512353 2013
HPQ0010.1177/1359105313512353Journal of Health PsychologyBouras et al.
Article
Preterm birth and maternal psychological health
Journal of Health Psychology 2015, Vol. 20(11) 1388–1396 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313512353 hpq.sagepub.com
Georgios Bouras, Nikoletta Theofanopoulou, Panagioula Mexi-Bourna, Antonios Poulios, Ioannis Michopoulos, Ioanna Tassiopoulou, Anna Daskalaki and Christos Christodoulou
Abstract Studies have shown that preterm birth significantly influences mothers’ psychological health. This study aimed to identify factors associated with preterm birth and assess postnatal depression and anxiety symptoms in mothers of preterm infants (n = 75) compared to mothers who delivered at term (n = 125) in a Greek sample. Multiple pregnancies, assisted reproduction technology, caesarean section, non-Greek ethnicity and smoking during pregnancy were associated with preterm delivery. Moreover, preterm infants’ mothers had higher depression, state anxiety and trait anxiety scores. These findings suggest that addressing preventable causes of preterm delivery is crucial, while mothers of preterm infants should receive postnatal support.
Keywords family, health care, postpartum, pregnancy, psychological distress
Introduction Preterm birth is defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation (World Health Organization (WHO), 1992). A study based on data from 184 countries suggests a worldwide estimate of 14.9 million preterm births for the year 2010, representing 11.1 per cent of all live births worldwide, 5 per cent in several European countries and 12 per cent in the United States. There is a dramatic survival gap between highincome and low-income countries, with more than 90 per cent of the infants born before 28 weeks gestation surviving in the former, while only 10 per cent or less survive in the latter (Blencowe et al., 2012). There seems to be a
worldwide trend towards higher preterm birth rates (Beck et al., 2010), with a recent Greek epidemiological study showing that preterm births in Greece have increased more than twofold over the past three decades, accounting for 9.62 per cent of live births in 2008, when the respective rate in 1980 was 4.66 per cent (Baroutis et al., 2013). Attikon University Hospital, Greece Corresponding author: Georgios Bouras, 2nd Department of Psychiatry of the University of Athens, Attikon University Hospital, 1 Rimini Street, Chaidari, Athens 14562, Greece. Email: [email protected]
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Bouras et al. Numerous studies have investigated the association between the incidence of preterm birth and various epidemiological and clinical risk factors, highlighting the aetiological heterogeneity of preterm birth and its multifactorial origins (Savitz et al., 1991). Maternal age both at the upper (Goldenberg et al., 2008) and lower end of the reproductive years, Afro-American ethnicity (Martius et al., 1998), previous induced abortion (Moreau et al., 2005) and a prior preterm birth (Mercer et al., 1999) have been associated with an increased probability of preterm delivery. Additionally, pregnancies obtained with assisted reproduction technology (ART; Dhont et al., 1999) and multiple pregnancies (Lumley, 2003) appear to have a worse perinatal outcome than normally conceived pregnancies. Maternal smoking during pregnancy (Shah and Bracken, 2000), prenatal depression (Dayan et al., 2006) and anxiety (Dole et al., 2003; Vigod et al., 2010) have also been consistently associated with preterm delivery. Finally, maternal medical complications during the pregnancy can prevent the baby from being carried to term and preterm labour must often be induced for medical reasons (Berkowitz and Papiernik, 1993). Modern advances in perinatal medicine have resulted in a significant increase in the survival rates of preterm infants over the last decades (Cooke, 2006); however, the emotional distress of the parents brought about by the preterm birth and the subsequent hospitalisation of the infant remains substantial (Davis et al., 2003; Meyer et al., 1995; Miles et al., 1991). Feelings of disappointment, fears regarding the child’s survival and altered parental experiences, including separation and reduced opportunities to interact with the infant in the neonatal intensive care unit (NICU), are all very difficult and stressful for parents (Affleck et al., 1991). The traumatic delivery evokes feelings of self-blame, shame, personal incapability and guilt that add to the anguish (Mendelsohn, 2005). Mothers of preterm infants experience more severe levels of psychological distress in the neonatal period than mothers of full-term infants (Singer et al., 1996), with symptoms of
depression and anxiety being prominent (Correia and Linhares, 2007; Garel et al., 2004). Maternal depression has been found to have negative effects for maternal responsiveness and sensitivity to infants, which in turn can have negative outcomes for the infant’s development (Bugental et al., 2008; Galler et al., 2000). The same applies to the presence of high levels of maternal anxiety, as it has been associated with emotional and behavioural problems during childhood and adolescence (Correia and Linhares, 2007). The aim of this study was to identify factors that are associated with preterm delivery and to measure levels of postnatal depression and anxiety in mothers of preterm infants in comparison to mothers of full-term infants. It was hypothesised that the mothers of the preterm infants would show higher levels of psychological distress than the mothers of the infants born at term and that factors such as the ethnicity and smoking habits of the mother, previous abortions and preterm births, the use of ART, multiple gestation and problems during pregnancy would influence preterm delivery. Due to the individual and public health consequences of preterm birth, further research is needed in order to obtain a better understanding of its underlying mechanisms, patterns and risk factors, so as to be able to identify and treat affected women and prevent the negative consequences on their offspring.
Methods Participants The study was conducted between September 2010 and December 2011 at Attikon University Hospital, Athens. Women were recruited during a 1-month period after they had given birth at the Department of Obstetrics and Gynaecology. Mothers were required to have working knowledge of the Greek language in order to participate in the study. Exclusion criteria were previously diagnosed mental disorders and drug use. The study group consisted of mothers who had delivered a preterm baby at 23–36 weeks’ gestation with the baby having received care in
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the NICU for at least 1 week. Of those eligible, 75 mothers who delivered 88 infants agreed to participate. All of the preterm infants survived in the period of the study. A control group of 125 mothers who delivered 126 infants at term was also recruited. The babies were healthy and did not require admission to the NICU.
