How teen mothers participating in a teen mother and child program narrate their own identities as mothers and women

Women undergo many changes associated with pregnancy, both biological and psychological. The focus of this study was to explore the construction of motherhood identity by teen mothers. Specifically I explored how pregnant teens narrate and perform motherhood in a Teen Mother and Child Program. Data were gathered using observation, informal and formal interviews, and field notes. Narrative analysis and the Burkean Pentad were used to analyze these data. Teens were cast a supporting cast members by the omnipresent narrator in the Teen Mother and Child Program, the certified nurse-midwives (CNM). The positioning of cast members was performed by the CNMs and not challenged by teen mothers and often supported in their position of power by the teen mothers and their support people. The star of the narrative in the clinic was the unborn child. In the personal narratives, from in-depth interviews, the teen mothers told stories of change, in three acts. The three acts are labeled, The Test, The Loss of My Body, and In My Arms. The cast members were similar but arranged in different positions of lead and supporting roles. Teen mothers cast themselves as the lead throughout the three acts of their narratives. The casting illuminated a disconnect between the clinic and the personal narratives of teen mothers. The implications to nurses and nurse-midwives abound and include the need to understand how teen mothers position themselves in the construction of their own mother identity.

HOW TEEN MOTHERS PARTICIPATING IN A TEEN MOTHER AND CHILD PROGRAM NARRATE THEIR OWN IDENTITIES AS MOTHERS AND WOMEN by Janelle LaNae Bassett Macintosh A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing The University of Utah August 2011 Copyright © Janelle LaNae Bassett Macintosh 2011 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Janelle LaNae Bassett Macintosh has been approved by the following supervisory committee members: Kristin G. Cloyes , Chair March 28, 2011 Date Approved Lauren Clark , Member March 28, 2011 Date Approved Pamela Hardin , Member March 28, 2011 Date Approved Diane Kelly , Member March 28, 2011 Date Approved Caren Frost , Member March 28, 2011 Date Approved and by Maureen R. Keefe , Chair of the Department of Nursing and by Charles A. Wight, Dean of The Graduate School. ABSTRACT Women undergo many changes associated with pregnancy, both biological and psychological. The focus of this study was to explore the construction of motherhood identity by teen mothers. Specifically I explored how pregnant teens narrate and perform motherhood in a Teen Mother and Child Program. Data were gathered using observation, informal and formal interviews, and field notes. Narrative analysis and the Burkean Pentad were used to analyze these data. Teens were cast a supporting cast members by the omnipresent narrator in the Teen Mother and Child Program, the certified nurse-midwives (CNM). The positioning of cast members was performed by the CNMs and not challenged by teen mothers and often supported in their position of power by the teen mothers and their support people. The star of the narrative in the clinic was the unborn child. In the personal narratives, from in-depth interviews, the teen mothers told stories of change, in three acts. The three acts are labeled, The Test, The Loss of My Body, and In My Arms. The cast members were similar but arranged in different positions of lead and supporting roles. Teen mothers cast themselves as the lead throughout the three acts of their narratives. The casting illuminated a disconnect between the clinic and the personal narratives of teen mothers. The implications to nurses and nurse-midwives abound and include the need to understand how teen mothers position themselves in the construction of their own mother identity. This manuscript is dedicated to my husband, Christopher Ian Macintosh, and to my parents, Carl and Linda Bassett and my family whose untiring love and unending support have made this journey possible. TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii ACKNOWLEDGEMENTS ............................................................................................. viii Chapter 1 INTRODUCTION .........................................................................................................1 The Socially Constructed Mother ................................................................................. 2 Statement of Purpose and Aims .....................................................................................5 Purpose ................................................................................................................. 5 Aims ......................................................................................................................6 Conceptual and Operational Definitions ........................................................................7 2 REVIEW OF LITERATURE .......................................................................................11 Marginalization Based on Race, Class, Gender and Age ............................................11 Adolescent Development .............................................................................................15 Previous Research with Teens .....................................................................................20 Teen Pregnancy ............................................................................................................21 Children of Teens .................................................................................................23 Pregnancy and Medicine .............................................................................................24 Attachment Theory and Maternal Role Theory ..........................................................25 Attachment Theory Synthesis of Major Work and Ideas...................................26 Critique ........................................................................................................28 Maternal Role Theory Synthesis of Major Work and Ideas ..............................29 Critique ........................................................................................................32 Critique of Attachment and Maternal Role Theories .............................33 Identity Theory, Maternal Identity and Maternal Archetypes ....................................34 Major Tenets of Identity Theory ........................................................................35 Major Tenets of Role Theory .............................................................................36 Contrasting Identity and Role Theories ............................................................37 Exploring Maternal Identity in Teens .........................................................................38 Significance of the Study ............................................................................................41 v 3 THEORETICAL FRAMEWORK AND METHODS ...................................................45 Social Constructionism ...............................................................................................46 Locating Myself ..........................................................................................................47 Ethnography ................................................................................................................48 Narratives and Identity ................................................................................................51 Narrative Analysis ......................................................................................................52 Dramatism/Burkean Pentad ........................................................................................59 Description of Data Collection ...................................................................................61 Recruitment and Informed Consent ...................................................................61 Setting ................................................................................................................63 Sample................................................................................................................66 Compensation ....................................................................................................66 Participant Characteristics .................................................................................67 Sources of Data ..............................................................................................................68 Interviews ...........................................................................................................68 Interview Procedure ...........................................................................................68 Observations ......................................................................................................72 Field Notes .........................................................................................................74 Potential Risks ...............................................................................................................75 Protection Against Risks .....................................................................................75 Narrative Analysis Procedure ........................................................................................76 Transcription and Data Review ..........................................................................76 Coding .................................................................................................................78 Pentadic Analysis Procedure ..........................................................................................83 4 PENTADIC FINDINDS ................................................................................................85 The Pentadic Elements ....................................................................................................86 The Scene ............................................................................................................86 The Actor(s) .......................................................................................................91 The Action ..........................................................................................................95 Overall Well Being of the Teen ................................................................96 Nutrition ....................................................................................................97 Exercise .....................................................................................................97 When to Call the -Doctor‖ ........................................................................98 The Agency .......................................................................................................100 The Purpose ......................................................................................................105 Relationships between Pentadic Elements ...................................................................108 Scene-Action Ratio ...........................................................................................109 Scene-Actor Ratio .............................................................................................110 Scene-Agency Ratio..........................................................................................112 Assuring Trustworthiness ...........................................................................................114 vi 5 NARRATIVE FINDINGS ..........................................................................................117 Findings.....................................................................................................................117 The Metastory ...................................................................................................117 The Test ...............................................................................................118 The Loss of My Body ..........................................................................127 In My Arms .........................................................................................131 Summary of the Metastory................................................................................136 Framing Motherhood ........................................................................................141 Consequences ........................................................................................142 Pregnancy Is a Gift................................................................................143 New Position in Society ........................................................................144 Almost a Mom/ a Little Bit of a Mom ..................................................145 Audience Members ...........................................................................................146 6 SUMMARY AND CONCLUSION ...........................................................................149 Discussion ................................................................................................................149 Synchronicity and Disconnects of Findings ............................................................153 Implications to Nursing............................................................................................156 Recommendations ....................................................................................................158 Limitations .......................................................................................................158 Strengths ..........................................................................................................158 Future Research ........................................................................................................159 Conclusion ................................................................................................................162 APPENDICES A. LETTER OF SUPPORT .........................................................................................165 B. RECRUITMENT FLYER .......................................................................................167 C. RECRUITMENT LETTER.....................................................................................169 D. CONSENT DOCUMENT- TEEN MOTHER ........................................................171 E. CONSENT DOCUMENT- TEEN MOTHER AND CHILD PROGRAM STAFF MEMBER ...............................................................................................................175 F. INTERVIEW GUIDE ..............................................................................................179 G. CODING EXAMPLES ............................................................................................181 REFERENCES ................................................................................................................187 ACKNOWLEDGEMENTS I am grateful to the multitude of people who helped to make this academic journey possible. The George S. and Delores Doré Eccels Foundation and the Gamma Rho Chapter of Sigma Theta Tau International for their commitment to the future of healthcare and healthcare personnel who each in part provided the funding necessary to pursue this degree. I thank my committee for their encouragement, patience, support, and persistence. Doctor Kristin Cloyes continually mentored, energized, comforted and consoled me through my progression. Her dedication and efforts in reading this document many, many times, and in refining my focus and building my knowledge have been invaluable. Doctors Clark, Frost, Kelly and Hardin have also provided invaluable assistance to the qualitative design of this research and through their detailed and thought provoking