Posttraumatic stress symptoms in mothers of preterm infants

International Journal of Africa Nursing Sciences 3 (2015) 8–17

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International Journal of Africa Nursing Sciences journal homepage: www.elsevier.com/locate/ijans

Systematic review

Posttraumatic stress symptoms in mothers of preterm infants Kaboni Whitney Gondwe ⇑, Diane Holditch-Davis School of Nursing, Duke University, Durham, NC 27708, USA

a r t i c l e

i n f o

Article history: Received 26 September 2014 Received in revised form 10 April 2015 Accepted 7 May 2015 Available online 23 June 2015 Keywords: Posttraumatic stress Preterm Postpartum Maternal-infant relationship Coping

a b s t r a c t PTS symptoms are a common negative emotional response of mothers of preterm infants. PTS symptoms are one of the least explored emotional responses in postpartum period and in mothers of preterm infants. Malawi has the highest preterm birth in the world, but little is known about PTS symptoms following preterm birth in Malawi. The purpose of this paper is to review evidence on the incidence, prevalence, and impact of PTS symptoms following preterm birth, predictors of PTS symptoms, screening and management, and to identify the gaps and the applicability of the evidence to developing countries such as Malawi. A literature search was conducted using PubMed, PsychINFO, CINAHL, and ERIC databases. Articles were limited to PTS symptoms in mothers after preterm birth and up to 24 months. A total of 23 articles were included in the analysis. Findings showed that most literature was from developed countries. Fifteen instruments were identified and the PPQ was the most commonly used instrument. Time points for measurement varied. Mothers of preterm infants presented with at least one PTS symptom and they had higher PTS symptoms than mothers of healthy full-term infants, but no significant differences were seen with mothers of sick full term infants. Maternal, infant, and external factors predicted the onsets of PTS symptoms. Psychoeducation and counseling significantly reduced PTS symptoms, although mothers were only referred if symptoms were severe. Research in developing or low-income countries like Malawi is needed and researchers need to engage more in longitudinal approaches. Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents 1. 2. 3.

4.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.1. Screening for PTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2. Incidence, prevalence, and impact of PTS symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.3. Predictors of Postpartum PTSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.4. Approaches for managing PTS symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1. Introduction Preterm birth (<37 weeks), whether planned or unplanned, is an unexpected experience that may result maternal guilt over failure

⇑ Corresponding author at: School of Nursing, Duke University, 3322 DUMC, Durham, North Carolina 27708, USA. Cell: +1 9197987737. E-mail address: [email protected] (K.W. Gondwe).

to deliver a healthy term baby (Holditch-Davis & Miles, 2000). Preterm birth triggers negative maternal emotional responses such as posttraumatic stress (PTS), depressive symptoms, anxiety, and worry symptoms (Brandon et al., 2011; Dudek-Shriber, 2004; Lasiuk, Comeau, & Newburn-Cook, 2013). Mothers also experience feelings of uncertainty about infant outcome, lack information, have financial burdens, and experience miscommunications with providers (Harbaugh & Brandon, 2008). Intensive care supports

http://dx.doi.org/10.1016/j.ijans.2015.05.002 2214-1391/Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

K.W. Gondwe, D. Holditch-Davis / International Journal of Africa Nursing Sciences 3 (2015) 8–17

the preterm infant’s extrauterine adaptation and prevents complications, but maternal separation from the infant and severity of infants condition increases the risk for maternal PTS, depressive symptoms, anxiety, and worry symptoms (Brandon et al., 2011; Chiu & Anderson, 2009; Holditch-Davis, Cox, Miles, & Belyea, 2003; Holditch-Davis, Schwartz, Black, & Scher, 2007; Muller-Nix et al., 2004). Posttraumatic stress disorder is an anxiety disorder resulting from directly experiencing, witnessing, learning about a family members’ experience, or experiencing first-hand repeated or extreme exposure to a traumatic event (American Psychiatric Association., 2013). Posttraumatic stress disorder presents with three core PTS symptoms; re-experiencing, avoidance, and hyper-arousal about the traumatic experience (Franich-Ray et al., 2013; Nagata et al., 2008). Re-experiencing trauma involves an individual’s attempts to make sense of the experience or reactions to reminders of the trauma that brings back the painful experiences as if they are happening all over again (Nagata et al., 2008), for example, frequent dreams, reacting as if the event is occurring, and recollecting the images, thoughts, or the event (Franich-Ray et al., 2013; Nagata et al., 2008). Avoidance is a high-level coping strategy in which a mother deals with memories of the birth experience and tries to numb or block general responsiveness towards those memories (Nagata et al., 2008). The individual denies reality of the event and avoids thinking or talking about it and places, activities, or people associated with the event (Franich-Ray et al., 2013; Nagata et al., 2008). During arousal, the body and mind are alert to future threats (Nagata et al., 2008). Mothers of preterm infants experience some or all these symptoms, which may cause suffering (Habersaat et al., 2014; Holditch-Davis, Bartlett, Blickman, & Miles, 2003). Globally, research on negative maternal postpartum emotional responses is growing. Anxiety and depressive symptoms have been widely explored and shown to affect the mother-infant relationship (Davies, Slade, Wright, & Stewart, 2008; Korja et al., 2008). Malawi, a low-income country in sub-Saharan region of Africa, faces the highest preterm birth rate in the world, estimated at 18.1 per 100 live births (World Health Organization., 2014). In 2010 alone, 37% of the 18,000 neonates who died did so from complications of preterm birth (Zimba et al., 2012). With limited resources and increased probability of infant loss following preterm birth, Malawian mothers are at a high risk for negative emotional responses. However, little is known about PTS symptoms in Malawian mothers as compared to depressive symptoms. The few studies on perinatal mental health issues have focused on incidence and predictors of depressive symptoms and its impact on pregnancy and infant outcomes in general or in HIV positive mothers (Stewart, 2007; Stewart et al., 2010). Few researchers have explored PTS symptoms in the postpartum period or following preterm birth. The World Health Organization emphasizes improving psychological wellbeing of postpartum mothers (March of Dimes, Child Health, & World Health Organization, 2012). The purpose of this systematic review was to critique evidence on incidence, prevalence, and impact of PTS symptoms following preterm birth; to examine predictors, screening and management strategies for PTS symptoms; and to identify the gaps and determine the applicability of the literature to Malawi. A systematic review of current literature was necessary to explore what work has been done on PTS symptoms following preterm birth to provide a basis for work on perinatal PTS symptoms research in the Malawian health care system and other low-income countries facing high preterm birth rates. This evidence will be crucial to postpartum health care providers in understanding PTS symptoms in mothers of preterm infants, promoting psychological wellbeing mothers and improving infant outcomes following preterm delivery.

