Introduction

The birth of a child, mainly the first, plays a determinant role in the passage to a new phase in the lifecycle, involving the restructuring of the family system, with the consequent redefinition of roles and tasks. Thus, the parental tasks modify the couple’s daily life, especially the mother’s, who assumes most of the responsibilities in care for the baby. She enters an universe that is sometimes unknown, highly demanding, imposing constant learning and a profound adaptation to the new situation as a mother and caregiver for the baby.¹⁾ In this respect, Mendes² underlines that “the postpartum is a period marked by great emotional vulnerability for both parents in general and for the woman in particular”. The author adds that, although great physiological and psychosocial changes are observed during the pregnancy, the birth and postpartum entail new events (inexperience in care for the child; changes in the daily routine; consolidation of the mother/child, father/child, marital and family relationships) that can aggravate preexisting situations and lead to marital conflicts, divorces and maternal depression. ⁽³

Throughout this period, the mothers feel weakened and any change in the normal routine or any deviation from what is supposed to happen entails implications for her emotional condition. If mothers are unable to take care of the baby or even breastfeed for any reason, they feel impotent, sad and tearful.^4-5 This emotional vulnerability is one of the characteristics of the postpartum, particularly in the first weeks.^4-5) Thus, mothers and fathers needs to develop a set of behaviors to face the requirements this new phase imposes, which relate to care for the baby (breastfeeding, hygiene, etc.),^4,6) or to the new marital life routine⁷ that imply the restructuring of both partners’ role in the couple. Hence, the transition process to parenthood demands skills from the couple to jointly balance the tensions and difficulties that emerge.⁸

We conceive this transition to parenthood according to Meleis⁹⁾ Theory of Transitions, which presents the adjustment model centered on the concept of Transition, understand as the “passage from one life phase, condition or status to another (…)”, and which can involve more than one person and is part of a certain context and situation. This model implies a change in the individuals’ needs, requiring the integration of new knowledge and skills, modification of behavior and therefore a (re)definition of roles.

Therefore, Nursing as a discipline plays a preponderant role, as its focus is related to the study of the human responses to the transitions of life, periods of great vulnerability and risk for the individuals’ health. Hence, we believe that the use of the Theory of Transitions strengthens the importance of Nursing care in this transition of life marked by the birth of the first child, concretely in the support for the parental figures to gain competences related to the performance of their parental role. Thus, the study presented in this article, based on the Theory of Transitions, intends to give voice to the primiparous mothers, aiming to identify the main difficulties they feel after the discharge from the maternity during the first six months of the infant’s life. The article integrates results from the first study of a doctoral project in Nursing Science on this theme.

Methods

A level I exploratory-descriptive study was undertaken to answer the following question: “What difficulties do first-time mothers feel after leaving the maternity hospital during the first six months of the baby’s life?” The information was collected through a focus group, a research tool in the form of a structured discussion that involves the sharing of ideas and opinions on the same phenomenon. The research this study is part of obtained a favorable opinion from the Ethics Committee of the Health Sciences Research Unit - Nursing (UICISA: E) at Escola Superior de Enfermagem de Coimbra (ESEnfC). The participants were recruited through intentional sampling, in the preparatory courses for parenthood, offered at a maternity, ward of the central region of Portugal. The group consisted of 11 first-time mothers after full-term pregnancies and without obstetric complications. The Focus Group took place in December 2015, in a classroom at the Escola Superior de Enfermagem de Coimbra, Portugal, as this was a space that provided appropriate acoustic and thermal conditions, both for mothers and babies. Previously, the researchers have introduced themselves, as they were not known to the participants, and presented the investigation project, where the main objectives and goals of the study were clarified.

The participants received guarantees of information confidentiality and secrecy. First, authorization was requested to record the focus group, and the mothers were asked to sign the free and informed consent form. They were also asked to complete a questionnaire, aimed at collecting information on theirs and the infants’ sociodemographic characteristics. The focus group session was moderated by the researcher, being the primary author of this paper, with the cooperation of two other researchers who served as observers and registered the field notes. The session started with an introductory question as the general discussion theme to give the participants the opportunity to reflect on their experiences. Then, new questions were gradually introduced, based on the research developed and in accordance with the study objectives, aiming to facilitate the participants’ discourse.

