Original Article
Impact of Depressive Symptoms on Mother Infant Attachment among Mothers of Preterm Neonates
Authors:
Binu Margaret, Assistant Professor- Selection Grade, Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India,
Leslie Edward Lewis, Professor, Department of Pediatrics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India,
Ramesh Bhat Y, Professor, Department of Pediatrics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India,
Baby S Nayak, Professor, Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India,
Mamatha Shivananda Pai, Professor, Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India.
Suneel C Mundkur, Professor, Department of Pediatrics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
Address for Correspondence
Binu Margaret
Assistant Professor- Selection Grade,
Department of Child Health Nursing,
Manipal College of Nursing, Manipal,
Manipal Academy of Higher Education,
Manipal, Karnataka, India - 576104.
E-mail: binumarg@gmail.com.
Citation
Margaret B, Lewis LE, Bhat RY, Nayak BS, Pai MS, Mundkur SC. Impact of Depressive Symptoms on Mother Infant Attachment among Mothers of Preterm Neonates. Online J Health Allied Scs.
2018;17(1):1. Available at URL:
https://www.ojhas.org/issue65/2018-1-1.html
Submitted: Jan 11,
2018; Accepted: Apr 3, 2018; Published: May 15, 2018 |
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Introduction:
Premature birth and the admission of the baby to Neonatal Intensive Care Unit (NICU) is one of the significant risk factors for postnatal depression in mothers and has an influence on quality of mother infant attachment. (1) It is a traumatic experience for parents which makes their interaction with their infant more challenging. Worldwide, about 12.9 million births, or 9.6% of all births were preterm. (2) In India, the number of preterm births have increased from 12.3% to 14.7%. (3) With increasing number of preterm births, the psychological factors affecting the parenting and their interaction with their infants is also on the rise to a higher end.
Depressive symptoms among the mothers of preterm neonates is one of the major public health concerns which adversely affects the health of the mother and their interaction with their preterm babies. (4) In Asian countries, the prevalence of postpartum depression ranged from 3.5% to 63.3%, where Malaysia had the least prevalence and Pakistan had the highest prevalence. (5-6) The mothers of preterms had two fold more depression than the mothers with full term babies (29.4 vs. 17.3%), (p < 0.001). (7) The overall prevalence of depressive symptoms among postnatal women in rural area was 27.0% (95% CI, 18.8%-37.2%). In the developing countries, the prevalence of postpartum depression was higher (31.3%; 95% CI, 21.3%-43.5%) compared to the developed countries (21.5%; 95% CI, 10.9%-38.0%). (8) During the early postpartum period, the rate of depressive symptoms among mothers of premature was as high as 40%. (9) The birth of a very low birth weight infant, female infant, low social support for mothers, preterm birth, lower gestational age, young mothers with low monthly income and low secondary education, were significant risk factors of postpartum depression in mothers. (5-10)
Mother infant interaction is critical for the smooth transition of the mother to take up the new role of motherhood. The birth of a premature infant with low birth weight can affect this interaction of the mother with her baby. Mother should be sensitive and have awareness to identify the infant cues and respond appropriately to the cues. The intrusiveness depends on the mother’s ability to organize and adjust the behavior with current needs, interest and mood of the baby. The good quality of affective behavior depends on the positivity and warmth in the tone of mother’s voice, body movements and rhythm and timing of expression. (11) Various factors such as maternal depression, anxiety, severity of prematurity, parenting stress, social support, family support, socioeconomic status of family, can influence these behaviors. (1, 12-13) The quality interaction of the mother with the preterm infant is extremely important for the positive interaction with the infant which is highly challengeable. (14) Mother infant interaction with premature babies had a significant difference in the quality of maternal interaction behavior compared to the full term infants. (15)
Maternal depression was related to quality of the interaction like maternal remoteness and negative affective state with the infant. (1) Also, the signs of postnatal depression is negatively associated with the maternal interaction behavior with the premature infants. (16) Mother infant interaction is influenced by the premature birth and postpartum depression. (6) Distorted representation of interaction were observed in mothers with depressive symptoms. (17)
The birth of a premature baby is a traumatic experience for the mothers, which has an influence on the maternal infant attachment. (18) The aim of this study was to examine the level of depressive symptoms and maternal infant interaction among mothers of premature babies and to find the relationship between depressive symptoms and maternal infant attachment.
