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Psychosocial factors and maternal wellbeing: An exploratory path analysis
International Journal of Nursing Studies 48 (2011) 725–731
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Psychosocial factors and maternal wellbeing: An exploratory path analysis Fei-Wan Ngai a,*, Sally Wai-Chi Chan b a
School of Nursing, The University of Hong Kong, Room 417, 4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574, Singapore
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 June 2010 Received in revised form 6 November 2010 Accepted 9 November 2010
Background: Developing a sense of well-being and achieving competence and satisfaction in the maternal role have a tremendous impact on the quality of parenting behaviour and the child’s psychosocial development. Little is known about the mechanisms through which learned resourcefulness, social support and stress affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. Objectives: To test a conceptual model that examines the relationships between learned resourcefulness, social support, stress, maternal role competence and satisfaction, and postnatal depression in first-time Chinese mothers. Design: A predictive correlational study using secondary analysis of data from an intervention study. Settings: The study was conducted in two regional public hospitals in Hong Kong. Participants: A total of 181 first-time Chinese mothers were followed at six weeks postpartum. Methods: Participants completed five instruments at six weeks post-partum: the SelfControl Schedule, Medical Outcomes Study Social Support Survey, Social Readjustment Rating Scale, Parenting Sense of Competence Scale and Edinburgh Postnatal Depression Scale. Path analysis was employed. Results: The findings indicate that learned resourcefulness and social support have a direct impact on maternal role competence and satisfaction and on postnatal depression. Stress affected postnatal depression directly and maternal role competence and satisfaction indirectly, via learned resourcefulness and social support. Both learned resourcefulness and social support mediated the effects of stress on maternal role competence and satisfaction and postnatal depression. Conclusions: This study establishes potential mechanisms through which learned resourcefulness, social support and stress contribute to maternal role competence and satisfaction and postnatal depression during early motherhood. Culturally competent healthcare should be developed to provide support and equip women with learned resourcefulness skills to combat the stress of early motherhood, thereby enhancing maternal role competence and satisfaction and minimizing the risk of postnatal depression. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Learned resourcefulness Maternal role competence and satisfaction Postnatal depression Social support
What is already known about the topic?
* Corresponding author. Tel.: +852 28192628; fax: +852 28726079. E-mail addresses: [email protected] (F.-W. Ngai), [email protected] (S.-C. Chan). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.11.002
Developing a sense of well-being and achieving competence and satisfaction in the maternal role are critical to parenting behaviour and child development.
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Coping resources such as learned resourcefulness and social support have a potential impact on maternal adaptation during the transition to motherhood. Little is known about the mechanisms through which learned resourcefulness, social support and stress affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. What this paper adds Learned resourcefulness and social support are important coping resources that mediate the effect of stress on maternal role competence and satisfaction and on postnatal depression. Intervention strategies that aim at promoting maternal wellbeing should strengthen woman’s learned resourcefulness and foster the development of social network in order to optimize maternal and infant health. 1. Introduction Developing a sense of well-being and achieving competence and satisfaction in the maternal role are considered critical components of maternal adaptation during the transition to motherhood. A positive transition period is known to impact on the quality of parenting behaviour and, ultimately, on the child’s psychosocial development (Luoma et al., 2001; Jones and Prinz, 2005). However, in a meta-synthesis of nine studies of women’s transition to first-time motherhood, women were often found to express feelings of inadequacy in the mothering role and a loss of control over their emotions (Nelson, 2003). Postnatal depression was found to affect 19.2% of women in a meta-analysis of 28 studies across diverse countries and cultures (Gavin et al., 2005). In an epidemiological study of 959 Hong Kong Chinese women, 13.5% were reported to suffer from depressive symptoms in the first three months after delivery (Lee et al., 2001). Psychosocial factors, in particular stress and social support, have consistently been identified as significant predictors of postnatal depression and maternal role competence and satisfaction (Mercer, 2004; Robertson et al., 2004). However, little is known about the mechanisms through which these psychosocial factors affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. Thus, the identification of psychosocial factors and the relationships among them that may assist in the prevention and treatment of postnatal depression and promotion of maternal role competence and satisfaction is imperative for the health and wellbeing of both mother and child. A conceptual model that seeks to understand the relationships among the psychosocial factors of stress, learned resourcefulness, social support, maternal role competence and satisfaction, and postnatal depression has been developed by the authors. This adaptation model is based on the transactional model of stress and coping (Lazarus and Folkman, 1984), the learned resourcefulness theory (Rosenbaum, 1990) and the self-efficacy theory (Bandura, 1989) to understand the relationships among
the psychosocial factors that influence maternal role competence and satisfaction and postnatal depression. Lazarus and Folkman (1984) contend that the relationship between a stressor and behavioural and emotional responses is mediated by the person’s internal and external coping resources. One of those resources is learned resourcefulness, which is defined as a repertoire of cognitive-behavioural skills for the self-regulation of internal responses, such as emotion, pain and negative cognitions, that interfere with the execution of target behaviour. During the transition to motherhood, learned resourcefulness is believed to influence women’s actions towards reducing the interfering effects of stress reactions on the mothering role; thus, they have more confidence in their ability to deal with the demands of parenting and experience less emotional disturbance (Rosenbaum, 1990). Learned resourcefulness was found to be a significant predictor of maternal depression in a community-based study of 122 mothers in the United States (Chang et al., 2007). In a survey of 360 Chinese childbearing women, those with greater learned resourcefulness reported a lower level of depressive symptoms (Ngai et al., 2008). In addition to personal resources, environmental resources such as the availability of social support may ease the stress of new motherhood and facilitate maternal role-taking (Lazarus and Folkman, 1984). As proposed by Bandura (1989), social persuasion and observation of the parenting behaviour of significant support figures are important sources of information that contribute to building a woman’s sense of competence in parenting. In a survey of the transition experience to parenthood among 114 couples in the United States, social support was identified as a significant predictor of parenting competence and satisfaction (Knauth, 2000). Furthermore, emotional support and practical assistance in childcare from family members, friends and professionals may help women adapt to the stress and emotional challenges during the early weeks of motherhood, thus minimising the risk of postpartum depression. In a comparative study of the predictors of postnatal depression in Taiwan and mainland China, social support was found to be a significant predictor among 197 women living in mainland China (Wang et al., 2003). Furthermore, depression and maternal role competence and satisfaction are related closely and may have reciprocal effects on each other (Ngai et al., 2007; Silver et al., 2006). Bandura (1989) suggested that feelings of selfinefficacy in fulfilling the maternal role affected the evaluation of self-worth, and led to depression. Moreover, women suffering from postpartum depression tend to recall previous task failures selectively and to recast all events in a more negative light. This cognitive bias may lead a mother to a more negative appraisal of her childrearing capabilities, and to low maternal role competence and satisfaction. In a survey of 279 mothers in the United States, maternal depression was found to be significantly associated with a poor sense of parenting competence (Silver et al., 2006). Ngai et al. (2007) also found a negative relation between maternal role competence and depression among 170 Chinese mothers.