Measures The questionnaires used for the survey were previously validated research instruments. State-Trait Anxiety Inventory–Form Y. The StateTrait Anxiety Inventory–Form Y (STAI-Y) is a 40-item self-report questionnaire designed to evaluate anxiety in adults, consisting of two subscales, one for assessing state anxiety and one for trait anxiety (Spielberger et al., 1970). The range of scores is 20–80, with higher scores indicating greater anxiety. Beck Depression Inventory. The Beck Depression Inventory (BDI) is a 21-item self-report rating scale designed to assess the existence and severity of symptoms of depression. Higher scores indicate more severe depression symptoms. The BDI is one of the most widely used instruments for measuring the presence and the severity of depression, and it has been reported to be highly reliable regardless of the population (Beck et al., 1961).
Demographic data Maternal demographic data were collected using a demographic questionnaire, which was completed from the mothers, and infant data, including birth weight (grams) and gestational age (weeks), were collated from the medical personnel of the department of Obstetrics and Gynaecology.
Procedure The mothers of the preterm infants were approached to participate in the study approximately 1 month after infant admission to the
NICU. This time period was given in order to give the mothers sufficient time to physically recover from childbirth and become familiar with the environment and the personnel of the unit and for the infants’ medical condition to stabilise. The average length of stay in the NICU was approximately 25 days. The mothers who delivered at term were also approached during their stay at the hospital (4 days after delivery). After information about the study was provided and verbal informed consent was obtained, mothers were then asked to complete the above listed questionnaires.
Statistics Comparison of maternal and infant characteristics in the two groups was carried out using Pearson r bivariate correlations and independent t-tests for normally distributed data, Spearman rho, Mann–Whitney U test for nonnormally distributed variables and the chisquare test for categorical data. A binary sequential logistic regression was then performed to assess prediction of preterm delivery. The sequential procedure was preferred in order to examine separately the contribution of variables that preceded the conception (first set), at the time of conception (second set) and during the pregnancy (third set). Only those variables with significant associations with the dependent variable were entered into the final model. Statistical analyses were performed in SPSS version 20 (SPSS Inc., Chicago, IL).
Results Of the 200 mothers who took part in the study, 37.5 per cent had given birth to premature infants, and 62.5 per cent had given birth to full-term infants. The mean age of the mothers in the sample was 31.3 years. Regarding the smoking habit during pregnancy, 16 per cent gave a positive response. The majority of the mothers (90%) had conceived their infants naturally, while the remaining 10 per cent had conceived using ART. Problems during pregnancy
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Bouras et al. Table 1. Maternal characteristics for those who delivered preterm and at term.
Maternal age, mean (SD) Educational level, n (%) Secondary education Tertiary education Ethnicity, n (%) Greek Other Previous abortion, n (%) Previous preterm birth, n (%) Smoking during pregnancy, n (%) Assisted reproduction, n (%) Multiple pregnancies, n (%) Caesarean section, n (%) Problems during pregnancy, n (%)
Preterm (n = 75)
Full term (n = 125)
p value
32 (6.3)
30.9 (4.6)
40 (53.3) 29 (38.7)
56 (44.8) 60 (48.0)
58 (77.3) 17 (22.7) 14 (18.7) 6 (8.1) 26 (34.7) 16 (21.3) 10 (13.3) 50 (66.7) 38 (50.7)
114 (91.2) 11 (8.8) 18 (14.4) 4 (3.2) 6 (4.8) 4 (3.2) 1 (.8) 62 (49.6) 20 (16.0)
.182 .346 .006 .426 .126 .000 .000 .000 .019 .000
SD: standard deviation.
were reported in 29 per cent of the cases; 10.5 per cent reported risk of miscarriage, 4 per cent hyperemesis gravidarum, 3.5 per cent high blood pressure and 2.5 per cent gestational diabetes. The method of delivery was caesarean section for 56 per cent of the mothers, and 20 per cent reported problems during childbirth. Maternal age and educational level were similar between the two groups of mothers. Furthermore, there was no statistically significant association between a prior abortion (p = .426) or preterm birth (p = .126) and preterm delivery. Multiple pregnancies, ART, caesarean section, ethnicity and smoking during pregnancy were associated with preterm birth (Table 1). The infants’ gestational ages ranged from 23 to 41 weeks, with a mean of 35.8 weeks. Birth weight ranged from 692 to 4335 g, with a mean of 2592 g. A total of 56 per cent of the infants were male, with the remaining 44 per cent being female (Table 2). Using an independent t-test, the relationship between BDI scores and preterm birth was examined (Table 3). There was a statistically significant association between BDI scores (p = .001) and preterm birth, with mothers of preterm infants having higher scores. Another independent t-test was carried out to examine the relationship between scores on the state
anxiety scale of the STAI-Y and preterm birth. The results revealed statistically significant associations between state anxiety scores (p = .000) and trait anxiety scores (p = .000), with the mothers who delivered preterm infants scoring higher in every scale than the mothers who delivered at term. Statistically significant associations were also found between smoking during pregnancy and problems during pregnancy (p = .015), preterm delivery (p = .000), gestation week (p = .000), scores in the BDI (p = .008), scores in the state anxiety scale (p = .008) and scores in the trait anxiety scale (p = .002) (Table 4). Having determined the factors that were significantly related to preterm delivery, we proceeded to the statistical prediction of it through the aforementioned logistic regression whose results are presented in Table 5. The first set of logistic regression predictors included mother’s ethnicity (Greek or other) and maternal trait anxiety. The second set involved the use of ART (yes or no) and multiple gestation (yes or no). The predictors in the third set were smoking during pregnancy and problems during pregnancy (yes or no). The log-likelihood ratios for models for the sequential sets of the analysis showed statistically significant contribution in the predictions by all three sets of the predictive variables. The final
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Table 2. Infant characteristics for those born preterm and at term.
