Internal conflicts of Iranian first-time mothers in adaptation to maternal role.

BACKGROUND: Studies indicate that becoming a mother is accompanied by prominent physical, social, and psychological changes which can affect not only mother's psychological healthiness, but also all other aspects of her personal and family life. The purpose of this research was to explore the struggles experienced by Iranian first-time mothers in adapting to their maternal role between 0 and 1 year after giving birth.
MATERIALS AND METHODS: A qualitative design was used in this study. Twenty-one first-time mothers with diverse ethnic backgrounds were recruited in their home or healthcare centers in Tehran and Ahwaz. Data collected through in-depth interviews were analyzed by qualitative content analysis.
RESULTS: THE ANALYSIS PRODUCED FOUR THEMES: "Unpreparedness," "lack of control," "incomplete maternal feelings," and "unstable relations." The main theme, "internal conflict," integrates all other categories and encapsulates the major changes to which women are subjected, as well as the factors distressing this experience.
CONCLUSION: Discrepancies between subjective expectations and postnatal experiences take an influential role in causing postpartum conflict and strain. The more accurate information mothers and families have about this transitory stage, the better they can get prepared to deal with it. This specifies the pivotal role of midwives, midwifery educators, and healthcare policy makers in incorporating these concepts into training programs and protocols of healthcare and support services in due time, form, and content that is in accordance with mothers' mental and psychological needs.

INTRODUCTION

The postpartum stage for women is marked by a feeling of contentment and pleasure while being stressful and problematic.[1] Various studies undertaken in fields related to this experience indicate that becoming a mother is accompanied by prominent physical, social, and psychological changes which can affect not only mother's psychological healthiness, but also all other aspects of her personal and family life.[23]

Mother's views about herself and her social and family roles take a turn in this period.[2] In fact, she should care for the child while adapting herself to the new situation;[4] hence, she is confronted with numerous challenges through the process of adaptation.[2] This increase in mother's gender roles brings about a role strain that is, in fact, mother's emotional responses to her postnatal experiences.[5]

According to the role strain theory, since everyone's time and energy is limited, any rise in the number of their social roles could expose them to more role conflicts which threaten both their physical and psychological healthiness.[6] These changes leave profound impacts upon the quality of mothers’ lives, especially those of first-time mothers, and make this postnatal period, in a way, unbearable to them.[7] Mothers’ distress in this phase endangers both their psychological healthiness and the integration of their maternal role; it also hinders their ability to do the affairs and weakens the quality of their relationships and social engagement while giving them a sense of anxiety, incompetence, loneliness, added to a feeling of losing independence, time, appearance, and job identity.[89]

Becoming a mother for most new mothers is not the same as what they expected and used to think about it. Having heard from the society and medias that becoming a mother is an easy and fulfilling natural experience, new mothers are usually reluctant to talk about the problems they face in this regard.[1011] In spite of the extensive surveys carried out about maternity experiences in different countries, there are still numerous unknown aspects to this stressful stage. This could be due to the lack of a safe and proper outlet through which they can express their concerns in this experience.[11] Being aware of new mothers’ postnatal challenging experiences and the factors and conditions that give rise to them expands our knowledge about the ways that they react in this situation, while identifying the differences and complexities of such experiences; this recognition could not be achieved without examining various populations and societies.

Not much research information around maternal adaptation and the social and psychological factors that can affect it is available in Iran. This paper reports a qualitative study of the maternal experiences from the perspective of first-time mothers in the current social and cultural environment of Iran.

MATERIALS AND METHODS

In this qualitative study, one-to-one interviews with a semi-structured in-depth interview schedule were used to shed light upon the experiences of first-time mothers in their maternal role adaptation.

Participants

This research project ran from January 2011 until July 2011 in Tehran (the capital of Iran) and Ahwaz (a south-western city of Iran).

The study participants were a group of 21 first-time mothers whose average age was 26 years and the average duration of their married life was 3 years. Three of them were employed and the others were housewives. Their education level ranged from high school to postgraduate degrees. The inclusion criteria were as follows: First-time mothers over 18 years of age with a full-term pregnancy and no experience of high-risk pregnancy, speaking in Farsi, having a healthy child from 0 to 1 year old, no history of depression, no serious illness before or after giving birth, and good cooperation during interviews. They were also chosen from different demographic and ethnographic backgrounds. According the sampling strategy for qualitative studies, purposeful sampling was conducted with maximum variation and interviews were continued until they reached a saturation point.

