subjects who had garding this decision. The subject the least amount of role conflict both who had the most difficulty in meet- stated consistently that they felt they ing her expectations of “mother” always had empathy and insight was planning to return to work six to into the feelings and needs of their nine weeks postpartum. She felt un- child. Of these two subjects, one had prepared for the deep emotional at- constant rooming-in with her baby. tachment that she had for the baby She had allowed no visitors during and found that the reality of caring her hospitalization so that the baby for a child was much more demand- would not have to be kept in the ing than she had anticipated. “Role nursery a t a n y time. T h e other conflicts occur when a person oc- mother had a cesarean delivery and cupies two or more positions simul- had her infant with her as much as taneously a n d when the role ex- possible during her seven-day hospipectations of one are incompatible tal stay. These two women experiwith the role expectations of the enced no problems with breastfeedother.”’ This subject’s emotions re- i n g a n d expressed n o concerns garding her return to her career regarding the issue of competency. were interfering with the task of role One further variable was that the transition. two mothers were the only two in The role-role conflict of career the study who felt they had adeand mothering is but one aspect of quate and helpful nursing care durinvalid role perceptions. Maternal ing their postpartum hospital stay. role adjustment also appears to be adversely affected by the amount of Discussion A woman’s ability to achieve a change in lifestyle necessitated by an infant’s integration into the home. sense of being a mother is dependent Role enactment is facilitated by the on the valid and defined perception woman’s ability to adapt her baby of the role of mother and its ininto her lifestyle rather t h a n at- tegration into her self-identity. The tempting to adapt to the baby. The critical factor in role enactment durwomen who expected t h a t they ing the postpartum period appears would have to change their lifestyles to be dependent on the degree of appreciably had a more difficult role conflict between the woman’s transition than the women who per- perception of the maternal role and ceived motherhood as being an in- the perception of her feminine identegral part of their identity forma- tity. tion. Thus, less restructuring of their In our society, women are geared self-concepts was needed. The most for many roles. They are indoctridifficult adjustment was found in nated with the sense that being only the subject who felt the reality of the wife and mother is an invalid prec h i l d c r e a t e d m u c h more of a scription for a satisfying and meanchange than anticipated. Again this ingful life. Being the “total woman” seems to validate the importance of involves being able to integrate carole perceptions and expectations. reer, successful marriage, creative At two weeks postpartum, three of mothering, and personal growth into the subjects felt that becoming a a secure feminine identity. Women mother was a crisis in their lives and must be alluring, assertive, able to that attaining competency in mother- climb the corporate ladder, and play January/February 198 1 JOGN Nursing
the male power games; then return home, and totally meet the demands of a fussy infant, and have insight into the child’s feelings and needs. As if this were not already an overwhelming task, the woman is expected to do this in a society where extended families are often nonexistent or unavailable, where there is no formal preparation for mothering, little if any previous experience with infant care, and almost no recognition of the worth and dignity of motherhood. If the definition of role is understood as “a patterned sequence of learned actions or deeds performed by a person in an interaction situation,’” and if the actions that are patterned into roles are learned through intentional instruction and incidental learning, then it follows that, as there is no intentional training for motherhood and much of our incidental learning is invalid due to the changing status of woman, role expectations that are the residue of prior experience will be ambiguous. These unclear expectations offer women no guidelines by which to model their actions. Role performance is based on hit-and-miss types of activities. Well-defined identities may be able to weather these insecurities; however, weaker egos will need to use coping skills to assure self-maintenance or a crisis situation will exist. T h e lack of knowledge and skills concerning infant care will increase i d e n t i t y confusion a s energies will be directed toward reestablishing self-control and competency. Empathy for the child’s needs will also be impossible t o achieve until competency issues are resolved. Any physical disabilities or lack of support systems will further potentiate this crisis situation.
