Maternal Post-traumatic Stress And Depression Symptoms And .
Gateau et al. BMC Pregnancy and -0(2021) 21:48RESEARCH ARTICLEOpen AccessMaternal post-traumatic stress anddepression symptoms and outcomes afterNICU discharge in a low-income sample: across-sectional studyKameelah Gateau1,2, Ashley Song2,3, Douglas L. Vanderbilt4, Cynthia Gong2,5, Philippe Friedlich2,Michele Kipke6 and Ashwini Lakshmanan2,5,7*AbstractBackground: Having a preterm newborn and the experience of staying in the neonatal intensive care unit (NICU)has the potential to impact a mother’s mental health and overall quality of life. However, currently there are fewstudies that have examined the association of acute post-traumatic stress (PTS) and depression symptoms andinfant and maternal outcomes in low-income populations.Design/ methods: In a cross-sectional study, we examined adjusted associations between positive screens for PTSand depression using the Perinatal Post-traumatic stress Questionnaire (PPQ) and the Patient Health-Questionnaire2 (PHQ-2) with outcomes using unconditional logistic and linear regression models.Results: One hundred sixty-nine parents answered the questionnaire with 150 complete responses. The majority of oursample was Hispanic (68%), non-English speaking (67%) and reported an annual income of 20,000 (58%). 33% of theparticipants had a positive PPQ screen and 34% a positive PHQ-2 screen. After adjusting for confounders, we identified thata positive PHQ-2 depression score was associated with a negative unit (95% CI) change on the infant’s Vineland AdaptiveBehavior Scales, second edition of 9.08 ( 15.6, 2.6) (p 0.01). There were no significant associations between maternalstress and depression scores and infant Bayley Scales of Infant Development III scores or re-hospitalizations or emergencyroom visits. However, positive PPQ and screening score were associated with a negative unit (95% CI) unit change on thematernal Multicultural Quality of Life Index score of 8.1 ( 12, 3.9)(p 0.01) and 7.7 ( 12, 3) (p 0.01) respectively.Conclusions: More than one-third of the mothers in this sample screened positively for PTS and depression symptoms.Screening scores positive for stress and depression symptoms were associated with a negative change in some infantdevelopment scores and maternal quality of life scores. Thoughtful screening programs for maternal stress and depressionsymptoms should be instituted.Keywords: Post-traumatic stress, Post partum depression, Low-income, NICU* Correspondence: alakshmanan@chla.usc.edu2Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine,Children’s Hospital Los Angeles, Keck School of Medicine, University ofSouthern California, 4650 Sunset Boulevard, MS #31, Los Angeles, CA 90027,USA5Leonard D. Schaeffer Center for Health Policy and Economics, University ofSouthern California, Los Angeles, CA, USAFull list of author information is available at the end of the article The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver ) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48BackgroundPreterm birth is a significant contributor to neonataland under five morbidity and mortality worldwide [1].Of those who survive beyond the neonatal period, manyvery low birth weight (VLBW infants 1500 g) [2] facesignificant lifelong disabilities including neurocognitivedeficits and visual impairment, along with systemic illnesses including respiratory and cardiac disabilities whilelate preterm infants also have been shown to havepoorer neurodevelopmental outcomes and worse TotalSchool Readiness Scores at kindergarten [3, 4]. Inaddition to the morbidities preterm infants potentiallyface, there is also significant economic, psychosocial andemotional impact on the families [5].Many studies have evaluated the various emotionaland mental health challenges that the mothers of neonates, both term and preterm, that can present at birthand in the first few years after NICU discharge [6, 7].One systematic review by Gavin et al. reviewed currentavailable literature on the incidence and prevalence ofperinatal depression, and found that in the time periodduring pregnancy to 3 months post-delivery, up to 19%of women have depressive symptoms with 