2012. Vol.3, Special Issue, 810-817
Published Online September 2012 in SciRes (
Copyright © 2012 SciRes.
“Smile through It!” Keeping up the Facade While Suffering from
Postnatal Depressive Symptoms and Feelings of Loss:
Findings of a Qualitative Study
Kari Vik1, Marit Hafting2
1Department for Child and Adolescent Mental Health, Sorlandet Hospital, Kristiansand, Norway
2Department for Child and Adolescent Mental Health, Voss Hospital, Voss, Norway
Received May 23rd, 2012; revised June 24th, 2012; accepted July 28th, 2012
This qualitative study describes a research project in Norway comprising 15 mothers with postnatal de-
pression and/or depressive symptoms and their experiences of loss in the early period following childbirth.
During in-depth interviews, the mothers provided detailed descriptions of various loss subjects. Qualita-
tive analysis revealed three global themes: loss of former identity, loss of self-reliance and lack of capac-
ity for self-care. The analysis and discussions include perspectives from medicine and sociology. The de-
scriptions may be valuable for health professionals’ understanding and assessment of postnatal depressive
symptoms in mothers. The findings may also help to bridge the gap between medicine and sociology;
furthermore, the results demonstrate the importance of an interdisciplinary approach to this multifaceted
and complex phenomenon.
Keywords: Postnatal Depression; Loss; In-Depth Interviews; Qualitative Study; Primary Health Care
Services; Interdisciplinary
The transition to motherhood comprises a range of physical,
psychological and social changes both for the new mother and
the family. Traditionally, the postnatal period was defined as
roughly 40 days in most cultures. If economy and social status
allowed, the new mother was supposed to rest, sleep, enjoy the
baby and adjust to the new situation (Eberhard-Gran et al.,
2003). Currently, the trend is an increasingly earlier discharge
from the maternity unit. Many new mothers are discharged from
the maternity unit even before breastfeeding routines are estab-
lished, although it is quite common for mothers to feel insecure
in caring for their newborns (Kurth et al., 2010). At home, the
mothers are mostly left on their own with limited possibilities
for rest and support.
In contemporary western societies, freedom of choice is val-
ued highly (Giddens, 1991). Couples choose their spouses based
on love rather than traditions. Expecting parents are challenged
by many choices related to the care of the baby and must cope
with the fundamental impacts of their choices on their family
(Giddens, 1992). This challenge constitutes a heavy burden of
responsibility. Simultaneously, impressions from popular media
indicate that having a baby seems to be taken lightly in many
families. Birth is represented as something that simply occurs
while life continues as previously, and mothers have time and
additional energy to see friends and carry on with career build-
ing and marital life as previously. Subjects such as bodily
changes or loss of professional identity are often themes in the
popular press along with the myth of the happy mother (James,
1998; Lloyd & Hawe, 2003; Oakley, 1985). Support from ex-
tended families such as grandparents is replaced by greater
demands on the caring abilities of fathers, reflected in social
legislation and longer postpartum paternity leave periods. The
triadic relationship comprising mother, father and child is
strengthened and plays a more important role than previously
(Hedenbro, 2006). Simultaneously, single motherhood, broken
marriages and conflicts related to custody and the care of chil-
dren are increasing.
Much of the existing research literature on postnatal depress-
sion and/or depressive symptoms (PND/S) (Matthey et al.,
2001) focuses on issues such as risk factors, prevalence, effects
on offspring and treatment and management. These issues are
important and must be addressed. However, this focus reveals
that pregnancy and childbirth are dominated by the medical
discourse and might gain from considering other perspectives,
such as sociology (Lewis & Nicolson, 1998). Thurtle (1995)
states that biological and psychological approaches do not pre-
sent a full picture of the postpartum period and suggests that
sociological approaches drawing on feminist, stress and label-
ling models may contribute. For example, a feminist viewpoint
regarding questions of motherhood was included in a study of
negative thoughts following childbirth (Hall & Wittkowski,
2006). Such thoughts are common also among nondepressed
mothers. Fisher et al. (2006) indicate the ever-increasing bio-
medical instrumentation over an event that in most societies
was viewed as a woman-centred, non-medical event.