comments on the manuscripts. They have steadily demonstrated their commitment to excellence and learning. The Teen Mother and Child Program have contributed immeasurably to this work by helping me understand the organization in which the research was conducted and by offering me entry into that organization. I must also thank the participants who volunteered their time and were willing to share their stories; without them, this research would never have occurred. viii I am thankful for the knowledge and guidance of the entire faculty at the University of Utah, who have walked beside me on this journey. I am grateful for my PhD cohort and fellow students. We have laughed and we cried, but mostly we enjoyed and encouraged one another. I would be bereft without thanking all of my family, my siblings for their love and support, my parents for their hopes of this better life for me and for the basement where I could avoid distraction, but most important of all, I want thank my dear husband for encouraging and supporting me and for being willing to learn alongside me, the time and effort required for this process. CHAPTER 1 INTRODUCTION Women undergo many changes from the time they first discover they are pregnant through the life of their child. Some of these changes are observable: the manifestations of pregnancy and the reality of a child coming into the world. Some changes, however, are unseen: the incorporation of the role of motherhood or the transitioning of the internal sense of who a woman is, i.e., from teenage daughter to mother as an identity. Most research on mothering has focused on behavorialist theories of attachment that center on the needs of the child and the individual psychological role or process of the woman. This kind of research leaves a gap of understanding about the social construction of motherhood as a part of identity. Research on teen pregnancy has often focused on the negative social and health outcomes for the children and their mothers, such as the incidence and prevalence rates of teen pregnancy; the confounding factors that lead to teen pregnancy; the original family structure of the teen mother; the negative consequences of teen pregnancy on teens and their children; societal costs; and the effectiveness of prevention programs (Bretherton, 1992; SmithBattle, 1995; Doğan-Ateş & Carrión-Basham, 2007; Erdmans & Black, 2008; Eshbaugh & Luze, 2007; Giardino et al., 2007; Hoffman & Maynard, 2008; Mercer, 1981, 1985, 2004; Pike, 2007; Rubin, 1984). 2 The literature draws attention to the reported risks and implications of teen pregnancy to the teen mother, her child, and society as numerous. The potential negative complications of teen pregnancy centered on the teen mother include social exclusion and stigma, inimical health outcomes, increased psychological stress and depressive symptoms, higher suicide rates, behavioral and juvenile justice costs, constraints on education and employment, increased dependence on welfare programs, poor prenatal care, and increased pregnancy complications, leading to increased infant mortality and child morbidity (Breheny & Stephens, 2007; Brubaker & Wright, 2006; Doğan-Ateş & Carrión-Basham, 2007; Giardino et al., 2007; Pike, 2007; Tripp & Viner, 2005). While most of these implications are thought to have a direct influence on the teen mother and her child, they also bolster the discourse of teen pregnancy as a disruptive and unwanted burden that the teen mother does not carry alone, but is forced upon the other members of society. Studies have primarily focused on teen pregnancy as a phenomenon linked to individual behaviors and risky lifestyle choices (SmithBattle, 2009). Little research has focused on the experiences and perspectives of teen mothers (Herrman, 2008; Herrman & Waterhouse, 2010). This study explores and describes the experiences of young pregnant women contextually within the established social and cultural ideals and expectations of the definition of motherhood. The Socially Constructed Mother The identity of -mother‖ is constructed in no small part through a shared social image. It cannot be taken out of the culture and society in which it is rooted. There are legion of meanings and ideals connected to our understandings of motherhood that have 3 to be shared between people through language and socially motivated performances. The stories we tell ourselves about who we are and how we got here are immersed in the process of uniting our past and present, as well as negotiating our future (Gergen, 2001). Motherhood and appropriate, or -good,‖ mothering are discourses that permeate our society. Included in the socially constructed ideal of motherhood are the behaviors and sentiments consistent with a -good‖ mother. This discourse draws on the premise of love as a basic natural instinct and motivation for the behaviors and motivations of motherhood. Teen mothers may be at odds with the socially constructed ideals of a good mother being part of a mature, devoted couple and family. A community‘s and society‘s future rests with its children and therefore also with good mothers who are given the responsibility to guard, guide, parent, and teach the norms of behaviors, speech, interactions, and thinking for participation in that society (Lessa, 2006; Sandifer, 2008). In many communities, especially those of minority and low socioeconomic status, women are the sole parents and providers for their children (Burns & Lesko, 1999; Henriques & Manatu-Rupert, 2001; Sandifer, 2008). Mothers are given the social responsibilities of caring for the family and community. Similarly, mothers are also charged with keeping families and communities together and functioning. Many pregnant teens are labeled as being either part of or the product of -dysfunctional families,‖ families with problems like drug abuse, physical or emotional abuse, and the incarceration of parents (Sandifer, 2008). Societal norms and ideals support the notion that patterns of family relationships are passed from one generation to the next due to the care of mothers, and these damaging cyclical patterns can then erode the ability to pass on stable and socially acceptable norms. 4 Women learn to be mothers in communities that may or may not provide the resources and support needed, especially when other labels and identities complicate or compete with motherhood identities. Teen motherhood potentially entangles and challenges socially shared stereotypes, labels, and identities, which include conforming to a peer group, nonconformity to other groups, naive, inexperienced, lost between childhood and adulthood, transitional, malleable, energetic, sexual, adolescent, high school student, daughter, and friend. Little is known about the experiences of pregnant and parenting young women, especially concerning being a mother and the assimilation of motherhood identity into their own identities. This study examines the narratives and performances of teen mothers as they incorporate the concept of -motherhood‖ into their own identities, how they come to see themselves as mothers, and the personal and cultural meanings and experiences of motherhood. Teen mothers were chosen because of the multiple potential identities of the girls. This study is a contextual narrative analysis that utilize dramatism and narrative analysis to investigate how teen mothers construct, narrate, and perform their own identities as mothers within a medical setting of the teen mother and child program. The study particularly focuses on how these young women, who may have been identified by others or who have identified with other stigmatized and socially devalued labels, see their motherhood identity interacting with, negating, and/or superseding these other identities. An urban maternal health and teen pregnancy clinic in a western state was chosen for the site of data collection. I conducted in-depth semistructured interviews, informal interviews and conversations, and extended observations as well as wrote field notes as 5 methods of data collection. I use narrative analysis to describe and explore how teen mothers incorporate the concept of motherhood into their own identities, including how they come to see themselves as mothers and the personal and cultural meanings and experiences of motherhood they use to make this identification. Statement of Purpose and Aims Purpose We do not know nor do we understand the perspectives and processes teen mothers utilize in their self-identification as a mother. This descriptive and exploratory study looks to further our understanding of this self-identification, which I am calling -motherhood identity,‖ in contrast to the more traditional behaviorist use of terms such as -role.‖ Maternal role is related to the observable actions and behaviors related to a female parent. As a noun, motherhood is defined as the condition or fact of being a mother. Motherhood as an adjective is defined as having or relating to an inherent worthiness, justness, of being protective (Oxford American Dictionary, 2003). In scientific literature motherhood is associated with the actions of being a mother, of taking on the role of being a mother (Fowles & Horowitz, 2006; Mercer, 2004). In contrast, motherhood identity encompasses a broader, deeper, and more complete sense of how women learn to identify with powerful sociocultural images and concepts of -mother.‖ Images, icons, and concepts are used as bits and pieces to negotiate and construct socially and personally acceptable roles and behaviors used to represent the 6 self as a mother. Motherhood identity moves beyond the narrow perspectives of behavior or psychologizing models and ideals to incorporate critical social and cultural contexts. Therefore, motherhood identity is theorized as more than just the execution of observable actions and behaviors. Motherhood identity is understood as the synergistic interplay between individuals and powerful social systems like families and communities. Motherhood identity represents a socially and culturally constructed process of a woman, in this case a teen, coming to identify herself as a mother in the specific situations that make up the everyday lives of women. It takes into account the complexities and various influences of identity as opposed to an observable role to be filled. Identities are actively made by people in the situations of everyday life. Studies have supported the theory that the self-identification of mother, or motherhood identity, has a positive influence in the lives of marginalized women, the unimportant or powerless within a society, and has helped them to change from choosing behaviors believed be detrimental (to harm or inflict danger with little regard for the effects on themselves) toward choosing more hopeful, protective, and productive behaviors (Ingram & Hutchinson, 1999; Lesser et al., 1999; Sandifer, 2008). Aims The purpose of this study is to describe and explore how young women participating in a teen mother and child program incorporate the concept of motherhood into their own identities, including how they come to see themselves as mothers and the personal and cultural meanings and experiences of motherhood they use to make this identification. 7 Aim 1: Explore the personal, social, and cultural construction of motherhood of young women participating in a teen mother and child program. Aim 2: Describe individual experiences, including personal, social, and cultural influences and talk contributing to the construction of mother identity. Conceptual and Operational Definitions I have used some very familiar terms in possibly unfamiliar ways throughout this paper. Therefore, I am including this section to concretize and explain how each of the terms is used. They are listed in alphabetical order for convenience. Each of these terms and their operationalized meanings are also found in the body of this text. Attachment theory: A theory developed by Bowlby and Ainsworth (Bretherton, 1992), used to categorize relationships between an infant or child and its mother or caregiver. This primary focus of this theory is on the infant or child. Culture: Concepts and meanings inherited by participants, used to communicate in symbolic forms, such as language, art, music, and dance. Perpetuated and used to develop their knowledge about and attitudes toward life (Geertz, 1973). A function of culture is in the construction of meaning within the world to make it understandable and to share that meaning through interaction. Identity: Identity has been defined as the quality or condition of being a specific person or thing (Oxford American Dictionary, 2003). Research on identity reports multiple definitions, ranging from very broad to more detailed and complex, and heavy influences from personal, social, and cultural surroundings, meanings, and expectations (Bucholtz & Hall, 2005; Klein, Spear, & Reicher, 2007). I define identity as a highly dynamic and 8 subjective sense of self, not just the set of behavioral or personal characteristics by which an individual is recognized as a member of a group. Identities are dynamic, actively made identifications of self, often in answer to the question -Who am I?‖ Identity theory: This theory is based on the general idea that people put themselves and others into categories, labeling them with a perceived identity, and the effect this practice has on the collection of roles people play in their lives. Categories are constructed and reinforced through socially shared systems of communication. Meaning and identity are constructed and performed socially and relationally and are situated in both personal and cultural contexts (Hole, 2007). Mainstream: Mainstream is the representation of the prevalent attitudes, values, and practices of the dominant group or majority of a society. Marginalize: The most basic definition of marginalize is making or treating as insignificant (Oxford American Dictionary, 2003). Social-scientific definitions include the relegating of people to an unimportant or powerless position within a society or group. In research literature, marginalization is understood as a fluid and contingent label that is related to those in power being labeled as normal, dominant, and the controlling group of people-marginalization is the resulting opposite (Webster, 2008). A margin implies and reinforces a center, so these two aspects are mutually established and support each other‘s existence. Maternal role: Rubin (1984) introduced the theory of maternal role attainment. The theory focuses on the mother and conceptualizes the phases and behaviors thought to be associated with being a mother. Maternal role attainment is used interchangeably with 9 motherhood by Mercer (2004). It is a universalized construct that focuses on individual development. Motherhood: As a noun, motherhood is defined simplistically as the condition or fact of being a mother (Oxford American Dictionary, 2003). In scientific literature, motherhood is associated with the actions of being mother, of taking on the role of being a mother (Fowles & Horowitz, 2006; Mercer, 2004). Mercer defines motherhood as observable actions and behaviors associated with women who have achieved role attainment. Motherhood identity: Motherhood identity, which is the construct of focus for this study, encompasses a broader, deeper, and more complete sense of self in respect to being a mother, including how women learn to identify with personal, social, and cultural images and concepts of mother. Narrative: Narratives are the stories we tell about ourselves and our lives to an audience. The intended audience could be ourselves or others. Identity is told and performed through stories (May 2004). Riessman refers to personal narratives as the -talk organized around consequential events. The teller in a conversation takes a listener into a past time or ‗world‘ and recapitulates what happened‖ (1993, p. 3). Stories are constructed creatively and they are full of rhetorical moves, assumptions, and interpretations of all parties involved in the performance. Narrative and story are used interchangeably in this text. Narrative analysis: Narrative analysis is the investigation of the story told within a context and to a specific audience. Sandelowski stated that the -study of narratives has linked the sciences with history, literature and everyday life‖ (1991, p. 161). 