Stress and Coping Strategies among Parents of Preterm Infants Admitted to Three Hospitals in Nepal
Abstract
Background Hospitalization in neonatal care units (NCUs) is distressing to parents. Stress and inadequate coping hinder parents’ emotional health and parenting roles. Furthermore, it may impact short- and long-term developmental, cognitive, academic, and mental health outcomes among preterm infants (PTIs). This study aimed to explore the stress and coping mechanisms adopted by parents in NCUs.
Data and Methods The descriptive phenomenological study was conducted in the NCUs of three public tertiary hospitals in Kathmandu, Nepal. In-depth interviews were conducted with 15 purposively selected parents, both mothers and fathers, of preterm and low birth weight infants admitted to the NCUs. The data were descriptively analyzed employing the Colaizzi method to elucidate the stress experiences and coping strategies of parents.
Results The exploration of parents’ experiences yielded two overarching themes, namely psychological distress and insecurity and coping with the support system. Parents’ distress was linked to PTIs’ condition, infant–parent separation, altered parenting roles, and prolonged hospitalization. Family, friends, peer parents, and NCU staff were parents’ support sources. They coped with the situation by sharing experiences with peer parents, fostering closeness with the PTIs, and actively involving in care.
Conclusion Admission of PTIs to NCUs was distressing to parents. Parents valued NCU staff’s support for coping and expected more support. The provision of free newborn care service is pivotal in alleviating financial burden. Opportunities for fostering infant–parent attachment, active care involvement, and peer-to-peer support are effective coping measures for parents. Improving parental support provision in NCUs considering this stress and coping mechanisms would enhance psychological well-being of parents.
References
Ohuma EO, Moller A-B, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: A systematic analysis. Lancet. 2023;402(10409):1261–71. https://doi.org/10.1016/S0140-6736(23)00878
Lawn JE, Ohuma EO, Bradley E, Idueta LS, Hazel E, Okwaraji YB, et al. Small babies, big risks: Global estimates of prevalence and mortality for vulnerable newborns to accelerate change and improve counting. Lancet. 2023;401(10389):1707–19. https://doi.org/10.1016/S0140-6736(23)00522-6
Gurung A, Wrammert J, Sunny AK, Gurung R, Rana N, Basaula YN, et al. Incidence, risk factors and consequences of preterm birth – findings from a multi-centric observational study for 14 months in Nepal. Arch Public Health. 2020;78(1):64. https://doi.org/10.1186/s13690-020-00446-7
Subedi S, Hazel EA, Mohan D, Zeger S, Mullany LC, Tielsch JM, et al. Prevalence and predictors of spontaneous preterm births in Nepal: Findings from a prospective, population-based pregnancy cohort in rural Nepal–a secondary data analysis. BMJ Open. 2022;1;12(12):e066934. https://doi.org/10.1136/bmjopen-2022-066934
United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2017, Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2017. https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2017
WHO. Survive and thrive: transforming care for every small and sick newborn. Geneva: World Health Organization (WHO); 2019. https://apps.who.int/iris/bitstream/handle/10665/326495/9789241515887-eng
Ashorn P, Ashorn U, Muthiani Y, Aboubaker S, Askari S, Bahl R, et al. Small vulnerable newborns - big potential for impact. Lancet. 2023;401(10389), 1692–1706. https://doi.org/10.1016/s0140-6736(23)00976-5
Kuppusamy N, Vidhyadevi A. Prevalence of preterm admissions and the risk factors of preterm labor in rural medical college hospital. Int. J. of Scientific Study. 2016;4(9):123–6.
Adhikari S, Rao KS, B K G, Bahadur N. Morbidities and outcome of neonatal intensive care in western Nepal. J Nepal Health Res Counc. 2017;15(2):141–5. https://doi.org/10.3126/jnhrc.v15i2.18203.