Many new mothers describe the perinatal period as a paradox
in which they are happy to be mothers and simultaneously un-
happy due to the losses in their lives resulting from the new
situation: losses of autonomy and time, appearance, femininity
and occupational identity (Nicolson, 1999). Sethi (1995) de-
scribes this as a dialectic process in which new mothers’ ex-
periences may comprise a dichotomy of feelings between the
giving of themselves to the baby and losses of autonomy and
freedom. The solution was a redefining of the self, relationships
and professional goals. Stern (2004) terms the period prior to
and following childbirth “the motherhood constellation” and
states that the mother is in a life crisis that disorganises and
reorganises much of her psychological life.
In a metasynthesis comprising 18 qualitative studies, Beck
(2002) describes four overarching perspectives involved in
PND: incongruity between expectations and the reality of
motherhood, spiralling downward, pervasive loss and making
gains. Pervasive loss was inter alia described as loss of auton-
omy and time, appearance, femininity, sexuality, occupational
identity, support and control, control of negative emotions and
the former self. Further, Beck emphasises that it is suitable that
loss be identified before the healing grief work can begin;
hence, knowledge of these phenomena can guide clinicians to
differentiate and acknowledge the many forms of loss that new
mothers can face.
In a qualitative study of PND/S and video interaction guid-
ance (VIG) carried out in Norway (Vik, 2010), a sense of loss
emerged from the interview data. In this paper, we present
identified aspects of the loss phenomena from rich descriptions
offered by the mothers. The results presented here will supple-
ment the body of knowledge about the loss phenomenon and
The main aim of this paper is to present analysis of new
mothers’ descriptions of loss related to childbirth and PND/S.
The paper also aims to bridge the gap between sociology and
medicine. We attempt to do this by analysing and discussing
the topic through the integration of sociological theory in a
traditional medical field.
Materials and Methods
Sampling Procedures
The participants were recruited from a health centre. At a
routine check-up six weeks following delivery, all new mothers
completed the Edinburgh Postnatal Depression Scale (EPDS)
(Cox et al., 1987), a screening instrument validated for use in
Norway (Berle et al., 2003; Eberhard-Gran et al., 2001). A low
cut-off score (8) was chosen to secure variation in the material
and PND/S. Recruitment lasted 20 months, from August 1,
2003 to April 1, 2005. Subsequently, after all identifying in-
formation was removed, the forms were sent to the first author
(K. Vik, 2010), who calculated the scores. Next, she contacted
the health centre for identification of the mothers who scored
above the cut-off point and invited them to continue participa-
tion in the study. The sample size was estimated to be 10 - 15
mothers. It was determined that 15 were necessary for variation.
See Table 1 for a description of the sample.
Data Collection and Study Material
Data were collected by K. Vik and consist of in-depth semi-
structured interviews prior, immediately following, and six
months subsequent to the VIG intervention. All 45 interviews
were tape recorded and transcribed verbatim by K. Vik. The in-
terviews lasted from 22 to 92 minutes with an average of 62
and a median value of 60 minutes. The interviews were con-
ducted according to an interview guide with open-ended ques-
tions. The 15 participating mothers described that they felt
themselves to be struggling with depression or depressive
symptoms, and the mothers had scored between 8 and 19 on the
EPDS screening. None of the participants was asked explicitly
about experiences of loss.
Analysing Methods and Procedures
This study focused on documenting the individual mothers’
account of reality rather than the objective reality itself (Smith,
Table 1.
An overview of descriptive features of the sample.
Mother’s age Number of children Civil status Education Housing situation Baby’s age1 EPDS-score
27 2 M S OH 6 10
24 1 M St RF 14 18
22 1 C P RF 9 10
19 1 S St PH 7 19
24 1 M P RF 6 8
25 1 M T OH 6 14
30 2 M T OH 18 19
34 2 M T OH 9 10
24 2 C P OH 9 11
26 4 M S OH 7 15
33 2 M T OH 8 8
40 2 M S OH 9 9
32 2 M T OH 22 11
22 1 S P RH 20 15
21 2 S P RH 7 14
Mean 27.6 Mean 10.5 Mean 12.7
Median 26 Median 9 Median 11
Explanations: Civil status: married = M, co-habitant = C, single mother = S; Education: primary school = P, secondary school = S, student = St, tertiary level (col-
lege/university) = T; Housing situation: own detached house = OH, rented house = RH, rented flat = RF, parental home = PH; Baby’s age: age of newborn (in weeks) at the
time of the first interview.