10 Personal identity: Personal identity is part of identity theory; this aspect asserts that people identify themselves with personal and socially constructed categories. A person‘s self-concept is a collection of identities that is constantly changing with each new experience and as new information is received. Personhood: The most basic definition of personhood is being distinguished as or being an individual person (Oxford American Dictionary, 2003). Personhood has also been defined as the status or standing that is bestowed by one human being to another within the context of relationships and social being (Fowler 2001; O‘Conner et al., 2007). Personhood is a larger construct than motherhood identity and encompasses legions of other aspects and identities of the self. Roles: Roles are the defined norms, the duties, expectations, and standards for behavior typically associated with a social position and status. Role theory: Based in behaviorism, role theory asserts that people define the roles they fill based on social norms. The theory suggests that people act and fill the roles they adopt. Roles, once integrated, are thought to be a permanent trait. Teen mother: A young woman between the ages of 15 and 19 who is pregnant and/or is parenting at least one child to whom she has given birth. CHAPTER 2 REVIEW OF LITERATURE In this chapter I review some of the literature that has shaped and informed this study. I review the concepts of marginalization, adolescent development, teen pregnancy, previous research with teens, the medicalization of pregnancy, attachment theory and maternal role theory and identity theory including a look at maternal identity and maternal archetypes. Marginalization Based on Race, Class, Gender, and Age The normative pattern or trajectory of life for contemporary middle-class women in the United States has gradually shifted to include higher education, a career, and then children (Wilson & Huntington, 2005). Women who do not follow this design or who change the order may be at risk for becoming stigmatized and marginalized. Pregnant teens especially are often labeled as or are part of groups that have historically been marginalized in the United States especially during the 20th century. The marginalization of groups based on identities centered on race, class, gender, and age in relation to pregnant teens warrants discussion. However, teen mothers are often described in demographic terms, leaving the individual and group experiences in the periphery. 12 To marginalize is basically defined as making or treating as insignificant (Oxford American Dictionary, 2003). More scientific definitions include relegating people to an unimportant or powerless position within a society or group. Webster (2008) stated that marginalization in its subtlest form can be simple aversion. Webster also stated that marginalization can progress to disgust, sneering, and revulsion with the purpose of distancing oneself from that which is marginalized. Ernst (2006) argues that groups that are relatively privileged may attempt to symbolically and physically distance themselves from marginalized groups in fear of exclusion by dominant society. Social classification, like other classifications, may be used simply as a mode of ordering and arranging things into groups. However, there are pitfalls associated with the segregation and separation into groups with associated values. Those that are categorized as less valuable by those with power are relegated to the margins of society. Race, class, gender, and age are all examples of categorizations that have been and are currently used to value or devalue people (Acker, 2006; Biernat & Kobrynowicz, 1997; Kilbourne, England, & Beron, 1993; Payne & Grew, 2005; Weber, 2008). Race/ethnicity categorization and/or marginalization may be made on the grounds of race, color, nationality, or ethnic origins. Marginalization based on race is often referred to in the United States as racism, discrimination, or less favorable treatment or opportunity (Equality and Human Rights Commission, n.d.). Social discourses surrounding teen pregnancy often cast pregnant teens in a socially deviant role, a problem to be solved if not an epidemic in need of urgent intervention, especially when minority groups are included (Brubaker, 2007; Kirkman, Harrison, Hillier, & Pyett, 2001). 13 Class has traditionally been used as a tool or measurement in the categorization of people and individuals. Webster (2008) stated that class distinctions historically have been centered on socioeconomic status, poverty level, privilege, and moral judgments. These judgments pivot on the ideas of work ethic, pleasures and excess, consumption of alcohol, failure to save money, and -a life lived day-to-day without care for what the future may bring‖ (Webster, 2008, p. 299). Those who are poorer or of a lower socioeconomic status are often seen as refusing to work; those who generally are thought to consume in excess are deemed less valuable, as being carried by society, and viewed with contempt. Class, like ethnicity, gender, and age is complex and relational. It is constructed in and a product of social relationships (Payne & Grew, 2005; Webster, 2008). Gender is an established mode of marginalizing categorization. In the United States we typically recognize two genders or sexes, male and female. Females have historically been seen as having lesser value than males and are therefore marginalized (Heilman, 2001; Sherif, 1982). Age is also a categorical label that can be used to assign value to people or groups of people. Youth is considered a category with limited input and can be considered to be marginalized. Marginalization in social-scientific definitions includes relegating people to an unimportant or powerless position within a society or group. In research literature, marginalization is understood as a fluid and contingent label related to those in power being labeled as normal, dominant, and the controlling group of people-marginalization is the resulting opposite (Webster, 2008). A margin implies and reinforces a center, so 14 these two aspects, a center and its margins, mutually establish and support each other‘s existence. Those at the center can only secure their place and status by continuing to reinforce the margins as undesirable, relegating the margin as having little or no power in relation to the center. Pregnant teens are likely to represent the intersection and overlap of a number of devalued and marginalized social categories; they are young women, often also from minority populations and of low socioeconomic status or on government assistance. Each of these categories can be marginalized from the larger social norm. Pregnant teens are at times thought of as children while at the same time women, causing conflict within categories. Without an established category they are again relegated to the margins. Pregnant teens could be female and young and poor. Any combination of these categories can result in marginalization, but the combination of marginalized categories not only further distances them from the mainstream, but can also position them as marginalized from the center of the margin. Understanding and performing multiple self-representations, roles, and identities is common during all stages of life, but is thought to proliferate during adolescence (Harter, Bresnick, Bouchey, & Whitesell, 1997). As people enter their teenage years they begin to describe themselves according to the interpersonal context in which interactions occur. Adolescents, for example, talk and perform differently for parents, teachers, friends, best friends, boy and girlfriends, medical personnel, and strangers. The inner sense of self and identity is also thought to be in flux during adolescence. At times the identities may be in harmony while at other times they may be in discord. The potential -conflict of the 15 different Me‘s‖ (James, W., 1890 as quoted in Harter et al., 1997, p. 836) represents this multiplicity. The grand narrative of teen motherhood is described as being -a story in which they [teen mothers] are judged and condemned‖ (Kirkam, Harrison, Hillier, & Pyett, 2001, p. 282). Young women who are pregnant or parenting are thus marginalized. Flanagan (1998) stated it this way: -Teen mothers pushing their scarlet letters in fancy strollers are seen as having made a mistake‖ (p. 242). Teen mothers have been denounced as having made wrong choices or gone down the wrong road, limiting their options and the potential resources available to them. Teens that are pregnant or parenting are often unmarried, poor, and are by definition underage. When negative messages from the dominant social and cultural groups about teen pregnancy are internalized, there can be an increase in sense of failure, lower self-esteem, even a belief that they are doomed because of choices they have made and the consequences associated with those choices. These ideas and social messages contrast and complicate maternal identity in young women. Adolescent Development Teen mothers are seen as first and foremost teens (Flanagan et al., 1995). Adolescence is a time marked by turbulence and change. There are immense changes in physical growth with the onset of puberty. Erikson and Piaget are two developmental theorists who have had an immense influence and effect on how adolescence is viewed in western culture and medicine. Eriksonian theories are mainly concerned with the adaption of role and identity(s) 16 associated with that role. Piagetian theories focus on the cognition of children as they mature into adulthood. Since the introduction of Erikson‘s theory on identity crisis, adolescence has been associated with the purpose of self-discovery, behavioralist role assimilation. Steinberg & Morris (2001) recount the idea that adolescence indeed has been and continues to be deemed as a time when teens begin to explore the characterization of themselves with the intent of discovering who they really are, the role they play, and how they fit in the larger social world in which they find themselves. Piaget is more interested in the cognitive aspects of a maturing mind. Erikson is prolific in child and adolescent development texts and research. His ideas are mentioned in almost every university level child and adolescent development class. Eriksonian theories and ideas have shaped and constructed the cultural understanding of adolescents in the worlds of academics, the medical profession, and society as a whole. Erikson agreed with psychologists who preceded him that adolescence is a time marked by an increase in energies: physical, sexual, and emotional. Erikson thought the increases in energy and drive were disruptive and part of a problem surrounding the common difficulties and struggles in which adolescents engage with their parents and society at large. Adolescents are faced with new challenges, social demands, and conflicts that add to the confusion and distress they feel. The primary task of adolescents, according to Erikson, is to establish a new sense of self, or ego identity. Erikson believed ego identity to be -a feeling for who one is and one‘s place in the larger social order‖ (Crain, 2005, p. 287). 17 The search for personal identity is thought to come to a crisis during adolescence. There are so many inner changes, so many future social and personal commitments and possibilities during adolescence that previous identities may seem inadequate. Teens are thought to grapple with this potentially overwhelming expanse of possibilities and mental and physical change. This is the definition of an identity crisis. Teenagers can grow so quickly and experience change in so many aspects of their lives that they may not recognize themselves. Identity is not, however, solely linked to the physical changes of adolescence. Identity formation is a life-long process irrevocably tied to the society and culture in which we find ourselves. Adolescents gauge and evaluate themselves both overall and in specific areas of their lives. Areas of specific evaluation include academia, athletics and athletic ability, appearance, social relationships, and moral conduct (Masten et al., 1995). Identity is often formed through identifications and dichotomous associations. For example, if I excel at soccer I am a soccer player, or if I am not a boy then I am a girl. Teens may not be aware of this identification process. People in general, teens included, often identify with people who appeal to them, or to whom they would like to be like or be associated with, and therefore become more like these people. In this sense identity is at least in part a synthesis and/or rejection of many identifications and partial identities (Crain, 2005). Through task completion, teens are able to develop a sense of accomplishment and an identity associated with that task. Learning how to read, write, draw, play a sport, etc. all add to the sense of who a person is. Teenagers identify themselves as people who can do these things. When the thing that is learned and incorporated into a sense of self 18 has value in the society and culture of the teen, there can be a positive and lasting sense of identity (Crain, 2005; Steinberg & Morris, 2001). Hailed as one of the most influential developmental theorists in the field, Jean Piaget focused on cognitive development (Crain, 2005; Müller, Carpendale & Smith, 2009). He asserted that cognition evolves through a gradual and sequential process. Knowledge is not passively absorbed from the society, culture, or environment. Rather it is constructed, including the integration of a sense of self. Piaget focused his research and theory of adolescence on the formation of -formal operations.‖ The theory has implications regarding the sense of self and personality that is socially associated as emerging and cementing during young adult and adulthood. The transition from child to adult begins during the last Piagetian stage of development. This stage is believed to begin at about 11 or 12 years of age and continues through adulthood. The major theoretical tenet of this stage is a young person‘s ability to move from systematic thinking, limited by being able to refer only to concrete objects and activities, to broader thinking, with the ability to refer to abstract and hypothetical ideas, and deductive reasoning (Moshman, 2009). Piaget presented the idea of adolescence as a time when teens begin to think about and consider themselves as equals to adults, judging the adult and themselves to be on the same plane. Adolescents also participate and incorporate the ideas, ideals, and ideologies of the larger social and cultural group, thus preparing to take their place as an adult in that society. By integrating into the adult group, they leave behind the label of child and autonomously plan for their future, moving from concrete actions and objects to abstract ideas and ideals. 