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The coping resources of learned resourcefulness and social support are interrelated and may influence each other (Rosenbaum, 1990; Zauszniewski et al., 2006). Rosenbaum (1990) suggested that situational factors that reflected environmental resources such as social support might enhance the individual’s ability to be resourceful. Moreover, resourceful people would seek assistance from others when unable to function independently under stressful situations. Zauszniewski et al. (2005) conducted a study of 200 African-American women and found a positive relation between learned resourcefulness and social support. Although past studies suggest that learned resourcefulness and social support may serve as protective factors, buffering against depression in the postnatal period and promoting maternal role competence and satisfaction (Ngai et al., 2008; Wang et al., 2003), limited information is available on the mechanisms through which these factors affect maternal adaptation during the transition to early motherhood, particularly among Chinese populations. Postnatal depression is a pervasive, costly public health problem that cannot be ignored. Sequelae include poor quality parenting behaviour that may ultimately influence infants’ cognitive, emotional and behavioural development (Luoma et al., 2001). An understanding of the factors that influence maternal adaptation and the mechanism through which they affect maternal role competence and satisfaction and postnatal depression would assist in the planning and development of psychosocial interventions to promote optimal adjustment and parenting among postpartum mothers. The current study was designed to test a conceptual model of how learned resourcefulness, social support and stress contribute to maternal role competence and satisfaction and postnatal depression among first-time Chinese mothers. The specific aims were: (a) to examine the relationships between learned resourcefulness, social support, stress, maternal role competence and satisfaction, and postnatal depression; and (b) to determine whether learned resourcefulness and social support can mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. The study was a secondary analysis of data from an intervention study
[()TD$FIG] Learned resourceful
+
+ Maternal role competence & satisfaction
Intervention _ _ – + Stress
+
– +
– Social support
Postnatal depression –
Fig. 1. Theoretical relationships between study variables.
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which examined the effect of a childbirth psychoeducation program on learned resourcefulness, maternal role competence and satisfaction and perinatal depression. The intervention was based on the concept of learned resourcefulness which focused on cognitive restructuring, problem-solving and efficacy enhancement (Ngai et al., 2009). The proposed model, linking the psychosocial variables to maternal role competence and satisfaction and postnatal depression, is depicted in Fig. 1. We expected that women undergoing less stress but with greater learned resourcefulness and better social support would have a stronger sense of maternal role competence and satisfaction and fewer depressive symptoms at six weeks postpartum. We also expected that learned resourcefulness and social support would mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. 2. Methods 2.1. Design A secondary analysis of data from an intervention study was used. The intervention was a childbirth psychoeducation program based on the concept of learned resourcefulness, which focused on teaching learned resourcefulness skills, such as cognitive restructuring, problem-solving and efficacy enhancement (Ngai et al., 2009). Participants were pregnant women of 18 years or above, married, Hong Kong Chinese residents, primiparous with singleton and uneventful pregnancies, able to read the Chinese language, and without a past or family psychiatric history. Post-test data at 6 weeks postpartum from both intervention (n = 91) and control groups (n = 90) were used in this study (total n = 181). A good rule of thumb for path analysis is to have, at minimum, 10–20 times as many observations as variables. There were six variables in this study, thus, a sample size of 181 was adequate to provide sufficient statistical power (Hair et al., 2010). 2.2. Measures 2.2.1. Parenting Sense of Competence Scale The Parenting Sense of Competence Scale (PSOC) is a 17-item instrument consisting of two subscales: eight items in the efficacy subscale measuring parents’ perceived competence in the parenting role and nine in the satisfaction subscale assessing parents’ satisfaction and comfort with parenting (Gibaud-Wallston and Wandersman, 1978). Each item is rated on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Total scale scores range from 17 to 102. Higher scores indicate higher competence in parenting. The Chinese version of the PSOC has been validated with a sample of Hong Kong Chinese mothers. Reported internal consistency was 0.82, and 4-week test–retest reliability was 0.84. Significant correlations with measures of self-esteem and depression demonstrated construct validity (Ngai et al., 2007). The internal consistency for this study was 0.87.
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2.2.2. Edinburgh Postnatal Depression Scale The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item instrument used to assess the presence of depressive symptoms in the postnatal period (Cox et al., 1987). The Chinese version of the EPDS has been validated with a sample of Chinese mothers. Sensitivity was 82% and specificity was 86%, using a cut-off score of 9/10 at six weeks post-partum. It has satisfactory concurrent validity with the Beck Depression Inventory and the General Health Questionnaire. Reported internal consistency was 0.91 (Lee et al., 1998). The Cronbach alpha for this study was 0.86.
2.3. Procedure Ethical approval was obtained from the Clinical Research Ethics Committees. Eligible women were approached at the antenatal clinic and the nature of the study explained. Written consent forms were obtained from women who agreed to participate in the study. At six weeks postpartum, the Chinese versions of PSOC, EPDS, MOS-SSS, SCS and SRRS were sent to women through the post, completed at home and returned in pre-addressed, stamped envelopes. 2.4. Data analysis
2.2.3. Social Readjustment Rating Scale The Social Readjustment Rating Scale (SRRS) covers 43 significant life events. Responses of ‘‘yes’’ or ‘‘no’’ for each event are used to indicate whether that event occurred in the past 12 months. A life-change unit number is assigned to ‘‘yes’’ responses, varying for each event and indicating the severity of such specific events (Holmes and Rahe, 1967). The higher the value, the more readjustment is required and the more stressful the event. Respondents are also asked to rate the perceived stressfulness of each event experienced on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely severe). Summing scores for all events generates a total stress intensity score. A higher score indicates a more stressful perception. The Chinese version of the SRRS has been modified and validated to include 39 significant life events (Shek and Mak, 1987). The internal consistency for this study was 0.77. 2.2.4. Self-Control Schedule The Self-Control Schedule (SCS) is a 36-item instrument designed to measure an individual’s tendency to apply learned resourcefulness skills to stressful situations (Rosenbaum, 1980). Each item is rated on a 6-point Likert-type scale ranging from 0 (very uncharacteristic) to 5 (very characteristic). Total scale scores range from 0 to 180, with a higher score indicating greater resourcefulness. The SCS has been translated into Chinese and validated with Hong Kong Chinese pregnant women. Reported internal consistency was 0.83 and 4-week test–retest reliability was 0.91. Significant correlations with measures of self-efficacy, self-esteem and depression demonstrated construct validity (Ngai et al., 2008). The Cronbach alpha for this study was 0.87.
