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Abstract
Objectives This goal of this research is to present a comprehensive method for evaluating stress and the factors that contribute to it in mothers of premature babies.
Design Analytical cross-sectional study.
Setting Data were collected from inpatient service for preterm infants including neonatal intensive care unit, and neonatal step-down units of the Aga Khan University Hospital—a private tertiary care hospital in Karachi, Pakistan.
Participants Mothers aged 18 years and above who delivered preterm infants (gestational age of preterm below 37 weeks) in a private tertiary care hospital in Karachi, Pakistan.
Primary outcome Stress in mothers of preterm infants.
Results 200 participants with a mean age of 30.12 years (SD ±5.21) were assessed. The level of stress identified using the perceived stress scale (PSS) among mothers who had delivered preterm infants was significantly higher as compared with other countries around the world. Based on the criteria of PSS scoring, the majority of the participants (92%, n=184) were categorised as having high perceived stress and 8% (n=16) of the mothers fell into the category of moderate stress.
Conclusions The study findings suggest high levels of perceived stress among mothers of preterm infants. The factors associated with the stress among mothers of preterm infants included immunisation of newborn, education and occupation status of mothers, substance abuse by mother, gender preference from family, planning for further children, consumption of balance diet, education status of husband, mode of socialisation, years of marriage and hours of sleep.
- obstetrics
- maternal medicine
- psychological stress
- stress, psychological
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This is the first study that assessed level of stress among mothers of preterm infants in Karachi, Pakistan.
The self-developed questionnaire used in the study was approved by the experts after achieving satisfactory rating in content validity index.
The perceived stress scale (PSS) tool used in the study has been validated nationally and internationally in various languages.
The PSS tool has been administered to similar groups of participants as in the current study.
This study was conducted in a private hospital; therefore, the sample size cannot be generalised for government settings.
Introduction
In the context of obstetrics, ‘preterm’ refers to delivery of an infant prior to the completion of 37 weeks of pregnancy.1 Compared with term newborns, preterm infants have different needs. Preterm babies are more likely to experience infections, hypothermia, poor suck reflex, difficulty feeding, effort to gain weight, and impaired lung maturation.2
Preterm births are escalating, globally. Each year, approximately 15 million newborns are delivered preterm globally.3 One of the reasons for the substantial prevalence of neonatal deaths is preterm births, which accounts for 28% of all neonatal deaths worldwide.4 Almost 45% of the children who die below the age of 5 years are newborns; among these 60%–80% are those born prematurely.2
Pakistan is determined to work on this challenging issue, as Pakistan is ranked third in the world for neonatal mortality and accounts for about 7% of the universal neonatal death.5 Moreover, the high burden of neonatal morbidity and mortality rates in the nation can be attributed to preterm births. The prevalence of neonatal mortality in Pakistan is such that for every 1000 live births, there are 42 neonatal deaths.6 Furthermore, to achieve Sustainable Development Goal 3.2, which states to reduce neonatal and below 5 mortalities, the matter of preterm births needs to be addressed. Among the four provinces of Pakistan, Balochistan has the highest prevalence of neonatal mortality at 63 deaths per 1000 live births.6
Stress can be described as an innate response of an individual to undesirable circumstances that disturbs the body’s equilibrium and stability.7 Stress on the birth of preterm infants produces physical and psychological stressors for both the newborn and the mothers. The need for intensive care treatments, feeding difficulties and low birth weight are among the physical challenges for preterm infants. These physical problems for the newborn often lead to psychological impacts on the health of the mothers as well. Preterm infants may have enduring effects of prematurity, preoccupation with the survival of the newborn leading to the development of stress, depression and post-traumatic stress disorders in mothers.8 The mother-child bond is at risk when a preterm infant is born because of the early detachment of the infant from the mother, due to the aggressive treatment requisites for the newborn. A mother’s stress stemming from a particular course of treatment for her preterm infant hinders the development of a stable parent-child bond.9
The incidence of postpartum depression in Pakistan is 63.3%.10 Preterm births potentially create disturbing effects on the newborn, while simultaneously initiating distressing challenges for the mothers. These difficult challenges account for the advancement of stress resulting in high levels of depression in some mothers.11 Furthermore, this challenging issue makes the mother of a preterm more prone to mental instabilities, in contrast to mothers of term babies. The incidence of stress in mothers of preterm infants is as elevated as 30%–40% in contrast to 6%–12% in mothers with infants born at the completion of the gestational period.12 In the initial postnatal period, mothers of preterm infants have been found to have more stress and depression than mothers of term babies.10
A multitude of factors contribute to the upsurge in stress experienced by mothers of preterm newborns. According to a research conducted in India, hospitalisation of the child in the critical care setting, socio-economic status and environmental support in the hospital setting for the mothers and the newborn are frequently associated with stress in mothers of preterm infants.13
This study is important because the identification of stressors can lead to careful planning for the interventions and prevention programmes for mothers of premature babies, in the future. This research potentially facilitates the accomplishment of the Sustainable Development Goal 3, by reducing maternal and infant mortalities and morbidities.
