Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant

The impact of neonatal posthemorrhagic hydrocephalus of prematurity on family function at preschool age

AIMS

To determine the impact on families (IOF) of former preterm infants (gestational age < 32 weeks) after posthemorrhagic hydrocephalus requiring shunt (PHH-S), and to identify risk factors of family dysfunction.

STUDY DESIGN

38 preterm infants with PHH-S were matched for gestational age, birthweight, and gender with preterm infants with normal cranial ultrasonography. IOF questionnaire was administered at 5.7 ± 2 years (higher IOF score indicates worse impact).

RESULTS

Families of PHH-S children exhibited significantly worse IOF compared to controls in financial (9.2 ± 2.2 vs 5.9 ± 1.4), family-personal (26.6 ± 5.2 vs 20.2 ± 2.8), and disruptive social (21.4 ± 4.9 vs 16.7 ± 3.1) domains (P < 0.001). Multivariate regression incorporating neonatal risk factors revealed an independent effect of parenchymal brain involvement (β:0.4, P:0.002) and neonatal seizures (β:0.3, p:0.007) on total IOF. Neurosensory morbidity was significantly higher in the PHH-S group, including cerebral palsy (81.6%), epilepsy (47.4%), problems with vision (63.2%), feeding (39.5%) and hearing (18.4%), chronic health problems (44.7%) and hospital admissions in the last 6 months (44.7%). Worse IOF scores of PHH-S families were associated with socioeconomic status and neurodevelopmental morbidities: cerebral palsy severity, feeding problems, number of neurosurgeries, low cognitive, personal-social, and adaptive scores (P < 0.05). Multivariate analysis indicated an independent contribution from cerebral palsy severity (β:0.5, p:0.002) and socioeconomic status (β:-0.4, P: 0.01).

CONCLUSIONS

Families of preterm children after PHH-S exhibit significantly worse IOF scores compared to families of preterm peers. Worse IOF is associated with severe hemorrhage, neurodevelopmental morbidities and socioeconomic status. A family centered intervention is warranted after PHH-S.

Maternal Distress in the Neonatal Intensive Care Unit: A Concept Analysis

BACKGROUND

The neonatal intensive care unit (NICU) can cause significant psychological distress in a mother. There is no common definition of maternal distress in the NICU currently in use.

PURPOSE

To develop a clear conceptual understanding of maternal distress in the NICU using conceptual definitions and empirical findings.

METHODS/SEARCH STRATEGY

A literature search was conducted using EBSCOhost, MEDLINE, CINAHL, PsychINFO, and Google Scholar. The concept analysis was guided by Walker and Avant's (2011) guide.

FINDINGS/RESULTS

Maternal distress in the NICU consists of a combination of depressive, anxiety, trauma, and posttraumatic stress symptoms. The symptoms occur together on a spectrum and present differently in each mother. The antecedents to maternal distress are a NICU hospitalization and a perceived interruption to the transition to motherhood. Consequences of maternal distress in the NICU are issues with developing a healthy maternal-infant bond, adverse infant development, and decreased maternal quality of life.

IMPLICATIONS FOR PRACTICE

A complete understanding of maternal distress in the NICU will lead to increased awareness of adverse mental health states in this population.

IMPLICATIONS FOR RESEARCH

Identification of mothers at risk for maternal distress in the NICU, as well as the identification of antecedents and consequences related to the mother and the infant from maternal distress in the NICU. Using a single, clear definition of maternal distress in the NICU population will lead to a more cohesive body of literature.

A Prospective Study of Parent Health-Related Quality of Life before and after Discharge from the Neonatal Intensive Care Unit

OBJECTIVE

To determine how infant illness and parent demographics are associated with parent health-related quality of life (HRQL) during and 3 months after hospitalization in the neonatal intensive care unit (NICU). We hypothesized that parents of extremely preterm infants would report lower NICU HRQL than other parents, and that all parents would report improved HRQL after discharge.

STUDY DESIGN

This prospective study of parent-infant dyads admitted to a level IV NICU for ≥14 days from 2016 to 2017 measured parent HRQL before and 3 months after discharge using the Pediatric Quality of Life Inventory Family Impact Module. Multivariable regression was used to identify risk factors associated with HRQL differences during hospitalization and after discharge.

RESULTS

Of the 194 dyads, 167 (86%) completed the study (24% extremely preterm; 53% moderate to late preterm; 22% term). During the NICU hospitalization, parents of extremely preterm infants reported lower adjusted HRQL (-7 points; P = .013) than other parents. After discharge, parents of extremely preterm infants reported higher HRQL compared with their NICU score (+10 points; P = .001). Tracheostomy (-13; P = .006), home oxygen (-6; P = .022), and readmission (-5; P = .037) were associated with lower parent HRQL 3 months after discharge, adjusted for NICU HRQL score.

CONCLUSIONS

Parents of extremely preterm infants experienced a greater negative impact on HRQL during the NICU hospitalization and more improvement after discharge than parents of other infants hospitalized in the NICU. Complex home care was associated with lower parent HRQL after discharge. The potential benefit of home discharge should be balanced against the potential negative impact of complex home care.

Longitudinal Study of music Therapy's Effectiveness for Premature infants and their caregivers (LongSTEP): protocol for an international randomised trial

INTRODUCTION

Preterm birth has major medical, psychological and socioeconomic consequences worldwide. Music therapy (MT) has positive effects on physiological measures of preterm infants and maternal anxiety, but rigorous studies including long-term follow-up are missing. Drawing on caregivers' inherent resources, this study emphasises caregiver involvement in MT to promote attuned, developmentally appropriate musical interactions that may be of mutual benefit to infant and parent. This study will determine whether MT, as delivered by a qualified music therapist during neonatal intensive care unit (NICU) hospitalisation and/or in home/municipal settings following discharge, is superior to standard care in improving bonding between primary caregivers and preterm infants, parent well-being and infant development. METHODS AND ANALYSIS: Design: international multicentre, assessor-blind, 2×2 factorial, pragmatic randomised controlled trial; informed by a completed feasibility study. Participants: 250 preterm infants and their parents. Intervention: MT focusing on parental singing specifically tailored to infant responses, will be delivered during NICU and/or during a postdischarge 6-month period. Primary outcome: changes in mother-infant bonding at 6-month corrected age (CA), as measured by the Postpartum Bonding Questionnaire. Secondary outcomes: mother-infant bonding at discharge and at 12-month CA; child development over 24 months; and parental depression, anxiety and stress, and infant rehospitalisation, all over 12 months.

ETHICS AND DISSEMINATION

The Regional Committees for Medical and Health Research Ethics approved the study (2018/994/REK Nord, 03 July 2018). Service users were involved in development of the study and will be involved in implementation and dissemination. Dissemination of findings will apply to local, national and international levels.

TRIAL REGISTRATION NUMBER

NCT03564184.

The World Health Organization ACTION-I (Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns) Trial: a multi-country, multi-centre, two-arm, parallel, double-blind, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at risk of imminent birth in the early preterm period in hospitals in low-resource countries

Background

Antenatal corticosteroids (ACS) have long been regarded as a cornerstone intervention in mitigating the adverse effects of a preterm birth. However, the safety and efficacy of ACS in hospitals in low-resource countries has not been established in an efficacy trial despite their widespread use. Findings of a large cluster-randomized trial in six low- and middle-income countries showed that efforts to scale up ACS use in low-resource settings can lead to harm. There is equipoise regarding the benefits and harms of ACS use in hospitals in low-resource countries. This randomized controlled trial aims to determine whether ACS are safe and efficacious when given to women at risk of imminent birth in the early preterm period, in hospitals in low-resource countries.

