Impaired sleep and well-being in mothers with low-birth-weight infants

Sleep-wake timing and chronotype in perinatal periods: longitudinal changes and associations with insomnia symptoms, sleep-related impairment, and mood from pregnancy to 2 years postpartum

Across the perinatal transition, existing research focuses mainly on significant changes in sleep duration and quality, neglecting sleep timing. This study investigated change trajectories of sleep timing and chronotype from late pregnancy to 2 years postpartum and examined longitudinal associations of chronotype with symptoms of insomnia, daytime sleep-related impairment, and mood. Data were from a two-arm randomised controlled trial testing parent-focused wellbeing interventions. Participants were a community sample of nullipara without severe sleep/mental health conditions. Participants self-reported bedtime, rise-time, chronotype, insomnia symptoms, sleep-related impairment, depression, and anxiety at seven time points: gestation Weeks 30 and 35, and postpartum Months 1.5, 3, 6, 12 and 24. Trajectories were estimated using mixed-effects models with continuous time, quadratic splines, and a knot at childbirth, controlling for age and group allocation. A total of 163 participants (mean [SD] age 33.35 [3.42] years) took part. Bedtime and rise-times delayed during late pregnancy (~8 and ~20 min, respectively) but became progressively earlier (~20 and ~60 min, respectively) over the 2 postpartum years. Chronotype became more eveningness in late pregnancy, and more morningness after childbirth, however changes were small. Controlling for sleep duration and efficiency, greater morningness was associated with significantly less symptoms of insomnia and sleep-related impairment over time (all p < 0.001); longitudinal associations between chronotype and symptoms of depression and anxiety were non-significant (all p > 0.65). Sleep-wake timing and chronotype became progressively earlier from pregnancy to 2 years postpartum. Morningness chronotype may be sleep-protective during the transition from pregnancy to parenthood. Mechanisms underlying these associations require further research.

Sleep, circadian activity patterns and postpartum depression: A systematic review and meta-analysis of actigraphy studies

Transition to motherhood is a period full of challenges and demands. In this review, we focused on the associations of sleep and circadian activity patterns during and after pregnancy with postpartum mental health factors. A systematic review and meta-analysis were conducted (PROSPERO reference 316,505). A search for articles was performed using PsycARTICLES, PsycINFO, PubMed, MEDLINE, Scopus, Cochrane, DARE, hand search, and citation tracking. The search was meant to identify peer-reviewed, experimental and observational studies reporting on women over 18 years old that assessed sleep and circadian activity patterns during pregnancy or postpartum using actigraphy, and investigated postpartum mental health factors. Nineteen relevant publications were selected. Postpartum total sleep at night was the indicator that was most closely related to the psychological functioning of women after childbirth. The results of the systematic review indicated that postpartum total sleep at night was related to postpartum fatigue, and the results of the meta-analysis suggested that total sleep at night was most strongly linked with postpartum depression. More studies are needed to estimate the associations of sleep-wake rhythm during pregnancy and in the postpartum period with postpartum mental health factors.

A Feasibility Study to Assess Sleep and Subsequent Breast Milk Volume Among Mothers With Hospitalized Preterm Infants

BACKGROUND

Sleep is essential for optimal health, and disturbed postpartum sleep is associated with compromised infant attachment. The postpartum experience of mothers with preterm infants is unlike the biological norm, as they are separated from their infants and often express breast milk.

PURPOSE

The purpose of this study was to examine the feasibility of conducting a clinical research study among women with hospitalized preterm infants. We also explored for associations between maternal sleep patterns and sleep-related psychological states and subsequent breast milk volume.

METHODS

Participants were recruited from Magee-Womens Hospital, located in Pittsburgh, Pennsylvania New mothers completed daily sleep and pumping logs and scales to measure stress, trauma, depression, fatigue, and sleep quality.

RESULTS

A total of 78 women were screened, 18 women consented, and a total of 8 participants completed the study. Screening from the postpartum unit increased recruitment. The participants experience worsening sleep quality over time, moderate stress, and fatigue. Stress, postnatal depression, and fatigue are negatively associated with milk volume.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Postpartum recruitment with frequent follow-ups improved recruitment and retention. We present a preliminary association between maternal stress, fatigue, and depression, and subsequent breast milk volume. Sleep-related psychological states may negatively influence milk volume.

Sleep hours and quality before and after baby: Inequalities by gender and partnership

While prior studies have examined sleep across the lifecourse, few studies have investigated sleep around the birth of a child, one of the most important events to cause sleep deprivation. This study investigates changes in sleep hours and quality, paying attention to differences by gender and partnership status. Using the UK Household Longitudinal Study, we follow approximately 1,000 participants as they transition into parenthood in a three-year window. We use OLS and logistic regression to analyze changes in sleep hours and sleep quality. Results suggest that women's sleep is reduced by an average of 0.7 hours (42 min) on becoming a mother. Whilst before parenthood women sleep more than men, after childbirth women and men sleep similar amounts. Cohabiting men experience a greater reduction in sleep by around 0.5 hours (30 min) than married men, to the level similar to women, suggesting that new cohabiting fathers may experience more sleep disturbances.

