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2019-11

Predictors of Depression and Anxiety in Mothers of

Moderate and Late Preterm Infants in Level II

Neonatal Intensive Care Units

Kearl, Julie

Kearl, J. (2019). Predictors of Depression and Anxiety in Mothers of Moderate and Late Preterm

Infants in Level II Neonatal Intensive Care Units (Unpublished master's thesis). University of

Calgary, Calgary, AB.

http://hdl.handle.net/1880/111275

master thesis

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UNIVERSITY OF CALGARY

Predictors of Depression and Anxiety in Mothers of Moderate and Late Preterm Infants

in Level II Neonatal Intensive Care Units

by

Julie Kearl

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF MASTER OF NURSING

GRADUATE PROGRAM IN NURSING

CALGARY, ALBERTA

NOVEMBER, 2019

© Julie Kearl 2019

ii

Abstract

Postpartum depression (PPD) and postpartum anxiety (PPA) affect up to 19% and 17% of

women, respectively. In mothers of preterm infants, depression (68%) and anxiety (72%)

symptoms may be increased due to the stressful neonatal intensive care (NICU)

environment. In 2015, 8.7% of infants, born in Alberta, were born preterm requiring

hospitalization in the NICU, with 86% categorized as moderate or late preterms. Preterm

birth, together with PPD and PPA, may have serious consequences for mother and infant

outcomes. This observational correlational study included 197 mothers with data

collected at admission and discharge from the NICU. The aim was to explore the

prevalence, time course, comorbidity and predictors of postpartum maternal depression

and anxiety in the moderate and late preterm population. Mothers reported depression

(18%) and anxiety (42%) symptoms at admission to the NICU, a slight decrease of

symptoms from admission to discharge, comorbidity of depression and anxiety symptoms

with no identifiable maternal, infant, or pregnancy-related risk factors on the admission

survey for depression or anxiety symptoms. These results suggest that universal

screening may be critical for early identification of PPA and PPD. Psychological support

and evidence-based interventions have the potential to decrease maternal depression and

anxiety to improve long-term outcomes of mother and infant.

Keywords: depression, anxiety, postpartum, mothers, moderate and late preterm

infants

iii

Acknowledgements

I would like to thank all the people who contributed to the work described in this

thesis. First and foremost, I thank my academic advisor, Dr. Karen Benzies for accepting

me into her team. During my graduate studies she contributed to a rewarding graduate

school experience by engaging me in new ideas and demanding a high quality of work in

all my endeavors. She shared her expertise, provided me with constant guidance,

patience, and time spent to help bring this study to completion. Additionally, I would

like to thank my committee members, Dr. Andrea Nelson and Dr. Candace Lind for their

time and effort they put into my thesis with their unique knowledge, constructive

comments, and suggestions. Finally, I would like to acknowledge my family who

supported me during this time. I would like to thank my husband Derek, my three

children; Dan, Emily and Scott, and my Dad, Lynn Rosenvall, for their constant love,

support and encouragement throughout this endeavor.

iv

Dedication

I dedicate this thesis to my oldest son Dan, who was born at 27 weeks gestation

weighing only 770 grams. It was my journey, together with him, in the Neonatal

Intensive Care Unit that kindled my interest into the experience of having a preterm

infant. That experience taught me about resiliency and the strength of the human soul to

endure and overcome challenges. Dan is my hero and I have been in awe over how he

overcome the challenges he faced as a result of his prematurity. He has since completed

a university education, is a junior high science teacher, is married to a lovely girl and is

the father to a sweet baby boy. I am forever grateful for the nurses who cared for him,

and our family during his hospitalization to help us endure that difficult time. I have

since become a neonatal nurse and am constantly striving to deliver that same care and

attention to the families I am privileged to help in their journey of having a preterm

infant.

v

Table of Contents

Abstract ............................................................................................................................... ii Acknowledgements ............................................................................................................ iii Dedication .......................................................................................................................... iv Table of Contents .................................................................................................................v List of Tables .................................................................................................................... vii List of Abbreviations ....................................................................................................... viii Epigraph ............................................................................................................................. ix

Chapter 1 Background .........................................................................................................1 Preterm Birth ....................................................................................................................1 Psychological Distress and Preterm Birth .......................................................................2 Identifying Mothers at Risk .............................................................................................4 Predictors of PPD and PPA .............................................................................................5

Chapter 2 Review of Literature ............................................................................................7 Postpartum Depression ....................................................................................................7 Postpartum Anxiety .........................................................................................................9 Rates of Depression and Anxiety ...................................................................................12 Comorbidity Between PPD and PPA .............................................................................13 Time Points for PPD and PPA Screening ......................................................................14 Screening Tools .............................................................................................................14

Depression ................................................................................................................14 Anxiety .....................................................................................................................15

Maternal and Infant Characteristics Associated with PPD and PPA .............................15 Predictors of Depression ................................................................................................18

Maternal demographic characteristics ......................................................................18 Psychosocial factors .................................................................................................18 History of mental health problems ...........................................................................19 Infant characteristics and pregnancy related factors ................................................19

Predictors of Anxiety .....................................................................................................19 Purpose of Study ............................................................................................................20 Significance of this Research .........................................................................................22 Theoretical Framework ..................................................................................................22

Chapter 3 Methods .............................................................................................................25 Study Design ..................................................................................................................25 Setting ............................................................................................................................25 Participants .....................................................................................................................26

Recruitment. .............................................................................................................26 Eligibility criteria. .....................................................................................................26

Measurement ..................................................................................................................30 Edinburgh Postnatal Depression Scale .....................................................................30 State-Trait Anxiety Inventory ...................................................................................30 Parental Stressor Scale: NICU (PSS – NICU) .........................................................31

Procedures ......................................................................................................................32 Prevalence and Time Course of Depression and Anxiety Symptoms ...........................35

vi

Prevalence of depression symptoms .........................................................................35 Prevalence of anxiety symptoms ..............................................................................35 Time course ..............................................................................................................36

Strength of Association Between Depression and Anxiety Symptoms, and Stress .......36

Chapter 5 Discussion .........................................................................................................39 Prevalence of Depression Symptoms ............................................................................40 Prevalence of Anxiety Symptoms ..................................................................................41 Time Course of Depression and Anxiety Symptoms .....................................................42 Strength of Association Between Depression and Anxiety Symptoms .........................43 Predictors of Depression and Anxiety Symptoms .........................................................43

Parental stress. ..........................................................................................................43 Strengths ........................................................................................................................46 Limitations .....................................................................................................................47

Chapter 6 Conclusion .........................................................................................................49 Universal screening ..................................................................................................50 Psychological support services .................................................................................53 Family-Centred Care ................................................................................................54 Evidence-based interventions. ..................................................................................56 Role of Nurses ..........................................................................................................57

Future Research .............................................................................................................59 Conclusion .....................................................................................................................61

References ..........................................................................................................................63

Appendix A: Mother Survey on Admission ...................... Error! Bookmark not defined.

vii

List of Tables

Table 1. Characteristics of Study Sample (N = 197) ........................................................ 28

Table 2. Scores on Psychosocial Distress Measures ......................................................... 36

Table 3. Summary of Pearson’s Intercorrelations between EPDS/STAI-state scores at Discharge and Independent Variables at Admission ................................................ 38

viii

List of Abbreviations

AHS Alberta Health Services DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition EPDS Edinburgh Postnatal Depression Scale FCC Family Centred Care FICare Family Integrated Care GA Gestational Age GAD Generalized Anxiety Disorder NICU Neonatal Intensive Care Unit OCD Obsessive-Compulsive Disorder PD Panic Disorder PPA Postpartum anxiety PPD Postpartum depression PSS:NICU Parental Stressor Scale: Neonatal Intensive Care Unit SAD Social Anxiety Disorder SPSS Statistical Package for the Social Sciences STAI State-Trait Anxiety Inventory U of C University of Calgary

ix

Epigraph

“Mental pain is less dramatic than physical pain, but it is more common and also more

hard to bear. The frequent attempt to conceal mental pain increases the burden: it is easier

to say “My tooth is aching” than to say “My heart is broken.”

C.S. Lewis

1

Chapter 1 Background

Preterm Birth

In 2017, Canada had a preterm birth rate of 8.1%, with 14% of preterm births

being early preterms, born before 32 weeks and zero day’s gestation, and the remaining

86% considered moderate or late preterm, born between 32 weeks 0/7 and 36 weeks 6/7

day’s gestation (Public Health Agency of Canada, 2017). In 2015, Alberta had the

second highest rate (8.7%) of preterm birth among the Canadian provinces (Canadian

Institute for Health Information, 2017). The target population for this study is mothers of

moderate and late preterm infants. The age of women giving birth in Alberta is

increasing (Statistics Canada, 2018) due to higher levels of education and greater labour

force participation (Government of Alberta, 2011). Delayed childbearing is associated

with infertility, which results in more demand for assisted reproductive technologies

(World Health Organization, 2016). Mothers who are older are more likely to have other

conditions such as high blood pressure and diabetes that can cause complications

requiring preterm delivery (Centers for Disease Control and Prevention, 2018). Both

delayed childbearing and use of assisted reproductive technologies increase the risk for

multiple births and subsequently, increase the risk of preterm birth (World Health

Organization, 2016). There are increased costs for preterm infants with lengthy hospital

stays (Petrou, Eddama, & Mangham, 2010), hospital readmissions (Petrou et al., 2010),

and additional use of health and education resources long-term (Cheong et al., 2017;

Petrou et al., 2010).

The birth of an infant is a time of joy and celebration for most families. When an

infant is born preterm requiring hospitalization in the NICU, it may become an

2

overwhelming experience that can potentially disrupt the functioning of a family (Turner,

Chur-Hanse, Winefield, & Stanners, 2015) and create psychological distress for the

mother (Miles, Holditch-Davis, Schwartz, & Scher, 2007). Psychological distress is a

“general term for the end result of factors (psychogenic pain, internal conflicts and

external stress) that prevent a person from self-actualisation and connecting with

significant others” (Segen's Medical Dictionary, 2011). Most commonly, psychological

distress includes postpartum depression (PPD) and postpartum anxiety (PPA). For this

thesis, unless there is a clearly indicated medical diagnosis, PPD and PPA will refer to

symptoms typically captured with screening tools.

Psychological Distress and Preterm Birth

In mothers of preterm infants, psychosocial distress is elevated compared to

mothers of term infants (Trumello et al., 2018). Although the rates of depression and

anxiety in mothers of preterm infants decreased over time, they remained elevated

compared to mothers of term infants (Bergstrom, Wallin, Thomson & Flacking, 2012;

Greene et al., 2015; Pace et al., 2016; Vasa et al., 2014). In an Australian study,

compared to mothers and fathers of healthy term infants, rates of depression and anxiety

in mothers and fathers of preterm infants, born less than 30 weeks gestation were higher

(Pace et al., 2016). Their study reported that 40% of the preterm population reported

depressive symptoms compared to 6% of the term population, measured within three

weeks of birth, using the Center for Epidemiological Studies Depression Scale (Pace et

al., 2016). Similarly, 48% of the preterm population compared to 13% of the term

population, within three weeks after birth, experienced anxiety symptoms, using the

Hospital Anxiety and Depression Scale, anxiety subscale (Pace et al., 2016). Poehlmann,

3

Schwichtenberg, Bolt, and Dilworth-Bart (2009) found that mothers who had multiple

maternal, infant, and family risks prior to the infant’s NICU discharge showed less

decline in depressive symptoms in the months following the child’s birth, with their

symptoms remaining higher compared to mothers who had fewer risk factors. In mothers

of preterm infants, psychological distress may remain elevated up to 2 years after birth

(Poehlmann et al., 2009; Singer et al., 1999).

While the majority of mothers with infants in the NICU, experienced stress at

birth (Lefkowitz, Baxt, & Evans, 2010), significant and prolonged psychosocial distress

is important to recognize and mitigate because of the negative impact on maternal and

infant outcomes (Ahlqvist-Bjorkroth, Boukydis, Axelin, & Lehtonen, 2017; Lefkowitz et

al., 2010). Psychosocial distress may be attributed to disappointment and feelings of

responsibility for the preterm birth (Kawafha, 2018), uncertainty about how to interact

with their infant (Ahlqvist-Bjorkroth et al., 2017), and fear of losing their child (Clottey

& Dillard, 2013). The unsettling sights and sounds in the NICU (Franck, Cox, Allen, &

Winter, 2005; Trumello et al., 2018), appearance of their infant (Greene et al., 2015), and

use of complex medical language and technology (Lefkowitz et al., 2010) may also

contribute to increased maternal psychosocial distress. Mothers must manage day to day

medical crises (Holditch-Davis et al., 2015) and accept the possibility their child may

have ongoing health and developmental problems (Ahlqvist-Bjorkroth et al., 2017).

