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The Process by which Mothers of One- to Two-month-old Infants Seek Help from Nursing Professional

Aim: This study aims to clarify the process leading mothers of oneto two-month-old infants to seek help from nursing professional and to contribute to the discussion of how best to support mothers in seeking help. Method: Semi-structured interviews were conducted with 10 primipara mothers of oneto two-month-old infants, and the data were analyzed qualitatively and inductively using the Modified Grounded Theory Approach. Results: The process by which these mothers seek help from nursing professional began with feeling “trivial concerns about their own child that arise regularly” during parenting. Parents fall into a “cycle amplifying parenting anxiety” and this process was impacted by “disappointment in the response of nursing professional”, “satisfaction with the response of nursing professional”, and an “affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers”. The process ultimately impacted the mothers’ “idea and decision to seek help from nursing professional” while their feelings about help-seeking spiraled back and forth. Conclusion: These results suggested that reducing barriers to help-seeking and establishing an environment where support is readily available even if barriers arise are important ways to assist mothers in seeking help from nursing professional.


I. Introduction
The number of child abuse incidents in Japan continues to rise, with 2019 marking a record high. 1 Meanwhile, the rate of maternal suicide is reported to be roughly double that of maternal mortality. 2 According to the final survey of the Healthy Parents and Children 21 campaign, there had been no improvement in the percentage of mothers who were not confident in their parenting or other indicators based on mothers' subjective perceptions. 3 Thus, despite the various parenting support measures available in Japan, problems of postpartum depression, maternal suicide, and child abuse persist and even seem to be worsening. Today, as both national systems and local services are being established, there is a need to identify the circumstances of mothers who do not or cannot seek out this support, to ensure that appropriate assistance reaches as many mothers as possible. Biological mothers, the most frequent perpetrators in cases of death resulting from child abuse, face a variety of psychological and psychiatric issues. In murder-suicide cases, the most common issues tend to be "parenting anxiety" and "depression," while in cases of death resulting from child abuse, "low child-rearing ability" and "parenting anxiety" are consistently prevalent. 4 A report investigating the status of maternal suicide in the 23 wards of Tokyo reported a total of 63 cases of maternal suicide over a 10-year period, from 2005 to 2014. Of these, 40 of the mothers were at less than one year postpartum, with frequency peaking at four months postpartum, followed by three months, then six months. 2 These reports suggest the need for preventive mental ─ ─ The Process by which Mothers of One-to Two-month-old Infants Seek Help from Nursing Professional health care focusing on maternal mental health.
In each year since the 1 st report in 2005 to the 16 th report in 2020, most victims in cases of death by child abuse have been children under the age of one, with cases of death of children aged below four months accounting for 72.7％. Meanwhile, postpartum depression has been shown to appear within several months of giving birth, with the highest incidence within the first four weeks after childbirth . 5 Studies have also reported that the maternal suicide rate is highest four months postpartum. 2 Mothers of 1-to 2-month-old infants who are in the puerperal period (around 6 to 8 weeks after giving birth) engage in daily childcare by trial-and-error as their body recovers after childbirth. As mothers take the initiative to consult nursing professional such as midwives and public health nurses about their worries and anxieties, improving their abilities to seek help would lead to the prevention of mental health problems such as parenting neurosis and postpartum depression.
In the fields of mental health and clinical psychology, the phenomenon in which one is experiencing a problem but does not seek professional help is called the service gap. 6 Increasing mental health help-seeking awareness and behaviors is a major public health education project of the American Psychological Association. 7 In Japan, there has been much research focusing on "help-seeking" and "help-seeking preference" . [8][9][10][11][12][13][14] When first introduced in the field of social psychology, "help-seeking" was defined as "the act of directly seeking help from others when one needs to solve a problem in a situation in which it is recognized that the problem could be solved or lessened if another gave their time, effort, or other resources" . 15 Mizuno and Ishikuma defined a sub-concept of help-seeking known as "help-seeking preference," which refers to "the cognitive framework concerning whether an individual will seek help from a professional helper such as a teacher or a specialist in counseling or mental health services, or an informal helper such as a friend or family member, for a major emotional or behavioral real life problem. 16 "help seeking" and "help-seeking preference" indicate an individual' s behavior or attitude towards seeking help for problems, and it is sought from professional and informal helpers. On the other hand, regarding perinatal mental health, there is a risk that by the time a mother perceives the problem, it will have reached the most tragic outcome of poor mental health, namely, infant abuse or maternal suicide.Therefore, in this study, we focused on nursing professional as mothers with worries that are not strongly perceived as a problem would seek help from them. Although some research on childcare support focusing on a mother' s capacity to seek help has studied mothers of toddlers or infants, none have addressed mothers with one-to two-month-old babies. Kasahara found that mothers have high intentions of seeking help from professionals but, in reality, only a small percentage move on to help-seeking behaviors. 17 The study showed that the rate of help-seeking from professionals for stress and poor mental health associated with parenting is particularly low. However, the research subjects were mothers of children younger than 3 years, rather than only those of infants. Moreover, mothers tended to seek help from nursery teachers. While they are childcare specialists, only a small proportion of mothers exhibited help-seeking behaviors about their worries towards nursery teachers, and not many recognized nursery teachers as specialists with whom they could discuss their stress and poor mental health associated with parenting. Yuasa et al. further found that having many worries about parenting increased the barriers to help-seeking even for mothers with high help-seeking preferences. These barriers were even higher when mothers had a higher stress response concerning problems with their status as a parent. 18 These studies reveal that many mothers who have high help-seeking preferences are in reality unable to move on to help-seeking behaviors and, further, that help-seeking preference is lower when the worries concern the mother herself, compared to worries about her child. Although this study elucidated the structure of barriers to help-seeking from public health nurses, the research subjects were mothers of children aged 4 months, 6 months, 1 year, and 3 years who came for infant health checkups. Furthermore, the barriers applied for public health nurses and help-seeking preference were measured regarding other individuals including specialists and non-specialists, and it was not limited to nursing professional. Research has also shown that the scale and severity of one' s worries and stress impact help-seeking , [19][20][21][22] higher depressive tendencies in pregnant women make seeking help difficult, 23 poor self-esteem increases psychological resistance to help-seeking, 24 and a fear of not being believed or of being criticized by the helper is one of the reasons why mothers do not seek help. 25 Further, many studies have shown that mothers with past experiences of seeking advice are more likely to have help-seeking behaviors. [17][18][19]24,26 Studies on infants have shown that the variation and seriousness of the worries affected help-seeking behavior and barriers, but whom the mothers sought help from was not limited to specialists with whom they can discuss their physical and mental health. As infants and toddlers are in different development stages, the mother' s worries also vary depending on the stage, and these worries should be analyzed separately. 27 Specifically, primipara mothers of 1-to 2-month-old infants tend to experience large fluctuations in hormonal dynamics and are more vulnerable to poor mental health during the puerperal period when their bodies are recovering after childbirth. These mothers engage in parenting activities for the first time through daily trial-and-error, but there has not been a study on how they should seek help from nursing professional. Furthermore, while nursing professional such as midwives and public health nurses are an important support system during the perinatal period , no studies have limited the target of help-seeking to nursing professional. A questionnaire survey, conducted by the author, 28 concerning factors influencing help-seeking attitudes in mothers of infants identified three factors as barriers faced in seeking help from a professional. The first factor, "concern about coercion╱disrepute," pertains to concerns about being pressurized (that they may be forced to do something if they seek advice for a small concern or they may worry that their problem does not feel like a major one) and concerns regarding poor reputation (that they may be thought of as an incompetent mother if they seek such advice). The second factor, "concern about responsiveness," pertains to concerns about the helper' s response when they seek advice; for example, whether they would treat the problem with care or offer advice no matter how small the problem. The third factor, "ignorance," concerns not knowing what kinds of professionals are available in one' s area or the kind of support one can receive. However, Morioka who outlined trends in help-seeking research in the field of mental health, 29 identified a limitation of factor analysis research: although quantitative research can suggest several factors that influence a mother' s choice to get help from a professional, how each factor leads to help-seeking, under what kind of individual circumstances, and under the influence of which factors remain unclear. Therefore, this study aims to clarify the process leading mothers of one-to two-month-old infants to seek help from nursing professional. It is thought that increasing mothers' intentions to seek help from nursing professional when their daily parenting anxieties or worries are small-before they begin to feel like major troubles, worries, or problems-in other words, increasing their capacity for help-seeking, will prevent the exacerbation of parenting anxieties or parenting neurosis later on, thereby preventing suicide and abuse.

