Maternal Distress in the Neonatal Intensive Care Unit: A Concept Analysis

Extending the concept of moral distress to parents of infants hospitalized in the NICU: a qualitative study in Greece

BACKGROUND

The hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation.

METHODS

The present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis.

RESULTS

Three themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists' caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint.

CONCLUSIONS

In general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

Are women with preterm labour at risk for negative birth experience? a comparative cross-sectional study from Iran

BACKGROUND

The unpredictable nature of preterm labour can be a stressful experience for the mother. The occurrence of preterm birth can lead to the failure of the mother's previous expectations regarding the process of labour and birth leading to negative perception towards birth.

METHODS

This descriptive-analytical cross-sectional study was conducted in Tabriz, Iran. We employed convenience sampling to recruit eligible mothers with term birth (314 women) and preterm birth (157 women). Childbirth Experience Questionnaire 2.0, Preterm Birth Experiences and Satisfaction Scale, and Delivery Fear Scale were used to measure the woman's fear of delivery during labour and birth experience. Data were analysed by general linear model.

RESULTS

The prevalence of negative birth experience in the term and preterm birth groups was 31.8% and 14.3%, respectively. The results of the multivariable general linear model, after the adjustment of demographic and obstetric characteristics, showed that there was no statistically significant difference between the two groups of mothers with term and preterm birth [β (95% CI): -0.06 (-0.22 to 0.09); p = 0.414] in terms of childbirth experience. However, the fear of delivery had a significant relationship with the childbirth experience [-0.02 (-0.03 to -0.01); p < 0.001].

CONCLUSION

There was no statistically significant difference in terms of women's childbirth experience between the mothers with term and preterm births. The fear of delivery during labour was the predictor of childbirth experience. In order to improve women's childbirth experience, interventions should be made to reduce their fear during labour.

From Expressing Human Milk to Breastfeeding-An Essential Element in the Journey to Motherhood of Mothers of Prematurely Born Infants

BACKGROUND

Lactation and breastfeeding present an extraordinary challenge for mothers of prematurely born infants.

PURPOSE

To explore the significance of and the circumstances that affect lactation for mothers of premature infants.

METHODS

A qualitative exploratory study based on single, in-depth, semistructured interviews with 16 purposefully sampled mothers of premature infants admitted to the neonatal intensive care unit (NICU). Data were analyzed using content analysis. The study was reported according to Standards for Reporting Qualitative Research.

FINDINGS

The overall theme was "From expressing human milk to breastfeeding-an essential element in the journey to motherhood." The theme emerged from 3 categories: the birth preparation time has been interrupted; expressing human milk is essential for lactation; and the motherhood journey encompasses breastfeeding. The analysis also revealed that the categories were impacted by initiating, performing, and maintaining lactation and further influenced by inhibitors and promoters.

IMPLICATIONS FOR PRACTICE

The promoters for performing milk expression and breastfeeding should be stimulated and the inhibitors should be eliminated. The achievement of "zero separation" and mother-infant couplet care in the NICU would be beneficial. In order for mothers to maintain successful lactation, it is essential that they receive supportive around-the-clock access to health professionals with expertise in lactation and breastfeeding until exclusive breastfeeding is well established.

IMPLICATIONS FOR RESEARCH

The study highlights the need to investigate mother-infant as one entity rather than separately as mother and infant.

The influence of nurse characteristics on practice skills and attitudes towards working with families in critical care: A regression analysis

OBJECTIVES

The study aimed to identify nurse characteristics that influence their self-perceived practice skills in working with families and their attitudes towards engaging families in adult and neonatal intensive care units.

RESEARCH METHODOLOGY/DESIGN

Secondary data analysis using a descriptive, cross-sectional design.

SETTING

An online survey was completed by 256 nurses from six adult intensive (73% response rate) and two neonatal intensive and one intermediate care unit (27% response rate) in a Swiss, university affiliated hospital.

MAIN OUTCOME MEASURES

Nurses' self-perceived practice skills in working with families were assessed with the "Family Nursing Practice Scale". Attitudes towards families were measured with the "Families' Importance in Nursing Care - Nurses' Attitudes Scale". Data were analysed with multiple linear regression models.