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Table 1 Literature search words. Database

Search words

PubMed

(‘‘Mother-Child Relations’’[Mesh] OR ‘‘mother child’’[tiab] OR ‘‘maternal-infant’’[tiab] OR ‘‘mother-infant’’[tiab]) AND ‘‘Premature Birth’’[Mesh] OR ‘‘Infant, Premature’’[Mesh] OR ‘‘premature birth’’[tiab] OR ‘‘premature births’’[tiab] OR ‘‘premature infant’’[tiab] OR ‘‘Premature infants’’[tiab] OR ‘‘Preterm infant’’[tiab] OR ‘‘preterm infants’’[tiab] AND (‘‘Stress Disorders, Post-Traumatic’’[Mesh] OR ‘‘post-traumatic stress’’[tiab] OR ‘‘posttraumatic stress’’[tiab]) (TI ‘‘preterm infant’’ OR AB ‘‘preterm infant’’ OR TI ‘‘preterm birth’’ OR AB ‘‘preterm birth’’ OR TI ‘‘premature infant’’ OR AB ‘‘premature infant’’ OR TI ‘‘preterm births’’ OR AB ‘‘preterm births’’ OR TI ‘‘preterm infants’’ OR AB ‘‘preterm infants’’ OR TI ‘‘premature infants’’ OR AB ‘‘premature infants’’ OR (TI ‘‘premature births’’ OR AB ‘‘Premature births’’) AND (TI ‘‘motherchild’’ OR TI ‘‘mother-infant’’ OR TI ‘‘maternal-infant’’ OR AB ‘‘mother-child’’ OR AB ‘‘mother-infant’’ OR AB ‘‘maternal-infant’’ OR DE ‘‘Mother Child Relations’’ OR DE ‘‘Mother Child Communication’’) AND (‘‘Post-traumatic stress disorder’’ OR AB ‘‘Post-traumatic stress disorder’’ OR DE ‘‘Posttraumatic Stress Disorder’’) (TI ‘‘preterm infant’’ OR AB ‘‘preterm infant’’ OR TI ‘‘preterm birth’’ OR AB ‘‘preterm birth’’ OR TI ‘‘premature infant’’ OR AB ‘‘premature infant’’ OR TI ‘‘preterm births’’ OR AB ‘‘preterm births’’ OR TI ‘‘preterm infants’’ OR AB ‘‘preterm infants’’ OR TI ‘‘premature infants’’ OR AB ‘‘premature infants’’ OR MH ‘‘Infant, Premature’’) OR (MH ‘‘Childbirth, Premature’’ OR TI ‘‘premature births’’ OR AB ‘‘Premature births’’) AND (MH ‘‘Mother-Child Relations’’ OR TI ‘‘mother-child’’ OR TI ‘‘mother-infant’’ OR TI ‘‘maternal-infant’’ OR AB ‘‘mother-child’’ OR AB ‘‘mother-infant’’ OR AB ‘‘maternal-infant’’) AND (‘‘Post-traumatic stress disorder’’ OR AB ‘‘Post-traumatic stress disorder’’ OR MH ‘‘Stress Disorders, Post-Traumatic’’) (TI ‘‘preterm infant’’ OR AB ‘‘preterm infant’’ OR TI ‘‘preterm birth’’ OR AB ‘‘preterm birth’’ OR TI ‘‘premature infant’’ OR AB ‘‘premature infant’’ OR TI ‘‘preterm births’’ OR AB ‘‘preterm births’’ OR TI ‘‘preterm infants’’ OR AB ‘‘preterm infants’’ OR TI ‘‘premature infants’’ OR AB ‘‘premature infants’’ OR (TI ‘‘premature births’’ OR AB ‘‘Premature births’’) AND (TI ‘‘motherchild’’ OR TI ‘‘mother-infant’’ OR TI ‘‘maternal-infant’’ OR AB ‘‘mother-child’’ OR AB ‘‘mother-infant’’ OR AB ‘‘maternal-infant’’ OR DE ‘‘Mother Child Relations’’ OR DE ‘‘Mother Child Communication’’) AND (‘‘Post-traumatic stress disorder’’ OR AB ‘‘Post-traumatic stress disorder’’ OR DE ‘‘Posttraumatic Stress Disorder’’)

PsychInfo

CINAHL

ERIC

2. Methods This was systematic review on PTS symptoms following preterm birth. We performed a systematic search of the literature using Public MEDLINE (PubMed), Psychological Information (PsychINFO), Cumulative Index to Nursing and Allied Health (CINAHL), and Education Resource Information Center (ERIC) databases. The search terms used for each database are summarized in Table 1. The search was limited to peer reviewed articles published in English and involving human subjects. As summarized in Fig. 1, ERIC yielded no articles and the others databases yielded a total of 31 articles. Six duplicates were removed leaving 25 articles for further review. Articles included in the review focused on posttraumatic stress in mothers after preterm birth and up to 24 months corrected age for prematurity. The exclusion criteria were studies focusing on PTS symptoms in mothers of infants with other high-risk conditions or only focusing on full-term infants. Abstracts and titles were scanned and we removed nine articles that focused on other conditions such as jaundice, immunizations, massage therapy, brain disorder, and PTS symptoms before birth. The full texts of the remaining 16 articles were reviewed based on the inclusion criteria and two articles were removed because they were study protocols without data. The bibliographies of the articles were

