I Was a Premature Baby and I'm Anxious

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• Published: 09 Baronial 2014

Mental health in women experiencing preterm nativity

BMC Pregnancy and Childbirth volume 14, Article number:263 (2014) Cite this article

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Abstract

Background

The aim of the study was to explore the degree of psychological distress, anxiety, and trauma related stress reactions in mothers who experience preterm nascency. Secondarily, we wanted to place possible predictors of maternal mental health problems.

Methods

Twenty-nine mothers of 35 premature children built-in earlier 33rd week of pregnancy were assessed within two weeks later given nascence. The standardized psychometric methods; Impact of Consequence Scale (IES), General Health Questionnaire (GHQ) and State Anxiety Inventory (STAI) assessed mental health problems. The predictors for maternal distress, anxiety, and trauma related stress reactions were pregnancy variables, preterm delivery, Gestation Age, maternal trait anxiety and parity. In improver, maternal prevalence of mental health problems was assessed past clinical diagnoses.

Results

Our written report revealed a loftier prevalence (52%) of posttraumatic stress responses in the mothers.

Conclusions

Our results advise an early examination of mothers' psychological reactions to preterm birth at the maternity ward. An early on intervention should exist considered while the child yet is in the neonatal intensive care unit.

Peer Review reports

Background

In general, childbirth may get a traumatic event when intense fear, helplessness, hurting and loss of control are experienced in labor and delivery [i, 2]. Many of these factors are likely to be present in a preterm birth situation. For mothers, the experience of giving preterm birth, and the subsequent experiences in the neonatal intensive care unit (NICU), may therefore cause substantial psychological distress. Exploring maternal mental health reactions post-obit preterm birth is interesting from an attachment perspective equally maternal mental health is known to impact children's concrete and mental development [3, 4]. Previous research has shown that women with preterm deliveries experience significantly higher levels of stress and low than women who deliver at term [five–10]. Even so, less is known of maternal posttrauma reactions to preterm birth [eleven]. Stress is a psychological phenomenon that may nowadays equally anxiety, depression and trauma reactions. The co-morbidity of feet and depression in posttraumatic reactions is well known, but the noesis of traumarelated stress reactions after preterm childbirth is still limited [12].

Behavioral and cognitive problems in prematurely born infants have been the master focus in research for several decades [13]. In improver to the severity of the kid's medical gamble factors, parental mental health is known to contribute substantially to children's cognitive, emotional, social and concrete development [13–16]. A number of studies have explored maternal depression following preterm birth. This research has reported that preterm mothers are at college risk of depression than term mothers presently after preterm birth and that mothers with very-low-birth-weight infants take a continued risk for depression in the first postpartum year [10]. Furthermore, follow-up studies of term babies have shown that persisting parental depressive symptoms are an of import predictor of child dysfunction [17, xviii]. The predictors of postpartum low that have achieved the greatest amount of consensus are previous psychiatric disorder, higher family disposal of psychiatric disorder, besides as poor social support, marital problems, and a higher amount of stress during pregnancy [i].

Nosotros know that near 1.v to three% of full term nascence women show signs of posttraumatic stress disorder (PTSD) half dozen months later on giving nascence, still, the maternal trauma reactions post-obit a preterm birth is less explored. But the trauma and post trauma connexion, yet, is still unexplained [19].

One study revealed that a preterm birth experience may crusade a long lasting traumatizing effect on parents; 49% of the mothers reported significant trauma reactions i year after delivery [20]. Muller-Zilch et al. establish a correlation between traumatic stress reactions and disturbances in mother-child interaction [21]. The force of parents' post-traumatic stress symptoms (PTSR) afterward preterm delivery is reported to be the most important predictor of the child'south sleeping and eating bug [22]. Yet, studies of mental health problems later on preterm delivery are in general small non-randomized studies with differing trauma measurements.

The primary aim of the nowadays study was to explore the degree of psychological distress, anxiety, and traumarelated stress reactions in mothers who evangelize preterm. Secondarily, we wanted to explore the nature of maternal psychological distress and identify the predictors of maternal mental health problems.