1There were several reasons why some interviews did not begin immediately following recruitment, e.g., the baby was premature, the mother had accidentally
taken the EPDS form with her and it was delivered several weeks later, or it took some time to find a suitable occasion.
Copyright © 2012 SciRes. 811
1999). A phenomenological approach (Sokolowski, 2000) helped
the participants to provide their own stories, whereas the re-
searchers’ preconceptions are placed in brackets. We have strived
to maintain a reflexive attitude towards the collection and ana-
lysis of the material. This attitude includes our own theoretical
and experiential perspectives (Hammersley & Atkinson 1983).
Under these circumstances, “the loss theme” emerged from the
mothers’ stories but was never subject to direct questioning.
Thus, an immersion/crystallisation analysing approach (Borkan
1999) was a first step in the analysing process. Then, we con-
structed a categorisation facilitated by thematic net- works as
an analytic tool (Attride-Stirling, 2001). Thematic net- works
are weblike illustrations summarising main themes that consti-
tute pieces of texts. This manner of presenting the networks
illustrates the non-hierarchal nature of the findings and empha-
sises the interconnectivity among them. Following further dis-
cussions and back- and forth investigations of the material, the
data were condensed into three global themes: 1) Loss of for-
mer identity; 2) Loss of self-reliance; and 3) Lack of capacity
for self-care. The analysing process was assisted by NVivo 8
qualitative software. We offer an example to illustrate the ana-
lysing process: Analysis of the entire text identified “insecu-
rity” as a basic element, expressed as the mothers’ insecure
attitude and feelings in their experience of the organising theme
of “not mastering new tasks”, which was one dimension of the
global theme 2, loss of self-reliance. The data were analysed by
both authors in collaboration; however, the main body of work
was conducted by the first author.
The project was approved by the Regional Committee for
Medical Research Ethics and the Norwegian Social Science
Data Services. The participants were informed both in oral and
written form before they signed a statement of consent. The
participants were assessed by an experienced psychiatrist to
ensure that they were referred for further treatment if needed.
The mothers who declined to participate were offered other
types of treatment or follow-up.
The data analysis revealed three global themes related to loss in
the early postpartum period as experienced by the mothers:
1) Loss of former identity;
2) Loss of self-reliance;
3) Lack of capacity for self-care.
In this section, we explore and describe the basic elements of
these global themes expressed by the mothers. Furthermore,
using a phenomenological approach, thematic networks and our
own theoretical background and presuppositions, we elaborate
the organising categories through which these expressions are
experienced as interpreted by the authors. The global themes
and organising categories are illustrated in Figure 1. Both
global themes and organising categories overlap each other at
times. Quotes from first-time mothers (primipara) are marked
with a capital P in parentheses, and quotes from second-time or
more (multipara) mothers are marked with (M). In addition, the
ages of the mothers are added. All quotations are depersonal-
Loss of Former Identity
“During pregnancy, of course I knew it would be hard, but I
didn’t know that it completely changed everything!” (P, 25).
The mothers experienced the newborns’ total dependence and
fragility as overwhelming and felt invaded and confused. The
mothers described a loss of former self for which they were not
prepared, and when they compared birth with other changes in
life, for example work changes, they found giving birth to be
totally different. They realised that becoming and being a moth-
er is not a role that one can escape. The mothers reflected on
this; for example, some of them questioned whether their ex-
pectations might be too high. Despite these reflections, which
seemed to be on a theoretical level, the mothers were not able
to integrate this part of their identity. Loss of former identity is
presented in the following organising categories: 1) Missing
professional and social life; 2) loss of former body and 3) con-
flicting feelings regarding the roles of mother and partner. Loss
Figure 1.
Loss of identity, loss of self-reliance and lack of capacity for self-care.
Copyright © 2012 SciRes.
of former body comprises the physical body, the sense of the
body and the body image. We present them by degrees and
offer quotations from the mothers as illustrations.
