Maternal psychological distress after preterm birth: Disruptive or adaptive?

BACKGROUND: Maternal postpartum distress is often construed as a marker of vulnerability to poor parenting. Less is known, however, about the impact of postpartum distress on parenting an infant born prematurely. The present study investigated whether high distress levels, which are particularly prevalent in mothers of preterm born infants, necessarily affect a mother's quality of parenting. METHOD: Latent Class Analysis was used to group mothers (N=197) of term, moderately, and very preterm born infants, based on their levels of distress (depression, anxiety, and PTSD symptoms) at one month postpartum, and their quality of parenting at one and six months postpartum. Parenting quality was assessed on the basis of maternal interactive behaviors (sensitivity, intrusiveness, and withdrawal) using observations, and maternal attachment representations (balanced, disengaged, or distorted) using interviews. RESULTS: A 5-Class model yielded the best fit to the data. The first Class (47%) of mothers was characterized by low distress levels and high-quality parenting, the second Class (20%) by low distress levels and low-quality parenting, the third Class (22%) by high distress levels and medium-quality parenting, the fourth Class (9%) by high distress levels and high-quality parenting, and finally the fifth Class (2%) by extremely high levels of distress and low-quality parenting. CONCLUSIONS: While heightened distress levels seem inherent to preterm birth, there appears to be substantial heterogeneity in mothers' emotional responsivity. This study indicates that relatively high levels of distress after preterm birth do not necessarily place these mothers at increased risk with regard to poor parenting. Conversely, low distress levels do not necessarily indicate good-quality parenting. The results of the present study prompt a reconsideration of the association between postpartum distress and parenting quality, and challenge the notion that high levels of maternal distress always result in low-quality parenting practices.

Parenting in Complex Conditions: Does Preterm Birth Provide a Context for the Development of Less Optimal Parental Behavior?

OBJECTIVE: To examine the predictive value of parent, infant, and contextual factors related to preterm childbirth for later parenting behaviors. METHODS: Mothers (n = 217) and fathers (n = 204) of term, moderately preterm, and very preterm infants were interviewed 1 month postpartum using the Clinical Interview for Parents of high-risk infants (CLIP), to assess their experiences and perceptions related to the pregnancy, delivery, infant, hospitalization, support system, and their narratives. Their responses were factor analyzed and entered into prediction models of parental behaviors (National Institute of Child Health and Human Development observations) 6 months postpartum. RESULTS: Preterm birth was associated with negative experiences and concerns in parents. Regression analyses revealed, however, that irrespective of preterm birth, negative and unrealistic parental perceptions predicted less sensitive, more intrusive, and more withdrawn behavior. CONCLUSIONS: Not prematurity per se, but particularly the presence of negative perceptions in parents, is predictive of difficulties in parent-infant interaction. The CLIP is a potentially useful instrument to identify families at risk.

Effectiveness of hospital-based video interaction guidance on parental interactive behavior, bonding, and stress after preterm birth: A randomized controlled trial.

OBJECTIVE: This study examined the effectiveness of hospital-based Video Interaction Guidance (VIG; Eliëns, 2010; Kennedy, Landor, & Todd, 2011) for mothers and fathers of infants born preterm (25-37 weeks of gestation). METHOD: VIG is a preventive video-feedback intervention to support the parent-infant relationship. One hundred fifty families (150 infants, 150 mothers, 144 fathers) participated in a pragmatic randomized controlled trial to evaluate the effects of VIG as adjunct to standard hospital care. Primary outcome was parental interactive behavior (sensitivity, intrusiveness, and withdrawal) as observed in videotaped dyadic parent-infant interaction. Secondary outcomes comprised parental bonding, stress responses, and psychological well-being based on self-report. The intervention effects were assessed at baseline, mid-intervention, 3-week, 3-month, and 6-month follow-ups. Data were analyzed on an intention-to-treat basis, using multilevel modeling and analyses of covariance. RESULTS: VIG proved to be effective in enhancing sensitive behavior and diminishing withdrawn behavior in mothers (Cohen's d range = .24-.44) and in fathers (d range: .54-.60). The positive effects of VIG were particularly found in mothers who experienced the preterm birth as very traumatic (d range = .80-1.04). The intervention, however, did not change parents' intrusive behavior. Analyses additionally revealed positive effects on parental bonding, especially for fathers, yet no significant effects on stress and well-being were detected. CONCLUSIONS: The results indicate that VIG is a useful addition to standard hospital care, reducing the possible negative impact of preterm birth on the parent-infant relationship. VIG appeared particularly beneficial for fathers, and for mothers with traumatic birth experiences. High levels of parental intrusiveness, however, need complementary intervention. (PsycINFO Database Record

Maternal and paternal infant representations: a comparison between parents of term and preterm infants.