II. Research objective
This study aims to clarify the process by which primipara mothers of one-to two-month-old infants seek help from nursing professional and to contribute to the discussion of how best to make it easier for mothers to seek help.

III. Definition of terms
Help-seeking: The intention of a mother, who is willing to seek help from nursing professional when she has some kind of worry that she does not yet perceive as an extreme problem. Nursing professional: In this study, we define nursing professional as midwives, public health nurses, and nurses who are involved in maternal support at the preventive stages before any medical diagnosis or intervention is required.

Research design
The research design of this study was a qualitative, inductive, exploratory study.

Research participants
Research participants were 10 primipara mothers of one-to two-month-old infants.

Survey period
The survey period was from September 2013 to January 2014.

Data collection method
Interviews included questions about any concerns or troubling experiences concerning parenting after discharge from the hospital, who they considered getting advice from at those times, whether they demonstrated help-seeking behaviors toward nursing professional and the barriers encountered at those times, feelings about receiving further help and the helpers' attitude, and whether they would seek help from nursing professional if they wanted advice on something again in the future.
Participants were asked to provide their basic attributes (age, employment, pregnancies, deliveries, postpartum course, their baby' s health, whether they returned to their parents' home, etc.) through a form.
We held discussions and decided on the date and time to interview participants from a core regional hospital who signed the consent form after receiving written and oral explanations about the purpose of the study, the freedom to discontinue study participation, and confidentiality about their personal information during the onemonth health checkup of their infant. Semi-structured interviews following the aforementioned interview questions were administered after the one-month check-up, on a day that was convenient for the participant, either at their home or a private room in the hospital. One interview, lasting 30 to 60 minutes, was conducted with each participant. Interview audio was recorded with the participant' s consent. To make sure that there was no subject and researcher bis, the interviewer was not involved in any part of the participants' pregnancy, childbirth, and puerperal course, and had no prior relationship with the participants. The researcher had experience in providing puerperal care as a midwife, was affiliated with the Japanese Society of M-GTA and had received training to conduct the interview and analysis.

Ethical considerations
This study was conducted after passing an epidemiology ethics review by the Gunma University School of Medicine (confirmation no. 24-37) and receiving approval from the ethics committee of the facility collaborating on the study.

Analysis method
Kinoshita' s Modified Grounded Theory Approach (M-GTA) 30 was used for data analysis. M-GTA, which finds its origins in the Grounded Theory Approach (GTA) proposed by Glaser and Straus in the 1960s, is a research method used to generate independent theories from close analysis of data. M-GTA is suited to research studying processes or in the human services field, pertaining to social interaction in which people communicate directly ─ ─ The Process by which Mothers of One-to Two-month-old Infants Seek Help from Nursing Professional with one another. This study pertains to the process from developing troubles or concerns during parenting after discharge from the hospital to reaching the decision to get help from nursing professional and the various experiences and feelings affecting this process in primipara mothers with one-to two-month-old infants. Analysis using M-GTA was further judged to be appropriate because the process of seeking help from nursing professional is thought to develop through social interaction with nurses and other supporters.

1) Analysis procedure
Semi-structured interviews were conducted, and transcripts were generated from the data collected. Analysis focused on "primipara mothers of one-to twomonth-old infants" and the analysis theme was "what kinds of experiences and thoughts lead mothers of oneto two-month-old infants to seek help from nursing professional when they develop concerns or troubles regarding their daily parenting.

Ensuring fidelity and validity
All stages-from generating the first concept to setting the analysis theme, the process of generating categories from concepts, and creating the results diagram and storyline-were supervised by three qualitative researchers of maternal nursing and midwifery. Concepts and categories changed as analysis progressed and when reviewing them, researchers always returned to the data and repeatedly revised the analysis process. To avoid the risk of the researcher arbitrarily biasing concept interpretation during their analysis, analyses including counter examples were carefully performed under supervision and with efforts to ensure data fidelity and validity. (Table 1) Subjects were 10 mothers between the ages of 28 and 43 years (35.6 ± 4.7 years) ( Table 1). Interview duration ranged from 38 to 80 minutes (56 ± 15 minutes). As all 10 participants discussed help-seeking during parenting, all 10 participants became analysis subjects. As we were unable to find a new concept after the analysis of eight participants, we confirmed the theoretical saturation 30 after analyzing two more participants.

Analysis results
The process by which mothers of one-to twomonth-old infants seek help from nursing professional comprised one core category, six categories, and 21 concepts (Table 2). Below, the core category will be indicated with《 》 , categories with [ ], and concepts with ＜ ＞. The results diagram was created with consideration for the process over time and interactions between concepts, categories, and the core category ( Fig. 1). A summary of all analysis results and their structure was further described using a written storyline.
1 ) Storyline of the process by which mothers of one-to two-month-old infants seek help from nursing professional The process by which primipara mothers of one-to two-month-old infants seek help from nursing professional begins with ＜trivial concerns about their own child that arise regularly＞ during parenting and ultimately leads to ＜the idea and decision to seek help from nursing professional＞ as feelings about seeking help spiral back and forth ( Fig. 1). While [desperately parenting, with their only priority being caring for their child], mothers felt [hesitation toward seeking help from nursing professional for trivial worries] and developed [persistent anxiety because they could not solve these problems through their own methods] such as seeking advice from easily available resources like the internet, family, or friends. While going back and forth between these, they ultimately fell into a《cycle amplifying their parenting anxiety》 . However, mothers reached ＜the idea and decision to seek help from nursing professional＞ without hesitation when they ＜felt their child' s health or life was in danger＞. Furthermore, [disappointment in the response of nursing professional] due to the cut-anddried and inconsiderate response of nursing professional inhibited the help-seeking process, and magnified the [hesitation toward seeking help from nursing professional for trivial worries] and brought mothers back to the 《cycle of amplifying parenting anxiety》 . Conversely, [satisfaction with the response from nursing professional] and [affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers] enhanced the help-seeking process. Specifically, [satisfaction with the response from nursing professional] helped reduce [hesitation toward seeking help from nursing professional for trivial worries] and was important in turning mothers from the《cycle of amplifying parenting anxiety》 to＜the idea and decision to seek help from nursing professional＞.
2 ) Concepts comprising the process by which mothers of one-to two-month-old infants seek help from nursing professional (1) The cycle amplifying parenting anxiety Mothers of one-to two-month-old infants were parenting while being faced with ＜trivial concerns about their own child that arise regularly＞ but which were not significant problems that would threaten the child' s life or health, such as the child crying, feeling that they were not producing enough breast milk, or concern about their child' s every move. These trivial concerns were ＜concerns amplified by even trivial, everyday things when it comes to their child＞. Further, ＜anxiety about their own child-rearing amplified by comparison to other mothers and children＞ arose through interactions with other mothers. At the same time, mothers were [desperately parenting, with their only priority being caring for their child] while feeling ＜anxiety, amplified by feeling backed into a corner by putting their all into parenting＞, so much so that they did not have time even to care for themselves, and were ＜at an impasse due to their living alone with their child and thus only giving in a one-sided way, without recognition＞ because one-to two-monthold children respond only minimally to their mother' s care. While [desperately parenting, with their only priority being caring for their child], mothers tried to cope by consulting first with easily available resources such as the  Fig. 1 The process by which mothers of one-to two-month-old infants seek help from nursing professional ─ ─ The Process by which Mothers of One-to Two-month-old Infants Seek Help from Nursing Professional Table 2 Concepts and definitions of the process by which mothers of one-to two-month-old infants seek help from nursing professional