Paudel L, Kalakheti B, Sharma K. Prevalence and outcome of preterm neonates admitted to the neonatal unit of a tertiary care center in Western Nepal. J Lumbini Med Coll. 2018; 8;6. https://nepjol.info/index.php/JLMC/article/view/23659
World Health Organization. Standards for improving quality of care for small and sick newborns in health facilities. Geneva: World Health Organization; 2020. https://www.who.int/publications/i/item/9789240010765
WHO. WHO recommendations on interventions to improve preterm birth outcomes. Geneva: World Health Organization; 2015. ISBN 978 92 4 150898 8. https://www.who.int/publications/i/item/9789241508988
WHO. WHO recommendations for care of the preterm or low birth weight infant. Geneva: World Health Organization; 2022. https://apps.who.int/iris/handle/10665/363697
Provenzi L, Santoro E. The lived experience of fathers of preterm infants in the neonatal intensive care unit: A systematic review of qualitative studies. J Clin Nurs. 2015;24(13–14):1784–94. https://doi.org/10.1111/jocn.12828
Al Maghaireh DF, Abdullah KL, Chan CM, Piaw CY, Al Kawafha MM. Systematic review of qualitative studies exploring parental experiences in the neonatal intensive care unit. J Clin Nurs. 2016;25(19–20):2745–56. https://doi.org/10.1111/jocn.13259
Byiringiro S, Wong R, Logan J, Kaneza D, Gitera J, Umutesi S, et al. A qualitative study to explore the experience of parents of newborns admitted to neonatal care unit in rural Rwanda. PLoS One. 2021;16(8):e0252776. https://doi.org/10.1371/journal.pone.0252776
Murthy S, Guddattu V, Lewis L, Nair NS, Haisma H, Bailey A. Stressors and support system among parents of neonates hospitalized with systemic infections: Qualitative study in South India. Arch Dis Child. 2021;106(1):20 LP – 29. https://doi.org/10.1136/archdischild-2020-319226
Bernardo J, Rent S, Arias-Shah A, Hoge MK, Shaw RJ. Parental stress and mental health symptoms in the NICU: Recognition and interventions. NeoReviews. 2021;22(8):e496–505. https://doi.org/10.1542/neo.22-8-e496
Shrestha T, Singh A, Bhattarai SKG, Raut KS. Experience of mothers having preterm newborns in neonatal care units. J Karnali Acad Heal Sci. 2020;3(2):47–56. https://doi.org/10.3126/jkahs.v3i2.30782
Wang L-L, Ma J-J, Meng H-H, Zhou J. Mothers’ experiences of neonatal intensive care: A systematic review and implications for clinical practice. World J Clin cases. 2021;26;9(24):7062–72. https://doi.org/10.12998/wjcc.v9.i24.7062
Fernández Medina IM, Granero-Molina J, Fernández-Sola C, Hernández-Padilla JM, Camacho Ávila M, López Rodríguez M del M. Bonding in neonatal intensive care units: Experiences of extremely preterm infants’ mothers. Women and Birth. 2018;31(4):325–30. https://doi.org/10.1016/j.wombi.2017.11.008
Salomè S, Mansi G, Lambiase C V, Barone M, Piro V, Pesce M, et al. Impact of psychological distress and psychophysical wellbeing on posttraumatic symptoms in parents of preterm infants after NICU discharge. Ital J Pediatr. 2022;48(1):13. https://doi.org/10.1186/s13052-022-01202-z
Heidari H, Hasanpour M, Fooladi M. Stress management among parents of neonates hospitalized in NICU: A qualitative study. J caring Sci. 2017;6(1):29–38. https://doi.org/10.15171/jcs.2017.004
Loewenstein K, Barroso J, Phillips S. The experiences of parents in the neonatal intensive care unit: an integrative review of qualitative studies within the transactional model of stress and coping. J Perinat Neonatal Nurs. 2019;33(4). https://doi.org/10.1097/JPN.0000000000000436
Ncube RK, Barlow H, Mayers PM. A life uncertain - my baby’s vulnerability: mothers’ lived experience of connection with their preterm infants in a Botswana neonatal intensive care unit. Curationis. 2016;39(1):e1–9. https://doi.org/10.4102/curationis.v39i1.1575
Yu X, Zhang J, Yuan L. Chinese parents’ lived experiences of having preterm infants in NICU: A qualitative study. J Pediatr Nurs. 2020;50:e48–54. https://doi.org/10.1016/j.pedn.2019.11.002
Acharya S, Bhandari S, Gaire H, Bhattarai S. Experiences of mothers having preterm infants admitted in neonatal intensive care unit. J Chitwan Med Coll. 2021;11(38):4-8. https://doi.org/10.54530/jcmc.454
Abuidhail J, Al-Motlaq M, Mrayan L, Salameh T. The lived experience of Jordanian parents in a neonatal intensive care unit: A phenomenological study. J Nurs Res. 2017;25(2):156–62. https://doi.org/10.1097/JNR.0000000000000134
