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

Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis

BACKGROUND

Few studies have examined the associations between pregnancy and birth complications and long-term (>12 months) maternal mental health outcomes.

OBJECTIVES

To review the published literature on pregnancy and birth complications and long-term maternal mental health outcomes.

SEARCH STRATEGY

Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

SELECTION CRITERIA

Three reviewers independently reviewed titles, abstracts and full texts.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and appraised study quality. Random-effects meta-analyses were used to calculate pooled estimates. The Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

MAIN RESULTS

Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). Termination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20-1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20-1.71). Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38-2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11-1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32-1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41-2.27) and post-traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52-5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75-8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta-analyses.

CONCLUSIONS

Exposure to complications during pregnancy and birth increases the odds of long-term depression, anxiety disorder and PTSD.

Achieving sufficient milk supply supports mothers to cope with premature birth

AIM

To explore whether and how expressing breast milk is perceived as helpful in coping with negative emotions due to premature birth by mothers of very low birth weight (VLBW) infants.

METHODS

Qualitative interviews and a retrospective cross-sectional questionnaire with mothers of VLBW infants were conducted and analysed using an exploratory sequential mixed-method design. Hypotheses were built using qualitative content analysis and quantitatively tested using multivariate regression analysis.

RESULTS

Interviews with 12 mothers and questionnaires of 518 mothers were analysed. Coping with prematurity by expressing milk was seen as a way to maintain the caregiving role for the mothers, where three relevant factors arouse: making up for what happened, providing the best for their infant and fear of low milk supply. Quantitative analysis showed that mothers with a high milk supply (Coef. = 1.1, p < 0.000) and more feelings of guilt due to premature birth (Coef. = -0.1; p = 0.015) perceived expressing breast milk significantly more as a resource for coping.

CONCLUSION

This study adds knowledge on how expressing breast milk for their VLBW infant may support mothers in coping with premature birth, by revealing the association with milk supply and feelings of guilt due to premature birth.

Lactation support in neonatal intensive care units in Germany from the mothers' perspective - a mixed-method study of the current status and needs

BACKGROUND

Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs).

METHODS

This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.

RESULTS

The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.

CONCLUSION

The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

Perinatal hair cortisol concentrations linked to psychological distress and unpredicted birth complications

Maternal well-being and stress during the perinatal period have been hypothesized to influence birth outcomes and the postnatal development of offspring. In the present study, we explored whether hair cortisol concentration (HCC) was related to symptoms of psychological distress during the perinatal period and with unpredicted birth complications (UBCs). Surveys measuring symptoms of perceived stress, state/trait anxiety, and depression were collected from 53 participants (mean age = 31.1, SD = 4.04; 83% Caucasian, 17% other races) during the third trimester and again at two and six months after birth, 24.5% of which reported UBCs. In a subset of participants, we measured HCC in hair samples collected during the third trimester (27-39 weeks) and six months after birth. Compared to participants reporting normal births, those reporting UBCs had significantly elevated composite stress, anxiety, and depression (SAD) scores two months after birth, but scores decreased by six months postpartum. During the third trimester, HCC was positively associated with reported SAD scores, and HCC was elevated in participants reporting birth complications. Logistic regression showed HCC, but not SAD scores, predicted UBCs (p = 0.023, pseudo R2= 19.7%). Repeated measures MANOVA showed HCC varied over the perinatal period depending on both SAD scores reported at two months postpartum and the experience of UBCs; but when SAD scores reported at six months postpartum were included in the model, the association between HCC and SAD scores and the influence of UBCs was diminished. Although generalizability is limited by our relatively small, homogeneous sample, findings support a positive association between reported psychological distress and HCC during pregnancy and at two months postpartum. We also report a novel finding that chronically elevated cortisol concentrations during pregnancy were related to the risk of UBCs and remain elevated through the early postpartum period, suggesting the importance of monitoring both psychological distress and HCC during the perinatal period.

Pressure to provide milk among mothers of very low birth weight infants: an explorative study

BACKGROUND

Pump-dependent mothers of very low birth weight (VLBW, < 1500g) infants experience specific challenges achieving sufficient milk supply in the neonatal intensive care unit (NICU) and are therefore less frequently able to achieve (exclusive) breast milk feeding. Stress due to the limitations on participating in the infant's care may contribute to this problem. Some explorative studies suggest that pressure to provide milk may be an additional stressor in mothers. However, the type of pressure to provide milk perceived by mothers of VLBW infants has rarely been examined.

METHODS

A retrospective and anonymous questionnaire was conducted with mothers of VLBW infants aged 6 to 24 months at the time of data collection. Quantitative data and written comments were used to examine the mothers' perceptions. Descriptive and bivariate tests (Spearman´s rho, Pearson's chi2) were performed to show correlations between pressure to provide breast milk, parental stress (PSS:NICU: role alteration subscale), milk volume, and maternal factors. Pressure to provide milk was measured through two self-developed single items to differentiate between internal and external pressures.

RESULTS

Data of n = 533 mothers of VLBW infants was analysed. More than 70% of the mothers agreed that they pressured themselves to provide milk for their infant. In contrast, 34% of the mothers agreed that they felt pressure from outside to provide milk. Higher milk volume 14 days post-partum was significantly correlated with higher internal (Spearman´s rho = 0.2017, p = 0.000) and higher external pressure to provide milk (Spearman´s rho = 0.2991; p = 0.000). Higher PSS:NICU parental role alteration scores were significantly correlated with more internal (Spearman´s rho = -0.2865, p = 0.000) and more external pressure to provide milk (Spearman´s rho = -0.1478; p = 0.002). Milk volume 14 days post-partum and the PSS:NICU were not significantly correlated (Spearman´s rho = -0.0190; p = 0.701). Qualitative analyses highlighted these results and enhanced the bidirectional relationships between maternal pressure to provide milk and milk volume.

CONCLUSIONS

Especially internal pressure to provide milk is perceived by many mothers, being mutually dependent on milk supply and parental stress. Pressure to provide milk may be an important factor to decrease maternal stress in the NICU and, therefore, lead to more positive pumping and breastfeeding experiences. More research and validated instruments are needed to adequately measure pressure to provide milk with its different psychological, social, and environmental dimensions.

Effect of adverse perinatal outcomes on postpartum maternal mental health in low-income and middle-income countries: a protocol for systematic review

INTRODUCTION

More than three-fourths of adverse perinatal outcomes (preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death) occur in low-income and middle-income countries. These adverse perinatal outcomes can have both short-term and long-term consequences on maternal mental health. Even though there are few empirical studies on the effect of perinatal loss on maternal mental illness, comprehensive information on the impact of adverse perinatal outcomes in resource-limited settings is scarce. Therefore, we aim to systematically review and synthesise evidence on the effect of adverse perinatal outcomes on maternal mental health.

METHODS AND ANALYSIS

The primary outcome of our review will be postpartum maternal mental illness (anxiety, depression, post-traumatic stress disorder and postpartum psychosis) following adverse perinatal outcomes. All peer-reviewed primary studies published in English will be retrieved from databases: PubMed, MEDLINE, CINAHL Ultimate (EBSCO), PsycINFO, Embase, Scopus and Global Health through the three main searching terms-adverse perinatal outcomes, maternal mental illness and settings, with a variant of subject headings and keywords. We will follow the Joanna Briggs Institute critical appraisal checklist to assess the quality of the studies we are including. The review findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Estimate-based meta-analysis will be performed. We will assess heterogeneity between studies using the I2 statistics and publication bias will be checked using funnel plots and Egger's test. A subgroup analysis will be conducted to explore potential sources of heterogeneity (if available). Finally, the certainty of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Since this systematic review does not involve human participants, ethical approval is not required. The review will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023405980.

