- Email: [email protected]
Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants
Sexual & Reproductive Healthcare 4 (2013) 107–112
Contents lists available at SciVerse ScienceDirect
Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants R. Flacking a,b,c,⇑, G. Thomson a, L. Ekenberg a, L. Löwegren a, L. Wallin c,d a
Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden c School of Health and Social Studies, Dalarna University, Falun, Sweden d Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden b
a r t i c l e
i n f o
Article history: Received 18 March 2013 Revised 23 April 2013 Accepted 18 June 2013
Keywords: Skin to skin Co-care Mother Neonatal intensive care unit Parental stress Preterm infant
a b s t r a c t Objective: To investigate the influence of co-care facilities and amount of skin-to-skin contact during Neonatal Intensive Care Unit (NICU) stay on maternal stress in mothers of preterm infants at two months corrected age. Methods: A prospective cohort study that involved 300 mothers of pre-term infants was conducted in four NICUs (two with co-care facilities and two with non co-care) in Sweden. Data on duration of skinto-skin contact per day for all days admitted to the NICU were collected using self-reports. Maternal stress was measured by the Swedish Parental Stress Questionnaire (SPSQ) at two months of infant’s corrected age. Results: Mothers whose infants were cared for in a NICU with co-care facilities reported significantly lower levels of stress in the dimension of ‘incompetence’ compared to mothers whose infants had been cared for in non co-care NICUs. The amount of skin-to-skin experienced during the neonatal stay was not significantly associated with levels of maternal stress at two months corrected age. Conclusion: The finding that mothers who do not experience co-care facilities experience greater levels of stress in relation to feelings of incompetence is of concern. Improvements to NICU environments are needed to ensure that mother-infant dyads are not separated. Ó 2013 Elsevier B.V. All rights reserved.
Introduction When an infant is born preterm (<37 gestational weeks) the woman is often not prepared for motherhood [1]. Often attention is focused on the infant’s survival and his/her physical needs, and there is less concern about the contact between the mother and her infant. Early physically and emotionally closeness between mother-infant dyads is believed to be crucial for bonding and the formation of positive attachment relationships [2]. Mothers of infants admitted to the Neonatal Intensive Care Unit (NICU) have been identified to exhibit higher than average levels of emotional distress. Research has identified that between 30–76% of mothers of pre-term infants experience depressive symptoms; or symptoms of psychological trauma during their time in the NICU [3–5]. A study undertaken by Bergstrom, Wallin, Thomson and Flacking [6] also demonstrated that approximately 15% of mothers of preterm infants in Sweden were depressed, and that the culture of the unit was highly influential in determining a mothers’ emo⇑ Corresponding author at: School of Health and Social Studies, Dalarna University, 79188 Falun, Sweden. Tel.: +46 23778541. E-mail address: rfl@du.se (R. Flacking). 1877-5756/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.srhc.2013.06.002
tional response. The higher prevalence of depressive symptoms in mothers of preterm infants compared to those of full term infants may be explained by a stressful birth, concern for their infant’s well-being and the NICU experiences [7]. In addition, the mother’s concerns for the infant’s present and future medical status are considered to impact upon the development of a healthy and positive relationship [8]. However, it is important to note that most of the studies that have explored depression and anxiety in mothers of preterm infants have been conducted in NICUs where mothers and infants have been separated from each other. Early physical separation from the infant within 24 h of birth is related to increased parental stress [9]. Furthermore, prolonged separation between mothers and infants is also reported to cause feelings of not ‘‘belonging’’, maternal incompetence, stress, anxiety and powerlessness [3,10]. Mother’s feelings of maternal incompetence may also be reinforced by health professionals who take over the care of the infant and minimize the maternal role [11]. In the NICU where there is a more accentuated power differentials between mothers and professionals, compared to an ordinary maternity unit, the need for supportive care is increased [1]. Key ways in which the parent-infant relationship may be supported is through co-care and skin-to-skin contact. The provision of co-care, in which
108
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
mothers (and possibly fathers) can room-in (stay alone or together with infant) at the NICU 24 h per day enables parents to stay close and be present with their infants to a higher extent than those who have to stay at home or within a maternity unit [12]. Increased maternal presence can enhance and facilitate episodes of mother-infant skin-to-skin contact [13], which is regarded as a successful way to empower mothers to become familiar with their infants and strengthen their mothering abilities at their own pace [14,15]. Furthermore, research has demonstrated that mothers who practice skin-to-skin contact are less anxious, feel more competent and are more secure in their maternal role [14,16,17]. After the infant’s discharge from the NICU, the mother’s feelings are suggested to oscillate between emotional exhaustion and relief [8,18]. In a qualitative study, Flacking et al. [18] reported that unresolved grief, the NICU’s institutional authority and experiences of shame (e.g. due to feelings of not being a good-enough mother) led to a home situation where the mother felt emotionally exhausted and experienced barriers in the development of a secure mother-infant relationship. Research indicates that mothers’ psychological distress does not decrease with time and this depressive state is associated with social isolation, post-traumatic symptoms and feelings of guilt persisting several years after the birth [19]. Mothers of preterm infants are also reported to be more controlling, actively engaged and/or intrusive with their infants compensating for their guilt or shame for not being the mother they wanted to be during hospitalization or for their preterm infants’ inactive behavior [18,20]. The association between skin-to-skin contact, materal competence and depression has been well investigated. However, not all anxious or stressed mothers are depressed and less research has been paid to the association between the amount of skin-toskin contact and feelings of maternal stress. Furthermore, to our knowledge, the association between co-care facilities and maternal stress after discharge has previously not been investigated. Therefore the aim of this study was to investigate whether co-care facilities at NICU’s and the amount of skin-to-skin experienced with their infants on the NICU’s were associated with maternal stress at two months corrected age.