Parental sleep when their child is sick: A phased principle-based concept analysis

Sleep is a common challenge for parents with sick children and can impact parents' health, wellbeing, and caregiving responsibilities. Despite the vast research around parental sleep when their child is sick, the concept is not clearly defined. A phased principle-based concept analysis that includes triangulation of methods and quality criteria assessment was used to explore how the concept is described, used, and measured in the current literature. The aim was to analyse and clarify the conceptual, operational, and theoretical basis of parental sleep when their child is sick to produce an evidence-based definition and to identify knowledge gaps. A systematic literature search including databases CINAHL, Embase, MEDLINE, PsychARTICLES, PsychINFO, Pubmed, Scopus and Web of Science, identified 546 articles. The final dataset comprised 74 articles published between 2005 and 2021 and was assessed using a criteria tool for principle-based concept analysis. Data were managed using NVivo, and thematic analysis was undertaken. A precise definition is not present in the literature. Various tools have been used to measure parents' sleep, as well as exploration via interviews, open-ended questions, and sleep diaries. The terminology used varied. Parental sleep when their child is sick is interrelated with other concepts (e.g., stress). A recommended definition is offered. A conceptual understanding of parental sleep when their child is sick will help to guide translational research and to conduct studies critical to clinical practice and research. Future research includes developing a measurement tool for parental sleep when their child is sick to be used in study design and future interventions.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep patterns and psychosocial health of parents of preterm and full-born infants: a prospective, comparative, longitudinal feasibility study

Background

The early birth and hospitalization of a preterm infant in neonatal intensive care unit can produce several emotional and behavioural responses including sleep problems for parents. Few studies have explored sleep and its associations with health and HRQoL over time in this vulnerable parent population. This purpose of this study was to evaluate the feasibility of a prospective, comparative, longitudinal study of the sleep patterns and psychosocial health of preterm and full-born infants’ parents during the first postpartum year.

Methods

A prospective, comparative, longitudinal feasibility study was conducted. Parents of preterm infants were compared to parents of full-born infants to identify if there were differences in outcomes between the groups. The parents were instructed to wear actigraphs and complete sleep diaries for two consecutive weeks, and responded to a digital questionnaire covering stress, insomnia, fatigue, depression, social support, self-efficacy, and health-related quality of life. Survey data were collected at infant ages of 2, 6, and 12 months, actigraphy and sleep diary data were collected at infant age of 2 months only. Descriptive analysis was used to describe recruitment and attrition rates. Differences between completers and dropouts were analysed with a chi-square test (categorical data) and Mann–Whitney–Wilcoxon test for two independent samples (continuous variables).

Results

Between June 2019 and March 2020, 25 parents of a preterm infant and 78 parents of a full-born infant were recruited from four neonatal intensive care units and two maternity wards, respectively, in four Norwegian hospitals. Feasibility was predefined as recruiting ≥ 75 parents each of preterm and full-born infants. The target for the full-born group was reached. However, the preterm group recruitment was challenging. Actigraphs, sleep diaries, and questionnaires were evaluated as feasible for use in a future study. Attrition rates were high in both groups at 6 and 12 months. No parent-related characteristics were associated with participation at 6 months. At 12 months, dropouts had a statistically significantly lower age in the full-born group (both parents) and higher age and body mass index in the preterm group (fathers).

Conclusions

A longitudinal study is feasible; however, procedural changes, including using active methods and contacting participants, are necessary to increase the recruitment of preterm infants’ parents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04862-1.

Maternal caring ability with the preterm infant: A Rogerian concept analysis

AIM

To analyze the concept of maternal caring ability for a preterm infant to develop an operational definition.

BACKGROUND

Each year, many newborns are born preterm and admitted to the neonatal intensive care unit (NICU). Although their mothers are prepared for discharge home by the staff, it is difficult to identify an operational definition of their maternal caring ability for the preterm infant.

DESIGN

Concept analysis.

DATA SOURCES

Searches used PubMed, as the primary health-related literature, ProQuest, Science Direct, CINHAL, web of science, Scopus, and Google Scholar. Keywords caring ability, mother, and preterm infant were used to analyze the development of the concept from 1965 to 2020.

METHODS

Rogers' and Knafl's evolutionary approach has been used to explain the concept of maternal caring ability for the preterm infant.

RESULTS

The combined searches yielded 23,291 documents published in English. After the screening process, 43 documents were selected. The Graneheim and Lundman analysis method was used to identify the themes related to the attributes of maternal caring ability. Findings showed the caring ability to have four antecedents (maternal characteristics, support systems, infant characteristics, and the illness severity), four attributes (knowledge and skill in neonatal care, self-efficacy, sensitivity, responsibility, and problem-solving), and three consequences (parental adjustment, improving infant growth and development, and improving parent-infant relationships).

CONCLUSION

The caring ability of the mother of a preterm infant is grounded in an adequate knowledge of caregiving needs of a preterm infant, high caregiving skills, a sense of self-efficacy, problem-solving, sensitivity, and responsibility.

Quality of life among mothers of preterm newborns in a Malaysian neonatal intensive care unit

Background

As Quality of Life (QoL) becomes progressively vital in health care services, its importance in mother and child health is of no exception too. Quality of life among mothers with a premature newborn is an issue that has led to growing concerns in the health care system. Yet, despite the knowledge about mother's QoL being essential to family-centered planning on prematurity integrated healthcare, current evidence has been scant.

Objective

To examine factors related to the QoL of mothers having preterm newborns hospitalized in the neonatal critical unit.

Methods

A non-probability convenience survey was used in a public hospital in Malaysia, covering 180 mothers whose preterm newborns were hospitalized into level III Neonatal Intensive Care Unit (NICU) through the completion of a 26-questions survey of the World Health Organization Quality of Life (WHOQOL-BREF) and the 26-questions of Parental Stress Scale: Neonatal Intensive Care Unit (PSS: NICU). The data were analyzed using descriptive statistics, bivariate analysis, and Pearson correlation coefficients.