Methods/design

The trial design is a parallel, two-arm, double-blind, individually randomized, placebo-controlled trial of ACS (dexamethasone) for women at risk of imminent preterm birth. The trial will recruit 6018 women in participating hospitals across five low-resource countries (Bangladesh, India, Kenya, Nigeria and Pakistan). The primary objectives are to compare the efficacy of dexamethasone with placebo on survival of the baby and maternal infectious morbidity. The primary outcomes are: 1) neonatal death (to 28 completed days of life); 2) any baby death (any stillbirth postrandomization or neonatal death); and 3) a composite outcome to assess possible maternal bacterial infections. The trial will recruit eligible, consenting pregnant women from 26 weeks 0 days to 33 weeks 6 days gestation with confirmed live fetuses, in whom birth is planned or expected within 48 h. The intervention comprises a regimen of intramuscular dexamethasone sodium phosphate. The comparison is an identical placebo regimen (normal saline). A total of 6018 women will be recruited to detect a reduction of 15% or more in neonatal deaths in a two-sided 5% significance test with 90% power (including 10% loss to follow-up).

Discussion

Findings of this trial will guide clinicians, programme managers and policymakers on the safety and efficacy of ACS in hospitals in low-resource countries. The trial findings will inform updating of the World Health Organization’s global recommendations on ACS use.

Trial registration

ACTRN12617000476336. Registered on 31 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3488-z) contains supplementary material, which is available to authorized users.

Association of the previous history of maternal depression with post-partum depression, anxiety, and stress in the neonatal intensive care unit

BACKGROUND

A history of depression in post-partum women who have infants admitted to the neonatal intensive care unit (NICU), is associated with higher risk for anxiety and stress. These conditions, which can be harmful to neonates, may be missed if maternal mental health screening is confined to depression.

OBJECTIVE

To determine if the history of a previously diagnosed depression would be associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress) among mothers with infants in the NICU.

DESIGN

Prospective survey questionnaire-based study conducted over a period of 9 months.

SETTING

Urban inpatient hospital-based setting, serving mainly low-income population.

PARTICIPANTS

A total of 118 mothers of newborns who had been in the NICU for 7-29 days were approached for enrollment. Out of 118, 96 mothers consented to be screened and were asked to fill out the 21-item Depression Anxiety and Stress Scale-21 (DASS-21) questionnaire.

OUTCOME

Primary outcome was to determine whether the history of a previously diagnosed depression is associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress).

RESULTS

Out of the 96 subjects, 36 (37.5%) had a previous history of depression before delivery (Group A) while 60/96 (62.5%) did not (Group B) and 46/96 (48%) of the mothers were positive for either depression, anxiety, or stress. This included 22/96 (22.9%) mothers who screened positive for depression; 37/96 (38.5%) who screened positive for anxiety; and 32/96 (33.3%) who screened positive for stress. After adjusting for maternal drug abuse, birth weight and maternal gravidity, the association between a previous history of depression and current depression scores were statistically significant (p = .04), as were the associations between previous depression and current anxiety and stress scores (p = .02 and p = .003, respectively).

CONCLUSIONS AND RELEVANCE

A history of depression, documented in the antepartum medical record, identifies post-partum women who are at higher risk for anxiety and stress. Screening for depression alone may lead to missing these mental health issues.

Smartphones and Text Messaging are Associated With Higher Parent Quality of Life Scores and Enrollment in Early Intervention After NICU Discharge

The purpose of this study was to evaluate the impact of access to communication technology on caregiver quality of life, neurodevelopmental, and medical outcomes (eg, rehospitalization, emergency room visits, or surgeries) in preterm infants, and enrollment in public assistance programs. In this cross-sectional study, we surveyed families of preterm infants in a high-risk infant-follow-up clinic. We estimated associations of access to various modes of communication technology with outcomes, adjusting for sociodemographic and infant characteristics using linear and unconditional logistic regression. Access to email, text messaging, and smartphones was associated with higher quality of life scores on the Multicultural Quality of Life Index, and email and smartphone access was significantly associated with increased enrollment in early intervention. Evaluating smartphone and email access on neonatal intensive care unit discharge is important when considering enrollment in community programs and caregiver quality of life.

The Level and Sources of Stress in Mothers of Infants Admitted in Neonatal Intensive Care Unit

BACKGROUND

Hospitalization of a new-born child is stressful for parents. This study was done to determine the level and sources of stress in mothers of infants admitted in Neonatal Intensive Care Unit (NICU) and variance in stress by infant and maternal characteristics.

MATERIALS AND METHODS

Parental Stressor Scale for NICU was used as the primary outcome measure. Maternal socio-demography, maternal and infant characteristics such as gravidity, number of prenatal visits, perceived support from family members, perceived level of discomfort that the baby underwent, pregnancy and delivery complications, gestational age, sex, birth weight, length of NICU stay and ventilator support, and neonatal morbidity were also collected from maternal and infant hospital records.

RESULTS

Amongst these rural and poorly educated mothers, the appearance of the baby, sights and sounds of NICU environment were major sources of stress. Higher maternal stress was found to be associated with poor family support during pregnancy, mothers' perception of the baby's discomfort, lower birth weight of the baby, baby on ventilator, post-partum depression, and moderate to severe anxiety symptoms. Mothers who had higher levels of education and those with pregnancy complications were more stressed.

CONCLUSIONS

Before designing remediation programs for parents, local demography and the predominant NICU stressors need to be kept in mind. Possibility of screening at-risk mothers by questioning them about perception of baby's discomfort needs to be evaluated further.

"Weathering the storm:" Mothers' and fathers' experiences of parenting a preterm infant

Parenting preterm infants is a unique experience distinct from parenting full-term infants, characterized by a delayed transition to parenthood and limited caregiving opportunities. This study explored mothers' and fathers' lived experiences of parenting during infancy in the context of preterm birth. Semistructured qualitative interviews were conducted with 13 parents (6 fathers, 7 mothers) of preterm infants. Data were analyzed using interpretative phenomenological analysis. Four superordinate themes emerged: (a) An unnatural disaster: The traumatic nature of preterm birth, (b) The immediate aftermath: Disconnected and displaced, (c) Breaking the ice: Moving from frozen to melted, and (d) Aftershocks: Transitioning home. Both parents experienced preterm birth as traumatic. Similarities and differences in mothers' and fathers' experiences were identified. Preterm birth posed challenges for nurturant and social caregiving and resulted in anxiety, hypervigilance, and overprotective parenting behavior. The results highlight the need for trauma-informed care and further research developing and testing empirically based interventions.

Enfoque desde la violencia perinatal: visita del padre a su hijo prematuro durante su hospitalización

Este trabajo reflexiona sobre la participación del padre en las unidades de neonatología, comprendiendo que ser padre/madre de un recién nacido pretérmino es complejo, estresante y puede llenar de temores, ansiedad e incertidumbre. En el contexto actual, se tiende a recargar el rol de cuidado en la madre, lo que limita las oportunidades de participación del padre. El análisis se centra en las experiencias del servicio de neonatología de un hospital de Santiago de Chile, Chile, y en una revisión de la literatura sobre el papel de los padres y su participación en este contexto.

Knowledge, Family Support and Self-Reliance Capital when Caring for Low Birth Weight Babies

Introduction: Low birth weight (LBW) infants are very susceptible to illness.LBW treatment with the principle of preventing infection is very important athome. The purpose of this study was to determine the relationship betweenmaternal knowledge and family support with the prevention of infection at home.Methods: This study used a correlation design. The samples were 160 motherswho had low birth weight infants with inclusion criteria mothers give birth tobabies weighing less than 2,500 grams with ages 0-2 months. The samples wereobtained through purposive sampling. The dependent variable was the mother&#39;sability to prevent infection while the independent variable was the mother&#39;sknowledge and family support. The instruments used were questionnaires. Thisresearch analyzed using Spearman Rho.Results: The results showed that there was a strong correlation betweenknowledge and the ability to prevent infection in treating low birth weight (r =0.696; p = 0.00) and that there was a moderate correlation between familysupport and infection prevention ability when treating a low birth weight (r =0.54. p = 0.000).Conclusion: Factors of maternal knowledge about infection prevention andfamily support need to be considered in increasing the ability of mothers to carefor babies with LBW. The factor of maternal knowledge about prevention ofinfection has a strong correlation value when compared to family support factors.Further research is needed on the model of increasing maternal knowledge aboutLBW infants during home care. 

