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Research in Nursing & Health, 2009, 32, 3849

Life Course Theory as a


Framework to Examine
Becoming a Mother of
a Medically Fragile
Preterm Infant
Beth Perry Black,1* Diane Holditch-Davis,2** Margaret S. Miles1**

1
University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina
2
Duke University School of Nursing, Durham, North Carolina
Accepted 12 July 2008

Abstract: Life course theory, a sociological framework, was used to analyze


the phenomenon of becoming a mother, with longitudinal narrative data from
34 women who gave birth prematurely after a high-risk pregnancy, and whose
infant became medically fragile. Women faced challenges of mistimed birth
and mothering a technologically dependent infant. Before social ties were
established, legal and biological ties required mothers to make critical
decisions about their infants. Liminality characterized mothers early
involvement with their infants. The mothers worked to know, love, and
establish deeper attachments to this baby. The infants homecoming was a
key turning point; it decreased liminality of early mothering, increased
mothers control of infants care, and gave them time and place to know their
infants more intimately. 2008 Wiley Periodicals, Inc. Res Nurs Health 32:3849,
2009

Keywords: ante/intra partal/post partum care; attachment/involvement; birth;


parenting; parent-child relationships; pregnancy

Nurse scholars frequently borrow theoretical ogy, life course theory is congruent with nurses
frameworks from other established physical, holistic focus on the lives of individuals and
biological, and social sciences (Munhall, 2007). families. The purpose of this study was to assess
Although it is important that theoretical founda- the usefulness of application of life course theory
tions distinct to nursing research and practice are to the phenomenon of becoming a mother. We
developed, the use of extant frameworks from describe this phenomenon in women who became
other disciplines may offer unique insights into mothers after a high-risk pregnancy ended in
phenomena of interest to nurses. Life course preterm delivery of an infant who became
theory is one such framework. Rooted in sociol- medically fragile.

Contract grant sponsor: National Institute for Nursing Research, National


Institutes of Health; Contract grant number: NIH R01 02868.
Correspondence to Beth Perry Black, UNC at Chapel Hill School of Nursing, CB 7460,
Chapel Hill, NC 27599.
*Assistant Professor.
**Professor.
Published online 22 August 2008 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/nur.20298

2008 Wiley Periodicals, Inc.


LIFE COURSE/BECOMING A MOTHER / BLACK ET AL. 39

High-risk pregnancy, a condition in which tures, and historical change (Elder & Johnson,
substantial risks exist to the health of the woman 2003). Life course theory has five distinct
and the fetus, is an important predictor of infant principles: (a) time and place; (b) life-span
birth outcome (Lobel, DeVincent, Kaminer, & development; (c) timing; (d) agency; and (e)
Meyer, 2000). Medically fragile refers to infants linked lives. We used these principles to examine
with life-threatening chronic illness who are, at and explain high-risk pregnancy, its premature
least temporarily, technology-dependent, and who conclusion, and subsequent mothering of medi-
have health sequelae requiring extended hospita- cally fragile preterm infants. After a brief
lization or frequent rehospitalization (Miles, description of each principle, we explain how we
Holditch-Davis, Burchinal, & Nelson, 1999). We view its applicability to the phenomenon of
first describe the major principles and concepts of becoming a mother under these particular circum-
life course theory. Then we demonstrate our stances.
application of life course theory to this phenom-
enon.
Time and Place