Male infant, n (%) Singleton birth, n (%) Birth weight (g), mean (SD) Weight < 1000 g, n (%) Gestation weeks, mean (SD) Born < 28 weeks, n (%)
Preterm (n = 88)
Term (n = 126)
p value
52 (59.1) 65 (73.9) 1501 (657) 22 (25) 31.0 (3.2) 14 (15.9)
66 (52.4) 124 (98.4) 3231 (462) – 38.8 (1.2) –
.331 .000 .000 .000
SD: standard deviation.
Table 3. Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scores for preterm and term mothers.
BDI BDI scores, mean (SD) State anxiety scale State anxiety scores, mean (SD) Trait anxiety scale Trait anxiety scores, mean (SD)
Preterm (n = 75)
Term (n = 125)
p value
n = 68 10.26 (7.88) n = 52 41.56 (13.41) n = 53 39.0 (11.48)
n = 107 7.06 (7.98) n = 114 33.62 (9.89) n = 107 32.1 (10.03)
.001 .000 .000
SD: standard deviation.
Table 4. Problems during pregnancy, preterm delivery, gestation weeks, BDI and STAI scores for mothers who smoked and did not smoke during pregnancy.
Problems during pregnancy, n (%) Preterm delivery, n (%) Gestation weeks, mean (SD) BDI BDI scores, mean (SD) State anxiety scale State anxiety scores, mean (SD) Trait anxiety scale Trait anxiety scores, mean (SD)
Smoking (n = 32)
Not smoking (n = 168)
p value
15 (46.9) 26 (81.3) 31.75 (4.86) n = 30 11.03 (8.02) n = 23 44.26 (16.69) n = 22 41.05 (11.21)
43 (25.6) 49 (29.2) 36.65 (3.99) n = 145 7.74 (7.99) n = 143 34.79 (10.13) n = 138 33.33 (10.62)
.015 .000 .000 .008 .008 .002
BDI: Beck Depression Inventory; STAI: State-Trait Anxiety Inventory; SD: standard deviation.
model including the three sets of predictors was statistically significant (p = .000).
Discussion The aims of this study were to identify factors that are associated with preterm birth and to
measure levels of postnatal depression and anxiety in mothers of preterm infants compared to mothers who delivered at term. Our findings support those of previous studies that have shown a strong association between assisted reproduction (Dhont et al., 1999), multiple pregnancies (Lumley, 2003) and preterm birth.
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Bouras et al. Table 5. Logistic regression table: significant factors associated with preterm birth. Predictors
B
Step 1 Ethnicity (non-Greek) Trait anxiety Step 2 Ethnicity (non-Greek) Trait anxiety ART (yes) Multiple gestation (yes) Step 3a Ethnicity (non-Greek) Trait anxiety ART (yes) Multiple gestation (yes) Smoking during pregnancy (yes) Problems during pregnancy (yes)
SE
Wald
df
Exp (β)
−.38 .06
.53 .17
6.63 12.94
1 1
.25** 1.06***
−1.77 .06 −1.89 −2.34
.55 .05 .80 1.18
10.22 12.79 5.59 3.87
1 1 1 1
.17** 1.06*** .15 .09
−2.10 .04 −1.70 −2.31 −1.97 −1.84
.61 .02 .91 1.29 .62 .46
11.92 4.13 3.46 3.19 10.07 15.49
1 1 1 1 1 1
.12** 1.04* .18 .09 .13** .15***
df: degrees of freedom; SE: standard error; ART: assisted reproduction technology. Nagelkerke R2 = .17 (Step 1); Nagelkerke R2 = .33 (Step 2); Nagelkerke R2 = .51 (Step 3). aNonsignificant; ART, multiple gestation. *p < .05; **p < .01; ***p < .001.
