ENFERMERÍA Y PERSPECTIVA DE GÉNERO

 

Experiences in a support group for mothers with children under a year

Experiencias en un grupo de apoyo para madres con hijos menores de un año

 

 

Berlanga Fernández, Sofía*; Pérez Cañaveras, Rosa M^a**; Vizcaya Moreno, M^a Flores**; Berlanga Fernández, Francisco*; González López, Noelia Antonia*

*Nursing. Instituto Catalán de la Salud. E-mail: sbf10@hotmail.es
**Nursing. Alicante University.

The Nursing School in Barcelona has contributed with its help to the development of this research granting this Project with a partial financing in the frame of help to Research Projects 5326-11.

 

 

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ABSTRACT

The process of motherhood, according to Mercer, implies the mother's psychological birth, creating a new identity under constant growth and development. The model of this author can serve to the nurse to value, plan, implement and assess the nurse care of mothers and their babies in their interventions.
This is a qualitative study, of an ethnographic approach, directed to groups of mothers with children under a year that would use the participant observation and the field diary to describe and relate the contents and the group dynamics with the development of the maternal role. Three categories and 50 codes are identified and it is enhanced that nurses, as competent professionals in conceptual and technical aspects of their discipline, use the Mercer's and Beck's models to accompany the mothers and coordinating with other professionals.

Key words: Mercer; Beck; Etnography; Qualitative, Participant observation; support groups.

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RESUMEN

El proceso de la maternidad, según Mercer, implica que la madre nazca psicológicamente, dando lugar a una nueva identidad en constante crecimiento y desarrollo. El modelo de esta autora puede servir a la enfermera para valorar, planificar, ejecutar y evaluar el cuidado enfermero de las madres y sus bebés en sus intervenciones
Este estudio cualitativo, de enfoque etnográfico, dirigido a grupos de madres con hijos menores de un año, utilizará la observación participante y el diario de campo para describir y relacionar los contenidos de las dinámicas grupales con el desarrollo del rol maternal. Se identifican 3 categorías y 50 códigos y se destaca que las enfermeras, como profesionales competentes en aspectos conceptuales y técnicos propios de su disciplina, utilizan los modelos de Mercer y Beck para acompañar a las madres coordinándose con otros profesionales.

Palabras clave: Modelos; Mercer; Beck; Etnografía; Cualitativo, Observación Participante; Grupos de Apoyo.

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Introduction

The process of motherhood implies the psychological birth of the mother as the baby is born physically, creating in her mind a new identity: the sense of being mother⁽¹⁾.

The establishment of the identity in a mother after the birth contributes to the psychosocial development of the woman ⁽²⁾. In this process, the mothers acquire a mental attitude that organizes their mental life, reorienting their preferences, pleasures and reorganizing some of their personal values.

This attitude is kept during their whole life, although it doesn't occupy the first place, it is always present, it waits and arises when it is necessary. In this way, it is confirmed that the birth of a mother is under constant growth and development⁽¹⁾.

In this line, Ramona Mercer proposes that the term "adoption of the maternal role" may be substituted by "becoming mother" ⁽²⁾ considering it as a process of continuous and non-finite evolution, influenced by factors related to the environment, the child and the mother that is configured by different stages during the first year of life: commitment and preparation; knowledge, practice and physical recuperation and normalization and integration of the maternal identity ⁽²⁾.

The nurse accompanies the mother during this process and she can use the Mercer's model to provide nurse care to the new mothers and their babies in the individual or group interventions that they carry out ⁽³⁾.

Through the group dynamics, the nurse offers information and knowledge at the same time that invigorates a set of participants that lets learning by their suggestions, generating emotions, taking part in attitudes, facilitating the learning through imitation and providing security to the individual⁽⁴⁾. Moreover, the evidence suggests that intensive interventions during the first year after the birth can produce a significant difference both in the maternal and breastfeeding results ⁽⁵⁾.

In the Primary Health Attention centre, Amadeo Torner, group dynamics for mothers with their under a year children have been carried out for nine years, directed by a clinic psychologist and a nurse that accompanies the families during the maternal process.

By means of this method in Education for Health, it is intended to carry out a study with the following aims: to describe the contents of the group dynamics; to relate the worked contents in the group with the development of the maternal role and to adopt the nursing theory in this type of activity, due to, among other things, the fact that despite the continuous efforts of the research to identify the variables related to the transition towards the motherhood, the health professionals have made little progress in translating the knowledge of these variables into practice ⁽⁵⁾.

