Health Care for Women International
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Frequency of illness in mother‐infant dyads L. Colette Jones RN, PhD & Peggy Parks PhD To cite this article: L. Colette Jones RN, PhD & Peggy Parks PhD (1990) Frequency of illness in mother‐infant dyads, Health Care for Women International, 11:4, 461-475, DOI: 10.1080/07399339009515915 To link to this article: http://dx.doi.org/10.1080/07399339009515915
Published online: 14 Aug 2009.
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Date: 06 November 2015, At: 09:17
FREQUENCY OF ILLNESS IN MOTHER-INFANT DYADS L. Colette Jones, RN, PhD College of Nursing, University of Nebraska Medical Center
Peggy Parks, PhD
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School of Nursing, University of Maryland
The purpose of this study was to identify the frequency and types of illnesses experienced by mothers and their infants who were in the second half of the first year of life, the actions taken concerning these illnesses, the number of days the mother was hospitalized or in bed because of illness, and the subjective health status of both as rated by the mothers. During home visits mothers (N = 182) completed the Health Status Interview. They were asked about infant and maternal illness in the previous month and the actions taken in response to them. The number and types of illnesses reported indicate that mothers of full-term infants who were healthy at birth must deal with a number of minor illnesses in themselves and in their infants. The possible relationship of maternal illness to stress is discussed and suggestions are given for interventions by health professionals. In the first few months after birth mothers must respond to many new demands. Among those causing much concern is illness in their infants. Sometimes mothers are ill or both mother and infant are ill at the same time. Many factors together may cause illness, but we propose that a major contributor may be the stress of role change, increased responsiL. Colette Jones, RN, PhD, is a professor and Associate Dean for Graduate Programs at the University of Nebraska Medical Center College of Nursing. Peggy Parks, PhD, is an associate professor at the University of Maryland School of Nursing in Baltimore. Preparation of this article was supported in part by grant R21 NU00829-01-03 (Dr. Elizabeth Lenz and Dr. Mary Neal, principal investigators) from the Division of Nursing (DHHS) and by the University of Maryland Computer Centers at Baltimore and College Park. The authors thank Patricia Rowland, Louise Jenkins, Jan Perini, Suellyn Boyd, and Joyce Rasin for their contributions to data collection and preparation and Karen Peddicord and Barker Bausell for their helpful comments on an earlier draft of the paper. First published in Stern, P. N. (Ed.). (1989). Pregnancy and Parenting (pp. 169-183). Washington, DC: Hemisphere. Health Care for Women International, 11:461-475, 1990 Copyright © 1989 by Hemisphere Publishing Corporation
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bilities, and lack of rest. In this chapter we describe the illness experiences of mother-infant dyads in the second half of the first year of life and discuss the role of health professionals in the care of mothers and their infants. The first year after the birth of an infant is a stressful period for mothers. Meeting the needs of the infant and adjusting to a change in family dynamics requires physical and emotional energy at a time when these resources may be low due to the birth process (Belsky & Rovine, 1984). Mothers may experience many types of illnesses as a direct result of this stress (e.g., headaches), or as an indirect result of having lower resistance (Brown, 1980; Lovell & Fiorino, 1979). Maternal illness is a further source of stress if the infant is also ill and needs additional care. Furthermore, any type of infant illness is a source of concern for mothers and can be stressful. For a working mother, infant illness may necessitate absence from her job, adding to her own stress. Illness, as used in this study, was the mother's perceptions of the manifestations of disease processes in both herself and her infant, rather than disease processes as observed and measured by health care providers (Feinstein, 1967). For professionals, the degree of seriousness of illness has been defined in terms of the potential to result in severe, acute, or chronic conditions, but for mothers and infants in the first year after birth any illness may be perceived as serious by mothers because of the stress they are experiencing. A diaper rash, for example, may be perceived by the mother as serious because she has no experience with it. The infant is fretful and additional diaper changes are required. A mother's respiratory infection may seem more serious to her than to health professionals because it impairs her functioning as a mother and may result in a fussy baby and a disrupted household. There have been few studies of illnesses among mothers and infants during the first year after birth, perhaps because the types of illnesses expected in normal mother-infant dyads during this period are not considered serious by authors contributing to the medical and empirical literature. Previous researchers have surveyed illness among women (Reis, 1985; Woods, 1980) and among infants (Denny & Clyde, 1983; Loda, Glezen, & Clyde, 1972; Shapiro, McCormick, Starfield, Krischer, & Bross, 1980) but not among mothers and their infants. Furthermore, results of these studies did not reveal what mothers did about the illnesses they or their infants experienced. Health care providers in pediatric and obstetrical practice can identify the type and frequency of illnesses experienced by mothers and infants who seek their care, but they cannot determine whether mothers and infants are experiencing illnesses for which care is not sought. This
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would only be possible through a survey of mothers and infants who are selected for study when they are not seeking care for illness. Data on frequency and type of illness experienced by mothers and infants is important because health professionals can help mothers prevent some illnesses through anticipatory guidance and can assess and treat many other illnesses. They may also help mothers reduce stress due to illness. Opportunities may exist for interventions with mothers and infants that are not being actualized. Our purpose in conducting this study was to identify the frequency and types of illnesses (primarily physical) experienced in a study population of mothers and their infants who were in the second half of the first year of life and the actions taken concerning these illnesses. A second purpose was to describe the degree of seriousness of illnesses as reflected in the number of days mothers and infants were hospitalized in the previous year (excluding childbirth), the number of days the mother was in bed because of illness in the previous month, and the subjective health status of both as rated by the mother. The conceptual framework guiding the study was the well documented relationship linking emotional and physical stress to occurrences of illness (Selye, 1980). In this framework developmental life events such as the addition of a child to the family are stressors and can contribute to illness (Carrieri, Lindsey, & West, 1986; Kjervik & Martinson, 1986). Although the theoretical relationships in this framework were not tested by the current study, we described the illnesses experienced by a group of mothers, all of whom were experiencing the same stressful event. Major assumptions guiding the study were that (a) parenting is a stressful experience and (b) increased stress may be related to type and frequency of illness. Two research questions were posed: 1. What were the types and frequencies of illnesses experienced in the second 6 months of life by infants who were full term and by their mothers? 2. What was the perceived degree of seriousness of these illnesses? Data used for this report came from two separate studies funded by a Doctoral Research Emphasis Grant. While each study had a different overall purpose, the project directors of both studies obtained data on the illnesses experienced by mothers and their infants using the Health Status Interview (HSI) (Lenz, Jones, & Parks, 1980). Both studies were conducted in a large metropolitan area over approximately the same time period, which spanned all 12 months of the year.
