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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 203-211

Being with and for mother: From perceived difficulties to rebalancing the mothering role in women with breast cancer


1 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
2 Department of Paediatric Nursing, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Medical Surgical Nursing, School of Nursing and Midwifery, Haematology and Oncology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
5 Department of Anaesthesia/Pain, Palliative Care Unit, Multidisciplinary Oncology Centre, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria

Date of Submission15-Apr-2020
Date of Decision23-May-2020
Date of Acceptance13-Dec-2020
Date of Web Publication23-Jul-2021

Correspondence Address:
Leila Valizadeh
Department of Paediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz.
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nms.nms_31_20

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  Abstract 

Background: Breast cancer is the most common cancer and the 5th leading cause of death in Iranian women. Many of these women are at the age of fertility and have dependent children. Objectives: This study aimed to explore the experiences of mothers with breast cancer of the support they receive for playing and rebalancing their mothering role. Methods: This qualitative content analysis study was conducted from 2018 to 2019. Participants were 22 mothers with breast cancer purposively recruited from Shahid Ghazi Tabatabaee Hospital in Tabriz, Iran. Data were collected through semi-structured interviews and analyzed through a conventional content analysis method. Results: Participants’ experiences were categorized into three main categories, namely, perceived difficulties, being with and for mother, and rebalancing family functions. The four subcategories of the first category were the physical limitations in performing the mothering role, the psychological burden of the disease, role strain in playing the mothering role, and children’s social difficulties. The second category included five subcategories, namely, assistance with the mothering role, emotional attachment to the mother, provision of family expenses and medical costs, normalization of appearance following cancer-induced changes, and social support resources. Finally, the third category included two subcategories, namely, the stability of the mother’s roles and promoting a health-oriented perspective in the family. Conclusion: Mothers with breast cancer face difficulties in performing their role as mothers. Identifying and providing supportive interventions for them by the health-care providers not only can be effective in achieving role stability for the mother but also in rebalancing family functions.

Keywords: Breast cancer, Family support, Iran, Mothering role, Social support


How to cite this article:
Mazaheri E, Valizadeh L, Zamanzadeh V, Ghahramanian A, Onyeka TC. Being with and for mother: From perceived difficulties to rebalancing the mothering role in women with breast cancer. Nurs Midwifery Stud 2021;10:203-11

How to cite this URL:
Mazaheri E, Valizadeh L, Zamanzadeh V, Ghahramanian A, Onyeka TC. Being with and for mother: From perceived difficulties to rebalancing the mothering role in women with breast cancer. Nurs Midwifery Stud [serial online] 2021 [cited 2021 Dec 2];10:203-11. Available from: https://www.nmsjournal.com/text.asp?2021/10/3/203/322223




  Introduction Top


Breast cancer is the most common cancer among women in the world. About 2.1 million newly diagnosed breast cancer cases were reported in women in 2018.[1] Many of these women are of childbearing age, have dependent children, and have multiple responsibilities toward their children and family.[2]

Breast cancer is a major challenge not only to the patient but also to the patient’s family.[3] In particular, young women with breast cancer are stressed, feel low parental self-efficacy, and lack of support.[4] They also suffer from many physical problems such as fatigue, weakness, and side effects related to the treatments.[5] All these affect the quality of their communication and regular childcare activities.[6] A systematic review showed that mothers with breast cancer often experience a failure to fulfill parental responsibilities.[7] Mothers try to use self-management strategies and seek support from the family and external support networks to compensate for their shortcomings in caring for their children and to promote normal family functioning.[8],[9],[10],[11],[12]

The studies in Iranian culture also show that patients with cancer encounter many psychosocial problems,[13],[14] and that support received from family is essential for overcoming these problems.[15] A study showed that family functioning, existential, and spiritual well-being in mothers with breast cancer was significantly weaker than that of healthy women. Women with breast cancer were also weaker in the areas of problem-solving, communication, and role function.[12] Another study also reported that changes due to breast cancer affect women’s experiences of their maternal role, and the quality of these experiences varies according to the sociocultural and family circumstances in which the individual lives.[16]

Despite knowing that breast cancer has a detrimental impact on the mothers and their family members, we do not know how Iranian mothers overcome these threats, what support systems are available for them, and how they maintain their family functioning. A review of the literature also reveals that very little is known globally about these issues in mothers with breast cancer who have very young and dependent children.[17],[18] Therefore, the question remains unanswered that how Iranian mothers with breast cancer face threats of the disease to their maternal role and the support they receive to play and rebalance this role.

