Introduction

Becoming a mother is an important transition for a woman that adds new roles and responsibilities to their lives (1). It is a time of great change and heightened vulnerability, and a mother faces tremendous challenges as she undergoes this transition. After childbirth, in order to fit into the maternal role, a woman has to use her knowledge, skills, and abilities to adjust to the physical, psychological, and social status (2).

Developing a way of well-being and achieving maternal-role competency are considered as the important elements of maternal adaptation. However, as a mother, women often express feelings of inadequacy in their role (3). Maternal identity formation and role attainment are developmental procedures evolving predominantly during the earliest stages of pregnancy and continuing until the postpartum period.

First-time motherhood represents a principal transition in a woman’s life, inflicting the examination of one’s capability to provide care for another human being. It is potentially a time of stress, as well as time for joy (4). It also involves several challenges, which revolves around learning neonatal care tasks, getting to know the newborn, and confronting one’s self-expectation as a mother (5). A mother plays a fundamental role in many physiological and psychological aspects leading to a high-quality lifestyle and good health. Good health could be related to providing primary needs and suitable care for the child by a mother. As a result, the children are healthy with few medical visits and medical care costs are reduced for the duration of the lifespan.

According to Walker and Avant, “the process of examining the basic elements of a concept is known as concept analysis” (6). To conduct a concept analysis, there are many reasons related to practice, research, and nursing education. The ability to distinguish one concept from another was led by the systematic process of concept analysis. It can help clarify the concepts that are frequently used or misused in nursing practice, or those concepts that are imprecise or have not been clearly defined within theory (6).

Maternal role is a concept, frequently used by the nurses who work in the maternal, neonatal, and pediatric department. In practice, it was observed that motherhood plays a significant role in positive maternal and neonatal care. A clear conceptual perception of maternal role is important because the transition to motherhood is a universal experience for childbearing women (5). There are many studies related to a woman’s transition to motherhood (3), becoming a mother (5), role attainment (7), bonding between the mother and newborn (8).

However, there have been no appropriate clarification and explanation about maternal role. Therefore, in the present concept analysis about maternal role, the authors sought to provide clarity for the identification of attributes, antecedents, and consequences of maternal role in order to inform the nurses and midwives. The objective of this analysis was to clarify the defining attributes of maternal role and identify the antecedents and the consequences of maternal role.

 Materials and Methods

Walker and Avant’s (6) method of analysis was used to examine the concept of maternal role. According to this method, concept analysis allows nursing scholars to examine the attributes or characteristics of a concept. As suggested by Walker and Avant ⁶_, this concept analysis utilized the eight-step methodology. These steps included (1) selecting a concept, (2) determining the aims or purpose of analysis, (3) identifying all the possible uses of the concept, (4) clarifying the defining attributes, (5) identifying model case, (6) recognizing borderline, as well as related, contrary, invented, and illegitimate cases, (7) discovering the antecedents and consequences, and (8) explaining empirical referents.

The data were collected through searching the databases, namely CINAHL, Google Scholar, PubMed, and MEDLINE, using (a) maternal role, (b) maternal identity, (c) maternal role attainment, (d) transition to motherhood, and (e) becoming a mother as keywords by the connectors, such as AND/OR between the keywords. The area of interest was limited to nursing, midwifery, medicine, as well as maternal and child health literature. The studies published from 1995 to 2016 were included in the present study. In addition, the inclusion criteria were the definitions of the words in abstract/title and the available full version of the texts in English language (i.e., an international language and most of the articles are published in English in international journals) (Table 1). 

Moreover, the included articles met the following criteria: (1) containing a definition of maternal role, (2) discussing the history of concept of maternal role, (3) identifying the relationship between maternal role and associated outcomes, and (4) reporting the findings of all the studies regarding the analysis of concept of maternal role or related concepts.  The articles investigated in this review included quantitative and qualitative studies. After reviewing the articles for relevance, 25 articles were included in this analysis. Figure 1 shows the specific procedure in the collection of information sources.

     Among the articles, both analysis and synthesis of extracted data were carried out using a descriptive technique, allowing the researcher to observe, count, describe and classify the data in order to obtain knowledge on the topic. To break down the data into concepts, open coding was used. The constant comparative method was used to analyze this concept. Regarding the concept, words, phrases, lines, sentences, and paragraphs were searched and then compared for similarities and contrasts. The categories were developed by grouping the related concepts.

Then, a figure was designed based on the definition of maternal role, identification of model cases, antecedents, and consequences of maternal role.

