Maternally administered interventions for preterm infants in the NICU: effects on maternal psychological distress and mother-infant relationship

A Scoping Review of Multimodal, Dyadic Early Relational Health Interventions in NICUs in the United States

BACKGROUND

Early relational health (ERH) interventions can buffer toxic stress and improve the developmental trajectories of neonatal intensive care unit (NICU) infants.

PURPOSE

The purpose was to examine the current state of the science related to multimodal, dyadic ERH interventions implemented in the NICU setting in the United States and identify gaps in the current literature.

DATA SOURCES

PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycInfo were searched in November 2022 and November 2023 for original studies and conference proceedings from 1970 to present in the English language. Gray literature searches were performed in February 2023 and December 2023.

STUDY SELECTION

English language, original research, with a focus on multimodal, dyadic ERH interventions that took place primarily in a NICU in the United States were included. Outcome measures could be related to implementation, relational health, or physical and/or mental health outcomes of parent and/or infant. Eighteen of 2021 reviewed articles met the inclusion criteria.

DATA EXTRACTION

Data were extracted for author, year, intervention, purpose, methods, sample, paternal inclusion, dyadic components, non-dyadic components, and major outcomes/results and distilled for study characteristics, multimodal, dyadic intervention characteristics, and outcome measures.

RESULTS

Several multimodal dyadic interventions exist to aid ERH in the NICU, providing evidence of improved outcomes for infants and families. More research is required using higher sample sizes and replication studies.

IMPLICATIONS FOR PRACTICE AND RESEARCH

ERH interventions show promise in improving neurodevelopmental, behavioral, and maternal mental health outcomes and should be considered for implementation into NICU services.

Early psychosocial parent-infant interventions and parent-infant relationships after preterm birth-a scoping review

Objective

Early psychosocial interventions for preterm infants and their parents are diverse. This study aimed to structure the knowledge on psychosocial parent-infant interventions and to identify gaps in the intervention studies.

Methods

We included studies on early (during first year of life) psychosocial parent-infant interventions with parent-infant relationship outcomes after preterm birth (< 37 weeks). We excluded studies that did not focus on preterm infants, failed to indicate the studied intervention and outcomes, were not written in English, were not controlled or peer-reviewed studies, or did not provide essential information for eligibility. The search included studies published between January 2000 and March 2024 in PubMed and PsycINFO. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in reporting. Psychosocial parent-infant intervention studies were classified adapting the International Classification of Health Interventions (ICHI) and the Template for Intervention Description and Replication (TIDieR).

Results

The included 22 studies reported data from 18 different interventions with preterm infants (< 37 weeks). Studies excluded preterm infants with health risks (19/22, 86%), with very low gestational age and/or birth weight (7/22, 32%), and/or mothers with psychosocial risks (14/22, 64%). Of the 18 interventions, 12 (67%) were classified as counseling, 3 (17%) as emotional support, 2 (11%) as psychotherapeutic, and 1 (6%) as educational. The parent-child relationship was assessed using 30 different methods and varying time points up to 18 months of age. Most studies (17/22, 77%) reported positive changes in the parent-child relationship favoring the intervention group.

Conclusion

We identified four types of interventions to influence parenting behavior; the most used was counseling. All four intervention types showed positive effects on parent-infant relationships, although the preterm populations studied were selective, the effects were evaluated using different methods, and the follow-up periods were short. These findings indicate a need for studies with standardized methods, longer follow-up, and less-restricted preterm populations to develop guidelines for all families with preterm infants.

A parent-administered sensorimotor intervention for oral feeding in infants born preterm: A randomized clinical study

AIM

To evaluate the effect of a parent-administered sensorimotor intervention (PASI) program on developmental outcomes of infants born preterm during their stay in the neonatal intensive care unit (NICU).

METHOD

A randomized clinical study was conducted with 94 infants (mean gestational age 31 weeks [SD 2.2 weeks]; 1658 g [SD 478 g]; 49 males, 45 females) initially enrolled and randomly assigned to an experimental or a control group. Infants in the experimental group received a PASI, consisting of tactile input to oral structures, trunk/limbs, and non-nutritive sucking for 15 minutes, once a day, for 10 days. Infants in the control group received standard care. Outcomes included attainment of complete oral feeds, occurrence of direct breastfeeding at hospital discharge, and motor function assessed using the Test of Infant Motor Performance (TIMP).

RESULTS

A total of 80 infants completed the study. Infants in the experimental group achieved complete oral feeds sooner (11.9 [SD 4.3] vs 15.3 [SD 6.5] days, p = 0.013), and a greater number of them received direct breastfeeds (22 vs 12, p = 0.010) than controls. Infants in both groups had equivalent motor functions scores on the TIMP (46.9 [SD 4.8], 46.8 [SD 8.4], p = 0.961).

INTERPRETATION

A PASI program may enhance an infant's oral feeding skills. These findings provide evidence to advocate for the institution of PASI in NICUs.

Relationship Between Maternal Emotional Distress and Early Dyadic Interactions During Hospitalization of Preterm Infants in Malawi

OBJECTIVE

To examine the relationship between emotional distress and mother-preterm infant interactions among mothers who used skin-to-skin care and to explore their experiences of childbirth and continuous skin-to-skin care.

DESIGN

A sequential, explanatory, mixed-methods design.

SETTING

A neonatal nursery in a tertiary-level hospital in Malawi.

PARTICIPANTS

Forty-four mother-preterm infant dyads; we interviewed 15 of these mothers.

METHODS

We administered surveys to assess emotional distress (i.e., depression, anxiety, posttraumatic stress, and worry about infant health) and video-recorded mother-infant interactions. We used regression analysis to assess the relationship between indicators of emotional distress and mother-infant interactions and further examined whether skin-to-skin care was associated with maternal distress. We used in-depth interviews to collect qualitative data and used content analysis to identify common themes.

RESULTS

Symptoms of emotional distress were negatively associated with the frequency of infant negative behaviors and gestures, infant smiling, and mother looking and infant smiling when we controlled for the number of days administering continuous skin-to-skin care, gestational age, and severity of the infant's condition. Mothers reported that they felt stressed by providing continuous skin-to-skin care but appreciated its positive effects on the infant.

CONCLUSION

Emotional distress while providing continuous skin-to-skin care was associated with poorer mother-preterm infant interactions The mental distress that mothers undergo while delivering continuous skin-to-skin care to their infants can be draining. It is essential for nurses to offer the required psychological support to enhance maternal mental health and encourage positive infant behavior and development. Health care systems need to support this level of nursing care.

Effect of the COPE Program on Self-Efficacy in Mothers of Preterm Infants: A Pretest-Posttest Quasi-Experimental Study

The birth of a premature infant and its subsequent hospitalization in the neonatal intensive care unit are stressful experiences for mothers. Because of uncertainty concerning interactions with a premature baby, mothers often feel helpless and only hesitantly assume their maternal role. This may have a negative impact on the mother-child interaction and prevents mothers from taking an active part in E46www.jpnnjournal.com the care for their child. "Creating Opportunities for Parent Empowerment" (COPE) is a 4-phase educational intervention program aiming to systematically involve parents into caring for their premature infant. In this pretest-posttest quasi-experimental study in 2 Swiss university hospitals, we focused on maternal self-efficacy. We compared self-efficacy in mothers receiving the COPE program or standard care alone at baseline and 3 months after estimated delivery date. To measure maternal self-efficacy, we used the "Tool to measure Parenting Self-Efficacy" (TOPSE). While scores for "Emotion and Affection," "Empathy and Understanding," as well as "Learning and Knowledge" increased in both groups, only "Learning and Knowledge" scores were significantly higher in the intervention group. Given the intention of improving learning and knowledge, the COPE program might be a promising intervention contributing to enhanced maternal self-efficacy.

Maternal Stress Experience in the Neonatal Intensive Care Unit after Preterm Delivery

OBJECTIVE

Preterm delivery with the admission of a child in the neonatal intensive care unit (NICU) is extremely challenging for parents. Being separated from the baby and seeing her infant feeling pain and being sick together with the complexity of the NICU environment, the mother experiences great anxiety, fear, and stress. The purpose of the study was to assess NICU-related stress and to identify maternal and infant factors associated with increased stress in mothers of preterm infants.

