Abstract
Objectives
The study was aimed to assess the maternal stress level due to their infant’s neonatal intensive care stay and to understand the factors contributing to it.
Method
This prospective observational study was conducted in the level III neonatal intensive care unit (NICU) of a tertiary level public hospital in India. Mothers (N = 100) were interviewed according to the Parental Stress Score (PSS) questionnaire, during days 6–8 of their infant’s admission to the NICU.
Results
Maternal stress was found to be highest due to sights and sounds in the NICU followed by alteration of the parental role. Stress due to staff behaviour and communication was least stressful followed by baby look and behaviour. The stress due to sights and sounds was significantly higher than stress due to baby’s look and behaviour [(2.7 ± 1.4 vs 1.98 ± 2.02), p = 0.004] and staff behaviour [(2.7 ± 1.4 vs 1.58 ± 1.31), p = 0.00] while was not significantly higher than stress due to parental role [(2.7 ± 1.4 vs 2.29 ± 1.60), p = 0.055]. The stress level due to baby’s look and behaviour was not significantly higher than parental role [(1.98 ± 2.02 vs 2.29 ± 1.60), F = 1.4, p = 0.23] or staff behaviour [(1.98 ± 2.02 vs 1.58 ± 1.31), F = 2.7, p = 0.09]. The demographic characteristics such as maternal age, parity, educational stress, type of delivery, gestation, need of ventilatory support, feed intolerance and kangaroo mother care (KMC) in infants individually did not significantly affect the stress scores.
Conclusion
The involvement of mothers in neonatal care while the infants were in the NICU, early KMC and involvement of mothers in enteral feeding practices may alleviate her stress levels.
Introduction
Admission of a neonate in a neonatal intensive care unit (NICU) soon after birth is a stressful experience to the mother. 1 This stress is caused by multiple factors such as prematurity and sickness of the newborn, sophisticated NICU environment, inability to perform parental role to her satisfaction and her postpartum health status.1–3 Persistent stress in mothers related to the prolonged NICU stay of their infant is associated with severe psychological disorders including posttraumatic stress disorder and depression which will have long-term health impact to these mothers.4–6 This state will have a direct impact on the emotional, social and cognitive development of the infant.7,8 Hence, assessment of parental stress during their newborn’s NICU stay is very essential so as to identify the factors responsible for their stress and undertake measures to alleviate the same. Understanding the needs of the mother during her NICU stay and being empathic towards her may improve her confidence to look after her baby.
The most commonly used scale to assess the level of stress experienced by the parents of babies admitted to the NICU is the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU). 9 The three domains attributing to stress evaluated using this scale include parental role, infant’s behaviour and appearance, and the sight and sound in the NICU.1,3,4 Parental stress in the NICU may be influenced by several maternal and neonatal characteristics.1,3,4 Maternal factors such as elderly primigravida, those belonging to low socioeconomic status, poor educational level, young mothers with high educational status and inability to breastfeed their baby are attributed to their increased stress level during NICU stay of their infants.1,10,11 Neonatal factors attributing to increased maternal stress include prematurity, low birth weight, cardiorespiratory issues and prolonged NICU stay of babies.3,10
Recently, interventions such as kangaroo mother care and maternal involvement in routine care have shown to improve maternal anxiety and stress.12,13 Our institute being a nodal centre for kangaroo mother care (KMC) and since the mothers are allowed to be with their infants in the NICU not only for KMC but also for routine care of their newborns, we believe that parental stress will be definitely reduced by these interventions. 14 Though parental stress in the NICU has been studied in developed countries, not much research has been done in Indian population. We therefore undertook this study to examine the stress levels in mothers whose babies are admitted to the NICU in a level III hospital and also to assess other factors such as infant and maternal factors influencing the maternal stress.
Methodology
This prospective observational study was conducted in the level III NICU of a tertiary level public hospital in India. The centre is one of the largest referral Unit for neonates in Western India with an annual inborn delivery rate of approximately 6000. Nearly 1500 newborn infants are managed in the NICU annually. The study was approved by the Institutional Ethics Committee dated 12th August 2019. Written informed consent was obtained from the mothers before enrolment in the study. Participants were interviewed according to a questionnaire, Parental Stress Score (PSS) on day 6 to day 8 of admission of the neonate. 100 mothers were recruited.
Participants
Mothers of newborn infants admitted in the NICU and fulfilling the following criteria: (a) age of mothers ≥18 years and (b) NICU stay of mother >5 days were enrolled in the study. Enrolled mothers were interviewed according to the Parental Stress Score (PSS) questionnaire, on day 6 to day 8 of admission of the neonate.