The Involvement of Neonatal Intensive Care Unit and Other Perinatal Factors in Postpartum PTSD After Cesarean Section

BACKGROUND

The experience of a neonate hospitalised in the Neonatal Intensive Care Unit (NICU) is an understandably traumatic experience for the parents, especially, for the mothers of neonates. This mental distress resulting from preterm birth and/or NICU hospitalisation can be understood as post-traumatic symptomatology, according to the Diagnostic and Statistical Manual-5 version. The aim of this study is to investigate the impact of the admission of a neonate to the NICU (from any reason) on the development of postpartum post-traumatic stress disorder (PTSD) in a sample of women after cesarean sections.

MATERIAL AND METHODS

A total of 469 women who gave birth with cesarean section from July 2019 to June 2020 participated in this study, from the original sample of 490 women who consented to participate. Data were obtained from the researcher's socio-demographic questionnaire, the past traumatic Life Events Checklist, the perinatal stressor Criterion A, and the Post-Traumatic Stress Checklist from the Diagnostic and Statistical Manual-5 version.

RESULTS

A percentage of 46.64% of sample experienced postpartum PTSD. Factors associated with PTSD were placenta previa type4, abruption, bleeding (β = .07, p = .049), premature contractions (β = .08, p = .039), heavy medical history or previous gynecological history and preeclampsia (β = .08, p = .034), abnormal heart rate, premature rupture of membrane, premature contractions, infections (β = .14, p = .004), life of child in danger (β = .12, p = .025), complications involving child (β = .15, p = .002), complications involving both (child and mother) (β = .12, p = .011), traumatic cesarean section (β = .041, p < .001) and prematurity (β = .12, p = .022).

CONCLUSIONS

Additional measures must be taken for mothers of children who have been admitted to the NICU with psychological support interventions and reassessment of their mental state.

Separation in Unity: Dialogical Transformation of Maternal Bond

The objective of this paper is to explore mothers' psychological adaptation related to separation from their newborn children immediately after birth. Mother and child separation has traditionally received attention from the child's perspective, but given that the bond is dyadic, the mother's wellbeing should also be considered. This qualitative study is based on interview data with mothers of premature infants. From the analysis, three themes emerged: concerns during pregnancy about premature birth; emotional strain caused by separation; and the need to protect and to be close to the newborn. Drawing on the perspectives of dialogical self theory and semiotic regulation model, the paper will focus on intra-psychological dynamics and will analyze the adaptation process in terms of I-positions. Based on the analysis, the maternal bond represents the integration of the I-position I-as-mother and My child, which is integrated during the pregnancy into the core of the self. It can be assumed that rupture of the self-continuity is activated by the birth of the child, which is then compounded if the child leaves. The maternal superordinate viewpoint (meta-I-position) directs a woman's behavior and allows for a sense of coherence under dynamic organization related to the birth of the child. The potential for psychological adaptation is presented as an ability to establish self-continuity.

Group trauma focused cognitive behavior therapy for parents of premature infants compared to individual therapy intervention

BACKGROUND

The current study compares results of a group-based intervention developed to reduce symptoms of posttraumatic stress, depression, and anxiety in parents of premature infants with a prior study using an individual version of the treatment manual.

METHODS

26 mothers of preterm infants (25-34 weeks' gestational age; >600 g) received 6 sessions of trauma-focused cognitive behavior therapy (CBT). Outcomes were compared with those of a previously published RCT, which tested an individual therapy based on the same model in a group of 62 mothers. Results were also compared across in-person and telehealth treatment.

RESULTS

From baseline to follow up, the individual intervention showed greater improvement in trauma symptoms assessed with the Davidson Trauma Scale (d = 0.48, p = 0.016), although both conditions showed clinically significant improvement. Similar patterns were found for maternal depression and anxiety. In-person treatment was found to be superior to telehealth treatment administered during the COVID-19 pandemic, although the difference was not significant.

CONCLUSIONS

Group-based trauma focused CBT is an effective treatment modality for parents of premature infants with symptoms of psychological distress but not as effective as individual therapy using the same treatment model.

Examining the impact of premature birth on parental mental health and family functioning in the years following hospital discharge: A review

BACKGROUND

This review provides an update of the current research related to the impact of extreme and very premature birth on parental mental health and family functioning following discharge from hospital.

METHODS

Full-text peer reviewed articles in English, describing parents' and families' health and wellbeing after the discharge from hospital of their baby using validated questionnaires, were evaluated. Results of included studies are presented in a summarized format. Embase, Medline and PsycINFO databases were accessed in January 2021.

RESULTS

38 studies were included. Nine manuscripts reported on parental mental health and 13 on stress, which are a concern after the birth of a premature infant, especially in the first year. Depression, anxiety, and stress are known to measure higher compared to parents of infants born at term. Over several years, these measures of mental health decrease significantly. Four reported on quality of life for parents of premature infants, which is reduced immediately after discharge, but then improves over time. The impact of premature birth on the family functioning was described in ten included studies and was described to have positive and negative consequences.

CONCLUSION

The negative impact of the premature birth and hospital journey on parental mental health lessens significantly with time.

The Prevalence of PTSD of Mothers and Fathers of High-Risk Infants Admitted to NICU: A Systematic Review

Admission of a preterm or sick full-term infant to the neonatal intensive care unit (NICU) is a stressful experience for parents. Indeed, the 'NICU experience' may constitute a traumatic event for parents, distinct from other birth-related trauma, leading to significant and ongoing posttraumatic stress disorder (PTSD) symptoms. However, the rates at which this outcome occurs are not well understood. This review aimed to identify the prevalence of PTSD in mothers and fathers of high-risk infants admitted to the NICU, specifically focusing on the NICU experience as the index trauma. The PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were used to conduct this review. We searched PsycINFO, PubMed, Scopus, EMBASE, Web of Science, ProQuest Dissertations and Theses databases, and reference lists of included articles (1980-2021). Two independent reviewers screened titles and abstracts and conducted the full-text screening assessment. Of the 707 records identified, seven studies met the inclusion criteria. In this systematic review, PTSD symptomatology was assessed by self-report measures rather than a clinical interview. We identified significant variations in the methodologies and quality between studies, with a wide variation of reported prevalence rates of PTSD of 4.5-30% in mothers and 0-33% in fathers. Overall, the findings indicate that up to one-third of parents experience PTSD symptomatology related to the NICU experience. These results emphasize the importance of universal routine antenatal and postnatal screening for symptoms of PTSD to identify parents at risk of distress during the NICU experience and after discharge.Trial registration: The study protocol was registered with Prospero registration number CRD42020154548 on 28 April 2020.

