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ORIGINAL ARTICLE
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Stress, postpartum depression, and anxiety in mothers of neonates admitted in the NICU: A cross-sectional hospital-based study


1 Department of Psychiatry, Dr D Y Patil Medical College, Dr D Y Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
2 Department of Psychiatry, Indira Gandhi Institute of Medical Sciences (IGIMS), Sheikhpura, Patna, Bihar, India

Date of Submission31-May-2021
Date of Acceptance06-Jun-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Santosh Kumar,
Associate Professor of Psychiatry, Indira Gandhi Institute of Medical Sciences (IGIMS), Sheikhpura, Patna . 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_93_22

   Abstract 


Background: Mothers of neonates admitted to a neonatal intensive care unit (NICU) experience heightened distress, anxiety, depression, and trauma symptoms. Despite their prevalence, these conditions are generally neither recognized nor treated due to the constraints of time and concerns about the social acceptability of screening. Aim: To study stress, postpartum depression, and anxiety in mothers of neonates admitted to the NICU. Materials and Methods: One hundred forty consecutive mothers having preterm and low birth weight neonates in the NICU were taken for the study as cases and an equal number of mothers of full-term neonates matched for age and socioeconomic status (SES), were recruited as controls with their informed consent. Subjects were assessed with the Acute Stress Disorder Scale (ASDS), Post-Traumatic Stress Disorder (PTSD) Symptom Scale (PSS), Edinburgh Postnatal Depression Scale (EPDS), and Perinatal Anxiety Screening Scale (PASS). Results: Mothers of preterm neonates in NICU had significantly higher scores on the ASDS, PSS, EPDS, and PASS compared to controls. There was a significant association of ASDS and PSS scores with younger age, higher education, middle SES, joint family, urban residence, unplanned pregnancy, and male child. There was a significant association of the EPDS scores with lower SES, low education, unemployment, and male child. There was a significant association of the PASS scores with younger age, lower SES, and cesarean section. Conclusion: Mothers of preterm neonates admitted to the NICU compared to controls have significantly higher levels of stress, anxiety, and depression.

Keywords: Anxiety, depression, mothers, NICU, preterm and low birth weight neonates, PTSD, stress



How to cite this URL:
Garg D, Chaudhury S, Saldanha D, Kumar S. Stress, postpartum depression, and anxiety in mothers of neonates admitted in the NICU: A cross-sectional hospital-based study. Ind Psychiatry J [Epub ahead of print] [cited 2023 Jan 27]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=363009



Preterm birth is defined as birth before 37 weeks of gestation.[1] Advances in neonatal intensive care have significantly increased the survival rates of preterm neonates at 23 weeks from 0% to 65% at some centers.[2] Nevertheless, preterm birth is still associated with considerable childhood mortality and morbidity. A parent's psychological experience is correlated with the quality of parental attachment representations and affects the parent-infant relationship and infant outcomes.[3] Mothers of neonates who require special care initiate their experience of parenthood in the unknown and terrifying environment of the neonatal intensive care unit (NICU), which may result in hampered maternal attachment.[4],[5] Neonates who are born sick and are isolated from their mothers, as well as mothers who are highly anxious or depressed, are at the highest risk for disturbances in the establishment of maternal newborn attachment.[6] Parents of neonates admitted to a NICU experience increased anxiety, depression, and trauma symptoms, compared with parents of healthy neonates. This is related to multiple factors, including adapting to having a sick neonate, the stress of the NICU environment, the physical and emotional separation from the child, as well as the normal stresses of parenthood.[7]

Postpartum depression (PPD) affects upto 15% of women in the first three months after delivery.[8] Mothers of premature neonates have almost double PPD rates (28%–40%), particularly in the early postpartum period.[9] PPD vulnerability has been associated with previous mental health disorders, the unique stress of premature birth, and NICU stay.[10],[11] Maternal depression is of concern not only because of its disabling effects on a mother herself but also because it has been related to neonatal cognitive, emotional, and developmental delay. Even though all neonates may be exposed to the effects of maternal depression, premature neonates are at the highest risk due to their reduced responsiveness and increased need for stimulation.[12]