Materials and Methods:
This cross sectional survey was conducted among 100 mothers whose preterm neonates were admitted in the Neonatal Intensive Care Unit (NICU) of Kasturba Hospital, Manipal which is a tertiary care referral unit. Purposive sampling technique was used to collect the data. Ethical clearance was taken from the Institutional Ethical Committee. The study enrolled mothers of preterms babies who were less than 37 weeks of gestation with birth weight less than 2000 grams and admitted to the NICU of Kasturba hospital for at least one week. The participants were enrolled after obtaining written informed consent and the confidentiality was maintained. The mothers of preterms who had cognitive impairment, severe acute illness and who did not give the consent were excluded from the study.
Data Collection Tools:
The data was collected using the tools, Background proforma, Edinburgh Postnatal Depression Scale (EPDS) and Mother Infant Attachment Scale.
The baseline information was collected using a background proforma. The information included the age of the mother, education status, occupation of mother, monthly income, birth weight of the baby, gestational age, birth order, number of days child being hospitalized.
The presence of depressive symptoms were assessed using EPDS. The scale shows relatively good reliability with a Cronbach’s alpha of 0.88. (19- 20) It is a ten item questionnaire which measures the level of depressive symptoms experienced by the mother in the past seven day’s period. The mothers were expected levels of depressive symptoms to report the frequency of each experience on a four point scale. Each item is rated from 0 to 3, with a total score of 30. The minimum score is 0 and the maximum score is 30. The items 3, 5, 6, 7, 8, 9 and 10 were reverse scored as 3, 2, 1 and 0. A total score of 10 and above indicate possibility of depression. Higher the scores more severe is the level of depression. The EPDS depressive scores are categorized into four categories: No depression (0- 9); Mild to moderate depression (10- 16); Moderate to severe depression (17 – 21); Very severe depression (22- 30). (21) A score 13 and above indicate that the mother has clinical depression symptoms. (22)
The mother infant attachment was assessed using a 15 item Mother Infant Attachment Scale (r=0.83) developed by Bhakoo. (23) This tool was designed to quantify mother infant attachment among the Indian population. It is a five point likert scale with options of strongly agree, agree, undecided, disagree and strongly disagree. The most favorable response was given a score of five and the least favorable response was given a score one. The minimum score was 15 and the maximum score was 75. Higher scores indicated good mother infant attachment. A score of 1 to 25 was considered as poor attachment, 26 to 50 was moderate attachment and a score of 51 to 75 was considered as good attachment.
Stastical Analysis
Data was analyzed using statistical package for social sciences SPSS version 16. The descriptive and inferential statistics was used to analyze the variables under study. The categorical variables are reported by frequency and percentage and the continuous variables are reported by mean and standard deviation. To find the relationship between variables, Pearson product moment correlation coefficient was used and was tested at 0.05 level of significance.
Results
The study was conducted among 100 mothers whose preterm neonates were admitted to NICU.
Demographic Profile:
The demographic characteristics of the participants are depicted in Table 1.
