Prematurity, maternal stress and mother-child interactions

Parents' expectations of staff in the early bonding process with their premature babies in the intensive care setting: a qualitative multicenter study with 60 parents

BACKGROUND

During the first weeks of hospitalization, premature babies and their parents encounter difficulties in establishing early bonds and interactions. Only a few studies have explored what caregivers can do to meet parents' needs in relation to these interactions and help optimize them. This study sought to explore parents' perception of these first interactions and to identify the actions of caregivers that help or hinder its development.

METHODS

Prospective study, qualitative discourse analysis of 60 face-to-face interviews conducted with 30 mothers and 30 fathers of infants born before 32 weeks of gestation (mean ± SD: 27 ± 2 weeks of gestational age), during their child's stay in one out of three NICUs in France. Interviews explored parental experience, from before birth up to the first month of life.

RESULTS

Data analysis uncovered two main themes, which were independent of parents' geographical or cultural origin but differed between mothers and fathers. First, fathers described the bond with their child as composed more of words and looks and involving distance, while mothers experienced the bond more physically. Secondly, two aspects of the caregivers' influence were decisive: nurses' caring attitude towards baby and parents, and their communication with parents, which reduced stress and made interactions with the baby possible. This communication appeared to be the locus of a supportive and fulfilling encounter between parents and caregivers that reinforced parents' perception of a developing bond.

CONCLUSIONS

At birth and during the first weeks in the NICU, the creation of a bond between mothers and fathers and their premature baby is rooted in their relationship with the caregivers. Nurses' caring attitude and regular communication adapted to specific needs are perceived by parents as necessary preconditions for parents' interaction and development of a bond with their baby. These results might allow NICU staff to provide better support to parents and facilitate the emergence of a feeling of parenthood.

A review of postpartum depression, preterm birth, and culture

Postpartum depression (PPD) varies worldwide and is considered a serious issue because of its devastating effects on mothers, families, and infants or children. Preterm birth may be a risk factor for PPD. In 2005, the global incidence of preterm birth was estimated to be 9.6%, and of these births, 85% occurred in Africa and Asia. Among Asian countries, Pakistan has a preterm birth rate of 15.7% and the highest prevalence rate of PPD (63.3%). A literature review was therefore undertaken to better understand the potential contribution of preterm birth to PPD and to identify gaps in the scientific literature. Limited studies compare prevalence rates of PPD in mothers of full-term infants and mothers of preterm infants. Furthermore, meta-analyses examining predictors of PPD have not included preterm birth as a variable. The interrelationship between preterm birth and PPD may be explained by early parental stress and mother-infant interaction among mothers of preterm infants. Culture plays an important role in shaping communication between mothers and their infants and defines social support rituals that may or may not mediate PPD. More research is needed to provide evidence for practice.

Mothers are not fathers: differences between parents in the reduction of stress levels after a parental intervention in a NICU

AIMS

The study examined the effects of a parental intervention to reduce parents' stress levels during the hospitalization of their very preterm infants in a NICU, taking into account possible differences between mothers and fathers.

METHODS

Parents of infants born ≤ 32 weeks gestational age (GA) were randomly assigned to a standard support group (N = 21) or intervention group (N = 21). The intervention was based both on a joint observation method and infant massage provided by both parents. Parents' stress was assessed by the Parental Stressor Scale: Neonatal Intensive Care Unit, after the first week of admission and at the infant's discharge.

RESULTS

At discharge, intervention group parents showed significantly lower levels of stress related to infants' appearance/behaviour and to parental role alteration (PRA) than those of the standard support group (p = 0.000). Overall, mothers reported more stress compared with fathers (p ≤ 0.05). The intervention was effective in reducing the stress-role alteration in mothers (p < 0.05), but not in fathers.

CONCLUSIONS

Mothers reported more stress compared with fathers, above all for PRA. A parental intervention was effective in reducing stress-role alteration in mothers, but not fathers. Parental interventions should take into account that help for fathers could be different from help for mothers.

Anxiety in adolescents born preterm or with very low birthweight: a meta-analysis of case-control studies

AIM

To determine if adolescents who are born very preterm (<32 wks; of gestation) and/or with very low birthweight (VLBW; <1500 g) have a higher risk of experiencing clinically significant anxiety problems.

METHOD

We used a systematic review and meta-analysis. We searched the databases ISI Web of Knowledge, PubMed, PsycNET, Educational Resources Information Center (ERIC), Latin American and Caribbean Literature on the Health Sciences (LILACS), and Virtual Health Library (VHL) with equivalent search expressions (from the databases' inception to June 2011). Also, we screened reference lists of identified articles. We selected case-control studies of adolescents 11 to 20 years old who were very preterm/VLBW and had a matched reference group born at term with normal birthweight that reported a validated anxiety outcome measure. For data extraction, two authors independently reviewed titles, abstracts, and full articles identified through the searches. Subsequently two authors independently extracted data.

RESULTS

We included six studies with 1519 adolescents (787 very preterm/VLBW, 732 comparisons). The general risk of developing clinically significant anxiety problems was nearly doubled (p<0.05) in the very preterm/VLBW population (OR 2.27, 95% confidence interval 1.15-4.47). The overall prevalences were 9.9% in the very preterm/VLBW group and 5.5% in the comparison group.

INTERPRETATION

Those born very preterm/VLBW have an increased risk of developing clinically significant anxiety problems in adolescence.

Parenting Stress, Social Support, and Mother-Child Interactions in Families of Multiple and Singleton Preterm Toddlers

The study investigated family support as a buffer of stress in 153 mothers and preterm toddlers. Data were collected regarding maternal depressive symptoms, parenting stress, and family support; infant health; and videotaped mother-child interactions. Although more parenting stress related to less optimal child play, only information support functioned as a protective factor. Information support predicted positive play under high, but not low, maternal stress. Mothers of multiples reported more parenting stress than mothers of singletons.