Pregnancies resulting from the use of ART place women at greater risk for preterm delivery probably due to the physical implications of fertility treatment and their strong association with multiple pregnancies (Dhont et al., 1999; Lumley, 2003). Additionally, maternal medical problems during pregnancy may increase the risk of preterm birth and the probability of delivery by caesarean section due to the medical urgency of the situation. It should be noted here that the high rate of births by caesarean section in this study is consistent with the findings of recent studies that report a rise in these rates in Greece (Dinas et al., 2008; Mossialos et al., 2005; Tampakoudis et al., 2004). The expected association between preterm delivery and a previous abortion or a prior preterm birth was not found. It was found that maternal non-Greek ethnicity, trait anxiety and smoking during pregnancy are associated with preterm birth. Possible explanations for the higher prevalence of preterm birth in the immigrant group could be lower socioeconomic status, psychosocial stress and adverse
life events, which have been reported to increase the risk of preterm birth (Hedegaard et al., 1996; Newton et al., 1979). Women with higher levels of trait anxiety may be in greater risk of preterm delivery than women with lower trait anxiety levels as they also tend to show increased levels of anxiety during pregnancy, that in turn have been associated with obstetric complications and negative delivery outcome (Alder et al., 2007; Galler et al., 2000; Rizzardo et al., 2010). Finally, smoking during pregnancy has consistently been associated with lower gestational age and negative perinatal outcome (Shah and Bracken, 2000). Furthermore, the results of this study show that preterm delivery has a significant influence on maternal psychological health. Mothers of preterm infants present higher levels of depression and anxiety during the neonatal period compared to mothers of full-term infants. The foundations of the mother–child relationship start to develop as early as in the intrauterine period (Cannella, 2005). The pregnancy period is when the meeting of the mother and the child is
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being prepared and processed. Preterm birth can not only intensely disrupt this preparatory period but can also cause a serious narcissistic injury to the mother (Pavoine et al., 2004), due to the feeling of being a parent to an ‘incomplete’ child, of ‘not having produced the right thing at the right time’ (Freud, 1981), the perceived inability to bring her child safe to life, to protect him or her and ensure his or her existence (Bouras, 2011). It has been argued that physical contact, proximity, reciprocity and commitment are the central characteristics that promote the attachment between mother and child postnatally (Goulet et al., 1998). When the pregnancy is abruptly terminated and the infant needs care in the NICU immediately after the delivery, the separation from the baby complicates the establishment of the mother– infant bond, as the mother is not fully prepared, and the development of maternal identity is delayed (Aagaard and Hall, 2008). She has a strong desire to be close to her newborn, but she sacrifices it in order for the infant to receive lifesaving care from the health-care staff of the unit (Wigert et al., 2006). She often feels as a stranger or an outsider (Heermann et al., 2005), as she is not able to make choices for the care of her own child and has limited opportunities to interact with it (Lupton and Fenwick, 2006). Feelings of ambivalence regarding her desire for her baby (Jackson et al., 2003) and a fear to form a connection with it arise, since she finds herself between hope and hopelessness on the outcome of her newborn’s hospitalisation (Hall, 2005). The mother of a preterm infant has to assume the maternal role under stressful circumstances for which she was not prepared (Wigert et al., 2006). The meeting with the fragile infant and the first sight of the strange and unfamiliar environment of the NICU is overwhelming and frightening for the mother; she is worried about the medical condition of her baby and wants to know what is going on in the unit (Miles et al., 1992). The separation from the infant and the lack of control of the situation have been found to be the most difficult and stressful aspects of the baby’s hospitalisation (Nyström and Axelsson, 2002). The results should be interpreted within the
limitations of the study, including reliance on self-report data and the correlational nature of the study that does not permit any causative links to be identified.
Recommendations The findings of this study agree with those of previous studies, indicating that the birth of a premature infant involves a great deal of emotional distress for the mother. Thus, it is important to keep in close contact with pregnant women not only for antenatal medical consultation to prevent pregnancy problems but also in order to identify high-risk groups for preterm delivery, such as immigrant mothers or mothers with high trait anxiety and provide them with psychological support. Additionally, stop-smoking programmes might be effective for reducing the risk of preterm birth. Taking into account the high percentage of postnatal anxiety and depression symptoms in preterm neonates’ mothers identified in this study, it is also recommended that mothers who go through preterm delivery be routinely screened for postpartum depression and anxiety. If deemed necessary, they should receive postnatal support to cope with the emotional distress brought about by preterm birth. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
References Aagaard H and Hall EO (2008) Mothers’ experiences of having a preterm infant in the neonatal care unit: A meta-synthesis. Journal of Pediatric Nursing 23(3): e26–e36. Affleck G, Tennen H and Rowe J (1991) Infants in Crisis: How Parents Cope with Newborn Intensive Care and Its Aftermath. New York: Springer Verlag. Alder J, Fink N, Bitzer J, et al. (2007) Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of MaternalFetal & Neonatal Medicine 20(3): 189–209.
