The Relationship of Breastfeeding Patterns in the Neonatal Intensive Care Unit to Maternal Symptoms of Anxiety and Depression

Abstract

Background:

The studies related to psychiatric disorders have demonstrated high frequency of maternal stress, anxiety, and postpartum depression in mothers who have infants in neonatal intensive care unit (NICU). It is well known that maternal anxiety and depression adversely affect breastfeeding. The research aims to examine the association between the anxiety and depressive symptom severity of NICU mothers and feeding type (exclusively breastfed [EBF] or mixed fed [MF]) of their infants within first week of life in NICU.

Methods:

Data were collected from 93 mothers and 105 infants in a single-center, prospective, cross-sectional, descriptive study. The state–trait anxiety and depressive symptom severity of NICU mothers were evaluated using the Spielberger State–Trait Anxiety Inventory (STAI, including Spielberger State–Trait Anxiety Inventory-State [STAI-S], Spielberger State–Trait Anxiety Inventory-Trait [STAI-T]), and Edinburgh Postnatal Depression Scale (EPDS).

Results:

Breastfeeding exclusivity in NICU infants was significantly related to gestational age, birth weight, prenatal steroid, and assisted reproductive technology (ART; p = 0.022, 0.041, 0.028, 0.017, respectively). The comparison of STAI-S, STAI-T, and EPDS scores of NICU mothers between EBF and MF groups revealed that STAI-T score was significantly high in EBF group than that in the MF group (p = 0.019). Logistic regression analyses showed that a 1-unit increase in STAI-T score in NICU mothers was significantly associated with a 5.7% increase in the odds of breastfeeding exclusivity within first week in postpartum period (p = 0.033; odds ratio = 1.057, 95% confidence interval = 1.004–1.113).

Conclusions:

Contrary to estimates, clinically significant state and trait anxiety symptoms and depressive symptoms of NICU mothers do not affect breastfeeding exclusivity negatively within first week of life in NICU. Preterm infants under 32 gestational weeks and infants born with ART have a tendency to being EBF.

Introduction

Neonatal intensive care unit (NICU) is a scary, worrisome, and traumatic place for parents who were separated from their infants physically and emotionally. They feel unfamiliar to the place involving medical equipment, lights, alarms, doctors, nurses, and medical terminology. Beyond this foreign environment, the major stressor for parents is having a sick infant in need of ventilator, catheter, and medical treatments to survive. Mostly, they think that the infant lying in the incubator suffers from pain and they feel helpless to relieve this pain. All these factors result in sense “loss of control” and psychiatric symptoms.^1–4

The studies related to psychiatric disorders have demonstrated high frequency of maternal stress, anxiety, and postpartum depression (PPD) in mothers who have infants in NICU.^5–11 Ong et al.⁵ reported a high level of state–anxiety (85.5%) and a high level of trait–anxiety (67.8%) among 180 mothers who had preterm infants in the NICU. Literature revealed higher rates of PPD (28–70%) in NICU mothers compared with mothers of healthy term infants who do not need NICU.¹¹ However, Tahirkheli et al.⁷ reviewed that sociodemographic factors such as poverty, low social support, high levels of stress, and low maternal education in mothers of preterm or low birth weight infants are risk factors for PPD. Therefore, providing psychosocial support to NICU mothers is considered equally important for providing medical care and developmental support to the infant. The authors emphasized that despite increased awareness, attention to this underdiagnosed and undertreated entity is not adequately addressed in NICUs yet.

It is well known that maternal anxiety and depression adversely affect breastfeeding. A systematic review on postpartum anxiety and breastfeeding revealed that in some studies, women with postpartum anxiety were less likely to initiate breastfeeding and frequently tend to use formula during their hospitalization.¹² Similarly, postnatal depressive symptoms of mothers were shown to be associated with an increased risk of the discontinuation of breastfeeding.¹³

To date, many studies have demonstrated the negative consequences of maternal anxiety and depressive symptoms on breastfeeding in short and long-term periods.^13–16 However, studies evaluating the relationship of breastfeeding exclusivity and maternal mental health were conducted mostly at later times during the postpartum period or in infancy period.^13,15–18 There is a gap in the literature on breastfeeding exclusivity in early postpartum period in the NICU. So, we aimed to investigate the relation between breastfeeding exclusivity of NICU infants and the severity of anxiety and depressive symptoms of NICU mothers in early postpartum period together with demographic and socioeconomic factors.

