Orit Taubman - Ben-Ari
Shirley Ben Shlomo
The Louis and Gabi Weisfeld School of Social Work
Bar-Ilan University,
Ramat Gan, Israel
Eyal Sivan
Mordechay Dolizki
Sheba Medical
Center, Israel
Running Head: GROWTH IN THE
TRANSITION TO MOTHERHOOD
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Send correspondence to: Orit Taubman - Ben-Ari, School of Social Work, Bar-Ilan University, Ramat-Gan 52900, Israel. Fax: 972-3-5347228, Email: taubman@mail.biu.ac.il
This research was conducted as a part of the Ph.D. dissertation carried out at the The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University by the second author under the supervision of the first author. It was supported by the Schnitzer Foundation for research on the Israeli economy and society.
ABSTRACT
The study examined both positive (mental health, personal growth) and negative (perceived costs) implications of the transition to motherhood, as well as the contribution of internal resources (self-esteem, self-mastery, attachment style), external resources (marital relationship, maternal grandmother's support), cognitive appraisals (threat, challenge, self-efficacy), and coping strategies (emotion-focused, problem-focused, support seeking).
One hundred and two first-time mothers were approached during the third trimester of pregnancy, and again approximately two months after the delivery. The results showed an improvement in mental health and an increase in the sense of personal growth between the prenatal and postnatal measurements. Mothers with greater internal and external resources who perceived the transition as less threatening and made lower use of emotion-focused coping maintained higher mental health. Mothers with lower internal resources reported on a higher perception of costs. Mothers with greater external resources who perceived the transition as more challenging and made greater use of problem-solving coping reached a higher sense of growth.
The
study highlights the need for preventive interventions at an early stage
aimed at promoting the factors that can ease the transition.
Keywords: Mental Health, Growth, Cognitive Appraisal, Coping, Transition to Motherhood
Along with the obvious benefits of the transition to motherhood, this event in a woman’s life may exact certain costs. While it is considered a major life event that arouses joy and a sense of fulfillment and challenge, it may also be a stressful experience, generating anxiety and feelings of incompetence and interpersonal loneliness, as well as a sense of loss in terms of autonomy, time, appearance, and occupational identity (e.g., Nicolson, 1999). Following previous research (e.g., Folkman & Moskowitz, 2000), the current study examined both positive and negative aspects of becoming a mother for the first time. Moreover, it sought to explore internal and external resources that might contribute to the various outcomes.
Mental Health, Perceived Costs, and Growth in the Transition to Motherhood
One of the outcomes of coping with stress or a life transition that has received considerable attention is mental health, whether as viewed from the negative perspective of distress, loss of control, and depression, or from the positive perspective of well-being and adaptation (Pavot & Diener, 2004; Veit & Ware, 1983). As mental health relates to internal experiences and their cognitive evaluation, rather than to any "objective" measure, it is often labeled "subjective well-being" or, conversely, “psychological distress” (Diener, 1994).
Major life transitions are liable to adversely affect mental health, arousing emotions such as anxiety, sadness, depression, guilt, anger, and a yearning for the past (Tedeschi & Calhoun, 2004). In the case of pregnancy and child birth, women may experience a sense of loss in view of the changes generated by the event in respect to the time they have for themselves, the ability to manage their time, their control over their body, their body image, and their social relationships (Nicolson, 1999). Such losses, or perceived costs, may lead to psychological distress or a decline in subjective well-being.
At the same time, however, the need to adapt to highly demanding circumstances may also engender personal growth (Tedeschi & Calhoun, 2004). This term is used not simply to denote a return to baseline, but to indicate an experience of improvement that may sometimes be profound. Thus, in the transition to motherhood, women may gain self-esteem, new meaning in life, a sense of competence, and awareness of the positive assets of themselves and their social environment (Wells, Hobfoll, & Lavin, 1999). As growth refers to positive psychological changes experienced as a result of the struggle with demanding life circumstances (Calhoun & Tedeschi, 2001), which require adaptive resources and challenge the way people understand the world and their place in it (Janoff-Bulman, 1992), Tedeschi and Calhoun (2004) argue that some degree of enduring psychological distress is necessary not only to set the process in motion, but also for the enhancement and maintenance of growth. Moreover, they contend that this distress does not emerge only in the wake of a traumatic event. Thus, positive experiences that are life-altering, such as the transition to motherhood, may be equally as challenging to the individual’s schemas and life narrative, and thus have similar effects on growth.
Research has shown that both internal and external resources, or the lack of these resources, may contribute to growth (Tedeschi & Calhoun, 2004). In other words, certain personality traits, cognitive appraisals, and coping responses, as well as social support, may aid the individual to regulate distress and experience personal growth in the wake of demanding circumstances. In the current study, we therefore sought to examine the contribution to growth of the cognitive appraisal and coping responses, the internal resources of self-esteem, self-mastery, and attachment style, and the external resources of the marital relationship and the support provided by maternal grandmothers.
Stress and Coping Theory
The theory of psychological stress and coping developed by Lazarus and his colleagues (e.g., Folkman & Lazarus, 1985; Lazarus & Folkman, 1984) identifies the two processes of cognitive appraisal and coping as critical contributors to stressful person-environment relations and their immediate and long-term outcomes.