Data were analysed using the Statistical Package for Social Sciences (SPSS) for Windows version 18.0. Descriptive statistics were employed to summarise demographic characteristics and study variables. Pearson product– moment correlations were conducted to assess the relationships between the study variables. Analysis of Moment Structures (AMOS) 18.0 was used for path analysis, with stress as a predictor variable, learned resourcefulness and social support as mediator variables, and depressive symptoms and maternal role competence and satisfaction as outcome variables. The intervention status was included as a predictor variable and expected to have a direct impact on learned resourcefulness. The overall model fit was examined using goodness-of-fit indices. A non-significant Chi-square value, a comparative fit index (CFI), a Tucker–Lewis index (TLI), an incremental fit index (IFI) of >0.90 (Kline, 2005), and a root-mean-square of approximation (RMSEA) <0.08 indicated acceptable mode fit (Brown and Cudeck, 1993). The hypothesized model (Fig. 1) was tested, followed by modifications to improve the overall model fit. Modification indices were considered to examine other, non-predicted relationships within the data, in conjunction with consideration of the theoretical underpinnings for the model. Colinearity was addressed by performing colinearity statistics. Tolerance was greater than 0.10 and variance inflation factors (VIF) were less than 10 for all study variables, indicating the absence of colinearity (Pallant, 2007). All study variables met the assumption of univariate normality. 3. Results 3.1. Sample
2.2.5. Medical Outcomes Study Social Support Survey The Medical Outcomes Study Social Support Survey (MOS-SSS) is a 20-item instrument with one item assessing the number of support persons, and 19 items measuring the availability of social support (Sherbourn and Stewart, 1991). Each item is rated on a 5-point Likert scale, with total scores ranging from 0 to 100. The Chinese version of the MOS-SSS has demonstrated high internal consistency of 0.98 and a 2-week test–retest reliability of 0.84. Validity has been supported by significant correlations with measures from the Multidimensional Perceived Social Support Survey and the Hospital Anxiety and Depression Scale (Yu et al., 2004). The internal consistency for this study was 0.89.
The mean age of the participants was 31.3 years (SD = 3.8), and all had at least a secondary-school education. The majority of participants were employed (84%), and the median monthly household income was HK$26,012 (US$3335) (Table 1). The participants were thus predominately well-educated middle-class women. Means and standard deviations of the study variables are presented in Table 2. 3.2. Relationships between study variables The correlations between study variables are presented in Table 3. The hypothesized model yielded inadequate fit,
[()TD$FIG]
F.-W. Ngai, S.-C. Chan / International Journal of Nursing Studies 48 (2011) 725–731 Table 1 Demographic characteristics of the participants (n = 181). Variables
Learned resourceful
0.15 Intervention
n (%)
Age (years), M (SD) Education level Secondary Tertiary, university or above Employment status Unemployed Employed Monthly household incomeHK$40,000
729
0.38 -0.35
31.3 (3.8)
Maternal role competence & satisfaction
-0.16
93 (51.4) 88 (48.6)
-0.20
-0.56
0.14
Stress
29 (16.0) 152 (84.0) 55 59 29 38
0.35 0.16 0.22 Postnatal depression
-0.28
(30.4) (32.6) (16.0) (21.0)
Social support
-0.17
Fig. 2. Path model of relationships between study variables.
Table 2 Means and standard deviations of study variables (n = 181). Variables
M (SD)
PSOC EPDS SCS MOS-SSS SRRS PSOC total scale
69.1 7.7 117.4 77.8 306.1 69.1
stress on maternal role competence and satisfaction and postnatal depression. The direct relationship between maternal role competence and satisfaction and postnatal depression was significant, as was that between learned resourcefulness and social support. Intervention status has a direct impact on learned resourcefulness, social support and stress. The final model accounted for 50% of the variance in maternal role competence and satisfaction and 49% of the variance in postnatal depression.
(10.5) (4.7) (15.2) (18.0) (163.2) (10.5)
Notes. PSOC, Parenting Sense of Competence Scale; SCS, Self-Control Schedule; EPDS, Edinburgh Postnatal Depression Scale; MOS-SSS, Medical Outcomes Study Social Support Survey; SRRS, Social Readjustment Rating Scale.
4. Discussion The conceptual model of adaptation presented in this paper was supported. Maternal role competence and satisfaction was directly predicted by greater learned resourcefulness, high social support and low depressive symptoms; and indirectly predicted by stress, mediated by learned resourcefulness and social support. Postnatal depression was directly predicted by an increased level of stress, poor learned resourcefulness, low social support and a poor sense of maternal role competence and satisfaction. The direct impact of stress on postnatal depression was consistent with the transactional model of stress and coping: that high levels of stress will exceed the coping resources available to the individual and impair subsequent well-being (Lazarus and Folkman, 1984). The results are similar to those of previous studies suggesting that women who experience higher levels of stress are more vulnerable to postnatal depression (Lee et al., 2004; Wang et al., 2003). Stress did not have a direct impact on maternal role competence and satisfaction given that its effect is mediated by learned resourceful-
despite significant regression weights for all but one path. The direct effect of stress on maternal role competence and satisfaction was not significant in a model incorporating all the study variables. This path was removed from the model and two direct paths from intervention status to stress and social support were added, as suggested in the modification indices. This modified model (Fig. 2) provided a good fit for the data (x2[3] = 7.22, p = 0.07, CFI = 0.982, TLI = 0.910, IFI = 0.983, RMSEA = 0.088), with all individual paths significant at p < 0.05. The direct effect of learned resourcefulness and social support on maternal role competence and satisfaction and postnatal depression was significant. The direct effect of stress on postnatal depression was also significant, but not on maternal role competence and satisfaction. The indirect effect of stress on maternal role competence and satisfaction and postnatal depression, via learned resourcefulness and social support, was significant. The results suggest that learned resourcefulness and social support mediate the effect of Table 3 Pearson’s correlations between study variables (n = 181).