Missing Professional and Social Life
The mothers reported that they missed their professional and
social lives and wanted their jobs, social lives and leisure ac-
tivities. Simultaneously, they found this hard to admit even to
themselves and felt that those surrounding them expected them
to be happy and content:
I had hoped it shouldn’t be like this. During pregnancy,
me and my husband talked a lot about these matters, for
instance how to organise our lives so that we could bring
the baby with us and go on like before. And maybe we have
been taking him out too much; he is still just a few weeks, but
nevertheless we prioritise social life. And I really should
wish that my whole life wasn’t totally changed, but it is;
to a certain degree it really is. (P, 25)
Some of the mothers expressed self-reproach when they ac-
knowledged that they found it boring to stay at home. Disclos-
ing this feeling was hard and at the same time, the mothers
found these feelings socially unacceptable among new mothers
and in society. However, the mothers really missed their jobs
and their professional identities and found the transition to
motherhood difficult:
I think it would have done me good to have some other
plans. But many people envy me, I am aware of that, um,
that I can start every day without a special timetable. But,
I envy them, a little. Because I think it is important to ··· I
mean I feel my brain is shrinking when the only thing I do
is change nappies. (M, 33)
This quotation also describes a feeling of worthlessness as a
mother. In the mother’s view, worth was connected to other
tasks, for example professional life. The mothers expressed that
they could no longer use their former abilities and competen-
cies. Another dimension of the loss of social life was described
by this young primipara:
What bothers me is that I know that if I hadn’t had him I
would still have the opportunity to have fun. Not that I’m
talking about getting drunk or things like that, just to
dance, dance for hours wearing high-heeled shoos, be-
cause I love to dance... I am confused; on the one hand I
want my friends to call; on the other I am better off with-
out them. (P, 19)
Loss of Former Body
“I was not sick, just pregnant” (P, 25). This quotation reflects
a very confusing sentiment related to the bodily changes that
naturally follow pregnancy and childbirth. On the one hand, the
mothers experienced this statement as true: pregnancy and
childbirth are not an illness but a natural process. On the other
hand, the process was followed by fundamental though varying
bodily changes and altered appearances. Hence, loss of former
identity was also expressed as difficulties accepting and inter-
nalising the “new” body. The mothers had difficulties adjusting
to weight gain and stretch marks, and they missed their former
appearances; for most of them, a slim and fit body was replaced
by a feeling of being heavy, clumsy and unattractive. Again, the
mothers seemed to be aware of these changes on a theoretical
level, but they were nonetheless hard to accept:
I discovered myself after birth, um, being there with the
child and I looked awful. I wasn’t prepared at all, think of it,
a woman that is slim and fit and working all the time, do-
ing exercise and workouts, and suddenly she is supposed
to sit at home with the baby, um ··· then you rapidly gain
weight. (P, 24)
Conflicting Feelings Regarding the Roles of Mother and
Some mothers expressed that a feature of their frustration
was confusion about and difficulties choosing between the baby
and the husband. These conflicting feelings were not inflicted
on the mothers externally but rather stemmed from their own
Like when we went to bed at night, on the one hand I
wanted to lie close to my husband because I figured it
would be so good to be myself again, without that big
belly. And he was so safe and protective so I wanted him.
And on the other hand I just wanted to have the baby with
me in bed. So this was a huge conflict for me. It was hard
to choose between the two. (P, 25)
Loss of Self-Reliance
“The insecurity, the fact that I am in doubt all the time, this is
much worse than I had imagined” (P, 22). This loss theme
dominated most frequently in the immediate postpartum period.
The primiparas in particular described a lack of security and
self-confidence in their new role that was much worse than they
had imagined. However, some of the multiparas also experi-
enced this insecurity. For example, the multiparas had expecta-
tions of a baby similar to their firstborn, but the reality turned
out to be different; additionally, they found it hard to cope with
two children with different demands. The organising themes in
this section are as follows: 1) not mastering new tasks; 2) un-
able to cope with conflicting demands; 3) lack of support from
partner and 4) loss of emotional control.
Not Mastering New Tasks
“I wake up quite often just to make sure that she’s alive” (M,
26). The mothers described the loss of self-reliance as anxiety,
frustration and lack of self-confidence in their new role. The
mothers perceived their babies as so tiny and fragile, and they
didn’t know how to handle the responsibility, which they found
overwhelming. The mothers experienced the baby as com-
pletely dependent on them for survival and described anxiety
related to the baby’s life and wellbeing, for example the fear of
sudden infant death syndrome. Some of the mothers described
this insecurity as lack of information:
I think it’s really hard; you just get a baby on your lap and
that’s it, and the child is supposed to be with you your
whole life. A small child, it cannot express what it wants
or needs. It was very hard, there was no information. (P,
Unable to Cope with Conflicting Demands
The majority of mothers in this category were multipara, and
the conflict was between the needs of the newborn baby and an
older child, most often a toddler. The mothers described deep
Copyright © 2012 SciRes. 813
frustration in situations in which they had to choose between
the baby and the older child. The mothers felt insecure and
expressed that they had lost their self-reliance.