Materials and Methods

Design

The study design was a single-center, prospective, cross-sectional, descriptive-relational pattern, self-report survey. First, we aimed to determine the demographic and socioeconomic characteristics, the severity of state–trait anxiety symptoms and depressive symptoms of NICU mothers with using the following two measures: the Spielberger State–Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale (EPDS). Second, the aim was to evaluate the associations between these measures and feeding type (exclusively breastfed [EBF] or mixed fed [MF]) of their infants in the first week of life in the NICU. The Institutional Ethics Committee approved the study (No. 25403353-050.99-E.279) and informed consent forms were received from all parents before inclusion in the study.

Setting

The study was conducted in level-III NICU of Eskisehir Osmangazi University Hospital, Eskişehir, Turkey, between November 1, 2018 and February 1, 2020. Our hospital had baby-friendly hospital certificate. According to our NICU enteral nutrition protocol, the first choice was breast milk and the second choice was preterm/term infant formula in case of complete absence or inadequate amount of maternal breast milk. Minimal enteral nutrition was initiated on the first day of life at a volume of 10–20 mL/kg/day in infants with a birth weight of <1,500 g and 21–40 mL/kg/day in infants with a birth weight of ≥1,500 g. The enteral nutrition volume was increased by 10–15 mL/kg/day if possible and finally reaching 150–180 mL/kg/day. All infants received enteral nutrition every 3 hours ( × 8/day). Infants who could not suck bottles adequately were fed by orogastric feeding tubes. Total parenteral nutrition was initiated according to nursery protocol in very low birth weight (<1,500 g) infants and in those for whom enteral nutrition was not sufficient to achieve optimal energy supply.

Sample

All preterm and term infants admitted to the NICU setting for any reason and their mothers were eligible for the study. Exclusion criteria were as follows: infants with congenital or chromosomal abnormalities, inherited metabolic diseases, hydrops fetalis, infants who were hospitalized <7 days because of discharge or death, mothers younger than 18 years old, mothers who cannot give breast milk owing to medical problems, and immigrant mothers who do not know Turkish.

Measurement

Demographics

Maternal demographic and socioeconomic characteristics including age, marital status, education level, employment status, family type at home, and household income was recorded. NICU mothers asked for the assessment of social support (insufficient, average, and sufficient) and the presence of unmet needs (warming/harboring/food/clothing). The social worker of our NICU performed family meetings and supported the families financially when needed.

The prenatal data included maternal morbidities (hypertensive disorders, diabetes mellitus, and premature rupture of membrane), parity, number of children, pregnancy with assisted reproductive technology (ART), multiple gestation in the current pregnancy, prenatal steroid, smoking, and psychiatric support before enrollment to the study. Natal data including gestational age (categorized as <32, 32–36, >37 weeks), gender, birth weight, mode of delivery, need of aggressive resuscitation in delivery room (positive pressure ventilation through bag and mask or endotracheal tube, chest compression, or drug administration) were recorded. Postnatally, the indications of NICU admission (cardiac, respiratory, infection, metabolic, and others), the need of mechanical ventilation (invasive or noninvasive support) and feeding type were recorded.

Feeding type

All infants in the study were fed according to our institutional NICU nutritional protocol. Feeding type (EBF or MF) of NICU infants within first week of life was recorded. EBF/breastfeeding exclusivity was determined as feeding with only breast milk, without any additional food or formula, not even water. MF was defined as feeding with breast milk and formula.

Spielberger State–Trait Anxiety Inventory

Maternal anxiety was evaluated using the Spielberger State–Trait Anxiety Inventory (STAI). The STAI is a self-report questionnaire including 40 items: state anxiety (20) and trait anxiety (20). State-anxiety scale captures the mothers' current anxiety level questioning how respondents feel “right now,” using items representing subjective feelings of apprehension, tension, nervousness, worry, and activation/arousal of the autonomic nervous system. Trait-anxiety scale reflects a stable measure of anxiety including general states of calmness, confidence, and security. Both of them use a 4-point Likert scale of which cumulative score differs between 20 and 80. Responses for the state scale reflect intensity of current feelings “at this moment”: (1) not at all, (2) somewhat, (3) moderately so, and (4) very much so. Responses for the trait scale evaluate frequency of feelings “in general”: (1) almost never, (2) sometimes, (3) often, and (4) almost always.¹⁹

The original version of the STAI was translated from English to Turkish, and the validity and reliability studies were performed by Oner and Le Compte.²⁰ The internal consistency for the State Anxiety Tool of the STAI was between 0.94 and 0.96.²¹ Scores between 40 and 59 were indicative of moderate anxiety, whereas scores between 60 and 80 were indicative of severe anxiety. We accepted the cutoff score >40 (minor/major anxiety symptoms) as suggested by Dennis et al.²² and scores >40 indicated the presence of clinically significant state and trait anxiety symptoms in this study.

