ANNUALLY, there are nearly 140 million births globally.1 With every birth, there exists a mother who faces a marked transition in her life. The transition into motherhood is a dynamic process. Reva Rubin spent her nursing research career exploring, explaining, and publishing on this process. Her student, Ramona Mercer, continued to develop ideas regarding a woman's transition into motherhood. Rubin2 called this transition "attainment of the maternal role," which was later reconceptualized to "maternal role attainment" (MRA). In 2004, Mercer3 published an article suggesting MRA be revised to "becoming a mother" (BAM). This theory is situated in the context of other nursing theories such as Parse's4 the paradigm of human becoming and the middle-range theory of Meleis et al,5 experiencing transitions, both which will be explored. The purpose of this article is to conduct a theory analysis of this theory known as both MRA and BAM according to the methods described by Walker and Avant6 and discuss its relevance to nursing practice and theory today.
Before exploring this theory, the authors would like to acknowledge that these concepts exist within larger power relations of race, gender, and class. Both Rubin and Mercer appeared to be White women who were nursing theorists who developed this theory decades ago when existing power structures often overshadowed or even made invisible the heterogeneity of the mothering and family experience. These types of imbalances continue to permeate today, and the authors of this article would like to disclose their position relative to race, gender, and class. The first author identifies as a White, middle-class woman, and the second author identifies as Asian American, middle-class woman. Efforts have been made throughout this article to use more inclusive language and acknowledge the heterogeneity of the experience of motherhood and family life.
Statements of Significance
What is known or assumed to be true about this topic?
Nursing theory is foundational to practice. Nurses working with birthing people or families during this time have the responsibility to be aware of the milestones of this transition to best support mothers through this challenging shift in life and family dynamics.
What this article adds:
This article summarizes what is known about the theory of maternal role attainment and how it transitioned to the name of becoming a mother. In addition, we, the authors, offer further development of this theory with original models (Figures 1-3).
BACKGROUND: A THEORY IN EVOLUTION
Rubin's 1967 landmark article, "Attainment of the maternal role: Part I," presents findings of a biological field study. Methods and results were very similar to a modern-day qualitative study, which was an up-and-coming methodology at the time of this 1967 publication.2 Rubin observed and interviewed 5 primiparas and 4 multiparas, as well as 70 other women as controls. Results were classified into 2 categories: the self-system and operations. The self-system had 3 components: ideal image, self-image, and body image. The operations were divided into 5 categories: mimicry, role-play, fantasy, introjection-projection-rejection, and grief work with maternal identity being the final destination. Although the article does not include any figures or models, Rubin gives a written description of a visual representation of the theory:
If the entire process is visualized as a sphere with the core of the sphere as role identity, the direction is from the outer layers of the sphere inwards. It is in that order that the operations described as Mimicry, Role-Play, Fantasy, Introjection-Projection-Rejection, and Grief-Work are presented.2(p240)
To provide better visualization of Rubin's findings, a figure was created according to the previous description (Figure 1).2
Rubin7 also published an article describing the maternal tasks in pregnancy, which can be considered a subcategory under the idea of MRA. In the article, Rubin describes 4 tasks of pregnancy, stating how they change through the 3 trimesters, how they are interwoven like a tapestry, and how they lay the foundation "to form the qualitative matrix of mothering."7(p375) The 4 tasks include the safe passage, acceptance of the child by significant others, binding-in, and giving of oneself. A major limitation of this article is that there is no mention of sample, methods, or analysis, so it is unclear how Rubin came to these conclusions.
In 1977, Rubin published a similar article only this time describing "binding-in," which takes place during the end of pregnancy and the postpartum period of forming the maternal role.8 Rubin describes 3 aspects of binding-in: polarization, identification, and claiming. Polarization involves "the physical and conceptual separating-out process of the incorporated infant of pregnancy into a separate, external and constant entity post partum."8(p70) Identification involves proprioceptive senses postpartum; seeing, touching, hearing, and smelling the baby. "The purpose of identification of the child is to locate the child in order to locate oneself and one's behavior in relation to the child."8(p68) Claiming involves including the child in a larger social sphere of close relationships. Like the previous article, this article has a major limitation in there is no mention of methods, sample, or analysis. It is unclear how Rubin arrived at these conclusions.