OBJECTIVE: Research on parental attachment representations after preterm birth is limited and inconclusive. The present study is the first in which maternal and paternal attachment representations after term, moderately and very preterm birth are compared. In addition, special attention was directed toward disrupted attachment representations. METHOD: Mothers and fathers of term infants (≥ 37 weeks of gestational age, n=71), moderately preterm infants (≥ 32-37 weeks of gestational age, n=62) and very preterm infants (<32 weeks of gestational age, n=56) participated in the present study. Attachment representations (balanced, disengaged, distorted) about their infants were evaluated with the Working Model of the Child Interview (WMCI). To asses disrupted representations the coding of the WMCI was extended with the disrupted scale (WMCI-D). RESULTS: The three main classifications of attachment representations were not affected by preterm birth. In addition, there were no gender differences in the rate of balanced representations. In case of non-balanced representations however, maternal representations were more often distorted, whereas fathers showed more often disengaged representations. Results further revealed that maternal disrupted attachment representations were marked by role/boundary confusion or disorientation, whereas paternal disrupted attachment representations were characterized by withdrawal. CONCLUSION: Given the gender differences it is essential to tailor interventions according to the attachment representations of the parent, in order to be able to alter their non-balanced and/or disrupted attachment representations.

Parental perceptions and experiences after childbirth: a comparison between mothers and fathers of term and preterm infants.

BACKGROUND: Parents experience a lot of positive and negative feelings and emotions after birth. The main purpose of this study was to compare perceptions and experiences of mothers and fathers with term, moderately and very preterm infants. METHODS: We included 202 infants with both parents, divided into three groups: 1) term infants (≥ 37 weeks' gestation), 2) moderately preterm infants (≥32-<37 weeks' gestation) and 3) very preterm infants (< 32 weeks' gestation). The Clinical Interview for Parents of High-risk Infants (CLIP) was used to examine parental perceptions and experiences in eight areas: 1) Infant's current condition, 2) Course of the pregnancy, 3) Labor and delivery, 4) Relationship with infant and feelings as a parent, 5) Reactions to hospital and staff, 6) Support system, 7) Discharge and beyond, and 8) Quality of narratives during the interview. RESULTS: The lower the gestational age of the infant, the more negative parental experiences and perceptions were on the following five areas: infant's current condition, pregnancy course, labor and delivery, relationship with the infant, and discharge and beyond. No differences were found between maternal and paternal perceptions on any of the eight CLIP areas. CONCLUSIONS: Negative parental perceptions and experiences were mainly associated with the gestational age of the infant and not at all with the gender of the parent. These findings resulted in several recommendations to optimize care for parents after preterm birth.

The impact of premature childbirth on parental bonding.

The development of an affectionate parent-infant bond is essential for a newborn infant's survival and development. However, from evolutionary theory it can be derived that parental bonding is not an automatic process, but dependent on infants' cues to reproductive potential and parents' access to resources. The purpose of the present study was to examine the process of bonding in a sample of Dutch mothers (n = 200) and fathers (n = 193) of full-term (n = 69), moderately premature (n = 68), and very premature infants (n = 63). During the first month postpartum parents completed the Pictorial Representation of Attachment Measure (PRAM) and Postpartum Bonding Questionnaire (PBQ). Longitudinal analyses revealed that mothers' PRAM scores decreased after moderately preterm delivery, whereas decreases in PRAM scores occurred in both parents after very preterm delivery. As lower PRAM scores represent stronger feelings of parent-infant connectedness, our findings suggest a higher degree of bonding after premature childbirth. Results of the PBQ analysis were in line with PRAM outcomes, as parents of preterm infants reported less bonding problems compared to parents of full-terms. These findings support the hypothesis that in affluent countries with adequate resources, bonding in parents of preterm infants on average may be higher than in parents of full-term infants.

The effectiveness of video interaction guidance in parents of premature infants: a multicenter randomised controlled trial.

BACKGROUND: Studies have consistently found a high incidence of neonatal medical problems, premature births and low birth weights in abused and neglected children. One of the explanations proposed for the relation between neonatal problems and adverse parenting is a possible delay or disturbance in the bonding process between the parent and infant. This hypothesis suggests that due to neonatal problems, the development of an affectionate bond between the parent and the infant is impeded. The disruption of an optimal parent-infant bond -on its turn- may predispose to distorted parent-infant interactions and thus facilitate abusive or neglectful behaviours. Video Interaction Guidance (VIG) is expected to promote the bond between parents and newborns and is expected to diminish non-optimal parenting behaviour. METHODS/DESIGN: This study is a multi-center randomised controlled trial to evaluate the effectiveness of Video Interaction Guidance in parents of premature infants. In this study 210 newborn infants with their parents will be included: n = 70 healthy term infants (>37 weeks GA), n = 70 moderate term infants (32-37 weeks GA) which are recruited from maternity wards of 6 general hospitals and n = 70 extremely preterm infants or very low birth weight infants (<32 weeks GA) recruited by the NICU of 2 specialized hospitals. The participating families will be divided into 3 groups: a reference group (i.e. full term infants and their parents, receiving care as usual), a control group (i.e. premature infants and their parents, receiving care as usual) and an intervention group (i.e. premature infants and their parents, receiving VIG). The data will be collected during the first six months after birth using observations of parent-infant interactions, questionnaires and semi-structured interviews. Primary outcomes are the quality of parental bonding and parent-infant interactive behaviour. Parental secondary outcomes are (posttraumatic) stress symptoms, depression, anxiety and feelings of anger and hostility. Infant secondary outcomes are behavioral aspects such as crying, eating, and sleeping. DISCUSSION: This is the first prospective study to empirically evaluate the effect of VIG in parents of premature infants. Family recruitment is expected to be completed in January 2012. First results should be available by 2012. TRAIL REGISTRATION NUMBER: NTR3423.