LIFE COURSE FRAMEWORK: Human lives are shaped by questions of when and
PRINCIPLES where in a sociohistorical sense, making the
principle of time and place foundational to life
Prior to the development of life course theory, course research. Culture defines a specific place
social scientists explained human behavior in two in time (Gieryn, 2000). Use of obstetric technol-
ways. First, a social relations approach was used to ogy expanded in the late 20th and early 21st
examine the effects social structures such as centuries, marking the beginning of a cultural shift
marriage and family had on individuals. Subcate- in which prenatal testing, ultrasonography (US),
gories of this approach include functionalism, and electronic fetal monitoring (EFM) have
exchange theory, and ecological systems theory. become the norm Similarly, neonatal technology
Second, a temporal approach was used to examine has created a culture that includes a language of
lives that were followed or explained longitudi- laboratory values, ventilator settings, and feeding
nally (Giele & Elder, 1998). The complexities of volumes that replace conversations typical of
lives, however, were not completely captured by parents, relatives, and friends after the birth of a
these approaches (Giele & Elder); neither alone fullterm infant. The technical and medicalized
was adequate to explore the intricate interrelation- culture of both obstetric and neonatal care may
ship between social structures and the impact influence womens experiences of high-risk preg-
of time, place, and history on individuals lives. nancy and subsequent mothering.
Research from these approaches converged to
shape the development of life course theory in
the second half of the 20th century (Elder, 1996). Life Span Development
Life course research is distinctive in its weaving
of a fabric of methodological pluralism from The second principle, life span development, is
social sciences and humanities (ORand, 1998, characterized by the view that humans develop in
p. 53). Continuity and change, social structures, biologically, socially, and psychologically mean-
and the relationships among time, place, and lives ingful ways beyond childhood (Elder et al., 2003).
as contexts for developmental processes are foci of New situations encountered in adulthood are
life course research (Elder, 1996; Elder, Johnson, shaped by earlier experiences and their attached
& Crosnoe, 2003; Settersten, 2003). In the past meanings (Marshall & Mueller, 2003), suggesting
two decades, life course researchers have recog- that how women become a mother to a sick infant
nized the significance of the physical body (Elder, will be shaped by their previous relationships and
1996) and that the mind and body are inseparable mothering.
(Magnussen & Torestad, 1993). This important
paradigmatic development in life course studies is
congruent with nursing research and practice Timing
focus on biological and psychosocial responses
of humans in health and illness over time. Timing may affect womens responses to mother-
A fundamental assumption of life course theory ing an ill infant. The concept of time here refers to
is that lives are lived in a reasonably ordered chronological ordering of events, rather than
manner in patterns shaped by age, social struc- situating events in historical cultural contexts.
Research in Nursing & Health
40 RESEARCH IN NURSING & HEALTH

Although life events are not rigidly predeter- KEY LIFE COURSE CONCEPTS:
mined, certain biological events are chronologi- TRAJECTORY, TRANSITION, AND
cally ordered such that, if experienced out of order, TURNING POINT
physical and social consequences will vary from
those that occur within the expected timing or In addition to these principles, three key and
order. For instance, preterm birth is a biologic related conceptstrajectory, transition, and turn-
event in which delivery occurs earlier than ing pointare commonly used in life course
expected. Life course theory suggests that a research to describe human developmental phe-
womans own development and pre-existing nomena. Trajectories are paths of change in
behavioral patterns will shape how she and those developmental processes (van Geert, 1994, p.
within her social sphere contend with this out-of- 31) and mark the long view of the life course.
sequence event. Long-term human phenomena such as work life,
education, parenting, and marriage are often
described in terms of trajectories.
Transitions are entry points for new states or
Agency roles within trajectories (Hagestad, 2003). A
transition is a gradual change often associated
Agency is based on the assumption that humans with acquiring or relinquishing roles, such as
are not passive recipients of a predetermined life changing careers within the work life trajectory
course but make decisions that determine the (Elder & Johnson, 2003). In the life course
shape their lives. Decisions are influenced by ones framework, roles are the positions that
temporal orientations to the situation, with some persons occupy within social institutions, such as
decisions requiring intense focus on the present mother within a family (MacMillan & Copher,
and others influenced by long-term goals (Hitlin & 2005). Transition is often used to describe
Elder, 2007). Agency has particular salience in the womens developmental challenge of becoming a
context of preterm birth. Mothers make life- mother (e.g., Drake, Humenick, Amankwaa,
shaping decisions for themselves and their sick Younger, & Roux, 2007; Kitzinger & Kitzinger,
infants, with limited insight into the consequences 2007), and is a common theme in perinatal nursing
of those decisions. literature.
Transitions have a liminal quality, that is, being
on the threshold or edge of a physical or
Linked Lives psychological state (Turner, 1974). Liminality is
neither here nor there, betwixt and between all
The core life course principle is linked lives, the fixed points of classification (Turner, 1969, p.
perspective that lives are lived interdependently 232). Liminal phenomena evoke negative feelings
and reflect sociohistorical influences (Marshall & (Jackson, 2005), reflecting ambiguity that is
Mueller, 2003). Linked lives refers to an integra- threatening because it disturbs ones sense of
tion of social relationships extending beyond order (Turner, 1969, 1974). Womens transition
formal family ties, such as friends, neighbors, between pregnancy and motherhood of a medi-
and work colleagues who provide a distinct cally fragile preterm infant may be characterized
orienting context (Marshall & Mueller, p. 11). by ambiguity, a liminal state where one is not fully
Social linkages shape how individuals interpret situated within the state from which one is
life events. People vary widely in the manner and emergingthe mistimed end of pregnancyyet
degree in which they integrate social norms, not firmly established in the state towards which
relationships, and institutions. Integration may one is making a transitionmotherhood.
be discontinuous or disrupted under certain Turning points involve abrupt and substantial
circumstances (Giele & Elder, 1998). The lives change from one state to another (Cairns &
of mother and infant are uniquely linked, Rodkin, 1998). Shin and White-Traut (2007)
shaping and being shaped by each other in the identified the removal of a preterm infant from
continuing process of human development. How- the isolette and discharge from the NICU as
ever, becoming a mother of a medically fragile turning points in the transition to motherhood. The
preterm infant is complicated by the unexpected sudden end of pregnancy, the birth of a preterm
and unknown. The discontinuous or disrupted infant, and the infants illness may serve as turning
nature of this mistimed biological event may points in womens lives resulting in substantial
affect the manner in which initial linkages are adjustments in the childbearing and mothering
formed. trajectory.
Research in Nursing & Health
LIFE COURSE/BECOMING A MOTHER / BLACK ET AL. 41