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Bouras et al. Baroutis G, Mousiolis A, Mesogitis S, et al. (2013) Preterm birth trends in Greece, 1980–2008: A rising concern. Acta Obstetricia et Gynecologica Scandinavica 92(5): 575–582. Beck AT, Ward CH, Mendelson M, et al. (1961) An inventory for measuring depression. Archives of General Psychiatry 4(6): 561–571. Beck S, Wojdyla D, Say L, et al. (2010) The worldwide incidence of preterm birth: A systematic review of maternal mortality and morbidity. Bulletin of the World Health Organization 88(1): 31–38. Berkowitz GS and Papiernik E (1993) Epidemiology of preterm birth. Epidemiologic Reviews 15(2): 414–443. Blencowe H, Cousens S, Oestergaard MZ, et al. (2012) National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: A systematic analysis and implications. The Lancet 379(9832): 2162–2172. Bouras G (2011) Preterm birth: Particularities and difficulties in the development of motherinfant relationship. In: Papachristopoulos N and Samartzi K (eds) Health, Illness and Social Bond. Athens: Opportuna, pp. 735–742. Bugental DB, Beaulieu D and Schwartz A (2008) Hormonal sensitivity of preterm versus fullterm infants to the effects of maternal depression. Infant Behavior & Development 31(1): 51–61. Cannella BL (2005) Maternal–fetal attachment: An integrative review. Journal of Advanced Nursing 50(1): 60–68. Cooke RW (2006) Preterm mortality and morbidity over 25 years. Archives of Disease in Childhood: Fetal and Neonatal Edition 91(4): F293–F294. Correia LL and Linhares MB (2007) Maternal anxiety in the pre- and postnatal period: A literature review. Revista Latino-Americana de Enfermagem 15(4): 677–683. Davis L, Edwards H, Mohay H, et al. (2003) The impact of very premature birth on the psychological health of mothers. Early Human Development 73(1–2): 61–70. Dayan J, Creveuil C, Marks MN, et al. (2006) Prenatal depression, prenatal anxiety, and spontaneous preterm birth: A prospective cohort study among women with early and regular care. Psychosomatic Medicine 68(6): 938–946. Dhont M, Sutter P, Ruyssinck G, et al. (1999) Perinatal outcome of pregnancies after assisted reproduction:
A case-control study. American Journal of Obstetrics and Gynecology 181(3): 688–695. Dinas K, Mavromatidis G, Dovas D, et al. (2008) Current caesarean delivery rates and indications in a major public hospital in northern Greece. Australian and New Zealand Journal of Obstetrics and Gynaecology 48: 142–146. Dole N, Savitz DA, Hertz-Picciotto I, et al. (2003) Maternal stress and preterm birth. American Journal of Epidemiology 157(1): 14–24. Freud WE (1981) To be in touch. Journal of Child Psychotherapy 7(2): 141–143. Galler JR, Harrison RH, Ramsey F, et al. (2000) Maternal depressive symptoms affect infant cognitive development in Barbados. Journal of Child Psychology and Psychiatry 41(6): 747–757. Garel M, Bahuaud M and Blondel B (2004) Conséquences pour la famille d’une naissance très prématurée deux mois après le retour à la maison. Résultats de l’enquête qualitative d’EPIPAGE. Archives de Pédiatrie 11(11): 1299–1307. Goldenberg RL, Culhane JF, Iams JD, et al. (2008) Epidemiology and causes of preterm birth. The Lancet 371(9606): 75–84. Goulet C, Bell L, St-Cyr D, et al. (1998) A concept analysis of parent-infant attachment. Journal of Advanced Nursing 28(5): 1071–1081. Hall EO (2005) Being in an alien world: Danish parents’ lived experiences when a newborn or small child is critically ill. Scandinavian Journal of Caring Sciences 19(3): 179–185. Hedegaard M, Henriksen TB, Secher NJ, et al. (1996) Do stressful life events affect duration of gestation and risk of preterm delivery? Epidemiology 7(4): 339–345. Heermann JA, Wilson ME and Wilhelm PA (2005) Mothers in the NICU: Outsider to partner. Pediatric Nursing 31(3): 176–200. Jackson K, Ternestedt BM and Schollin J (2003) From alienation to familiarity: Experiences of mothers and fathers of preterm infants. Journal of Advanced Nursing 43(2): 120–129. Lumley J (2003) Defining the problem: The epidemiology of preterm birth. BJOG: An International Journal of Obstetrics and Gynaecology 110: 3–7. Lupton D and Fenwick J (2006) ‘They’ve forgotten that I’m the mum’: Constructing and practising motherhood in special care nurseries. Social Science & Medicine 53(8): 1011–1021. Martius JA, Steck T, Oehler MK, et al. (1998) Risk factors associated with preterm (
HPQ0010.1177/1359105313512353Journal of Health PsychologyBouras et al.
Article
Preterm birth and maternal psychological health
Journal of Health Psychology 2015, Vol. 20(11) 1388–1396 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313512353 hpq.sagepub.com
Georgios Bouras, Nikoletta Theofanopoulou, Panagioula Mexi-Bourna, Antonios Poulios, Ioannis Michopoulos, Ioanna Tassiopoulou, Anna Daskalaki and Christos Christodoulou
Abstract Studies have shown that preterm birth significantly influences mothers’ psychological health. This study aimed to identify factors associated with preterm birth and assess postnatal depression and anxiety symptoms in mothers of preterm infants (n = 75) compared to mothers who delivered at term (n = 125) in a Greek sample. Multiple pregnancies, assisted reproduction technology, caesarean section, non-Greek ethnicity and smoking during pregnancy were associated with preterm delivery. Moreover, preterm infants’ mothers had higher depression, state anxiety and trait anxiety scores. These findings suggest that addressing preventable causes of preterm delivery is crucial, while mothers of preterm infants should receive postnatal support.
Keywords family, health care, postpartum, pregnancy, psychological distress
Introduction Preterm birth is defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation (World Health Organization (WHO), 1992). A study based on data from 184 countries suggests a worldwide estimate of 14.9 million preterm births for the year 2010, representing 11.1 per cent of all live births worldwide, 5 per cent in several European countries and 12 per cent in the United States. There is a dramatic survival gap between highincome and low-income countries, with more than 90 per cent of the infants born before 28 weeks gestation surviving in the former, while only 10 per cent or less survive in the latter (Blencowe et al., 2012). There seems to be a
worldwide trend towards higher preterm birth rates (Beck et al., 2010), with a recent Greek epidemiological study showing that preterm births in Greece have increased more than twofold over the past three decades, accounting for 9.62 per cent of live births in 2008, when the respective rate in 1980 was 4.66 per cent (Baroutis et al., 2013). Attikon University Hospital, Greece Corresponding author: Georgios Bouras, 2nd Department of Psychiatry of the University of Athens, Attikon University Hospital, 1 Rimini Street, Chaidari, Athens 14562, Greece. Email: [email protected]