7.1% ofmothers having major depressive episodes [8]. Of thestudies that have assessed mental health outcomes inmothers of preterm neonates, most studies describemental health perturbations like post-traumatic stressdisorder (PTSD) and depression as being strongly associated with the birth of preterm infants [8–15]. Prevalencerates for depression among mothers caring for preterminfants discharged from the NICU have been describedto range between 28 and 40% [16]. Additionally, it haspreviously been established that when mothers developmental health problems there is significant impact onparent-child attachment, cognitive, developmental andoverall health outcomes in infants [17, 18]. Given thatpreterm neonates are a particularly vulnerable population already with an increased risk of poor health outcomes, it becomes of the utmost importance to identifythe factors that contribute to the development of poormental health outcomes amongst their mothers.While many studies have evaluated some of the riskfactors associated with developing poor mental healthoutcomes in mothers after their children have been discharged from the NICU, most of these studies have beenin homogenous populations, and have not assessed parental maternal health in the discharge period, or haveassessed only a few predictors of stress. Furthermorethere are still very few studies that have been doneamongst socioeconomically diverse populations thathave also looked specifically at socio-demographic andmedical outcomes of preterm infants post NICU discharge and how those factors potentially impact amother’s overall well-being and mental health. In thisPage 2 of 10study, our objectives were to 1) describe the prevalenceof positive screens for acute posttraumatic stress and depression symptoms among low-income families afterNICU discharge, 2) examine the adjusted association ofPTS and depression symptoms and child neurodevelopmental and medical outcomes and 3) evaluate the adjusted association of PTS and depression symptoms andmaternal quality of life.MethodsStudy design and participantsThe study design was a single-center, cross-sectionalstudy. One caregiver of preterm ( 37 weeks’ gestation)infants up to 24 months corrected age with completeddevelopmental assessments attending a high-risk infantfollow-up clinic at a quaternary urban children’s hospitalbetween 2013 and 2015 was enrolled. A 150-item questionnaire with components validated in English andSpanish was administered to participants about life afterdischarge from the NICU. Patient recruitment, surveyadministration and population characteristics are detailed in previous work [19, 20]. The Institutional ReviewBoard at Children’s Hospital Los Angeles approved thestudy protocol. Written informed consent was obtainedfrom all study participants.MeasurementsA summary of the primary outcomes and mental healthassessments along with developmental and adaptive assessments are listed below.Mental healthPTS and depression symptoms were assessed utilizingthe modified Perinatal Posttraumatic Stress DisorderQuestionnaire (PPQ) and the Patient Health Questionnaire 2 (PHQ-2). The original PPQ was designed toidentify mothers who were experiencing symptoms ofpost-traumatic stress [21]. Through a series of 14 questions, mothers are asked using a 5-point scale (0 beingnot at all and 4 being often) to assess how frequentlythey experienced symptoms of post-traumatic stress including flashbacks, fear, avoidance, and hyper vigilance.The standard PPQ assesses these symptoms in individuals by administering it to participants who gave birthup to 4 months before the questionnaire was administered, and for that reason the modified PPQ was developed, which changed the phrasing to present tense toassess symptoms within the immediate postpartumperiod. The modified PPQ was utilized in our study [22].Additionally, a PPQ screen was considered positive whena participant acknowledged the presence of six or moresymptoms [7]. The PHQ-2 consists of 2 questions thatassess the frequency of depression and anhedonia overthe previous 2 weeks, with a score ranging from 0 to 6