Closeness and separation in neonatal intensive care

In this paper, we highlight the need for acknowledging the importance and impact of both physical and emotional closeness between the preterm infant and parent in the neonatal intensive care unit. Physical closeness refers to being spatially close and emotional closeness to parental feelings of being emotionally connected to the infant (experiencing feelings of love, warmth and affection). Through consideration of the literature in this area, we outline some of the reasons why physical closeness and emotional closeness are crucial to the physical, emotional and social well-being of both the infant and the parent. These include positive effects on infant brain development, parent psychological well-being and on the parent–infant relationship. The influence of the neonatal unit environment and culture on physical and emotional closeness is also discussed.

The impact of premature childbirth on parental bonding

The development of an affectionate parent-infant bond is essential for a newborn infant's survival and development. However, from evolutionary theory it can be derived that parental bonding is not an automatic process, but dependent on infants' cues to reproductive potential and parents' access to resources. The purpose of the present study was to examine the process of bonding in a sample of Dutch mothers (n = 200) and fathers (n = 193) of full-term (n = 69), moderately premature (n = 68), and very premature infants (n = 63). During the first month postpartum parents completed the Pictorial Representation of Attachment Measure (PRAM) and Postpartum Bonding Questionnaire (PBQ). Longitudinal analyses revealed that mothers' PRAM scores decreased after moderately preterm delivery, whereas decreases in PRAM scores occurred in both parents after very preterm delivery. As lower PRAM scores represent stronger feelings of parent-infant connectedness, our findings suggest a higher degree of bonding after premature childbirth. Results of the PBQ analysis were in line with PRAM outcomes, as parents of preterm infants reported less bonding problems compared to parents of full-terms. These findings support the hypothesis that in affluent countries with adequate resources, bonding in parents of preterm infants on average may be higher than in parents of full-term infants.

Mother and child behaviour in very preterm and term dyads at 6 and 8 years

AIM

Mothers of very preterm children have been reported to behave less sensitively and to be more controlling. It is unknown whether this is the result of maternal factors or due to maternal adaptation to children's cognitive problems.

METHOD

We investigated a geographically defined prospective whole-population sample of very low birthweight (<1500 g) or very preterm (<32 wks' gestation; VLBW/VP) children (n = 267, 124 females, 143 males) and a comparison group born at term (n = 298, 146 females, 152 males) in Germany. Mother-child interactions were videotaped during a play situation and analysed with a standardized coding system at children's mean ages of 6 years 3 months and 8 years 5 months.

RESULTS

At both 6 years 3 months and 8 years 5 months, VLBW/VP children were less task persistent and socially active (p<0.001) whereas their mothers behaved less sensitively and were more controlling than term mother-child dyads (p<0.001). Cross-sectional group differences in maternal behaviour remained when scores where adjusted for social factors but disappeared once adjusted for child IQ. High maternal sensitivity predicted higher task persistence (p<0.001), in particular in those children with cognitive problems.

INTERPRETATION

Mothers of VLBW/VP children adapt their behaviour to their children's level of cognitive functioning. High maternal sensitivity is particularly beneficial for task persistence in children with cognitive deficits.

Mutter-Kind-Interaktion bei Frühgeborenen

Die Mutter-Kind-Interaktion (MKI) Frühgeborener ist im Vergleich zu Reifgeborenen durch eine erhöhte mütterliche Intrusivität und Kontrolle gekennzeichnet. Analysiert wurde die MKI von Früh- und Reifgeborenen im Alter von 36 Monaten. 39 Frühgeborene < 1500 g (Studiengruppe) und 26 Reifgeborene (Kontrollgruppe) wurden im korrigierten Alter von 36 Monaten mittels Mannheimer Methode zur standardisierten Beobachtung der MKI im Kleinkindalter untersucht. Hierzu werden zwei fünfminütige Interaktionssituationen videographisch aufgezeichnet. Für die Lernsituation konnte nachgewiesen werden, dass die Mütter Frühgeborener weniger supportiv, häufiger restriktiv und unangemessen steuern, „negativer“ auf ihre Kinder reagieren und häufiger „negative“ Interaktionsauffälligkeiten zeigen. In der Spielsituation zeigte sich, dass Mütter frühgeborener Kinder häufiger negative Interaktionsauffälligkeiten sowie eine höhere negative Gestimmtheit und eine unangemessenere Steuerung aufweisen. Die Lernsituation zeigte sich in der Gruppe der Frühgeborenen als die „schwierigere“ Interaktion. Die Problematik der Mutter- Kind-Interaktion Frühgeborener bedarf besonderer Beachtung sowie früher Interventionen.

Difference in mother-child interaction between preterm- and term-born preschoolers with and without disabilities

AIM

To investigate differences in the quality of mother-child interaction between preterm- and term-born children at age 5, and to study the association of mother-child interaction with sociodemographic characteristics and child disability.

METHODS

Preterm children (n = 94), born at <30 weeks' gestation and/or birth weight <1000 g, and term children (n = 84) were assessed at corrected age of 5 using a mother-child interaction observation. Disabilities were assessed using an intelligence test, behaviour questionnaires for parents and teachers, and motor and neurological examinations.

RESULTS

Mothers of preterm-born children were less supportive of and more interfering with their children's autonomy than mothers of term-born children. This difference was only partly explained by sociodemographic factors. Dyads showed a lower quality of mother-child interaction if children had a severe disability, especially when mothers had a lower level of education.

CONCLUSION

Five years after birth, mother-child interaction of very premature children and their mothers compared unfavourably with term children and their mothers. Mothers with sociodemographic disadvantages, raising a preterm child with severe disabilities, struggle most with giving adequate sensitive support for the autonomy development of their child. Focused specialized support for these at risk groups is warranted.