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STUDY 1 Participants were recruited for a study designed to measure relationships among maternal characteristics, environmental variables, and infant development. Records of a suburban community hospital were used to select this convenience sample. From medical records we obtained names of mothers (over 18 years of age) whose infants were of normal birth weight and without congenital abnormalities. When the infants were 6 months of age, we contacted the mothers by telephone, invited them to participate, and scheduled a time for data collection. The participation rate was 82%. This study group consisted of 79 mothers and their infants who were 6 months of age ( ± 2 weeks). Mothers ranged in age from 19 to 39 years (mean, 26.52), were mostly married (90%) and white (96%), had at least a 12th-grade education (94%), were not employed (80%), and either were using contraceptives or were pregnant (82%). Approximately half of the infants were firstborns and males (49.4% and 50.6%, respectively); most were delivered vaginally (81%) and were being bottle fed (69.6%). Socioeconomic status of these families (measured with the Hollingshead Four Factor Index of Social Status) ranged from a low of 14 (unskilled laborers, menial service workers) to a high of 63 (major business and professional) with a mean of 35.40 (skilled craftsmen, clerical, sales workers) and a standard deviation of 12.37. STUDY 2 Participants were recruited for a longitudinal study investigating paternal attachment in the newborn period. While fathers were the primary focus of this study, maternal characteristics were also studied. We recruited families for this convenience sample after the birth of their infants at a community hospital. The infants were all full term, healthy (never put in special care nursery), and the product of a normal pregnancy and uncomplicated vaginal or cesarean delivery. Data on fatherinfant interaction for 157 dyads in the newborn period are reported elsewhere (Jones & Lenz, 1986). This report includes data from 103 of these 157 who were followed up. Attrition on follow-up was primarily due to families moving from the area. Thus the participants consisted of 103 mothers and their infants who were 9.5 months of age (SD = 1.58). Mothers ranged in age from 18 to 38 (mean, 25.67), were married (93%) and white (81%), had at least a 12th-grade education (90%), were employed (62%), and either were using contraceptives or were pregnant (78%). All of the infants were firstborns; approximately half were males (52%); most were delivered vaginally (77%) and were being
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bottle fed (73%). Socioeconomic status of these families (measured with the Hollingshead Four Factor Index of Social Status) ranged from a low of 7 to a high of 66 with a mean of 41.72 (medium business, minor professional, technical) and a standard deviation of 12.16.
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METHOD The Health Status Interview We collected data for both studies during home visits. Among the instruments we administered were the HSI and the demographic questionnaire requiring 15 to 30 minutes of the mother's time. The HSI consisted of a series of structured questions to obtain information about the following variables for mothers and infants: (a) subjective health status, (b) illnesses experienced in the month prior to data collection, (c) actions taken for the illnesses experienced, (d) number of days of hospitalization in the year prior to data collection (excluding childbirth), and (e) number of days in the prior month mothers were in bed because of illness. We measured subjective health status by asking mothers to rate their own health in the last year and their infant's health since birth using the following scale: 1 = very poor; 2 = moderately poor; 3 = somewhat poor; 4 = undecided; 5 = somewhat good; 6 = moderately good; 7 = excellent. The illnesses experienced in the month prior to data collection were measured by reading mothers a list of 27 categories of illnesses (see Table 1 for a list of these) and asking them to indicate whether they or their infants had experienced each of them. The categories are those commonly used in obtaining a medical history. For each illness experienced by mother or infant, we asked the mothers what action they took using the following choices: nothing, self-treatment, asked a friend or relative for advice, called a doctor or health worker for advice, visited a doctor, visited a health care worker other than doctor. Mothers could indicate more than one type of action taken for an illness. Finally, we asked mothers how many days they had been hospitalized in the last year (excluding the birth of the infant), how many days they had been in bed due to illness, and how many days their infants had been hospitalized in the last year. We developed the HSI for these and other studies in the beginning families project; therefore, there was no previously established reliability and validity. During development of the instrument several interviews used by federal agencies (e.g., National Health Interview Survey) were reviewed. Many of them contained health ratings and lists of illnesses, which were read to participants who responded as to whether they had experienced the condition. We used both ratings and lists of
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liable 1. Percentage of Mothers Reporting Illnesses Experienced in the Month Prior to Data Collection Study 2 (N -• 103)
Total (N - 182)
n
%
n
%
n
5* ! 2: 21
(46) (38) (18) (18)
36 35 26 16
(37) (36) (27) (16)
46 41 25 19
(83) (74) (45) (34)
15) (19)
(15) (15)
16 13
(17) (13)
18 15
(32) (28)
1() i:! iS 11 ') i!
(13) (10) (10) (9) (5) (6) (4)
12 12 11 9 8 5 6 5 4 0 3 3 2 2 1 0 0 0 0 0 0
(12) (12) (11) (9) (8) (5) (6) (5) (4) (0) (3) (3) (2) (2) (1) (0) (0) (0) (0) (0) (0)
14 12 10 10 7 6 5 4 4 3 5 2 2 2 1 1 1 1 1 0 0
(25) (22) (19) (18) (13) (11) (10) (8) (7) (5) (10) (4) (3) (3) (2) (1) (1) (1) (1) (0) (0)
Study 1 (N - 79)
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Illness Tiredness or fatigue Headaches or migraines Cough, cold, or flu Sore throat Indigestion, vomiting, or stomach problems Gynecological or female problems Diarrhea, constipation, or bowel problems Back problems Hemorrhoids Eczema, rashes, or other skin problems Asthma or hay fever Breast pain or lumps Joint or bone problems Fever Bladder, urinary, or kidney problems Injury Anemia or blood problems Blacking out or fainting Earache Cysts or tumors High blood pressure Venereal disease Heart problems Bronchitis or pneumonia Varicose veins, phlebitis, or blood clot Diabetes Epilepsy, convulsions, or seizures
%
e
It
(3)
II
(3)
( '•>
(5)
:I
(2) (1) (1) (1) (1) (1) (1) (1) (1) (0) (0)
0 ()
Note. The number in parentheses is the number of mothers reporting the illness category.
illnesses common to previous interviews. The 27 illness categories were chosen to represent a comprehensive systems review for the respective subjects. For mothers, all 27 categories were appropriate; for infants only 17 were appropriate. An illness category could include more than one specific illness but was limited to include only one system (e.g., upper respiratory). The illness categories reported are those experienced
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by the mothers for themselves and perceived by them to be experienced by the infants. They were not asked for a specific diagnosis, and illnesses were not verified by medical diagnosis. Categories of illnesses were not always mutually exclusive, and it is possible that some of the illnesses categories were experienced simultaneously (e.g., fever and cough, cold, flu). Evidence for the validity of the interview was determined by correlating the health rating and the total number of illnesses experienced. For mothers, the relationship for Study one and Study two, respectively, was - .46 (77), p < .01 and - .36 (101), p < .01 (Pearson r); for infants, the relationship for Study one and Study two, respectively, was - . 3 1 (77), p < .01 and - . 4 4 (101),p < .01 (Pearson r). RESULTS Sample Differences Between Study Groups Differences between demographic characteristics of the two study groups were tested with chi-square and Mests. There was a significant difference in the age of the infants, f(180) = 17.67, p < .001, which was attributable to the recruitment process for the two studies. There was a significant difference in the racial composition of the groups (x2 = 8.51, p < .05) with a smaller percentage of nonwhites in Group 1 (4%) than in Group 2 (19%). The socioeconomic status as measured by the Hollingshead Four Factor Index of Social Position was significantly higher for Study 2 than for Study 1, t(H9) = 3.43, p < .001, but the actual difference was not large (means of 35 and 41 for Groups 1 and 2, respectively, on a 0 to 66 scale). Work status for the two samples was significantly different with a smaller proportion of working mothers in Group 1 (20%) than in Group 2 (62%), x = 29.92, p < .001. Mothers in Group 2 with 9 1/2-month-old infants who were firstborns were more likely to have returned to work than mothers in Group 1 with 6-month-old infants, half of whom were later born. The larger number of working mothers in Study 2 could also have contributed to the higher Hollingshead scores. The number of children in a family, which varied in Group 1, was not statistically related to frequency of the illnesses in mothers or infants. Data for the study variables were first compared for each group because of the differences in their demographic characteristics. There were differences between the groups on frequency of illnesses among mothers and infants in only one category. A higher percentage of mothers in Group 1 (younger infants and more children to care for) reported fatigue in the previous month than mothers in Group 2. Data for illness
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Table 2. Percentage of Mothers Reporting Illnesses for Their Infants in the Month Prior to Data Collection Study 1 79)
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(N •-
Study 2 (N •- 103)
Total (N - 182)
Illness
%
n
%
n
%
n
Cough, cold, or flu Eczema, rashes, or other skin problems Fever Diarrhea, constipation, or bowel problems Earache Indigestion, vomiting, or stomach problems Sore throat Bronchitis or pneumonia Asthma or hay fever Injury Anemia or blood problems Heart problems Blacking out or fainting Joint or bone problems Diabetes Epilepsy, convulsions, or seizures Bladder, urinary, or kidney problems
34 19 19
(27) (15) (15)
33 33 33
(34) (34) (34)
34 49 27
(61) (27) (49)
23 4
(18) (3)
23 14
(24) (15)
23 10
(42) (18)
6 4 5
(5) (3) (4)
1
(1)
2 1 1 0 1 0 0 0
(2) (1)
8 6 4 5 1 1 1 1 0 0 0 0
(8) (6) (4) (5) (1) (1) (1) (1) (0) (0) (0) (0)
7 5 4 3 2 1 1 1 1 0 0 0
(13) (9) (8) (6) (3) (2) (2) (1) (1) (0) (0) (0)
(1)
(0) (1) (0) (0) (0)
Note. The number in parentheses is the number of infants experiencing the illness category.