 

Material and methods

This is a study of qualitative design and ethnographic approach. The used technique is the observation of the participants, in which the main investigator was included in a group of mothers with their children under a year during seven weekly sessions in the Health Primary Attention Centre Amadeo Torner in Hospitalet del Llobregat, between April and May 2012.

Each session took two hours and a half, ten mothers and their babies who had been selected by their nurse of reference participated. For being included in the group, mothers should implicate themselves in attending the sessions and they couldn't present any idiomatic difficulty in the communication.

The nurse, as main researcher, participated in all the sessions of the group, using the field diary as a tool for gathering the data.

The field diary has been thoroughly analysed, dividing the texts of the diary in units of meaning encompassed in different categories attending to the factors that Ramona Mercer describes in her Theory of the maternal role-to become mother⁽³⁾, to the concepts that Beck describes in his Theory of the post-partum depression⁽³⁾, and concepts of health promotion and illness prevention. From these categories the pertinent codifications were obtained.

After the analysis of the field diary and with the aim of offering rigour to the obtained information, the categorizations and codifications, as much as the results, were discussed and analysed with the psychologist that took part in the workshop. Regarding interpretation differences, other nurses that participated in similar group dynamics were asked to solve them.

Finally, the ethical criteria that the ethic committee of our institution applies were respected. Mothers were asked permission for taking notes and during the whole process data were registered and analysed without implication of the identity of the participants.

 

Results

Three categories have been identified in total: "Mercer's characteristics", "Beck's concepts" and "Promotion of the health and prevention of the illness" (table 1)

 

 

These categories include a total of 50 codes, which are ordered by the times that they appear (absolute frequency). These are the following:

The first category, "Mercer's characteristics" (table 2), includes the following factors: social support, signals of the breastfeeding, union, tension due to the role, child's characteristics, family, partner, adoption of the maternal role, mother-father relationship, self-concept, running of the family, anxiety, stress, reward-satisfaction, child's temperament, maternal identity, attitudes towards upbringing, flexibility, self-esteem and perception of the experience of birth.

 

 

The first of these factors, the social support, became explicit through a game proposed by the clinical psychologist in relation with the description of the familiar dynamics. Through it, the mother's role, the family, the father or partner, the mother-father relationship and the function of the family; sixth, seventh, ninth and eleventh factors regarding the highest order of appearance are developed.

"The father and I are together; in front of us is my daughter. My mother and my mother-in-law are separated from the group, because they have to be apart."

"The child is between the father and me. My father is always opposite. My father is very fond of children and he spoils him, but at any situation, he always comes very quickly. My father has always helped me. He's an unconditional, he's always there"

These four factors are included in a microsystem. It's about one of the three main environments that influences, according to Mercer's theory. In the process of becoming a mother: the closest and most intimate.

"My social life is reduced to the child"

"I start to work tomorrow. I will start the night shift. The family took the child to the village while I was working. At the beginning, I had a really bad time"

This social support can be classified in emotional, informative, physic and of valuation. These are observed in the different interventions at the workshop.

"When you are with more people, you relax and catch the environmental emotion because there's a good climax. Then you relax too"

"What happens to me is that I'm very lost and I need the other mothers, the contact with other people".

Although the social support tries to provide satisfaction to the mothers with the help that they offer, this is felt by them as unsatisfactory:

"I can't stand the social pressure that tells me what I have or I don't have to do. The nurse told me that I had to take my daughter, to indulge her and to stay with her. My mother puts pressure on me for not to take the child and I think that I have little time before starting working"

"The people's opinion makes you feel a bad mother...I have doubts regarding sleeping in our bed. My partner and I agree in the fact of sleeping with the child and you feel all the time questioned and I'm going to do what I consider more consequent..."

Also, it is observed that through the social support developed in the group, concerns of the mothers and the job they carry out interpreting the signals of the breastfeeding emerge, this is the second factor in order of appearance. This is shown through the answers that the mothers give when the baby cries, as much as the feeding demands, rest and position, among others.