RESULTS

Prior education in family nursing significantly influenced nurses' self-perceived practice skills in working with families. Nurses' clinical speciality had a significant influence on their attitudes towards overall, and on the subscale "family as a burden". Neonatal intensive care nurses showed more open attitudes towards families overall, but perceived family more often as a burden than nurses in adult intensive care. Nurses' perceived skills and attitudes in family engagement significantly influenced each other.

CONCLUSION

The results suggest that nurses' prior education in family nursing and clinical speciality determine their ability to work with and engage families in critical care. Our study suggests that integration of family nursing engagement practices in critical care requires educational implementation strategies combined with culture change efforts.

Women during Lactation Reduce Their Physical Activity and Sleep Duration Compared to Pregnancy

Sleep, mental health and physical activity are fundamental for wellbeing, and some of these factors are interrelated. However, these aspects are not usually considered during pregnancy and lactation, which are particularly vulnerable periods. Therefore, our aims were to conduct a cross sectional study to assess the psychological capital, quality of life, sleep hygiene and physical activity in a cohort of women during pregnancy and lactation periods. Women were recruited from Spanish maternity and lactation non-profit associations and social networks through an online platform with the following inclusion criteria: pregnancy (in any period of gestation) or breastfeeding period (≤6 months postpartum). The cohort was categorized into ≤12 weeks of gestation (n = 32), >12 weeks of gestation (n = 119) and lactation (n = 60). The women self-reported the sociodemographic data, obstetric complications and full breastfeeding or mixed practices. In addition, women responded to the psychological capital instrument, the health survey form, the Pittsburg sleep quality index and the pregnancy physical activity questionnaire. Overall, the groups were similar in sociodemographic variables. Women in the lactation period perceived lower social support compared to the gestation period. No statistically differences were found between groups in the psychological capital nor in the general health survey form. However, the models adjusted by employment and civil and economic status and perceived social support, demonstrated that the sleep duration negatively associated with the lactation period (β = 1.13 ± 0.56; p-Value = 0.016), and the household tasks were associated with this period (β = 2147.3 ± 480.7; p-Value < 0.001). A decrease in physical daily activities were associated with both the end of gestation and the lactation periods. In addition, the decreasing total activity was associated with the lactation period (β = 1683.67 ± 688.05; p-Value = 0.016). In conclusion, during lactation, the poorer sleep and physical activity, together with a lower social support of the woman, may lead to deficient mental health adjustment. Our data suggest that women are at higher risk of vulnerability in lactation compared to the gestation period.

Associations Among Postpartum Posttraumatic Stress Disorder Symptoms and COVID-19 Pandemic-Related Stressors

INTRODUCTION

Coronavirus disease 2019 (COVID-19) pandemic-related stressors (eg, exposure, infection worry, self-quarantining) can result in heightened levels of distress and symptoms of postpartum posttraumatic stress disorder (PTSD).

METHODS

Using a cross-sectional descriptive design, we collected survey data from a convenience sample of 670 postpartum persons who gave birth to a newborn during the first 6 months of the COVID-19 pandemic in the United States. The presence of PTSD symptoms was measured using the 21-item Birth Memories And Recall Questionnaire (BirthMARQ) and defined as an affirmative rating for each item (score of 5 to 7 on a 1 to 7 agreement scale). Symptoms counts were computed for each of the 6 BirthMARQ domains, 2 symptom clusters (intrusive; mood and cognition alterations), and the total number of symptoms. Symptom counts were analyzed using descriptive statistics. We explored associations among COVID-19 experiences (self-quarantine behaviors, infection worry, exposure) and counts of PTSD symptoms using negative binomial regression models while controlling for postpartum depression screening scores, neonatal intensive care unit admissions, number of weeks postpartum, race, and marital status.

RESULTS

Almost 99% of participants reported experiencing at least one of 21 PTSD symptoms (mean, 8.32; SD, 3.63). Exposure to COVID-19 was associated with a 34% greater risk for experiencing intrusive symptoms, specifically, symptoms of reliving the birthing experience as if it were happening now (47% greater risk). Worry surrounding COVID-19 infection was associated with a 26% increased risk for experiencing intrusive recall symptoms in which birth memories came up unexpectantly. COVID-19 quarantining behaviors were not significantly related to increasing PTSD symptoms. Many of the demographic variables included were associated with increasing PTSD symptoms.