Cognitive appraisal is defined as the process by which a person evaluates whether a particular encounter with the environment is relevant to his or her well-being, and if so, in what ways (Folkman, Lazarus, Dunkel-Schetter, & Gruen, 2000). Primary appraisal relates to the question of whether something has occurred which might affect the individual’s social image or self-esteem. One aspect of primary appraisal is threat appraisal, that is, the belief that a transaction with the environment may endanger the person’s well-being. Another aspect is the evaluation of the challenge involved, i.e., the possibility for mastery or benefit (Lazarus & Folkman, 1984). Secondary appraisal relates to coping options and evaluation of the personal resources available for coping with the situation. It is, in effect, a self-efficacy appraisal of the ability to manage the demands of an encounter or actualize personal commitments (e.g., Folkman & Lazarus, 1985).
Coping is defined as the individual's constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding his or her resources (Lazarus & Folkman, 1984). This implies that no strategy is considered more desirable than others, that coping is a process which occurs in a certain context, and that the strategies exist even if they are not successful (Folkman et al., 2000).
The two major functions of coping are to regulate stressful emotions (emotion-focused coping) and to alter the person-environment relationship that is causing the distress (problem-focused coping). Numerous studies indicate that strategies aimed at performing both functions are employed in most stressful encounters, suggesting that what is effective in one situation may well be ineffective in another (e.g. Folkman & Lazarus, 1980, 1985).
Self-esteem is generally defined as the overall positive or negative attitude one holds toward oneself, and refers to feelings of self-worth, self-respect, and self-acceptance (Rosenberg, 1979). Self-mastery is defined as a general sense of personal control or mastery over life events, and refers to confidence in the ability to influence or control the forces affecting one’s life (Pearlin & Schooler, 1978). Both resources have been found to be positively related to mothers’ psychological adjustment. Women with high self-esteem have been shown to perceive the transition to motherhood as less threatening to their health (Terry, Mchugh, & Noller, 1991), while mothers of newborns in intensive care who believed they had greater personal control over their child’s recovery tended to experience less depression and significantly fewer major stress reactions (Affleck, Tennen, & Gershman, 1985). Similarly, Hobfoll and Lerman (1988) found that among mothers of well, acutely ill, or chronically ill children, those high on self-mastery experienced less psychological distress than those low on this trait. Moreover, an extensive study of mothers raising children with a variety of chronic illnesses found that the women displaying more positive views of their self-worth and a greater sense of control over life events reported fewer symptoms of psychological distress (Silver, Bauman, & Ireys, 1995).
In addition to self-perception, the individual's ability to regulate emotions is also significant in respect to stressful life events. Bowlby (1988) maintained that the quality of attachment interactions during infancy produces mental working models which organize cognition, affect, and behavior, and shape the self-image as well as social and intimate relationships. Furthermore, he claimed that the successful accomplishment of affect-regulation functions in early life results in attachment security, that is, the sense that the world is a safe place, that one can rely on protective others, and therefore that one can securely explore the environment and engage effectively with other people.
Recently, studies of this notion have employed two basic dimensions to measure attachment: avoidance and anxiety (Brennan, Clark, & Shaver, 1998). People low on the two dimensions exhibit the secure style; they are comfortable with closeness and interdependence, and rely on support seeking and other constructive means to cope with stress. Those high on avoidance are characterized by a distrust of others’ goodwill and a preference for emotional distance, relying mostly on themselves and failing to use proximity seeking to relieve distress. Individuals scoring high on anxiety display a strong need for closeness combined with an overwhelming fear of rejection; they tend to dwell mentally on their emotional state and rely on emotion-focused coping strategies. Moreover, those high on either anxiety or avoidance are likely to appraise stressful events in negative terms, and to report high levels of distress (Fraley & Shaver, 1997).
Studies have found that individuals with secure attachment display higher well-being and lower distress than those with an insecure attachment. Furthermore, they evaluate stressful events as more challenging and themselves as more capable of coping effectively with the stress (Mikulincer & Florian, 1995). In contrast, individuals with an insecure attachment react to stress with difficulties in affect regulation, strong negative emotions, and high levels of anxiety (Mikulincer & Orbach, 1995). Pregnant women with secure attachment have been found to generate a more positive relationship with their fetus from the first trimester and throughout pregnancy, as well as to seek support from their environment, thus lowering their sense of stress. In contrast, avoidant women were characterized by distancing, and anxious women by emotional overload (Mikulincer & Florian, 1999). Similarly, mothers with secure attachment have been shown to appraise motherhood in more positive terms, perceive more available support, be more likely to seek support, and report less psychological distress than mothers with insecure attachment (e.g., Berant, Mikulincer, & Florian, 2001).
Social support is defined as an interpersonal transaction involving both an emotional dimension, that is, the expression of love, caring, solidarity, and fulfillment of personal needs, and an instrumental dimension, including the rendering of goods, services, and tangible assistance such as money and help with tasks (Wandersman, Wandersman, & Kahn, 1980). Research has shown it to be one of the main resources of individuals coping with stress in general (Hobfoll, 1989; Sarason, Pierce, & Sarason, 1990). In particular to motherhood, whereas social support was associated with better mental health and marital adaptation among mothers of children with a disability (Florian & Findler, 2001), lack or inadequacy of support in stressful situations increased vulnerability to psychological distress, emotional and functional problems, and somatic illnesses (e.g., Cohen, 1988). Moreover, a study of the association between stress and social support on the one hand, and maternal attitudes and early mother-infant interactive behavior on the other, found that mothers with increased stress and decreased support were less positive in their attitudes and behaviors toward their infants (Crnic, Greenberg, Ragozin, Robinson, & Basham, 1983).
