Maternal stress and depressive symptoms associated with quality of developmental care in 25 Italian Neonatal Intensive Care Units: A cross sectional observational study

Prevalence of and factors associated with postnatal depression and anxiety among parents of preterm infants: A systematic review and meta-analysis

BACKGROUND

This study aimed to determine the prevalence of and factors associated with postpartum depression and anxiety among mothers and fathers of preterm infants and to examine the relationships between maternal and paternal symptoms.

METHODS

Six electronic databases were searched to identify eligible studies reporting parental depression and anxiety within 1 year postpartum. Data were extracted for a random-effects meta-analysis to estimate the prevalence with 95 % confidence intervals (CIs). Subgroup and meta-regression analyses were conducted to analyze associations between study characteristics and prevalence estimates.

RESULTS

In total, 79 studies were included. The meta-analysis of studies on mothers generated estimates of prevalence for depression (29.2 %, 95 % CI, 21.8 %-37.9 %) and anxiety (37.7 %, 95 % CI, 24.1 %-53.6 %). The meta-analysis of fathers indicated a pooled depression prevalence of 17.4 % (95 % CI, 12.5 %-23.8 %) and an anxiety estimate of 18.3 % (95 % CI, 8.1 %-36.3 %). Assessment time points and methods as well as the geographic continent in which the study was conducted were significant moderators of depression and anxiety. Significant inter-correlations were found between mothers' and fathers' depression and anxiety symptoms (p < 0.05).

LIMITATIONS

Limited data from specific geographic continents, including Africa and Asia.

CONCLUSIONS

Prevalence of depression and anxiety among preterm infants' parents was high, highlighting the need for early psychological screening and assessment. Further research is required to improve services that focus on parents' postpartum psychological needs in the family context.

Factors Influencing Mothers' Quality of Sleep during Their Infants' NICU Hospitalization

STUDY OBJECTIVES

The purpose of this study is to identify factors associated with Neonatal Intensive Care Unit (NICU) mothers' quality of sleep as measured with the General Sleep Disturbance Scale (GSDS).

METHODS

Recruitment took place in a level 3 NICU. At enrollment, mothers completed a socio-demographic questionnaire, described their presence in the unit and their breast milk expression behavior. They also completed online or paper questionnaires about NICU-related stress, symptoms of postpartum depression, family-centered care, perception of noise and light in the unit, and sleep disturbances. Data regarding the infant's clinical condition were collected from their medical file. Pearson correlations were performed to identify associations between mothers' quality of sleep and other study variables. Subsequently, to compare mothers with a clinically significant GSDS score to mothers with a non-significant score, a binary logistic regression model was conducted.

RESULTS

132 mothers participated. Sleep disturbances of mothers with an infant hospitalized in the NICU was positively correlated with stress (r = 0.40; p = .00), depressive symptoms (r = 0.51; p = .00), and breast milk expression (r = 0.23; p = .01). In addition, for mothers with significant levels of depressive symptoms (OR = 1.19; p = .00), with greater presence in the unit (OR = 1.36; p = .04), or with other children at home (OR = 3.12; p = .04), the likelihood of clinically significant sleep disturbances was increased.

CONCLUSIONS

These results improve our understanding of the factors influencing the quality of sleep of mothers whose premature infant is hospitalized for 2 weeks or more in the NICU. In addition, these results allow the identification of mothers having a higher possibility for sleep disturbance, which enables the implementation of targeted interventions to promote adequate sleep.

COVID-19 restrictions and psychological well-being of fathers with infants admitted to NICU-An exploratory cross-sectional study

AIM

To describe the impact of the COVID-19 restrictions on the caregiving activities and psychological well-being of fathers with infants admitted to neonatal units.

METHODS

Cross-sectional study using adapted COPE-IS and COPE-IU tools. Participants' recruitment occurred online via social media and parents' associations. Online survey in English, French and Italian were distributed and promoted via websites and social media platforms of parent's associations. The study was undertaken across 12 countries in Asia, Australia, Africa and Europe.

RESULTS

A total of 108 fathers of NICU infants completed the survey. COVID-19 related restrictions were categorised into 3 types: no restrictions, partial and severe restrictions. Fathers who experienced partial restrictions reported more involvement in caregiving activities but high levels of emotional difficulties and sleeping problems compared to those who experienced full or no restrictions.