No longer pregnant, not yet a mother: giving birth prematurely to a very-low-birth-weight baby

In this article we present the findings of a qualitative examination of 30 mothers of very-low-birth-weight babies. Interviews conducted with the mothers when the babies were still in neonatal hospitalization show that virtually all the mothers described their delivery both as a traumatic event, and as a nonevent in which they felt that they barely participated. Most of them blamed themselves for not carrying full term, some blamed others, and some believed the premature delivery saved their baby's life. Following their truncated pregnancies, their "nonparticipation" in the delivery, and their separation from their newborn immediately after the delivery, virtually all the women reported difficulty grasping that they were mothers. Many reported a sense of loss, emptiness, and frustration that the baby was no longer inside. The women took a variety of measures, including magical means and parenting behaviors, to safeguard their vulnerable babies and to become mothers within the constraints of the neonatal unit.

Preventive interventions for preterm children: effectiveness and developmental mechanisms

This article provides an integrative review of the effectiveness of and possible developmental mechanisms associated with preventive interventions for preterm children. An analysis of randomized clinical trials carried out within the last 15 years was framed within a contemporary developmental model emphasizing the role of parental adjustments to preterm children's characteristics. Evidence suggested positive outcomes could be understood in terms of improvements in developmental pathways associated with parental sensitive-responsiveness and child participation in intensive intervention-oriented child care. Implications for the critical role of the Medical Home model for preventive interventions for preterm children were discussed.

The Effects of Baby Massage on Attachment between Mother and their Infants

PURPOSE

This study was conducted to examine the effect of baby massage on attachment between mothers and their newborns.

METHODS

This study was carried out from June 2008 to February 2010 in a quasi-experimental design (57 in the experimental group, 60 in the control group). Between the dates of the study, all healthy primipara mothers and their healthy babies were included. Data were collected regarding their demographic characteristics and by using the Maternal Attachment Inventory (MAI). All mothers were assessed on the first and the last days of the 38-day study period. In the experimental group, the babies received a 15-minute massage therapy session everyday during the 38 days.

RESULTS

There was no significant difference found in the pretest mean value baseline of the MAI score in both groups. The posttest mean values of the MAI of the experimental group mothers (90.87 ± 10.76) were significantly higher than those of control group (85.10 ± 15.50). There was a significant difference between groups (p < .05).

CONCLUSION

The results of the study have shown that baby massage is effective in increasing the mother-infant attachment.

The effect of extremely preterm birth on attachment organization in late adolescence

BACKGROUND

Prior studies have examined the impact of preterm birth on the quality of the attachment relationship to the mother in infancy, but few have examined extremely preterm born infants and almost no data have been reported on prematurity and its impact on the attachment organization attained after childhood.

METHODS

Thirty-nine adolescents born extremely preterm and 39 full-term born control participants were assessed with the Adult Attachment Interview.

RESULTS

The prematurely born showed lower scores regarding measures of attachment security and, in particular, a higher proportion of insecure dismissive patterns. This difference seemed to be clear and persistent even when controlled for intelligence and socio-economic variables.

CONCLUSIONS

Because insecure attachment as well as prematurity may be considered as significant risk factors for developing psychopathology, they deserve careful attention in future research and clinical follow-ups.

Family nurture intervention (FNI): methods and treatment protocol of a randomized controlled trial in the NICU

BACKGROUND

The stress that results from preterm birth, requisite acute care and prolonged physical separation in the Neonatal Intensive Care Unit (NICU) can have adverse physiological/psychological effects on both the infant and the mother. In particular, the experience compromises the establishment and maintenance of optimal mother-infant relationship, the subsequent development of the infant, and the mother's emotional well-being. These findings highlight the importance of investigating early interventions that are designed to overcome or reduce the effects of these environmental insults and challenges.

METHODS

This study is a randomized controlled trial (RCT) with blinded assessment comparing Standard Care (SC) with a novel Family Nurture Intervention (FNI). FNI targets preterm infants born 26-34 weeks postmenstrual age (PMA) and their mothers in the NICU. The intervention incorporates elements of mother-infant interventions with known efficacy and organizes them under a new theoretical context referred to collectively as calming activities. This intervention is facilitated by specially trained Nurture Specialists in three ways: 1) In the isolette through calming interactions between mother and infant via odor exchange, firm sustained touch and vocal soothing, and eye contact; 2) Outside the isolette during holding and feeding via the Calming Cycle; and 3) through family sessions designed to engage help and support the mother. In concert with infant neurobehavioral and physiological assessments from birth through 24 months corrected age (CA), maternal assessments are made using standard tools including anxiety, depression, attachment, support systems, temperament as well as physiological stress parameters. Quality of mother-infant interaction is also assessed. Our projected enrolment is 260 families (130 per group).

DISCUSSION

The FNI is designed to increase biologically important activities and behaviors that enhance maternally-mediated sensory experiences of preterm infants, as well as infant-mediated sensory experiences of the mother. Consequently, we are enlarging the testing of preterm infant neurodevelopment beyond that of previous research to include outcomes related to mother-infant interactions and mother-infant co-regulation. Our primary objective is to determine whether repeated engagement of the mother and her infant in the intervention's calming activities will improve the infant's developmental trajectory with respect to multiple outcomes. Our secondary objective is to assess the effectiveness of FNI in the physiological and psychological co-regulation of the mother and infant. We include aspects of neurodevelopment that have not been comprehensively measured in previous NICU interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01439269.

Measuring maternal stress and perceived support in 25 Italian NICUs

AIMS

To determine the validity and reliability of the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) and the Nurse Parental Support Tool (NPST) for use with Italian parents; to investigate to which extent demographic variables and/or situational factors affect NICU-related maternal stress.

