Resilience in the Perinatal Period and Early Motherhood: A Principle-Based Concept Analysis. — TEI-tagged view

Susan Elizabeth HannonpersName, Déirdre DalypersName, Agnes HigginspersName (2022date). “Resilience in the Perinatal Period and Early Motherhood: A Principle-Based Concept Analysis..” International Journal of Environmental Research and Public Healthtitle·j.

Object of study — how women's resilienceterm·dom is defined, conceptualised and researched in the perinatal periodterm·key and early motherhood

Research question — how resilienceterm·dom is conceptualised and operationalised in empirical research on the perinatal periodterm·key and early motherhood

Contribution — resilienceterm·dom in this literature is narrowly operationalised by mental ill-health and parental role, and women's own perspectives are absent

Full text — tagged

Resilienceterm·dom in the Perinatal Periodterm·key and Early Motherhood: A Principle-Based Concept Analysisterm·mth.

Abstract A context-specific delineation of research approaches to resilienceterm·dom in the perinatal and early motherhood literature is currently lacking. A principle-based concept analysisterm·mth was used to establish a description of how women’s resilienceterm·dom is currently conceptualised and operationalised within empirical research in the perinatal periodterm·key and early motherhood (defined as up to five-years postpartum). CINAHL, Medline, PsychInfo, EMBASE, ASSIA, Web of Science, Scielo, Maternity and Infant Care, the Cochrane Library, and the World Health Organization were systematically searched (January/February 2020 and March 2022). Fifty-six studies met the inclusion criteria. Analysis demonstrated interchangeable use of associated concepts such as ‘copingterm·dom’, ‘coping strategiesterm·dom’, and ‘adaptationterm·dom’. Resilienceterm·dom was frequently operationalised as the absence of illness symptomatology, rather than the presence of mental well-being. Investigations of positive areas of functioning were predominately related to the mother’s family role. There was limited qualitative exploration of women’s perspectives. Recommendations for the pragmatic application of resilienceterm·dom research were not well developed. The narrow operationalisation of resilienceterm·dom by mental ill-health and parental role, and the distinct absence of women’s perspectives, restricts the logical maturity and pragmatic application of the concept. Future research may benefit from exploration of women’s insights on indicators that might best reflect positive functioning and resilienceterm·dom in this period.

Keywords: resilienceterm·dom, mental healthterm·dom, perinatal, early motherhood, principle-based concept analysisterm·mth 1. Introduction Positive aspects of mental healthterm·dom and well-being are receiving increased research interest [ 1 ], particularly as there has been growing recognition that broader inquiry may advance our understanding beyond the contested conceptualisation of mental healthterm·dom as consisting of either illness or the absence of illness [ 2 ]. This shift also extends to the perinatal mental healthterm·dom literature [ 3 ]. Perinatal mental healthterm·dom research has typically focused on risk factors and negative outcomes, rather than on investigation from a positive or strengths-based perspective [ 4 ]. However, a growing body of research is emerging on women’s psychological health and resilienceterm·dom, and it seems that this interest is driven, at least in part, by the growing recognition that supporting mothers also supports families and improves outcomes for all [ 5 , 6 ].

The concept of resilienceterm·dom has been promoted as a perspective on health and well-being, which assists in shifting research foci away from ‘deficit’ models of illness and psychopathology [ 7 , 8 ], towards a better understanding of the processes, assets, or protective factors that enable mental healthterm·dom to be regained or maintained despite adversity [ 9 ].

Resilienceterm·dom is a debated topic within the literature and has been the subject of several discursive reviewsterm·mth, critiques, and analyses [ 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Some discussions have aimed to bring clarity to the concept independently of contextual elements [ 20 ], while others have endeavoured to explore the application of resilienceterm·dom within a specific context, such as in populations with HIV/AIDs [ 21 ], in adolescence [ 22 ], and mental healthterm·dom settings [ 23 ].

Scholars routinely draw attention to the on-going debate concerning the concept’s various definitions, the range of methods through which resilienceterm·dom is measured, and remark upon the consequent challenges to research synthesis and evaluation [ 15 , 24 , 25 ]. Definitions of resilienceterm·dom are often broadly grouped as taking trait or process perspectives.

Resilienceterm·dom research is, however, not amendable to discrete categorisation. Even within these perspectives, there is nuance and fluidity in the use of terminology, methodology and operationalisation, which makes categorisation in any context a challenge.

For example, Fletcher and Sarkar state that resilienceterm·dom perspectives may be organised by ‘trait, process, or outcome’ [ 15 ] (p. 3). However, references to various ‘outcomes’ of resilienceterm·dom are used with both ‘trait’ and ‘process’ orientations.

Trait conceptualisationsterm·dom regard resilienceterm·dom as a stable characteristic within an individual, whereas process conceptualisationsterm·dom consider the interacting influence of biological, psychological, social, cultural, and contextual factors on the individual’s experience [ 9 , 16 , 26 ]. Although there is less theoretical writing on resilienceterm·dom as an ‘outcome orientation’ within the literature, it has been described as maintaining or regaining mental wellbeing following a stressor, with the consideration that resilienceterm·dom is modifiable and influenced by factors that may protect against negative outcomes [ 24 ]. This is a description that echoes ‘process’ delineations.

