Introduction

There is no doubt that one of the most crucial relationships in human dynamics is the relationship between a mother and her child. Secure attachment of the infant to his mother or her surrogate is crucial to normal growth and development and an integral part of a child’s ability to develop a sense of mastery, identity and self-worth. Although current trends in post-natal care in the United States have greatly diminished the extent of contact between nurses and new mothers, the professional nurse continues to have a unique and important impact on how mothers perceive and attain their maternal role. The work of nurse scientists, such as Ramona Mercer’s Maternal Role Attainment Theory, can be an invaluable resource for new and experienced nurses, helping them to learn how they can foster the mother-child bond most effectively within the parameters determined by current health care practice and provider constraints.

Overview

First proposed in 1991 by nursing theorist Ramona Mercer, a pediatric nurse manager, educator and clinician with extensive experience in maternal child health, the Maternal Role Attainment Theory is a model that describes the processes through which a woman develops maternal identity and bonds with her child. Mercer first developed the theory as a framework for implementing the nursing process in the care of non-traditional mothers, such as adoptive or foster mothers or those who were unexpectedly thrust into a mothering role (for example, through the illness or death of a family member.) However, the model also is a useful framework through which nurses can assess, prioritize and address the needs of all new mothers, especially those who are dealing with unusual stressors, such as a sick infant, personal health issues, financial difficulties, postpartum depression or a lack of psychosocial support.

Concepts

The primary concept in Mercer’s theory of Maternal Role Attainment (revised to “Becoming a Mother” in her 1995 book “Becoming a Mother: Research on Maternal Identity from Rubin to the Present”) is that motherhood is a developmental and interactional process through which the mother and child bond over time. She describes four distinct phases in the process, the names of which she revised in 2004.

1. Commitment, Attachment and Preparation (formerly the Anticipatory Stage) During this initial stage the mother-to-be begins to adjust to the anticipated realities of her new role. This stage includes learning the social expectations associated with motherhood, adapting to the physical and physiological changes of pregnancy, fantasizing about motherhood and dealing with health concerns, including pre-natal care and preparation for childbirth.


2. Acquaintance, Learning and Physical Restoration Stage (formerly the Formal Stage) The stage immediately after childbirth, adoption or bringing a new child into the home, this is the stage during which the new mother adapts to her role by modeling learned behaviors and conforming closely to social and family norms.


3. Moving towards a New Normal (formerly the Informal Stage) This is the period in which the mother begins to develop her own maternal identity and becomes more comfortable with her decision-making and mothering skills.


4. Achievement of Maternal Identity (formerly the Personal Stage) This final stage, which typically occurs at about four months after birth, is the point at which the new mother has successfully integrated prior learning with personal experience. She feels confident, competent, and accomplished in her role and begins to fully experience the joy of motherhood and secure attachment to the child.

Mercer theorized that these stages are sequential, but that each woman moves through them at her own pace. Additionally, she believed that maternal identity and attachment cannot exist independently of each other: that is, maternal identity develops concurrently and in tandem with attachment to the child.

1. Influences - Mercer describes multiple factors that influence women as they move through the process of attaining maternal identity. These can be broken down into four primary areas: birth experience, social stressors, self-concept and health status.


2. Birth experience - Although a positive birth experience contributes to and strengthens the mother-child bond, many new mothers feel disappointment, guilt or inadequacy when the birth experience fails to live up to their expectations or what they perceive to be the norm. Prematurity, an unplanned Caesarean birth or other medical complications can negatively impact the new mother’s attitude towards her infant and limit her ability to bond with the child.


3. Social Stressors -Social support is an important factor in the development of maternal identity. New mothers who receive appropriate guidance and information, emotional support and appraisal of their parenting skills feel competent and confident. Conversely, a lack of social support can lead to feelings of inadequacy, confusion, resentment and guilt, all of which have an adverse effect on maternal attachment and identity.


4. Self-concept -This is a broad term that includes factors such as self-esteem, self-worth and the mother’s perception of her abilities as a caretaker for her child. Issues such as changing body image and sexual desirability can profoundly affect a woman’s self-concept immediately after giving birth. Additionally, role conflicts, such as the desire to go back to work versus the desire to be a “good” mother often surface at this time.


5. Health Status - The health status of both the mother and the infant are essential components of developing maternal identity. For the new mother, issues ranging from episiotomy pain to postpartum depression can have an impact on her ability to care for and relate to her child. Conversely, a sick or disabled infant who is confined to the neonatal ICU is both physically and emotionally isolated from the mother, which can pose a significant barrier to attachment during the first days and weeks of the child’s life. Furthermore, a child’s temperament or ability to respond to maternal cues can negatively, albeit unconsciously, impact the mother’s emotional response and attachment to the child.

Nursing Implications

In the more than two decades since Ramona Mercer first published her theory on Maternal Role Attainment, much has changed in our understanding of maternal-child health. Nevertheless, Mercer’s basic premise and its implications for nursing practice remain sound. As the health care practitioners who are most closely aligned with women in the pre-natal and post-natal periods, nurses are uniquely equipped to assess, prioritize and address the needs of women who are striving to meet the demands of motherhood in an increasingly complex and—in many ways—increasingly isolated world. Applying the nursing process to any of the factors that influence the new mothers adaptive processes is one of the profession’s most enduring challenges and one of the most important, for the future of our children and our planet depend to a very great extent on our ability to foster the essential bond between mother and child.