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Bouras et al. Numerous studies have investigated the association between the incidence of preterm birth and various epidemiological and clinical risk factors, highlighting the aetiological heterogeneity of preterm birth and its multifactorial origins (Savitz et al., 1991). Maternal age both at the upper (Goldenberg et al., 2008) and lower end of the reproductive years, Afro-American ethnicity (Martius et al., 1998), previous induced abortion (Moreau et al., 2005) and a prior preterm birth (Mercer et al., 1999) have been associated with an increased probability of preterm delivery. Additionally, pregnancies obtained with assisted reproduction technology (ART; Dhont et al., 1999) and multiple pregnancies (Lumley, 2003) appear to have a worse perinatal outcome than normally conceived pregnancies. Maternal smoking during pregnancy (Shah and Bracken, 2000), prenatal depression (Dayan et al., 2006) and anxiety (Dole et al., 2003; Vigod et al., 2010) have also been consistently associated with preterm delivery. Finally, maternal medical complications during the pregnancy can prevent the baby from being carried to term and preterm labour must often be induced for medical reasons (Berkowitz and Papiernik, 1993). Modern advances in perinatal medicine have resulted in a significant increase in the survival rates of preterm infants over the last decades (Cooke, 2006); however, the emotional distress of the parents brought about by the preterm birth and the subsequent hospitalisation of the infant remains substantial (Davis et al., 2003; Meyer et al., 1995; Miles et al., 1991). Feelings of disappointment, fears regarding the child’s survival and altered parental experiences, including separation and reduced opportunities to interact with the infant in the neonatal intensive care unit (NICU), are all very difficult and stressful for parents (Affleck et al., 1991). The traumatic delivery evokes feelings of self-blame, shame, personal incapability and guilt that add to the anguish (Mendelsohn, 2005). Mothers of preterm infants experience more severe levels of psychological distress in the neonatal period than mothers of full-term infants (Singer et al., 1996), with symptoms of
depression and anxiety being prominent (Correia and Linhares, 2007; Garel et al., 2004). Maternal depression has been found to have negative effects for maternal responsiveness and sensitivity to infants, which in turn can have negative outcomes for the infant’s development (Bugental et al., 2008; Galler et al., 2000). The same applies to the presence of high levels of maternal anxiety, as it has been associated with emotional and behavioural problems during childhood and adolescence (Correia and Linhares, 2007). The aim of this study was to identify factors that are associated with preterm delivery and to measure levels of postnatal depression and anxiety in mothers of preterm infants in comparison to mothers of full-term infants. It was hypothesised that the mothers of the preterm infants would show higher levels of psychological distress than the mothers of the infants born at term and that factors such as the ethnicity and smoking habits of the mother, previous abortions and preterm births, the use of ART, multiple gestation and problems during pregnancy would influence preterm delivery. Due to the individual and public health consequences of preterm birth, further research is needed in order to obtain a better understanding of its underlying mechanisms, patterns and risk factors, so as to be able to identify and treat affected women and prevent the negative consequences on their offspring.
Methods Participants The study was conducted between September 2010 and December 2011 at Attikon University Hospital, Athens. Women were recruited during a 1-month period after they had given birth at the Department of Obstetrics and Gynaecology. Mothers were required to have working knowledge of the Greek language in order to participate in the study. Exclusion criteria were previously diagnosed mental disorders and drug use. The study group consisted of mothers who had delivered a preterm baby at 23–36 weeks’ gestation with the baby having received care in
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the NICU for at least 1 week. Of those eligible, 75 mothers who delivered 88 infants agreed to participate. All of the preterm infants survived in the period of the study. A control group of 125 mothers who delivered 126 infants at term was also recruited. The babies were healthy and did not require admission to the NICU.
Measures The questionnaires used for the survey were previously validated research instruments. State-Trait Anxiety Inventory–Form Y. The StateTrait Anxiety Inventory–Form Y (STAI-Y) is a 40-item self-report questionnaire designed to evaluate anxiety in adults, consisting of two subscales, one for assessing state anxiety and one for trait anxiety (Spielberger et al., 1970). The range of scores is 20–80, with higher scores indicating greater anxiety. Beck Depression Inventory. The Beck Depression Inventory (BDI) is a 21-item self-report rating scale designed to assess the existence and severity of symptoms of depression. Higher scores indicate more severe depression symptoms. The BDI is one of the most widely used instruments for measuring the presence and the severity of depression, and it has been reported to be highly reliable regardless of the population (Beck et al., 1961).
Demographic data Maternal demographic data were collected using a demographic questionnaire, which was completed from the mothers, and infant data, including birth weight (grams) and gestational age (weeks), were collated from the medical personnel of the department of Obstetrics and Gynaecology.
Procedure The mothers of the preterm infants were approached to participate in the study approximately 1 month after infant admission to the
NICU. This time period was given in order to give the mothers sufficient time to physically recover from childbirth and become familiar with the environment and the personnel of the unit and for the infants’ medical condition to stabilise. The average length of stay in the NICU was approximately 25 days. The mothers who delivered at term were also approached during their stay at the hospital (4 days after delivery). After information about the study was provided and verbal informed consent was obtained, mothers were then asked to complete the above listed questionnaires.
Statistics Comparison of maternal and infant characteristics in the two groups was carried out using Pearson r bivariate correlations and independent t-tests for normally distributed data, Spearman rho, Mann–Whitney U test for nonnormally distributed variables and the chisquare test for categorical data. A binary sequential logistic regression was then performed to assess prediction of preterm delivery. The sequential procedure was preferred in order to examine separately the contribution of variables that preceded the conception (first set), at the time of conception (second set) and during the pregnancy (third set). Only those variables with significant associations with the dependent variable were entered into the final model. Statistical analyses were performed in SPSS version 20 (SPSS Inc., Chicago, IL).
Results Of the 200 mothers who took part in the study, 37.5 per cent had given birth to premature infants, and 62.5 per cent had given birth to full-term infants. The mean age of the mothers in the sample was 31.3 years. Regarding the smoking habit during pregnancy, 16 per cent gave a positive response. The majority of the mothers (90%) had conceived their infants naturally, while the remaining 10 per cent had conceived using ART. Problems during pregnancy
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Bouras et al. Table 1. Maternal characteristics for those who delivered preterm and at term.