Home Immunization with Palivizumab-A Randomized Pilot Study Describing Safety Aspects and Parents' Preferences

Among prematurely born infants and newborns with chronic conditions, a respiratory syncytial virus (RSV) infection may cause (re-)admission and later respiratory complications. Therapeutic protection is possible with monthly injections of a specific monoclonal antibody, palivizumab, during RSV season. Standard care is giving up to five injections in clinic-based settings. Immunization at home could be an alternative to standard care for vulnerable infants to reduce the number of revisits and associated risk of RSV infection. The aim of this randomized pilot trial was to evaluate safety aspects and explore parents' preferences of home versus hospital immunization with palivizumab during one RSV season. Immediate adverse events (AEs) were observed and registered by a pediatric specialist nurse. Late-onset AEs were reported by parents. Parents' perceptions were collected through a questionnaire and analyzed using content analysis. The study population consisted of 43 infants in 38 families. No immediate AEs occurred. Three late-onset AEs were reported in two infants in the intervention group. Three categories emerged in the content analysis: (1) protect and watch over the infant, (2) optimal health and well-being for the whole family, and (3) avoid suffering for the infant. The study results show that home immunization with palivizumab is feasible if safety aspects are considered and that parental involvement in the choice of place for immunization after a neonatal intensive care experience can be important.

Increased Risk of Parental Instability for Children Born Very Preterm and Impacts on Neurodevelopmental Outcomes at Age 12

Caring for a child born preterm places significant emotional and financial burdens on family relationships. This paper examines (a) the extent to which children born very and extremely preterm are more likely to experience parental change/caregiver instability than children born full term, (b) predictors of parental change/s for preterm infants, and (c) whether exposure to parental change/caregiver instability increases child neurodevelopmental risk. Data were collected as part of a prospective longitudinal study of 110 very preterm and 113 full-term born infants and their parents studied from birth to corrected age 12 years. At ages 2, 4, 6, 9 and 12 years, detailed information was collected about the frequency and nature of all parent/caregiver changes for 3-6 monthly intervals of each child's life. At age 12, all children completed a comprehensive neurodevelopmental evaluation of their emotional and behavioural adjustment, cognition, and educational achievement. Results showed that children born very preterm were at increased risk of experiencing parental/caregiver changes, with this risk being greatest for those born extremely preterm. Neonatal medical complexity, family socioeconomic disadvantage, maternal psychological wellbeing, and child neurodevelopmental impairment were associated with a higher risk of parental change. Preterm birth and exposure to parental change/instability contributed additively to poorer child outcomes. Findings support the need for family-focused neonatal and postnatal care strategies for high-risk infants, to support parents as well as their infants to optimize child health and developmental outcomes.

Parenting Record Handbook: The Needs of Mothers Raising Low Birth Weight Infants

This study investigated the necessity for a parenting record handbook that is specifically tailored to the needs of low birth weight infants (LBWIs) and their families, especially mothers, who face parenting difficulties and challenges. The participants were 20 mothers, raising LBWIs, discharged from the neonatal intensive care unit. The mean age and weight of the children were 2.75 ± 0.35 years and 1417.50 ± 152.06 g, respectively; the mean duration of neonatal intensive care unit hospitalization was 78.75 ± 14.10 days. At the time of the study, 35% (7/20) were nursery children, 10% (2/20) were kindergarten children, 20% (4/20) were using rehabilitation centers, and 10% (2/20) were using the medical rehabilitation handbook. The needs of the mothers were investigated through focus group interviews or individual interviews, and content analyses were performed. The mothers required the promotion of peer support that assists the alleviation of mental burden and postpartum mental and physical care, as well as the publication of counseling service counters and reliable information sources for parenting difficulties in the parenting record handbook. The mothers required the publication and recording of the growth indicators of LBWIs, parenting records, information management of children since birth, and for the handbook to function as a multidisciplinary information sharing tool. In addition, the requirements for the parenting record handbook were the early provision of the parenting record handbook and measures to cope with poor maternal physical condition. The results of this study suggest that mothers with LBWIs require a parenting record handbook that can provide comprehensive maternal and child health assurance, starting from pregnancy, to resolve childcare difficulties for LBWIs, as well as mental support.

Maternal Mood and Perception of Infant Temperament at Three Months Predict Depressive Symptoms Scores in Mothers of Preterm Infants at Six Months

Postpartum depression is more prevalent in mothers and fathers of preterm infants compared to parents of full-term infants and may have long-term detrimental consequences for parental mental health and child development. The temperamental profile of an infant has been postulated as one of the important factors associated with parental depressiveness in the first months postpartum. This study aimed to examine the longitudinal relationship between depressive symptoms and perceived infant temperament at 3 months corrected age, and depressive symptoms at 6 months corrected age among mothers and fathers of infants born preterm. We assessed 59 families with infants born before the 34th gestational week using the Edinburgh Postnatal Depression Scale (EDPS) and the Infant Behavior Questionnaire-Revised. We found that mothers’ scores on EPDS and infants’ Orienting/regulation at 3 months corrected age predicted mothers’ EPDS scores at 6 months corrected age. In particular, higher depressive scores were related to higher depressive symptoms at 6 months corrected age, whereas higher infant Orienting/regulation was related to lower depressive symptoms at 6 months corrected age. Due to the low internal consistency of EPDS at 6 months for fathers, we were unable to conduct similar analyses for fathers. Our results point to the importance of considering both early indices of maternal mood as well as mother-reported measures of preterm infant temperament in the attempts to predict levels of maternal depressiveness in later months of an infant’s life. Further studies are urgently needed in order to better understand the associations between depressiveness and infant temperament in fathers, and with more consideration for the severity of the effects of infant prematurity.

Psychological impact of neonatal intensive care unit admissions on parents: A regional perspective

OBJECTIVE

This study aimed to report the prevalence of adverse psychological symptoms and health behaviours of parents who had a baby admitted to a regional neonatal intensive care unit to spotlight mental health care in these unique settings.

DESIGN

This was a prospective, prevalence-based study using quantitative data.

SETTING

The study was conducted at the Townsville University Hospital, Queensland.

PARTICIPANTS

Participants comprised 114 parents of 79 infants enrolled in the study (mothers = 69 and fathers = 45).

MAIN OUTCOME MEASURES

Trauma, depression, anxiety, stress, alcohol and drug use, prior mental health history and bonding experience were assessed by standardised self-report questionnaires and a structured diagnostic interview within 2 weeks and at 3 months post-admission to neonatal intensive care unit.

RESULTS

Clinically significant acute trauma symptoms (16% of mothers only), depression (22% mothers; 4% of fathers), anxiety (27% mothers; 11% fathers) and stress (24% mothers; 13% fathers) were reported within the first 2 weeks after their baby was admitted to the neonatal intensive care unit. Notably, 18% of parents reported engaging in harmful alcohol use behaviour within 2 weeks post-birth; 29% of fathers continued to report risky drinking at 3 months. At 3 months, 21%, 8% and 6% of mothers met diagnostic criteria for generalised anxiety disorder, major depressive disorder and post-traumatic stress disorder, respectively.

CONCLUSION

Screening for psychological distress and alcohol use of parents of neonatal intensive care unit babies can ensure that support services are made available post-discharge to optimise family function and development of the preterm infant.

Identifying research priorities in newborn medicine: a Delphi study of parents' views

OBJECTIVE

Neonatal conditions can have lifelong implications for the health and well-being of children and families. Traditionally, parents and patients have not been included in shaping the agenda for research and yet they are profoundly affected by the neonatal experience and its consequences. This study aimed to identify consensus research priorities among parents/patients of newborn medicine in Australia and New Zealand.