Data gathering

All the interviews were digitally recorded with permission of the interviewees and the moral committee of Tehran University of Medical Sciences, with the assurance that all the information would be kept as confidential. The participants were asked to talk about their personal experiences with maternal role adaptation. The recorded interviews which were transcribed verbatim along with the notes taken during the interviews were carefully analyzed. As this step was in progress, new ideas and questions useful to this study emerged. Locations for the performance of interviews were decided by the participants and every single interview took 40-80 min.

Data analysis

Qualitative content analysis was used for data analysis. The analysis started with reading of the collected information to get an overall view of it. Then the parts containing the experiences of the participants were picked out inductively and gathered as a separate text which made the core of the analysis. It was then summarized and outlined based on the meaning units which were coded and condensed. The second and the third co-writers also examined all the collected codes and notes; numerous codes were constantly compared based on the differences and similarities. The experimental categories which were obtained by making frequent references to the original texts were discussed and examined to reach an agreement. Finally, the basic meanings derived from the implied analysis of these categories introduced the theme.[1213]

RESULTS

Central theme

The central theme extracted from the analysis of interviews with 21 first-time mothers, named “internal conflicts,” consisted of four categories as follows: 1. feeling of unpreparedness, 2. lack of control and domination, 3. undeveloped maternal feelings and emotions, and 4. instability in relationships. All these feelings were associated with the central theme.

Unpreparedness

The scrutiny of the first-time mothers’ experiences in this study reveals the existence of a sense of unpreparedness in them during the first days or weeks after child birth. First-time mothers came up with a change in their feelings and emotions after giving birth. They repeatedly used phrases like “emergence of strange feelings” or “feeling a change in deeds and attitudes,” and “unknown or vague sense of motherhood.” Confusion, disturbance, bewilderment, as well as ambivalence caused by the new condition were repeatedly pointed out in their expressions. The mother of a 1.5-month-old baby said:

“I had pain and didn't know what to do. Everybody said something, some said do this; some said don't. I was frequently stressed and didn't know what to do.”

Mothers’ expectations, imaginations, and dreams about child's appearance and the way of life before and after giving birth are not the same. This is also true for those mothers who had attended prenatal educational classes. A 24-year-old mother, for example, referring to her 5-month-old baby said:

“To tell the truth, I didn't really like him at first, after 9 months bearing the burden of holding a child, I expected something more than just a little thing. I asked myself: Is that all?”

In addition to this, mother is suddenly encountered with others’ new expectations for which she is not prepared. They expect her to be like a typical mother and act in a way that best suits her new role. A mother said thus:

“I feel that others expect more from me. For instance, when I joke they say: You have a child now; this is not a proper thing for you to do any more.”

Lack of control and domination

Among mothers’ experiences during the first weeks after giving birth, lack of control and domination over affairs is quite conspicuous. In studying their experiences, we repeatedly encountered phrases like “it's very difficult,” “I was really annoyed,” “sometimes I find it unbearable and I’m hard-pressed on every side,” which denote the hardship of the new situation and mother's inconvenience with it.

As for the role of child temperament in giving a sense of discontentment to them, a mother with a 1.5-month-old baby said: “baby's annoyances and his bad sleeping habits are so difficult to me. Sometimes I breast feed him so much that I feel like dying.” These pressures on mothers give way to physical and psychological disorders which are frequently remarked in their speeches through phrases like “nerve-racking,” “exhaustion,” “impatience,” “sleep deprivation,” feeling pain,” etc. She constantly feels obligated to bear the imposed restrictions for the sake of her child.

Having to stay at home and taking care of the child, changing their routines, wearing special clothing suitable for breast feeding, and ignoring their dreams and desires are all instances of restraints that pave the way for nostalgic feelings about the past. They felt nostalgic for their past desires, their previous appearance, and the images they used to hold about themselves; they missed participation in social activities and whatever else they had lost due to being a mother. A mother with a 1.5-month-old baby said:

“I feel like a stay-at home-mom. Even the way I dress myself is changed; my body shape is changed. Sometimes I don't find time to take bath, leave alone sleeping or making myself look pretty,… I crave going to the park or shopping, but when I see that I should feed the baby or change his nappy, then I say, forget it; it's better to stay at home.”

Fear of losing the baby and anxiety about his/her health, which seem to be a never-ending worry for first-time mothers, and a sense of incompetence that reveals itself with diffidence and inhibition enhance this lack of control over affairs. A mother of a 7-month-old baby said:

“At first it was so difficult, I was inexperienced and always got flustered. In the very early days when my baby cried, I cried too. I thought I couldn't do anything; all was in vain. It didn't change until he was 3 months old.”