Maternal age, mean (SD) Educational level, n (%) Secondary education Tertiary education Ethnicity, n (%) Greek Other Previous abortion, n (%) Previous preterm birth, n (%) Smoking during pregnancy, n (%) Assisted reproduction, n (%) Multiple pregnancies, n (%) Caesarean section, n (%) Problems during pregnancy, n (%)
Preterm (n = 75)
Full term (n = 125)
p value
32 (6.3)
30.9 (4.6)
40 (53.3) 29 (38.7)
56 (44.8) 60 (48.0)
58 (77.3) 17 (22.7) 14 (18.7) 6 (8.1) 26 (34.7) 16 (21.3) 10 (13.3) 50 (66.7) 38 (50.7)
114 (91.2) 11 (8.8) 18 (14.4) 4 (3.2) 6 (4.8) 4 (3.2) 1 (.8) 62 (49.6) 20 (16.0)
.182 .346 .006 .426 .126 .000 .000 .000 .019 .000
SD: standard deviation.
were reported in 29 per cent of the cases; 10.5 per cent reported risk of miscarriage, 4 per cent hyperemesis gravidarum, 3.5 per cent high blood pressure and 2.5 per cent gestational diabetes. The method of delivery was caesarean section for 56 per cent of the mothers, and 20 per cent reported problems during childbirth. Maternal age and educational level were similar between the two groups of mothers. Furthermore, there was no statistically significant association between a prior abortion (p = .426) or preterm birth (p = .126) and preterm delivery. Multiple pregnancies, ART, caesarean section, ethnicity and smoking during pregnancy were associated with preterm birth (Table 1). The infants’ gestational ages ranged from 23 to 41 weeks, with a mean of 35.8 weeks. Birth weight ranged from 692 to 4335 g, with a mean of 2592 g. A total of 56 per cent of the infants were male, with the remaining 44 per cent being female (Table 2). Using an independent t-test, the relationship between BDI scores and preterm birth was examined (Table 3). There was a statistically significant association between BDI scores (p = .001) and preterm birth, with mothers of preterm infants having higher scores. Another independent t-test was carried out to examine the relationship between scores on the state
anxiety scale of the STAI-Y and preterm birth. The results revealed statistically significant associations between state anxiety scores (p = .000) and trait anxiety scores (p = .000), with the mothers who delivered preterm infants scoring higher in every scale than the mothers who delivered at term. Statistically significant associations were also found between smoking during pregnancy and problems during pregnancy (p = .015), preterm delivery (p = .000), gestation week (p = .000), scores in the BDI (p = .008), scores in the state anxiety scale (p = .008) and scores in the trait anxiety scale (p = .002) (Table 4). Having determined the factors that were significantly related to preterm delivery, we proceeded to the statistical prediction of it through the aforementioned logistic regression whose results are presented in Table 5. The first set of logistic regression predictors included mother’s ethnicity (Greek or other) and maternal trait anxiety. The second set involved the use of ART (yes or no) and multiple gestation (yes or no). The predictors in the third set were smoking during pregnancy and problems during pregnancy (yes or no). The log-likelihood ratios for models for the sequential sets of the analysis showed statistically significant contribution in the predictions by all three sets of the predictive variables. The final
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Table 2. Infant characteristics for those born preterm and at term.
Male infant, n (%) Singleton birth, n (%) Birth weight (g), mean (SD) Weight < 1000 g, n (%) Gestation weeks, mean (SD) Born < 28 weeks, n (%)
Preterm (n = 88)
Term (n = 126)
p value
52 (59.1) 65 (73.9) 1501 (657) 22 (25) 31.0 (3.2) 14 (15.9)
66 (52.4) 124 (98.4) 3231 (462) – 38.8 (1.2) –
.331 .000 .000 .000
SD: standard deviation.
Table 3. Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scores for preterm and term mothers.
BDI BDI scores, mean (SD) State anxiety scale State anxiety scores, mean (SD) Trait anxiety scale Trait anxiety scores, mean (SD)
Preterm (n = 75)
Term (n = 125)
p value
n = 68 10.26 (7.88) n = 52 41.56 (13.41) n = 53 39.0 (11.48)
n = 107 7.06 (7.98) n = 114 33.62 (9.89) n = 107 32.1 (10.03)
.001 .000 .000
SD: standard deviation.
Table 4. Problems during pregnancy, preterm delivery, gestation weeks, BDI and STAI scores for mothers who smoked and did not smoke during pregnancy.
Problems during pregnancy, n (%) Preterm delivery, n (%) Gestation weeks, mean (SD) BDI BDI scores, mean (SD) State anxiety scale State anxiety scores, mean (SD) Trait anxiety scale Trait anxiety scores, mean (SD)
Smoking (n = 32)
Not smoking (n = 168)
p value
15 (46.9) 26 (81.3) 31.75 (4.86) n = 30 11.03 (8.02) n = 23 44.26 (16.69) n = 22 41.05 (11.21)
43 (25.6) 49 (29.2) 36.65 (3.99) n = 145 7.74 (7.99) n = 143 34.79 (10.13) n = 138 33.33 (10.62)
.015 .000 .000 .008 .008 .002
BDI: Beck Depression Inventory; STAI: State-Trait Anxiety Inventory; SD: standard deviation.
model including the three sets of predictors was statistically significant (p = .000).
Discussion The aims of this study were to identify factors that are associated with preterm birth and to
measure levels of postnatal depression and anxiety in mothers of preterm infants compared to mothers who delivered at term. Our findings support those of previous studies that have shown a strong association between assisted reproduction (Dhont et al., 1999), multiple pregnancies (Lumley, 2003) and preterm birth.