"I can notice in her face when she's hungry immediately"

"He feels hot and that's why he cries. I think that if he was naked, he would be better"

"He has uncovered his hands. I've observed that if he approaches things to his face, he relaxes and it helps him to sleep better"

"He finds to go poop hard and that makes him to be grouchier...he has colic and I have already assumed it. He relaxes when I catch him and I speak to him".

If the mother doesn't interpret correctly the signs of the breastfeeding, it can affect in their emotional state, what generates tension due to the role.

"She's a bit weepy...I don't know, sometimes I think if I'm a bad mother, because sometimes it exasperates you"

"When the baby cries. I can't stand the crying of the baby, I have to leave. Then I need someone's help"

In spite of the fact the tensions that any mother can feel towards the performance of her role, she feels and affective and emotional filter, and from here the union emerges.

"Sometimes I leave her in the park, but she doesn't entertain herself a lot, and she calls me immediately. She could be more entertained, couldn't she? Then I leave hiding myself, but she realizes how I move away and she cries. Then I approach her and start speaking to her. The voice calms her down and by means of it I tell her that I'm here".

"When she was vaccinated she cried a little, but I broke into tears and I thought, why she has to pass this! Poor girl! What a trifle! That's a connection. It is a tension you can't avoid"

The creation of a link between the mother and her baby, as much as the development of tasks related to the care of role and the pleasure and gratification that are produced in the performance of it, led to the factor of the adoption of a maternal role that many mothers express to be in process of development.

"I know my baby better and better. I've overcome the problems related to the feeding..."

"In the mornings I stay with her. We play: she looks at me and smiles. I give her my hand and she calms down, then I sing her and she looks at me. She starts smiling and she's happier"

Eventually, other factors such as the child's characteristics, stress, self-concept, maternal identity, child's temperament, and gratification-satisfaction, perception of the experience of born, attitudes towards upbringing, self-esteem, flexibility and health state have been identified.

The second identified category, "Beck's concepts" (table 3), includes the anxiety and insecurity, stress regarding the care of the baby, guilt and shame, vital stress, maternal sadness and emotional feebleness factors.

 

 

The factor "anxiety and insecurity" led to the feeling of being overcome in her new maternal role showing over-attention in relatively trivial topics.

"I went yesterday to the nurse to weight him because I had the feeling that he hadn't practically gained weight, but it was ok...the next week he will be vaccinated, and I don't know, I have a bad time. Everything distressed me in the past"

"Last week my daughter touched her ear. I thought it was a hearing infection and from that I thought about meningitis. I took her to the emergency paediatrics. The conclusion was that she was ok and that she may be discovering that she had ears"

In the second factor, stress in the care of the child, the expressed difficulties related to feeding and rest topics is demonstrated:

"Eating is a stressful moment for my son. I'm afraid that he could have problems for adapting to eat like now"

"At the beginning I couldn't sleep, I had cracks and problems related to the breastfeeding. Now the baby has difficulties for eating porridges. I felt like coming and seeing other experiences"

It is worth mentioning that the anxiety, the insecurity and the stress regarding the care of the child can have an effect on the guilt-shame feelings that mothers show under certain situations.

"This week I've decided stop the breastfeeding and starting with the feeding bottle. But if I don't breast-feed him, I feel so bad. Tonight I've slept six hours and I feel happy! But I've read so many advantages about the benefits of the maternal breastfeeding that...I can't avoid it!"

"When she starts crying, I start sweating. People say things and you don't know what to do".

"The beginning of the weaning has been hard because she turns herself to the breast when she's on me, and that desperate me, above all at night, when she cries and she can disturb the neighbours and the she asks me the breast...and I have to give her the baby bottle".

Finally, during the sessions other three Beck's factors have been identified. It is the vital stress, maternal sadness and emotional weakness.

"I couldn't stop crying during the first month and I was unbearable. I cried as soon as I was grouchy"

"The first moments can be very hard. Related to the personal emotions, I wanted to be happy but I was really sad and I felt like crying..."

Once the category 1, Mercer's factors, and category 2, Beck's factors have been developed; it will be commented the category 3 related to the concepts of health promotion and prevention of the illness.

The category 3 (table 4), "health promotion and prevention of the illness", includes five items. The first one is the mature development constituted by: psychomotor and physical development, dummy, postural advice, over-stimulation, massage, water activities, essential upbringing acts, Moses basket and television.