During the session, some non-directive interpellations took place, aiming to engage all participants and guarantee more fluid and continuous discourse and thoughts. The focus group session took one hour and 50 minutes and was closed off when the researchers considered that all information had been exhausted. Then, the mothers’ discourse was heard and fully transcribed simultaneously by two researchers to avoid transcription errors. To guarantee the secrecy of the participants’ identity, their names were replaced by the letter “M” (mother), followed by a number corresponding to each participant’s identification. An expert, who was a researcher with proven experience in qualitative research, validated the transcription. As, during the session, the participants’ opinions were validated either by the moderator or by the observers, returning the transcriptions to the focus group participants was unnecessary.

The data saturation was discussed during a meeting with the primary researcher, the two observers and a guest expert, after fully reading the focus group transcripts. For the data treatment, the content analysis method was chosen, in line with Bardin,¹⁰ using the string tool in SPSS (Statistical Package for Social Science), Word and Excel.

Results

The mothers who were part of this study were aged between 27 and 46 years old, with an average age of 32 years. To what the marital status is concerned, the large majority of the mothers were married or lived with a fixed partner. Most mothers held a higher education degree. Concerning the infants, the youngest was one month old and the eldest five months old. With regard to the type of feeding, most infants received mother’s milk. Three categories emerged from the participants’ discourse that constituted the main themes, related to the difficulties the mothers felt in this period: Postpartum recovery, Baby care and Marital Relationship.

Table 1 Analytic categories, subcategories and sub-subcategories 

In the category Postpartum recovery (cf. Table 1), one of the main difficulties the mothers expressed in the context of their recovery were the postpartum complications, concretely the pain and fatigue motivated by the energy spent during the birth and postpartum, huge back pain and fatigue, great physical and psychological fatigue (M1), I was very tired too (…) the first weeks were really very complicated (M11). These complications resulting from the immediate postpartum made the mothers’ physical recovery very difficult and, at the same time, limited their capacity to take care of the babies.

The complications during breastfeeding were also identified as one of the difficulties the mothers experienced, namely the cracking nipples I had cracking nipples in both breasts (M3), the breast engorgement, although he drank every two hours, the next session I had two stones in my breasts, it was horrible (M3).

Another subcategory that emerged from the mothers’ discourse refers to the discomfort due to the perineal surgical wound, concretely the difficulties to cope with the pain in the perineal region. Episiotomy! I only had two small stitches, but (…), auch!auch! very strong pain (M3) and difficulties related to the regularization of the intestinal movements, I though I’d tear as soon as I pushed (M10).

The self-image was another subcategory that emerged in this study, concretely the difficulty to return to the physical form the women had before the pregnancy. Some mothers mentioned they had started gaining weight early in the pregnancy, but the majority indicated difficulties to lose weight in the postpartum. Therefore, at the physical level, I faced some difficulty to cope with my self-image (…) after 2 months I was still unable to wear my jeans (M5), as well as the emotional level, one of the things that moves us and even the couple’s relationships, I felt that I wasn’t the person I used to be and that this could disappoint my partner (M8). The emotions and negative feelings related to their self-image were also present in other mothers’ discourse, it undoubtedly affected me emotionally, I felt inferior (…) or, better, I felt belittled (M5), I was really feeling desperate (…) I only wanted to cry (M3), and I also looked in the mirror (…) I feel like, it seems as if I was run over (M3). The fact that they dedicated themselves almost exclusively to the care for their babies made them have little time available to take care of themselves, it has been difficult to make time for myself (M7), I remember that the first waxing I had was (…) after two months, (…) you can hardly notice, (laughs) I look like a monkey (M6). In this category, the mothers’ discourse revealed difficulties related to the initial phase of motherhood, such as the pain and fatigue associated with the postpartum and breastfeeding complications, as well as the limitations related to the presence of a perineal surgical wound and to their self-image.