1. 2. 3. 4. 5. 6. *
Stress Learned resourcefulness Social support Depressive symptoms Maternal role competence and satisfaction Intervention
p < .05. ** p < .01.
1
2
3
4
5
– .23** .31** .31** .24** .16*
– .41** .44** .47** .18**
– .36** .38** .21**
– .67** .25**
–
6
.25**
–
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ness and social support. The current findings reveal that both learned resourcefulness and social support mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. These results are in accordance with the theory of stress and coping (Lazarus and Folkman, 1984), suggesting that coping resources play a significant role in helping women manage the stress and complexity of the maternal role, thereby reducing the risk of postnatal depression and enhancing their sense of competence and satisfaction in taking up that role. The positive impact of learned resourcefulness on both maternal role competence and satisfaction and postnatal depression is consistent with Rosenbaum’s view (1990) that individuals with a high level of learned resourcefulness cope with challenges more effectively. Highly resourceful women may use various learned resourcefulness skills, such as cognitive reframing and problem-solving strategies, to minimize or eliminate disturbing thoughts and feelings. Consequently, they function at an optimal level, experience less emotional disturbance and feel more competent and satisfied when faced with the challenges of new motherhood. The findings are in line with previous studies: that women who possess a high level of learned resourcefulness are less susceptible to depression (Chang et al., 2007; Ngai et al., 2008). The current findings also reveal a positive effect of social support on maternal role competence and satisfaction and postnatal depression. Such an effect on maternal role competence may be influenced by social persuasion and observation of the parenting behaviour of significant support figures (Bandura, 1989). Women are likely to feel more confident in their maternal role if they experience support from those in their immediate environment. For example, friends and relatives may reassure a woman that she is a good mother, and reinforce appropriate childcare practices. Such findings are consistent with previous studies demonstrating a significant relation between social support and maternal role competence (Knauth, 2000; Wang et al., 2003). The positive effect of social support on depression may work through the Chinese tradition whereby the family has a moral duty to care for sick and vulnerable relatives, and the cultural practice of ‘‘doing the month’’, when the mother is accompanied by a female family member during the first month after delivery (Lee et al., 2004; Wong and Pang, 2000). This ritual ensures the passing on of child-rearing knowledge, together with practical and probably emotional support which might protect women against depression in the first three months after giving birth to a baby (Lee et al., 2004). Although the traditional postpartum practice of ‘‘doing the month’’ provides mothers with a certain degree of support, women’s negative experiences of confinement particularly when there is mother-in-law conflict may offset the potential benefit and could contribute to poor mental health in the postpartum (Wong and Fisher, 2009). The positive relation between learned resourcefulness and social support also reflects the complementary effect of these factors in facilitating
maternal adaptation during the transition to early motherhood. The finding of a negative relationship between maternal role competence and depressive symptoms in this study indicates that women who feel competent about their ability to function effectively as mothers have better psychological adjustment. Consistent with the self-efficacy theory (Bandura, 1989), women with a strong sense of competence and satisfaction in the maternal role will persist in the demanding tasks of parenting, avoid blaming themselves for any perceived failures, and experience less emotional disturbance. However, women with poor mental health tend to appraise their parenting abilities more negatively, and may have difficulty in meeting role obligations and achieving competence in their maternal role. The findings are consistent with the results of previous studies demonstrating a negative relation between maternal role competence and satisfaction and postnatal depression (Ngai et al., 2007). Generalization of these results is limited by the homogeneity of the sample, which was composed of middle-class, well-educated Chinese primipara. It is recommended that further research be conducted with women in lower social classes and multiparas to investigate whether these relationships occur in other communities. Although the direction of the relationships between study variables is based on theoretical models, care must be taken in drawing firm conclusions as the data in this survey are cross-sectional in nature, and directionality cannot therefore be inferred. 5. Conclusions The present study provides support for the conceptual model of adaptation to motherhood by confirming the significant impact of learned resourcefulness, social support and stress on maternal role competence and satisfaction and postnatal depression in first-time Chinese mothers. Learned resourcefulness and social support have a direct impact on maternal role competence and satisfaction and on postnatal depression. They also mediated the effects of stress on maternal role competence and satisfaction and postnatal depression. The findings highlight important implications for healthcare professionals in the development and provision of culturally appropriate care for Chinese mothers. Interventions should provide mothers with opportunities to interact with other postpartum mothers fostering mutual support and the development of effective coping strategies, such as learned resourcefulness. Such skills assist women to better deal with the stress and the demands of early motherhood in Chinese society. Learned resourcefulness skills, including techniques of cognitive restructuring, problem solving and efficacy enhancement, could be taught to women in childbirth education classes to facilitate maternal adaptation during the stressful period of role transition. Such programs have the potential to promote a sense of competence and satisfaction in the maternal role and reduce the risk of postnatal depression among Chinese mothers.