 

 

"I realize that she looks at the toys and then I sit her on the blanket. She wants to throw away the objects and to take them to her mouth, but she can't"

"She wants to be sat and she propels herself forwards to adopt the position. Maybe I have to sit her on the pram".

The two following are the feeding and the rest. The feeding would include from advice related to the introduction of the complementary feeding, maternal breastfeeding, feeding with a relational and communicational element between parents and children, as much as the problems that parents perceive in the feeding of their baby.

"She doesn't gain much weight and that worries me. In one week she has only gained 80 grams. She doesn't want to eat. I feed her every four hours and she doesn't ask for food..."

"I had the experience that my sister had breastfed my nephews. I thought that I would try it and that if I liked the experience, I would go on, but I left the hospital with cracks and an ointment. I didn't enjoy the experience. But my daughter gained weight. Two weeks ago my breast started not to pain and I don't have any cracks. Now I start to enjoy my daughter".

Rest is related to advice about activity patterns and normal rest as much as sleep disorders, either for inadequate habits or difficulties in maintaining a correct balance wakefulness-sleep.

"She has overcome the fever and the virus. The problem is that she has changed the sleeping patterns. She eats every four hours. During the day she sleeps more peaceful but at nights she sleeps anxiously. She slept better before".

"He has always eaten and slept very well. Now she wakes up scared. At night, she has nightmares and rigid movements. That worries me"

The fourth item, management of health problems (49) is formed by: cry (20), stools (10), colic (5), skin care (5), vomits (3), mucus (2), mosquitoes (2) and fever (1). In this section, mothers show situations that worry them or that have worried them during the months of the workshop.

"She spent 5 days without going poop last week and I massaged her because she had to do it. The paediatrician told me that she had the poo very fluffy and that it could take time. For me, it was a relief when she did it. However, the truth is that you need a solution at that moment on the paediatrician half. And people.some told me that I had to put stick with oil, others that I had to look on the internet.but when she went poop, it was like if it was me. If people had told me that I had to eat yellow food, I would have done it for my daughter".

"He's had a cold these days. We took him to the emergency services and he's still with mucus and he eats less. The baby is tired. He has a bad time because of the mucus. I suffered because it seemed that he couldn't breathe either the mucus".

To sum up, the accidents prevention item (22) would occupy the last place. This is composed by: vaccines (13), accidents (6), wave of heat (2) and hygiene and sterilization (1).

All these factors and items come from the dynamic in a workshop developed since an observation proposal that the professionals do to the mothers, finding them the support of the professionals and other mothers in the accompany to these experience, what they assess very positively.

"I like seeing other situations and how other mothers have acted at the same time you have given us advice. Being with other mothers help you to see things more naturally and to understand that it is normal"

"The group lets you to share experiences. I was very worried because of the breast. I've seen other mothers that have experienced the same that me, the difficulties that they have faced. I've discovered that I'm more patient".

"Socially, you feel under pressure for doing things correctly. It is like if you were constantly evaluated. Everything has been different as I thought. Coming here has helped me to manage better that pressure. I don't feel as nervous as I felt before. I see things better now".

 

Discussion

Among the most significant results appear that the women who participated in this group are, according to the theory of Mercer's maternal role, between the second and fourth stage of the process of becoming mothers. The progress through the stages would be influenced by the aspects related to the factors of the mother and the baby ^(6,7). Mercer describes a total of 23 factors ^(3,8), some of them are identified in the results section corresponding to category 1.

The one that appears more frequently is the social support, considering this as the help that it is really received as much as the satisfaction that this help produces and the people that offer it⁽³⁾, these people can be the professionals and/or friends and/or mother's relatives. The social support must be approached according to other authors ⁽⁹⁾ due to the fact that the quality of itself seems to be a transcendent factor in the maintenance and aggravation of the postpartum depression. In the participant mothers, it is observed that this support is received more from the microsystem but in spite of the fact that this is the one that most appears, it can be also detected the mesosystem and the macrosystem ^(3,6,8)

The signals of the breastfeeding is the second code that more appear and that makes reference to those behaviours that babies have and that provoke an answer in their mother⁽³⁾. The occasions in which mothers show difficulties interpreting the signals that their children send out are diverse, being at the same time a considered a relevant aspect in the professional interventions according to authors ⁽¹⁰⁾. These situations provoke stress related to the care of the baby, as much as guilt-shame feelings or those of anxiety-insecurity.

