Objective. To ascertain whether a trauma-preventive psychological intervention program for parents of premature infants during hospitalization in a level III NICU may reduce the severity of symptomatic response to the traumatic impact of premature birth.
Methods. Mothers of premature infants were enrolled consecutively in a sequential control group design. Intervention group mothers received a structured psychological intervention in the first days after birth. Each mother could make use of additional psychological support if required and was actively approached at critical times during her infant's NICU stay. Control group mothers did not receive psychological intervention but could ask for counseling by the hospital minister. At discharge, mothers of both groups answered a questionnaire covering key outcome variables (symptoms of traumatization, emotions at discharge, and sample and control variables).
Results. At discharge, intervention group mothers (N = 25) showed significantly lower levels of symptomatic response to the traumatic stressor “premature birth” than those in the control group (N = 25; mean overall symptom level 25.2 [SD: 13.9] vs 37.5 [SD: 19.2]).
Conclusions. This intervention program for parents after premature birth, combining early crisis intervention, psychological aid throughout the infant's hospitalization, and intense support at critical times, reduced the symptoms of traumatization relating to premature birth.
The premature birth of an infant and the following neonatal intensive care cause psychological distress and can have a traumatizing effect on parents.1 A large proportion of mothers showed symptoms of traumatization long after hospital discharge and described painful memories of the postnatal period both 6 and 18 months after their infant's discharge.2 These memories were mostly unpleasant and intrusive, and recollections were often connected with attempts to avoid reminders of the experiences that followed from premature birth. Intrusion and avoidance are 2 symptoms of posttraumatic stress disorder. In another study, mothers of premature infants had significantly more symptoms of intrusion and avoidance than mothers of healthy term infants and also of hyperarousal, the third symptom found in posttraumatic stress disorder.3
An unresolved psychological trauma may result in a posttraumatic stress disorder,4 which may have negative, long-term impact on parental well-being, attitude, and behavior. Emotional conditions determine parental self-confidence; this has a significant influence on those parent–child relationships that are crucial for a favorable outcome.5 Biological conditions are decisive in this respect, but psychosocial factors also can alter developmental deficits. In a follow-up study in 10-year-old children, those born at 24 to 31 weeks performed less well in school than term children, but environmental factors were stronger predictors of school performance than were perinatal complications. The environmental influence was more pronounced in children who were born preterm.6 These data suggest that it may be beneficial to set up an early, secondary prevention program based on the principles of trauma prevention.
Against this background, a psychological intervention program for parents of premature infants during their NICU stay was set up and evaluated. The theoretical basis for this intervention program involves a model of psychological traumatization,4 incorporating aspects relating to the development of the parent–child relationship after premature birth.7 A similar intervention program had proved effective in a previous study.7 Our hypothesis was that this intervention would reduce the extent of symptomatic parental response to the traumatic impact of premature birth.
The crisis intervention program, which took place in a 12-bed level III NICU, was evaluated in a sequential control group design; this design was chosen for ethical reasons. In the critical situation after the premature birth of their infant, many parents are seeking psychological support. In the emotionally sensitive NICU setting, it seemed unjustifiable to provide some parents with this support but deny it to others for reasons of randomization. Therefore, the evaluation started with the control group, with the intervention program being installed immediately after data collection had been completed for this group. The study protocol was approved by the institutional ethics committee, and written informed consent was obtained from parents.
Inclusion criteria were as follows: birth of a premature infant (<37 weeks), no congenital malformation, infant born at and/or admitted to the NICU at Tuebingen University Hospital during the first 2 days of life, hospital stay expected to last for >14 days, mother German speaking, and provision of parental consent. Exclusion criteria were birth of quadruplets or higher, parental psychiatric illness, maternal drug abuse or substitution, and infant's death during hospitalization.
Control group mothers were recruited consecutively over a 7-month period from infants who met inclusion criteria. They did not receive psychological intervention but could ask for counseling by the hospital minister. Support through pastoral care had been a regular offer for all parents of children who were hospitalized in the unit; for ethical reasons, it was not considered appropriate to deny parents this support during the course of the study.
Intervention group mothers were recruited consecutively from infants who met inclusion criteria during the 7-month period immediately after control group recruitment. The intervention consisted of a one-off crisis intervention combined with additional psychological aid throughout the infant's hospitalization, both conducted by the departmental psychologist (M.J.), who approached parents within 5 days after their infant's birth. It involved general trauma preventive measures8 as well as components specifically geared toward premature birth.9,10 The crisis intervention contained the following elements:
A reconstruction of the occurrences shortly before and during the infant's birth as well as during the first few days of NICU treatment. This was considered necessary because mothers often have difficulty recollecting the events involved, particularly when these were traumatic for them.