MOTHERING THE MEDICALLY- neonatal care in the U.S. in the latter decades of the
FRAGILE PRETERM INFANT 20th century and early 21st century. Although
commonly used in nursing literature, context has
Becoming a mother means moving from a known often been defined narrowly as the setting for
to an unknown reality (Mercer, 2004). The practice (e.g., Swansons 1990 phenomenology of
decision to become a mother is characterized by providing care in the NICU) or the patients
ambivalence, calculation of the timing of preg- immediate social situation (e.g., Hagren, Petter-
nancy, and determination of effects on significant sen, Severinsson, Lutzen, & Clynes, 2005
relationships (Sevon, 2005). Women whose preg- description of the lives of patients receiving
nancies are high risk and who deliver prematurely hemodialysis). We examined ambiguous and
face substantial challenges in developing their liminal aspects of becoming a mother to a
maternal role and identity, working to become medically fragile preterm infant, identifying
mother to this specific infant (Lupton & Fenwick, significant turning points at which women moved
2001; Nystrom & Axelsson, 2002), especially from a liminal state to explicit identification as
when the infant is medically fragile. mother of this infant.
Early interactions between mothers and their
preterm infants occur in the atypical environment
of the NICU, where mothers experience uncer- METHOD
tainty, powerlessness, loss of control, role altera-
tions, and being an outsider (Nystrom & Axelsson, This study is a secondary analysis of data from a
2002; Siedeman et al., 1997; Wereszczak, Miles, longitudinal study of medically fragile infants, the
& Holditch-Davis, 1997). Facing the possibility of process of parental role attainment, and its
infant death, poor prognoses, and loss of the ideal influence on parenting outcomes (Miles et al.,
infant (Docherty, Miles, & Holditch-Davis, 2002; 1999). In the original study, 83 fullterm and
Mercer, 1995), mothers struggle to provide care medically fragile preterm infants were enrolled
for their preterm newborns, experiencing diffi- while still hospitalized and followed until
culty feeling like mothers (Lupton & Fenwick, 16 months of age. Infants mothers were the
2001). primary informants.
When the infant is medically fragile, these
experiences are intensified. Mothers of medically
fragile infants face significant distress, including Sample
depression and grief (Aite et al., 2003; Docherty
et al., 2002; Miles et al., 1999). Separations caused For this study, data were analyzed from 34 mothers
by infants hospitalizations impede mothers from of these infants who met inclusion criteria: (a) they
providing care (Brunssen & Miles, 1996; Miles & were diagnosed with a high-risk prenatal con-
Frauman 1993). Once the infant is home, the dition such as pre-eclampsia; and (b) they
mother is burdened by providing illness care in delivered a preterm singleton infant who became
addition to usual care (Carey, Nicholson, & Fox, medically fragile. Demographic characteristics of
2002; Carnevale, Alexander, Davis, Rennick, & the sample are in Table 1. Both the original study
Troini, 2006). Mothers face additional challenges and this secondary analysis were approved by the
because their infants severe complications place institutions human subjects review board.
them at higher risk for social deficits than healthier
infants (Landry, Chapieski, Richardson, Palmer,
& Hall, 1990). Mothers may not recognize Procedures
immature cues or atypical responses of these
infants (Goldberg, Morris, Simmons, Fowler, & Data were obtained in a series of hour-long semi-
Levison, 1990; Landry, Smith, Miller-Loncar, & structured individual interviews that focused on
Swank, 1997; Singer et al., 2003), especially in the salient elements of the mothers current experi-
first 6 months after birth, although mothers may ences, such as early hospitalization, discharge
compensate for the medically fragile infants preparations, and being home with the infant.
social deficits by being more responsive (Hol- Interviews were conducted at five time points:
ditch-Davis, Cox, Miles, & Belyea, 2003). at study enrollment, which occurred once the
Using a life course perspective in this study, we infant was expected to survive for at least
focused on becoming a mother as an aspect of several months; 1 month after discharge home;
adult development within a sociohistorical context and then at approximately 6, 12, and 16 months of
characterized by highly medicalized obstetric and age, corrected for prematurity. These time points
Research in Nursing & Health
42 RESEARCH IN NURSING & HEALTH