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Acknowledgments I would like to express my sincere thanks to Dr. David Wong for his expert advice on statistical analysis and to all women participated in the study. Conflict of interest: None declared. Funding: None. Ethical approval: Ethical approval was obtained from the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee and the New Territories West Cluster Clinical Research Ethics Committee. References Bandura, A., 1989. Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology 25, 729–735. Brown, M.W., Cudeck, R., 1993. Alternative ways of assessing model fit. In: Bollen, K.A., Long, J.S. (Eds.), Testing Structural Equation Models. Sage, Newbury Park, pp. 136–162. Chang, H.J., Zauszniewski, J.A., Heinzer, M.M., Musil, C.M., Tsai, W.C., 2007. Adaptive functioning and depressive symptoms in school-aged children. Journal of Advanced Nursing 60, 502–512. Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150, 782–786. Gavin, N.I., Gaynes, B.N., Lohr, K.N., Meltzer-Brody, S., Gartlehner, G., Swinson, T., 2005. Perinatal depression: a systematic review of prevalence and incidence. Obstetrics and Gynecology 106, 1071–1083. Gibaud-Wallston, J., Wandersman, L.P., 1978. Development and utility of the Parenting Sense of Competence Scale. In: Paper presented at the Meeting of the American Psychological Association, Toronto, Canada. Hair, J.F., Anderson, R.E., Tatham, R.L., Black, W.C., 2010. Multivariate Data Analysis, 7th ed. Prentice-Hall, Upper Saddle River, NJ. Holmes, T.H., Rahe, R.H., 1967. The social readjustment rating scale. Journal of Psychosomatic Research 11, 213–218. Jones, T.L., Prinz, R.J., 2005. Potential roles of parental self-efficacy in parent and child adjustment: a review. Clinical Psychology Review 25, 341–363. Kline, R.B., 2005. Principles and Practice of Structural Equation Modeling, 2nd ed. Guilford Press, New York. Knauth, D.G., 2000. Predictors of parental sense of competence for the couple during the transition to parenthood. Research in Nursing and Health 23, 496–509. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal and Coping. Basic Books, New York. Lee, D.T.S., Yip, A.S.K., Chiu, H.F.K., Leung, T.Y.S., Chan, K.P.M., Chau, I.O.L., Leung, H.C.M., Chung, T.K.H., 1998. Detecting postnatal depression in Chinese women: validation of the Chinese version of the Edinburgh postnatal Depression Scale. The Royal College of Psychiatrists 172, 433–437. Lee, D.T., Yip, A.S., Chiu, H.F.K., Leung, T.Y.S., Chung, T.K.H., 2001. A psychiatric epidemiological study of postpartum Chinese women. The American Journal of Psychiatry 158, 220–226. Lee, D.T.S., Yip, A.S.K., Leung, T.Y.S., Chung, T.K.H., 2004. Ethnoepidemiology of postnatal depression: prospective multivariate study of socio-
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Psychosocial factors and maternal wellbeing: An exploratory path analysis Fei-Wan Ngai a,*, Sally Wai-Chi Chan b a
School of Nursing, The University of Hong Kong, Room 417, 4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574, Singapore
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 June 2010 Received in revised form 6 November 2010 Accepted 9 November 2010
Background: Developing a sense of well-being and achieving competence and satisfaction in the maternal role have a tremendous impact on the quality of parenting behaviour and the child’s psychosocial development. Little is known about the mechanisms through which learned resourcefulness, social support and stress affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. Objectives: To test a conceptual model that examines the relationships between learned resourcefulness, social support, stress, maternal role competence and satisfaction, and postnatal depression in first-time Chinese mothers. Design: A predictive correlational study using secondary analysis of data from an intervention study. Settings: The study was conducted in two regional public hospitals in Hong Kong. Participants: A total of 181 first-time Chinese mothers were followed at six weeks postpartum. Methods: Participants completed five instruments at six weeks post-partum: the SelfControl Schedule, Medical Outcomes Study Social Support Survey, Social Readjustment Rating Scale, Parenting Sense of Competence Scale and Edinburgh Postnatal Depression Scale. Path analysis was employed. Results: The findings indicate that learned resourcefulness and social support have a direct impact on maternal role competence and satisfaction and on postnatal depression. Stress affected postnatal depression directly and maternal role competence and satisfaction indirectly, via learned resourcefulness and social support. Both learned resourcefulness and social support mediated the effects of stress on maternal role competence and satisfaction and postnatal depression. Conclusions: This study establishes potential mechanisms through which learned resourcefulness, social support and stress contribute to maternal role competence and satisfaction and postnatal depression during early motherhood. Culturally competent healthcare should be developed to provide support and equip women with learned resourcefulness skills to combat the stress of early motherhood, thereby enhancing maternal role competence and satisfaction and minimizing the risk of postnatal depression. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Learned resourcefulness Maternal role competence and satisfaction Postnatal depression Social support
What is already known about the topic?
* Corresponding author. Tel.: +852 28192628; fax: +852 28726079. E-mail addresses: [email protected] (F.-W. Ngai), [email protected] (S.-C. Chan). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.11.002
Developing a sense of well-being and achieving competence and satisfaction in the maternal role are critical to parenting behaviour and child development.
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Coping resources such as learned resourcefulness and social support have a potential impact on maternal adaptation during the transition to motherhood. Little is known about the mechanisms through which learned resourcefulness, social support and stress affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. What this paper adds Learned resourcefulness and social support are important coping resources that mediate the effect of stress on maternal role competence and satisfaction and on postnatal depression. Intervention strategies that aim at promoting maternal wellbeing should strengthen woman’s learned resourcefulness and foster the development of social network in order to optimize maternal and infant health. 1. Introduction Developing a sense of well-being and achieving competence and satisfaction in the maternal role are considered critical components of maternal adaptation during the transition to motherhood. A positive transition period is known to impact on the quality of parenting behaviour and, ultimately, on the child’s psychosocial development (Luoma et al., 2001; Jones and Prinz, 2005). However, in a meta-synthesis of nine studies of women’s transition to first-time motherhood, women were often found to express feelings of inadequacy in the mothering role and a loss of control over their emotions (Nelson, 2003). Postnatal depression was found to affect 19.2% of women in a meta-analysis of 28 studies across diverse countries and cultures (Gavin et al., 2005). In an epidemiological study of 959 Hong Kong Chinese women, 13.5% were reported to suffer from depressive symptoms in the first three months after delivery (Lee et al., 2001). Psychosocial factors, in particular stress and social support, have consistently been identified as significant predictors of postnatal depression and maternal role competence and satisfaction (Mercer, 2004; Robertson et al., 2004). However, little is known about the mechanisms through which these psychosocial factors affect postnatal depression and women’s sense of competence and satisfaction in the maternal role. Thus, the identification of psychosocial factors and the relationships among them that may assist in the prevention and treatment of postnatal depression and promotion of maternal role competence and satisfaction is imperative for the health and wellbeing of both mother and child. A conceptual model that seeks to understand the relationships among the psychosocial factors of stress, learned resourcefulness, social support, maternal role competence and satisfaction, and postnatal depression has been developed by the authors. This adaptation model is based on the transactional model of stress and coping (Lazarus and Folkman, 1984), the learned resourcefulness theory (Rosenbaum, 1990) and the self-efficacy theory (Bandura, 1989) to understand the relationships among