Methodology
Study design
The analytical cross-sectional study design was employed to identify stress and its associated factors among mothers of preterm infants. The analytical cross-sectional study design is beneficial when the plan of the study is to identify the prevalence of a problem, its associated factors and the association between exposure and outcome.14 To ascertain an association between the level of stress, and its associated factors, an analytical cross-sectional study design was considered relevant for this study.
Sampling method
A consecutive sampling method was used for selecting participants. Consecutive sampling involves enlisting a group of people from the available population that meets the eligibility criteria over a particular period. Consecutive sampling is an enhanced approach as it minimises bias in the study, as compared with the convenience sampling method.14
Sample size
The sample size of the study must be preplanned, systematically considered and adequately large to depict the population.15 The sample size was calculated using the OpenEpi software.
Sample size for the prevalence of stress among mothers of preterm infants
The prevalence of stress among mothers of preterm infants was reported to be 75%.16 The reported prevalence of stress was used to calculate the sample size, with a 95% CI, 10% room for error and a non-response rate of 10% was also adjusted. To achieve the study objective, the final sample size was determined as 73+7, that is, 80.
Sample size for determining the associated factors of stress among mothers of preterm infants
The sample size was also calculated for associated factors by considering the prevalence of comorbidities in mothers of preterm infants. The prevalence of comorbidities among mothers of preterm infants was 38.41% and for mothers of term infants was 20.76%.17 Considering the proportions, with a study power of 80%, a 95% CI, two-sided hypotheses, a 1:1 ratio for unexposed and exposed groups and an estimated prevalence ratio of 1.8, the approximate sample size was calculated to be 213. Adding a 10% non-response rate, that is, 21, the final sample size was 234.
Since the required sample size for studying the associated factors of stress among mothers of preterm infants was 234, this sample size was planned for the study. However, during data collection, due to the non-availability of mothers in the neonatal intensive care unit (NICU), a sample size of 200 was ultimately achieved.
Recruitment process of participants
The selection of relevant participants is fundamental for the correct interpretation of the population in a study.18 First, permission for the research was taken from the Chief Medical Officer of the Aga Khan University Hospital.
After getting the required permissions, the recruitment process of participants was started. The researcher approached the participants in the NICU and neonatal step-down units. In addition, the researcher evaluated the participants based on eligibility criteria with the help of the patient’s medical record numbers. After screening the relevant participants, the researcher shared the aim of the study with the participants. Moreover, the benefits of the study were also explained.
Study period
This quantitative analytical cross-sectional research study was completed over a 5-month period, from December 2022 to April 2023.
Study variables
Stress levels among mothers of preterm infants were the dependent variable of the study. The stress levels among mothers were assessed using the perceived stress scale (PSS). This scale measures the overall level of stress by assessing control over oneself and life circumstances, personal confidence and the ability to manage important aspects of life. The scores from the scale were examined in the research study.
The factors associated with the stress among mothers of preterm infants were considered the independent variables in the study. The following were the independent variables of the study:
Newborn’s information
Mother’s demographic data
Pregnancy-related variables
Family information
Coping mechanisms
Data sources
Demographic data were obtained from the medical records, which were accessed through confidential files and the hospital’s electronic system, considering both the mother and the newborn. Additionally, a study-specific self-developed questionnaire, which included components of demographic data for both mothers and newborns, was used. Moreover, pregnancy, family and coping-related variables were also included. Furthermore, the PSS was used to collect data from the mothers.
Eligibility criteria
Defining the inclusion and exclusion criteria for the study participants enhances the reliability of the results and reduces the likelihood of recruiting inappropriate participants.19 The participants for the study were selected based on the below mentioned inclusion and exclusion criteria.
Inclusion criteria
The inclusion criteria of a study define the key characteristics that potential participants must possess; these criteria include demographic factors and other relevant characteristics related to the study.20 The inclusion criteria for this study included:
Mothers aged 18 years and above.
Gestational age of preterm below 37 weeks.
Mothers who were willing to participate and give consent.
Exclusion criteria
The exclusion criteria of the study specify the subjects who meet the inclusion criteria but possess other characteristics that are not favourable for the study and need to be excluded.20 The exclusion criterion for this study included:
Mothers who could not communicate in Urdu or English.
Data collection tool
Data collection tools must be validated by the researcher prior to use to ensure their appropriateness in a particular context to minimise any bias.15 An internally developed questionnaire was used for the data collection. This tool included components regarding demographic data for mothers and newborns. Moreover, pregnancy, family and coping-related variables were also included. Furthermore, the PSS was also integrated into the questionnaire.
The study-specific tool was reviewed using a CVI, where four experts in the concerned field were approached. Each expert rated the questions in the questionnaire for relevance and clarity, giving marks out of 4. The rating scale ranged from 1 (not relevant or not clear) to 4 (very relevant and very clear). After the experts’ evaluations, the results were combined; the relevance score was 0.86 and clarity score was 0.92, both of which are considered satisfactory.