CONCLUSION

Given the impact on the psychological well-being of fathers, restrictions should be avoided as much as possible in the neonatal unit and fathers given free access to their infants if they follow appropriate infection control precautions.

Maternal speech decreases pain scores and increases oxytocin levels in preterm infants during painful procedures

Preterm infants undergo early separation from parents and are exposed to frequent painful clinical procedures, with resultant short- and long-term effects on their neurodevelopment. We aimed to establish whether the mother's voice could provide an effective and safe analgesia for preterm infants and whether endogenous oxytocin (OXT) could be linked to pain modulation. Twenty preterm infants were exposed to three conditions-mother's live voice (speaking or singing) and standard care-in random order during a painful procedure. OXT levels (pg/mL) in saliva and plasma cortisol levels were quantified, and the Premature Infant Pain Profile (PIPP) was blindly coded by trained psychologists. During the mother's live voice, PIPP scores significantly decreased, with a concomitant increase in OXT levels over baseline. The effect on pain perception was marginally significant for singing. No effects on cortisol levels were found. The mother's live voice modulated preterm infants' pain indicators. Endogenous OXT released during vocal contact is a promising protective mechanism during early painful interventions in at-risk populations.

Reliability and Validity of the Arabic Version of the Parental Stressor Scale and Nurse Parental Support Tool: Opening Up Research on Parental Needs in Neonatal Intensive Care Units in Egypt

BACKGROUND

The admission of a newborn infant to a neonatal intensive care unit (NICU) due to preterm birth or high-risk conditions, such as perinatal injury, sepsis, hypoxia, congenital malformation, or brain injury, is a stressful experience for mothers. There is currently a lack of research on maternal perceived stress and support in Egyptian NICUs and no validated Arabic tool to investigate this further.

PURPOSE

To determine the reliability and validity of the Arabic language versions of the Parental Stressor Scale: NICU (PSS:NICU) and the Nurse Parental Support Tool (NPST).

METHODS

Egyptian mothers completed the PSS:NICU and the NPST at the time of their infants' discharge from the NICU. Reliability was assessed with Cronbach α and Spearman-Brown coefficient. The multifactorial structure of the PSS:NICU Arabic version was tested. Associations with sociodemographic and clinical variables were explored with bivariate correlations and t tests.

RESULTS

Sixty-eight mothers of preterm (PT) infants and 52 mothers of ill full-term (IFT) infants completed the study. Mothers of PT and IFT infants did not differ for sociodemographic variables. High internal consistency (α range between .93 and .96) emerged for both tools. Spearman-Brown coefficients ranged between 0.86 and 0.94. The multidimensional structure of the PSS:NICU was confirmed and 3 core dimensions explained up to 71.48% of the variance. Perceived nursing support did not diminish the effects of stress in mothers of infants admitted to the NICU, regardless of PT or IFT infants' status. A longer NICU stay was associated with greater stress in mothers of PT infants. The presence of comorbidities was significantly associated with stress of mothers of IFT infants.

IMPLICATIONS FOR RESEARCH

Future research is needed to develop evidence-based support for mothers whose infants are admitted to a NICU in Egypt. The availability of validated and reliable PSS:NICU and NPST scales in Arabic will facilitate cross-country and cross-cultural research on maternal stress in the NICU.

IMPLICATIONS FOR PRACTICE

Neonatal care nurses in Egypt will be able to increase their understanding of the stressors experienced by mothers of infants admitted to the NICU. This will in turn enable the introduction of neonatal care policies aimed at reducing specific stressors and provide improved maternal support.

An integrative review of maternal distress during neonatal intensive care hospitalization

To synthesize literature addressing maternal distress and associated variables in response to infant hospitalization in the NICU. CINAHL, Medline, PubMed, PsychINFO, and Scopus were searched for studies addressing maternal distress during NICU hospitalization published between January 2009 and August 2019. The initial literature search yielded 862 articles. Articles were included for analysis if (a) they were peer-reviewed, (b) maternal distress was defined or measured, and (c) maternal distress occurred in the NICU. Ultimately, 33 articles were included for analysis. Distress symptoms were not consistently measured across the literature by one specific instrument. However, despite the variety of instruments, distress was prevalent in this population. Individual elements of maternal distress in the NICU include depression, anxiety, trauma, and post-traumatic stress symptoms. These elements often occur together and tend to follow a specific trajectory during hospitalization. This body of literature was inconsistent regarding the timing of distress measurement as well as the relationship between relevant associated variables (e.g., marital status or infant illness severity) and maternal distress. Additionally, researchers often excluded mothers of non-preterm infants and infants with congenital anomalies from investigation. Researchers and clinicians should carefully consider timing and instrumentation in their interpretations of maternal distress measurement during a NICU hospitalization. Future work should focus on developing a comprehensive, valid, and reliable screening tool for clinicians and researchers to use to identify maternal distress in the NICU. Additionally, future research should address gaps in the populations included in studies.

