The Head Start Program Performance Standards mandate that family and health care providers offer services for pregnant women that address both physical and mental health needs. Head Start is in a position to provide invaluable support to expectant and new mothers. This article will explore some of the emotional needs of mothers and discuss areas for fruitful exploration and intervention to help in that process.
Pregnancy ushers in a tremendous physical and psychological transformation. Besides the bodily changes, there are disruptions in basic physiological processes that affect sleep, appetite, and digestion. Hormonal surges can affect mood and the ability to think and to remember. There are also intensely ambivalent emotions and fantasies about the process of labor and delivery.

A woman also experiences changes in her sense of self. She has to expand her sense of who she is to incorporate her child as a part of herself, yet also as a separate being. The appearance of a child will change her intimate relationships, such as with extended family members, as well as her role in society.

Mental Work and Reworking
In looking at the period surrounding a woman's giving birth, Daniel Stern (1995) described this as a time when she must engage in the greatest amount of "mental work and reworking" in her life. He says that this is especially true for the birth of the first child since no amount of babysitting or exposure to siblings can prepare a woman for the intense empathic connection needed to mother successfully a child. There is no other activity in a woman's life that will require her full emotional presence and involvement as much as raising a child. Stern identifies four concerns that preoccupy the expectant mother.

First, the expectant mother is afraid of not being able to maintain the baby's life. She has fears for her own and the new baby's survival. Once the child is born, she wonders if she will be able to provide the care that will allow the infant to grow, progress, and thrive. She is very vulnerable to the criticism and judgment of others. Society expects the birth of a new baby to be a happy time. For many women, even those who are in the most supportive circumstances, it is conflictual and stressful.
Second, the expectant mother wonders if she will really be able to feel love for her baby. Will she feel the bond that society says she is supposed to feel? Will that bond allow her to develop the special sensitivity that will allow her to read and respond to her baby's needs?

The next concern is the expectant mother's ability to create and maintain an adequate support network for herself. There are no societal structures that function in place of the extended family. As a result, there is greater stress on the father, if he is present, to provide the emotional support so that the mother will be able to devote herself to the child. Stern sees inherent dangers for a mother who has a limited support network and therefore, limited sources for feedback, information, and emotional support. She may be seen as an inadequate mother by the father or the extended family; the father may compete with the baby for her attention; or the father may compete with her to be the "better" parent.

A new mother may fear emotional as well as physical abandonment. In the past, a supportive network of women who surrounded the mother and baby, keeping males outside of the protective circle, used to be something that all women could rely upon. Besides her baby, the new mother's major involvement would have been with these maternal figures.

A new mother also reflects on her relationship to her own mother. This allows her to remember the intricacies of this first important relationship, and to form either positive or negative models of parenting to guide her own behavior.

The fourth concern deals with a woman's need to rework her sense of identity from "daughter to mother, companion to parent." A preoccupation with the memories and emotions connected to the long line of women throughout the family history causes a woman to reconsider her beliefs and her choices. Stern says that this is how the intergenerational transmission of family values and behaviors occurs.

Babies cannot wait. During their waking hours, the mother must be able to set aside her own preoccupations and concerns so that she can be attuned to her child's needs. The work of Selma Fraiberg (1980) and other infant researchers tells us that an infant stirs up many intense, raw emotions that reflect the mother's unresolved conflicts with her own mother and father.

Reviving Old Patterns
These "ghosts" from the mother's past can have an enormous impact on her entire pregnancy experience and on her ability to connect to her child. Simply having mixed feelings about being a mother can raise significant conflict and guilt for women who are not comfortable accepting emotions typically seen as negative. For example, a woman may expect her child to be active and controlling, as her own mother always described her and this would influence the way she perceives the needs and behaviors of her child. The key for a healthy relationship between mother and child is for the mother to be consciously aware of the issues between her and her mother, thereby avoiding displaced anger or feelings of abandonment or loss. This will help her not to be preoccupied with winning or avoiding power struggles as they arise with her young child.