A crucial resource within the nuclear family is the mother's relationship with her spouse. Marital satisfaction derives from a wide variety of life areas in which partners attempt to maintain a positive emotional equilibrium between their own needs and the needs and expectations of their spouse (see: Bradbury, Fincham, & Beach, 2000). Numerous studies report a decrease in marital satisfaction and increase in negative affect between spouses with the birth of a child (e.g., Cox, Paley, Burchinal, & Payne, 1999; Levy-Schiff, 1994). Yet some couples appear more capable of coping with extended stress, making significant adaptations in family life and maintaining a positive view of their marriage in spite of the additional burden (Belsky & Rovine, 1990; Cox et al., 1999). Studies have found that when the marital relationship is based on the ability to share feelings and to be empathic and understanding toward the needs of the spouse, women report higher well-being during the transition to motherhood (Leathers, Kelly, & Richman, 1997; Simpson, Rholes, Campbell, Tran, & Wilson, 2003).
In addition, although clinical reports acknowledge the great value of the extended family as an informal support system, scant research has been devoted to the unique contribution of the grandparents. The few studies that have addressed this issue found grandparents to play a crucial role in the adjustment of both mothers and fathers (e.g., Findler, 2000; Mirfin-Veitch, Bray, & Watson, 1996). Moreover, maternal grandparents, and especially the maternal grandmother, have been found to provide more support than paternal grandparents (Byrne, Cunningham, & Sloper, 1988; Findler, 2000).
As the current study sought to investigate the dynamic of the transition to motherhood, a prospective design was adopted, approaching first-time mothers during the third trimester of their pregnancy and again about two months after giving birth. Following Lazarus and his colleagues' theory (e.g., Lazarus & Folkman, 1984), we examined both positive and negative effects of the transition, as well as the contribution of internal and external resources. As growth has been found to be higher among individuals going through harsher experiences or displaying a lower level of personal resources (e.g., Tedeschi & Calhoun, 2004), and as these two circumstances are likely to coincide (Folkman & Moskowitz, 2000), we expected the internal resources to be similarly associated with both perceived costs and growth. However, in view of the literature regarding adaptation to stressful events, growth, and mental health, we predicted differential associations between the external resources, cognitive appraisals, and coping strategies on one hand, and reported costs and growth on the other. More specifically, we hypothesized that:
Three further issues were examined exploratively: (a) differences between the two measurements (Intervals 1 and 2) of the outcome variables: mental health, perceived costs and growth; (b) the associations between mental health, growth and costs on one hand, and the use of problem-focused coping, emotion-focused coping, and support seeking coping, on the other and (c) the unique and combined contributions of the internal and external resources, cognitive appraisals, and coping strategies to the outcome variables, both during pregnancy and after delivery. For these issues, we couldn't find previous findings which could help in proposing specific hypotheses in advance.
METHOD
Participants
The sample consisted of 102 first-time mothers aged 20 to 38 (Mean age 28, SD=3.26). Most (80.6%) had an academic education (B.A), and most defined their economic status as average (79%). All women were married, and their own mothers were alive.
Instruments
The Appraisal Scale (Folkman & Lazarus, 1985) was adapted to specifically assess women's cognitive appraisal of pregnancy and childbirth. The scale consisted of 16 items, six evaluating challenge appraisals (e.g., the degree to which the woman believed that motherhood would help her know herself better) and seven assessed threat appraisals (e.g., the degree to which she believed that motherhood would limit her independence). Three additional items assessed self-efficacy, i.e., how well she believed she could cope efficiently with the demands of motherhood. Responses were given on a 5-point scale from 1 (very little) to 5 (very much). In the present study, Cronbach's Alpha was .81 for challenge, .80 for threat, and .67 for self-efficacy. Each participant was therefore assigned 3 scores for cognitive appraisal by averaging her responses on the relevant items, with higher scores indicating a higher level of each aspect of appraisal.
The revised Ways of Coping Checklist (Folkman & Lazarus, 1985) was adapted to examine the coping strategies adopted by the mothers to cope with their new situation. The scale consisted of 21 items, 7 relating to problem-focused coping (e.g., "I try to analyze the situation to understand the problem better"), 10 to emotion-focused coping (e.g., "I tell myself things that help me feel better"), and 4 to support-seeking coping (e.g., "I look for sympathy and understanding from someone else"). Responses were given on a 5-point scale from 1 (seldom) to 5 (very often). In the present study, Cronbach's Alphas were .78, .72, and .73 for problem-focused, emotion-focused, and support-seeking coping, respectively. Each participant was therefore assigned 3 coping scores by averaging her responses on the relevant items, with higher scores indicating greater use of each coping strategy.