STUDY DESIGN

The maternal stress level was assessed in 122 mothers of preterm infants using the Parental Stressor Scale: NICU (PSS: NICU) in which items were distributed in three subscales as follows: Sights and Sounds of NICU-subscale 1 (S1), Infant Appearance and Behavior-S2, and Parental Role Alteration-S3.

RESULTS

Maternal total PSS: NICU score was 3.46 ± 0.71. Parenteral Role Alteration was the most stressful (4.20 ± 0.79) followed by Infant Appearance and Behavior (3.51 ± 0.91) and Sights and Sounds subscale (2.28 ± 0.95); p (S1-S2) < 0.001, p (S1-S3) < 0.001, and p (S2-S3) < 0.001. Total PSS: NICU and Infant Appearance and Behavior scores correlated positively with maternal age (r = 0.189; p = 0.040 and r = 0.204; p = 0.027, respectively) and duration of NICU treatment (r = 0.188; p = 0.044 and r = 0.190; p = 0.042). More visits in NICU by a mother were associated with a lower PSS: NICU score (p = 0.049) and neonatal seizures and invasive ventilation in infants were associated with higher stress scores (p = 0.007 and p = 0.042).

CONCLUSION

Mothers of preterm infants admitted in the NICU experience significant stress which is correlated with maternal age and NICU treatment duration and is associated with frequency of NICU visits, presence of neonatal seizures, and need for ventilator support. Parental role alteration is the greatest stressor followed by Infant Appearance and Behavior and NICU-surrounding stressor factors which show the need for interventions and counseling focused on mothers' role, their involvement in infant's care, and thus, family-centered care implementation.

KEY POINTS

· Mothers of preterm infants experience significant stress.. · Parental role alteration is the greatest maternal stressor.. · Maternal stress is correlated with age and NICU duration, and is associated with the frequency of NICU visits and infant's health status.

Effect of Maternal Speech on Neural Development in Premature Infant

INTRODUCTION

Maternal speech has been shown to benefit premature infants by improving feeding outcomes and potentiating the development of the auditory cortex. To our knowledge, limited studies have addressed the benefits of exposure to maternal speech on neural development in premature infants. The objective of this study was to investigate the effect of early controlled exposure to maternal recording a passage of speech on heart rate variability (obtained before, during, and after playback of a test stimulus of a female stranger speaking the same passage) in very low-birth-weight premature infants tracked weekly from 28 to 34 weeks.

METHODS

Prospective, randomized controlled trial, longitudinal, and repeated-measures design were conducted on 49 subjects. Infants heard a recording of their mother's speech twice a day from either 28 to 34 weeks (group 1) or from 32 to 34 weeks (group 2). Spectral analysis was measured weekly for 45 seconds before, during, and after playback of maternal speech. A generalized linear mixed model was conducted to examine the 2-way interaction in the log high-frequency power between groups, genders, sessions, and conditions.

RESULTS

It was found that there were no significant differences between groups before, during, and after playback of the stimulus. A significant difference, however, was noted between conditions (before vs during period).

CONCLUSION

It can be concluded cautiously that playing back of maternal speech recordings to the premature infant has a beneficial impact on neural development after 32 weeks gestational age.

Effectiveness and family experiences of interventions promoting partnerships between families and pediatric and neonatal intensive care units: a mixed methods systematic review

OBJECTIVE

The objective of this mixed methods review was to examine the effectiveness and family experiences of interventions promoting partnerships between families and the multidisciplinary health care team in pediatric and neonatal intensive care units.

INTRODUCTION

Hospitalization of infants and children in neonatal intensive care units and pediatric intensive care units has a significant effect on their families, including increased stress, anxiety, and depression. Available evidence syntheses focused on specific family-centered care, but not on partnership, which is another aspect that may improve families' outcomes and experiences.

INCLUSION CRITERIA

This review considered studies that focused on effectiveness or family experiences of interventions by health professionals in partnership with families of infants or children hospitalized in an intensive care unit. For the quantitative component of the review, the type of intervention was a partnership between the health care team and the family, and focused on outcomes of stress, anxiety, depression, quality of life, attachment, or satisfaction with family-centered care. For the qualitative component, the phenomenon of interest was family experiences of interventions that included collaboration and partnering with the health care team in the pediatric or neonatal intensive care unit. Quantitative, qualitative, and mixed methods studies, published from 2000 to August 2022 in English or French, were eligible for inclusion.

METHODS

The JBI methodology for convergent segregated mixed methods systematic reviews was followed using the standardized JBI critical appraisal and data extraction tools. Ten databases were searched in December 2019 and again in August 2022. Study selection, critical appraisal, and data extraction were performed by 2 reviewers independently. Findings of quantitative studies were statistically pooled through meta-analysis and those that could not be pooled were reported narratively. Qualitative studies were pooled through meta-synthesis.

RESULTS

This review included 6 qualitative and 42 quantitative studies. The methodological quality varied, and all studies were included regardless of methodological quality. Meta-analyses showed improvements in anxiety, satisfaction with family-centered care, and stress, yet no conclusive effects in attachment and depression. These results should be interpreted with caution due to high heterogeneity. Qualitative analysis resulted in 2 synthesized findings: "Interventions that incorporate partnerships between families and the health care team can improve the family's experience and capacity to care for the child" and "Having a child in intensive care can be an experience of significant impact for families." Integration of quantitative and qualitative evidence revealed some congruence between findings; however, the paucity of qualitative evidence minimized the depth of this integration.

CONCLUSIONS

Partnership interventions can have a positive impact on parents of children in intensive care units, with improvements reported in stress, anxiety, and satisfaction with family-centered care.

REVIEW REGISTRATION

PROSPERO CRD42019137834.

SUPPLEMENTAL DIGITAL CONTENT

A Chinese-language version of the abstract of this review is available at http://links.lww.com/SRX/A50 . A French-language version of the abstract of this review is available at http://links.lww.com/SRX/A51 .

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis

OBJECTIVE

Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder.

DATA SOURCES

PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023.

STUDY ELIGIBILITY CRITERIA

Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English.

METHODS

Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials.

RESULTS

A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists.

CONCLUSION

Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

Spanish Translation and Cultural Adaptations of Physical Therapy Parent Educational Materials for Use in Neonatal Intensive Care

Background

A paucity of Spanish language, culturally relevant parent education materials in the healthcare setting results in suboptimal care for Latinx families and further perpetuates health disparities. The purpose of this article is to describe the process for Spanish translation and cultural adaptations to parent education materials of a parent-centered physical therapy program designed to support maternal mental health and infant development during Neonatal Intensive Care (NICU).

Methods

Two bilingual physical therapy (PT) students translated educational materials from English to Spanish and were proofread by a professional translator. Next, we conducted a materials review with 5 members of the Latine Community Review Board (CRB), a "standing" advisory group of natively Spanish-speaking, Latine North Carolinians who contract with research teams under the coordination of the Inclusive Science Program (ISP) of the North Carolina Translational and Clinical Sciences Institute (NC TraCS). Review session recruitment, facilitation, and data analysis were conducted by bilingual NC TraCS project managers and the primary investigator for the main feasibility study. Readability analyses were performed at the final stage of translation and adaptation.

Results

Themes from CRB review sessions for improvement included to 1) use parent-friendly language, 2) use the plural masculine form of gendered language for caregivers to include all gender identities in this neonatal context, 3) address challenges with direct translation, and 4) use written education materials to supplement in-person, hands-on training with parents and their infants. All translated materials received a grade level of 5 on the Crawford grade-level index.

Conclusion

Based on CRB feedback and readability analysis, the translation and cultural-adaptation process resulted in comprehensible written parent education materials for Spanish-speaking families. Review meetings with the CRB reinforced the need for Spanish materials in the healthcare setting. Further assessment of these materials with Spanish-speaking families in the NICU setting is needed.