Result

The mean scores for mothers' quality of life were (M = 3.67, SD = 0.73) and maternal stress (M = 3.03, SD = 0.90) out of 5. A mother's occupation was found to be the only factor associated with the quality of life among mothers who have preterm newborns admitted to the NICU. Furthermore, maternal role change was found to have a moderate negative relationship with the quality of life (r = 0.310, p = 0.05).

Conclusion

The findings of this study revealed that the main factors contributing to the mother's QoL during their preterm newborns' NICU admission were role change-related stress. Thus, to maintain a better QoL among this group of mothers during this traumatic period, a special nursing intervention program must be implemented immediately, right after the preterm newborns' admission, to relieve the mothers' stress which has been proven to have a direct effect on the mothers' QoL. The study results will alert healthcare providers, particularly neonatal nurses, on the need to support mothers psychologically in terms of role change. This is to ensure a better quality of life among mothers whose newborns were admitted to the NICU.

Effect of Kangaroo Mother Care on the Psychological Stress Response and Sleep Quality of Mothers With Premature Infants in the Neonatal Intensive Care Unit

OBJECTIVE

To investigate the effect of kangaroo mother care on the psychological stress response and sleep quality of mothers with premature infants admitted to the neonatal intensive care unit (NICU).

METHODS

A randomized controlled design was used to recruit participants. The study recruited 126 mothers of premature infants in the NICU from January 2019 to January 2020. The participants were divided into the experimental and control groups according to the random number table method (63 mothers per group). The control group was managed with conventional premature infant treatment, nursing programme, and discharge education, whereas the experimental group was managed with a 4-week kangaroo mother care intervention. The psychological stress state and sleep status of mothers with preterm infants in both the groups were evaluated using the Symptom Check List 90 (SCL-90) and Assens Insomnia Scale (AIS).

RESULTS

After the intervention, the total SCL-90 score and factor scores such as coercion, interpersonal relationships, depression, anxiety, hostility and additional factors, were lower in the experimental group than those in the control group (P < 0.05). The total AIS score and the items such as night waking, total sleep time, total sleep quality, daytime mood and daytime body function were lower in the experimental group than those in the control group (P < 0.05).

CONCLUSIONS

The Kangaroo mother care approach can relieve adverse psychological stress and improve the sleep status of mothers of NICU premature infants after mother-infant separation. It can be promoted and used in mothers of premature infants in the NICU to enhance physical and mental health.

Mothers' quality of life delivering kangaroo mother care at Malawian hospitals: a qualitative study

Introduction

Kangaroo mother care is known to help save the lives of preterm and low birthweight infants, particularly in resource-limited health settings, yet barriers to implementation have been documented. Mothers and their families are very involved in the process of providing kangaroo mother care and the impact on their well-being has not been well explored. The objective of this research was to investigate the perspectives and experiences of a mother’s quality of life while delivering facility-based kangaroo mother care.

Methods

This study is a secondary analysis of the qualitative data collected within the “Integrating a neonatal healthcare package for Malawi” project. Twenty-seven health workers and 24 caregivers engaged with kangaroo mother care at four hospitals in southern Malawi were interviewed between May–August 2019. All interviews were face-to-face and followed a topic guide. Content analysis was conducted on NVivo 12 (QSR International, Melbourne, Australia) based on the six World Health Organization Quality of Life domains (physical, psychological, level of independence, social relationships, environment, spirituality).

Results

Fifty-one interviews were conducted with 24 caregivers and 14 health workers. Mothers experienced multidimensional challenges to their quality of life while delivering facility-based KMC. Though kangaroo mother care was considered a simple intervention, participants highlighted that continuous kangaroo mother care was difficult to practice. Kangaroo mother care was an exhausting experience for mothers due to being in one position for prolonged periods, compromised sleep, restricted movement, boredom, and isolation during their stay at the hospital as well as poor support for daily living needs such as food.

Discussion

A heavy burden is placed on mothers who become the key person responsible for care during kangaroo mother care, especially in resource-limited health settings. More focus is needed on supporting caregivers during the delivery of kangaroo mother care through staff support, family inclusion, and conducive infrastructure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01823-8.

Sleep patterns, problems, and ecology in young children born preterm and full-term and their mothers

BACKGROUND

Previous studies of sleep patterns and problems in preterm infants compared to full-term infants have yielded mixed results, with little known about sleep ecology. The aims of this study were to compare sleep patterns, sleep problems, and sleep ecology across developmental stages (birth to 36 months) in preterm (3 or more weeks early) infants and toddlers to those born full-term, in addition to their mothers' sleep.

METHODS

Mothers of 834 young children in Brazil (ages 0-35.9 months), half preterm and half full-term (matched for sex and chronological age), completed the Brief Infant Sleep Questionnaire and the Pittsburgh Sleep Quality Index.

RESULTS

Across the entire sample, preterm and full-term infants were similar for most sleep parameters, including sleep onset latency, number and duration of night awakenings, and sleep duration, as well as sleep ecology parameters, including falling asleep independently and sleep location. However, preterm infants were more likely to be held to initiate sleep, given a bottle to resume sleep after waking, and less likely to be breastfed to resume sleep after waking. Mothers of preterm infants, however, were more likely to report a parent-perceived sleep problem, although maternal-perceived confidence in managing child sleep and bedtime difficulty were similar. Finally, maternal sleep parameters were similar between groups.

CONCLUSIONS

Overall, these results indicate that sleep patterns, sleep problems, and sleep ecology among preterm infants and toddlers and their mothers are largely similar to those of full-term infants and toddlers and their mothers, even within the first few months.