Objectives

This study aimed to explore the experiences of mothers with breast cancer of the support they receive for playing and rebalancing their mothering role.


  Methods Top


Study design and participants

A qualitative conventional content analysis was conducted on 22 mothers with breast cancer. All mothers newly completed cancer treatment in Shahid Ghazi Tabatabaee Hospital, Tabriz, Iran, and were in their follow-up period. The inclusion criterion included having at least a child younger than 16 years old and being in the follow-up period of cancer treatment. Participants were selected through purposive sampling from May 2018 to January 2019, with maximum variation sampling respecting their age, education level, type of treatment, and the number of children.

Data collection

Data collection was performed by the first author through in-depth semi-structured interviews. Examples of interview questions were, “What problems did you have in performing your maternal duties during the disease?” “What resources are available to help you with doing your mothering tasks?” “Can you describe your experiences in this area?” Based on the participants’ responses, probing questions were asked. These questions included “What do you mean by this?” and “Could you explain more about this?” The duration of interviews ranged between 35 and 85 min. Interviews were conducted at participants’ preferred time and places, mostly in a private room at the oncology clinic of the aforementioned Hospital. All interviews were audiotaped and transcribed verbatim. Interviewing stopped when data saturation occurred and no new conceptual codes or concepts emerged from the data, and all categories were fully developed.

Ethical considerations

The study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences (approval code: IR.TBZMED.REC.1396.1253). Informed consent was obtained from all participants and they were provided with information about the study aims and methods, the confidentiality of their data, the voluntariness of participation, and freedom to voluntarily withdraw from the study.

Data analysis and trustworthiness

Data analysis was performed simultaneously with data collection. To analyze the data, we used the method suggested by Graneheim and Lundman.[19] The first and second authors read the interviews several times. Then, meaning units, which were those parts of the interviews that could express the participants’ experiences, were extracted and were transformed to condensed meaning units and codes. Next, we compared the codes for similarities and differences to form subcategories and categories. An example of data analysis is presented in [Table 2]. The MAXQDA Analytics Pro version 10 (VERBI GmbH, Berlin, Germany) was used for data management.
Table 2: A sample of data analysis for the category of “rebalancing family function”

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Trustworthiness was achieved through the Lincoln and Guba four criteria.[20] Credibility was established through allocating adequate time to data collection and analysis, prolonged engagement with the data, maximum variation sampling, member checking, peer checking, and external debriefing. For transferability of the data, selected interviews along with codes and categories were shared with two mothers with breast cancer other than the primary participants, and they agreed that these codes represent their real experiences. To ensure dependability, two experts other than the research team who were familiar with qualitative analysis approved the meaning units, subcategories, and categories. Peer checking by coauthors also helped establish the dependability of the findings. To ensure confirmability, all steps of the study were clearly described for external auditing.[19]


  Results Top


The average age of the mothers was 42 ± 4.38 years. The mothers’ demographics are summarized in [Table 1]. Data analysis led to the emergence of three main categories and 11 subcategories. The categories include perceived difficulties, being with and for mother, and rebalancing family function [Table 3].
Table 1: Characteristics of the study participants

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Table 3: Categories and subcategories of the study

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Category 1: Perceived difficulties

Mothers experienced difficulties such as movement limitations, fatigue, disability, and pain. These symptoms might be attributable to the treatments such as chemotherapy and mastectomy, and can occur in months and sometimes years after the disease and its treatment. This category had four subcategories, namely, physical limitations in performing the mothering role, the psychological burden of the disease, role strain in playing the mothering role, and children’s social difficulties in the trajectory of the disease.

Physical limitations in performing the mothering role

Participants frequently shared their experiences of problems such as reduced motor strength, inability to carry a child in their arms, fatigue, pain, and backache after carrying the child with the same arm. Such limitations resulted from physical limitations such as limited range of motion of the shoulder due to pain, swelling, and stiffness of the shoulder joint after mastectomy, and weakness, fatigue, and pain related to chemotherapy and medical treatments or exacerbation of the disease.

 “After surgery, my left hand was numb, swollen, and very painful. I cannot take my child out and play with him … I get tired very easily. Sometimes I have severe backache and I cry because of the pain in my bones… ”(P. 6).