Joint observation in NICU (JOIN): study protocol of a clinical randomised controlled trial examining an early intervention during preterm care

INTRODUCTION

Preterm birth may generate significant distress among the parents, who often present with difficulties in appropriating their parental role. Parental stress and low perceived parental self-efficacy may interfere with the infant's socioemotional and cognitive development, particularly through disrupted parent-infant interactions. Perceived parental self-efficacy represents the belief of efficacy in caring for one's own infant and successful incarnation of the parental role, as well as the perception of one's own abilities to complete a specified task. Interventions to support parental role, as well as infant development, are needed, and parental self-efficacy represents a useful indicator to measure the effects of such early interventions.

METHODS AND ANALYSIS

This study protocol describes a randomised controlled trial that will test an early intervention in the neonatal intensive care unit (NICU) (JOIN: Joint Observation In Neonatology) carried out by an interdisciplinary staff team. Mothers of preterm neonates born between 28 and 32 6/7 weeks of gestational age are eligible for the study. The intervention consists of a videotaped observation by a clinical child psychologist or child psychiatrist and a study nurse of a period of care delivered to the neonate by the mother and a NICU nurse. The care procedure is followed by an interactive video guidance intended to demonstrate the neonate's abilities and resources to his parents. The primary outcome will be the difference in the perceived maternal self-efficacy between the intervention and control groups assessed by self-report questionnaires. Secondary outcomes will be maternal mental health, the perception of the parent- infant relationship, maternal responsiveness and the neurodevelopment of the infant at 6 months corrected age.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 496/12). Results from this study will be disseminated at national and international conferences, and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02736136, Pre-results.

Internalizing symptoms in very low birth weight preschoolers: Symptom level and risk factors from four rating perspectives in a controlled multicenter study

BACKGROUND

Preterm births rates of infants with very low birth weight (VLBW < 1500 g) are increasing. Prematurity poses several risks for emotional child development, e.g., internalizing symptoms. Our understanding of this condition in young children is limited, for at preschool age, symptoms have mostly been assessed from the mother's perspective only.

METHODS

As part of the longitudinal HaFEn cohort-study in Hamburg, Germany, we measured the level of internalizing symptoms in VLBW and term preschoolers as well as predictors from four informants' perspectives: mother, father, teacher, and child. A multilevel model was constructed to examine predictors of internalizing symptoms. n = 104 VLBW and n = 79 term children were included.

RESULTS

From both their parents' perspective, children with VLBW had a significantly higher level of internalizing symptoms. From the teacher's and child's own perspectives, there were no significant mean group differences. In the multilevel analyses, the results were different regarding the four perspectives. VLBW did not predict internalizing symptoms. From mother's perspective, her own postpartum psychological distress, and from father's perspective, his postpartum and current psychological distress predicted a higher level of internalizing symptoms in their offspring. From teacher's perspective, socio-economic status predicted internalizing symptoms.

LIMITATIONS

The sample size was relatively small. Exclusion criteria and drop out of families could have created some selection bias.

CONCLUSIONS

Our findings point to the importance of early identification of parental postpartum psychological distress given the potential for later internalizing symptoms in their children or the perception of their offspring as vulnerable and symptomatic, which may also impact the child's development.

Parent Perspectives on Readiness for Discharge Home after Neonatal Intensive Care Unit Admission

OBJECTIVE

To explore the parent perspective on discharge home from the neonatal intensive care unit (NICU).

STUDY DESIGN

We interviewed parents of NICU graduates with a range of demographic characteristics and medical complexities to explore parent perspectives on readiness for discharge. Interviews were transcribed and coded by a 6-member team. We performed content analysis to identify themes and develop a family-centered conceptual framework around readiness for NICU discharge.

RESULTS

We interviewed a total of 15 parents who experienced NICU stays with 18 infants. Parents who have experienced NICU discharge have a spectrum of needs that evolve from the time the child is in the NICU, at time of discharge, and at home afterward. These needs consistently centered around 5 themes-communication, parent role clarity, emotional support, knowledge sources, and financial resources.

CONCLUSIONS

Parents described many ways the system could have better prepared them and connected them with essential resources. Summarizing the voices of the parents who participated in this study, we have compiled a series of practical recommendations for clinicians to use in daily practice to help parents feel prepared and confident for the transition home from the NICU.

A whole new world: a qualitative investigation of parents' experiences in transitioning their preterm child with cerebral palsy to developmental/rehabilitation services

BACKGROUND

Parents' experiences transitioning their children from neonatal to developmental/rehabilitation services (DRS) are unknown.

METHODS

A qualitative descriptive approach was used, including interviews with 18 parents (13 mothers and 5 fathers) of children born preterm and diagnosed with cerebral palsy (CP), located in a large urban center in Canada. Interview data underwent thematic analysis.

RESULTS

Parents' experiences with transition to DRS were a whole new world with three key themes: Wanting to know what to expect, feeling supported in their transition, and getting there emotionally and physically. Transition broke an emotional bond with neonatal services while parents were simultaneously entering DRS, experiencing their child's CP diagnosis, and reliving prior emotional trauma.

CONCLUSIONS

The findings reveal a cumulative emotional burden for parents in the first 3 years of life; a known critical period for parenting and early childhood development. Early transition interventions should consider including enhanced supports and services for parents.

NICU infant health severity and family outcomes: a systematic review of assessments and findings in psychosocial research

Many infants (7-15%) spend time in the neonatal intensive care unit (NICU) and continue to experience medical issues after discharge. Family psychological responses range widely depending on burden of care, access to resources, and parental characteristics. The current systematic review examined how infant health severity is assessed and related to family psychological (e.g., mental health) and social (e.g., parent-infant attachment) outcomes. Seventy articles were deemed relevant. Infant health was operationalized in several ways including validated assessments, indices of infant health (e.g., diagnosis, length of stay), or novel measures. Parents of infants with increased medical complications reported greater family impact, increased stress, and more intrusive parenting style. A validated assessment of infant health that utilizes parent report is warranted to allow for more accessible and easily disseminated research across medical centers. Understanding NICU infant health severity and family outcomes can be used to identify families at risk for negative psychosocial sequelae.

Infant, Maternal, and Neighborhood Predictors of Maternal Psychological Distress at Birth and Over Very Low Birth Weight Infants' First Year of Life

OBJECTIVE

To use a social-ecological conceptualization to analyze change of maternal distress, defined as depression, anxiety, and perinatal-specific post-traumatic stress (PPTS), across very low birth weight (VLBW) infants' first year of life and to identify infant, maternal, and neighborhood predictors of these changes over time.

METHODS

Mothers of VLBW infants (n = 69) completed psychological distress questionnaires 2 to 4 weeks after infant birth, 2 weeks before infant discharge from neonatal intensive care unit, and at infants' 4- and 8-month corrected age (age adjusted for prematurity). Infant and maternal sociodemographic data were collected from medical chart review. Neighborhood data were obtained through US census data. Multilevel linear growth modeling was used to (1) predict unstandardized estimates of mothers' initial levels of depression, anxiety, and PPTS at the time of infant's birth and the rate of change of these markers of distress over time and (2) model unstandardized estimates of infant, maternal, and neighborhood as predictors of distress at infants' birth and change over time.