DESIGN

Parents/patients with experience of neonatal care in Australia and New Zealand completed an online Delphi study to identify research priorities across four epochs (neonatal admission, early childhood, childhood/adolescence and adulthood). Parents/patients first generated key challenges in each of these epochs. Through inductive thematic analysis, recurring topics were identified and research questions generated. Parents/patients rated these questions in terms of priorities and a list of questions consistently rated as high priority was identified.

PARTICIPANTS

393 individuals participated, 388 parents whose children had received neonatal care and 5 adults who had received neonatal care themselves.

RESULTS

Many research questions were identified as high-priority across the lifespan. These included how to best support parental mental health, relationships between parents and neonatal clinical staff (including involvement in care and communication), bonding and the parent-child relationship, improving neonatal medical care and addressing long-term impacts on child health and neurodevelopment.

CONCLUSIONS

Parents with experience of newborn medicine have strong, clear and recurring research priorities spanning neonatal care practices, psychological and other impacts on families, and impacts on child development. These findings should guide neonatal research efforts. In addition to generating new knowledge, improved translation of existing evidence to parents is also needed.

[Preterm birth: a risk for mental health?]

One in 12 children is born before 37 completed weeks of gestation and during the last decades survival rates and developmental outcomes of even very premature children have significantly improved. As a result, mental health sequelae of preterm birth are more frequently addressed. The manifestation of a distinct psychopathological profile with co-occurrence of symptoms associated with attention deficit/hyperactivity, autism spectrum and anxiety disorders has been recognized and discussed as "preterm behavioral phenotype", mainly affecting high-risk children with very low birth weights. Current research findings on parental psychological distress and early childhood developmental conditions after preterm birth indicate contextual factors that are of relevance, also for clinicians in psychotherapeutic practice.

Maternal Mental Health Disorders Following Very Preterm Birth at 5 Years Post-Birth

OBJECTIVE

Mothers of children born very preterm (VP) are at increased risk of developing postnatal depression, anxiety, and post-traumatic stress symptoms. However, mental health disorder rates are rarely assessed in this population compared with full-term peers, and it is unclear if postnatal distress symptoms precede higher rates of maternal mental health disorders at 5 years post-birth in both birth groups.

METHODS

Mothers of children born VP (n = 65; mean [SD] age at birth, 33.9 [5.0]; 72.1% tertiary educated) and full-term (n = 90; mean [SD] age at birth, 33.4 [4.0]; 88.2% tertiary educated) completed questionnaires assessing symptoms of depression, anxiety, and trauma within 4 weeks of birth. At 5 years post-birth, they participated in a structured diagnostic interview assessing mood, anxiety, and trauma-related mental health disorders, both current and over the lifetime.

RESULTS

There was little evidence for differences between mothers in the VP and full-term groups in rates of any mental health disorder at 5 years (VP = 14%, full-term = 14%) or lifetime (VP = 41%, full-term = 37%). In mothers of children born VP, elevated postnatal post-traumatic stress symptoms were associated with higher rates of mental health disorders at 5 years (odds ratio = 21.5, 95% confidence interval = 1.35-342).

CONCLUSIONS

Findings suggest that preterm birth may not lead to increased odds of later developing maternal mental health disorders, despite known risks of elevated postnatal distress following a VP birth. However, those with post-traumatic stress symptoms following a VP birth could be more vulnerable, and assessment and monitoring is recommended.

The Soundscape of Neonatal Intensive Care: A Mixed-Methods Study of the Parents' Experience

Parents who have infants hospitalised in neonatal intensive care units (NICUs) experience high levels of stress, including post-traumatic stress disorder (PTSD) symptoms. However, whether sounds contribute to parents’ stress remains largely unknown. Critically, researchers lack a comprehensive instrument to investigate the relationship between sounds in NICUs and parental stress. To address this gap, this report presents the “Soundscape of NICU Questionnaire” (SON-Q), which was developed specifically to capture parents’ perceptions and beliefs about the impact that sound had on them and their infants, from pre-birth throughout the NICU stay and in the first postdischarge period. Parents of children born preterm (n = 386) completed the SON-Q and the Perinatal PTSD Questionnaire (PPQ). Principal Component Analysis identifying underlying dimensions comprising the parental experience of the NICU soundscape was followed by an exploration of the relationships between subscales of the SON-Q and the PPQ. Moderation analysis was carried out to further elucidate relationships between variables. Finally, thematic analysis was employed to analyse one memory of sounds in NICU open question. The results highlight systematic associations between aspects of the NICU soundscape and parental stress/trauma. The findings underscore the importance of developing specific studies in this area and devising interventions to best support parents’ mental health, which could in turn support infants’ developmental outcomes.

Pediatric medical traumatic stress (PMTS) in parents of newborns with a congenital anomaly requiring surgery at birth

BACKGROUND

Pediatric medical traumatic stress (PMTS) is a psychological and physiological response of children and their families to pain, serious illness, and invasive medical procedures. We aimed to apply the PMTS model to parents of newborns operated at birth for a congenital malformation and to identify clinical and sociodemographic risk factors associated with PMTS symptoms at 6 months.

METHODS

We designed a cross-sectional study to assess PMTS symptoms (avoidance, arousal, reexperiencing) in parents of six months children operated on for a congenital anomaly, with the Italian version of the Impact of Event Scale - Revised (IES-R).

RESULTS

One-hundred-seventy parents form the object of the study. Eighty-two parents (48.2%) fell over the clinical cut-off. Ventilatory time (p = 0.0001), length of hospital stay (p = 0.0001), associated anomalies (p = 0.0002), medical devices at discharge (p = 0.0001) and Bayley motor scale (p = 0.0002) were significantly correlated with IES-R Total and Subscale Scores. Multivariate linear regression showed length of hospital stay and number of associated anomalies as significant predictors of IES-R Scores.

CONCLUSIONS

Regardless the type of anomaly and sociodemographic factors, it is the clinical history of the child which seems to predict the severity of PMTS symptoms in this population of parents. PMTS represents a useful model to describe the psychological reactions of parents of newborns operated at birth for a congenital malformation. NICU and outpatient pediatric staff should be aware of risk factors to identify families who may request early multidisciplinary interventions since the first admission.

LEVEL OF EVIDENCE

Prognosis study, level II.

Prevention of posttraumatic stress disorder in mothers of preterm infants using trauma-focused group therapy: Manual development and evaluation

BACKGROUND

Preterm birth has been associated with a number of adverse maternal psychological outcomes.

AIMS

The current study aims to develop and evaluate the feasibility of a trauma-focused group intervention that is designed to reduce maternal symptoms of anxiety, depression, and posttraumatic stress in a sample of mothers of preterm infants hospitalized in a neonatal intensive care unit (NICU).

STUDY DESIGN

The study was a one-group pre-/post quasi-experimental design. Participants received a 6-session intervention targeting parental trauma.

SUBJECTS

English-speaking mothers (N = 19) greater than 18 years of age of infants 23-34 weeks gestational age hospitalized in the NICU at Lucile Packard Children's Hospital Stanford.

OUTCOME MEASURES

Beck Anxiety Inventory (BAI), Beck Depression Inventory, Second Edition (BDI-II), Davidson Trauma Scale (DTS).

RESULTS

Results from the study indicate that the intervention is feasible, able to be implemented with a high degree of fidelity, is rated as highly satisfactory by participants, and leads to statistically significant reductions in symptoms of anxiety, depression, and posttraumatic stress at 6-week and 6-month follow-ups.

CONCLUSIONS

Though encouraging, these findings are preliminary, and future studies should strive to reproduce these findings with a larger sample size and a comparison group.