METHODS

Mothers (N = 156) of very preterm (VPT) infants from 25 Italian NICUs completed a socio-demographic form, the PSS: NICU and the NPST at discharge. Psychometric properties of both tools were evaluated.

RESULTS

High internal consistency and split-half reliability were found for both measures. The multi-dimensional structure of the PSS:NICU was confirmed. Alteration in parental role emerged as the greatest source of NICU-related stress. Length of stay in NICU and familiar socio-economic status explained partial variance in the PSS: NICU scores. NPST score mitigates the stress because of the infant's appearance and behaviour, but not that related to the parental role alteration.

CONCLUSIONS

PSS: NICU and NPST demonstrated adequate psychometric properties in a large sample of Italian mothers. The need for a psychologically informed support to NICU mothers is suggested.

What helps the mother of a preterm infant become securely attached, responsive and well-adjusted?

OBJECTIVE

To investigate the relationship between the predictor variables of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support, and the criterion variables of maternal attachment, maternal psychological symptoms and maternal responsiveness, after controlling for birth weight.

DESIGN

A quantitative survey study.

METHOD

The participants were 127 mothers of preterm infants (delivery prior to 37 weeks gestation, <24 months corrected age) recruited through parent support organisations. The web-based survey included measures of: demographics, postpartum support and prenatal expectations (compared to postnatal experience)-all designed for this study, as well as maternal attachment, (MPAS) maternal responsiveness (MIRI), experiential avoidance (AAQ), maternal psychological symptoms (DASS-21) and relationship satisfaction (RQI). Three standard multiple regression analyses were conducted.

RESULTS

The combined effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support accounted for a significant 21% of variance in maternal attachment, Fch (4,121)=8.01, p<.001, a significant 38% of variance in maternal psychological symptoms Fch (4,121)=18.38, p<.001, and a significant 11% of variance in maternal responsiveness, Fch (4,121)=3.78, p=.013 after controlling for birth weight.

CONCLUSION

The four predictor variables predicted maternal attachment, psychological symptoms and responsiveness after controlling for birth weight, with experiential avoidance being the most important predictor, followed by prenatal expectations (compared to postnatal experience), relationship satisfaction, then postpartum support. This has implications for designing interventions to optimise attachment and responsiveness, and minimise psychological symptoms, in mothers of infants born preterm.

Emotional responses of mothers of late-preterm and term infants

OBJECTIVE

To compare the emotional responses of mothers of late-preterm infants (34 0/7 to 36 6/7 weeks gestation) with those of mothers of full-term infants.

DESIGN

A mixed method comparative study.

SETTING

A southeastern tertiary academic medical center postpartum unit.

PARTICIPANTS

Sixty mothers: 29 mothers of late-preterm infants and 31 mothers of full-term infants.

METHODS

Measures of maternal emotional distress (four standardized measures of anxiety, postpartum depression, posttraumatic stress symptoms, and worry about infant health) and open-ended semistructured maternal interviews were conducted in the hospital following birth and by phone at one month postpartum.

RESULTS

Mothers of late-preterm infants experienced significantly greater emotional distress immediately following delivery, and their distress levels continued to be higher at one month postpartum on each of the standardized measures. Mothers of late-preterm infants also discussed the altered trajectories in their birth and postpartum experiences and feeling unprepared for these unexpected events as a source of ongoing emotional distress.

CONCLUSION

Mothers of late-preterm infants have greater emotional distress than mothers of term infants for at least one month after delivery. Our findings suggest that it may not be a single event that leads to different distress levels in mothers of late-preterm and full-term infants but rather the interaction of multiple alterations in the labor and delivery process and the poorer-than-expected infant health outcomes. In the future, researchers need to examine how and when mothers' emotional responses change over time and how their responses relate to parenting and infant health and development.

Reliability of the assessment of mother-infant sensitivity-chinese version for preterm and term taiwanese mother-infant dyads

PURPOSE

The objectives of this study were to translate and modify the Assessment of Mother-Infant Sensitivity scale into a Chinese version (modified AMIS-C) and to examine its reliability with preterm and term Taiwanese mother-infant dyads.

METHOD

A total of 241 mother-infant pairs (179 preterm dyads and 62 term dyads) were prospectively recorded and their behaviour in feeding assessed using the modified AMIS-C when infants were at 4 and 6 months corrected age. A subset of the sample was used for interrater reliability testing, and the whole sample was used for assessment of internal consistency.

RESULTS

Interrater reliability was high for the modified AMIS-C section and total scores (intra-class correlation coefficients=0.91-0.99). Internal consistency was good to excellent for the maternal section and total score (α=0.71-0.86) and was fair to good for the infant and dyadic section score (α=0.44-0.75).

CONCLUSIONS

The modified AMIS-C scale is a clinically feasible and reliable instrument for assessing mother-infant interaction of preterm and term dyads during early infancy.

Separation anxiety disorder increases among neonatal intensive care unit graduates

AIM

To evaluate whether separation anxiety disorder (SAD) develops in the later life of the infants, who were separated from their mothers in relation to being in neonatal intensive care unit (NICU).

METHODS

A group of 57 children, ages over 6 years old who were cared in NICU has been evaluated retrospectively by using the SAD diagnostic scale which is adapted according to DSM-IV. Another age and sex matched 50 children who admitted to the outpatient unit were selected as control group.

RESULTS

We found that the scores and incidence of SAD were increased among children who were cared in the NICU and both were correlated with the duration of stay in the NICU.

CONCLUSION

The NICU should be arranged to support the development of the baby. Families should be informed about the necessity of sustaining an early mother-infant interaction. By supporting mother-infant interaction, it will be provided that the baby will establish a more secure relation with his/her mother, develop more healthy and have less behavior problems in the future life.