Methods

Study design

This study used an explorative cohort design.

From June 2005 to July 2008 through two periods of 8 and ten months, the psychological responses of 29 consecutive mothers of 35 premature children born before 33rd week of pregnancy at the Oslo University Hospital, Norway were assessed. The data collection was performed as soon equally the mothers were able to attend the interview after preterm childbirth, (median 11 days (4–30)). Mothers of severely ill babies with uncertain survival and not-Norwegian speakers were not included. Medical charts and questionnaires were used to collect information nearly the childbirth, the child's physical land, maternal previous mental health history, and socio-demographics.

The study group was a homogeneous grouping with loftier scores on socio-demographic variables like education, income, and housing standard. They all lived in a relatively flush city district in the Oslo area. Most of them were giving nascence beginning time late in their twenties or early on thirties. All of them lived with the kid'due south father and none reported any relationship bug. Only two mothers were diagnosed with a chronic somatic illness. Twenty-8 percentage of the mothers had become meaning by IVF.

The babies in the study group had relatively high Apgar mean scores and merely 23% of the babies needed mechanical ventilation for more than 24 hours.

The neonatal intensive intendance unit had applied several aspects of the newborn individualized developmental care and assessment programme (NIDCAP) in their treat the preterm babies and in their parental support and supervising [23]. The parents included in the study were offered psychological care during hospital stay. Mothers with high levels of mental health reactions were referred to further psychological treatment after hospitalization.

Measurements of maternal mental health bug

Maternal mental health problems were measured by the standardized psychometric methods Touch of Issue Scale (IES), Full general Health Questionnaire (GHQ), and State/Trait Feet Inventory (STAI-X1/X2).

The 15-detail version of the Impact of Consequence Scale (IES) [24] was used to assess behavioral aspects of distress. Clinically important stress related cognition and beliefs were defined every bit an IES score ≥xix. In this study, the stress factor was defined every bit "Preterm childbirth". The IES-fifteen has 2 subscales measuring symptoms of intrusive psychological distress (7 items) and avoidant knowledge and behavior (eight items). Intrusion is characterized by unbidden thoughts and images, troubled dreams, potent pangs or waves of feelings, and repetitive behavior. Avoidance responses include ideational constriction, denial of the pregnant and consequences of the event, blunted sensation, behavioral inhibition or counter-phobic activity, and awareness of emotional numbness. The scoring range for each item is 0 (non at all) to v (very much). A subscale score of 0–8 usually denotes minor responses, ix–nineteen moderate responses and scores ≥20 announce astringent responses. IES has been thoroughly validated and is one of the key psychometric assessments methods in traumatic stress research [24, 25].

The General Health Questionnaire (GHQ) [26] is a widely used screening musical instrument for assessing the presence of distress, psychopathology, and overall well-being, showing well established reliability and validity. The GHQ includes both positive and negative questions, and the short version GHQ-xxx contains 30 items roofing symptoms considered to reflect psychological distress and the subscales for depression and feelings of incompetence/low self-esteem (too referred to as well-beingness). Each question is answered on a iv point scale. The answers to each item may be treated both as Likert sum score (recommended for employ in longitudinal studies when measuring modify) with weights assigned to each response (0-ane-2-3) with a possible scale of 0–90, and as case sum score with weights (0-0-1-1) and possible range 0–30. When using the GHQ-thirty as a screening instrument for overall psychological distress, equally in this written report, case-score has exhibited acceptable values for sensitivity and specificity. Clinically important psychological distress was divers as case total scores ≥half dozen [26–28].

The Spielberger State Trait Anxiety Inventory (STAI-X1 and STAI-X2) [29] was used to appraise maternal anxiety . STAI-X1 is a measure out of land anxiety levels reflecting subjective feelings of tension, apprehension, nervousness and worry. STAI-X1 has a 20 item and a 12 item version. The 12 item STAI-X1 was used in the start data collection menses and the 20 detail STAI-X1was used in the 2nd data collection period. Both versions consist of items eliciting to what extent the respondent is currently experiencing the symptom or sign: "Non at all", "Somewhat", "Moderately" or "Very much" and rated on a four-step scale (one-2-3-4) with a possible score range of twenty–eighty for the 20 item version and 12–48 for the 12 item version. Higher scores indicate more anxiety.