were then pooled across the groups because of the similarity of findings, and because frequency of illness in most categories was very low. General Health Measures of general health status of the total group (N = 182) revealed good health for mothers and infants. A high percentage (94.5%) of the infants had not been hospitalized and a high percentage (94.0%) of the mothers had not been hospitalized (except for the birth) in the year prior to data collection. Mothers rated both themselves and their infants as "moderately healthy" in the year (mothers) or the partial year (infants) prior to data collection. Infant Illness Mothers reported that their infants experienced illnesses in an average of two categories in the month prior to data collection. The percentage of mothers reporting each illness by category for their infants is dis-
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played in Table 2. The illness category reported to be experienced by the largest percentage of infants was cough, cold, or flu (34%). Twentythree percent or more of the mothers reported that their infants experienced the following four illness categories: cough, cold, or flu; eczema, rashes, or other skin problems; fever; and diarrhea, constipation, or bowel problems. Maternal Illness
Mothers reported experiencing an average of 2.7 of the illness categories in the month prior to data collection. The percentage of mothers reporting each illness category is displayed in Table 1. The two illness categories experienced by the highest percentage of mothers were tiredness or fatigue (46%) and headaches or migraines (41%). Fifteen percent or more of the mothers reported experiencing the following six illness categories: tiredness or fatigue; headaches or migraines; cough, cold, or flu; sore throat; indigestion, vomiting, or stomach problems; and gynecological or female problems. Table 3. Responses to Four Infant Illness Categories Experienced in the Month Prior to Data Collection
or flu
Eczema, rashes, or other skin problems
Fever
Diarrhea, constipation, or bowel problems
24
21
25
19
2
2
0
0
20 42
16 14
10 51
26 41
2
0
2
0
0 6 4
33 10 4
0 12 0
0 14 0
Cough, cold, Response Self-treatment Received advice from friend or relative Called MD or other health care provider Visited MD Visited health care provider other than MD Self treatment and visit MD Did nothing Other
Note. The numbers represent the percentage of infants experiencing each illness condition whose mothers reported taking the action.
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Tkble 4. Responses to Six Maternal Illness Categories Experienced in the Month Prior to Date Collection
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Response Self treatment Received advice from friend or relative Called MD or other health care provider Visited MD Visited health care provider other than MD Did nothing Other
Tiredness or fatigue
Indigestion, vomiting, Headache Cough, cold, Sore or stomach Gynecological or migraines or flu throat problems problems 54
62
50
59
11
0 4
0 9
2 7
0 9
0 19
11 50
0 51 2
0 18 0
0 25 0
0 38 0
3 16 3
0 28 0
43
0
Note. The numbers represent the percentage of the total number of mothers reporting illnesses in each categowho took the action.
Actions Taken in Response to Illness Tables 3 and 4 present the actions taken for the four most commonly occurring illness categories for infants (Table 3) and the six most common in mothers (Table 4) for the two samples combined. For no infant illness category was self-treatment the most common action. Visiting a physician was the most common action for the following categories: cough, cold, or flu; and diarrhea, constipation, or bowel problems. Selftreatment combined with visiting a physician was the most common action for eczema, rashes, or other skin problems. Doing nothing or visiting a health care provider other than a physician were not common actions. For the maternal illnesses of headaches or migraines; cough, cold, or flu; sore throat; and indigestion, vomiting, or stomach problems, the most common action was self-treatment. For tiredness or fatigue, the most common action was "did nothing," and for gynecological problems, the most common action was visiting a physician. Calling a physician or other health care provider or visiting a health care provider other than a physician was not a common action. Across the six illness catego-
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ries, doing nothing ranged from 16% (indigestion, vomiting, or stomach problems) to 51 % (tiredness or fatigue). At least one day in bed because of illness was reported by 18% (n = 33) of the group with most of these mothers having only one or two days in bed (28 mothers). Across mothers and infants, cough, cold, and flu was the most commonly reported illness category, but mothers' actions were different for themselves than for their infants. Mothers tended to treat themselves, but took their infants to physicians. For this commonly reported category, which represented primarily contagious conditions, there was a significant relationship between mothers and infants experiencing it (x = 16.14, p < .001). Dyads tended to either both experience cough, cold, or flu (15%) or both not experience cough, cold, or flu (55%). Among the dyads in which only one member experienced cough, cold, or flu, it was more frequently the baby than the mother. There was no relationship between the total number of illness categories experienced by mothers and the total number experienced by infants (r = .14). Across the illness categories with the highest frequencies, mothers tended to do nothing for their own illnesses more often than they did nothing for their infants' illnesses. In addition, mothers tended to call a physician or other health care provider more often for their infants' illnesses than for their own illnesses. Taken as a whole, a pattern emerges of higher dependence upon physicians for infant illness than for maternal illness. DISCUSSION The types of infant illness reported here are predominantly the common minor acute illnesses of infancy. Respiratory infections (bronchitis; throat; ear; and cough, cold, flu) accounted for the majority of illnesses reported. Because data for both studies were collected over at least one full year, this percentage is probably not due to seasonal variation. The significant relationship between mothers' and infants' frequency of cough, cold, or flu indicated the contagiousness of the conditions in this category. Gastrointestinal problems (stomach, bowel) constituted the second most frequently reported group of illness, with dermatological conditions the third in the infants. Selection of only healthy infants eliminated the possibility of those with gross congenital abnormalities or those of low birth weight who would be expected to have more episodes of illness. The only evidence of possible long-term illness was the report of two infants with heart problems and six with asthma. Thus, these findings reflect the illnesses of a group of "well" infants. The analysis of maternal illness revealed a high frequency of respiratory problems similar to infants, but a higher number of asthmatic prob-
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lems than for infants. What might be considered residual effects of childbirth—hemorrhoids, varicose veins, gynecological, urinary, and breast problems—together accounted for a large number of reported illnesses. Although this could be anticipated in the first months postpartum, the high frequency of these illnesses in the 6-12-month period is surprising. We speculate that these findings may reflect the combined effects of childbirth, lactation, and sexual activity. Illness may result from one or more causes including exposure to illness-producing agents, life-style, and other environmental factors. The high reported frequency of fatigue, headache, gastrointestinal, and back problems among mothers, as well as other less frequently reported illnesses, may be partially stress-related, however. Lovell and Fiorino (1979) suggested that "motherhood, as institutionalized in today's society, imposes stressors which impair the health of women who mother" (p. 79). They list possible sources of stress: a sense of powerlessness, the good mother/bad mother conformity, and an external source of identity. In their study population of 26 mothers of infants who voluntarily met to explore everyday problems of parenthood, the authors found clinical data to support their conceptualization of maternal stress. All mothers reported vague feelings of achiness and discomfort that were not severe enough to be classed as illness. None participated in regular exercise programs, and all expressed some concern with parenting skills. Further, they saw themselves as the least important member of the family and lacking in specific personal goals. Although their children were the source of most daily activitiy, the mothers reported little personal contact or meaningful interaction with their children. The authors concluded that the clinical findings supported their conceptualization of motherhood as a source of stressors. The physical effects of stress will not be reviewed here in detail, but are well documented (Selye, 1976). Neurohormonal and immunological changes are often demonstrated in stress-induced illness. Essential hypertension, ulcers, colitis and other gastrointestinal ailments, asthma, general malaise, chronic pain, and tension headaches have been related to psychosocial stress. New mothers suffer not only from psychosocial stress but also from physical stress due to the increased demands of infant care. It is possible that picking up and carrying a growing, older infant aggravates hemorrhoids, varicose veins, and back problems related to stress and lack of exercise. In addition, many mothers return to work in the second half of the first year with increased physical and psychological stress. Perceived level of maternal stress was not measured in this study, but many of the health problems reported, such as fatigue, tiredness, headache, and asthma, have been strongly related to reaction to stress. If the
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contention that motherhood is stressful is accepted, the outcome may be mediated by both external and internal forces such as coping ability and social support.