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48[23]. The authors identify a cut-off score of 3 as a clinicallymeaningful value to screen for depression/anxiety [24].These tools have been used in similar populations [21, 23].Medical outcome assessmentWe asked parents questions about their infant’s healthstatus since discharge including the number of emergency department visits, monthly clinic appointmentsand hospitalizations, immunizations, dependence ondurable medical equipment, and administration of prescription medications.Neuro-developmental assessmentsEarly development was assessed using the Bayley Scalesof Infant and Toddler Development, Third Edition (Bayley-III). The Bayley Scales identify children with developmental delay and assist with planning of appropriateinterventions in children aged 1–42 months. The fivedistinct scales of assessment include Cognitive (91items), Language (97 items), Motor (138 items), caregiver ratings of Social Emotional (35 items), and Adaptive Behavior (241 items). Cognition is subdivided intotwo categories: expressive language (48 items) and receptive language (49 items), and motor is assessed asboth fine (66 items) and gross (72 items) tasks. The agecorrected mean score of the Bayley-III is 100 with astandard deviation of 15. A higher score indicates moreadvanced development [25].Vineland adaptive behavior scale II (VABS II)Personal, social and communication skills were assessedusing the Vineland Adaptive Behavior Scales, secondedition (VABS-II) [26]. Adaptive behavior refers to anindividual’s day-to-day activities needed for personal andsocial sustenance; these scales assess what a person doesas opposed to what he or she should be able to do.There are four domains assessed: communication, dailyliving skills, socialization and motor skills. A compositescore is provided across the four domains to summarizean individual’s performance. The age-corrected mean is100 with a standard deviation of 15 with higher scoresindicating higher function.Maternal quality of lifeThe multicultural quality of life index (MQLI) fromMezzich et al. was used to assess parent’s health status[27]. The MQLI was developed to assess health-relatedquality of life through targeted areas including: physicalwell-being, psychological/emotional well-being, self-care,occupational functioning, interpersonal functioning,social-emotional functioning, social emotional support,community and services support, personal and spiritualfulfillment. Participants were asked to rate these domains on a 10 point scale, with 1 being poor and 10Page 3 of 10being excellent. They were also asked to self-report theiroverall health status through a series of 12 yes/no questions and a 5-point overall health rating scale rangingfrom poor to excellent. Questions asked included thoseassessing overall health status, limitation on physical activity, energy levels, depression, and pain.Statistical analysisThe characteristics of the study population were described using means and proportions. The frequency ofcovariates (race/ethnicity, income level, maternal education, language, infant birth weight, infant gestational age,neonatal co-morbidities, use of medical equipment andpost discharge diagnoses) were compared across PPQand PHQ-2 scores. P-values were derived using t-testsfor two group comparisons. Given the small subset of fathers, fathers’ responses were excluded from the multivariable analysis. Multivariable logistic regressionestimated the adjusted odds of readmissions and emergency room visits and multivariable linear regression estimated adjusted developmental and parental quality oflife scores with PPQ and PHQ-2 scores. The modelswere adjusted for confounders such as race/ethnicity,maternal education, primary language, neonatal comorbidities, post discharge diagnoses and use of medicalequipment. Beta coefficients (linear regression results)and odds ratios (ORs) with 95% confidence intervals(CIs) and two-sided P-values for individual variable categories are reported.We also conducted an E-value analysis for the qualityof life outcomes, which is a type of sensitivity analysisthat quantifies unmeasured confounding to determinewhether unmeasured confounding may have contributedto the observed effects [28]. As detailed in previous workconducted by our group [29], the E-value analysis addresses the extent to which unmeasured confounding maynegate the observed results. A relatively low E-value in thecontext of statistical adjustments made suggests that theresults could easily be nullified by a confounder. Conversely, a very high E-value relative to the point estimatemay imply that the observed effect is in fact plausible, because the strength and association of the unmeasuredconfounder with the exposure group and outcome mustbe very high to negate the observed effect [29].Power calculationA sample size of at least 150 with unequal groupsachieves 99% power to reject the null hypothesis of equalmeans when the population difference in PPQ scores is6 with a SD of 10 with a significance level (alpha) of 0.05using a two sided two sample equal variance t-test (summary statement generated in PASS).All statistical analyses were carried out using SAS, v.9.4 (SAS Institute, Cary, NC, USA). E-values were then
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48calculated using the R package “EValue” provided by theE-value creators [30].ResultsOne hundred sixty-nine participants were recruited and150 completed PPQ and PHQ-2 screening (Fig. 1). Themajority of our sample was Hispanic (68%), non-Englishspeaking (67%) and reported an annual income of 20,000 (58%). 34% of the participants had a positive PHQ-2screen and 33% a positive PPQ screen (Table 1). Only 9( 7%) participants were fathers. Maternal education andlanguage were not associated with PPQ or PHQ-2 scores.When looking at birth weight, gestational age, presence ofneonatal comorbidities or use of equipment, there was nostatistically significant differences between groups thatscreened positively and those who did not (Table 1).As demonstrated in Fig. 2, after adjusting for confounders, we identified that a positive PHQ-2 depressionscore was associated with a negative unit (95% CI) changeon the infant’s Vineland score of 9.08 ( 15.6, 2.6)(p 0.01) in 89 participants. There were no significant association between participant depression and stress scoresand infant Bayley-III scores (motor or cognitive). As anticipated, use of medical equipment was associated (95% CI)with lower Bayley-III motor and cognitive scores andVABS-II scores (Supplemental Tables 1 and 2) independent of PPQ screening: 18.7 ( 27, 9.8) and 24.3 ( 35, 13) and 11.3 ( 19, 4). Similarly, Bayley-III motorand cognitive scores (95% CI) and VABS-II scores werelower independent of PHQ-2 screening, 18.6 ( 28, Fig. 1 Enrollment and recruitmentPage 4 of 109.7) and 24 ( 35, 13) and 12 ( 19, 5). Additionally, while the sample was small, Black Non-Hispanic racewas also associated (95% CI) with lower Bayley-III motorscores, 41 ( 66, 15) independent of PPQ screening,and independent of PHQ-2 screening, 42 ( 67, 17)(Supplemental Table 1 and 2). After adjusting for observable confounders, there was no statistically significant association between PPQ or PHQ-2 screening andrehospitalizations and emergency room visits (Table 2).Positive PPQ and PHQ-2 screening scores were associated with a negative unit (95% CI) unit change on theparticipant Multicultural Quality of Life Index score of 8.1 ( 12, 3.9)(p 0.01) and 7.7 ( 12, 3) (p 0.01) respectively (Fig. 3 and Supplemental Table 3). Asubsequent E-value analysis demonstrated that the associated E-value (95% CI) for PPQ was 2.27 (1.03) and forthe PHQ-2 screen was 2.21 (1.62).DiscussionMore than one-third of the participants in this samplescreened positively for PTSD and depression. Screeningscores positive for stress and depression were associatedwith a negative change in some infant developmentscores and maternal quality of life scores. While studieshave examined the impact of maternal mental health onthe mother and fetus [31], few have examined the prevalence of PTSD and depression after NICU discharge in adiverse and underserved population as presented [32].Studies have found that Hispanic and Black mothershave higher rates of post partum depression due to lack