Mothers encounter feelings of ambivalence, shame, guilt, and failure that are associated with social prejudice. Mothers think that their neonates in NICU will have problems in growth and development and that they are responsible for giving birth to a sick neonate.[13] The mothers of premature neonates experience altered parenting roles and frustration when they are admitted to the mother/baby unit. This incident may be harmful to the family system by affecting the behaviors, responsibilities, and cognitions displayed by the parents towards the neonate. Parents' responsibilities are also increased, and the special needs of the neonate leaves them with a feeling of inadequacy.[14],[15] The most commonly revealed parents' responses to alteration in the parental role are the inability to secure the neonate from pain and provide appropriate pain management, anxiety, helplessness, loss of control, fear, uncertainty, and worries about the premature neonate's outcomes.[16] Despite their prevalence, these disorders are generally not diagnosed and treated due to the constraints of time and concerns about the social acceptability of screening. Very few Indian studies have explored this field. In view of the above, the present work was conceived to evaluate stress, postpartum depression, and anxiety in the mothers of neonates admitted to the NICU.


   Materials and Methods Top


This hospital-based, cross-sectional, case-control study was conducted from September 2017 to August 2019 in the NICU and the obstetric wards in a tertiary care hospital affiliated with a medical college. The Institutional Ethics Committee clearance was obtained before starting the study (DPU/R&R (M)/31/(81)/2018 dt 12/1/2018). All the cases and control subjects were informed about the nature of the study and the extent of involvement required regarding time and sharing of details and then gave their written informed consent.

Sample

Consecutive mothers of preterm and low birth weight neonates in the NICU and in the age group of 18 to 45 years were included as cases. Equal numbers of age and socioeconomic status matched mothers of full-term neonates, were recruited to the control group.

Inclusion criteria

  1. Mothers aged 18 to 45 years of preterm neonates (born before 37 weeks of gestation) and low birth weight neonates (less than 2.5 kg) in the NICU for at least three days.
  2. For the control group, age and socioeconomic status matched mothers of full-term neonates in the obstetric wards for at least three days.


Exclusion criteria

  1. Mothers with major psychiatric disorders.
  2. Mothers with major medical disorders.
  3. Mothers who did not give consent.


Sample size calculation



Where: t = 1.96

m = 0.05

p = 10% (estimated prevalence)

Sample size calculated = 138.297 ~ 140

Tools

Socio-demographic and clinical profile: This proforma was specially designed to document the socio-demographic profile and clinical details of the participants.

The Acute Stress Disorder Scale (ASDS): The ASDS is a19-item self-report inventory. The respondents rate the presence of each symptom on a 5-point scale, which is summed up to give a total score. A cutoff score ≥9 on dissociation combined with a cutoff score ≥28 for the cumulative scores on the reexperiencing, avoidance, and arousal had good sensitivity (95%) and specificity (83%) for identifying acute stress disorder. Test-retest reliability was strong (r = 0.94).[17]

The Post-Traumatic Stress Disorder (PTSD) Symptom Scale (PSS): The PSS is a 17-item semi-structured interview that evaluates the presence and severity of The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition PTSD symptoms. The severity over the last two weeks of each item on the PSS was rated by the interviewer using a 4-point scale. A total PSS score is obtained by adding the score of all the items. The Cronbach's alpha coefficient was 0.91 for female participants. The four-week temporal stability was acceptable (r = 0.64, P < 0.001).[18],[19]

The Edinburgh Postnatal Depression Scale (EPDS): The EPDS contains 10 items rated on a four-point scale, giving maximum scores of 30. Higher scores indicate more depressive symptoms. Mothers who score ≥10 are likely to be suffering from a depressive illness. The Cronbach's alpha was 0.79. Two-factor analyses showed that anhedonia and depression were two explanatory factors.[20]

The Perinatal Anxiety Screening Scale (PASS): The PASS is a 31-item self-report screen for problematic anxiety in antenatal and postpartum women. The severity over the previous month of each item on the PASS is rated by the interviewer using a 4-point scale, which is summed up. Mothers who score 21 or more on the scale are likely to be suffering from anxiety of varying severity. The PASS has excellent reliability with Cronbach's α = 0.96 and is validated for use in hospital, mental health, and community samples.[21]

Methods

Consecutive mothers, aged 18 to 45 years, of preterm and low birth weight neonates in the NICU were included in the study as cases. An equal number of mothers of full-term neonates matched for age and socioeconomic status were recruited as controls. After filling the specially designed socio-demographic profile and clinical details in the proforma, all the cases and controls were administered: ASDS, PSS, EPDS, and PASS.

Statistical analyses

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 16 (IBM, Chicago, USA) using both descriptive and inferential statistics.