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K.W. Gondwe, D. Holditch-Davis / International Journal of Africa Nursing Sciences 3 (2015) 8–17

Fig. 1. Flow diagram of literature search and selection.

reviewed for additional articles and four articles were identified through snowball technique. Five other articles were also found through a repeat general search on PubMed. Thus, 23 articles met the inclusion criteria for the systematic review. Information was abstracted from the articles into a matrix (Garrard, 2010) under the headings author(s), year, title, aim, concepts, research design, sample and setting, intervention, measures/instruments, findings/results, strengths and weakness, and contributions to research and practice (see Table 2).

3. Results Twenty-three studies were included in the final review. As listed in Table 2, 17 were quantitative studies, two were mixed method studies, two were quasi-experimental studies (one of which was a pilot study), and one was a randomized control trial. These studies were from developed countries such as the United States of America, France, Canada, Switzerland, and Germany. Only one study was from a developing country, Iran. The search

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K.W. Gondwe, D. Holditch-Davis / International Journal of Africa Nursing Sciences 3 (2015) 8–17 Table 2 Study design, sample and instruments for traumatic stress. Author

Design

Sample

Instruments for traumatic stress

Time Points

Brandon et al. (2011) Callahan et al. (2006)

Prospective Mixed method Retrospective Survey

29 mothers of late preterm infants and 31 mothers of full-term infants 47 mothers of premature infants, 86 mothers of full-term infants, and 11 mothers of medically fragile infants

Perinatal PTSD Questionnaire

Birth and 1 month Once

Callahan and Hynan (2002) DeMier et al. (1996) Feeley et al. (2011) Forcada-Guex et al. (2011) Ghorbani et al. (2014) Goutaudier et al. (2011)

Retrospective Survey

111 mothers of high-risk infants born 6 38 weeks, 52 mothers of healthy full-term infants born P 38, and 10 mothers medically fragile, full-term infants 78 mothers of preterm infants, 50 mothers of health full-term infants, and 14 mothers of hospitalized full-term infants 21 mothers of preterm infants weighing less than 1,500 g

Modified-Perinatal PTSD Questionnaire Impact of Events Scale Modified-Perinatal PTSD Questionnaire Impact of Events Scale Perinatal stress survey Perinatal PTSD Questionnaire

6 months

47 mothers of preterm born before 34 weeks and 25 mothers of full-term infants born at or greater than 37 weeks 82 couples with preterm infants and 82 couples with full-term infants 27 mothers of preterm infants

Perinatal PTSD Questionnaire

6 months

DSMIV Post-traumatic stress disorder symptoms scale French version of the Impact of Event Scale-Revised

Once (within 2 months of birth) Once

74 mothers of very preterm infants

Parental Stress Scale: NICU Perinatal PTSD Questionnaire Parental Stress Scale: NICU

12 months

Habersaat et al. (2014) Holditch-Davis, Bartlett, et al. (2003) Holditch-Davis et al. (2009)

Jotzo and Poets (2005) Kersting et al. (2004)

Lefkowitz et al. (2010) Muller-Nix et al. (2004) Pierrehumbert et al. (2003) Quinnell and Hynan (1999) Shaw et al. (2014) Shaw, Bernard, et al. (2013)

Retrospective Survey Descriptive, correlational study Descriptive Descriptive, comparative study Cross-sectional mixed method study Descriptive, correlational study Longitudinal, descriptive, correlational study Descriptive, correlational study

Quasiexperimental design Prospective longitudinal study - descriptive Prospective, descriptive, correlational study Descriptive, correlational study Descriptive, correlational study Descriptive, correlational study

30 mothers of premature infants (18 white, 11 African American, and 1 Asian) 177 African American mothers of preterm infants

54 mothers of preterm infants in control group and 48 mothers in intervention group 50 mothers after birth of a VLBWI (<1500g) and/or birth before 32 completed gestational week; and 30 mothers of healthy infants born 40 weeks, average birth weight of 3,500g 89 mothers and 41 fathers of preterm infants

47 mother-preterm dyads (19 low risk and 28 high-risk) at 6 months and 45 dyads at 18 months and 25 mother full-term infant dyads 50 families with premature infants (25-33 weeks) and 25 families with full-term infants 91 mothers of high-risk infants and 51 mothers of healthy fullterm

Descriptive, correlational study Descriptive, correlational study - Longitudinal design RCT

137 mothers of infants born between 26 and 34 weeks gestation and weighing over 1000g 56 mothers recruited with only 50 mothers with follow-up data at 1 month. Caucasian 56%, Hispanic 20%, Asian 20%, and the remaining 4% were others races/ethnicities

Shaw, Sweester, et al. (2013) Shaw et al. (2009)

Pilot study

8 mothers of infants born between 26 and 34 weeks old, weighing over 1000 grams 18 parents of preterm infants

Verreault et al. (2012)

Descriptive, correlational study

Shaw, John, et al. (2013)

Descriptive, correlational study

105 mothers with infants born between 25 and 34 weeks born at or transferred within the first week of birth. 62 in intervention and 43 in the comparison group

308 women, with assessments at four time points: 25–40 weeks gestation, 4–6 weeks postpartum, 3 and 6 months postpartum

Parental Stress Scale: NICU Perinatal PTSD Questionnaire The Parental Stress Scale: Prematurely Born Child Impact of Events Scale Peritraumatic Dissociative Experience Questionnaire DSM-IV PTS symptoms Structured Clinical Interview for DSM-IV Impact of Events Scale PTSD symptom checklist