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Implications for Health Care Delivery Although the data show that only seven mothers called or saw health care providers other than physicians, it is obvious that many of the reported health problems of both mothers and infants in this study could be addressed by nurses or other health care professionals in various settings and roles. Those in the health professions who see the dyad over a period of time have an even greater opportunity to assess individual learning needs and abilities. They can tailor guidance regarding common illness for each client. Home care is a growing area for nursing and health care delivery. Early postpartum discharge provides little time for teaching, and common illnesses are often not addressed in the early postpartum period. Nurses involved in follow-up home care can begin to provide such information over time, as the mother is able to focus beyond childbirth. It is apparent that mothers need a core of information that health care professionals can provide about the illnesses that they and their infants are most likely to experience. For example, new mothers need to know that respiratory infections are very common in infants as well as in themselves. Written guidelines reinforced by individual teaching for home treatment, assessment of possible complications, and infection control should be included for mothers in routine well-baby visits and in parent support groups. The common problems of infant constipation and diarrhea and minor dermatological problems can be addressed in a similar manner. For example, color photographs of common rashes might be mounted in examining rooms or given to new mothers with accompanying instructions at an early visit. In general, for the problems identified here, mothers need to know the common symptoms, possible causes, self-management, and when to call a health care provider. Results from the present study and from Lovell and Fiorino (1979) reveal a high frequency of maternal illness that may be stress related. In addition, Lovell and Fiorino (1979) reported that mothers had problems with personal and maternal identity. Interventions other than education and support that may address these problems are instruction in relaxation techniques, exercises to strengthen back and abdominal muscles for lifting, help in planning a schedule to make time for themselves, and help with setting realistic short- and long-term goals. Attention to the needs of the mother during routine child care visits and realistic reassurance about her mothering skills may help build self-esteem in her new
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role. Support groups led by nurses could provide professional and peer support for various maternal needs in the first year after birth. The findings also suggest that physicians, instead of nurses or other health care professionals, are frequently used in the diagnosis and treatment of common health problems of mothers and infants. While the finding that physicians are treating minor problems is not surprising, it raises the possibility that anticipatory guidance given by nurses could have prevented the minor problems. For example, advice about feeding could prevent bowel problems. Additionally, the minor problems are ones that health care providers other than physicians could diagnose and manage. In addition to routine infant care in the first year, most mothers must deal with several episodes of both their own and their infant's minor acute illnesses. Parmelee (1986) suggested that parental behavior changes when a child is ill and that common childhood illnesses are significant in the development of social competence. These observations, in tandem with those concerning the stress of motherhood, indicate that complex changes take place in maternal-infant interaction during even minor illnesses. In this study we identified those categories of illnesses that are most common and therefore need the most emphasis from health professionals. By giving mothers information and support and by intervening appropriately, both the internal and external forces that mediate reactions to stress can be strengthened. Frequency of illness-related reactions to the stress of motherhood should be minimized, increasing the time and energy mothers have to devote to child care and other activities. REFERENCES Belsky, J., & Rovine, M. (1984). Social-network contact, family support, and the transition to parenthood. Journal of Marriage and Family, 46, 455-462. Brown, B. B. (1980). Perspectives on social stress. In H. Selye (Ed.), Selye's Guide to Stress Research (pp. 21-45). New York: Van Nostrand-Reinhold. Carrieri, V. K., Lindsey, A. M., & West, C. M. (1986). Pathophysiological Phenomena in Nursing: Human response to illness. Philadelphia: W. B. Saunders. Denny, F. W., & Clyde, W. A. (1983). Acute respiratory infections: An overview. Pediatric Research, 17, 1023-1076. Feinstein, A. R. (1967). ClinicalJudgment. Baltimore: Williams & Wilkins. Jones, L. C., & Lenz, E. R. (1986). Father-newborn interaction: Effects of social competence. Nursing Research, 35, 149-153. Kjervik, D. K., & Martinson, I. M. (Eds.). (1986). Women in Health and Illness: Life experiences and crises. Philadelphia: W. B. Saunders. Lenz, E. R., Jones, L. C., & Parks, P. (1980). Health status interview. Unpublished instrument.
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Loda, F. A., Glezen, W. P., & Clyde, W. A. (1972). Respiratory diseases in group daycare. Pediatrics, 49, 428-437. Lovell, M. C., & Fiorino, D. L. (1979). Combating myth: A conceptual framework for analyzing the stress of motherhood. Advances in Nursing Science, 1, 75-84. Parmelee, A. H. (1986). Children's illnesses: Their beneficial/effects on behavioral development. Child Development, 57, 1-10. Reis, P. (1985). Health characteristics according to family and personal income: United states (DHHS Publication No. PHS 85-1575, Series 10, No. 147). Washington, DC: U.S. Government Printing Office. Selye, H. (1976). The Stress of Life (2nd ed.). New York: McGraw-Hill. Selye, H. (Ed.). (1980). Selye's Guide to Stress Research. New York: Van NostrandReinhold. Shapiro, S., McCormick, M. C., Starfield, B. H., Krischer, J. P., & Brass, D. (1980). Relevance of correlates of infant death for significant morbidity at one year of age. American Journal of Obstetrics and Gynecology, 137, 363-373. Woods, N. F. (1980). Women's roles and illness episodes: A prospective study. Research in Nursing and Health, 3, 137-145.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Frequency of illness in mother‐infant dyads L. Colette Jones RN, PhD & Peggy Parks PhD To cite this article: L. Colette Jones RN, PhD & Peggy Parks PhD (1990) Frequency of illness in mother‐infant dyads, Health Care for Women International, 11:4, 461-475, DOI: 10.1080/07399339009515915 To link to this article: http://dx.doi.org/10.1080/07399339009515915
Published online: 14 Aug 2009.
