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Human lives are shaped by questions of when and where in a sociohistorical sense, making the principle of time and place foundational to life course research. Culture defines a specific place in time Gieryn, Use of obstetric technology expanded in the late 20 th and early 21 st centuries, marking the beginning of a cultural shift in which prenatal testing, ultrasonography US , and electronic fetal monitoring EFM have become the norm Similarly, neonatal technology has created a culture that includes a language of laboratory values, ventilator settings, and feeding volumes that replace conversations typical of parents, relatives, and friends after the birth of a fullterm infant.

The second principle, life span development, is characterized by the view that humans develop in biologically, socially, and psychologically meaningful ways beyond childhood Elder et al. The concept of time here refers to chronological ordering of events, rather than situating events in historical cultural contexts. Although life events are not rigidly predetermined, certain biological events are chronologically ordered such that, if experienced out of order, physical and social consequences will vary from those that occur within the expected timing or order.

For instance, preterm birth is a biologic event in which delivery occurs earlier than expected. Agency is based on the assumption that humans are not passive recipients of a predetermined life course but make decisions that determine the shape their lives. Agency has particular salience in the context of preterm birth. Mothers make life-shaping decisions for themselves and their sick infants, with limited insight into the consequences of those decisions.

Social linkages shape how individuals interpret life events.

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People vary widely in the manner and degree in which they integrate social norms, relationships, and institutions. The lives of mother and infant are uniquely linked, shaping and being shaped by each other in the continuing process of human development.

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However, becoming a mother of a medically fragile preterm infant is complicated by the unexpected and unknown. The discontinuous or disrupted nature of this mistimed biological event may affect the manner in which initial linkages are formed. In addition to these principles, three key and related concepts — trajectory, transition, and turning point — are commonly used in life course research to describe human developmental phenomena. 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 roles within trajectories Hagestad, Transitions have a liminal quality, that is, being on the threshold or edge of a physical or psychological state Turner, Shin and White-Traut identified the removal of a preterm infant from the isolette and discharge from the NICU as turning points in the transition to motherhood.

Becoming a mother means moving from a known to an unknown reality Mercer, The decision to become a mother is characterized by ambivalence, calculation of the timing of pregnancy, and determination of effects on significant relationships Sevon, When the infant is medically fragile, these experiences are intensified. Mothers of medically fragile infants face significant distress, including depression and grief Aite et al. Using a life course perspective in this study, we focused on becoming a mother as an aspect of adult development within a sociohistorical context characterized by highly medicalized obstetric and neonatal care in the U.

Although commonly used in nursing literature, context has often been defined narrowly as the setting for practice e. We examined ambiguous and liminal aspects of becoming a mother to a medically fragile preterm infant, identifying significant turning points at which women moved from a liminal state to explicit identification as mother of this infant.

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This study is a secondary analysis of data from a longitudinal study of medically fragile infants, the process of parental role attainment, and its influence on parenting outcomes Miles et al. In the original study, 83 fullterm and medically fragile preterm infants were enrolled while still hospitalized and followed until 16 months of age. For this study, data were analyzed from 34 mothers of these infants who met inclusion criteria: Demographic characteristics of the sample are in Table 1. Interviews were conducted at five time points: The data were collected in response to the research questions that guided the original larger study.

The application of life course theory as a secondary analytical framework was unique to this smaller study. Data were analyzed by one investigator, although research team meetings were held to discuss the ongoing analysis. Questions of analytic precision and fit of the data to life course principles and concepts were the focus of discussions among the investigators.

This is a structured approach to the text. Ambiguous or liminal phenomena that appeared to be related to becoming a mother but did not clearly meet the definitions were noted and set aside for further analysis to determine how they were related to these key concepts. Application of life course theory to the phenomenon of becoming a mother, about which a significant literature exists, allowed for an expansion of the understanding of mothering a medically fragile preterm infant.

An important caveat in applying an existing framework to data for analysis is that the meaning of the text may be obscured by an overly strict interpretation based on the constructs of the framework Flick, An important safeguard to prevent this is careful paraphrasing to explain the text, not to replace it.