Infant massage as a stress management technique for parents of hospitalized extremely preterm infants

Mothers of infants born extremely preterm requiring prolonged medical intervention in the Neonatal Intensive Care Unit (NICU) are at high risk of developing stress. Parent-administered infant massage is a well-established, safe intervention for preterm infants with many developmental benefits, but the published literature has mostly examined its impact on infants and parents through self-reported or observational measures of stress. The aim of this study was to measure salivary cortisol, a biomarker for stress, in extremely preterm infants and their mothers immediately pre and post parent-administered infant massage in order to detect potential changes in physiologic stress. Twenty-two mother-infant dyads completed massage education with a physical or occupational therapist. All dyads provided salivary cortisol samples via buccal swab immediately pre- and post-massage at the second session. Of mothers determined to be "cortisol responders" (15/22), salivary cortisol levels were lower after massage (pre-minus post-level: -26.47 ng/dL, [CI = -4.40, -48.53], p = .016, paired t-test). Our primary findings include a clinically significant decrease (as measured by percent change) in maternal cortisol levels immediately post parent-administered massage, indicating decreased physiological stress. Integration of infant massage into NICU clinical practice may support maternal mental health, but further powered studies are necessary to confirm findings.

A randomized-controlled trial of parent-administered interventions to improve short-term motor outcomes in hospitalized very low birthweight infants

BACKGROUND

Premature infants are at increased risk for cerebral palsy (CP). Early interventions with a motor focus and administered by parents may improve motor outcomes.

AIMS

Secondary study evaluating the short-term motor outcomes and risk for CP in very low birthweight (VLBW) infants randomized to multimodal interventions with a motor focus provided by parents versus usual care.

STUDY DESIGN

Randomized controlled trial (intervention vs. usual care (control group)).

SUBJECTS

Infants (<32 weeks' gestational age (GA) and/or <1500 grams birthweight) born between March 2019 and October 2020.

OUTCOME MEASURES

Short-term motor outcomes and risk for CP was evaluated using the Hammersmith Infant Neurological Evaluation (HINE, primary motor outcome), the General Movement Assessment (GMA) and the Test of Infant Motor Performance (TIMP) at 3 months' postmenstrual age (PMA).

RESULTS

70 participants were enrolled (GA 28.3±2.7 weeks, birthweight 1139.2±376.6 grams, 64.3% male). The in-person follow-up rate was 73%, lower than expected, in part due to COVID-19 restrictions, resulting in 25 infants (intervention) and 26 infants (control) with outcome data available for analysis. There was not a significant difference in the HINE, GMA or TIMP at 3 months' PMA between groups.

CONCLUSION

Multimodal interventions with a motor focus and provided by parents need further investigation to determine if they can improve short-term motor outcomes in VLBW infants. These interventions are evidence-based and the evaluation of broader implementation into routine care is also needed.

Evaluating the impact of sling provision and training upon maternal mental health, wellbeing and parenting: A randomised feasibility trial

BACKGROUND

Close body contact interventions such as Kangaroo Mother Care have been shown to improve maternal mental health following birth. Infant carriers ('slings') facilitate hands-free close body contact. No studies have specifically examined whether sling use improves maternal mental health. A full-scale efficacy study is needed to examine whether sling use is beneficial to maternal mental health. The current study is a feasibility study designed to gather information to support the design of a future RCT, such as acceptability and study parameters, including recruitment rates, consent rate and attrition.

METHOD

Mothers of infants aged 0-6 weeks were randomised to one of two conditions: intervention (n = 35) vs. waitlist control (n = 32). Intervention participants received sling training, support, and free sling hire for 12 weeks. Participants completed self-report measures of mood, wellbeing and parenting at baseline (Time 1), and 6- (Time 2) and 12- (Time 3) weeks post-baseline.

RESULTS

Eligibility and consent rates met feasibility objectives, though there were some difficulties with retention of participants in the study. Preliminary effectiveness analyses showed a non-significant improvement with a small effect size in postnatal depression from T1 to T3, and a significant improvement with a medium effect size in maternal self-efficacy from T1 to T3. Qualitative feedback indicated acceptability of the intervention and study participation. Intervention participants attributed greater autonomy, bonding with their baby, and parental self-confidence, to the intervention.

CONCLUSIONS

These findings indicate a randomised study of the impact of a sling and related support intervention upon maternal mental health is feasible. These findings should be interpreted within the context of sampling bias (due to the use of volunteer sampling methods), an absence of feedback from those who discontinued participation in the study, and the study not being adequately powered.

TRIAL REGISTRATION

Registration number ISRCTN88575352.

A Feasibility Study of a Physical and Occupational Therapy-Led and Parent-Administered Program to Improve Parent Mental Health and Infant Development

AIMS

Extremely premature birth puts infants at high risk for developmental delay and results in parent anxiety and depression. The primary objective of this study was to characterize feasibility and acceptability of a therapist-led, parent-administered therapy and massage program designed to support parent mental health and infant development.

METHODS

A single cohort of 25 dyads - parents (24 mothers, 1 father) and extremely preterm (<28 wk gestation) infants - participated in the intervention. During hospitalization, parents attended weekly hands-on education sessions with a primary therapist. Parents received bi-weekly developmental support emails for 12 months post-discharge and were scheduled for 2 outpatient follow up visits. We collected measures of parent anxiety, depression, and competence at baseline, hospital discharge, and <4 and 12 months post-discharge.

RESULTS

All feasibility targets were met or exceeded at baseline and discharge (≥70%). Dyads participated in an average of 11 therapy sessions (range, 5-20) during hospitalization. Lower rates of data collection adherence were observed over successive follow ups (range, 40-76%). Parent-rated feasibility and acceptability scores were high at all time points.

CONCLUSIONS

Results support parent-rated feasibility and acceptability of the TEMPO intervention for extremely preterm infants and their parents in the Neonatal Intensive Care Unit.

Unmet Parental Mental Health Service Needs in Neonatal Follow-Up Programs: Parent and Service Provider Perspectives

Parental mental health services in neonatal follow-up programs (NFUPs) are lacking though needed. This study aimed to determine (1) the unmet mental health needs of parents and (2) the parent and provider perspectives on barriers and opportunities to increase mental health service access. Study 1: Parents in a central Canadian NFUP (N = 49) completed a mixed-method online survey (analyzed descriptively and by content analysis) to elucidate their mental health, related service use, barriers to service use, and service preferences. Study 2: Virtual focus groups with NFUP service providers (N = 5) were run to inform service improvements (analyzed by reflexive thematic analysis). The results show that parents endorsed a 2-4 times higher prevalence of clinically significant depression (59.2%), anxiety (51.0%), and PTSD (26.5%) than the general postpartum population. Most parents were not using mental health services (55.1%) due to resource insecurity among parents (e.g., time, cost) and the organization (e.g., staffing, training, referrals). Consolidating parents' and service providers' perspectives revealed four opportunities for service improvements: bridging services, mental health screening, online psychoeducation, and peer support. Findings clarify how a central Canadian NFUP can address parental mental health in ways that are desired by parents and feasible for service providers.

NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015-2020

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995-2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

Effects of kangaroo mother care on maternal and paternal health: systematic review and meta-analysis

Objective

To investigate the effect of kangaroo mother care for low-birth-weight and preterm infants on parents' mental and physical health.

Methods

The Cochrane Central Register of Controlled Trials, Cochrane Register of Studies Online, PubMed®, Web of Science, Scopus and EMBASE® databases were searched on 16 January 2023 for randomized and quasi-randomized trials on kangaroo mother care. Records identified were screened independently by two reviewers. Pooled relative risks (RRs) are reported for categorical variables, and standardized mean differences (SMDs) or mean differences are reported for continuous variables. Evidence quality was assessed using the GRADE approach.

Findings

The search identified 30 studies involving 7719 preterm or low-birth-weight infants. There was high-certainty evidence that kangaroo mother care substantially reduced the risk of moderate-to-severe postpartum maternal depressive symptoms compared with no kangaroo mother care (RR: 0.76; 95% confidence interval, CI: 0.59 to 0.96). In addition, there was low-certainty evidence that kangaroo mother care reduced scores for maternal stress (SMD: -0.82; 95% CI: -1.32 to -0.32) and anxiety (SMD: -0.62; 95% CI: -1.01 to -0.23) and increased mother-infant attachment and bonding scores (SMD: 1.19; 95% CI: 0.27 to 2.10). Limited evidence indicated father-infant interactions may be improved, though no marked effect on paternal depression or stress was observed. No trial reported parental physical health outcomes.