Table 1. Demographic Characteristics of definitions were noted and set aside for further
34 Mothers of Preterm, Medically Fragile Infants analysis to determine how they were related to
these key concepts.
Means
(SD) Range
This directed content analysis varied somewhat
from Hsieh and Shannons (2005) version in that
Maternal age 31.4 (5.25) 1739 the life course framework is not a theoretical
Education (years) 15.2 (1.22) 918 rendering of mothering, but rather is a general
Infant Birthweight (g) 1,002 (547) 5102,600 framework applicable to a variety of human
Gestational age (weeks) 27.7 (2.23) 2434 experiences occurring over time. Application of
Frequencies (%) life course theory to the phenomenon of becoming
Previous children
None 20 (59)
a mother, about which a significant literature
1 14 (41) exists, allowed for an expansion of the under-
Marital status standing of mothering a medically fragile preterm
Single 11 (32) infant. An important caveat in applying an existing
Married 23 (68) framework to data for analysis is that the meaning
Ethnicity of the text may be obscured by an overly strict
African American 11 (32) interpretation based on the constructs of the
White 19 (56) framework (Flick, 2002). An important safeguard
Other 4 (12) to prevent this is careful paraphrasing to explain
Infant gender the text, not to replace it.
Female 8 (24)
Male 26 (76)
Each womans experience had unique features;
however, early in the analysis, differences
emerged between experienced mothers (n 14)
and those with no previous mothering experience
were necessarily fluid, contingent on the infants (n 20). Three experienced mothers were 24 years
ongoing health and maternal constraints such as old or younger; 1 of these was an adolescent
returning to work, child care availability, and (19 years old). Of those with no previous
subsequent pregnancy. The data were collected in experience, 9 were 24 years old or younger; 3 of
response to the research questions that guided the these were adolescents less than 20 years old.
original larger study. The application of life course Subsequently, within-group comparisons of
theory as a secondary analytical framework was experienced and inexperienced mothers were
unique to this smaller study. made to examine similarities and divergence in
their experiences of their high-risk pregnancy and
mothering of their medically fragile preterm
Data Analysis infant. Later, between-group comparisons were
made. This flexible analytic strategy allowed for
Data were analyzed by one investigator, although the development of findings supported by the data
research team meetings were held to discuss the that went beyond the initial life course principles
ongoing analysis. Questions of analytic precision and concepts.
and fit of the data to life course principles and Importantly, although mothers were inter-
concepts were the focus of discussions among the viewed about five times over the course of the
investigators. study, the timing of these interviews in relation to
Content analysis is a classical procedure for the infants post-menstrual age varied consider-
analyzing textual material (Flick, 2002, p. 190). ably. The nature of each infants particular illness
Specifically, directed content analysis (Hsieh & and degree to which they were technology-
Shannon, 2005) allowed for the examination of the dependent varied substantially. Therefore, cross-
phenomenon of becoming a mother of a sick infant sectional analysis at specific time points was not a
using an existing framework. This is a structured useful analytic strategy.
approach to the text. Data were first examined for
evidence of the five key principles of life course
theory and then identifying transitions and turning FINDINGS
points in mothers narratives. Giele and Elders
(1998) definitions of each of the five life course Mothers stories yielded both retrospective and
principles were used in this analysis. Ambiguous prospective longitudinal data. Narratives about
or liminal phenomena that appeared to be related pregnancy were necessarily retrospective, with
to becoming a mother but did not clearly meet the mothers beginning to make meaning of the end of
Research in Nursing & Health
LIFE COURSE/BECOMING A MOTHER / BLACK ET AL. 43