RESULTS

Unstandardized estimates from multilevel linear growth modeling revealed depression (-2.8), anxiety (-1.4), and PPTS (-0.7) declined over infants' first year of life (<0.001). Mothers residing in lower-income homes and neighborhoods, respectively, reported lower anxiety (-11.2, p = 0.03) and PPTS (-31.1, p = 0.01) at infant birth. Greater infant birth weight predicted both lower anxiety (-0.02, p = 0.02) and lower PPTS (-0.02, p = 0.005).

CONCLUSION

Mothers psychologically recover over VLBW infants' first year of life. Results add to a building literature about socioeconomically disadvantaged mothers of preterm infants, reporting lower distress; this warrants additional research.

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

BACKGROUND

Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries.

METHODS

We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014.

FINDINGS

We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0-12·0), equating to an estimated 14·84 million (12·65 million-16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3-30·9) in North Africa to 8·7% (6·3-13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3-10×9) in 2000, and 10×6% (9×0-12×0) in 2014.

INTERPRETATION

Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting.

FUNDING

WHO and the March of Dimes.

Music Therapy Self-Care Group for Parents of Preterm Infants in the Neonatal Intensive Care Unit: A Clinical Pilot Intervention

Background: The parents of preterm infants face major mental health challenges in the Neonatal Intensive Care Unit (NICU). Family-centered music therapy actively integrates and empowers parents in their infants' care. With the aim to better understand and address parental needs separately from their babies' needs, a music therapy (MT) self-care group was implemented as part of clinical practice at the hospital Clínica de la Mujer, in Bogotá, Colombia. Methods: The group was provided for both parents, twice a week, in the NICU. Music guided relaxations, breathing techniques, and self-expression were at the center of the MT group sessions. The parents completed a pre/post self-administered Numeric Rating Scale (NRS), including anxiety levels, stress levels, mood and motivation. Results: The parents highly valued the MT self-care group in the NICU. On average, there was a 37% improvement in anxiety levels, 28% improvement in stress levels, and 12% improvement in mood, restfulness and motivation. Being able to relax, to distract themselves from their worries and having time for themselves are amongst the most frequently mentioned benefits. Conclusions: Addressing parents' needs separately from their babies' treatment, with culturally sensitive interventions aimed at improving parental mental health, is essential for continuing the development of family-centered music therapy interventions in the NICU.

Aberrant structural and functional connectivity and neurodevelopmental impairment in preterm children

Background

Despite advances in antenatal and neonatal care, preterm birth remains a leading cause of neurological disabilities in children. Infants born prematurely, particularly those delivered at the earliest gestational ages, commonly demonstrate increased rates of impairment across multiple neurodevelopmental domains. Indeed, the current literature establishes that preterm birth is a leading risk factor for cerebral palsy, is associated with executive function deficits, increases risk for impaired receptive and expressive language skills, and is linked with higher rates of co-occurring attention deficit hyperactivity disorder, anxiety, and autism spectrum disorders. These same infants also demonstrate elevated rates of aberrant cerebral structural and functional connectivity, with persistent changes evident across advanced magnetic resonance imaging modalities as early as the neonatal period. Emerging findings from cross-sectional and longitudinal investigations increasingly suggest that aberrant connectivity within key functional networks and white matter tracts may underlie the neurodevelopmental impairments common in this population.

Main body

This review begins by highlighting the elevated rates of neurodevelopmental disorders across domains in this clinical population, describes the patterns of aberrant structural and functional connectivity common in prematurely-born infants and children, and then reviews the increasingly established body of literature delineating the relationship between these brain abnormalities and adverse neurodevelopmental outcomes. We also detail important, typically understudied, clinical, and social variables that may influence these relationships among preterm children, including heritability and psychosocial risks.

Conclusion

Future work in this domain should continue to leverage longitudinal evaluations of preterm infants which include both neuroimaging and detailed serial neurodevelopmental assessments to further characterize relationships between imaging measures and impairment, information necessary for advancing our understanding of modifiable risk factors underlying these disorders and best practices for improving neurodevelopmental trajectories in this high-risk clinical population.

Mothers' Depression, Anxiety, and Mental Representations After Preterm Birth: A Study During the Infant's Hospitalization in a Neonatal Intensive Care Unit

Aim: This paper aimed to explore psychological functioning and mental representations in mothers of preterm infants during the child's hospitalization in a Neonatal intensive care unit (NICU).

Methods: A sample including 62 mothers of premature infants (gestational age < 37 weeks) was recruited in a NICU. According to the gestational age at the time of delivery, we considered two groups: Group A included mothers whose children were born before 32 weeks of pregnancy; Group B included mothers whose children were born at or after 32 weeks of pregnancy.

Within one week of childbirth, mothers were administered two self-report questionnaires: the Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI). When their infants' medical conditions became stable, the Clinical Interview for Parents of High-Risk Infants (CLIP) was administered to mothers.

Results: The results showed high levels of depression and anxiety in both groups of mothers, with higher state anxiety scores in Group A than Group B. Besides, a series of hierarchical regression analyses were conducted with STAI, EPDS, and gestational age as predictors on the CLIP scores. Results indicated that EPDS scores predicted CLIP scores on parental self-image, support system, and readiness for discharge (p < 0.001); moreover, the interaction among depression, anxiety, and gestational age predicted the CLIP dimension of feeling of mutual recognition (p < 0.005).

Conclusions: These findings suggested that a premature birth and the child's hospitalization might exert a negative effect on the mothers' emotional state, their perception of parental self-image and, consequently, the early bond with the child—independent from the infants' gestational age at the time of the preterm delivery. The data underlined the importance of involving NICU nurses and clinicians in order to optimize the care for mothers immediately after the preterm birth and during the infant's hospitalization, taking into account psychological needs of mothers of both very preterm and moderately preterm infants.

A mindfulness intervention to reduce maternal distress in neonatal intensive care: a mixed methods pilot study

Mothers with an infant in the neonatal intensive care unit (NICU) are at risk for depression, anxiety, and trauma symptoms, with negative implications for maternal-infant bonding, maternal well-being, and infant development. Few interventions to promote NICU mothers' mental health, however, have been developed or tested. This pre-post pilot study assessed feasibility, acceptability, and preliminary outcomes of a mindfulness intervention for NICU mothers. Twenty-seven mothers were recruited from a university NICU and offered a mindfulness intervention via introductory video and audio-recorded practices. Participants completed a baseline self-report survey. After 2 weeks of engaging with intervention materials, participants completed a second survey and in-depth interview. Quantitative data were analyzed using paired t tests; qualitative data were analyzed using thematic coding. Twenty-four women (89%) completed the study. Quantitative data indicated significant improvements in depressive, anxiety, and trauma symptoms, negative coping, NICU-related stress, and sleep (p < 0.05). Qualitative data identified themes of perceived improvements in psychological distress and stress symptoms, self-care, and relationships. Findings support the mindfulness intervention's feasibility, acceptability, and potential promise for reducing maternal distress and promoting well-being. Use of video and audio modalities may facilitate program sustainability and scale up. Further research on the program is merited.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Sleep and its relationship to health in parents of preterm infants: a scoping review

BACKGROUND

Sleep is essential for human health and functioning. Parents of preterm infants are susceptible to sleep disturbances because of stress related to the preterm birth. Poor sleep has the potential to affect parental health and well-being. The aim of this study was to identify and map evidence on sleep and its relationship to health in parents of preterm infants. No review has summarized the evidence on this topic.

METHODS

A scoping review was conducted. Seven health and medical electronic research databases were searched for relevant quantitative and qualitative primary studies, including grey literature. The search was performed March 2-7, 2017.