Nursing Implications How do these considerations influence nursing practice? How can maternal adjustment be facilitated, a n d at which time in the childbearing process are women most receptive to intervention? If we consider that postpartum adjustment is facilitated by lack of conflict between role perceptions, expectations, and role enactment, the first step in intervention must occur before the child is conceived. Nurses January/February 198 1 JOGN Nursing
who are involved in our educational system, especially at the high school level, should work toward adapting curricula which will include information on child care and mothering. We prepare young women for career roles but preparation for the role of mother, which is an irreversible role and certainly an important one in regards to future generations, is neglected. We cannot expect, or even wish, that society return to a time when women were prepared at home to be mothers. These skills should now be an intrinsic part of every woman’s education. Such training, however, is a long-range goal and cannot be reached overnight. More immediate is the need of childbirth educators and nurses in obstetrical practices to become involved in focusing on the crisis of maternal adaptation, not just on labor and delivery. It might be advisable to ask ourselves which emphasis will be most helpful to parents in the long run. Maternal expectations could be defined during childbirth classes or during office visits. Couples should be made active participants in discussion of their perceptions and previous experiences. Expected physical discomforts, the demands of a new baby, emotions, the depth of attachment, conflicts with career a n d other roles should all be described and discussed. If the childbirth instructor is comfortable with role playing, she might ask a couple to enact their responses to a baby who has not slept in the last 12 hours. Discussion should also focus on how the family will integrate the child into their lifestyle. If prospective parents have friends with young children, they could be encouraged to practice a few child care skills. Postpartum couples could return for a class to discuss their adaptation to parenthood. Preparation should be given for cesarean deliveries, not only for the delivery itself but also for the postoperative condition. Emphasis should be put on the importance of available support systems, not only family and friends, but also applicable community resources. The merits of rooming-in and the importance of early contact with the infant should also be considered. Postpartum classes may be helpful for later parenting experiences but
no new mother who is physically exhausted and having difficulties with her infant is going to travel out to a class in the first few weeks after delivery. Women in this study complained a b o u t t h e lack of support from nurses during the postpartum hospital stay. T h r e e women who had problems breastfeeding had received either little or inaccurate counseling from their nurses. Nurses who work on postpartum units should receive in-service education in childcare skills, breastfeeding, and the psychological needs of t h e postpartum woman. The new mother does not need the nurse to whisk in and take the baby back to the nursery when it is crying. She needs guidance in how to handle these situations. Most of all she needs to be encouraged that she is doing the right thing. The new mother has an acute desire to learn and to succeed. The findings of this study are in concurrence with Rubin’s observation that these first few days are a time of optimal readiness for learning.3 Classes on the postpartum unit should not be on breastfeeding and baby care alone, but s h o u l d also i n c l u d e ,discussion groups with mothers to help clarify their expectations and perceptions, discuss their emotions and concerns, and answer their questions. These groups could be available every day. Information could be given regarding physical recovery and normal discomforts. Cesarean mothers could be given an opportunity to discuss their feelings concerning their cesarean deliveries. The use of a maternity clinical specialist on the postpartum unit could be invaluable in terms of inservice education, program development, group leadership, counseling, and discharge planning. Since many postpartum problems occur after discharge, a telephone service set up to provide mothers with information and answers to questions during the first few weeks at home would be helpful. Pediatricians should be encouraged to make their first assessment visit at two weeks rather than the usual four- to six-week visit. Pediatric clinical specialists could be utilized at this time to make a well family assessment.
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As we move into the use of maternity centers where new mothers stay only six to 24 hours, the health care delivery system is going to have to provide home c a r e services for mothers and their babies. Instruction for care during the postpartum period is too often colored with an attitude of normalcy that provides routine care bordering on neglect. If nurses would understand the new mother in terms of her crisis of role transition and identity reformation, they would discover that the postpartum period is a time for creative and invaluable nursing intervention. It is a time when a small amount of support and guidance can have lasting effects. Intervention must focus on a plan of care that will provide each woman with the individual strengths and skills needed to complete successfully role enactment and identity reformation.