Results

 Definitions and uses of concept 

The analysis of the database showed that various terms were used to define maternal role as a concept. Various terms indicating the same concept included ‘motherhood’, ‘maternal identity’, ‘mothering’, ‘maternal role develop-ment’, and ‘maternal role attainment’. Many authors used the term maternal role attainment with only a few ones who gave a definition. Maternal role defined the behavioral responses to the expectations from a new mother and mother’s perception of responsive mothering (9, 10).

Maternal role as defined by Mercer is a process in which the mother achieves competence in the role and integrates the mothering behaviors into her established role in a way that she feels comfortable with her identity as a mother (5). Maternal competence reflects a mother’s belief in her capacity to precisely perform mothering duties. In addition, maternal satisfaction refers to a mother’s feeling of relief and contentment with parenting (9, 10). Maternal capacity includes nurturing, supplying love and caring for children to promote their physical and emotional well-being, as well as a feeling of responsibility for fulfilling the cultural expectation of children’s moral development (5).

The social practice of nurturing and caring for infants and people was known as mothering, and therefore it is not the exclusive domain of women (1,.12, 13). Maternal role has two components, including the first component as child care activities, such as feeding, holding, clothing, cleaning the infant, protecting from harm, and providing mobility. The second component is cognitive-affective, which includes motherliness and attitudes of tenderness, awareness, and concern for the child's needs and desires (5, 13,14).

 Defining attributes

Listing the characteristics that are associated with a concept are defining attributes. Any concept analysis consists of more than one defining attribute; however, one needs to determine which attributes are appropriate for the exploration of the concept ⁵. The mothers must develop a good relationship with their infants and be able to adjust themselves to motherhood. The important task of motherhood is to fulfill the physical, emotional, social, intellectual, and moral needs of children^.

After childbirth, a mother plays a crucial role in nurturing, caring, and protecting the neonate. The behavioral dimensions of mothering include nurturing, protecting, and caretaking activities provided in the context of the mother-infant/child relationship (3, 14). After childbirth, a mother needs to provide newborn care (15), create a safe environment for the neonate, learn new roles, develop family sensibility (16), cope with the problems arising from the new condition, and adapt to a new body image(17, 18).

It is essential to establish a bond between a mother and her newborn to grow and thrive in the mother’s care. Bonding makes a mother shower her baby with love and affection, as well as protecting and nourishing the little one (19).  Bonding makes the parents get up in the middle of the night to feed the hungry baby and makes them attentive to the baby's wide range of cries (19). After childbirth, a mother needs to undergo role function adaptation for new maternal role.  Mothers should develop a good relationship with their infants as for maternal role and be able to adjust themselves to their role.

The mothers need to understand their infants' behaviors, as well as maintaining their functions as a wife and working woman (17, 18). During the early postpartum period, first-time mothers do not naturally adapt to their new maternal role. Therefore, they need to continuously learn and adjust.  To fit into the maternal role, first-time mothers must use their potentials and capabilities to alter their physical, psychological, and social status (18).

A woman begins to structure her mothering to fit herself and her family while moving towards a new normal stage. Much cognitive restructuring takes place as she learns her infant's cues, and what is the best for her infant and adjusts to her new actuality (5, 17) Mothers can suitably respond to their infants' needs because they understand and perceive their infants' behaviors (19). Crying, moving, and eye contact are the cues expressed by infants as their needs. Cues are bids for interaction or signs of infant's needs, such as hunger and discomfort, including wetness and change in temperature or noise (11).

Model Case

Based on Walker and Avant (6) “a concept that demonstrates all the related defining attributes is an example of a model case”.  Mrs. S is a 27-year-old primi mother working in a Bank as a cashier who delivered a healthy female neonate. She attained the prenatal clinic; therefore, she had knowledge about neonatal care. She breastfed her baby every 2 hourly, and while feeding she interacted with the baby and sometimes held the baby’s hand and kiss her.  She wiped the baby’s whole body daily with soft cloths and gave her bath twice a week. Through practicing baby care, she learned to comfort and care for the newborn. 

When the baby is crying, in spite of breastfeeding and checking the dipper, a mother can guess she has painShe was slowly developing the knowledge and skills regarding caring for her baby; consequently, her confidence level was increasing. Her husband was supportive and careful; he took care of the child and asked her wife to do her personal activities. She balanced the two roles as a mother and wife, learned new roles, and developed family sensibility. At work, there were nursery facilities and some break time for maternal breastfeeding. Although she had more responsibilities than before she loved her life.  Both husband and wife were enjoying their parenthood.