The major stress for mothers of preterm infants is separation from their infant

(Ahlqvist-Bjorkroth et al., 2017; Vigod, Villegas, Dennis, & Ross, 2010) and the loss or

alteration of the maternal role as they had previously envisioned it to be (Franck et al.,

2005; Lefkowitz et al., 2010; Trumello et al., 2018). Prolonged separation of a mother

4

and her infant can lead to maternal feelings of grief and despair (Nystrom & Axelsson,

2002). In the NICU, a mother may have limited opportunities for caregiving and must

share these responsibilities with neonatal care providers (Rossman, Greene, & Meier,

2015). O’Brien et al. (2013) reported that some parents have described themselves as

visitors who are ‘allowed’ to hold their infants.

Preterm birth is physiologically traumatic for the infant in the short-term, and

increases the risk of developmental and learning difficulties long-term (Ahlqvist-

Bjorkroth et al., 2017; Cheong et al., 2017; Jiang, Warre, Qiu, O’Brien, & Lee, 2014).

PPD and PPA in the general population of postpartum women are associated with

negative cognitive, behavioral and emotional developmental outcomes for the child

(Field, 2018; O’Hara, 2009). However, preterm infants may be more sensitive to the

consequences of poor maternal mental health than full term infants (Bugental, Beaulieu,

& Schwartz, 2008; Huhtala, et al., 2012; Neri, Agostini, Salvatori, Biasini, & Monti,

2015). PPD and PPA, coupled with preterm birth, may have a synergistic effect

compounding the problematic developmental trajectory of preterm infants (Vasa et al.,

2014).

Identifying Mothers at Risk

One of the biggest challenges with PPD (Beck, 2003) and PPA (Field, 2018) is

early identification. Routine screening for maternal psychosocial distress in the term

population (Ali, 2018; Beck, 2003; Field, 2018; O’Hara & McCabe, 2013) and preterm

population (Cherry et al., 2016; Hynan et al., 2015; Trumello et al., 2018; Vasa et al.,

2014; Yurdakul et al., 2009) has been recommended to facilitate early detection and

timely management to improve maternal and infant outcomes (Australian Government

5

Department of Health, 2018). Mothers are often underdiagnosed and undertreated

because of a lack of universal screening (Cherry et al., 2016) and mothers’ reluctance to

seek help due to stigma associated with mental illness (Beck, 2003). Contributing to

under diagnosis of PPD and PPA in mothers of preterm infants is that the focus of care in

the NICU is on the unwell infant, rather than the mother and family (Cherry et al., 2016).

Routine maternal screening for PPD and PPA in the NICU may normalize help-seeking

for mental illness, enhance awareness, and increase neonatal care providers’ competency

and comfort level in supporting mothers with PPD and PPA (Cherry et al., 2016).

Predictors of PPD and PPA

It is important to recognize the risk factors for maternal psychosocial distress, so

women at risk can be identified, and provided options for early intervention (Poehlmann

et al., 2009). A meta-analysis performed by Robertson, Grace, Wallington, and Stewart

(2004) found that a personal or family history of depression, depression or anxiety during

pregnancy, stressful life events, and lack of social support were risk factors for PPD in

mothers of term infants. A systematic review suggested factors that contribute to PPD in

the preterm population are similar to those for mothers of term infants (Vigod et al.,

2010). In addition to risk factors for PPD in the term population of postpartum women,

mothers of preterm infants had additional risk factors, including perception of the infant’s

illness severity, poor coping skills, and increased parental stress (Rogers, Kidokoro,

Wallendorf, & Inder, 2013).

In a narrative review, Field (2018) identified being a young mother, having more

education, being employed, lack of family support, marital or family conflict, and social

health issues as risk factors for PPA in the term population. Being a first-time mother has

6

been reported as a significant predictor of PPA in mothers of preterm infants (Greene et

al., 2015; Misund, Nerdrum, & Diseth, 2014). The aim of this study was to investigate

the prevalence, time course, comorbidity and predictors of psychosocial distress, namely

PPD and PPA, in mothers of moderate and late preterm infants.

7

Chapter 2 Review of Literature

In this Chapter, I will describe the review of the literature with a focus on

predictors of PPD and PPA and implications on outcomes for mothers of moderate and

late preterm infants. The chapter begins with a description of the literature search.

I performed a literature search using the keywords ‘neonatal intensive care unit’,

‘depression’, ‘anxiety’, ‘postpartum’, ‘mothers’, ‘moderate and late preterm infants’. I

included articles that spanned a time range from 2009 to 2018. After reviewing full text

of the articles, I included 13 articles of relevance to my study. Eight studies were from

the United States (Cherry, et al., 2016; Greene et al., 2015; Hawes, McGowan,

O’Donnell, Tucker, & Vohr, 2016; Lefkowitz et al., 2010; Poehlmann et al., 2009;

Rogers et al., 2013; Segre, McCabe, Chuffo-Siewert, & O’Hara, 2014; Vasa et al., 2014),

and one each from Canada (Ballantyne, Benzies & Trute, 2013), Australia (Pace et al.,

2016), Italy (Trumello et al., 2018), Norway (Misund et al., 2014), and Sweden

(Bergstrom et al., 2012). The only study from Canada was conducted in the province of

Ontario. No published research, to my knowledge, has assessed prevalence and

predictors of PPD and PPA in mothers of moderate and/or late preterm infants in the

NICU in Alberta.

Postpartum Depression

In the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition

(DSM-5), the American Psychiatric Association (2013) defines PPD as a ‘Major

Depressive Disorder’ with a ‘peripartum onset’ specifier, beginning by 4 weeks

postpartum and lasting up to 1 year. Symptoms may include depressed mood, loss of

interest or pleasure, change in appetite or weight, difficulty sleeping, psychomotor

8

retardation or agitation, loss of energy or fatigue, feelings of worthlessness or guilt,

impaired concentration, indecisiveness, or recurrent thoughts of death or suicidal ideation

or attempt (American Psychiatric Association, 2013). Beck (2008) conducted a review

and reported that women with PPD may have uncontrollable mood swings, a fear of

hurting one’s partner or the baby, withdrawal and isolation from friends and family, fear

of being alone, and a feeling of hopelessness or being overwhelmed. Mothers with PPD

can be less responsive to infant cues, appear more withdrawn, and exhibit less

affectionate behavior toward their infant (Beck, 2003).

In the American Journal of Maternal/Child Nursing, Beck (2008) reported PPD as

the most common complication of childbirth, based on a review of 141 PPD studies from

around the world, including United States, Australia, Canada, China, Finland, Iceland,

Sweden, Turkey, and Malaysia. There is high variability in the prevalence of PPD due to

different populations, varying criteria for PPD, and differing periods of time under

consideration (O’Hara & McCabe, 2013). An Annual Review published by O’Hara and

McCabe (2013), estimated prevalence of PPD ranging from 13% to 19%. It is important

to note that the review by O’Hara and McCabe (2013) had wide confidence intervals for

prevalence of PPD, which questions the reliability of such prevalence estimates. A meta-

analysis based on 59 studies with a total of 12,810 participants reported an overall

prevalence of PPD of 13% (O’Hara & Swain, 1996). In Italy, a study with 1,066 women,

using the Edinburgh Postnatal Depression Scale, reported a prevalence of 9.6% of major

and minor depression from the third month of pregnancy to one-year postpartum (Banti et

al., 2011). In Spain, a study with 1453 women at six weeks postpartum, reported 18.1%

prevalence of PPD using the Edinburgh Postnatal Depression Scale (Navarro et al.,

9

2008). These large studies further highlight the variability in PPD prevalence estimates

in developed countries.

PPD can occur anytime during the first year after delivery (Beck, 2006), with

highest prevalence during the second and third months postpartum (Gavin et al., 2005).

PPD is different from ‘postpartum blues,’ a mild and transient mood disturbance, which

occurs in 40 to 80% of women during the first week postpartum (Buttner, O’Hara, &

Watson, 2012). PPD negatively affects maternal quality of life (O’Hara & McCabe,

2013), but can also have devastating consequences on mother-infant attachment (Beck,

2008; O’Hara & McCabe, 2013; Zauderer, 2008), and child development (Beck, 2008;

O’Hara & McCabe, 2013). There are increased costs to the health care system associated

with PPD (O’Hara, 2009). Mothers with PPD access acute care and emergency services

for their infant more often than regular health services, such as well-child visits (Mandl,

Tronick & Brennan, 1999).

Postpartum Anxiety

A narrative review of the general population of postpartum women by Field

(2018) reported that, compared to the substantial research on PPD, there is significantly

less research on prevalence, predictors, and consequences of PPA. PPA is inconsistently,

and not formally, defined (Leach, Poyser, & Fairweather-Schmidt, 2017; Misri,

Abizadeh, Sanders, & Swift, 2015). According to the American Psychological

Association (2013), there are different types of anxiety disorders such as Generalized

Anxiety Disorder (GAD), Panic Disorder (PD), Agoraphobia, Social Anxiety Disorder

(SAD) as well as other ‘anxiety-related’ disorders such as Obsessive-Compulsive

Disorder (OCD) and trauma related disorders. Furthermore, there are cases of those with

10

pregnancy specific anxiety and fear of childbirth that could be considered to have an

adjustment disorder if symptoms were significantly distressing and interfering (Storksen,

Eberhard-Gran, Garthus-Niegel & Eskild, 2012).

Currently, there is a lack of anxiety measures that have been validated in perinatal

populations (Misri, et al., 2015) despite use of several anxiety measures that have been

used in these populations (Fairbrother, Young, Zhang, Janssen, & Antony, 2017). One

measure was developed specifically for this population, the Perinatal Anxiety Screening

Scale (PASS) however, no studies have used, nor validated, this measure in a NICU

sample to date (Somerville et al., 2014). Nevertheless, anxiety is common during the

perinatal period for women, with 17.4% of women meeting full diagnostic criteria for one

or more anxiety disorders during the first three months postpartum (Fairbrother, Janssen,

Antony, Tucker, & Young, 2016). Fairbrother et al. (2017) also found that there was a

significant increase in the onset of diagnosed anxiety disorders in those with high-risk

pregnancies. A review conducted by Leach et al. (2017) on maternal perinatal anxiety,

suggested that anxiety symptoms peak shortly after childbirth and decreases

progressively up to 6 months postpartum.

If mothers (a) had a caesarean delivery, (b) feared the birth, death during delivery,

or loss of control during labor, (c) had low self-confidence for the process of delivery, or

(d) had premature delivery, they were at higher risk for PPA (Field, 2018). PPA can have

negative effects on (a) breastfeeding (Ali, 2018; Field, 2018), (b) bonding (Ali, 2018;

Field, 2018), (c) mother-infant interactions (Ali, 2018; Field, 2018; Misri et al., 2015), (d)

infant temperament (Misri et al., 2015), (e) short and long term child development (Misri

et al., 2015), and (f) later mental health disorders in children and adolescents (Ali, 2018;

11

Field, 2018). There have been significant comorbidities reported between PPD and PPA

(Ali, 2018; Field, 2018; Segre et al., 2014).

To summarize, the evidence regarding the prevalence, predictors, and outcomes

associated with PPD and PPA is limited by the quality of the studies. Sample sizes

ranged from 29 (Misund et al., 2014) to 734 (Hawes et al., 2016); some studies may have

been underpowered. All studies investigated maternal depression symptoms compared to

only six studies that assessed maternal anxiety symptoms (Greene et al., 2015; Misund et

al., 2014; Pace et al., 2016; Rogers et al., 2013; Segre et al., 2014; Trumello et al., 2018).

A prospective study design was used in eight studies, an observational study was used in

two studies, a cross-sectional design in two studies, and an exploratory design in one

study. All studies included mothers of infants hospitalized in the NICU. Mothers were

included in all the studies, with fathers being included in two studies (Lefkowitz et al.,

2010; Pace et al., 2016). Five studies included all infants hospitalized in the NICU,

regardless of gestation, with eight studies specific to infants born less than 37 weeks’

gestation.

Categorization of Early, Moderate, and Late Preterms

Several studies focused on mothers of early preterm infants (Greene et al., 2015;

Misund et al., 2014; Pace et al., 2016; Poehlmann et al., 2009; Rogers et al., 2013).