I feel that it is very hard with the toddler; he is a bit jeal-
ous so I feel a bit torn between them. I cannot concentrate
a 100% on both of them. I wasn’t prepared for two kids
screaming and that I had to choose between them. That
feeling, um, I was not prepared for how hard that feeling
was, torn apart every day. And I don’t know how to deal
with it. (M, 27)
Lack of Support from Part ner
Loss of self-reliance expressed as lack of support from a
spouse was experienced by all the mothers who were married or
cohabiting. The mothers particularly longed for support that
they themselves did not initiate and that they did not have to
fight for (or even ask for). The mothers missed recognition
from their partners and felt simultaneously disappointed and an
unspoken pressure to give their spouses some space away from
the family:
I really want him to stay more at home, but it is really dif-
ficult to ask. I don’t want our friends, or him, to think that
I am prudish; rather I want them to think that I give him
the freedom he needs. (M, 27)
The mothers wanted their spouses or others to take the baby
occasionally on their own initiative so that the mothers them-
selves would not be the one that always complained. The
mothers were devastated by the responsibility and felt that they
had to cope with it alone, that the partner often regarded the
situation very lightly:
I get the feeling that, um, that he is only my responsibility
and when that’s on top of the whole situation with depres-
sion and the like it only makes things worse. It seems as
though it is easy for men to think that it is mothers that
have the responsibility. They can just leave and consider it
for granted that I will take care of him. (P, 22)
Loss of Emotional Control
“I feel tired and I feel that it makes me very unstable. And
when I am unstable I get sad. And I feel that I get sad because
I’m tired, or maybe it’s the opposite” (M, 34). The mothers
experienced altered moods varying from clinical depression and
anxiety to distress expressed as sadness, insecurity, fear, and/or
anger. Some of these feelings were concretely related to, for
example, traumatic birth experiences or memories of past births,
difficulties in close relationships, crises and traumas from the
past, such as neglect and abuse. Other feelings were unexpected,
and the mothers could not explain or understand them and
found it difficult to control these feelings:
Just that little episode, I was talking on the phone and
suddenly I upset my coffee cup and there was coffee all
over the table and I just could not cope, no, no! I just sat
down and started to cry and it was like, um, why did I do
that? Why did I despair so much just because I upset the
coffee cup? (M, 40)
Lack of Capacity for Self-Care
The mothers reported that they missed the ability or opportu-
nity to take care of themselves, for example, with regard to
hygiene and meals. First and foremost, the newborn baby was
the centre of their attention and after that, other issues came
before their own needs. Lack of support from partners as de-
scribed in 2.3 was also explained as a feature of the lack of
capacity for self-care. The mothers claimed that if the partner
had participated more, the mothers would have had the oppor-
tunity to eat, take a shower or rest. The organising themes in
this section are 1) too little time on her own and 2) keeping up
the facade.
Too Little Time on Her Own
“It is too little sleep. I can’t sleep during the day when he is
taking a nap. I am far too anxious”. (M, 32) The constant lack
of sleep was a characteristic of lack of self-care shared by all
the mothers, who described that they felt always tired and often
overwhelmed by an urge to sleep. The mothers felt it hard to
lose their former independence, and even if they were prepared
for this on a cognitive level, it still overwhelmed them.
So... it is all very busy and, yes I have been very tired and
no matter how much I sleep there is never enough of it.
Even if my husband takes him in the morning and I can
sleep for long it is not enough. (P, 24)
In addition to lack of sleep, the mothers described frustration
in their everyday lives because they were unable to conduct
simple everyday activities concerning their own wellbeing,
such as taking a shower, going to the toilet, eating breakfast and
the like. The baby was always present and demanding their
There is one thing that depresses me, that is, um, that is
that I cannot get out. I feel locked up. As soon as there is a
chance for me to dress and get out for some fresh air then
I have to feed him again, and then I have to feed myself,
because that I had forgotten to do. And when I have eaten
then it’s his turn again, and... I feel trapped. (P, 22)
Keeping up the Facade
“Smile through it!” said one of the mothers (M, 30), referring
to her own mother. The quotation reflects some of the circum-
stances under which she was born and bred. It was important
for this family to maintain a facade in all circumstances. This
example reflects another characteristic of the mothers’ reduced
ability to care for themselves and to identify and recognise their
own needs. Keeping up the facade stole their time and attention.