Not only do differing conceptualisations influence researchers’ strategies for studying resilienceterm·dom, resilienceterm·dom is researched differently by context [ 24 ]. How resilienceterm·dom is operationalised in one particular circumstance may not be helpful or appropriate in another [ 9 ]. Thus, consolidating research within a specific context may allow researchers to identify recurring themes, strengths, and weaknesses within the literature and establish areas in which the concept has been well developed, or requires improvement.

This concept analysis aims to evaluate how women’s resilienceterm·dom is currently defined, conceptualised, and researched within the empirical literature, as it occurs in relation to the perinatal periodterm·key and early motherhood, and to consider the concept’s degree of maturity, utilising Penrod and Hupcey’s [ 25 ] principle-based approach. The strength of this approach is that it uses scientific literature as data to reveal the ‘existing state of the science’ [ 25 ] (p. 403), to establish how the concept is currently used and conceptualised within the research according to the principles of epistemology, linguistics, pragmatism, and logic. Several concept analysis frameworks involve the identification of attributes frequently associated with the concept, for example, Walker and Avant [ 26 ], Rodgers [ 27 ], and Rodgers and Knafl [ 28 ]. However, such frameworks were considered unsuited to the aim of the current investigation, as attributes which appear to emerge from the analyses may be a result of frequently used measures.

In contrast to other styles of concept analysis, Penrod and Hupcey’s [ 25 ] methodology does not require the researchers to produce hypothetical cases to exemplify the concept. This feature of the framework was considered appropriate to the research aim of capturing the state of the science and avoids a researcher-produced interpretation of the manifestations of resilienceterm·dom.

2. Materials and Methods 2.1. Data Sources and Search Strategy A protocol and search strategy for the concept analysis was developed a priori. The electronic bibliographic databases of CINAHL, Medline, PsychInfo, EMBASE, ASSIA, Web of Science, Scielo, Maternity and Infant Care, the Cochrane Library, and the World Health Organization (WHO) were systematically searched. As the population of interest was women in the perinatal periodterm·key and the first five years postpartum, keywords for the first concept were (pregnan *) or ‘pregnant wom *’ or primigravid * or primipara * or ‘gravid *’ or multigravida * or multipara * or nullipara * or nulligravid * or childbearing or child-bearing or antenatal or ante-natal or prenatal or pre-natal * or ‘expect * mother *’ or perinatal * or peri-natal * or postnatal * or post-natal * or postpartum or post-partum * or ‘new mum *’ or maternal * or mother *. Keywords for the second concept, resilienceterm·dom (‘psychological resilienceterm·dom’/exp or resil *.) were combined using the Boolean operand ‘AND’. No date limit was applied, in order to capture all citations relevant to the analysis and identify development of the concept over time. Data were collected in January/February 2020 and March 2022.

2.2. Inclusion Criteria Primary research published in English, where there was a clear expression that at least one of the phenomena examined or found was psychological/mental resilienceterm·dom of pregnant women and mothers up to five years postpartum. Research involving mothers and partners were included only where mothers’ data could be separated from partner data.

2.3. Exclusion Criteria Articles were excluded if (i) resilienceterm·dom was examined during pregnancy only, (ii) if mothers’ resilienceterm·dom was explored in relation to infertility, miscarriage, stillbirth, or a child’s death, or (iii) if mothers’ resilienceterm·dom was operationalised by child health or development outcomes; and (iv) to avoid skewing the analysis, resilienceterm·dom research conducted with adolescent mothers was excluded. Adolescent motherhood entails period-specific challenges and navigation of dual adolescent and maternal identities [ 29 ], which women who become mothers in adulthood do not confront. In addition, education-related outcomes are common in adolescent resilienceterm·dom literature [ 22 ] and unlikely to feature as a life-stage appropriate domain of investigation for most mothers in adulthood. Articles evaluating interventions, or participant’s satisfaction with resilienceterm·dom interventions, conference abstracts, case studies, theses, reviewsterm·mth, and editorials were excluded; as were animal studies, non-English articles, and studies related to immunology or physical health.

2.4. Data Analysis Articles were analysed following Penrod and Hupcey’s [ 25 ] principle-based concept analysisterm·mth, which involved evaluation of data according to four philosophical principles: epistemology, linguistics, pragmatism, and logic. Penrod and Hupcey [ 25 ] acknowledge that concept analysis involves a degree of subjective interpretation, principles are not mutually exclusive, and points of interest that emerge in one principle may simultaneously hold relevance in another.

A data extraction tool adapted from O’Malley et al. [ 30 ] was used. Data included lead author’s discipline, study design, aim, sample characteristics, and country of origin. The tool also contained questions pertaining to the four philosophical principles. Each researcher (S.E.H., D.D., A.H.) analysed three studies independently using the data extraction tool and then discussed points of consistency and divergence within and between analyses. The researchers agreed on minor amendments to the extraction tool, and one researcher (S.E.H.) analysed the remaining studies.

The analysis did not entail a quality assessment of the included papers. The aim of the analysis was not to identify and synthesize findings from the individual papers, but to identify and evaluate the predominant methodological and philosophical approaches within the literature in this context.

3. Results A total of 23,080 citations were retrieved, with 15,051 citations following duplicate removal. Title and abstract screening removed 14,830 citations, leaving 221 articles for full-text screening, 164 of which did not meet the inclusion criteria. A total of 56 studies were included for data extraction and analysis ( Figure 1 ) [ 31 ].

Prisma 2020 flow chart (adapted from Page et al., 2021) [ 31 ].