The PSS is a widely used functional tool for assessing stress among individuals experiencing difficult circumstances. This tool has been validated in the Pakistani context for evaluating stress levels among individuals.21 This tool consists of 10 items, where participants rate their emotions and mindset in relation to the events and circumstances they experienced in the past month. Each item is rated on a 5-point Likert scale, ranging from 0 (never) to 4 (very often). Six items are negative (1, 2, 3, 6, 9, 10), and the remaining four are positive (4, 5, 7, 8). To calculate the score, the four positive items are reverse-scored, and then all the items are summed, with a total score ranging from 0 to 40. This scoring system includes three levels: 0–13 (low stress), 14–26 (moderate stress) and 27–40 (high perceived stress).22 A higher score indicates an elevated level of stress.
Internal consistency
The internal consistency of the measuring tool is determined by the inter-relationship of all items developed for measurement within the tool.23 The internal consistency is assessed using Cronbach’s alpha. The Cronbach’s alpha value for the total perceived stress score is 0.87, indicating acceptable internal consistency.24 In the current study, the calculated Cronbach’s alpha for the PSS tool is 0.70, which is considered satisfactory.
Construct validity
Validity reflects whether the assessment tool measures the attributes it is intended to measure.22 The construct validity of the tool was evaluated, and the factor structure was assessed to determine whether the associations between the different variables in the tool accurately measure the intended construct. The test-retest reliability score (r) for the total perceived stress score is 0.86.24 This value indicates satisfactory construct validity of the tool.
Data analysis plan
Data analysis was conducted using the SPSS version 22. Both descriptive and inferential analyses were performed in the study.
Descriptive analysis
Descriptive analysis is a method used to portray the data in a comprehensive manner, examining the patterns and relationships within the data in the research study.25 Demographic variables of the study, including categorical data, frequencies and proportions, were analysed using descriptive analysis. Continuous data were analysed by calculating the mean and SD. The level of stress among mothers of preterm infants, as assessed through the questionnaire, was categorical in nature, and reported using frequencies and percentages.
Inferential analysis
The inferential analysis is used to determine the consistency of outcomes regarding a population, based on the data collected from the sample in the research study.25 Inferential analysis of the study findings was initially carried out by differentiating between categorical and continuous variables. Analysis was further conducted using the χ2 test for the categorical variables and the t-test for two independent samples for continuous variables. During the analysis, a 95% CI and a p value of <0.05 was considered statistically significant.
Ethical considerations
Ethical considerations are important throughout the research process. Participants were informed of their right to withdraw from the study at any time before the data coding was complete. They were assured that withdrawal from the study would not affect their treatment process. Additionally, the informed consent form was provided in both English and Urdu to ensure that participants fully understood the process. Furthermore, it was explained to the participants that participation in the study was voluntary and that no incentives would be provided for participating in the study.
The privacy and confidentiality of the study participants were considered important, and the survey was conducted in separate rooms. The data were accessible only to the primary investigator, supervisor and committee members of the research study. It was stored in both soft and hard formats. The hard copies were kept by the primary investigator and stored under lock and key. The soft copies were saved using password protection. For publication of the research study, the data will be presented in a deidentified manner. In addition, participants were assigned codes in the data entry system to protect their identities.
Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Research question and outcome measures were not informed by patients’ priorities, experiences and preferences. Patients were not involved in the design and recruitment of this study. Moreover, results will be disseminated through publication in a reputable journal. Randomised controlled trials were not used in this study.
Results
Descriptive analysis
A total of 200 mothers who delivered preterm infants were recruited for the study. For descriptive analysis, continuous variables were summarised using mean and SD. The categorical variables were reported as frequencies and percentages.
Sociodemographic characteristics of the mothers of preterm infants
The sociodemographic characteristics of the mothers who delivered preterm infants are illustrated in table 1. The mean age of these mothers was 30.12 years (SD ±5.21), with ages ranging from 18 to 44 years. The majority of the participants were Urdu-speaking, accounting for 82.5% (n=165).
Sociodemographic characteristics of mothers of preterm infants (n=200)
Most of the mothers, approximately 97% (n=195), had completed their education, ranging from matriculation to postgraduate level and beyond. The use of substances such as betel nuts and other forms of substance was reported by 9% (n=18) of the mothers. Around 16.5% (n=33) of the mothers were employed, while nearly 83.5% (n=167) were housewives. The household income was treated as continuous data, with a mean of 109 250.00 PKR (SD ±21 027.32), ranging from 50 000 to 160 000 PKR. Most of the mothers, approximately 89.5% (n=179), were satisfied with their financial status.