Methods Design and sample The data reported in this paper was collected as part of a quasiexperimental study to evaluate the effects of facilitation support in the implementation of Kangaroo Mother Care (KMC) guidelines (intervention study is described elsewhere – blind for review). In this study we report on, and describe factors associated with early parental stress. The study was conducted at four NICUs located at four county hospitals in Sweden in 2001–2003. All units experienced full patient occupancy (NICU A 104%, NICU B 93%, NICU C 122% and NICU D 113%) during the study period. Two of the units (NICU A and NICU C) provided co-care facilities for all mothers and infants; which meant that mothers could room in for 24 h/day during the infants’ hospital stay at the NICU. This meant that mothers were offered a room at the NICU, sometimes apart from the infant and sometimes in the same room as the infant, depending on the infant’s medical state. At NICU C the mother’s post-partum care was also provided at the NICU. In the two non co-care NICUs, mothers could usually room-in when the infant was critically ill or in the end of the hospital stay, depending on the availability of rooms. All infants born <37 gestational weeks, cared for within the hospital for at least 72 h and who were residents in the catchment area
of the NICU’s were eligible in the first step of population sampling (n = 811). Participants were excluded if the mother was not Swedish-speaking (n = 47) or had severe medical or psychological problems that prevented inclusion (n = 30). Further exclusions occurred if the infant was referred to another hospital unit (n = 75), had a severe congenital malformation or died during hospital stay (n = 26). From the remaining 663 eligible infants, 51 mothers of these infants were overlooked during the recruitment procedures and a further 189 mothers refused to participate. For the purpose of this study, 123 twins were excluded. The final sample consisted of 300 mothers of singleton preterm infants. Ethics The study was approved by the Research Ethics Committee of the Medical Faculty at Uppsala University. All participants were provided with an information sheet and the purpose of the study was verbally explained. All participants were also asked to sign a consent form prior to participation. Ethical guidelines of confidentiality, withdrawal and anonymity were adhered to throughout the study. Procedure and measures Data on infant (gender, gestational weeks at birth, method of delivery, breathing support, incubator care and length of hospital stay) and maternal (parity and maternal age) characteristics were obtained from the infant’s patient record by a contact nurse working at each of the NICUs. Data on the mother’s educational level and smoking status were obtained from a survey questionnaire mailed to the mothers at two months of infant’s corrected age. Data on skin-to-skin contact were gathered through parental self-reports. The self-report comprised a calendar which covered a 2-week period. On the calendar, the parents (primarily the mothers) were requested to mark the initiation and ending of each skinto-skin episode, rounded to the nearest 5 or 10-min interval, on a daily basis. At the end of the 2-week period, the contact nurse revisited the mother, collected the calendar and provided a new calendar for the following 2-week period. This procedure continued for the whole period of hospital stay. Information on how skinto-skin contact was defined (infant placed skin-to-skin on mother or father, having only a diaper and a cap/socks on when necessary and covered with a blanket) and on how to complete the calendar was also provided to the parents in verbal and written format. This information was provided as soon as the infant was stable enough to initiate skin-to-skin contact, which usually occurred within the first few days after delivery. It was also emphasized to the parents that participation in the study should not be understood as a recommendation or as guidance to carry out skin-to-skin contact; rather, it was a recording of ‘usual care’. To measure maternal stress, the Swedish Parental Stress Questionnaire (SPSQ) was used. Mothers received the questionnaire by post at two months of infant’s corrected age and were asked to return the completed questionnaire in a pre-paid envelope. Two hundred and seventy-six of the 300 eligible mothers completed the SPSQ questionnaire. The Swedish Parenthood Stress Questionnaire (SPSQ) [21] is an adapted and modified version of the Parenting Stress Index [22]. SPSQ comprises five dimensions: Incompetence, Role Restriction, Social Isolation, Spouse Relationship Problems and Health Problems [21]. The SPSQ is considered to be a valid and reliable instrument for measuring parental stress in Sweden [21,23] and has been used with mothers of preterm infants [24,25]. The instrument consists of 34 items, scored on 5point Likert-type scales, in which mothers were asked to rate the extent to which they agreed or disagreed with each statement. Eleven of the items were positively worded and in the analysis the
109
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
scores were reversed so that a higher score indicated a higher level of perceived stress. For each dimension, the score was calculated as the mean of the responses. The total stress score was calculated from the mean of all responses.
of incompetence was adjusted for covariates that previously had been found to be associated to incompetence (maternal age and incubator care).
Statistical analysis Results Data were analyzed using the statistical package SPSS 20.0 for Windows and a two-sided 5% level of significance was used. The independent variables investigated were NICU co-care facilities and skin-to-skin contact with the dependent variables being maternal stress in each of the five dimensions (incompetence, role restriction, social isolation, spouse relationship problems, health problems) and the total stress score. Covariates assessed were maternal age (<28 years or P28 years), level of education (upper secondary school or less or university/college), parity (primi or multi), smoking (yes or no), gestational weeks at birth (<32 or P32 gestational weeks), method of delivery (section or vaginal delivery), breathing support (continuous positive airway pressure/ventilator or no breathing support), incubator care (yes or no) and length of hospital stay (days). The differences in maternal stress between mothers who had or had not experienced co-care facilities were investigated through independent Student T-tests with Bonferroni correction. The association between skin-to-skin contact and the dependent variables were analyzed with bivariate linear regression analyses. Furthermore, the association between covariates and maternal stress were assessed through Student T-tests with Bonferroni correction. The association between co-care facilities and maternal stress was also investigated in multivariate linear regression analyses, in which the association between co-care facilities and maternal stress in the dimension
Characteristics of mothers and infants Overall, 114 of the dyads experienced co-care facilities and 186 dyads experienced no co-care facilities. Data on mothers’ and infants’ characteristics are presented in Table 1. There were no significant differences between the mother or infant characteristics for those who had or had not experienced co-care facilities or non co-care except in the use of incubator and need of breathing support. In the co-care NICUs 32% of the infants had used an incubator whereas 89% had used an incubator in the non co-care NICUs (p < 0.001). Infants in co-care NICUs had less breathing support (39%) compared to infants in non co-care NICUs (59%) (p = 0.001). In regard to the infant’s length of hospital stay (mean ± SD), there was no significant difference between the co-care (28 days ± 21) and the non co-care (26 days ± 18) NICUs (p = 0.08). There were no differences between the variables presented in Table 1 or the infant’s length of stay with the duration of skinto-skin contact per day during all days admitted to NICU (not presented in table). Regardless of whether co-care or non co-care facilities were provided, very preterm infants (<32 gestational weeks) had similar amounts of skin-to-skin contact as moderately preterm infants (P32 gestational weeks); 130 min on average ± 78 vs. 126 min ± 102 (p = 0.70).