Rubin's work is most comprehensively explained in her book Maternal Identity and the Maternal Experience.9 In this book, there exists evidence of previously reported findings, but it is also clear that her ideas around the maternal transition had matured, evolved, and transformed. Rubin's 1967 idea around self-system endured the years of evolution and appears in the book with the exact same 3 aspects: ideal image, self-image, and body image. Notably or indeed, her results from the 1976 article appeared in the book with the 4 categories unchanged from their original article. However, the 5 operations of MRA appear in the book differently. Rubin now refers to this aspect as the maternal identity with the subcategories of replication, fantasy, and dedifferentiation. Rubin cites her methods as a naturalistic collection of data using open-ended interviews with a sample size of 3000 to 5000. According to the literature search for this article, Rubin's book appears to be her last publication. She passed away May 13, 1995, at the age of 76.10
Ramona Mercer was a student of Rubin who further developed and tested Rubin's theory. In 1981, Mercer published an article merging Rubin's findings with Thornton and Nardi's11 role acquisition theory. This organized MRA into 4 stages: anticipatory, formal, informal, and personal.12 Although Mercer did not offer any visual models, one has been constructed for purposes of this article (Figure 2).12 Later that same year, Mercer published an article regarding nursing tasks to aid the mother in the transition in early postpartum. This included integrating birth experiences, helping with grief work, aiding with infant care, and helping redefine roles.13
Mercer then began conducting longitudinal quantitative research studies to test MRA theory. In 1981, she conducted a longitudinal study measuring factors that influence MRA. The examined factors included maternal age, marital status, and self-concept among others, and infant factors included temperament and illness. Maternal role attainment was operationally defined using 3 measurements: attachment, competency, and acceptance.14 In 1985, Mercer published the results of a mixed-methods study exploring the process of MRA during the first year postpartum where she offers a clear definition of MRA.15 Citing from Rubin's 1967 article, Mercer states "Maternal role attainment is defined as a process in which the mother achieves competence in the role and integrates the mothering behaviors into her established role set so that she is comfortable with her identity as a mother."15(p198) In this mixed-methods study, MRA is tested using 4 tools as the operational definition. These tools included Feelings About the Baby,16 Gratification in the Mothering Role,17 Maternal Behaviors,18 and Ways of Handling Irritating Child Behaviors.19 Results included that MRA did not differ by age and 64% of mothers identified that "they had internalized the maternal role by 4 months."15(p203) It also noted that 4% of participants "failed to internalize the maternal role within the time frame of 1 year. The question may be raised whether all women ever do."15(p203) Mercer and Ferketich20 conducted another study testing an aspect of Rubin's theory by examining predictors of maternal role competence by risk status. In this article, there is a change in terminology from MRA to maternal role competence. These articles helped operationally define MRA and produced results that further developed MRA theory.
In 2004, Mercer published a landmark article titled "Becoming a Mother Versus Maternal Role Attainment," where she uses the literature to make the argument to change MRA to BAM.3 She identified that McBride and Shore21 first made the argument to retire the term MRA because it indicates a static point of arrival rather than a continuing evolution. Mercer then uses the literature to support the use of BAM. In her review of the literature, she highlights the findings of 29 articles, pointing to the impact this theory had made on the body of scientific literature. The reported articles included both qualitative and quantitative work, as well as an article about a research instrument. Toward the end of the article, Mercer states:
Although the last stage in MRA is the achievement of maternal identity, the dynamic transformation and evolvement of the woman's persona are not captured by MRA. The theory of MRA does not include the continued expansion of the self as a mother.3(p231)
She then goes on to explain the new stages of the transformation. The first stage involves "commitment, attachment, and preparation"3(p231) of pregnancy. The next phase begins at birth and continues 2 to 6 weeks postpartum and involves "acquaintance, learning, and physical restoration."3(p231) Next, the woman moves toward a new normal beginning 2 weeks postpartum until 4 months after birth. The final stage remains the same as in Rubin's 1967 theory: maternal identity.