Core category Category Concept Definition
Trivial concerns about their own child that arise regularly While they are not major problems, trivial concerns about their child arise regularly.
Cycle amplifying their parenting anxiety Desperately parenting, with their only priority being caring for their child Concerns amplified by even trivial, everyday things when it comes to their child Even for trivial matters, their concerns increase when they are about their child.
Anxiety about their own child-rearing amplified by comparison to other mothers and children They witness other mothers' situations and coping methods and feel they must do the same, but feel distress because they are not fully convinced.
At an impasse due to their living alone with their child and thus only giving in a onesided way, without recognition While living alone with their child, they feel they are at an impasse because they provide for their child in a one-sided way, without recognition.
Anxiety, amplified by feeling backed into a corner by putting their all into parenting After their release from the hospital, there are many things they do not know as they begin their life with their child for the first time and are unable to do anything else, including care for themselves, making them feel they are backed into a corner because they dedicated themselves fully to parenting.
Persistent anxiety because they could not solve these problems through their own methods The Internet has too much information and they do not know what is true The internet has excess information and they are unable to solve their problems because they do not know the authenticity of the information they find.
Not convinced by their mother' s advice, which is based on outdated parenting methods They are not convinced by their mother' s advice because her generation and parenting methods are different.
Cannot depend on their husband as it is his first time parenting, too Even if their husband is present, they cannot depend on him because it is his first time parenting too.
Cannot be reassured by their friends' stories because they do not know if they are applicable to themselves They cannot be reassured by stories from more experienced mothers or friends because they do not know whether such stories are applicable to their own situation.
Hesitation toward seeking to get help from nursing professional for trivial worries Cannot judge whether it' s best to consult nursing professional for trivial concerns They hesitate because they do not know whether it is best to consult with nursing professional for a trivial concern that does not warrant a trip to the hospital.
Worry about responsiveness if they do choose to get help for a trivial concern They worry that even if they consult with nursing professional about a trivial concern, they might be considered a nuisance or might not be sincerely listened to.
Disappointment in the response of nursing professional Disappointment in seemingly cold, derivative responses They are disappointed that when they did seek help, they were given a seemingly cold, derivative response from the nursing professional rather than having their concern or anxiety carefully addressed.
Disappointment in responses inconsiderate to the mother and child They are disappointed that when they did seek help, they were given a response that was inconsiderate of their anxieties and their child' s situation.

Disappointment in one-sided instructions or suggestions
They are disappointed that the nursing professional gave them one-sided instructions or suggestions without carefully addressing their concerns and anxieties.
Satisfaction with the response of nursing professional A sense of relief because of an environment in which they can speak freely The experience of gaining a sense of relief because of being able to speak freely to an expert (nursing professional).
Trust in interactions in which their current anxieties will be carefully addressed The experience of gaining trust and reassurance in nursing professional because the nursing professional warmly listened to even their trivial concerns.
Being convinced by the advice offered by an expert (nursing professional) The experience of being convinced by advice from nursing professional who has expert knowledge.
Affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers Reduced reluctance from hearing typical experiences of other mothers They feel peace of mind from witnessing friends and other people have experiences similar to their own.
Reassurance from sympathizing with the stories of other mothers that were similar to their own They feel less reluctant about seeking help because of hearing positive feedback about expert help from friends.