Descriptive statistics: Data summarization was done with the help of percentages and summary statistics were with mean, range, and standard deviation.

Inferential statistics: The frequency data were compared using the Chi-Square test and the Fisher Exact test, and the ordinal data were compared using the Mann-Whitney U test. A P value < 0.05 was considered for statistical significance.


   Results Top


A total of 140 mothers of neonates admitted to the NICU formed the study group. An equal number of mothers of full-term neonates who were in obstetrics wards formed the control group. On the socio-demographic characteristics, there were no significant differences between the two groups except that a significantly more number of cases were employed [Table 1]. Comparing scores of controls and cases on the PASS, EPDS, ASDS, and PSS revealed that on the EPDS, ASDS, and PSS the cases had significantly higher scores as compared to controls [Table 2]. The number of subjects scoring above the cut-off score on the PASS and EPDS was significantly higher in the cases as compared to controls [Table 3]. A statistically significant association of anxiety with age was found in the range of 19–24 years, but not in the range of 25–30 years, while depression had a statistically significant association with both age groups [Table 4]. Association of anxiety and depression with pregnancy planning status, history of abortion, mode of delivery, and sex of the child is shown in [Table 5]. The association of scores of ASDS and PSS with age, education, occupation, and domicile in the cases and controls is given in [Table 6]. The association of ASDS and PSS with pregnancy planning status, previous abortions, mode of delivery, and sex of the child is shown in [Table 7].
Table 1: The socio-demographic and clinical profile of cases and controls

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Table 2: The comparison of the scores on the perinatal anxiety screening scale (PASS), Edinburgh postnatal depression scale (EPDS), The Acute Stress Disorder Scale (ASDS), and PTSD symptom scale (PSS) between the cases and controls

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Table 3: The comparison of the prevalence of Perinatal anxiety, depression and stress between the cases and controls

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Table 4: The association of anxiety & depression with age, education, occupation and domicile in cases and controls

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Table 5: The association of anxiety and depression with pregnancy planning status, history of abortion, mode of delivery and gender of child in cases and controls

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Table 6: The association of scores of Acute Stress Disorder Scale (ASDS) and PTSD symptom scale (PSS) with age, education, occupation, and domicile in the cases and controls

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Table 7: The association of Acute Stress Disorder Scale (ASDS) and PTSD symptom scale (PSS) with pregnancy planning status, previous abortions, mode of delivery, and sex of the child

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   Discussion Top


Reproductive Mental Health is an essential subspecialty in the field of psychiatry. It is likely that most psychiatrists will encounter mood disorders in pregnant and postpartum women in their practice at some time, given that this specific time in a woman's life is in itself a high-risk factor. By recognizing the various contributing factors and risks associated with mood disorders, and by offering timely and appropriate treatment, a healthy outcome is more likely for both the mother and her family. Maternal characteristics and infant characteristics among other variables identified as important in the literature. Many published studies provide information about the stressors that parents face when having a child hospitalized in the NICU, the needs that parents deem most important, and the types of coping strategies that parents use, yet there is a paucity of Indian studies which focused on the NICU as a source of stress for parents.

In the present study, the mean age of the cases was 22.84 with an age range of 19–30 years and the majority (80%) of the cases were in the age group of 19–24 years. These findings are similar to an earlier study which reported a mean age of 24.7 years with a range between 19–32 years and the majority of cases falling in the age group of 19–25 years.[22] The majority of the cases in the study (85.71%) were Hindus, as the population of this area is mostly Hindus who outnumber minority groups like Muslims or Christians. This finding is similar to an earlier Indian study, in which 80% were Hindus.[23] The findings regarding education show that the majority, i.e., 68.57% had completed secondary schooling, 16.43% went to primary school, 10% were educated up to the level of graduate or above, and 5% were illiterates. Similar findings were reported by Chourasia et al.,[22] in which 59% received high school education, 14% had a bachelor's degree, 16% went to primary school, and 11% were not formally educated. Occupation-wise distribution among cases shows that the majority, i.e., 92.1% were homemakers and 7.9% were employed. The finding is similar to an earlier study, in which 92.6% were homemakers and 7.4% were employed.[24] The majority of the cases, i.e., 69.3% were residing in the urban area and 31.7% were from the rural area. This is in concordance with a previous study.[25] The majority of the cases, i.e., 63.6% belonged to a joint family and 36.4% belonged to a nuclear family. The finding is similar to the findings of an earlier study.[26] The majority of the cases, i.e., 89.3% hailed from lower socioeconomic status and 10.7% from middle socioeconomic status. An earlier study also had similar findings.[27] The reported prevalence of 5.7% domestic violence in the present study is similar to the 5.9% domestic violence reported by a previous study.[28]