Health Needs of Mothers of Infants in a Neonatal Intensive Care Unit : A Mixed-Methods Study

BACKGROUND

Mothers with babies in the neonatal intensive care unit (NICU) face a host of challenges following childbirth. Limited information is available on these mothers' postpartum health needs and access to services.

OBJECTIVE

To identify health needs of NICU mothers, access to services, and potential service improvements.

DESIGN

A mixed-methods study including a retrospective cohort study, in-depth interviews, and focus groups.

SETTING

Large, Level IV, regional referral, university-affiliated hospital in the United States.

PARTICIPANTS

Mothers of live-born infants born from 1 July 2014 to 30 June 2016 (n = 6849). Interviews included 50 NICU mothers and 59 stakeholders who provide services to these mothers or their infants.

MEASUREMENTS

Severe maternal morbidity, chronic health conditions, health care encounters from discharge through 12 weeks postpartum, maternal health needs, care access, and system improvements.

RESULTS

Compared with mothers of well babies, NICU mothers had more chronic diseases, experienced more perinatal complications, and utilized more acute care postpartum. Qualitative analyses revealed the desire to be at the baby's bedside as a driver of maternal health-seeking behaviors, with women not seeking or delaying medical care so as to stay by their infant. Stakeholders acknowledged the unique needs of NICU mothers and cited system challenges, lack of clarity about provider roles, and reimbursement policies as barriers to meeting needs.

LIMITATIONS

The study was conducted within a single health care system, which may limit generalizability. Qualitative analyses did not explore the influence of fathers, other children in the home, or length of NICU stay.

CONCLUSION

Universal screening and convenient access to maternal health services for NICU mothers should be explored to reduce adverse maternal health outcomes.

PRIMARY FUNDING SOURCE

Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

Clinician Opinions and Approaches to Manage Risk Related to Safe Sleep During Skin-to-Skin Care

OBJECTIVE

To understand the opinions of clinicians about the risks, benefits, barriers, and facilitators to the practice of parent sleep during skin-to-skin care in hospital settings.

DESIGN

Cross-sectional survey.

SETTING

Online survey.

PARTICIPANTS

Clinicians who self-identified as infant care providers, that is, neonatal clinicians (N = 158).

METHODS

We sent an online survey invitation to neonatal clinicians through neonatal websites, conferences, and social media sites in the United States and used snowball recruitment. We used a risk management framework to analyze qualitative data. We used descriptive statistics and the chi-square and Fisher's exact tests to determine if opinions differed based on clinician and organizational characteristics.

RESULTS

Respondents' support of parent sleep during skin-to-skin care (yes/no) did not differ on the basis of whether the clinician had taken a formal course on skin-to-skin care, facilitated skin-to-skin care more than 100 times, or frequently promoted skin-to-skin care in current practice. Respondents who supported parent sleep (n = 93, 59% of respondents) reported greater implementation of risk control strategies than nonsupporters (n = 53 [57%] vs. n = 3 [5%]; p < .001), such as frequent monitoring of vital signs (n = 33 [35%] vs. n = 2 [3%]; p < .001), use of devices to support skin-to-skin care (n = 49 [53%] vs. n = 19 [29%]; p = .003), and proper positioning (n = 20 [22%] vs. n = 0 [0%]; p < .001). Nonsupporters more frequently reported that parent sleep during skin-to-skin care violates safe sleep recommendations, is habit forming for home, poses a fall risk, and jeopardizes the infant's airway.

CONCLUSION

Most respondents supported parent sleep during skin-to-skin care, but concerns regarding safety for the infant remained a barrier. The use of a risk management framework may help facilitate a systematic approach to improve the implementation of safe skin-to-skin practices.

Sleep in parents of preterm infants: A systematic review

BACKGROUND

Sleep disruption during the first postpartum year is associated with several negative health outcomes including postpartum depression. Such disruption may be a greater issue for parents of preterm neonates, yet literature on this subject has not been critically reviewed.

OBJECTIVE

To synthesize literature on sleep quantity, sleep quality, and factors influencing sleep among parents of preterm infants during infant hospitalization and following discharge.

DESIGN

A systematic review.

DATA SOURCES

Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Cochrane Database of Systematic Reviews were searched from their inception to February 2017.

METHODS

Potentially eligible citations were reviewed by two independent reviewers. Both quantitative and qualitative studies were eligible for inclusion. Data on eligible studies and review outcomes were extracted using a customized form.

FINDINGS

Eighteen reports from 16 studies met inclusion criteria. Four studies included a control group of parents of full-term infants. Three studies reported sleep quantity means, of which only one provided values for an exclusive sample of mothers of preterm infants and found on average, mothers obtained 6.3 h of sleep/day in the first 5-10 days. Twelve studies reported on sleep quality; most (n = 10) relied on self-reported measures and identified poor subjective sleep quality whereas two studies objectively measured sleep of poor quality. Parental stress was the most consistent factor associated with sleep quality.

CONCLUSION AND IMPLICATIONS

Quality and quantity of sleep among parents of preterm infants is inadequate and may negatively influence family health outcomes. Further research on correlates and changes in sleep is required to identify at-risk parents and inform targeted clinical recommendations and interventions aimed at maximizing sleep for parents of preterm infants.

Sleep and its relationship to health in parents of preterm infants: a scoping review

BACKGROUND

Sleep is essential for human health and functioning. Parents of preterm infants are susceptible to sleep disturbances because of stress related to the preterm birth. Poor sleep has the potential to affect parental health and well-being. The aim of this study was to identify and map evidence on sleep and its relationship to health in parents of preterm infants. No review has summarized the evidence on this topic.