Ten items from the 20 items version are overlapping in the 2 versions (item no: 1, two, 3, 5, vii, 11, 12, 13, 14, 15). A common ten particular STAI version was constructed for our analyses. For the 10 item version clinically important state anxiety was defined as a STAI score ≥20 (corresponding to ≥ 40 for 20 item version). STAI-X2 is a mensurate of trait feet that refers to private differences in anxiety proneness i.eastward. in the trend to see the world as dangerous and threatening, and in the frequency with which anxiety states are experienced. It consists of 20 items and the scoring range is 20–60. Clinically of import significant trait feet was divers equally ≥ forty.

STAI-X1 and X2 are reliable and widely used cocky-evaluation questionnaires that have been used in several studies in like populations [29].

To explore the prevalence of anxiety, low, and PTSR in particular, a tentative clinical diagnosis or not, based on the clinical diagnostic guidelines in the ICD-10 Nomenclature of mental and behavioural disorders [thirty], was assessed past a psychiatrist (terminal writer). The assessment was based on all data available in a clinical perusal of the psychometric self-reports IES, GHQ and STAI of each of the 29 preterm mothers, and blinded to the physical and socio-demographic characteristics of the mothers and their children.

Statistical methods

Values of continuous variables are presented every bit ways (SD) or if skewed as median and range. Categorical variables are given as proportions and percentages. Correlations between usually distributed and continuous variables were measured using Pearson's correlation coefficient or Spearman's correlation coefficient when the variables had a skewed distribution. Forwards linear regression analysis was used to place possible predictors of mental wellness and psychological distress within the study grouping. The three variables with the strongest bivariate associations were included in the multiple linear regression model. A careful check of the model assumptions, including an investigation of residue plots, did not reveal whatsoever violation of the assumptions. All analyses were performed in SPSS version 18. Two-sided statistical tests were applied, a 5% statistical significance level was called.

Ethics

Written informed consent was obtained from participants prior to study start. The written report protocol was approved by the Norwegian National Committee for Inquiry Ethics (S-05068 and Southward-07096b) and by the Data Inspectorate (12360 and 07/1088). The study protocol was carried out in accordance with the Declaration of Helsinki.

Results

Xx-nine of 34 families (85.3%) that met the inclusion criteria were included in the study group. Five mothers refused to participate in the study. The reasons for refusal were lack of energy or mental chapters or lack of time for being interviewed. None of the families that refused to participate differed from the participants regarding characteristics of the child'southward medical status or socio-demographic groundwork.

Baseline physical and socio-demographic characteristics of mothers and children are shown in Tabular array i.

Table one Socio-demographic and physical characteristics of the mothers given preterm birth and their children

Full size tabular array

Maternal mental health problems

The mothers in the study grouping reported significant mean scores in the clinical important range for psychological distress in all items on IES, GHQ and STAI (Table ii). Regarding the IES subscales, the Intrusion subscale showed the highest mean score. The proportion of Intrusion case score were 65.five%, while the proportion of Avoidance case score was 27.half dozen% (Tabular array three).

Tabular array ii Psychological distress, anxiety and trauma related stress reaction in mothers given preterm birth

Full size table

Table iii Proportion of clinically important psychological distress, anxiety and trauma related stress

Full size tabular array

The clinical diagnosis assessment revealed that 28% of the mothers had depression, 17% had anxiety and 52% PTSR. Twenty-1 percent of the mothers had more than than i diagnosis.

Associations between concrete variables and maternal mental health problems

In that location were significant bivariate associations betwixt several physical variables (planned Cesarean section, GA, nativity weight, Apgar score, need of mechanical ventilation, patent ductus arteriosis (PDA), neonatal surgery), mother'due south didactics, trait feet, parity, and previous psychological problems (Table 4). Increased maternal mental health bug were significantly associated with the mother's education, trait anxiety, parity and the child's GA, birth weight, and Apgar score. Other concrete problems in pregnancy like planned Caesarean section and physical neonatal complications (mechanical ventilation, neonatal surgery, patent ductus arteriosis) were inversely associated with maternal mental health problems.