A history of abortion was present in 35% of cases in the present study. A similar finding was noted by Ege et al.[24] The majority of the cases (68.6%) had an unplanned pregnancy and 31.4% had a planned pregnancy in the present study which was on expected lines. This finding is in contrast to an earlier study, in which 70.1% had a planned pregnancy and 29.9% had an unplanned pregnancy.[24] The majority of the cases, i.e., 84.3% had a cesarean section and 15.7% had a normal vaginal delivery. [Table 1] The finding is similar to a previous study, in which 88.1% had a cesarean section and 11.9% had a normal vaginal delivery.[29] Most of the cases, i.e., 55.7% delivered a male child and 44.3% delivered a female child. This finding is similar to the results of earlier studies.[23],[27]

Anxiety, depression, and stress in mothers of preterm infants

A comparison of the levels of anxiety as quantified by the total PASS score revealed the presence of significantly higher levels of anxiety in mothers of preterm infants as compared to the mothers of full-term infants [Table 2] and [Table 3]. This finding is similar to the study by Carter et al.[7]

Analysis indicated significantly higher levels of depression on the EPDS in mothers of preterm infants as compared to the mothers of full-term infants in the current study [Table 2]. This finding is in concordance with the findings noted by Yurdakul et al.[30] A comparison of the levels of stress between the mothers of preterm babies and the mothers of full-term babies revealed the presence of significantly higher levels of stress as assessed by scores on ASDS and PSS, in mothers of preterm infants as compared to mothers of full-term infants. [Table 2] This finding is similar to the study by Board et al.[31] and Gateau et al.[32] but not with Lau et al.[33]

Association of anxiety, depression, and stress with socio-demographic and clinical profile of cases

The present study found a significant association between anxiety and the age group in the range of 19–24 years. [Table 4] In contrast to this, an earlier study did not find an association between maternal age and higher levels of anxiety.[30] The lack of association between depression and the age of the mothers in the present study is similar to the results of a few earlier studies.[30],[31],[34],[35],[36] The finding of an association between stress and the age group in the range of 19–24 years in the present study is in contrast to the findings of two earlier studies, which reported a significant association between increasing age of mother and higher levels of stress.[26],[22] This was probably due to the fact that the majority of our subjects belonged to a younger age group.

The present study found a significantly higher level of anxiety in mothers who completed secondary schooling. [Table 6] In contrast to the above, one study reported that anxiety was more frequent in women with higher education (above secondary level).[26] The present study found significantly higher levels of depression in mothers who were educated up to the secondary level [Table 6]. This finding is similar to the results of a number of studies,[24],[26],[36],[37] which found a significant association between higher levels of depression and low education. The present study found significantly higher levels of stress in mothers who were educated up to the level of graduation or above [Table 6]. A similar finding was observed by Bener et al.[26] This finding is in contrast to the study by Chourasia et al.,[22] which revealed no association between the education of mothers and higher levels of stress. Obviously, this aspect requires further study.

The lack of a significant association between working status and the higher levels of anxiety in mothers in the present study parallels the results of Yurdakul et al.[30] The finding of a statistically significant association of depression in mothers who were homemakers is in concordance with the findings of Bener et al.,[26] but is in contrast to the study by Yurdakul et al.,[30] which showed no association between working status and higher levels of maternal depression. The present study found a significant association between working status and higher levels of stress in mothers. This finding is in contrast to the study by Chourasia et al.,[22] which reported no association between working status and higher levels of stress in mothers.

A statistically significant association of the anxiety with both groups of domicile among cases as compared to controls was found in the study. The study did not find a significant association between higher levels of depression in mothers and domicile. In contrast, Inadi et al.[38] found a significant association between higher levels of depression in mothers and rural area. The present study found a significant association between higher levels of maternal stress and urban area. [Table 6] This finding is in contrast to the study by Feiziet et al.,[25] which did not find any association between higher levels of maternal stress and domicile. The discrepant findings may be due to the higher number of subjects from the urban area in the current study.

The present study did not find an association of family type with higher levels of anxiety and depression in cases. [Table 6] These findings are similar to the study by Bener et al.[26]

The current study found a significant association between joint family and higher levels of maternal stress. [Table 4] This finding is in contrast to the study by Bener et al.,[26] which found no association between family type and higher levels of maternal stress.