Data were extracted from 41 quantitative, 11 qualitative, and four mixed-methods design studies, conducted since 2004. Approximately half of the included studies were published before the year 2020, and averaged at two per year prior to this date. The year 2020 saw a significant increase in research interest in resilienceterm·dom in the perinatal periodterm·key and early motherhood, with eight studies published in 2020, 17 in 2021, and three in 2022. However, only eight of the 28 studies published since March 2020 included data from perinatal women living through the COVID-19 pandemic [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ].

3.1. Epistemological Principleterm·mth: Key Findings The epistemological principleterm·mth considers how a concept is defined and made distinct from other concepts within the literature [ 25 ]. An analysis of the included studies from the epistemological principleterm·mth necessitates a consideration of two issues: (i) the provision and orientation of a formal definition of resilienceterm·dom, and (ii) how resilienceterm·dom is conceived by individual studies through reviewterm·mth of the operationalisation and theoretical discussion of the concept. Of the 56 studies, 20 did not include any definition. Thirty-four studies formally defined resilienceterm·dom, of which 22 provided definitions that were from a trait perspective, and ten provided a process definition. Two studies gave an operational definition of resilienceterm·dom. Categorisations of definitions were determined by the explicit definition provided by the authors of each paper. ( Table 1 ). Although orientations of resilienceterm·dom have been described as ‘trait, process, or outcome’ [ 15 ] (p. 3). A reviewterm·mth of the theoretical discussion and operationalisations of resilienceterm·dom in the perinatal and early motherhood literature demonstrates that, overall, resilienceterm·dom was conceptualised in three ways: as a trait, which in some cases was simultaneously considered a protective factor; a process evidenced in mental healthterm·dom or well-being outcomes; and/or a trajectory exemplified by temporal patterns of low symptomatology.

Summary of Study Characteristics.

Nineteen quantitative [ 35 , 37 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ], two mixed-method [ 32 , 34 ], and one qualitative study [ 57 ] provided a definition which positioned resilienceterm·dom as a trait or ability. Adopting this perspective means resilienceterm·dom may also be regarded as a protective factor against negative outcomes, as demonstrated by Angeles García-León et al. [ 40 ], who used the Connor–Davidson resilienceterm·dom scale (CD-RISC) to explore resilienceterm·dom as a trait that is protective against pregnancy-specific stress.

Five quantitative studies [ 58 , 59 , 60 , 61 , 62 ] and five qualitative studies [ 63 , 64 , 65 , 66 ] conceived of resilienceterm·dom as a dynamic process, in which ‘psychological, social, environmental and biological factors interact to make an individual, at any stage of life, develop, maintain or regain their mental healthterm·dom despite exposure to adversity’ [ 67 ] (p. 1). Two studies offered multiple definitions, from both trait and process perspectives [ 45 , 68 ].

Resilienceterm·dom was researched by four studies as a pattern or trajectory of mental healthterm·dom outcomes evident in longitudinal data [ 69 , 70 , 71 , 72 ], each of these studies identified four temporal trajectories in mental healthterm·dom outcomes. These trajectories were determined as symptomology absence [ 71 , 72 ], or low scores of depressive symptomatology [ 70 ] and high quality of life (QoL) [ 69 ]. Denckla et al. [ 70 ] did not provide a conceptual or operational definition of resilienceterm·dom. However, Fonseca et al. operationally defined a resilient trajectory as demonstrated by the ‘maintenance of healthy adjustmentterm·dom over time, without disruption of functioning’ [ 69 ] (p. 113), similarly Kikuchi et al. defined resilienceterm·dom as women who were ‘not depressed throughout 1 year postpartum’ [ 71 ] (p. 632).

Twenty studies did not provide a formal conceptual definition of resilienceterm·dom. Within the 13 quantitative and two mixed methods studies, this left the reader to deduce how resilienceterm·dom was perceived, through consideration of the study’s methodological approach. For example, as a trait or ability, as would be suggested by the use of validated resilienceterm·dom scales [ 33 , 36 , 38 , 73 , 74 ]; as a protective factor [ 74 , 75 , 76 , 77 , 78 ]; as an outcome of low depressive [ 77 , 79 ]; or PTSD symptoms [ 80 ]; or as previously mentioned, a trajectory of low depressive symptoms [ 70 ]. Among the five qualitative studies that did not provide a definition, resilienceterm·dom was typically presented in relation to descriptions of copingterm·dom [ 81 , 82 , 83 , 84 ], or through the identification of resiliency or protective factors [ 85 , 86 ].

Definitional Elements The analysis found that the term ‘maternal resilienceterm·dom’ was used in six of the 56 studies [ 40 , 41 , 44 , 58 , 63 , 87 ]. However, none of the studies using this term provided a specified definition. It appears the authors’ use of ‘maternal resilienceterm·dom’ was intended to connect the concept of resilienceterm·dom to the context of the perinatal periodterm·key and motherhood, rather than a term denoting some qualities or facets of resilienceterm·dom that are distinct to this period of life.

3.2. Linguistic Principleterm·mth: Key Findings The linguistic principleterm·mth evaluates if terminology is context appropriate and consistently used. There was evidence of fluidity in the use of resilienceterm·dom with associated terms and concepts, shifts in meaning or application of the concept varied across papers and it was challenging to disentangle linguistic and operationalised use; as such, linguistic consistency was not easily categorised.