Implementing a standardized screening protocol for parental depression, anxiety, and PTSD symptoms in the Neonatal Intensive Care Unit

The aim of this paper is to describe the development of a standardized screening program for parents of infants in the Neonatal Intensive Care Unit (NICU) and to assess its implementation. The standardized screening protocol assessed parental mental health symptoms including depression, anxiety and trauma. Screening began at 14 days post NICU admission and was implemented as part of routine medical care for all caregivers with infants admitted to the NICU at two weeks of age. Screenings were facilitated by pediatric social workers and psychology postdoctoral fellows and included review of critical self-harm items. A total of 158 parents ages 18-42 years (mean = 31.04) were eligible for screening, with 150 completed screenings. Positive screens on any of the three measures resulted in a mental health referral. Approximately 27% of parents had a positive screen that resulted in a mental health referral. The standardized screening protocol was found to be feasible, widely accepted, and effective in establishing referrals for in house mental health services. This model can be used as an example to help other NICUs implement their own universal screening protocols.

Prevalences and predictive factors of maternal trauma through 18 months after premature birth: A longitudinal, observational and descriptive study

Posttraumatic reactions are common among mothers of preterm infants and can have a negative influence on their quality of life and lead to interactional difficulties with their baby. Given the possible trajectories of posttraumatic reactions, we hypothesized that prevalences of postpartum posttraumatic reactions at given times underestimate the real amount of mothers experiencing these symptoms within 18 months following delivery. Additionally, we examined whether sociodemographic and clinical characteristics of dyads influence the expression of posttraumatic symptoms among these mothers. A sample of 100 dyads was included in this longitudinal study led by 3 french university hospitals. Preterm infants born before 32 weeks of gestation and their mothers were followed-up over 18 months and attended 5 visits assessing the infants’ health conditions and the mothers’ psychological state with validated scales. Fifty dyads were retained through the 18 months of the study. The period prevalence of posttraumatic reactions was calculated and a group comparison was conducted to determine their predictive factors. Thirty-six percent of the mothers currently suffered from posttraumatic symptoms 18 months after their preterm delivery. The 18 months period prevalence was 60.4% among all the mothers who participated until the end of the follow-up. There was a statistical link between posttraumatic symptoms and a shorter gestational age at delivery, C-section, and the mother’s psychological state of mind at every assessment time. Only a small proportion of mothers were receiving psychological support at 18 months. Preterm mothers are a population at risk of developing a long-lasting postpartum posttraumatic disorder, therefore immediate and delayed systematic screenings for posttraumatic symptoms are strongly recommended to guide at-risk mothers towards appropriate psychological support.

Posttraumatic Stress Symptoms in Mothers and Fathers of Very Preterm Infants Over the First 2 Years

OBJECTIVE

Mothers and fathers of infants born very preterm (VPT) are at increased risk for posttraumatic stress symptoms (PTSSs), such as reexperiencing the event, persistent avoidance, or increased reactivity within the early months, compared with parents of term-born infants. This study aimed to assess PTSSs in mothers and fathers of VPT infants over the first 2 years of life, including changes over time and relationship with medical and social risk.

METHOD

A longitudinal, prospective, cohort study of PTSSs in parents of VPT infants. PTSS was assessed at term equivalent age (TEA) and 12 and 24 months using the Posttraumatic Stress Disorder Checklist Specific Version. Participants were 105 parents of 131 infants born at <30 weeks' gestational age with PTSS data at least once (92 mothers and/or 75 fathers).

RESULTS

At TEA and 12 and 24 months, elevated PTSSs were reported by 36%, 22%, and 18% of mothers and 35%, 25%, and 19% of fathers, respectively. The mean symptom scores and rates of elevated PTSSs declined over time: mean (95% confidence interval) change in PTSS score per year = -1.52 (-2.33 to -0.72, p < 0.001). There was little evidence for difference in these patterns for mothers or fathers (interaction p = 0.46 [total score] and 0.71 [elevated category]) or that medical and social risk were associated with PTSSs over time.

CONCLUSION

Although the rates of parents experiencing clinically elevated symptoms declined over time, it is concerning that one-fifth of mothers and fathers reported elevated PTSSs at 24 months. Further research is needed to identify factors associated with increased risk and resilience for PTSSs after VPT birth in mothers and fathers to provide effective and appropriate support.

Perinatal risk factors and reactive attachment disorder: A nationwide population-based study

AIM

To examine the association between several perinatal and obstetric risk factors and reactive attachment disorder in children diagnosed in specialised services.

METHODS

In this nested case-control study, 614 cases with reactive attachment disorder and 2423 controls matched with age and sex were identified from Finnish national registers. Conditional logistic regression was used to examine the association between a number of perinatal risk factors and reactive attachment disorder.

RESULTS

In the adjusted analysis, a low birthweight of <2500 g was associated with an increased odds of reactive attachment disorder, with an odds ratio (OR) of 1.96 and 95% confidence interval (CI) of 1.17, 3.30 and a birthweight of 4000-4499 grams was associated with decreased odds OR 0.49 (95% CI 0.31, 0.75). The odds for being diagnosed with reactive attachment disorder increased with a gestational age of <32 weeks OR 3.72 (95% CI 1.52, 9.10), induced labour OR 1.34 (95% CI 1.03, 1.75) and monitoring in a neonatal intensive care unit (NICU) OR 1.67 (95% CI 1.09, 2.55).

CONCLUSION

We found associations between low birthweight, preterm birth, NICU admission and reactive attachment disorder. The findings add to the current literature on the understanding of the development of reactive attachment disorder in children.

A longitudinal study of bonding failure related to aspects of posttraumatic stress symptoms after childbirth among Japanese mothers

Background

Posttraumatic stress symptoms (PTSS) after childbirth may affect mother-infant bonding. This study examined the relationship between aspects of PTSS after childbirth and bonding failure for mothers at 1 month and 4 months after delivery.

Methods

This longitudinal study surveyed 130 mothers at 1 month (T1) and 4 months (T2) after delivery. We performed multiple regression analysis with the Postpartum Bonding Questionnaire (PBQ) as the dependent variable and the Impact of Event Scale-Revised (IES-R), Edinburgh Postnatal Depression Scale (EPDS), Relationship Questionnaire (RQ), Family Adaptation, Partnership, Growth, Affection, and Resolve score (F.APGAR), and demographic data as independent variables.

Results

The rate of mothers with an IES-R score of ≥ 25 was 6.2% at T1 and 3.8% at T2. The IES-R and the EPDS were relevant factors for the PBQ at T1. The IES-R was not a relevant factor, but the EPDS was a relevant factor for the PBQ at T2. The IES-R at T1 was not a predictor for the PBQ at T2. The PBQ at T1 was the largest predictor for the PBQ at T2, when compared with the EPDS, F.APGAR, and dismissive attachment pattern (RQ) at T1.

Conclusions

PTSS after childbirth had a strong influence on bonding failure at T1. However, the important factor affecting bonding failure was not PTSS after childbirth, but depression at T2. If PTSS after childbirth are accompanied by depression at T2, bonding failure may be affected. Bonding failure affected by PTSS after childbirth at T1 could affect bonding failure at T2. Health professionals should assess the degree of PTSS after childbirth and start to care for mothers at T1.