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Date: 06 November 2015, At: 09:17
FREQUENCY OF ILLNESS IN MOTHER-INFANT DYADS L. Colette Jones, RN, PhD College of Nursing, University of Nebraska Medical Center
Peggy Parks, PhD
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School of Nursing, University of Maryland
The purpose of this study was to identify the frequency and types of illnesses experienced by mothers and their infants who were in the second half of the first year of life, the actions taken concerning these illnesses, the number of days the mother was hospitalized or in bed because of illness, and the subjective health status of both as rated by the mothers. During home visits mothers (N = 182) completed the Health Status Interview. They were asked about infant and maternal illness in the previous month and the actions taken in response to them. The number and types of illnesses reported indicate that mothers of full-term infants who were healthy at birth must deal with a number of minor illnesses in themselves and in their infants. The possible relationship of maternal illness to stress is discussed and suggestions are given for interventions by health professionals. In the first few months after birth mothers must respond to many new demands. Among those causing much concern is illness in their infants. Sometimes mothers are ill or both mother and infant are ill at the same time. Many factors together may cause illness, but we propose that a major contributor may be the stress of role change, increased responsiL. Colette Jones, RN, PhD, is a professor and Associate Dean for Graduate Programs at the University of Nebraska Medical Center College of Nursing. Peggy Parks, PhD, is an associate professor at the University of Maryland School of Nursing in Baltimore. Preparation of this article was supported in part by grant R21 NU00829-01-03 (Dr. Elizabeth Lenz and Dr. Mary Neal, principal investigators) from the Division of Nursing (DHHS) and by the University of Maryland Computer Centers at Baltimore and College Park. The authors thank Patricia Rowland, Louise Jenkins, Jan Perini, Suellyn Boyd, and Joyce Rasin for their contributions to data collection and preparation and Karen Peddicord and Barker Bausell for their helpful comments on an earlier draft of the paper. First published in Stern, P. N. (Ed.). (1989). Pregnancy and Parenting (pp. 169-183). Washington, DC: Hemisphere. Health Care for Women International, 11:461-475, 1990 Copyright © 1989 by Hemisphere Publishing Corporation
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bilities, and lack of rest. In this chapter we describe the illness experiences of mother-infant dyads in the second half of the first year of life and discuss the role of health professionals in the care of mothers and their infants. The first year after the birth of an infant is a stressful period for mothers. Meeting the needs of the infant and adjusting to a change in family dynamics requires physical and emotional energy at a time when these resources may be low due to the birth process (Belsky & Rovine, 1984). Mothers may experience many types of illnesses as a direct result of this stress (e.g., headaches), or as an indirect result of having lower resistance (Brown, 1980; Lovell & Fiorino, 1979). Maternal illness is a further source of stress if the infant is also ill and needs additional care. Furthermore, any type of infant illness is a source of concern for mothers and can be stressful. For a working mother, infant illness may necessitate absence from her job, adding to her own stress. Illness, as used in this study, was the mother's perceptions of the manifestations of disease processes in both herself and her infant, rather than disease processes as observed and measured by health care providers (Feinstein, 1967). For professionals, the degree of seriousness of illness has been defined in terms of the potential to result in severe, acute, or chronic conditions, but for mothers and infants in the first year after birth any illness may be perceived as serious by mothers because of the stress they are experiencing. A diaper rash, for example, may be perceived by the mother as serious because she has no experience with it. The infant is fretful and additional diaper changes are required. A mother's respiratory infection may seem more serious to her than to health professionals because it impairs her functioning as a mother and may result in a fussy baby and a disrupted household. There have been few studies of illnesses among mothers and infants during the first year after birth, perhaps because the types of illnesses expected in normal mother-infant dyads during this period are not considered serious by authors contributing to the medical and empirical literature. Previous researchers have surveyed illness among women (Reis, 1985; Woods, 1980) and among infants (Denny & Clyde, 1983; Loda, Glezen, & Clyde, 1972; Shapiro, McCormick, Starfield, Krischer, & Bross, 1980) but not among mothers and their infants. Furthermore, results of these studies did not reveal what mothers did about the illnesses they or their infants experienced. Health care providers in pediatric and obstetrical practice can identify the type and frequency of illnesses experienced by mothers and infants who seek their care, but they cannot determine whether mothers and infants are experiencing illnesses for which care is not sought. This
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would only be possible through a survey of mothers and infants who are selected for study when they are not seeking care for illness. Data on frequency and type of illness experienced by mothers and infants is important because health professionals can help mothers prevent some illnesses through anticipatory guidance and can assess and treat many other illnesses. They may also help mothers reduce stress due to illness. Opportunities may exist for interventions with mothers and infants that are not being actualized. Our purpose in conducting this study was to identify the frequency and types of illnesses (primarily physical) experienced in a study population of mothers and their infants who were in the second half of the first year of life and the actions taken concerning these illnesses. A second purpose was to describe the degree of seriousness of illnesses as reflected in the number of days mothers and infants were hospitalized in the previous year (excluding childbirth), the number of days the mother was in bed because of illness in the previous month, and the subjective health status of both as rated by the mother. The conceptual framework guiding the study was the well documented relationship linking emotional and physical stress to occurrences of illness (Selye, 1980). In this framework developmental life events such as the addition of a child to the family are stressors and can contribute to illness (Carrieri, Lindsey, & West, 1986; Kjervik & Martinson, 1986). Although the theoretical relationships in this framework were not tested by the current study, we described the illnesses experienced by a group of mothers, all of whom were experiencing the same stressful event. Major assumptions guiding the study were that (a) parenting is a stressful experience and (b) increased stress may be related to type and frequency of illness. Two research questions were posed: 1. What were the types and frequencies of illnesses experienced in the second 6 months of life by infants who were full term and by their mothers? 2. What was the perceived degree of seriousness of these illnesses? Data used for this report came from two separate studies funded by a Doctoral Research Emphasis Grant. While each study had a different overall purpose, the project directors of both studies obtained data on the illnesses experienced by mothers and their infants using the Health Status Interview (HSI) (Lenz, Jones, & Parks, 1980). Both studies were conducted in a large metropolitan area over approximately the same time period, which spanned all 12 months of the year.