The psychological burden of the disease

Mothers experienced severe psychological burden due to the fear of the disease. They repeatedly mentioned issues such as the fear of cancer, the impaired mother-child relationship, and the despairing and discouraging thoughts of an insecure future for their children, as issues that made them anxious or depressed and unable to carry out their mothering role effectively.

“I cannot speak to the children without the fear of illness, and. my children are always worried about losing. I am worried about the weakening of my relationship with children” (P. 14).

In addition to the negative state-of-mind which threatened the participants’ mothering role, negative comments by people, frustration arising from pity felt by others for them, and the humiliation aroused from the changes in their physical appearance, sometimes contributed to the loss of interest in taking care of their children.

“I was always worried about the worsening of my disease and being unable to do my daily routines. This makes me feel that others are pitying me” (P. 20).

“I was embarrassed about removing one of my breasts; I did not like anyone to know that” (P. 13).

Role strain in playing the mothering role

The physical and psychological burden of the disease and the overwork caused by multiple roles, made mothers feel pressure in playing the mothering role. They were under pressure to play the role of both mother and wife. This pressure was felt more in single-parent families. As a result, some participants were reluctant to take part in some of their mothering duties or became dependent on other people to help them.

“Caring for children and being sick at the same time is a very heavy responsibility, especially for employed women who have several responsibilities at the same time” (P. 17).

Children’s social difficulties in the trajectory of the disease

Mothers were not able to meet the physical and psychological needs of their children. They were also worried about the pressure and social isolation experienced by their children due to their disease.

 “My eldest son, who was very depressed early in my illness, wanted to commit suicide, but he explained it to me later when I was a little better, and I felt that my two sons were under a lot of pressure in that situation.” (p. 21).

 “My daughter, who is in charge of most of the housework, is very upset and has lost weight.”(p. 22).

In the absence of the father, as occurs with single-parent families, financial pressure is often imposed on the mother and her sons. These children experienced consequences such as academic failure and leaving the school to work.

 “My eldest son could not continue his education. My illness, the absence of a father, and the high cost of medicines made him work in a car repair shop to support his family.” (p. 11).

Category 2: Being with and for mother

The mothers participating in this study needed support from within and outside of the family to cope with complications of diseases and role strain. Their experiences about support were categorized in a central category called “being with and for mother.” This category had five subcategories as follows:

Assistance with the mothering role

The majority of participants stated that many of their family members and neighbors were trying to create a positive and helping atmosphere by accepting new duties in the family. These aids ranged from doing household chores to making out time to meet the needs of the children.

 “My husband tries to make me and my children happy by buying gifts” (P. 14).

 “I cannot do housework anymore, so my children do all the housework, and my eldest daughter cooks food to make me happy”(P. 21).

Emotional attachment to mother

Emotional attachment means a sense of belonging that is shown by individuals toward the patients. Family members displayed positive emotions toward the mothers. Participants stated that the family members and other individuals supported them with affectionate behaviors and comfort, which helped them with adjusting to the expectations of being a sick mother. They also noted that their children concealed their true emotions about the illness.

“When my son comes back from school, he tries to make a joke out of something. I feel my family is much kinder now” (P. 14).

Provision of current family expenses and treatment costs

The participants stated that their spouses had shifted the expenses from the children’s needs to the mothers’ treatment. They also worked overtime to pay for the costly courses of chemotherapy and radiotherapy. Donations from other individuals, mosques, and charities also expanded their financial support.

“My treatment costs a lot, and my husband spends most of his income on my treatment. He has had to take up several jobs at the same time” (P. 17).

Some of the participants referred to receiving food packages from charities, receipt of free pharmaceutical drug prescriptions, or buying them at a discounted rate.

“I was looking for someone or somewhere to help me get medical and living expenses. The only benefit I received from the Charity X was that, with a letter from them, I got a discount on my medicine” (P. 12).

Attempts at normalization of appearance following cancer-induced changes

According to the experiences of mothers, breast cancer and its therapeutic interventions resulted in changes in their appearance. They stated that family members did not talk about the illness or the changes in the patient’s appearance, but helped mothers overcome these changes by avoiding the use of the word, “cancer,” refraining from talking about mastectomy, coping with physical changes in the mother, and encouraging the mother to use a prosthesis and wigs, where applicable.