The Experiences in Close Relationships Scale (ECR; Brennan et al., 1998), consisting of 36 items, was used to tap the dimensions of attachment anxiety (e.g., “I worry about being abandoned”) and avoidance (e.g., “I prefer not to show a partner how I feel deep down”). Participants rated the extent to which each item was descriptive of their feelings on a 7-point scale ranging from 1 (not at all) to 7 (very much). The reliability and validity of the scale have previously been demonstrated (Brennan et al., 1998). In the current sample, Alpha Cronbach coefficients were .82 for anxiety and .87 for avoidance. Accordingly, scores were computed for each participant for each of the subscales by averaging her responses on the relevant 18 items, with higher scores reflecting a higher level of the style.
Rosenberg’s (1979) Self-Esteem Scale was employed to assess the perceived self-esteem of the mothers. The questionnaire consisted of 10 items rated on a 4-point scale from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s Alpha for all items in the current sample was .84. Each participant was thus assigned a self-esteem score equal to the average of her responses on all 10 items, with higher scores indicating more positive self-esteem.
Pearlin and Schooler (1978) Self-Mastery Scale was used to measure the mothers’ feelings of control over their environment and future. Responses to the 7 items (e.g., ”What happens to me in the future mostly depends on me”) are indicated on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). In the present study, Cronbach’s alpha for the questionnaire was.77. The average of each participant’s responses on all items was therefore computed to produce her self-mastery score, with higher scores indicating a higher sense of self-mastery.
The Evaluating and Nurturing Relationship Issues Communication and Happiness Scale (ENRICH; Fowers & Olson, 1989) was used to assess marital relationship. We employed a short version consisting of 10 items (Lavee, 1995), on which respondents indicated their relationship with their spouse (e.g., "to which extent can you and your spouse discuss experiences and emotions") on a 5-point Likert-type scale ranging from 1 (very strongly agree) to 5 (very strongly disagree). As Cronbach’s Alpha for the questionnaire was .77 in the present sample, a martial relationship score was assigned to each participant by averaging her responses on all items, with higher scores representing a more positive perception of marital relationship.
The Support Functions Scale (Dunst, Trivette, & Deal, 1988) was used to assess the support provided by maternal grandmothers. As adapted for new mothers (Taubman – Ben-Ari et al., 2007), this self-report scale consists of 19 items, 11 relating to emotional support (e.g., “Someone to encourage you when you are down”), and 8 to instrumental support (e.g., “Someone who helps you with household chores”). Responses are marked on a 5-point scale from 1 (never) to 5 (often). In the present study, Cronbach's Alpha was .95. A total score for perceived maternal grandmother’s support for each participant was therefore computed by averaging her responses on all items, with higher scores indicating higher perceived support.
The Mental Health Inventory (MHI; Veit & Ware, 1983) was used to measure the mothers’ mental health. It consists of 38 items relating to affective states (e.g. “difficulty trying to calm down”, “relaxed and free of tension”), with participants indicating how often they had experienced each of these states during the past month on a 5- or 6-point Likert-type scale. Cronbach’s Alpha for the inventory in the present study was .91, so that an overall mental health score was calculated for each participant, with a higher score indicating better mental health.
Perceptions of Costs and Growth in the Transition to Motherhood Scales. Two instruments were especially designed for this study to assess perceived costs and growth in the transition to motherhood. In order to generate these measures, we first conducted a preliminary qualitative study on ten first-time mothers in which we examined the adaptability of three existing questionnaires: the Texas Revised Inventory of Grief (TRIG; Faschingbauer, 1981), which relates to perceived costs in comparison to the past, and is often used to assess loss as a result of the death of a relative; the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1995, 1996), and the Stress-Related Growth scale (SRG; Park, Cohen, & Murch, 1996). This qualitative study took the form of an open interview in which the participants were told that the aim was to explore mothers' feelings, emotions, and thoughts during pregnancy and after giving birth. The interview first addressed general questions regarding their experiences of pregnancy and childbirth. More specific questions were then presented, for example, whether anything had changed in their lives as a result of their motherhood. Finally, participants were asked directly about perceptions of costs and growth in the transition to motherhood. Their responses were taped and later transcribed. The interviews were then subjected to content analysis by three researchers (a psychologist and two social workers), working separately to identify the central themes. Comparison of the results produced a pool of 100 items which were presented to a new sample of 10 mothers for clarification and fine-tuning.
The final questionnaire used to assess perceived costs in the transition to motherhood consisted of 25 items relating to mothers’ displeasure with their physical appearance, conflicts with people around them, feelings of depression, and so on. Four items were adapted from the TRIG (Faschingbauer, 1981) and the others phrased as a result of the content analysis in the preliminary study (e.g., “I have become more withdrawn, “I feel less attractive”). The questionnaire yielded a Cronbach’s alpha of .91 during pregnancy, and .86 after the birth.
The questionnaire constructed to assess growth consisted of 19 items relating to meaning in life, self-confidence, and the amount of warmth and love mothers give to others. Five items were drawn from the PTGI (Tedeschi & Calhoun, 1995, 1996), four from the SRG (Park et al., 1996), and the other 10 items were formulated in the wake of the preliminary study (e.g., “I am more satisfied with my life”, “I feel more mature”). The final instrument yielded a Cronbach’s alpha of .89 during pregnancy, and .90 after the birth.