Under such circumstances, more than any other time, she feels troubled by finding herself alone and having no time to care for both the baby and herself; she expects to receive informational help and practical support (especially from her mother) as well as emotional support (especially from her husband). A mother said thus:

“I think being alone and having no one to help make everything difficult to me, it's really difficult.”

Undeveloped maternal feelings and emotions

The experiences of the participants reveal the fact that mothers in the first days after child birth, in spite of what they have seen or heard about strong maternal feelings about the newborn, have no feeling toward the baby and they involve themselves more with the changes and the new condition than expressing their maternal affections to the child. As a result of these imperfect or undeveloped maternal feelings, they feel sinful and force themselves to exhibit maternal feelings and behaviors. One of the participants with a 7-month-old child said:

“Everybody said that it feels really good to become a mother, but I didn't have a good feeling. I thought it is a must to love him.” Another mother with a 4-month-old baby said:

“I haven't really said this to anybody so far, but first, I didn't like him that much. Perhaps because I was very annoyed…. At first I breastfed him as a duty and I didn't like to do it, if it was possible I would give him formula milk.”

Instability in relationships

The pressure aroused by the changes and the new condition in the first days or weeks after child birth deviates mother's concentration and gives way to a kind of instability in her relations with her husband and the society. Mother is conscious and worried about the fragility of physical and emotional relations with her husband. She is constantly faced with his complaints in this regard and consciously attempts for the betterment of their shaking marital relations. A mother said thus:

“I used to care a lot for my husband, but now I can't, perhaps because I’m very busy, I have less patience for my husband…. I don't know what to do. He is always grumbling at me.”

In addition to this, detachment from normal social relations (paying visits to family and friends) brings about a sense of isolation which intensifies her conflicts.

DISCUSSION

As revealed in this research, the first postnatal days, weeks, and months for Iranian new mothers are associated with a great deal of stress and conflicts. These conflicts, which are in turn the outcome of a collection of issues, diminish mother's capacity for adapting to her new role while introducing us with the aspects that should be discerned and attended to so as to improve and increase mothers’ psychological healthiness in this stage. According to the findings of this research, both mothers and others do not have the essential information and perception into the situation; neither do they have a proper mental background about mothers’ state in this transition.

In Iran, as in many other countries, the training and supervision given during pregnancy and after delivery are generally centered on physical condition of mothers rather than their psychological or mental health condition. The critical role of these training sessions during pregnancy is generally limited to unregistered training concerning nutrition, personal health, etc. Therefore, despite the promotion of the level and amount of training given to mothers in recent years, neither midwives nor mothers and families have proper information and a sound mental image about becoming a mother and the changes and problems associated with that.

Lack of proper training about what really happens after childbirth, and the variety and contradiction that exists in the tips and instructions given by professional advisors and common people around that could be confusing for new mothers. Neither the family nor the society grants her proper time and opportunity to adapt to her maternal role, and they expect her to perform in a way she is not prepared for. Consequently, she finds her real postnatal experience contrary to the happy scenario she used to imagine. This state of unpreparedness is not only evident among Iranian new mothers, but also reported in some other studies performed in this regard.[141516]

Raynor (2006) has acknowledged the existence of a vast range of contradictory and opposing feelings and thoughts that appear after giving birth.[17] Wilkins (2006) and Miller (2011) have also revealed in their studies that mothers’ unfulfilled expectations during pregnancy and after delivery signify a distance between what they had expected and what they faced in reality. The present study is in substantial agreement with their findings.[1819] Yet, it differs from the study results of Harwood et al. (2007) who reported that mothers’ pre-childbirth expectations were consistent with what they experienced after that.[14] Barkley et al. refer to some major themes like “unpreparedness,” “loneliness,” and “loss,” which stand out among the themes they have encountered in motherhood process, and assert that nurses and midwives should talk to mothers about the challenges to which they are exposed in this respect.[20]

Insufficient dominance and control over affairs is one of the major challenges for mothers in the motherhood process; feeling of hardship and discontentment which results from the overwhelming new condition, child's temperament, and mother's physical and mental tensions, and a sense of loss and restriction alike are influential in creating stress and conflict. A feeling of extreme and overwhelming tiredness, and loss of physical and mental energy after delivery have been indicated in many studies.[152122] According to Troy (1999), women within the whole first year after delivery feel tired and de-energized.[22] Nystrom and Ohrling have also admitted that the most outstanding theme in parents’ experiences in the first year after childbirth is that they live in a “a new overwhelming world.”[23] It goes without saying that child's difficult temperament also plays an important part in the way parents experience it.

