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Postpartum depression, delayed maternal adaptation, and mechanical infant

caring: A phenomenological hermeneutic study

Article in International Journal of Nursing Studies · April 2008

DOI: 10.1016/j.ijnurstu.2006.10.002 · Source: PubMed

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 ARTICLE IN PRESS

International Journal of Nursing Studies 45 (2008) 362–369

www.elsevier.com/locate/ijnurstu

Postpartum depression, delayed maternal adaptation,

and mechanical infant caring: A phenomenological
hermeneutic study
Jennieffer Anne Barr
Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland 4520, Australia
Received 29 March 2006; received in revised form 2 October 2006; accepted 4 October 2006

Abstract

Background: With 10–15 percent of mothers experiencing postpartum depression this mental health problem is a
significant public health issue. One concern is that normal infant development is at risk. Understanding how
Postpartum depression impacts on mothering is important knowledge in managing this health problem.
Objectives: To:

 explore what is it like to become a mother, and

 examine how postpartum depression impacts on maternal adaptation

Design: A hermeneutic approach was used guided by the philosophical works of Heidegger and Gadamer
Setting: A relatively affluent metropolitan area, including surrounding rural areas within Australia.
Participants: Via purposeful, maximum variation sampling, eleven women who had been medically diagnosed with
postpartum depression following childbirth but who were not experiencing psychosis participated in the study.
Methods: In-depth interviews and reflective journaling.
Results: Mothers with postpartum depression become ‘‘stuck’’ in a liminal state, an incomplete process of the rite of
passage. Therefore, adaptation to the social role of a mother was found to be delayed. Additionally, a delay in
becoming competent in parenting skills was evident. A lack of maternal–infant attachment was noted, however,
mothers continued to care for their infants but in an unthinking manner that was labelled ‘‘mechanical infant caring’’.
Conclusions: The distress caused by the delay in adapting to being a mother could be addressed by providing a mentor
to at-risk women. The mentor should be a mother who has previously recovered from postpartum depression and
would act as a symbol of hope. Additionally, on-going education and the insight that occurs during the liminal phase
can facilitate mothers with postpartum depression to adapt appropriately.
r 2006 Published by Elsevier Ltd.

Keywords: Postpartum depression; Rite of passage; Liminality; Mother; Adaptation; Hermeneutics

Tel.: +61 7 3864 5951; fax: +61 7 3864 3814.

E-mail address: j.barr@qut.edu.au.

0020-7489/$ - see front matter r 2006 Published by Elsevier Ltd.

