Newborn Behavioral Observation, maternal stress, depressive symptoms and the mother-infant relationship: results from the Northern Babies Longitudinal Study (NorBaby)

Parenting Stress Following a Neonatal Intensive Care Unit Hospitalization: A Longitudinal Study of Mothers and Fathers

A neonatal intensive care unit (NICU) hospitalization can add significant stress to the postpartum period. Parents experience isolation and uncertainty, which can affect their capacity to bond with their new baby. Understanding how stress is shaped by and changes following a NICU experience will help in developing supports for these families. We examined patterns of parenting stress over the first year of life following a NICU stay to better understand changes in stress, differences in maternal and paternal stress, and how medical and developmental variables impact parent stress. Parents of infants (n = 51) who had experienced a NICU hospitalization and met criteria for California's High-Risk Infant Follow-Up program completed assessments at 6, 9, and 12 months. A comparison group (n = 38) from a historic dataset included parents of infants born full term without medical complications. NICU parents reported higher levels of parenting stress at 6 months, but not 12 months, with mothers and fathers reporting similar stress levels. Parenting-related stress was found to be relatively stable and consistent over this period. Among NICU parents, lower developmental level at 12 months was associated with more distress in interacting with their child. These findings highlight the importance of monitoring parenting stress following discharge from the NICU and developing interventions for supporting parents of NICU graduates showing developmental delays.

Home-visiting Parenting Programs to Improve Mother-Infant Interactions at Early Ages: A Systematic Review

Objective: To systematically review studies examining the effects of home-visiting preventive parenting programs (HV-PPs) on improving the quality of mother-child interactions in early childhood. Method: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, we identified 3,586 studies published between 2018 and 2022 by searching the following databases: PubMed, Web of Science, BVS/LILACS, SciELO, and PsycNET/PsycINFO. After applying the eligibility criteria, 17 articles were selected for review. Results: Most studies were conducted in high-income countries (53%) and the remainder were conducted in upper-middle-income countries, predominantly using a randomized controlled trial design and with strong methodological quality. The 17 studies applied 13 different HV-PPs, predominantly using video feedback, based on various dosages and schedules. Most studies (77%) showed significant positive effects on mother-child interactions by improving mainly positive maternal behaviors (e.g., sensitivity and responsiveness). Positive effects occurred independent of the study design, sample characteristics, measures, and constructs assessed. However, the findings suggest that the combination of fewer than six sessions, durations shorter than three months, and a very early start did not impact mother-child interactions, as expected. Few studies have explored negative maternal behaviors, children's behaviors, and dyadic interactions such as mutuality and synchrony. Conclusions: HV-PPs positively impacted mother-child interactions in early childhood despite the large heterogeneity across program designs, outcome measures, and overlapping constructs. Based on the results, we discuss the practical and economic implications of using parenting programs as a preventive approach.

The effect of perceived social support on postpartum stress: the mediating roles of marital satisfaction and maternal postnatal attachment

BACKGROUND

Multiple factors may be responsible for the development of postpartum stress, including perceived social support, marital satisfaction, and maternal postnatal attachment. However, the underlying mediation mechanisms remain unclear. This study examined the complex relationships between perceived social support and postpartum stress among Chinese women.

METHODS

A convenience sample comprising 406 postpartum women was recruited from six hospitals in Nantong, Jiangsu Province, China. The participants completed general survey questionnaires and were evaluated using the Maternal Postpartum Stress Scale, the Perceived Social Support Scale, the Maternal Postnatal Attachment Scale, and the Marital Satisfaction Scale. Furthermore, we evaluated the relationship between postpartum stress and the various influencing factors by performing a multiple linear regression analysis. The potential mediating roles of marital satisfaction and maternal and infant attachment in the association between perceived social support and postpartum stress were explored by performing a mediation analysis.

RESULTS

According to the multivariate regression analysis, perceived social support, marital satisfaction, and maternal postnatal attachment contributed to postpartum stress levels (P < 0.05). The mediation analysis revealed that marital satisfaction and maternal postnatal attachment played parallel mediating roles in the association between perceived social support and postpartum stress, and the mediating effect of marital satisfaction was - 0.1125 (95% confidence interval [CI]: -0.1784 to -0.0520), accounting for 33.20% of the total effect, and the mediating effect of maternal postnatal attachment was - 0.0847 (95% CI: -0.1304 to -0.0438), accounting for 25.00% of the total effect.

