Maternal Psychological Distress and Mother-Infant Relationship: Multiple-Birth Versus Singleton Preterm Infants

Unique Characteristics of Women and Infants Moderate the Association between Depression and Mother-Infant Interaction

Research has shown mixed results regarding the association between women's postpartum depression and mother-infant interactions, suggesting that a woman's unique experience and context may moderate how depression shapes these interactions. We examined the extent to which a woman's comorbid anxiety, her exposure to adversity, and infant characteristics moderate the relationship between depressive symptoms of women and interactions with their infants at 6 (n = 647) and 12 months (n = 346) postpartum. The methods included standardized coding of mother-infant interactions and structural regression modeling. The results at 6 months of infant age indicated that infant male sex and infant negative affectivity were risk factors for mothers' depression being associated with less optimal interactions. At 12 months of infant age, two moderators appeared to buffer the influence of depression: a woman's history of trauma and infant preterm birth (≤37 weeks gestation). The results reinforce the salience of infant characteristics in the relationship between maternal depression and mother-infant interactions. The findings also suggest that experiences of trauma may offer opportunities for psychological growth that foster constructive management of depression's potential effect on mother-infant interactions. Further research is needed to clarify the underlying processes and mechanisms that explain the influence of these moderators. The ultimate goals are to reduce the risk of suboptimal interactions and reinforce healthy dyadic relations.

Twin pregnancy and severe maternal mental illness: a Canadian population-based cohort study

Twin pregnancy is a risk factor for postpartum depression and anxiety. Whether this translates into a higher risk of severe maternal mental illness in the short-term or long-term is unknown. This study was a population-based retrospective cohort study, using linked health administrative databases for the entire province of Ontario, Canada. Included were primiparas aged 15-50 years with a twin vs. singleton hospital livebirth, between January 1, 2003, and March 31, 2019. Propensity-score inverse probability of treatment weights accounted for potential confounding. The primary outcome of severe mental illness comprised a composite of an emergency department visit or hospitalization for mental illness or self-injury, or death by suicide, assessed in the first year after birth, and in long-term follow-up, up to 17 years thereafter. Fifteen thousand twenty-four twin and 796,804 (15,022 weighted) singleton births were included, with a mean (IQR) duration of follow-up of 9 (5-13) years. After weighting, the mean (SD) maternal age was 31.3 (5.5) years. In the first 365 days postpartum, severe mental illness occurred at rates of 10.5 and 8.7 per 1000 person-years in twin and singleton mothers, respectively, corresponding to a hazard ratio (HR) of 1.21 (95% CI 1.07-1.47). From 366 days onward, the corresponding figures were 5.9 and 6.1 per 1000 person-years (HR 0.96, 95% CI 0.89-1.04). Individuals with a twin birth appear to experience an increased risk for severe mental illness in the first year postpartum, but not thereafter. This suggests a potential need for targeted counselling and mental health services for mothers within the first year after birth.

Exploring Perceived Stress in Mothers with Singleton and Multiple Preterm Infants: A Cross-Sectional Study in Taiwan

Objective: The aim of this study was to explore mothers’ perceived level of stress one month after hospital discharge following the birth of singleton and multiple preterm infants. Design: A cross-sectional design was used to compare mother’s perceived stress in two groups of postpartum mothers and the relationship of the theoretical antecedents and these variables. Setting: A neonatal intensive care unit in a medical center in Taiwan. Participants: Mothers of 52 singletons and 38 multiple premature infants were recruited. One month after the infant was discharged, the participants completed a self-reported questionnaire that included demographic data about the mother and infant, the 21-item Social Support Scale, and the 15-item Perceived Stress Scale. This was returned by email or completed at the outpatient unit. Analysis: Descriptive and inferential analysis. Results: The mean social support scores were 76.6 and 76.5 (out of 105) for mothers with singleton and multiple birth infants, respectively. The most important supporter was the husband. The mean perceived stress scores of 25.8 and 31.0 for mothers with singleton and multiple birth infants, respectively, were significantly different (p = 0.02). Sleep deprivation and social support were predictive indicators of perceived stress in mothers with preterm infants. Conclusions: We suggest that the differences in stress and needs of mothers with singleton and multiple births should be recognized and addressed in clinics. The findings of this study serve as a reference for promoting better preterm infant care.