Mercer further explains and develops BAM in 2 articles published in 2006.22,23 In the first article, she blends BAM with Bronfenbrenner's theory of the ecology of the family.24 This situates BAM in the context of 3 ecological levels: an intimate support network of family and friends, a larger community, and the broader society. Although Mercer did not provide a visual of the updated theory, a model has been created to further depict these concepts and relationships (Figure 3). This idea was further developed by Mercer and Walker in 2006, which reviewed 28 articles and classified findings into 5 categories: "infant caregiving (N = 5), building awareness of and responsiveness to infant interactive capabilities (N = 11), fostering maternal-infant attachment (N = 6), maternal/social role preparation (N = 3), and interactive therapeutic nurse-client relationships (N = 3)."23(p570) According to Scopus and MEDLINE databases, the latter article was the last article published by Mercer.
METHODS
Walker and Avant6 state that the main aim of the analysis is understanding through systematic and objective approaches without subjective bias or values. The 7 steps of this method of theory analysis include origins, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability. To conduct a theory analysis, there needs to be 1 specific theory to examine. Since MRA/BAM is a theory that has been in evolution for decades, the most updated version of the theory from Mercer22 was used for this analysis, with background content pulled from earlier publications.
FINDINGS
Origins
The origins of a theory include both where it stems from and its underlying assumptions.6 As described earlier, Mercer's BAM originated from the synthesis of 3 theories: MRA,2 role acquisition,11 and the ecology of the family.24 This theory is both deductive and inductive. It is deductive because it stems from the synthesis of other theories. However, there also exist inductive aspects to BAM; it is based on research2 and refined by research.14,15,20,25 There exist several underlying assumptions in this theory's origins.
* The first is the woman herself is giving birth to the child. This is not true for adoptive mothers, foster mothers, stepmothers, intended parents, and gestational carriers. Therefore, this transition may look different for them.
* Another assumption is that a woman does in fact transition at the time of motherhood. There exist contrary examples to this assumption, for example, women who place their babies for adoption or have their child removed for safety reasons. In these situations, there is an interruption in the transition. Even in Mercer's work, she found that 4% of the parenting women did not reach the stage of maternal identity in 1 year.15
* Finally, a third assumption is that the woman is situated in the larger context of friends and family, community, and society. Although this is true for most women, it is not true for all. For example, there are situations where women give birth while incarcerated, which places them in a very different context and can also disrupt the theoretical transition into motherhood.
These contrary examples to this theory's underlying assumptions point to the heterogeneity of motherhood and family structure, and they are suggestive of the need for further research and development.
Meaning
Examining meaning in a theory analysis involves examining the definitions of concepts, the relationships between concepts, as well as their boundaries, and evidence for these relationships.6 There are 9 major concepts in BAM theory (Table 1). The first is the concept of becoming. Becoming is used to describe "the dynamic transformations and evolvement of the woman's persona."3(p231) An important aspect of this use of becoming is that it has no point of arrival but is a continual process of evolution. The next concept is the term "mother." In the context of this theory, a mother is a woman who gives birth and subsequently parents her offspring. This excludes foster mothers, adoptive mothers, stepmothers, intended parents, and gestational carriers, as well as fathers or female-identifying coparents who also go through a parental transition. The next 4 concepts are the 4 stages involved in the process of BAM. The first stage is "commitment, attachment, and preparation."3(p231) This stage is described as a time before birth in which the woman begins her transition to incorporating her new child into her life. This process of preparation may begin before pregnancy but intensifies after conception. The next concept is the second stage, involving acquaintance, increased attachment, learning infant care, and physical recovery from birth. This stage lasts 4 to 6 weeks. The next concept is the third stage, which involves developing a new normal. This stage overlaps with stage 2 and ends once stage 4 is reached, usually around 4 months. Stage 4 is when the mother achieves her maternal identity and is competent and confident in her new role. The final 3 concepts are the contexts in which the woman is situated: intimate environment, community, and society. A woman's intimate environment involves her family and friends. Her community includes facilities such as "health care, cultural, employment, protection, and recreational."22(p650) The society involves broad cultural norms and laws affecting the woman and the child.