DISCUSSION

Screening perinatal persons for PTSD is critically important, especially during public health crises like the COVID-19 pandemic. The integration of comprehensive mental health screening, including specific screening for trauma and symptoms of PTSD, across health care settings can help improve delivery of quality, patient-centered care to postpartum persons.

Benefits of Kangaroo Mother Care on the Physiological Stress Parameters of Preterm Infants and Mothers in Neonatal Intensive Care

It is well documented that the stress of separation of mother and baby can lead to short-term physiological instability as well as neurological, sociological or psychological consequences that may last a lifetime. Objective: The goal was to estimate the effect of kangaroo mother care (KMC) on physiological and biochemical parameters of preterm infant stress and maternal stress in neonatal intensive care. Methods: The investigation involved 112 preterm infants. Two groups were compared according to the mean duration of KMC during 12 days of study: the KMC group (mean duration more than 90 min daily) and the control group (less than 90 min). Results: Kangaroo mother care for more than 90 min on average per day in preterm infants is associated 12 days after the intervention with lower mean cortisol levels (p = 0.02), greater weight gain and less need for parenteral nutrition in preterm infants, as well as less postpartum depression (p = 0.02) and lower cortisol levels (p = 0.002) in the mothers of preterm infants. Conclusions: This study suggests that KMC can be used to improve the stress of preterm infants and their mothers, and that the greater weight gain observed in these preterm infants could contribute to a shorter average hospital stay and lower healthcare expenditure.

Psychometric properties of the Post Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) in Greek women after cesarean section

The aim of this study was to examine psychometric properties of the revised Posttraumatic Stress Checklist (PCL-5) for Diagnostic and Statistical Manual- 5th Edition (DSM-5) in Greek postpartum women after Cesarean Section(CS) (emergency-elective).So far, there was no study in Greece assessing psychometric properties of the PCL-5 in women after CS. The participating women (N = 469), who gave birth with emergency and elective CS at the Greek University Hospital of Larisa, have consented to participate in two phases of the survey and completed self-report questionnaires, the 2nd day after CS and at the 6th week after CS. Measures used in this study were the PCL-5 for DSM-5, the Life Events Checklist (LEC-5), Criteria B, C, D, E, and Criterion A, specifically designed for detection of posttraumatic stress disorder (PTSD) symptoms in postpartum period. To evaluate the internal reliability of the PCL-5 two different indices of internal consistency were calculated, i.e., Cronbach's alpha (.97) and Guttman'ssplit-half (.95), demonstrating high reliability level. The data were positively skewed, suggesting that the reported levels of PTSD among our participants were low. Factor analyses demonstrated acceptable construct validity; a comparison of thePCL-5 with the other measures of the same concept showed a good convergent validity of the scale. Overall, all the results suggest that the four-factor PCL-5 seemed to work adequately for the Greek sample of women after CS.

A different kind of battle: the effects of NICU admission on military parent mental health

OBJECTIVE

To determine the incidence of mental health symptoms in military families after prolonged NICU admission.

STUDY DESIGN

Prospective cohort study of military-affiliated NICU parents participating in serial electronic surveys, which included validated screening tools for acute stress (ASD), post-traumatic stress (PTSD), and depression disorders.

RESULTS

Among 106 military parents surveyed after NICU admission, 24.5% screened positive for ASD and 28.3% for depression. 77 (72.6%) parents continued participation beyond discharge, with 7.8% screening positive for PTSD and 15.6% for late depression. Positive ASD correlated with later symptoms of PTSD (OR 8.4 [2.4-30]) and early depression with both PTSD symptoms (OR 5.7 [1.7-18.8]) and late depression (OR 8.4 [2.4-30]) after discharge. Secondary analysis determined these findings were independent of deployment and other military related factors.

CONCLUSION

This study highlights the potential mental health burden experienced by military-affiliated NICU parents. Early ASD and depression screening may identify parents at risk for mental health symptoms after discharge.