The category Baby care (cf. Table 1) was very significant in this group of mothers. The difficulties related to breastfeeding the baby were highly evident in this category, concretely the doubts related to the breastfeeding. I had to turn to Nurse X a couple of times (…) mainly during the first weeks at home with breastfeeding doubts (M5), I had no idea, if he could regurgitate (M3), The first time I went to the health center (…) I went home full of doubts, I left there worse than I entered (M8). The mothers also mentioned that breastfeeding was very difficult, because the baby did not attach effectively, he didn’t hold onto my breast, I had very small nipples and it was a struggle from the start (M2), breastfeeding (…) he didn’t attach (M4), the nurses put it in the baby’s mouth, but nothing! (M9). The identification of signs that the baby was full was one of the difficulties for the mothers. I had no idea if my milk would be sufficient or not (M9), not being able to give what he needs (…) afraid that I am not taking care well of my child (M10), (…) he would not be feeding enough (M4).

The difficulties related to providing hygiene care and comfort to the baby were evidenced in the perception of the thermal environment, it was difficult to perceive the temperature at home (…) we discovered that he felt cold (M3), perceiving the right temperature (baby’s environment) I also found it hard to perceive (M11). During the baby’s bath and skin hydration as well. If we were holding the baby well, sometimes they say to put, sometimes not to put soap on the head (M8), Ah! He gave the first bath, he has very small and fat hands so holding a baby made him feel confused (M1), not putting cream, putting cream, if he has a rash, if he doesn’t have a rash, the information we had is that the babies do not need cream and I, on the first day, the nurse at the hospital told me - this little one needs cream, put cream on top. (M8). The care for the umbilical cord stump was another difficulty frequently mentioned in the mothers’ discourse, I felt confused by the umbilical cord because it looked different (…) I didn’t know if I was cleaning it well, if I had to clean it more (M3), it was the umbilical cord that made me feel most confused, (M1), (…) at night, the umbilical cord was stuck by a little string that looked very strange, we panicked (M11). In short, what the provision of hygiene care and comfort to the baby is concerned, in this group of mothers, difficulties emerged related to maintaining the appropriate environmental temperature for the baby, as well as the fear of handling the baby safely during the bath and care with proper skin hydration. Care for the umbilical cord stump was also identified as a situation that was difficult for the parents to manage.

Understanding the rhythms of the baby also stood out as a difficulty in the mothers’ discourse, concretely coping with the sleep and rest, Sometimes he sleeps, sometimes he doesn’t (M1), he sleeps one hour at most (M4), I don’t know anymore what it means to sleep a whole night (M3). Understanding the baby’s crying was also described as anguishing for the mothers, he was very calm at first but not that much now (M3), he always cried very quietly (...) we end up feeling psychologically tired that stress that wears us out (M10), one of my main difficulties is to put her in her cradle, because she seems to have peaks (…) when I’m going to put her in her cradle she starts crying (M4).

Another great difficulty the mothers identified were the babies’ colic, due to the lack of knowledge on how to act on them, dealing with the colic is very hard, you truly need many strategies, some nights he doesn’t sleep, (…) there are moments of despair (…) the colic is hard, isn’t it baby? (M5), My main difficulty is the colic, (…) Mariana has plenty of colic and I don’t know what to do anymore (M6), she had plenty of colic, it was very difficult (M11). Not knowing how to put relief strategies like massage in practice, I try massages and I’ve bought I don’t know how many books to know how to massage, but (M6), I don’t know how they do it (…) she did come calm and quiet (M7).

Daily parental practice requires that the parents keep the baby safety, a state of constant alertness to assure their baby’s wellbeing. Issues related to the baby’s safety were present in some mothers’ discourse when they revealed some unrest in the practice of their role, concretely the fear of accidents. Whether he’s sleeping well or not, we’re always there watching over him, until today (M3), When he’s going to his grandma’s home, watch out! Don’t leave the baby alone! Don’t put him in your bed! He might fall! (M2), I’m very afraid of what might happen to the baby, we’re always very alert (M10), and also situations in which the babies suffocate during their sleep and we (…) we’re always watching to see if the baby’s breathing (…) that’s anguishing (…) nobody told us that and about the care we need to take (M7). The difficulties to know how to act on unexpected situations like Choking, what to do if he choked (M4), he really choked a lot. (M2), I’m afraid he’ll choke on his soup (M5).