CONCLUSION

Our study revealed that perceived social support could influence postpartum stress not only through direct effect (41.80% of the total effect), but also through the indirect effect (mediation effect) of marital satisfaction and maternal postnatal attachment (58.20% of the total effect), suggesting that improving postpartum women's social support, enhancing maternal and infant attachment, and improving their marital satisfaction could help lower postpartum stress.

Home-visiting programs based on the Brazelton approach: a scoping review

This review maps and summarizes the quantitative studies on the main outcomes associated with home visiting (HV) programs using Brazelton methods aimed at supporting expectant and new parents. One hundred thirty-seven records were identified, and 19 records were selected. The design of our study was based on the methodological framework for conducting scoping reviews. Quality was assessed through the Jadad scale. Studies were coded for participant characteristics (number, mean age, and risk status), methodology (recruitment, home visit frequency, age of the child, Brazelton method, and research design), and intervention outcomes (on infants, parents, and home visitors). The studies mostly focused on the impact of Brazelton HV programs on infant development, the mother's psychological well-being, mother-infant interaction, and home visitor satisfaction. Experimental and quasi-experimental studies consistently have shown that parents receiving the intervention have greater knowledge of their children. Results are less conclusive regarding the intervention's impact on other domains of child development, mothers' psychological well-being, and mothers' sensitivity to the relationship with the child. Overall, the results suggest that the improvements associated with the intervention are mainly influenced by the risk status of families. Further research is needed to better understand the benefits of HV based on the Brazelton approach and the target population that may benefit most from this intervention.

CONCLUSION

 Although the impact of the Brazelton home visiting intervention is not yet fully understood, there is promising evidence of its positive effects on child development, maternal well-being, and parental knowledge. Further research with consistent methodologies and larger sample sizes is needed to strengthen our understanding. However, existing findings in the literature underscore the importance of preventive interventions such as the Brazelton program in improving family well-being, with potential long-term benefits.

WHAT IS KNOWN

• Home visiting programs based on the Brazelton approach aim to increase parents' knowledge and sensitivity to their children. • There is no clear picture in the literature of the effectiveness of these programs.

WHAT IS NEW

• Existing studies consistently show the effectiveness of these programs to improve parents' knowledge of their children. • Findings on the impact of these programs on child development, mothers' psychological well-being and sensitivity to their child are inconclusive and may be influenced by the risk status.

The role of midwives in supporting the development of the mother-infant relationship: a scoping review

BACKGROUND

The mother-infant relationship is complex and dynamic, informing the psychological development of the infant through bonding and attachment. Positive early interactions influence the quality of this relationship. Midwives are well placed to support the developing relationship between the mother and baby, yet there has been limited research exploring the role of the midwife in this context.

AIM

To explore interventions that have been provided by the midwife which support the development of the maternal-fetal or mother-infant relationship amongst a low-risk population from pregnancy, and up to six weeks postnatal. The review also sought to understand the types of interventions developed, format and delivery, outcomes measured and if cultural considerations had been incorporated.

METHODS

A scoping review of the research literature was undertaken using the Joanna Briggs Institute framework. Five online databases were searched for relevant articles published in English from 2000 to 2021.

FINDINGS

Sixteen articles met the inclusion criteria. Three themes emerged: (1) viewing the fetus as separate from the mother, (2) focused activities on the maternal-infant relationship and (3) targeted educational interventions.

DISCUSSION

Providing focused activities and targeted education during the pre and postnatal periods support the development of the mother-infant relationship. Significantly, there was insufficient research that considered the influence of culture in supporting the mother-infant relationship.

CONCLUSION

Further research is required to develop interventions that include a diverse sample to ensure culturally appropriate activities can be integrated into care during pregnancy and/or the postnatal period provided by midwives.