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Bouras et al. Table 5. Logistic regression table: significant factors associated with preterm birth. Predictors
B
Step 1 Ethnicity (non-Greek) Trait anxiety Step 2 Ethnicity (non-Greek) Trait anxiety ART (yes) Multiple gestation (yes) Step 3a Ethnicity (non-Greek) Trait anxiety ART (yes) Multiple gestation (yes) Smoking during pregnancy (yes) Problems during pregnancy (yes)
SE
Wald
df
Exp (β)
−.38 .06
.53 .17
6.63 12.94
1 1
.25** 1.06***
−1.77 .06 −1.89 −2.34
.55 .05 .80 1.18
10.22 12.79 5.59 3.87
1 1 1 1
.17** 1.06*** .15 .09
−2.10 .04 −1.70 −2.31 −1.97 −1.84
.61 .02 .91 1.29 .62 .46
11.92 4.13 3.46 3.19 10.07 15.49
1 1 1 1 1 1
.12** 1.04* .18 .09 .13** .15***
df: degrees of freedom; SE: standard error; ART: assisted reproduction technology. Nagelkerke R2 = .17 (Step 1); Nagelkerke R2 = .33 (Step 2); Nagelkerke R2 = .51 (Step 3). aNonsignificant; ART, multiple gestation. *p < .05; **p < .01; ***p < .001.
Pregnancies resulting from the use of ART place women at greater risk for preterm delivery probably due to the physical implications of fertility treatment and their strong association with multiple pregnancies (Dhont et al., 1999; Lumley, 2003). Additionally, maternal medical problems during pregnancy may increase the risk of preterm birth and the probability of delivery by caesarean section due to the medical urgency of the situation. It should be noted here that the high rate of births by caesarean section in this study is consistent with the findings of recent studies that report a rise in these rates in Greece (Dinas et al., 2008; Mossialos et al., 2005; Tampakoudis et al., 2004). The expected association between preterm delivery and a previous abortion or a prior preterm birth was not found. It was found that maternal non-Greek ethnicity, trait anxiety and smoking during pregnancy are associated with preterm birth. Possible explanations for the higher prevalence of preterm birth in the immigrant group could be lower socioeconomic status, psychosocial stress and adverse
life events, which have been reported to increase the risk of preterm birth (Hedegaard et al., 1996; Newton et al., 1979). Women with higher levels of trait anxiety may be in greater risk of preterm delivery than women with lower trait anxiety levels as they also tend to show increased levels of anxiety during pregnancy, that in turn have been associated with obstetric complications and negative delivery outcome (Alder et al., 2007; Galler et al., 2000; Rizzardo et al., 2010). Finally, smoking during pregnancy has consistently been associated with lower gestational age and negative perinatal outcome (Shah and Bracken, 2000). Furthermore, the results of this study show that preterm delivery has a significant influence on maternal psychological health. Mothers of preterm infants present higher levels of depression and anxiety during the neonatal period compared to mothers of full-term infants. The foundations of the mother–child relationship start to develop as early as in the intrauterine period (Cannella, 2005). The pregnancy period is when the meeting of the mother and the child is
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being prepared and processed. Preterm birth can not only intensely disrupt this preparatory period but can also cause a serious narcissistic injury to the mother (Pavoine et al., 2004), due to the feeling of being a parent to an ‘incomplete’ child, of ‘not having produced the right thing at the right time’ (Freud, 1981), the perceived inability to bring her child safe to life, to protect him or her and ensure his or her existence (Bouras, 2011). It has been argued that physical contact, proximity, reciprocity and commitment are the central characteristics that promote the attachment between mother and child postnatally (Goulet et al., 1998). When the pregnancy is abruptly terminated and the infant needs care in the NICU immediately after the delivery, the separation from the baby complicates the establishment of the mother– infant bond, as the mother is not fully prepared, and the development of maternal identity is delayed (Aagaard and Hall, 2008). She has a strong desire to be close to her newborn, but she sacrifices it in order for the infant to receive lifesaving care from the health-care staff of the unit (Wigert et al., 2006). She often feels as a stranger or an outsider (Heermann et al., 2005), as she is not able to make choices for the care of her own child and has limited opportunities to interact with it (Lupton and Fenwick, 2006). Feelings of ambivalence regarding her desire for her baby (Jackson et al., 2003) and a fear to form a connection with it arise, since she finds herself between hope and hopelessness on the outcome of her newborn’s hospitalisation (Hall, 2005). The mother of a preterm infant has to assume the maternal role under stressful circumstances for which she was not prepared (Wigert et al., 2006). The meeting with the fragile infant and the first sight of the strange and unfamiliar environment of the NICU is overwhelming and frightening for the mother; she is worried about the medical condition of her baby and wants to know what is going on in the unit (Miles et al., 1992). The separation from the infant and the lack of control of the situation have been found to be the most difficult and stressful aspects of the baby’s hospitalisation (Nyström and Axelsson, 2002). The results should be interpreted within the
limitations of the study, including reliance on self-report data and the correlational nature of the study that does not permit any causative links to be identified.
Recommendations The findings of this study agree with those of previous studies, indicating that the birth of a premature infant involves a great deal of emotional distress for the mother. Thus, it is important to keep in close contact with pregnant women not only for antenatal medical consultation to prevent pregnancy problems but also in order to identify high-risk groups for preterm delivery, such as immigrant mothers or mothers with high trait anxiety and provide them with psychological support. Additionally, stop-smoking programmes might be effective for reducing the risk of preterm birth. Taking into account the high percentage of postnatal anxiety and depression symptoms in preterm neonates’ mothers identified in this study, it is also recommended that mothers who go through preterm delivery be routinely screened for postpartum depression and anxiety. If deemed necessary, they should receive postnatal support to cope with the emotional distress brought about by preterm birth. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
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