19 Adolescence is often considered a time of exploration of the possibilities the future holds for teens. It is also a time used to establish and redefine relationships and roles with family and peers. Adolescence is often seen as a dynamic and highly romanticized phase of life fraught with experimentation, especially with identities. Teens try on new identities, save or reshape old identities, and even try on other ideas of self. Discovering and trying on identities, defining roles, and establishing independence from parents and family may cause conflict with maternal role attainment and motherhood identity formation. Both theorists offer insight into the developing adolescent, but neither alone allows for a complete understanding of how teens view themselves in their roles and their senses of self. Both have constructed and created the categories and elements associated with their theory of development. Both are widely used in science and research. Erikson complements Piaget by reinforcing the idea that concrete actions and objects are the focus of early adolescents, seen in the adaption of a role and the behaviors associated with that role. Piaget, however, allows for a greater sense of exploration into the thought processes of self-identification, including motherhood identity. Although both Erikson and Piaget are recognized as important to the understanding of development, they do not account for the personal, historical, political, and cultural challenges and abilities of adolescents. Socially constructed ideals, stages, and expectations of the developmental stage of adolescence have been intricately woven into Western standards of teenage behavior and thought processes. It seems, however, that the constructivist nature of the origin and development-labeling and construction of adolescents is presumed to be knowledge, centered in the discovery of scientific truth- 20 has been forgotten. Although grounded in biology and essentialist assumptions, developmental theorists do offer a jumping-off point for the exploration of teen motherhood within the bounds and constructs of Western medicine. Previous Research with Teens The idea and notion of adolescence as a stage of life was constructed during and after the industrial revolution, when young people left their homes to move to the city in search of employment as apprentices, domestic help, and factory workers. The transition from being influenced by and dependent on their families to being independent has been cited as a catalyst in the creation of this stage and its associated roles and rules. This stage has been viewed anxiously by adults since its construction, labeled as the -criminal stage‖ and the -dangerous age‖ with the notion of -juvenile delinquency‖ (Wilson & Huntington, 2005). Current popular images of teenagers have long been those of a peer culture characterized by self separation from adult society, which does not share nor often understand the values of the adolescent society. Research on adolescent development has historically been focused on -describing, predicting and ameliorating problematic behavior‖ (Steinberg & Morris, 2001, p. 85). The formal study of adolescents began in the 1940s. Soon after the initiation of the formal study of teenagers James Dean burst onto the scene, changing the perceptions of adolescents forever. Political and economic changes influence the characterization of adolescence as a time of transition and flux. The long-standing tradition of researchers looking at adolescents with a pathological eye beginning with Freud continues still. The study of teenagers, like everything else, is practiced within a context. The ideals rise from 21 the golden age of America, the postwar boom of the 1950s. The original iconic depressive teenager fighting against adults and the dominant culture of the 1950s may seem tame by today‘s standards. The persona, however, set in motion the adolescent characteristics that are pathologized by adults (V.R., 1995). Today adolescence is still associated with a tumultuous transition in ways that no other stage of life is. Studies focusing on the biological aspects of adolescence abound. Some suggest that the influence biology has had on the mood and personality of teenagers is overstated. Studies have been conducted to explore the effects puberty has on moodiness and the role of hormone changes in emotional development. These studies show that the association between hormones and moodiness is weaker than stereotypically portrayed. Buchanan et al. show moodiness to be no less a characteristics of adolescence than of childhood (as reported in Steinberg & Morris, 2001). Other studies have shown a small correlation between hormones and negative affect, however, social influences account for considerable more variance than hormones (Brooks-Gunn et al., 1994). The pathologizing of adolescence by adults, through scientific study, may be thought to reinforce the power and authority of adult control. Teen Pregnancy Between 400,000 and 450,000 teens give birth in the United States each year (Hamilton, Martin, & Venture, 2007). National efforts have been made to decrease these numbers; however teen pregnancy rates remain high. The National Vital Statistics Reports of the CDC report that the birth rate for teenagers in the U.S. fell to an all time low in 2009 to 39.1 per 1000. This is down from 41.5 births per 1000 in 2008 and 42.5 in 22 2007 (Hamilton, Martin, & Venture, 2009, 2010). National teen birth rates increased by 5% between 2005 and 2007 and have followed the national trend of birth rates for all women, declining by about 2% between 2007 and 2008. In Utah, 6.9% of all live births in 2007 were to mothers under the age of 20. This increased from 6.6% in 2006 (Hamilton et al., 2009). The birth rate for young women ages 15-19 in Utah was 34.4 per 1000 in 2008 down slightly from 34.7 per 1000 in 2007, (Sundwall & Babitz, 2010; Nangle, 2009). Teen mothers have been stigmatized as ill equipped for the challenges of motherhood, often labeled as uncaring or neglectful (SmithBattle, 2009). Previous research involving teen pregnancy has focused on the negative social and health outcomes for the children and their mothers, such as the incidence and prevalence rates of teen pregnancy; the confounding factors that lead to teen pregnancy; the original family structure of the teen mother; the negative social, health-related, and developmental consequences of teen pregnancy on teens and their children; societal costs; the effectiveness of prevention programs; and the financial responsibilities and burden felt by teen mothers (Abma, Martinez, & Copen, 2010; Bretherton, 1992; Chase-Lansdale, Brooks-Gunn, & Paikoff, 1992; Doğan-Ateş & Carrión-Basham, 2007; Erdmans & Black, 2008; Eshbaugh & Luze, 2007; Flanagan, 1998; Flanagan et al., 1995; Giardino et al., 2007; Hoffman & Maynard, 2008; Mercer, 1981, 1985, 2004; Pike, 2007; Rubin, 1984; SmithBattle, 2006; Walker & Montgomery, 1994). Little research has focused on the experiences and perspectives of pregnant teens as they begin to see and think of themselves as mothers. 23 Children of Teens Children of teens have unique challenges. The 1988 National Health Survey reports that children born to teen mothers are more likely to have additional or increased health risks than children born to older mothers. Risks include lower birth weight, higher likelihood of living with a smoker, decreased use of child seats and seat belts, irregular bedtimes, and higher likelihood of hospitalization for short stays. Children born to teens are reported to have poorer overall health, more learning disabilities, more emotional or behavioral problems, and higher rates of being uninsured (Bowman et al., 1997). Emotional, psychological, and behavioral problems such as anxiety, guilt, shame, fear, low self-esteem, truancy, aggression, and drug or alcohol use have been identified as negative consequences of teen pregnancy. Children of both young and older teenage mothers are at greater risk for coming into contact with the justice system, leading to an increase in incarceration rates and the amount of time incarcerated (Gabel & Johnston, 1995; Grogger, Scher, & Hoffman, 2001; Hagan & Dinovitzer, 1999; Manlove et al., 2001; Sandifer, 2008; Simmons, 2000). Chase-Lansdale et al. (1992) report -preschoolers of teenagers seem to be more active aggressive and undercontrolled than children of older mothers‖ (p. 297). They also state that the differences between children of teens and children of older mothers are minimal during infancy and progressively become more apparent as the children age. Children of teens are at risk for being more vulnerable as they enter elementary school and throughout their school years. The differences become significant during their adolescent years. In one study, children of teen mothers were found to be more likely to have failed a grade, have behavior problems in school, have higher rates of delinquency, 24 and have earlier sexual activity than children of older mothers (Chase-Lansdale et al., 1992). These problems have been and are currently positioned as socially or public-health related. Teen motherhood has also at times been -implicated by its juxtaposition with suicide, crime and/or drug-taking‖ (Wilson & Huntington, 2005, p. 62). Pregnancy and Medicine Research on teen pregnancy and reproductive health in general has largely ignored the formal medical and health care systems and the role they play in a woman‘s reproductive process (Brubaker, 2007). Medicalization is defined as a process that gives medical meaning to behaviors or conditions. Riessman (1993) defines it as a process in which -medical practice becomes a vehicle for eliminating or controlling problematic experiences that are defined as deviant, for the purpose of securing adherence to social norms‖ (p. 4). Teen pregnancy indeed has been and continues to be viewed through the institutional discourse of medicalization, needing an expert to help solve the institutional problem. Teen pregnancy has been pathologized and labeled as the beginning of a cycle that results in depressed, defeated, and welfare-dependent young, unmarried, marginalized mothers with many children (Sarrel, 1967). Medicine has come to be regarded as an authority that penetrates many aspects and arenas of our everyday lives (Barker, 1998; Cahill, 2001; Nichols, Fox, & Heffernan, 2010). Human behaviors once thought to be moral failings, legal violations, or merely organic faults and even natural life events have been reconstructed or reconceptualized to be interpreted and treated by biomedical methods. Medicine has in essence taken over as a culturally accepted authority. The medicalization of female reproduction, including 25 pregnancy and prenatal care, is a fairly recent phenomenon, happening in the twentieth century. Barker (1998) reports that -as late as the 1940‘s most pregnant women received no prenatal care‖ (p. 1068). Prenatal care has seen a dramatic increase since the 1940s. Almost 96% of pregnant women sought regular prenatal care in 1994 (U.S. Department of Health and Human Services, 1996). The increased rates of utilization of medical prenatal care make it apparent that the medicalization and understanding of prenatal health, including that of the good mother ideology, has become hegemonic, or the predominant ideal in twenty-first century Western medicine. Although pregnancy, labor, and childbirth are still considered natural events, they are also considered fraught with the potential for pathological complications. Medicalization was presented and over time believed to be the best and only viable avenue to avoiding those potential complications. An example of rhetoric used to construct and reinforce this process is the analogy of the host-parasite (Zurub, 2007). There is an unequal relationship where the pregnant woman is responsible for the care and growth of the child inside her, who leeches what it needs from her body. Often when this analogy is applied to woman-child, the -parasite‖ is regarded as the more valued member of the dyad. Attachment Theory and Maternal Role Theory Many pre- and perinatal teen mother programs either explicitly or implicitly draw on the widely recognized behavioral or psychological theories that have been constructed and popularized in the 20th century, especially attachment theory and maternal role 26 theory. I discuss attachment theory and maternal role theory as they have been reported, including the major tenets and offerings of each and I offer a critique of each theory. Attachment Theory Synthesis of Major Work and Ideas Attachment theory has evolved and continues to be adapted by researchers since its inception in the 1940s when John Bowlby worked with post-WWII children as a way to define the relationship between a child and its caregiver, usually a mother. Attachment was thought to occur as a natural survival instinct in an infant. Bowlby focused on the needs of the infant to attach to the mother. John Bowlby was joined by Mary Ainsworth to study the phenomenon of separation (Bretherton, 1992). A major theme in Bowlby‘s work relied on the premise that for a child to grow up mentally healthy, the child needs a warm, intimate, and continuous relationship with its mother or mother substitute. He continues that this relationship needs to be equally satisfying and rewarding for both the mother and the infant (Bretherton, 1992). Mary Ainsworth began working with Bowlby in the late 1950s. Ainsworth was profoundly influenced by security theory. One of the major tenets of security theory is that children need to develop a secure reliance on their parents or mother before they can enter into any strange, new, or difficult situation. Without this secure base from which to branch out, a child will be handicapped in forming new skills and interests. Later in her work Ainsworth developed Strange Situation, a tool used to measure children‘s comfort level when placed in several situations with and without their parent present. Bowlby and Ainsworth hypothesized that when infants feel threatened they will turn to their primary 27 caregiver, usually the mother, for protection and comfort if attachment has been achieved. A child‘s attachment is believed to be instinctive whereas a parent‘s attachment is effected by their previous attachments and relationships. A parent‘s ability to bond and attach to their infant is influenced by years of being loved and cared for or betrayed and rejected. Slade (2004) stated, -Just as the child is born with the capacity to signal and seek care from the caregiver, the caregiver should have the capacity to provide a secure place for the child, and his/her needs‖ (p. 272). For more than 50 years the ideas of attachment from Bowlby and Ainsworth have been accepted and applied to the mainstream population. The focus of attachment theory is on the infant and the infant-mother relationship. Bowlby believed that attachment, once achieved, was a trait, or lasting characteristic, of the child. Attachment theory follows the basic tenets of evolution. Human beings select for social behaviors that make individual or group survival more likely. Bowlby believed that a toddler, for instance, would seek the proximity of the person to whom they have attached when danger was sensed (Bretherton, 1992). He asserted that there is an advantage for survival in the capacity to sense possibly dangerous conditions such as unfamiliarity, being alone, or rapid approach, and that such conditions are likely to activate the survival mode, causing infants or children to seek proximity to the person to whom they have attached. The focus is completely on the child. Attachment theory revolutionized the thoughts of bonding and the need for a parent and child to interact and connect with one another. Ainsworth‘s studies informed much of the theory and allowed for empirical testing using the Strange Situation 28 assessment. Ainsworth‘s empirical tests are used to discover and subsequently classify a children‘s attachment to their caregivers, usually a mother. Observational data are used to categorize children and the child-mother relationship into one of four classifications. Once again, the classification is thought to be an unchanging trait or characteristic of children that they will then carry into their adult lives and will even be perpetuated by their children (Fonagy, Steele, & Steele, 1991; Main, Kaplan, & Cassidy, 1985; Steele, Steele, & Fonagy, 1996). Critique Attachment theory focuses on the psychological needs of the infant or child and implies that the duty of the parent is to respond appropriately without regard to the sense of self, or identity of that parent. Attachment theory is limiting and an oversimplified theory that does not take into account that the so-called attachment occurs within a historical, social, and cultural context wherein people learn how to love, connect, touch, discipline, and define needs. Attachment theory is reductionistic and pathogizes people and situations that do not fit neatly into the theory‘s classification system. This simplification is problematic when challenges come from the psychological history and background of the parent and also from the wide variety of sources outside the mother-baby dyad. The theory cannot account for historical, societal, and cultural influences. Attachment theory fails to account for how women learn to become mothers within social, cultural, economic, and political contexts. It relies too heavily on ideas about instinct and innate characterizations. 