doi:10.1016/j.ijnurstu.2006.10.002
 ARTICLE IN PRESS
J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
What is already known about the topic?
 Ten to 15 percent of mothers experience postpartum
depression (PPD), which is a significant public health
issue.
 Mothers with PPD are influenced by the social and
cultural beliefs and attitudes about being a mother,
and about experiencing a mental health problem.
 The rite of passage (ROP) has facilitated under-
standing about the maternal adaptation process
following childbirth.
What this paper adds
 The new conceptualisation, ‘‘mechanical infant car-
ing’’ that refers to and describes the way women with
PPD undertake infant care, will aid the under-
standing about PPD held by nurses and midwives.
 Demonstrates that women experiencing PPD have a
delay in adapting to being a mother, thus requiring
clinical management that reflects this context.
 Presents clinical management of PPD to enhance the
adaptation to the mothering role, which includes
developing new, realistic images of mothering,
mentoring, and timely education about parenting.
1. Introduction
Worldwide research has consistently reported that
10–15 per cent of women will experience postpartum
depression (PPD) (Pope et al., 2000; Sierra Manzano,
2002). Considering the potential morbidity for the
mother, her infant and other immediate family mem-
bers, it could be argued that PPD is a significant
public health issue. Normal infant development is at
risk. Consequences can include affects to cognitive
development such as language and speech problems
(Brockington, 1996). Children can develop impaired
social skills and behavioural problems (Beck, 1999).
A significant contributing factor to these consequences
appears to be related to the lack of maternal–infant
attachment with no confidence in mothering skills
(Logsdon et al., 2003). Therefore, this current study
was concerned with what it was like to become a mother
and how PPD impacted on this adaptation.
2. Background
As women with PPD are also mothers, it was
important to consider typical issues relating to mother-
ing in contemporary society that have been discussed in
the literature. The myths of happy mothering still
363
prevail in contemporary society with connotations that
those mothers who feel fulfilled in their new social role
and selflessly and happily attend to infant tasks are the
‘‘good mothers’’. It is well known that this dominant
ideology does not reflect the typical realities of most
mothers (Barclay et al., 1997; Maushart, 1997; Stern,
1999). It is possible to appreciate how distressing it must
be for such a mother when she recognises that she is
often different from the image of the ‘good mother’
(Nicholson, 1990). Being depressed or being severely
anxious interferes with the person’s functioning ability;
therefore, the moments of happy mothering can be
infrequent for mothers who have a mental health
disorder. It is not possible for these mothers to live up
to society’s expectation of the ‘happy and good mother’.
2.1. Conceptual framework
The rite of passage (ROP) model has previously been
used to describe women adapting to the new social role
of a mother (Maushart, 1997; Martin-McDonald, et al.,
2002). The ROP refers to any transition from one form
to another. The ROP model was first conceptualised as
stages by van Gennep (trans. 1960) who argued that
ROP occurs in a tripartite process. Turner (1969) also
conceptualised social change in the same way and
extended some of van Gennep’s arguments. The first
stage of the ROP was called separation where a person
moves away from a previous social position or status.
The second stage was called transition (van Gennep,
1960) or liminal phase (Turner, 1969). The liminal phase
(referred to throughout this paper as liminality) is when
change has begun but the person has not yet reached the
new social position or status.
Originally, the term liminal, a Latin word, denoted
rituals of transition (Harrison and Kahn, 2004). How-
ever, applying these original principles to other issues in
contemporary time has expanded the understanding of
being in a liminal state. Gardner (1998) noted that
people in a liminal state are often portrayed as passive.
The liminal phase is characterized by ambiguity with
none of the social attributes from the previous or future
social status (Harrison and Kahn, 2004).
The third and final stage, incorporation (van Gennep,
1960) or aggregation (Turner, 1969) is generally recog-
nised as the person having reached the social position or
status. The literature discusses the psychological, phy-
sical, emotional and social changes requiring major
reorganisation within the thinking and way of living
once one becomes a mother (Barclay and Llyod, 1996;
Bewley, 1999). As women adapt to their new social roles,
they also shed ‘part of [their] former self; relationships,
roles and activities which are incompatible with’ their
roles as mothers (Barclay and Llyod, 1996, p. 137).
Mothers need to challenge previous assumptions about
themselves and their worlds and replace them with new
 ARTICLE IN PRESS
364 J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
altered images and understandings of how they are
changing in their daily lives (Oakley, 1980). Once they
achieve this change to their thinking and behaviour and
they can relate to their social peers, these women have
progressed through the incorporation phase and their
journey through the ROP is complete.
Martin-McDonald et al. (2002) caution that ROP was
not meant to be an examination of individual responses