RESULTS

Ten American studies and one Australian study were included in the review. Most research was quantitative and focused on maternal sleep and mental health within the first two weeks after the childbirth. Both objective and subjective sleep measures were used to study sleep at the hospital; actigraphs were not used after discharge. Maternal sleep was poor early postpartum, and this was associated with negative health outcomes. Two cohort studies compared sleep in mothers of preterm and term infants, but the results were conflicting. In one qualitative study, fathers described their inability to catch up on sleep after homecoming with a preterm baby.

CONCLUSIONS

Quantitative studies reporting on maternal sleep early postpartum was most frequently occurring in the results. Qualitative research on the topic was identified as a knowledge gap. More cultural and geographical breadth, including research on fathers' sleep, is recommended in future research.

A Qualitative Study of the Experiences of Norwegian Parents of Very Low Birthweight Infants Enrolled in a Randomized Nutritional Trial

PURPOSE

The aim of this study was to examine how parents of very low birth weight (VLBW) infants experienced having their newborn infant enrolled in a randomized controlled intervention trial (RCT).

DESIGN AND METHODS

A qualitative descriptive design was used. Data were collected through individual semi-structured interviews with 15 parents of 9 participating VLBW infants. The data were then made the object of an inductive qualitative content analysis.

RESULTS

The parents expressed trust in the competence and motivation of the researchers and were confident that participating in the project would do no harm, but instead would potentially benefit their infant. The parents felt privileged for being given the chance to participate, to commit to the project; they were willing to invest their time and effort in the project. Participation could be stressful for the parents, ranging from minor irritation to situations in which they felt overwhelmed and not entirely in control. Many families lived stressful lives, and participation, particularly the follow-up after being discharged, may have added to this.

CONCLUSIONS

Infant participation in an RCT can be a positive experience, making the parents feel that they are given a chance to both contribute and receive something special. Participation can also be stressful because of conditions both related and unrelated to the RCT.

PRACTICE IMPLICATIONS

We identified several issues that researchers in future trials with VLBW infants need to address to minimize parental stress. Recruitment to intervention studies within the immediate period around birth should be avoided, if possible.

Effect of maternal psychopathology on neurodevelopmental outcome and quality of the dyadic relationship in preterm infants: an explorative study

Background: The literature shows that parents of preterm infants are at risk of psychological distress and that this may impact on the quality of the parent-child relationship and on the child's development.Aim: This longitudinal study was conducted to examine in preterm infants relationships between maternal psychological variables, parental protective factors, perinatal infant variables, and neurodevelopmental outcome. Furthermore, we explored the impact of these variables on the quality of the mother-infant relationship (dyadic synchrony).Subjects and methods: A total of 29 preterm infants (GA < 34 weeks) and their mothers were evaluated twice: at t₀, during the infant's hospitalization in the neonatal intensive care unit (NICU), and at 12 months of infant corrected age (t2).Results: With the exception of decreases in anxiety and perceived social support and an increase in the rate of severe depression at follow-up, there were no significant changes between t₀ and t₁ assessments. The infant's perinatal risk status was the variable that impacted most on maternal psychopathology. Furthermore, our data revealed that baseline maternal stress related to the appearance of the child and to the mother's perception of her parenting role represent a risk factor in relation to developmental outcome at 12 months of corrected age. Finally, no correlations emerged between dyadic synchrony and infant perinatal data, maternal psychological variables (at t₀ and at t₁), or child developmental outcome at t₁.Conclusions: Our results underline the need to identify negative maternal affective states early in the mother-child relationship and to provide mothers with adequate support in the NICU, to enhance their parental role.

The cost of preterm labor and preterm birth for mothers with uncomplicated pregnancies and their infants in Italy: a retrospective cohort study

BACKGROUND

Preterm labor (PTL)/preterm birth (PTB) impose significant burden on health-care systems. Women with uncomplicated pregnancies at risk of PTL/PTB have not been widely investigated, and published evidence on the costs of these women and their infants in Italy is absent. We aimed to describe women with uncomplicated pregnancies and associated costs for these women and their infants.

METHODS

Data on women aged 12-44 years with uncomplicated pregnancies who delivered between 1 September 2009 and 31 December 2014 with PTL diagnosis alone or PTL and PTB were included from four Italian databases. Costs were examined during pregnancy, delivery, and 3 years after delivery for mothers and infants, overall and by gestational age (GA).

RESULTS

A total of 3058 mothers linked to 3333 infants were included. Costs during pregnancy were €1777. Costs during delivery for PTL/PTB mothers and their infants ranged from €3174 (GA ≥37) to €21007 (GA <28). Combined maternal and infant costs appeared higher for births with lower GAs (<37) in the three-year follow-up.

CONCLUSIONS

In Italy, PTL/PTB mothers with uncomplicated pregnancies with infants at lower GAs appeared to incur higher medical costs compared to mothers with infants at higher GAs in all three time periods, with particularly marked differences found when considering mother and infant combined costs.

Maternal mental health during the neonatal period: Relationships to the occupation of parenting

PURPOSE

To (1) examine the extent of a range of early mental health challenges in mothers with a very preterm infant hospitalized in the NICU and mothers of full-term infants, (2) identify family social background and infant medical factors associated with higher levels of maternal psychological distress, and (3) assess the relationship between maternal psychological distress and maternal perceptions of the parenting role, parenting confidence and NICU engagement.

METHODS

At hospital discharge 37 mothers of very preterm infants (≤32 weeks gestation) and 47 mothers of full-term infants (≥37 weeks gestation) completed structured assessments of their psychological wellbeing and transition to parenting. Mothers of very preterm infants were also questioned about their NICU visitation and involvement in infant care.

RESULTS

Sixty-four percent (n = 54) of mothers experienced psychological distress (n = 26, 70% of preterm; n = 28, 60% of full-term). Lower infant birthweight was associated with maternal psychological distress (p = .03). Mothers of very preterm infants had significantly more psychological distress related to having a Cesarean section delivery (p = .02). Higher levels of psychological distress were associated with lower levels of parenting confidence in mothers of both very preterm and full-term infants (p < .02).

CONCLUSION

Although parents of very preterm infants have higher rates of maternal mental health challenges, mothers of full-term infants at high social risk are also impacted.

Mindfulness-Based Neurodevelopmental Care: Impact on NICU Parent Stress and Infant Length of Stay; A Randomized Controlled Pilot Study

BACKGROUND/PURPOSE

Experiences of premature birth and neonatal intensive care unit (NICU) hospitalizations result in stress and family separation that have far-reaching implications. Prior studies of neonatal neurodevelopmental care show improved infant outcomes. Previous studies of mindfulness show improved stress and health outcomes in varied disease processes. No neonatal studies of parent training in mindfulness-based neurodevelopmental care exist. This study examines the impact of parent education and participation in mindfulness-based neurodevelopmental care on parent outcomes (stress, bonding, and satisfaction) and infant length of stay (LOS).

METHODS

This randomized controlled trial pilot study utilized a convenience sample of 55 parent-infant dyads. Parametric and nonparametric statistical tests examined differences in and between study groups in demographics and dependent study variables (stress, bonding, satisfaction, and LOS).

RESULTS

No statistically significant differences in parent outcomes were seen between groups. However, experimental group (EG) parents showed a significant reduction in stress scores from enrollment to discharge (P = .012) and EG infants had significantly shorter LOS (P = .026-.047) than control.

IMPLICATIONS FOR PRACTICE AND RESEARCH

While further research to confirm study results is warranted, changes in current NICU practices to incorporate additional parent education in mindfulness-based neurodevelopmental care may help alleviate parent stress and decrease LOS that impact financial, physical, and psychosocial outcomes for patients, families, healthcare systems, and society.

Parenting stress, anxiety, and depression in mothers with visually impaired infants: a cross-sectional and longitudinal cohort analysis

AIM

This study examined cross-sectional and longitudinal patterns of parenting stress, adult anxiety, and depression in mothers of children with profound or severe visual impairment (PVI or SVI) at 1 year and 2 years of age.