In relation to these feelings, it has been considered as convenient to link the Mercer's anxiety factor and the Beck's anxiety-insecurity. Moreover, the Mercer's depression factor has been substituted by Beck's maternal sadness and emotional weakness.

This author stands that the anxiety-insecurity feelings, drive to a feeling of being overtaken in their new maternal role showing an over attention in relatively trivial topics⁽³⁾, concepts that Mercer refers as anxiety, that makes to perceive stressful situations as dangerous or threaten.

At last, it describes the guilt-shame feelings as those in which the woman perceives that she is doing her role in a wrong way, in relation to her baby, negative thoughts⁽³⁾.

During the sessions other three Beck's factors have been identified, from the 22 that she identifies in her Theory of the Postpartum Depression and that they would complement the Mercer's theory. It is vital stress, maternal sadness and emotional feebleness, factors to which the increase of the maternal sensitivity can have contributed; ant that are a relevant aspect of the professional attention according to some authors ⁽¹⁰⁾. These two emotions have been selected as they are more precise that the depression described by Mercer: affective component of being upset or having depressing symptoms ⁽³⁾.

The emotional states of the mother can generate tension due to the role, defined by her as conflicts and difficulties that a mother feels in her duties in the maternal role ⁽³⁾.

In spite of the fact that the tensions that every mother can have in the management of her role, she feels an affective and emotional connection towards her baby ⁽³⁾. The creation of a link between the mother and her baby, as much as the development of the tasks of the role care and the pleasure and reward that are produced during them⁽³⁾ led to the adoption of a maternal role⁽²⁾.

All these factors and items rise from the dynamics in a workshop developed since an observation proposal that the professionals show to the mothers. The observation lets detecting the situations that interest them and that they want to comment on. This produces a motivation for learning that it is adapted to the necessities of each mother, trying to promote the natural knowledge they have, although they believe they don't have it and it limits the smoothness of the topics they deal with in the workshops, which are developed in other dynamic groups.

Through the developed thematic in this workshop, the clinic psychologist and the nurse act as two professionals that complement each other with a common goal: to easy and promote the autonomy on the half of the parents in the care of their children, by means of doing interventions that promote the health and prevent the family problems, in situations of change and/or crisis in the vital cycle of the family, in this way, the role of the family as promoter of the health is achieved, strengthening the link and family network ⁽⁸⁾.

This has been observed from the analysis of content of this workshop, in which nurses, as competent professionals in conceptual and technical aspects of their discipline, can take advantage of Mercer's and Beck's models to accompany the mothers during the process of becoming mothers⁽²⁾.

The professionals are not the only ones who answer the doubts that appear. The social support that it is produced among the participants is important as they feel identified with other people that are in the same situation ⁽⁵⁾.

That makes that the participation of mothers in a group dynamic like the described can be useful to provide social support and to influence in the perception of their capacities about motherhood, decreasing the stress and anxiety and improving the management of the parents as much as the effective running of the family ^(11,12).

The social support that it is produced among the participants is important as they feel identified with other people that are in the same situation. This shows the necessity of dialogue and the emphatic listening to understand the worries and to gain confidence in the capacities of the mothers as carers ⁽⁶⁾.

To sum up, in spite of the fact that the evidence is limited about the way of promoting the feelings of the mother about herself and the sticking to her baby ⁽⁷⁾, and that the group interventions related to the care of the healthy baby doesn't have any effect in the sense of the maternal competence, the social perception, the support or the isolation, the self-esteem, the anxiety or the depression in mothers of high risk ⁽¹²⁾; the mothers show a positive evaluation in the participation of the workshops.

However, it would be interesting to develop research that let analyse the contents of this type of workshops using conceptual models of the nursing discipline itself, as much as considering the qualitative assessment of the participant mother using different tools of this methodology.

 

Conclusions

This study has described and related the contents of the group dynamics with the development of the maternal role identifying three categories and 50 codes. For that, a qualitative methodology has been employed, with an ethnographic approach, which has used the participant's observation and the field diary.

Mercer's and Beck's models have been useful to value, plan, carry out and evaluate the nursing care to the mothers and their babies in their interventions not only in an autonomous way but also with other professionals.

 

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