Obstetric and gynaecological characteristics of mothers of preterm infants
Among the mothers who delivered preterm infants, the average gestational age was 33.26 weeks (SD ±2.86). Nearly 70.5% (n=141) of the mothers had experienced multiple pregnancies, and 38.5% (n=77) had one child. More than half of the study participants (59.5%, n=119) reported that during their pregnancy, their other children were taken care of by their family members. Almost 73% (n=146) of the mothers reported that their current pregnancy was planned. More than half of the participants (53%, n=106) reported that they planned to have more children. Gender preference within the family was reported by nearly 45.5% (n=91) of the participants, with 42.5% (n=85) expressing a preference for male child, and only 3% (n=6) expressing a preference for a female child.
About 12% (n=24) of the mothers had fertility and gynaecological issues, including polycystic ovary syndrome, uterine fibroids, bicornuate uterus and anovulatory infertility. All of the study participants had experienced a complication during their current pregnancy. The most common complication was preterm labour, reported by 30.5% (n=61) of the mothers. The mode of delivery was predominantly caesarean section, with 81% (n=162) of the mothers undergoing a cesarean delivery. A history of previous complications was also noteworthy, with 33% (n=66) of participants having experienced a miscarriage, 13.5% (n=27) having had preterm deliveries, 6.5% (n=13) reporting intrauterine deaths (IUD) and 2.5% (n=5) having experienced an abortion. More than half of the study participants (62.5%, n=125) started their antenatal visits during the initial weeks of pregnancy.
Nearly 64% (n=128) of the participants reported that they had completed their immunisation. Nearly all the study participants (96%, n=192) had conceived naturally. More than half of the study population (76%, n=152) used artificial methods for family planning. Consuming a well-balanced diet during their pregnancy was reported by 92% (n=184) of the mothers. Most of the study participants (79.5%, n=159) reported that they slept for 5–6 hours per day. The obstetric and gynaecological characteristics of the mothers of preterm infants are illustrated in table 2.
Obstetrics and gynaecological characteristics of the mothers of preterm infants (n=200)
Marital and familial characteristics and coping-related factors
Among the study participants, 75% (n=150) lived in extended families. Nearly all the study participants (96.5%, n=193) had comorbidities in their families. Among them, 83.5% (n=167) had endocrine disorders. Almost all the families had earning members, out of which, 53.5% (n=107) had two earning members in the family. The average age of the husbands was 35.08 years (SD ±5.43). The educational status of the husbands was high; most of the husbands (65%, n=130) had studied up to graduation. All the husbands were employed; 53% (n=106) of them were doing business. There was a wide range of substance abuse among the husbands, which included 32% (n=64) smoking a cigarette, and 29.5% (n=59) using betel nut, pan, gutka and naswar.
Among the study participants, 65.5% (n=131) had non-consanguineous marriages. Almost half of the study participants (40.5%, n=81) had been married for <5 years. Nearly all the participants (97%, n=194) were satisfied to a greater extent in the relationship with their husbands. On the other hand, more than half of the mothers (84%, n=168) reported being satisfied, to some extent or to a lesser extent, with their relationship with their in-laws.
Practising coping in stressful situations was reported by almost every participant. Among these, 38.5% (n=77) talked to their husbands in stressful situations. Almost all the study participants (99%, n=198) worked on finding a solution for the stressful situation. All the participants in the study had some reliable person with whom they could talk and share their feelings in stressful situations. Socialisation was reported by every participant with 39% (n=78) linking family as a mode of socialisation. Marital and familial characteristics and coping-related factors of the mothers of preterm infants are illustrated in table 3.
Marital and familial characteristics and coping-related factors of the mothers of preterm infants (n=200)
Newborn characteristics
The average age of preterm neonates was 10.11 days (SD ±13.98). The average weight and height of neonates was 1.97 kg (SD ±0.65) and 43.75 cm (SD ±5.46), respectively. More than half of the newborns (62%, n=124) were males. The APGAR score of the neonates at the first minute of life was 7.66 (SD ±1.04). Moreover, preterm neonates were admitted with a range of complaints; among them 31.5% (n=63) were suffering from the Respiratory Distress Syndrome (RDS). More than half of the newborns (51%, n=102) did not receive their immunisation. Most of the newborns (43.5%, n=87) were transferred from the NICU to the step-down unit. More than half of the preterm infants (65%, n=130) were on orogastric (OG) tube feeding, and 59.5% (n=119) were receiving breast milk. Newborn characteristics are illustrated in table 4.
Newborn characteristics (n=200)
Outcome variables
The PSS tool was used in the study to identify the level of stress among mothers of preterm infants. The level of stress reported by mothers using the PSS tool was significantly higher, as indicated by the PSS scale scores. This scoring included three levels, 0–13 low stress, 14–26 moderate stress and 27–40 is considered high perceived stress.22 Based on the PSS scoring criteria, the majority of the participants (92%, n=184) were classified as having high perceived stress, while the remainder were categorised as experiencing moderate stress. Table 5 depicts the level of stress among mothers of preterm infants.