Edinburgh Postnatal Depression Scale

EPDS is a commonly used screening measure for mother's postnatal level of depressive symptoms.²³ This scale includes 10 questions assessing emotional and cognitive symptoms of PPD during the past week. This self-report measure uses a four-point Likert-type scale and the aim was to identify the risk of depression and not to diagnose it. The translated version of EPDS is validated by the study of Aydın et al.²⁴ According to this study cutoff at 12.5 gives sensitivity at 75.5% and specificity at 71%. The EPDS has shown Cronbach's alpha value as 0.72. We accepted the scores >12 as the presence of clinically significant depressive symptoms in this study. If the STAI and EPDS scores were less than the chosen cutoff scores, the mothers were defined as mothers with no clinically significant state and/or trait anxiety and depressive symptoms.

Data collection

Mothers were invited to participate in the questionnaire-based study 48 hours after the admission to NICU in the first week. Written consent was obtained from the mothers who agree to participate. In the quiet information room, mothers independently completed the questionnaire of the scales in the form of self-report with a paper and pencil. The researchers were nearby to provide any assistance during the session. After the completion of questionnaire, the researchers checked the suicidal ideation item (i.e., item No. 10 of the EPDS) to help the mother for immediate psychiatric support. In addition, the NICU mothers were informed of the results by researchers and offered referral to the psychiatrist by the researcher in case of high scores indicating anxiety and depression. Furthermore, the social worker of our NICU kept in touch with the NICU mothers and social service supported the mothers when needed. In addition, the demographic and clinical characteristics of the infants were recorded.

Data analysis

The statistical data were analyzed with IBM SPSS 21.0. Summary statistics of continuous variables were shown as mean ± standard deviation (SD) or median (Q1–Q3), whereas categorical variables were presented as count and percentages. Normality of continuous variables was evaluated with Shapiro–Wilk test. For the normally distributed groups, the comparisons were performed with t-test for two groups and one-way analysis of variance (ANOVA) for three groups. For non-normal distributed group comparisons, Mann–Whitney U-test and Kruskal–Wallis test were used. Bonferroni and Dunn's tests were used for multiple comparisons of ANOVA and Kruskal–Wallis, respectively.

Association between continuous variables was evaluated with Spearman correlation analysis. Chi-square analysis was conducted to assess the relationship between categorical variables. Factors affecting breastfeeding exclusivity were investigated by logistic regression analysis. There were 93 mothers but 105 infants owing to multiple gestations in 11 women; hence, the analysis evaluating the relation between feeding type and clinically significant symptoms of anxiety and depression of NICU mothers was performed according to the first child because the feeding type of twins and triplets were same. p-Values <0.05 were considered significant.

Results

A total of 93 women with a mean age of 30.61 years (SD = 5.03, range = 27–34) and 105 infants in the NICU were recruited. The mean time to complete the questionnaires was 5 ± 2 days. Seventy-five of 105 infants in the study were preterm, 30 of them were born at term. Detailed data including demographic, socioeconomic, and clinical characteristics of NICU mothers and infants in the study are given in Table 1.

Table 1.

Demographıc, Socioeconomic and Clınıcal Characterıstıcs of Neonatal Intensive Care Unit Mothers (N = 93) and Infants (N = 105) ın the Study

