Postnatal infant crying and maternal tiredness : examining their evolution and interaction in the first 12 weeks postpartum

A new mother lazing in childbed is a blessing for her family” is an old Swiss proverb.
Maternal rest and recuperation after birth was a common concern in the past and was
frequently supported by the extended family. However, mothers today barely enjoy restful
days after birth; instead they enter directly into the challenge of combining baby- and selfcare.
They often struggle to soothe a crying baby, while coping with their own exhaustion,
which can adversely affect family health. Surveys on maternal health consistently report
tiredness and fatigue as the most frequent complaint postpartum, affecting 46%-87% of new
mothers [1, 2]. Inconsolable infant crying is the most cited reason why parents consult health
professionals [3]. To date little is known on how mothers confront and handle these
challenges after birth. Routine postnatal care lacks effective strategies to alleviate the burden
of infant crying and maternal tiredness which can adversely affect family health in the earliest
stage.
Following the traditional division between neonatal and maternal healthcare, research has
usually focussed on conditions affecting either the mother or the neonate, but little attention
has been given to the interplay of infant crying and maternal tiredness. While maternal
tiredness after birth can be seen as normal reaction to the efforts of gestation and birth [4],
maternal fatigue is more severe than tiredness, and can be defined as imbalance of activity
and rest [5]. Whereas tiredness is naturally relieved in the circadian rhythm by periods of
sleep, fatigue persists through the circadian rhythm, cannot be relieved through a single period
of sleep, and is accompanied with a negative feeling [6]. Fatigue hampers the well-being of
the affected person and is known as risk factor for the development of postpartum depression
[7] and for a slightly less optimal development of the infants’ fine motor and coordinative
skills [8].
Postnatal infant crying is currently regarded as a normal part of a child’s neuro-behavioural
development following a typical curve which peaks during the sixth week postpartum at
nearly 3 hours crying per day, and declines to below 1 hour per day by 12 weeks of age, with
large inter-individual variation [9, 10]. Excessive crying is usually defined by ‘Wessel’s rule
of three’. It lasts more than 3 hours on more than 3 days per week, and recurs for more than 3
weeks [3, 11]. Such crying behaviour is a known risk factor for the development of maternal
postpartum depression, dysfunctional parent-child relation and, in extreme cases, for shaken
baby syndrome or other forms of child abuse [12-14]. Our interest in the present research project was not limited to the pathologic forms of maternal
fatigue and excessive crying, but embraced the entire continuum from physiologic maternal
tiredness to fatigue, and from normal to excessive infant crying. If healthcare is to address the
prominent concerns of parents caring for a neonate, we need a deeper understanding of how
infant crying and maternal tiredness develop and interact, and what support new parents need
to overcome these early challenges to family health. The aim of this study was therefore to
explore the evolution and interaction of postnatal infant crying and maternal tiredness.
Understanding these interactions could hold potential to develop evidence based
interventions to enhance the adaptive circularity of infant soothing and maternal recovery, and
to prevent a vicious circle of infant crying and maternal fatigue and its’ adverse effects on
family health.
A mixed methods approach was used, which combined qualitative and quantitative methods
for data collection and analysis. We first conducted a systematic review to synthesize the
evidence on the interconnectedness of infant crying and maternal tiredness in the first three
months postpartum. Both quantitative and qualitative studies were included. Evidence from
this review showed that infant crying was related to the experience of tiredness and/or fatigue
in new mothers. Whereas the included quantitative studies mainly implied that infant crying
was a predictor of maternal tiredness, the qualitative studies also depicted how maternal
tiredness can negatively impact a mother’s capacity to respond to her child’s needs. We
concluded that the interconnectedness of infant crying and maternal tiredness is a cyclical
process. Second, we conducted a case control study to analyse socio-demographic,
reproductive-maternal, and neonatal predictors of crying problems as reported by midwives
conducting postnatal home care. We found that the interconnectedness of maternal conditions
and infant crying was already evident in the immediate postpartum period, as maternal
distress during the first ten days after birth was strongly associated with reports of crying
problems. Finally, we added the perspective of new mothers’ lived experiences by conducting
a longitudinal qualitative study that used an interpretive phenomenological approach.