but rather to understand a group process. However,
Gardner (1998) found it useful to use a metaphoric
application of the ROP when analysing narratives in
order to illuminate an individual’s journey from one
social position to another. This framework makes it
possible to inductively draw inferences about the
possible experiences of a group using the theoretical
framework of ROP through the collection of individual
stories about the same societal role.
3. The study
3.1. Aim
The aim of this study is to explore the phenomenon of
maternal adaptation for women experiencing PPD using
the ROP model. Ethical approval was sought and
obtained from QUT University Human Research Ethics
Committee. The two research questions investigated
were:
(1) what is it like to become a mother; and
(2) how does PPD impact on the adaptation experience?
3.2. Methodology
The hermeneutic ideas published by Heidegger (1962,
trans.) and Gadamer (1975, trans.) that people will find
meaning in experiences (sorge) and they will use
language to share this meaning with others, were
fundamental principles applied to guide this study.
Interpretation was aided by the use of the hermeneutic
circle. The hermeneutic circle is a metaphor that explains
how a researcher questions the data to ensure reporting
a truthful account of the meaning contained within the
stories provided.
Obtaining a detailed sense of the context of a situation
is a strategy that has evolved from Heidegger’s notion
that people are affected by time and by Being-in-the-
world-with-others (a world filled with other people).
Past experiences and anticipating the future, as well as
other people’s actions and opinions, all shape an
individual’s view of the world. This argument can be
used to understand how women perceive themselves as
mothers when having a mental health problem. Society’s
understanding about mental illness is shrouded in
cultural and social beliefs, just like those societal
understandings about motherhood. In turn, these
understandings will influence an individual’s experience
of having PPD.
Before the data were collected the prejudices held by
the researcher about being a mother and being a mother
who is experiencing PPD, were identified. In particular,
a list of all the known myths about happy selfless
mothering was made in the critical reflective journal. My
own personal ideals about being a mother of my two
children were also noted. These notations were useful to
begin inquiry but were also used to question data
analysis at a later stage of the research (Gadamer, 1975,
trans.).
3.3. Sampling
A purposeful sample of eleven women experiencing
PPD was obtained by recruiting through general practi-
tioners, a local newspaper and a community support
group. Patton (2002) referred to this as information-rich
cases. When Eddy and Mellalieu (2003) used Patton’s
guidelines in their research, they argued that an informa-
tion-rich case was one that provided a great deal
information and detail related to the research inquiry.
The sample technique also used maximum variation,
which aims to obtain as many aspects of a phenomenon as
possible (Meadows and Morse, 2001). As the analysis of
the study unfolded the phenomenon of maternal adapta-
tion, it became important to recruit women who were at
different stages of their journey. For example, when the
data analysis highlighted that most women interviewed for
the study had recently been diagnosed, a general practi-
tioner approached a number of women who had been
experiencing PPD for at least 6 months in order to canvas
their interest in participating in this project. This sampling
technique was successful as I did obtain participants with
an array of experiences associated with PPD (length of
time from diagnosis ranged from 2 to 11 months).
3.4. Sample
The sample consisted of eleven participants who had
been medically diagnosed with, and continued to
experience PPD. All women were married and living
with their partner other than one who had separated
from her husband within the previous twelve months.
The women were aged between 20 and 34 years. The
ages of the babies ranged from two to 11 months. The
length of the experiences of PPD ranged from two to 11
months.
3.5. Data collection
Two methods were used to collect data: (1) in-depth
interviews, and (2) critical reflective journaling. Following
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J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
consent, the interviews were conducted. Typically the
interviews were held in the participant’s home in the form
of a conversation so that the participant could direct the
inquiry and share the meaningful aspects of their
experiences. This reflects Heidegger’s belief that people
focus on what is meaningful to them (‘sorge’) (1962
trans.). Each interview (averaging two hours in duration)
commenced by asking the participant to tell me what it
was like to live with PPD.
The second data collection strategy, critical reflective
journaling, was used throughout the project. First it
was used to note all pervious knowledge (prejudices)
that the researcher was consciously aware of. The
journal was also used to note observations like body
language and the researcher’s thoughts after each
interview. Additionally, as data analysis commenced
immediately after the first interview, the journal was
used to question if the participant had sufficiently
explained the phenomenon in detail to aid interpreta-
tion. Most participants were interviewed and then a
follow-up telephone call (second interview) was made to
substantiate and clarify detail and preliminary meanings