Table 1 Mother and infant characteristics (n = 300). Variables
Co-care (n = 114) n (%)
Not Co-care (n = 186) n (%)
p-Value
Maternal education Upper secondary school or less University/College
56 (57) 43 (43)
82 (47) 93 (53)
0.133
Parity Primiparous Multiparous
73 (64) 41 (36)
123 (66) 63 (34)
0.710
Smoking Yes No
10 (10) 90 (90)
16 (9) 161 (91)
0.832
Mother’s age <28 years P28 years
49 (43) 64 (57)
61 (33) 125 (67)
Mode of delivery Sectio Vaginal
58 (51) 55 (49)
105 (57) 78 (43)
0.337
Gestational age at birth <32 weeks P32 weeks
35 (31) 79 (69)
68 (37) 118 (63)
0.319
Ventilation/CPAP Yes No
45 (39) 69 (61)
110 (59) 76 (41)
0.001
Incubator care Yes No Average minutes of skin-to-skin contact/day
36 (32) 78 (68) 115 ± 95
166 (89) 20 (11) 135 ± 93
<0.001
0.083
0.080
110
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
Table 2 Independent variables and covariates associated to maternal stress. Independent variables
Incompetence
Role restriction
Social isolation
Spouse relationship problem
Health problem
Total score
Mean
SD
p
Mean
SD
p
Mean
SD
p
Mean
SD
p
Mean
SD
p
mean
SD
p
1.83 2.02
0.49 0.62
<0.01*
3.44 3.50
0.81 0.78
0.53
2.01 2.04
0.66 0.62
0.65
1.94 2.00
0.76 0.8
0.53
2.37 2.41
0.64 0.7
0.65
2.28 2.38
0.47 0.50
0.12
0.64
R2 0.000
0.76
R2 0.000
0.98
R2 0.002
0.07
R2 0.004
0.29
R2 0.000
0.48
3.43 3.56 3.40
0.77 0.81 0.81
0.22
2.07 1.9 2.40
0.58 0.70 0.73
0.14
1.89 2.13 2.36
0.68 0.91 1.09
<0.05*
2.28 2.59 2.31
0.61 0.74 0.64
<0.01*
3.49 3.25 3.60 3.53 3.37
0.79 0.81 0.74 0.78 0.80
1.99 2.03 2.03 2.07 1.95
0.61 0.63 0.64 0.63 0.65
1.94 1.94 2.00 2.01 1.93
0.73 0.84 0.75 0.81 0.72
2.40 2.20 2.49 2.47 2.24
0.68 0.63 0.66 0.66 0.68
2.31 2.40 2.41 0.57 2.34 2.23 2.40 2.40 2.24
Co-care facilities No co-care facilities Skin-to-skin contact/daya
R2 0.001
Covariates Primiparous Multiparous Smoking
1.93 1.98 1.90
0.56 0.62 0.51
No smoking Age <28 years Age >27 years Incubator care No incubator care
1.95 1.84 2.00 2.00 1.84
0.59 0.55 0.59 0.61 0.52
0.75
0.03* <0.05*
0.59
<0.01* 0.11
<0.01
0.96 0.14
*
<0.05
0.53 0.43
*
0.53
<0.01* <0.01*
0.80
0.45 0.54
0.12 0.50
0.48 0.50 0.47 0.50 0.50
<0.01* <0.05*
a *
Duration of skin-to-skin contact (minutes)/day during all days admitted to NICU analyzed with bivariate linear regression analyses, presented with R2. Significance p < 0.05.
Associations between co-care, skin-to-skin contact, covariates and maternal stress The analysis to determine the association between co-care facilities and parenting stress at two months of corrected age revealed that mothers who had not experienced co-care facilities reported significantly higher stress levels in the dimension of incompetence (p < 0.01). No significant differences were found regarding co-care and the other stress dimensions (Table 2). Further tests were also performed to assess differences in maternal stress between the two co-care NICUs and between the two non co-care NICUs. The results revealed that there were no differences between the two co-care NICUs, or between the two non-co-care NICUs in reported levels of maternal stress. No significant associations were found between the duration of skin-to-skin contact per day during all days admitted to NICU and maternal stress (Table 2). The covariates which had a significant association with maternal stress on any of the investigated dimensions or the total stress score were parity, smoking, maternal age and incubator care (Table 2). Maternal education, infant’s gender, gestational age at birth, method of delivery, breathing support, and length of hospital stay were not associated to any dimension of, or total, maternal stress at two months of corrected age (not shown in Table 2). Association between co-care and dimension of incompetence In a multivariate linear regression analysis, with a stepwise backward approach, we analyzed the association between co-care and perceived incompetence, adjusting for maternal age and incubator care. The final model, adjusted for maternal age and incubator care, revealed an explained variance of 4% for perceived incompetence (R2 0.04, adjusted R2 0.03, F (3, 266) = 5.58, p = 0.04). Discussion From this study it would appear that mothers whose infants are admitted to co-care and non co-care facilities are able to experience comparable levels of skin-to-skin contact with their infants. Furthermore, the amount of skin to skin experienced did not significantly affect the mothers’ reported stress levels in the post-natal period. However, this study did reveal that mothers who did not experience co-care facilities had a significantly higher mean level of perceived stress in the dimension of incompetence compared
to the mothers who had experienced co-care facilities. This association was also significant when adjustments were made for influential covariates (maternal age and incubator care). Whilst the underlying reasons for the association between non co-care and mothers levels of perceived stress in the dimension of incompetence can only be speculated, research has identified that ‘closeness’ (i.e. both physical and emotional closeness) through skin-to-skin contact, increased visiting hours, single family room design, is important for the formation of a secure parent-infant relationship [2]. By enabling mothers to stay in the NICU day and night, and to become more actively involved in the infant’s care, they may more easily understand and interpret their infant’s behavioral cues, and therefore feel more competent as mothers [26]. Conversely, the isolation experienced between mothers and infants through admission onto a non co-care unit, or infants being situated in an incubator, can place strain on mothers, leading to them feeling less confident, more alienated from their infants and subsequently incompetent in the parental role [27]. Emerging evidence suggests that when physical and emotional closeness between the mother-infant is supported, the prevalence of maternal depression decreases to levels reported in mothers of term infants [28]. The lack of association between skin-to-skin contact and maternal stress is somewhat surprising. Previous research by Feldman and colleagues [14] identified that mothers who experience skinto-skin contact with their infants (for at least one hour daily for 14 consecutive days) provide a better home environment at three months of corrected age, compared to mothers who experience traditional care. We believe that the lack of association is more likely to be an effect of other, more important, factors that influence stress in the first months at home. Further research to identify such issues is warranted. The average amount of hours of skin-to-skin contact per day in NICUs with co-care facilities was slightly less than two hours, and in NICUs with no co-care facilities slightly more than two hours (p = 0.08). Although more infants in the non co-care NICUs had breathing support and incubator care, the non co-cared infants had on average 20 min more skin-to-skin contact compared with those in co-care units. This finding suggests that co-care facilities per se do not necessarily increase skin-to-skin contact. We therefore consider, in concordance with others, that in addition to a facilitative design, where mothers can room-in and stay close to their infants, supportive nursing staff practices are vital for the implementation and usage of skin-to-skin contact [29].
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
Our study focused on maternal stress when their infants were two months corrected age. Previous studies have assessed maternal stress in later ages, for example 18 months of age [25,30]. In these studies it was revealed that mothers perceived their highest mean levels of stress in the dimension of role restriction, regardless of the population and the timing [25,30]. In comparison to the study by Jackson et al. [25], the mothers in our study rated their levels of stress lower in all but one dimension (i.e. role restriction). Similarly, in comparison to Widarsson et al. findings [30], the mothers in our study rated their level of stress as lower in all dimensions apart from social isolation. However, due to substantial differences in the timing of maternal reports, no valid conclusions can be drawn from these comparisons. There are a number of limitations associated with this study. First, a large number of mothers did not want to participate. Due to ethical reasons (e.g. a lack of consent) we could not investigate whether these mothers were demographically different to the participating mothers, thereby restricting the generalizability of the findings. It may be that the mothers who refused to participate experienced higher levels of stress, increasing the risk for a statistical type II error within the reported findings. Secondly, maternal presence in NICUs, whether it was in co-care NICUs or not, was not recorded. Therefore, we do not know whether the actual amount of maternal presence differed between co-care and non co-care NICUs. However, we believe, in concordance with findings from other studies, that the possibility to room-in at the NICU for the entire hospital stay, or being offered choices of support, which signal that mothers are valued and recognized as primary caregivers [6,31], can enhance mothes’ feelings of competence. Thirdly, in future studies, unit context should be assessed, using an instrument such as the Alberta Context Tool [32] that measures aspects of leadership, culture, interactions and resources, in order to enforce the validity of the conclusions. Finally, both parents registered data on skin-to-skin contact and no differentiation was made between the parents. The reported findings on the lack of association between skin-to-skin contact and maternal stress should therefore be interpreted with caution.