Table iv Significant correlations between socio-demographic, physical, and maternal mental health upshot variables

Full size table

At the 10% statistical significance level previous psychological treatment and intraventricular hemorrhage (IVF) grade 1 or 2 were associated with increased maternal mental health problems measured past the GHQ and the IES scale, respectively.

Predictors of maternal mental wellness problems

The results of the frontwards multiple regression analyses are shown in Table 5. At that place was ane meaning predictor of the IES. "Planned Caesarean section" explained 10% of the variance in the IES (p < 0.05). Planned Caesarean was negative ($\widehat{b}=-\mathit{14.46}$) meaning that planned Caesarean section predict low IES scores. "Maternal trait anxiety" measured by STAI-X2 and "Other infection in pregnancy than preeclampsia" were significant predictors of GHQ Likert sum scores and explained thirty% of the variance (p < 0.01, p < 0.05). While "Maternal trait anxiety" predicted high GHQ Likert sum scores ($\widehat{b}=\mathit{1.97}$), infection in pregnancy predicted low GHQ scores ($\widehat{b}=-\mathit{2.60}$). The pregnant predictors of STAI-X1 were the "Kid's Gestational Age (GA) at birth" and "Parity", explaining 41% of the variance (p <0.001 and p < 0.01, respectively).

Table 5 Frontward entry multiple regression analyses predicting mental health outcomes for mothers afterwards preterm birth

Full size table

A farther forward multiple regression analysis was performed of the IES subscales. The results yielded "Planned Caesarean section" as a predictor of low IES Intrusion sum scores (p < 0.05), and "Vaginal delivery" was found to exist a predictor of high IES Avoidance sum scores (p < 0.05). The two predictors explained 8% (Rⁱⁱadjusted = .08) and 10% (R²adapted = .10), respectively, of the variance.

Word

The present written report revealed that mothers who delivered preterm reported levels of psychological distress in the clinically important meaning range ii weeks afterwards commitment.

In this study nosotros detected that 52% of the mothers showed traumarelated symptoms and less than one tertiary of the mothers showed symptoms of depression two weeks after the preterm commitment. The predictors for maternal mental wellness problems post-obit preterm nascence were related to the pregnancy, the preterm commitment, the child's GA, the maternal trait anxiety, and parity.

Epidemiologically loftier levels of mental wellness problems has been revealed [31, 32]. The prevalence of mental health bug in Norway is reported to be in accordance with prevalence in other European countries; about xxx% in a 12-month catamenia and about 50% in a lifetime span [32–34]. The loftier prevalence of maternal stress and anxiety following preterm commitment in our written report corresponds with previous studies [5–8]. Our results are considerably college than expected when we compare them with other pure samples of patients with physical illness only [26]. Whether psychological distress should be seen as a normal reaction to preterm nativity or not is still an open up question. Compared with another Norwegian study of mothers giving birth at term for instance we found a prevalence of clinically of import maternal psychological distress of 79%, while they reported 37% [35]. In addition, the same study detected that ix% of the term mothers reported severe intrusive stress symptoms in IES. In comparison 34.v% of the preterm mothers in our study reported severe intrusive stress symptoms in IES.

The clinical diagnostic cess of the preterm mothers showed that posttraumatic stress reactions (PTSR) represented the most common reactions. The prevalence of PTSR, depression, and anxiety was 52%, 28%, and 17%, respectively. Our results are comparable to a study that reported 49% significant trauma reactions amongst mothers i year after delivery [20], but differ from another study which revealed a relation between high levels of maternal posttraumatic stress symptoms (>33%) and loftier levels of depression (>53%) [36]. Interestingly we revealed a high prevalence of severe intrusion stress symptoms measured past IES. Our upshot is comparable to some other study that reported higher mean scores in the IES intrusion subscale in a preterm sample at discharge from the infirmary [xx]. Our written report showed that preterm commitment may correspond a significant trauma experience for the mother and that the prevalence of depression and anxiety was depression compared to post-traumatic stress responses.