Feel their child' s health or life is in danger
The state of feeling that their child' s health or life is in danger.
The idea and decision to seek help from nursing professional They have the idea and make the decision to seek help from nursing professional about a parenting worry or trouble.
Internet, family, and friends, but felt that ＜the Internet has too much information and they do not know what is true＞. Even when consulting with family, they felt that they were ＜not convinced by their mother' s advice, which is based on outdated parenting methods＞ and they ＜cannot depend on their husband as it is his first time parenting, too＞. When seeking advice from friends, they ＜cannot be reassured by their friends' stories because they do not know if they are applicable to them-selves＞ and thus had [persistent anxiety because they cannot solve their problems through their own methods]. At the same time, mothers anxiously felt that they ＜cannot judge whether it' s best to consult nursing professional for trivial concerns＞ and ＜worry about responsiveness if they do seek help for a trivial concern＞, including concern about the nursing professional' s reaction, for example whether they might be considered a nuisance, or whether they would be honestly listened to, and thus felt [hesitation toward seeking help from nursing professional for trivial worries]. Mothers bounced back and forth between [hesitation toward seeking help from nursing professional for trivial worries] and [persistent anxiety because they cannot solve their problems through their own methods] before returning to [desperately parenting, with their only priority being caring for their child]. These steps formed the 《cycle amplifying parenting anxiety》 , which magnified parenting anxiety more and more. However, the mothers reached ＜the idea and decision to seek help from nursing professional＞ without hesitation when they ＜felt their child' s health or life was in danger＞, such as intense skin redness, vomiting, or the child not waking up until the morning.
(2) Factors influencing the help-seeking process Mothers reached ＜the idea and decision to seek help from nursing professional＞ as their feelings about seeking help spiraled back and forth. Three categories were extracted as factors influencing this help-seeking process. The first, [disappointment in the response of nursing professional], was a factor inhibiting help-seeking process. This factor includes ＜disappointment in seemingly cold, derivative responses＞ such as "I don' t know unless I actually see the child directly," ＜disappointment in responses inconsiderate to the mother and child＞ such as being made to wait a long time before receiving help, and ＜disappointment in one-sided instructions or suggestions＞. Regarding mothers who were hesitant to bring their one-to two-month-old infant to the hospital, those who had experienced this [disappointment in the response of nursing professional] felt that they did not want to get help from nursing professional if the response would once again be lacking in consideration. This [disappointment in the response of nursing professional] was an inhibiting factor to the help-seeking behavior towards nursing professional and promoted the spiraling that led to greater [hesitation toward seeking help from nursing professional for trivial worries] and brought mothers back to the《cycle of amplifying parenting anxiety》 .
Meanwhile, [satisfaction with the response from nursing professional] and [affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers] were factors promoting the help-seeking process. [Satisfaction with the response from nursing professional] included ＜a sense of relief because of an environment in which they can speak freely＞ even about trivial concerns, ＜trust in interactions in which their current anxieties will be carefully addressed＞, and＜being convinced by the advice offered by an expert (nursing professional)＞ that could not be achieved through advice from family or friends. Mothers who had experienced this were less hesitant about seeking help from nursing professional.This [satisfaction with the response from nursing professional] promoted help-seeking behaviors towards nursing professional. It was an important factor that turned mothers from the 《cycle of amplifying parenting anxiety》 to ＜the idea and decision to seek help from nursing professional＞. At the same time, having [affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers] were also factors promoting the choice to get help from nursing professional. Mothers had ＜reduced reluctance from hearing typical experiences of other mothers＞, for example through word of mouth from other mothers who are in the same situation. Further, some mothers also felt ＜reassurance from sympathizing with the stories of other mothers that were similar to their own＞. Thus, experiences shared with other mothers led to the peace of mind that they were not the only ones feeling anxiety or worry.
VI. Discussion 1. The process by which mothers of one-to two-monthold infants seek help from nursing professional 1 ) The cycle amplifying parenting anxiety In this study, we identified the starting point of the help-seeking process as the ＜trivial concerns about their own child that arise regularly＞, rather than the serious concerns that mothers have. Subsequently, it was clarified that because their concerns were trivial and regular and not recognized as obvious problems, the mothers possessed a barrier, namely, [hesitate to seek help from nursing professional], or that they failed to reach a resolution after freely consulting the Internet or their own mother and finally fell into the《cycle of amplifying parenting anxiety》 . Although mothers have parenting anxiety, it is important to empower them with the strength to seek help from nursing professional before their mental health deteriorates from not being able to break free of this 《cycle of amplifying parenting anxiety》 . The process by which primipara mothers of one-to two-month-old infants seek help from nursing professional began with ＜trivial concerns about their own child that arise regularly＞ during parenting after their discharge from the hospital. These concerns ranged from those commonly seen as parenting anxieties in mothers during this period, 31,32 such as feeling that they were not producing enough breast milk or dealing with their child' s crying, to every little thing about their child, such as how they sleep and cry, their facial expressions, their skin condition, to how to properly use a baby carrier or when to take their child out and about. Nohara and Nakata found that mothers' parenting concerns peaked at one month postpartum, with as many as 75％ of mothers reporting concerns about parenting. This rate had significantly decreased at six months and twelve months. 