There were several examples of copingterm·dom or coping strategiesterm·dom used synonymously with resilienceterm·dom [ 54 , 58 , 81 , 82 ]. For Nishi and Usada, ‘stress-coping ability’ [ 46 ] (p. 3) was equated with resilienceterm·dom. Others considered copingterm·dom a manifestation of resilienceterm·dom [ 83 ] or distinguished copingterm·dom as an ‘attribute of resilienceterm·dom rather than a concept in its own right’ [ 63 ] (p. 435), while Werchan et al. [ 39 ] quantitatively categorised pregnant and postpartum women into four behavioural profiles associated with either ‘low’, ‘passive’, ‘active’, or ‘high’ copingterm·dom styles, using depression, anxiety, global distress, and behavioural copingterm·dom surveys. The terms ‘resistance’, ‘adaptationterm·dom’, and ‘protection’ were a frequent feature of the literature, and occasionally used synonymously with resilienceterm·dom [ 34 , 53 , 56 , 60 , 76 , 77 ]. In these instances, resilienceterm·dom was evidenced in positive patterns of scoring on mental healthterm·dom scales, which were considered demonstrative of an adaptive response, or resistance to negative outcomes [ 49 ]. For example, Grote and Bledsoe, using a ‘risk and resilienceterm·dom’ theoretical framework [ 60 ] (p. 109), examined if optimism during pregnancy might impact on depression severity postpartum and interpreted the positive moderating effect of optimism on depressive symptoms as conferring resilienceterm·dom, protection, and resistance. The topic of adaptationterm·dom in qualitative data was associated with self-care or activities that the authors considered as ‘resiliency building’, such as getting exercise and eating well, use of mindfulness practices and meditation, prayer, and accepting help [ 34 ].

Resilienceterm·dom research is considered to offer a divergence from ‘deficit’ models of illness and psychopathology [ 7 ] (p. 1). However, the use of ‘deficit’ language appeared, albeit infrequently. For example, Asunción et al. [ 75 ] when referring to Schachman and Lindsey’s [ 61 ] research findings, cited the absence of ‘self-resilience’ as meaning women who ‘lack a positive attitude, perseverance, self-efficacy, and the ability to adapt to the stress of having a new baby’ [ 75 ] (p. 831). However, Schachman and Lindsey did not employ language suggesting inadequacy but rather used positive terms, suggesting mothers met challenges with ‘self-reliant’ and ‘can-do’ attitudes [ 61 ] (p. 164). Deficit language appeared in Bennett and Kearney’s commentary that a personal commitment to breastfeeding may sustain women to ‘continue to breastfeed despite any shortcomings in their support network or resilienceterm·dom’ [ 41 ] (p. 8). While this phrasing may simply be an oversight rather than a judgment on women, the use of deficit language sits incongruously with resilienceterm·dom as a strengths-based approach. Additionally, the use of resilienceterm·dom scales was occasionally accompanied by the categorisation of women as possessing ‘low’, ‘high’ [ 35 , 52 , 53 , 73 ], and, in one case, ‘normal’ [ 49 ] resilienceterm·dom levels based on cut-off scoring.

3.3. Pragmatic Principleterm·mth: Key Findings The pragmatic principleterm·mth focuses on how the concept has been used within the literature, whether it accurately describes the phenomenon, and its usefulness to clinical practice.

Forty-one studies used quantitative measures for resilienceterm·dom; 17 operationalised resilienceterm·dom through mental healthterm·dom outcomes and/or positive functioning [ 32 , 39 , 49 , 51 , 58 , 59 , 60 , 61 , 69 , 70 , 71 , 72 , 76 , 77 , 78 , 79 , 80 ], while 23 employed a resilienceterm·dom scale alongside one or more surrogate outcomes [ 35 , 36 , 37 , 38 , 40 , 41 , 42 , 44 , 45 , 46 , 47 , 48 , 50 , 52 , 53 , 54 , 55 , 56 , 62 , 68 , 73 , 74 , 75 , 93 ], and one operationalised the sense of coherence scale for resilienceterm·dom [ 43 ]. Among the 11 qualitative studies, five studies linked resilienceterm·dom to evidence of copingterm·dom or coping strategiesterm·dom [ 63 , 64 , 81 , 82 , 83 ], and two to adaptationterm·dom to difficult life circumstances [ 57 , 84 ].

3.3.1. Operationalisation and Research Pragmatism As in the wider literature, facets of mental healthterm·dom such as depression, anxiety, or stress were utilised as surrogate outcomes for resilienceterm·dom. In such cases, absent or low-level symptomatology were considered indicative of resilienceterm·dom. Scales developed specifically for use in the perinatal periodterm·key and parenthood were employed to explore outcomes such as parenting stress [ 43 , 59 ], maternity blues [ 52 ], pregnancy pressure [ 55 ], pregnancy-specific stress [ 40 ], postpartum emotional distress [ 79 ], pregnancy-related anxiety [ 93 ], and pregnancy distress [ 41 ]. Other outcomes included post-traumatic stress disorder (PTSD) [ 34 , 36 , 42 , 45 , 47 , 48 , 55 , 58 , 68 , 80 ], suicidal ideation [ 56 ] or suicidal behaviour [ 75 ], psychopathological symptoms [ 38 , 40 ], anxiety [ 35 , 54 , 74 , 79 ], loneliness [ 33 ], and, most frequently, depression [ 35 , 42 , 44 , 45 , 47 , 48 , 49 , 54 , 60 , 61 , 62 , 70 , 72 , 73 , 74 , 75 , 76 , 77 , 79 , 80 , 93 ].