Planned Caesarean section was found to predict both low IES sum scores in the forwards multiple regression analysis. In the study grouping, most of the Caesareans were emergency, but for a few hospitalized mothers with different physical bug like infections or growth retardation in fetus, the Caesarean section was planned some time in accelerate, and they had at least about a week to prepare themselves for the procedure. The results of the IES analyses may bespeak that fourth dimension to set oneself of a preterm birth as a planned Caesarean could reduce the traumatic stress response.

The child's gestational age (GA) at birth and maternal parity were the predictors of maternal stress and anxiety land levels (STAI-X1). It is noteworthy that numbers of previous childbirths are related to high anxiety state sum scores. The clan between loftier GA and high levels of state stress and anxiety corresponds with findings in a report of term nascency with ultrasound detections [37]. A Norwegian written report on maternal psychological responses after ultrasound scan at 18 weeks of GA, with or without detection of fetal anomalies, as well reported that advanced GA at diagnosis of fetal anomalies was one of the strongest predictors of psychological distress [38].

There may be several variables that could explain why advanced GA predict high levels of psychological distress. The preparation for the motherhood is close in time and outset fourth dimension mothers may worry about their express experiences with parenthood. In improver, our results may exist hypothesized to be a result of growing relationship to the fetus during pregnancy [39, 40]. The "fearfulness of losing the infant" evoked by a preterm birth and "growing relationship" to the infant are probably closely related. Several studies have focused on preterm deliveries and the "fright of losing the infant", and on the relationship between the "intensity of grief" and increasing GA, when mothers have experienced pregnancy termination or pregnancy loss [41–43].

A recent study including an zipper research instrument (Developed Zipper Projective) revealed that 67% of mothers that had experienced a preterm birth showed unresolved posttraumatic problems regarding the "anxiety of losing the baby" 6 years afterwards the preterm birth [42, 44]. In attachment theory, a "threat" is understood as a crucial chemical element in the onset of human behavioral strategies [45] and psychological distress might be the event when the strategies practice not work or do not eliminate the "threat". "fear of losing the baby" is likely to be experienced every bit a "threat" in a psychological sense. Attachment theory might well stand for a theoretical framework that could broaden our understanding of the loftier levels of the maternal mental health responses afterward a preterm birth in our study.

Personal vulnerability factors such equally previous mental health problems and trait feet were associated with general psychological distress in the GHQ Likert sum scores, as well every bit existence significant predictors of general psychological distress measured by GHQ Likert sum scores. Our finding corresponds with another study that explored the prevalence of post-traumatic stress symptoms following childbirth [46]. Thus, the maternal previous mental health history seems to be important to include in the medical charts of mothers that deliver at preterm when assessing the female parent's demand of psychological support afterwards birth.

Our written report revealed an inverse association between pregnancy complications and psychological distress, anxiety and trauma related stress. Pregnancy complications practise not measure the female parent's "fear of losing the baby" explicitly, but may be an indicator of this phenomenon. Indeed the pregnancy complication variables "planned Caesarean section", and "infection in pregnancy" turned out to be the predictors of low maternal psychological distress and traumarelated stress scores in the IES and the GHQ. A planned Caesarean implies more control in labor than an emergency Caesarean or a spontaneous vaginal delivery. Previous studies that have explored the association between maternal distress and physical complications in pregnancy and in infants in the perinatal or postnatal period have reported results that run counter to those of our written report [41, 47–52].

Some of the results in our written report have been difficult to explain but should be mentioned for future research purposes. For instance, we found an pregnant clan in our correlation analysis between lower maternal mental health bug in STAI-X1 and two medical atmospheric condition the kid was treated for after birth; the common condition patent ductus arteriosis (PDA) and the more astringent hypospadias condition.