Borderline Case

Borderline cases are “those examples or instances that contain most of the defining attributes of the concept being examined but not all of them” (6). Mrs. A, a 30-year-old woman, delivered a male newborn. The neonate was born with meconium stained. Therefore, she was admitted to neonatal unit for further management.  She was very worried and upset about the baby’s condition. She went to neonatal unit every hour and held her newborn and talked to him. She sometimes kissed the baby’s forehead. She was well-supported with her husband and family. She did not breastfeed her neonate because her baby was restricted to feed orally. This case showed some defining attributes but not all. As an example, Mrs A was not able to breastfeed her baby and stay with her after delivery.

Contrary Case

According to Walker and Avant (6), an example of a contrary case is the one that does not represent the concept and contains any of the defining attributes. Mr. R is a 19-year-old unmarried woman who came to the emergency room complaining about severe abdominal and back pain. She delivered a baby girl through C-session. The patient did not want to breastfeed and refused to hold her newborn. She did not touch the neonate even her diaper was wet, and she cried. She refused to stay in the room with her baby. She was just worried about her health. For boarding, the infant was transferred to the neonatal intensive care unit. Further discussion was carried out with the mother by the pediatrician and she expressed the desire to offer the adoption to someone who can take care of her neonate. In this contrary case, none of the defining attributes were presents.

Antecedents

According to Walker and Avant (6), the antecedents are what occur before the described concept takes place. To perform maternal role, first, a woman must become pregnant and delivers a neonate (5). The process of maternal role development starts in pregnancy and continues over 4–6 months postpartum when most mothers obtain competence and satisfaction in their role (5, 13).

A woman’s responsibility in the first stage of commitment to the pregnancy, safe delivery, and care for her unborn baby was associated with her positive adaptation to motherhood (20). To fulfill maternal role, a woman relinquishes her previous roles, which involves developing a maternal identity and maternal behaviors appropriate to the developmental stage of growing fetus/infant (21).  Maternal role was associated with several factors and the woman’s sense of competency in the role. Several variables influence maternal role, such as age, marital status, educational background, economic status, social and cultural factors, perception of birth experience, psychological state, and personality traits (3, 13, 19-22).

A woman begins the transformative process of becoming a mother once she becomes pregnant.  She seeks new information, adapts to a new body image, and begins to define her new role by searching for models during pregnancy that encompass the desired attributes, abilities, and ideal elements she can incorporate into her own maternal identity (23). In performing the maternal role, maternal perception of the infant's behavior was observed to be positively related to maternal confidence.

A mother should have maternal identity in order to develop maternal role, which is perception and emotion as a mother when finding herself in relation to her infant. Maternal identity consists of self-identity as a mother and identification with the infant (2). Among these factors, a more important antecedent for maternal role is self-identity. As a mother, a woman with a positive self-identity generally has a higher sense of mastery in taking care of the infant with sensitive mothering (24).

Consequences

The consequences are the events or incidents that happen as the results of a concept ⁶. During maternal role, some issues increased, including demands, challenges, and disruptions such as developing the knowledge and skills to care for the infant(s), changing to employment status, balancing multiple roles, adjusting to the woman’s own routine and that of her family, and managing social activities while maintaining responsibility for the infants (12, 13).

Although in the new role of mother, there are achievements, such as the pleasure and joy of having a new baby and social recognition, there are also losses, including the loss of income, sleep, stress, freedom, control, and sense of self (12, 13, 19). This sense of being loved is vital for the baby’s optimal development, as well as the stimulation of interaction (23). A mother gains confidence in her ability to nurture and ensure her infants’ physical, emotional, behavioral, and social development when she successfully adapts to her maternal role (13).

Most women look forward to their new role as a mother, in spite of understanding that it will dramatically change their lives.  Being satisfied in the maternal role requires a successful adjustment that can be expressed through self-confidence, self-esteem, competence, mastery, and role contentment (14). In maternal role, during the transition to motherhood, the
sense of competence and satisfaction has a tremendous effect on the quality of parenting behavior (16). The major predictor of maternal competence was learning to balance the roles of wife, mother, and employee that can be difficult and may lead to role strain (5). 

Moreover, other predictors of competence were self-esteem, mastery (i.e., sense of control), anxiety, and prenatal attachment (25) To achieve balance in a woman's new role, she becomes increasingly proficient in her caretaking skills, assumes the maternal identity, and begins to feel competent in her role as a mother. Competency in maternal role should increase with time and as the woman’s self-concept develops in the role.