Conclusion

Kangaroo mother care for preterm and low-birth-weight infants was associated with less postpartum maternal depression, stress and anxiety and better mother-infant attachment and bonding. More research is required to evaluate effects on paternal health.

The effectiveness of kangaroo mother care in lowering postpartum depression in mothers of preterm and low birth weight babies: a systematic review and meta-analysis

Background

Kangaroo mother care (KMC) intervention involves skin-to-skin contact between mother and infant. Some studies have shown a decrease in postpartum depression (PPD) in mothers of preterm and low birth weight (LBW) infants. However, the literature is scattered and of variable quality.

Aims

To conduct a systematic review of available literature and provide a comprehensive picture of the effect of KMC on PPD among mothers of preterm and LBW infants.

Methods

The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. After PROSPERO registration, a systematic search was conducted using PubMed, Cochrane Central Library, and Google Scholar from the inception of the databases till 14 June 2021. Of the 2944 studies assessed for titles and abstracts, nine studies with 2042 participants were included in the review. Included articles targeted mothers with LBW (<2500 g) or preterm infants (<37 weeks), used an authentic PPD tool, and had standard care or an incubator as the control group. Studies not published in English and in which mothers had a previous psychiatric illness were excluded. The risk of bias was assessed using the Cochrane Risk of Bias Tool for randomized control trials and the Newcastle-Ottawa Scale for observational studies. All the results were converted to standard mean deviation and pooled together using a random-effects model with a 95% CI. A P-value of less than 0.05 is considered significant.

Results

KMC Intervention was significantly associated with a lower depression score than control groups. The reduction in depression in the intervention (KMC) group was moderate: SMD=-0.38 (-0.68 to -0.08; 95% CI; I 2=86%; P=0.013). No significant difference was found between the PPD scores of both groups using the Edinburgh Postpartum Depression Scale score.

Conclusions

The authors conclude that the negative effects of LBW and preterm birth experience on maternal mental health can be avoided to a moderate degree by KMC. Due to a lack of methodological uniformity, different scales for outcome measurement, and discrepancies in intervention features, significantly high heterogeneity was detected. The authors need further larger-scale studies with a uniform study design to better predict the efficacy of KMC better.

Benefits of maternally-administered infant massage for mothers of hospitalized preterm infants: a scoping review

OBJECTIVES

Infant massage (IM) is a well-studied, safe intervention known to benefit infants born preterm. Less is known about the benefits of maternally-administrated infant massage for mothers of preterm infants who often experience increased rates of anxiety and depression in their infants' first year of life. This scoping review summarizes the extent, nature, and type of evidence linking IM and parent-centered outcomes.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for scoping reviews (PRISMA-ScR) protocol was followed using three databases: PubMed, Embase, and CINAHL. Thirteen manuscripts evaluating 11 separate study cohorts met pre-specified inclusion criteria.

RESULTS

Six primary topics related to the influence of infant massage on parent outcomes emerged: 1) anxiety, 2) perceived stress, 3) depressive symptoms, 4) maternal-infant interaction, 5) maternal satisfaction, and 6) maternal competence. Emerging evidence supports that infant massage, when administered by mothers, benefits mothers of preterm infants by reducing anxiety, stress, and depressive symptoms and improving maternal-infant interactions in the short-term, but there is limited evidence to support its effectiveness on these outcomes in longer periods of follow-up. Based on effect size calculations in small study cohorts, maternally-administered IM may have a moderate to large effect size on maternal perceived stress and depressive symptoms.

CONCLUSIONS

Maternally-administered IM may benefit mothers of preterm infants by reducing anxiety, stress, depressive symptoms, and by improving maternal-infant interactions in the short-term. Additional research with larger cohorts and robust design is needed to understand the potential relationship between IM and parental outcomes.

Symptoms of post-traumatic stress disorder in parents of preterm newborns: A systematic review of interventions and prevention strategies

Background

Preterm birth and subsequent NICU admission can be a traumatic experience for parents who may subsequently develop post-traumatic stress (PTS) disorder (PTSD). Given that developmental issues are common among children of parents with PTSD, interventions for prevention and treatment are essential.

Objective

To assess the most effective non-pharmacological interventions to prevent and/or treat PTS symptoms in parents of preterm newborns.

Methods

Systematic review performed in accordance with the PRISMA statements. Eligible articles in English language were searched in MEDLINE, Scopus, and ISI Web of Science databases using the following medical subject headings and terms: “stress disorder, post-traumatic,” “parents,” “mothers,” “fathers,” “infant, newborn,” “intensive care units, neonatal,” and “premature birth.” The terms “preterm birth” and “preterm delivery” were also used. Unpublished data were searched in ClinicalTrials.gov website. All intervention studies published until September 9th, 2022 and including parents of newborns with gestational age at birth (GAb) &lt;37 weeks which underwent ≥1 non-pharmaceutical interventions for prevention and/or treatment of PTS symptoms related to preterm birth were included. Subgroup analyses were conducted by type of intervention. The quality assessment was performed according to the criteria from the RoB-2 and the “NIH Quality Assessment Tool for Before-After studies.”

Results

Sixteen thousand six hundred twenty-eight records were identified; finally, 15 articles (1,009 mothers, 44 fathers of infants with GAb ≤ 366/7 weeks) were included for review. A good standard of NICU care (effective as sole intervention: 2/3 studies) and education about PTSD (effective in association with other interventions: 7/8 studies) could be offered to all parents of preterm newborns. The 6-session Treatment Manual is a complex intervention which revealed itself to be effective in one study with low risk of bias. However, the effectiveness of interventions still remains to be definitively established. Interventions could start within 4 weeks after birth and last 2–4 weeks.

Conclusion

There is a wide range of interventions targeting PTS symptoms after preterm birth. However, further studies of good quality are needed to better define the effectiveness of each intervention.

The effects of multisensory stimulation on the length of hospital stay and weight gain in hospitalized preterm infants: A systematic review with meta-analysis

BACKGROUND

Multisensory interventions, such as auditory-tactile-visual-vestibular intervention (ATVV), tactile-kinesthesic stimulation (TKS), and the kangaroo mother care (KMC), have been commonly applied in hospitalized preterm infants.

OBJECTIVE

To investigate the effectiveness of the ATVV, the TKS, and the KMC combined to standard care compared to standard care in the length of hospital stay and weight gain of hospitalized preterm infants.

METHODS

PubMed, Scopus, Web of Science, Embase, SciELO Citation Index, CINAHL, Cochrane, and LILACS databases were searched from the inception to May 06, 2022 without language restrictions. We included randomized controlled trials. Two independent reviewers selected studies and extracted information about participants, interventions, outcomes, and the risk of bias. The body of evidence was synthesized through GRADE. Data were pooled using a random-effects model.

RESULTS

Sixty-three randomized clinical trials included a range of 20-488 preterm infants (gestational age=25 to <37 weeks). Evidence was low to very low due to risk of bias, inconsistency, and imprecision. Most studies presented some concerns about methodological quality. The ATVV and the KMC increased weight gain. The TKS reduced the number of days at the hospital and increased the daily weight gain and the total weight gain.

CONCLUSIONS

Adding ATVV, TKS, or KMC to standard care was more effective than standard care alone to improve weight gain. Only the TKS combined with standard care was more effective than standard care alone to reduce the length of hospital stay.

Acceptability and feasibility of a digital educational intervention designed to improve the psychological well-being of parents with a preterm infant at the neonatal intensive care unit: A pilot project

BACKGROUND

Families experience psychological distress when their preterm infant is in the Neonatal Intensive Care Unit. A tailored educational intervention may be beneficial for their psychological well-being. Unfortunately, existing websites have moderate to low information quality and there is no educational website for French-speaking parents.

AIM

To measure the acceptability and feasibility of a digital educational intervention designed to improve the psychological well-being of parents with a preterm infant, as well as the acceptability and feasibility of the study methods used.