However, mothers of moderate and late preterm infants are also vulnerable to PPD and

PPA (Trumello et al., 2018). Fetal growth and maturation occurs along a continuum

throughout a pregnancy (Shapiro-Mendoza & Lackritz, 2012) with the risk of infant

mortality and morbidity declining dramatically with increasing gestational age (Kirby &

Wingate, 2010). The majority of preterm related deaths occurred among early preterm

12

infants; however, moderate and late preterm infants are still at risk of mortality (Shapiro-

Mendoza et al., 2008). Morbidity rates nearly doubled for each gestational week earlier

than 38 weeks, from 5.9% with morbidity if born at 37 weeks’ gestation to 51.7%

morbidity at 34 weeks’ gestation (Shapiro-Mendoza et al., 2008). Moderate and late

preterm infants are at risk for neonatal complications including respiratory distress

requiring ventilation (Hibbard, Wilkins, & Sun, 2010; Wang, Dorer, Fleming, & Catlin,

2004), bacterial sepsis (Escobar et al., 2005; Wang et al., 2004), hypoglycemia (Wang et

al., 2004), apnea and bradycardia (Wang et al., 2004), temperature instability (Wang et

al., 2004), hyperbilirubinemia (Escobar et al., 2005; Wang et al., 2004), and feeding

problems (Escobar et al., 2005).

One study of PPD and PPA differentiated between mothers of early preterms,

born <32 weeks, and those with moderate and late preterms, >32 weeks gestation

(Trumello et al., 2018). Hawes et al. (2016) studied PPD and differentiated between

early preterms (<32 weeks), moderate preterms (32-33 weeks) and late preterms (34-36

weeks). A comparison of mothers and fathers of preterms and term infants in Australia

was investigated in one study and found that rates of depression and anxiety were higher

in mothers and fathers of preterm infants both after birth and at six months compared to

term infants (Pace et al., 2016). There is a gap in research about PPD and PPA in

mothers of moderate and late preterm population, yet this population comprises more

than 80% of preterm infants.

Rates of Depression and Anxiety

There was significant variability in the prevalence of depression and anxiety in

mothers of infants hospitalized in the NICU. The wide variation in prevalence of

13

depression and anxiety symptoms in the literature may be attributed to the timing of the

screening, population being screened, screening tools and cut-off scores used for

measurement. Rates of depression ranged from as low as 18%, using the EPDS with a

cut off score of >10 (Hawes et al., 2016) to as high as 68% using the EPDS with a cut off

score of >8 (Trumello et al., 2018). Rates of anxiety ranged from 17%, using the STAI

with clinically significant state anxiety score >40 (Misund et al., 2014) to 72%, using the

cut-off of >39 for state anxiety (Trumello et al., 2018). It is challenging to compare

across studies because of various cut-offs, and without clear clinical cut-off scores it is

difficult to conclusively determine prevalence using the existing literature.

Comorbidity Between PPD and PPA

In the term population, there are high levels of comorbidity between PPD and

PPA reported. A study that took place in Australia, reported that 37.7% of mothers (N =

235) in the major depression sample, also had a comorbid anxiety disorder (Austin et al.,

2010). A study performed in the United States (N = 200) suggested a significant

comorbidity between PPD and PPA in mothers of preterm infants (Segre et al., 2014).

This cross-sectional study evaluated mothers of newborns hospitalized in the NICU with

infant gestation ranging from 23 to 41 weeks and reported that 51% of women who

reported clinically significant anxiety symptoms, also reported depressive symptoms, and

55% of women reported clinically significant depression symptoms, also reported anxiety

symptoms (Segre et al., 2014). There is evidence of comorbidity between PPD and PPA

in mothers of preterm infants.

14

Time Points for PPD and PPA Screening

Measurement of psychosocial distress was taken at only one time point in seven

of the studies, and varied from (a) the first week after birth (Lefkowitz et al., 2010; Segre

et al., 2014; Trumello et al., 2018), (b) 2 weeks after birth (Cherry et al., 2016), (c) prior

to discharge (Ballantyne et al., 2013), (d) at discharge (Rogers et al., 2013), and (e) 1

month post-discharge (Hawes et al., 2016). Three studies measured psychosocial distress

at two time points (a) during first month of NICU stay and 2 weeks before discharge

(Greene et al., 2015), (b) within 2 weeks of birth and 8 to 10 months later (Misund et al.,

2014), and (c) 1 month and 4 months after discharge (Bergstrom et al., 2012). Multiple

time points were measured in three of the studies starting from birth until 24 months

corrected age (Pace et al., 2016; Poehlmann et al., 2009; Vasa et al., 2014). Variability in

time frames for measurement creates challenges in understanding the natural peaks and

valleys in PPD and PPA, and scores that indicate more intensive intervention is required.

Screening Tools

Depression. Various scales were used to measure PPD. The Edinburgh Postnatal

Depression Scale (EPDS), is the most commonly used screener for PPD found in the

literature; used in six of 13 studies (Bergstrom et al., 2012; Hawes et al., 2016; Rogers et

al., 2013; Segre et al., 2014; Trumello et al., 2018, Vasa et al., 2014). Four studies that

used the EPDS used cut-off scores of 10 (Hawes et al., 2016) and 12 (Bergstrom et al.,

2012; Segre et al., 2014; Vasa et al., 2014). Matthey, Henshaw, Elliot, and Barnett

(2006) recommend that a validated score of >13 be used for reporting probable major

depression in postnatal English-speaking women.

15

The Center for Epidemiologic Studies Depression Scale (CES-D) was used in

four studies (Ballantyne et al., 2013; Greene et al., 2015; Pace et al., 2016; Poehlmann et

al., 2009). The CES-D lacks validity with postnatal populations because it is a general

depression questionnaire (Beck, 2008), that does not contain items tailored to the

experience of postpartum mothers (Greene et al., 2015; Holditch-Davis et al., 2015). In

addition, the CES-D does not include suicidal ideation items, that were added to the

revised version (Center for Epidemiological Studies Depression Scale Revised, 2019).

The Postpartum Depression Screening Scale (PDSS) was used in two studies (Cherry et

al., 2016; Lefkowitz et al., 2010). Misund et al. (2014) used the depression subscale of

the General Health Questionnaire (GHQ). Thus, variability in measures and clinical cut-

offs created challenges when comparing results across studies.

Anxiety. Different scales were used to measure anxiety. The State-Trait Anxiety

Index (STAI), a reliable measurement tool for anxiety in the general population (Field,

2018), was used in four studies (Greene et al., 2015; Misund et al., 2014; Rogers et al.,

2013; Trumello et al., 2018). A cut-off score of 40 on the STAI was used in three studies

(Green et al., 2015; Misund et al., 2014; Rogers et al., 2013), and a cut-off score of 39

was used by Trumello et al. (2018). The Hospital Anxiety and Depression Scale (Pace et

al., 2016) and Beck Anxiety Inventory (Segre et al., 2014) were used in one study each.

Similar to measurement of PPD, variability in measures of PPA created challenges in

comparing results across studies.

Maternal and Infant Characteristics Associated with PPD and PPA

All of the studies explored a variety of maternal demographic characteristics,

psychosocial characteristics, and infant characteristics as potential risk factors for PPD

16

and PPA. Typically, maternal demographic risk factors included age (Ballantyne et al.,

2013; Bergstrom et al., 2012; Cherry et al., 2016; Greene et al., 2015; Hawes et al., 2016;

Lefkowitz et al., 2010; Misund et al., 2014; Pace et al., 2016; Poehlmann et al., 2016;

Rogers et al., 2013; Segre et al., 2014; Trumello et al., 2018; Vasa et al., 2014), marital

status (Ballantyne et al., 2013; Bergstrom et al., 2012; Cherry et al., 2016; Greene et al.,

2015; Hawes et al., 2016; Lefkowitz et al., 2010; Misund et al., 2014; Pace et al., 2016;

Poehlmann et al., 2016; Rogers et al., 2013; Segre et al., 2014; Trumello et al., 2018;

Vasa et al., 2014), education (Ballantyne et al., 2013; Bergstrom et al., 2012; Cherry et

al., 2016; Greene et al., 2015; Hawes et al., 2016; Lefkowitz et al., 2010; Misund et al.,

2014; Pace et al., 2016; Poehlmann et al., 2016; Rogers et al., 2013; Segre et al., 2014;

Trumello et al., 2018), income (Ballantyne et al., 2013; Bergstrom et al., 2012; Greene et

al., 2015; Hawes et al., 2016; Misund et al., 2014; Poehlmann et al., 2016; Rogers et al.,

2013; Segre et al., 2014; Vasa et al., 2014), race (Cherry et al., 2016; Greene et al., 2015;

Hawes et al., 2016; Lefkowitz et al., 2010; Poehlmann et al., 2016; Rogers et al., 2013;

Segre et al., 2014; Vasa et al., 2014), ethnicity (Cherry et al., 2016; Greene et al., 2015;

Hawes et al., 2016; Lefkowitz et al., 2010; Segre et al., 2014), language (Pace et al.,

2016; Ballantyne et al., 2013), employment (Ballantyne et al., 2013; Bergstrom et al.,

2012; Lefkowitz et al., 2010; Misund et al., 2014; Pace et al., 2016; Segre et al., 2014;

Trumello et al., 2018; Vasa et al., 2014), immigration status (Bergstrom et al., 2012),

gravidity (Hawes et al., 2016; Green et al., 2015), parity (Bergstrom et al., 2012; Greene

et al., 2015; Misund et al., 2014; Trumello et al., 2018), other children at home (Greene et

al., 2015; Misund et al., 2014; Pace et al., 2016; Poehlmann et al., 2016), previous fetal

17

loss (Greene et al., 2015) or preterm delivery (Greene et al., 2015), and chronic illness

(Lefkowitz et al., 2010; Misund et al., 2014).

Maternal psychosocial characteristics of social support (Ballantyne et al., 2013;

Greene et al., 2015; Lefkowitz et al., 2010; Poehlmann et al., 2016; Rogers et al., 2013)

stressful life events (Ballantyne et al., 2013; Rogers et al., 2013), family functioning

(Ballantyne et al., 2013), involvement of father (Ballantyne et al., 2013; Vasa et al.,

2014), personal (Segre et al., 2014; Vasa et al., 2014) and family mental health history

(Greene et al., 2015), mental health treatment (Cherry et al., 2016, Hawes et al., 2016;

Misund et al., 2014; Segre et al., 2014) access to NICU support services (Hawes et al.,

2016; Pace et al., 2016, mothers involvement with child protective services (Greene et al.,

2015; Hawes et al., 2016), a history of domestic violence (Hawes et al., 2016), maternal

substance abuse (Greene et al., 2015; Hawes et al., 2016; Vasa et al., 2014), and smoking

(Rogers et al., 2013) were investigated.

Infant characteristics included gender (Ballantyne et al., 2013; Bergstrom et al.,

2012; Greene et al., 2015; Hawes et al., 2016; Misund et al., 2014; Pace et al., 2016;

Trumello et al., 2018), gestational age (Ballantyne et al., 2013; Bergstrom et al., 2012;

Greene et al., 2015; Hawes et al., 2016; Misund et al., 2014; Pace et al., 2016; Poehlmann

et al., 2016; Segre et al., 2014; Trumello et al., 2018; Vasa et al., 2014), birth weight

(Ballantyne et al., 2013; Bergstrom et al., 2012; Greene et al., 2015; Hawes et al., 2016;

Misund et al., 2014; Pace et al., 2016; Poehlmann et al., 2016; Segre et al., 2014), length

of stay in the NICU (Bergstrom et al., 2012;; Greene et al., 2015; Hawes et al., 2016;

Lefkowitz et al., 2010; Poehlmann et al., 2016; Rogers et al., 2013; Vasa et al., 2014),

single or multiple birth (Ballantyne et al., 2013; Misund et al., 2014; Pace et al., 2016;

18

Poehlmann et al., 2016; Rogers et al., 2013), major resuscitation at birth (Pace et al.,

2016), Apgar scores (Misund et al., 2014), length of ventilation (Greene et al., 2015;

Misund et al., 2014; Pace et al., 2016; Poehlmann et al., 2016; Rogers et al., 2013),

comorbidities (Ballantyne et al., 2013; Segre et al., 2014; Vasa et al., 2014), severity of

illness in the NICU (Ballantyne et al., 2013), and use of breast milk (Hawes et al., 2016),

oxygen (Greene et al., 2015) and feeding tube (Greene et al., 2015) upon discharge.