the pregnancy and delivery by the time of the tracheostomy. Another mother described sadness
initial interview. The prospective nature of sub- upon seeing her fetus on ultrasound as a healthy
sequent interviews allowed mothers to articulate baby who was just coming too early. This mother
both their current concerns regarding their infant refused to watch the screen during subsequent
and mothering and a retrospective view of what examinations to protect herself from the painful
had happened since the last interview. prospect that her healthy baby was likely to die.
Photographs were another form of informa-
tional technology for the mothers. After delivery,
Time and Place: A Culture photographs of their infants were given to mothers
of Technology who could not yet see them first hand. As with
ultrasound images, photos yielded ambiguous
Mothers narratives across time reflected two information requiring interpretation. Half of the
distinct technological cultures: pregnancy, in women had cesarean sections and protracted
which technology was focused on her, her body, recovery periods. Separated from the reality of
and the developing fetus, and the NICU, in which the birth, many mothers awakened from general
technology was focused on the infant. Mothers anesthesia fearing that the infant had died. Photos
frequently referred to informational technology allayed these fears. However mothers usually had
(electronic fetal monitoring [EFM], ultrasonog- to ask nurses to interpret monitoring and life
raphy, photography, infant monitors) and suppor- support devices in the photographs. Thus, most
tive technology (ventilators and feeding tubes). mothers did not find photos to be particularly
Both types of technology were simultaneously reassuring except as evidence of the infants
reassuring and confusing as meanings of these survival. Later however these same photos pro-
data were often ambiguous. vided unambiguous evidence of the infants
Some women experienced tension between the progress and growth since birth.
physical and the technologicalwhat the mothers The infants supportive technology shaped
experienced within their bodies and the health care womens mothering experiences substantially.
providers reliance on technological data. This Mothers marked time and infant progress by
was particularly true of EFM. Several women ventilator settings and oxygen requirements. For
related that despite tocolysis, signs and symptoms these mothers, presence of the ventilator signified
of active labor were ignored by labor nurses who a troublesome impediment in establishing a
trusted the EFM over womens complaints of physical and emotional relationship with their
labor. One woman delivered a very small infant in infants. High ventilator settings were particularly
her bed as her nurse told a colleague that the worrisome; one mother vividly described the high
monitor didnt show any contractions. One pressures her infant required as beating his lungs
mother with repeated fetal losses, however, had to death. Decreasing oxygen and ventilator
the opposite experience. An ultrasound examina- settings allowed mothers more freedom to interact
tion revealed that her cervix was dilated 4 cm. She with their infants and less worry about extubation
did not appreciate the presence of contractions and overstimulation.
until the EFM showed them. For this woman, Mothers learned to manage the infants tech-
technology refuted her physical experience of no nology, including nasal cannulae, oxygen gen-
labor. erator concentrators, and tube feedings. Although
Similarly, ultrasonography during pregnancy competence was their goal, mothers mourned the
yielded ambiguous findings. Occasionally, these loss of what they never had: the opportunity to
examinations contradicted estimates of fetal parent their newborn as healthy. Their mourning
gestational age based on the womans last was particularly apparent in early mothering.
menstrual period (LMP), leading to obstetric Mothers later reflected on the sadness of those
management uncertainty, especially when the early days, although at the same time recognizing
fetus appeared to be younger than the womans the necessity of technology for the infants
LMP suggested. One fetus with a large neck mass survival. One mother recognized the heavily
was given poor odds for survival, although the technologized environment that her infant
physician admitted that she did not have much required to survive: He came into a totally
information on which to make that assessment. different world. Although their infants need for
Despite this grim prognosis, the mother was told supportive technology was unambiguous,
not to be alarmed when given photos of the mothers own place within the technologically
baby immediately after birth, although the laden culture was liminal, requiring them to
mass obstructed his airway, necessitating a remain physically distant at a time when their
Research in Nursing & Health
44 RESEARCH IN NURSING & HEALTH