This study focuses on women who h a d planned pregnancies, strong self-concepts, and available support systems. Assessing t h e role perceptions, expectations, degree of identity formaton, a n d potential crisis situations for women who are not in such advantageous positions is even more crucial in providing nursing care which will aid maternal adjustment a n d thereby foster improved health.
References 1. Rubin R: Maternity nursing stops too soon. Am J Nurs 75:1680-1684, 1975 2. Sarbin TR: Role theory, Handbook of Social Psychology, Edited by: G. Lindzey Reading, Massachusetts, Addison-Wesley, 1964, 223-258 3. Rubin R: Puerperal changes. Nurs Outlook 3:753-755, 1961 4. Rubin R: Attainment of the maternal role, Part 1: Processes. Nurs Res 16:237-245, 1967
Bibliography Anthony EJ, Benedek T (eds): Parenthood. Boston, Little, Brown & Co, 1970 Caplan G: An Approach to Community Mental Health. New York, Grune & Stratton, 1961 Erikson E: Identity and the life cycle, Psychological Issues. New York, International Univeristies Press, 1959 Address for correspondence: Franci A. Sheehan, RN, Box 198, Trapelo Road, Lincoln, MA 01773. Franci Sheehan is an ob/gyn nurse practitioner at East Boston Health Center. She has worked as a clinical instructor on a postpartum unit, a prepared childbirth instructor, and a community health nurse. Ms. Sheehan's undergraduate degree is from the University of Kentucky in Lexington, and her M S degree is from Boston College-Harvard Medical School. She is a member of NAACOG.
Appendix: Description of Clinical Tool for Assessing Adaptation to Motherhood through Six Weeks Postpartum Presented below are the basic questions used in three questionnaires: one for the prenatal interview, one for the interview at three days postpartum, and one for the interviews at two and six weeks postpartum. Words in parentheses are changes or additions made in the second and third questionnaires. Words in brackets indicate words in the first questionnaire that were deleted for the second and third questionnaires. Italics are explanatory. On each questionnaire, the following directions were given: "The following statements are thoughts, feelings, or beliefs that people may have. After reading each statement please indicate how much you either agree with the statement or how frequently you think or feel the way the statement describes". The respondents then had the choice of checking Never, Sometimes, Often, or Always. The first 10 statements assess the woman's preception of pregnancy or motherhood as a potential crisis in her life, her ability to adapt and cope with this event, and her situational supports and coping mechanisms. The next 15 statements employ a series of either I-sentences or statements in which adjectives are the significant terms (qualities. traits, habits) which enable inferences to be made about the woman's level of identity.2 They measure the level of ego development along Erikson's series of psychosocial crises and critical areas in the organization of the self as defined by Sar-
bin.2 Sarbin's view of self-determination ends with the establishment of the social self during the stage of initiative versus guilt; however, these qualities can be reinforced and redefined throughout life. These ego traits that influence role transition are timebinding (trust and autonomy), flexibility (autonomy and initiative), empathy or "as if" behavior (initiative), and self-perception versus the perception of others (autonomy through identity). The last 20 statements assess the woman's ability to perceive and enact roles and record her role expectations regarding motherhood. Validity of role perception can be measured by availability of role models and concurrence with societal views. Skill in role enactment is related to the use of "as if" behavior, degree to which expectations mesh with reality, and areas of potential conflict.* The timing of these assessment periods is based on Rubin's study of "Attainment of Maternal-R~le".~ During the last month of pregnancy, the woman begins to view her child as a separate individual. The first phase of the postpartum period ends on the third day. At this point, Rubin says that the new mother begins to take hold, assert her independence and focus on what must be done. This phase lasts until approximately two weeks when the woman begins to focus outside her immeditate family. By six weeks, the postpartum period should be over and the role-taking phase completed.