33 This is consistent with the present study in which all participants had many specific examples to offer for this concept. Although these concerns do not include extreme problems that threaten their child' s life or health, they comprise numerous trivial concerns about their child arising in day-to-day parenting. While they may not be serious when considered individually, the accumulation and amplification of trivial concerns over time is likely to lead to poor mental health in mothers later on. The《cycle amplifying parenting anxiety》 was the one core category generated for the process by which mothers seek help from nursing professional. This core category comprises the three categories of [desperately parenting, with their only priority being caring for their child], [persistent anxiety because they cannot solve problems through their own methods], and [hesitation toward seeking help from nursing professional for trivial worries]. Mothers' parenting anxiety is thought to amplify as their thoughts and feelings about whether or not to seek help for parenting anxieties and worries bounce back and forth between these three categories. In this cycle, parenting anxiety accumulates and is amplified, resulting in concerns that may lead to postpartum depression or parenting neurosis. Further, concerning [desperately parenting, with their only priority being caring for their child], mothers had a variety of trivial concerns while carrying out the everyday duties of parenting for the first time, but even so, they cared excessively for their children, so much so that they set aside concern for themselves. Motomura et al. noted that mothers with minimal interest in their children were less likely to exhibit signs of parenting anxiety. 34 Thus, [desperately parenting, with their only priority being caring for their child] was thought to arise precisely because the mothers were so deeply concerned about their babies. Parenting anxiety does not refer to temporary or momentary doubts or concerns during parenting, but is defined as a state of persistent, accumulated anxiety. 35 Parenting anxiety is something that all mothers have to some extent. Thus, the issue is not having anxiety, but allowing that anxiety to build up to a pathological level resulting in the loss of normal judgment. 34 Although mothers at the stage of trivial concerns do not yet require special mental health intervention, there is concern that this parenting anxiety will continue to amplify and accumulate, leading to poor mental health in the future. Thus, preventive involvement at this stage is essential. Concerning [persistent anxiety because they cannot solve problems through their own methods], mothers first attempted to cope by seeking advice through readily accessible methods such as the Internet or family members, but felt that ＜the Internet has too much information and they do not know what is true＞. Even when they asked family members, they were ＜not convinced by their mother' s advice that was based on outdated parenting methods＞, and felt that they＜cannot depend on their husband as it' s his first time, too＞. The final survey of the Healthy Parents and Children 21 campaign also found that the frequency of mothers consulting "the Internet" rose drastically from 0.8％ to 9.6％ during the campaign. 3 Thus, it is becoming apparent that although the number of mothers who use a quick online search first is increasing, they ultimately cannot solve their problems this way as they are unsure of what is correct due to the excess amount of information. Concerning advice from their own mothers, they felt they were ＜not convinced by their mother' s advice that was based on outdated parenting methods＞. Further, we cannot assume that mothers are getting enough support simply because they are returning to their parents' home after childbirth. As discussed by Kobayashi,36 issues involving generational differences in perspectives on parenting and excessive involvement of their own mothers may arise when new mothers return to their parents' home after giving birth. Their own mother' s meddling and advice that differs from what they themselves were instructed can further increase parenting anxiety. Thus, there is a need to carefully evaluate the types of anxieties mothers are facing, beginning with their relationships with their own mothers. With regard to seeking advice from friends, mothers felt they ＜cannot be reassured by their friends' stories because they do not know if these are applicable to them-selves＞. While advice from other mothers with comparable experiences did give them peace of mind, by giving them ＜reassurance resulting from sympathizing with the stories of other mothers that were similar to their own＞, dissimilar stories did not reassure them. Peer support from other mothers has been reported to free mothers from feelings of isolation and increase their feeling of self-approval. 35 The present study found that peer support is also a factor that encourages mothers to seek help from nursing professional. It is surmised that other mothers' stories can either become fuel for reassurance or anxiety, depending on their content. It is therefore necessary to establish settings for interaction and information exchange in which other mothers become an effective source of support.