Perceived stress score of mothers of preterm infants (n=200)
Inferential analysis
Inferential analysis of the study findings was carried out first by differentiating categorical variables and continuous variables. Analysis was further continued by using the χ2 test for the categorical variables and t-test for two independent samples for continuous variables in the study.
Categorical variables
Most of the mothers in the high perceived stress category had male child (62.5%, n=115), and 31% (n=57) reported RDS as the presenting complaint of their newborns. More than half of the mothers (53.3%, n=98) reported high perceived stress due to their newborn’s incomplete immunisation status, and 42.9% (n=79) had babies transferred from the NICU. On the other hand, mothers in moderate levels of stress had similar findings, except three-quarters (75% n=12) of mothers in this category reported complete immunisation status of their newborns.
Around half of the mothers in the high perceived stress category had completed their graduation. However, three-quarters (85.9%, n=158) were housewives, and the majority of mothers (89.7%, n=165) were satisfied with their financial status. Most mothers (65.2%, n=120) were in non-consanguineous marriages, and 7.6% (n=14) reported substance abuse. On the other hand, mothers in the moderate stress category had similar findings, except that 37.5% (n=6) had completed postgraduate education or higher.
A small number of mothers in the high stress category (8.7%, n=16) reported that their children had comorbidities, including congenital heart diseases, metabolic disorders, seizures disorders and genetic disorders. In addition, more than half of the mothers (59.2%, n=109) reported having family support to help care for other children during pregnancy. Mothers in the moderate stress category had similar findings, except none reported any comorbidities in their children.
Almost three-quarters (74.5%, n=137) of the study participants in high stress category had planned their pregnancy, and more than half (55.4%, n=102) planned to have more children in the future. However, 45.1% (n=83) had a family preference for a male child. The findings in the moderate stress category were similar, except that more than half (56.3%, n=9) of the mothers were undecided about planning more children.
A small number of mothers in the high perceived stress category (12.5%, n=23) reported gynaecological issues. The complications during their pregnancies included preterm labour (31%, n=57), gestational diabetes mellitus (GDM) (23.4%, n=43) and pre-eclampsia (21.7%, n=40). Most mothers (81.5%, n=150) underwent a caesarean section as their mode of delivery. A history of miscarriage, abortion, preterm deliveries and IUD was reported by 32.6% (n=60), 2.2% (n=4), 13% (n=24) and 6.5% (n=12) of mothers, respectively. On the other hand, mothers in the moderate stress category had similar findings, except that 37.5% (n=6) had premature rupture of membranes instead of pre-eclampsia.
Majority of mothers in the high perceived stress category (93.5%, n=172) consumed a balanced diet during pregnancy. More than half of the mothers (64.7%, n=119) started the antenatal visits in the initial weeks of pregnancy, and 62.5% (n=115) had complete immunisation status. The findings for mothers in the moderate stress category were similar, except that the majority (56.3%, n=9) started antenatal visits in the first trimester.
Majority of mothers in the high perceived stress category (66.8%, n=123) used OG tube feeding as the mode of feeding for their babies. Additionally, 58.7% (n=108) of these mothers were breastfeeding their newborns. Three-quarters (75%, n=138) were using artificial methods for family planning. However, there were no significant differences in the moderate stress category regarding these findings.
Majority of mothers in the high perceived stress category (76.1%, n=140) were living in extended families, and 85.3% (n=157) had family members with endocrine disorders. Most mothers (67.4%, n=124) reported that their husbands had graduated, 52.7% (n=97) were running their own business, 32.6% (n=60) smoked cigarettes and 31% (n=57) chewed betel nut, pan, gutka and naswar. Almost all of the mothers in the high perceived stress category (96.7%, n=178) were satisfied with their relationships with their husbands. However, most mothers (84.8%, n=156) reported being satisfied to some extent, or to a lesser extent, with their relationship with their in-laws. The findings were similar in the moderate stress category, except that 43.8% (n=7) of mothers had husbands with postgraduate education or higher.
Approximately half of the mothers in the high perceived stress category (40.8%, n=75) reported talking to their husbands during stressful situations. Nearly all the mothers (99.5%, n=183) stated that they found solutions during stressful situations, and almost half (39.7%, n=73) used family outings as a mode of socialisation. The findings for mothers in moderate stress category were similar, except that 50% (n=8) shared their stress with someone other than their husbands and engaged in different modes of socialisation, rather than family outings. Table 6 shows the inferential statistics for the categorical variables in the study.
Inferential statistics for categorical variables of stress among mothers of preterm infants (n=200)
Continuous variables
The mean age, weight and length of newborns in mothers with high levels of perceived stress was 9.88 (SD +13.47), 1.97 (SD +0.66) and 43.75 (SD +5.54), respectively. The mean APGAR score for neonates was 7.65 (SD +1.05), and the mean gestational age of mothers was 33.21 (SD +2.91). However, these scores were comparatively higher for mothers in the moderate stress category compared with those in the high perceived stress category.