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Three experienced mothers were 24 years old or younger; 1 of these was an adolescent 19 years old. Of those with no previous experience, 9 were 24 years old or younger; 3 of these were adolescents less than 20 years old. Subsequently, within-group comparisons of experienced and inexperienced mothers were made to examine similarities and divergence in their experiences of their high-risk pregnancy and mothering of their medically fragile preterm infant.

Later, between-group comparisons were made. This flexible analytic strategy allowed for the development of findings supported by the data that went beyond the initial life course principles and concepts.

A Life Course Framework

Therefore, cross-sectional analysis at specific time points was not a useful analytic strategy. Narratives about pregnancy were necessarily retrospective, with mothers beginning to make meaning of the end of the pregnancy and delivery by the time of the initial interview. The prospective nature of subsequent interviews allowed mothers to articulate both their current concerns regarding their infant and mothering and a retrospective view of what had happened since the last interview.

Mothers frequently referred to informational technology electronic fetal monitoring [EFM], ultrasonography, photography, infant monitors and supportive technology ventilators and feeding tubes. Both types of technology were simultaneously reassuring and confusing as meanings of these data were often ambiguous. This was particularly true of EFM. An ultrasound examination revealed that her cervix was dilated 4 centimeters.

She did not appreciate the presence of contractions until the EFM showed them. For this woman, technology refuted her physical experience of no labor. Similarly, ultrasonography during pregnancy yielded ambiguous findings. One fetus with a large neck mass was given poor odds for survival, although the physician admitted that she did not have much information on which to make that assessment.

Photographs were another form of informational technology for the mothers. After delivery, photographs of their infants were given to mothers who could not yet see them first hand. As with ultrasound images, photos yielded ambiguous information requiring interpretation. Half of the women had cesarean sections and protracted recovery periods. Separated from the reality of the birth, many mothers awakened from general anesthesia fearing that the infant had died. Photos allayed these fears. However mothers usually had to ask nurses to interpret monitoring and life support devices in the photographs.

Mothers marked time and infant progress by ventilator settings and oxygen requirements. For these mothers, presence of the ventilator signified a troublesome impediment in establishing a physical and emotional relationship with their infants. Although competence was their goal, mothers mourned the loss of what they never had: Their mourning was particularly apparent in early mothering. One mother recognized the heavily technologized environment that her infant required to survive: The two concepts will be considered together as the issues of timing, especially the disruption of high-risk pregnancy ending prematurely, and the ensuing adult developmental issues for the mothers were closely related.

Distinct developmental differences were found between first-time mothers and experienced mothers. However, activities of late adolescence and early adulthood such as unencumbered socializing were replaced with the responsibilities of parenthood.

Life Course Framework: Principles

For young first-time mothers, these experiences resulted in accelerated maturation, leaving them out of step developmentally with their childless peers and those with normal pregnancies and deliveries. This meant that they inhabited an ambiguous developmental space, older adolescents or young adults by age but facing responsibilities usually reserved for older persons. Preterm birth represented a turning point for these young mothers, forcing them into adulthood early. Like younger, first-time mothers, experienced mothers also described developing patience and strength to face future setbacks.

However, older, experienced mothers described this situation in relation to their previous experiences. These mothers felt competent, even when this was their first preterm infant. Experienced mothers made the needs of children at home a priority over those of the hospitalized infant; the sick infant had caregivers around the clock, while children at home depended on her. These mothers described increased patience and willingness to see the pain of others. Issues of faith were also salient to adult development.

Mothers frequently commented on an increased reliance on faith and religion, striving to discern meaning or a larger sense of purpose in their lives. Issues of agency were most salient to women at two particular occasions: At the end of pregnancy, the locus of agency lay outside the women. The end of pregnancy was often sudden and unexpected, catching the women off-guard. This situation underscored their liminal state.

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Agency was a matter of weighing the unforeseeable or ambiguous consequences of their decisions, balancing their own needs and desires for a child against the suffering and sequelae that the infant might endure. The principle of linked lives explains the ways that mothers formed social and emotional linkages with their infants. First-time mothers generally had different experiences from mothers with previous children. Mothers with previous children found that their attention and energy were, regrettably, divided between the hospitalized infant and their children at home.