the psychosocial factors that influence maternal role competence and satisfaction and postnatal depression. Lazarus and Folkman (1984) contend that the relationship between a stressor and behavioural and emotional responses is mediated by the person’s internal and external coping resources. One of those resources is learned resourcefulness, which is defined as a repertoire of cognitive-behavioural skills for the self-regulation of internal responses, such as emotion, pain and negative cognitions, that interfere with the execution of target behaviour. During the transition to motherhood, learned resourcefulness is believed to influence women’s actions towards reducing the interfering effects of stress reactions on the mothering role; thus, they have more confidence in their ability to deal with the demands of parenting and experience less emotional disturbance (Rosenbaum, 1990). Learned resourcefulness was found to be a significant predictor of maternal depression in a community-based study of 122 mothers in the United States (Chang et al., 2007). In a survey of 360 Chinese childbearing women, those with greater learned resourcefulness reported a lower level of depressive symptoms (Ngai et al., 2008). In addition to personal resources, environmental resources such as the availability of social support may ease the stress of new motherhood and facilitate maternal role-taking (Lazarus and Folkman, 1984). As proposed by Bandura (1989), social persuasion and observation of the parenting behaviour of significant support figures are important sources of information that contribute to building a woman’s sense of competence in parenting. In a survey of the transition experience to parenthood among 114 couples in the United States, social support was identified as a significant predictor of parenting competence and satisfaction (Knauth, 2000). Furthermore, emotional support and practical assistance in childcare from family members, friends and professionals may help women adapt to the stress and emotional challenges during the early weeks of motherhood, thus minimising the risk of postpartum depression. In a comparative study of the predictors of postnatal depression in Taiwan and mainland China, social support was found to be a significant predictor among 197 women living in mainland China (Wang et al., 2003). Furthermore, depression and maternal role competence and satisfaction are related closely and may have reciprocal effects on each other (Ngai et al., 2007; Silver et al., 2006). Bandura (1989) suggested that feelings of selfinefficacy in fulfilling the maternal role affected the evaluation of self-worth, and led to depression. Moreover, women suffering from postpartum depression tend to recall previous task failures selectively and to recast all events in a more negative light. This cognitive bias may lead a mother to a more negative appraisal of her childrearing capabilities, and to low maternal role competence and satisfaction. In a survey of 279 mothers in the United States, maternal depression was found to be significantly associated with a poor sense of parenting competence (Silver et al., 2006). Ngai et al. (2007) also found a negative relation between maternal role competence and depression among 170 Chinese mothers.
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The coping resources of learned resourcefulness and social support are interrelated and may influence each other (Rosenbaum, 1990; Zauszniewski et al., 2006). Rosenbaum (1990) suggested that situational factors that reflected environmental resources such as social support might enhance the individual’s ability to be resourceful. Moreover, resourceful people would seek assistance from others when unable to function independently under stressful situations. Zauszniewski et al. (2005) conducted a study of 200 African-American women and found a positive relation between learned resourcefulness and social support. Although past studies suggest that learned resourcefulness and social support may serve as protective factors, buffering against depression in the postnatal period and promoting maternal role competence and satisfaction (Ngai et al., 2008; Wang et al., 2003), limited information is available on the mechanisms through which these factors affect maternal adaptation during the transition to early motherhood, particularly among Chinese populations. Postnatal depression is a pervasive, costly public health problem that cannot be ignored. Sequelae include poor quality parenting behaviour that may ultimately influence infants’ cognitive, emotional and behavioural development (Luoma et al., 2001). An understanding of the factors that influence maternal adaptation and the mechanism through which they affect maternal role competence and satisfaction and postnatal depression would assist in the planning and development of psychosocial interventions to promote optimal adjustment and parenting among postpartum mothers. The current study was designed to test a conceptual model of how learned resourcefulness, social support and stress contribute to maternal role competence and satisfaction and postnatal depression among first-time Chinese mothers. The specific aims were: (a) to examine the relationships between learned resourcefulness, social support, stress, maternal role competence and satisfaction, and postnatal depression; and (b) to determine whether learned resourcefulness and social support can mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. The study was a secondary analysis of data from an intervention study
[()TD$FIG] Learned resourceful
+
+ Maternal role competence & satisfaction
Intervention _ _ – + Stress
+
– +
– Social support
Postnatal depression –
Fig. 1. Theoretical relationships between study variables.
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which examined the effect of a childbirth psychoeducation program on learned resourcefulness, maternal role competence and satisfaction and perinatal depression. The intervention was based on the concept of learned resourcefulness which focused on cognitive restructuring, problem-solving and efficacy enhancement (Ngai et al., 2009). The proposed model, linking the psychosocial variables to maternal role competence and satisfaction and postnatal depression, is depicted in Fig. 1. We expected that women undergoing less stress but with greater learned resourcefulness and better social support would have a stronger sense of maternal role competence and satisfaction and fewer depressive symptoms at six weeks postpartum. We also expected that learned resourcefulness and social support would mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. 2. Methods 2.1. Design A secondary analysis of data from an intervention study was used. The intervention was a childbirth psychoeducation program based on the concept of learned resourcefulness, which focused on teaching learned resourcefulness skills, such as cognitive restructuring, problem-solving and efficacy enhancement (Ngai et al., 2009). Participants were pregnant women of 18 years or above, married, Hong Kong Chinese residents, primiparous with singleton and uneventful pregnancies, able to read the Chinese language, and without a past or family psychiatric history. Post-test data at 6 weeks postpartum from both intervention (n = 91) and control groups (n = 90) were used in this study (total n = 181). A good rule of thumb for path analysis is to have, at minimum, 10–20 times as many observations as variables. There were six variables in this study, thus, a sample size of 181 was adequate to provide sufficient statistical power (Hair et al., 2010). 2.2. Measures 2.2.1. Parenting Sense of Competence Scale The Parenting Sense of Competence Scale (PSOC) is a 17-item instrument consisting of two subscales: eight items in the efficacy subscale measuring parents’ perceived competence in the parenting role and nine in the satisfaction subscale assessing parents’ satisfaction and comfort with parenting (Gibaud-Wallston and Wandersman, 1978). Each item is rated on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Total scale scores range from 17 to 102. Higher scores indicate higher competence in parenting. The Chinese version of the PSOC has been validated with a sample of Hong Kong Chinese mothers. Reported internal consistency was 0.82, and 4-week test–retest reliability was 0.84. Significant correlations with measures of self-esteem and depression demonstrated construct validity (Ngai et al., 2007). The internal consistency for this study was 0.87.
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2.2.2. Edinburgh Postnatal Depression Scale The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item instrument used to assess the presence of depressive symptoms in the postnatal period (Cox et al., 1987). The Chinese version of the EPDS has been validated with a sample of Chinese mothers. Sensitivity was 82% and specificity was 86%, using a cut-off score of 9/10 at six weeks post-partum. It has satisfactory concurrent validity with the Beck Depression Inventory and the General Health Questionnaire. Reported internal consistency was 0.91 (Lee et al., 1998). The Cronbach alpha for this study was 0.86.