(understandings). Moreover the critical reflective journal
became a log of research strategies, which facilitated
rigour of the study.
3.6. Data analysis and rigour
Identifying, clustering and naming units of meaning
(UOM) was a fundamental data analysis strategy (van
Manen, 1990). Examining the data for UOMs that were
associated, influenced or occurred with other UOMs
identified patterns in the data. Alternative possibilities of
what the UOM could otherwise be named, or when this
UOM was not representative of some data were
important considerations (Polit and Beck, 2004). Being
willing and humble to realise that a UOM can be
incorrect and inaccurate in describing or explaining
some data is a critical stance for a hermeneutic
researcher. At this point, a responsible researcher should
return to the data and re-examine the information. An
additional strategy used for clarification was to conduct
a second interview, usually in the form of a phone
interview, previously consented at the time of obtaining
the initial ethical consent. At this time additional detail
and verification of preliminary understanding could be
obtained from the participants.
The hermeneutic circle (Gadamer, 1975, trans.)
involved the researcher returning to the prejudices
(presuppositions) to consider if the UOM merely
reflected a previous opinion, or, if it reflected the data.
Additionally, an aspect (part) of the experience was
examined individually and then examined within the
context of the whole story to see if the suggested
meaning was plausible. At this point, having a cynical
and questioning attitude was important to ensure a
365
truthful and authentic account that was based on critical
appraisal and reflexivity.
4. Findings
The findings for this research project focused on three
key areas: (1) state of liminality, (2) symptomatology,
and (3) mechanical infant caring. The findings and
theorizing undertaken in this research project using the
conceptual framework of ROP found that women with
PPD are ‘‘suspended’’ between their former and future
selves (Purves, 2004).
4.1. ‘‘Stuck’’ in the liminal phase
All participants of this research project articulated the
change in their lives since the birth of their babies. They
all realized they needed to learn and adapt to the
mothering role, however, they all claimed they were yet
to reach this adaptation. Therefore, all participants in
this study were in the liminal phase of the ROP. The
women (fictitious names used) of this research project
described this state of liminality as being different to
other mothers who are perceived to have adapted to the
new social role of the mother. This was described as:
It’s a totally different world [being a mother] and its
like going into a new job, you have to learn things
that you are not trained for but at the same time I
was still struggling with something in here [she points
to her chest] that stops me moving on like other
people y I just wasn’t like them [other mothers].
(Wendy)
Mothering for me is very different to most mothers I
know y you have to learn to be like real mothers y
you don’t know how to do this, you know, be like
them. (Julie)
4.2. Symptomatology
The analysis found that having a mental health
problem had a major impact on adapting to becoming
a mother for all these participants. The symptoms of
PPD that were experienced interfered with learning to
mother in a number of ways. For example, mothers in
this study reported a reduced ability to function due to
fatigue. Fatigue was generally described as:
I felt tired all the time, I still do. Exhausted actually. I
can’t pull myself out of it. I am so tired most of the
time and have great difficulty staying awake y I
even bought a book, what’s it called, on babies but I
don’t seem to be able to read even a paragraph on
some days. (Sharon)
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366 J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
You’re constantly feeling tired, no exhausted. Every-
thing is an effort (Kate)
Planning is a significant part of how mothers manage
the multiple tasks of infant care and housework.
However, the symptoms of a mental illness interfered
with this aspect of mothering. Being indecisive made it
difficult to plan for all these participants. Some examples
were:
Decision-making was something that I didn’t do
through that whole timey I never got around to
doing anything. (Wendy)
I would wake in the morning and I would think what
am I going to feed you today. I didn’t know what to
feed him and I didn’t know how to plan ahead and I
would be in tears. I didn’t know what should be in his
diet. (Julie)
Being unable to plan not only caused distress but also
appeared to contribute to a lack of confidence about
caring for the infants for these mothers. One comment
that reflected this lack of confidence included:
I just couldn’t remember what I was suppose to do.
What did he need? I couldn’t believe that this is what
it would be like all day. I just couldn’t do it. I
couldn’t be alone. I was so afraid that things would
go wrong. (Sharon)
Additionally, these participants described the inability
to commence or complete a task, like housework. They
said:
[I was] unable to look after myself and everything
was an effort. I didn’t even want to get out of bed but
my family expected me to get up, so I did. But it was
an effort, too much hard work. I didn’t care about
me, the baby or anything. I wouldn’t even remember
to have a shower, clean my teeth. y I think Mum
just thinks I should pull my socks up but you can’t.
(Sharon)
You just function. Nothing gets done well and