Instruments to measure interaction of mothers and newborns: A systematic review

Interactions between newborns and their parents/primary caregivers are characterized by asymmetric and dependent relationships. This systematic review mapped, identified, and described the psychometric parameters, categories, and items of instruments used to assess mother-newborn interaction. Seven electronic databases were accessed in this study. Furthermore, this research included neonatal interaction studies describing instruments' items, domains, and psychometric properties while excluding studies that focused on maternal interactions and lacked items for assessing newborns. Additionally, studies validated with older infants that did not have a newborn in the sample were used for test validation, which is a criterion used to decrease the risk of bias. Fourteen observational instruments from 1047 identified citations were included that addressed interactions using varying techniques, constructs, and settings. Particularly, we focused on observational settings that assessed interactions with communication-based constructs in the context of proximity or distance as influenced by physical, behavioral, or procedural barriers. These tools are also used to predict risk behaviors in a psychological context, mitigate feeding difficulties, and conduct neurobehavioral assessments of mother-newborn interactions. The elicited imitation was also an observational setting. This study found that the most described properties in the included citations were inter-rater reliability followed by criterion validity. However, only two instruments reported content, construct, and criterion validity, as well as a description of an internal consistency assessment and inter-rater reliability. Finally, the synthesis of the instruments reported in this study can guide clinicians and researchers in selecting the most appropriate one for their own application.

Parental Postnatal Depression in the Time of the COVID-19 Pandemic: A Systematic Review of Its Effects on the Parent-Child Relationship and the Child's Developmental Outcomes

The international literature has shown that maternal and paternal postnatal depression (PND) is one of the most common mental illnesses in the perinatal period, with significant consequences for parent-infant relationships and infant development. The COVID-19 pandemic has increased the rates of prevalence of PND, exacerbating the mental health risk for new families. This systematic review aims to examine the effect of maternal and paternal PND on parent-infant relationships and children's development in the first 36 months after childbirth during the COVID-19 outbreak. Eligible studies were identified using the following databases: Medline, CINAHL, SCOPUS, PsycINFO, PsycARTICLES, ScienceDirect, and Web of Science. Of the 1252 studies considered, 10 studies met the inclusion criteria. Results showed that maternal PND significantly affected the quality of the early mother-infant relationship and the infant's motor, self-regulation, and socio-emotional development. In addition, the detrimental impact of maternal PND on the quality of early mother-infant relationships seems to become stronger as COVID-19 concerns increase. No studies included fathers. These findings strengthened the importance of planning targeted prevention and treatment strategies to prevent PND and its short- and long-term consequences, especially in the case of stressful and traumatic events. They also suggested the urgent need for further exploration of fathers.

Relationships between parent-infant bonding, dyadic adjustment and quality of life, in an intra-partner sample

The transition to parenthood represents a moment of change and adaptation in which the dyadic marital relationship becomes a triadic relationship. Facilitating a positive transition requires a thorough understanding of the explanatory model of the relationship between parental-infant bonding, dyadic adjustment and quality of life (QoL) from an integrative perspective of the family unit. The aim of this work was to analyse the relationships between parent-infant bonding, dyadic adjustment and QoL from an intra-partner perspective, 6-12 months after the birth of a child. A cross-sectional observational study was performed in a convenience sample of 222 couples 6-12 months postpartum, enrolled from October 2013 to March 2016. The mean age of the mothers was 34.07 years (SD = 3.67), and for the fathers, it was 35.75 years (SD = 4.02). Mothers perceived better QoL and greater mother-infant bonding compared to fathers. The perception of an adequate dyadic adjustment, together with positive parent-infant bonding, had positively influenced the individual QoL of both members of the couple 6-12 months after birth. From an intra-partner perspective, the positive transition was influenced by the relationship between parent-infant bonding, dyadic adjustment and QoL. Positive parent-infant bonding in mothers and fathers, as well as promotion of the quality of the relationships between couples, can help promote a better QoL. Positive health results can be achieved in terms of individual and family well-being by designing healthcare interventions that encourage the presence and participation of the family unit.