Equally significant for the mothers, around the age of 4/6 months were the difficulties related to feeding. The transition from exclusive lactation to the introduction of solid foods was very hard for some mothers, as well as the replacement and/or complementation of mother’s milk by formulas. The difficulties related to the introduction of supplements were manifested in different manners: they gave it with all feeding sessions there, then I got home and they told me I’ll only give it once at night (M2), then the pediatrician: no, that’s the triple of what it should be (…) then this little girl’s stomach expands and widens and I said: oh my God I’m creating an obese girl (M9). What the introduction of diversified foods is concerned, I found the soups very difficult because I didn’t know well how to do it some people said I should start at the age of 4 months others at 5 and you’re in doubt (M1), plenty of contradictory information (…) I often felt insecure and confused (M11), as for the way to make the soups and mashes (M5), (…) mashes and soups oh, I feel really confused, I have this flyer to tell me how (…) I just don’t know the amounts of vegetables and water for the soup, it’s hard! (M9), it was kind of liquid, hm, I don’t know, if I noticed something bad, but the baby actually ate it (M9). Part of the information received from the health professionals is not always clear and concise and may even leave the mothers not know what interval to respect between the introduction of foods, leading to difficulties at that level.

In summary, in this group of mothers, the daily parental tasks required understanding and solving some issues related to the baby’s wellbeing, which caused difficulties and insecurities in the performance of this function. Most of these difficulties were related to care for the baby since, as they were first-time mothers, these situations were new to them. Hence, they mentioned difficulties related to breastfeeding, including doubts and insecurities to identify the baby’s satiety and nutritional needs and correct attachment. Other difficulties were related to hygiene care and comfort, concretely in the thermal environment, bathing and hydration and the umbilical cord stump. In addition, there were difficulties to understand the babies’ sleep and rest rhythms, to decode the causes of crying and colic. Other difficulties identified concerned safety aspects, which were very important for the mothers and crossed the baby’s development cycle. The changes in the baby’s eating patterns, particularly the introduction of diversified foods, also caused doubts and concerns.

The final category that emerged from the mothers’ discourse was Marital relationship (cf. Table 1), specifically concerning the sharing of daily tasks by both partners and the restart of sexual activities. The mothers in this category mentioned the difficulties related to the sharing of daily tasks. Some mothers referred that, at first, marital conflict increased, sometimes causing discussion, At first it was very complicated, we started to discuss about everything (…) sometimes about insignificant things (M3), at first A. was really upset with me (M5), sometimes due to the lack of communication and lack of time between the mothers and their partners. The mothers also mentioned that sharing the daily tasks with their partner was not always as balanced as expected Ahm right, the housework, so I do everything, my husband says he doesn’t like it and doesn’t know how to do it (M2), Ahm sometimes it didn’t work that well when he arrived feeling more tired (…) so, but you (mother) didn’t do anything? (M9), but he (husband) does not always give up one or two things, I don’t know, playing soccer (M6). On the other hand, one of the mothers had her partner’s active participation in daily tasks, since I’ve come home he practically does everything (…) sometimes he prefers to do the housework (M9).

The restart of sexual activity was one of the difficulties the mothers strongly highlighted, often associated with pain and discomfort, particularly in those situations in which the delivery involved episiotomy, that’s still very complicated, I feel some looseness, not everything has returned to its place, there (M3), ah! I had a cesarean section, so it’s still very early, this zone here is still very painful (M7), Because I feel great pain (…) I used some ova to help, but nevertheless it’s very difficult. (M10), ah! It’s still uncomfortable and I don’t know. I am waiting for the day it stops, but it still is for now (M9), and still because of my self-esteem perhaps, I feel that I don’t have the same desire, his desire is stronger than mine. (M6). The fear also created difficulties in this group of mothers to restart the sexual intimacy, return to the relationship, ah! I can’t say it has been that easy, (…) I didn’t feel very well yet (…) that has to go little by little (M6), the restart of the sexual activity was even more complicated (…) it’s a big deal (M10), ah! He was really anxious for the six weeks to arrive and I wasn’t. Until today, Zé Pedro is five months and a half and it’s still complicated (M9), no way, because I don’t feel prepared for this yet (M2) and I’m scared to hurt myself, because I totally feel like a virgin (M1). These mothers’ discourse revealed that the great barrier to experience the couple’s intimacy is essentially related to the fear of the unknown, how things are going to happen, motivated in our belief by a lack of knowledge.