METHODS

A scoping review was conducted. Seven health and medical electronic research databases were searched for relevant quantitative and qualitative primary studies, including grey literature. The search was performed March 2-7, 2017.

RESULTS

Ten American studies and one Australian study were included in the review. Most research was quantitative and focused on maternal sleep and mental health within the first two weeks after the childbirth. Both objective and subjective sleep measures were used to study sleep at the hospital; actigraphs were not used after discharge. Maternal sleep was poor early postpartum, and this was associated with negative health outcomes. Two cohort studies compared sleep in mothers of preterm and term infants, but the results were conflicting. In one qualitative study, fathers described their inability to catch up on sleep after homecoming with a preterm baby.

CONCLUSIONS

Quantitative studies reporting on maternal sleep early postpartum was most frequently occurring in the results. Qualitative research on the topic was identified as a knowledge gap. More cultural and geographical breadth, including research on fathers' sleep, is recommended in future research.

The Role of Circadian Rhythms in Postpartum Sleep and Mood

Women often experience sleep disturbances and worsening sleep quality throughout pregnancy and postpartum. Circadian rhythms are closely linked to sleep problems and mood disorders. This systematic review provides a summary of studies of circadian rhythms and associated sleep problems and maternal distress, among postpartum women. Articles were idenitfied through a systematic literature search. Circadian rhythm disturbances were strongly correlated with depression, social factors and mothers`s exposure to light postpartum. Future research should include larger, prospective studies as well as randomized controlled trials for measuring effect of circadian rhythm interventions on postpartum mental health outcomes.

A systematic review of the amount and timing of light in association with objective and subjective sleep outcomes in community-dwelling adults

Light is considered the dominant environmental cue, or zeitgeber, influencing the sleep-wake cycle. Despite recognizing the importance of light for our well-being, less is known about the specific conditions under which light is optimally associated with better sleep. Therefore, a systematic review was conducted to examine the association between the amount and timing of light exposure in relation to sleep outcomes in healthy, community-dwelling adults. A systematic search was conducted of four databases from database inception to June 2016. In total, 45 studies met the review eligibility criteria with generally high study quality excepting for the specification of eligibility criteria and the justification of sample size. The majority of studies involved experimental manipulation of light (n = 32) vs observational designs (n = 13). Broad trends emerged suggesting that (1) bright light (>1000 lux) has positive implications for objectively assessed sleep outcomes compared to dim (<100 lux) and moderate light (100-1000 lux) and (2) bright light (>1000 lux) has positive implications for subjectively assessed sleep outcomes compared to moderate light (100-1000 lux). Effects due to the amount of light are moderated by the timing of light exposure such that, for objectively assessed sleep outcomes, brighter morning and evening light exposure are consistent with a shift in the timing of the sleep period to earlier and later in the day, respectively. For subjectively assessed sleep outcomes, brighter light delivered in the morning was associated with self-reported sleep improvements and brighter evening light exposure was associated with worse self-reported sleep.

Quality of life of parents of very preterm infants 4 months after birth: a mixed methods study

Background

Knowledge about parental quality of life (QoL) is paramount to family-centred and integrated healthcare on prematurity, but evidence is limited. We aimed to explore mothers’ and fathers’ perspectives about their QoL 4 months after a very preterm childbirth.

Methods

This is a cross-sectional mixed methods study using a convergent design. Parents of very preterm infants were systematically recruited at all level III neonatal intensive care units in the Northern health region of Portugal for one year. Four months after childbirth, 61 mothers and 56 fathers filled-in the World Health Organization Quality of Life – BREF Inventory, and 26 couples were interviewed. Linear regression models were computed to assess the association between participants’ characteristics and the QoL. Qualitative data were thematically analysed.

Results

A quantitative analysis revealed that the perception of QoL was not significantly different by gender. QoL scores increased slightly from the environment (Mean (SD): 72.1 (14.2)) to the psychological domains (Mean (SD): 78.7 (14.4)). All scores were influenced by psychological characteristics. Socioeconomic position influenced both parents’ perceptions concerning the environment domain, and maternal physical and psychological QoL. Infant-related factors were associated with overall QoL among women and with the physical, psychological, social and environment domains among men. Qualitative findings indicated accommodation mechanisms that intertwine the focus on constraining factors (surveillance, sleep disturbances, non-supportive healthcare policies, hygienization) with facilitating factors (social support, accessibility/quality of healthcare, opportunities for developing parental skills). These processes were anchored in child-centredness and a framework that construct hierarchies of hope and expectations about infant’s health and development.

Conclusions

To capture parental QoL using mixed methods raises awareness for developing intersectoral family-centred policies, integrated health services and focused-interventions to decrease the disempowering effects of surveillance and hygienization.

An Integrative Review of the Sleep Experiences of Mothers of Hospitalized Preterm Infants

OBJECTIVE

To determine what is known about the sleep experiences of mothers of hospitalized preterm infants.

DATA SOURCES

A literature search of PubMed and CINAHL was performed in February 2018. Additional articles were identified from reference lists.

STUDY SELECTION

Whittemore's integrative review methodology was used to synthesize existing literature; 17 articles met eligibility criteria.

DATA EXTRACTION

Data were reported in tabular format, including subjects, purpose, setting, interventions, sleep measurements, psychometric instruments, analyses, and results.

DATA SYNTHESIS

Overall, sleep is disrupted and of poor quality, and many mothers report insomnia with less total sleep time. Potential beneficial interventions include bright light therapy, relaxation guided imagery, and progressive muscle relaxation.