METHODS

A pilot randomized controlled trial was conducted. Participants were randomized to have access to either an educational website or information pamphlet. They were invited to complete an online questionnaire about stress and depressive symptoms 2 and 4 weeks after recruitment. An online questionnaire regarding the acceptability of the intervention and the data collection process was completed 5 weeks after recruitment.

RESULTS

Twenty parents participated. All participants with access to the website considered it was acceptable in terms of the appropriateness, convenience, and efficiency to meet their informational needs. 85 % of participants assigned to the website viewed it 1 to 3 times per day during the data collection period and 69.4 % consulted the website for 5 to 20 min each time. The data collection process was acceptable for 85 % to 95 % of participants.

DISCUSSION

The educational website was an acceptable and feasible intervention and the data collection process used was acceptable according to participants.

Effect of the Kangaroo Mother Method after Preterm Delivery on Maternal Stress and Anxiety in the Context of the COVID-19 Pandemic-A Cohort Study

BACKGROUND

The kangaroo mother method (KMM) may benefit infants and mothers in many ways. However, few studies focused on its efficacy on maternal anxiety and stress, especially in the context of the COVID-19 pandemic.

OBJECTIVE

To examine the effect of the kangaroo mother method (KMM) on postnatal stress and anxiety in mothers of preterm infants in neonatal intensive care, in the context of the COVID-19 pandemic.

METHODS

A cohort study of two groups of 56 mother-infant dyads recruited from a neonatal intensive care unit was conducted. Two groups were compared in terms of the mean duration of KMM during the twelve days of the study: the intervention group (mean duration of more than ninety minutes per day) and the control group (less than ninety minutes). Maternal stress was measured using the Parental Stressor: Neonatal Intensive Care Unit (PSS: NICU) scale and STAI E/R questionnaire before and after intervention (KMM). Demographic and other maternal covariates were extracted from medical records. Daily NICU records were used to track the frequency and duration of KMM sessions.

RESULTS

Mothers of the intervention group scored lower on the PSS: NICU and STAI E/R, although no statistically significant differences were found (p > 0.05).

CONCLUSIONS

Contrary to research based on biological and physiological parameters in newborns or performed before the COVID-19 pandemic, the differences found in applying subjective scales in mothers in the context of the COVID-19 pandemic were not significant. Therefore, mothers' perception of physical contact with their preterm infants may not have been as positive due to their fear of transmitting COVID.

Culturally adapted psychological intervention for treating maternal depression in British mothers of African and Caribbean origin: A randomized controlled feasibility trial

BACKGROUND

Women are likely to suffer from maternal depression due to childbirth difficulties and parenting responsibilities, leading to long-term negative consequences on their children and families. British mothers of African/Caribbean origin uptake of mental healthcare is low due to the lack of access to culturally appropriate care.

METHODS

A mixed-methods randomized controlled feasibility trial was adopted to test the appropriateness and acceptability of Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP+CaCBT) for treating maternal depression compared with Psychoeducation (PE). Mothers (N = 26) aged 20-55 were screened for depression using the Patient Health Questionnaire (PHQ-9). Those who scored >5 on PHQ-9 were further interviewed using the Revised Clinical Interview Schedule to confirm the diagnosis and randomized into LTP+CaCBT (n = 13) or PE (n = 13) groups. Assessments were taken at baseline, end of the intervention at 3- and 6-months post-randomization. N = 2 focus groups (LTP+CaCBT, n = 12; PE, n = 7) and N = 8 individual interviews were conducted (LTP+CaCBT, n = 4; PE, n = 4).

RESULTS

The LTP+CaCBT group showed higher acceptability, feasibility and satisfaction levels than the PE group. Participants experienced the intervention as beneficial to their parenting skills with reduced depression and anxiety in the LTP+CaCBT compared to the PE group.

CONCLUSIONS

This is the first feasibility trial of an integrated online parenting intervention for British African and Caribbean mothers. The results indicated that culturally adapted LTP+CaCBT is acceptable and feasible. There is a need to study the clinical and cost-effectiveness of LTP+CaCBT in an appropriately powered randomized control trial and include the child's outcomes.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (no. NCT04820920).

Effective stress intervention programs for parents of premature children: A systematic review

The birth of a child alters family dynamics and can be stressful for parents, especially in the case of prematurity. This article carried out a systematic review on interventions in parents to reduce the stress experienced by the birth of a premature infant. The aims were to describe and classify the different interventions and to have an overview of their effectiveness. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guide and the PICO model. For searching the bibliography, we used Web of Science, Science Direct, PubMed and PsycINFO databases. From a total of 450 articles identified, this review finally included 46 studies with empirical evidence. The articles clustered into different types of interventions, such as psychoeducational and parental or maternal support programs, relaxation techniques, expressive writing, art therapy, music therapy and interventions related to interaction and tactile stimulation. There is a wide range of effectiveness in reducing parental stress to a greater or lesser degree. There is a great heterogeneity of interventions. Despite that, they all have a parental educational component that needs to be studied in greater depth.

Effects of Infant Massage: A Systematic Review

Infant massage is performed in various international contexts. There is a need for an updated literature review on this topic. The purpose of the current review was to investigate the effects of infant massage. A systematic literature review was conducted to investigate the effects of infant massage on the following outcomes: pain relief, jaundice, and weight gain. The inclusion criteria were infants from 0-12 months. The literature search was performed until January 2022, using the CINAHL, PubMed, and PsycINFO databases, and included studies published from 2017-2021, returning 16 RCT/CCT studies with a total of 1416 participating infants. A review template was used by two independent reviewers to assess the risk of bias in the included studies. The results were synthesized and presented in the form of tables and narratives. In five of seven studies (n = 422 resp. n = 717) investigating pain relief, infant massage was found to alleviate pain. In all six studies (n = 455) investigating effects on infant massage and jaundice, beneficial effects were found on bilirubin levels. In all four studies (n = 244) investigating weight gain, increased weight gain was found among participants who received infant massage. The present literature review provides an indication of the current state of knowledge about infant massage and identifies its positive effects; however, the results must be interpreted with caution. Infant massage may be effective at relieving pain, improving jaundice, and increasing weight gain. Although statistically significant differences were not found between all experimental and control groups, no adverse effects of infant massage were observed. By placing the aforementioned effects in the context of child health care, infant massage may prove beneficial on these outcomes. Given the dearth of research on infant massage in the context of child health care, further research is warranted.

Scaffolding Parenting and Health Development for Preterm Flourishing Across the Life Course

Advances in obstetrics and neonatal medicine have resulted in improved survival rates for preterm infants. Remarkably, >75% extremely (<28 weeks) preterm infants who leave the NICU do not experience major neurodevelopmental disabilities, although >50% experience more minor challenges in communication, perception, cognition, attention, regulatory, and executive function that can adversely impact educational and social function resulting in physical, behavioral, and social health issues in adulthood. Even late premature (32-36 weeks) infants have more neurodevelopmental challenges than term infants. Although early intervention and educational programs can mitigate risks of prematurity for children's developmental trajectories, restrictive eligibility requirement and limitations on frequency and intensity mean that many premature infants must "fail first" to trigger services. Social challenges, including lack of family resources, unsafe neighborhoods, structural racism, and parental substance use, may compound biological vulnerabilities, yet existing services are ill-equipped to respond. An intervention system for premature infants designed according to Life Course Health Development principles would instead focus on health optimization from the start; support emerging developmental capabilities such as self-regulation and formation of reciprocal secure early relationships; be tailored to each child's unique neurodevelopmental profile and social circumstances; and be vertically, horizontally, and longitudinally integrated across levels (individual, family, community), domains (health, education), and time. Recognizing the increased demands placed on parents, it would include parental mental health supports and provision of trauma-informed care. This developmental scaffolding would incorporate parenting, health, and developmental interventions, with the aim of improved health trajectories across the whole of the life course.

Experiences of Malawian Mothers During Their Infants' Hospitalization

BACKGROUND

Hospitalization of a newborn infant is stressful for all mothers. Hospitals in Malawi have limited nursing staff and support, so mothers are the primary care providers for their hospitalized infants. Few studies have explored the experience of these mothers as both care providers and mothers.