Factors That Influence Women's Symptoms of Postpartum Depression After Discharge of Their Preterm Infants From the NICU

OBJECTIVE

To examine resourcefulness, perception of child vulnerability, and stress in relation to symptoms of postpartum depression (PPD) in women after discharge of their preterm infants from the NICU.

DESIGN

Cross-sectional, descriptive, correlational study.

SETTING

An urban NICU follow-up clinic, a pediatric office in the northeastern United States, and an online NICU parent support group.

PARTICIPANTS

Seventy-four women who gave birth to preterm infants who were discharged home from the NICU.

METHODS

The participants completed a demographic data questionnaire, the Resourcefulness Scale, Child Vulnerability Scale, Perceived Stress Scale, and Edinburgh Postnatal Depression Scale. I examined the relationships among these data using correlational analysis and hierarchical multiple linear regression analysis.

RESULTS

Perception of child vulnerability and stress were predictors of symptoms of PPD; these variables accounted for 9% (p = .001) and 18% (p < .001) of the variation in symptoms of PPD, respectively. Although resourcefulness initially predicted PPD, it was no longer significant when controlling for demographic variables in the final regression analysis.

CONCLUSIONS

These results supported previously reported findings on the effects of women's perceptions of their child's vulnerability and stress on symptoms of PPD. However, the findings are not consistent with those of previous research regarding the inverse relationship between resourcefulness and symptoms of PPD. Nurses can implement interventions for women regarding perceptions of child vulnerability and stress to decrease symptoms of PPD after their preterm infant's discharge from 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.

Maternal postpartum depression: risk factors, impacts, and interventions for the NICU and beyond

PURPOSE OF REVIEW

Postpartum depression (PPD) negatively impacts caregivers, infants, siblings, and entire families. Mothers with infants admitted to the neonatal intensive care unit (NICU) face additional risk for PPD, coupled with risk factors extending beyond a NICU admision. The novelty of this review is the focus on maternal PPD for mothers with infants admitted to the NICU. Interventions aimed at limiting and preventing PPD in this population include: prenatal and postpartum depression screening, PPD symptom awareness and monitoring, and trauma-informed care.

RECENT FINDINGS

PPD, the most frequent complication of childbirth, affects approximately 10-15% of mothers worldwide. Prevalence rates increase to 40% for mothers whose infant is admitted to the NICU. PPD can affect maternal and child health across the life course and predispose future generations to a myriad of developmental, psychosocial, and physical challenges. Prevalence rates are higher for racial and ethnic minorities, immigrant and refugee populations, and mothers in rural locations. Trauma-informed care is suggested at individual and organizational levels, leading to better care for those with and without previous trauma exposure.

SUMMARY

Increasing PPD symptom awareness, screening for PPD, and connections with resources should begin during prenatal visits. Care teams should discuss barriers to resources for mothers, children, and families to improve access and support.

An integrative review of maternal distress during neonatal intensive care hospitalization

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

The Relationship of Breastfeeding Patterns in the Neonatal Intensive Care Unit to Maternal Symptoms of Anxiety and Depression

Background: The studies related to psychiatric disorders have demonstrated high frequency of maternal stress, anxiety, and postpartum depression in mothers who have infants in neonatal intensive care unit (NICU). It is well known that maternal anxiety and depression adversely affect breastfeeding. The research aims to examine the association between the anxiety and depressive symptom severity of NICU mothers and feeding type (exclusively breastfed [EBF] or mixed fed [MF]) of their infants within first week of life in NICU. Methods: Data were collected from 93 mothers and 105 infants in a single-center, prospective, cross-sectional, descriptive study. The state-trait anxiety and depressive symptom severity of NICU mothers were evaluated using the Spielberger State-Trait Anxiety Inventory (STAI, including Spielberger State-Trait Anxiety Inventory-State [STAI-S], Spielberger State-Trait Anxiety Inventory-Trait [STAI-T]), and Edinburgh Postnatal Depression Scale (EPDS). Results: Breastfeeding exclusivity in NICU infants was significantly related to gestational age, birth weight, prenatal steroid, and assisted reproductive technology (ART; p = 0.022, 0.041, 0.028, 0.017, respectively). The comparison of STAI-S, STAI-T, and EPDS scores of NICU mothers between EBF and MF groups revealed that STAI-T score was significantly high in EBF group than that in the MF group (p = 0.019). Logistic regression analyses showed that a 1-unit increase in STAI-T score in NICU mothers was significantly associated with a 5.7% increase in the odds of breastfeeding exclusivity within first week in postpartum period (p = 0.033; odds ratio = 1.057, 95% confidence interval = 1.004-1.113). Conclusions: Contrary to estimates, clinically significant state and trait anxiety symptoms and depressive symptoms of NICU mothers do not affect breastfeeding exclusivity negatively within first week of life in NICU. Preterm infants under 32 gestational weeks and infants born with ART have a tendency to being EBF.

