Maternal stress in NICU setting is often a neglected area. There are only few Indian studies quantifying stress among NICU mothers. It is very crucial for NICU staff and doctors to identify specific stressors among NICU mothers so that appropriate intervention protocols can be developed to address the mother’s fear, reduce their stress and enhance their ability to understand and cope up with the complex NICU environment. Present study was a step in that direction. In a study by Dudek-Shriber, titled “Parent Stress in the Neonatal Intensive Care Unit and the Influence of Parent and Infant Characteristics” and by Reid T titled “Using the Parental Stressor Scale: NICU with a British sample of mothers of moderate risk preterm infants”, younger parents experienced more stress owing to their less experience in the parental role [9, 12, 13]. However, the results of a study by Pichler-Stachl E titled “Parental Stress Experience and Age of Mothers and Fathers After Preterm Birth and Admission of Their Neonate to Neonatal Intensive Care Unit; A Prospective Observational Pilot Study” were directly opposite . A study by Trombini E titled “Environmental factors associated with stress in mothers of preterm newborns” and by Franck L titled “Measuring neonatal intensive care unit-related parental stress” no correlation was found between age of parents and stress levels [14, 15]. Present study did not show any correlation between maternal age and degree of stress. Mean stress scores for all the 3 domains were compared for all the subgroups to look for statistically significant association between the occupation of mother and degree of stress. It showed a statistically significant difference in the mean stress scores of the “Sights and Sounds of the Unit” domain among different occupation with mothers having clerical job experiencing highest level of stress (1.92 ± 1.53) followed by mothers with semi-professional occupation (1.67 ± 1.16). In a study by Dudek-Shriber, parents who were working non-professionals obtained a significantly higher frequency score in the NICU sight and sound than parents who were home-makers-unemployed . Our study showed the similar results. Possible explanation for this could be that these groups of mothers have a better understanding of the technology and equipment owing to their level of education and knowledge and that these equipment and sounds represent the criticality of their baby. Significantly higher frequency mean stress scores were obtained for domain 2 (Looks and Behaviour of the Infant) and domain 3 (Parental Role and Relationship) for term babies.
As per studies by Chourasia N, Schappin R, Dudek-Shriber, Carter J, Minde K and Trause M having preterm baby resulted in significantly higher stress scores and was predictive of stress, and these findings seem sensible also since extremely premature babies are physiologically unstable, demonstrate many aspects in their physical appearance that are different and are less responsive to social interaction than infants who are born later in a pregnancy [1, 5, 12, 16,17,18]. Present study however did not show any such correlation which is contradictory when compared to above studies. The principal reason behind this contradictory finding appears to be the nature of study population, our study included almost equal proportion of term (n = 62) and preterm neonates (n = 58), whereas in all of the above studies proportion of the pre-term babies was more. Also, in our study term, babies were more critical with diagnosis of birth asphyxia, congenital heart disease, congenital malformation and pneumonia being more common in them when compared to preterm babies. The preterm babies with prematurity and small for gestational age as a criteria for admission also included babies having birth weight less than 1500 g who were kept in the higher dependency unit for observation, as per our NICU protocol and that might have caused less stress in mothers of such babies when compared to mothers having term baby with a more critical diagnosis. This appeared to be the reason behind mothers having term babies experiencing greater levels of stress in comparison to those having preterm babies.
There were 111 out of 120 (92.5%) mothers with high level of stress in domain 3 (Parental Role and Relationship). There were 89 out of 120 (74.1%) mothers with medium level of stress in domain 2. There were 110 out of 120 (91.6%) mothers with low level of stress in domain 1.
Using the PSS: NICU, Kegler JJ et al. identified that most stressful domain for parents (n = 204) in their study was alteration the parent-infant relationship and the appearance of the infant while the sights and sounds of the unit domain caused relatively lesser stress . Study by Chourasia N et al. and Franck L also showed similar pattern of results in their study [1, 15]. The findings of present study are consistent to that of above studies. In present study the mean subscale stress score was highest for Parental Role and Relationship domain (4.19), followed by Looks and Behaviour of the Infant domain (3.75) and least for Sights and sound of the unit the domain (2.20). Among the individual items, “Being separated from my baby” (4.43) and “Feeling staff is closer to my baby than I am” (4.39) were the questions with maximum scores.
There are certain limitations to the present study such as Present study measures only mother’s stress levels and father’s stress is not measured or compared. As mother and father both are involved in up-bringing of the child hence stress experiences of fathers is equally important. Furthermore, improvement in paternal perception of neonates suggests that father can actively engage in caring for mothers and sick infants more readily than in past. Further study is required to compare motherhood and fatherhood, to compare culture-sensitive training and thus support medical environment in better care of NICU admitted babies. Another limitation of is that findings of the study cannot be generalised because of the small sample size, study population restricted to one hospital and to one geographical location. Recommendations of future research would include using a larger, randomly selected sample of parents in NICUs that represent different geographical locations of India. Finally, in applying this study finding in practice, this needs to be kept in mind that environment of each NICU has its own unique set of circumstances that can potentially contribute to the stress that parents’ experience.