Conclusions The results from this study indicate that mothers whose infants are admitted to co-care or non co-care NICUs are able to experience comparable levels of skin-to-skin contact with their infants. Furthermore, the amount of skin-to-skin contact did not significantly affect the mothers’ reported stress levels in the post-natal period. However, the associations between non co-care facilities and feelings of maternal incompetence requires consideration. This finding emphasizes the importance of creating changes within the NICU environment to prevent mother-infant separation and to provide co-care facilities. Efforts should be made to promote and protect the parents’ and infants’ inherent needs through changes to the NICU architecture to ensure that parents can stay close to their infants day and night during the hospital stay.
Conflict of interest No author has had a conflict of interest.
Contributors’ list Renée Flacking had primary responsibility for data analysis and writing the manuscript. Gillian Thomson participated in data analyses and writing of the manuscript.
111
Linda Ekenberg participated in data analyses and writing of the manuscript. Linda Löwegren participated in data analyses and writing of the manuscript. Lars Wallin had primary responsibility for design and data collection, participated in the data analyses and contributed to the writing of the manuscript. All authors have seen and approved the final and submitted version of the manuscript.
Acknowledgements This research was funded by Dalarna University, the Vardal Foundation and the Faculty of Medicine of Uppsala University, Sweden. The research was independent of the funders.
References [1] Bruschweiler Stern N. Early emotional care for mothers and infants. Pediatrics 1998;102(5 Suppl E):1278–81. [2] Flacking R, Lehtonen L, Thomson G, Axelin A, Ahlqvist S, Moran VH, et al. Closeness and separation in neonatal intensive care. Acta Paediatr 2012;101(10):1032–7. [3] Miles MS, Holditch-Davis D, Schwartz T, Scher M. Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr 2007;28(1):36–44. [4] Jotzo M, Poets CF. Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention. Pediatrics 2005;115(4):915–9. [5] Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics 2006;47(3):206–12. [6] Bergström E-B, Wallin L, Thomson G, Flacking R. Postpartum depression in mothers of infants cared for in a Neonatal Intensive Care Unit – incidence and associated factors. J Neonatal Nurs 2012;18:143–51. [7] Brandon DH, Tully KP, Silva SG, Malcolm WF, Murtha AP, Turner BS, et al. Emotional responses of mothers of late-preterm and term infants. J Obstet Gynecol Neonatal Nurs 2011;40(6):719–31. [8] Eriksson BS, Pehrsson G. Emotional reactions of parents after the birth of an infant with extremely low birth weight. J Child Health Care 2005;9(2):122–36. [9] Franck LS, Cox S, Allen A, Winter I. Measuring neonatal intensive care unitrelated parental stress. J Adv Nurs 2005;49(6):608–15. [10] Wigert H, Johansson R, Berg M, Hellstrom AL. Mothers’ experiences of having their newborn child in a neonatal intensive care unit. Scand J Caring Sci 2006;20(1):35–41. [11] Fenwick J, Barclay L, Schmied V. Struggling to mother: a consequence of inhibitive nursing interactions in the neonatal nursery. J Perinat Neonatal Nurs 2001;15(2):49–64. [12] Wigert H, Berg M, Hellstrom AL. Parental presence when their child is in neonatal intensive care. Scand J Caring Sci 2010;24(1):139–46. [13] Blomqvist YT, Nyqvist KH. Swedish mothers’ experience of continuous Kangaroo Mother Care. J Clin Nurs 2011;20(9–10):1472–80. [14] Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics 2002;110(1):16–26. [15] Conde-Agudelo A, Belizan JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2011;(3):CD002771. [16] de Macedo EC, Cruvinel F, Lukasova K, D’Antino ME. The mood variation in mothers of preterm infants in Kangaroo mother care and conventional incubator care. J Trop Pediatr 2007;53(5):344–6. [17] Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Davanzo R, et al. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr 2010;99(6):820–6. [18] Flacking R, Ewald U, Starrin B. I wanted to do a good job: experiences of becoming a mother and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med 2007;64(12):2405–16. [19] Eriksson BS, Pehrsson G. Evaluation of psycho-social support to parents with an infant born preterm. J Child Health Care 2002;6(1):19–33. [20] Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics 2006;118(1):e107–114. [21] Ostberg M, Hagekull B, Wettergren S. A measure of parental stress in mothers with small children: dimensionality, stability and validity. Scand J Psychol 1997;38(3):199–208. [22] Abidin RR. Parenting stress index: professional manual. 3rd ed. Odessa, FL: Psychological Assessment Resources, Inc.; 1995. [23] Ostberg M, Hagekull B. A structural modeling approach to the understanding of parenting stress. J Clin Child Psychol 2000;29(4):615–25.
112
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
[24] Tommiska V, Ostberg M, Fellman V. Parental stress in families of 2 year old extremely low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2002;86(3):F161–164. [25] Jackson K, Ternestedt BM, Magnuson A, Schollin J. Parental stress and toddler behaviour at age 18 months after pre-term birth. Acta Paediatr 2007;96(2):227–32. [26] Nordhov SM, Kaaresen PI, Ronning JA, Ulvund SE, Dahl LB. A randomized study of the impact of a sensitizing intervention on the child-rearing attitudes of parents of low birth weight preterm infants. Scand J Psychol 2010;51(5):385–91. [27] Jackson K, Ternestedt BM, Schollin J. From alienation to familiarity: experiences of mothers and fathers of preterm infants. J Adv Nurs 2003;43(2):120–9. [28] Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants’ length of stay and improving parents’ mental
[29]
[30]
[31]
[32]
health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics 2006;118(5):e1414–1427. Niela-Vilen H, Axelin A, Salantera S, Lehtonen L, Tammela O, Salmelin R, Latva R. Early physical contact between a mother and her NICU-infant in two university hospitals in Finland. Midwifery; 2013. Widarsson M, Engstrom G, Rosenblad A, Kerstis B, Edlund B, Lundberg P. Parental stress in early parenthood among mothers and fathers in Sweden. Scand J Caring Sci 2012. http://dx.doi.org/10.1111/j.1471-6712.2012.01088.x. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to becoming a mother and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med 2006;62(1):70–80. Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta context tool. BMC Health Serv Res 2009;9:234.