Skillful and sensitive care will be provided by first-time mothers with maternal competence that responds to infants' needs and fosters infant development (13).  The effective factors on maternal role were the maternal perception of infant behavior, social support, maternal perception of parenting, maternal competence, and depression (13, 26, 27). A mother establishes intimate knowledge of her infant in the achievement of maternal role, such as feeling competent and confident in her mothering activities and feeling love for her infant; she needs to fulfill multiple roles, maternal role strain, and role conflict (28).

 Identification of empirical referents

     Empirical referents are the final step of Walker and Avant's method of concept analysis. The existence of empirical referents, which are classes or categories of a real phenomenon, demonstrates the existence of the concept itself (6). According to Walker and Avant, it was suggested that identified empirical referents are very useful in instrument development as they are demonstrably connected to the theoretical base of the concept. In the late 1960s, Rubin introduced the concept of maternal role attainment (14). She described maternal role as a complex cognitive and social process that is learned, reciprocal, and interactive. The process of becoming a mother with four stages was described by Mercer (5). The involvement in commitment and preparation for the infant during pregnancy is the first stage. The second stage is the involvement in getting to know and learning how to care for the infant.

The third stage is the involvement in moving toward a “new normal”. Finally, the fourth stage concerns the achievement of maternal identity. A measuring instrument has not been developed regarding maternal role. Parenting sense of competence scale is used to measure a new mother’s beliefs, values, and perceived skills in terms of being a mother (29).

 Discussion

In the present analysis, the purpose was to clarify the defining attributes of maternal role and identify the antecedents and consequences of maternal role. Becoming a mother includes moving from a known and present reality to an unknown and new reality.  Mercer defines role performance process as the attainment of maternity role and achievement of the ability to combine maternal behaviors in the established order (5).

The woman has to undergo role function adaptation to their new maternal role after becoming a mother. The mothers have to understand their infants' behaviors as defined in maternal role in a way they can suitably respond to their infants' needs. This finding was in line with the results of a previous study conducted by Barnes et al. (19) in which mothers understand and perceive their infant's behaviors. In order to fit into maternal role, a mother should use her knowledge, skills,
and abilities to adjust to her physical, psychological, and social states (16).

After childbirth, a mother needs to provide baby care, create a safe environment for the baby, and learn new roles. This finding is consistent with the results of a previous study conducted by Aman kwaa et al. (11) Competency in maternal role should increase with time and as the woman’s self-concept develops in the role. Skill and sensitive care will be provided with maternal competence that responds to infants' needs and fosters infant development (5). The effective factors on maternal role were social support, maternal perception of infant behavior and parenting, maternal competence, as well as depression (13, 26).

A mother has established the intimate knowledge of her infant while achieving maternal role; therefore, activities and feels love for her infant. She has settled in mother, role conflict, and role strain influence maternal role (7, 27). The results of a study conducted by Shin (24) showed that a woman as a mother with a positive self-identity usually has a higher sense of mastery in taking care of her infant. In maternal role during the transition to motherhood, a sense of competence and satisfaction can have a tremendous effect on the quality of parenting behaviors (29).

There were some limitations in this concept analysis carried out on maternal role. The findings might be restricted due to the limited utilization of the search terms. The data were searched only on CINAHL, PubMed, and MEDLINE databases with the limitations regarding the nursing, midwifery, medicine, and psychology literature. In addition, all the investigations were limited to English articles from 1995 to 2016 with the inclusion of only 25 papers. It is suggested that future studies focus on the inclusion of search terms that might reflect maternal role in the earlier literature.

Conclusion

The objective of this analysis was to clarify the defining attributes of maternal role and identify the antecedents and consequences of maternal role. This concept analysis was a challenging exercise to differentiate between maternal role and other concepts. The present analysis identified common attributes, antecedents, and consequences. In addition, this analysis differentiated the concept from similar and related concepts that led to greater clarification of maternal role in nursing and midwifery. Developing an understanding of maternal role process will lay a foundation for midwives and other caregivers to design appropriate care for new families. The present concept analysis of maternal role provided clarity and therefore contributed to the body of knowledge regarding maternal identity/role and offered an approach to guide nurses and midwives in their practice and research.

Acknowledgements

       We would like to thank all the women who volunteered for this research.

Conflicts of interest

       The authors declare no conflicts of interest.