Provision of simple relaxation and calming techniques
An explanation of stress and trauma reactions to allow mothers to view the emotional storm going on inside them as a normal response to a stressful or traumatizing event
Provision of support during emotional outbursts
An exploration of basic psychological coping strategies, including those used by the mother in previous experiences with stressful situations and available to her during the current crisis
A discussion of personal resources and current social support to determine those that could be used during the current crisis
An exploration of possible solutions for concrete problems (eg, care for older siblings, arrangements with employers), including provision of practical support over achieving satisfactory outcomes
Arrangements for follow-up
Components that were specifically geared toward premature birth included the following:
Exploring the parental perception of their infant's condition to detect and, potentially, address avoidance strategies
Obtaining a detailed history concerning pregnancy, labor, and delivery to identify particularly traumatic events that occurred during this period
Exploring parent–infant relationships and the development of the parental role to identify potential problems and facilitate relationship buildup
Addressing reactions to the NICU environment and relationship with staff, encouraging parents to voice any criticisms that they might have
Discussing the relationship with the spouse and the family to identify ways of improving the level of support given
After this initial crisis intervention, the psychologist visited mothers in the intervention group, on a regular basis, to assess the emotional status of both mother and infant. These contacts took place in the NICU, on average 2 times a week, and lasted 5 to 15 minutes. Mothers in the intervention group could make use of additional psychological help if required. Usually they asked for an appointment, which took place in the psychologist's office and lasted 30 to 90 minutes, depending on the mother's needs. This offer was used on average once every 2 weeks. At critical times (reintubation, surgery, or transfer to another unit), intervention group mothers were attended by the psychologist on a daily basis. These interventions were designed to be consistent among intervention group mothers.
At the time of their infant's discharge, mothers of both groups were given a questionnaire. This was administered by the psychologist in the intervention group and the attending neonatologist on the step-down unit in the control group. It covered key outcome variables (symptoms of traumatization, affect at discharge) and sample as well as control variables.
Fathers could participate in the program if they wished. Usually only mothers were admitted together with their infant. Therefore, fathers were not included in the data collection.
The traumatic impact of the premature birth and the associated circumstances at the time of discharge were evaluated using the Impact of Event Scale (IES).11 This instrument contains the scales “intrusion” (7 items), “avoidance” (8 items), and “hyperarousal” (7 items) and has a cutoff point for determining clinically significant trauma.4 The relevance and the validity of this instrument have been demonstrated.12,13
Dissociate experiences during premature delivery were controlled with the Peritraumatic Dissociative Experience Questionnaire (PDEQ). It contains 10 items and is a reliable instrument to gain information about the experiences made during traumatic situations.11 It was developed to access important dissociative experiences.14 Aspects of pregnancy and delivery were controlled using a questionnaire that was drawn up for this study, covering aspects of pregnancy including complications and hospitalizations, expectation of the premature delivery, delivery mode, previous (premature) deliveries, and previous loss of a child.15,16
Personal and family aspects, including age, nationality, educational level, family status, partnership duration, and number of children, were also obtained. Medical data were obtained from the hospital notes. Data of interest included multiple birth, gender, gestational age, birth weight, duration of mechanical ventilation, stay in the NICU, and perinatal complications. Questionnaires were analyzed, without knowledge of treatment assignment, by a student of psychology.
Data were analyzed using SPSS for Windows, version 10.2 (SPSS, Chicago, IL). Differences in baseline characteristics and PDEQ scores were tested using the χ2 test or 2-sided t test for independent samples, as appropriate. The 2-sided t test for independent samples was also used to test for group differences with regard to the intervention effect. P < .05 was considered statistically significant.
During recruitment of the control (and intervention) group, 54 (48) of 100 (117) mothers who were screened for eligibility fulfilled the inclusion criteria. Seven (7) mothers refused consent, and 16 (11) infants were transferred to other hospitals. Of the remaining 31 (27) mothers, 25 (25) returned a completed questionnaire. Non-German mothers included 1 Turkish and 1 Thai in the intervention and 1 Turkish, 1 Serbian, and 1 Swiss in the control group. Additional maternal baseline characteristics are given in Table 1.
There were 4 sets of twins, 3 of these in the intervention group. For data collection regarding each infant's characteristics in twins, we used the data of the child who experienced more perinatal complications during his stay. Additional baseline characteristics of the infants in the intervention and control groups are provided in Table 2.