desire was to hold, feed, and care for their own of the hospitalized infant; the sick infant had
baby. caregivers around the clock, while children at
home depended on her. These mothers described
increased patience and willingness to see the pain
Life-Span Development and Timing of others. One mother explained her experience as
Related to Childbearing making her more attentive. . .to everything and
everybody around me. I notice things I didnt
Development across the life-span and timing were notice before.
highly salient life course concepts in mothers Issues of faith were also salient to adult
experiences. The two concepts will be considered development. Mothers frequently commented on
together as the issues of timing, especially the an increased reliance on faith and religion, striving
disruption of high-risk pregnancy ending prema- to discern meaning or a larger sense of purpose in
turely, and the ensuing adult developmental issues their lives. They recognized the disordered nature
for the mothers were closely related. Distinct of their experience and sought to impose order,
developmental differences were found between often through understanding their infants condi-
first-time mothers and experienced mothers. tion in context of faith or religion. They explained
In particular, young (  24 years old) first-time the preterm birth as Gods will or attributed
mothers described their adult development and survival to Gods plan or miraculous intervention.
maturation as notable responses to unplanned Mothers often referred to their miracle baby in
pregnancy, preterm birth, and infant illness. terms of the small size or severe illness that the
Although most of these pregnancies were infant overcame. One mother explained her
unplanned, they were accommodated into the infants struggles in terms of his future: He is
womens work, family and social lives with ease. meant to be something someday.
However, activities of late adolescence and early
adulthood such as unencumbered socializing were
replaced with the responsibilities of parenthood. A Agency: Choices and Actions Related to
young first-time mother explained, You know, the Pregnancy and Mothering
you look at that child, and you say, Okay, thats Experience
my responsibility, and thats a big responsibility.
Another young first-time mother pursued higher Issues of agency were most salient to women at
education, believing that her own self-improve- two particular occasions: the end of the pregnancy
ment ensured a good life for her infant, and at times of severe infant illness when
although her infants frequent hospitalizations discontinuation of life support was considered.
delayed her plans. For this mother, a key point At the end of pregnancy, the locus of agency lay
came when she understood that the infants outside the women. The end of pregnancy was
prematurity was not my fault, allowing her a often sudden and unexpected, catching the women
more mature understanding of the complications off-guard. Bombarded with change was one
causing her premature delivery. mothers comment who recalled having no
For young first-time mothers, these experiences choice in the matter in preparing for hospital-
resulted in accelerated maturation, leaving them ization and transfer to a medical center. Passivity
out of step developmentally with their childless was evident among the women, who frequently
peers and those with normal pregnancies and used language such as they told me [what was
deliveries. This meant that they inhabited an going to happen] and I didnt know. . . [what the
ambiguous developmental space, older adoles- plans were]. Health care providers, not the
cents or young adults by age but facing respon- women, determined that the pregnancy was
sibilities usually reserved for older persons. ending or needed to end; women had no real
Preterm birth represented a turning point for these choice except to acquiesce to decisions and plans
young mothers, forcing them into adulthood early. of others.
Like younger, first-time mothers, experienced In contrast to their experiences at pregnancys
mothers also described developing patience and end when they had no say in their own care,
strength to face future setbacks. However, older, mothers were asked by neonatologists to make life
experienced mothers described this situation in and death decisions about their infants when the
relation to their previous experiences. These stakes were the highest. This situation under-
mothers felt competent, even when this was their scored their liminal state. Agency was a matter of
first preterm infant. Experienced mothers made weighing the unforeseeable or ambiguous con-
the needs of children at home a priority over those sequences of their decisions, balancing their own
Research in Nursing & Health
LIFE COURSE/BECOMING A MOTHER / BLACK ET AL. 45

needs and desires for a child against the suffering difficult circumstances. Mothers differentiated
and sequelae that the infant might endure. between feeling love for the infant and the
Although agency vis-a-vis the infants was not establishment of a bond between them. For some,
situated solely with the mothers, mothers of feelings of love began in pregnancy but were
the sickest infants recalled being asked to make placed in a state of suspension after birth until the
significant decisions at points of the most severe babys survival was likely. Mothers recognized a
complications. Mothers most commonly adopted lack of depth or significant attachment to the infant
a wait and see posture, continuing current after birth that functioned to spare their feelings if
medical interventions although maintaining the the infant died. They occupied a liminal space
right to change their minds if infant did not where love was present but deeper bonds that tied
improve. A 29-year-old first-time mother recalled the infant to them and their extended social
the conversation with the health care team about network were not yet forged. Oh my god, I love
discontinuing her infants support: They were this baby! was one mothers response to the
ask. . .telling me, or sort of urging me, I think, to image of her 16-week fetus on the ultrasound
turn off the respirator on him, and just let him go screen. She delivered at 25-week gestation a sick
because theres no way hes going to make it infant whose early critical illness led this mother
anyway. But I just cant take matters into my own to make a distinction between her love for the
hands and say, okay, this is the day that youre infant while not yet form[ing] a bond with the
going to die. In a clear act of agency, and over child.
mounting pressure to terminate support, she took Several mothers initially were equivocal in their
an active stance on behalf of her infant: You dont desire to see their infant, afraid that this would
get it, you know. Im not turning off the machine. cause them more suffering if the infant died. One
The mother reported that a nurse later apologized mother described her 26-week preterm infant as
for pressuring her. a micro-preemie who looked bad, and whom
she did not want to live, really when seeing her
for the first time. Another described her complex
role as an advocate for her infant, a kind of
Linked Lives: Network of Shared monitor whose most important work was to just
Relationships try to be here for, be here, and you know, just love
her and just try to bond with her. Mothers
The principle of linked lives explains the ways that described love for their infants preceding the
mothers formed social and emotional linkages development of deep bonds of attachment.
with their infants. First-time mothers generally Knowing the infant was key in the development
had different experiences from mothers with of deep bonds, learning to recognize the infants
previous children. First-time mothers focused specific behaviors, cries and responses through
primarily on the infant, secondarily on immediate close contact over time. Mothers were required to
family ties including the infants father, then the occupy a liminal position for a sustained time until
extended family, and last on the larger social their infants health improved and behavioral cues
network of friends, coworkers, and church family. could be recognized.
Mothers with previous children found that their Use of the phrase becoming a mother
attention and energy were, divided between the revealed the primacy of the work for first-time
hospitalized infant and their children at home. A mothers who had no prior maternal identity.
mother who had a previous child born prematurely Specifically, they needed to recognize that they
described her older child at home as not doing were now, unambiguously, a mother, then the
very well. Although recognizing that this might mother of this specific infant. A first-time mother
sound heartless, but. . ., she described her prior- described a tearful epiphany in the NICU:
ity as maintaining normalcy for her preschooler at One day I started crying, I said, Well, now Im
home. Experienced mothers described social a mom! Experienced mothers, on the other hand,
hierarchies similar to those of new mothers, with already had a maternal identity.
the exception that their previous children took An important turning point for all mothers was
priority over the hospitalized infant. taking the infant home for the first time. Home was
Liminality characterized all mothers early closely tied to becoming the mother of this
involvement with the infant, requiring them to particular infant. Taking the infant home
forego previous expectations of the perfect baby decreased the liminal quality of early mothering:
and enter into a process of coming to know, love they now had more control of the infants care and
and then bond with this particular baby under more time and a place to know their infants more
Research in Nursing & Health
46 RESEARCH IN NURSING & HEALTH