| Table 1: Demographic Profile of Participants in the Study |
Demographics of participants ( n = 100 ) |
n (%) |
Age of the mother (in years) |
20- 25 |
23 (23) |
26- 30 |
49 (49) |
31- 35 |
20 (20) |
36- 40 |
8 (8) |
Birth Order |
First-born |
71 (71) |
Second |
27 (27) |
Third |
2 (2) |
Education of the mother |
Primary school |
7 (7) |
Middle school |
22 (22) |
High school |
24 (24) |
PUC |
20 (20) |
Graduate and above |
27 (27) |
Occupation of the mother |
Employed |
85 (85) |
Unemployed |
15 (15) |
Monthly family income (in rupees) |
< 5546 |
22 (22) |
5546- 13,873 |
49 (49) |
>13,873 |
29 (29) |
Type of family |
Nuclear |
20 (20) |
Joint |
80 (80) |
Religion |
Christian |
3 (3) |
Hindu |
89 (89) |
Muslim |
8 (8) |
The data presented in Table 1 revealed that 49 (49%) mothers of preterms belonged to the age group 26–30yrs, 71(71%) were primiparous. Majority of mothers 80 (80%) lived in joint family and followed Hindu 89(89%) religion. Majority, 85% of the mothers were unemployed. Majority of the mothers (90%) received family support during their pregnancy and their stay in hospital. The mean age of the mothers of preterms was 28.6 ± 4.4 and the mean gestational age was 31.23 ± 2.5. The mean birth weight was 1283.65 ± 291.13 and at discharge the mean weight was 1721 ± 153.14.
| Table 2: Clinical Profile of the Preterm infants |
Clinical Profile of participants ( n = 100 ) |
n (%) |
Preterm Classification |
Extreme Preterm |
7 (7) |
Very Preterm |
48 (48) |
Moderate Preterm |
26 (26) |
Late Preterm |
19 (19) |
Birth weight (g) |
Extreme Low Birth Weight (<1000 g) |
19 (19) |
Very Low Birth Weight (1000- 1499 g) |
58 (58) |
Low Birth Weight (1501- 2000 g) |
23 (23) |
Gestational Age (weeks) |
< 28 |
7 (7) |
28- 30 |
22 (22) |
31- 32 |
24 (24) |
33- 34 |
20 (20) |
35-36 |
27 (27) |
Gender of the baby |
Male |
45 (45) |
Female |
55 (55) |
Number of days child has been in hospital |
1-10 |
3 (3) |
11-20 |
20 (20) |
21-30 |
16 (16) |
More than 30 |
61 (61) |
Clinical profile of preterm neonates:
Table 2 describes the clinical profile of the preterm neonates. The gestational age of 7(7%) neonates were less than 28 weeks who belonged to the category of extreme preterms, 48% of neonates belonged to the category very preterms in the gestational age between 28 and 31 weeks, 26% were moderate preterms in the gestational age of 32 to 33 weeks and 19% were late preterms in the gestational age of 34 to 36 weeks. Majority 55(55%) of the preterms were females. Birth weight of majority 58(58%) of preterms were between 1000 and 1499 grams who belonged to the category of very low birth weight, while 19% of preterms were extremely low birth weight babies with the birth weight less than 1000 grams. The number of days of hospital stay for majority 61% of the preterm neonates were more than 30 days.
Level of depressive symptoms and mother infant attachment:
The frequency and percentage distribution of level of depressive symptoms and mother infant attachment is given in Table 3.
| Table 3: Frequency distribution of Level of depressive symptoms and mother-infant-attachment |
( n = 100 ) |
n (%) |
Level of depressive symptoms |
No depression |
30 (30) |
Mild depression |
28 (28) |
Moderate depression |
25 (25) |
Severe depression |
17 (17) |
Level of Mother infant attachment |
Good attachment |
77 (77) |
Moderate attachment |
18 (18) |
Poor attachment |
5 (5) |
About 25(25%) mothers of preterms experienced moderate depressive symptoms and 17 (17%) severe level of depressive symptoms, while 30(30%) mothers had no depressive symptoms. Majority of the mothers 77(77%) of preterms had good attachment and only 5(5%) had poor attachment. Mean depressive symptom score was 14.36±7.47 and mean mother-infant-attachment score was 58.00 ±12.95.
Impact of depressive symptoms on Mother-Infant Attachment:
Depressive symptoms and mother-infant-attachment showed a moderate negative correlation, (ρ=--0.506), (p=0.001). The findings shows that as the depressive symptom level decreases, there is a scope for the mother-infant-attachment to increase.