Although this approach is common within resilienceterm·dom literature as a whole, operationalising resilienceterm·dom as the absence of psychopathologyterm·dom has been criticised [ 98 ]; as the absence of illness does not necessarily indicate the presence of health or successful adaptationterm·dom, which is considered a hallmark of resilienceterm·dom [ 99 ].

Two studies operationalised reports of perceived benefit following adverse life conditions as a positive outcome [ 42 , 80 ]. Seventeen of the quantitative studies operationalised positive domains of functioning to explore resilienceterm·dom beyond absent symptomatology. Positive function was regarded as high scores in QoL [ 45 , 69 , 76 ], psychological well-being [ 32 , 33 , 40 ], posttraumatic growth [ 46 , 50 ], postpartum mastery and family specific well-being [ 47 ], family adaptationterm·dom [ 43 ], postpartum sense of competence [ 44 , 47 ], sense of coherence [ 73 ], self-compassion and mindfulness [ 32 ], mastery [ 37 ], flourishing, maternal confidence, self-compassion, psychological flexibility [ 62 ], and maternal attachment [ 53 ].

However, two studies, which intended to capture evidence of a well-being component of resilienceterm·dom applied scales designed to measure psychopathology. For example, Bennett and Kearney [ 41 ] used the mother and baby interaction scale (MABISC) [ 100 ], which was developed to assess maternal distress and suboptimal mother-infant bonding rather than maternal well-being, as was the authors’ intention. Likewise, Gerstein et al. [ 59 ] proposed to operationalise parental well-being through the Symptom Checklist-35 [ 101 ], though this scale measures symptomatic distress [ 102 ].

3.3.2. Stakeholders’ Interpretations of Resilienceterm·dom in the Context of the Perinatal Periodterm·key and Early Motherhood Penrod and Hupcey state that the pragmatic maturity of a concept involves the members of the discipline recognising the ‘manifestations of the concept; it should ring true with experience’ [ 25 ] (p. 405). A salient question to ask then is ‘who has identified the manifestations of resilienceterm·dom in the perinatal periodterm·key and early motherhood; researchers, healthcare professionals, or mothers?’

In five qualitative studies, resilienceterm·dom emerged inductively from researchers’ analysis of data. For example, Farewell et al.’s [ 85 ] socio-ecological investigation of protective resources available to mothers in areas of deprivation developed codes a priori, to link interpersonal supports, and community level and societal-level factors in promoting resilienceterm·dom/positive mental healthterm·dom and well-being. In other studies, authors concluded that resilienceterm·dom was manifested through the use of coping strategiesterm·dom among mothers with perinatal depression [ 81 , 83 ]. Others suggested that social support and copingterm·dom style gave rise to resilienceterm·dom by counterbalancing psychosocial stressors [ 82 ].

In Rossman et al.’s [ 63 ] study, resilienceterm·dom was related to copingterm·dom; however, the authors provided a rounded discussion on the frequent synonymous use of the term copingterm·dom and resilienceterm·dom, and clearly stated their understanding of the functional difference between the two concepts. This study, though specific to the complexities of mothering an infant in NICU, emphasised the practical role that healthcare professionals may have as a resilience-promoting influence for women. This support was identified by women as being pivotal for their mental healthterm·dom and navigation of their unexpected circumstances and was interpreted by the researchers as enhancing resilienceterm·dom through nurturing a woman’s confidence in her capabilities as a mother.

Schaefer et al.’s [ 64 ] focus group data from both women participants and service providers offered insight on how resilienceterm·dom may be understood from different stakeholder perspectives. The resilienceterm·dom of women who were exposed to intimate partner violence during pregnancy was conceived as ‘utilizing resources to keep moving forward’ (p. 13). Data relating to perseverance, self-reliance, and reconnecting to community, which were described by the authors as resilienceterm·dom enhancing, were identified more frequently within data obtained from service providers than from narratives offered by mothers. This led the authors to suggest that women were less likely than service providers to identify their own strengths and the assets that are pivotal to resilienceterm·dom responses.

No study reported on women’s views of resilienceterm·dom and mental healthterm·dom in the perinatal periodterm·key and motherhood. Although the interview schedule from one study contained the question ‘What does perinatal resilienceterm·dom mean to you?’, the findings from this question were not reported [ 87 ] (p. 3).

3.3.3. Clinical Pragmatismterm·mth: Clinical pragmatismterm·mth focuses on the utility of the concept within, and its potential to guide, clinical practice. Two themes evident in authors’ recommendations for the clinical application of their findings were that healthcare professionals should support and inform, and assess and screen.

Rossman et al. [ 63 ] highlighted breastfeeding peer counsellors’ and neonatal intensive care unit (NICU) nurses’ unique role as support sources for women, and detailed practical ways that nurses can foster resilienceterm·dom in mothers, such as promoting women’s sense of maternal self-efficacy through validating and normalising their experience. Bennett and Kearney advocated ‘supporting women to support themselves’ [ 41 ] (p. 609), and suggested that healthcare professionals offer support to women, in the form of breastfeeding education, to enable women to build their own supports independently. Two studies that linked successful copingterm·dom with resilienceterm·dom proposed that women be informed of, and supported in, the use of coping strategiesterm·dom [ 81 , 83 ]. However, the practicalities of where, how, and by whom these recommendations might be implemented were not described.