Consequences of cervical pessary for subsequent pregnancy: follow-up of randomized clinical trial (ProTWIN)

OBJECTIVE

To evaluate the effect of cervical pessary, as a strategy to prevent preterm birth (PTB), on the outcome of subsequent pregnancy and maternal quality of life 4 years after the index twin pregnancy.

METHODS

Between 2009 and 2012, the ProTWIN trial randomized women with a multiple pregnancy to pessary use vs standard care for the prevention of PTB. The trial showed no benefit in unselected women with a twin pregnancy, but showed a 60% reduction in poor perinatal outcomes in favor of the pessary group in the subgroup of women with a mid-trimester short cervix (cervical length < 38 mm). All women were invited to participate in a follow-up study 4 years after their participation in the ProTWIN trial. In this follow-up study, maternal quality of life was assessed using the EQ-5D-3L questionnaire and women were asked separate questions about subsequent pregnancies. Results were compared between women who were randomized to the pessary vs the control group in the ProTWIN trial by calculating relative risk (RR) and 95% CI. Subgroup analysis was performed for women with a mid-trimester short cervix (cervical length < 38 mm).

RESULTS

Of the 813 women included in the ProTWIN trial, 408 (50.2%) participated in this follow-up study, comprising 228 randomized to the pessary group and 180 to the control group in the original trial. The median interval between participation in the ProTWIN trial and participation in this follow-up study was 4.1 (interquartile range (IQR), 3.9-7.1) years. Ninety-eight (24.0%) participants tried to conceive after their participation in the ProTWIN trial. Of those, 22 (22.4%) women did not have a subsequent pregnancy (no difference between pessary and control groups), seven (7.1%) women had at least one miscarriage but no live birth, and 67 (68.4%) women had at least one live birth (35 in the pessary vs 32 in the control group; RR, 0.93 (95% CI, 0.8-1.07)). In two women, the pregnancy outcome was unknown. Preterm delivery (< 37 weeks of gestation) of the first live birth occurred in three women in the pessary vs one woman in the control group (all singleton; RR, 2.57 (95% CI, 0.28-23.44)). No differences were found between the pessary and control groups in the subgroup of women with mid-trimester short cervix, but the numbers analyzed were small. The median health state index score was 0.95 (IQR, 0.82-0.95), with no difference between the pessary and control groups.

CONCLUSION

Our findings suggest that there are no long-term effects of pessary use on the outcome of subsequent pregnancies and maternal quality of life. Data on obstetric outcome were limited due to the small numbers. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A Chatbot to Engage Parents of Preterm and Term Infants on Parental Stress, Parental Sleep, and Infant Feeding: Usability and Feasibility Study

BACKGROUND

Parents commonly experience anxiety, worry, and psychological distress in caring for newborn infants, particularly those born preterm. Web-based therapist services may offer greater accessibility and timely psychological support for parents but are nevertheless labor intensive due to their interactive nature. Chatbots that simulate humanlike conversations show promise for such interactive applications.

OBJECTIVE

The aim of this study is to explore the usability and feasibility of chatbot technology for gathering real-life conversation data on stress, sleep, and infant feeding from parents with newborn infants and to investigate differences between the experiences of parents with preterm and term infants.

METHODS

Parents aged ≥21 years with infants aged ≤6 months were enrolled from November 2018 to March 2019. Three chatbot scripts (stress, sleep, feeding) were developed to capture conversations with parents via their mobile devices. Parents completed a chatbot usability questionnaire upon study completion. Responses to closed-ended questions and manually coded open-ended responses were summarized descriptively. Open-ended responses were analyzed using the latent Dirichlet allocation method to uncover semantic topics.