Concerning their [hesitation toward seeking help from nursing professional for trivial worries], mothers ＜ cannot judge whether it is best to consult nursing professional for trivial concerns＞ that cause them anxiety during their day-to-day parenting, and they ＜worry about responsiveness if they seek help for a trivial concern＞ including concern that they might be considered a nuisance, or might not be honestly listened to even if they did seek advice from nursing professional for a trivial concern. This was consistent with the help-seeking barrier "reservation" and its content proposed by Yuasa et al., 18 as well as with the help-seeking barrier "concern about responsiveness" -pertaining to whether the helper would treat the problem with care, or whether they would offer counseling no matter how small the problem -from a quantitative study conducted by the author. 28 Nursing professional are inclined to instruct patients to "contact us if you have any concerns," but mothers often hesitate or cannot judge whether it is best to seek help for such trivial worries. Consequently, there is a need to consider how best to help reduce this barrier. On the other hand, mothers decide ＜to seek help from nursing professional＞ without hesitation when they ＜feel their child' s health or life is in danger＞. This is consistent with the findings of past studies that the extent and seriousness of the worry or stress have an impact on help-seeking. [19][20][21][22] However, mothers in the puerperal period tend to experience large fluctuations in hormonal dynamics and are prone to poor mental health. Hence, it is concerning when the mothers perceive their worries as serious, as their poor mental health could lead them to worst-case scenarios such as infant abuse and maternal suicide. Therefore, to support their mental health, it is important for mothers to seek help from nursing professional from the stages of having trivial concerns that occur regularly and resolve them before they become serious.
2 ) Factors influencing the process by which mothers seek help from nursing professional The factor that considerably affected the mothers' help-seeking behavior towards nursing professional was their satisfaction or disappointment in the responses, where [satisfaction with the response of nursing professional] promoted the help-seeking process and was important in turning mothers from the《cycle of amplifying parenting anxiety》 to ＜the idea and decision to seek help form nursing professional＞. Mothers sought help from nursing professional without hesitation if they deemed the problem as serious. However, they tended to feel [hesitation toward seeking help from nursing professional for trivial worries] because these occurred as part of routine childcare, and constituted a barrier for them to seek help from nursing professional. However, the sense of relief that mothers felt from being in an environment where they can freely speak about trivial concerns, and trust nursing professional who would help with any worries or concerns have contributed to diminishing this barrier. As barriers diminish, mothers will be able to seek help from nursing professional before becoming excessively anxious from going back and forth in the《cycle of amplifying parenting anxiety》 and experiencing poor mental state. Further, mothers felt [persistent anxiety because they cannot solve problems through their own methods] even when they sought advice from easy sources such as the Internet, family, or friends, but were able to achieve peace of mind through ＜being convinced by the advice offered by an expert (nursing professional)＞. Kusakabe found that mothers seek different kinds of support from different sources. 36 A study of mothers of preschoolers by Kasahara 19 reported that help-seeking intention was strengthened when the source was recognized by the parent as possessing advising expertise. The experience of seeking advice and approval from nursing professional about an anxiety or concern related to their child' s health and being convinced by the advice provided seems to increase a mother' s capacity for help-seeking. At the same time, the experience of [disappointment in the response of nursing professional] further amplified the mothers' [hesitation toward seeking help from nursing professional for trivial worries] and inhibited them from breaking free of the《cycle amplifying parenting anxiety》 in seeking help from nursing professional. Considering the major impact nursing professional' responses have on a mother' s help-seeking process, interactions with midwives and public health nurses are considered integral as these nursing professionals have the most opportunities to interact with pregnant women and new mothers. When parenting, it is not enough for mothers to learn to seek help. Rather, they should keep improving their ability to seek help from nursing professional as needed. In this study, the experiences of mothers in being satisfied or disappointed with the response of nursing professional significantly affected their help-seeking process. The involvement of nursing professional is important for a mother who was able to reach the help-seeking process to continue seeking help repeatedly in the future without falling into the cycle of amplifying parenting anxiety. We identified a spiral process of going back and forth that ends with mothers seeking help from nursing professional. However, to do so repeatedly over the course of parenting, nursing professional must be involved in transforming this into a smooth process that results in help-seeking behavior. We identified that the starting point of the help-seeking process for primipara mothers with 1-to 2-month-old infants as the ＜trivial concerns about their child that arise regularly＞ during childcare after being discharged. We believe that it is important to offer support that would nurture the ability to respond to any worries or insecurities about childcare in the future and learn how to seek help at this stage of parenting. We believe that such support will enable the mothers to take appropriate measures in future childcare and prevent them from experiencing poor mental health state as a result of excessive parenting anxiety. They will also be better equipped to rely on nursing professional in the future.
