Maternal posttraumatic stress response after the birth of a very low-birth-weight infant

Assessing the feasibility and acceptability of an intervention to reduce anxiety and enhance sensitivity among mothers of very low birth-weight infants

PURPOSE

A pilot study was conducted to assess the feasibility and acceptability of an intervention program for mothers of very low birth-weight infants in the neonatal intensive care unit (NICU).

SUBJECTS

Thirty-three mothers of infants born weighing less than 1500 g.

DESIGN

A single-group, pretest-posttest design was used.

METHODS

Preintervention mothers completed self-report questionnaires and their interaction with their infant was observed. Mothers then received the intervention program. Mothers were assessed twice postintervention, first when the infant was 1/2 months old and again at 6 months. At the postintervention assessments, mothers completed the same questionnaires and interaction was observed.

MAIN OUTCOME MEASURES

Mothers completed the State-Trait Anxiety Inventory, the revised Parental Stress Scale: Neonatal Intensive Care Unit, the NICU Parental Beliefs Scale, and the Perinatal PTSD Questionnaire. Interactions between mothers and infants were rated by trained research staff using the Index of Parental Behaviour in the NICU. Postintervention mothers also responded to a questionnaire that assessed their perceptions of the intervention program.

RESULTS

It was feasible to enroll mothers because 62% of eligible mothers agreed to participate. However, 39% of mothers who enrolled withdrew. Most of the mothers who withdrew did so before even beginning the intervention, and many of these women were mothers of multiples. It was also feasible to provide the intervention because more than 80% of mothers who began the intervention received all 6 teaching sessions. Mothers found both the content and the format of the program to be acceptable. There were nonetheless several challenges in conducting an intervention study with mothers early in the NICU hospitalization.

CONCLUSIONS

The results of this pilot study are encouraging. It was found to be both feasible and acceptable to provide the intervention program to mothers during the NICU hospitalization. The effectiveness of this program needs to be assessed in a randomized controlled trial.

Emotional state and dreams in pregnant women

The aim of this study was to investigate the frequency of recall and the content of dreams during pregnancy, as well as their correlation with socio-demographic, obstetric and physician-patients relationship variables, emotional state and duration of labour. A questionnaire, designed to analyse background characteristics, was given to 290 women in the third trimester of gestation. The psychiatric analysis of anxiety and depression was performed using the Hamilton Rating Scale for Anxiety and the Montgomery-Asberg Depression Rating Scale, while dreams were divided into masochistic and pleasant according to Beck's criteria. Oneiric activity was found to be associated with age >or= 35 years, higher family income, higher educational level, and a "satisfactory" physician-patient relationship. Masochistic content was associated with age<35 years, quality of information and frequent thoughts of delivery. Concerning the emotional state, depression levels were higher in women reporting masochistic dreams, while no difference in anxiety levels was found. Labour duration was shorter in the dreamer group and in patients with masochistic dream content. These findings may indicate that, also in pregnancy, the number and the content of dreams are influenced by women's mood and that the evaluation of the oneiric activity might represent a useful tool for clinicians either to investigate the women's emotional state or to predict its repercussions on the course of labour.

The Cues and Care Trial: a randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants

BACKGROUND

Very low birthweight infants are at risk for deficits in cognitive and language development, as well as attention and behaviour problems. Maternal sensitive behaviour (i.e. awareness of infant cues and appropriate responsiveness to those cues) in interaction with her very low birthweight infant is associated with better outcomes in these domains; however, maternal anxiety interferes with the mother's ability to interact sensitively with her very low birthweight infant. There is a need for brief, cost-effective and timely interventions that address both maternal psychological distress and interactive behaviour. The Cues and Care trial is a randomized controlled trial of an intervention designed to reduce maternal anxiety and promote sensitive interaction in mothers of very low birthweight infants.

METHODS AND DESIGN

Mothers of singleton infants born at weights below 1500 g are recruited in the neonatal intensive care units of 2 tertiary care hospitals, and are randomly assigned to the experimental (Cues) intervention or to an attention control (Care) condition. The Cues intervention teaches mothers to attend to their own physiological, cognitive, and emotional cues that signal anxiety and worry, and to use cognitive-behavioural strategies to reduce distress. Mothers are also taught to understand infant cues and to respond sensitively to those cues. Mothers in the Care group receive general information about infant care. Both groups have 6 contacts with a trained intervener; 5 of the 6 sessions take place during the infant's hospitalization, and the sixth contact occurs after discharge, in the participant mother's home. The primary outcome is maternal symptoms of anxiety, assessed via self-report questionnaire immediately post-intervention. Secondary outcomes include maternal sensitive behaviour, maternal symptoms of posttraumatic stress, and infant development at 6 months corrected age.

DISCUSSION

The Cues and Care trial will provide important information on the efficacy of a brief, skills-based intervention to reduce anxiety and increase sensitivity in mothers of very low birthweight infants. A brief intervention of this nature may be more readily implemented as part of standard neonatal intensive care than broad-based, multi-component interventions. By intervening early, we aim to optimize developmental outcomes in these high risk infants.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00918472. The Cues and Care Trial: A randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants.

How is maternal recollection of the birth experience related to the behavioral and emotional outcome of preterm infants?

OBJECTIVES

To investigate how mother's recollections of birth experiences and first contact with the newborn relate to the child's behavioral and emotional problems at five to six years of age.

METHODS

The study included 28 mothers of preterm (birth weight < or =2500 g) and 39 mothers of full-term children, born in Tampere University Hospital in 1998. When the children were five to six years old, maternal recollections of the birth experiences were assessed using the Clinical Interview for Parents of High-Risk Infants (CLIP) and children's behavioral and emotional problems were assessed using the Child Behavior Checklist (CBCL).