Discussion

Motherhood and fatherhood are events that modify the couple’s life, particularly the mother’s, who usually assumes most parental responsibilities in care for the child. These changes are even more demanding for first-time mothers.¹¹ Being a “Mother” is not an easy task, it entails a whole adaptation to a new lifecycle that can be more or less stressful, that can contain more or less difficulties that will dominate the mother’s daily life and, consequently, change their entire routine. The discourse of the mothers who participated in this study strengthens this experience of motherhood as a transition, mirroring difficulties that conditioned their life as mothers, women and wives/partners. In this study, the difficulties related to “Baby care” were highly evident in this group of mothers. The difficulties with the baby’s daily care routines were highlighted, concretely those related to the doubts and insecurities about breastfeeding, hygiene care and comfort, namely the care for the umbilical cord stump, maintaining a thermal environment appropriate to the baby’s needs and bathing and skin hydration.

During the first week of the infant’s life, the difficulties related to care for the umbilical cord stump were particularly clear, as this is a new situation that mothers had never had contact with, arousing feelings of incapacity and sadness because they did not know how to take care and because they might be putting their baby’s health at risk.¹²

Some of the difficulties that were demonstrated in our study were also present in Strapasson and Nedel’s¹³ study about the meaning of motherhood. The authors¹³ found that “breastfeeding has been one of the main difficulties the participants found in the immediate postpartum due to social, cultural and esthetic issues” (p. 524). Difficulties were also mentioned to understanding the baby’s rhythms, concretely regarding sleep and crying. The baby’s colic was identified as a source of great anguish for these mothers, concretely because they did not know pain relief strategies and when performing massage. The difficulties related to the care for the baby the mothers mentioned are frequently referred in the literature.^4,6,14,15 In a study by Resta¹² that was intended to identify the implications of motherhood in adolescence, it was also verified that most of the mothers’ difficulties and insecurities were related to care for the infant, particularly for the umbilical cord stump, breastfeeding, bathing and the baby’s sleep. Another study showed similar results, concretely difficulties to deal with the baby’s crying¹⁶, which caused feelings of impotence and frustration in first-time mothers.¹³

The aspects related to the baby’s safety, how to act, how to protect in case of an accident, were also present in some mothers’ discourse in our study. Similar difficulties were observed in Castillo-Espitia and Ocampo-González’s¹⁷ study about the mothers’ experiences in care for their premature infants during the first night after discharge. The mothers’ main anguish was the fear that the baby would stop breathing. With the help of small lanterns or even using the light of their mobile phone, these mothers spent the night monitoring the baby’s respiratory movements. As the baby grew and developed, other difficulties emerged in the mothers’ routine, specifically when to start diversified food, which revealed to be complex task that raised doubts. This same aspect was identified in a study by Elliott,¹⁸ in a sociological approach to women’s return to work after motherhood. The category “postpartum recovery” also emerged from the mothers’ discourse with a very strong impact. In an initial phase, the difficulties related to the physical or breastfeeding complications were also emphasized more strongly, including fatigue, pain, cracking nipples and breast engorgement. The results of a quantitative study by Munhoz, Schmdt and Fontes⁵ support these results. The presence of the perineal surgical wound was considered one of the main sources of discomfort the woman felt during the postpartum, not only due to the discomfort the pain provoked, but also to the limited mobility it imposes, conditioning their physiological readiness to perform other types of activities.^19,20 All of these complications made the mothers’ physical recovery and ability to take care of the babies more difficult. The husbands’ help was fundamental and represented an important source of support in this phase.¹¹