2.3. Procedure Ethical approval was obtained from the Clinical Research Ethics Committees. Eligible women were approached at the antenatal clinic and the nature of the study explained. Written consent forms were obtained from women who agreed to participate in the study. At six weeks postpartum, the Chinese versions of PSOC, EPDS, MOS-SSS, SCS and SRRS were sent to women through the post, completed at home and returned in pre-addressed, stamped envelopes. 2.4. Data analysis
2.2.3. Social Readjustment Rating Scale The Social Readjustment Rating Scale (SRRS) covers 43 significant life events. Responses of ‘‘yes’’ or ‘‘no’’ for each event are used to indicate whether that event occurred in the past 12 months. A life-change unit number is assigned to ‘‘yes’’ responses, varying for each event and indicating the severity of such specific events (Holmes and Rahe, 1967). The higher the value, the more readjustment is required and the more stressful the event. Respondents are also asked to rate the perceived stressfulness of each event experienced on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely severe). Summing scores for all events generates a total stress intensity score. A higher score indicates a more stressful perception. The Chinese version of the SRRS has been modified and validated to include 39 significant life events (Shek and Mak, 1987). The internal consistency for this study was 0.77. 2.2.4. Self-Control Schedule The Self-Control Schedule (SCS) is a 36-item instrument designed to measure an individual’s tendency to apply learned resourcefulness skills to stressful situations (Rosenbaum, 1980). Each item is rated on a 6-point Likert-type scale ranging from 0 (very uncharacteristic) to 5 (very characteristic). Total scale scores range from 0 to 180, with a higher score indicating greater resourcefulness. The SCS has been translated into Chinese and validated with Hong Kong Chinese pregnant women. Reported internal consistency was 0.83 and 4-week test–retest reliability was 0.91. Significant correlations with measures of self-efficacy, self-esteem and depression demonstrated construct validity (Ngai et al., 2008). The Cronbach alpha for this study was 0.87.
Data were analysed using the Statistical Package for Social Sciences (SPSS) for Windows version 18.0. Descriptive statistics were employed to summarise demographic characteristics and study variables. Pearson product– moment correlations were conducted to assess the relationships between the study variables. Analysis of Moment Structures (AMOS) 18.0 was used for path analysis, with stress as a predictor variable, learned resourcefulness and social support as mediator variables, and depressive symptoms and maternal role competence and satisfaction as outcome variables. The intervention status was included as a predictor variable and expected to have a direct impact on learned resourcefulness. The overall model fit was examined using goodness-of-fit indices. A non-significant Chi-square value, a comparative fit index (CFI), a Tucker–Lewis index (TLI), an incremental fit index (IFI) of >0.90 (Kline, 2005), and a root-mean-square of approximation (RMSEA) <0.08 indicated acceptable mode fit (Brown and Cudeck, 1993). The hypothesized model (Fig. 1) was tested, followed by modifications to improve the overall model fit. Modification indices were considered to examine other, non-predicted relationships within the data, in conjunction with consideration of the theoretical underpinnings for the model. Colinearity was addressed by performing colinearity statistics. Tolerance was greater than 0.10 and variance inflation factors (VIF) were less than 10 for all study variables, indicating the absence of colinearity (Pallant, 2007). All study variables met the assumption of univariate normality. 3. Results 3.1. Sample
2.2.5. Medical Outcomes Study Social Support Survey The Medical Outcomes Study Social Support Survey (MOS-SSS) is a 20-item instrument with one item assessing the number of support persons, and 19 items measuring the availability of social support (Sherbourn and Stewart, 1991). Each item is rated on a 5-point Likert scale, with total scores ranging from 0 to 100. The Chinese version of the MOS-SSS has demonstrated high internal consistency of 0.98 and a 2-week test–retest reliability of 0.84. Validity has been supported by significant correlations with measures from the Multidimensional Perceived Social Support Survey and the Hospital Anxiety and Depression Scale (Yu et al., 2004). The internal consistency for this study was 0.89.
The mean age of the participants was 31.3 years (SD = 3.8), and all had at least a secondary-school education. The majority of participants were employed (84%), and the median monthly household income was HK$26,012 (US$3335) (Table 1). The participants were thus predominately well-educated middle-class women. Means and standard deviations of the study variables are presented in Table 2. 3.2. Relationships between study variables The correlations between study variables are presented in Table 3. The hypothesized model yielded inadequate fit,
[()TD$FIG]
F.-W. Ngai, S.-C. Chan / International Journal of Nursing Studies 48 (2011) 725–731 Table 1 Demographic characteristics of the participants (n = 181). Variables
Learned resourceful
0.15 Intervention
n (%)
Age (years), M (SD) Education level Secondary Tertiary, university or above Employment status Unemployed Employed Monthly household income
729
0.38 -0.35
31.3 (3.8)
Maternal role competence & satisfaction
-0.16
93 (51.4) 88 (48.6)
-0.20
-0.56
0.14
Stress
29 (16.0) 152 (84.0) 55 59 29 38
0.35 0.16 0.22 Postnatal depression
-0.28
(30.4) (32.6) (16.0) (21.0)
Social support
-0.17
Fig. 2. Path model of relationships between study variables.
Table 2 Means and standard deviations of study variables (n = 181). Variables
M (SD)
PSOC EPDS SCS MOS-SSS SRRS PSOC total scale
69.1 7.7 117.4 77.8 306.1 69.1
stress on maternal role competence and satisfaction and postnatal depression. The direct relationship between maternal role competence and satisfaction and postnatal depression was significant, as was that between learned resourcefulness and social support. Intervention status has a direct impact on learned resourcefulness, social support and stress. The final model accounted for 50% of the variance in maternal role competence and satisfaction and 49% of the variance in postnatal depression.
(10.5) (4.7) (15.2) (18.0) (163.2) (10.5)
Notes. PSOC, Parenting Sense of Competence Scale; SCS, Self-Control Schedule; EPDS, Edinburgh Postnatal Depression Scale; MOS-SSS, Medical Outcomes Study Social Support Survey; SRRS, Social Readjustment Rating Scale.
