Coping mechanism against high levels of daily stress by working breastfeeding mothers in Iran.

OBJECTIVES: Breastfeeding mothers returning to work undertake multiple conflicting roles at home and work that can result in high levels of stress. Exploring coping skills amongst these mothers can help in planning useful programmes to promote family wellbeing. This study aims to explore the experiences of working breastfeeding mothers and their coping mechanism against high levels of daily stress.
METHODS: In this qualitative study, we described the experiences of 20 Iranian breastfeeding mothers through in-depth and semi-structured interviews. All interviews were recorded, transcribed and analysed using thematic analysis.
RESULTS: Two main themes emerged as follows: 1) self-management with subthemes of a) attitude reconstruction, b) order and planning, c) creating a boundary between work and family and d) reprioritising life affairs; and 2) seeking help with subthemes of a) family member support, b) childcare facilities and c) spirituality.
CONCLUSIONS: Findings suggest that women need support from family members and family-friendly policies at the workplace. Breastfeeding mothers may benefit from educational programmes that focus on effective coping strategies.

Introduction

Mothers working outside of the home make up a significant proportion of the labour force [1]. Despite the changes in the status of women in the world, the burden of housework and care of children continues to falls on them [2]. The transition to parenthood is a stressful life event [3]. When an employee becomes a mother, a new role is added to the previous role [1]. New mothers have to cope with a heavy workload at home, including housework and childcare [4]. Although some studies have shown that employment positively affects the psychological wellbeing of working women, those with very young children feel overloaded and experience conflicts in their role. These experiences can diminish the positive effects of working [5].

Previous reports have shown that full-time working mothers with children under 5 years old are vulnerable to psychological stress [6]. Other studies have shown that breastfeeding mothers face stressful challenges when they return to work whilst staying committed to breastfeeding [7,8]. Although 88.8% of working mothers breastfeed during maternity leave, only 24.1% continue to breastfeed after returning to work [8].

Stress is a part of life and a subject that is difficult to avoid [9]. Stress is a growing problem for all employees, but it is experienced at a high level for working breastfeeding mothers. The rate of stress-related illnesses amongst women is two times the rate of those in men [10]. Stress occurs following an inconsistency in a person's ability to meet the perceived demands of the environment [11]. A review of literature showed that stress is negatively related to the mental health of mothers and can cause depression and anxiety in the postpartum period [12].

Balancing family and job responsibilities is difficult, particularly for breastfeeding mothers; therefore, learning how to manage the different roles of motherhood can help working mothers reduce their stress levels [13].

To reduce stress and achieve a family–work balance, working mothers may use some supportive coping mechanisms [14]. Stress management is the process of change that individuals use to reduce stress [15]. Lazarus and Folkman presented a cognitive appraisal model of coping. The coping strategies in this model are categorised as problem focused (try to manage or change the problems that cause the stress) and emotional focused (try to adjust emotional responses to the stressful situation) [16]. Working mothers usually use childcare facilities, reduce their hours of work to part time and undertake long maternity leave as coping mechanisms [17]. However, not all working mothers can afford or are offered these measures. Furthermore, a mothers' performance at her job and her home often reveals her ability to cope with the concurrent demands of work and family [18]. Community resources, such as recreational facilities for exercise, creative arts, self-care promotion, social support and cognitive skill development, are also available to help mothers reduce stress [19]. However, not all women have access to these resources for stress management.

Iran is a developing country and has a population of over 75 million [20]. The working mothers in this country account for 13% of the labour force [21]. In Iran, women who work in public organisations can use 9 months of maternity leave. In addition, they often have access to and can use additional months of unpaid leave as per the Iranian administration regulation. In the private sector, the length of maternity leaves is often short. Some pieces of evidence have shown that short maternity leave is related to high levels of stress for women as they desire to take care of their babies [22]. In Iranian families, women have a central role in maintaining peace and family unity [23]. A woman's role as a spouse, a mother and an employee often overlaps and creates conflict. Effective coping mechanisms are thus essential to bring balance and reduce stress.

Few studies have examined the daily stressors for working mothers and their stress management strategies [[24], [25], [26]]. No study in Iran has focused on working mothers who want to continue breastfeeding after returning to work and to maintain their family equilibrium. Assessing an individual's coping strategies should be conducted within a particular social and cultural context [27]. In this study, we explored the experiences of working mothers who returned to work and continued to breastfeed whilst managing family and household responsibilities. Exploring the strategies that mothers use could help in planning useful programmes for health promotion of working breastfeeding mothers.