NICU Mothers	N = 93	NICU infants	N = 105
Maternal age in years, mean ± SD	30.61 ± 5.03	Gestational age
		<32 weeks	28 (26.7)
		32–36 weeks	47 (44.8)
		>37 weeks	30 (28.5)
Marital status, n (%)		Birth weight
Married	91 (97.8)	<1,500 g	30 (28.6)
Single	1 (1.1)	1,500–2,499 g	34 (32.4)
Divorced	1 (1.1)	>2,500 g	41 (39)
Education, n (%)		Gender (female/male)	41/64 (39%/61)
Elementary school	26 (28.0)
Secondary-high school	41 (44.1)
Bachelor's degree	26 (28.0)
Employment status at enrollment, n (%)		Mode of delivery
Not employed	68 (73.1)	V	16 (15.2)
Employed	25 (26.9)	C/S: cesarean section	89 (84.8)
Family type at home		Resuscitation in the delivery room	29 (27.6)
Nuclear family	82 (88.2)
Extended family	11 (11.8)
Household income (TL), n (%)		Need of mechanical ventilation	53 (50.5)
<1,600 TL	23 (24.7)
1,600–3,200 TL	44 (47.3)
>3,200 TL	26 (28.0)
Parity, n (%)		Indications of NICU admission
Primiparous	38 (40.9)	Cardiac	2 (1.9)
Multiparous	55 (59.1)	Respiratory	74 (70.5)
		Infection	2 (1.9)
		Metabolic	18 (17.1)
		Others	9 (8.6)
Number of children		Feeding type
One	34 (36.6)	Exclusively breast-fed	45 (42.9)
More than one child	59 (63.4)	Mixed (breastfed+formula)	60 (57.1)
Multiple gestation in the current pregnancy	11 (11.8)	Initiation of first feeding
		First 24 hours	47 (44.8)
		25–48 hours	46 (43.8)
		49–72 hours	12 (11.4)
Pregnancy with ART	7 (7.5)
Morbidities
Hypertensive disorders	22 (23.7)
Diabetes mellitus	14 (15.1)
Premature rupture of membrane	6 (6.5)
Smoking	14 (15.1)
Mothers receiving psychiatric support before enrollment of the study	5 (5.4)
Prenatal steroid	40 (40.3)

ART, assisted reproductive technology; C/S, cesarean section; NICU, neonatal intensive care unit; SD, standard deviation; V, vaginal.

The scores revealed from STAI and EPDS, which indicates the severity of anxiety and depressive symptoms of NICU mothers, are given in Table 2. The scores of Spielberger State–Trait Anxiety Inventory-State (STAI-S) (a), Spielberger State–Trait Anxiety Inventory-Trait (STAI-T) (b), and EPDS (c) were strongly correlated with each other (r_ab = 0.639, p < 0.001; r_ac = 0.750, p < 0.001; r_bc = 0.685, p < 0.001). According to these tools, 40 NICU mothers (43.0%) had clinically significant state and/or trait anxiety symptoms, 24 of them (25.8%) had both clinically significant state and/or trait anxiety and depressive symptoms and 29 of them (31.2%) had neither clinically significant state and/or trait anxiety nor depressive symptoms.

Table 2.

Anxiety and Depression Level of Neonatal Intensive Care Unit Mothers (N = 93)

High EPDS score >12, n (%)	24 (25.8)
EPDS score^a	8 (4–13)
High STAI-S score >40, n (%)	48 (51.6)
STAI-S score^b	41.08 ± 11.20
High STAI-T score >40, n (%)	54 (58.1)
STAI-T score^b	42.49 ± 8.84
Mothers have no clinically significant state and/or trait anxiety and depressive symptoms	29 (31.2%)
Mothers have clinically significant state and/or trait anxiety symptoms	40 (43.0%)
Mothers have both clinically significant state and/or trait anxiety and depressive symptoms	24 (25.8%)

Median (Q1–Q3).

Mean ± SD.

EPDS, Edinburgh Postnatal Depression Scale; STAI-S, Spielberger State–Trait Anxiety Inventory-State; STAI-T, Spielberger State–Trait Anxiety Inventory-Trait.

There was no relationship between the variables in Table 1 and the presence of clinically significant state and/or trait anxiety and depressive symptoms. However, 63.8% of the mothers who had high STAI-S scores found social support as insufficient or average, whereas 68.9% of the mothers who had no clinically significant state and/or trait anxiety symptoms found it sufficient (p = 0.001). The presence of unmet needs (warming/harboring/food/clothing) were higher in the mothers presenting clinically significant state and/or trait anxiety symptoms (19.2%) than in those mothers presenting no clinically significant state and/or trait anxiety symptoms (2.3%; p = 0.026). In addition, 75% of the mothers with clinically significant depressive symptoms found social support as insufficient or average, whereas 61.8% of the mothers without clinically significant depressive symptoms found it sufficient (p = 0.004). The presence of unmet needs was higher in mothers with clinically significant depressive symptoms (25%) than that in mothers without clinically significant depressive symptoms (6%; p = 0.014).