Contents lists available at SciVerse ScienceDirect
Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants R. Flacking a,b,c,⇑, G. Thomson a, L. Ekenberg a, L. Löwegren a, L. Wallin c,d a
Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden c School of Health and Social Studies, Dalarna University, Falun, Sweden d Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden b
a r t i c l e
i n f o
Article history: Received 18 March 2013 Revised 23 April 2013 Accepted 18 June 2013
Keywords: Skin to skin Co-care Mother Neonatal intensive care unit Parental stress Preterm infant
a b s t r a c t Objective: To investigate the influence of co-care facilities and amount of skin-to-skin contact during Neonatal Intensive Care Unit (NICU) stay on maternal stress in mothers of preterm infants at two months corrected age. Methods: A prospective cohort study that involved 300 mothers of pre-term infants was conducted in four NICUs (two with co-care facilities and two with non co-care) in Sweden. Data on duration of skinto-skin contact per day for all days admitted to the NICU were collected using self-reports. Maternal stress was measured by the Swedish Parental Stress Questionnaire (SPSQ) at two months of infant’s corrected age. Results: Mothers whose infants were cared for in a NICU with co-care facilities reported significantly lower levels of stress in the dimension of ‘incompetence’ compared to mothers whose infants had been cared for in non co-care NICUs. The amount of skin-to-skin experienced during the neonatal stay was not significantly associated with levels of maternal stress at two months corrected age. Conclusion: The finding that mothers who do not experience co-care facilities experience greater levels of stress in relation to feelings of incompetence is of concern. Improvements to NICU environments are needed to ensure that mother-infant dyads are not separated. Ó 2013 Elsevier B.V. All rights reserved.
Introduction When an infant is born preterm (<37 gestational weeks) the woman is often not prepared for motherhood [1]. Often attention is focused on the infant’s survival and his/her physical needs, and there is less concern about the contact between the mother and her infant. Early physically and emotionally closeness between mother-infant dyads is believed to be crucial for bonding and the formation of positive attachment relationships [2]. Mothers of infants admitted to the Neonatal Intensive Care Unit (NICU) have been identified to exhibit higher than average levels of emotional distress. Research has identified that between 30–76% of mothers of pre-term infants experience depressive symptoms; or symptoms of psychological trauma during their time in the NICU [3–5]. A study undertaken by Bergstrom, Wallin, Thomson and Flacking [6] also demonstrated that approximately 15% of mothers of preterm infants in Sweden were depressed, and that the culture of the unit was highly influential in determining a mothers’ emo⇑ Corresponding author at: School of Health and Social Studies, Dalarna University, 79188 Falun, Sweden. Tel.: +46 23778541. E-mail address: rfl@du.se (R. Flacking). 1877-5756/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.srhc.2013.06.002
tional response. The higher prevalence of depressive symptoms in mothers of preterm infants compared to those of full term infants may be explained by a stressful birth, concern for their infant’s well-being and the NICU experiences [7]. In addition, the mother’s concerns for the infant’s present and future medical status are considered to impact upon the development of a healthy and positive relationship [8]. However, it is important to note that most of the studies that have explored depression and anxiety in mothers of preterm infants have been conducted in NICUs where mothers and infants have been separated from each other. Early physical separation from the infant within 24 h of birth is related to increased parental stress [9]. Furthermore, prolonged separation between mothers and infants is also reported to cause feelings of not ‘‘belonging’’, maternal incompetence, stress, anxiety and powerlessness [3,10]. Mother’s feelings of maternal incompetence may also be reinforced by health professionals who take over the care of the infant and minimize the maternal role [11]. In the NICU where there is a more accentuated power differentials between mothers and professionals, compared to an ordinary maternity unit, the need for supportive care is increased [1]. Key ways in which the parent-infant relationship may be supported is through co-care and skin-to-skin contact. The provision of co-care, in which
108
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
mothers (and possibly fathers) can room-in (stay alone or together with infant) at the NICU 24 h per day enables parents to stay close and be present with their infants to a higher extent than those who have to stay at home or within a maternity unit [12]. Increased maternal presence can enhance and facilitate episodes of mother-infant skin-to-skin contact [13], which is regarded as a successful way to empower mothers to become familiar with their infants and strengthen their mothering abilities at their own pace [14,15]. Furthermore, research has demonstrated that mothers who practice skin-to-skin contact are less anxious, feel more competent and are more secure in their maternal role [14,16,17]. After the infant’s discharge from the NICU, the mother’s feelings are suggested to oscillate between emotional exhaustion and relief [8,18]. In a qualitative study, Flacking et al. [18] reported that unresolved grief, the NICU’s institutional authority and experiences of shame (e.g. due to feelings of not being a good-enough mother) led to a home situation where the mother felt emotionally exhausted and experienced barriers in the development of a secure mother-infant relationship. Research indicates that mothers’ psychological distress does not decrease with time and this depressive state is associated with social isolation, post-traumatic symptoms and feelings of guilt persisting several years after the birth [19]. Mothers of preterm infants are also reported to be more controlling, actively engaged and/or intrusive with their infants compensating for their guilt or shame for not being the mother they wanted to be during hospitalization or for their preterm infants’ inactive behavior [18,20]. The association between skin-to-skin contact, materal competence and depression has been well investigated. However, not all anxious or stressed mothers are depressed and less research has been paid to the association between the amount of skin-toskin contact and feelings of maternal stress. Furthermore, to our knowledge, the association between co-care facilities and maternal stress after discharge has previously not been investigated. Therefore the aim of this study was to investigate whether co-care facilities at NICU’s and the amount of skin-to-skin experienced with their infants on the NICU’s were associated with maternal stress at two months corrected age.