Predictors of Depression

Studies of predictors for depression in mothers of preterm infants hospitalized in

the NICU show mixed results. Three of the 13 studies that explored predictors of PPD

showed no significant associations (Misund et al., 2014; Pace et al., 2016; Trumello et al.,

2018). In the study that categorized mothers of early preterm relative to the moderate and

late preterm population (N = 62), no predictors of PPD reached statistical significance in

the moderate and late preterm population (Trumello et al., 2018).

Maternal demographic characteristics. Marital status, an independent variable

included in every study, was the most common predictor of depression with single

motherhood a predictor of PPD (Ballantyne et al., 2013; Bergstrom, et al., 2012; Greene

et al., 2015; Hawes et al., 2016). A study conducted in the United States (N = 73)

reported a surprising result that being married was a positive predictor of depression

(Rogers et al., 2013). Mothers from racial or ethnic minority groups reported

significantly higher symptoms of depression than Caucasian mothers in one study of

mothers of infants less than 35 weeks’ gestation (Poehlmann et al., 2009).

Psychosocial factors. Psychosocial factors produced many statistically

significant associations with predictors of PPD. Lefkowitz (2010) reported mothers (N =

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85) of infants, not necessarily preterm infants, in NICU were at higher risk of PPD if they

had concurrent life stressors. Ballantyne et al. (2013) reported that poorer family

functioning and lower social support were predictors of maternal depressive symptoms in

the preterm population. Women who had involvement with child protective services or

had substance abuse issues were at higher risk of PPD (Hawes et al., 2016).

History of mental health problems. For mothers of preterm infants, a history of

mental health problems predicted PPD. Mothers who (a) had a history of depression

before pregnancy (Cherry et al., 2016), (b) were treated for depression before pregnancy

(Bergstrom et al., 2016; Cherry et al., 2016), (c) felt depressed during the current

pregnancy (Bergstrom et al., 2012; Lefkowitz et al., 2010; Vasa et al., 2014), (d) had

depression in last pregnancy (Vasa et al., 2014), or (e) had a family history of depression

(Lefkowitz et al., 2010) were at higher risk of PPD.

Infant characteristics and pregnancy related factors. The only statistically

significant infant characteristic that predicted depression in mothers of preterms in the

NICU was prolonged ventilation (Rogers et al., 2013). In a study of mothers (N = 131)

of all infants in the NICU, not just preterm infants, complications during delivery

predicted depressive symptoms (Vasa et al., 2014). A study with mothers (N = 181) who

had infants born less than 35 weeks, found that a multiples birth predicted PPD

(Poehlmann et al., 2009).

Predictors of Anxiety

Similar to depression, there were mixed results about predictors of anxiety in

mothers of preterm infants hospitalized in the NICU, with fewer risk factors identified.

Most noteworthy, is that of the six studies that explored predictors of maternal anxiety,

20

there were no statistically significant predictors of anxiety in three of them (Pace et al.,

2016; Rogers et al., 2013; Trumello et al., 2018). Being a first-time mother was a

significant predictor of PPA in two studies (Greene et al., 2015, Misund et al., 2014). A

study of mothers (N = 29) of preterm infants less than 33 weeks, found that a lower

gestational age was a predictor of PPA (Misund et al., 2014). Segre et al. (2014)

evaluated depression and anxiety symptoms together as negative emotionality, and found

that infant illness, birth weight, gestational age, and self-reported perinatal depressed

mood were significant predictors of psychosocial distress. Thus, there is limited research

on predictors of anxiety in mothers of moderate and late preterm infants warranting

further research.

Purpose of Study

The purpose of this current study was to investigate the prevalence, time course,

comorbidity and risk factors for psychosocial distress, namely depression and anxiety

symptoms, in mothers of moderate and late preterm infants in five Level II NICUs across

Alberta at admission and discharge. My primary and secondary research questions with

hypotheses were as follows.

Primary Research Questions

What are the predictors of PPD in mothers of moderate and late preterm infants

cared in a Level II NICU at time of discharge? Based on findings in the literature review,

I expected marital status would be a significant predictor of maternal depressive

symptoms such that being single would be associated with greater depressive symptoms

(Ballantyne et al., 2013; Bergstrom, et al., 2012; Greene et al., 2015; Hawes et al., 2016).

In addition, I anticipated less social support (Ballantyne et al., 2013), minority race and

21

ethnicities, and multiple birth (Poehlmann et al., 2009) would be predictive of greater

maternal depressive symptoms at discharge.

What are the predictors of PPA in mothers of moderate and late preterm infants

cared for in a Level II NICU at time of discharge? As found by Greene et al. (2015) and

Misund et al. (2014), I hypothesized that being a first-time mother would significantly

predict greater maternal anxiety. Based on findings by Misund et al. (2014), I also

expected lower gestational age would be a significant predictor of PPA.

Secondary Research Questions

What is the prevalence of depression and anxiety symptoms in mothers of

moderate and late preterm infants at admission to and discharge from the NICU? I

hypothesized that the prevalence of maternal depressive and anxiety symptoms would be

elevated, with a higher proportion above the clinical cut-off, in mothers of moderate and

late preterm infants compared to mothers of full-term infants, as cited in the literature

(O’Hara & McCabe, 2013; Trumello et al., 2018).

What is the time course of depression and anxiety symptoms from admission to

and discharge from the NICU? I hypothesized that maternal depressive and anxiety

symptoms would decrease slightly from admission to discharge in mothers of moderate

and late preterm infants (Bergstrom et al., 2012; Greene et al., 2015; Lefkowitz et al.,

2010; Pace et al., 2016; Poehlmann et al., 2009).

What is the strength of the association between depressive and anxiety symptoms

in mothers of preterm infants? As per Segre et al. (2014), I hypothesized that maternal

depressive and anxiety symptoms in the postpartum period would be strongly correlated

in mothers of moderate and late preterms in the NICU.

22

Significance of this Research

Preterm birth is a public health concern that has negative effects on infants,

mothers, families, and society due to increased psychological distress, complications and

associated costs, as compared to term infants. This research will quantify maternal

symptoms of depression and anxiety in this vulnerable population, and may highlight

how difficult it is to identify mothers with PPD and PPA based on maternal, infant or

pregnancy-related factors alone. The study could highlight the need to improve screening

early on with screening tools, and emphasize the need to incorporate evidence-based

interventions in the NICU that decrease maternal psychosocial distress with the potential

of enhancing maternal bonding and improving child development outcomes in the long-

term. It will hopefully be the impetus for more resources to be employed in Level II

NICUs with routine screening and evidence-based interventions for mothers of moderate

and late preterm infants. This could be a cost savings to the publicly funded health care

system, which is facing fiscal challenges as it tries to meet the needs of all Albertans.

Theoretical Framework

A theoretical framework is necessary to guide the research through the process of

generating and testing phenomena (Saleh, 2018). The relationship between clinical

practice, research, and theory are reciprocal and cyclical in nature. Clinical practice

generates questions for research and knowledge for theory. Research then guides our

practice and increases our knowledge through theory development. Applying a theory

enables the researcher to provide evidence to support or refute the theoretical framework

proposed. Theories help to explain, predict and understand phenomena more effectively

and can challenge and expand existing knowledge (Jairath, Peden-McAlpine, Sullivan,

23

Vessey, & Henly 2018). Theory provides structure to research and a lens for defining the

domain, evaluating knowledge that currently exists, asking questions for discovery of

knowledge and obtaining new data with the potential to enhance the knowledge base

further (Jairath et al., 2018). Theory can guide our research and improve clinical practice

(Saleh, 2018).

This study was guided by the Pathways of Influence in Parenting Prematurely

Born Children that recognizes the importance of parents in the lives of preterm infants

(Miles & Holditch-Davis, 1997). This conceptual framework suggests that pre-existing

and concurrent personal and family factors, such as parental age, gender, ethnicity,

socioeconomic status, employment situation, personality traits, family configuration,

level of social support, and previous loss of an infant or child are brought into the

situation when an infant is born prematurely. Prenatal experiences, such as history of

infertility, high-risk pregnancy, problematic labor and/or delivery, and perceptions of the

premature delivery also influence the emotional response of parents and can negatively

impact their relationship. Miles and Holditch-Davis (1997) highlight five concepts that

can impact emotional distress in parents once the preterm infant is born: (a) loss of the

normal parenting role, (b) illness severity, (c) treatments, (d) appearance of the infant,

and (e) concerns about outcomes for the infant. Parents of preterm infants may feel

helplessness, loss of control, fear, guilt and shame, and a sense of failure and

disappointment, which can result in a loss of self-confidence and self-esteem, anxiety and

depression. At the same time, they can feel great hope that their infant will survive and

develop normally with no developmental delays. These neonatal experiences may result

in a different parenting orientation than was originally imagined that can affect the span

24

of a preterm child’s life. This theory guided my research in choosing the concepts of

altered maternal role, increased maternal stress, and measuring pre-existing and current

maternal, infant and pregnancy-related factors that can have an impact on maternal

psychosocial distress when an infant is born preterm.

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Chapter 3 Methods

Study Design

The current study was a sub-study within a cluster randomized controlled trial

(cRCT) (Benzies et al., 2017). The cRCT was conducted in 10 Level II NICUs in

Alberta with five intervention sites and five control sites. This study was a secondary

analysis of data collected at the five control sites. This is an observational correlational

study with maternal depressive and anxiety symptoms data collected at admission to and

discharge from the NICU. I evaluated how many mothers scored in the referral range for

symptoms of depression and anxiety. I analyzed the time course of depression and

anxiety symptoms and the strength of the association between maternal depression and

anxiety symptoms. Marital status, maternal age, single parenting, social support,

education, employment status, income, immigration status, ethnicity, parental stress,

parity, use of assisted reproductive technology, gestational age, birth weight, singleton or

twin births, and smoking, alcohol, prescription drugs or street drugs during pregnancy

were measured potential predictors of maternal depression and anxiety in the postpartum

period.

Setting

Alberta is a province in Western Canada with a population of 4.08 million (World

Population Review, 2018). Alberta has the second highest crude birth rate (13.2%) in

Canada with the average age of mothers increasing (Statistics Canada, 2018).

Approximately 81% of Alberta’s population lives in urban areas with nearly 14%

belonging to visible minority groups (World Population Review, 2018). Alberta has a

single, publicly funded health services system (Alberta Health Services) with universal

26

access to care. This is advantageous for multicentre studies with many of the processes

and structures standardized in hospitals across the province (Benzies et al., 2017).

Control sites included two semi-urban hospitals and three urban hospitals.

Participants

Recruitment. Participants were recruited at each hospital using convenience

sampling. There were similar recruitment procedures across all sites. Mothers were

recruited by specially trained nurses who approached eligible mothers, obtained consent,

and collected data.

Eligibility criteria. Participants were mothers of infants born between 32 0/7

weeks and 34 6/7 weeks gestational age (GA) with a primary admission or transfer within

72 hours after birth to a Level II NICU. Infant GA was confirmed by first trimester

ultrasound or date of last menstrual period. The GA of 34 6/7 weeks ensured infants

from the intervention group (not part of the current study) had a 1-week ‘dose’ of Family-

Integrated Care (FICare). Mothers were excluded if they had health, social, or language

issues that interfered with communication with the health care team. Mothers of triplets

or higher-order multiple births, and mothers of infants requiring palliative care or with

severe congenital or chromosomal anomalies were excluded because they may receive

additional supports and services that may affect PPD and PPA. My study included

mothers from the control group with complete data on depression and anxiety symptoms

at admission and discharge. Mothers who completed the surveys plus or minus 7 days

from admission and plus or minus seven days from discharge were included in this

sample. My study included 197 mothers of moderate and late preterm infants admitted to

five Level II NICUs across Alberta.

27

Maternal age of the sample was 31.63 (SD = 5.19) with the majority of mothers

reporting Caucasian ethnicity (67%, n = 132). The majority reported being married

(69.5%, n = 137) or living common-law (24.4%, n = 48), while only 3% (n = 6) reported

single parent status. Most mothers reported post high school education (84.3%, n = 166),

and a family income of more than $80,000 CDN per year (54.8%, n = 108). The mean

GA of the infants was 33.5 (SD = 0.72) weeks with a mean birthweight of 2172 (SD =

375.41) grams. Additional maternal, infant, and pregnancy-related characteristics are

provided in Table 1.