2. How best to support mothers of one-to two-monthold infants in seeking help from nursing professional Research has shown that cases of death by child abuse are most common in children under one year old, with children under four months old accounting for 72.7％ of such cases. 4 Research has also shown that maternal suicide occurs most frequently at four months postpartum. 2 While this study revealed the process by which primipara mothers one to two months postpartum seek help from nursing professional, it is essential to consider how best to assist mothers in their help-seeking in the early postpartum stages to prevent postpartum mental health issues from becoming more serious and potentially leading to suicide or infant abuse. 1 ) Support that lowers barriers that prevent mothers from seeking help from nursing professional This study demonstrated that interactions with nurses is an essential factor influencing the process by which mothers seek help from nursing professional. Thus, the expert midwives, public health nurses, and other nursing professional who stay by a woman' s side and offer continuous care from pregnancy to delivery to parenting can be said to play an integral role. There is concern that mothers who have experienced [disappointment in the response of nursing professional], including ＜seemingly cold, derivative responses＞, ＜ responses inconsiderate to the mother and child＞, and ＜ one-sided instructions or suggestions＞, will have had their self-esteem damaged through such responses and, as a result, give up on or refuse to seek help. Further, mothers are trying more and more to cope on their own by seeking advice on the Internet or from friends but are ultimately unable to solve their problems, which amplifies their parenting anxiety and may lead to postpartum depression or parenting neurosis. Thus, it is first necessary that nursing professional ensure their interactions with mothers are warm and considerate to avoid such disappointing experiences. At the same time, [satisfaction with the response of nursing professional] promoted the help-seeking process. It is essential that support offers an ＜environment in which mothers can speak freely＞ even about trivial concerns or worries, interactions in which＜their current anxieties are carefully addressed＞, and expert approval and advice based on evidence. It is thought that giving mothers a sense of relief and trust through their interactions with nursing professional will be a successful experience for them and will lead to increased self-efficacy in seeking help from nursing professional. In Japan, the Comprehensive Pregnancy and Delivery Support Project was launched in 2015 to enhance seamless support from pregnancy and delivery and through the childrearing period. Even in regions, support systems have been built for pregnant women to help them from the moment they notify their pregnancy until after childbirth. In the future, hopefully, there will be enhanced seamless support from the gestational period to the childrearing period, along with maternal examinations at hospitals and support for pregnant women at the time of childbirth. Moreover, it would also be effective to provide preventive health education on postpartum mental health by using the birthing and parenting class from the gestational period and focusing on the mothers' ability to seek help. Tamaki found that 23.1％ of mothers had received education or instruction about perinatal mental health, while 76.3％ had not. 39 Thus, classes for mothers or parents, which currently teach primarily about the labor process and infant care techniques such as bathing, must go beyond this and reassure mothers that it is okay to seek help for trivial anxieties or concerns. As described above, there is a need to give mothers more experiences of success through interaction with nursing professional and to provide support that utilizes opportunities for health education beginning at pregnancy to reduce barriers to help-seeking.
2 ) Establishing a readily available support environment for mothers Along with reducing barriers to help-seeking, it is vital to assist mothers in seeking help from nursing professional by establishing an environment in which help is readily available even if barriers arise. Although mothers experienced [hesitation toward seeking help from nursing professional for trivial worries] as a barrier to help-seeking, some mothers mentioned in their interviews that they chose to get help for other parenting concerns without hesitation while using outpatient lactation services. Using outpatient lactation services as an opportunity to casually talk with nursing professional about trivial, everyday concerns unrelated to breasts or suckling led to [satisfaction with the response of nursing professional]. As such, encouraging mothers to visit the hospital for outpatient lactation services, even if they do not have any issues with their breasts, may also be helpful. The importance of early postpartum checkups (e.g., two weeks postpartum or one month postpartum) in preventing the abuse of newborns and postpartum depression has been identified in recent years. Although financial support for two postpartum checkups was issued as policy beginning in 2017, only 15.0％ of municipalities perform these postpartum checkups. 40 Performing two-week postpartum checkups, which aim not only to evaluate physical recovery but also to assess maternal mental health and offer parenting support, are also considered a useful opportunity to encourage maternal help-seeking. Many studies have reported that mothers who have past experience with seeking advice are more likely to have help-seeking behaviors [17][18][19]24,26 and that high satisfaction with regard to advising increases feelings of wanting to seek advice again. These findings suggest that increasing experiences of being able to casually seek advice and achieve satisfying interactions with nursing professional through outpatient services or health checkups lead to increased help-seeking capacity in mothers. Modern-day mothers are becoming more isolated and are parenting on their own more often. It is necessary that nursing professional intentionally provide settings for mothers to casually seek help, unlike in the past when Japan' s childrearing environment made such settings readily available. Parenting classes facilitated by nursing professional and other group education settings are an effective means of support for maternal help-seeking as they allow for effective peer support, receiving expert advice when needed, and, in certain situations, connection with more specialized interventions.