To a variable degree, all the mothers in this study were busy
keeping up the facade, demonstrating how happy they were and
how perfectly they managed mothering and their other roles:
“No one can see that I actually do not manage” (M, 33). The
mothers often had visitors and were occupied with demonstrate-
ing a clean and cosy home and serving coffee and cookies:
Well, I should have calmed down, taken things more eas-
ily and then just said that “no, we don’t deal with visitors
right now”. But I was also proud and happy and every-
thing, so it wasn’t easy to know what was the right thing
to do. But we should have just relaxed and enjoyed our-
selves and the new baby, our own little family. (M, 24)
This sentiment demonstrates that it was complicated for these
mothers in the immediate postpartum period to identify and
recognise their needs and determine what was best for them and
Copyright © 2012 SciRes.
their family.
Another dimension of the facade theme was that the mothers
compared themselves to other mothers, the neighbour next door,
relatives or friends and in that comparison, they did not, in their
own eyes, compare favourably:
Yes, that’s what I do, I look at others. There is this super-
mammy next door and I was glad that I hadn’t seen her
after I extended kindergarten time for the eldest. Then by
accident I ran in to her the other day and I just hurried in-
side. I didn’t want to meet her and tell her that due to my
condition I have extended kindergarten. It is difficult; it
feels really bad. (M, 21)
We have reported excerpts from 15 mothers’ descriptions of
various loss themes categorised into three global themes: loss
of former identity, loss of self-reliance and lack of capacity for
self-care. We will discuss the various themes and categories in
light of their basic elements and theories and other studies on
similar subjects.
Much of the loss phenomena concentrated on loss of former
identity. This finding is also reported by others; for example,
Davies and Welch (1986) state that being a person and being a
mother can be experienced as mutually exclusive, especially
when there is a high level of idealism about motherhood. The
idealism lies in unspoken demands from friends, relatives,
neighbours and dominating cultural beliefs expressed in the
popular media and communicates that a good mother should
master numerous tasks in addition to mothering shortly after
childbirth (Lee, 1997). In our sample, this idea was expressed
as loss of professional and social life, bodily changes and con-
fusion over mother and spouse roles. This idealism or cultural
expectation of happiness can be associated with a female “ethic
of care” as described by Gilligan (1982). This ethic is to a high
degree an ethic of self-sacrifice. Davies and Welch extrapolate
this point, claiming the following about mothering: “however
willingly this is done, the price, loss of sense of self and loca-
tion in the world can be hard to cope with” (1986: p. 419).
An enormous volume of information about the transition to
motherhood is available in western contemporary societies.
Hence, one should presuppose that the changes regarding loss
of former identity related to having and caring for a baby would
be properly addressed. However, the information from health
authorities is not sufficient. Lewis and Nicolson (1998) argue
that it is the medical/clinical discourse on these matters, as
described in the introduction, which regulates mothers’ organi-
sation of subjective experience and perception of motherhood.
Another perspective is that pregnancy and childbirth are natural,
and there is the societal norm that emphasises freedom of
choice and individual responsibility. Brudal (2000) suggests
that giving birth should be considered an existential crisis. A
new identity is about to be formed, and women expand their
roles to encompass the role of becoming and being a mother.
This crisis is most fundamental for first-time mothers but is
also experienced by multiparas. Regarding loss of the former
body, the attitude expressed by some mothers of not being sick,
simply pregnant is also a dominant attitude in the popular me-
dia (James, 1998); therefore, the attitude is an understandable
though not realistic ideal for the mothers and many young
mothers-to-be. In an Australian study, the tension between
motherhood (the private sphere) and achievement (the public
sphere) is explained as one source of PND. The researchers
suggest that a solution to the problem is to educate the mothers
and families to have a realistic view of parenting (Lloyd &
Hawe, 2003).