29 Maternal Role Theory Synthesis of Major Work and Ideas In this section I discuss the major works and ideas associated with maternal role theory. The major contrast of maternal role theory to attachment theory is the focus on the mother instead of the infant. A number of researchers have attempted to define and even quantify the concept of motherhood in sociological and psychological terms. For example, nurse theorists Rubin and Mercer (Mercer, 1981, 1985, 2004; Rubin, 1984) were foundational in the development of maternal role attainment theory, in which the maternal role is theorized as a series of developmentally progressive stages beginning in pregnancy and ending when the mother feels she is confident in her new, task-oriented role. Maternal role attainment is based on the behavioral and objective aspects of being a mother. Observed and measured behaviors are often used to mark the progression of women in the process of maternal role attainment. In 1967 Reva Rubin introduced her groundbreaking work on maternal role attainment, which was distinguished from attachment. Rubin was a nurse who studied the mother‘s perspective of pregnancy, childbirth, and maternal identity. Her most famous work centered on maternal role attainment during the antenatal and postnatal periods. Rubin (1984) describes postpartum maternal role attainment, which she termed maternal identity, as the culmination of the process that begins during pregnancy. She theorized that maternal identity consists of two things: a woman‘s internal sense of certainty and her perception of her own competence in the maternal role and her knowledge of her infant. Rubin theorized that women go through three general phases of developmental tasks in the process of maternal role attainment: the taking in phase, the taking hold 30 phase, and the letting go phase. These phases are all thought to occur and begin during pregnancy and can take up to a year to culminate. The taking in phase refers to the time shortly after delivery, when it is theorized that the woman begins to adjust to her new role. She may have difficulty making decisions and has a great need to relive and discuss the delivery process. The mother is thought to be more dependent on care during this phase. Rubin believed this to be a first and vital step to the integration of mother into a woman‘s self-concept. The second stage, or taking hold phase, is thought to begin quickly after the taking in phase (from a few hours to a couple of days after birth). It is believed that in this stage, after the mother has rested and feels she has more strength, she begins to concentrate on her infant. First-time mothers are thought to require reassurance that they are giving adequate care to their infants. The third, or letting go phase, is believed to begin anywhere from a few days to several weeks after a child is born and is associated with grief. Rubin believed that mothers must let go of previous roles to define their role as a mother, sometimes requiring that a woman go through some or all of the stages of grief (Klossner & Hatfield, 2006). These phases are presented as sequential building blocks, or developmental tasks, associated with each phase. In order for a woman to move from one phase to the next she must complete or achieve all the developmental tasks of the previous phase. If she does not achieve these tasks she cannot continue in the process and will not achieve maternal role attainment. 31 Ramona Mercer, who, during her doctoral studies, was taught and mentored by Rubin, continued researching variables that affect maternal role attainment. According to Meighan et al., -Rubin‘s research not only served as a stimulus but became the foundation of Mercer‘s research‖ (1997, p. 408). Rubin was interested in maternal role attainment from the beginning of pregnancy to shortly after the birth of the child, but Mercer focused beyond that to one year postpartum. Mercer, talking about Rubin‘s work, stated -An ideal image of self as mother is constructed from her [the mother‘s] extensive psychological work during pregnancy and postpartum, and through this image the maternal identity is incorporated into her self-system‖ (2004, p. 226). Mercer proposed that attachment constitutes an integral part of the mother role and identity. Maternal role attainment is defined by Mercer as the progression through four stages: the anticipatory stage, the formal stage, the informal stage, and the personal stage. The first, or anticipatory stage, is believed to begin during pregnancy. During this stage the mother is thought to begin adjusting to the expectations of the role of mother. The second, or formal stage, begins with the birth of the child. Behavioral and role expectations are believed to be guided and influenced by the people surrounding the mother and her immediate support system. The informal stage begins when the mother begins to adapt to her own individual ways-ways that may not be conventional to her social system-of dealing with the demands of her new role. The final stage, according to Mercer, is the personal stage. During this stage the mother is perceived to have a sense of harmony, confidence, and competence in the unique way she is performing the role of mother. Mercer believed that maternal identity 32 is at this point achieved. Mercer thought that the process of becoming a mother cannot be completed until the infant is at least six to nine months of age. She believed that this process is repeated with every child, as every mother-child relationship is unique. Mercer (2004) reports that the ideal image is a reflection of the characteristics, attributes, traits, attitudes, and accomplishments that the woman finds desirable in motherhood. Mercer did most of her studies only involving women who had given birth to the children they were mothering. Critique Maternal role theory studies have been conducted with a homogenous sample of white middle-class adult women and have not taken into account the historical, social, and cultural contexts in which women reside. Maternal role theory is based on the observable and empirical behavioral aspects of being a mother. Observed and measured behaviors are used to mark the progression of women through the process of maternal role attainment. Women are measured against the unvaried nonminority adult women that were used as participants in the creation of this theory. Maternal role theory studies that have been conducted with a homogenous group of women leave us with an overgeneralized view of the process of completing role attainment in pregnancy and in the postnatal period. Vulnerable populations, ethnic minority groups, and adolescents were not included in the original studies. Maternal role theory has since been applied to women as an all-encompassing explanation of what women should expect during pregnancy and the first postnatal year. Little is 33 acknowledged about the differences in history, society, or culture that affect these women. Like attachment theory, maternal role theory does not include the context and resources beyond individual psychology that women use to construct their images and ideals of motherhood. The focus shines brightly on behaviors in the progression of role attainment while it leaves the culture, stories, and histories of the lives of the individual women unexplored. The terms role and identity are often used interchangeably in the nursing field, but there are fundamental and significant differences between -maternal role‖ and -mother identity.‖ In maternal role theory, behaviors are counted when a woman performs and fulfills the maternal role according to an objectified set of standards. In contrast, the concept of identity includes a highly personal and subjective sense of self, one that is linked to historical, societal, and cultural influences. Motherhood identity, unlike maternal role, describes a process of coming to identify oneself as a mother in the specific situations that make up the everyday lives of women. Motherhood identity is a dynamic lifelong process of discovery and performance. Critique of Attachment and Maternal Role Theories Attachment and maternal role theories both have a common weakness: a lack of contextualization. The context of history, society, and culture are absent. At the same time, attachment is presented as a blanket theory applicable to all children and the people to whom they attach and used as a quantifiable approach to bonding. 34 Identity Theory, Mother Identity, and Maternal Archetypes This descriptive and exploratory study focuses on understanding the talk and performances of motherhood by young women participating in a teen mother and child program construct the concept of motherhood and how they incorporate it into their own identities within the context of personal, social, and cultural meanings and the experiences they have with motherhood. These goals cannot be undertaken nor met with the limiting and functionalist views of attachment theory and maternal role theory. I will now explain identity theory and highlight the features of identity theory that make it the best choice as a theoretical framework for this study. Identity is fundamentally defined as the quality or condition of being a specific person or thing (Oxford American Dictionary, 2003). Research surrounding identity reports multiple definitions ranging from very broad to complex and specific, involving personal and social aspects (Bucholtz & Hall, 2005; Klein, Spear, & Reicher, 2007). My operational definition of identity is a highly personal sense of self, not just the set of behavioral or personal characteristics by which an individual is recognized as a member of a group. All societies have mythology or ideology surrounding the ideas of the good mother, -women who are nurturant, kind, and selfless‖ (Birns & Hay, 1988, p. 3). The characteristics of motherhood that are acceptable in western society are the archetypes and icons often used to guide behavior. The mother archetype is described by Jung as a connection that is shared by the collective society (Boeree, 2006). The construction of motherhood is deeply embedded in individual and collective subconscious, and therefore has tremendous power in culture and society. 35 The mother archetype is used to recognize a certain relationship, that of mothering. Jung believed that people are likely to project the archetype out into the world and onto a particular person. When an archetype does not have a particular real person available, people turn the archetype into a mythological, even perfect storybook, character. This character then symbolizes the archetype (Boeree, 2006). The good mother archetype is multidimensional, embodying spirit, emotions, physicality, and personality (Spore, Harrison, & Haggerson, 2002). Identities are often negotiated and shared by a society and/or culture (Gee, 2005). The good mother archetype permeates the dominant culture and in so doing remains a vital and even helpful archetype. The cultural identification of mother can be a Jungian archetype. Identity is a complicated and multifaceted part of all women‘s lives, especially for women whose experiences as mothers are not represented in mainstream media and are identifiable within the good mother archetype, which transcends time and culture. Major Tenets of Identity Theory Identity is described as the way we think about ourselves, the idiosyncrasies that differentiate us from one another, and the collection of roles people might play in their everyday lives (Leary & Tangney, 2003). The tenets of personal identity were explored and found to be helpful during this study. Identity theory is based on the idea that people put themselves and others in various social categories. They often categorize by putting others (and themselves) into distinct but not exclusive groupings. Labeling is a practice of saying other things about those things that are categorized and labeled; if someone is a mother then he/she cannot 36 be a father (Ashford & Mael, 2004). People identify themselves with personally, socially, and culturally constructed categories. They identify with certain groups that have attributes to which they aspire. They compare themselves and groups with other people and groups, usually finding a favorable difference toward the group to which they belong. Identity is constantly changing due to new experiences and information acquired in daily interactions with others. Identities can be defined as a person‘s answers to the question -Who am I?‖ Many of the answers (e.g., I am a mother) are linked to the roles people occupy, but are not entirely or exclusively defined by these roles. Identity theory supports the notion that the self is a collection of identities, each of which is connected within the context of a person‘s everyday life, a role, or an ideal (Stryker & Burke, 2000). Identity is thought to be a personal process of self-verification. The process of self-verification is done in relation of social structures to identities. The identities then continue to create and sustain social structures (Stryker & Burke, 2000). Major Tenets of Role Theory I now discuss role theory, its basic tenets, and how it differs from identity theory. Role theory is based in behavioralism. Roles are the defined norms, duties, expectations, and standards for behavior typically associated with a social position and status. The degree to which a woman is labeled a good mother is knitted to her being seen as acting like and behaving like a socially acceptable mother. The basic tenets of role theory are that a) people define roles for themselves and others based on socially accepted ideals, b) expectations about the roles are formed, c) 37 others are encouraged to act within the role expectations and d) people will act according to the roles they adopt (Changingminds.org). Once a role has been attained or filled it is thought to be a constant and fixed aspect of life. Very rarely does a woman state that she was once a mother but is not any longer. Maternal role theory tracks the progress of women through a set number of stages beginning in pregnancy and ending with maternal role attainment. There are guidelines and standardized markers as to the time this progression should take and the levels of appropriate behaviors. Contrasting Identity and Role Theories There are fundamental differences between identity and role theory. Identity is linked to the highly personal sense of self that is dynamic, malleable, and based in personal, societal, and cultural meaning. Role theory is based on objective behaviors and actions that, once achieved, are believed to be an unchanging, constant aspect of that person, not taking into account changing personal, cultural, or societal perspectives. Identity theory focuses on the self-the attributes, personal ideas, and images that we use to create our sense of being and identity. Role theory is based on objective, observable actions and behavior that are used to track progress toward the