28

Table 1. Characteristics of Study Sample (N = 197) Characteristics Frequency (%)

Maternal Characteristics Marital Status Single 7 (3.6) Married 137 (69.5) Common-law 48 (24.4) Live in partner 3 (1.5) Separated 1 (0.5) Prefer not to answer 1 (0.5) Single Parent No 191 (97.0) Yes 6 (3.0) Social Support Grandparents 152 (77.2) Extended family 145 (73.6) Friends 147 (74.6) Neighbors 54 (27.4) Other 19 (9.6) Prefer not to answer 2 (1.0) Education Less than High School 10 (5.1) High School Diploma 21 (10.7) Certificate of diploma after High School 48 (24.4) College or University degree 118 (59.9) Employment status Full time (>30 hours a week) 54 (27.4) Part time (<30 hours a week) 7 (3.6) Unemployed, but looking for work 4 (2.0) Not in the labor force 3 (1.5) Student employed part or full time 5 (2.5) Student not employed 1 (0.5) Retired 1 (0.5) Homemaker 24 (12.2) Maternity leave 90 (45.7) On disability 2 (1.0) Other 4 (2.0) Prefer not to answer 1 (0.5) Don’t know 1 (0.5) Income Less than 20,000 6 (3.0) 20,000 to 39,999 6 (3.0) 40,000 to 59,999 26 (13.2)

29

60,000 to 79,999 20 (10.2) More than 80,000 108 (54.8) Prefer not to answer 19 (9.6) Don’t know 11 (5.6) Ethnicity Caucasian 132 (67.0) Aboriginal 9 (4.6) South Asian 8 (4.1) Chinese 3 (1.5) Black 9 (4.6) Filipino 16 (8.1) Latin American 7 (3.6) Arab 2 (1.0) Southeast Asian 3 (1.5) Korean 2 (1.0) Other 5 (2.5) Infant Characteristics Sex Male 107 (54.3) Female 90 (45.7) Gestational Age 32 weeks 26 (13.2) 33 weeks 53 (26.9) 34 weeks 118 (59.9) Pregnancy-Related Characteristics Parity Primiparas 111 (56.3) Multiparas 86 (43.7) Use of Assisted Reproductive Technology Yes 28 (14.2) No 169 (85.8) Multiples Singleton 159 (80.7) Twins 38 (19.3) Smoking in pregnancy No 172 (87.3) Yes 24 (12.2) Alcohol use in pregnancy No 172 (87.3) Yes 7 (3.6) Prescription drugs in pregnancy No 128 (65.0)

30

Yes 67 (34.0) Prefer not to answer 1 (0.5) Street drugs in pregnancy No 192 (97.5)

Yes 4 (2.0) Note. Missing data: Maternal age n = 4 (2%), Income n = 1 (0.5%), Ethnicity n = 1 (0.5%), Prescription drugs n = 1 (0.5%), Street drugs n = 1 (0.5%).

Measurement

Edinburgh Postnatal Depression Scale. The EPDS is a 10-item, self-reported

scale that reflects maternal mood in the last 7 days (Cox, Holden, & Sagovsky, 1987).

Mothers are asked to respond to items on a 4-point Likert-type scale 0 (disagree) to 3

(strongly agree). The theoretical range of scores is 0 to 30, with a score >13 predictive of

a depressive illness (Matthey et al., 2006). The EPDS has a sensitivity of 86%,

specificity of 78%, with a positive predictive value of 73% in English-speaking women in

the general postpartum population, (Shrestha, Pradhan, Tran, Gualano, & Fisher, 2016).

The EPDS is the most commonly used screening tool in clinical practice to identify

women at risk of postnatal depression (Kernot, Olds, Lewis & Maher, 2015). In the

current study, Cronbach’s alpha was .86 at admission and .85 at discharge. The EPDS

takes 5 to 10 minutes to complete.

State-Trait Anxiety Inventory. The STAI is a self-reported measure of anxiety

(Spielberger, Gorsuch, & Lushene, 1970) that contains two distinct concepts of anxiety:

dispositional/trait and current state. There are 20 items for each concept for a total of 40

items. The responses for the Trait anxiety scale assesses frequency of feelings in general

with response categories ranging from 1 (almost never) to 4 (almost always). State

anxiety refers to how one feels at a particular moment with response categories to assess

31

intensity ranging from 1 (not at all) to 4 (very much so). The theoretical range of scores

for each subscale is 20 to 80, with higher scores indicative of greater anxiety. A cut-off

score of > 40 indicates clinically significant symptoms for state anxiety (Julian, 2011).

Internal consistency (Cronbach’s alpha = .86 to .95) and test-retest (.73 to .86)

reliabilities are high in the adult population. STAI has been used in the population of

mothers with infants in the NICU (Greene, 2015; Holditch-Davis et al., 2015; Melnyk et

al., 2006; Zelkowitz et al., 2011). In the current study, Cronbach’s alpha for the STAI-

state was .93 at admission and .93 at discharge; STAI-trait had a Cronbach’s alpha of .91

at admission. The STAI takes 10 minutes to complete.

Parental Stressor Scale: NICU (PSS – NICU). PSS: NICU is designed to

measure parental perceptions of stress arising from the physical and psychosocial

environment of the NICU (Miles, Funk & Carlson, 1993). The 26-item version of the

PSS: NICU with four subscales including sights and sounds, appearance and behavior of

the infant, and the relationship with the infant the parental role was recommended for this

study (personal communication, Margaret Miles May 6, 2019). The PSS: NICU uses a 5-

point Likert-type scale that includes response categories ranging from 1 (not at all

stressful) to 5 (extremely stressful). Higher scores indicate higher levels of stress.

Internal consistency (.89 to .94 for the total scale) and test-retest (.87) reliabilities were

high. The PSS: NICU has been used broadly with mothers in the NICU (Holditch-Davis

et al., 2015; O’Brien et al., 2013; Turner, Chur-Hanse, Winefield & Stanners, 2015;

Zelkowitz et al., 2011). In the current study, Cronbach’s alpha for the PSS:NICU was .94

at admission and .97 at discharge. The PSS: NICU takes 15 minutes to complete.

32

Procedures

Coordination of the cRCT was through the University of Calgary (U of C),

Faculty of Nursing. All study nurses were employed through Alberta Health Services

(AHS) or Covenant Health. Study nurses at control sites received four hours of

specialized training specific to the purpose of the study, screening for eligibility,

informed consent, and data collection. Study nurses used a standardized script to inform

mothers of the study. If the mother was interested, a study nurse screened mothers for

eligibility and addressed any issues or concerns.

Data were collected at two time points: admission to and discharge from the

NICU, using electronic tablets using either Fluid Surveys or Qualtrics platforms.

Measures were taken to protect confidentiality with participants assigned a study

identification number. Mothers who scored above the clinical cut-off on the EPDS were

flagged for follow-up by (a) nursing staff if the infant was still in the NICU, or (b)

research staff if the infant had been discharged. Data were stored on university servers

that were backed-up daily and accessible only via timed-out, password-protected

computers. These computers were located in locked research offices accessible only by

research staff and designated graduate students. Data were downloaded from Fluid

Surveys or Qualtrics and transferred to the statistical software, SPSS, for analysis.

Data Analysis

Prior to data analysis, I examined the data to ensure it met the assumptions of

proposed statistical tests. Variables were screened for outliers and normal distributions.

A p value < .05, was considered statistically significant. All data analyses were

performed on SPSS software version 24. I used descriptive statistics (means/standard

33

deviations and frequencies/percentage) to describe characteristics of mothers and their

infants at admission to the NICU (See Table 1). I described scale scores using

means/standard deviations and proportions of mothers in the clinical range for

depression, >13, and anxiety, >40 (See Table 2). To evaluate whether depression and

anxiety symptoms changed from admission to discharge, I conducted a paired t-test for

both EPDS and STAI-state using continuous scores. To assess for the strength of the

association between depression, using the EPDS continuous scores, and anxiety

symptoms, using the STAI-state continuous scores, I calculated a Pearson’s point biserial

correlation at two time points; admission and discharge.

To identify predictors of depression and anxiety symptoms at discharge from the

NICU, I performed a Pearson’s point biserial correlation to assess for statistically

significant correlations among the dependent and independent variables (See Table 3).

This was done to assess for multicollinearity, and to determine what variables to include

in a hierarchal, step-wise, multiple linear regression model. The independent variables,

collected at admission, included maternal age (ratio), family support (nominal)marital

status (nominal), single parenting (nominal), education (ordinal), family income

(ordinal), employment (nominal), ethnicity (nominal), singleton or twin pregnancy

(nominal), parity (interval), use of assisted reproductive technology (nominal), sex

(nominal), infant gestational age (ratio), alcohol (ordinal), smoking (ordinal), street drugs

or prescription use during pregnancy (nominal). There were no statistically significant

associations between the independent variables of maternal, infant and pregnancy-related

characteristics at admission and the dependent variables of EPDS scores and STAI-state

34

at discharge. As a result, no further analyses using multiple linear regression to identify

predictors of EPDS and STAI-state at discharge were performed.

35

Chapter 4 Results

Prevalence and Time Course of Depression and Anxiety Symptoms

Prevalence of depression symptoms. At admission to the NICU, the mean

EPDS score was 7.92 (SD = 4.84) with 18.3% (n = 36) of mothers of moderate and late

preterms having an EPDS score >13, indicative of probable depression (See Table 2). At

discharge from the NICU, the mean EPDS score was 7.07 (SD = 4.61), with 12.2% (n =

24) of mothers with probably depression. Item 10 on the EPDS asks if the mother has

had thoughts of self-harm. At admission; 4% of mothers reported ‘hardly ever and 2%

reported ‘sometimes’ they had thoughts of self-harm. At discharge; 2% of mothers

reported ‘hardly ever’, 2% reported ‘sometimes’, and nearly 1% reported ‘yes, quite

often’ they had thoughts of self-harm.

Prevalence of anxiety symptoms. At admission to the NICU, mothers of

moderate and late preterm infants reported a mean STAI-state score of 37.22 (SD =

11.19), with 42.1% (n = 83) reporting a STAI-state score >40, indicative of moderate to

severe levels of anxiety. At discharge, mothers reported a mean STAI-state score of

32.52 (SD = 9.90), with 23.4% (n = 46) reporting a STAI-state score >40. Mothers

reported a mean STAI-trait score of 34.75 (SD = 8.83),which was assessed only at

admission.

36

Table 2. Scores on Psychosocial Distress Measures Admission Discharge

Scale scores Mean (SD) Mean (SD) EPDS 7.92 (4.84) 7.07 (4.61) STAI-State 37.22 (11.19) 32.52 (9.90) STAI-Trait 33.31 (8.49) --- PSS:NICU 2.59 (0.82) 3.24 (0.82) Proportion in Clinical Range Frequency (%) Frequency (%) EPDS (>13) 36 (18.3%) 24 (12.2%) STAI-State (>40) 83 (42.1%) 46 (23.4%) STAI-Trait (>40) 58 (29.4%) ---

Note. EPDS = Edinburgh Postnatal Depression Scale; STAI = State Trait Anxiety Index; PSS: NICU = Parental Stressor Scale: Neonatal Intensive Care Unit.

Time course. Maternal EPDS scores decreased significantly between admission

and discharge, t(196) = 2.7, p = .008, 95% CI [.23, 1.48]. Similarly, maternal STAI-state

scores decreased significantly between admission and discharge, t(196) = 6.2, p = .000,

95% CI [3.2, 6.2].

Strength of Association Between Depression and Anxiety Symptoms, and Stress

There was a strong, positive linear correlation between EPDS and STAI-state

scores at both admission, r = 0.64; p < .001 and discharge, with a slightly stronger

correlation at discharge, r = 0.71; p<.001. Thus, there was a significant relationship

between depression and anxiety symptoms at both time points. There was a statistically

significant correlation between parental stress, measured with the PSS: NICU at

admission and depression scores at discharge, r = .27, p < .001, measured by the EPDS.

Predictors of depression and anxiety symptoms

There were no statistically significant associations between the independent

variables of maternal, infant and pregnancy-related characteristics at admission and the

dependent variable of EPDS scores at discharge. There were no statistically significant

37

associations between the independent variables a of maternal, infant and pregnancy-

related characteristics at admission and the dependent variable STAI-state at discharge.