Once

Once

Enrollment and 6 months

Enrollment, 2, 6, 12, 18, and 24 months

Once at discharge

1–3 days, 14 days, and 6 and 14 months

1 month

Perinatal PTSD Questionnaire

18 months

Perinatal PTSD Questionnaire

18 months

Perinatal PTSD Questionnaire Impact of Events Scale Penn Inventory Stanford Acute Stress Reactions Questionnaire Stanford Acute Stress Reactions Questionnaire Davidson Trauma Scale

Once

The Traumatic Events Questionnaire Davidson Trauma Scale Stanford Acute Stress Reactions Questionnaire Parental Stress Scale: NICU Davidson Trauma Scale

Once

Stanford Acute Stress Reaction Questionnaire Parental Stress Scale: NICU Davidson Trauma Scale The PTSD Module of the Structured Clinical Interview for DSM-IV The Modified PTSD Symptom Scale Self-Report The Trauma History Questionnaire

4 months 1 month

1–2 weeks after birth and I week after intervention Baseline and 1–2 weeks after intervention

25–40 weeks gestation, 4–6 weeks postpartum, 3 and 6 months postpartum

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did not yield specific studies on PTS symptoms in mothers of preterm infants in African or other low-income countries. The majority of the samples in most studies were Caucasian mothers rather than other races, except for Holditch-Davis et al. (2009) that specifically recruited African-American mothers. The studies were mainly located in regional or university hospitals (e.g., level 3 NICUs) and a few studies recruited participants from ‘World Wide Web sites’ aimed at parents of preterm and other high-risk infants, undergraduate psychology courses, conferences or meetings targeting parents of premature and other high-risk infants, and a health center. Table 2 shows the sample sizes in all studies. The number of participants in these studies also varied from 8 to 308. Approximately one-third (5) of the studies recruited fewer than 30 mother-preterm infant dyads and effect sizes were not reported. Shaw, Sweester, et al. (2013), which recruited only eight mothers, was a pilot study. Nine studies compared experiences of mothers of preterm infants with mothers of full-term infants and three studies had an additional high-risk full-term dyad group, although the samples were very small ranging from 10 to 14 (Callahan, Borja, & Hynan, 2006; Callahan & Hynan, 2002; DeMier, Hynan, Harris, & Manniello, 1996). Two studies included fathers (Ghorbani, Dolatian, Shams, Alavi-Majd, & Tavakolian, 2014; Lefkowitz, Baxt, & Evans, 2010). One study, Shaw et al. (2009), had a high attrition rate, starting with 40 participants but ending with only 18 participants for their analysis. 3.1. Screening for PTS We explored the nature of instruments used in measuring PTS symptoms and the time for measurement in order to assess available instruments and their validity and reliability. Various instruments were used to measure PTS in the postpartum period. Table 2 lists the 15 instruments identified in the studies, some studies used only one instrument while others used more (see Table 2). Majority of the instruments are valid and reliable. The most commonly used instrument was the Perinatal PTSD Questionnaire developed by DeMier et al. (1996) and Quinnell and Hynan (1999) and later modified by Callahan et al. (2006). Other instruments used in several articles, but less frequently than the Perinatal PTSD Questionnaire, were the Impact of Events Scale from Horowitz, Wilner, and Alvarez (1979); Parental Stressor Scale: Neonatal Intensive Care Unit from Miles, Funk, and Carlson (1993); Davidson Trauma Scale from Davidson et al. (1997); and Stanford Acute Stress Reactions Questionnaire from Classen, Koopman, Hales, and Spiegel (1998) and Koopman, Classen, and Spiegel (1994). Instruments used in only one article were the DSMIV PTS symptoms from First, Gibbon, Spitzer, and Williams (1996) and Wittchen, Zaudig, and Frydrich (1996); Perinatal Stress Survey from DeMier et al. (1996); Peritraumatic Dissociative Experience Questionnaire from Fischer (2000); PTSD symptom checklist from Weathers and Ford (1996); Social Readjustment Rating scale from Holmes and Rahe (1967); Traumatic Events Questionnaire from Vrana and Lauterbach (1994); Penn Inventory from Hammarberg (1992); PTSD Module of the Structured Clinical Interview for DSM-IV from First, Spitzer, and Gibbon (1997); Modified PTSD Symptom Scale Self-Report from Falsetti, Resnick, Resick, and Kilpatrick (1993); and Trauma History Questionnaire from Green (1996). All of these instruments had good reported reliability and validity. The Perinatal PTSD Questionnaire was highly positively correlated with the Impact of Events Scale (Callahan & Hynan, 2002; Callahan et al., 2006; Quinnell & Hynan, 1999) and the Penn Inventory (Quinnell & Hynan, 1999), and the Impact of Events Scale and Penn Inventory were correlated (Quinnell & Hynan, 1999). The other studies did not examine correlations among the