The difficulties related to the self-image also emerged from the mothers’ discourse very strongly. The mothers described the bodily changes associated with motherhood as a discontinuity between the person they were and the person they became after giving birth. Despite the perception that the changes in the maternal body result from the whole pregnancy-postpartum process, they nevertheless provoked some dissatisfaction and even some annoyance resulting from their self-image. They found themselves different as women and minimized in a society where the culture of beauty and the perfect body is predominant. Other studies strengthen these results when they found that the bodily changes associated with motherhood provoked discontent and dissatisfaction in the mothers, motivated by the lack of availability for self-care.^2,11 In the category “Marital relationship”, the mothers’ discourse revealed difficulties related to the sharing of daily tasks and the restart of sexual activity. Although sharing daily tasks between the couple is a reality in most families today, in these mothers’ discourse reports contrary to this sharing emerged, some with “macho” characteristics, sometimes motivating discussions in the couple. Other studies¹⁴ also identified the mothers as the main responsible for the housework and child care, motivating greater fatigue and limited willingness to restart their sexual activity. In a systematic literature review,⁸ it was also demonstrated that the couples tend to become more traditional in the division of tasks after a child is born, thus motivating the conflict between both. We know today that the couple’s sexual activity is an important element of the marital relationship and that, during the time after birth, it is common for the woman to be less motivated for sexual relationships, for reasons of physical recovery, hormonal reasons and fatigue. Nevertheless, if the father cooperates in the daily routines, the mother will obviously be less tired and may return to her sexual activity more easily. The couple’s sexual/affective relationship is inevitably influenced by the baby’s birth, which can entail conflicts.² Therefore, it is important for them to be aware that they need to dialogue, share difficulties and mutual anguish in order to find strategies of mutual understanding and cooperation.

In conclusion, according to the results of our study, we can affirm that this group of mothers report many difficulties during the first six months of motherhood. The difficulties related to postpartum and breastfeeding complications stood out, the recovery of their physical shape and the limited availability to take care of their self-image. The difficulties related to baby care were also very significant in our study, concretely those related to feeding, the baby’s hygiene and comfort and colic. Difficulties related to safety, feeding and understanding the baby’s rhythms were also strongly present in the mothers’ discourse. The couple’s relationship also went “back and forth” according to these mothers, particularly concerning the sharing of daily tasks, marked by the partners’ hardly cooperative attitudes, and also concerning the restart of sexual activities, essentially marked by feelings of fear and insecurity. In fact, dealing with all of these requirements, particularly imposed on the mother when she is responsible for taking care of a child, can hinder her capacity to answer effectively and simultaneously make her more vulnerable to physical or emotional disorders, which interfere in hers and the baby’s wellbeing. In that sense, the studies by Cardoso, Silva and Marín²¹ reveal that, despite the existence of preparatory courses for birth and parenthood during pregnancy, mothers and fathers still need to integrate new knowledge and skills to guarantee the care for their child as (s)he grows and develops. The mothers and fathers’ learning needs are not concentrated within a specific period but distributed over time. Therefore, extended interventions over time are a need to promote parenthood.²¹

The results of our study strengthens this idea, about the need for extended interventions, as they revealed a set of difficulties the first-time mothers expressed, which can raise barriers for the healthy development of motherhood. With a view to a salutogenic perspective of the motherhood experience, investments are needed in these mothers’ empowerment, in their knowledge, skills, motivation, so that they feel more autonomous and confident in the course of their motherhood. The nurses’ effective intervention in this area can change this scenario by creating and promoting parental intervention programs that are sensitive to all of these difficulties, capable of providing these mothers with knowledge, capacities, attitudes and interpersonal skills that promote parental efficacy and contribute to the promotion of healthy parenthood.

As a limitation in this study, we should mention the intentional sampling, which does not permit generalizations, as well as the fact that this group of mothers possesses specific characteristics that are not representative of the general population. Therefore, for the sake of future research, we suggest comparative studies between first-time and multiparous mothers, studies that also include the fathers’ voice, as well as other types of families, such as single-parent and homosexual families, among others.