Analysis revealed significantly increased levels of anxiety in mothers who were hailing from lower socioeconomic status. [Table 6] A study by Carter et al.[7] also had a similar finding. This finding is in contrast to the study by Bener et al.,[26] which did not find an association between socioeconomic status and higher levels of anxiety.

A significant association between lower socioeconomic status and higher levels of depression was found in the present study. [Table 6] This is similar to the findings of a few earlier studies.[36],[38],[39]

The finding of a significant association between middle socioeconomic status and higher levels of stress in the present study [Table 6] is in contrast to the study by Carter et al.,[40] which showed an association between lower socioeconomic status and higher levels of stress in mothers.

In contrast to the study by Bener et al.,[26] which showed a significant association between unplanned pregnancy and higher levels of anxiety in mothers, the current study did not find a significant association between unplanned pregnancy and higher levels of maternal anxiety [Table 7]. The finding of lack of association between unplanned pregnancy and higher levels of depression in mothers in the present study is in agreement with few studies.[41],[42] This finding is in contrast to the studies by Bener et al.[26] and Inandi et al.,[38] which showed a significant association between higher levels of depression in mothers and unplanned pregnancy. The study found a significant association between unplanned pregnancy and higher levels of maternal stress [Table 7]. This finding is in contrast to the study by Bener et al.,[26] which found no association between unplanned pregnancy and higher levels of stress.

The present study did not find a significant association between anxiety and previous history of abortion. This finding is in contrast to a study that showed a significant association between maternal anxiety and previous history of perinatal loss.[43] This study did not find a significant association between higher levels of depression in mothers and previous history of abortion. [Table 5] This finding is similar to the study by Ege et al.[24] and Inadi et al.,[37] but is in contrast to the study by Armstrong et al.[43] The present study did not find a significant association between higher levels of stress and previous history of abortion. These findings are in contrast to the study by Armstrong et al.,[43] which showed a significant association between maternal stress and previous history of perinatal loss.

The finding of a significant association between cesarean section and increased levels of anxiety in the cases is in agreement with an earlier study,[26] but is in contrast to the finding of Yurdakul et al.[30] and Salah et al.[27] Further study in this area is needed.

The levels of depression were not related to the mode of delivery in the current study. This finding is in agreement with few studies.[30],[44],[45] As opposed to this, Bener et al.,[26] Lee et al.[46] and Koutra et al.[47] showed significantly higher levels of depression among mothers who had a cesarean section. The present study did not find a significant association between the mode of delivery and higher levels of maternal stress, which is in agreement with Chourasia et al.[22]

The lack of a significant association between the sex of the child and levels of anxiety in mothers of preterm babies in the present study is in agreement with earlier studies.[27],[30] The finding of significantly higher levels of depression in mothers of a male child could be due to the fact that a male child is prized and the illness of the child may have produced a low mood. This finding is in contrast to the studies by Yurdakulet. et al.[30] and Inadi et al.,[38] which did not find an association between the sex of the child and higher levels of depression in mothers.


   Strengths of the study Top


This study is one of the few Indian studies that have assessed psychological distress in mothers of neonates admitted to the NICU with a fairly large sample size.

Limitations of the study

The present study was cross-sectional, case-control, and follow-up could not be done. A longitudinal case-control study evaluating the cases and the healthy subjects at baseline and follow-up would have been superior. This is a hospital-based study and the findings cannot be generalized to a larger population.


   Conclusion Top


The admission of a preterm neonate to the NICU was associated with significantly higher levels of stress, anxiety, and depression in the mothers. Higher levels of depression were significantly associated with lower socioeconomic status, low education, unemployment, and male child. Higher levels of anxiety were significantly associated with age groups in the range of 19–24 years, lower socioeconomic status, and cesarean section. Higher levels of stress were significantly associated with age groups in the range of 19–24 years, higher education, middle socioeconomic status, joint family, urban residential area, unplanned pregnancy, and male child.

Directions for future research

The present study findings have implications for practice and further research. The results provide evidence of parents' need for support during the infant's hospitalization in the NICU. With the current trend towards early hospital discharge of preterm infants, parents at high risk for psychiatric morbidity should be identified and these vulnerable patients should be targeted for information and supportive psychotherapy. Also, adequate follow-up care should be provided following discharge and the high-risk groups should be exposed to professional psychiatric consultation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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