PURPOSE

The purpose of this study was to explore the experiences of mothers during the hospitalization of the infant. The goal was to increase knowledge of their primary concerns about the hospital stay.

METHODS

This was a descriptive qualitative study conducted at Queen Elizabeth Central Hospital in Malawi. Mothers were interviewed prior to their infant's discharge. We used the directed content analysis approach to analyze our data.

RESULTS

Twenty mothers of preterm or full-term infants were interviewed. The primary concerns were perinatal experiences, the infant's condition and care including breastfeeding, support from family members, and support and care from healthcare providers. Additionally, mothers of preterm infants were concerned about the burdens of kangaroo mother care.

IMPLICATION FOR PRACTICE

In hospitals that provide limited nursing support to mothers and their infants, it is important to identify a support system for the mother and provide mothers with information on infant care.

IMPLICATIONS FOR RESEARCH

Future research should identify specific supports and resources in the community and hospital settings that are associated with positive hospital experiences.

A feasibility randomized controlled trial of a NICU rehabilitation program for very low birth weight infants

Motor disability is common in children born preterm. Interventions focusing on environmental enrichment and emotional connection can positively impact outcomes. The NICU-based rehabilitation (NeoRehab) program consists of evidence-based interventions provided by a parent in addition to usual care. The program combines positive sensory experiences (vocal soothing, scent exchange, comforting touch, skin-to-skin care) as well as motor training (massage and physical therapy) in a gestational age (GA) appropriate fashion. To investigate the acceptability, feasibility and fidelity of the NeoRehab program in very low birthweight (VLBW) infants. All interventions were provided by parents in addition to usual care. Infants (≤ 32 weeks' GA and/or ≤ 1500 g birthweight) were enrolled in a randomized controlled trial comparing NeoRehab to usual care (03/2019-10/2020). The a priori dosing goal was for interventions to be performed 5 days/week. The primary outcomes were the acceptability, feasibility and fidelity of the NeoRehab program. 36 participants were randomized to the intervention group and 34 allocated to usual care. The recruitment rate was 71% and retention rate 98%. None of the interventions met the 5 days per week pre-established goal. 97% of participants documented performing a combination of interventions at least 3 times per week. The NeoRehab program was well received and acceptable to parents of VLBW infants. Programs that place a high demand on parents (5 days per week) are not feasible and goals of intervention at least 3 times per week appear to be feasible in the context of the United States. Parent-provided motor interventions were most challenging to parents and alternative strategies should be considered in future studies. Further studies are needed to evaluate the relationship between intervention dosing on long term motor outcomes.

Giving parents support: a randomized trial of peer support for parents after NICU discharge

BACKGROUND

Peer support during inpatient hospitalization has been recommended for NICU parents and can improve maternal mental health. Less is known about the impact of peer support after NICU discharge on parental mental health and infant healthcare utilization.

METHODS

Three hundred families of infants approaching discharge from a Level IV NICU were randomized to receive a care notebook (control) or care notebook plus peer support for 12 months (intervention). Participants reported on measures of stress, depression, anxiety, self-efficacy, and infant healthcare utilization. Analysis compared outcomes between control and treatment groups.

RESULTS

Parental depression, anxiety, stress, and self-efficacy improved significantly for all participants, yet there were no differences between control and intervention groups. Infant ED visits, hospitalizations, immunization status, and developmental status at 12 months did not differ between groups.

CONCLUSIONS

Peer support after NICU discharge did not improve self-reported parental mental health measures or infant healthcare utilization.

CLINICAL TRIAL REGISTRATION

NCT02643472.

Perception of Stress and Styles of Coping with It in Parents Giving Kangaroo Mother Care to Their Children during Hospitalization in NICU

The experience of hospitalization of a newborn in the Neonatal Intensive Care Unit (NICU) may become distressing both for the baby and parent. The study aimed to assess the degree of parental stress and coping strategies in parents giving KMC to their babies hospitalized in NICU compared to the control group parents not giving KMC. The prospective observational study enrolled a cohort of 337 parents of premature babies hospitalized in NICU in 2016 in Eastern Poland. The Parental Stressor Scale: Neonatal Intensive Care Unit, Coping Inventory for Stressful Situations were used. The level of stress in parents giving KMC was defined as low or moderate. Analysis confirmed its greater presence in the group of parents initiating KMC late (2–3 weeks) compared to those starting this initiative in week 1 of a child’s life. An additional predictor of a higher level of stress in parents initiating KMC “late” was the hospital environment of a premature baby. Task oriented coping was the most common coping strategy in the study group. KMC and direct skin-to-skin contact of the parent with the baby was associated with a higher level of parental stress only initially and decreased with time and KMC frequency.

Socio-demographic factors related to parent engagement in the NICU and the impact of the SENSE program

BACKGROUND

Early parent engagement in the neonatal intensive care unit (NICU) is important for both parent and infant mental health and for improving developmental outcomes. It remains unclear how different programs, such as the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, may empower parents from various socio-demographic groups to engage in the NICU. An improved understanding could aid in individualizing interventions for those at the highest risk for health disparities.

AIMS

This exploratory study, which was part of a larger study, sought to explore 1) socio-demographic factors related to parent presence and engagement in the NICU and 2) if the SENSE program related to increased parent presence and engagement among different socio-demographic groups.

METHODS

Seventy parent-infant dyads (born ≤ 32 weeks gestation) were randomized to SENSE programming (parent education and age-appropriate, positive sensory interventions for parents to conduct with their infants every day of hospitalization) or standard care after admission to the NICU. The amount of parent presence and participation in sensory activities was tracked using bedside logs, nursing records, and research team documentation.

RESULTS

Being married (p = 0.048; p = 0.01), having private insurance (p < 0.001; p = 0.01), and having fewer children (p = 0.004; p = 0.03) related to more parent presence and engagement respectively. Parents who were Black had less presence and engagement in the NICU (p = 0.04; p = 0.02). Participation in the SENSE program was related to more parent presence and engagement among younger mothers (p = 0.002; p ≤0.001) and among parents living farther distances from the hospital (p < 0.001; p = 0.004).

CONCLUSION

Programming, such as the SENSE program, can improve parent engagement in the NICU among high-risk groups.

Relationship between mindfulness and maternal stress and mother - Infant bonding in neonatal intensive care unit

BACKGROUND

Having a baby admitted to a neonatal intensive care unit (NICU) is so stressful, has a negative impact on mother well-being, and also disrupts mother-infant bonding process because the infant spend the first several weeks or months in the NICU. Previous studies have shown the positive association of the mindfulness and various health conditions. This study investigated the relationship between mothers' dispositional mindfulness and level of stress and bonding in mothers with infants in the NICU.

MATERIALS AND METHODS

A cross-sectional study was performed during 2019 on 140 mothers with newborns admitted to the NICUs in two hospitals in Qom city in Iran. The self-report measures of dispositional mindfulness, Parental Stressor Scale: NICU, and the Postpartum Bonding Questionnaire were administered to mothers on the 2^nd-5^th day after birth. The data analysis was carried out by using a stepwise multiple regression model.

RESULTS

The mean scores of mindfulness, stress, and bonding were 3.32 ± 0.52, 2.32 ± 0.77, and 0.47 ± 0.37, respectively. There was a statistically significant inverse relationship between total mindfulness score and stress (P < 0.001). Furthermore, high scores of mindfulness were associated with better bonding (P = 0.04).

CONCLUSIONS

Improvement in mindfulness helps mothers to reduce stress and make better bonding with infants. It is recommended that mindfulness interventions use during pregnancy also after birth, especially for mothers that their infants admitted to in the NICUs.

The Importance of Rhythmic Stimulation for Preterm Infants in the NICU

The fetal environment provides the fetus with multiple potential sources of rhythmic stimulation that are not present in the NICU. Maternal breathing, heartbeats, walking, dancing, running, speaking, singing, etc., all bathe the fetus in an environment of varied rhythmic stimuli: vestibular, somatosensory, tactile, and auditory. In contrast, the NICU environment does not offer the same proportion of rhythmic stimulation. After analyzing the lack of rhythmic stimulation in the NICU, this review highlights the different proposals for vestibular and/or auditory rhythmic stimulation offered to preterm infants alone and with their parents. The focus is on the beneficial effects of auditory and vestibular stimulation involving both partners of the mother-infant dyad. A preliminary study on the influence of a skin-to-skin lullaby on the stability of maternal behavior and on the tonic emotional manifestations of the preterm infant is presented as an example. The review concludes with the importance of introducing rhythmic stimulations in the NICU.