instruments, but different instruments generally agreed on the presence of posttraumatic stress disorder. However, Verreault et al. (2012) showed that percentage of mothers who met full criteria for posttraumatic stress disorder using the Modified PTSD Symptom Scale Self-Report was higher than with the Structured Clinical Interview for DSM-IV. Time points for assessment varied in these studies, ranging from first week following birth to 24 months corrected age of prematurity. Some studies were retrospective, and mothers had to recall events that occurred almost a decade since the birth. Only three studies were longitudinal measuring PTS symptoms at three or more time points (Holditch-Davis et al., 2009; Kersting et al., 2004; Verreault et al., 2012) although 12 studies assessed PTS at two time points. PTS symptoms were more intense in the first month after birth than in subsequent assessments (Shaw, Bernard, Storfer-Isser, Rhine, & Horwitz, 2013; Verreault et al., 2012). However, Brandon et al. (2011) showed no significant change over one month in the intensity of PTS symptoms, and Kersting et al. (2004) found that mothers of preterm infants showed no significant reduction in PTS symptoms over 14 month period. This situation suggests that mothers of preterm infant experience PTS symptoms over a long period of time. 3.2. Incidence, prevalence, and impact of PTS symptoms The incidence of maternal PTS symptoms following birth of preterm infants is high. Feeley et al. (2011) found that the level of PTS symptoms in 23.8% of mothers of preterm infants scored in the clinical range, indicating possibility of posttraumatic stress disorder diagnosis. Shaw et al. (2009) also found that 18% of mothers of preterm infants met the criteria for posttraumatic stress disorder. In addition, Goutaudier, Lopez, Séjourné, Denis, and Chabrol (2011) found that 77.8% of mothers of preterm infants had potential posttraumatic stress disorder with scores of 36 or more on French version of the Impact of Event Scale-Revised. Shaw, Bernard, et al. (2013) found that one-third (30%) of mothers of preterm infants are diagnosed with posttraumatic stress disorder one month after discharge. A comparison of incidence in mothers and fathers of preterm infants showed that mothers report higher levels of PTS symptoms than fathers. Lefkowitz et al. (2010) found that 27 (45%) mothers of 89 mothers and five (20%) of the 41 fathers reported re-experiencing trauma. In addition, 10 (16.7%) mothers and three (12%) fathers reported avoidance and 18 (30%) mothers and seven (28%) fathers reported heightened arousal (Lefkowitz et al., 2010). Evidence showed that mothers of preterm infants experienced at least one or more PTS symptoms. The nature of PTS symptoms reported included re-experiencing, avoidance, and hyper-arousal about the traumatic experience (Holditch-Davis, Bartlett, et al., 2003). Most studies showed that mothers of preterm infants with PTS often presented with one or more PTS symptom (Habersaat et al., 2014; Holditch-Davis, Bartlett, et al., 2003; Lefkowitz et al., 2010). Holditch-Davis, Bartlett, et al. (2003) found that all 30 mothers of preterm infants in their study had at least one PTS symptoms: 12 mothers reported two symptoms and 16 mothers reported all three PTS symptoms. Twenty-six mothers reported heightened arousal, whereas 24 reported avoidance and re-experiencing. Avoidance of trauma involved with aspects of the infant’s birth and hospitalization was seen in their interviews as mothers tried to forget the experience, avoid thinking about the experience, suppress reminders, or deny potential problems in the baby (Holditch-Davis, Bartlett, et al., 2003). Increased arousal was displayed through overprotection of the child, persistent fears that the child might die or become sick again, sleep difficulties, and generalized anxiety (Holditch-Davis, Bartlett, et al., 2003). Habersaat et al. (2014) found that mothers of preterm

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infants reported a mean score of 3 or 4 on the perinatal PTSD questionnaire with cut-off for posttraumatic stress disorder set at 6 points (2 points in the ‘hyperarousal’ category, 3 in the ‘avoidance’, and 1 for ‘re-experiencing’). Although the presence of only one PTS symptoms may cause suffering, most of their mothers were below the clinical threshold for posttraumatic stress disorder (Habersaat et al., 2014). Some mothers may not receive treatment because they do not meet criteria for a diagnosis of posttraumatic stress disorder, although they may be negatively affected by the symptoms. High levels of PTS symptoms in mothers of preterm infants necessitated the diagnosis of posttraumatic stress disorder, however, a discrepancy was seen depending in the instrument of measurement. Verreault et al. (2012) found a discrepancy in the percentages of mothers meeting the criteria of posttraumatic stress disorder, the Modified PTSD Symptom Scale Self-Report showed higher percentages than Structured Clinical Interview for DSM-IV, and in addition higher rates of posttraumatic stress disorder occurred at one month than at three and six months. Approximately 4.9% to 7.6% of mothers of preterm infants met the criteria at some point postpartum for full posttraumatic stress disorder on the Modified PTSD Symptom Scale Self-Report, and 4.3 to 16.6% met the criteria at some point postpartum for partial posttraumatic stress disorder on the Modified PTSD Symptom Scale Self-Report (Verreault et al., 2012). In the end about 72 (26%) were diagnosed with posttraumatic stress disorder using Modified PTSD Symptom Scale Self-Report (Verreault et al., 2012). In contrast, approximately 0 to 1.1% and 1.2 to 3.2% mothers of preterm infants met criteria at some point postpartum for full or partial posttraumatic stress disorder on Structured Clinical Interview for DSM-IV, and in total about 17 (5.6%) were diagnosed with postpartum posttraumatic stress disorder (Verreault et al., 2012). Mothers of preterm infants had significantly higher trauma experience and intensity of PTS symptoms than mothers of healthy full-term infants (Brandon et al., 2011; DeMier et al., 1996; Feeley et al., 2011; Ghorbani et al., 2014; Kersting et al., 2004; Muller-Nix et al., 2004; Quinnell & Hynan, 1999). However, no significant differences were reported between mothers of preterm infants and mothers of high-risk term infants during hospitalization (Callahan et al., 2006; DeMier et al., 1996; Muller-Nix et al., 2004). Brandon et al. (2011) found that mothers of late preterm infants had significantly higher levels of PTS symptoms than mothers of full-term infants, and that both groups were stable over time (following delivery and at one month) in PTS symptoms. Ghorbani et al. (2014) also found that mothers of preterm infants experienced more traumatic symptoms than mothers of full-term infants. Kersting et al. (2004) found mothers of preterm and very low birth weight infants experienced higher traumatic symptoms at all time points (1–3 days, 14 days, 6 months, and 14 months) than mothers of full-term infants and that mothers of preterm infants displayed a significant reduction on avoidance behaviors, but no significant reduction in intrusion or the total Impact of Events Scale score over time. This slightly differs from Brandon et al. (2011) perhaps because Kersting et al. (2004) followed mothers of preterm infants over a longer time. However, the levels of intrusive symptoms on Impact of Events Scale and intrusion scale remained stable over time. Forcada-Guex, Borghini, Pierrehumbert, Ansermet, and Muller-Nix (2011) found no difference in traumatic stress levels between mothers of preterm singletons and of multiple birth sets. Findings showed that mothers of preterm infants experienced more trauma than mothers of full-term infants and even though the symptoms may reduce over time, significant differences between the two groups continued with mothers of preterm infants being more affected. High PTS symptoms coupled with preterm birth were linked to negative maternal and infant outcomes. Mothers of preterm

