Effect of Early Support on the Stress of Mothers with Preterm Infants in Neonatal Intensive Care Units: A Quasi-experimental Study

During pregnancy, women have expectations of their future baby, and preterm delivery may negatively affect such expectations. On the other hand, postpartum maternal stress is a well-established issue, which intensifies with the birth of a premature infant. Preterm birth is an unexpected experience and a multifaceted incident that leads to two main consequences, which are the medical and neurophysiological complications of the infant (especially in very-low-birth-weight infants weighing less than 1,500 grams and aged less than 32 weeks) and the adverse effects on the mother-infant relationship due to the prolonged admission of the infant to the neonatal intensive care unit (NICU). If the infant is not discharged, the mother will be unable to fully assume their maternal role. Therefore, proper intervention protocols help reduce maternal stress and empower mothers to cope with the complex and technological environment of the NICU. The present study aimed to evaluate the impact of evidence-based early supportive interventions on the maternal stress caused by preterm birth.

This quasi-experimental study was performed at the NICUs of Mahdieh Hospital and Shahid Akbarabadi Hospital in Tehran, Iran. Sampling started on February 14, 2016 and continued until May 14, 2016. Both centers were teaching, referral hospitals with three levels of NICUs. NICU level one is designed for generally ill and low-birth-weight infants who do not require intensive care (minimal care and basic care following delivery), NICU level two is considered for the infants who need other intensive care than ventilator support and surgical care, and NICU level three is designed for the critically ill infants who require life-sustaining therapies, particularly auxiliary ventilation and optimally tailored neonatal intensive care. In this study, the hospitals were considered as random allocation units, with Mahdieh Hospital assigned to the intervention site and Shahid Akbarabadi Hospital assigned to the control site. The sample population included mothers with premature infants. Preterm infants and their mothers were selected within three months based on the inclusion and exclusion criteria of the study. The inclusion criteria were having an infant with the gestational age of less than 37 weeks, birth weight less than 2,500 grams, and high probability of survival, maternal consent for enrollment, Iranian nationality, and the ability to communicate verbally. The exclusion criteria were infants with abnormalities or severe debilitative conditions (e.g., grade III or IV intraventricular hemorrhage). During the study period, 75 mothers and infants were classified as the intervention group, and 68 mothers and infants were assigned to the control group. The intervention was designed based on the model of the support system of mothers with premature infants. In this model, parents and infants are at the center of the support model and should be supported during critical transitional periods, including pre-fertilization, before delivery, NICU admission, discharge, and at home. Based on the model, various interventions were provided to the mothers at the NICUs, which gradually started upon the admission of the premature infant to the NICU, continued throughout the admission, followed-up the subjects until three months since the birth of the infant. In the intervention group, the mothers were provided with continuous informational support (emphasis on the continuous provision of information to the mothers about the infantschr('39') illness, treatment, growth and care, infantschr('39') emotional and behavioral needs and responses, and maternal rights and responsibilities during admission). Furthermore, we provided spiritual support (in an illness crisis, spirituality may be essential to coping and have a positive impact on the response of individuals since reliance upon a higher power could become a source of hope for a positive outcome. Fostering spiritual values protects individualschr('39') integrity and gains spiritual perseverance to encounter hardships), appraisal support (strengthening and supporting the maternal role and encouraging mothers to strengthen their relationship with their infants and actively partake in their care since doing their best in the care of the infant makes them feel better. In fact, encouraging mothers to participate in care of preterm infants allows them to conceive their maternal role), and emotional support (addressing the feelings and concerns of the mothers and showing concern for their health and the health of the newborn so that they could adopt to the infantchr('39')s illness and the other affected aspects of their lives). The control group received routine care. Upon discharge, maternal stress was measured using the parental stressor scale: neonatal intensive care unit (PSS-NICU). The main sources of maternal stress included the NICU environment, infantchr('39')s appearance, special behaviors of treatment of the infant, mother-infant relationship, and maternal role. Data analysis was performed in the STATA software version 13 using t-test, Chi-square, and inverse probability of treatment weighting (IPTW).

After adjusting the pre-treatment variables by the IPTW, the mean difference in the adjusted stress score regarding the NICU environment was estimated at 0.55 (range: 0.89-0.2) (P<0.001), while it was 0.37 (range: 0.68-0.06) regarding the changes in the maternal role (P=0.02), and 0.29 (-0.43-0.37) regarding the infantchr('39')s appearance and behavior and treatment of the infant (P=0.89). In addition, the total stress score was estimated at 0.25 (range: 0.58-0.07) regarding the NICU environment (P=0.13), and the stress score of the intervention group was significantly lower compared to the control group regarding the changes in the maternal role.

For the successful implementation of interventions designed based on scientific evidence and facilities, it is suggested that policy-makers implement these evidence-based interventions to improve the quality of care of premature infants and reduce maternal stress in the form of family-centered support models in NICUs. Furthermore, it is recommended that similar investigations be performed on fathers. Although the results of this study confirmed the effects of the intervention on reducing maternal stress regarding the technological NICU environment and changes in the maternal role, it may not lead to the significant reduction of total stress and stress about infantschr('39') appearance, behavior, and treatment in mothers. As such, detailed studies should be conceived based on effective interventions in this regard.