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STUDY 1 Participants were recruited for a study designed to measure relationships among maternal characteristics, environmental variables, and infant development. Records of a suburban community hospital were used to select this convenience sample. From medical records we obtained names of mothers (over 18 years of age) whose infants were of normal birth weight and without congenital abnormalities. When the infants were 6 months of age, we contacted the mothers by telephone, invited them to participate, and scheduled a time for data collection. The participation rate was 82%. This study group consisted of 79 mothers and their infants who were 6 months of age ( ± 2 weeks). Mothers ranged in age from 19 to 39 years (mean, 26.52), were mostly married (90%) and white (96%), had at least a 12th-grade education (94%), were not employed (80%), and either were using contraceptives or were pregnant (82%). Approximately half of the infants were firstborns and males (49.4% and 50.6%, respectively); most were delivered vaginally (81%) and were being bottle fed (69.6%). Socioeconomic status of these families (measured with the Hollingshead Four Factor Index of Social Status) ranged from a low of 14 (unskilled laborers, menial service workers) to a high of 63 (major business and professional) with a mean of 35.40 (skilled craftsmen, clerical, sales workers) and a standard deviation of 12.37. STUDY 2 Participants were recruited for a longitudinal study investigating paternal attachment in the newborn period. While fathers were the primary focus of this study, maternal characteristics were also studied. We recruited families for this convenience sample after the birth of their infants at a community hospital. The infants were all full term, healthy (never put in special care nursery), and the product of a normal pregnancy and uncomplicated vaginal or cesarean delivery. Data on fatherinfant interaction for 157 dyads in the newborn period are reported elsewhere (Jones & Lenz, 1986). This report includes data from 103 of these 157 who were followed up. Attrition on follow-up was primarily due to families moving from the area. Thus the participants consisted of 103 mothers and their infants who were 9.5 months of age (SD = 1.58). Mothers ranged in age from 18 to 38 (mean, 25.67), were married (93%) and white (81%), had at least a 12th-grade education (90%), were employed (62%), and either were using contraceptives or were pregnant (78%). All of the infants were firstborns; approximately half were males (52%); most were delivered vaginally (77%) and were being
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bottle fed (73%). Socioeconomic status of these families (measured with the Hollingshead Four Factor Index of Social Status) ranged from a low of 7 to a high of 66 with a mean of 41.72 (medium business, minor professional, technical) and a standard deviation of 12.16.
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METHOD The Health Status Interview We collected data for both studies during home visits. Among the instruments we administered were the HSI and the demographic questionnaire requiring 15 to 30 minutes of the mother's time. The HSI consisted of a series of structured questions to obtain information about the following variables for mothers and infants: (a) subjective health status, (b) illnesses experienced in the month prior to data collection, (c) actions taken for the illnesses experienced, (d) number of days of hospitalization in the year prior to data collection (excluding childbirth), and (e) number of days in the prior month mothers were in bed because of illness. We measured subjective health status by asking mothers to rate their own health in the last year and their infant's health since birth using the following scale: 1 = very poor; 2 = moderately poor; 3 = somewhat poor; 4 = undecided; 5 = somewhat good; 6 = moderately good; 7 = excellent. The illnesses experienced in the month prior to data collection were measured by reading mothers a list of 27 categories of illnesses (see Table 1 for a list of these) and asking them to indicate whether they or their infants had experienced each of them. The categories are those commonly used in obtaining a medical history. For each illness experienced by mother or infant, we asked the mothers what action they took using the following choices: nothing, self-treatment, asked a friend or relative for advice, called a doctor or health worker for advice, visited a doctor, visited a health care worker other than doctor. Mothers could indicate more than one type of action taken for an illness. Finally, we asked mothers how many days they had been hospitalized in the last year (excluding the birth of the infant), how many days they had been in bed due to illness, and how many days their infants had been hospitalized in the last year. We developed the HSI for these and other studies in the beginning families project; therefore, there was no previously established reliability and validity. During development of the instrument several interviews used by federal agencies (e.g., National Health Interview Survey) were reviewed. Many of them contained health ratings and lists of illnesses, which were read to participants who responded as to whether they had experienced the condition. We used both ratings and lists of
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liable 1. Percentage of Mothers Reporting Illnesses Experienced in the Month Prior to Data Collection Study 2 (N -• 103)
Total (N - 182)
n
%
n
%
n
5* ! 2: 21
(46) (38) (18) (18)
36 35 26 16
(37) (36) (27) (16)
46 41 25 19
(83) (74) (45) (34)
15) (19)
(15) (15)
16 13
(17) (13)
18 15
(32) (28)
1() i:! iS 11 ') i!
(13) (10) (10) (9) (5) (6) (4)
12 12 11 9 8 5 6 5 4 0 3 3 2 2 1 0 0 0 0 0 0
(12) (12) (11) (9) (8) (5) (6) (5) (4) (0) (3) (3) (2) (2) (1) (0) (0) (0) (0) (0) (0)
14 12 10 10 7 6 5 4 4 3 5 2 2 2 1 1 1 1 1 0 0
(25) (22) (19) (18) (13) (11) (10) (8) (7) (5) (10) (4) (3) (3) (2) (1) (1) (1) (1) (0) (0)
Study 1 (N - 79)
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Illness Tiredness or fatigue Headaches or migraines Cough, cold, or flu Sore throat Indigestion, vomiting, or stomach problems Gynecological or female problems Diarrhea, constipation, or bowel problems Back problems Hemorrhoids Eczema, rashes, or other skin problems Asthma or hay fever Breast pain or lumps Joint or bone problems Fever Bladder, urinary, or kidney problems Injury Anemia or blood problems Blacking out or fainting Earache Cysts or tumors High blood pressure Venereal disease Heart problems Bronchitis or pneumonia Varicose veins, phlebitis, or blood clot Diabetes Epilepsy, convulsions, or seizures
%
e
It
(3)
II
(3)
( '•>
(5)
:I
(2) (1) (1) (1) (1) (1) (1) (1) (1) (0) (0)
0 ()
Note. The number in parentheses is the number of mothers reporting the illness category.
illnesses common to previous interviews. The 27 illness categories were chosen to represent a comprehensive systems review for the respective subjects. For mothers, all 27 categories were appropriate; for infants only 17 were appropriate. An illness category could include more than one specific illness but was limited to include only one system (e.g., upper respiratory). The illness categories reported are those experienced
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by the mothers for themselves and perceived by them to be experienced by the infants. They were not asked for a specific diagnosis, and illnesses were not verified by medical diagnosis. Categories of illnesses were not always mutually exclusive, and it is possible that some of the illnesses categories were experienced simultaneously (e.g., fever and cough, cold, flu). Evidence for the validity of the interview was determined by correlating the health rating and the total number of illnesses experienced. For mothers, the relationship for Study one and Study two, respectively, was - .46 (77), p < .01 and - .36 (101), p < .01 (Pearson r); for infants, the relationship for Study one and Study two, respectively, was - . 3 1 (77), p < .01 and - . 4 4 (101),p < .01 (Pearson r). RESULTS Sample Differences Between Study Groups Differences between demographic characteristics of the two study groups were tested with chi-square and Mests. There was a significant difference in the age of the infants, f(180) = 17.67, p < .001, which was attributable to the recruitment process for the two studies. There was a significant difference in the racial composition of the groups (x2 = 8.51, p < .05) with a smaller percentage of nonwhites in Group 1 (4%) than in Group 2 (19%). The socioeconomic status as measured by the Hollingshead Four Factor Index of Social Position was significantly higher for Study 2 than for Study 1, t(H9) = 3.43, p < .001, but the actual difference was not large (means of 35 and 41 for Groups 1 and 2, respectively, on a 0 to 66 scale). Work status for the two samples was significantly different with a smaller proportion of working mothers in Group 1 (20%) than in Group 2 (62%), x = 29.92, p < .001. Mothers in Group 2 with 9 1/2-month-old infants who were firstborns were more likely to have returned to work than mothers in Group 1 with 6-month-old infants, half of whom were later born. The larger number of working mothers in Study 2 could also have contributed to the higher Hollingshead scores. The number of children in a family, which varied in Group 1, was not statistically related to frequency of the illnesses in mothers or infants. Data for the study variables were first compared for each group because of the differences in their demographic characteristics. There were differences between the groups on frequency of illnesses among mothers and infants in only one category. A higher percentage of mothers in Group 1 (younger infants and more children to care for) reported fatigue in the previous month than mothers in Group 2. Data for illness
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Table 2. Percentage of Mothers Reporting Illnesses for Their Infants in the Month Prior to Data Collection Study 1 79)
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(N •-
Study 2 (N •- 103)
Total (N - 182)
Illness
%
n
%
n
%
n
Cough, cold, or flu Eczema, rashes, or other skin problems Fever Diarrhea, constipation, or bowel problems Earache Indigestion, vomiting, or stomach problems Sore throat Bronchitis or pneumonia Asthma or hay fever Injury Anemia or blood problems Heart problems Blacking out or fainting Joint or bone problems Diabetes Epilepsy, convulsions, or seizures Bladder, urinary, or kidney problems
34 19 19
(27) (15) (15)
33 33 33
(34) (34) (34)
34 49 27
(61) (27) (49)
23 4
(18) (3)
23 14
(24) (15)
23 10
(42) (18)
6 4 5
(5) (3) (4)
1
(1)
2 1 1 0 1 0 0 0
(2) (1)
8 6 4 5 1 1 1 1 0 0 0 0
(8) (6) (4) (5) (1) (1) (1) (1) (0) (0) (0) (0)
7 5 4 3 2 1 1 1 1 0 0 0
(13) (9) (8) (6) (3) (2) (2) (1) (1) (0) (0) (0)
(1)
(0) (1) (0) (0) (0)
Note. The number in parentheses is the number of infants experiencing the illness category.