Mental health concerns of the premature infant through the lifespan

Because of increased survival rates, neurodevelopmental issues, chronic medical problems, and sometimes complex family issues involved with prematurity, mental health clinicians commonly assess preterm clients and manage their behavioral and mental health problems. Understanding prematurity survival and neurodevelopmental outcomes is important for contextualizing the mental health problems seen in this high-risk population. This article provides a brief overview of prematurity outcomes in the domains of prematurity relevant to practicing child psychiatrists. Prematurity is also examined as it relates to parental mental health challenges, infant mental health outcomes, high frequency attention problems, and psychiatric disorders. The complex interactions between prematurity and family well-being are also highlighted. Finally, evidence-based treatment modalities involved in prevention and management are explored.

Maternal speech to preterm infants during the first 2 years of life: stability and change

BACKGROUND

Studies on typical language development documented that mothers fine-tune their verbal input to children's advancing skills and development. Although premature birth has often been associated with delays in communicative and language development, studies investigating maternal language addressed to these children are still rare.

AIMS

The principal aim of this longitudinal study was to investigate the maternal speech directed at very preterm children by examining its changes across time and the stability of maternal individual styles.

METHODS & PROCEDURES

A sample of 16 mother-preterm infant dyads participated in semi-structured play sessions when children were 6, 12, 18 and 24 months of corrected age. Maternal speech directed at the children was analysed in terms of lexical and syntactical complexity as well as verbal productivity. Also children's motor, cognitive and communicative skills were assessed.

OUTCOMES & RESULTS

Results highlight an overall increase in the lexical and syntactical complexity and in the amount of maternal speech across the first years of life. At the same time, individual maternal communicative styles seem stable as infants grow older, even if between 12 and 18 months all the indices' predictive values decrease, indicating a noteworthy modification in individual maternal styles. Furthermore, between 12 and 18 months predictive relationships between children's motor and vocal skills and maternal changes in input were found.

CONCLUSIONS & IMPLICATIONS

Verbal input addressed to children born preterm during the first 2 years of life does not seem to differ considerably from the language usually used with full-term infants. Nevertheless, maternal verbal adjustments seem to be predicted by earlier infant achievements in vocal and motor development. This suggests that infants' motor skill maturation may function as a major signal for mothers of preterm babies to adjust aspects of their linguistic interactive style.

Biopsychosocial risk factors for preterm birth and postpartum emotional well-being: a case-control study on Turkish women without chronic illnesses

AIMS AND OBJECTIVES

The study aimed to determine bio-psycho-social risk factors for preterm birth in a sample of Turkish women without chronic illnesses and evaluate their anxiety and depression in early postpartum period.

BACKGROUND

Preterm birth is a devastating event with long-term health and social implications. Studies have identified several risk factors; however, the contribution of these causes differs by ethnic groups.

DESIGN

This case-control study was conducted in a tertiary hospital in Istanbul over one year. In total, 149 preterm mothers were included in the case group and 150 term mothers who delivered in the same day with a case group woman were included in the control group. Chronic illnesses and anomalies were excluded.

METHOD

Data were gathered using a form that addressed risk factors for preterm birth. Multidimensional Scale of Perceived Social Support, Beck Depression Inventory and Spielberger's State-Trait Anxiety Inventory were administered within 24-72 hours after birth.

RESULTS

Logistic regression analysis revealed that partner's lower education (≤ 8 years), history of preterm birth, antenatal hospitalisation, genitourinary infection and irregular prenatal care were significant risk factors. Perceived social support from family and friends were significantly lower in preterm group. Preterm mothers experienced significantly more anxiety and depressive symptoms in early postpartum.

CONCLUSION

Many of the socio-economical and obstetric causes of preterm births were similar to other countries with higher preterm birth rates. Preterm births were associated with lower social support along with more anxiety and depressive symptoms in early postpartum.

RELEVANCE TO CLINICAL PRACTICE

Women who have established risk factors can be targeted for more intensive antenatal care for the prevention of preterm birth. Increased maternal anxiety and depression reveal the necessity of emotional support immediately after birth.

Mothers seeing their VLBW infants within 3 h after birth are more likely to establish a secure attachment behavior: evidence of a sensitive period with preterm infants?

OBJECTIVE

Close contact of mother and child in the first hours after birth is essential for the establishment of a secure attachment behavior in term infants. To date, studies investigating whether a 'sensitive period' also exists for very low birth weight (VLBW) preterm infants are lacking.

STUDY DESIGN

Attachment patterns of 62 VLBW infants were assessed using the 'strange situation' setting and correlated with the time mothers saw their child for the first time. Furthermore, maternal and infant covariates possibly influencing the attachment behavior were analyzed. As maternal factors the mother's age, social status and pregnancy history were recorded and at three time points (time 1, 2 and 3 (t-1, t-2 and t-3)), a semi-structured interview, a depression and a social support questionnaire were performed. As infant factors neonatal basic data, ventilation time and length of hospital stay were recorded. Disease severity was scored using the clinical risk index for babies, score for neonatal acute physiology (SNAP), SNAP perinatal extension and nursery neurobiological risk score. At time points t-2 and t-3, the infants were examined using the second edition of Bayley scales of infant development.

RESULTS

In all, 53.2% of the children showed a secure, 33.9% an insecure-avoidant, 3.2% an insecure-ambivalent and 9.7% an insecure-disorganized attachment behavior. Preterm infants whose mothers had seen them within 3 h after birth had a higher rate of secure attachment than preterm infants with no early contact (76 versus 41%, P=0.009). Firstborns showed a significantly higher rate of insecure attachment behavior (93 versus 67%, P=0.01). No influence on attachment behavior was shown for any other maternal or infant factor.