Multiple authors recommended that screening or assessment of mothers could be a practical application of their findings [ 87 , 93 ]. Edge and Roger [ 81 ] drew attention to the need for perinatal mental healthterm·dom screening to be culturally sensitive. Muzik et al. [ 56 ] called for multiple points of contact and assessment for postpartum women, beyond the traditional six-week period; and Fonseca et al. (p. 120) [ 69 ] suggested that parents of infants with a congenital abnormality could benefit from comprehensive assessment of their ‘adjustmentterm·dom indicators’ using psychological distress and QoL tools. However, the varied ways in which resilienceterm·dom was conceptualised across the studies raises questions on how screening should be achieved, and a dialogue as to whom, how, when, and where they should be conducted was not elaborated upon. Questions on whether screening is best conducted using resilienceterm·dom scales or mental healthterm·dom tools did not emerge from the analysis. Additionally, ethical issues concerning consent and autonomy [ 103 ] and acceptability of screening procedures to women and healthcare professionals [ 104 ] were not addressed.

3.4. Logical Principleterm·mth: Key Findings The logical principleterm·mth examines the theoretical integration of the concept in question with associated concepts. Within the 56 studies, concepts relating to mental healthterm·dom, QoL, adaptationterm·dom and adjustmentterm·dom, copingterm·dom, and coping strategiesterm·dom emerged alongside resilienceterm·dom.

3.4.1. Mental Healthterm·dom Several studies acknowledged that psychological outcomes should extend beyond the absence of psychopathologyterm·dom and contain measures intended to capture positive psychological or mental healthterm·dom outcomes. Angeles García-León et al. [ 40 ] employed a psychological well-being scale, and, though not situated directly as mental healthterm·dom, QoL was operationalised by three studies as a domain that may demonstrate a positive outcome of resilienceterm·dom [ 45 , 69 , 76 ]. Davis et al. [ 32 ] operationalised resilienceterm·dom through scales measuring mindfulness and self-compassion, and mental healthterm·dom as both stress and well-being; while, Monteiro et al. [ 62 ] explored the well-being aspect of resilienceterm·dom through scales for flourishing, maternal confidence, self-compassion and psychological flexibility. However, the most frequently utilised measures were those designed to measure mental distress/illness, such as anxiety, depression, or PTSD. This method of operationalisation risks the absence of mental distress/illness being conceived of as exemplifying resilienceterm·dom in the perinatal periodterm·key and early motherhood.

3.4.2. Adaptationterm·dom and Adjustmentterm·dom Adaptationterm·dom and adjustmentterm·dom are perhaps expected within the context of motherhood, given that it is widely regarded as a transitory period [ 105 ]. However, conceptual boundaries between resilienceterm·dom and adaptationterm·dom or adjustmentterm·dom were not always clear. For example, Fonseca et al. [ 69 ] operationalised parental adjustmentterm·dom through measures of psychological distress and QoL. Resilienceterm·dom was conceived as a trajectory of low distress and high QoL scores over time, such that ‘good’ parental adjustmentterm·dom was defined as the ‘resilient’ trajectory. In this way, parental adaptationterm·dom and resilienceterm·dom were one and the same, without a linguistic or functional distinction being made by the authors. Similarly, Handelzalts et al. [ 76 ] operationalised positive postpartum adjustmentterm·dom as low depression and high QoL, interpreting the moderating effect of religiosity and spirituality on these measures as having a resilience-enhancing influence. Additionally, adaptationterm·dom was typically aligned with measures of functioning that were specifically situated in the context of a mothering role, such as Schachman et al.’s [ 61 ] investigation of maternal role adaptationterm·dom, Sexton et al.’s [ 47 ] use of family specific well-being and postpartum Mastery measures, Sahin’s [ 53 ] use of maternal attachment, and Sexton et al.’s [ 48 ] exploration of postpartum positive functioning.

3.4.3. Copingterm·dom The degree to which copingterm·dom was regarded as distinct from or integrated with resilienceterm·dom varied within the included studies. Several studies [ 39 , 46 , 83 ] conceived of copingterm·dom as a manifestation or appropriate operationalisation of resilienceterm·dom, which may be considered an intentional blurring of concepts, as copingterm·dom was considered to be held within resilienceterm·dom. Mikuš et al. explicitly equated stress copingterm·dom ability with resilienceterm·dom and defined it as ‘inseparable from anxiety, depression and stress reactions’ [ 52 ] (p. 345).

Gagnon et al.’s [ 58 ] conceptualisation was vaguer, appearing to situate coping strategiesterm·dom somewhere between an attribute and an outcome. For others, resilienceterm·dom and copingterm·dom were used interchangeably, and it would seem, though not discussed by the authors, that these were understood to be, if not synonymous, then held within the construct of the other [ 81 , 82 ].

Some authors investigated copingterm·dom and coping strategiesterm·dom as attributes or associates of resilienceterm·dom [ 34 , 54 ]. Rossman et al. considered copingterm·dom as an attribute of resilienceterm·dom and made a distinction between resilienceterm·dom as a contextually variable process ‘oriented toward positive outcomes’, while copingterm·dom was understood as ‘the behaviour that follows the appraisal’ [ 63 ] (p. 435). The point of difference being that adaptive copingterm·dom was related to resilienceterm·dom, in contrast to maladaptive copingterm·dom mechanisms, which led to negative outcomes.