RESULTS

Mothers of the preterm children still had more negative recollections of the labor (p < 0.001) and first contact with the newborn (p < 0.001) than mothers of the full-term children. These recollections related to the child's behavioral and emotional symptoms when the child was five to six years old in the preterm group but not in the full-term group.

CONCLUSION

The impact of mother's birth experience seems to have long-lasting effects on the preterm child. This finding emphasizes the importance of early physical mother-infant contact and supporting the mothers of preterm infants, especially if they articulate negative or traumatic experiences related to the birth of their child.

Parents' mental health after the birth of an extremely preterm child: a comparison between bereaved and non-bereaved parents

OBJECTIVE

To assess the impact of extremely preterm birth (24-26 weeks of gestation) on the mental health of parents two to six years after delivery, and to examine potential differences in post-traumatic growth between parents whose newborn infant died and those whose child survived.

METHOD

A total of 54 parents who had lost their newborn and 38 parents whose preterm child survived were assessed by questionnaires with regard to depression and anxiety (HADS) and post-traumatic growth (PTGI).

RESULTS

Neither group of parents had clinically relevant levels of depression and anxiety. Mothers showed higher levels of anxiety than fathers. Bereaved parents with no other, living child reported higher levels of depression than bereaved parents with one or more children. Mothers reported higher post-traumatic growth compared to fathers. In particular, bereaved mothers experienced the value and quality of their close social relationships more positively compared to the non-bereaved parents.

CONCLUSION

In the long term, bereaved and non-bereaved parents cope reasonably well with an extremely preterm birth of a child. Post-traumatic growth appears to be positively related to bereavement, particularly in mothers.

Regulation of anxiety during the postpartum period

Healthy mother-infant interactions are critical for the physical, cognitive, and psychological development of offspring. Such interactions rely on numerous factors, including a positive maternal emotional state. However, many postpartum women experience emotional dysregulation, often involving elevated anxiety. Neuroendocrine factors contributing to the onset of postpartum anxiety symptoms are mostly unknown, but irregularities in hypothalamic-pituitary-adrenal axis function, reduced prolactin and oxytocin signaling, or parturitional withdrawal of ovarian, placental and neural steroids could contribute to anxiety in susceptible women. Although the causes of initial onset are unclear, postpartum anxiety can be mitigated by recent contact with infants. Numerous neurochemical systems, including oxytocin, prolactin, GABA, and norepinephrine mediate this anxiolytic effect of infant contact. Insight into the etiology of postpartum anxiety disorders, and how contact with infants helps counter existing anxiety dysregulation, will surely facilitate the diagnosis and treatment of postpartum women at risk for, or experiencing, an anxiety disorder.

Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants

OBJECTIVE

(1) To compare maternal characteristics and psychological stress profile among African-American, Caucasian and Hispanic mothers who delivered very low birthweight infants. (2) To investigate associations between psychosocial factors, frequency of milk expression, skin-to-skin holding (STS), and lactation performance, defined as maternal drive to express milk and milk volume.

STUDY DESIGN

Self-reported psychological questionnaires were given every 2 weeks after delivery over 10 weeks. Milk expression frequency, STS, and socioeconomic variables were collected.

RESULT

Infant birthweight, education, and milk expression frequency differed between groups. Trait anxiety, depression and parental stress in a neonatal intensive care unit (PSS:NICU) were similar. African-American and Caucasian mothers reported the lowest scores in state anxiety and social desirability, respectively. Maternal drive to express milk, measured by maintenance of milk expression, correlated negatively with parental role alteration (subset of PSS:NICU) and positively with infant birthweight and STS. Milk volume correlated negatively with depression and positively with milk expression frequency and STS.

CONCLUSION

Differences between groups were observed for certain psychosocial factors. The response bias to self-reported questionnaires between groups may not provide an accurate profile of maternal psychosocial profile. With different factors correlating with maintenance of milk expression and milk volume, lactation performance can be best enhanced with a multi-faceted intervention program, incorporating parental involvement in infant care, close awareness and management of maternal mental health, and encouragement for frequent milk expression and STS.

Mothers' psychological distress 1 year after very preterm childbirth. Results of the EPIPAGE qualitative study

BACKGROUND

The objectives of this study were to assess qualitatively mothers' physical and psychological health, their perception of their child's health and development, and their difficulties with childcare from 2 months post discharge to 1 year after a very preterm delivery.

METHODS

The study population included all mothers who delivered before 33 weeks of amenorrhea between November 1998 and November 1999 in a Parisian maternity unit and between February 2000 and February 2001 in a maternity unit located in Rouen (France). Twenty-one of the 38 mothers contacted agreed to participate (55%). Semi-structured interviews were conducted by a clinical psychologist at the woman's home. They were taped, fully transcribed and subjected to content analysis.

RESULTS

The main difficulties reported by mothers at 1 year were fatigue, depressive mood, anxiety and physical symptoms. Depressive mood was associated with social isolation, post-traumatic symptoms, withdrawal and feelings of guilt. Most mothers also described their child as being difficult and tiring. Mothers' reports about their own health and difficult behaviour of their child were more negative at 1 year than at 2 months post discharge.

CONCLUSIONS

The mothers' psychological distress following a very preterm birth did not improve between 2 months post discharge and 1 year after delivery. Comprehensive follow-up care programmes should take into account this consequence of a very preterm birth and provide access to adequate psychological support, care or treatment.

Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research

This paper provides a synthesis of current knowledge about post-traumatic stress symptoms following childbirth. In particular it presents a two dimensional conceptual framework for understanding the development of symptoms based upon predisposing (pre-pregnancy/pregnancy), precipitating (perinatal) and maintaining (postnatal) factors, which relate to internal (within individual), external (environmental) and interactional factors. In addition key methodological issues and areas for further research are identified.