Maternal post-traumatic stress and depression symptoms and outcomes after NICU discharge in a low-income sample: a cross-sectional study

Background

Having a preterm newborn and the experience of staying in the neonatal intensive care unit (NICU) has the potential to impact a mother’s mental health and overall quality of life. However, currently there are few studies that have examined the association of acute post-traumatic stress (PTS) and depression symptoms and infant and maternal outcomes in low-income populations.

Design/ methods

In a cross-sectional study, we examined adjusted associations between positive screens for PTS and depression using the Perinatal Post-traumatic stress Questionnaire (PPQ) and the Patient Health-Questionnaire 2 (PHQ-2) with outcomes using unconditional logistic and linear regression models.

Results

One hundred sixty-nine parents answered the questionnaire with 150 complete responses. The majority of our sample was Hispanic (68%), non-English speaking (67%) and reported an annual income of <$20,000 (58%). 33% of the participants had a positive PPQ screen and 34% a positive PHQ-2 screen. After adjusting for confounders, we identified that a positive PHQ-2 depression score was associated with a negative unit (95% CI) change on the infant’s Vineland Adaptive Behavior Scales, second edition of − 9.08 (− 15.6, − 2.6) (p < 0.01). There were no significant associations between maternal stress and depression scores and infant Bayley Scales of Infant Development III scores or re-hospitalizations or emergency room visits. However, positive PPQ and screening score were associated with a negative unit (95% CI) unit change on the maternal Multicultural Quality of Life Index score of − 8.1 (− 12, − 3.9)(p < 0.01) and − 7.7 (− 12, − 3) (p = 0.01) respectively.

Conclusions

More than one-third of the mothers in this sample screened positively for PTS and depression symptoms. Screening scores positive for stress and depression symptoms were associated with a negative change in some infant development scores and maternal quality of life scores. Thoughtful screening programs for maternal stress and depression symptoms should be instituted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03536-0.

Correlation between Kind of Cesarean Section and Posttraumatic Stress Disorder in Greek Women

A birth experience with cesarean section (CS) can be a cause of the development of post-traumatic stress disorder after a cesarean (PTSD-AC) or profile PTSD, for a percentage of women. So far, there is no data on the frequency of PTSD-AC in Greece and this syndrome is often associated with other mental disorders of the postpartum period. The purpose of this research is to associate the kind of CS with PTSD-AC for Greek mothers and the combination of factors that make them less resistant to trauma. A sample of ahundred and sixty-six mothers who gave birth with emergency cesarean section (EMCS) and elective cesarean section (ELCS) at a Greek University hospital have consented to participate in the two phases of the survey, in the 2nd day postpartum and a follow-up in the 6th week postpartum. Medical/demographic data and a life events checklist (LEC-5) with Criterion A and post-traumatic stress checklist (PCL-5) were used to diagnose PTSD and PTSD Profile. Out of166 mothers enrolled, 160 replied to the follow-up (96.4%), ELCS 97 (97%) and EMCS 63 (95%). Twenty (31.7%) EMCS had PTSD and nine (14.3%) had Profile. One (1%) ELCS had PTSD and 4 (4.1%) had Profile. This survey shows a high prevalence rate of PTSD after EMCS with additional risk factors of preterm labor, inclusion in the Neonatal Intensive Care Unit (NICU), a lack of breastfeeding, and a lack of support from the partner.