sometimes not at all. You know you have to do
something, somehow you can’t get your body to
actually do it [pause] that’s the bad days. On a better
day you can do it but you certainly don’t enjoy it.
(Jill)
4.3. Mechanical infant caring
Being depressed or anxious often impairs the mater-
nal–infant attachment (Buist, 1996). This lack of
attachment can be profound for women with PPD as
they struggle to find the sense of love for their newborns.
Betty’s comment articulates how profound this response
can be when women suffer from PPD. She said:
I remember thinking that’s not my baby, actually, I
actually said that!yEven after I nursed him he didn’t
feel like mine yI really felt that it wasn’t my child. I
didn’t want to be near him (Betty)
All participants at the time the data was collected
were all actively undertaking infant care, regardless of
the lack of maternal–infant attachment. Infant care
experiences were described as having little interaction
embedded in these mothering tasks and the purpose of
these childcare duties was to complete the task. All the
mothers described this phenomenon but Kate and Jill
articulated it in a way that provided a succinct summary.
They said:
I change his nappies and fed him but I would rather
be doing something else. I just do it and try to get it
over and done with as soon as I can. I get cranky with
him if he doesn’t lie still as it drags it out but I don’t
want someone else to do it for me. (Kate)
You don’t care about the baby, oh you meet her
needs like changing a nappy and things and you
focus on her. It’s like a primal love. An instinct. An
instinct to protect, to nurture, to look after this baby.
We bath and we read. Boy do we read! I can’t read all
the time but when I can, I doy I feel I have to learn
how to do this [mothering]. That is my job. I just do
it. Mind you, everything is a chore. You just
function. (Jill)
5. Discussion
The conceptual framework of ROP was useful in
aiding the development of a theory about women with
PPD adapting to becoming a mother. The findings of the
study showed that women with PPD experience a delay
in adapting to the mothering role. PPD appeared to
interfere with this progression through the ROP and
these women became suspended between their former
and future selves (Purves, 2004).
Whilst these women in this study had yet to adapt to
the mothering role, they did undertake some infant care.
In their liminal state they were aware of their
responsibilities to their babies. Even with debilitating
symptoms some women continued to care for their
infants, but it tended to be in an automatic manner. This
theme was given the title of ‘Mechanical Infant Caring’.
‘Mechanical Infant Caring’ refers to when mothers may
change a nappy and there is no sense of connection to
the baby or thought about the task. For these women it
was something they felt obliged to do, as it was the
correct and responsible way to be. ‘Mechanical Infant
Caring’, aforementioned, is simply carrying out duties in
an automatic and non-thinking manner.
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J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
However, the women in this study were clad in doubt
and uncertainty about their new social role as mothers
and their ability to provide effective infant care (Beck,
1999; Irving, 2004). Walker et al. (1986a) noted that self
confidence was correlated with role performance as a
mother. This lack of confidence was reflected in the
comments these mothers made about being unlike other
mothers.
Walker et al. (1986b) previously noted the significance
of maternal role attainment and identity in the
postpartum period. A positive regard for infants and
for mothers’ view of themselves as mothers, was
reported as being important in the adaptation to
becoming a mother. These authors go on to explain
that the maternal role attainment is associated with
enacting the behaviours of other mothers, as defined by
the culture and society in which mothers are part of.
A significant influence on parenting skill is materna-
l–infant attachment (Beck 1999). Research has consis-
tently reported poor attachment as a key feature
associated with PPD (Milgrom et al., 1999). In turn,
this has also been connected with poor infant develop-
ment. A study by Righetti-Veltema et al. (2002)
compared mother–baby dyads experiencing PPD to
those who were not. Negative trends were found such
as babies of depressed mothers showing diminished
verbal performance at 18 months of age. Roux et al.’s
(2002) study noted that adaptation was not apparent for
the women in this study who were depressed until at
least the first year and extending into the second year
postpartum. Like this reported study here, Roux et al.’s
study was therefore, not able to confirm the time
required to adapt to being a mother when one has
PPD as many of the women were still to complete
adaptation.
The awareness of the women that they are in this ‘‘in-
between’’ state has been reported by research conducted
in other health care areas by Harrison and Kahn (2004)
and Purves (2004). They claim that people do become
insightful during the liminal phase as they try to make
sense of the meanings attached to their experiences and
to explain what is happening to them. This reflective
stage was also identified in the current study. Therefore,
the liminal phase can lead to personal understanding of
the situation.
The complexity of the postpartum situation means
that the mental illness symptoms can often be confused
with the uncertainty and chaos experienced as ‘‘normal’’
components to mothering. All new mothers experience