38

Table 3. Summary of Pearson’s Intercorrelations between EPDS/STAI-state scores at Discharge and Independent Variables at Admission

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

1.EPDS --- 2.STAI – state .709** --- 3.PSS:NICU .270** .088 --- 4.Age -.051 -.062 -.031 --- 5.Single parent .075 .059 -..042 -.022 --- 6.Social support -.028 .074 .024 -.162* -.136 --- 7.Education .068 .010 .078 .204* -.114 -.139 --- 8.Employment .112 .047 -.062 .177* -.018 .106 -.072 --- 9.Income -.052 -.020 -.006 .1 -.301** .191* .151** .050 --- 10.Ethnicity -.062 -.083 -.052 -.21** -.005 -.127 .026 -.135 -.178* --- 11.Sex .060 .029 .072 .004 .015 -.063 -.131 -.002 -.102 .038 --- 12.Parity -.135 -.091 .002 .13 .235** -.157* .204** -.078 -.248** .167* .208** --- 13.ART .101 .024 .060 -.16* .012 -.089 -.101 -.026 -.086 .099 -.006 .178* --- 14.Multiple birth

-.021 .033 -.081 -.063 -.012 -.006 .061 .086 .114 .187* .042 -.065 243** ---

15.Smoking -.090 -.103 -.049 -.195** .185** .078 -.251** -.052 -.027 .183* .148* -.162* .111 -.110 --- 16.Alcohol -.003 -.013 .0119 .014 -.034 -.026 .071 -.025 -.074 -.001 .099 -.022 .078 -.094 .161* --- 17.Street drugs .013 -.077 .110 -.13 -.026 .047 -.023 .052 -.072 -.080 .084 .009 .059 -.071 .252** .361** --- 18.Prescriptions .059 .073 -.031 .279** -.128 .001 .039 .015 .055 .091 -.028 .058 -.154* .122 -.123 -.026 -.031 ---

Note. EPDS = Edinburgh Postnatal Depression Scale; STAI = State Trait Anxiety Index; PSS: NICU = Parental Stressor Scale: Neonatal Intensive Care Unit; ART = Assisted Reproductive Technology. *p < .05. **p < .01.

39

Chapter 5 Discussion

In this study, the prevalence, time course, comorbidity, and predictors of maternal

depressive and anxiety symptoms were examined in mothers of moderate and late

preterm infants between admission to and discharge from a level II NICU. Mothers of

moderate and late preterms experienced similar levels of depressive symptoms and

elevated levels of anxiety symptoms, compared to other studies of mothers in the term

population. Symptoms of depression and anxiety decreased slightly between the

admission and discharge and depressive and anxiety symptoms were comorbid as

expected. However, none of the maternal, infant, or pregnancy-related risk factors

evaluated in this study predicted depressive or anxiety symptoms at discharge.

Most of the existing literature has focused on the maternal experience with an

early preterm infant (Greene et al., 2015; Misund et al., 2014; Pace et al., 2016;

Poehlmann et al., 2009; Rogers et al., 2013), or preterm infants as a whole (Ballantyne et

al., 2013; Greene et al., 2015; Hawes et al., 2016; Misund et al., 2014; Poehlmann et al.,

2009; Rogers et al., 2013; Trumello et al., 2018) without categorization by GA. This

study is unique in that it specifically assessed mothers of moderate and late preterm

infants, which comprise 86% of preterm infants in Alberta. It is important to recognize

that the experience of having an early preterm and having a moderate or late preterm,

although similar in some ways due to infant being hospitalized, should be recognized as

different due to severity of infants’ illness and length of stay in the NICU (Shapiro-

Mendoza & Lackritz, 2012).

40

Prevalence of Depression Symptoms

The EPDS was used in this study, with symptoms of clinically significant

depression determined by a score of >13. In this sample, 18% of mothers of moderate

and late preterm infant at admission, and 12% at discharge, reported an EPDS score

indicative of probable depression. These rates are similar to rates of up to 19%, reported

by mothers of full term infants (O’Hara & McCabe, 2013) and do not support my

hypothesis that rates of depression in mothers of moderate and late preterm infants would

be elevated compared to mothers of term infants (Trumello et al., 2018). In comparison,

two other studies of mothers of moderate and late preterm infants found that 60% of

mothers reported significant depressive symptoms within one week of childbirth

(Trumello et al., 2018). However, postpartum physiological changes typically generate

“baby blues” within the first 2 to 5 days that can last up to 10 to 14 days postpartum

(Buttner et al., 2012). Thus, measuring PPD within the first week postpartum may

actually be capturing “baby blues” rather than symptoms indicative of a major depressive

episode. Compared to rates collected during the first two weeks postpartum, rates of

depressive symptoms were lower when collected one month post-discharge from the

NICU, and ranged from 18% to 22% (Hawes et al., 2016). These authors used lower cut-

off scores of eight and 10, respectively, which may explain the higher prevalence.

Other studies using the EPDS reported similar proportions of depressive

symptoms (i.e., 19% [Vasa et al. 2014], and 20% [Rogers et al., 2013], with cut-off

scores of 12 [Vasa et al., 2014] and 13 [Rogers et al., 2013]) when measured after the

first two weeks postpartum. However, these samples included mothers of all infants

admitted to the NICU, and not only mothers of moderate and late preterm infants.

41

Moreover, studies that directly compare depression scores of NICU mothers and mothers

of full term infants have found greater depression symptoms in NICU mothers that are

maintained over 6 months (Pace et al., 2016). However, the current study did not have a

direct comparison group to directly assess this hypothesis and the variability of

prevalence rates of perinatal depression symptom in the literature seems to be large.

Thus, direct comparisons of rates of depression symptoms across studies is challenging

because of variability in samples, measurement scales, clinical cut-off scores, and timing

of measurement.

Prevalence of Anxiety Symptoms

In the current study, there was a strong relationship between trait and state anxiety

scores at admission and a modest relationship between trait scores at admission and state

scores at discharge. Given that the trait and state anxiety measured at admission were not

perfectly correlated, the anxiety mothers reported at discharge is not due solely to

temperamental traits. However, having a temperament that is vulnerable to anxiety

predicted anxiety at discharge. Assessing trait and state anxiety at admission, may be

important to predict state anxiety at discharge.

In regard to anxiety symptoms of mothers in the current study, approximately

42% of mothers reported state anxiety scores above the clinical cut-off at admission and

23% at discharge. These rates are well within the range of 17% (Misund et al., 2014) to

72% (Trumello et al., 2018) reported in other studies of mothers of infants in the NICU.

The elevated levels of anxiety symptoms in mothers of moderate and late preterms

supports my hypothesis. Fairbrother et al. (2016) reported 17% of mothers in the general

population met criteria for an anxiety disorders in the postpartum period.

42

The current findings are similar to Trumello et al. (2018) who used the STAI with

a cut-off score of >40 and reported 45% of mothers of moderate and late preterms

reported moderate to severe anxiety within the first week of childbirth. Using the

Hospital Anxiety and Depression Scale and preterm infants less than 30 weeks’ gestation,

48% of mothers reported anxiety above the clinical cut-off at admission with 25% above

the cut-off at 6 months (Pace et al., 2016). This current study had a mean gestational age

of 33.5 weeks. Greene et al. (2015) reported similar findings prior to NICU discharge

with 23% of mothers reporting scores above clinically cut-off using the STAI; however,

their population included infants with birth weights less than 1500 grams. Pace et al.

(2016) reported that mothers and fathers of preterm infants less than 30 weeks’ gestation

had higher symptoms of anxiety than mothers and fathers of full-term infants. Variability

in samples, clinical cut-off scores and timing of measurements influence the differences

across studies.

Time Course of Depression and Anxiety Symptoms

As hypothesized for the current study, the mean EPDS scores showed a

statistically significant decrease between NICU admission and discharge, which is in line

with other studies that measured symptoms at more than one time point (Bergstrom et al.,

2012; Greene et al., 2015; Lefkowitz et al., 2010; Pace et al., 2016; Poehlmann et al.,

2009). In the current study, the STAI-state scores decreased between admission and

discharge, similar to other studies that measured prevalence at more than one time point

(Greene et al., 2015; Pace et al., 2016). While it is important to recognize that for

mothers of preterms, psychosocial distress does decrease over time; depression and

anxiety symptoms remain elevated compared to full-term infants (Pace et al., 2016) and

43

mothers should continue to be monitored and offered support to reduce depression

symptoms, anxiety and stress while in the NICU..

Strength of Association Between Depression and Anxiety Symptoms

Results from my study revealed a strong, positive relationship between depression

and anxiety symptoms at both admission to and discharge from the NICU, as expected.

The EPDS has three items that assess anxiety symptoms and could account for at least

part of this association (Matthey, Fisher & Rowe, 2013). Results for the current study are

consistent with Segre et al. (2014) who reported that 51% of mothers with a score >40 on

the STAI, also had scores >12 on the EPDS. Similarly, 55% of women who reported

probable depression also reported moderate to severe levels of anxiety symptoms. These

findings of comorbidity between PPD and PPA in both the term and preterm population

highlights the importance of screening, and further clinical diagnostics and specific

treatment strategies for both PPD and PPA (Austin et al., 2010; Wardrop & Popadiuk,

2013).

Predictors of Depression and Anxiety Symptoms

Parental stress. Parental stress measured at admission, was the only independent

variable significantly correlated with depressive symptoms at discharge. This result is

congruent with the theoretical framework for this study, Pathways of Influence

Prematurely Born Children (Miles & Holditch-Davis, 1997). The theory suggests that the

experience of having a preterm infant can impact emotional distress due to loss of normal

parenting role, illness severity, treatments, appearance of the infant, and concerns about

outcomes for their infant. Furthermore, parents may feel helplessness, loss of control,

44

fear, guilt and shame, and a sense of failure and disappointment, which can result in

increased parental stress contributing to depression.

My hypothesis that family support, marital status, ethnicity, and multiple births

(i.e., twins) would predict depressive symptoms, and first-time mothers and lower

gestational age would predict anxiety symptoms was not supported. None of the

maternal, infant, or pregnancy-related characteristics on the admission survey predicted

depressive or anxiety symptoms on the discharge survey. This result, although

inconsistent with my hypotheses, is consistent with several other studies. Three of the 13

published studies that explored predictors of depressive symptoms found no statistically

significant risk factors (Misund et al., 2014; Pace et al., 2016; Trumello et al., 2018).

Three of six studies that evaluated predictors of anxiety, also found no statistically

significant risk factors (Pace et al., 2016; Rogers et al., 2013; Trumello et al., 2018).

Failure to predict depressive and anxiety symptoms from maternal, infant, or pregnancy

risk factors may be due to small samples as low as 29 (Misund et al., 2014).

Alternatively, there may indeed be no association between maternal, infant and

pregnancy risk factors and maternal depressive and anxiety symptoms.

A study in Chicago that included infants with a birthweight less than 1500 grams

evaluated predictors of depression and anxiety in mothers using the CES-D as a measure

at two time points: within the first month of NICU stay and 2 weeks before discharge

(Green et al., 2015). They reported no predictors for depressive and anxiety symptoms at

discharge. At admission, they did however find that being single or being in a

relationship, but not cohabiting, was a predictor of depressive symptoms and being a first

time mother was a predictor of anxiety symptoms.

45

I hypothesized that marital status would be a significant predictor of maternal

depressive symptoms at discharge, with being single associated with greater depressive

symptoms as reported in other studies (Ballantyne et al., 2013; Bergstrom, et al., 2012;

Greene et al., 2015; Hawes et al., 2016). In the current study, single parenting was

correlated with depressive symptoms at admission, but not at discharge. None of these

studies were specific to the moderate and late preterm population and only two studies

used the EPDS to measure depressive symptoms (Bergstrom, et al., 1012; Hawes et al.,

2016). Ballantyne et al. (2013) and Greene et al. (2015) used time points close to

discharge, which was similar to the current study and with similar results. An interesting

finding was the slight increase at discharge (n = 10), compared to admission (n = 6), of

those who reported being a single parent. The elevated stress of having an infant

hospitalized in the NICU may explain marital separation during this time.

A vast amount of literature suggests that a previous history of a mental health

disorder before or during pregnancy is a strong predictor of depression (Bergstrom et al;

2012; Hawes et al., 2016; Lefkowtiz et al; 2010; Misund et al., 2014; Segre et al; 2014;

Vasa et al., 2014) and anxiety (Misund et al., 2014; Segre et al; 2014) after the birth of a

preterm infant. In the current study, which was a secondary analysis of data already

collected to answer the primary research question about hospital length of stay, mental

health history was not collected in the survey administered at admission.

Based on results of past research (Ballantyne et al., 2013), it was expected that

lower social support and poorer family functioning would predict maternal depression

symptoms at discharge, however the current data did not support this hypothesis. In the

current study, mothers reported support from numerous categories including

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grandparents, extended family, friends, neighbors, and others. Nearly 90% of mothers

reported support from grandparents or extended family. However, the variable assessed

if they had support from specific groups of people (See Appendix A), rather than

satisfaction with the support that was provided. Maternal perceptions of the quality of

support may have influenced the relationship between social support and depressive and

anxiety symptoms. It is also important to recognize that although well intended, support

from family or friends who do not fully understand the experience of having an infant in

the NICU, may actually increase parental stress (Hall, Ryan, Beatty, & Grubbs 2015).