goal of mother. Identity lends itself to understanding the experiences of women relating to motherhood in a personal manner. Role theory does not allow for the personal perceptions and cultural and societal influences of the women being studied. At the heart of identity theory is the idea that identities are changeable, plural, and intersectionally linked. The construction of an identity is influenced by diverse social 38 interactions and personal perceptions that cause flux to the sense of self. Role theory purports that once a stage has been completed it then crystallizes. Role theory perpetuates the idea that once a role has been attained it is a permanent part of a person or that a person has permanent residence in that role or set of behaviors. A role is an objective thing or space to be filled, but identity is a process that intimately involves a person and the historical, social, and cultural positions and activities of their everyday life. Unlike role theory, identity theory provides for a changing sense of self that allows the young women of this study to tell the stories of who they are, who they were, and who they hope to be. There is also a sense in which roles seem to supersede people, existing before and apart from those who take up the roles. Identity theory accepts the influence of personal, societal, and cultural perceptions in the construction of who people believe themselves to be. Role theory does not take into account that people live and interact within a setting of time, society, and culture. It is structuralist and normative. Identity theory allows for the exploration of the cultural construction of mother by women anywhere, but this construction is not incorporated into role theory. The meaning of motherhood has strong personal, social, and cultural meaning that is fluid and contextual. Exploring Maternal Identity in Teens There are diverse findings in studies where adolescents are the subject of scrutiny, some of which are confusing or confound traditional ideas. Where can researchers find information and clarity on maturation experiences and identity development, especially maternal identity? Child development theories are limited in their application to 39 motherhood due to the ideals of socially acceptable child and adolescent roles. Maternal role theorists like Rubin and Mercer have focused singularly on white adult women in the normative role attainment of motherhood. Few studies have shed light on the perceptions and experiences of young women balancing between the ideal images of teenagers and motherhood. Myths surrounding sexuality, pregnancy, and childbearing of young girls that were prominent in the 1950s and 1960s and their influence can still be felt today. In essence, the myths were that white unmarried girls get pregnant due to deep psychological dysfunction or trauma. Black girls supposedly have inherent insatiable sex drive. It was thought that it was natural for black girls to get pregnant early but white girls must be mentally disturbed to become pregnant at a young age. Myths persist today about young women who are pregnant. Such racial and age stereotypes are used by the dominant culture to stigmatize and marginalize teen mothers; they are the other, not like the mainstream of the group (SmithBattle, 2007b). Painting teens as villains or victims negates and marginalizes them and their own personal realities, narratives, and experiences (Flanagan, 1998). Flanagan (1998) confirms that every young woman embarking on the journey of early motherhood does so under a highly personal set of circumstances. Her motivations and assumptions about her world and her future, including her own relationship and experiences with her own mother or mother figures, are unique to her. There are many reasons why a teen may become pregnant. She may become pregnant because she is ignorant, unable to equate cause and effect, or unable to think or plan in an abstract way, or birth control or contraception may not be available, she may 40 not trust using it, or she may feel that obtaining contraception may make her sexual activity public. Some young women also choose to become pregnant. She may see pregnancy and motherhood as a means of escaping an unwanted situation at home or of being able to elevate herself from the role of child to a prominent and voiced member of a family or society. Flanagan (1998) suggests that it is more likely that girls get pregnant because of the positive reinforcement and incentives surrounding motherhood. She stated, -The status of motherhood itself is an important motivation in favor of pregnancy‖ (p. 244). There are other positive incentives, such as the idea that a mother is someone with a clear role and solid identity (SmithBattle, 2009). There is an increase in responsibility, authority, and even a purpose. Being a mother can be seen as raising a teen‘s status from child to adult. Pregnancy and motherhood may be seen as a way to elevate one to be more like her mother, sisters, or other adult women. It is also thought that the baby itself can be an incentive. There will always be someone around to love the teen, it can be a solid manifestation of love and commitment to her partner, and even something to leave behind, the legacy of the teen mother. Many teens are responsible and pregnancy and motherhood can be thought of as acceptable or even good for both the mother and the baby. Flanagan (1998) reports about the positive experiences she has with many teen mothers in her practice as a pediatrician. She reports that teen mothers, even very young ones, can be good mothers if they have access to and use the resources they need. She does note that there is often a need for special resources for teen mothers. 41 In earlier research Flanagan et al. (1995) report on the experiences of motherhood and the conceptualization of maternal role of teens as it relates to their psychosocial and cognitive development. They report on a study that had one arm that was qualitative in nature followed by a quantitative arm to verify the results of the previous arm. They report that every culture and age group varies widely in the construction of maternal identity speaking of maternal role. They continue that maternal role, like any other societal role, is a product of culture and development-in this case it refers to the actions that a woman is expected to perform. This is done by learning, integrating, and successfully performing the expectations of the role. Significance of the Study Pregnancy is usually considered the beginning of the miracle of birth. The phase of pregnancy can be seen as a preparatory time. This period of time allows for the focus on the initiation of both the biological and psychological changes of pregnancy and birth during the process and development of maternal identity. By focusing on the antenatal period I could talk with the teen mothers about their expectations of motherhood, gaining a sense of the images, icons, and experiences they use to create their own mother identity. This study allowed for my interactions with pregnant young women. It focuses on the stories and narratives young women tell to perform and describe motherhood, motherhood identity, and womanhood within a medical clinic setting. This new knowledge has potential to be used in several ways, including a return to the scope of the societal and cultural symbols and discourses available to these young women that are 42 used in identity construction and interaction in their everyday lives. A fuller, more complete picture of the world is produced. This understanding may lead to development of new teen mother and child programs as well as intervention and prevention programs that are more tailored to the cultural and personal needs of participating young women. A greater understanding of maternal identity development and meaning among pregnant teens may be used to identify where the needs of medical, specifically nursing resources in particular situations lie. Knowledge of maternal identity development contributes to the increase of nursing knowledge and could be used to promote quality developmentally, socially, and culturally appropriate care to teens during pregnancy and parenting. Nurses provide great efforts in the care of pregnant and postpartum women, including teens. Nurses listen to and promote images and ideals of motherhood. Prenatal, labor and delivery, and postpartum nurses are integral members of the audience of maternal identity construction and performance. Nurses respond to performance and help women achieve developmental tasks often associated with good mothering. In recent years, health promotion and prevention-including health promotion of teens and teen pregnancy-has become the focus and has been labeled as the proper use of health care dollars. Health policy may be drafted in states to initiate more programs to help teen mothers. Nurses fill a health promotion role and provide information to young women about mothering; they also are often seen as role models. Nurse-family partnership programs are an example of the influence that nurses have on the health and well-being of pregnant and parenting women. The nurse-family 43 partnership is a program that was introduced to provide support to vulnerable first-time mothers. The purpose of the program is to allow nurses to give support for a healthy pregnancy and to assist women in becoming knowledgeable and responsible parents and to support the mother in providing her baby with the best start in life possible. -The relationship between mother and nurse provides the foundation for strong families, and lives are forever changed-for the better‖ (Nurse-Family Partnership, n.d.) Utah currently participates in this program. The experiences and ideals of adolescents who bridge the worlds of teens and adults by their pregnancies are left unstudied, leaving their voices unheard and their stories untold. A greater understanding of the stories in the personal, societal, and cultural contexts in which the women of this study live and interact sheds light on that -something that guides‖ (Gee, 2005, p. 68) these meanings, returning to the social and cultural world. The personal leads to the more global, especially in practices, behaviors, and ideals that are the context in which we live and negotiate meaning in our everyday lives. Using the views and perspectives of many gives a more complete and fuller picture of the world. The narratives and stories of the young women in this study aid in the illumination of parts of the world that have previously been left in shadow. It allows for a -look back at the self in all its cultural particularity from a more distant, critical objectifying location‖ (Harding, 1991, p. 151). By paying attention to and increasing the understanding of the way pregnant teens come to think and talk about themselves as mothers, including their decision making, meaning making, and reactions to the world, researchers can develop more personalized 44 intervention prevention and support programs for these and other young women and their families. It is also possible that the knowledge generated in interaction with this population may be suitable for other groups of women who also face the risks of marginalization and difference because of the situations in which they become or perform as mothers, such as incarcerated women, families with same-sex partnerships, etc. CHAPTER 3 THEORETICAL FRAMEWORK AND METHODS This study is informed by social constructionism in general and a performance view of narrative language in particular to explore and describe the construction of motherhood and related experiences for adolescent girls participating in a teen mother and child program. Epistemologically fundamental in narrative analysis is the assumption that humans make sense of the random events and experiences of their lives through narration (Bell, 2002). Stories provide an opportunity for a person to interpret the events of their lives and assign meaning to those events. A Burkean analysis of narratives allows for a greater sense of context in which the story is performed. In this section I briefly orient the reader to how the social and person construction of narratives combine in a focus on how young women in a teen mother and child program incorporate motherhood into their own identities. I also detail narrative analysis, and dramatism. I describe data collection including sources of data and the process of analysis for this study and in preparation for the analytical findings to follow in Chapters 4 and 5. 46 Social Constructionism Social constructionism holds that people have the ability to create and change their environment and the meaning of objects (Crotty, 2005). Learning is a socially mediated activity that affects understanding of surroundings and consciousness. Historical and social events and environments mingled with personal interpretations are the foundations for constructing meaning. Women, including adolescent mothers, interpret the events of their lives utilizing historical, social, and material contexts. These contexts include subjective as well as collective social, political, historical, and economical forces as elements used to shape identities and meaning (Racine, 2008). Adolescent mothers, as well as others, are constantly and actively constructing reality by thinking, talking, and acting in everyday situations. This reality is then negotiated with others through performing their stories by whatever means are available to them such as narrative, art, dance, etc. Reality is based first in language and then in the culture to which it is grounded. Gee (2005) stated that -we use language to get recognized as taking on a certain identity‖ (p. 11). He reminds readers that people all have multiple identities and they build and perform them through language. Meaning and identity are not static. Meaning is fluid and flexible and requires that language also be an active part of building or assembling the situated meanings of the world. The experiences people may have are situated in context but can be understood in fact to have multiple meanings. I use the idea of how the building blocks of language and signs either alone or in combination are used by the adolescent mothers participating in this study to construct and transmit meaning 47 and perform mother identities through the stories they tell. I explore how the teen mothers in this study construct and negotiate their identities through narration. Meaning and context are often shared and negotiated between people through the use of language. Exploring and describing the experiences of young women in the teen mother and child program has helped to explore and describe the social and cultural context in which they are related. Using language to explore and describe the experiences of these young women does not just tell about the young women themselves but allows a return to look at the larger social and cultural world. Locating Myself I think it only fair to locate myself in the interviews and analysis thus far. I am a white, middle class, highly educated doctorally prepared, closer to middle age than I would like, woman. The idea for this study about motherhood and maternal identity was created beginning with my work as a nurse in a Newborn ICU. I have spent many years talking with, listening to, and teaching parents about caring for a premature infant. I also have had a longing to consider myself as a mother for almost my entire life. Having not given birth to a child myself, but mothering and caring for children, I still do not think of myself as a mother. The ideas for this study grew over a few years and after a brief and abrupt diversion, I began this study focusing on teen mother identity. Shortly after the inception of this study focused on a teenage population, I began dating a man who has two teenage children. After what can only be called a whirlwind romance and extremely short dating period we