Many studies have acknowledged a direct association between parents’ distresses and having a child with difficult temperament.[2425] Feeling nostalgic about their past and what they have lost, added to the restrictions and undertakings imposed by the new condition, as Barkley et al. (1997) have also indicated, leave new mothers with a sense of discontentment, grief, and depression.[20]

Insufficient control over affairs (practical control) can reduce self-confidence and hinder maternal role attainment.[26] Studies have shown that mothers’ self-reliance could account for the absence or existence of stress and anxiety in mothers;[27] i.e., mothers with more self-confidence can pass through the transition state more easily while their general health is less intimidated.[28] Fear and anxiety which have been frequently observed in Iranian first-time mothers and is most likely rooted in protective culture of eastern mothers can have a negative effect on their control and dominance. The most significant aspect of this anxiety is fear of losing the child, as it has been mentioned by Cornford et al.[29]

Unmet personal needs could render mothers susceptible to stress.[2130] One thing that concerns women after delivery is that they do not want to be left alone; when they do not have someone around to help, they take the difficulties much more seriously; they imagine that they could be more supported when others are around.[31] In this research, getting support from different sources, such as practical support especially provided by new moms’ mothers, affectional support mainly given by their husbands, and informational or subjective support offered by midwives or other advisors, is maintained as an essential element that facilitates a successful adaptation to the maternal role. The point has also been indicated in other studies.[7303132]

They like to be understood and totally appreciated by others, especially their husbands, about their appearance, performance, house-keeping, and motherly behaviors; otherwise, their control and dominance could be disrupted. Seeking support from others could be a sign of mother's endeavor to keep or make some time for themselves to relax and get accustomed to the new condition. This has also been mentioned in this research and other studies as well.[22021] The study participants revealed that they have not yet accepted the child as an integral being and impose motherly deeds and maternal feelings upon themselves as they have seen or heard from others. Therefore, there is an inverse relationship between social support and neediness, i.e., mothers’ sense of neediness to get more support implies the weak state of the supporting system.

According to researches, getting prepared for maternal role attainment starts with pregnancy and develops gradually over time.[33] They have always heard that becoming a mother must be the happiest event in a woman's life or that maternal love is endless and stable. But now, being afraid of the fact that their experience has questioned all the established cultural beliefs and that it may incite negative judgments about them, they prefer not to convey their feelings while this intensifies their internal conflicts.

According to the experiences of participants in this study, the duration and the range and intensity of these mental states differ from one to another. A mother, for instance, claimed that it was only the day after delivery that she had such feelings, while some others said that it took about a week or even more than a month to pass through these states. Some have only experienced one or few of these states; yet, with respect to their social relationship, all unanimously admitted the instability of their relationships, especially matrimonial relationships.

Although most couples believe that having a child can strengthen their relationship, most of the researches reveal that after childbirth, parents do not form satisfactory relationships and their mutual and positive relations diminish.[34353637] Mothers spend more time on child care and house chores and less time with their husbands, family, friends, work, etc., while this can decrease marital satisfaction and bring about social exclusion.[38] Likewise, their desire for sexual activities dissipates, while both parents are aware of these changes.[39] This supports the findings of the present study. Mothers’ awareness of these changes and the fear that they may get worse help to foster more anxiety and intensify their internal conflict.

Limitations

With regard to ethnic diversity in Iran, best attempt has been made to choose study participants with different ethnic backgrounds. Findings of this research, therefore, do not reflect maternal experiences of all ethnic groups living in Iran. Despite the existing restrictions, this study attempts to present a proper description of view points and experiences of today's Iranian first-time mothers.

According to the present research findings, experiences of Iranian first-time mothers in dealing with challenges and strains of maternal role adaptation have a lot in common with counterpart studies that have been mainly conducted in western countries. The intense attachment of personal, social, and cultural factors which give rise to these challenges and crises denotes the existence of some other reasons beyond biomedical factors.

At the same time, the embedded resemblance of these experiences despite social, cultural, and geographic differences admits the existence of shared factors in creating the aforementioned crisis, which calls for additional research so as to provide awareness and proper outlooks toward such experiences among different groups of people around the world. What is evident is that the discrepancies between subjective expectations and postnatal experiences take an influential part in causing these problems. The more accurate information mothers and families have about this transitory stage, the better they can get prepared to tackle with it. This specifies the significant role of midwives, midwifery educators, and healthcare policy makers and practitioners to include these concepts in training programs and protocols of healthcare and support services in due time, form, and content that is in accordance with mothers’ mental and psychological needs.