VII. Limitations and future challenges
This study elucidated the help-seeking process of mothers of one-to two-month-old infants in the puerperal period from nursing professional. With this becoming clearer, nursing practices that focus on the mothers' abilities to seek help from nursing professional would help prevent problems that arise from the poor mental health state of mothers, such as postpartum depression, suicide, and infant abuse. However, the analysis performed in this study has the methodological limitation of being applicable only to primipara mothers of one-to two-month-old infants. It is, therefore, essential to also study differences in the process by which mothers seek help from nursing professional in different postpartum stages. There is also a need for further research addressing differences in maternal help-seeking for the different types of worry or concern, for example, whether it pertains to the child or the mother herself.

VIII. Conclusion
The process by which primipara mothers of one-to two-month-old infants seek help from nursing professional began with feeling ＜trivial concerns about their own child that arise regularly＞ during parenting. Parents fall into a《cycle amplifying parenting anxiety》 and this process was impacted by [disappointment in the response of nursing professional], [satisfaction with the response of nursing professional], and an [affirmative attitude toward help-seeking and reassurance from hearing typical experiences of other mothers]. The process ultimately impacted the mothers' ＜idea and decision to seek help from nursing professional＞ while their feelings about seeking help spiraled back and forth. These results suggested that both reducing barriers to help-seeking and establishing an environment in which support is readily available even if barriers arise are important ways to assist mothers in seeking help from nursing professional.