Internal and External Resources and the Adjustment of Parents of Premature Infants

Studies have shown premature birth and infant hospitalization to be associated with increased levels of parental distress. Internal and external psychological resources have been found to mitigate distress among persons coping with stressful medical events. The current study evaluated psychological resources and distress in 87 parents (57 mothers and 30 fathers) to whom an infant was born prematurely and hospitalized in the NICU of a large tertiary medical center. Parents were administered standardized measures of internal (problem-solving skills) and external (total spousal support, adequacy of spousal support) psychological resources and of psychological distress (depression, posttraumatic symptoms, and mood). Findings indicated that higher levels of problem-solving skills and more adequate spousal support, but not total spousal support, were related to lower levels of parental distress. Adequacy of spousal support and parents' problem-solving skills accounted for 18% of the variance in overall mood and 13.8% of the variance in posttraumatic stress symptoms. A significant two-way interaction was found between adequacy of spousal support and problem-solving skills such that individuals with better problem-solving skills reported better overall mood independent of the adequacy of spousal support they receive. However, for individuals with poor problem-solving skills, the adequacy of the spousal support they receive was a significant factor in determining their overall mood. The theoretical and clinical implications of these findings are discussed in terms of the accessibility of these resources to assessment and their potential for change via existing intervention approaches.

Maternal pre and perinatal experiences with their full-term, preterm and very preterm newborns

Background

Mothers’ reports about pregnancy, maternity and their experiences during the perinatal period have been associated with infants’ later quality of attachment and development. Yet, there has been little research with mothers of very preterm newborns. This study aimed to explore mothers’ experiences related to pregnancy, premature birth, relationship with the newborn, and future perspectives, and to compare them in the context of distinct infants’ at-birth-risk conditions.

Methods

A semi-structured interview was conducted with women after birth, within the first 72 h of the newborn’s life. A total of 150 women participated and were divided in three groups: (1) 50 mothers of full-term newborns (Gestational Age (GA) ≥ 37 weeks; FT), (2) 50 mothers of preterm newborns (GA 32–36 weeks; PT) and (3) 50 mothers of very preterm newborns (GA < 32 weeks; VPT).

Results

Mothers of full-term infants responded more often that their children were calm and that they did not expect difficulties in taking care of and providing for the baby. Mothers of preterm newborns although having planned and accepted well the pregnancy (with no mixed or ambivalent feelings about it) and while being optimistic about their competence to take care of the baby, mentioned feeling frightened because of the unexpected occurrence of a premature birth and its associated risks. Mothers of very preterm newborns reported more negative and distressful feelings while showing more difficulties in anticipating the experience of caring for their babies.

Conclusion

The results indicate that Health Care Systems and Neonatal Care Policy should provide differentiated psychological support and responses to mothers, babies and families, taking into account the newborns’ GA and neonatal risk factors.

What Do We Know About the Preterm Behavioral Phenotype? A Narrative Review

Preterm birth is associated with a significantly increased risk for childhood and adolescent psychopathology relative to full-term birth, with an inverse relationship between gestational age at birth and later risk for psychopathology. The manifestation of symptomatology and comorbidity profiles of emotional and behavioral adjustment problems in this high-risk group have been shown to be distinct from the broader pediatric population. Acknowledging these differences, a preterm behavioral phenotype has been proposed and increasingly recognized, highlighting the unique, frequent co-occurrence of symptomatology associated with attention-deficit/hyperactivity disorder, autism spectrum disorder, and anxiety disorders. The current state-of-the-art review provides a comprehensive characterization of this phenotype to date and further highlights key knowledge gaps primarily regarding the evolution of symptoms, co-occurrence of disorders and/or symptomatology within the phenotype, and associations of the phenotype with chronological age and degree of prematurity.

Does Birth-Related Trauma Last? Prevalence and Risk Factors for Posttraumatic Stress in Mothers and Fathers of VLBW Preterm and Term Born Children 5 Years After Birth

Previous research suggests that the birth of a preterm child with very low birth weight (VLBW; <1,500 g) can be traumatic for both parents and lead to short-term consequences like clinical levels of posttraumatic stress symptoms (PTSS) or even to the development of a Posttraumatic Stress Disorder (PTSD). However, little is known about possible mid- and long-term psychological consequences in affected parents. The purpose of this study were (a) to examine the prevalence of parental birth-related PTSS and PTSD in a group of parents with VLBW preterm infants compared to parents of full-term infants 5 years after birth and (b) to investigate potential associations with risk factors for parental PTSS at 5 years postpartum. Perinatal factors (VLBW preterm or term, perceived stress during birth), psychological factors (perceived social support and PTSS 4-6 weeks postpartum, psychiatric lifetime diagnosis) and sociodemographic characteristics (number of children, singleton or multiple birth, socio-economic status), were included in the analysis. The sample consisted of 144 families (77 VLBW, 67 term birth) who participated in the prospective longitudinal cohort study "Hamburg study of VLBW and full-term infant development" (HaFEn-study) and were initially recruited at three perinatal care centers in Hamburg, Germany. PTSD prevalence and PTSS of mothers and fathers were assessed with the Impact of Event Scale-Revised (IES-R), social support with the Questionnaire of Social Support (SOZU-K-22), and lifetime psychiatric diagnoses with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID-I). Data were analyzed by hierarchic multiple regression analyses. Results showed that 5 years after birth none of the parents fulfilled the criteria for a birth-related PTSD diagnosis. For mothers, postnatal PTSS and a VLBW preterm birth significantly predicted PTSS 5 years postpartum. For fathers, psychiatric lifetime diagnosis and postnatal PTSS significantly predicted PTSS 5 years after birth. Early identification of parents with higher risk of PTSS, especially after VLBW preterm birth, and their clinical needs seems beneficial to reduce the risk of long-term consequences. More research is needed on the paternal perspective and on potential effects of preterm birth on both parents and their children's mental health outcomes.

Reciprocal Influence of Depressive Symptoms Between Mothers and Fathers During the First Postpartum Year: A Comparison Among Full-Term, Very Low, and Extremely Low Birth Weight Infants

Background: Perinatal depression (PND) in mothers and fathers of very low and extremely low birth weight (VLBW and ELBW) infants has not been studied extensively. In particular, no studies investigated the reciprocal influence of depressive symptoms during the first 12 months postpartum. This study aimed at exploring the impact of the severity of prematurity on maternal and paternal PND during the first postpartum year; specifically, we used an Actor-Partner Interdependence Model (APIM) to test the interdependence of both partners on depressive symptoms. Methods: A total of 177 mothers and 177 fathers were recruited, divided into 38 couples with ELBW infants, 56 with VLBW, and 83 of full-term (FT) infants. PND was evaluated by the Edinburgh Postnatal Depression Scale (EPDS) at 3, 9, and 12 months postpartum (corrected age for preterm infants). Results: Maternal depressive symptoms at 3 months were positively related to those at 9 and 12 months in the 3 groups. Conversely, paternal depressive symptoms assessed at 3 months were positively related to those measured at 9 months for the ELBW group, 12 months for the VLBW group, 9 and 12 months for FT condition. Furthermore, a significantly positive partner effect was observed regarding the influence of 3 month maternal depressive symptoms on paternal depressive symptoms at 9 months, but only in the case of the VLBW group. Conclusion: Prematurity represents a very specific scenario in the transition to parenthood, leading to specific reactions in mothers and fathers, especially in high-risk conditions. Results should be deepened given the relevance of their clinical implications.