CONCLUSIONS

Our results support the hypothesis that the first hours after birth are a 'sensitive period' for the development of attachment behavior in VLBW infants. When a mother is enabled to see her infant shortly after birth, the 'sensitive period' right after birth may be used to help forming an important basis for the secure attachment of the preterm infant.

Declining cognitive development from 8 to 18 months in preterm children predicts persisting higher parenting stress

BACKGROUND

Higher parenting stress in mothers of children born very preterm may be in part a response to poorer neurobehavioral development, reflecting realistic concerns in addition to adaptation to the trauma of preterm delivery. To our knowledge, there are few longitudinal studies of parenting stress that have addressed child cognitive competence.

AIMS

To examine parenting stress in preterm and full-term children at 8 and 18 months corrected chronological age (CCA), in relation to child cognitive development and behavior.

SUBJECTS

Participants were N=152 children (98 preterm born ≤32 weeks gestation, and 54 full-term) seen at 8 and 18 months CCA, and the primary caregiver parent. STUDY DESIGN/OUTCOME MEASURES: The Parenting Stress Index questionnaire was completed by a parent, child interactive behavior was videotaped, and the Bayley Scales of Infant Development (BSID II, Mental Development Index; MDI) were administered at both ages.

RESULTS

Total Parenting Stress was higher in preterm than full-term children at 8 and 18 months CCA (p<.02), accounted for primarily by the Child domain. Hierarchical regression showed (after controlling for neonatal risk, number of children in the home, child interactive behavior and maternal education) that decreasing Bayley MDI scores from 8 to 18 months CCA predicted higher parenting stress for preterm children. For full-term children, number of children in the home and child interactive behavior predicted parental stress at 18 months.

CONCLUSION

Higher parenting stress persisting to 18 months CCA in preterm children may partly reflect realistic parental concerns with their child's development.

The relationship between intimate partner violence and children's asthma in 10 US states/territories

Intimate partner violence (IPV) has been shown to negatively impact the health of both the adults who experience IPV and the children who are exposed to IPV. Although IPV experienced by women has been linked to children's asthma, this study is the first to examine this question among both women and men, and the first study in the United States to examine this question as part of a population-based data set. In 2005, ten US states/territories administered an IPV module and a children's asthma module within the Behavioral Risk Factor Surveillance System (BRFSS). Lifetime IPV was assessed by four questions that asked about threatened, attempted, or completed physical violence, as well as unwanted sex, by a current or former intimate partner. The children's asthma module asked respondents to report whether a randomly selected child in their household had ever been diagnosed with asthma and whether the same child currently had asthma. Women who experienced lifetime IPV, in contrast to women who never experienced IPV, were significantly more likely to report that their children had ever had asthma and currently have asthma. Among men, significant differences were not found when comparing men who reported lifetime IPV to those that did not report lifetime IPV. The results highlight the importance of primary prevention of IPV, as reducing the occurrence of IPV could improve not only the long-term health of those who experience IPV but also the health of their children.

Maternal resolution of grief after preterm birth: implications for infant attachment security

OBJECTIVE

This study explored the association between mothers' unresolved grief regarding their infant's preterm birth and infant-mother attachment security. We hypothesized that mothers with unresolved grief would be more likely to have insecurely attached infants at 16 months and that this association would be partially mediated by maternal interaction quality.

METHODS

This longitudinal study focused on 74 preterm infants (age of <36 weeks) and their mothers who were part of a larger study of high-risk infants. The present analysis included assessment of neonatal and socioeconomic risks at NICU discharge; maternal depression, Reaction to Preterm Birth Interview findings, and quality of parenting at a postterm age of 9 months; and infant-mother attachment at postterm age of 16 months. Associations among findings of grief resolution with the Reaction to Preterm Birth Interview, quality of parenting interactions, and attachment security were explored by using relative risk ratios and logistic and multivariate regression models.

RESULTS

The relative risk of developing insecure attachment when mothers had unresolved grief was 1.59 (95% confidence interval: 1.03-2.44). Controlling for covariates (adjusted odds ratio: 2.94), maternal feelings of resolved grief regarding the preterm birth experience were associated with secure infant-mother attachment at 16 months. Maternal grief resolution and interaction quality were independent predictors of attachment security.

CONCLUSION

Maternal grief resolution regarding the experience of preterm birth and the quality of maternal interactions have important implications for emerging attachment security for infants born prematurely.

Prematurity, maternal posttraumatic stress and consequences on the mother-infant relationship

OBJECTIVE

Premature birth is a stressful experience for parents. This study explores the links between maternal posttraumatic stress, maternal attachment representations of the infant and mother-infant dyadic interactions.

METHODS

The study enrols 47 preterm (GA<34 weeks) and 25 full-term infants. The Perinatal Posttraumatic Stress Disorder Questionnaire was administered to evaluate maternal posttraumatic stress symptoms. At 6 months of corrected age, maternal attachment representations of the infant were explored and coded with the Working Model of the Child Interview. Interactive characteristics were explored in a videotaped play session and coded with the Care Index.

RESULTS

Full-term mothers were more likely to follow a "Cooperative" dyadic pattern of interaction with the infant and demonstrate Balanced representations of the infant. Preterm mothers with high posttraumatic stress symptoms were more likely to follow a "Controlling" dyadic pattern of interaction, with more Distorted representations. In contrast, preterm mothers with low posttraumatic stress symptoms were more likely to fall into a "Heterogeneous" group of patterns of dyadic interaction, with Disengaged representations. Interestingly, in Cooperative preterm dyads, only 23% of the mothers demonstrated Balanced representations, despite rates of 69% in full-term Cooperative dyads.