4. Discussion Resilienceterm·dom has been widely researched in relation to periods of growth and transition, and there is a general acknowledgement that resilienceterm·dom can be attained or develop at any point in life. However, there has been little research in the context of the perinatal periodterm·key and motherhood. This represents an exciting opportunity to develop and advance this research, and apply the lessons learned from the wider literature, as well as those emerging from the current analysis, in order to improve upon the clarity and consistency in this context. This concept analysis offers a timely analysis of common epistemological and methodological trends in resilienceterm·dom research with perinatal women and women in the early years of motherhood. Twenty-eight of the 56 included studies were published between 2004 and 2019, a 15-year timespan, while 28 were published in the last two years, between 2020 and 2022.

A challenge in evaluating consistency in the use of the term resilienceterm·dom, in the context of the perinatal periodterm·key and motherhood, is that first, varying definitions and interchanging use of terms and concepts is an issue already remarked upon in relation to resilienceterm·dom in any context [ 15 , 106 ]. Second, authors’ conceptualisations of resilienceterm·dom shape how it is used linguistically and how it is researched practically and logically within individual studies.

Examining the contextual use of resilienceterm·dom unveiled some overlap between the epistemological and linguistic principlesterm·mth, as demonstrated by the use of the term ‘maternal resilienceterm·dom’. Though ‘maternal resilienceterm·dom’ was used within six studies, its use is potentially misleading. Epistemologically, it implies the existence or investigation of boundaries that establish distinct elements of resilienceterm·dom within the subject of maternity or motherhood. However, ‘maternal resilienceterm·dom’ was not employed to denote unique definitional or conceptual features of resilienceterm·dom as it occurs within the perinatal periodterm·key and motherhood. Linguistically, it became apparent that the usage within the studies was simply to place the phenomenon of resilienceterm·dom within the context of the perinatal periodterm·key and motherhood. Luthar et al. [ 9 ] encourage the use of terminology that links resilienceterm·dom to the context in which it is being researched, as doing so brings specificity to findings and demonstrates a clear boundary, which resilienceterm·dom, considered evident in the positive outcomes of one domain, does not imply resilienceterm·dom across domains. Researchers should be careful to specify the relevance of the areas or concepts used to operationalise resilienceterm·dom and be conscious that the outcomes in which resilienceterm·dom is explored are not global, but compartmentalised indications of resilienceterm·dom [ 18 ].

Although Nuyts et al. [ 87 ] utilised Van Haeken et al.’s definition of ‘perinatal resilienceterm·dom’ of mothers and partners in the first 1000 days of life as a ‘circular process towards greater well-being’ [ 107 ] (p. 1), specific definitional elements, which may be inimitable to this timeframe, did not emerge in the analysis of the included studies. This is perhaps a reflection of the emergent nature of the research in this context and an indication that the topic may benefit from further investigation and advancement.

Overall, definitions typically borrowed from conceptualisations found in the wider literature. This is not a criticism of the research concerning the perinatal periodterm·key and motherhood, as the definitional conflicts of resilienceterm·dom are a matter of differing theoretical perspectives rather than context and will likely continue to be a matter of contention among theorists. However, the included studies seldom addressed the definitional issues and subsequent empirical consequences for the wider literature, or the implications for research in the perinatal periodterm·key and motherhood.

Researchers should take care to address the relevant concerns surrounding the multifaceted interpretation of resilienceterm·dom as a concept and remain mindful of its limitations. One practical measure that researchers may take to improve conceptual clarity is to provide clear definitional and conceptual positions of resilienceterm·dom and its operationalisation within their research. Readers with an interest in resilienceterm·dom would benefit from researchers maintaining consistency between the conceptual definitions and methods used to operationalise resilienceterm·dom within their research. Furthermore, research may be improved through the provision of a clear exploration of the concepts and constructs employed within resilienceterm·dom research, and researchers should take care to demonstrate recognition of the capacity and limitations of tools designed to measure illness, in order to prevent ‘absence of illness’ being confused with the presence of health.

Additionally, a possible avenue for advancement may be through the inclusion of women’s perspectives regarding resilienceterm·dom in this context. Though data from several qualitative studies were included in the analyses, none specifically sought women’s views on how resilienceterm·dom may be defined or manifest in the perinatal periodterm·key and early motherhood. Typically, resilienceterm·dom was not the primary concept of interest among the qualitative studies; rather it emerged in researchers’ analysis of data regarding mothers’ experience and responses to multiple adverse life circumstances. A more inclusive understanding of mothers’ perspectives on resilienceterm·dom and their insights into the factors leading to vulnerability and protection has the potential to inform the development of effective prevention and intervention strategies.

Concepts associated with resilienceterm·dom, such as copingterm·dom appeared frequently, though with marked variability between studies with regards to whether copingterm·dom was considered distinct from, or integrated with, resilienceterm·dom. Similarly, adaptationterm·dom and adjustmentterm·dom were commonly used. Beyond the association of these terms with motherhood as a period of transition, their use may also reflect the shifting focus of resilienceterm·dom research from absence of psychopathologyterm·dom to ‘positive adaptationterm·dom’, which features in several resilienceterm·dom definitions [ 108 ]. Pragmatic and logical analysis demonstrated that resilienceterm·dom was operationalised most frequently by the absence of pathological symptoms. This approach has been critiqued for framing resilienceterm·dom as illness absence, but resilienceterm·dom extends beyond ill-health; it includes variables that contribute to its development and consolidation [ 17 ] and may manifest in personal achievements, social competencies, or developmental milestones [ 18 ].