Sample and Control Variables
Comparing intervention and control group mothers, no differences were found in demographic variables or in those concerning family aspects, pregnancy, and delivery. This absence of difference was found also in the PDEQ. Significantly more intervention group infants were male. Infants in the intervention group had a significantly longer duration of continuous positive airway pressure and more often a diagnosis of sepsis and patent duct. No differences were found in other clinical variables (Tables 1 and 2).
Mothers in the intervention group showed significantly lower traumatic impact arising from premature birth, as indicated by lower symptoms of trau-matization in general. This effect was apparent also in lower symptoms of intrusion, avoidance, and hyperarousal at their infants' discharge (Table 3).
In the control group, 19 (76%) mothers showed symptoms of clinically significant psychological trauma4 at discharge, compared with 9 (36%) in the intervention group (P < .01). There was no significant correlation between the magnitude of the intervention effect and illness severity or gestational age (data not shown).
This trauma-preventive intervention for mothers of premature infants resulted in significantly less traumatic impact of premature birth, shown by lower levels of symptomatic response to the traumatic stressor “premature birth” at hospital discharge. Also, there was a significant difference in the occurrence of clinically significant trauma. Approximately one third of mothers met these criteria after the intervention, compared with two thirds in the control group.
After the preterm birth of their infant, parents and particularly mothers show symptoms of traumatization, some of them even a long time after hospital discharge. In a study that used the IES to ascertain parental traumatization related to premature birth, 77% of mothers showed significant symptoms of psychological trauma 1 month after birth, and 49% still showed significant symptoms 1 year later.15 Another study, using the perinatal Posttraumatic Stress Disorder Questionnaire, showed that parents of premature infants at 18 months of age had higher indices of posttraumatic reaction than parents of healthy term infants.17 An intervention study testing a one-off crisis intervention with mothers of premature infants in a NICU showed that 59% of mothers who did not receive psychological intervention showed symptoms of psychological trauma at discharge.7
The above data provided the theoretical framework required to base our intervention on the concept of psychotraumatology. For decades, the psychological processes that occur in parents of premature infants have been described in terms of trauma.2,18–21 Nevertheless, most studies evaluated these issues within the theoretical framework of the stress concept.22–24 This concept, however, does not cover the destruction of psychological structures and functions, which are the basic subject of psychotraumatology. It is only in recent years that research has started to focus on the traumatization of parents by the premature birth of their child,1,3,7,15,17 including interventions based on the concept of parental trauma.1,25 Even with this change in focus, the effects of these interventions were still not measured in terms of traumatization25 and/or in an uncontrolled study design.26 We have tried to avoid these pitfalls by using a control group design with a reasonable sample size, standardizing our intervention as far as possible and measuring its effect with a suitable instrument.
The results of the present study are in agreement with those from an earlier evaluation of a one-off crisis intervention, designed as a program for secondary trauma prevention and, in our study, conducted in an extended form. Mothers in the earlier study received only 1 crisis intervention within 72 hours after birth of their premature infant, but their infants were less immature and had fewer complications. These mothers also showed significantly lower levels of overall symptoms of traumatization as well as lower levels of intrusion, avoidance, and hyperarousal after intervention.7 There were also significant group differences in the occurrence of clinically significant trauma at discharge; 27% of mothers in the intervention group fulfilled criteria for clinically significant trauma, compared with 59% in the control group. Differences in symptom severity between the present and our earlier study7 are likely to be related to differences in gestational age, birth weight, and complication rates. As mentioned above, illness severity correlates with the amount of parental traumatization,15,20 although this could not be confirmed in the present study, possibly because of insufficient sample size.
Sample and control variables of mothers in the intervention and control groups did not differ significantly. This indicates that the intervention effect cannot be attributed to sample bias. Intervention group infants showed even higher levels of disease severity. This was indicated, for example, by a longer duration of respiratory support and a more frequent diagnosis of sepsis and patent duct. Given that the traumatic impact of premature birth increases with illness severity,15,20 this may have introduced a conservative error.
We were unable to differentiate between whether the effect seen in this study was intervention specific or merely related to the presence and emotional support of the psychologist. Nevertheless, the IES specifically evaluates the effect of a traumatic event on a individual's psychic condition focusing on the dimensions of intrusion, avoidance, and hyperarousal.11 It mirrors the adaptational processes that occur after a traumatic experience, which showed better results in intervention group mothers.