Preterm birth as a risk factor for postpartum depression: A systematic review and meta-analysis

BACKGROUND

This systematic review aimed to critically analyze the studies that explored preterm birth as risk factor for postpartum depression in the last 10 years.

METHODS

Two independent researchers performed a systematic review of indexed studies in PubMed/Medline, Web of Science and PsycInfo database. The PRISMA for reporting systematic review model was used to conduct data extraction. A meta-analysis was performed including a sub-group of studies.

RESULTS

The final sample consisted of 26 studies and 12 were included in the meta-analysis. Most of the studies supported the association between preterm birth (PTB) and postpartum depression (PPD). However, 8 studies did not find such association and, even among studies with positive findings, results were heterogeneous, given the methodological discrepancies among the studies. The meta-analysis provided evidence of higher risk for PPD among mothers of preterm infants in assessments performed up to 24 weeks after childbirth.

LIMITATIONS

Most of the studies did not consider the role of important confounding variables, such as previous history of depression. Heterogeneity of assessment tools and cut-off scores were also considered a limitation.

CONCLUSIONS

Further prospective population-based studies with an integrative approach of PPD are needed to provide consistent evidence of such association. Important confounding variables and biological measures implicated in PPD should be considered. Our findings highlight the importance of maternal mental health care in this target population, as preterm birth experience seem to affect both babies and mothers. We encourage PPD assessment for mothers of preterm infants, especially in the early postpartum period.

Memories of Infant Pain in the Neonatal Intensive Care Unit Influence Posttraumatic Stress Symptoms in Mothers of Infants Born Preterm

OBJECTIVES

The birth of a preterm infant and witnessing ones' infant in pain is remembered by parents as being one of the most stressful aspects of the neonatal intensive care unit (NICU). Elevated posttraumatic stress symptoms (PTSS) are highly prevalent among mothers of preterm infants, however, little is known about mothers' memories of invasive procedures in the NICU and how these memories may contribute to the development of PTSS. We examined the relationships between number of invasive procedures, mothers' memories of these procedures, and their PTSS at discharge from the NICU.

MATERIALS AND METHODS

Participants included 36 mothers of infants born below 37 weeks gestational age recruited from a tertiary-level NICU. Medical chart review was performed between birth and discharge from the NICU. At discharge, a research nurse conducted a structured memory interview with the mothers to assess their memories of their infants' invasive procedures. Mothers also completed a self-report measure of PTSS (Posttraumatic Stress Disorder Checklist for the DSM-5).

RESULTS

Mothers of infants exposed to greater numbers of invasive procedures had more elevated PTSS at discharge (R=0.37). Moreover, mothers who recalled having greater anxiety about their infant's invasive procedures had greater symptoms of reexperiencing (R=0.34) and avoidance (R=0.28) at discharge from the NICU.

DISCUSSION

Greater neonatal exposure to invasive procedures and mothers' recall of these procedures were related to mothers' posttraumatic stress symptomatology at discharge. Invasive procedures in the NICU represent an important target area for neonatal intervention to reduce maternal distress and improve outcomes.

Depressive symptoms and maternal psychological distress during early infancy: A pilot study in preterm as compared with term mother-infant dyads

BACKGROUND

Preterm birth does not only affect infants but also represents an unexpected and traumatic event for parents. There are few reports on parenting stress during early infancy comparing preterm and term mothers, with the results being somewhat inconsistent.

METHODS

As part of a longitudinal study, preterm mother-infant and term mother-infant dyads were enrolled. Dyads were assessed twice: during hospitalisation in the neonatal intensive care unit (NICU) and at 3 months of infant age (corrected age for preterm). Each mother completed a self-report set of psychological questionnaire in both time points. All the children underwent a neurological examination at 40 weeks post conceptional age and at 3 months (corrected age for preterm).

RESULTS

20 preterm and 20 term dyads were included. NICU mothers reported elevated postnatal depressive symptoms and high stress level, even if the preterm infants were with low perinatal risk and normal neurological examination. Comparing preterm infant with low perinatal risk and normal neurological examination with term-born children at 3 months, we found higher parental stress in term mothers than in preterm mothers.

LIMITATIONS

This study was limited by a relatively small sample size; findings are preliminary and warrant further investigation in larger-scale study.

CONCLUSIONS

Findings confirm that becoming a mother of a preterm infant is an event associated with emotional distress. These symptoms may resolve with time, and sometimes are independent of the infant's clinical severity. Assessing parental sources of stress and subsequent follow-up is essential to promote parental support, both for preterm and term mothers.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT02736136, Pre-results.

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

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

The interplay between prematurity, maternal stress and children's intelligence quotient at age 11: A longitudinal study

Very premature children (<33 weeks of gestational age (GA)) experience greater academic difficulties and have lower, though normal-range, intelligence quotients (IQs) versus their full-term peers. These differences are often attributed to GA or familial socio-economic status (SES). However, additional factors are increasingly recognized as likely contributors. Parental stress after a child's premature birth can present as post-traumatic stress disorder (PTSD) symptoms and can in turn reinforce difficulties in parent-child interaction pattern. Following a longitudinal design, we studied the interplay between a premature child's perinatal history and maternal PTSD symptoms on intelligence abilities assessed at 11 years of age. Thirty-three very preterm and 21 full-term mother-children dyads partook in the study. Children's perinatal risk was evaluated at hospital discharge, maternal PTSD symptoms were assessed when the children were 18 months old, and children's IQ was measured at 11 years old. IQ was significantly lower for preterm than full-term children, without reliable influences from perinatal risk scores. However, lower maternal PTSD symptoms predicted higher IQ in preterm children. This preliminary study highlights the importance detecting maternal PTSD symptoms after a preterm birth and suggests interventions should target reducing maternal PTSD symptoms during early childhood to enhance very preterm children's intelligence development.

Determinants of Child Attachment in the Years Postpartum in a High-Risk Sample of Immigrant Women

Our goal was to examine maternal mental health and associated stresses in a sample of high-risk immigrant mothers, and its association with child insecure attachment in the years following childbirth. Mothers and their child (Mage = 37 months) were recruited through a Health and Social Service organization in the Parc-Extension neighborhood in Montreal, Quebec. Mothers completed the Hopkins Symptoms Checklist (HSCL-25), the Multidimensional Scale of Perceived Social Support (MPSS) and a sociodemographic questionnaire that included questions on premature delivery and birth weight. Attachment behaviors were coded out of a videotaped free play sequence using the Preschool and Early School-Age Attachment Rating Scales (PARS). Analysis revealed high levels of clinical anxiety and depression, low social support and low attachment security. Significant mean differences and associations were found between anxiety, depression, social support, preterm delivery and child attachment. These results underscore the importance of screening for anxiety and depression early in the postnatal years, in order to prevent associated consequences such as child insecure attachment. Results also highlight the importance of building positive social networks, especially with immigrant populations.

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

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

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

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

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

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

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

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

Adolescent Substance Use and Effects on the Birth Experience

Depression, violence, and infant complications are recognized risk factors for negative birth experiences. Substance use, which often co-occurs with these risk factors, is unexplored for its role upon the birth experience. The frequency of these risk factors among childbearing adolescents suggests a need for research in this area. This study revealed direct and indirect effects by all risk factors on the adolescent's birth experience. Implications for nursing practice suggest collaboration between maternal child health and mental health nurses in prenatal, hospital, and follow-up healthcare settings to provide essential assessment of risk factors and resources and referrals across the perinatal period.