The relationships between these concepts are all associational rather than causal because the relationships lack certainty. There exists a linear relationship between the 4 stages. "The stages are not discrete; they overlap."22(p649) The 4 stages then lay the base for BAM, which is "an enlargement of self ... as a woman achieves maternal identity in BAM."3(p231) This process is nested inside the woman's 3 levels of her environment. "The mother-infant dyad is embedded in three major environments."22(p650) A model of these relationships has been created (Figure 3).
The BAM theory has wide boundaries as it "is highly abstract, covers a large content area, and is applicable in a large number of cases."6(p199) Mercer does identify some boundaries for this theory when she explores the need for further study of BAM, including mothering "of a school-age child, an adolescent, an adult, or becoming a grandmother."3(p231) It can be assumed that since there is a need for further study of BAM in these areas, the current theory does not include these times of transition. Additional boundaries include the time frame of the theory: pregnancy through 4 months postpartum. In addition, boundaries of the theory are established by limiting motherhood to women who give birth and parent their infants. As stated earlier, this theory does not include stepmothers, foster mothers, adoptive mothers, intended parents, gestational carriers, fathers, or other family members. This again points to inaccuracies in the theory's underlying assumptions and suggests the need for further research and development.
The last step in examining relationships is to assess the empirical support for the statements. Mercer3 provides thorough evidence for BAM theory through her in-depth review of the literature, using both qualitative and quantitative studies. Empirical evidence will continue to grow as this theory is further tested (Table 2).
Logical adequacy
The empirical evidence of BAM strengthens its logical adequacy. When women transition into motherhood, they go through a radical change that must be incorporated into their lives, and this involves adaptation occurring through a process. It makes sense to map out this process to better understand how to support women during this time.
However, a logical inconsistency lies at the center of this theory. Mercer3 proposed to change the name of this theory from MRA to BAM specifically to acknowledge that the transition into motherhood does not have a static point of arrival. Mercer lays out 4 discrete and linear stages in this process with the last stage being the achievement of the maternal identity at 4 months, which is described as a static point of arrival. To reconcile these contradictory points, the authors of this article have taken the liberty to add the 4 stages to establish the base for an ongoing process rather than complete the process in and of itself (Figure 3). This is in addition to the BAM theory as a way of addressing this core inconsistency.
Becoming a mother provides a broad picture of the transformation of motherhood, but it is difficult to make predictions from the theory itself. To do this, further study is needed on antecedents and consequences of this process. Mercer's earlier work began to map out antecedents, including age, race, marital status, perception of the birth experience, social support, social stress, self-concept, and personality traits, but these relationships were not incorporated into the updated version of this theory.14,15,20,25 Further study on antecedents and consequences is needed to strengthen the predictions that can be made from this theory.
Usefulness
Walker and Avant6 identify 3 aspects of a theory's usefulness: the research it has generated, relevant clinical problems, and potential influence on the field of nursing. To evaluate this theory's impact, a literature search was conducted examining the number of citations for 2 articles, Rubin2 and Mercer.3 The literature also searched for the key words "maternal role attainment" and "becoming a mother." The number of citations ranges from 41 to 370, with an average of 157 citations per database. The listed number of citations points to the impact the MRA/BAM theory has had on the scientific literature (Table 2). This theory also has relevance to nursing practice, which is discussed later.
Generalizability
"Generalizability can be determined by examining the boundaries of the theory and by evaluating the research that supports the theory."6(p204) As described earlier under the meaning section of this article, BAM has wide boundaries with some limitations. Mercer3 did a thorough job of explaining the research that supports her theory. Since 2004, BAM has been cited in many articles (Table 2).
Parsimony
Parsimony refers to a theory's ability to elegantly simplify complex and broad content with a model being a good measure of parsimony.6 Mercer does not provide a pictorial model of BAM, but one has been constructed from her articles (Figure 3).22 The transition into motherhood is a complex process, and Mercer makes an admirable attempt of simplifying and clarifying this process. The theory, however, is lacking in parsimony because of the complex nature of the topic at hand.