Among 105 infants, 45 infants (42.9%) were EBF and 60 infants (57.1%) were MF in NICU within first week of life. Breastfeeding exclusivity in NICU infants was significantly related to gestational age, birth weight, prenatal steroid, and ART (p = 0.022, 0.041, 0.028, and 0.017, respectively) (Table 3). The comparisons of state and/or trait anxiety and depression scores of NICU mothers between EBF and MF group revealed that STAI-T score was significantly high in EBF group than that in MF group (p = 0.019). STAI-S and EPDS scores were also high in EBF group than that in MF group but statistically not significant (p = 0.153, 0.162, respectively) (Table 4).

Table 3.

The Significant Variables Affecting the Breastfeeding Exclusivity of Neonatal Intensive Care Unit Infants Within First Week of Life

Feeding type/variables	Exclusively breastfed group, N = 38 (%)	Mixed fed group (breastfed+formula), N = 55 (%)	p
Gestational age
<32 Weeks	16 (42.1%)	9 (16.4%)	0.022
32–36 Weeks	12 (31.6%)	27 (49.1%)
>37 Weeks	10 (26.3%)	19 (34.5%)
Birth weight			0.041
<1,500 g	16 (42.1%)	11 (20%)
1,500–2,499 g	11 (28.9%)	16 (29.1%)
>2,500 g	11 (28.9%)	28 (50.9%)
Prenatal steroid	22 (57.8%)	18 (32.7)	0.028
Pregnancy with ART	6 (15.7%)	1 (1.8%)	0.017

Bold is significant.

Table 4.

Comparison of Anxiety and Depression Scores of Neonatal Intensive Care Unit Mothers According to the Feeding Type of Their Infants Within First Week of Life

Feeding type	Exclusively breastfed group, N = 38	Mixed fed group (breastfed+formula), N = 55	p
STAI-S score^a	43.07 ± 10.75	39.69 ± 11.39	0.153
STAI-T score^a	45.05 ± 9.30	40.72 ± 8.11	0.019
EPDS score^b	10.0 (5.0–14.0)	7.0 (4.0–13.0)	0.162

Bold is significant.

Mean ± SD.

Median (Q1–Q3).

Logistic regression analysis was performed by putting the variables including maternal age, education, household income, preterm birth, multiple gestation, STAI-S, STAI-T, and EPDS scores in backward stepwise model to find the effective variable for breastfeeding exclusivity. This analysis revealed that a 1-unit increase in STAI-T score in NICU mothers was significantly associated with a 5.7% increase in the odds of breastfeeding exclusivity within first week in postpartum period (p = 0.033; odds ratio = 1.057, 95% confidence interval = 1.004–1.113).

Discussion

Our study revealed that in the first week of NICU admission, breastfeeding exclusivity was 42.9% among NICU infants and it was not related to the presence of clinically significant anxiety and depressive symptoms of NICU mothers. Exclusive breastfeeding in the first 3 days after birth was reported as 59% according to 2013 Turkey demographic and health survey.²⁵ Our results can be a reflection of decreased lactation in NICU mothers.

In general, it is predicted that women with postpartum anxiety and/or depression are less likely to succeed exclusively breastfeeding and more likely to discontinue breastfeeding and choose formula feeding.^12,13,26 Fallon et al.¹² reviewed that six of the eight studies investigating the relationship between postpartum anxiety and breastfeeding exclusivity reported inverse relationship. Similar to our study, two cohort studies demonstrated no relationship between postpartum anxiety and breastfeeding exclusivity.^27,28 In addition, a Brazilian cohort study revealed no relationship between state or trait anxiety and milk production in the first month postpartum.²⁹ In addition, no association was detected between prenatal anxiety and breastfeeding initiation or exclusivity in a systematic review.¹⁶ In our study, 5 of 93 mothers (5.4%) received psychiatric support before enrollment of the study, but no association was detected with breastfeeding exclusivity.