The mean age and monthly income of mothers with high levels of perceived stress were 30.27 (SD +5.16) and 110 054.35 (SD +21 051.51), respectively, which was higher compared with mothers in moderate stress category. The mean of years of marriage and number of earning members in the family for mothers with high levels of stress were 1.80 (SD +0.80) and 1.93 (SD +0.75), respectively, which were comparatively lower than those for mothers in the moderate stress category. The mean gravida, hours of sleep and age of husbands of mothers with high levels of perceived stress were 2.78 (SD +1.65), 3.01 (SD +0.45) and 35.24 (SD +5.40), respectively, which were higher than those for mothers in the moderate stress category. The mean number of children alive and deceased for mothers with high levels of perceived stress were 2.17 (SD +1.21) and 1.09 (SD +0.35), respectively, which were similar to those for mothers in the moderate stress category. Table 7 shows the inferential statistics for the continuous variables in the study.
Inferential statistics for continuous variables of stress among mothers of preterm infants (n=200)
Discussion
Level of stress among mothers of preterm infants
This study focused on the level of stress and its associated factors among mothers of preterm infants in Karachi, Pakistan. To assess the level of stress, the PSS tool was incorporated into a self-developed questionnaire. PSS has been used extensively around the globe to measure stress across various populations. Additionally, it is employed to gauge the level of stress experienced by mothers of preterm infants in countries such as Taiwan and Pakistan.
In our study, 92% of the study participants fell under the category of high perceived stress, which is considerably higher than what has been reported in other studies. For instance, a study conducted in Kenya on the prevalence of psychological distress among mothers of term and preterm infants found that 83.7% who delivered preterm infants experienced stress.26 Additionally, a systematic review conducted in high-income countries (HIC) on post-traumatic stress symptoms in mothers of preterm infants reported that 77.8% of the mothers had stress and met the criteria for potential post-traumatic stress disorder following the birth of a preterm infant.25 These findings support the results of the current study, as they are similar to a great extent.
On the contrary, a recent systematic review conducted in urban HIC on the prevalence of stress among mothers of preterm infants admitted to the NICU reported a stress prevalence of 39.9%.27 Additionally, a study conducted in Malaysia found that 56.5% of mothers of preterm infants admitted to the NICU experienced high levels of stress.28 However, these findings are relatively lower than those of the current study. The plausible difference may be attributed to the diverse socio-cultural stressors related to the income levels of the two countries, as Malaysia is classified as an upper-middle-income country, while Pakistan is categorized as a lower-middle-income country (LMIC).29
Another study conducted in the USA regarding the association between preterm birth and maternal mental health found that 11.26% of the mothers who delivered preterm infants reported experiencing stress.30 A recent study conducted in the USA, focusing on maternal mental health after the discharge of preterm infants from the NICU, showed that 29% of mothers experienced stress and depressive disorders.31 However, the level of stress reported in these studies is relatively lower compared with the findings of the current study conducted in Pakistan, where the stress levels among mothers are significantly higher. When comparing the results from studies conducted in the USA, which is considered a HIC, with those from Pakistan, a noticeable difference in stress levels emerges. This difference may be attributed to factors such as cultural differences in reporting stress, variations in income status or differences in care approaches between the two settings.
Factors affecting stress levels among mothers of preterm infants
The literature suggests that the social, cultural and environmental factors in LMIC, such as Pakistan, contribute to increased exposures to stressors, which in turn elevate the risk of stress and depression among mothers during pregnancy and childbirth.32 Additionally, several factors have been identified in the literature as being associated with higher levels of stress among mothers of preterm infants. Among the cultural determinants, unplanned pregnancy and the preference of male children over female children are key contributors to stress.32 Another study conducted in Pakistan also highlighted that the limited autonomy of mothers in making decisions related to pregnancy and reproductive health is a significant factor associated with higher stress levels among mothers of preterm infants.33 In addition, Pakistani women are more susceptible to stress and depression due to overlapping socio-economic factors, such as unemployment and lack of education. Obstetric factors, including multiple and unplanned pregnancies, as well as psycho-social factors, such as verbal and physical abuse by husbands and mothers-in-law, further contribute to this risk.33
The current study found that nearly half of the mothers in the moderate stress group and one-quarter of those in the high stress group had unplanned pregnancies. These findings are consistent with a study conducted in Kenya, which also identified unwanted and unplanned pregnancies, poor social support, marital discord and low socio-economic status of as significant factors contributing to stress among mothers of preterm infants.26 Kenya is also an LMIC with similar social, cultural and environmental factors like Pakistan. Therefore, this study validates the findings of the current research in a comparable context.
The study conducted in Kenya also identified domestic violence as a factor associated with stress among mothers of preterm infants.26 However, this finding contrasts with the results of the current study, where the majority of mothers reported being highly satisfied with their relationship with their husbands.