Nursing Interventions to Reduce Stress in Families of Critical Care Patients: An Integrative Review

BACKGROUND

Having a family member admitted to an intensive care unit is a stressful experience that may lead to psychological symptoms including depression, anxiety, and posttraumatic stress disorder.

OBJECTIVE

To better understand the phenomenon of stress experienced by families of intensive care unit patients and identify nursing interventions that may help reduce it.

METHODS

An integrative literature review was performed to identify principal stressors for families of patients receiving care in neonatal, pediatric, and adult intensive care units and recommended nursing interventions.

RESULTS

The principal stressors in the 3 types of intensive care units were change in parental role or family dynamics, appearance and behavior of the patient, the care setting, and communication with the health care staff. Nursing interventions should focus on valuing the role of family members in patient care, improving communication, and providing accurate information.

CLINICAL RELEVANCE

Family members of intensive care patients will benefit from nursing interventions that adequately acknowledge and address the stress they experience.

CONCLUSION

Nurses play a crucial role in helping to reduce the stress experienced by family members of intensive care unit patients.

A global perspective on parental stress in the neonatal intensive care unit: a meta-analytic study

OBJECTIVES

The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) is a well-validated tool to assess different sources of stress in parents during the NICU hospitalization of their infant. The present meta-analytic study assessed the relative impact of different NICU-related sources of parental stress in a pool of studies conducted in a wide set of different countries. Also, differences in stress levels by parent gender and country, as well as the impact of infants' neonatal characteristics and clinical conditions were explored.

METHODS

Records were searched on PubMed, Scopus, and Web of Science (January 1993-December 2019). A purposive open search string was adopted: ["PSS:NICU"] OR ["PSS-NICU"] OR ["Parental Stressor Scale"]. A multiple random-effect meta-analysis was conducted on data from 53 studies extracted by independent coders.

RESULTS

Parental role alteration emerged as the greatest source of stress for both mothers and fathers. Mothers reported higher stress levels compared to fathers. A significant difference emerged only for the subscale related to sights and sounds physical stimuli. No significant effects of infants' neonatal characteristics (gestational age, birth weight) and clinical conditions (comorbidities) emerged. A marginal positive effect of NICU length of stay emerged on the global level of parents' stress.

CONCLUSIONS

The current meta-analysis underlines that parental stress related to NICU admission is a worldwide healthcare issue. Immediate and tailored support to parents after the birth of their at-risk infant should be prioritized to reduce parental stress and to promote mothers and fathers' emotional well-being and new-born neurodevelopmental outcomes.

Healthcare Satisfaction and Unmet Needs Among Bereaved Parents in the NICU

BACKGROUND

Learning directly from bereaved parents about their experiences in the neonatal intensive care unit (NICU) can improve services at end-of-life (EOL) care. Parents who perceive that their infant suffered may report less satisfaction with care and may be at greater risk for distress after the death. Despite calls to improve EOL care for children, limited research has examined the EOL experiences of families in the NICU.

PURPOSE

We examined parent perceptions of their infant's EOL experience (eg, symptom burden and suffering) and satisfaction with care in the NICU.

METHODS/SEARCH STRATEGY

Forty-two mothers and 27 fathers (representing 42 infants) participated in a mixed-methods study between 3 months and 5 years after their infant's death (mean = 39.45 months, SD = 17.19). Parents reported on healthcare satisfaction, unmet needs, and infant symptoms and suffering in the final week of life.

FINDINGS/RESULTS

Parents reported high levels of healthcare satisfaction, with relative strengths in providers' technical skills and inclusion of the family. Greater perceived infant suffering was associated with lower healthcare satisfaction and fewer well-met needs at EOL. Parents' understanding of their infant's condition, emotional support, communication, symptom management, and bereavement care were identified as areas for improvement.