were then pooled across the groups because of the similarity of findings, and because frequency of illness in most categories was very low. General Health Measures of general health status of the total group (N = 182) revealed good health for mothers and infants. A high percentage (94.5%) of the infants had not been hospitalized and a high percentage (94.0%) of the mothers had not been hospitalized (except for the birth) in the year prior to data collection. Mothers rated both themselves and their infants as "moderately healthy" in the year (mothers) or the partial year (infants) prior to data collection. Infant Illness Mothers reported that their infants experienced illnesses in an average of two categories in the month prior to data collection. The percentage of mothers reporting each illness by category for their infants is dis-
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Frequency of Illness
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played in Table 2. The illness category reported to be experienced by the largest percentage of infants was cough, cold, or flu (34%). Twentythree percent or more of the mothers reported that their infants experienced the following four illness categories: cough, cold, or flu; eczema, rashes, or other skin problems; fever; and diarrhea, constipation, or bowel problems. Maternal Illness
Mothers reported experiencing an average of 2.7 of the illness categories in the month prior to data collection. The percentage of mothers reporting each illness category is displayed in Table 1. The two illness categories experienced by the highest percentage of mothers were tiredness or fatigue (46%) and headaches or migraines (41%). Fifteen percent or more of the mothers reported experiencing the following six illness categories: tiredness or fatigue; headaches or migraines; cough, cold, or flu; sore throat; indigestion, vomiting, or stomach problems; and gynecological or female problems. Table 3. Responses to Four Infant Illness Categories Experienced in the Month Prior to Data Collection
or flu
Eczema, rashes, or other skin problems
Fever
Diarrhea, constipation, or bowel problems
24
21
25
19
2
2
0
0
20 42
16 14
10 51
26 41
2
0
2
0
0 6 4
33 10 4
0 12 0
0 14 0
Cough, cold, Response Self-treatment Received advice from friend or relative Called MD or other health care provider Visited MD Visited health care provider other than MD Self treatment and visit MD Did nothing Other
Note. The numbers represent the percentage of infants experiencing each illness condition whose mothers reported taking the action.
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Tkble 4. Responses to Six Maternal Illness Categories Experienced in the Month Prior to Date Collection
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Response Self treatment Received advice from friend or relative Called MD or other health care provider Visited MD Visited health care provider other than MD Did nothing Other
Tiredness or fatigue
Indigestion, vomiting, Headache Cough, cold, Sore or stomach Gynecological or migraines or flu throat problems problems 54
62
50
59
11
0 4
0 9
2 7
0 9
0 19
11 50
0 51 2
0 18 0
0 25 0
0 38 0
3 16 3
0 28 0
43
0
Note. The numbers represent the percentage of the total number of mothers reporting illnesses in each categowho took the action.
Actions Taken in Response to Illness Tables 3 and 4 present the actions taken for the four most commonly occurring illness categories for infants (Table 3) and the six most common in mothers (Table 4) for the two samples combined. For no infant illness category was self-treatment the most common action. Visiting a physician was the most common action for the following categories: cough, cold, or flu; and diarrhea, constipation, or bowel problems. Selftreatment combined with visiting a physician was the most common action for eczema, rashes, or other skin problems. Doing nothing or visiting a health care provider other than a physician were not common actions. For the maternal illnesses of headaches or migraines; cough, cold, or flu; sore throat; and indigestion, vomiting, or stomach problems, the most common action was self-treatment. For tiredness or fatigue, the most common action was "did nothing," and for gynecological problems, the most common action was visiting a physician. Calling a physician or other health care provider or visiting a health care provider other than a physician was not a common action. Across the six illness catego-
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ries, doing nothing ranged from 16% (indigestion, vomiting, or stomach problems) to 51 % (tiredness or fatigue). At least one day in bed because of illness was reported by 18% (n = 33) of the group with most of these mothers having only one or two days in bed (28 mothers). Across mothers and infants, cough, cold, and flu was the most commonly reported illness category, but mothers' actions were different for themselves than for their infants. Mothers tended to treat themselves, but took their infants to physicians. For this commonly reported category, which represented primarily contagious conditions, there was a significant relationship between mothers and infants experiencing it (x = 16.14, p < .001). Dyads tended to either both experience cough, cold, or flu (15%) or both not experience cough, cold, or flu (55%). Among the dyads in which only one member experienced cough, cold, or flu, it was more frequently the baby than the mother. There was no relationship between the total number of illness categories experienced by mothers and the total number experienced by infants (r = .14). Across the illness categories with the highest frequencies, mothers tended to do nothing for their own illnesses more often than they did nothing for their infants' illnesses. In addition, mothers tended to call a physician or other health care provider more often for their infants' illnesses than for their own illnesses. Taken as a whole, a pattern emerges of higher dependence upon physicians for infant illness than for maternal illness. DISCUSSION The types of infant illness reported here are predominantly the common minor acute illnesses of infancy. Respiratory infections (bronchitis; throat; ear; and cough, cold, flu) accounted for the majority of illnesses reported. Because data for both studies were collected over at least one full year, this percentage is probably not due to seasonal variation. The significant relationship between mothers' and infants' frequency of cough, cold, or flu indicated the contagiousness of the conditions in this category. Gastrointestinal problems (stomach, bowel) constituted the second most frequently reported group of illness, with dermatological conditions the third in the infants. Selection of only healthy infants eliminated the possibility of those with gross congenital abnormalities or those of low birth weight who would be expected to have more episodes of illness. The only evidence of possible long-term illness was the report of two infants with heart problems and six with asthma. Thus, these findings reflect the illnesses of a group of "well" infants. The analysis of maternal illness revealed a high frequency of respiratory problems similar to infants, but a higher number of asthmatic prob-
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lems than for infants. What might be considered residual effects of childbirth—hemorrhoids, varicose veins, gynecological, urinary, and breast problems—together accounted for a large number of reported illnesses. Although this could be anticipated in the first months postpartum, the high frequency of these illnesses in the 6-12-month period is surprising. We speculate that these findings may reflect the combined effects of childbirth, lactation, and sexual activity. Illness may result from one or more causes including exposure to illness-producing agents, life-style, and other environmental factors. The high reported frequency of fatigue, headache, gastrointestinal, and back problems among mothers, as well as other less frequently reported illnesses, may be partially stress-related, however. Lovell and Fiorino (1979) suggested that "motherhood, as institutionalized in today's society, imposes stressors which impair the health of women who mother" (p. 79). They list possible sources of stress: a sense of powerlessness, the good mother/bad mother conformity, and an external source of identity. In their study population of 26 mothers of infants who voluntarily met to explore everyday problems of parenthood, the authors found clinical data to support their conceptualization of maternal stress. All mothers reported vague feelings of achiness and discomfort that were not severe enough to be classed as illness. None participated in regular exercise programs, and all expressed some concern with parenting skills. Further, they saw themselves as the least important member of the family and lacking in specific personal goals. Although their children were the source of most daily activitiy, the mothers reported little personal contact or meaningful interaction with their children. The authors concluded that the clinical findings supported their conceptualization of motherhood as a source of stressors. The physical effects of stress will not be reviewed here in detail, but are well documented (Selye, 1976). Neurohormonal and immunological changes are often demonstrated in stress-induced illness. Essential hypertension, ulcers, colitis and other gastrointestinal ailments, asthma, general malaise, chronic pain, and tension headaches have been related to psychosocial stress. New mothers suffer not only from psychosocial stress but also from physical stress due to the increased demands of infant care. It is possible that picking up and carrying a growing, older infant aggravates hemorrhoids, varicose veins, and back problems related to stress and lack of exercise. In addition, many mothers return to work in the second half of the first year with increased physical and psychological stress. Perceived level of maternal stress was not measured in this study, but many of the health problems reported, such as fatigue, tiredness, headache, and asthma, have been strongly related to reaction to stress. If the
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contention that motherhood is stressful is accepted, the outcome may be mediated by both external and internal forces such as coping ability and social support.