Co-regulation and parenting stress over time in full-term, very low birthweight preterm, and psycho-socially at-risk infant-mother dyads: Implications for fostering the development of healthy relationships

From birth, mothers and infants co-regulate their interactions that are shaped by their socio-emotional development, relationship history, current circumstances, and goals. However, few studies have longitudinally explored co-regulation in the context of medical and psycho-social risk. The present 4-wave longitudinal study sought to shed light on factors associated with co-regulation over time in infants from 6- to 48-months. The objectives were to 1) identify differences in co-regulation among low- and at-risk infant-mother dyads, 2) explore changes in co-regulation over time, and 3) explore the associations between infant-mother co-regulation and parenting stress in these low- and at-risk groups over time. Participants included three groups of infant-mother dyads (full-term [FT], n = 48; very low birthweight/preterm [VLBW/preterm] born 26-32 weeks, weighing 800-1500 g, n = 61; psycho-socially at-risk where parents had histories of socioeconomic disadvantage, n = 54) followed longitudinally at 6-, 12-, 18-, and 48-months of age. Dyads engaged in a free play in their homes that was coded for co-regulation using Fogel, de Koeyer, Secrist, Sipherd, Hafen, and Fricke's (2003) Revised Relational Coding System (RRCS), and mothers reported on their level of parenting stress. Results from MANOVAs at each time point indicated significant differences between the groups at 18-months, with psycho-socially at-risk dyads engaging in more one-sided interactions than FT and VLBW/preterm dyads, and more dysregulation and miscommunication than VLBW/preterm dyads. Multi-level models of co-regulation revealed that dyads became progressively less synchronous from 6- to 12-months, followed by greater synchrony and mutual reciprocity from 12-months onwards. Parenting stress was associated with less synchrony and less mutual reciprocity amongst the at-risk groups. Maternal education was associated with greater engagement and girls tended to engage in more synchronous interactions than boys. Our results underscore the value and implications of considering background risk and concurrent parent perceptions in the development and reciprocity of parent-infant co-regulation and their subsequent relationships from infancy onwards.

Does Parental Reflective Functioning Mediate the Associations between the Maternal Antenatal and Postnatal Bond with the Child in a Community Sample?

Although establishing an affective tie with a child during perinatality is considered one of the most important maternal tasks, little is still known about the mediators of the association between maternal antenatal and postnatal bonding with the infant. This prospective study addresses this gap by evaluating a community sample of 110 Italian women to assess whether maternal pre- and postnatal bonds with the infant are mediated by parental reflective functioning (PRF), as assessed at the third trimester of pregnancy and three months postpartum. Controlling for confounding variables, the hierarchical regression analyses show the maternal prenatal quality of attachment to the fetus as the main predictor of maternal postnatal attachment to the child (β = 0.315; t = 0.2.86; p = 0.005). The mediation analyses show that mothers’ PRF (b = 0.245; SE = 0.119; 95% CI = 0.071, 0.531) explains 39% of the relationship between maternal pre- and postnatal bonding with the child. The findings of this study contribute to research on the association between prenatal and mother-to-infant bonding by additionally investigating the importance of taking into account maternal PRF as a mediating variable. This provides support for the clinical utility of interventions focused on maternal PRF.

The role of early adversity and cognitive vulnerability in postnatal stress and depression

The purpose of the present study was to examine vulnerability factors in expecting parents that might lead to mental illness in the perinatal period. Specifically, we studied how parental early adversity, attentional bias to infant faces, repetitive negative thinking, and demographic factors, were associated with pre- and postnatal depressive symptoms and parenting stress. Participants were expecting parents taking part in the Northern Babies Longitudinal Study, where assessments were made both pre- and postnatally. Assessments included both questionnaires and cognitive tasks. About half of the participants received the Newborn Behavior Observation (NBO)-intervention after birth, between pre- and postnatal assessments. Results show that repetitive negative thinking was a significant predictor of both depressive symptoms and parenting stress, while education, social support, and parity came out as protective factors, especially in mothers. Parental early adversity had an indirect effect on postnatal depressive symptoms and parenting stress, mediated by prenatal and postnatal depressive symptoms, respectively. The NBO intervention did not affect the results, signifying the importance of early childhood adverse events and negative thinking on parents' postnatal adjustment and mood, even when an intervention is provided. In conclusion, repetitive negative thinking is a significant vulnerability factor independent of the presence of depressive symptoms, and health professionals must be aware of parents’ thinking style both during pregnancy and after birth.