Methods Design and sample The data reported in this paper was collected as part of a quasiexperimental study to evaluate the effects of facilitation support in the implementation of Kangaroo Mother Care (KMC) guidelines (intervention study is described elsewhere – blind for review). In this study we report on, and describe factors associated with early parental stress. The study was conducted at four NICUs located at four county hospitals in Sweden in 2001–2003. All units experienced full patient occupancy (NICU A 104%, NICU B 93%, NICU C 122% and NICU D 113%) during the study period. Two of the units (NICU A and NICU C) provided co-care facilities for all mothers and infants; which meant that mothers could room in for 24 h/day during the infants’ hospital stay at the NICU. This meant that mothers were offered a room at the NICU, sometimes apart from the infant and sometimes in the same room as the infant, depending on the infant’s medical state. At NICU C the mother’s post-partum care was also provided at the NICU. In the two non co-care NICUs, mothers could usually room-in when the infant was critically ill or in the end of the hospital stay, depending on the availability of rooms. All infants born <37 gestational weeks, cared for within the hospital for at least 72 h and who were residents in the catchment area
of the NICU’s were eligible in the first step of population sampling (n = 811). Participants were excluded if the mother was not Swedish-speaking (n = 47) or had severe medical or psychological problems that prevented inclusion (n = 30). Further exclusions occurred if the infant was referred to another hospital unit (n = 75), had a severe congenital malformation or died during hospital stay (n = 26). From the remaining 663 eligible infants, 51 mothers of these infants were overlooked during the recruitment procedures and a further 189 mothers refused to participate. For the purpose of this study, 123 twins were excluded. The final sample consisted of 300 mothers of singleton preterm infants. Ethics The study was approved by the Research Ethics Committee of the Medical Faculty at Uppsala University. All participants were provided with an information sheet and the purpose of the study was verbally explained. All participants were also asked to sign a consent form prior to participation. Ethical guidelines of confidentiality, withdrawal and anonymity were adhered to throughout the study. Procedure and measures Data on infant (gender, gestational weeks at birth, method of delivery, breathing support, incubator care and length of hospital stay) and maternal (parity and maternal age) characteristics were obtained from the infant’s patient record by a contact nurse working at each of the NICUs. Data on the mother’s educational level and smoking status were obtained from a survey questionnaire mailed to the mothers at two months of infant’s corrected age. Data on skin-to-skin contact were gathered through parental self-reports. The self-report comprised a calendar which covered a 2-week period. On the calendar, the parents (primarily the mothers) were requested to mark the initiation and ending of each skinto-skin episode, rounded to the nearest 5 or 10-min interval, on a daily basis. At the end of the 2-week period, the contact nurse revisited the mother, collected the calendar and provided a new calendar for the following 2-week period. This procedure continued for the whole period of hospital stay. Information on how skinto-skin contact was defined (infant placed skin-to-skin on mother or father, having only a diaper and a cap/socks on when necessary and covered with a blanket) and on how to complete the calendar was also provided to the parents in verbal and written format. This information was provided as soon as the infant was stable enough to initiate skin-to-skin contact, which usually occurred within the first few days after delivery. It was also emphasized to the parents that participation in the study should not be understood as a recommendation or as guidance to carry out skin-to-skin contact; rather, it was a recording of ‘usual care’. To measure maternal stress, the Swedish Parental Stress Questionnaire (SPSQ) was used. Mothers received the questionnaire by post at two months of infant’s corrected age and were asked to return the completed questionnaire in a pre-paid envelope. Two hundred and seventy-six of the 300 eligible mothers completed the SPSQ questionnaire. The Swedish Parenthood Stress Questionnaire (SPSQ) [21] is an adapted and modified version of the Parenting Stress Index [22]. SPSQ comprises five dimensions: Incompetence, Role Restriction, Social Isolation, Spouse Relationship Problems and Health Problems [21]. The SPSQ is considered to be a valid and reliable instrument for measuring parental stress in Sweden [21,23] and has been used with mothers of preterm infants [24,25]. The instrument consists of 34 items, scored on 5point Likert-type scales, in which mothers were asked to rate the extent to which they agreed or disagreed with each statement. Eleven of the items were positively worded and in the analysis the
109
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
scores were reversed so that a higher score indicated a higher level of perceived stress. For each dimension, the score was calculated as the mean of the responses. The total stress score was calculated from the mean of all responses.
of incompetence was adjusted for covariates that previously had been found to be associated to incompetence (maternal age and incubator care).
Statistical analysis Results Data were analyzed using the statistical package SPSS 20.0 for Windows and a two-sided 5% level of significance was used. The independent variables investigated were NICU co-care facilities and skin-to-skin contact with the dependent variables being maternal stress in each of the five dimensions (incompetence, role restriction, social isolation, spouse relationship problems, health problems) and the total stress score. Covariates assessed were maternal age (<28 years or P28 years), level of education (upper secondary school or less or university/college), parity (primi or multi), smoking (yes or no), gestational weeks at birth (<32 or P32 gestational weeks), method of delivery (section or vaginal delivery), breathing support (continuous positive airway pressure/ventilator or no breathing support), incubator care (yes or no) and length of hospital stay (days). The differences in maternal stress between mothers who had or had not experienced co-care facilities were investigated through independent Student T-tests with Bonferroni correction. The association between skin-to-skin contact and the dependent variables were analyzed with bivariate linear regression analyses. Furthermore, the association between covariates and maternal stress were assessed through Student T-tests with Bonferroni correction. The association between co-care facilities and maternal stress was also investigated in multivariate linear regression analyses, in which the association between co-care facilities and maternal stress in the dimension
Characteristics of mothers and infants Overall, 114 of the dyads experienced co-care facilities and 186 dyads experienced no co-care facilities. Data on mothers’ and infants’ characteristics are presented in Table 1. There were no significant differences between the mother or infant characteristics for those who had or had not experienced co-care facilities or non co-care except in the use of incubator and need of breathing support. In the co-care NICUs 32% of the infants had used an incubator whereas 89% had used an incubator in the non co-care NICUs (p < 0.001). Infants in co-care NICUs had less breathing support (39%) compared to infants in non co-care NICUs (59%) (p = 0.001). In regard to the infant’s length of hospital stay (mean ± SD), there was no significant difference between the co-care (28 days ± 21) and the non co-care (26 days ± 18) NICUs (p = 0.08). There were no differences between the variables presented in Table 1 or the infant’s length of stay with the duration of skinto-skin contact per day during all days admitted to NICU (not presented in table). Regardless of whether co-care or non co-care facilities were provided, very preterm infants (<32 gestational weeks) had similar amounts of skin-to-skin contact as moderately preterm infants (P32 gestational weeks); 130 min on average ± 78 vs. 126 min ± 102 (p = 0.70).