Discussion
This study aimed to investigate the level of depressive symptoms and mother infant attachment among mother of preterm neonates. Further, the study investigated the relationship between the depressive symptoms and the quality of mother infant attachment. The preterm birth itself is a devastating experience for the parents. Due to the technological advances, the survival of the extreme preterm who are less than 28 weeks of gestation are increasing. In the present study, the number of extreme preterms were 7% and 22% of preterms were between the gestational age of 28 and 30 weeks. A study done in India by Narayan in 2003 showed a prevalence of extreme preterm birth as 1.07%. (24) The gestational age of 35% of mothers was less than 30 weeks. (25) In 2011, the percentage of extreme preterm birth of all preterm birth was 6% in United States. (26) This supports the present study findings which shows an increase in the trend in the prevalence of the survival of the extreme preterm birth as the year progresses.
Preterm birth also causes psychological distress among the mothers which can disrupt the interaction of the mother with their baby. Postpartum depression among mothers of preterms in increasing than the full term infants. (7) In this present study, it was identified that mothers of preterms 42 (42%) had a moderate to severe level of depressive symptoms. This finding is supported by several studies conducted in India and across the globe. In a study conducted in Pakistan showed a prevalence of postpartum depression of 35.3% among mothers of preterm, whereas among mothers of full terms it was 15.3%, which showed an increase in the level of depressive symptoms among preterm infants. (27) The prevalence of postpartum depression was 31.4% in a study conducted in rural Karnataka (28). But a study conducted in North India showed a prevalence of 15.8%. (29) The incidence of postpartum depression was 21.5% in another Indian study conducted by Saldanha (30). A systematic review conducted on postpartum depression among mothers of preterms showed a prevalence 40% which is of a high rate. (9) This show that postpartum depression among mothers of preterms is of high concern and regular screening has to be done among mothers of preterms to identify the depressive symptoms at an early stage.
The interaction of mother with the preterm is important for the care of the babies and for the optimum development of the preterms. The present study showed a negative correlation between mother infant interaction and depressive symptoms. A study conducted by Nielsen (31) showed an association between postpartum depression and mother infant attachment. High prevalence of depressive symptoms were related to low maternal sensitivity in the interaction with the infant (1).
The study further strengthens the findings of previous studies, which indicates that postpartum depression is a significant factor that can affect the quality of parent infant interaction. (1, 31) The study was limited to the mothers whose preterms were admitted in the neonatal intensive care unit. The participants were recruited from one setting which is a tertiary level referral unit. The father’s role in moderating the effects of depression was not considered which limits the study. The fathers of preterms also play a major role in the interaction and support for the mothers, which could minimize the effects and intensity of the depressive symptoms. Further studies, to deepen the area of knowledge and investigate the possible influences on the depressive symptoms and mother infant interaction is needed.
The premature birth significantly affects the mental health of the mothers, which can affect the quality of interaction of the mother infant attachment. Hence, the postpartum depression has to be recognized and identified early, treated with utmost importance to enhance the quality of interaction of the mother with her preterm baby. This will further positively improve the caregiving needs of the premature baby and ultimately improve the developmental outcomes.
Health care professionals also play a major role in identifying the mothers who are having depressive symptoms by interacting with them, recognize the challenges they face in caring the preterms and the social support they receive in care of the preterm infants. Nurses should be aware that preterm birth can potentially increase the risk of postpartum depression and should plan the daily care accordingly to enhance the confidence of the mothers and improve their competence and interaction in taking care of their premature babies.
Conclusion:
Mothers of preterm neonates exhibit high levels of depressive symptoms which can influence the mother–infant-interactions. Early identification of depressive symptoms has implications for support of mothers during hospitalization of their preterm neonates and in turn can improve their attachment towards their neonates. Health care professionals should routinely screen the mothers of premature babies for postpartum depressive symptoms and plan comprehensive interventions to counsel, educate and support the mothers to provide optimum care and thereby enhance the quality of interaction with their preterms.
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