For those women who have had significant difficulties growing up or have been the victims of trauma or abuse, it is important to help them identify the good qualities of their mother among the difficult memories of their early lives. The demands of being in the mothering role can be a terrifying experience for women unable to resolve a deep-seated belief in their own "badness" or fear of "turning into their mother." Attempting to relate to a helpless, crying, demanding, and dependent infant can trigger old patterns of behavior from the mother's childhood where she was perceived negatively because of her own mother's unmet needs and psychological difficulties. Without awareness of her past and the feelings associated with the trauma or abuse, she may in fact treat her child the way she was treated rather than in a more healthy, protective, and nurturing fashion.

Family Dynamics
A new baby also changes the dynamics between the couple and within the nuclear family. The father experiences a significant change in role and identity. In today's western culture, a father's role is more than financial; men are expected to take on increasing amounts of responsibility for the child's emotional and physical care. A man may feel ambivalence about the changes in his partner. He may also feel abandoned and excluded as the woman turns her attention to her pregnancy and new baby. On the mother's part, it may not be easy to share caretaking with the father since it has traditionally been the domain of women. Without awareness, issues of power and control may arise. As the partners move from being a couple to a family, all decisions will need to consider the needs and the role of the child.

Emotional Stress and the Infant
Current research, particularly the work of Megan Gunnar (1998), demonstrates the negative effects that emotional stress has on the developing fetus. Those who provide services to pregnant women and their families need to help expectant parents talk openly and fully about positive and negative feelings associated with pregnancy and their role as parents, including fears about the pain of childbirth. They need to explore how the new child will affect their relationship with extended family and discuss boundary issues that may arise if a family member is perceived as too helpful, too distant, or too critical. Important discussions can occur about the values that each parent holds, such as around discipline or religious matters. Older siblings also need to be prepared for the new baby and helped to deal with the anxious and jealous feelings before and after the birth.

Women need to be educated about maternal depression and its consequences for the development of their child. Support groups for pregnant women, a doula (a labor and post-childbirth support person), non-medical childbirth coaching, mother/baby groups, and father/baby groups can be useful in providing the needed support and in assessing potential difficulties. Pairing more experienced mothers with new, young mothers who can mentor and be positive role models may also be useful.

Teaching parents about the stages of development allows them to anticipate the joys and challenges that they will face as their child grows. In those situations where the mother's emotional difficulties require more than community support, or a child's temperamental or constitutional factors lead to a difficult fit between parent and child, referrals to early intervention or qualified infant mental health practitioners can be necessary.

Helping our Head Start families become emotionally prepared during pregnancy can go a long way in preventing emotional difficulties after the baby is born. We know that times of change can bring great opportunities. The birth of a new baby should be a joyful time. For many of our families who have severe external stressors, such as financial difficulties, young or unwanted pregnancies, traumatic abuse, or substance abuse histories, this is a time when our active intervention can open up unseen possibilities and provide much needed insight and support. 

References

Fraiberg, S. 1980. Clinical interventions in infant mental health: The first year of life. New York: Basic Books.

Gunnar, M.R. & R.G. Barr. 1998. Stress, early brain development, and behavior. Infants and Young Children 11 (1).

Stern, D. 1995. The motherhood constellation. New York: Basic Books.

PUTTING THIS TO WORK IN YOUR CENTER
Steps that programs can take to promote the mental health of new mothers and fathers–

• Form support groups for pregnant women to share fears and expectations and educate them about pregnancy, childbirth, and child development;
  
• Form activity groups like knitting or craft groups as a vehicle for support and discussion;
  
• Pair young mothers with older, more experienced mothers as mentors;
  
• Form support groups for fathers;
  
• Form mother/baby and father/baby groups to encourage responsive interactions and reciprocal play;
  
• Use videotapes as a tool in teaching how to respond to an infant's cues;
  
• Provide anticipatory guidance showing new parents what to expect at each phase of development;
  
• Explore in-depth the themes described in this article with both parents, whether or not they are together.
  

Head Start Program Performance Standard 1304.40c iii
Early Head Start grantee and delegate agencies must assist pregnant women to access comprehensive prenatal and postpartum care, through referrals, immediately after enrollment in the program. This care must include mental health interventions and follow-up, including substance abuse prevention and treatment services, as needed.

Beverly Gould was a Head Start Fellow (2000-2001). T: 202-554-0484; E: priyadarsa@aol.com.