Table 1 Mother and infant characteristics (n = 300). Variables
Co-care (n = 114) n (%)
Not Co-care (n = 186) n (%)
p-Value
Maternal education Upper secondary school or less University/College
56 (57) 43 (43)
82 (47) 93 (53)
0.133
Parity Primiparous Multiparous
73 (64) 41 (36)
123 (66) 63 (34)
0.710
Smoking Yes No
10 (10) 90 (90)
16 (9) 161 (91)
0.832
Mother’s age <28 years P28 years
49 (43) 64 (57)
61 (33) 125 (67)
Mode of delivery Sectio Vaginal
58 (51) 55 (49)
105 (57) 78 (43)
0.337
Gestational age at birth <32 weeks P32 weeks
35 (31) 79 (69)
68 (37) 118 (63)
0.319
Ventilation/CPAP Yes No
45 (39) 69 (61)
110 (59) 76 (41)
0.001
Incubator care Yes No Average minutes of skin-to-skin contact/day
36 (32) 78 (68) 115 ± 95
166 (89) 20 (11) 135 ± 93
<0.001
0.083
0.080
110
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
Table 2 Independent variables and covariates associated to maternal stress. Independent variables
Incompetence
Role restriction
Social isolation
Spouse relationship problem
Health problem
Total score
Mean
SD
p
Mean
SD
p
Mean
SD
p
Mean
SD
p
Mean
SD
p
mean
SD
p
1.83 2.02
0.49 0.62
<0.01*
3.44 3.50
0.81 0.78
0.53
2.01 2.04
0.66 0.62
0.65
1.94 2.00
0.76 0.8
0.53
2.37 2.41
0.64 0.7
0.65
2.28 2.38
0.47 0.50
0.12
0.64
R2 0.000
0.76
R2 0.000
0.98
R2 0.002
0.07
R2 0.004
0.29
R2 0.000
0.48
3.43 3.56 3.40
0.77 0.81 0.81
0.22
2.07 1.9 2.40
0.58 0.70 0.73
0.14
1.89 2.13 2.36
0.68 0.91 1.09
<0.05*
2.28 2.59 2.31
0.61 0.74 0.64
<0.01*
3.49 3.25 3.60 3.53 3.37
0.79 0.81 0.74 0.78 0.80
1.99 2.03 2.03 2.07 1.95
0.61 0.63 0.64 0.63 0.65
1.94 1.94 2.00 2.01 1.93
0.73 0.84 0.75 0.81 0.72
2.40 2.20 2.49 2.47 2.24
0.68 0.63 0.66 0.66 0.68
2.31 2.40 2.41 0.57 2.34 2.23 2.40 2.40 2.24
Co-care facilities No co-care facilities Skin-to-skin contact/daya
R2 0.001
Covariates Primiparous Multiparous Smoking
1.93 1.98 1.90
0.56 0.62 0.51
No smoking Age <28 years Age >27 years Incubator care No incubator care
1.95 1.84 2.00 2.00 1.84
0.59 0.55 0.59 0.61 0.52
0.75
0.03* <0.05*
0.59
<0.01* 0.11
<0.01
0.96 0.14
*
<0.05
0.53 0.43
*
0.53
<0.01* <0.01*
0.80
0.45 0.54
0.12 0.50
0.48 0.50 0.47 0.50 0.50
<0.01* <0.05*
a *
Duration of skin-to-skin contact (minutes)/day during all days admitted to NICU analyzed with bivariate linear regression analyses, presented with R2. Significance p < 0.05.
Associations between co-care, skin-to-skin contact, covariates and maternal stress The analysis to determine the association between co-care facilities and parenting stress at two months of corrected age revealed that mothers who had not experienced co-care facilities reported significantly higher stress levels in the dimension of incompetence (p < 0.01). No significant differences were found regarding co-care and the other stress dimensions (Table 2). Further tests were also performed to assess differences in maternal stress between the two co-care NICUs and between the two non co-care NICUs. The results revealed that there were no differences between the two co-care NICUs, or between the two non-co-care NICUs in reported levels of maternal stress. No significant associations were found between the duration of skin-to-skin contact per day during all days admitted to NICU and maternal stress (Table 2). The covariates which had a significant association with maternal stress on any of the investigated dimensions or the total stress score were parity, smoking, maternal age and incubator care (Table 2). Maternal education, infant’s gender, gestational age at birth, method of delivery, breathing support, and length of hospital stay were not associated to any dimension of, or total, maternal stress at two months of corrected age (not shown in Table 2). Association between co-care and dimension of incompetence In a multivariate linear regression analysis, with a stepwise backward approach, we analyzed the association between co-care and perceived incompetence, adjusting for maternal age and incubator care. The final model, adjusted for maternal age and incubator care, revealed an explained variance of 4% for perceived incompetence (R2 0.04, adjusted R2 0.03, F (3, 266) = 5.58, p = 0.04). Discussion From this study it would appear that mothers whose infants are admitted to co-care and non co-care facilities are able to experience comparable levels of skin-to-skin contact with their infants. Furthermore, the amount of skin to skin experienced did not significantly affect the mothers’ reported stress levels in the post-natal period. However, this study did reveal that mothers who did not experience co-care facilities had a significantly higher mean level of perceived stress in the dimension of incompetence compared
to the mothers who had experienced co-care facilities. This association was also significant when adjustments were made for influential covariates (maternal age and incubator care). Whilst the underlying reasons for the association between non co-care and mothers levels of perceived stress in the dimension of incompetence can only be speculated, research has identified that ‘closeness’ (i.e. both physical and emotional closeness) through skin-to-skin contact, increased visiting hours, single family room design, is important for the formation of a secure parent-infant relationship [2]. By enabling mothers to stay in the NICU day and night, and to become more actively involved in the infant’s care, they may more easily understand and interpret their infant’s behavioral cues, and therefore feel more competent as mothers [26]. Conversely, the isolation experienced between mothers and infants through admission onto a non co-care unit, or infants being situated in an incubator, can place strain on mothers, leading to them feeling less confident, more alienated from their infants and subsequently incompetent in the parental role [27]. Emerging evidence suggests that when physical and emotional closeness between the mother-infant is supported, the prevalence of maternal depression decreases to levels reported in mothers of term infants [28]. The lack of association between skin-to-skin contact and maternal stress is somewhat surprising. Previous research by Feldman and colleagues [14] identified that mothers who experience skinto-skin contact with their infants (for at least one hour daily for 14 consecutive days) provide a better home environment at three months of corrected age, compared to mothers who experience traditional care. We believe that the lack of association is more likely to be an effect of other, more important, factors that influence stress in the first months at home. Further research to identify such issues is warranted. The average amount of hours of skin-to-skin contact per day in NICUs with co-care facilities was slightly less than two hours, and in NICUs with no co-care facilities slightly more than two hours (p = 0.08). Although more infants in the non co-care NICUs had breathing support and incubator care, the non co-cared infants had on average 20 min more skin-to-skin contact compared with those in co-care units. This finding suggests that co-care facilities per se do not necessarily increase skin-to-skin contact. We therefore consider, in concordance with others, that in addition to a facilitative design, where mothers can room-in and stay close to their infants, supportive nursing staff practices are vital for the implementation and usage of skin-to-skin contact [29].
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
Our study focused on maternal stress when their infants were two months corrected age. Previous studies have assessed maternal stress in later ages, for example 18 months of age [25,30]. In these studies it was revealed that mothers perceived their highest mean levels of stress in the dimension of role restriction, regardless of the population and the timing [25,30]. In comparison to the study by Jackson et al. [25], the mothers in our study rated their levels of stress lower in all but one dimension (i.e. role restriction). Similarly, in comparison to Widarsson et al. findings [30], the mothers in our study rated their level of stress as lower in all dimensions apart from social isolation. However, due to substantial differences in the timing of maternal reports, no valid conclusions can be drawn from these comparisons. There are a number of limitations associated with this study. First, a large number of mothers did not want to participate. Due to ethical reasons (e.g. a lack of consent) we could not investigate whether these mothers were demographically different to the participating mothers, thereby restricting the generalizability of the findings. It may be that the mothers who refused to participate experienced higher levels of stress, increasing the risk for a statistical type II error within the reported findings. Secondly, maternal presence in NICUs, whether it was in co-care NICUs or not, was not recorded. Therefore, we do not know whether the actual amount of maternal presence differed between co-care and non co-care NICUs. However, we believe, in concordance with findings from other studies, that the possibility to room-in at the NICU for the entire hospital stay, or being offered choices of support, which signal that mothers are valued and recognized as primary caregivers [6,31], can enhance mothes’ feelings of competence. Thirdly, in future studies, unit context should be assessed, using an instrument such as the Alberta Context Tool [32] that measures aspects of leadership, culture, interactions and resources, in order to enforce the validity of the conclusions. Finally, both parents registered data on skin-to-skin contact and no differentiation was made between the parents. The reported findings on the lack of association between skin-to-skin contact and maternal stress should therefore be interpreted with caution.