Methods

Design

A qualitative approach was selected as the most appropriate methodology to provide a full understanding of a particular human phenomenon by exploring the perspective of those experiencing it [28].

Study setting

The study was conducted in the city of Tabriz, which is the capital of the East Azerbaijan Province and located in the north western region of Iran.

Participants and recruitment

Participants included 20 employed mothers who returned to work during the breastfeeding period. These women recorded a high daily stress level by using a perceived stress scale. This tool was originally developed in 1983 and asks about the person's feeling and thoughts during the last month with scores ranging from 0 to 40 [29]. Participants were recruited by purposive sampling. A flyer was developed and distributed in several health centres where mothers came for newborn screenings. For maximum diversity, purposive sampling included participants from different occupations and educational backgrounds. A second recruitment strategy, snowball sampling, was used when women recommended and referred other participants to the study. Table 1 shows the demographic characteristics of the participants.

Table 1

Demographic characteristics of the participants.

Participant's code	Age in years	Education	Occupation	Work antecedent in years	Type of delivery	Age of infant in months
P.1	30	Master	Fixed shift nurse	5	C/S	14
P.2	31	Bachelor	Fixed shift nurse	6	C/S	14
P.3	28	Master	Computer engineer	4	NVD	16
P.4	37	Bachelor	Teacher	17	C/S	20
P.5	33	Bachelor	Nurse	3	C/S	18
P.6	29	Bachelor	University staff	4	C/S	14
P.7	30	High school diploma	Patient transport orderly	10	C/S	12
P.8	27	Associated degree	Private sector employee	8	C/S	14
P.9	32	High school diploma	Airport staff	9	C/S	11
P.10	37	Bachelor	Nurse	11	C/S	20
P.11	33	Bachelor	Teacher	8	C/S	12
P.12	29	Bachelor	Midwife	2	C/S	21
P.13	30	Bachelor	Private sector employee	5	C/S	18
P.14	27	Bachelor	Typist	2	C/S	19
P.15	32	Master	University staff	8	C/S	13
P.16	30	Bachelor	Private sector employee	4	NVD	15
P.17	29	High school diploma	Waiter	6	NVD	22
P.18	31	Bachelor	Private sector employee	9	C/S	20
P.19	27	High school diploma	Seller	3	C/S	23
P.20	29	High school diploma	Clerk	5	C/S	19

Data collection

Twenty two face-to-face semi-structured interviews were conducted with employed breastfeeding mothers after maternity leave. Semi-structured interviews were used to allow each woman to discuss her experience. The use of some key questions helped guide the discussion. Examples of the key questions asked were ‘How has your life changed at the end of maternity leave with your return to work?’ and ‘What have you done to cope with stress of life since your return to work?’ Follow-up and exploratory questions starting with ‘please explain more’ were used as data collection progressed to encourage further description of experiences. Data analysis was undertaken concurrently with data collection. Following the 16th interview, common patterns began to form and continued until saturation was reached. Interview sessions were held at the participants' workplace, home and other locations, such as a park, that were convenient to the participant. Each interview lasted 45–70 min and was recorded using a digital recording device. Only two participants were interviewed two times for data clarification.

Ethical considerations

This study was approved by the ethics committee at Tabriz University of Medical Sciences and research council approval under number 7159. Participants were assured of their anonymity, privacy and voluntary engagement before signing a written informed consent form, wherein the study objectives, methods and analysis process were explained.

Data analysis

Interviews were audio recorded and transcribed after several reviews by the research team. The transcripts were read and reread, and thematic analysis was undertaken. The data were coded as common patterns emerged. The patterns formed themes and subthemes in accordance with their relations with one another in a constituent pattern [30]. A process of constant comparison between researchers led to two final themes. Analysis was initiated after the first interview and was done concurrent with data collection [31].

Rigor

Lincoln and Guba criteria used in this study included credibility, transferability, dependability and confirmability. Several strategies, such as maximum variation sampling, member checking and prolonged engagement of research team, were used to improve credibility [32]. For data conformability, the entire sets of codes and categories were reviewed by research supervisors and academic advisors. Original raw data, the categories and subthemes remained intact for an audit trial [33]. Precise data documentation, study methods and decisions made during data analysis ensured dependability.