Predicting posttraumatic stress and depression symptoms among adolescents in the extended postpartum period

BACKGROUND

Adolescent childbirth continues as a public health concern, and investigation of postpartum posttraumatic stress symptoms (PTSS) and depression is important to inform future research and practice. Longitudinal studies exploring PTSS alone or in combination with depression are non-existent for postpartum adolescent populations. This study aimed to identify stress/PTSS and depression symptoms at 72 hours and three, six, and nine months postpartum, and determine if symptoms at each time point predicted later symptoms.

METHODS

A convenience sample of 303 adolescents 13-19 years of age were recruited from two postpartum units of one, large, public hospital. The Impact of Event Scale and the Edinburgh Postpartum Depression Inventory provided a screen of symptoms for stress/PTSS and depression at all time points. A lagged autoregressive model was developed to assess the predictive power of symptoms at each time point to the next across the extended postpartum period.

RESULTS

About 30% of adolescents displayed early symptoms; 20% showed symptoms at the final time point. Early symptoms did not predict symptoms at 3 months; yet, symptoms at 3 months predicted symptoms at 6-9 months.

LIMITATIONS

Attrition at final time points necessitated pooled data. Adolescents were primarily older, Hispanics, and recruited from one public hospital decreasing demographic representation. Use of screening tools prevented diagnostic outcomes. Unknown stressors occurring before and after pregnancy or birth may have influenced final outcomes.

CONCLUSIONS

Early symptoms were common and 3 month symptoms predicted later symptoms. For at risk adolescents, a plan for follow-up beyond hospital discharge is recommended.

Resilience Rather than Medical Factors: How Parents Predict Quality of Life of Their Sick Newborn

OBJECTIVE

To assess the influence of resiliency and stress on parental perspectives of the future quality of life (QOL) of neonatal intensive care unit (NICU) newborns at high risk of neurodevelopmental disability.

STUDY DESIGN

We conducted a prospective multicenter questionnaire study. Perspectives from parents of newborns at high risk of disability as per neonatal follow-up criteria were compared with a low-risk group consisting of parents of all other NICU newborns. Parental anxiety and resiliency, measured using Brief Symptom Inventory and Sense of Coherence scales, respectively, were associated with QOL projections.

RESULTS

Parents returned 129 (81%) questionnaires. Parents considering their newborn as currently sicker were more stressed (P = .011) and worried about future physical (P < .001) and mental (P < .001) health, QOL (P < .001), coping (P = .019), and financial (P < .001) and emotional (P = .002) impact on the family. Ooverall, there was no difference between parents of high-risk and low-risk newborns on QOL projections. Almost all parents projected a good future QOL. Less resilient parents projected more pain (P = .04), more financial (P = .019), and emotional (P = .031) impact on their family, and were 10 times more likely to predict that their newborn would remain chronically ill.

CONCLUSIONS

Parental projection of future QOL of NICU newborns is not associated with risk of disability. Most parents predict overall a good future QOL and focus more on familial impact. The Sense of Coherence scale may be used in clinical settings to identify less resilient parents.

Postpartum posttraumatic and acute stress in mothers and fathers of infants with very low birth weight: Cross-sectional results from a controlled multicenter cohort study

BACKGROUND

The birth of a preterm infant can be stressful and traumatic for parents and may cause posttraumatic stress symptoms and disorders. There is a dearth of data from controlled studies regarding level, prevalence, risk, and predictors of these symptoms in parents after preterm birth.

METHODS

As part of the longitudinal HaFEn-study, data from parents of infants with very low birth weight (VLBW), and term infants were cross-sectionally analyzed. We recruited parents at the three largest perinatal care centers in Hamburg, Germany. Posttraumatic stress symptoms were assessed with a standardized questionnaire, and acute and posttraumatic stress disorders with a clinical interview one month postpartum. Stress during birth, lifetime psychiatric diagnoses, social support, pregnancy risks, and mode of delivery were also evaluated. To examine predictors of posttraumatic stress symptoms in both parents simultaneously, we constructed multiple random coefficient models.

RESULTS

230 mothers and 173 fathers were included. The risk for acute stress disorder was increased in mothers with VLBW infants but not in fathers. While the risk for posttraumatic stress disorder was not elevated, the level of posttraumatic stress symptoms was higher in both parents with VLBW infants. Predictors for posttraumatic stress symptoms were stress during birth, low social support, psychiatric lifetime diagnoses, the birth of a VLBW infant, and female parent sex.

LIMITATIONS

Results reported here are cross-sectional. Thus, no temporal relationships can be established.

CONCLUSIONS

Although posttraumatic stress disorders were rare, our results suggest that posttraumatic stress symptoms and acute stress disorders are common in parents of VLBW infants.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validating the Psychometric Characteristics of the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) in a Chinese Context

BACKGROUND

Perinatal posttraumatic stress disorder (PPTSD) is a common stress-induced mental disorder worldwide. The Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) is an excellent questionnaire that measures the symptoms of PPTSD, but has not been translated into Chinese yet.

OBJECTIVES

The aims of this study were to develop a translated Chinese version of the (PPQ) and validate the psychometric characteristics of the PPQ in a Chinese context.

METHODS

After translation, back-translation, and expert discussion, 280 mothers at 1 to 18months postpartum filled out the questionnaires through the Internet. Then the reliability and validity of the translated questionnaire were tested.

RESULTS

The Chinese version of PPQ (PPQ-C) was composed of 14 items. Cronbach's α coefficient was 0.84, test-retest reliability was 0.88, and the content validity was 0.99. Exploratory factor analysis extracted three factors (representing "arousal", "avoidance" and "intrusion") accounted for 53.30% of the variance. The established 3 factors model was well fitted with the collected data (χ²=76.40, p<0.05).

IMPLICATIONS FOR PRACTICE

The PPQ-C is a short, reliable, and valid instrument that measures the symptoms of PPTSD, and it is recommend for clinical screening.

IMPLICATIONS FOR RESEARCH

Further research could involve diverse participants, as well as better adapt the PPQ-C to Chinese culture.

Breastfeeding Challenges and the Preterm Mother-Infant Dyad: A Conceptual Model

Breastfeeding is an experience that only a mother and her infant(s) can share. Infants who can feed from the breast receive not only the best nutrition but also, due to the close physical contact between mother and child, it is the optimal nurturance they can receive from their mother. When breastfeeding is trouble free, maternal well-being is uniquely heightened. However, breastfeeding remains a challenge for many mother-infant dyads and more so for those whose infants are born prematurely. This article introduces a conceptual model of the breastfeeding challenges facing preterm mother-infant dyads. It distinguishes between a maternal caregiving and an infant growth/development components. Within the maternal component, two primary elements are considered, that is, maternal behavioral and nutritional care. The two primary elements within the infant component include infant non-nutritional and nutritional growth/development. It is proposed that an improved understanding of the factors associated with these four elements and how they interplay with each other within individual dyads will facilitate the identification of the breastfeeding challenges facing these mother-infant entities. Due to the intimate relationships existing between a mother and her infant(s), it is further advanced that breastfeeding studies would be optimized if mother-infant pairs are studied as one entity rather than mother and infant separately. It is proposed that this conceptual model will assist health professionals develop personalized breastfeeding management plans for individual preterm mother-infant dyads, while furthering the development of evidence-based interventions to optimize their breastfeeding experiences.