Maternal Administration of Interventions for the Preterm Infants in the NICU: Effects on Maternal Distress and Mother- Infant Interactions Diane Holditch-Davis, PhD, RN, FAAN Rosemary White-Traut, DNSc, RN, FAAN Janet Levy, PhD Richard David, MD T. Micheal O’Shea, MD Victoria Geraldo, MD

Maternal Consequences of Prematurity Psychological Distress Depressive Symptoms Anxiety Post Traumatic Stress

Maternal Distress Disrupts the mother-child relationship Thus, contributing to health and developmental problems in the infant

Purpose of This Study To examine the effects of the auditory- tactile-visual-vestibular (ATVV) intervention and kangaroo care on maternal psychological well-being and the maternal-child relationship as compared to an attention control group.

Interventions Kangaroo Care (KC)—Holding with skin-to-skin contact

Interventions ATVV Intervention—Structured massage that included auditory stimulation (affectionate talking), tactile stimulation, visual stimulation (eye-to-eye contact), and vestibular stimulation (rocking)

Interventions Attention Control—Education about equipment needed for home care of preterm infants

Methods: Sample 240 mothers and their preterm infants –Infants weighed less than 1750 gm Recruited from 4 hospitals when their infant was no longer critically ill Randomly assigned to intervention –Stratified by hospital –Stratified by multiple vs singleton

Infant Characteristics Control ATVV Kangaroo Mean (SD) Mean (SD) Mean (SD) ________________________________________________________ Gestational Age (Weeks) 27.5 (3.1) 27.0 (2.8) 27.2 (2.9) Birthweight in Grams 1030 (343) 989 (324) 1012 (319) Sex: % Male 46.9% 45.7% 46.4% Size: % AGA 80.3% 84.6% 76.9% Apgar Score: 1 Minute 5.4 (2.4) 4.8 (2.6) 5.0 (2.5) 5 Minute 7.5 (1.6) 7.1 (1.7) 7.1 (1.7) Mechanical Ventil. (Days) 14.6 (19.9) 19.2 (36.7) 15.4 (18.7) IVH: None 67.9% 73.1% 60.7% % Grade I/II 27.2% 18.0% 26.2% % Grade III/IV 4.9% 9.0% 13.1% % Having Surgery 40.0% 30.8% 38.5% % Multiple Births 16.1% 19.0% 19.2%

Maternal Characteristics Control ATVV Kangaroo Mean (SD) Mean (SD) Mean (SD) ________________________________________________________ Maternal Age 26.8 (6.5) 26.4 (5.4) 28.0 (6.2) Race: Non-Hisp. White 17.5% 21.3% 19.7% Non-Hisp. Black 77.5% 66.3% 67.1% Hispanic 5.0% 10.0% 10.5% Other 0.0% 2.5% 2.6% % Mothers Married 26.3% 36.3% 32.9% % First-Time Mothers* 43.8% 66.7% 57.7% Education in Years 13.1 (2.3) 13.6 (2.0) 13.5 (2.5) % Cesarean Section 58.0% 61.7% 53.9% % on Public Assistance 22.5% 18.8% 19.7%

Procedures Study nurses instructed the mothers in the intervention and supported the mother in administering the interventions during hospitalization Data collected at enrollment and again at discharge, 2, 6 & 12 months –Home visits at 2 & 6 months 45-minute videotapes of mother-infant interactions HOME Inventory scored

Maternal Psychological Well- Being Variables Depressive symptoms Situational anxiety Post-traumatic stress symptoms Parenting stress Worry about child health

Maternal Psychological Well- Being for the Intervention Groups Anxiety Post-Traumatic Stress Symptoms Parenting Stress ---- Control ---- ATTV ---- Kangaroo

Depressive Symptoms for the Intervention Groups ---- Control ---- ATTV ---- Kangaroo Weeks Past EDC

Worry for the Intervention Groups Weeks Past EDC

Maternal Parenting Variables Interactive Dimensions –Maternal Positive Involvement –Developmental Stimulation –Maternal Negative Control –Child Social Behaviors –Child Developmental Maturity –Child Irritability HOME total

Maternal Parenting Variables

Child Irritability

Child Developmental Maturity +++ ATTV +++ Control +++ Kangaroo Care

Child Locomotion --- ATTV --- Control --- Kangaroo Care

Child Arousal/Activity Level Sleep Sedentary Activity

Conclusions Kangaroo care had both positive and negative effects on maternal psychological well-being –slowing the decrease in depressive symptoms over time –increasing the decline in worry about child health ATVV did not affect maternal psychological well-being

Conclusions Child developmental maturity was higher for the ATTV infants. –This was due to the greater motor maturity of the ATTV infants. –Kangaroo care infants showed less arousal and lower activity levels, especially at 2 months. These findings indicate that kangaroo care and ATVV have minor but important effects on the mother-premature infant relationship.

Attrition 195 dyads completed the study Control ATVV Kangaroo ________________________________________ Completed Study 82.7% 79.8% 76.3% Study Withdrawals Early Infant Death 2.5% 2.4% 3.8% Later Infant Death 1.2% 0.0% 1.3% Early Withdrawal 8.6% 16.7% 13.8% Late Withdrawal 4.9% 1.2% 5.0%

Nurse Contacts of the ATVV and Kangaroo Care Mothers Both ATVV Kangaroo ___________________________________ No Contacts Contact Contacts Contacts or More

Maternal Reports of Engaging in ATVV and Kangaroo Care ATVV Kangaroo Control GroupGroup Group ___________________________________ ATTV None 7.3% 77.8% 69.1% < 1/week14.6% 3.7% 7.3% 1-3 / week51.2% 9.3% 23.6% 3 or more26.8% 9.3% 0.0% Kangaroo Care None68.3% 5.6% 61.8% < 1/week26.8% 20.4% 16.4% 1-3 / week 4.9% 46.3% 21.8% 3 or more 0.0% 27.8% 0.0%