At present, we have learnt “reciprocal relationship” between depression and breastfeeding. It is known that depression negatively affects breastfeeding; on the contrary, breastfeeding plays a role in improving the symptoms of depression.²⁶ Hahn-Holbrook et al.³⁰ suggested that breastfeeding plays an important role in the mental health of mothers by downregulating the hypothalamic, pituitary, and adrenal axis circadian rhythm to decrease the response to stress by stimulating the nervous system. However, Pope et al.³¹ reported no association between PPD and breastfeeding evaluating the confounders of low income, perceived stress/social support, and no history of depression/abuse. Similarly, our study revealed that the presence of clinically significant depressive symptoms in NICU mothers was not related to breastfeeding exclusivity. Conversely, the median of EPDS scores of the mothers in EBF group (10.0 [5.0–14.0]) was higher than that in MF group (7.0 [4.0–13.0]; p = 0.162) (Table 3).

We studied potential confounders for breastfeeding exclusivity such as maternal age, education, household income, preterm birth, multiple gestation, STAI-S, STAI-T, and EPDS scores, and finally the results revealed that only STAI-T score was significantly associated with breastfeeding exclusivity. A 1-unit increase in STAI-T score in NICU mothers was significantly associated with a 5.7% increase in the odds of breastfeeding exclusivity. Depending on this surprising result, we suggested that clinically significant anxiety and/or depressive symptoms may have a positive motivating effect on mothers to give breast milk for the infant in NICU. Supplying breast milk may be the only way of holding on for a woman who is unable to fulfill her parenting activities in NICU such as feeding, holding, bathing, or diaper changing.^1,2,4 Interrupted maternal role causes symptoms of anxiety and/or depression² and this emotional condition may increase the NICU mothers' motivation for exclusive breastfeeding. Depending on the multifactorial dynamics, breastfeeding exclusivity may change in the next weeks.

When the significant variables affecting breastfeeding exclusivity of NICU infants within first week of life were examined, preterm birth was noted. The frequency of EBF infants were high especially in preterm infants under 32nd gestational week, <1,500 g of birth weight, and infants who were treated with prenatal steroid. This significant relation may be a result of our insistence on feeding preterm infants with breast milk and the requirement of small volumes of nutrition in preterm infants compared with term infants. The mothers who conceive through ART were 85.7% more likely to exclusively breastfeed. This may be related to the desire and motivation of the mothers to have a child.

The postpartum period carries high risk for both anxiety disorders and depression.^31,32 In this critical period, NICU mothers were more likely to present symptoms of maternal stress, anxiety, and PPD.^5–7 A review reported that anxiety was detected in 24% of NICU mothers.⁹ A study showed that anxiety decreases over time in the postpartum period.³³ Similarly, another population-based study demonstrated high score (>40) on the STAI in 22.6% of mothers at first week, subsequently in 17.2% of mothers at 4 weeks, and in 14.8% of mothers at 8 weeks. However, STAI was shown as a good tool to detect postpartum anxiety even in early postpartum period.²² A cutoff point of >40 on the STAI in our study revealed that 48 mothers (51.6%) had high STAI-S score and 54 mothers (58.1%) had high STAI-T score.

However, according to EPDS, 24 mothers (25.8%) had high EPDS scores. Only 29 mothers (31.2%) had no clinically significant state and/or trait anxiety and depressive symptoms. Another study in NICU reported a frequency of 40% for depression risk according to EPDS and 17.8% for anxiety according to another scale from STAI.⁶ Our results demonstrated that NICU mothers substantially present pyschiatric symptoms and compared with the literature we detected higher rates of clinically significant state and/or trait anxiety but lower rates of clinically significant depressive symptoms. The high rate of depression risk may be related to the cutoff point in EPDS, which differs among countries. The cutoff point for EPDS was >12 in our study, whereas it was >10 in many studies. So, the rate of depression risk (25.8%) was found lower than that of the others. On the contrary, a study from Turkey showed high rates of depression risk (38.3%, with a mean score of 10.97 ± 6.93) in NICU mothers at second week after delivery.³⁴ Distinctly, the median of EPDS of NICU mothers in our study was 8 (4–13). This may be related to different sociodemographic characteristics of mothers or the timing of studies.

Of interest, no relation was detected between the presence of clinically significant state and/or trait anxiety and depressive symptoms and the variables in Table 1. Only low social support (insufficient or average) and unmet needs were significantly higher in mothers with clinically significant state and/or trait anxiety and depressive symptoms. Similarly, Helle et al.³⁵ reported low social support beyond high trait anxiety, the birth of a very low birth weight infant, and high stress during birth as the most important predictors for postpartum state anxiety.