In order to avoid a response set, items from the perceived costs and growth questionnaires were combined and presented in random order. Instructions for completing the questionnaire were as follows: “Women who are about to become mothers for the first time often report changes in their thoughts, feelings and emotions about themselves and others. Some of these changes may be positive and pleasant, while others may be less so. Please indicate to what extent you feel that the changes described in the following statements represent the way you feel at this time.” Responses were marked on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). Each participant was assigned a score for costs and a score for growth by averaging her responses on all relevant items, with higher scores indicating greater perceptions of costs or growth.
A Demographic Questionnaire was administered to obtain the mother’s age, education, occupation, and family status, as well as to acquire data regarding the baby, including date of birth, gender, birth weight and week of gestation at birth.
Procedure
Following the approval of the study by the Institutional Review Boards of several hospitals in Israel, women who were about to give birth to their first child were located through hospital preparation for birth courses. After the goals of the study were explained to them, 108 mothers gave their informed consent to participate in both phases of the prospective design. They were then contacted by phone by a researcher in order to schedule a home visit to administer the questionnaires. Each interview lasted about 60 minutes. Two months after delivery, the same mothers were approached again in the same manner (a phone call followed by a home visit). The final sample consisted of 102 participants who completed the full set of questionnaires at both intervals. At Interval 1, the self-esteem, ECR, ENRICH, cognitive appraisal, MHI, perceived costs and growth in the transition to motherhood, and demographic instruments were administered. At Interval 2, the mothers completed the self-mastery, maternal grandmother’s support, Ways of Coping, MHI, and perceived costs and growth in the transition to motherhood questionnaires. The women were promised full confidentiality, and were given a small gift in return for their participation in the study.
Data analysis was conducted in three stages. The first examined differences between the two measurements of the outcome variables, the second checked for associations between the independent and outcome variables, and the third sought to identify the factors that might contribute to the mental health, perceived costs, and growth of first-time mothers.
In the first step, we conducted a one-way repeated MANOVA to examine differences in the outcome variables of mental health, perceived costs, and growth as measured pre- and post partum. Table 1 presents the means, standard deviations, and F scores for the individual ANOVAs.
[INSERT TABLE 1 ABOUT HERE]
As can be seen from Table 1, significant differences were found between the two intervals, F(3,99)= 13.80, p<.001, with higher mental health and growth reported after the birth than during pregnancy. However, Pearson correlations revealed strongly significant positive correlations between the two intervals, r's=.56, .45, .50, p<.001, for mental health, growth, and perceived costs, respectively.
We then performed Pearson correlations to examine the relationship between the outcome variables as measured at both intervals and each of the independent variables. The results of this analysis appear in Table 2.
[INSERT TABLE 2 ABOUT HERE]
In respect to the internal resources, the results reveal that, as expected, self-esteem was associated positively with mental health and negatively with perceived costs, both during pregnancy and after the birth. The two attachment dimensions also produced correlations with these variables in the expected directions, indicating that the more insecure the mother’s attachment, the lower her mental health and higher her perceived costs. However, whereas the correlations for attachment anxiety were significant at both intervals, those for attachment avoidance were significant only during pregnancy.
The results for external resources also confirmed our hypotheses in part. Marital relationship was positively associated with mental health at both intervals, as predicted. Moreover, a positive association was found for this variable with growth during pregnancy and a negative association with perceived costs after birth. However, maternal grandmother's support, measured at Interval 2, yielded only a significant negative correlation with perceived costs.
Partial confirmation was also obtained for our hypotheses regarding the three aspects of cognitive appraisal. Threat was found to be negatively related to mental health and positively to perceived costs both during pregnancy and after birth, whereas self-efficacy was positively related to mental health and negatively to perceived costs at both intervals. However, appraisal of challenge produced a significant positive correlation only with personal growth, again at both intervals.
Finally, we found that higher use of problem-focused and support seeking coping was associated with higher growth, but with lower levels of mental health; higher use of emotion-focused coping was associated with lower mental health and higher perceived costs, after delivery; higher use of support seeking coping was related with higher perceived costs.
In the third stage of the analysis, a series of hierarchical regressions were conducted in order to examine the unique and combined contribution of the study variables to the explained variance of mother's mental health, personal growth and perception of costs in the two study waves. For the regressions during pregnancy, the internal resources of self-esteem and attachment avoidance and anxiety were entered in Step 1, the cognitive appraisals of challenge, threat, and self-efficacy in Step 2, and the external resource of marital relationship in Step 3. In Step 4 we entered the interactions between the independent variables using a stepwise method, so that only variables showing significant contributions were entered in the equation. The results appear in Table 3.
As can be seen from Table 3, the independent variables explained 52% of the variance in mothers' mental health, 43% of the variance in their perception of costs, and 32% of the variance in personal growth. Internal resources accounted for 37% of the variance in mental health, indicating that the higher the mother’s self-esteem and the lower her attachment anxiety, the better her mental health during pregnancy. Cognitive appraisals added 3% to the explained variance, so that the lower the threat appraisal, the better the mental health. The external resource of marital relationship contributed an additional significant 4% to the explained variance of this variable, so that the better the marital relationship, the higher is the women's mental health. The interactions between mother's appraisal of threat and both attachment avoidance and anxiety accounted for an additional 8% of the variance in mental health during pregnancy. In examining the source of these interactions, it was found that among mothers characterized by lower attachment avoidance (below Mdn=4.18), the assessment of threat was negatively and significantly associated with mental health, r=-.42, p<.01, but this correlation was not significant among mothers with high attachment avoidance, r=.08, p>.05. Thus, only among less avoidant women, was a higher appraisal of threat related to lower mental health. In addition, among women higher on anxious attachment (above Mdn=4.79), the assessment of threat was negatively and significantly associated with mental health, r=-.31, p<.05, whereas this correlation was not significant for women scoring low on anxious attachment, r=.25, p>.05. In other words, only among more anxiously attached women was higher appraisal of threat related to lower levels of mental health.