CONCLUSION

Although some interventions show promise, there are significant limitations. Future research should consider maternal/infant separation and milk expression.

Sleep in the Intensive Care Unit in a Model of Family-Centered Care

The desire for families to be physically present to support their loved ones in the intensive care unit, and guidelines in favor of this open visitation approach, require that clinicians consider both patient and family sleep. This article reviews the causes of poor sleep for patients and their family members in the intensive care unit as well as the expected changes in cognition and emotion that can result from sleep deprivation. Measures are proposed to improve the intensive care unit environment to promote family sleep. A framework to educate family members and engage them in preservation of their and their loved one's circadian rhythm is also presented. Although further research is needed, the proposed framework has the potential to improve outcomes for patients and their families in the intensive care unit.

Quality of life among parents of preterm infants: a scoping review

PURPOSE

To synthesize the body of knowledge on the factors influencing the QoL of mothers and fathers of preterm infants.

METHODS

A scoping review was performed. Publications indexed in PubMed®, Web of Science™, CINAHL® and PsycINFO® were searched, targeting studies presenting original empirical data that examined parental perception on QoL after a preterm delivery. Eligibility and data extraction were conducted by two independent researchers. The main quantitative findings were synthesized and qualitative data were explored by content analysis.

RESULTS

The studies, 11 quantitative and 1 mixed methods, were derived mainly from the USA (n = 6). Heterogeneity across the studies was observed regarding the operationalization of QoL and the use of units of analysis (mothers, parents, families and caregivers). In a context where 40 out of 45 covariates were analysed by only one or two studies, results suggested that parental QoL after a preterm delivery is influenced by factors related with mother's characteristics, family issues and health care environment rather than infants' variables. Factors regarding fathers' characteristics and structural levels were not addressed.

CONCLUSIONS

Standardizing the operationalization of the QoL when analysing mothers and fathers of preterm infants calls for a structured questionnaire adapted to their specific needs. Further research should include both mothers and fathers, invest in mixed methods approaches and be performed in different countries and settings for allowing integration and comparison of findings.

Do changes in subjective sleep and biological rhythms predict worsening in postpartum depressive symptoms? A prospective study across the perinatal period

Abnormalities of sleep and biological rhythms have been widely implicated in the pathophysiology of major depressive disorder (MDD) and bipolar disorder (BD). However, less is known about the influence of biological rhythm disruptions across the perinatal period on postpartum depression (PPD). The objective of this study was to prospectively evaluate the relationship between subjective changes in both sleep and biological rhythms and worsening of depressive symptoms from pregnancy to the postpartum period in women with and without mood disorders. Eighty-three participants (38 euthymic women with a history of a mood disorder and 45 healthy controls) were studied. Participants completed subjective assessments of sleep (Pittsburgh Sleep Quality Index), biological rhythm disturbances (Biological Rhythms Interview of Assessment in Neuropsychiatry), and depressive symptoms (Edinburgh Postnatal Depression Scale) prospectively at two time points: third trimester of pregnancy and at 6-12 weeks postpartum. Multivariate regression analyses showed that changes in biological rhythms across the perinatal period predicted worsening of depressive symptoms in both groups. Moreover, women with a history of a mood disorder showed higher levels of sleep and biological rhythm disruption during both pregnancy and the postpartum period. These findings suggest that disruptions in biological rhythms during the perinatal period increase the risk for postpartum mood worsening in healthy pregnant as well as in pregnant women with a history of mood disorders.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND

Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders.

METHODS

Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included.

RESULTS

There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak.

LIMITATIONS

Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis.

CONCLUSIONS

Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

Mothers' strategies in handling the prematurely born infant: a qualitative study

INTRODUCTION

Family, especially mother, is faced with numerous challenges by experiencing a premature birth. Since knowing about mother's efforts regarding prematurely born infant helps us in our comprehensive understanding of the impact of this incident on the family system and its performance. The present study was carried out to explore the mothers' strategies regarding prematurely born infant.

METHODS

In a conventional qualitative content analysis, data was collected through purposive sampling by semi-structured deep interviews with 18 mothers who had prematurely born infant during 2012-2013 in the teaching hospitals of the north and northwest of Iran. All the interviews were recorded, typed, and finally analyzed.

RESULTS

Data analysis resulted in the extraction of categories of "asking for help, elevating capacity and reducing personal responsibilities and commitments". These categories were revealed in mothers respectively by the different sub-categories of "religious appeal and relying on beliefs, seeking information from the treatment and caring team, participating in infant's care, companionship and support of family and friends","focusing on positive thinking and imagination, patience and strength " and "ignoring some routine affairs and reducing role-related activities and duties".

CONCLUSION

Considering the uniqueness of the mother's role in responding to the needs of infants, healthcare system should consider mothers as real target in the intervention strategies in order to promote health and quality of life, so maybe this way, the burden of care and management of critical situations caused by a premature birth on the mother can be reduced.