Limitations

Our study has several limitations. First, this study was limited by a small sample size in a single center. Second, because of the cross-sectional design and the absence of repeated measures on the same individual, it was not possible to establish temporal relationships. We could not determine how these symptoms change in the first weeks/months of postpartum period. In addition, the scales were self-administered questionnaires that may cause response bias. In future studies with larger sample sizes, it will be more appropriate to evaluate NICU fathers and NICU mothers together.

Conclusion

Our study revealed high rates of clinically significant state and/or trait anxiety and depressive symptoms in NICU mothers. Contrary to estimates, presence of clinically significant state and/or trait anxiety and depressive symptoms do not affect breastfeeding exclusivity negatively. However, 1 unit increase in trait anxiety was associated with a 5.7% increase in the odds of breastfeeding exclusivity. By this study, we succeeded working in collaboration with our social worker as a part of NICU staff. The NICU mothers who screened positive for the risk of depression and anxiety were referred to psychiatry and mothers in need of harboring, clothing, and so on, were supported from social services. Screening NICU mothers for mental health, giving them a financial/social/psychiatric support will probably affect the family dynamics, child–mother interaction, breastfeeding, and finally, child well-being in a positive manner.^{3,7,11,13,26,36}

Further research is required to develop a deeper understanding of the relationships between paternal and maternal anxiety and/or depression on lactation, parenting activities and developmental outcomes of the infants in the NICU.

Ethics Committee Approval

The Institutional Ethics Committee approved the study (No. 25403353–050.99-E.279) and informed consent forms were received from all parents before inclusion in the study.

Footnotes

Acknowledgments

The authors are grateful to all NICU mothers who participated in this study during a critical time in their lives, and to the whole NICU staff.

Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

No funding was received for this article.

References

Staver

, Moore

, Hanna

. Maternal distress in the neonatal intensive care unit: A concept analysis. Adv Neonatal Care, 2019; 19:394–401.

Obeidat

, Bond

, Callister

. The parental experience of having an infant in the newborn intensive care unit. J Perinat Educ, 2009; 18:23–29.

McCabe-Beane

, Stasik-O'Brien

, Segre

. Anxiety screening during assessment of emotional distress in mothers of hospitalized newborns. J Obstet Gynecol Neonatal Nurs, 2018; 47:105–113.

Woodward

, Bora

, Clark

, et al. Very preterm birth: Maternal experiences of the neonatal intensive care environment. J Perinatol, 2014; 34:555–561.

Ong

, Abdullah

, Danaee

, et al. Stress and anxiety among mothers of premature infants in a Malaysian neonatal intensive care unit. J Reprod Infant Psychol, 2019; 37:193–205.

Bonacquisti

, Geller

, Patterson

. Maternal depression, anxiety, stress, and maternal-infant attachment in the neonatal intensive care unit. J Reprod Infant Psychol, 2020; 38:297–310.

Tahirkheli

, Cherry

, Tackett

, et al. Postpartum depression on the neonatal intensive care unit: Current perspectives. Int J Womens Health, 2014; 6:975–987.

González-Hernández

, González-Hernandez

, Fortuny-Falconi

, et al. Prevalence and associated factors to depression and anxiety in women with premature babies hospitalized in a neonatal intensive-care unit in a Mexican population. J Pediatr Nurs, 2019; 45:e53–e56.

Roque

ATF

, Lasiuk

, Radünz

, et al. Scoping review of the mental health of parents of infants in the NICU. J Obstet Gynecol Neonatal Nurs, 2017; 46:576–587.

10.

Helle

, Barkmann

, Ehrhardt

, et al. Postpartum posttraumatic and acute stress in mothers and fathers of infants with very low birth weight: Cross-sectional results from a controlled multicenter cohort study. J Affect Disord, 2018; 235:467–473.

11.

Mounts

. Screening for maternal depression in the neonatal ICU. Clin Perinatol, 2009; 36:137–152.

12.

Fallon

, Groves

, Halford

, et al. Postpartum anxiety and infant-feeding outcomes: A systematic review. J Hum Lact, 2016; 32:740–758.

13.

Sha

, Gao

, Chen

, et al. A prospective study of maternal postnatal depressive symptoms with infant-feeding practices in a Chinese birth cohort. BMC Pregnancy Childbirth, 2019; 19:388.

14.