Conclusions The results from this study indicate that mothers whose infants are admitted to co-care or non co-care NICUs are able to experience comparable levels of skin-to-skin contact with their infants. Furthermore, the amount of skin-to-skin contact did not significantly affect the mothers’ reported stress levels in the post-natal period. However, the associations between non co-care facilities and feelings of maternal incompetence requires consideration. This finding emphasizes the importance of creating changes within the NICU environment to prevent mother-infant separation and to provide co-care facilities. Efforts should be made to promote and protect the parents’ and infants’ inherent needs through changes to the NICU architecture to ensure that parents can stay close to their infants day and night during the hospital stay.
Conflict of interest No author has had a conflict of interest.
Contributors’ list Renée Flacking had primary responsibility for data analysis and writing the manuscript. Gillian Thomson participated in data analyses and writing of the manuscript.
111
Linda Ekenberg participated in data analyses and writing of the manuscript. Linda Löwegren participated in data analyses and writing of the manuscript. Lars Wallin had primary responsibility for design and data collection, participated in the data analyses and contributed to the writing of the manuscript. All authors have seen and approved the final and submitted version of the manuscript.
Acknowledgements This research was funded by Dalarna University, the Vardal Foundation and the Faculty of Medicine of Uppsala University, Sweden. The research was independent of the funders.
References [1] Bruschweiler Stern N. Early emotional care for mothers and infants. Pediatrics 1998;102(5 Suppl E):1278–81. [2] Flacking R, Lehtonen L, Thomson G, Axelin A, Ahlqvist S, Moran VH, et al. Closeness and separation in neonatal intensive care. Acta Paediatr 2012;101(10):1032–7. [3] Miles MS, Holditch-Davis D, Schwartz T, Scher M. Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr 2007;28(1):36–44. [4] Jotzo M, Poets CF. Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention. Pediatrics 2005;115(4):915–9. [5] Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics 2006;47(3):206–12. [6] Bergström E-B, Wallin L, Thomson G, Flacking R. Postpartum depression in mothers of infants cared for in a Neonatal Intensive Care Unit – incidence and associated factors. J Neonatal Nurs 2012;18:143–51. [7] Brandon DH, Tully KP, Silva SG, Malcolm WF, Murtha AP, Turner BS, et al. Emotional responses of mothers of late-preterm and term infants. J Obstet Gynecol Neonatal Nurs 2011;40(6):719–31. [8] Eriksson BS, Pehrsson G. Emotional reactions of parents after the birth of an infant with extremely low birth weight. J Child Health Care 2005;9(2):122–36. [9] Franck LS, Cox S, Allen A, Winter I. Measuring neonatal intensive care unitrelated parental stress. J Adv Nurs 2005;49(6):608–15. [10] Wigert H, Johansson R, Berg M, Hellstrom AL. Mothers’ experiences of having their newborn child in a neonatal intensive care unit. Scand J Caring Sci 2006;20(1):35–41. [11] Fenwick J, Barclay L, Schmied V. Struggling to mother: a consequence of inhibitive nursing interactions in the neonatal nursery. J Perinat Neonatal Nurs 2001;15(2):49–64. [12] Wigert H, Berg M, Hellstrom AL. Parental presence when their child is in neonatal intensive care. Scand J Caring Sci 2010;24(1):139–46. [13] Blomqvist YT, Nyqvist KH. Swedish mothers’ experience of continuous Kangaroo Mother Care. J Clin Nurs 2011;20(9–10):1472–80. [14] Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics 2002;110(1):16–26. [15] Conde-Agudelo A, Belizan JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2011;(3):CD002771. [16] de Macedo EC, Cruvinel F, Lukasova K, D’Antino ME. The mood variation in mothers of preterm infants in Kangaroo mother care and conventional incubator care. J Trop Pediatr 2007;53(5):344–6. [17] Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Davanzo R, et al. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr 2010;99(6):820–6. [18] Flacking R, Ewald U, Starrin B. I wanted to do a good job: experiences of becoming a mother and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med 2007;64(12):2405–16. [19] Eriksson BS, Pehrsson G. Evaluation of psycho-social support to parents with an infant born preterm. J Child Health Care 2002;6(1):19–33. [20] Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics 2006;118(1):e107–114. [21] Ostberg M, Hagekull B, Wettergren S. A measure of parental stress in mothers with small children: dimensionality, stability and validity. Scand J Psychol 1997;38(3):199–208. [22] Abidin RR. Parenting stress index: professional manual. 3rd ed. Odessa, FL: Psychological Assessment Resources, Inc.; 1995. [23] Ostberg M, Hagekull B. A structural modeling approach to the understanding of parenting stress. J Clin Child Psychol 2000;29(4):615–25.
112
R. Flacking et al. / Sexual & Reproductive Healthcare 4 (2013) 107–112
[24] Tommiska V, Ostberg M, Fellman V. Parental stress in families of 2 year old extremely low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2002;86(3):F161–164. [25] Jackson K, Ternestedt BM, Magnuson A, Schollin J. Parental stress and toddler behaviour at age 18 months after pre-term birth. Acta Paediatr 2007;96(2):227–32. [26] Nordhov SM, Kaaresen PI, Ronning JA, Ulvund SE, Dahl LB. A randomized study of the impact of a sensitizing intervention on the child-rearing attitudes of parents of low birth weight preterm infants. Scand J Psychol 2010;51(5):385–91. [27] Jackson K, Ternestedt BM, Schollin J. From alienation to familiarity: experiences of mothers and fathers of preterm infants. J Adv Nurs 2003;43(2):120–9. [28] Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants’ length of stay and improving parents’ mental
[29]
[30]
[31]
[32]
health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics 2006;118(5):e1414–1427. Niela-Vilen H, Axelin A, Salantera S, Lehtonen L, Tammela O, Salmelin R, Latva R. Early physical contact between a mother and her NICU-infant in two university hospitals in Finland. Midwifery; 2013. Widarsson M, Engstrom G, Rosenblad A, Kerstis B, Edlund B, Lundberg P. Parental stress in early parenthood among mothers and fathers in Sweden. Scand J Caring Sci 2012. http://dx.doi.org/10.1111/j.1471-6712.2012.01088.x. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to becoming a mother and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med 2006;62(1):70–80. Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta context tool. BMC Health Serv Res 2009;9:234.