became engaged and were married a few short months later. We became 48 engaged almost to the day of the beginning of data collection. We were married only three months after the beginning of data collection for this study. I therefore conducted this study and analysis while I myself had begun my own journey into motherhood. As with the teen mothers of this study, I have entered motherhood through a nontraditional route, as a stepmother. I have felt my own uncertainty and the dynamic nature of identity and the potential for tumultuous struggle to understand who I am. Ethnography Ethnography is commonly understood as an approach to data generation and collection as well as an end product, the writings and understandings of the researcher. Ethnography has been defined by Schwandt (2001) as -a methodology born in cultural anthropology that is distinguishable by the fact that it is the process and product of describing and interpreting cultural behavior‖ (p. 80). When utilizing ethnographic methodologies researchers are interested in the exploration of meaning and perceptions of the people participating in the research. In its most recognized form ethnography involves a researcher participating either overtly or covertly in the everyday lives of the people of interest. This involvement usually happens over an extended period of time while the researcher watches what happens within the groups, listens to what is said, and asks questions about the topic of interest (Hammersley & Atkinson, 1995). Ethnography literally means -writing culture‖ and the traditional product of ethnographic study is a written scientific report describing 49 cultures, aimed at increasing knowledge or understanding for persons outside the culture under study. The purpose of this study was not to produce an ethnography as the finished product. However, the methods of data collection associated with ethnographic research are very appropriate for a study of this nature. The basic premise of ethnography is to explore meaning and the perceptions of the participants of the study, which coincides with the purpose of this study. The tools of data collection associated most often with ethnography can be used to identify personal, societal, and cultural influences, concepts, and norms (Goepp et al., 2008; Guerrero et al., 1999). Some of the tools of commonly associated with ethnographic studies were employed during this study, such as in-depth interviewing, informal interviewing, and observation (Genzuk, 1999; Goepp et al., 2008; Guerrero et al., 1999; Hammersley & Atkinson 1995; McNall & Foster-Fishman, 2007; Trotter, Needle, Goosby, Bates, & Singer, 2001; Scrimshaw, n.d.). I employed semistructured formal interview procedures and nondirective forms of questioning as well as observations, informal interviews, field notes, and journaling as data collection and data analysis techniques. These data collection techniques offered me to a mode of exploring the interactions of teen and providers. I was also able to explore and describe my interactions and conversations with pregnant teenagers, who are literally marginalized out of normal adolescent society. I was able to interact with these young women as an outsider within (Hammersley & Atkinson, 1995). Through the privilege of access to the research cite I was able to employ these techniques to talk casually and formally with young women and 50 the health care providers and staff of the program as well as observe everyday clinic life and events to explore local beliefs and perceptions. There are dangers of assumptions that I, as the researcher, bring with me into this setting. There is also the inherent danger of the differentiation of power between myself, an educated White, middle-class, adult woman and the participants of this study. Hammersley & Atkinson (1995) remind researchers that field notes, reflexivity, self-reflection, and examination are helpful to ground researchers in a critical awareness of their own culture and story. Journaling and field notes have allowed me to examine my experiences as they occur and to reflect on them afterwards. I often had informal conversations with the staff and practitioners of the clinic during the 7 months I was observing and collecting data. During some of these informal conversations the staff members and I would discuss my observations and some of the beginning ideas of themes and members of the narratives as the stage was set for the performance of the personal narratives of the teen mothers. I had formal debriefing session with my chair and other colleagues. During these sessions I was able to discuss more in depth the themes and ideas of codes that were beginning to emerge. I analyzed narratives and the performance of motherhood from observations and interviews with pregnant teens using narrative analyses that draws on Burkean dramatic analysis (Burke, 1969). The stories people tell about themselves, as well as the way they cast themselves and perform stories and identities, can be seen as constructing and cocreating reality. Riessman (1993) stated, -It is in the telling that we make real the phenomena in the stream of consciousness‖ (p. 22). There is a hermeneutic relation between individual identity and the social world in which it is recognized. Riessman also 51 stated that stories are driven by human agency and imagination: -Individuals construct past events and actions in personal narratives to claim identities and construct lives‖ (1993, p. 2). Narratives and Identity The use of narratives in the social sciences is not a new phenomenon (Connelly & Clandinin, 1990; Polkinghorne, 2007). Connelly and Clandinin (1990) remind us -that people by nature lead storied lives and tell stories about those lives‖ (p.2). Narratives are the stories we tell about ourselves and our lives to an audience. The intended audience could be ourselves, others or both. Narratives are used to organize a series or group of events into a whole, for the purpose of relating meaning to a part or to the whole through its parts. Verbal narratives could be told or performed in many ways; fictional accounts, fairy tales, autobiographical or historical accounts. Identity is told and performed through stories (May 2004). Personal narratives are defined by Riessman (1993) as the -talk organized around consequential events. The teller in a conversation takes a listener into a past time or ‗world‘ and recapitulates what happened‖ (p. 3). Narratives are constructed for a definite audience creatively. The participation of the audience tailors and influences the performance, linking it to a point in time. Narratives are full of rhetorical moves, assumptions, and interpretations of all parties involved in the performance. The involvement of all parties offers insight into the meaning of the narratives, both thematically and performatively. Identity is not static, fixed, or a core essence of a person. Performance of an identity is a collaborative effort in which performer and audience each have a stake in 52 how an identity is performed. This does not mean that the identity is not authentic, only that it is situated and understood within the bounds of a certain social interaction and situation. This also does not assume that there is only one identity to be performed. At any given performance a teen (or anyone) selects the preferred self to be performed at that time. The preferred self may be the one that is believed to be most appropriate for the setting. Which self is chosen to be presented as the preferred self might be due to appropriateness and might also be determined by strategic means, what can a person gain by the performance, it may be chosen due to the emotional state of the performer, it may be chosen because it is the most commonly used and therefore the easiest self to perform. This preferred self is selected from the multitude of selves one uses to navigate life (Riessman, 2002, Sandelowski, 1999). Narrative Analysis Stories and narratives occur in everyday conversation however, in narrative research stories are solicited from others for the purpose of study. There is no single method of narrative analysis. Rather, narrative analysis is a spectrum of ways to read and interpret texts presented in narrative form. Narrative analyses do have commonalities: they all focus on a story. Stories are then used to explore and describe how people make sense of the events of their lives. A narrative, or life story, is created using speech, writing, images, or other modes of communication to describe a sequence of fictional or nonfictional events-a story. People are most able to make sense of their world by creating, recreating, and narrating stories. 53 One form of narrative analysis is investigating the story as a whole. Another is to closely examine the poetic form and structures used to communicate the narrative. Riessman (1993) informs us that in narrative analysis -diversity is displayed not so much by the contrasting themes different individuals choose to tell . . . but by the contrasting ways individuals choose to put their accounts together, that is, the form of telling‖ (p. 33). Narrative analysis is best used for exploratory purposes, sensitizing a researcher, and illustrating, but not itself validating, a theory. Due to the nature of narrative analysis, it is best suited to studies with limited participants typically 8-10 (Elliott, n.d.). A common focus is the exploration of ethical, moral, and cultural ambiguities. As Riessman stated, -Culture ‗speaks itself‘ through an individual‘s story‖ (1993, p. 6). Narrative analysis allows the participant to cast herself in the story of her life. Deeper understanding beyond a thematic analysis can be achieved by paying attention to the narrative segments of the data as well as the contextual construction of the narrative. Narrative analysis creates a -metastory‖ by shaping, revising, and re-creating the story as it was told into a hybrid that the researcher and participant coconstruct, retold by the researcher. The interpretation of the metastory is limited in that it is bound by time and history along with the culture of the reader. As Riessman stated, -Our subjects ‗do not hold still for their portraits‘‖ (1993, p. 15). Meaning is fluid, dynamic, and contextual. What researchers have to work with is the talk and texts that only partially, selectively, and imperfectly represent reality (Lindsay & Smith, 2003; Paley & Eva, 2005; Pellico & Chinn, 2007; Riessman, 1993; Sandelowski, 1991). 54 Riessman (1993) emphasized two strategies for doing narrative analysis: 1) reduction to core narrative and 2) analysis of poetic structures. The first, reduction to a core narrative, entails understanding that all narratives have two basic parts: the story and the plot. The story is the raw, time-oriented, sequential narrative of life. The plot becomes evident in the fortuitous twists and turns that allows the distinction of the performance or telling from the conventional story to be illuminated. Thematic narrative analysis is one of many approaches to narrative that also focuses on the core story. All narrative inquiry is interested in what is being communicated via verbal communication, writing, or other visual forms of narratives. Thematic narrative analysis is mostly interested in the told events and thoughts of the participant. The messy language of normal speech is cleaned up to make the transcript more readable. Thematic narrative analysis typically pays closer attention to how a story unfolds through the conversation that takes place between the researcher and the participants; especially the role the researcher plays in the exchange (Riessman, 2008). Thematic narrative analysis begins with the researcher identifying single interviews and isolating and ordering relevant episodes into a chronological biographical account. The process then continues as the researcher narrows the focus and identifies specific accounts and assumptions and names, or codes. Accounts and assumptions are then compared for patterns, including variations of patterns. Particular cases are selected to be used as exemplars of general patterns. By only focusing on the themes of narratives the issues of the audience and the subtle interactions as the researcher and participant construct meaning together slip away, out of focus. 55 Structural narrative analysis, the second strategy emphasized by Riessman (1993), is another approach, however as it would suggest, the focus shifts from the core, or plot of the narrative, to the poetic structure of the narrative. There is close attention to the details of speech. Particularly important is the narration, rather than the narrator. Structural narrative analysis answers questions of how a story is made whole and understandable by focusing on the parts that may be taken for granted when telling or hearing narratives. There is little focus in structural narrative analysis on the relationship between the storyteller and the listener or researcher. The coproduction of the story is also left unstudied. There is even less attention given to contextual and cultural discourses, power relationships, and intuitional expectations. Structural narrative analysis can be thought of as the -how‖ of narrative analysis. How language, specific words in particular, and other rhetorical moves, like pauses, are used as the focus of studying what meanings a story conveys. Dialogic/performance analysis is yet one more approach of narrative analysis. Riessman (2008) distinguished this approach of narrative analysis from other approaches by stating that this approach is not singularly focused on the themes nor structures of the narratives, rather this approach is a -broad and varied interpretive approach to oral narrative that makes selective use of elements of the other two methods and adds other dimensions‖ (p. 105). Dialogic/performance analysis proposes to expound narrative analysis beyond the limiting ideas of solely exploring -what‖ and -how‖ in stories. Stories are composed and constructed in contexts. Historical, institutional, cultural, and discursive elements and even the relationships and interactions between 56 storyteller and listener all enter into the storytelling process and the narratives told. Narratives are indeed a social practice. They can tell much about a society, the history and time in which the narrative is told, and the culture used to tell and interpret the meaning of the story. Narratives also tell about the person or people telling the story as well the intended audience. As with all analytical approaches, there are linked and discrete assumptions that underlie the thematic and performance approach to narrative analysis. Meaning is constructed by people using the language, historical, societal, and cultural guidelines available to them. Meaning is constructed using language within a context. People are all born into a society or culture that orients meaning to their worlds. People‘s society makes them aware of certain things, issues, activities, and identities and bestows them with meaning. This inherited meaning automatically allows some things to be brought into focus while others are ignored or left unstudied. Historical and interview context also need to be taken into account. During an interview there are new interactions, dialogues, and power relationships created. Meaning is produced by the interaction of the two speakers: researcher and participant. Erving Goffman (1959) reminds readers that people are forever constructing images and impressions of themselves. They project the definition of who they are or who they want to be, and the claims they make about themselves and the world in which they find themselves. People are constantly testing the world and negotiating their identities with themselves and others. When they are faced with a difficult situation they perform identities that are potentially more desirable. Goffman continues to emphasize that people spend more time not in giving information, but in giving shows. 