Maternal Anxiety, Infant Stress, and the Role of Live-Performed Music Therapy during NICU Stay in The Netherlands

Having an infant in the neonatal intensive care unit (NICU) elicits maternal anxiety, which may hamper parent-child bonding. We performed a prospective cohort study to describe anxiety in mothers of infants born before 30 weeks of gestation during NICU stay in The Netherlands, and investigated the influence of infant stress and gestational age. Second, we performed a randomized-controlled live-performed music therapy trial (LPMT trial) to investigate whether music therapy applied to the infant alleviated maternal anxiety. The relation between infant stress, gestational age, and maternal anxiety was measured in 45 mother-infant dyads, using the Neonatal Infant Stressor Scale and the State-Trait Anxiety Inventory (STAI). The effect of LPMT on anxiety was assessed in 21 mothers whose infants were assigned to either LPMT (n = 12) or waitlist (n = 9). Mothers completed the STAI before and after this period. Maternal anxiety decreased over time in all mothers, and was strongly related with infant stress (r = 0.706, p < 0.001), but not with gestational age. Anxiety scores decreased by 12% after LMPT, and increased by 1% after a waitlist period (p = 0.30). Our results indicate that LPMT in the weeks after birth may accelerate the reduction of maternal anxiety. Further research should focus on the effects on mother-child bonding.

Impact of Maternity Support Program on the Stress of Mothers in the First Encounter with the Preterm Infants

BACKGROUND

Mothers of premature infants experience a high level of stress. The current study was conducted aiming at investigating the impact of maternity support program on the stress of mothers in the first encounter with infants.

METHODS

This experimental study began in neonatal intensive care units (NICUs) of two hospitals of Tehran; that is, Mahdieh (intervention) and Shahid Akbar-Abadi (control), from Feb 14, 2016, to May 14, 2016. Both are educational and referral centers including three levels of NICU that were randomly allocated to intervention and control sites. In the span of study period all 75 infants and mothers with inclusion/exclusion criteria in the Mahdieh hospital were included in the intervention group and vis-à -vis all 68 infants and mothers in Shahid-Akbar-Abadi were enrolled in the control group. The designed intervention was conducted based on the support system pattern of mothers with premature infants in the interventional group. In the first stage of intervention, in the intervention group, mothers were provided informational, emotional, and spiritual support before and during the first exposure and were empowered for comfortable interactions. The control group received routine care. After the first exposure, the mothers' stress was measured by the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU). The data were analyzed by STATA software as well as t-test, Chi-square, and average treatment effects (ATEs) were estimated using inverse probability treatment weights (IPTW).

RESULTS

After adjusting pre-treatment variables by IPTW, the adjusted average difference in the stress score over the NICU environment, infant's behavior and appearance, the special treatments on him/her, and the change in the parental role and total stress were 1.47 (1.19-1.75), 1.06 (0.73-1.14), 1.21 (0.93-1.49), and 1.18 (0.93-1.44), which were lower than the control group (P < 0.001).

CONCLUSIONS

The intervention reduced significantly the stress of mothers. The policy-makers are suggested to conduct this method.

The effect of kangaroo mother care on aEEG activity and neurobehavior in preterm infants: a randomized controlled trial

OBJECTIVE

To evaluate the effect of kangaroo mother care (KMC) versus traditional care (TC) on aEEG activity and neurobehavior in preterm infants.

METHODS

A prospective randomized control single-blinded trial conducted in a tertiary level neonatal intensive care unit between October 2019 and October 2020. Preterm infants with gestational age of 31-33 weeks were randomly divided into either a KMC group or a TC group. Outcomes were compared between the groups including aEEG scores, the percentage of mature sleep-wake cycling (SWC) and background activity continuity, narrowband upper and lower bound amplitude, narrowband bandwidth, and neonatal behavioral neurological assessment (NBNA) scores on day 1, day 7, and day 14 after randomization.

RESULTS

A total of 65 infants (32 in KMC group and 33 in TC group) completed protocol. No significant differences were observed in outcomes on day 1. aEEG scores (p = .027 and p = .007, respectively) and the percentage of mature SWC (p = .034 and p = .039, respectively) were significantly higher in KMC group on day 7 and day 14. Compared to the TC group, KMC group had a narrower bandwidth on day 7 (p = .003) and day 14 (p = .016) and higher lower bound amplitude on day 14 (p = .002). Upper bound amplitude and the percentage of continuity were comparable between the groups on day 7 and day 14. The NBNA scores in the KMC group were significantly higher than that of the TC group on day 7 (p < .001) and day 14 (p < .001).

CONCLUSIONS

Preterm infants submitted to the KMC, compared to those non-submitted, have more mature aEEG activity and better neurobehavior performance on day 7 and day 14 after random.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900026363.

A Maternal-Administered Multimodal Neonatal Bundle in Hospitalized Very Preterm Infants: A Pilot Study

BACKGROUND

Premature infants are at an increased risk for developing cerebral palsy (CP). Evidence-based strategies designed to promote healthy brain development and facilitate adaptation after brain injury in infants still admitted to the neonatal intensive care unit (NICU) represent a novel approach that may lead to improved long-term outcomes.

PURPOSE

To investigate the feasibility of a maternal-administered early intervention bundle in very preterm infants prior to NICU discharge.

METHODS

A pilot trial evaluating a maternal-administered NICU-based bundle of interventions in preterm infants (≤32 weeks' gestational age and/or ≤1500 g birth weight). The impact of the bundle on short-term developmental outcomes of infants, as well as maternal stress, anxiety, and depression, is evaluated.

RESULTS

The intervention bundle was implemented in 11 mother-infant dyads (including 1 set of twins) for a median of 8 weeks and was overall well received. Vocal soothing, scent exchange, and comforting touch were feasible, performed at or above the predetermined goal of 71% of the time (5/7 days), while kangaroo care and infant massage were not. Maternal stress, anxiety, and depression were decreased during the study time.

IMPLICATIONS TO PRACTICE

A neonatal multimodal intervention bundle provided by mothers is feasible.

IMPLICATIONS TO RESEARCH

Additional randomized controlled studies are needed to determine whether this type of bundled interventions can (1) improve the neurodevelopmental outcomes of participating infants and (2) improve long-term parental outcomes, including decreased burden of anxiety and depression, as well as improved attachment and optimal patterns of social interaction.

Parental role alteration strongly influences depressive symptoms in mothers of preoperative infants with congenital heart disease

BACKGROUND

Mothers of infants with congenital heart disease are at risk for depression.

OBJECTIVES

This study explored the influence on maternal depressive symptoms of several known factors for mothers in the pediatric cardiac intensive care unit, including perceived stressors, attachment, and anxiety.

METHODS

This study was a secondary analysis of 30 mothers of infants awaiting cardiac surgery. Linear regressions were calculated to determine the relationships between perceived stressors, maternal attachment, anxiety, and maternal depressive symptoms.

RESULTS

Nearly half of mothers reported depressive symptoms above the measure cut-off score, indicating they were at risk for likely clinical depression. Subscales of perceived stress explained 61.7% of the variance in depressive symptoms (F = 11.815, p<0.0001) with parental role alteration subscale as the strongest predictor (standardized beta=0.694, p = 0.03).

CONCLUSIONS

Findings underscore the importance of mental health screening and instituting nursing practices to enhance parental role for mothers of infants awaiting cardiac surgery.

Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

BACKGROUND

Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities.

METHODS

The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms ("postpartum depression", "maternal depression", "postnatal depression", "perinatal depression" "mental health", "psychotherapy" "intervention", "treatment", "black Caribbean", "black African", "mothers" and "women"). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed.

RESULTS

Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.

CONCLUSION

In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.