Table 3 also reveals that mothers' internal resources accounted for 30% of the variance in perceived costs during pregnancy, with greater costs perceived the lower their self-esteem and the higher their attachment anxiety. The external resource of marital relationship did not contribute to the explained variance, nor did the three aspects of cognitive appraisal. However, in the final step, the interaction between mother's appraisal of threat and avoidant attachment accounted for an additional 12% of the variance in this variable. In examining the source of this interaction, it was found that among mothers characterized by higher attachment avoidance, appraisal of threat was positively and significantly associated with perceived costs, r=.32, p<.05, but this correlation was not significant among mothers with low attachment avoidance, r=.07, p>.05. Thus, only among more avoidantly attached women was higher appraisal of threat related to a higher perception of costs.
In respect to growth, Table 3 shows that mothers' personal resources were not found to make a significant contribution. The external resource of marital relationship contributed an additional 7% to the explained variance, so that the better the relationship, the higher the level of personal growth reported. An additional 19% were contributed by the women's cognitive appraisal entered in Step 3, with higher appraisal of challenge contributing to higher personal growth. No significant interactions were found for growth.
The hierarchical regressions for Interval 2, two months after delivery, comprised 6 steps. The outcome variables as measured at Interval 1 were entered in Step 1, the internal and external resources measured at Interval 1 (self-esteem, attachment avoidance and anxiety, and marital relationship) in Step 2, the cognitive appraisals of challenge, threat, and self-efficacy (measured at Interval 1) in Step 3, and the three coping strategies (measured at Interval 2) in Step 4. In Step 5, the internal resource of self-mastery and external resource of maternal grandmother's support, both measured at Interval 2, were entered. Finally, the interactions between the independent variables were entered in Step 6 using a stepwise method, so that only variables showing significant contributions were entered in the equation. The results appear in Table 4.
[INSERT TABLE 4 ABOUT HERE]
As Table 4 reveals, the variables explained 62% of the variance in mothers' mental health, 51% of the variance in their perception of perceived costs, and 50% of the variance in personal growth. Mental health during pregnancy accounted for 31% of the explained variance in mental health after delivery. A further 14% percent were contributed by sense of self-mastery, with higher self-mastery associated with better mental health after delivery. The coping strategies contributed an additional 10% to the explained variance, so that the higher the use of emotion-focused coping, the higher the level of mental health after the birth. Neither internal or external resources nor cognitive appraisals during pregnancy added significantly to the explained variance in mental health post partum. However, in the final step of the regression, the interaction between appraisal of threat and marital relationship was found to account for an additional 3% of the variance in mental health after delivery. In examining the source of this interaction, it was found that among mothers characterized by a poorer marital relationship (below Mdn=4.01), the appraisal of threat was negatively and significantly associated with mental health, r=-.33, p<.05, whereas this correlation was not significant among those reporting a better relationship with their spouse, r=.21, p>.05. Thus, only among women who did not perceive good marital relations during pregnancy was a higher assessment of threat related to a lower level of mental health after delivery.
Perceived costs during pregnancy contributed 19% to the explained variance in costs perceived after delivery. The coping strategies added 13% to the explained variance, so that the higher the use of emotion-focused and support seeking coping, the higher the perceived costs. Another 9% were contributed by self-mastery, with a higher sense of control associated with lower perception of costs after delivery. Mothers' internal and external resources during pregnancy, as well as their cognitive appraisals, did not add significantly to the explained variance in perceived costs after delivery. In the final step, the interaction between attachment avoidance and marital relationship accounted for a further 3% of the variance in perceived costs. In examining the source of this interaction, it was found that among mothers reporting a better marital relationship, attachment avoidance was positively and significantly associated with perceived costs, r=.40, p<.05, but this correlation was not significant among women with a poorer assessment of their marital relationship, r=.14, p>.05. Thus, only among women enjoying a better relationship with their spouse during pregnancy, was higher avoidance related to more perceived costs after delivery.
Finally, Table 4 shows that perception of personal growth during pregnancy contributed 25% to the explained variance in growth experienced after delivery. Cognitive appraisal accounted for another 6% of the explained variance, indicating that the higher the woman’s assessment of challenge in the transition to motherhood, the higher her perception of growth after delivery. Coping strategies added a further 13% to the explained variance, so that the greater the use of problem-focused coping, the higher the perceived growth. An additional 2% were contributed by the woman's perception of the support provided by her own mother. Although this contribution did not reach the level of significance, it suggests that more support from the maternal grandmother was associated with a higher perception of growth after delivery. None of the internal or external resources measured during pregnancy added significantly to the explained variance in growth experienced after delivery, nor did the internal resource of self-mastery. In addition, no significant interactions were found for this variable.