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infants were anxious, stressed, and helpless, and had problems with sleeping and eating, self-esteem, resuming tobacco use, marital conflict, and violence towards others (Goutaudier et al., 2011). Habersaat et al. (2014) found that high re-experiencing symptoms were significantly related with a flatter slope, which was indicative of cortisol dysregulation. Mothers with lower PTS symptoms had a steeper diurnal cortisol slope than mothers with high PTS symptoms (Habersaat et al., 2014). Habersaat et al. (2014) further explained that cortisol dysregulation might result in poor health outcomes. Preterm infants of mothers with high PTS symptoms also had sleeping and eating problems (Pierrehumbert, Nicole, Muller-Nix, Forcada-Guex, & Ansermet, 2003). High PTS symptoms were also associated with less positive mother-infant relationship. Mothers with high PTS symptoms had lowered maternal sensitivity and were unable effectively structure mother-infant interactions (Feeley et al., 2011; Muller-Nix et al., 2004). Mothers of high-risk preterm infants were also less sensitive than mothers with full-term infants, and mothers of low risk preterm infants were intermediate in sensitivity (Muller-Nix et al., 2004). Three significant interaction patterns were seen in mother-preterm dyads: a ‘‘cooperative’’ pattern [sensitive mother with cooperative infant, 28%], a ‘‘controlling’’ pattern [controlling mother with a compliant infant, 28%], and a heterogeneous group [sensitive mother with passive infant; controlling mother with a cooperative, difficult or passive infant; and an unresponsive mother with a cooperative, difficult or passive infant, 44%] (Forcada-Guex et al., 2011). Mothers with high PTS symptoms were significantly more likely to show controlling patterns, whereas mothers with low PTS symptoms were more likely to show the ‘‘heterogeneous’’ dyadic patterns. Mothers of full-term infants were most likely to display the cooperative pattern. Forcada-Guex et al. (2011) used interaction patterns to assess maternal attachment representations and classified them as balanced, disengaged, or distorted representations of attachment. The mothers of preterm infants, whether with high or low PTS symptoms, had less balanced representations of their infants than mothers of full-term infants. Mothers with lower PTS symptoms and in heterogeneous dyad interaction pattern showed more disengaged representations, while mothers with high PTS symptoms and in controlling dyadic patterns showed more distorted representations (Forcada-Guex et al., 2011). Although these findings showed the link between PTS symptoms and less positive mother-infants interactions, the study failed to clarify the distinction between the three representations. 3.3. Predictors of Postpartum PTSD Several maternal, infant, and external factors increased the risk of PTS in mothers of preterm infants (Brandon et al., 2011; DeMier et al., 1996; Pierrehumbert et al., 2003; Verreault et al., 2012). Generally, mothers were at higher risk of PTS than fathers (Ghorbani et al., 2014; Lefkowitz et al., 2010). Maternal factors that increased their risk for PTS included young maternal age (Callahan & Hynan, 2002; Holditch-Davis et al., 2009); housing and coping style whether anxiety, emotion-oriented, or problem-oriented (Ghorbani et al., 2014); being married (Holditch-Davis, Bartlett, et al., 2003); higher maternal education (Shaw, Bernard, et al., 2013); and US birthplace (Shaw et al., 2014). Mental health symptoms such as depression, anxiety, worry about the infant, and acute stress disorder and the number of concurrent stressors also increased the level of PTS symptoms (Holditch-Davis, Bartlett, et al., 2003; Lefkowitz et al., 2010; Shaw et al., 2009; Shaw, Bernard, et al., 2013; Verreault et al., 2012). Holditch-Davis et al. (2009) found that maternal distress was positively correlated with high depressive and PTS symptoms, and PTS scores decreased significantly over time in mothers with high depressive symptoms

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and extreme distress (mothers with highest scores on PSS: NICU, PPQ, and daily hassle subscale scores). Perinatal/postnatal complications such as unexpected timing of birth or young gestational age (Brandon et al., 2011; DeMier et al., 1996) and delivery mode such as caesarean section (Brandon et al., 2011; Callahan & Hynan, 2002) also contributed to maternal risks for PTS. Infant risk factors for PTS included length of stay/hospitalization (DeMier et al., 1996; Feeley et al., 2011; Holditch-Davis, Bartlett, et al., 2003), birth weight (Feeley et al., 2011), and medical condition or outcome (Brandon et al., 2011; Feeley et al., 2011; Muller-Nix et al., 2004; Pierrehumbert et al., 2003). External risk factors for PTS included mothers’ relationship with health care team (Brandon et al., 2011), stress from sights and sounds of the NICU (Shaw et al., 2009), and less social support during pregnancy and at 1 month postpartum (Verreault et al., 2012). On the other hand, some authors found non-significant associations between the level of PTS symptoms and maternal, infant, and external factors. Maternal factors such as age (Ghorbani et al., 2014; Habersaat et al., 2014; Shaw, Bernard, et al., 2013); parity (Ghorbani et al., 2014; Habersaat et al., 2014); socioeconomic status (Ghorbani et al., 2014; Habersaat et al., 2014; Muller-Nix et al., 2004; Verreault et al., 2012); occupation (Ghorbani et al., 2014); education (Ghorbani et al., 2014; Shaw et al., 2014); marital status (Habersaat et al., 2014; Shaw, Bernard, et al., 2013); stress (Shaw et al., 2009); nationality (Habersaat et al., 2014); and race, ethnicity and native language (Shaw et al., 2014) showed no significant associations with PTS symptoms. Obstetric factors not correlated with PTS included maternal delivery mode (Verreault et al., 2012), gestational age (Habersaat et al., 2014), and wanted pregnancy or infant gender (Ghorbani et al., 2014). Infant factors not correlated with PTS included birth weight (DeMier et al., 1996), medical condition (Holditch-Davis et al., 2009; Shaw et al., 2009), and history of infant hospitalization or NICU admission (Ghorbani et al., 2014).