Results

Data analysis revealed two main themes as a) self-management and b) seeking help. Mothers talked about their health being affected by assuming multiple roles without adequate support and discussed having self-management plans and the importance of seeking help.

Demographic characteristics

Twenty breastfeeding working mothers participated in this study. The age range of participants was from 27 to 37 with an average age of 30.55 ± 2.1 years. The age of children when their mothers returned to work ranged from 3 months to 12 months. The mean score of perceived stress was 27.05 ± 1.98. Scores ranging from 27 to 40 were considered high stress levels. Table 1 shows the demographic characteristics of the participants.

Theme 1: self-management

Mothers discussed how they try to relieve stress through self-management actions. The four subthemes linked to this theme were 1) attitude reconstruction, 2) order and planning, 3) creating a boundary between work and family and 4) reprioritising life affairs.

Several mothers stated that a change in attitude and attempting to reduce sensitivity towards certain things by self and from others help reduce expectations of themselves and others by leaving aside the desire to be perfect.

‘I used to be very sensitive towards orderly setting, especially my home's appearance. Everything has to be in its own place and very tidy. However, when I returned to work, additional demands on my time and energy are prohibitive, and taking care of everything is stressful. Thus, I decided to let go of stress by caring less about tidiness and perfect order of things'. (P2)

‘In the past, I easily get irritated by others’ comments or criticism. Now, I am less sensitive because my baby and my health are more important to me than any other things'. (P12)

Regarding order and planning, mothers stated that planning plays an important role in stress reduction by creating a boundary between home and job responsibilities. They said planning helps them perform tasks in less time by being orderly and organised.

‘As I prepare to sleep, I review and arrange my work for the next day and mentally organise what needs to be done from morning to evening’. (P4)

‘I prepare lunch ingredients the night before. Then, in the morning, I place them in a slow cooker with a time set to be ready for when I return home in the afternoon. I also do most of the cleaning and organising at night. In this way, everything is in order when I get home’. (P14)

Participants mentioned that, when they are at home, they try to focus on family affairs and free their mind from problems at the workplace. They noted that this way helps them relax.

“When I return home, I free my mind free from the affairs at the workplace … I believe that the problems at the office should remain there. In this way, I can handle the kid better.” (P10)

Participants also talked about reprioritising affairs and mentioned that their life priorities have changed after child birth as “the child” is their main priority at present.

‘When I return home, I attend to the child's affairs first. For me, the clutter in the home or the meal is less important than the child's needs, which cannot be compensated. Hugging and breastfeeding the baby is calming for me’. (P17)

Theme 2: seeking help

Another important stress reduction strategy by the participants was seeking help. The coordination of household duties with employment responsibilities without adequate support was impossible. Division of responsibilities amongst the family members reduced mothers' workload and led to some stress reduction. The mothers also stated that faith and appeal to a higher power with prayers help them reduce stress. Some of the participants stated their mother and husband offer the major support and help them reduce workload and stress. The three subthemes related to this theme were 1) family member support, 2) childcare facilities and 3) spirituality.

‘My mother always helps me. When I get tired of childcare, I ask her to relieve me as I rest. When I return home from work and feel very tired, she sometimes prepares food for the family’. (P9)

Participants expected help and empathy from and collaboration with their spouse rather than other family members. Most of the participants stated that emotional support and assistance from their spouse play an important role in their stress reduction.

‘My husband sometimes gets up to take care of our baby at night. He asks me to rest as already worked hard with my job and at home. His words are heartwarming and energising with love’. (P13)

Participants also noted the need for childcare facilities and support at work.

‘I wish we have a day care facility in our workplace or my employer will be flexible in approving leave of absence without pay, long maternity leave, use of my sick leave or vacation time, or a part-time work. Any of these options can help me continue my breastfeeding journey’. (P8)

Having faith and praying were common themes for reducing stress as mothers declared that a higher power helps them survive in multiple important roles under mental and psychological pressures. Participants stated the necessity for spiritual health and a strong relationship with God to remain calm in difficult situations.