Testability
"We support the idea that for a theory to be truly valid, it must be testable at least in principle. This implies hypotheses can be generated from the theory, research carried out, and the theory supported by the evidence or modified because of it."4(p205) Mercer tested earlier versions of MRA theory and found little difference in MRA between age groups and risk status (Table 3).14,15,20,25 Potential future hypotheses include BAM's impact on maternal mental health and maternal-child attachment. These hypotheses are examples of how this theory can be tested and establish its credentials as a testable theory.
DISCUSSION
Rubin's landmark article of 1967 is commonly cited in reference to MRA theory. However, in this review of literature, Rubin rarely used the term "theory" or the term "maternal role attainment" although the latter is very close to the title of the article, "Attainment of the maternal role: Part I."2 From this literature review, it is unclear when the term "maternal role attainment theory" first appeared, but according to the findings of this literature review, it was not Rubin herself who coined this phrase.
Since Rubin began her work in the 1960s, there have been significant changes to the landscape of mothering, parenting, and family in the United States and around the world.26 There exists an increased emphasis on recognizing the diversity of families and using inclusive language representative of this diversity. Changes include the increased accessibility of reproductive technologies making parenting accessible to a wider population, the increased average age of mothers, the increased number and visibility of same-sex partners, and the legalization of same-sex marriage. Other changes include the advancement of LGBTQIA+ rights with the inclusion of broader, nonbinary gender-identity language. As of now, "mother" remains an acceptable term in academia, but the changing landscape of families and inclusive language may further support updating the MRA/BAM theory and its name.
The name change from MRA to BAM is supported by examining Rosemarie Parse's4 grand theory, the paradigm of human becoming. In this theory, the term "becoming" is used to signify an ongoing process rather than a static point of arrival. "The concepts of the theory are written as participles with the "ing" ending. They were deliberately designed this way to make explicitly the process orientation of the theory."4(p37)
Another theory that relates to MRA and BAM is the middle-range theory of experiencing transitions by Meleis et al.5 According to the authors, pregnancy, childbirth, and parenthood are identified as "developmental and lifespan transitions." This is in comparison to other types of transitions such as "illness experiences" or "social and cultural transitions."5(p13) According to this theory, motherhood may be considered a transition of heightened vulnerability. Similar to MRA/BAM, Meleis et al identify the idea of mastery as a healthy terminal phase of transition that can be likened to achieving maternal role identity. Finally, the theory of experiencing transitions also recognizes that these transitions happen within the context of community and societal factors. Meleis et al offer a broad perspective of nurses working with persons and populations going through transitions, including motherhood, while MRA and BAM focus specifically on motherhood that gives an in-depth description of this particular transition.
The theory of MRA/BAM is relevant to any nurse who works with families during this transition time. It applies to a variety of nursing specialties, including antepartum, labor and delivery, postpartum, neonatal, lactation specialists, pediatric, family, community, and public health. This theory is especially relevant to 2 important clinical issues: maternal mental health and maternal-child attachment. Maternal mental health disorders are one of the most common complications of pregnancy and childbirth, affecting up to 20% of mothers.27,28 They are associated with poor outcomes, including difficulty with attachment.29 Impaired attachment can have a lasting impact on child development.30 The process of BAM is central to both maternal mental health and attachment, and BAM lays a theoretical framework to better understand both clinical phenomena. In addition, there have been nursing interventions developed that focus on maternal-child attachment, including the Nurse-Family Partnership and Minding the Baby.31,32 Maternal role attainment/becoming a mother provides a theoretical framework applicable to these nursing interventions.
CONCLUSION
Both Rubin and Mercer left significant contributions to the field of nursing through the development of their theory. Over the last 50 years, MRA/BAM theory has grown and evolved according to emerging evidence. The most updated version of the theory22 continues to be relevant to today's body of scientific literature related to a woman's transition into motherhood and its impact on nursing. There remains room for further growth and development of MRA/BAM, especially in light of the changing landscape of families. Future study is needed to further establish this theory's facilitators, barriers, antecedents, and consequences. "Theory building is a continual process as research findings provide evidence for clarification of concepts, additions, or deletions."3(p226)
REFERENCES