"Mommy Wars." It even has a name. This refers to the conflict between mothers working only at home versus mothers with outside employment. As the story goes, each group looks down on the other – the at-home mom decrying the lack of caring for the family of the employed, and the employed smirking at the intellectual plateau and lack of earnings of the home mom.

I think the much bigger Mommy War is inside the individual woman, however. Am I doing right by my family? Am I fulfilling my potential? Am I contributing enough to the family income? Am I going brain dead? Am I devoting enough time to raising my children? Should I be saving the world as I dreamed in college?

As a pediatrician, I see the emotional turmoil, ambivalence, and stress of mothers contributing, at its worst, to child behavior problems, maternal depression, and marital problems and, in its mildest form, to exhausted mothers not having much fun.

How can we, as pediatricians, support families in dealing with this issue of our time? While parents and families have to decide for themselves, we have an opportunity to help families clarify their values for parenting and family life.

It turns out that the best parenting occurs when a woman is satisfied with her role – whether at home full time or working outside – and with her marriage. While not all mothers have any choice about working (or being married), being satisfied can be promoted by mindful consideration and acceptance of the choices they do make. You can initiate even a brief pros and cons discussion about their family choices – a sort of problem solving counseling – to assist in the evolution of more satisfaction with "what is."

You can point out that there are many benefits to children who have working mothers. The added income can provide important resources such as educational opportunities, sports, and the arts. Having a mother who studies, collaborates, or creates value through her work provides a natural role model for the child’s future success in a career, as well as in being a parent. This is especially valuable for girls who may have the same dilemma about work in the future, but also for boys who may have greater respect for women in the workplace as well as in their future homes. Children may see more clearly the value in getting an education, and may have a better appreciation for the hard work it takes to get there when they observe their mothers in this role. Resentment is not likely as long as the mother shows affection and makes sure she knows them well.

Often a mother’s main concern, whether working outside the home or not, is whether she is giving her children enough love and attention. One fact I pass along is that studies show that the average at-home mother spends 20 minutes per day of one-on-one time playing with her child. I recommend moms spend 15 minutes of Special Time every day with each child, following their lead in play. This is like gold to the parent-child relationship, whether it is problematic or not. Having some fun with your child every day also gives some payback for this hard work. This guaranteed time makes the child feel loved, reduces behavior problems, and assuages some of the mother’s guilt so that she can keep to needed childrearing limits.

After residency, the most stressful part of my medical career was not medical; it was worrying about child care. Each (of the many) child care providers we employed had strengths and weaknesses not apparent in the hiring process, but in this case the impact was on our children. Many families have unreasonable fears that limit their child care choices, greatly affecting their overall family functioning. They may feel that a child care center is safer, based on old news stories of rare nanny abuse or abduction, when a well-chosen live-in or at least home-based caregiver could greatly ease family stress (and reduce viral infections to boot). By asking about how they are making child care decisions, you can give perspective on these relative risks.

Another question, stated tearfully, is whether her baby will "love her the best" if he goes to day care. The enthusiastic embrace the child has for the child care provider is regarded with mixed feelings by many mothers. You can reassure them that, even for infants, blood is thicker than water, and that the primary bond with mom will prevail! I emphasize that it is not possible to have an excess of people who love you!

Even in families with supportive husbands who endorse an equal role in parenting, mothers have been noted to do 75% of the maintenance of the family and house. This role discrepancy can be accepted or it can be a source of significant discontent. Asking "How do you [and your partner, husband, mother-in-law, etc.] work as a team?" can open the subject for discussion, if needed. Helping mothers negotiate tasks with whomever the other adults may be can ease tensions that could adversely affect the children. I recommend weekly family meetings to keep roles and responsibilities on the table for negotiation, making a trade of tasks as needed.

I remember being amazed by a dynamic friend who had children and a career that involved many presentations at night and on weekends. I asked her how she did it. She replied without hesitation, "I don’t sleep." Lack of sleep is epidemic in the United States, but it has extra potential impact on mothers. It can lead to irritability, depression, lack of sexual interest, inefficiency in every setting, and even car crashes. Asking how much sleep the parents are getting may not seem like a pediatric question, but it can reveal unnecessary stresses.

One thing you may discover is that the mother is up cleaning the house at 11 p.m. I hate Martha Stewart. What real mother can make little costumes for her candlesticks, which Martha advertises as "Easy Decorating for the Holidays"? Yet some women have trouble lowering their standards for "housekeeping" to a feasible level when they have children, much less children and outside employment. You can help provide the perspective that dust kittens in the living room and an occasional frozen dinner are a small price to pay for having family fun and maintaining sanity.

Did you hear about the father of two young girls who was told he had 1 year to live after his cancer diagnosis? He thoughtfully took on the project of aligning eight of his friends with different personal strengths to be godparents for his children, knowing that he would not be there. It struck me that this is an excellent idea for all of us. We can’t be everything to our children, whether we are home full time or working out of the house, but we can use our good judgment to arrange supplementary positive relationships for them. Asking a good friend to sign up as godmother tends to bring a commitment and involvement as well as support for the mother herself. If a family does not have friends for this role, it is time to make some. A religious community is often a good place to start. Finding a few people with whom you can exchange favors, borrow the jumper cables, or stand at the bus stop, turns out to be the best and most lasting way to way establish social support.

I was once in a work group on child development that included leaders in the field of relationship theory. One professor in his 60s revealed that his best friends now were the parents of his children’s preschool friends. Keeping up such a support system for parents of friends and relatives is a key protective factor, not only to prevent adult depression, but for child behavior outcomes as well. Often, work outside the home provides extra social support through colleagues and friends, but it is not inevitable and needs to be fostered. Mothers may be encouraged to have a "mother’s night out" and one for dad, also, to maintain this without feeling guilty. In fact, giving the other parent a chance for a regular "Dad’s night with the kids" is a gift. New adventures, play, a deepened relationship, and more confidence as a parent are wonderful side effects of mom’s absence and vice versa.

Many mothers are caught up in their present dilemma and may not see these two things:

• Part-time work may be a compromise they could negotiate, if feasible financially.

• The 20 or so years of staying home with children still allow for another phase of life in which mothers could accomplish their career goals.

After our discussions, a number of the mothers of my patients have chosen to stop working for a period of time, and they, their children, and their husbands all have benefitted from the decision.

The most important thing affecting your ability to support working mothers may be your own situation! It may be harder to be compassionate with the whining of mothers of your patients if you are giving up precious family time to practice medicine. Their pain may cause enough conflict in you to interfere with your ability to support them. It is important to examine your own thinking, ambivalence, satisfaction, or pain in the choices you have made so that you can respond objectively to theirs.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. She has a husband, two biological children, and two stepchildren. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.

Mommy Wars – Supporting working mothers