The present study sought new empirical evidence demonstrating that adaptation to the transition to motherhood may be affected by a combination of factors, including internal and external resources, cognitive appraisals, and coping strategies. Based on Lazarus' model of coping with stress, we wished to shed light on the relationship between self-esteem, self-mastery, attachment anxiety and avoidance, cognitive appraisals, coping strategies, and the external support provided by the woman’s relationship with her husband and with her mother on her mental health and perceptions of costs and growth when becoming a mother for the first time. The study indeed lends credence to the basic components of this model, indicating that appraisal and coping processes are critical elements in the transition to motherhood.
This study is unique in several ways. First, previous research has tended to look at mothers' adaptation in terms of level of distress (Nicolson, 1998, 1999). In contrast, we chose to examine both negative and positive outcomes, and to consider the general state of the mother’s mental health as well as the specific outcomes of perceived costs and growth. We believe that this approach enabled us to obtain a more multidimensional picture of women's experience of the transition to motherhood. In addition, numerous studies have investigated this transition retrospectively, that is after the birth of the baby. The present study aimed to examine the dynamics of the process of becoming a mother for the first time, and thus adopted a prospective design, measuring both contributors and outcomes during the third trimester of the pregnancy and again about two months after delivery. This design offered the opportunity to determine whether the concepts of costs and growth already exist during pregnancy, and what effect the various factors present at that time have on the mother’s adaptation after delivery. In addition, this design enabled to examine change in outcome variables. Finally, the opportunity for personal growth has traditionally been attributed to the experience of trauma or negative life events, and less so to positive life-events (Tedeschi & Calhoun, 2004). Although the transition to motherhood is considered a positive life event, women may have complex appraisals of its outcome, and indeed experience a variety of outcomes. This assumption was borne out by the results of our study.
The findings suggest that patterns which are established during pregnancy tend to be indicative of motherhood, as the relations between mental health, perceived costs, and growth in the two phases were quite substantive. However, while both mental health and the experience of growth were found to be somewhat higher after delivery, the level of perceived costs was almost the same. This may indicate that although a woman may feel better after giving birth and may begin to adapt to her new life circumstances, this does not necessarily impact on her experience of some kind of cost, which appears to remain stable.
To a large extent, the results support our predictions regarding the factors that inhibit or encourage the adaptation of first-time mothers. Both internal and external resources were found to contribute to mental health and perceived costs during pregnancy. Higher attachment anxiety and a higher perception of motherhood as a threat were related to lower levels of mental health, whereas higher self-esteem and better marital relationship were related to better mental health. Similarly, lower self-esteem, and higher attachment anxiety were associated with higher perceived costs during pregnancy. In addition, for women displaying high anxious attachment, a higher appraisal of threat was related to lower mental health. Among women low on attachment avoidance, a higher perception of motherhood as a threat was related to a lower level of mental health, while among those high on this characteristic, a higher threat appraisal was associated with greater perceived costs. These findings are consistent with previous research showing that more avoidant college students, who were yet to become parents, anticipated having more difficulty relating to their children (Rholes, Simpson, Blakely, Lanigan, & Allen, 1997), and that among more avoidant parents of infants, the more stressful they found parenting, the less meaningful and satisfying they perceived the role to be (Rholes, Simpson, & Friedman, 2006).
Our study thus suggests that in order to maintain mental health in the transition to motherhood, both internal and external resources are needed and the situation must be assessed as non-threatening. Once a threat is perceived, mental health tends to decline, especially among women who generally regard the world as a secure place in which they are loved and cared for. Such women also tend to be more self-aware and therefore sensitive to changes in their mental health.
Interestingly, only two variables were found to contribute to a higher sense of personal growth during pregnancy: better marital relationship and higher appraisal of motherhood as a challenge. Thus in contrast to perceived costs and mental health, growth did not prove to be enhanced by any internal resource, but only by the assessment of the situation as an opportunity and a supportive environment. Having experienced a critical life transition, the appraisal of the situation as less threatening may therefore lead to higher well-being, but in order to experience growth, the situation must be assessed as a challenge. This is in line with previous studies indicating that in order to experience growth, people have to learn something new about themselves and discover new meaning in life. It is possible that individuals with strong personal resources are less shaken by normative life events and transitions and can therefore maintain their well-being without the need for change. Hence, they do not experience a sense of growth in the wake of such circumstances (Park & Fenster, 2004).
Although mental health, perceived costs, and growth two months after delivery were explained most substantively by their levels during pregnancy, other variables also contributed to each outcome. Less use of emotion-focused coping and greater self-mastery, both measured after delivery, contributed to better mental health after the birth, while mothers who reported poorer marital relationships during pregnancy displayed lower mental health the more threatening they appraised motherhood to be.
Similarly, greater use of emotion-focused coping and a lower sense of self-mastery contributed to higher perceived costs after the birth, as did more use of support seeking. Furthermore, among mothers reporting more satisfactory marital relationships during pregnancy, higher attachment avoidance was associated with a higher perception of costs. Thus, emotion-focused coping and a lower sense of control over the situation may lead to a higher degree of negative feelings during the transition to motherhood, which may also increase the need for support from others. Consequently, the transition to motherhood may become associated with a sense of the loss of previous routines and disappointment in the mother’s new status (Park, 1998; Terry et al., 1991).