The unexpected lack of socio-demographic predictors of depressive or anxiety

symptoms at discharge highlights the importance of using reliable and valid screening

tools for mothers of moderate and late preterm infants admitted to the NICU. These

mothers are potentially at higher risk for probable depression and moderate to severe

anxiety. However, in the current study, we were unable to predict this psychological

distress at discharge based on maternal, infant, and pregnancy factors, therefore, we need

to assess the symptoms directly. It also emphasizes the difficulties of identifying mothers

at greatest risk of depressive and anxiety symptoms based on maternal, infant, and

pregnancy related characteristics alone.

Strengths

The current study contributes knowledge regarding depressive and anxiety

symptoms specifically in mothers of moderate and late preterms, a unique and under

researched population in the literature as a whole. Strengths of the study include a

moderately large, homogeneous sample size (N = 197) from five different NICUs in the

province of Alberta. Available variables included multiple maternal, infant, and

47

pregnancy-related factors. Mothers completed surveys within 7 days of NICU admission

and within 7 days of NICU discharge using reliable and valid scales, including the EPDS,

STAI and PSS:NICU.

Limitations

There are several methodological limitations of this current study that should be

considered when interpreting the results. First, the mothers in this study were primarily

Caucasian, married or living common-law, highly educated, and with middle to high-

incomes. Mothers were excluded from the study if they had health, social, or language

issues that interfered with communication with the health care team. Women with lower

socioeconomic and diverse ethnic backgrounds may not be adequately represented, thus

limiting generalizability of the results of this study. As well, my study only included

mothers from the control group with complete data on depression and anxiety symptoms

at admission and discharge, which could have eliminated depressed mothers who may

have been less likely to complete follow-up data, creating bias.

Second, this study was a secondary analysis of data that had already been

collected. There were factors, such as maternal mental health history and quality of

social support listed in the theoretical framework and found in the literature, that were not

collected for the primary study. Wording of some of the questions in the survey were

inconclusive (see Appendix A). For example, participants were asked “Do you have help

or support from the following?” The options were grandparents, extended family

(brothers, sisters, aunts, uncles) friends, neighbors, and other. The majority of

participants checked off multiple boxes making it difficult to effectively evaluate the

48

degree of actual social support available and the extent to which this support was utilized

and appreciated.

Third, there was no comparison group of mothers with full term infants to

compare depression and anxiety symptoms, prevalence and risk factors with the moderate

and late preterm population. Finally, depression and anxiety symptoms were measured

using maternal self-report. Data collected from self-report can be a versatile way to

know what people think or feel, but may not always be valid or accurate because people

tend to want to present themselves positively and this may conflict with the real truth

(Polit & Beck, 2017). The EPDS and STAI are not diagnostic tools, rather first level

screeners for depression and anxiety symptoms. A structured clinical interview with a

psychiatrist or clinical psychologist is necessary to diagnose mental health disorders. (BC

Reproductive Mental Health Program & Perinatal Services BC, 2014).

49

Chapter 6 Conclusion

Clinical Implications

Results from this study provide insight about the prevalence, time course,

comorbidity and predictors of depression and anxiety symptoms in mothers of moderate

and late preterm infants admitted to the NICU. The current study demonstrates that in

this population, mothers may have elevated depression and/or anxiety symptoms at

discharge with limited identifiable maternal, infant, or pregnancy factors that can be

predicted upon admission. The only significant predictor of depression symptoms on the

discharge survey in the current study was depression symptoms and parental stress on the

admission, measured by the PSS:NICU scale. Similarly, the only significant association

with anxiety symptoms on the discharge survey was anxiety symptoms and trait anxiety

on the admission survey. The recognition that some mothers do indeed experience

symptoms that are indicative of probable depression and anxiety, with the lack of

additional predictors, highlights the need to implement universal screening to identify

mothers at greatest risk based on validated self-report measures. Screening would then

need to be followed by appropriate referrals for further assessment, and evidence-based

interventions to decrease psychosocial distress in this population (Mendelson, Cluxton-

Keller, Vullo, Tandon & Noazin, 2017).

The physical environment of the NICU and nursing practices should also be

evaluated to identify stressors that can be decreased or modified with the potential of

reducing parental stress and in turn, have the potential to reduce symptoms of depression

and anxiety in parents. These stressors include (a) constant noises from equipment and

monitors, (b) other sick infants in the room, (c) feeling helpless and unable to protect the

50

infant from pain and painful procedures, (d) being separated from the infant, (e) being

unable to hold the infant as desired (f) being unable to care for the infant, like diapering

and bathing and (g) not having time alone with the infant (Miles et al., 1993).

Efforts should be made to improve maternal, infant, and system outcomes for this

population using evidence-based research and effective leadership at both the individual

and organizational levels of our health care system, incorporating a multi-disciplinary

approach. There is a need for improvements in (a) early detection of psychosocial

distress with universal screening (Cherry et al., 2016), (b) accessibility to psychological

support (Hynan et al., 2015), (c) FCC practices (American Academy of Pediatrics, 2012),

(d) resources to implement evidence-based interventions that have shown to reduce

depression and anxiety (O’Brien et al., 2018), and (e) recognition of the important role of

the bedside nurse to improve the experience of having an infant born preterm (Hall et al.,

2017).

Universal screening. Based on the results of the current study that was unable to

identify significant predictors of maternal depression and anxiety symptoms at discharge,

universal screening should take place in the NICU in anticipation of the vulnerable period

that appears to occur when an infant is born preterm and hospitalized (Ballantyne et al.,

2013; Cherry et al., 2016; Purdy, Smith, Chuffo-Siewert, & Ryan, 2017; Trombini et al.,

2008; Vasa et al., 2014). Early detection of depressive and anxiety symptoms and timely

management have the potential to improve mother-infant interactions and improve long-

term outcomes for mothers and preterm infants (Vasa et al., 2014) and their families. A

life-saving measure could be monitoring the question about self-harm in the EPDS that

51

could alert health care providers to make an immediate referral for psychological support

if a mother answers yes to thoughts of self-harm.

A multidisciplinary approach with effective communication and continuity of care

is needed from pregnancy, NICU hospitalization, and postpartum period up to one year

(Mckean, Caughey, Yuracko-McKean, Cabana & Flaherman, 2018). The need for

universal screening in the postpartum period is becoming widely recognized as important

for all mothers (American Academy of Pediatrics, 2012; Australian Government

Department of Health, 2018) with some suggestions that screening should begin in the

prenatal period to assess for risk factors and to initiate preventative strategies during

pregnancy for mothers at high risk (American Academy of Pediatrics, 2012; Hynan et al.,

2015; McDonald et al., 2012).

Cherry et al. (2016) suggest barriers of completing universal screening for PPD in

the NICU were establishing contact, administration of the measure and access to

referrals, which highlights the need for a multidisciplinary approach from administrators,

medical staff, and mental health specialists to ensure screening takes place. Validated

screening tools, such as the EPDS and STAI, should be utilized with timing (i.e., after

“baby blues”) of screening taken into consideration for effectiveness to be achieved.

In an effort to reduce respondent burden, it has been suggested that a three

question, subscale of the EPDS is as effective for screening for depressive symptoms and

identifying mothers with probable depression, if not more effective than the 10 question

version (Kabir, Sheeder & Kelly, 2008). The subscale identified 16% more mothers as

depressed than the original, longer questionnaire. The EPDS-3 could be an attractive

screening tool for healthcare providers who want to detect potential depression, not

52

severity, and then refer to a psychologist for a more comprehensive assessment and

intervention if warranted.

Infants in the moderate and late preterm population have a much shorter hospital

stay compared to early preterms, yet these mothers are vulnerable to depression and

anxiety. The average length of stay for preterms ranged from 9.8 days for those born at

34-36 weeks to 20.3 days for those born at 32-33 weeks (National Perinatal Information

Center, 2011). Hynan et al. (2015) recommends that screening be done within the first

week postpartum and then rescreened whenever it is deemed important and within 48

hours before discharge. Screening within the first week may not be accurate due to the

“baby blues”, therefore, perhaps screening would more accurately predict those with

clinically significant mood and anxiety difficulties in need of intervention if it were done

two-week postpartum. Currently, there are no data to my knowledge that indicate the

most valid, predictive and appropriate time for screening in the NICU population. Efforts

need to be made to help mothers build bridges from the NICU to the community with

coordination of care (Siewert, Cline & Segre, 2015). For mothers whose infants are

discharged before two weeks postpartum, screening should be done in the community by

postpartum public health nurses and/or physicians.

The goal should be to identify, communicate, coordinate, and refer mothers who

screen in the clinical range to appropriate mental health and psychosocial services. If

screening occurs before NICU discharge, this information needs to be communicated to

the community setting for appropriate follow-up if needed. Mothers should also be

informed and empowered to access the mental health and support services they need or

want. Longer term follow-up should occur for all mothers of moderate and late preterm

53

infants since PPD can occur anytime during the first year after childbirth (American

Psychiatric Association, 2013). Pace et al. (2016) found that although rates of depression

declined over time for mothers of preterms, they still remained elevated at 6 months

postpartum so post-discharge screen should be performed by public health nurses, and

family physicians during the first year (Hynan et al., 2015).

Psychological support services. Mothers identified with elevated levels of

depression and anxiety symptoms through screening, need to be further assessed in a

timely manner (Segre et al., 2014). Mental health professionals (social work, psychology

and/or psychiatry) are recommended and needed for evidence-based screening,

assessment and interventions for mental health conditions in the NICU (Hynan et al.,

2015). Steinberg and Patterson (2017) suggest NICUs have a psychologist embedded on

staff as a member of the health care team, so they can be familiar with the culture of the

NICU and more targeted needs of NICU parents, as compared to calling for

psychological or psychiatric consults when needed from other departments.

Greene et al. (2015) found that despite reported high prevalence (24 to 37%) of

psychosocial distress among mothers and fathers of infants in NICU, there was a very

low rate of enrollment in therapeutic services (9%) at the time of NICU discharge. A

study in the early preterm population by Trombini et al. (2008) investigated maternal

psychological distress in two NICUs with different parent accessibility and mental health

provider support systems. Lower levels of distress were reported on the unit with clinical

psychologists and unlimited parental presence on the unit. They concluded that

psychological support for mothers is critical in reducing maternal distress and can

54

positively affect mother-infant interactions which reduces the risk of long-term

developmental difficulties in infants of preterms.

Segre et al. (2014) found that mothers in the NICU not only displayed symptoms

of depression and anxiety, but may also demonstrate symptoms of other anxiety disorders

such as panic disorder, post-traumatic stress disorder, social anxiety, and obsessive

compulsive disorders. Mothers with mental health problems during pregnancy, such as

depression (Sanchez et al., 2013) and anxiety (Rose, Pana & Premji, 2015) have been

reported to have higher incidence of preterm birth, particularly anxiety. A mental health

care provider can properly diagnose mental health disorders and treat mothers more

specifically (Hynan et al., 2015). Providing these services within the NICU environment

improves accessibility and uptake of these essential services (Purdy et al., 2017).

It is important to recognize that having anxiety or depressive symptoms does not

indicate that the symptoms are pathological or even in need of an intervention; some of it

may be normative and temporary (Hynan et al., 2015). However, our goal is to identify

those with symptoms that are greater than what is normative for the situation and could

benefit from intervention that could reduce the excessive or unhelpful depressive or

anxiety symptoms.

Family-Centred Care (FCC). Hynan et al. (2013) recognizes that most NICU

parents will not need professional help but do need increased levels of emotional support,

that can be delivered through FCC practices. When delivered effectively, this may

inoculate many vulnerable parents from psychopathology. FCC is widely accepted as the

gold standard of care in the NICU (American Academy of Pediatrics, 2012). FCC is a

health-care approach based on mutually beneficial partnerships and collaboration

55

between families and neonatal care providers (Johnson, 2000). FCC recognizes that the

family is the constant in the child’s life (Shirazi, Sharif, Rakhashan, Pishva, & Jahanpour,

2016), honors diversity of all families (Lee, Carter, Stevenson, & Harrison, 2014) and

acknowledges family strengths and differing ways of coping (Gooding et al., 2011). FCC

is based on the belief that providing psychosocial care to the family is equitable to

providing medical and developmental support to the infant (Hall et al., 2015). Not only

can we address maternal mental health concerns with mental health professionals, but the

full NICU team and approach to care can have a significant impact as well (Segre,

Orengo-Aguayo & Chuffo-Siewert, 2015).