Vieira

, Caldeira

, Eugênio

, et al. Breastfeeding self-efficacy and postpartum depression: A cohort study. Rev Lat Am Enfermagem, 2018; 26:e3035.

15.

Silva

, Lima

, Sequeira-de-Andrade

LAS

, et al. Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. J Pediatr (Rio J), 2017; 93:356–364.

16.

Hoff

, Movva

, Rosen Vollmar

, et al. Impact of maternal anxiety on breastfeeding outcomes: A systematic review. Adv Nutr, 2019; 10:816–826.

17.

Whitley

, Wouk

, Bauer

, et al. Oxytocin during breastfeeding and maternal mood symptoms. Psychoneuroendocrinology, 2020; 113:104581.

18.

Arifunhera

, Srinivasaraghavan

, Sarkar

, et al. Is maternal anxiety a barrier to exclusive breastfeeding?. J Matern Fetal Neonatal Med, 2016; 29:2798–2801.

19.

Spielberger

CD.

State-Trait Anxiety Inventory STAI. Palo Alto, CA: Consulting Psychologists Press, 1983.

20.

Oner

, Le Compte

. Durumluk Surekli Kaygı Envanteri El Kitabı [in Turkish]. Istanbul: Bogazici Universitesi Yayınları, 1983.

21.

Franck

, Cox

, Allen

, et al. Measuring neonatal intensive care unit-related parental stress. J Adv Nurs, 2005; 49:608–615.

22.

Dennis

, Coghlan

, Vigod

. Can we identify mothers at-risk for postpartum anxiety in the immediate postpartum period using the State-Trait Anxiety Inventory?. J Affect Disord, 2013; 150:1217–1220.

23.

Cox

, Holden

, Sagovsky

. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry, 1987; 150:782–786.

24.

Aydin

, Inandi

, Yigit

, et al. Validation of the Turkish version of the Edinburgh Postnatal Depression Scale among women within their first postpartum year. Soc Psychiatry Psychiatr Epidemiol, 2004; 39:483–486.

25.

Paksoy Erbaydar

, Erbaydar

. Relationship between caesarean section and breastfeeding: Evidence from the 2013 Turkey demographic and health survey. BMC Pregnancy Childbirth, 2020; 20:55.

26.

Oyetunji

, Chandra

. Postpartum stress and infant outcome: A review of current literature. Psychiatry Res, 2020; 284:112769.

27.

Akman

, Kuscu

, Yurdakul

, et al. Breastfeeding duration and postpartum psychological adjustment: Role of maternal attachment styles. J Paediatr Child Health, 2008; 44:369–373.

28.

O'Brien

, Buikstra

, Hegney

. The influence of psychological factors on breastfeeding duration. J Adv Nurs, 2008; 63:397–408.

29.

Aragaki

Study about the trace and anxiety state of nursing mothers with the insufficient breastfeeding indicators presented by them and nursing mothers with normal breastfeeding. [translated from Portuguese]. Universidade de Sao Paulo, Sao Paulo, Brazil, 2002.

30.

Hahn-Holbrook

, Haselton

, Dunkel Schetter

, et al. Does breastfeeding offer protection against maternal depressive symptomatology?: A prospective study from pregnancy to 2 years after birth. Arch Womens Ment Health, 2013; 16:411–422.

31.

Pope

, Mazmanian

, Bédard

, et al. Breastfeeding and postpartum depression: Assessing the influence of breastfeeding intention and other risk factors. J Affect Disord, 2016; 200:45–50.

32.

Ross

, McLean

. Anxiety disorders during pregnancy and the postpartum period: A systematic review. J Clin Psychiatry, 2006; 67:1285–1298.

33.

Field

. Postnatal anxiety prevalence, predictors and effects on development: A narrative review. Infant Behav Dev, 2018; 51:24–32.

34.

Gönülal

, Yalaz

, Altun-Köroğlu

, et al. Both parents of neonatal intensive care unit patients are at risk of depression. Turk J Pediatr, 2014; 56:171–176.

35.

Helle

, Barkmann

, Ehrhardt

, et al. Postpartum anxiety and adjustment disorders in parents of infants with very low birth weight: Cross-sectional results from a controlled multicentre cohort study. J Affect Disord, 2016; 194:128–134.

36.

John

, Philip

, Santhanam

, et al. Activity based group therapy reduces maternal anxiety in the Neonatal Intensive Care Unit—A prospective cohort study. Early Hum Dev, 2018; 123:17–21.