intimately. Going home meant abiding links could social lives. Familial tensions occasionally flared
be forged among the mother, infant, and their under the stresses of parenting a sick infant. One
larger social world; mothers could finally establish mother described her own mother as getting on
deeper relational bonds with their infants without my nerves the most. Her mother and mother-in-
interruption of hospital routines. A first-time law colluded in ganging up on them as she and
mother of a hospitalized infant found that her husband tried to balance the needs of the
Mothers Day was especially painful: . . . it was hospitalized infant and their 5-year-old at home.
kinda tough. . .I told my mama one time I it For another mother, problems with her father that
didnt feel like I was really a mother yet, because I she believed had been resolved resurfaced.
havent had him home. I havent had him to Less intimate but important social relationships
myself. . .. Another said, I want to spend time including friends and church family were required
with her and get to know her, and I want her to feel to take secondary roles in mothers lives, particu-
like my baby. larly during the infants hospitalization. Social
Once home, a common goal for all mothers was activities were suspended while the infants
limiting infants exposure to potential sources of required supportive technology and were per-
infection, recognizing their extreme vulnerability ceived as vulnerable. All mothers lives were
and likelihood of rehospitalization. Thus they distilled to simple necessities: adequate food, rest,
imposed severe constraints on their social network and social support, and, for experienced mothers,
by placing unambiguous, nonnegotiable limits on attention to their previous children. Mothers often
contact with the infant. Despite mothers excite- relied on persons in their wider social network for
ment in taking the infant home, they understood material support: meals, gas money, transportation
that their experience was different from that of and care for older children. Occasionally, special
parents of healthy infants, whose homecomings offerings from church helped ease financial
are marked by celebrations and visits from friends. strains.
These mothers found their social network tem- Another important turning point in mothers re-
porarily limited to close family members although incorporation of their wider social network was
more casual social ties were suspended. Those the infants decreasing technological dependency,
behaviors and decisions related to the now-at- usually occurring by 6 months after initial
home infant also had important elements of discharge home. By this time, infants typically
agency, as mothers posture vis-a-vis their infants had decreased or no supplemental oxygen require-
was one of intense protectiveness. ment and were tolerating feeding either tube or
Sometimes mothers needed to overcome an bottle feedings, although some had more sub-
overly optimistic view of what being home stantial needs. Also, mothers were confident
entailed. Constant vigilance, exhaustion and lack experts in management of technology by
of routine were common at first. Many mothers this time. Perceiving their infant as less vulner-
met the challenges of home with relief that able, mothers cautiously restored activities with
signified the resolution of conflicts with the NICU friends and resumed attending church. Liminality
nurses whose control of the infant became and ambiguity were replaced by confidence in
increasingly problematic as mothers became more their mothering and incorporation of the infant
comfortable and competent in managing their into a sustained social network of family and
infants technology and basic care. At home, friends.
mothers management of their infants care
increased their intimate knowledge of the infant
and enhanced the establishment of deep emotional DISCUSSION
attachments.
Extended family, especially other women, Life course theory provided a useful means of
played vital roles in supporting the mothers elucidating womens experiences of becoming a
through the disrupted pregnancy, early delivery mother of a medically fragile preterm infant. This
and infant illness. Grandmothers or their surro- theoretical perspective allowed for examination of
gates, such as aunts, were allies in resolving the the social context of maternal development.
mothers disappointment with their pregnancy Mothers first narrowed and then widened their
outcomes. Second only to supportive husbands or social worlds over time in order to link the lives of
partners, female family members provided mate- their new infant with their families and other
rial support, including care for the children at significant persons. Narrowing meant that impor-
home, fixing meals and caring for the infant when tant persons in mothers social spheres were
parents returned to work and re-established their temporarily excluded from early interactions with
Research in Nursing & Health
LIFE COURSE/BECOMING A MOTHER / BLACK ET AL. 47