The Collateral Impact of COVID-19 Emergency on Neonatal Intensive Care Units and Family-Centered Care: Challenges and Opportunities

The ongoing Coronavirus disease 2019 (COVID-19) pandemic is disrupting most specialized healthcare services worldwide, including those for high-risk newborns and their families. Due to the risk of contagion, critically ill infants, relatives and professionals attending neonatal intensive care units (NICUs) are undergoing a profound remodeling of the organization and quality of care. In particular, mitigation strategies adopted to combat the COVID-19 pandemic may hinder the implementation of family-centered care within the NICU. This may put newborns at risk for several adverse effects, e.g., less weight gain, more nosocomial infections, increased length of NICU stay as well as long-term worse cognitive, emotional, and social development. This article aims to contribute to deepening the knowledge on the psychological impact of COVID-19 on parents and NICU staff members based on empirical data from the literature. We also provided evidence-based indications on how to safely empower families and support NICU staff facing such a threatening emergency, while preserving the crucial role of family-centered developmental care practices.

Skin-to-Skin Care is Associated with Reduced Stress, Anxiety, and Salivary Cortisol and Improved Attachment for Mothers of Infants With Critical Congenital Heart Disease

OBJECTIVE

To estimate the effect of skin-to-skin care (SSC) on biobehavioral measures of stress (anxiety and salivary cortisol) and attachment (attachment scores and salivary oxytocin) of mothers before and after their infants' neonatal cardiac surgery.

DESIGN

A prospective interventional, baseline response-paired pilot study.

SETTING

Cardiac center of a large, metropolitan, freestanding children's hospital.

PARTICIPANTS

Thirty women whose infants were hospitalized for neonatal cardiac surgery.

METHODS

Participants acted as their own controls before, during, and after SSC at two time points: once before and once after surgery. We measured the stress response of mothers, as indicated by self-reported scores of anxiety and maternal salivary cortisol, and maternal-infant attachment, as indicated by self-reported scores and maternal salivary oxytocin.

RESULTS

Significant reductions in self-reported scores of anxiety and salivary cortisol were found as a result of SSC at each time point, as well as increased self-reported attachment. No significant differences were found in oxytocin.

CONCLUSION

Our findings provide initial evidence of the benefits of SSC as a nurse-led intervention to support maternal attachment and reduce physiologic and psychological stress responses in mothers of infants with critical congenital heart disease before and after neonatal cardiac surgery.

Systematic review of family engagement interventions in neonatal, paediatric, and adult ICUs

AIMS AND OBJECTIVES

The purpose of this systematic review was to evaluate interventions that have been used to engage families in direct care activities (active family engagement) in adult, paediatric, and neonatal intensive care unit (ICU) settings.

BACKGROUND

Family engagement is universally advocated across ICU populations and practice settings; however, appraisal of the active family engagement intervention literature remains limited.

SEARCH STRATEGY

Ovid Medline, PsycArticles & PsycInfo, Scopus, and CINAHL were searched for family interventions that involved direct care of the patient to enhance the psychological, physical, or emotional well-being of the patient or family in neonatal, paediatric, or adult ICUs.

INCLUSION/EXCLUSION CRITERIA

Studies were included if an active family engagement intervention was evaluated. Studies were excluded if they were not published in English or reported non-interventional research.

RESULTS

A total of 6210 abstracts were screened and 19 studies were included. Most studies were of low to moderate quality and were conducted in neonatal ICUs within the United States. Intervention dosage and frequency varied widely across studies. The interventions focused on developmental care (neonatal ICU) and involved families in basic patient care. Family member outcomes measured included satisfaction, stress, family-centred care, confidence, anxiety, and depression. Most studies found improvements in one or more outcomes.

CONCLUSIONS

There is a paucity of literature about active family engagement interventions, especially in adult and paediatric populations. The optimal dosage and frequency of family engagement interventions remains unknown. Our systematic review found that data are limited on the relationship between family engagement and patient outcomes, and provides a timely appraisal to guide future research.

RELEVANCE TO CLINICAL PRACTICE

Further research on the efficacy of family engagement interventions is warranted. The translation of active family engagement interventions into clinical practice should also be supported.

Beyond the First Wave: Consequences of COVID-19 on High-Risk Infants and Families

The novel coronavirus disease 2019 (COVID-19) pandemic is affecting care for high-risk newborns in ways that will likely be sustained beyond the initial pandemic response. These novel challenges present an urgent imperative to understand how COVID-19 impacts parent, family, and infant outcomes. We highlight three areas that warrant targeted attention: (1) inpatient care: visitation policies, developmental care, and communication practices; (2) outpatient care: high-risk infant follow-up and early intervention programs; and (3) parent psychosocial distress: mental health, social support, and financial toxicity. Changes to care delivery in these areas provide an opportunity to identify and implement novel strategies to provide family-centered care during COVID-19 and beyond. KEY POINTS: · The COVID-19 pandemic is influencing care delivery for high-risk newborns and their families.. · Rapid changes to care delivery are likely to be sustained beyond the initial pandemic response.. · We have an urgent imperative to understand how COVID-19 impacts infant, parent, and family outcomes..

Revisiting the roots of attachment: A review of the biological and psychological effects of maternal skin-to-skin contact and carrying of full-term infants

During the early period of hypothesis building and empirical testing of attachment theory, a major emphasis was placed on mother-infant physical contact. In spite of this, mother-infant contact has received scant attention amongst attachment and child development researchers in the past decades. Here, a brief theoretical framework for mother-infant contact is presented, drawing on animal studies as well as human studies of preterm infants and neonates. Salient mechanisms may include an extended sensitive period during early infancy, requiring specific somatosensory stimuli for bio-behavioral homeorhesis; oxytocinergic and epigenetic pathways; kinesthetic stimuli and face-to-face proximity allowing for increased social interaction. Studies of extended human mother-full-term infant physical contact have demonstrated positive effects in multiple domains. For infants, these include sleep organization, temperature and heart rate regulation, behavioral response, crying/colic, socio-emotional development, attachment quality, speech development opportunities and mother-child interactions. For mothers, studies demonstrate improved depressive symptomatology, physiological stress regulation, contingent responsivity, breastfeeding and mother-child interactions. Parent-infant attachment quality has gained prominence as a trauma-resilience factor as well as a predictor of adult physical health. The potential role of mother-infant contact as an attachment promoting intervention as well as future research subjects are discussed. Current evidence supports the original attachment research that early maternal touch provision may influence infant socio-emotional development and attachment quality, with positive implications for mother-child relationship functioning.

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi

BACKGROUND

Mother-infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother-infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother-infant relationship in Malawi are limited and studies that observed mother-infant interactions could not be located.

PURPOSE

This study explored mother-infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants.

METHODS

This observational study explored maternal and infant interactive behaviors. We recruited 83 mother-infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads).

FINDINGS

Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births.

IMPLICATIONS FOR PRACTICE

Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants.

IMPLICATIONS FOR RESEARCH

Future studies of factors that contribute to positive interactions in Malawi are needed.

Impact of an integrated mother-preterm infant intervention on birth hospitalization charges

OBJECTIVE

To examine whether the H-HOPE (Hospital to Home: Optimizing the Preterm Infant's Environment) intervention reduced birth hospitalization charges yielding net savings after adjusting for intervention costs.

STUDY DESIGN

One hundred and twenty-one mother-preterm infant dyads randomized to H-HOPE or a control group had birth hospitalization data. Neonatal intensive care unit costs were based on billing charges. Linear regression, propensity scoring and regression analyses were used to describe charge differences.

RESULTS

Mean H-HOPE charges were $10,185 lower than controls (p = 0.012). Propensity score matching showed the largest savings of $14,656 (p = 0.003) for H-HOPE infants, and quantile regression showed a savings of $13,222 at the 75th percentile (p = 0.015) for H-HOPE infants. Cost savings increased as hospital charges increased. The mean intervention cost was $680 per infant.

CONCLUSIONS

Lower birth hospitalization charges and the net cost savings of H-HOPE infants support implementation of H-HOPE as the standard of care for preterm infants.

Couple and family therapies for post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD.

OBJECTIVES

The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings.

SEARCH METHODS

We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures.

MAIN RESULTS

We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses.

AUTHORS' CONCLUSIONS

There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.