Mothers’ accounts indicated that their personal beliefs about beneficial childcare practices
shaped the way they combined newborn and self-care and how they handled conflicting needs
in the context of changing postnatal care practices.
Synthesizing the findings of the three studies yields the following key aspects which
contribute to the current state of knowledge: The interconnectedness of postnatal infant crying and maternal tiredness cannot be
fully explained by a unidirectional cause-effect relationship. The complexity of this
interplay is better understood as a cyclical process embracing reciprocal influences of
maternal and infant factors, which are embedded and shaped by the specific family,
healthcare, socio-cultural and political context. Conditions which add to new mothers’ stress appear to have a deteriorating effect on
early infant crying problems. Potential sources of stress included maternal mood
states, physical health problems, and social conditions (i.e. immigrant status or plans
to resume paid work directly after the paid maternity leave of 14 weeks). The strongest protective factor for reported crying problems was having more than
one child. According to the mothers’ accounts, they acquired experience in response
to crying in a multi-dimensional learning process. During this process mothers’
attitudes and skills changed in a way which promoted a calmer and de-escalating
response to infant crying. A novel and surprising finding was how the women’s personal beliefs about
beneficial childcare practices shaped the way they cared for the newborn and their
own needs after birth. These beliefs reflected the ongoing discourse on beneficial
child rearing practices over the last decades, and ranged from an infant-centred
approach focused on the infant’s development of a basic sense of trust, to an
approach aimed at balancing infants’ demands with own needs. According to their
beliefs, mothers differed in their willingness to minimize their own needs for the
child’s sake, what influenced their opportunities to rest, and could mitigate or
contribute to maternal tiredness and exhaustion. Health professionals’ support played an important role in how mothers managed to
combine baby- and self-care. Some mothers experienced care attuned to their and
their child’s needs, which reduced stress and enhanced their well-being. Others
experienced care following a professional agenda even though it conflicted with their
specific needs, producing frustration and increasing maternal stress. Balancing of
infant’s and maternal needs was especially delicate when unsettled babies impeded
maternal sleep at night during the postpartum hospital stay. Whereas some
professionals showed empathy and offered the mother respite from child care, others appeared to expect mothers to take care of her baby alone. This approach could
contribute to maternal sleep deprivation and exhaustion.
Based on the findings of this research project, we propose a conceptual model which situates
the interplay of postnatal infant crying and maternal tiredness as embedded in and influenced
by the socio-cultural and political contexts (see p. 100/101). Changing discourses on
beneficial childcare and policies that regulate maternity and family leave appear to have a
clear impact on the strategies and resources of the involved persons. The support of the family
and professional caregivers can strengthen adaptive dynamics of infant soothing and maternal
repose when all the actors (i.e. the newborn, the mother, family members and health
professionals) are attuned to each other’s needs and abilities. Mothers’ prior experience with
infant care is an additional resource to sustain adaptive dynamics. However, lack of family
and professional support and diminished attunement constitute a risk for the adaptive
circularity of infant soothing and maternal repose, and can fuel a vicious circle of increased
crying and maternal fatigue.
This comprehensive conceptual model can be used as a guiding framework to plan both
research and interventions at the micro-, meso-, and macro-levels of maternal and child
healthcare. Areas of interest embrace direct clinical practice and postnatal care policies,
cultural perceptions of child care, and politics and laws affecting motherhood and early family
life. Future research should surmount the traditional division between women’s and child
health, scrutinize maternal, neonatal and paternal needs after birth, and consider the family as
unit of interest. Furthermore, research should evaluate individualized and family-friendly
forms of care provision, and investigate the impact of socio-cultural and political conditions
on family health after birth. Analogously, interventions have to target different levels.
Campaigns and publicity aimed at enhancing public awareness of health needs in the
postpartum period are needed to re-establish social conditions which enable adequate rest and
repose for new mothers. Initiatives to extend paid maternity and family leaves would further
strengthen conditions which are conducive for early family health. On the level of care
provision the challenge is to develop new models of care which are responsive to families’
postnatal needs of individualized care. Working in such care setting should prepare and
enable nurses and midwives to provide care, which is attuned to the mother’s, the newborn’s
and the family’s current situation. Such care has the potential to reduce the stress of families
who care for their newborn child after birth, to mitigate early crying problems and maternal
tiredness, and thereby, to protect and promote family health from the earliest stage.