Identifying Resilience Factors of Distress and Paranoia During the COVID-19 Outbreak in Five Countries

The ongoing COVID-19 pandemic outbreak has affected all countries with more than 100 million confirmed cases and over 2.1 million casualties by the end of January 2021 worldwide. A prolonged pandemic can harm global levels of optimism, regularity, and sense of meaning and belonging, yielding adverse effects on individuals' mental health as represented by worry, paranoia, and distress. Here we studied resilience, a successful adaptation despite risk and adversity, in five countries: Brazil, Colombia, Germany, Israel, and Norway. In April 2020, over 2,500 participants were recruited for an observational study measuring protective and obstructive factors for distress and paranoia. More than 800 of these participants also completed a follow-up study in July. We found that thriving, keeping a regular schedule, engaging in physical exercise and less procrastination served as factors protecting against distress and paranoia. Risk factors were financial worries and a negative mindset, e.g., feeling a lack of control. Longitudinally, we found no increase in distress or paranoia despite an increase in expectation of how long the outbreak and the restrictions will last, suggesting respondents engaged in healthy coping and adapting their lives to the new circumstances. Altogether, our data suggest that humans adapt even to prolonged stressful events. Our data further highlight several protective factors that policymakers should leverage when considering stress-reducing policies.

What are the effects of supporting early parenting by newborn behavioral observations (NBO)? A cluster randomised trial

BACKGROUND

Professional support to enhance the early parent-infant relationship in the first months after birth is recommended, but little is known about the effect of universal interventions. The objective was to investigate the effect of health visitors' use of the Newborn Behavioral Observations system in new families.

METHODS

A cluster-randomised study was conducted in four Danish municipalities. Health visitors' geographical districts constituted the units for randomisation (n = 17). In the intervention group, 1332 families received NBO from 3 weeks after birth; in the comparison group, 1234 received usual care. Self-administered questionnaires were collected at baseline one to two weeks after birth, and at follow-up three and nine months postpartum. The outcomes were change over time measured by The Karitane Parenting Confidence Scale (KPCS), The Major Depression Inventory (MDI), The Ages and Stages Questionnaire: social-emotional (ASQ:SE) and The Mother and Baby Interaction Scale (MABIC). Data were analysed with mixed-effects linear regression using the intention-to-treat approach.

RESULTS

At baseline, no significant differences between the two groups were seen regarding maternal and infant factors. At follow-up three and nine months after birth, the change in maternal confidence and mood, infant's socio-emotional behaviour, and early parent-infant relationship moved in a slightly more positive direction in the intervention group than in the comparison group, though not statistically significant. The only significant effect was that the intervention mothers reported higher level of knowledge about infant's communication skills, response to cues, and how to sooth and establish a relation with the infant, compared to the comparison group.

CONCLUSIONS

We found no effect of the NBO system delivered in a universal context to all families in a community setting. The only significant difference between groups was a higher maternal degree of knowledge regarding early parenting in the intervention group.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03070652 . Registrated February 22, 2017.

The effects of the Newborn Behavioral Observations (NBO) system in early intervention: A multisite randomized controlled trial

The purpose of this pilot study was to evaluate the effect of an infant mental health intervention, the Newborn Behavioral Observations system (NBO), versus usual care (UC) on infant neurodevelopment and maternal depressive symptoms in early intervention (EI). This multisite randomized trial enrolled newborns into the NBO (n = 16) or UC group (n = 22) and followed them for 6 months. Outcome measures included the Battelle Developmental Inventory (BDI-2), Bayley Scales of Infants Development (BSID-III), and Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D and BSID-III were collected at 3- and 6-months post EI entry and the BDI-2 was collected at EI entry and 6-months post-EI entry. We estimated group differences [95% CI], adjusting for program characteristics. At 6 months, the NBO group had greater gains in Communication (b = 1.0 [0.2, 1.8]), Self-Care (b = 2.0 [0.1, 3.9]), Perception and Concepts (b = 2.0 [0.4, 3.6]), and Attention and Memory (b = 3.0 [0.4, 6.0]) than the UC group. The NBO group also had greater decline in maternal postnatal depressive symptoms (b = -2.0 [-3.7, -0.3]) than the UC group. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months than infants receiving UC. Caregivers receiving NBO care had greater improvements in maternal depressive symptoms than caregivers receiving UC.