“We try not to talk about the disease, I do not even use the word ‘cancer’, and I say I removed a tumor. I was worried about the reaction of my husband to mastectomy. he said the breast was God-given, and God took it back” (P. 20).

Social support resources

In addition to benefiting from the support of family members and relatives, participants mentioned other sources of support in the community that helped them cope with their maternal roles. These resources included training/consulting and welfare/services resources in the community that help to care for children and household and also health-care providers that help to access the information they needed. Examples of some of these resources were nurseries services, food preparation centers, and the teachers and counselors in the children’s schools that provided emotional support for students with ill mothers and their moms.

“At the early stages of my illness, my son wanted to commit suicide, so I shared my problem with the school counselor and he advised me a lot” (P. 22).

“My children’s nursery school is very helpful in caring for them and training them(P. 2).

Mothers stated that members of the health system supported by providing family members with information, education, and medical advice on health and physical constraints of breast cancer and its treatment.

“The doctor said that cancer can relapse after some time, but urged me to be careful about eating, exercise, and control of stress. The behavior of medical personnel towards me is very good. If I have a question about chemotherapy and my illness, I can ask” (P. 2).

Category 3: Rebalancing the mothering role

In the process of dealing with breast cancer, participants strove to achieve stability in the mothering role. They gradually attempted to reduce dependence on people and resources outside the family. They tried to leave behind the experiences of their serious illness, to have a new and improved form of life with their children and other family members. This category had two subcategories, namely, role stability for the mother and promoting a health-oriented perspective in the family.

Role stability for mother

Participants revealed that besides the redivision of duties in the family, intimate relationships in the family were strengthened, which led to successful management of family issues despite the prevailing circumstances brought by the disease and its treatment. Gradually, during the recovery period, participants sought to move toward independence in child care by reducing the need for help in doing things.

“I tried to go back to doing some things by myself. Apart from the hardships that the illness brought to me and my children, there were some positive aspects” (P. 19).

Promoting a health-oriented perspective in the family

Developing a health-oriented perspective was a positive consequence of the disease for the mother and family members. By prioritizing their children’s health and pursuing their health-care programs, mothers showed an appreciation for their children’s health. Furthermore, through developing their self-care behaviors, changes in their lifestyle, exercise, and regular follow-up visits, they tried to improve their life after breast cancer.

“Right now, as a consequence of my sickness, we eat organic food, and I exercise more. Every 3 months, I receive a course of chemotherapy to follow up my treatment” (p. 20).


  Discussion Top


Findings showed that “physical limitations in performing the mothering role” was among the most important difficulties the mothers experienced after getting breast cancer. Physical limitations due to the illness and therapeutic interventions limit mothers’ ability to play multiple maternal roles, including caregiver, nurturer, and protector or keeping safe the children. An earlier study also reported that mothers with breast cancer struggle with physical, mental, and social challenges and all these negatively impact their family life and impede their mothering role.[17] The study participants were under considerable “psychological burden of illness” which restricted their ability to interact effectively with their children and accompanying children to social events. A recent study also reported that cancer interrupts maternal tasks and exacerbates the suffering of these mothers.[21] Health-care providers should pay attention to the psychosocial burden of cancer and its treatment and reduce their impacts on the patient’s life.

The findings of this study showed that mothers with breast cancer are worried about social difficulties their children face during the process of their disease. A former study also reported that children irrespective of age are affected by the cancer diagnosis of their parents.[22] Study findings showed that the disparity between mothers’ responsibilities, the lack of opportunities to enjoy childhood, and discomfort created by mothers’ absence due to hospitalization for follow-up treatment make children confused and frightened. Some earlier studies have also reported that the unmet children’s needs would result in psychological and educational problems for Iranian adolescents and young adults, with their greatest unmet psychosocial need being the need for information regarding parent’s ailment.[23],[24]

The interplay of maternal, family, and occupational roles of mothers with breast cancer made them feel role strain and prevented them from playing their mothering roles. Studies show that breast cancer changes women’s role from caregiver to care receiver and this negatively affects the ability to fulfill their mothering and familial roles.[17],[25]A study also demonstrated that mothers with cancer suffer from changing the family and child routines, and they have difficulties in caring for their children.[21]

The category “being with and for mother” in the current study reflected the supportive efforts of family members — especially children — and other people for creating a positive atmosphere in the family. This concept alludes to the fact that by perceiving the new situation in the family, children become obedient and modify their expectations to accept new responsibilities and learn housework skills. This finding is consistent with similar findings in a former study[26] that showed children try to be active in the care of their mother rather than being recipients of care. The involvement of family members and children in the care of their mother is of particular importance in the process of cancer treatment.[27] Iran—the country in which the study was conducted — is an Islamic country, with strongly religious people. Such strong religious beliefs that emphasize respect toward parents help Iranian adolescents cope with their parent’s cancer diagnosis and participate in their caring activities.