Another limitation is the lack of randomization, which was considered inevitable for ethical reasons. Also, our results are difficult to compare with other intervention studies involving parents of premature infants, which differed in their theoretical background or used different instruments or outcome variables.1,9,19,20,23 A conservative error may have been introduced by the availability of pastoral care to control group mothers, although we did not collect information on how often this offer was used. Finally, there are aspects of cross-cultural comparability. The ethnical grouping of our sample was very homogeneous. Our intervention concept thus can be assessed only within its cultural context.
Symptoms of traumatization may become chronic and then affect quality of life; this outcome has also been reported for other traumatizing experiences.4 Because depression is often a comorbidity of psychological trauma,4 maternal depression after premature birth may express an unsolved psychological trauma. This seems especially important with regard to the finding that postnatal depression is more common and levels of depression and anxiety are higher in mothers of preterm than term infants.23,27 How parents cope with the trauma of premature birth may also determine later parent–infant relationships. An unsolved psychological trauma, for example, may have a mediating effect on later sleep or eating problems in the infant.17 Our study design, however, did not allow for an evaluation of potential long-term effects of our intervention on mother–infant relationships; these considerations, therefore, remain, at present, speculative.
It would be desirable to compare the interventions described here with others, particularly those based on the stress concept or on an intervention that provides only emotional support. Such comparisons, performed as a randomized, controlled trial, would allow an assessment as to whether 1 specific mode of intervention is superior to others.
This study was supported by Hilfe für das kranke Kind e.V.
We are grateful to the participating families and to the staff at the NICU at Tuebingen University Children's Hospital, particularly Wolfgang Buchenau, MD, for help with this study; to Franziska Drescher for analyzing the questionnaires; and to Nicole Ata, MD, and Derek Stebbens, MA, for reviewing this manuscript.
- Accepted August 4, 2004.
- Reprint requests to (C.F.P.) Department of Neonatology, University Children's Hospital, Calwerstrasse 7, D-72076 Tuebingen, Germany. E-mail:
No conflict of interest declared.
- ↵Eriksson BS, Pehrsson G. Evaluation of psycho-social support to parents with an infant born preterm. J Child Health Care.2002;6 :19– 33
- ↵Affleck G, Tennen H, Rowe J. Infants in Crisis: How Parents Cope With Newborn Intensive Care and Its Aftermath. New York, NY: Springer; 1991
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- ↵Sarimski K. Frühgeburt als Herausforderung: psychologische Beratung als Bewältigungshilfe [The challenge of premature birth: psychological counseling to support the coping process]. Göttingen, Germany: Hogrefe; 2000
- ↵Fischer G. KÖDOPS. Kölner Dokumentationssystem für Psychotherapie und Traumabehandlung [The Cologne documentation system for psychotherapy and trauma treatment]. Köln, Germany: Deutsches Institut für Psychotraumatologie; 2000
- ↵Hütter B, Fischer G. Clinimetric evaluation of the german version of the impact of event scale (IES). In: Proceedings of the 5th European Conference of Traumatic Stress.1997:27
- ↵Jotzo M, Schmitz B. Traumatisierung der eltern durch die frühgeburt des kindes [Traumatization of parents resulting from the premature birth of a baby]. Psychotraumatologie [serial online]. 2002:38 . Available at: www.thieme-connect.de/
- ↵Jotzo M, Schmitz B. Eltern frühgeborener in den ersten wochen nach der geburt: eine prozess-studie zum verlauf von belastung, bewältigung, und befinden [Parents of prematures during the first weeks after birth: a process study on the development of stress, coping, and affect]. Psychol Erziehung Unterricht.2001;48 :81– 97
- ↵Als H. Individualized, family-focused developmental care for the very-low-birth-weight preterm infant in the NICU. In: Friedman SL, Sigman MS, eds. The Psychological Development of Low-Birthweight Children. Norwood, NJ: Ablex; 1994:341– 388
- ↵Meyer EC, Garcia Coll CT, Lester BM, Boukydis CF, McDonough SM, Oh W. Family-based intervention improves maternal psychological well-being and feeding interaction of preterm infants. J Pediatr.1993;93 :241– 246
- ↵Silcock A. Crises in parents of premature: An Australian study. Br J Dev Psychol.1984;2 :257– 268
- ↵Kersting A, Hörnig-Franz I, Klockenbusch W, Wesselmann U, Harms E, Arolt V. Posttraumatische symptomatik von müttern sechs monate nach der geburt eines sehr kleinen frühgeborenen [Posttraumatic symptoms of mothers 6 months after the birth of a very low birthweight infant]. Kinderärztliche Praxis.2002;73 :59
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