Sih DA, Bimerew M, Modeste RRM. Coping strategies of mothers with preterm babies admitted in a public hospital in Cape Town. Curationis. 2019;1;42(1):e1–8. https://doi.org/10.4102/curationis.v42i1.1872
Smith VC, SteelFisher GK, Salhi C, Shen LY. Coping with the neonatal intensive care unit experience: parents’ strategies and views of staff support. J Perinat Neonatal Nurs. 2012;26(4). https://doi.org /10.1097/JPN.0b013e318270ffe5
Yang YY, He HG, Lee SY, Holroyd E, Shorey S, Koh SSL. Perceptions of parents with preterm infants hospitalized in Singaporean neonatal intensive care unit. J Perinat Neonatal Nurs. 2017;31(3):263–73. https://doi.org /10.1097/JPN.0000000000000239
Ganguly R, Patnaik L, Sahoo J, Pattanaik S, Sahu T. Assessment of stress among parents of neonates admitted in the neonatal intensive care unit of a tertiary care hospital in Eastern India. J Educ Health Promot. 2020;30;9:288. https://doi.org/10.4103/jehp.jehp
Sharma B, Goyal N, Sonakshi, Singh DJ, Chawla V, Aggarwal R, et al. Predictors of significant stressors for parents of NICU admitted infants from tertiary care teaching hospital, Jalandhar, India. Int J Early Child Spec Educ. 2022;14(1): 2683-2688. https://doi.org/10.9756/INT-JECSE/V14I1.320
Sisodia P, Khan H, Shukla N, Rathoria R, Rathoria E, Bansal U, et al. Estimation of stress amongst the parents of neonates admitted to neonatal intensive care unit. Advances in Human Biology; 2023;13(2):205-210. https://doi.org/10.4103/aihb.aihb_132_22
Maharjan R, Shrestha M, Pokharel N, Rai G, Karna B, Chaudhary K, et al. Stress and coping strategies among parents of neonates admitted in neonatal intensive care unit: A hospital-based study. J Karnali Acad Heal Sci. 2022;5(3):1-5.
Kr P. Application of Colaizzi’s method of data analysis in phenomenological research. Medico Legal Update. 2022;21(2), 914–918. http://doi.org/10.37506/mlu.v21i2.2800
Stahl NA, King JR. Expanding Approaches for Research: Understanding and using trustworthiness in qualitative research. J Dev Educ. 2020;44(1):26–8. http://www.jstor.org/stable/45381095
Gul P, Hulya E. Experiences of new mothers with premature babies in neonatal care units: A qualitative study. J Nurs Pract. 2020;3(1):179–85. http://doi.org/10.36959/545/381
Mengesha EW, Amare D, Asfaw LS, Tesfa M, B Debela M, Ambaw Getahun F. Parental experiences in neonatal intensive care unit in Ethiopia: A phenomenological study. Ann Med. 2022;54(1):121–31. http://doi.org/10.1080/07853890.2021.2004320
Ionio C, Mascheroni E, Colombo C, Castoldi F, Lista G. Stress and feelings in mothers and fathers in NICU: Identifying risk factors for early interventions. Prim Heal Care Res Dev. 2019;20:1–7;20:e81. http://doi.org/10.1017/S1463423619000021
O’Donovan A, Nixon E. “Weathering the storm:” Mothers’ and fathers’ experiences of parenting a preterm infant. Infant Ment Health J. 2019;40(4):573–87. https://doi.org/10.1002/imhj.21788
Purdy IB, Melwak MA, Smith JR, Kenner C, Chuffo-Siewert R, Ryan DJ, et al. Neonatal nurses NICU quality improvement: Embracing EBP recommendations to provide parent psychosocial support. Adv Neonatal Care. 2017;17(1):33–44. https://doi.org/10.1097/ANC.0000000000000352
Gibbs D, Boshoff K, Stanley M. Becoming the parent of a preterm infant: A meta-ethnographic synthesis. Br J Occup Ther. 2015;78(8):475–87. https://doi.org/10.1177/0308022615586799
Hollywood M, Hollywood E. The lived experiences of fathers of a premature baby on a neonatal intensive care unit. J Neonatal Nurs. 2011;17(1):32–40. https://doi.org/10.1016/j.jnn.2010.07.015
Sunny AK, Gurung R, Gurung A, Basnet O, KC A. Out-of-pocket expenditure for sick newborn care in referral hospitals of Nepal. Matern Child Health J. 2020;24(1):57–65. https://doi.org/10.1007/s10995-020-02881-y
Ahmadzadeh N, Rezapour A, Ghanavatinejad Z, Nouhi M, Karimi S, Saravani A, et al. Estimation of economic burden of preterm and premature births in Iran. Med J Islam Repub Iran. 2017;13;31:78. https://doi.org/ 10.14196/mjiri.31.78
Franck LS, McNulty A, Alderdice F. The perinatal-neonatal care journey for parents of preterm infants: what is working and what can be improved. J Perinat Neonatal Nurs. 2017;31(3):244–55. https://doi.org/10.1097/JPN.0000000000000273
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