1. Becoming pregnant (a mother) was (is) a crisis in my life. 2. My husband has been (is being) supportive and understanding (during my pregnancy). 3.I have enjoyed (am enjoying) being pregnant (a mother). 4. My own mother has been (is being) very helpful to me during my pregnancy (in adjusting to motherhood). 5. I feel that I am at a point in my life where I am ready for motherhood. (Ifeel ready for motherhood at this point in my life.) 6. I have difficulty handling problems. (I feel that I am handling problems without difficulty.) 7. Most of the time I feel I act appropriately. 8. I find it easy to overcome frustration. 9. I do not feel that I will have to change my lifestyle appreciably after (now that) the baby is born. 10. I feel that I will adjust (am adjusting) easily to motherhood.
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11. made the decision to become pregnant. [Not used in second questionnaire.] 12. have been (am) successful in most of my undertakings. 13. have (had) a good relationship with my own mother (most of my life). 14. feel that I have many goals for myself. 15. would feel guilty i f I had negative feelings about my child. 16. find it upsetting if my needs are not met. 17. I feel that I have a lot of patience. ‘ 18. Most of the time I think before acting. 19. I find it very unpleasant to fail at a task. 20. How other people view me is very important to me. (I am very concerned how other people view my abilities as a mother.) 21. I think a lot about who I am. 22. I am basically happy with my life. 23. I feel that I have a lot of self-control. 24. I feel that I expect the same things of myself that others expect of me. 25. I find that I am easily annoyed. 26. I am a creature of immediate gratification. 27. I find it easy to adapt to new situations. 28. Becoming a mother is the most important event in my life thus far. 29. My own mother is a role model for me. 30.I have spent a great deal of time imagining what kind of mother I will be. (Thus far I am the kind of mother that I imagined myself to be.) 31. I feel that I know the sex of my child. (Ipredicted the sex of my child accurately.) 32. I have a good idea of what my child will look like. (My child looks much like what I imagined him/her to be.) 33. I can picture what it will be like to have a child. (Having a child is much like what I pictured it.) 34. Becoming a mother is a learned role and is not instinctive. 35. I want to have a career that is meaningful to me aside from wife and mother. [Not used in second questionnaire.] 36. I intend to resume or begin a career within a year after the baby’s born. [Not used in second questionnaire.] 37. I find that I am (already) acting “as if” (like) I were a mother. 38. I feel that I have a lot of empathy and insight into the feelings of others (my child). 39. I feel I have a clear idea of how a mother should behave. 40. My views of motherhood seem in conformance with the views of society. 41. 1 have begun to view my child as separate from me (a separate individual). 42. My mother was pleased with her pregnancy and my birth. [Not used in second or third questionnaire.] 43. I have had a lot of experience caring for babies. (I am not having difficulty learning to take care of my baby.) 44. I feel that I have already started changing my life in preparation for motherhood. [No similar item in second questionnaire. Third questionnaire: I am already changing my life in order to adapt to motherhood.] 45. I will have to give (have given) up a lot of my present (past) activities after the baby is born (since the baby’s birth). [No similar item in second questionnaire.] 46. I feel (that I was) well prepared for labor and delivery. In addition, in the third and fourth interviews (third questionnaire), the woman was asked to respond to four open-ended questions to allow for more in-depth indications regarding degree of difference or sameness in expectations versus realization:
1. The greatest concern that I have at this point in time is? 2. I am most unprepared for? 3. My biggest disappointment in becoming a mother has been? 4. The thing which has pleased me the most about becoming a mother is?
NURSE MIDWIVES “Whole Woman Health Care” will be the theme of the 26th Annual Convention of the American College of Nurse-Midwives. The convention will be held April 26-30, 1981, at the Denver Hilton in Colorado. Continuing education workshops are planned for April 26 and 27. For further information contact the American College of Nurse-Midwives, 1012 14th Street, NW, Suite 801, Washington, DC 20005, (202) 347-5445.
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