Medical weather that require treatment and surgery may easily be assumed as distressing for the parents. Why these weather lower the maternal anxiety in the STAI-X1 scale is non obvious, but may be explained by the extended support to the parents that the medical staff are likely to requite in such an occasion. Our study besides detected an association at the ten% significant level between intraventricular hemorrhage (IVF) grade 1 or 2 and high levels of maternal traumarelated issues measured by IES (Table 4). IVF grade 1 or 2 is less severe than course 3 or 4 which may be reflected in the level of support to the parents from the medical staff. The parents on the other manus could be distressed by the IVF class one or ii condition and be worried that the IVF incidence volition have an negative influence on their baby'south development.

Force/limitations

The preterm participants came from well-defined geographic areas and were included consecutively in the written report, thus minimizing option bias. The response rate is high. The psychometric instruments (IES, GHQ, STAI) used in our study are all well-validated. We have assessed several important aspects of mental health problems, like psychological distress, anxiety, and trauma-related stress and also assessed tentative clinical diagnosis for the prevalence of mental health problems.

The present study describes a small-scale grouping of mothers giving preterm birth with college educational attainments, older age and higher socioeconomic status than would be institute in a typical population of mothers who deliver preterm in Norway. Thus, one should exist cautious virtually generalizing from this report. The homogeneity of the report group in terms of socio-demographic background and distress related to it is clearly a limitation in this study. On the other hand our results were controlled for highrisk socio-economic groundwork variables. A more detailed assessment of maternal trauma related experiences prior to the pregnancy would of course take strengthened our written report. However, data was collected of the report grouping's mental history and about their pregnancy experiences.

A tentative clinical diagnosis based on information from the standardized self reports was assessed past a psychiatrist. A diagnostic semistructured interview, still, would take been preferable in addition to information from psychometric self-report questionnaires to make a right clinical diagnosis.

Conclusions

Our report revealed a substantial level of psychological distress in mothers who deliver preterm. Posttraumatic stress was the almost common psychological reaction to preterm delivery in this study. Significant physical predictors that were discovered should be further investigated. Our findings imply that mothers' psychological reactions to preterm birth demand to be taken into account at maternity wards. The need for intervention and psychotherapy should be considered at an early phase and while the infant notwithstanding is in the NICU. It is, however, necessary to investigate these results closer in a prospective and longitudinal report equally these psychological patterns might modify over time.

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Pre-publication history

• The pre-publication history for this newspaper can be accessed here:http://world wide web.biomedcentral.com/1471-2393/xiv/263/prepub

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Acknowledgements

The authors would like to thank the participants, the neonatal intensive care unit at Rikshospitalet, Oslo University Hospital, and particularly the parents who participated in the study.

The report was supported by the Centre for Child and Adolescent Mental Wellness, Eastern and Southern Norway, the Department of Children'due south Division, Oslo University Infirmary and the University College of Oslo and Akershus.

Author data

Affiliations

1. Kinesthesia of Health Sciences, University College of Oslo and Akershus, PO Box. 4, St. Olavs plass, N-0130, Oslo, Kingdom of norway

   Aud R Misund & Per Nerdrum

2. Department of Clinical Neurosciences for Children, Women and Children'due south Division, Oslo University Hospital, Rikshospitalet, PO Box 4950, Nydalen, NO-0424, Oslo, Norway

   Trond H Diseth

3. Section of Medicine, Constitute of Clinical Medicine, Academy of Oslo, PO Box 1171, Blindern, 0318, Oslo, Norway

   Aud R Misund & Trond H Diseth

Respective writer

Correspondence to Aud R Misund.

Additional information

Competing interests

The authors declare that they accept no competing interests.

Authors' contributions

The start author ARM initiated the study, collected and organized the data. ARM and THD performed the statistical analyses. ARM, PN and THD designed and critically revised the report, canonical the final version of the paper, and are accountable for all aspects of the work.

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Misund, A.R., Nerdrum, P. & Diseth, T.H. Mental health in women experiencing preterm nascency. BMC Pregnancy Childbirth 14, 263 (2014). https://doi.org/ten.1186/1471-2393-14-263

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• Received: 03 July 2014

• Accepted: 05 Baronial 2014

• Published: 09 August 2014

• DOI : https://doi.org/10.1186/1471-2393-14-263

Keywords

• Anxiety
• Depression
• Preterm birth
• Psychological distress
• PTSR

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