When comparing the results of the current study with previous research, it was found that although 50% of mothers had a higher education level, the majority were housewives, which could be a contributing factor to the unemployment rate in Pakistan. Furthermore, two-thirds of the mothers had planned their pregnancies, while most of them were carrying multiple pregnancies, which could contribute to the preference for male children. This implies that these elements are in line with the literature.
This study has highlighted multiple factors associated with increased stress levels among mothers of preterm infants. However, only those factors with a p value of <0.05 were considered statistically significant and were identified as key contributors to stress. The findings of the current study are consistent with factors identified in the literature, including hours of sleep, consumption of a balanced diet, immunisation status of the newborn, modes of socialisation, education and occupational status of mothers, substance abuse by the mother, education level of the husband, family gender preference, plans for additional children and years of marriage.
Immunisation status of the newborn is another factor associated with increased stress levels among mothers of preterm infants. High perceived stress was reported in a significant number of mothers whose preterm infants had incomplete immunisation. This finding is consistent with a systematic review on vaccination in preterm infants, which suggests that parents experience higher stress when vaccinating preterm infants compared with term infants.19 The plausible reasons included decreased weight of preterm infants compared with term infants, as well as delays in the vaccination to ensure the infant reaches the correct gestational age before receiving vaccines.19
The educational status of mothers was also a key factor associated with stress levels among mothers of preterm infants. In the current study, moderate and high levels of stress were reported in mothers who had graduated from high school. In contrast, a study conducted in Maichew, North Ethiopia, found that mothers with advanced levels of education reported no stress, while stress levels were higher among mothers with low education or no formal education.34 The contradiction may be explained by the fact that, in the current study, mothers with higher education may have wanted to work but felt the need to prioritise the care of their preterm infant.
The current study found that mothers who were not employed experienced higher levels of stress compared with working mothers. This finding is consistent with a study conducted in southeastern Ethiopia, which also reported higher stress levels in mothers who were housewives.34 A potential reason for the low levels of stress in working mothers could be the regular social interaction with friends and co-workers, which may provide a change of environment and enhance mental well-being. Thus, the current study highlights the importance of employment in reducing the stress among mothers of preterm infants.
Substance abuse by mothers is another risk factor associated with increased stress among mothers of preterm infants. In the current study, while the number of mothers reporting substance abuse was not statistically significant, those who did report substance use showed higher levels of stress. This finding is consistent with the findings of the study conducted in Maichew, North Ethiopia, where tobacco chewing was linked to higher stress levels among mothers.35 Substance abuse is associated with many health problems, including anaemia during pregnancy and lactation, as seen in the current study, particularly the impact of chewing betel nut. Therefore, the study highlights the need for counselling mothers to reduce substance abuse in order to improve the high levels of stress among mothers of preterm infants.
Planning for further children was also associated with higher levels of stress among mothers of preterm infants. In the current study, more than half of the mothers in the high perceived stress category reported plans to have more children. In contrast, mothers with moderate stress levels reported that they would decide later about having more children. A study conducted in China, which assessed parenting stress differences between mothers with one child and those with two, found that mothers with two children had significantly higher stress scores compared with those with one child.36 The finding is consistent to some extent, as planning for further children and parenting two children—while also caring for a preterm infant—can be a challenging situation that increases stress in mothers. One of the plausible reasons could be the minimal age gap between the two children, which may contribute to additional parenting stress for mothers who have delivered a preterm infant.
Gender preference was also a major factor associated with increased stress levels in mothers of preterm infants. In the current study, although the majority of mothers reported no gender preference, a significant number indicated a preference for male children. This finding is similar to another study conducted in Pakistan, which found that gender preference, particularly the preference for male children, was a contributing factor to unplanned pregnancies, and in turn, increased stress levels among mothers.32
In the current study, it was found that mothers with both moderate and high levels of stress were consuming a balanced diet, yet they still experienced increased stress levels. This finding is in contradiction with the findings of a study conducted in Taiwan, where a balanced diet was associated with lower levels of stress.10
The educational status of the husband was also an important factor associated with stress levels among mothers of preterm infants. In the current study, increased stress levels were reported among mothers whose husbands had a graduate-level education. This finding contrasts with a study conducted in India, which showed lower stress levels among mothers whose husbands had higher educational status.37 One possible reason for this contradiction could be the high unemployment rate in Pakistan. In this context, having a graduate degree but lacking employment opportunities may contribute to increased stress.
Socialisation is another important factor associated with stress among mothers of preterm infants. In the current study, all the mothers engaged in various modes of socialisation, such as outings with family, interactions with friends, social media and other activities, which helped reduce their stress by providing social support. This finding is also consistent with the study conducted in Taiwan, which suggested that social support from family, friends and social groups act as a mediator for mothers, boosting their self-esteem and providing emotional stability, especially in dealing with increased stress following the birth of a preterm infant.10 The current study has identified support groups and socialisation as the key factors in reducing stress levels among mothers of preterm infants.