‘I feel relaxed when I pray, especially now that I have no power to change my circumstances. I also feel relaxed when attending prayer sessions and reading the Quran’. (P11)

‘I read verses in the Quran when my baby is away from me and when I feel worried. In this way, I feel that guardian angels are with him and taking care of him. Thus, I feel relaxed’. (P9)

Discussion

Previous literature has shown that working women with very young children may have to cope with a heavy workload at home, including housework and childcare; thus, they experience work–family conflicts [4,8]. This result is similar to our finding that participants experienced high levels of stress in their daily lives. Our participants managed to reduce their stress by changing their attitude, order and planning, creating a boundary between work and family, reprioritising affairs and seeking help from family members, childcare facilities and spirituality.

Self-management

Mothers benefited from problem-solving skills, planning and organising to reduce stress, which is similar to the finding by Gunton [24]. Tobio in Spain advised working women to follow time management to overcome stress [34]. Whitehead and Kotze found that planning and problem solving are important for reducing stress [35]. Indeed, planning is an important strategy that can help in balancing work and family [34].

Several studies have reported self-control and changing attitudes to the expectation of self as an effective strategy to cope with stress amongst working mothers [6,24,36,37]. Nell mentioned that getting angry, wavering and self-blaming are the least useful ways to reduce stress [38]. Napholz found that changing attitude towards self is an appropriate method to reduce conflict and increase role satisfaction [39]. These findings are inconsistent with our subtheme of ‘changing attitude’. Kushner [25] noted the importance of prioritising and concentrating on one task at a time to minimise stress. Napholz considered setting priorities amongst roles as another way to maximise satisfaction in life [39]. Higgins argued that women voluntarily relinquish some tasks at home, which are important for them before, because their preferences have changed [40]. These findings are similar to our findings of reprioritising affairs. Campoine reported that working mothers emphasise the distinction between their jobs and house chores and stated that they avoid pressure in the abode of work to avoid its effect on their maternal role [41].

We found that working mothers, especially those who breastfeed, had reduced levels of stress when they were organised and did not blame themselves. However, caution should be exercised as not all women could be fully organised when they need to be flexible and work around the baby's needs, such as breastfeeding.

Seeking help

Our participants sought help from their husbands and mothers as an effective method to manage stress. As reported by Ugwu, working mothers with support from their spouse at home experience lesser stress compared with mothers who do not seek help [42]. Lu and Bianchi emphasised the importance of a support system at work for stress reduction amongst working mothers [43,44]. Support from the workplace enables working mothers achieve a balance between work and family affairs [46,47].

Employing a domestic helper is a common coping strategy used by working mothers [45,48]. This way allows women to spend much time on their paid work and professional duties [45]. In Iran, having a domestic helper is common; however, many cannot afford the extra cost and prefer to ask their relatives and family members for help. Okafor (2006) found that working women who employ a domestic helper experience low levels of stress [45]. At the same time, Easton described the need for a domestic support network to collaborate and listed spouse, family members, friends and childcare facilities to reach out to working mothers under stress [49].

In our study, intimacy with God and recourse to spirituality were mentioned as helpful approaches for stress reduction, and religion was perceived as an inseparable part of the Iranian culture. Seeking God's help is a common practice, and spirituality is a major part of life for Iranian families when faced with stressful situations. Some studies have reported the relation between certain religious behaviours and health promotion [47,50]. Motlagh demonstrated that participants believe that spiritual orientation improves their physical, psychological and emotional health and diminish stress and anxiety [50]. Similarly, the women in our study who practiced their faith through prayer experienced less stress when dealing with the demands of work and motherhood.

Limitations

Our sample was a small sample of homogeneous participants who were mostly university-educated and middle-income working mothers. This method was a purposeful selection of participants from only one city in Iran, and the study findings presented limited generalisability.

Conclusion

Breastfeeding mothers returning to work can suffer from fatigue and exhaustion as they attempt to fulfil their commitments at home and at work. The role of family members, especially that of the spouse, is vital in supporting mothers. We also find that workplace support needs to be expanded to include childcare facilities, long maternity leave, part-time work or flexible leave. In this way, women can continue to breastfeed their babies. Similar to the recommendations in [16, 51], we recommend an intervention programme for working mothers on effective stress management. These coping strategies can help support breastfeeding women, prolong the duration of breastfeeding for working mothers and promote family wellbeing.

Author contributions

SV, MH, HH contributed to the conception and design of the study. MH performed data collection. MH, EM, HH contributed in data analysis. MH and MF wrote the manuscript, AC edited the manuscript and SV supervised whole study process. All authors read and approve the final manuscript.

Disclosures

The authors declare no conflicts of interest.