Experienced mothers described social hierarchies similar to those of new mothers, with the exception that their previous children took priority over the hospitalized infant. Mothers differentiated between feeling love for the infant and the establishment of a bond between them. Mothers recognized a lack of depth or significant attachment to the infant after birth that functioned to spare their feelings if the infant died. They occupied a liminal space where love was present but deeper bonds that tied the infant to them and their extended social network were not yet forged.

Several mothers initially were equivocal in their desire to see their infant, afraid that this would cause them more suffering if the infant died. A first-time mother described a tearful epiphany in the NICU: An important turning point for all mothers was taking the infant home for the first time.

Parenthood, Childlessness, and Well-Being: A Life Course Perspective

Home was closely tied to becoming the mother of this particular infant. Taking the infant home decreased the liminal quality of early mothering: Going home meant abiding links could be forged among the mother, infant, and their larger social world; mothers could finally establish deeper relational bonds with their infants without interruption of hospital routines. Thus they imposed severe constraints on their social network by placing unambiguous, nonnegotiable limits on contact with the infant.

These mothers found their social network temporarily limited to close family members although more casual social ties were suspended. Constant vigilance, exhaustion and lack of routine were common at first. Extended family, especially other women, played vital roles in supporting the mothers through the disrupted pregnancy, early delivery and infant illness.

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  7. Second only to supportive husbands or partners, female family members provided material support, including care for the children at home, fixing meals and caring for the infant when parents returned to work and re-established their social lives. Familial tensions occasionally flared under the stresses of parenting a sick infant. For another mother, problems with her father that she believed had been resolved resurfaced.

    Social activities were suspended while the infants required supportive technology and were perceived as vulnerable. Mothers often relied on persons in their wider social network for material support: Occasionally, special offerings from church helped ease financial strains. By this time, infants typically had decreased or no supplemental oxygen requirement and were tolerating feeding either tube or bottle feedings, although some had more substantial needs.

    Also, mothers were confident experts in management of technology by this time. Perceiving their infant as less vulnerable, mothers cautiously restored activities with friends and resumed attending church. Liminality and ambiguity were replaced by confidence in their mothering and incorporation of the infant into a sustained social network of family and friends. This theoretical perspective allowed for examination of the social context of maternal development.

    Mothers first narrowed and then widened their social worlds over time in order to link the lives of their new infant with their families and other significant persons. These spheres widened later when mothers perceived their infants as less vulnerable and their confidence increased in their ability to manage infant care.

    At home, mothers claimed their role as primary protector and care provider without the constraints that the NICU imposed.

    Maternal role and identity were key issues in navigating the difficulties of mothering in a confusing technological context and a narrowed social sphere. First-time mothers faced the challenge of mothering without previous experience through which they felt competent. They worked at feeling like a mother first, and then the mother of this specific child.

    Experienced mothers were more confident in their maternal role and caretaking skills but still needed to accommodate this infant into the existing family structure and social world. Mothers employed two distinct measures to reduce liminality associated with their transition to motherhood of this child. First, they exhibited a high degree of protectiveness. In our analysis using life course theory, the transition into motherhood varied between first-time mothers and women with mothering experience, a phenomenon reported by Rubin in early work on maternal role attainment.

    More recently, Mercer challenged the concept of maternal role attainment, suggesting that the process of becoming a mother begins before or during pregnancy and ends when the woman has achieved the maternal identity, around 4 months postpartum. For women with no previous mothering experience, the birth of a preterm infant impels them into the parenting trajectory prematurely, marking a particularly ambiguous transition where maternal identity is as yet unclaimed. The nature of medically fragile infants is typified by uncertainty and frequent health setbacks, complicating but not precluding becoming a mother.

    Although commonalities existed among mothers of medically fragile preterm infants, idiosyncratic events and responses shaped how each woman comes to identify herself as mother of this infant. This is similar to the finding of Miles and Frauman in their study of 15 medically fragile preterm and fullterm infants. These concerns and ambivalence are imbedded in the experiences of mothers whose pregnancy were complicated by a high-risk condition and preterm delivery.

    Mothers whose preterm infants become medically fragile encounter additional challenges that both mirror and magnify the concerns of mothers of healthy infants. Protecting the vulnerable infant became the means to preserve the opportunity to mother this child fully.