There are barriers in policy and procedures and organizational constraints that

inhibit full implementation of FCC in the NICU. The literature overwhelmingly agrees

that the physical environment of the NICU and the culture within, should aim to meet the

medical, developmental, educational, emotional and social needs of infants and families

(Shirazi et al., 2016). The physical environment can be optimized by conforming to

standards for noise and lighting, and designed so communication can occur freely

between families and healthcare providers (Hall et al., 2015). Identifiable parental

stressors can be reduced by (a) silencing alarms, (b) providing single parent rooms or

privacy screens when infants are in the same bed spot, (c) closing curtains when

providing skin-to-skin care or breastfeeding, (d) recognizing parents as part of the

medical team, (e) encouraging parents to attend rounds, and (f) providing frequent

updates on infants condition without the use of complex medical terms. Parents should

have unlimited access, be encouraged to do containment when they are not able to hold

their infant, provide comfort to their infant during painful procedures, and encouraged to

56

provide all care they are able to by monitoring temperature, diapering, feeding and

bathing. Reducing parental stress in the NICU has the potential to decrease depression

and anxiety symptoms for mothers of moderate and late preterm infants (Miles, Holditch-

Davis et al., 2007).

Evidence-based interventions. There needs to be increased efforts to develop

effective interventions for alleviating stress in NICU mothers and preventing its potential

development into PPD and PPA. When an infant is born early and requires

hospitalization, the NICU is the place where the first mother-child encounter occurs and

the early dynamics of their relationship begins (Trumello et al., 2018). Hall et al. (2017)

believed that to improve outcomes in the NICU, attention should be focused on the often

underutilized and undervalued natural resource, the parent-infant relationship. Over time,

various FCC models of care have been developed to facilitate parent-infant interaction,

enhance parental competency in the NICU, improve the psychological well-being of the

mother, which improves attachment and optimizes infant development over the long-term

(Glazebrook et al., 2007; Kaareseen, Ronning, Ulvund, & Dahl, 2006; Melnyk et al.,

2006; Newnham et al., 2009). Melnyk et al. (2006) found that interventions in the NICU

that strengthen parental beliefs about their ability to care for their infant were associated

with lower levels of depression and anxiety after discharge from the NICU. Hynan et al.

(2015) suggest peer-to-peer support organizations with veteran parents, and parent

education groups weekly may be helpful to reduce stress, anxiety and depressive

symptoms when an infant is hospitalized in the NICU.

Interventions have mostly comprised of formal and informal education for

parents, often away from bedside. Despite these efforts, parents continue to feel

57

disconnected from their infants, not sufficiently involved in their infants’ care and

unprepared for discharge (Galarza-Winton, Dicky, O’Leary, Lee, & O’Brien, 2013). As

a result, the FICare model of care was developed to incorporate direct infant care by

parents, fully immersing them as equal partners (Bracht, O'Leary, Lee & O'Brien, 2013).

In FICare, parents have unlimited access to their infant and provide most of the daily care

including feeding, bathing, repositioning and providing comfort to the baby during

painful procedures. Parents were encouraged to spend 6 hours a day at bedside,

participate in daily rounds with the multidisciplinary team, attend group education

sessions, and are offered support from veteran parents who have had an infant in the

NICU.

The implementation of FICare as an intervention, has shown to increase parental

confidence, improve the parental relations with the multidisciplinary team, and decrease

maternal depressive and anxiety symptoms in the preterm population (O’Brien et al.,

2018). Thus, interventions, such as FICare, should become the standard care of practice

in the NICU to improve maternal psychosocial distress and long-term child development.

As FICare evolves in the NICU, I would recommend that universal screening and formal

psychological support from psychologists be included as part of the model to improve

maternal, and ultimately, infant outcomes in the NICU.

Role of Nurses. Mothers of preterm infants rely on neonatal care providers to

provide support during their NICU stay (Hall et al., 2017). Bedside nurses spend more

time with the family compared to other disciplines and are strategically positioned to help

mothers navigate the highly-specialized care in the NICU (Hall et al., 2017; Purdy et al.,

2017). The relationship that develops between the bedside nurse and parents has been

58

recognized as a key component in facilitating FCC practices, like FICare in the NICU

(Reis, Rempel, Scott, Brady-Fryer, & Van Aerde, 2010). Nurses can assist in

normalizing the NICU experience and offering guidance and encouragement to parents

(Turner & Chur-Hanse, 2014). Nurses can play a vital role in identifying symptoms of

depression and anxiety (Beck, 2003; Zauderer, 2008), initiating appropriate referrals

(Davis, Edwards, Mohay, Wollin, 2003), accessing psychological resources for parents

(Purdy et al., 2017), and delivering evidence-based interventions to decrease the rates of

maternal psychosocial distress (Trumello et al., 2018).

Despite neonatal nurses acknowledging positive benefits for infants and families

as a result of parent-focused interventions, challenges have emerged with the alteration in

the bedside nurse’s role (Broom, Parsons, Carlisle, & Kecskes, 2017). With FICare,

instead of providing most of the hands-on-care, bedside nurses assume the role of

facilitator and educator to include parents in direct participation of their infant’s care

(Galazra-Winton et al., 2013). Families are incorporated as part of the health care team,

as they are able, from the time of admission. Nurses are encouraged to support and

empower parents, which may require increased emotional investment on the part of the

nurse, which may be challenging for some nurses. This situation has been described as a

balancing act between caring for a critically ill child and the family at the same time in

the complex, technological NICU environment (Fegran & Helseth, 2009).

Due to this shift in practice, nurses need to expand their knowledge base to see the

infant and the family as one unit, caring not just for the infants’ medical needs but

incorporating the emotional and psychosocial needs of the family (Aloysius, Platonos,

Theakstone-Owen, Deieri, & Banarjee, 2018; Galazra-Winton et al., 2013). During the

59

development of the FICare model, it became apparent that enhanced nurse education,

based on evidence-based research, would be necessary to successfully implement this

new model of care (O’Brien et al., 2013). Neonatal care providers need formal guidance

on the normal response of parents with a hospitalized infant, perinatal mood, and anxiety

disorders (Hall et al., 2015). Staff education needs to include optimal methods of

communication with parents that focus on maximizing the neonatal care providers’

engagement, understanding, and empathy (Hall et al., 2015).

O’Brien et al. (2013) developed a 4-hour nurse education program that included

information, coaching, and role playing with veteran parents who shared their NICU

experience (O’Brien et al., 2013). The psychological implications on a family when a

child is born early were explained along with resources available to families and staff.

The responsibilities of nurses and parents were clearly articulated with an open

discussion on the challenges of developing a therapeutic relationship with parents.

Information was provided on how to be effective teachers while balancing a heavy

workload. Six months later, nurses who participated in the workshop overwhelmingly

felt the training helped them transition into their new role (Galarza-Winton et al., 2013).

Nurses reported an increased awareness of their individual nursing role to support and

nurture the parent–infant relationship.

Future Research

Future research is recommended to better understand maternal depressive and

anxiety symptoms in the moderate and late preterm population. Research should evaluate

the prevalence of depression and anxiety symptoms after discharge from the NICU and

the associations with child development and longer-term outcomes. While the term

60

‘anxiety’ is often used in a general sense, more research is needed to differentiate the

different types of anxiety and to assess criteria for a range of anxiety disorders more

specifically. More research could be done on parental stress in the NICU in the moderate

and late preterm population. It would also be interesting to assess and understand

fathers’ experiences with depression and anxiety symptoms in this population, and

compare what unique and shared experiences mothers and fathers encounter.

Knowledge Translation

I believe our health care system needs leaders at all levels to influence change and

engage in the process to improve health outcomes. The Canadian Nurses Association

(2008) describes Advanced Nursing Practice as an advanced level of clinical nursing

practice that maximizes the use of a graduate level, in-depth nursing knowledge and

expertise in meeting the health needs of individuals, families and communities. As an

Advanced Practice Nurse (APN), I will be a transformational leader to improve maternal

mental health for mothers of moderate and preterm infants by advocating for universal

screening, adequate psychological support, and implementation of evidence-based

interventions to decrease maternal and paternal psychosocial distress.

Assuming my role as an APN, I intend to disseminate my results to key

stakeholders including senior management, unit managers, and nurse educators. I will

share what I have learned from my research and articulate what improvements are needed

to decrease maternal psychosocial distress in the NICU. Using evidence-based research,

I will communicate how early mental health screening and evidence-based interventions

for same, positively impacts a mother’s well-being, enhances mother-infant attachment,

improves child development outcomes, and has the potential to be a cost-savings to the

61

health care system. I will emphasize the importance of structured nurse training and

present the evidence-based research curriculum that has already been developed and

proven beneficial in helping nurses transition to their new role as coaches and mentors to

mothers. I can show confidence knowing I have the clinical expertise and advanced

graduate degree to understand, interpret, and apply nursing theory and research into

practice (CNA, 2008).

As an APN, I can play a significant role as bedside nurse leader, by

acknowledging my role as a leader both to myself and to my coworkers (Larsson &

Sahlsten, 2016). I will be a bedside leader by empowering other nurses to change from

practices that are not evidence-based and lead by example, incorporating knowledge

gained from my research (Hamric et al., 2014). I will critically analyze each clinical

situation to understand the psychological needs of a mother, make any necessary referrals

to psychological support systems, and motivate in a collaborative manner to increase

mothers involvement and confidence caring for her infant in preparation of discharge

home.

I will further disseminate the findings from my study by presenting a poster and

will consider an oral presentation at a Neonatal Conference in 2020. There is potential

for manuscript publication of findings with an authorship agreement in place.

Conclusion

In conclusion, mothers of moderate and late preterm infants are potentially at

increased risk for depressive or anxiety symptoms during admission to NICU. There are

no additional maternal, infant, or pregnancy predictors above and beyond symptoms

measured with the STAI-trait and PSS:NICU at the admission survey. There is the risk

62

of identifying “baby blues” versus postnatal depression with screening that is done too

early, therefore, universal screening of psychosocial distress should be performed

routinely after two weeks postpartum or before discharge, with continuity of care into the

community. Women who screen positive for depression or anxiety symptoms in the

NICU should be provided further assessments by psychologists . Evidence-based

interventions, such as FICare, which has been shown to reduce depression and anxiety

symptoms should be considered for implementation. A holistic approach to care in the

NICU has the potential to improve maternal mental health with subsequent enhancements

to mother-infant attachment and improved developmental outcomes of preterm infants.

63

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Appendix A

Mother Survey on Admission Do you plan to parent alone?

c Yes c No c Prefer not to answer

Do you have help or support from the following?

c Grandparents c Extended family (brothers, sisters, aunts, uncles) c Friends c Neighbours c Other __________ c Prefer not to answer

What is your highest level of education?

c Less than high school c High school diploma c Certificate or diploma after high school c College or university degree

What is your present employment status?

c Employed full time (30 or more hours/week) c Employed part time (less than 30 hours/week) c Unemployed (but LOOKING for work) c Not in the labor force (NOT LOOKING for work) c Student employed part-time or full-time c Student not employed c Retired c Homemaker c Maternity leave c On disability c Other (please specify) __________ c Don’t know c Prefer not to answer

What is the TOTAL income of ALL members of your household for the past year, BEFORE taxes and deductions?

c Less than $20,000 c $20,000 to $39,999 c $40,000 to $59,999 c $60,000 to $79,999 c More than $80,000

83

c Don’t know c Prefer not to answer

People living in Canada come from many different backgrounds (Please select only one). Are you:

c White (Caucasian) c Aboriginal (e.g., First Nations, Inuit, or Metis) c South Asian (e.g., East Indian, Pakistani, Sri Lankan) c Chinese c Black c Filipino c Latin American c Arab c Southeast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian) c West Asian (e.g., Iranian, Afghan) c Korean c Japanese c Other (please specify) __________ c Prefer not to answer

During you pregnancy, did you consume any alcoholic drinks?

c Yes c No c Prefer not to answer

Did you smoke cigarettes during your pregnancy? c Yes c No c Prefer not to answer

Did you use street drugs during your pregnancy? (e.g. marijuana, cocaine, crystal meth, etc.)

c Yes c No c Prefer not to answer

Did you use prescription drugs during your pregnancy?

c Yes c No c Prefer not to answer