uncertainty when learning to mother a new baby
(Maushart, 1997). Therefore, education focusing on
the realities of parenting to identify the differences
between normal reactions to being a new mother and
having a mental illness is useful.
Additionally, other mothers can play an important
role as mentors to facilitate women with PPD to adapt.
367
An appropriate mentor could be a mother who has
previously experienced PPD, as she is able to relate to
the altered mothering experiences which women with
PPD face. Martin-McDonald et al. (2002) argued that a
mentor is a visible reassurance that the liminal stage is
temporary and that is likely to offer comfort to those
who are currently ‘‘stuck’’ in the liminal stage. This
could be particularly relevant for women with PPD who
have a sense of hopelessness that there is no future and
that change to the daily situation is not possible. These
recovered mothers are examples of being able to move
forward and beyond the liminal state to reach the
completion of the ROP and to adapt successfully to
being a mother.
5.1. Limitations of the study
A major limitation of this study was that the duration
was not sufficient to examine the whole transition from
childless mother to becoming a mother who subse-
quently was diagnosed with PPD. This study did not
extend to the final stage of ROP where women with PPD
do complete adaptation. Therefore, no conclusions can
be drawn about how long this process typically takes,
nor can any inferences be made about how adaptation
with PPD differs to non-depressed mothers (who will
also progress through the liminal phase). However, the
experiences of women in this study provide a major
contribution to advancing knowledge in this area.
6. Conclusions
The finding that women with PPD become ‘‘stuck’’ in
the liminal phase could be perceived as problematic.
However, the literature portrays an optimistic view
about people who are in liminal states. Purves (2004)
provides an interesting suggestion for clinical practice of
health professionals to view their clients as transforma-
tive and to encourage the clients to do the same. The
state of liminality is a chance to find new solutions and
to do things differently (Stern, 1999; Carnes, 2004). This
means that women with PPD could adapt to being a
mother that differs to the unrealistic social myth of
happy mothering. In this way, these women could view
becoming a mother in a realistic manner. Researching
ways to enhance this process could be useful.
The conclusions that mothers with PPD experience
delays in relating to other mothers and being confident
in conducting infant care are significant findings. The
sense of efficacy appeared to be poor and whilst these
women did function as mothers, they did so in an
unthinking manner, which I termed ‘Mechanical Infant
Caring’. ‘Mechanical Infant Caring reflects the lack of
attachment mothers with PPD experience with their
infants (Buist, 1996).
 ARTICLE IN PRESS
368 J.A. Barr / International Journal of Nursing Studies 45 (2008) 362–369
It is known that impaired maternal–infant attachment
reduces the mother’s ability to identify clues of infant
needs (Milgrom et al., 1999). This study also highlighted
that fatigue and other symptoms make it difficult to learn
and become confident in parenting skills. The nature of
PPD and its impact tends to be cyclic. PPD is associated
with parenting difficulties but in turn, mothers feel like
they have failed in the mothering role and such feelings
have been noted as exacerbating the symptoms of PPD
(Milgrom et al., 1999). Such complexity makes it
challenging to determine the best time for education
related to parenting skills. The timing of such education
on parenting skills when these women are able to
cognitively focus would be ideal for optimal learning,
although learning cannot wait until women are symptom
free due to the need to interact with the infant for both
improvement of the maternal–infant attachment and
infant development. Therefore, on-going education will
be important but support whilst adapting may be the
key. Such support could involve other mothers who have
recovered from PPD, who could act as mentors.
Additionally, there is scope for health professionals to
utilise this situation to facilitate women with PPD to
accept the opportunity for personal growth and self-
awareness that liminality produces (Martin-McDonald
et al., 2002). Moreover, this opportunity could be
extended so that mothers with PPD look at some of
the distorted views of motherhood that continue to
prevail in contemporary society and re-examine their
views so that they reflect the realities of mothering. As
Carnes (2004) highlights in the process of change,
liminality does create a situation where mothers could
regard familiar things in new ways and attach new
meanings that relate to how they interact with their new
social role. This could be realising that the way
mothering occurs now in contemporary society may be
different to how these mothers were mothered (Jeuaraj,
2004). Therefore, through thoughtful consideration,
counselling will aid women with postpartum depression
to review thinking, beliefs and understandings about
mothering in order for these women to embrace and
adapt to the new social role of being a mother in a
realistic manner that may or may not be the same as her
peers who are also mothers. Using the liminal phase in a
purposeful manner to develop insightful personal con-
clusions about mothering could be a crucial component
of the clinical management of PPD.
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