Exclusion criteria: Mothers with pre-existing depression were excluded from the study. Mothers whose infants had chromosomal or congenital anomalies, duration of NICU stay <5 days and multiple gestation were excluded.
Demographic details of the mother and the hospitalisation details of the babies were recorded from the Indoor papers. The questionnaire was translated into Marathi and Hindi. The interview was taken by doctors at a convenient time of the mothers in their most comfortable language of communication.
Outcomes
The primary outcome of interest was stress level in mothers whose infants were admitted in the NICU. Maternal stress level was assessed using the PSS-based questionnaire which contained 45 items.15,16 The Scale consisted of four subscales which included (i) sights and sounds in the NICU (5 items); (ii) Infant’s behaviour and appearance (19 items), (iii) relationship with the baby and parental role (10 items) and (iv) staff behaviour and communication (11 items).
The subscale of ‘sights and sounds’ was described as the physical environment, which included the machines, equipment, lights, noises, infants and staff. The next subscale of ‘infant appearance and behaviour’ was described as how a mother’s infant looked and behaved, usually quite different to a healthy new born infant because of the illness and medical treatments. Third subscale ‘parent-infant relationship’ was described as alterations to the normal parent-infant relationship and parental role, given the nurses being the primary caregivers in the NICU. Subscale ‘staff communication and behaviour’ described how the mothers were informed about their infant’s condition or treatment by the staff nurses.
Items were rated on a Likert scale as ‘applicable’ or ‘not applicable’, and ‘applicable’ items were rated on a 4-point Likert scale (1: not stressful, 2: mildly stressful, 3: moderately stressful and 4: extremely stressful). The mean score for each subscale and mean overall scores was calculated. Maternal stress was quantified using Likert scale as low (1–2.9), medium (3–3.9) and high (4–5). The raw scores of each domain were expressed as Domain-specific Percent Stress Scores (DPSS) of the maximum possible domain score. Mean Percent Stress Score (MPSS) was the arithmetic mean of the DPSS.
Other outcomes studied were (1) Maternal characteristics:
The maternal characteristics studied included age, parity, duration of marriage/relationship, educational level, occupation, type of delivery (vaginal or caesarean section), maternal complications like pregnancy induced hypertension (PIH), gestational diabetes mellitus, socioeconomic status, inborn or out born delivery. These information were obtained from the hospital records and from the mothers during their interview for stress assessment.
15
(2) Infant characteristics:
The infant characteristics studied included gestational age, birth weight, sex of the infant, respiratory distress syndrome, jaundice requiring phototherapy, feed intolerance, infections, renal failure, cardiovascular instability, central nervous system involvement, requirement of ventilatory support, parenteral nutrition and tube feeding. Kangaroo mother care (KMC) being routinely administered to NICU infants in our unit, was also studied for its influence on maternal stress levels.
Statistical analysis
Among mothers of infants admitted in the NICU, maternal stress level was studied by Ansari et al. 17 and found the combined stress mean score for (1) sights and sound, (2) looks and behaviour and (3) parental role alteration to be 2.9 ± 0.0.8. Observations from our unit suggested that interventions such as KMC and involvement of mothers in routine care of the infants could have an impact on maternal stress level. Hence, a sample size of 80 mothers was required to detect an absolute reduction in the primary outcome of maternal stress by 10% for a study power of 90% and two tailed significance level of 0.05.
Continuous variables were compared using two sample t test/Mann Whitney U test when appropriate. Categorical data was assessed using Fischer exact test. Univariate analysis was performed using ANOVA. A p value of <0.05 was considered as statistically significant. Analysis was performed by following intention to treat principle. Data was analysed using SPSS version 16 statistical package.
Results
Study characteristics.
Outcomes
PSS: NICU individual domains.
Maternal stress level in relation to demographic characteristics.
Maternal stress score subscale comparison
A univariate analysis of variance revealed significant differences between the four PSS: NICU subscales. Stress related to sight and sound was significantly higher than stress related to baby’s look and behaviour [(2.7 ± 1.4 vs 1.98 ± 2.02), F = 8.58, p = 0.004] and staff behaviour and communication [(2.7 ± 1.4 vs 1.58 ± 1.31), F = 34.1, p = 0.00]. There was no significant difference between the stress due to sight and sound versus parental role [(2.7 ± 1.4 vs 2.29 ± 1.60), F = 3.7, p = 0.055]. The stress level due to baby’s look and behaviour was not significantly higher than parental role [(1.98 ± 2.02 vs 2.29 ± 1.60), F = 1.4, p = 0.23] or staff behaviour [(1.98 ± 2.02 vs 1.58 ± 1.31), F = 2.7, p = 0.09] (Figure 1). Maternal stress score.