57 This does not mean that performances are not authentic. Performance of identities are situated and constructed for a particular audience. The importance of the audience in dialogic/performance narrative analysis is a shift from other forms of narrative analysis. The listener or researcher is an integral aspect of the story and the analysis of the narrative. Language is the common medium used to communicate narratives. Language is not a neutral medium. It does not freely pass between people as merely words without historical and cultural meaning. Language is not the private property of the storyteller, infused only with the teller‘s intentions. It is populated and rich with potential meanings and intentions of the multitude of people involved in the construction of the narrative: the storyteller, every member of the audience in person and invisible, and even the future readers. The members of the audience, which in this case includes the researcher, do not come to the interaction without their own identities and personal narratives. I came to the clinic for observations and to the formal interviews with many identities from which I could choose that each influenced the construction of the narratives. At times I was a nurse who specifically working with babies and parents in a Newborn ICU, listening and critiquing the advice and stories of the CNMs. At times I was a giddy girl, falling in love and not focusing on the future. At times I was a foreigner, seeking to learn the mannerisms and vernacular of the teen mothers, especially related to gang activity and membership. I was always a middle class white woman, a guest of the clinic and in the lives of the teen mothers. 58 Riessman (2008) stated, -investigators carry their identities with them like tortoise shells‖ (p. 139). Researchers need to look reflexively on the influence they have on the production and interpretation of the narratives collected as data. Meaning does not dwell solely in the storyteller‘s narrative, but it is also in the dialogue and interaction between the speaker and listener, the storyteller and the researcher, the text and the reader. History, culture, politics, and the dynamic presentation of self for an audience must be accounted for in the analysis of narratives. Research interests and questions arise for researchers‘ own narratives and shape the narrative plotline of each researcher (Clandinin & Connelly, 2000). The experiences of my own life have shaped the questions I ask as well as how I interact and perform my own identity during interviews and observation at the teen mother and child clinic. I recognize several identities while conducting this research project. I am a novice researcher, conducting my first solo research. I am a newlywed, fully giddily in love with my new husband, becoming a stepmother and an instant member of a family where I am a figure of authority, with a new identity that I had not anticipated as a younger person. My own feelings of flux and engaging in a much anticipated new identity are visible in the study as a whole. The focus of the study, questions I asked, the observations I made were all influenced by some aspect of my identity. This study would look different if any other person has been the researcher. Building on thematic and structural analysis, dialogic/performance narrative analysis attempts to answer questions about the interactions between the researcher and storyteller, the speaker and the setting where the story is told, including the history and culture used to create meaning (Riessman, 2008). Explaining the Burkean Pentad as one 59 model of narrative analysis, Riessman (1993) stated that the resources applied by people to perform their story -are contained in a pentad of terms; act, scene, agent, agency, purpose‖ (p. 19). Dramatism/Burkean Pentad Burkean analysis or dramatism is intimately linked to narrative. The stories performed are told within a setting and to an audience. The Burkean Pentad enables the researcher to highlight how people, teen mothers in this study, cast themselves in their own narratives, often as protagonists. Allowing for the unique view of centering the active constructions of the teen mothers rather than what is simply said about them or in which roles they are cast in by others. Kenneth Burke (1969) developed a critical technique founded on the concept of motive. This technique is called dramatism. Burke believed life does not merely imitate drama but that people live in drama. Researchers can explore the context in which a story is situated and the motive of the performance by engaging a set of five questions: Burke‘s Pentad. Burke‘s Pentad can be used with any discourse or text to tease out the motive of the cast-in this case the participants and researcher. The pentad consists of:  Act: what is happening, what is the action or thoughts, what is going on  Scene: where or when is the action taking place, what is the background of the action, the situation in which the act occurred  Agent (actor): who is doing the action, who else is involved in the action, what are their roles  Agency: how do they act, by what means do they act, what tools or instruments do they use and 60  Purpose: why do the actors act, what do the actors want By asking these five questions researchers are able to begin to understand not only what people do but also why they do what they do. Using Burke‘s Pentad I answered the questions with the narratives and performances of what was happening; what were the overarching stories being told, including recurring frames used to make sense of motherhood; when or where was the story being performed; to whom; and for what purpose. For this study the Burkean Pentad was used as follows. The act was performed during the observations. The scene was the Teen Mother and Child Program. The actors were the teen mothers, their family or support people attending clinic visits, the unborn child, and the staff and practitioners of the clinic. The action was the prenatal care and instruction given to the teen mother at the clinic. The agency was the narratives that were performed, the techniques used by the cast members in conveying the motherhood story. The purpose of the performance for teen mothers included the goal of performing motherhood in the -right‖ way and showing themselves to be good mothers. The purpose of the performance of prenatal care given by the nurse-midwives included affirming their authority and position of power. The purpose also takes into account the specific audience, of which I was part, for whom the narrative was performed. Dramatism, the Burkean Pentad, has been used as a method of data analysis by many scholars to examine the nature of texts and narratives and explore empirical questions of how people explain their actions to themselves and others, including exploring the importance of the cultural and social influences on and of these explanations. Manning (1999) uses the Burkean Pentad to explore high risk behavior by 61 placing the narrative analyzed in context. Weldon (2001) used the Pentad to explore the rhetorical construction of the Ebola virus. Beck (2006) also uses the Pentad to explore narratives of birth trauma stories. She was able to locate the narratives in a context that enhances the understanding of the experience by including the context of the narrative. The ability to understand the stories of teen mothers as they come to understand and construct identities of motherhood is essential. Narrative analysis and the Burkean Pentad allow for deeper inquiry into the stories themselves as well as the context in which those narratives are performed. Description of Data Collection Recruitment and Informed Consent Recruitment for this study was multifaceted. I spent seven months, each week consisting of two 8 hours days and one 5 hour day, at the Teen Mother and Child Program as an observer. I was able to gain entry into the program through the shared program of BirthCare HealthCare at the University of Utah, College of Nursing. I met with the director of the BirthCare HealthCare program, who is a faculty member at the College of Nursing. I presented my research idea and asked if I could be granted entry into the clinic for research. She readily supplied a letter of support and I was introduced to the midwives who are members of the BirthCare HealthCare program, a few of whom are the nurse-midwives who run the Teen Mother and Child program. See Appendix A for letter of support. Once I had obtained IRB approval I was introduced to the staff of the clinic. I was able to begin data collection within a week of meeting the staff. 62 My data collection began with observation. I observed encounters with teens, practitioners, and the staff before recruitment was initiated for interviews. Each nurse-nurse-midwife was approached in the morning and I asked if I could follow her that day. There were typically two midwives working each day. There was also a social work student and a mental health advocate who were available for observations on a more limited basis. I approached each of the practitioners and staff members each morning to see I could observe them that day. If a nurse-midwife or other staff member did not want me to follow and observe them on a particular day I would follow the other nurse-midwife or social work student that day, with their permission. There were only a couple of days when my request to follow and observe were declined by a nurse-midwife. I subsequently followed the other nurse-midwife that day. While following the nurse-midwives, the student or staff each teen mother was asked by the nurse-midwife, student or staff member if I could enter and observe before I came into the exam room. To inform potential teen mothers about and to recruit them to my study I posted flyers with my contact information in each of the 10 exam rooms. See Appendix B for a copy of the recruitment flyer. I didn‘t recruit any participants using this method. All participants for the interviews were approached either after an observed traditional appointment with the nurse-midwife or after an observed CenteringPregnancy© class. Teen mothers were given a copy of a letter introducing myself and the study. My contact information was also printed on the letter. See Appendix C for a copy of the recruitment letter. Participation was voluntary, and participants were informed that they could remove themselves from the study at any time, with out consequence. 63 Approval for this study was obtained from the Institutional Review Board (IRB) at the University of Utah prior to the initiation of the study. The informed consent form was constructed in accordance with the University of Utah IRB. All participants consented prior to initiating interviews and observations. See Appendices D and E for copies of interview consent forms. Setting Programs focusing on pregnant teens are not a new phenomenon. In 1967 Sarrel published an article about a new program being conducted by the Yale Department of Obstetrics and Gynecology specifically for unwed teenage mothers. Dr. Sarrel found, during his residency, high recidivism rates among unwed teen mothers, and a need to -isolate‖ (p. 1308) unwed teens from the general prenatal population with the intent of providing intensive medical and social services to the teens. The need for assistance was indeed seen to be great. Teen mother programs were themselves born from the need seen by medical professionals to eliminate the negative social consequences of teen pregnancy. Current teen mother programs are geared to the medical treatment, care, and education of teen mothers and their children. The setting for this study was The Teen Mother and Child Program located at the South Main Public Health Center of University of Utah Health Care. The program is under the combined direction of Dr. Joni Hemond, MD, General Pediatrics, and Celeste Thomas, CNM, College of Nursing. The practitioners of the Teen Mother and Child Program provide over 3,500 prenatal and pediatric visits and attend approximately 160 64 births by teens each year. Well-child visits, sick-child visits, birth control management, prenatal care, and labor and delivery support are provided as well. Pediatric care of the teens and their children is provided by physicians and residents who are experienced or training in adolescent and pediatric health care. Teen mothers are served until they are 20 years old and their children are served until they are five years old. Care for the pregnant teen is provided by the nurse-midwife service, BirthCare HealthCare, of the College of Nursing, led by Celeste Thomas. Licensed mental health professionals and social workers and social work students meet with each teen to develop a plan to address psychological and social needs. Salt Lake Valley Health Department services are co-located in the health center to increase the ease and convenience for teens to obtain WIC (Women, Infant, and Children) services and a Medicaid eligibility/financial counselor is available to each teen. The financial counselor meets with every new patient and for every pregnancy of a multiparous teen. Low-cost immunizations and laboratory services provided by the health department are also conveniently located in the building. The Teen Mother and Child Program offers prenatal care and education in two formats. Both formats of care begin when the teen makes her first appointment and follow the same format for initial appointments. The first follows the traditional medical model for prenatal care. Teens are seen in an extensive initial appointment. During the first appointment the teen has an examination by a nurse-midwife, a visit from a social worker or social work graduate student, and a meeting with a financial advisor to see if assistance is available for the care of the mother and her baby. In the traditional format 65 the teen is then seen at individual appointments with the nurse-midwife at standard intervals. The second format available for prenatal care is CenteringPregnancy©. I refer to this format using the term Centering through the remainder of this dissertation. Centering is a model of group prenatal care. The purpose is to integrate the major components of prenatal care: health assessment, education, and support. The groups are designed for 8 to 12 women. The groups allow teens to meet together, learn caregiving skills, develop a support network with other pregnant teens, and discuss pregnancy and their experiences within a supportive environment. There are a total of 10 group sessions, beginning in early pregnancy and ending in the early postpartum period. Centering groups at the teen mom clinic are offered according to the availability of facilitators and as there are sufficient number of young women at similar gestations to form a group. During each group the teens take their own blood pressure, weigh themselves, and receive a standard physical assessment by the nurse-midwife behind a screen for privacy. The teens mingle and have provided healthy snacks while others in the group are being seen by the nurse-midwife. After all the teens have been assessed, a topic of discussion for the week is introduced. The discussion is facilitated by the nurse-midwife or a nurse-midwife student. I observed a two different Centering groups for a total of fifteen classes. Centering provides a dynamic atmosphere where teens can offer suggestions for topics for discussion. This is thought to promote learning and the sharing of ideas and thoughts. It is thought that hearing other women talk about concerns and experiences that mirror their own helps women to normalize the experiences of pregnancy. This 66 unique model of care is thought to empower the teens to choose health-promoting behaviors (http://www.centeringhealthcare.org/index.php). Sample The participants for this study were selected from among the female teens that were currently using the