IMPLICATIONS FOR PRACTICE

Parents value comprehensive, family-centered care in the NICU. Additionally, monitoring and alleviating infant symptoms contribute to greater parental satisfaction with care. Improving staff knowledge about EOL care and developing structured bereavement follow-up programs may enhance healthcare satisfaction and family outcomes.

IMPLICATIONS FOR RESEARCH

Prospective studies are needed to better understand parental perceptions of EOL care and the influence on later parental adjustment.

Pain, Parental Involvement, and Oxytocin in the Neonatal Intensive Care Unit

Preterm infants (PTI) typically experience many painful and stressful procedures or events during their first weeks of life in a neonatal intensive care unit, and these can profoundly impact subsequent brain development and function. Several protective interventions during this sensitive period stimulate the oxytocin system, reduce pain and stress, and improve brain development. This review provides an overview of the environmental risk factors experienced by PTI during hospitalization, with a focus on the effects of pain, and early maternal separation. We also describe the long-term adverse effects of the simultaneous experiences of pain and maternal separation, and the potential beneficial effects of maternal vocalizations, parental contact, and several related processes, which appear to be mediated by the oxytocin system.

Developmental care, neonatal behavior and postnatal maternal depressive symptomatology predict internalizing problems at 18 months for very preterm children

OBJECTIVE

To provide a prospective developmental model for behavioral outcomes in preterm infants in relation to developmental care (DC) practices and postnatal maternal depression.

STUDY DESIGN

A longitudinal, multicenter, follow-up study conducted in 25 Italian tertiary neonatal intensive care units (NICUs). Participants were 162 healthy very preterm infants and their mothers. The level of quality of DC was assessed for each hospital. Infant's neurobehavioral profile was evaluated twice: at discharge (T1) and at 18 months for behavioral problems (T3). Maternal depressive symptomatology was measured at T1 and at 6 months (T2).

RESULTS

Low-quality DC in NICUs was associated with lower levels of infant neurobehavioral adaptability and higher levels of maternal depressive symptoms. Maternal depressive symptomatology in conjunction with higher infant dysregulation predicted more internalizing problems at 18 months of age.

CONCLUSION

DC interventions and postnatal maternal depression, as well as infant behavior have an impact on short- and long-term infant outcomes.

Parent Psychological Distress in the Neonatal Intensive Care Unit Within the Context of the Social Ecological Model: A Scoping Review

BACKGROUND

Neonatal intensive care unit (NICU) parents are at risk for psychological distress and impaired mental health, and statistics related to parent psychological distress vary.

OBJECTIVE

To determine the scope of literature regarding the mental health and psychosocial well-being of parents in the NICU.

DESIGN

A scoping review within the Arksey and O'Malley framework and the SEM was undertaken to answer, "What factors contribute to parent's mental health in the NICU?" A systematic review of the literature was performed using the PRISMA methodology.

RESULTS

Common socioeconomic factors and infant and parent characteristics may place parents at a greater risk for developing distress. History of mental illness, family cohesion, birth trauma, altered parenting role, gestational age, birth weight, and severity of prematurity/illness emerged as themes.

CONCLUSION

Further research is required to provide a standard for the screening and assessment of parents' mental health and psychosocial well-being during a NICU hospitalization. The experiences of nonbirth parents in the NICU should be explored to examine the effects of the hospitalization on all types of parents.

Systematic review of maternal voice interventions demonstrates increased stability in preterm infants

We systematically reviewed how effectively maternal voice interventions supported the clinical outcomes and development of preterm infants. A total of 512 preterm infants were included in 15 studies with different designs, from January 2000 to July 2015. Live and recorded maternal voice interventions were associated with the physiologic and behavioural stabilisation of preterm infants, with fewer cardiorespiratory events, but the evidence was insufficient to evaluate the long-term effects. Well-defined determinants and clear setting conditions are needed for such interventions.

CONCLUSION

Further research that investigates the long-term efficacy and effects of live maternal voices on preterm infant development is needed.

Does quality of developmental care in NICUs affect health-related quality of life in 5-y-old children born preterm?

BACKGROUND

Preterm birth and Neonatal Intensive Care Unit (NICU) stay are early adverse experiences, which may affect health-related quality of life (HRQoL) even in the absence of prematurity-related morbidities. The aim of this multicenter longitudinal study was to examine the relation between quality levels of NICU Developmental Care (DC) and HRQoL at 60 mo in children who were born preterm.