The second global theme in our study is loss of self-reliance,
exemplified by not feeling able to master new tasks, unable to
cope with conflicting demands, lack of support from spouse and
loss of emotional control. Drawing on sociological theory, we
state that in contemporary western societies, insecurity and
risks are increasingly related to uncertainty concerning the so-
cial and existential parts of our lives (Beck 1992). This insecu-
rity occurs on a subjective level of consciousness and identity.
Giddens (1991) states that currently, identity depends on the
formation of a reflexive self, which, in turn, emerges only in the
presence of ontological security. The dangers threatening hu-
man beings are no longer wild beasts but the risks of not man-
aging engagement in close relationships. Security, formerly
related to family and tradition, is jeopardised by these important
societal shifts that also influence the transition to motherhood
and the lack of self-reliance that the mothers in this study de-
With regard to loss of self-reliance, we focus on the third or-
ganising category in this discussion. Marital problems or con-
flicts most often focused on the partners’ lack of support and
understanding. The mothers longed for recognition and ac-
knowledgement in their new roles and were frequently reluctant
to ask for help; instead, they wanted their partner to see for
himself how he could contribute and support. Morgan et al.
(1997) report a similar result: “They hope their partners will
read their minds, provide necessary nurture and perceive how
their (the women’s) needs have changed since the arrival of the
baby” (p. 916). The level of satisfaction with partners’ contri-
butions to the household is a strong predictor of mothers’ psy-
chological wellbeing and pinpoints the importance of social
support, especially from partners, and its vital role in buffering
the effects of life events and stressors such as childbirth (Lee
1997). Therefore, awareness of this issue is of great importance
in clinical practice and counselling; and in particular, the gap
between the mothers’ unexpressed and expressed wishes re-
garding what they want from their partner.
Lack of self-care is the third global theme in this study. The
organising categories under this theme are: too little time on her
own and keeping up the facade. Lack of self-care was particu-
larly expressed as insufficient sleep. In preparations for moth-
erhood, sleep is an important issue, and mothers-to-be are ad-
vised to find ways to ensure that they sleep enough. Although
“everybody” understands the importance of sleep and that there
is less opportunity to sleep due to night-feedings and similar
tasks, the mothers prioritised, for example, keeping up the fa-
cade rather than sleeping during the day. Lack of self-care was
also described as being locked up. The presence of the baby
hindered the mothers in eating, taking a shower or getting some
fresh air. Wood et al. (1997) state this finding as follows: “She
is completely overwhelmed by the demands of her infant, and
feels trapped, angry and afraid” (p. 311).
We have organised the category of keeping up the facade
under the global theme lack of self-care, though it permeates all
the other themes. A heavy burden related to loss is the conflict
between, on the one hand societal norms, cultural beliefs and
demands, and on the other hand, the lives people actually live,
reflected in a very great number of references to the facade.
Whether these demands are real is of less importance as they
Copyright © 2012 SciRes. 815
are perceived as real by the mothers and hence bear real conse-
quences. Wood et al. (1997) report that “The facade of nor-
malcy” is a distinct feature of postpartum depression. Her in-
formants described a “former self” that focused on performance
and control in their former roles. Suffering depression, the
mothers no longer handled their lives and did not dare to dis-
play their misery to others. Other studies report the same need
for perfection and often on behalf of self-care (Morgan et al.