RESULTS

Of 45 enrolled participants (20 preterm, 25 term), 26 completed the study. Parents rated the chatbot as "easy" to use (mean 4.08, SD 0.74; 1=very difficult, 5=very easy) and were "satisfied" (mean 3.81, SD 0.90; 1=very dissatisfied, 5 very satisfied). Of 45 enrolled parents, those with preterm infants reported emotional stress more frequently than did parents of term infants (33 vs 24 occasions). Parents generally reported satisfactory sleep quality. The preterm group reported feeding problems more frequently than did the term group (8 vs 2 occasions). In stress domain conversations, topics linked to "discomfort" and "tiredness" were more prevalent in preterm group conversations, whereas the topic of "positive feelings" occurred more frequently in the term group conversations. Interestingly, feeding-related topics dominated the content of sleep domain conversations, suggesting that frequent or irregular feeding may affect parents' ability to get adequate sleep or rest.

CONCLUSIONS

The chatbot was successfully used to collect real-time conversation data on stress, sleep, and infant feeding from a group of 45 parents. In their chatbot conversations, term group parents frequently expressed positive emotions, whereas preterm group parents frequently expressed physical discomfort and tiredness, as well as emotional stress. Overall, parents who completed the study gave positive feedback on their user experience with the chatbot as a tool to express their thoughts and concerns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03630679; https://clinicaltrials.gov/ct2/show/NCT03630679.

What are the causes for low birthweight in Japan? A single hospital-based study

Low-birthweight (LBW; <2,500 g) babies are at a higher risk of poor educational achievement, disability, and metabolic diseases than normal-birthweight babies in the future. However, reliable data on factors that contribute to LBW have not been considered previously. Therefore, we aimed to examine the distribution of the causes for LBW. A retrospective review of cases involving 4,224 babies whose mothers underwent perinatal care at Keio University Hospital between 2013 and 2019 was conducted. The LBW incidence was 24% (1,028 babies). Of the 1,028 LBW babies, 231 babies were from multiple pregnancies. Of the 797 singleton LBW babies, 518 (65%) were born preterm. Obstetric complications in women with preterm LBW babies included premature rupture of membrane or labor onset (31%), hypertensive disorders of pregnancy (HDP, 64%), fetal growth restriction (24%), non-reassuring fetal status (14%), and placental previa/vasa previa (8%). Of the 279 term LBW babies, 109 (39%) were small for gestational age. Multiple logistic regression analyses revealed the following factors as LBW risk factors in term neonates: low pre-pregnancy maternal weight, inadequate gestational weight gain, birth at 37 gestational weeks, HDP, anemia during pregnancy, female sex, and neonatal congenital anomalies. HDP was an LBW risk factor not only in preterm births but also in term births. Our results suggest that both modifiable and non-modifiable factors are causes for LBW. It may be appropriate to consider a heterogeneous rather than a simple classification of LBW and to evaluate future health risks based on contributing factors.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

The role of sociodemographic factors in maternal psychological distress and mother-preterm infant interactions

Preterm birth has been associated with greater psychological distress and less positive mother infant interactions than were experienced by mothers of full-term infants. Maternal and infant sociodemographic factors have also shown a strong association with psychological distress and the mother-infant relationship. However, findings on their effects over time are limited. In this longitudinal analysis, we explored the relationship of maternal and infant sociodemographic variables (maternal age, maternal education, marital status, being on social assistance, maternal race, infant birth weight, and infant gender) to maternal psychological distress (depressive, posttraumatic stress, anxiety, parenting stress symptoms, and maternal worry about child's health) through 12 months corrected age for prematurity, and on the home environment, and mother-infant interactions through 6 months corrected age for prematurity. We also explored differences related to maternal obstetrical characteristics (gestational age at birth, parity, mode of delivery, and multiple birth) and severity of infant conditions (Apgar scores, need for mechanical ventilation, and infant medical complications). Although the relationship of maternal and infant characteristics with these outcomes did not change over time, psychological distress differed based on marital status, maternal education, infant gender, and infant medical complications. Older mothers provided more a positive home environment. Mother-infant interactions differed by maternal age, being on public assistance, maternal race, infant gender, and infant medical complications. More longitudinal research is needed to better understand these effects over time in order to identify and support at-risk mothers.