Parents' responses to stress in the neonatal intensive care unit

Background Parents' stress resulting from hospitalization of their infant in the neonatal intensive care unit (NICU) produces emotional and behavioral responses. The National Institutes of Health-sponsored Patient Reported Outcomes Measurement Information System (PROMIS) offers a valid and efficient means of assessing parents' responses. Objective To examine the relationship of stress to anxiety, depression, fatigue, and sleep disruption among parents of infants hospitalized in the NICU. Methods Thirty parents completed the Parental Stressor Scale (PSS:NICU) containing subscales for NICU Sights and Sounds, Infant Behavior and Appearance, and Parental Role Alteration, and the PROMIS anxiety, depression, fatigue, and sleep disturbance short-form instruments. Results PSS total score was significantly correlated with anxiety (r = 0.61), depression (r = 0.36), and sleep disturbance (r = 0.60). Scores for NICU Sights and Sounds were not significantly correlated with parents' outcomes; however, scores for Alteration in Parenting Role were correlated with all 4 outcomes, and scores for Infant Appearance were correlated with all except fatigue. Conclusion Stress experienced by parents of NICU infants is associated with a concerning constellation of physical and emotional outcomes comprising anxiety, depression, fatigue, and sleep disruption.

Maternal stress, well-being, and impaired sleep in mothers of children with developmental disabilities: a literature review

Having children with developmental disabilities (DDs) requires a high level of caregiving responsibilities, and existing studies support that mothers of children with DDs experience high levels of maternal stress as well as poor sleep and well-being. Given the fact that the number of children with DDs has increased, an up-to-date literature review is necessary to identify factors associated with maternal stress, sleep, and well-being. In addition, understanding these factors and their relationships may provide better strategies in designing effective interventions that can reduce the burden in mothers of children with DDs. This review summarized 28 scientific research papers that examined maternal stress, sleep, and well-being in mothers of children with DDs in past 12 years. The study findings indicate that mothers of children with DDs experience higher levels of stress than mothers of typically developing children, and it remains high over time. In addition, these mothers often encounter depressive symptoms as well as poor sleep quality. The study results also reveal that there is a bidirectional relationship between maternal stress and depressive symptoms as well as between poor sleep quality and depressive symptoms. For example, higher stress mothers experienced more depressive symptoms. Mothers of children with DDs with poor sleep quality are significantly associated with more depressive symptoms. Child behavior problems were significantly associated with both maternal stress and depressive symptoms, but cautious interpretation is warranted due to the shared variance between child behavior problems, maternal stress, and depressive symptoms. Methodological guidelines for future research involve the use of reliable and valid instruments for the measurement of child behavior problems, maternal stress, and sleep. Recommendations for future research are included.

Guided imagery: an innovative approach to improving maternal sleep quality

Mothers of preterm infants are at risk for poor sleep quality, which may adversely affect their health, maternal-infant attachment, and infant caretaking activities. This study examined the relationship of an 8-week relaxation guided imagery intervention on sleep quality and the association between sleep quality and maternal distress (perceived stress, depressive symptoms, and state anxiety) in 20 mothers of hospitalized preterm infants. Mothers received a CD (compact disc) with three 20-minutes recordings and were asked to listen to at least 1 recording daily for 8 weeks. This analysis used self-report data gathered at baseline and 8 weeks. Pearson correlations were used to examine the relationships between mean cumulative relaxation guided imagery use and measures of maternal distress and sleep quality scores at 8 weeks. Complete data on 19 mothers were available for analysis. At 8 weeks, higher mean relaxation guided imagery use was inversely correlated with sleep quality scores (r = -0.30); sleep quality scores were positively correlated with stress (r = 0.42), depressive symptoms (r = 0.34), and anxiety (r = 0.39) scores. In mothers of preterm infants, sleep quality was negatively affected by mental distress and may be improved by a guided imagery intervention.

The experiences of parents with infants in Neonatal Intensive Care Unit

BACKGROUND

In recent years significant medical science advances have been made in the field midwifery and infant care. The premature, low birth weight and ill infants are admitted to the technologically advanced NICU for care and they often require long-term stay. This study addresses parental experiences with the infant care in NICU, explores their concerns regarding nursing supports for parents and offers nurses' perspectives on performing duties.

MATERIALS AND METHODS

A qualitative inductive content analysis method was applied in 2011 that included a purposely selected group of parents, nurses and physicians from neonatal unit at the Medical Science University of Isfahan. Participants were surveyed and interviewed according to the institutional ethics committee approval and signed informed consents.

RESULTS

THE CONTENT ANALYSIS IDENTIFIED TWO MAIN CATEGORIES: 1) the definition of stress, which consisted of misgivings, nervous pressure, imbalance, separation and 2) the parents' reaction to stress, which revealed emotional, psychotic and behavioral reactions as subcategories.

DISCUSSION

The medical team awareness of NICU parent experiences is essential to the quality of care. Recognizing the type of parents' reaction to the whole process by the healthcare team seems essential to the optimum outcome.

Does activity matter: an exploratory study among mothers with preterm infants?

The purpose of this study was to describe the daytime activity levels and their association with sleep, fatigue, depressive symptoms, and quality of life. Wrist actigraphy and questionnaires were used to examine 51 mothers with a preterm infant during their second week postpartum. Circadian activity rhythms (CAR) were less synchronized in these mothers; they experienced sleep disturbances, fatigue, depressive symptoms, and poor health-related quality of life (H-QOL). Compared to high-activity mothers, mothers with low activity levels slept less during nighttime but napped more during daytime, and reported more postpartum depressive symptoms. Further research is needed to examine the effect of low activity level and sleep loss on postpartum depression, and to develop interventions for improving rest/activity patterns for new mothers.