1997). Additionally, nondepressed mothers have reported fear
of acknowledging negative thoughts and feelings because they
were frightened that it might lead to being regarded as unfit for
motherhood or being labelled mentally ill (Hall & Wittkowski,
Becoming a mother is expected to be a happy event. When
new mothers suffer PND, for which the prevalence is 13%
(O’Hara & Swain, 1996) or PNDS, with a prevalence of 16%
(Thio et al., 2006), the problem seems to be isolated first and
foremost to the individual mother and her infant and subse-
quently to the father and extended family and their GP or other
health institutions. The meaning that the mothers themselves
give to their situation is still somewhat absent, at least in the
health services that should help these women. Both experts and
lay people seem to consider PND to be distinct from the social
context of motherhood and childbirth. If losses of autonomy
and time, appearance, femininity and sexuality and occupa-
tional identity were acknowledged and the mothers were en-
couraged to grieve, PND could be considered a potentially
healthy process towards psychological re-integration and per-
sonal growth instead of a pathological response. Furthermore,
new mothers could experience psychological re-integration and
personal growth (Edhborg et al., 2005; Harris, 2003; Nicolson,
Are the loss experiences reported in this study a result of
PND/S, or do the burdens of loss lead to depression? Lee (1997)
claims that it is more reasonable to see PND as one end of a
continuum of normal adjustment to motherhood. Nonpsychotic
depression after birth is not qualitatively different from other
depressions and is best understood as lack of or inadequate
social support, high workloads and unrealistic expectations of
motherhood. In light of previous customs and rites related to
childbirth, it is evident that motherhood in contemporary west-
ern societies poses extensive adjustment problems for most wo-
men. The cultural expectation of happiness and mastery leads
many new mothers to suffer a combination of work overload
and guilt and causes reluctance among new mothers to share
their suffering. Edborgh et al. (2005) report that depressed new
mothers attempted to conceal their depressed mood because
they did not dare to reveal it or they did not have anyone to
speak to about this problem. When mothers do not share their
concerns, perceived demands cannot be corrected by people in
the new mothers’ environments. The mothers in our study were
clear about the solution of the loss phenomena reported here,
which was to display their problems and seek support. A slogan
for both mothers and health professionals may therefore be
“talk through it!” in contrast to “smile through it!” For this
solution to occur, there is a need to extend the strict biomedical
view of pregnancy and childbirth. The three global themes in
this study are closely related. The themes are all embedded in
existential questions that the medical domain alone cannot an-
swer without drawing from other perspectives, for example
sociological theories. This study is a brick in the wall in the
process of bridging the gap between medicine and sociology.
Strengths and Limitations
Regarding depression, the sample in this study is subclinical;
as such, the findings are not transferable to the general popula-
tion of new mothers. This is a limitation of the study. Never-
theless, the participants were recruited with a low EPDS cut-off
value, which was chosen to secure variation in the sample with
regard to symptom load. In addition, the sample was drawn
from a suburb area comprising a wide range of socio-economic
levels. Hence, we argue that the results are transferable to simi-
lar samples of mothers, which represent a larger group than a
purely clinical one. Additionally, if we consider loss connected
to childbirth as a general phenomenon that is also reported in
other studies (Hall & Wittkowski, 2006; Harris, 2003; Nichol-
son, 1999), we can argue that the findings are transferable to
the general population of new mothers in contemporary western
Both authors are mothers and grandmothers. Important input
to this study derived from lengthy discussions with each other
about our own experiences, discussions with friends and others,
and from theoretical preferences and research in the field. In a
study such as ours, with a phenomenological starting point and
a qualitative interpretation and analysing process, we cannot
ignore the importance of these inputs; however, we can take
them into consideration, reflect on them and interpret them as
data sources in the analysing process (Hammersley & Atkin-
son, 1983; Orange, 1995). This reflexive attitude is a strength
of the study; without such an attitude, our own lived experi-
ences might represent the opposite, a limitation.
None of the participants was asked explicitly about experi-
ences related to loss; the participants’ accounts of this subject
occurred spontaneously, as reported in the Materials and Meth-
ods section. We argue that this practice strengthens the study
because it represents an assurance against data collected through
leading questions. To ensure internal validity, we have at-
tempted to display the research process by thoroughly describ-
ing the different steps in the research process.
Clinical Implications
The present study demonstrates the importance of increased
awareness in the public health system regarding the complexity
of loss phenomena and PND/S. Knowledge must be imple-
mented at GPs’ offices, health centres, family centres and in
specialised mental health services. Preparations for an existen-
tially different and more exhausting life should be a routine part
of health visitors’, midwives’ and GPs’ contact with pregnant
women and their partners in birth preparation courses. Health
workers at all levels must help mothers (and fathers) to adjust
their expectations to life as new parents. Plans for the postpar-
tum period other than to rest and care for the baby are not nec-
essary. New mothers are successful as women if they consider
responsibility for the care of the baby and themselves as a suf-
ficient goal.
Furthermore, it is necessary to increase knowledge and con-
sideration of the existential dimension connected to pregnancy
and childbirth and to be aware that theoretical understanding of
these matters is often insufficient. Such knowledge must be
combined with an openness that creates trust and allows moth-
ers to reveal their thoughts, or “talk through it!” If expectations
were more realistic, and feelings of loss were simultaneously
validated, then loss experiences could be integrated as a healthy
part of life as a new mother.
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 817
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