The presence of family members and other individuals helping out in various ways served to relieve the mothers’ physical and mental suffering. These results are consistent with previous studies.[8],[16],[28] In Iran, due to the high costs of cancer treatments, most cancer patients are faced with financial difficulties, thus many cancer patients are cared for at home by their family members.[29] The results of this study correlate with previous studies, which emphasize the family-centered culture in Eastern countries.[29],[30] Physical appearance following body image alteration caused by the disease and its treatment was a concern to the participants. The findings of this study regarding the use of prostheses and wigs relate to those of Zeighami Mohammadi et al. that describe six coping strategies adopted by Iranian women with breast cancer to “reconstruct the feminine identity.”[31]

This study also reveals a support chain that includes spouses of women with breast cancer. This finding is congruent with a former study, suggesting that if one spouse has cancer, the other spouse’s efforts to be a good parent will increase.[32] Furthermore, social support such as advice, physical or emotional help from neighbors and friends, as well as socio-cultural and religious affiliations have been shown to improve the overall health of women with cancer.[12],[33]

According to the findings, social support can motivate mothers with breast cancer to rebalance their mothering role. The participants understood the need for returning to their roles as housewives to be able to care for their children and the rest of the family. This finding also corroborates a previous study that revealed that breast cancer patients continue to prioritize children and family needs above self needs.[26]

Another finding of the study was the mothers’ effort to return to role stability. By normalizing their function, mothers reduced their dependence on people and resources outside the family and came up with a new and improved form of life that was more valuable to themselves and their family members. Some earlier studies have also indicated that along with re-stabilizing their roles, parents try to prioritize the strategy of maintaining childcare practices to help family members adapt to the disease and minimize the changes caused by the disease.[5],[32]

Finally, the findings of the study showed that the participants experienced a positive outcome from the disease, which was termed “promoting a health-oriented perspective in the family.” Participants and family members focused on health-oriented activities by pursuing self-care behaviors, lifestyle changes, sports activities, and keeping appointments for health referrals to follow, stop, or delay the disease progression. These findings are in line with an earlier study that reported that being a mother and having breast cancer at the same time means changing and re-prioritizing values and giving meaning to life.[21]

Our study was limited to a single institution and mothers with children younger than 16 years old. Furthermore, most of our participants were of middle-class socioeconomic status and from the Iranian culture, and all these limit the generalizability of the findings to other socioeconomic groups and cultures. Therefore, more studies are needed to address these limitations. We also recommend further mixed-method studies in this regard and involving women with breast cancer in other cultural settings.


  Conclusion Top


This study shows that Iranian mothers with breast cancer face problems in their parenting roles with regards to their children and thus need to be supported. The physical limitations in performing the mothering role and the psychological burden of disease reduce mothers’ energies to care for their children. They need support from within and outside of the family to cope with these issues that result in the role strain. Mothers by receiving support from their spouses, children, and other family members can strive to achieve stability in their mothering role and hence reduce dependence on people and resources outside the family. The promotion of self-care behaviors by mothers, lifestyle changes, sports activities, and regular follow-up visits are encouraged as they will aid in improving the mothers’ perspective on life after the breast cancer diagnosis. Health policymakers should identify supportive strategies and resources for young breast cancer mothers. Enhancing and activating resources and coping strategies may help the families to manage the situation better and may prevent an imbalance in family life.

Acknowledgments

This article was derived from the doctoral dissertation in Nursing, Tabriz University of Medical Sciences, Tabriz, Iran. The authors would like to acknowledge the research deputy at Tabriz University of Medical Sciences for their support. We also are thankful to all mothers who participated in the study.

Financial support and sponsorship

The Tabriz University of Medical Sciences supported this study financially.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 2], [Table 1], [Table 3]



 

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Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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