coping strategies, discussions of personal resources, exploration of possible solutions, and arrangement for follow-up with mother on progress (Jotzo & Poets, 2005). This intervention specifically addressed parental perceptions of infant condition, obtained obstetric history, explored the parent-infant relationship, addressed reactions to the NICU, discussed relationships with the spouse, and provided frequent visits by the psychologists after completion of the crisis intervention. Shaw, John, et al. (2013) also found a significant decrease in maternal PTS symptoms in mothers receiving a three-to-four week intervention administered once or twice a week for 45–55 minutes per session (6 sessions) compared to mothers in the control group who received one 45-minute information session on NICU policies, procedures, and environment and information on parenting the premature infant. The intervention components included psychoeducation on PTSD and common parental feelings/thoughts about the NICU, cognitive restructuring to aid in recognition and challenging erroneous and maladaptive cognitions, progressive muscle relaxation for anxiety reduction, and development and processing of the mother’s trauma narrative (Shaw, John, et al., 2013). However, a faster decreasing rate in PTS symptoms was also associated with less education and lower household incomes regardless of the intervention (Shaw, John, et al., 2013). Other interventions that showed a decrease in PTS symptoms, though non-significant, were Shaw, Bernard, et al. (2013) three individual therapy sessions lasting 45 minutes over a 2-week time period (starting 1-2 weeks after the birth of the infant) and Shaw, Sweester, et al. (2013) manual targeting maternal sensitivity, parent-infant interaction treatment, and trauma treatment. Shaw, Sweester, et al. (2013) argued that their small sample size might have led to non-significant findings, but the manual can be used to train therapists to a high degree of fidelity and participants found the intervention satisfactory and helpful for their NICU experience.

3.4. Approaches for managing PTS symptoms 4. Discussion Initially, mothers of preterm infants used a variety of coping and comforting strategies manage their traumatic stress. These strategies included discussing with other mothers with similar experiences, seeking out information, spending more time with their infant to repair their relationship and/or to fight fears of death, or moving away from the hospital in order to start afresh (Goutaudier et al., 2011). Shaw, Bernard, et al. (2013) found that coping mechanisms used by mothers of preterm infants included adaptive/positive (emotion-focused and problem-focused) and maladaptive/negative (dysfunctional). Ghorbani et al. (2014) found that majority of mothers with high PTS symptoms used emotion-oriented (44.4%) and problem-oriented (44.4%) and a few mothers used anxiety coping mechanism (11.1%). However, Shaw, Bernard, et al. (2013) found higher baseline scores on dysfunctional and problem-focused coping in mothers with high PTS symptoms at 1 month follow-up than in mothers without PTS symptoms at 1 month follow-up, while no significant difference in PTS symptoms were seen with emotional coping. However, when coping mechanisms are inadequate in lowering PTS symptoms therapy has shown to significantly reduce PTS symptoms. However, Callahan et al. (2006) noted that referral for therapy is not automatic, but the possibility of referral doubled when mothers had a Perinatal PTSD Questionnaire score of 19 and above. Significant reduction in PTS symptoms at discharge were seen with a crisis intervention program that focused on reconstructing the occurrences shortly before and after birth and at the early days of NICU admission, simple relaxation and calming techniques, support during emotional outbursts, exploration of stress and trauma reactions, exploration of psychological and

Twenty-three studies were reviewed to understand the experience of PTS among mothers with preterm infants. These findings confirmed that mothers of preterm infants will present with at least one PTS symptom and mothers of preterm infant are at higher risk of developing PTS symptoms than mothers of healthy full-term infants, and these symptoms continued to be present over time (Brandon et al., 2011; DeMier et al., 1996; Feeley et al., 2011; Ghorbani et al., 2014; Kersting et al., 2004; Muller-Nix et al., 2004; Quinnell & Hynan, 1999). The findings are consistent with PTS studies assessing mothers of children in other patient populations and also following term birth. Davies et al. (2008)’s research on PTS in postpartum following childbirth also found that 21.3% of mothers in the postpartum period present with at least one PTS symptoms. In addition, mothers with PTS symptoms viewed their infants as less warm, more evasive, and more difficult in temperament than other infants, and they felt less attached to their infants (Davies et al., 2008). A variety of predictors were found to increase the risk of developing high PTS symptoms, but studies conflicted on some factors. However, most studies agreed that the unexpected timing of birth, perinatal complications, past and present mental/psychiatric disorders increased the risk of a traumatic experience (Brandon et al., 2011; DeMier et al., 1996; Holditch-Davis, Bartlett, et al., 2003; Lefkowitz et al., 2010; Pierrehumbert et al., 2003; Shaw et al., 2009; Shaw, Bernard, et al., 2013; Verreault et al., 2012). Mothers were also at higher risk of developing PTS symptoms than fathers (Ghorbani et al., 2014; Lefkowitz et al., 2010) This is consistent with research findings from mothers of children with cancer who