Bright Light Therapy to Promote Sleep in Mothers of Low-Birth-Weight Infants

Having a low-birth-weight (LBW) infant in a neonatal intensive care unit (NICU) can intensify a mother’s sleep disturbances due to both stress and the dim lighting in the ICU setting, which desynchronizes circadian rhythms. The purpose of this pilot study was to examine the effectiveness of a 3-week bright light therapy intervention on sleep and health outcomes of mothers with LBW infants in the NICU. Controlled stratified randomization was used to assign 30 mothers to a treatment or control group. Data were collected at pretreatment (second week postpartum) and after the 3-week intervention. Sleep data were assessed by wrist actigraph (total sleep time [TST], circadian activity rhythms [CARs]) and the General Sleep Disturbance scale. Other outcome variables were measured by the Lee’s Fatigue scale, Edinburgh Postpartum Depression scale, and the Medical Outcomes Short Form 36, version 2. Mothers averaged 26.6 ( SD = 6.3) years of age, and the majority were Black (73%). The mean gestational age for the infants was 27.7 ( SD = 2.0) weeks. Small to large effect sizes were found when comparing the pre- to posttreatment differences between groups. Although none of the differences were statistically significant in this small sample, for mothers in the treatment group nocturnal TST ( d = .33), CAR ( d = 1.06), morning fatigue ( d = .22), depressive symptoms ( d = .40), physical health–related quality of life ( d = .33), and mental health–related quality of life ( d = .60) all improved compared to the control group. Bright light therapy is feasible for mothers with infants in an NICU. Clinically significant improvements have been evidenced; a larger-scale trial of effectiveness is needed.

Stress and health-related well-being among mothers with a low birth weight infant: the role of sleep

This U.S.A.-based study examined the quantitative and qualitative characteristics of sleep, as well as the role of sleep, in the association of stress with depression, fatigue, and health-related quality of life (H-QOL) among mothers with a low-birth-weight, preterm infant in the neonatal intensive care unit at early postpartum. Fifty-five first-time mothers kept a sleep diary and filled out a battery of questionnaires. The wrist actigraphy method was also applied to collect information on maternal sleep. We tested a path model, with sleep disturbance and depression mediating the effect of stress on health-related well-being. Results showed that the majority of the study participants were stressed, depressed, fatigued, and at risk for poor physical and mental health. Poor sleep quality as perceived by mothers was significantly associated with their stress, fatigue, and poor mental and physical H-QOL. A cascading effect was found in the path model where maternal stress contributed to poor sleep quality and depression, which in turn contributed to poor mental H-QOL. In addition, poor sleep quality was associated with fatigue, which in turn contributed to poor physical and mental H-QOL. The underlying neurobiological mechanisms through which sleep affects the stress-health relation are discussed. The implications of sleep for intervention and prevention are also addressed.

Preterm birth prevention: a mandate for psychosocial assessment

Reviews panels on the prevention of preterm birth (PTB) conducted by the Office of the Surgeon General and the Eunice Kennedy Shriver National Institute of Child Health and Human Development made numerous novel recommendations for research on the assessment of risk factors for PTB and the development of personalized, specific interventions for the prevention of PTB. This paper discusses the particularly significant roles for nurses in assessment and intervention based on their education in pregnancy and in multiple health-related disciplines. General differences and specific anxiety assessment are presented based on the goals of research. An emphasis is placed on assessment of pregnancy-specific anxiety, and assessment and intervention methods that include the father/partner and couple using family system methodologies. The risks occurring with differences in partner intentions for pregnancy are discussed, and especially the benefits of male partner involvement and support. It is noted that interventions may need to be varied based on differences in gender, ethnic, cultural, and socioeconomic status. Differences in individual or group intervention psychotherapy approaches are considered. The special risks and needs of pregnant military couples, especially those with deployed partners are presented. Variations in anxiety are discussed in terms of implications for maternal/paternal fetal and child attachment from birth to adulthood. Discussion includes the considerable and varied parenting and financial strains that continue long after birth, with significant impact for parent-child mental and physical health, and the need for development of long-term interventions that include parental coping strategies and parental empowerment.

Circadian activity rhythms for mothers with an infant in ICU

Circadian rhythms influence sleep and wakefulness. Circadian activity rhythms (CAR) are altered in individuals with dementia or seasonal affective disorder. To date, studies exploring CAR and sleep in postpartum women are rare. The purpose of this report is to describe relationships between CAR, sleep disturbance, and fatigue among 72 first-time mothers during their second week postpartum while their newborn remain hospitalized in intensive care unit. Seventy-two mothers were included in this secondary data analysis sample from three separate studies. Participants completed the general sleep disturbance scale (GSDS), numerical rating scale for fatigue, and a sleep diary. The objective sleep data included total sleep time (TST), wake after sleep onset (WASO), and CAR determined by the circadian quotient (amplitude/mesor) averaged from at least 48-h of wrist actigraphy monitoring. The TST of mothers who self-reported as poor sleepers was 354 min (SEM = 21.9), with a mean WASO of 19.5% (SEM = 2.8). The overall sleep quality measured by the GSDS was clinically, significantly disrupted (M = 5.5, SD = 1.2). The mean score for morning fatigue was 5.8 (SD = 2.0), indicating moderate fatigue severity. The CAR was 0.62 (SEM = 0.04), indicating poor synchronization. The self-reported good sleepers (GSDS < 3) had better CAR (M = 0.71, SEM = 0.02) than poor sleepers (GSDS > 3) (t[70] = 2.0, p < 0.05). A higher circadian equation was associated with higher TST (r = 0.83, p < 0.001), less WASO (r = -0.50, p < 0.001), lower self-reported sleep disturbance scores (r = -0.35, p = 0.01), and less morning fatigue (r = -0.26). Findings indicate that mothers with a hospitalized infant have both nocturnal sleep problems and disturbed circadian activity rhythms. Factors responsible for these sleep and rhythm disturbances, the adverse effects on mother's physical and mental well-being, and mother-infant relationship require further study.