METHOD

Mothers of a national longitudinal cohort (OPTIMUM Project) of infants with congenital disorders of the peripheral visual system and PVI (light perception at best) or SVI (basic 'form' vision of non-light reflecting objects) participated. Infant age at baseline (T₁ ) was 8 to 16 months. Mothers completed the Parenting Stress Index - Short Form and the Hospital Anxiety and Depression Scale at T₁ (n=79) and at follow-up 12 months later (T₂ ) (n=73).

RESULTS

Mothers of the total group had higher parenting stress levels (34.6% in clinical range) than community normative data at T₁ (p=0.017). Mothers of infants in the PVI subgroup had elevated stress at T₁ (p=0.014) and T₂ (p=0.009). The PVI subgroup was also elevated in the Difficult Child subscale at T₂ (p=0.001). Within-sample differences in parenting stress between the visual impairment subgroups were found at T₂ only: the PVI subgroup scored higher than the SVI subgroup (p=0.029). Adult anxiety and depression in the total group were not elevated compared with community normative data at T₁ and T₂ ; however, higher parenting stress was related to raised adult anxiety and depression levels at T₁ and T₂ (p=0.001). Regression analysis found parenting stress and lower child vision level (T₁ ) predicted parenting stress (T₂ ) (p=0.001; 42% variance).

INTERPRETATION

Mothers of 1-year-old infants with visual impairment showed raised risk for parenting stress, which continued to be elevated for children with PVI and those perceived as 'difficult' at 2 years. This was also a psychological risk, with greater adult anxiety and depression in those mothers with raised parenting stress. The clinical significance is that identification of parenting stress and targeted parenting, and behavioural support of the child in the first years of life is highly indicated.

WHAT THIS PAPER ADDS

Mothers of infants with visual impairment are at increased risk of parenting stress. Parenting stress was higher in mothers of children with profound visual impairment than those with severe visual impairment. High levels of parenting stress and lower infant vision at 1 year of age predicted higher parenting stress at 2 years of age.

Improving cardiometabolic and mental health in women with gestational diabetes mellitus and their offspring: study protocol for MySweetHeart Trial, a randomised controlled trial

INTRODUCTION

Gestational diabetes mellitus (GDM) carries prenatal and perinatal risk for the mother and her offspring as well as longer-term risks for both the mother (obesity, diabetes, cardiovascular disease) and her child (obesity, type 2 diabetes). Compared with women without GDM, women with GDM are twice as likely to develop perinatal or postpartum depression. Lifestyle interventions for GDM are generally limited to physical activity and/or nutrition, often focus separately on the mother or the child and take place either during or after pregnancy, while their results are inconsistent. To increase efficacy of intervention, the multifactorial origins of GDM and the tight link between mental and metabolic as well as maternal and child health need to be heeded. This calls for an interdisciplinary transgenerational approach starting in, but continuing beyond pregnancy.

METHODS AND ANALYSIS

This randomised controlled trial will assess the effect of a multidimensional interdisciplinary lifestyle and psychosocial intervention aimed at improving the metabolic and mental health of 200 women with GDM and their offspring. Women with GDM at 24-32 weeks gestational age who understand French or English, and their offspring and partners can participate. The intervention components will be delivered on top of usual care during pregnancy and the first year postpartum. Metabolic and mental health outcomes will be measured at 24-32 weeks of pregnancy, shortly after birth and at 6-8 weeks and 1 year after childbirth. Data will be analysed using intention-to-treat analyses. The MySweetHeart Trial is linked to the MySweetHeart Cohort (clinicaltrials.gov/ct2/show/NCT02872974).

ETHICS AND DISSEMINATION

We will disseminate the findings through regional, national and international conferences and through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02890693; Pre-results.

Comprehensive Assessment of Risk Factors of Cause-Specific Infant Deaths in Japan

Background

Public attention is given to infants with socially high risks of child abuse and neglect, while clinical attention is provided to infants with a biologically high risk of diseases. However, few studies have systematically evaluated how biological or social factors cross over and affect cause-specific infant mortality.

Methods

We linked birth data with death data from the Japanese national vital statistics database for all infants born from 2003–2010. Using multivariate logistic regression, we examined the association between biological and social factors and infant mortality due to medical causes (internal causes), abuse (intentional external causes), and accidents (unintentional external causes).

Results

Of 8,941,501 births, 23,400 (0.26%) infants died by 1 year of age, with 21,884 (93.5%) due to internal causes, 175 (0.75%) due to intentional external causes, and 1,194 (5.1%) due to unintentional external causes. Infants with high social risk (teenage mothers, non-Japanese mothers, single mothers, unemployed household, four or more children in the household, or birth outside of health care facility) had higher risk of death by intentional, unintentional, and internal causes. Infant born with small for gestational age and preterm had higher risks of deaths by internal and unintentional causes, but not by intentional causes.

Conclusions

Both biological as well as social factors were associated with infant deaths due to internal and external causes. Interdisciplinary support from both public health and clinical-care professionals is needed for infants with high social or biological risk to prevent disease and injury.

The Socio-Communicative Development of Preterm Infants Is Resistant to the Negative Effects of Parity on Maternal Responsiveness

Humans are born completely dependent on adult care for survival. To get the necessary support, newborns rely on socio-communicative abilities which have both innate and learned components. Maternal responsiveness (MR), as a critical aspect of mother-infant interaction, is a robust predictor of the acquisition of socio-communicative abilities. However, maternal responsiveness (MR) is influenced by parity, since mothers rely on a limited capacity of cognitive control for efficient attachment with their offspring. This fact is of particular concern for preterms, whose developing brain already faces many challenges due to their premature emergence from the womb's controlled environment and may still have to compete with siblings for mother's attention. Thus, in the present work, we aimed to understand how parity interferes with MR and whether it affects the development of socio-communicative abilities of preterm infants. We used the Social Interaction Rating Scale (SIRS) and the mother-child observation protocol in 18 dyads with gestational age <36 weeks. Dyads were separated into three groups: primiparous with twin pregnancy (TPM), primiparous (PM), and multiparous (MP). Dyadic behavior was evaluated at 3, 6, 9, and 12 months. Our results show that offspring size affects MR, but not the socio-communicative development of preterm infants during the first year, suggesting a level of resilience of brain systems supporting the attachment to caregivers.

Enhancing NICU parent engagement and empowerment

Within the neonatal intensive care unit (NICU), parent engagement and empowerment are of critical importance, particularly when infants are at risk of developing severe complications, such as necrotizing enterocolitis (NEC). Stakeholders within the NICU, including the fragile patients, families, clinicians, staff, and administration, benefit when parents are a valued member of their baby's care team. The 2017 NEC Symposium explored the experiences of families whose infants were impacted by NEC, the barriers to effective partnership, and promising solutions. Parents want to participate in their baby's care, and crave honest, timely, comprehensive information regarding their baby's health and potential outcomes. Clinicians and staff should implement a specific set of Family-Centered Care policies and practices within the NICU to foster a culture of collaboration with parents of premature and fragile infants.

Hope in Parents of Very-Low Birth Weight Infants and its Association with Parenting Stress and Quality of Life

PURPOSE

Being a parent of a very-low-birth-weight (VLBW) infant can be stressful. We aimed to describe parental hope 42months after the birth of a VLBW infant and determine whether there is an association between hope and parenting stress with quality of life (QoL), respectively.

DESIGN AND METHODS

Fifty-nine parents of VLBW infants completed questionnaires about hope, parenting stress and QoL. Pearson correlation coefficients (r) and linear regression models were used to examine the relationship between the selected variables. To compare groups, t-test was used and Cohen's d for effect size was calculated.