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also reported higher levels of PTS symptoms than fathers (Boman, Kjallander, Eksborg, & Becker, 2013; Poder, Ljungman, & von Essen, 2008). Research on predictors of PTS following childbirth have also maternal history of psychological problems, trait anxiety, or obstetric procedures, experiences of negative relationships with staff, feelings of loss of control over the situation, and lack of partner support as predictors of PTS symptoms (Olde, van der Hart, Kleber, & van Son, 2006). In addition, in the cancer population parent gender (mothers), young parental age, having a Nordic origin, lack of employment, past experience of trauma, anxiety, and the condition of child have also been linked to increased risk for PTS (Boman et al., 2013; Nagata et al., 2008; Poder et al., 2008). The contradictory findings on predictors of PTS symptoms were also seen in Italian mothers with children in chemotherapy. Axia, Tremolada, Pillon, Zanesco, and Carli (2006) found that in being Italian, child age and gender, level of parent education, employment status, and family’s socioeconomic status did not influence PTS symptoms. The lower PTS symptoms were attributed to the close knit culture of Italians (Axia et al., 2006). Similarly, Malawi is a close-knit community and family members support new mothers during postpartum period. In addition, Malawian mothers are counseled to help support them psychologically for delivery and if the advise is negative it may cause poor maternal and infant outcomes (Kamwendo, 2009) Culture is known to largely influence the nature of maternal social support system and some aspects of the culture may contribute to maternal stress (Gulamani, Premji, Kanji, & Azam, 2013). Therefore, more research of PTS symptoms in Malawian women would provide evidence of the nature of their challenges that are applicable to other African and other low-income countries with similar culture. This will be key to improving care for mothers of preterm infants in developing countries. Shaw et al. (2014) and Shaw, Bernard, et al. (2013) found that higher maternal education and being a US citizen increased the risk of PTS. While higher education is usually considered positive, the mother’s ability to read and comprehend things increased the curiosity to access information on potential risks and complication of preterm birth that might potentially lead to fear. More research is required to explore the association of maternal education with risk of PTS symptoms. Therefore, developing evidence among Malawian mothers will help understand the cultural, educational, and health care system influence on the mothers’ experiences. This review also showed that several instruments are used in research to measure PTS in mothers of preterm infants. Some instruments are positively correlated with each other, but the level at which they detect the incidence of PTS symptoms might differ, as was seen with the Modified PTSD Symptom Scale Self-Report and Structured Clinical Interview for DSM-IV (Verreault et al., 2012). Evidence indicated that all mothers of preterm infants were at risk of having at least one symptom of PTS symptoms and a large proportion of these mothers are at risk of developing the diagnosis of posttraumatic stress disorder (Habersaat et al., 2014; Holditch-Davis, Bartlett, et al., 2003). Although not meeting the diagnostic criteria for posttraumatic stress disorder, even one PTS symptom is detrimental to mothers’ emotional health (Habersaat et al., 2014). Findings also showed that the PTS symptoms reduced over time (Holditch-Davis et al., 2009), but some studies failed to show change over time (Brandon et al., 2011; Kersting et al., 2004) However, the measurement time point differed among studies and very few studies were longitudinal. The majority of studies had only one or two times points, which makes it difficult to see the trajectory of PTS symptoms. For example Holditch-Davis et al. (2009) followed participants up to 24 months, while Brandon et al. (2011) only studied mothers in the first month following birth. Thus, more longitudinal approaches are needed to explore the incidence and impact of PTS on mothers of preterm

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infants over time. The vast majority of research on PTS symptoms following preterm birth was conducted in developed countries and with access to high-level intensive care, which might limit generalization of the findings to community or rural hospitals or in low-income countries. The lack of evidence from low-income countries, including African countries of which Malawi is one, slows progress in the care of maternal psychological wellbeing in countries where preterm birth rates are high and resources limited. Therapy is effective in managing PTS symptoms when internal and external coping mechanisms fail, but even with available interventions in high-income countries the findings show limited accessibility to services targeting PTS. Psychoeducation has effectively reduced PTS symptoms in mothers of preterm infants (Shaw, John, et al., 2013; Shaw, Sweester, et al., 2013). Health care providers can also be trained to effectively deliver the interventions for management of PTS (Shaw, Sweester, et al., 2013). However, referral for psychotherapy was dependent on having a high score on Perinatal PTSD Questionnaire, the probability of referral for treatment did not increase until a woman’s score was 19 (Callahan et al., 2006). The Malawian health care system can adopt these interventions and train their postpartum health care providers to manage mothers with PTS. Researchers need to look into psychoeducation interventions to assess whether they are culturally sensitive and effective in other settings, including Malawi. The cross-sectional and retrospective nature and small sample sizes of most studies limit external validity of the results. Retrospective studies require mothers to remember past symptoms, recalling a previous experience is prone error as mothers tend to forget and small sample sizes resulted in non-significant findings. Most of the studies, except one RCT, utilized convenience sampling and participants were mainly from developed countries with the study mainly set in either major tertiary hospitals or the Internet based databases. Caution is needed when applying these findings to low-resource settings and to mothers in primary or secondary level hospitals. Prospective longitudinal research is needed to examine the trajectory of perinatal PTS symptoms in mothers from both high and low income countries. These findings, engage more prospective longitudinal data collection, especially for Malawi, which has the highest preterm birth rate in the world. In conclusion, mothers of preterm infants have a higher risk of PTS than mothers of healthy full-term infants. Mothers may present with one or more PTS symptoms. Even if symptoms decline over time, they remain significantly higher than in the mothers of full-term infants. Several maternal, infant, and external factors predispose mothers to PTS, and positive coping mechanisms are needed to aid mothers to adapt to the abrupt changes and interruptions in the transition to motherhood. Given the high preterm birth rate in Malawi, research on emotional responses including PTS in mothers of preterm infants should be prioritized. Malawi needs to conduct more research on PTS and use that evidence to adapt interventions for prevention and management of PTS. In addition, Malawi needs to translate and validate, or develop measures such as the Perinatal PTSD Questionnaire for assessing PTS symptoms in order to pioneer the research of PTS in the postpartum period and in mothers of preterm infants. Research on interventions for PTS symptoms will help in developing culturally sensitive interventions that improve maternal psychological wellbeing. Conflict of interest None declared. References American Psychiatric Association. (2013). Posttraumatic stress disorder. Retrieved April 1, 2014, from .

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