Years of marriage was another factor associated with the level of stress among mothers of preterm infants. The current study found that fewer years of marriage were associated with higher levels of stress among mothers. This finding is similar to another study conducted in Pakistan, which showed that longer years of marriage contributed to a sense of satisfaction for mothers. With more experience in shared decision-making about family planning, including decisions on further pregnancies and gender preference, stress levels, unplanned pregnancies and gender preference were reduced.32
In the current study, reduced hours of sleep were found to increase stress levels among the participants. Mothers in the high perceived stress category had an average sleep duration of 3.01 hours (SD ±0.45). This finding is consistent with a study conducted in Taiwan, which found that 65% of the mothers of preterm infants experienced insufficient and poor sleep, factors associated with higher stress levels.10 The possible reasons for disturbed sleep quality could include frequent awakenings for feeding and caring for the preterm infant.
The factors associated with stress among mothers of preterm infants are well supported by national and international literature. The overall results of this study, within the context of Pakistan and focusing specifically on mothers of preterm infants, show many similarities with the existing literature.
Limitations of the study
The limitations of the research study are as follows:
An analytical cross-sectional study design was used in this study. However, to better explore the association between the study outcomes and the factors associated, longitudinal or prospective cohort studies could provide better results.
The study has limited generalisability, as the sample of the study included only mothers who delivered preterm infants.
This study was conducted in a private hospital; therefore, the sample size cannot be generalised to public or government settings.
Conclusion and recommendations
Education and counselling of the mothers regarding status of their neonate and ways to involve mothers in the care of their newborn are crucial. Kangaroo mother care is significant in reducing the separation time and improving the bond between the mother and the newborn. Additionally, teaching nurses therapeutic communication techniques is essential to provide emotional support to the mothers.
Nursing practice
Thorough training of the healthcare professionals is necessary for the assessment of mental health in mothers of preterm infants, and for conducting appropriate interventions. In addition, a specialised clinical pathway for the infants born preterm could be initiated. This pathway can include the details about the child and the mother, the associated risk factors and the scale used to assess the level of stress in mothers. It will also include the pertaining stress during pregnancy and the ongoing stress assessment for the mothers. Additionally, teaching coping strategies for stress management and newborn care should be incorporated into the clinical pathway. A role of the nurse practitioner that incorporates the care of both newborns and mothers at the same time must be initiated. This role will help nurses identify and address stress in mothers undergoing delivery, neonatal care and handling, ensuring holistic support for both the mother and infant during this critical period. The study findings identified high levels of perceived stress among mothers of preterm infants, highlighting the urgent need to emphasise psychological health screening in both antenatal and postnatal care. A support group should also be established, consisting of mothers who have delivered preterm infants. This support group would help reduce stress levels and enhance coping by providing mothers an opportunity to express their feelings and concerns related to preterm handling and care. Hospital administration should provide a separate area where the mothers of preterm infants can be individually assessed for stress levels, with tailored support and guidance provided. At the policy level, it should be mandatory to incorporate a multidisciplinary team approach, ensuring that a psychologist is part of the team to offer consultations to mothers of preterm infants during the postnatal period.
Nursing education
Nursing education should include a dedicated course on neonatal care, including the handling, feeding and support of mothers with preterm infants. The course should also cover basic assessment tools for evaluating maternal stress in mothers of preterm infants. Additionally, nursing students should be introduced to the role and concept of nurse practitioners in this field. These nurse practitioners would serve as a liaison between mothers and their preterm infants, helping students identify their areas of interest and potentially guiding their career choices in this specialty.
Nursing research
Given the findings of increased stress levels among mothers of preterm infants, there is a need for intervention studies aimed at improving their mental health. A cross-sectional study could also be conducted to assess the level of stress among mothers of term infants for comparison. Additionally, since this study focused on the stress levels and associated factors among mothers of preterm infants, a similar study could be carried out to explore the stress levels and related factors among fathers of preterm infants. Future studies with a multicentred approach, involving large sample sizes, are needed to validate the findings of this study. Additionally, research including public hospitals should be conducted to incorporate a broader range of healthcare settings, thereby improving the generalisability of the findings. A longitudinal follow-up study would also be valuable to provide deeper insights into the long-term effects of stress on mothers over time.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved after obtaining approvals from the Chief Medical Officer (CMO) and the Ethics Review Committee of Aga Khan University Hospital (reference number: 2022-7808-23288). Written informed consent was obtained from the participants after thoroughly explaining the study’s purpose and benefits.
Acknowledgments
I would like to thank His Highness Prince Karim Aga Khan for providing me the opportunity to fulfill my dreams in his prestigious university.
Footnotes
Contributors The study was conceptualised and designed by YNP. SA was involved in data collection, writing of the manuscript’s initial draft, revision, proofreading of the manuscript and data analysis. AA critically reviewed and proof read the manuscript multiple times. YNP and AA were involved in data analysis. The final draft of the manuscript was read and approved by all authors (SA, AA and YNP). YNP is the guarantor of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The authors guarantee that the manuscript has not been published or is being considered for publication elsewhere.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.