RESULTS

Parents of VLBW infants were more hopeful than the general population (p<0.001). Parenting stress and hope were both independently associated with QoL (p<0.001). The subgroup of parents of infants with birth weight <1000g had less hope (p=0.041) and higher parenting stress (p=0.041) than parents of infants with birth weight 1000-1500g.

CONCLUSIONS

Hope and parenting stress were both independent determinants of QoL. Parents of the presumably sickest infants had less hope and higher parenting stress than parents of VLBW infants with a birth weight over 1000g. Hope should be further explored as a coping mechanism in parents of VLBW infants.

PRACTICE IMPLICATIONS

The clinical implications of the strong association between hope, parenting stress and QoL remain to be determined, but reducing stress and strengthening hope seem to be important. This should be taken into account both at hospital discharge and at follow-up, especially for lower-birth-weight infants.

The Missing Siblings of Infants Born Preterm

BACKGROUND

Parents of very or extremely low birth weight infants have fewer subsequent children after preterm birth. Whether this applies to parents of less preterm infants is unknown.

METHODS

In this nationwide cohort study, we identified all 230 308 traceable (>99%) singletons (9983 preterm, 4.3%) live born in Finland between January 1, 1987, and September 30, 1990, and their parents. Quantitative contribution of gestational age of child to the birth of parental subsequent children was assessed by multivariate Cox regression models, stratifying by the number of previous children. The impact of gestational age on sibling count was estimated at individual and population level.

RESULTS

Mothers of extremely preterm (23-27 completed weeks) infants were, compared with mothers of term infants (39-41 weeks), less likely to have a subsequent live-born child (adjusted hazard ratio [HR]: 0.74; 95% confidence interval: 0.63-0.86). Corresponding HRs and confidence intervals were as follows: 28 to 31 weeks: 0.72 (0.65-0.80), 32 to 33 weeks: 0.82 (0.74-0.90), and 34 to 36 weeks: 0.90 (0.87-0.93). These HRs were consistent with those of fathers and couples. The cohort included 8002 firstborn preterm children, of whom 356 (4.4%) died in infancy. The 8002 children had a total of 13 826 subsequent siblings (1138 less than expected); per 1000 preterm births, this translates to the death of 44 preterm infants and 142 missing subsequent siblings.

CONCLUSIONS

Families with a preterm singleton child have fewer subsequent children. In a high-income country, the main population effect of preterm birth is caused by these "missing siblings," whose number exceeds the number of those preterm infants who die.

Elevated maternal anxiety in the NICU predicts worse fine motor outcome in VLBW infants

AIM

The literature is sparse with respect to the impact of elevated maternal psychological distress in the neonatal intensive care unit (NICU) on later neurodevelopmental outcome in VLBW infants. The objective of this study is to examine the impact of elevated maternal distress, defined as elevated depression, anxiety and perinatal-specific post-traumatic stress, during the NICU hospitalization on VLBW infant ND outcome at 20months corrected age (CA).

METHODS

This was a prospective study of 69 mothers and their VLBW infants recruited in 2011-2012. Elevated maternal distress was collected by maternal questionnaire in the NICU. Elevated depression was quantified with the Center for Epidemiological Studies-Depression Scale, anxiety with the Spielberger State-Trait Anxiety Inventory and perinatal-specific post-traumatic stress with the Modified Perinatal Posttraumatic Stress Disorder Questionnaire. VLBW infant ND outcome was assessed using the Bayley Scales of Infant & Toddler Development-III at 20months CA. Regression analyses determined the impact of elevated distress on ND outcome after adjusting for infant medical and maternal sociodemographic variables.

RESULTS

After controlling for infant and maternal covariates, elevated maternal anxiety in the NICU predicted lower fine motor scores at 20months CA.

CONCLUSION

Elevated maternal anxiety in the NICU is associated with adverse ND outcome in VLBW infants in the 2nd year of life. NICU-based support services may help mothers' quality of life and VLBW infant outcome.

Parenting stress trajectories in mothers of very preterm infants to 2 years

OBJECTIVE

To examine levels of parenting stress in mothers of preterm and term infants when the children were 2 years old; to determine the trajectory of stress over three time periods and to examine the association of maternal and neonatal factors and developmental outcomes with parenting stress.

DESIGN

It is a prospective longitudinal study to determine parenting stress in mothers of preterm and term infants with outcomes having been previously obtained at 4 and 12 months. At 2 years, 79 preterm mothers (96 babies) and 64 term mothers (77 babies) participated. The mothers completed the Parenting Stress Index-Short Form (PSI-SF), the Depression, Anxiety, Stress Scale (DASS) and the Child Behaviour Checklist (CBCL). The infants had a neurological examination and the Bayley-III scales were administered.

RESULTS

The mean total PSI-SF at 2 years was significantly higher for the preterm group compared with the term group of mothers (p=0.007). There was a significant increase in the mean total PSI over time for the preterm mothers (p<0.001). For mothers at 2 years, there was an association with high levels of parenting stress and abnormal scores on the DASS (p<0.001) and high total T-scores on the CBCL (internalising p<0.001; externalising p=0.006). There was no association between parenting stress and maternal demographics, neonatal factors or Bayley-III results.

CONCLUSIONS

Parenting stress in mothers of preterm infants continues to be high at 2 years having increased over time. Maternal mental health problems and infant behavioural issues contribute to the stress.

The neonatal intensive parenting unit: an introduction

This paper describes a paradigm shift occurring in neonatal intensive care. Care teams are moving from a focus limited to healing the baby's medical problems towards a focus that also requires effective partnerships with families. These partnerships encourage extensive participation of mothers and fathers in their baby's care and ongoing bi-directional communication with the care team. The term Newborn Intensive Parenting Unit (NIPU) was derived to capture this concept. One component of the NIPU is family-integrated care, where parents are intimately involved in a baby's care for as many hours a day as possible. We describe six areas of potentially better practices (PBPs) for the NIPU along with descriptions of NIPU physical characteristics, operations, and a relationship-based culture. Research indicates the PBPs should lead to improved outcomes for NIPU babies, better mental health outcomes for their parents, and enhanced well-being of staff.

Web-Based Intervention to Teach Developmentally Supportive Care to Parents of Preterm Infants: Feasibility and Acceptability Study

Background

Preterm birth affects 8% to 11% of the population and conveys a significant risk of developmental delays. Intervention programs that support child development have been shown to have a positive impact on early motor and cognitive development and on parental well-being. However, these programs are often difficult to implement in a real-life setting due to lack of resources. Hence, our multidisciplinary team developed Mieux Agir au Quotidien (MAQ) to teach developmentally supportive care to parents of preterm infants with the goal of improving child development and parental outcomes. Our intervention included 3 in-person workshops that occurred prior to hospital discharge and a Web-based platform with written and videotaped materials that addressed 5 main themes: (1) infant behavioral cues, (2) flexion positioning; (3) oral feeding support, (4) parent-infant interactions, and (5) anticipation of developmental milestones.

Objective

This study aimed to test the feasibility and acceptability of the intervention by parents of preterm infants and assess clinical benefits on child neurodevelopment and parental outcomes during the first year of life.

Methods

A total of 107 infants born at <30 weeks and admitted to Sainte-Justine Hospital neonatal intensive care unit and their parents were enrolled in a nonrandomized controlled before-and-after interventional study (intervention n=55, comparison n=52). Acceptability of the program was assessed with a user satisfaction questionnaire. When the infants were at 4 months’ corrected age, all parents completed questionnaires on infant temperament, parenting stress, sense of competence, and parenting satisfaction. At 12 months’ corrected age, neurodevelopmental testing was performed on infants using the Alberta Infant Motor Scale and the Bayley Scales of Infant and Toddler Development, Third Edition. Comparisons between the 2 groups were done using independent t tests, Wilcoxon rank-sum tests, and Fisher exact tests.