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Implications for Health Care Delivery Although the data show that only seven mothers called or saw health care providers other than physicians, it is obvious that many of the reported health problems of both mothers and infants in this study could be addressed by nurses or other health care professionals in various settings and roles. Those in the health professions who see the dyad over a period of time have an even greater opportunity to assess individual learning needs and abilities. They can tailor guidance regarding common illness for each client. Home care is a growing area for nursing and health care delivery. Early postpartum discharge provides little time for teaching, and common illnesses are often not addressed in the early postpartum period. Nurses involved in follow-up home care can begin to provide such information over time, as the mother is able to focus beyond childbirth. It is apparent that mothers need a core of information that health care professionals can provide about the illnesses that they and their infants are most likely to experience. For example, new mothers need to know that respiratory infections are very common in infants as well as in themselves. Written guidelines reinforced by individual teaching for home treatment, assessment of possible complications, and infection control should be included for mothers in routine well-baby visits and in parent support groups. The common problems of infant constipation and diarrhea and minor dermatological problems can be addressed in a similar manner. For example, color photographs of common rashes might be mounted in examining rooms or given to new mothers with accompanying instructions at an early visit. In general, for the problems identified here, mothers need to know the common symptoms, possible causes, self-management, and when to call a health care provider. Results from the present study and from Lovell and Fiorino (1979) reveal a high frequency of maternal illness that may be stress related. In addition, Lovell and Fiorino (1979) reported that mothers had problems with personal and maternal identity. Interventions other than education and support that may address these problems are instruction in relaxation techniques, exercises to strengthen back and abdominal muscles for lifting, help in planning a schedule to make time for themselves, and help with setting realistic short- and long-term goals. Attention to the needs of the mother during routine child care visits and realistic reassurance about her mothering skills may help build self-esteem in her new
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role. Support groups led by nurses could provide professional and peer support for various maternal needs in the first year after birth. The findings also suggest that physicians, instead of nurses or other health care professionals, are frequently used in the diagnosis and treatment of common health problems of mothers and infants. While the finding that physicians are treating minor problems is not surprising, it raises the possibility that anticipatory guidance given by nurses could have prevented the minor problems. For example, advice about feeding could prevent bowel problems. Additionally, the minor problems are ones that health care providers other than physicians could diagnose and manage. In addition to routine infant care in the first year, most mothers must deal with several episodes of both their own and their infant's minor acute illnesses. Parmelee (1986) suggested that parental behavior changes when a child is ill and that common childhood illnesses are significant in the development of social competence. These observations, in tandem with those concerning the stress of motherhood, indicate that complex changes take place in maternal-infant interaction during even minor illnesses. In this study we identified those categories of illnesses that are most common and therefore need the most emphasis from health professionals. By giving mothers information and support and by intervening appropriately, both the internal and external forces that mediate reactions to stress can be strengthened. Frequency of illness-related reactions to the stress of motherhood should be minimized, increasing the time and energy mothers have to devote to child care and other activities. REFERENCES Belsky, J., & Rovine, M. (1984). Social-network contact, family support, and the transition to parenthood. Journal of Marriage and Family, 46, 455-462. Brown, B. B. (1980). Perspectives on social stress. In H. Selye (Ed.), Selye's Guide to Stress Research (pp. 21-45). New York: Van Nostrand-Reinhold. Carrieri, V. K., Lindsey, A. M., & West, C. M. (1986). Pathophysiological Phenomena in Nursing: Human response to illness. Philadelphia: W. B. Saunders. Denny, F. W., & Clyde, W. A. (1983). Acute respiratory infections: An overview. Pediatric Research, 17, 1023-1076. Feinstein, A. R. (1967). ClinicalJudgment. Baltimore: Williams & Wilkins. Jones, L. C., & Lenz, E. R. (1986). Father-newborn interaction: Effects of social competence. Nursing Research, 35, 149-153. Kjervik, D. K., & Martinson, I. M. (Eds.). (1986). Women in Health and Illness: Life experiences and crises. Philadelphia: W. B. Saunders. Lenz, E. R., Jones, L. C., & Parks, P. (1980). Health status interview. Unpublished instrument.
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Loda, F. A., Glezen, W. P., & Clyde, W. A. (1972). Respiratory diseases in group daycare. Pediatrics, 49, 428-437. Lovell, M. C., & Fiorino, D. L. (1979). Combating myth: A conceptual framework for analyzing the stress of motherhood. Advances in Nursing Science, 1, 75-84. Parmelee, A. H. (1986). Children's illnesses: Their beneficial/effects on behavioral development. Child Development, 57, 1-10. Reis, P. (1985). Health characteristics according to family and personal income: United states (DHHS Publication No. PHS 85-1575, Series 10, No. 147). Washington, DC: U.S. Government Printing Office. Selye, H. (1976). The Stress of Life (2nd ed.). New York: McGraw-Hill. Selye, H. (Ed.). (1980). Selye's Guide to Stress Research. New York: Van NostrandReinhold. Shapiro, S., McCormick, M. C., Starfield, B. H., Krischer, J. P., & Brass, D. (1980). Relevance of correlates of infant death for significant morbidity at one year of age. American Journal of Obstetrics and Gynecology, 137, 363-373. Woods, N. F. (1980). Women's roles and illness episodes: A prospective study. Research in Nursing and Health, 3, 137-145.