4. Discussion The conceptual model of adaptation presented in this paper was supported. Maternal role competence and satisfaction was directly predicted by greater learned resourcefulness, high social support and low depressive symptoms; and indirectly predicted by stress, mediated by learned resourcefulness and social support. Postnatal depression was directly predicted by an increased level of stress, poor learned resourcefulness, low social support and a poor sense of maternal role competence and satisfaction. The direct impact of stress on postnatal depression was consistent with the transactional model of stress and coping: that high levels of stress will exceed the coping resources available to the individual and impair subsequent well-being (Lazarus and Folkman, 1984). The results are similar to those of previous studies suggesting that women who experience higher levels of stress are more vulnerable to postnatal depression (Lee et al., 2004; Wang et al., 2003). Stress did not have a direct impact on maternal role competence and satisfaction given that its effect is mediated by learned resourceful-
despite significant regression weights for all but one path. The direct effect of stress on maternal role competence and satisfaction was not significant in a model incorporating all the study variables. This path was removed from the model and two direct paths from intervention status to stress and social support were added, as suggested in the modification indices. This modified model (Fig. 2) provided a good fit for the data (x2[3] = 7.22, p = 0.07, CFI = 0.982, TLI = 0.910, IFI = 0.983, RMSEA = 0.088), with all individual paths significant at p < 0.05. The direct effect of learned resourcefulness and social support on maternal role competence and satisfaction and postnatal depression was significant. The direct effect of stress on postnatal depression was also significant, but not on maternal role competence and satisfaction. The indirect effect of stress on maternal role competence and satisfaction and postnatal depression, via learned resourcefulness and social support, was significant. The results suggest that learned resourcefulness and social support mediate the effect of Table 3 Pearson’s correlations between study variables (n = 181).
1. 2. 3. 4. 5. 6. *
Stress Learned resourcefulness Social support Depressive symptoms Maternal role competence and satisfaction Intervention
p < .05. ** p < .01.
1
2
3
4
5
– .23** .31** .31** .24** .16*
– .41** .44** .47** .18**
– .36** .38** .21**
– .67** .25**
–
6
.25**
–
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ness and social support. The current findings reveal that both learned resourcefulness and social support mediate the effect of stress on maternal role competence and satisfaction and postnatal depression. These results are in accordance with the theory of stress and coping (Lazarus and Folkman, 1984), suggesting that coping resources play a significant role in helping women manage the stress and complexity of the maternal role, thereby reducing the risk of postnatal depression and enhancing their sense of competence and satisfaction in taking up that role. The positive impact of learned resourcefulness on both maternal role competence and satisfaction and postnatal depression is consistent with Rosenbaum’s view (1990) that individuals with a high level of learned resourcefulness cope with challenges more effectively. Highly resourceful women may use various learned resourcefulness skills, such as cognitive reframing and problem-solving strategies, to minimize or eliminate disturbing thoughts and feelings. Consequently, they function at an optimal level, experience less emotional disturbance and feel more competent and satisfied when faced with the challenges of new motherhood. The findings are in line with previous studies: that women who possess a high level of learned resourcefulness are less susceptible to depression (Chang et al., 2007; Ngai et al., 2008). The current findings also reveal a positive effect of social support on maternal role competence and satisfaction and postnatal depression. Such an effect on maternal role competence may be influenced by social persuasion and observation of the parenting behaviour of significant support figures (Bandura, 1989). Women are likely to feel more confident in their maternal role if they experience support from those in their immediate environment. For example, friends and relatives may reassure a woman that she is a good mother, and reinforce appropriate childcare practices. Such findings are consistent with previous studies demonstrating a significant relation between social support and maternal role competence (Knauth, 2000; Wang et al., 2003). The positive effect of social support on depression may work through the Chinese tradition whereby the family has a moral duty to care for sick and vulnerable relatives, and the cultural practice of ‘‘doing the month’’, when the mother is accompanied by a female family member during the first month after delivery (Lee et al., 2004; Wong and Pang, 2000). This ritual ensures the passing on of child-rearing knowledge, together with practical and probably emotional support which might protect women against depression in the first three months after giving birth to a baby (Lee et al., 2004). Although the traditional postpartum practice of ‘‘doing the month’’ provides mothers with a certain degree of support, women’s negative experiences of confinement particularly when there is mother-in-law conflict may offset the potential benefit and could contribute to poor mental health in the postpartum (Wong and Fisher, 2009). The positive relation between learned resourcefulness and social support also reflects the complementary effect of these factors in facilitating
maternal adaptation during the transition to early motherhood. The finding of a negative relationship between maternal role competence and depressive symptoms in this study indicates that women who feel competent about their ability to function effectively as mothers have better psychological adjustment. Consistent with the self-efficacy theory (Bandura, 1989), women with a strong sense of competence and satisfaction in the maternal role will persist in the demanding tasks of parenting, avoid blaming themselves for any perceived failures, and experience less emotional disturbance. However, women with poor mental health tend to appraise their parenting abilities more negatively, and may have difficulty in meeting role obligations and achieving competence in their maternal role. The findings are consistent with the results of previous studies demonstrating a negative relation between maternal role competence and satisfaction and postnatal depression (Ngai et al., 2007). Generalization of these results is limited by the homogeneity of the sample, which was composed of middle-class, well-educated Chinese primipara. It is recommended that further research be conducted with women in lower social classes and multiparas to investigate whether these relationships occur in other communities. Although the direction of the relationships between study variables is based on theoretical models, care must be taken in drawing firm conclusions as the data in this survey are cross-sectional in nature, and directionality cannot therefore be inferred. 5. Conclusions The present study provides support for the conceptual model of adaptation to motherhood by confirming the significant impact of learned resourcefulness, social support and stress on maternal role competence and satisfaction and postnatal depression in first-time Chinese mothers. Learned resourcefulness and social support have a direct impact on maternal role competence and satisfaction and on postnatal depression. They also mediated the effects of stress on maternal role competence and satisfaction and postnatal depression. The findings highlight important implications for healthcare professionals in the development and provision of culturally appropriate care for Chinese mothers. Interventions should provide mothers with opportunities to interact with other postpartum mothers fostering mutual support and the development of effective coping strategies, such as learned resourcefulness. Such skills assist women to better deal with the stress and the demands of early motherhood in Chinese society. Learned resourcefulness skills, including techniques of cognitive restructuring, problem solving and efficacy enhancement, could be taught to women in childbirth education classes to facilitate maternal adaptation during the stressful period of role transition. Such programs have the potential to promote a sense of competence and satisfaction in the maternal role and reduce the risk of postnatal depression among Chinese mothers.
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