Results

The majority of parents (43/45) were satisfied with the intervention program and all would recommend MAQ to others. MAQ met their need for evidence-based information that proved useful to support their child development. No difference in parental or child neurodevelopmental outcomes was detected in this pilot study for most outcomes except for higher median scores for parental coercive behaviors in the intervention group, although proportions scoring in the coercive range did not differ.

Conclusions

Acceptability of the program was high among parents thus supporting the relevance of such intervention. A larger study using a randomized controlled trial design is needed to better document impact on parent and children and investigate how Web-based technologies can efficiently complement individualized intervention to alleviate the burden on health care resources.

Impact of preterm birth on parental separation: a French population-based longitudinal study

OBJECTIVE

The objective of this study was to investigate both the effects of low gestational age and infant's neurodevelopmental outcome at 2 years of age on the risk of parental separation within 7 years of giving birth.

DESIGN

Prospective.

SETTING

24 maternity clinics in the Pays-de-la-Loire region.

PARTICIPANTS

This study included 5732 infants delivered at <35 weeks of gestation born between 2005 and 2013 who were enrolled in the population-based Loire Infant Follow-up Team cohort and who had a neurodevelopmental evaluation at 2 years. This neurodevelopmental evaluation was based on a physical examination, a psychomotor evaluation and a parent-completed questionnaire.

OUTCOME MEASURE

Risk of parental separation (parents living together or parents living separately).

RESULTS

Ten percent (572/5732) of the parents reported having undergone separation during the follow-up period. A mediation analysis showed that low gestational age had no direct effect on the risk of parental separation. Moreover, a non-optimal neurodevelopment at 2 years was associated with an increased risk of parental separation corresponding to a HR=1.49(1.23 to 1.80). Finally, the increased risk of parental separation was aggravated by low socioeconomic conditions.

CONCLUSIONS

The effect of low gestational age on the risk of parental separation was mediated by the infant's neurodevelopment.

Using the EPDS to Identify Anxiety in Mothers of Infants on the Neonatal Intensive Care Unit

Despite the prevalence of postpartum depression and anxiety, current screening recommendations are limited to depression symptoms. Screening using the Edinburgh Postnatal Depression Scale-Anxiety subscale (EPDS-A) may enhance ability to detect distress in postpartum women. We aimed to replicate the EPDS-A in 200 mothers with infants hospitalized in the neonatal intensive care unit (NICU) and examine its incremental utility in identifying emotional distress. Presence of the EPDS-A was identified using exploratory factor analysis. Women experiencing elevated anxiety were identified using a previously established cutoff score. Results replicated the EPDS-A for the first time in mothers with infants hospitalized in the NICU. In all, 21.9% of these women had elevated anxiety symptoms and nearly one quarter of them would have been missed in routine depression screening. Use of the EPDS-A, in addition to the total EPDS score, is a promising approach to identifying anxious women in need of further evaluation, treatment, or support.

Direct Feeding at the Breast Is Associated with Breast Milk Feeding Duration among Preterm Infants

BACKGROUND

In spite of high rates of initiating breast milk feeding (BMF) among preterm infants, a significant rate of discontinuation occurs shortly after discharge.

AIM

To investigate the effect of mode (direct feeding at the breast vs. expressing) and exclusivity (breast milk combined with formula vs. breast milk only) as well as maternal perceptions on the duration of BMF among preterm infants.

METHODS

The study included mothers whose infants were born before 32 weeks gestation, between January 2012 and August 2015 at Sheba Medical Center (SMC). Perinatal data were collected retrospectively from infants' computerized charts. Mothers were approached >12 months postpartum and were asked to complete a questionnaire. Those who agreed to participate were asked (during their visit to the follow-up clinic or by phone or mail) to complete a questionnaire regarding mode and duration of BMF as well as reasons for its discontinuation. Mothers were also asked about their pre-partum intentions to feed directly at the breast.

RESULTS

Out of 162 eligible mothers, 131 (80.8%) initiated BMF during their intensive care unit (ICU) hospitalization. Of these, 66 (50.3%) discontinued BMF earlier than six months postpartum. BMF ≥ 6 months was significantly associated with direct feeding at the breast, duration of exclusive BMF, and singleton birth. Regression analysis revealed that direct feeding at the breast (any or only) and duration of BMF exclusivity were the only significant variables associated with BMF duration (Odds ratio (OR) 5.5 and 95% confidence interval (CI) 2.00-15.37; OR 1.5 and 95% CI 1.25-1.88, respectively). Milk supply (inadequate or nonexistent) was the most commonly reported cause for BMF discontinuation <6 months. Direct feeding at the breast was significantly associated with BMF duration and was more common among singletons.

CONCLUSIONS

Direct feeding at the breast and duration of exclusive BMF are associated with duration of BMF among infants born <32 weeks of gestational age (GA). These findings suggest that targeting these two factors may play a key role in prolonging BMF duration among preterm infants.

Obstetric risk factors for depression during the postpartum period in South Korea: a nationwide study

OBJECTIVE

Postpartum depression is related to many adverse effects in both mothers and their children; therefore, proper screening and early interventions are needed. This study aims to identify the risk factors of postpartum depression. Our primary focus is on obstetric risk factors.

METHODS

This study is a cross-sectional study which we extracted the data of women who gave birth between January 1st, 2010 and December 31st, 2012 from the Health Insurance Review and Assessment service (HIRA) database. We analyzed the data using multivariable logistic regression models.

RESULTS

A total of 17,483 (1.4%) women suffered from depression during the postpartum period. Younger (<20years) and advanced maternal age (≥35years), primiparity, previous depression, peripartum hysterectomy, uterine artery embolization, preterm delivery, placental abruption, cesarean delivery, induced labor, and preeclampsia were found to increase the likelihood of having depression after delivery.

CONCLUSIONS

Our findings suggest that there are several risk factors that lead women to postpartum depression. Therefore, early detection and well-management of the symptoms and risk factors for postpartum depression along with social support can help both physical and psychological conditions of women after childbirth.

Parents' early healthcare transition experiences with preterm and acutely ill infants: a scoping review

BACKGROUND

Parents undergo multiple transitions following the birth of an ill infant: their infant's illness-health trajectory, neonatal intensive care unit hospitalization and transfers from one healthcare setting to another, while also transitioning to parenthood. The objective of this review was to map and synthesize evidence on the experiences and needs of parents of preterm or ill infants as they transition within and between healthcare settings following birth.

METHODS

The scoping review followed Arskey and O'Malley's () framework, enhanced by Levac et al. (). Relevant studies were identified through a comprehensive search strategy of scientific and grey literature databases, online networks, Web of Science and citation lists of relevant articles. Inclusion criteria encompassed a focus on infants undergoing a healthcare transition, and the experiences and needs of parents during transition. Studies were appraised for design quality, and data relevant to parent experiences were extracted and underwent thematic analysis.

RESULTS

A total of 7773 records were retrieved, 90 full texts reviewed and 11 articles synthesized that represented a total sample of 435 parents of preterm or ill infants. Parents reported on their experiences in response to their infant's transition within and between hospitals and across levels of neonatal intensive care unit, intermediate and community hospital care. Ten studies used qualitative research methods, while one employed quantitative survey methods. Four key themes were identified: that of parent distress throughout transition, parenting at a distance, sources of stress and sources of support. Parents' stress resulted from not being informed or involved in the transition decision, inadequate communication and perceived differences in cultures of care across healthcare settings.

CONCLUSIONS

Opportunities to improve parents' early transition experiences include enhanced engagement, communication, information-sharing and shared decision-making between health care providers and parents. Future areas of research should focus on early transition interventions to advance parent capacity, confidence and closeness as the primary nurturer.