CONCLUSION

Premature birth affects both mother-infant interaction characteristics and maternal representations of attachment with the infant. In particular, a "Controlling" dyadic pattern was associated with high maternal posttraumatic stress symptoms and Distorted maternal representations. It is important to examine the impact of maternal posttraumatic stress on the parent-infant relationship in order to plan supportive, preventive interventions in the neonatal period.

Morbidity and discharge timing of late preterm newborns

Late preterm newborns (LPNs), those with gestational ages (GAs) between 34 weeks and 36 weeks 6 days, account for 70% of preterm births. Because they have a mature appearance and are often cared for in a well baby nursery (WBN), parents may anticipate that the nursery course will be similar to that of a term infant and that their newborn will be discharged with his/her mother. How frequently their hospitalizations are prolonged beyond that of their mothers and the morbidities associated with prolonged hospitalization (PH) have not been well described. The objectives of the study were to (1) determine the proportion of LPNs with a PH and (2) describe the most common morbidities in LPNs and identify those associated with PH. The authors conducted retrospective chart reviews of the neonatal courses of LPNs born between December 2002 and April 2007 at the University of Utah Hospital. They compared maternal and newborn discharge dates to determine the proportion of LPNs with a PH and calculated frequencies of conditions and interventions indicating morbidity and identified associations between each of the conditions/interventions and PH. Of 235 LPNs, 94 (40%) had a PH; 75% of 34-week LPNs had a PH compared with 50% of those with GAs of 35 weeks and 25% of those with GAs of 36 weeks. The most common conditions/interventions were an oxygen need, phototherapy for jaundice, and hypothermia requiring an isolette. A need for nasogastric feeding and antibiotic administration for >3 days was consistently associated with a PH. LPNs whose only intervention was phototherapy for jaundice or IV antibiotics for <3 days did not have a PH. As a group, two thirds of LPNs experienced one or more conditions/interventions indicating morbidity, and 40% had a PH. Both were much more common in LPNs with GAs of 34 weeks compared with LPNs with GAs of 36 weeks. Nursery clinicians should counsel parents of LPNs regarding the likely possibility of morbidity and PH.

Cortisol levels in relation to maternal interaction and child internalizing behavior in preterm and full-term children at 18 months corrected age

Cortisol levels were compared in children born preterm at extremely low gestational age (ELGA; 24-28 weeks), very low gestational age (VGLA; 29-32 weeks), and full-term in response to cognitive assessment at 18 months corrected age (CA). Further, we investigated the relationship between maternal interactive behaviors and child internalizing behaviors (rated by the mother) in relation to child cortisol levels. EGLA children had higher "pretest" cortisol levels and a different pattern of cortisol response to cognitive assessment compared to VGLA and full-terms. Higher cortisol levels in ELGA, but not full-term, children were associated with less optimal mother interactive behavior. Moreover, the pattern of cortisol change was related to internalizing behaviors among ELGA, and to a lesser degree VLGA children. In conclusion, our findings suggest altered programming of the hypothalamic-pituitary-adrenal (HPA) axis in preterm children, as well as their greater sensitivity to environmental context such as maternal interactive behavior.

Mothers' different styles of involvement in preterm infant pain care

OBJECTIVE

To describe and understand how mothers utilize the opportunity to actively participate in their preterm infants' pain care using facilitated tucking by parents (FTP).

DESIGN

Descriptive and exploratory study with postintervention interview.

SETTING

Finnish level III Neonatal Intensive Care Unit (NICU).

PARTICIPANTS

Twenty-three mothers who had preterm infants born at gestational ages of 32 to 34 weeks.

METHODS

The parents (N=45) of 29 preterm infants were taught to use FTP. In addition, all nurses in the NICU (N=76) received the same education to support the parents' use of FTP. After 2 to 4 weeks of FTP use, the mothers (n=23) were interviewed using the Clinical Interview for Parents of High-Risk Infants with additional questions related to the infants' pain care. The interviews were analyzed inductively with cross-case analysis and deductively with a previously developed coding scheme.

RESULTS

Facilitated tucking by parents was perceived positively and was used by all participating mothers. Three different styles of involvement in preterm infants' pain care with FTP were identified. They formed a continuum from external to random and finally to internalized involvement. In external involvement, the pain care with FTP was triggered by outside factors such as nurses, whereas in random and internalized involvement the motivation emerged from a parent. Mothers with external involvement thought that any person could apply the FTP. In random involvement, mothers were mainly absent during painful procedures, although they saw themselves as the best caregivers. In internalized involvement, the responsibility for infant pain care was shared within the family. Mothers' NICU-related stress and maternal attachment were associated with this variation.

CONCLUSION

This study showed that mothers' are willing to actively participate in their preterm infants' pain care. However, the participation is unique according to mother and her experiences before and during NICU admission. Nurses need to consider these differences in mothers when involving them in preterm infants' pain care.

Effectiveness of applying empowerment strategies when establishing a support group for parents of preterm infants

AIMS

The objectives of this study were to apply empowerment strategies to the establishing of a support group for parents of preterm infants who were recently discharged home and to examine its effectiveness in terms of self-efficacy, perceived stress and depression among the parents.

BACKGROUND

While the concept of empowerment has been applied when establishing various patient support groups, it has not been explicitly used for parents of preterm infants.

DESIGN

This study applied a quasi-experimental design.

METHOD

The inclusion criteria were parents of infants with a birth gestational age of <37 weeks who were expected to be discharged home within one week. A total of 70 parents of preterm infants participated in this study, made up of 35 participants each in the intervention and in the control groups. The intervention group received three months of support applying empowerment strategies, while the control group received usual care only.

RESULTS

The results, relative to the control group at post-test, demonstrated that the intervention group showed significantly higher scores for self-efficacy when using resources as well as significantly decreased scores for depression. For parents of preterm infants with a very low birth weight, the intervention group showed a significant decrease in perceived stress relative to controls, but this was not seen in parents of preterm infants without very low birth weight. There was no significant difference in the scores for self-efficacy when performing parental roles.