Discussion
The current study shows that the mothers experience mild overall stress (mean score 1.97) during the initial few days in the NICU. Maximum stress was perceived in the ‘Sights and Sounds’ domain (2.7), which essentially includes the NICU environment and was significantly higher than the stress due to parental role and staff behaviour. The stress perceived due to limitation of the parental role contributed as the next higher subdomain for overall stress (mean of 2.29). The other two subdomains-infant’s look and behaviour and staff behaviour and communication had the lowest stress scores of 1.98 and 1.97 respectively. Maternal and infant characteristics did not significantly affect the overall stress score in mothers.
The multitude of equipment, their sounds and alarms seem to be a major cause of moderate stress to the mothers. This is in contrast to the studies from western units, which have documented mild stress due to the NICU environment.3,4,11 This may be due to the routine practice of the clinicians and staff nurses in western units to counsel parents about the possibility of NICU admission in case the infant is born preterm or sick and make them visit the NICU to get familiar with the NICU environment. In addition, parents are explained about the various equipment and their use for monitoring the neonate. This aspect is limited in our NICU given that many mothers are admitted as referral cases from the peripheral hospitals in the last hour of birth which limits the counselling sessions to the parents. Moreover, the knowledge given to them about the NICU environment and different equipment are also limited. Therefore, the new and strange NICU environment brings a lot of stress to these mothers. Similar findings were reported in a study from Sri Lanka. 2
In typical circumstances when a neonate is born healthy and stays and feeds with the mother, it is reassuring for the mother that she is performing her role well. However, when a baby is admitted to the NICU after birth, mother may feel inadequate in performing her role as a care taker, as the role primarily will be performed by the nurses looking after the baby. Many studies from western units had assessed the stress in parents whose infants were admitted in the NICU and documented increased stress in parents given that NICU admission altered their parental role and relationship with their baby.3,4,11 Our study also showed stress in mothers attributed to alteration in their parental role but of moderate degree (mean 2.3) when compared to other studies with a mean score of 3.1,3,17 This decreased stress in mothers may be attributed to the practice of regularly allowing mothers to do routine care of their newborns such as changing diapers, spoon feeding and inhouse kangaroo mother care facilities.
The third most stressful subdomain was the appearance of the baby and how the infant looked and behaved. Skin injuries due to intravenous cannulation, skin abrasions due to skin probe application and mechanical ventilation of the infant were the most stressful factors to the mother. However, it was reassuring that the stress level was of mild degree which could be attributed to the constant presence of mothers in the NICU.
Staff behaviour and communication was the least stressful subdomain overall (average score 1.58), and this was reassuring for the NICU team. Most of the studies which had assessed maternal stress had included three subdomains-NICU environment, infant appearance and parental role.1,17 We had included the fourth subdomain-staff behaviour and communication in stress level assessment given the important role a NICU staff nurse plays in neonatal care and parent communication.
To our knowledge, this is the first study which had assessed maternal stress level using four subdomains in a tertiary level NICU from low-middle income countries. The influence of kangaroo mother care practice and maternal involvement in routine baby care on maternal stress reduction though not statistically significant is to be highlighted. The assessment was done at the end of first week of life in all mothers which is usually the most stressful period. The stress level in the fathers not being assessed could be a limitation of the study. In addition, reassessment of stress in mothers after the first week of life was not done.
The results of this study highlight the importance of timely counselling and communication to the parents, especially the mother about her infant’s status. The involvement of mothers in neonatal care while the infant is in the NICU, early KMC and involvement of mothers in enteral feeding practices may alleviate her stress levels.
Footnotes
Acknowledgements
The authors thank the Dean Dr Sangeeta Ravat for permitting to publish the manuscript.
Author contributions
AU conceptualised and designed the work, implemented the study, did the statistical analysis, edited the manuscript and gave final approval. AH implemented the study, drafted the initial manuscript, did statistical analysis and edited the final version. RN edited the manuscript, gave inputs and approved the final version.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
The study was approved by the Institutional Ethics Committee, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, and participants were enrolled after obtaining written informed consent. The study was conducted as per Declaration of Helsinki.