METHODS

HRQoL of 102 very preterm (VPT) children from 20 NICUs and 110 full-term controls was assessed using TNO-AZL Preschool Children's Quality of Life Questionnaire (TAPQOL). In VPT children, we compared HRQoL by splitting NICUs into units with high- and low-quality of DC according to the following two factors: (i) the infant centered care (ICC), and (ii) the infant pain management (IPM).

RESULTS

Compared to VPT children from NICUs with high-quality of ICC, VPT children from NICUs with low-quality in ICC scored lower in HRQoL component which resulted from the aggregation of lively, positive emotionality, social and motor functioning. No differences were found between VPT children from high-quality ICC NICUs and full-term children and for the IPM index.

CONCLUSION

Findings suggest that higher quality of DC in NICU related to ICC might mitigate long-term negative quality of life outcomes.

Language outcomes at 36 months in prematurely born children is associated with the quality of developmental care in NICUs

OBJECTIVE

The aim of this study was to examine the relationship between the quality levels of NICU developmental care (DC) and language skills at 36 months in very preterm (VPT) children.

STUDY DESIGN

Language skills of 78 VPT children from 19 NICUs and 90 full-term controls was assessed using a standardized language test. We compared children' language task performance by splitting NICUs into units with high- and low-quality of DC according to two main factors: (1) infant centered care (ICC), and (2) infant pain management (IPM).

RESULTS

VPT children from low-care units with respect to ICC obtained lower scores in sentence comprehension, compared to children from high-care units. No differences were found between preterm children from high-quality ICC NICUs and full-term children.

CONCLUSIONS

Findings suggest that higher quality of DC related to infant centered care can mitigate delays in language skills at 36 months in children born VPT.

Pathways to emotional closeness in neonatal units - a cross-national qualitative study

BACKGROUND

Research shows evidence for the importance of physical and emotional closeness for the infant, the parent and the infant-parent dyad. Less is known about how, when and why parents experience emotional closeness to their infants in a neonatal unit (NU), which was the aim of this study.

METHODS

A qualitative study using a salutogenic approach to focus on positive health and wellbeing was undertaken in three NUs: one in Sweden, England and Finland. An 'emotional closeness' form was devised, which asked parents to describe moments/situations when, how and why they had felt emotionally close to their infant. Data for 23 parents of preterm infants were analyzed using thematic networks analysis.

RESULTS

A global theme of 'pathways for emotional closeness' emerged from the data set. This concept related to how emotional, physical, cognitive and social influences led to feelings of emotional closeness between parents and their infants. The five underpinning organising themes relate to the: Embodied recognition through the power of physical closeness; Reassurance of, and contributing to, infant wellness; Understanding the present and the past; Feeling engaged in the day to day and Spending time and bonding as a family.

CONCLUSION

These findings generate important insights into why, how and when parents feel emotionally close. This knowledge contributes to an increased awareness of how to support parents of premature infants to form positive and loving relationships with their infants. Health care staff should create a climate where parents' emotions and their emotional journey are individually supported.

Differences and similarities between mothers and fathers of premature children: a qualitative study of parents' coping experiences in a neonatal intensive care unit

Background

The aim of this study was to explore and describe the coping experiences of parents to children admitted to a neonatal unit.

Methods

A qualitative research approach was chosen, using in-depth interviews with eight fathers and eight mothers.

Results

The main findings were that parents with previous complicated births had more difficulties in coping compared to those parents with no experience with complications. Coping seemed easier where parents’ opinions were heard regarding their baby’s care and when both parents were present in the neonatal intensive care unit (NICU). The main similarities between mothers and fathers were the reluctance to speak their opinions on childcare, and both experienced a sense of alienation and problems in bonding with the baby. They also needed a limitation on the number of visitors in the NICU. Differences between mothers and fathers were that fathers tried hard to be the strong partner in the relationship, and were more concerned with the mother if she was seriously ill postpartum, while mothers were more concerned for their baby. Mothers’ postpartum period was felt as more stressful if the father was not present, but mothers were also better at welcoming support from the health personnel.

Conclusion

This study highlights the parent’s coping experiences in NICUs. Coping seemed easier where parents’ opinions were heard. Nurses in the NICU should take the former experiences of the parents into consideration when nursing in the NICU and planning for discharge.