the mother after the infants birth and home- postpartum. For women with no previous mother-
coming. These spheres widened later when ing experience, the birth of a preterm infant impels
mothers perceived their infants as less vulnerable them into the parenting trajectory prematurely,
and their confidence increased in their ability to marking a particularly ambiguous transition where
manage infant care. maternal identity is as yet unclaimed. Barclay,
Increased confidence combined with effective Everitt, Rogan, Schmied, and Wyllie (1997) found
agency on behalf of their infants strengthened that the babys nature and social support are key in a
womens identification of themselves as mother of womans becoming a first-time mother. The nature
this child. Liminality and ambiguity decreased as of medically fragile infants is typified by uncer-
infants health improved, their technology depen- tainty and frequent health setbacks, complicating
dence decreased, and they came home from the but not precluding becoming a mother. Because the
hospital. At home, mothers claimed their role as psychoemotional tasks of pregnancy are inter-
primary protector and care provider without the rupted in preterm delivery, these new mothers faced
constraints that the NICU imposed. parenting with what Rogers (1957) calls an as if
Maternal role and identity were key issues in quality: not fully identified as mothers, they were
navigating the difficulties of mothering in a expected to interact with and make decisions on
confusing technological context and a narrowed behalf of their infants as if the transition into
social sphere. First-time mothers faced the motherhood is complete.
challenge of mothering without previous experi- Although commonalities existed among
ence through which they felt competent. They mothers of medically fragile preterm infants,
worked at feeling like a mother first, and then the idiosyncratic events and responses shaped how
mother of this specific child. Experienced mothers each woman comes to identify herself as mother of
were more confident in their maternal role and this infant. This is similar to the finding of Miles
caretaking skills but still needed to accommodate and Frauman (1993) in their study of 15 medically
this infant into the existing family structure and fragile preterm and fullterm infants. They found
social world. that although similarities exist across mothers and
Mothers employed two distinct measures to families in attainment of the parenting role and
reduce liminality associated with their transition identity, especially in terms of claiming control of
to motherhood of this child. First, they exhibited a their infants care, experiences varied widely even
high degree of protectiveness. Heightened protec- within basic patterns of role attainment. Sevon
tiveness may be related to an increased sense of (2005) described narratives of motherhood as
vulnerability and specialness of the child, and may fraught with concerns about good mothering
linger into the preschool years (Miles & Holditch- and ambivalence related to becoming pregnant.
Davis, 1997). Second, mothers were purposeful in These concerns and ambivalence are imbedded in
creating lasting attachments with their infants the experiences of mothers whose pregnancies
and to ensure the infants place within the family were complicated by a high-risk condition and
and social network over time. Flacking, Ewald, preterm delivery. Mothers whose preterm infants
and Starrin (2007) suggested that the formation of become medically fragile encounter additional
loving bonds and securing the infants survival challenges that both mirror and magnify the
are both foundational for mothering a premature concerns of mothers of healthy infants.
infant. The birth of a preterm infant results in a Linked lives was the goal of mothers of
series of stressful adaptations for mothers that medically fragile preterm infants, forming sus-
exceed those of mothers of fullterm infants tained bonds with their infants despite obstacles.
(Bakewell-Sachs & Gennaro, 2004; Holditch- Protecting the vulnerable infant became the means
Davis & Miles, 2000; Holditch-Davis, Miles, & to preserve the opportunity to mother this child
Belyea, 2000). fully. Ultimately, the woman moved from a liminal
In our analysis using life course theory, the state of socially ambiguous motherhood to full
transition into motherhood varied between first- identity of herself as the infants mother. In
time mothers and women with mothering experi- overcoming successfully the obstacles that
ence, a phenomenon reported by Rubin (1967) in mothering a medically fragile preterm infant
early work on maternal role attainment. More posed, women themselves underwent substantial
recently, Mercer (2004) challenged the concept of development and maturation. And although most
maternal role attainment, suggesting that the mothers reflected with regret on their pregnancy
process of becoming a mother begins before or difficulties and early days of their infants lives,
during pregnancy and ends when the woman has they later appreciated their own development in
achieved the maternal identity, around 4 months response to these experiences.
Research in Nursing & Health
48 RESEARCH IN NURSING & HEALTH

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