CONCLUSIONS

his study demonstrated the effectiveness of support groups for parents of preterm infants that apply empowerment strategies, which decreased parental depressive symptomatology and increased parental self-efficacy when utilising resources. The intervention also effectively decreased the perceived stress level in parents of infants with very low birth weight.

RELEVANCE TO CLINICAL PRACTICE

Health professionals should apply empowerment strategies when establishing parental support groups for preterm infants.

Maternal health after the birth of a medically complex infant: setting the context for evaluation of co-occupational performance

OBJECTIVE

Physical and psychological health indicators of mothers who gave birth to medically complex infants were examined to explore potential risk factors for the development of chronic conditions and to develop a scholarly base that supports the inclusion of maternal health in the scope of early intervention practice.

METHOD

Ten mothers completed the Perinatal Posttraumatic Stress Disorder Questionnaire and the State Trait Anxiety Form Y-1. Nine women completed 24-h Holter recording. Frequency of symptoms of posttraumatic stress disorder (PTSD) and anxiety were determined. High frequency heart rate variability was examined for indicators of autonomic dysregulation.

RESULTS

Nine of 10 women reported symptoms associated with PTSD, and 2 of these women reported more severe symptoms. Two women demonstrated indicators of autonomic dysregulation.

CONCLUSION

Further research examining psychological and physical characteristics in mothers of infants at high risk is important to determine whether these women are at greater risk for chronic health conditions.

Effects of gender on the health and development of medically at-risk infants

OBJECTIVES

To examine gender-differentiated health and cognitive/motor/language developmental outcomes among medically at-risk infants.

DESIGN

Longitudinal descriptive and comparative secondary analysis.

SETTING

Neonatal Intensive Care Unit, intermediate care unit, and infectious disease clinic of tertiary medical centers in the southeast and east United States.

PARTICIPANTS

One hundred eight (108) premature infants, 67 medically fragile infants, and 83 infants seropositive for HIV.

METHODS

Neonatal and later health variables were obtained from the medical record to determine the technology dependence scores and frequency of common health problems. Data for physical growth and cognitive/motor/language development were obtained through the physical measurement, including the Bayley Scales of Infant Development-Second Edition, the Vineland Adaptive Behavior Scale, the Toll Control Developmental Checklist, and the Preschool Language Scale-3 during home visits between 6 and 27 months corrected ages.

RESULTS

Fewer effects on health and developmental outcomes related to gender were observed with medically fragile infants than the other two groups of infants. The cognitive/motor/language scores were decreased with increasing age of the infants in all groups.

CONCLUSION

Male gender can be considered a significant biological risk factor for infants' cognitive and motor development, especially for premature infants. Because of their increased risk, it is recommended that male infants who are born prematurely or seropositive for HIV have early and advanced developmental screening tests by trained personnel through periodic pediatric clinic.

Late-preterm birth, maternal symptomatology, and infant negativity

The present study examined infant negativity and maternal symptomatology by term status in a predominately low-income, rural sample of 132 infants (66 late-preterm) and their mothers. Late-preterm and term infants were group-matched by race, income, and maternal age. Maternal depression and anxiety symptoms were measured with the Brief Symptom Inventory 18 (BSI-18) when infants were 2 and 6 months of age. Also at 6 months, infant negativity was assessed by global observer ratings, maternal ratings, and microanalytic behavioral coding of fear and frustration. Results indicate that after controlling for infant age, late-preterm status predicted higher ratings of infant negativity by mothers, but not by global observers or microanalytic coding, despite a positive association in negativity across the three measures. Further, mothers of late-preterm infants reported more elevated and chronic co-morbid symptoms of depression and anxiety, which in turn, was related to concurrent maternal ratings of their infant's negativity. Mothers' response to late-preterm birth and partiality in the assessment of their infant's temperament is discussed.

Romantic attachment in young adults with very low birth weight - The Helsinki Study of Very Low Birth Weight Adults

Early attachment relationships from infancy onward contribute to attachment patterns later in life, to the ability to build up close relationships and to well-being in general. Severely preterm birth may challenge the development of these attachment relationships. We studied whether there are differences in attachment patterns related to romantic relationships between young adults (mean age 22.4 years, s.d. 2.2 years) with very low birth weight (VLBW, <1500 g; n = 162) and their peers born at term (n = 172), who completed the Experiences in Close Relationships Questionnaire - Revised. Young adults born at VLBW showed lower attachment-related anxiety than their peers born at term (mean difference -9.5%, 95% CI -16.0 to -2.6) when adjusted for sex, age, parental education and being in a romantic relationship currently. The groups did not differ in attachment-related avoidance. In subgroup analyses, the VLBW women born small for gestational age (SGA, birth weight <-2 s.d.) scored on average 14.8% (95% CI 3.1-26.6) higher than the control women on attachment avoidance. The effects remained after the exclusion of 18 participants with neurosensory deficits. We found no evidence for a compromised attachment pattern in young adults born at VLBW, with a possible exception of women born SGA at VLBW. VLBW adults were rather characterized by a lower level of attachment-related anxiety.

DMM assessments of attachment and adaptation: Procedures, validity and utility

This article gives a brief over view of the Dynamic-Maturational Model of attachment and adaptation (DMM; Crittenden, 2008) together with the various DMM assessments of attachment that have been developed for specific stages of development. Each assessment is discussed in terms of procedure, outcomes, validity, advantages and limitations, comparable procedures and areas for further research and validation. The aims are twofold: to provide an introduction to DMM theory and its application that underlie the articles in this issue of CCPP; and to provide researchers and clinicians with a guide to DMM assessments.