Mental healthterm·dom is closely tied to resilienceterm·dom, and measures related to mental healthterm·dom and well-being are commonly operationalised in resilienceterm·dom research [ 17 , 98 ]. There are relevant parallels in the discussions between mental healthterm·dom and its conceptualisation, and resilienceterm·dom and its operationalisation. The study of mental healthterm·dom has frequently focused on issues that may be more accurately described as mental illness or disorder, leading to mental healthterm·dom being presented as absence of symptomology or disease [ 2 , 109 ]. Similarly, conceiving resilienceterm·dom as illness absence neglects to provide evidence of the frequently used definitional component of the concept as a positive adaptationterm·dom or function [ 23 , 110 ]. A predominant focus on mental illness with insufficient exploration of the well-being potential of resilienceterm·dom limits understanding. A closer focus on the outcomes which reflect, not only evidence of positive outcomes, but also positive outcomes that are specifically relevant to the perinatal periodterm·key and early motherhood, may benefit and advance the research, in understanding what it means to be resilient in this season of life, and illuminate the domains most indicative of resilienceterm·dom in this context.

Several studies operationalised scales related to positive domains of functioning outside of mental well-being or ill-health; such as parental well-being [ 59 ] or postpartum sense of competence [ 48 ], which are suggested to reflect resilienceterm·dom in this context. These investigations were centred, mainly, on a woman’s parenting and familial role. Future research may benefit from a wider exploration of the domains in which resilienceterm·dom manifests, including biological, social, and cognitive functioning. Additionally, this exploration may be enhanced with insights from mothers regarding the domains or indicators that best reflect ‘positive functioning’ and resilienceterm·dom during this period.

At this point in time, the pragmatic application of resilienceterm·dom in pregnancy and motherhood has limited use in clinical practice. Beyond advice to support and assess women, there was sparse discussion as to how findings may be applied in a practical manner. The issues around varying definitional viewpoints, and the lack of agreed or consistent domains in which outcomes should be measured, restrict the pragmatic application of resilienceterm·dom research within this context. In addition, recommendations for screening were mainly centred on identifying risk and psychopathology, as opposed to utilising findings to develop resilienceterm·dom promoting programmes, interventions, or models of care.

An interesting point regarding the literature’s usefulness to research is that the findings frequently highlight the heterogeneity of women’s mental healthterm·dom experiences and patterns during pregnancy and following birth. The analysis demonstrates that mental healthterm·dom and resilienceterm·dom outcomes during this time are complex, and that psychological outcomes are not always negative, even in the presence of known risk factors, and are influenced by an array of nuanced social, economic, and cultural factors [ 44 , 65 , 74 , 81 , 83 , 85 , 86 ]. While this awareness helps to shape and build upon the current knowledge base, it also underlines the need for further inquiry, in order to reach a comprehensive understanding of resilienceterm·dom during the perinatal periodterm·key and motherhood.

Limitations The inclusion criteria allowed for studies that did not provide a formal or operationalised definition of resilienceterm·dom. This may be considered a limitation, particularly in light of on-going definitional debates. However, it potentially informed a more accurate representation of the current state of literature in this context, because of the definitional debate. Researchers have routinely been invited to provide unambiguous expressions of their understanding of resilienceterm·dom, to avoid misunderstanding and enable other researchers to be aware of the particular framework employed by any given piece of research [ 108 ]. Researchers of resilienceterm·dom in the perinatal periodterm·key and early motherhood should also be mindful to pre-empt such a limitation in their own research and provide clear conceptual and operational definitions of resilienceterm·dom.

5. Conclusions This analysis consolidates the findings of resilienceterm·dom in the perinatal periodterm·key and early motherhood; identifies reoccurring themes, limitations, and potential areas for development as they became evident through the evaluation of the philosophical principles of epistemology, linguistics, pragmatism, and logic; and offers a base on which to advance the concept in this context.

In terms of the perinatal periodterm·key and early motherhood, an operationalised definition of the concept remains elusive. The study of resilienceterm·dom in this context allows the research focus to shift from pathogenic models, which have encapsulated this context thus far, by placing greater attention on protective mechanisms and psychosocial factors over risk and vulnerability, and positive adaptationterm·dom over maladjustmentterm·dom. While the analysis demonstrates that this focus features within the current research, as approximately half of the studies contained positive outcomes of well-being, positive functioning, or exploration of protective factors, a continued effort needs to be maintained to ensure that future research comprehensively embraces the health orientation of the concept of resilienceterm·dom.

The associated concepts of copingterm·dom, adaptationterm·dom, and adjustmentterm·dom are recurring themes within the literature and may prove useful avenues of future investigation and development. In addition, exploring women’s lived experience of resilienceterm·dom and their perspectives on the ways in which resilienceterm·dom in this context has been researched to date is an important area of further inquiry.

Acknowledgments S.E.H. is currently supported by Trinity College Dublin’s Provost’s PhD Project Award, this doctoral award is funded through alumni donations and Trinity’s Commercial Revenue Unit. The views expressed are those of the authors.

Author Contributions Conceptualization, S.E.H., D.D. and A.H.; data curation, S.E.H.; analysis, S.E.H., D.D. and A.H.; writing—original draft preparation, S.E.H.; writing—reviewterm·mth and editing, S.E.H., D.D. and A.H.; supervision, D.D. and A.H. All authors have read and agreed to the published version of the manuscript.

Funding This research received no external funding.

Institutional Reviewterm·mth Board Statement Not applicable.

Informed Consent Statement Not applicable.

Data Availability Statement Not applicable.

Conflicts of Interest The authors declare no conflict of interest.

Footnotes References Associated Data Data Availability Statement Not applicable.