A different set of variables was found to contribute to personal growth after delivery. The appraisal of motherhood as a challenge during pregnancy was the only factor measured at Interval 1 that contributed to growth at Interval 2. More problem-focused coping and maternal grandmother’s support also enhanced the experience of growth after the birth. These findings again indicate that the external resource of support, along with the way the situation is appraised and handled, rather than internal resources, play a role in the ability to grow from the transition to motherhood.
At both intervals, therefore, internal resources (self-esteem and attachment styles measured at Interval 1; self-mastery at Interval 2) contributed to mental health and perceived costs. In contrast, cognitive appraisal (challenge) and support systems (marital relationship measured at Interval 1; grandmother’s support at Interval 2) contributed to the psychological growth of first-time mothers. This lends support to the assumption that while mental health and perceived costs may be affected by the same factors, growth is a distinct dimension, rather than merely an increase in well-being or the opposite pole of perceived costs (Cordova, Cunningham, Carlson, & Andrykowski, 2001).
Several possible limitations of the study should be noted. First, it relies exclusively on mothers' self-reports. In order to provide a more comprehensive picture of mothers’ adaptation, future studies might include additional measures derived from other relevant sources (e.g., husbands, grandparents, other family members, physicians) or from observational methods. Secondly, the current study focused on psychological adjustment. It might be interesting to go beyond this aspect and include indices of mothers' physical health, social and career adjustment, etc. in future investigations. Thirdly, this study's design was correlational, and as correlations do not imply causality, we should take with caution the suggestion that our predictors actually caused changes in outcome variables. Finally, although Israel is in many ways a Western society, culture specific factors may have impacted on the present findings. Therefore, future studies might be conducted in other locales in order to obtain cross-cultural and cross-ethnic validation.
These limitations notwithstanding, the present study represents an attempt to consider the multivariate experience of becoming a mother for the first time. Further investigation is needed to examine additional contributing factors on the one hand, and adjustment outcomes on the other. Nevertheless, our findings already offer important insight for practitioners.
An understanding of the complex set of factors that play a role in the various stages of the transition to motherhood can enable the design of timely preventive interventions for first-time mothers. This could bring about a welcome change from the existing situation in which women are treated only after they display some form of pathological behavior. At present, few attempts are made to identify the factors that can enhance mental health and the experience of growth in the wake of stressful life circumstances, and therefore little is done to reinforce them (Gable & Haidt, 2005). For example, the fact that women with lower levels of internal resources and social support appear to undergo greater upheaval in the transition to motherhood suggests that they should be provided with more support at this time, as well as with emotional therapy aimed at strengthening the factors found to contribute to better mental health. Interventions of this sort might be offered either privately or at public venues, such as mother and infant clinics, health services, or general or psychiatric hospitals. Preparation for birth classes does not seem to be a sufficient response to this need. As they are generally given in the last months of pregnancy, they come very late in the woman’s process of coping with her new status. Moreover, they are typically of a practical nature, with little attention devoted to the emotional aspects of the transition in terms of both internal and interpersonal contents.
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Table 1
F Scores, Means and Standard Deviations for Mental Health, Costs, and Growth During Pregnancy and After Delivery
| ||||||||||||||||||||||||||||||
** p<.01, ***
p<.001
Table 2
Pearson Correlations between
the Study Measures During Pregnancy and After Delivery
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
* p<.05, ** p<.01, ** p<.001
(a) measured at Interval 1
(b) measured at Interval 2
Table 3
Hierarchical Regression Coefficients
(beta weights) for Mental Health, Costs and Growth During Pregnancy
| Mental Health | Costs | Growth | |||||||
| ß | T | ∆R2 | ß | t | ∆R2 | ß | t | ∆R2 | |
| Step 1 | .37*** | .30*** | .06 | ||||||
| Self-esteem | .42 | 4.78*** | -.27 | 2.93** | -.07 | .63 | |||
| Attachment avoidance | -.12 | 1.43 | .12 | 1.47 | .14 | 1.43 | |||
| Attachment anxiety | -.23 | 2.65** | .32 | 3.46*** | .13 | 1.18 | |||
| Step 2 | .03 | .01 | .19*** | ||||||
| Threat appraisal | -.19 | 2.16* | .08 | .80 | -.04 | .38 | |||
| Challenge appraisal | -.02 | .22 | .08 | 1.00 | .43 | 5.14*** | |||
| Self-efficacy appraisal | -.02 | .25 | -.01 | -.12 | -.06 | -.65 | |||
| Step 3 | .04** | .00 | .07** | ||||||
| Marital relationship | .21 | 2.72** | .01 | .16 | .28 | 2.97** | |||
| Step 4 | .08*** | .12*** | -- | ||||||
| Threat X Avoidance | .24 | 3.08** | -.32 | 3.82*** | |||||
| Threat X Anxiety | -.16 | 2.08* | -- | -- | |||||
| F | 11.80*** | 8.08*** | 6.75*** | ||||||
| R2 | .52*** | .43*** | .32*** | ||||||
* p<.05, ** p<.01, ** p<.001
Table 4
Hierarchical Regression Coefficients (beta weights) for Mental Health, Costs and Growth After Delivery
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
* p<.05, ** p<.01, ** p<.001