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48Page 5 of 10Table 1 Socio-demographics and infant characteristics and caregiver mental health measure scoresPerinatal Post-traumatic Stress Disorder Questionnaire (PPQ)(N 139)N (%)TotalSocio-demographicsPositiveNegative46 (33)93 (67)46 (100)93 (100)P-valuePatient Health Questionnaire-2 (PHQ-2) (N 152)N (%)TotalPositiveNegative51 (34)99 (66)P-valuePerson completing surveyMother139N/AFather14150 (98.0)91 (91.9)91 (2.0)8 (8.1)102 (3.9)8 (8.3)0.17Race/ethnicityWhite non-Hispanic101 (2.3)8 (8.7)0.32Hispanic10235 (79.6)67 (72.8)10941 (80.4)68 (70.1)Black non-Hispanic146 (13.6)8 (8.7)141 (2.0)13 (13.4)Other112 (4.6)9 (9.8)157 (13.7)8 (8.3)Less than 20,0008232 (69.6)50 (53.8)8836 (69.2)52 (52.0) 20,001– 40,000319 (19.6)22 (23.7)359 (17.3)26 (26.0) 40,001– 60,000111 (2.2)10 (10.8)144 (7.7)10 (10.0) 60,001– 80,00082 (4.4)6 (6.5)72 (3.9)5 (5.0)More than 80,00072 (4.4)5 (5.4)81 (1.9)7 (7.0)4513 (35.1)32 (38.1)At least some college 7624 (64.9)52 (61.9)0.07Income ( /Year)0.340.35Highest level of education (either parent) High school0.754819 (41.3)29 (33.3)8527 (58.7)58 (66.7)10139 (76.5)62 (62.6)4912 (23.5)37 (37.4)6221 (53.8)41 (53.3)0.36LanguageNon-English9333 (71.7)60 (64.5)0.39English4613 (28.3)33 (35.5) 500 to 10005819 (45.2)39 (59.1) 1000 to 15002712 (28.6)15 (22.7)3111 (28.2)20 (26.0) 1500 to 2500168 (19.1)8 (12.1)166 (15.4)10 (13.0) 250073 (7.1)4 (6.1)71 (2.6)6 (7.7)0.09Infant characteristicsBirthweight (grams)0.530.78Gestational age (weeks) 24 to 285216 (34.8)36 (51.4)5620 (48.9)36 (43.4) 28 to 324521 (45.7)24 (34.3)4817 (41.5)31 (37.4) 32 to 34127 (15.2)5 (7.1)133 (7.3)10 (12.1) 34 to 3772 (4.4)5 (7.1)71 (2.4)6 (7.2)Yes9436 (78.3)58 (62.4)10235 (67.3)67 (67.0)No4510 (21.7)35 (37.6)5017 (32.7)33 (33.0)Neonatal co-morbidities0.190.66a0.060.97Use of medical equipmentbYes4315 (32.6)28 (30.1)No9631 (67.4)65 (69.9)0.764612 (23.1)34 (34.0)10640 (76.9)66 (66.0)11537 (71.2)78 (78.0)3715 (28.8)22 (22.0)0.16 2 clinic appointments/monthYes10234 (73.9)68 (73.1)No3712 (26.1)25 (26.9)Post discharge diagnosesc0.920.35
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48Page 6 of 10Table 1 Socio-demographics and infant characteristics and caregiver mental health measure scores (Continued)Perinatal Post-traumatic Stress Disorder Questionnaire (PPQ)(N 139)N (%)TotalPositiveNegativeP-valueYes10037 (80.4)63 (90.0)0.14No169 (19.6)7 (10.0)Patient Health Questionnaire-2 (PHQ-2) (N 152)N (%)TotalPositiveNegative10737 (90.2)70 (84.3)174 (9.8)13 (15.7)P-value0.42Characteristics of neonates are shown as mean (standard deviation) for PPQ-14 and N (%) for PHQ-2 scores. P-values derived using t-test (for 2 group comparison)and ANOVA test (for multi-group comparison) for continuous variables, and chi-square and fisher’s exact test for categorical variablesaNeonatal co-morbidities include at least one diagnosis of: fetal growth restriction, surfactant deficiency, necrotizing enterocolitis, intraventricular hemorrhagegrade 3 or 4, patent ductus arteriosus, retinopathy of prematuritybUse of medical equipment includes: oxygen, tracheostomy, wheelchair, adaptive stroller, feeding tubecPost discharge diagnoses include at least one diagnosis of: attention deficit hyperactivity disorder, autism, global developmental delay, cerebral palsyof social support, access, trust, past depression andother factors and Black women may even be lesslikely to seek treatment due to stigma [33]. Moreover,studies have found that among Hispanic women, acculturation was associated with higher rates of perinatal depression suggesting nativity may affectoutcomes [34]. Previous maternal mental health disease has also been associated with lower levels ofreadiness for discharge [35]. In our sample, one thirdof participants screened positively for depressionwhich is consistent with previous literature [36, 37].Similarly, more than a third of participants screenedpositively for post-traumatic stress. Previous work hasidentified that maternal distress is often marked bypost-traumatic stress, depression and anxiety andprevalent in mothers whose infants have been hospitalized in the NICU [38]. Understanding both themother’s personal history of mental health disorders,social complexity and support systems are importantwhen interpreting depression and post-traumaticstress screening [39].We identified a negative unit change in our VABS-IIscore among Spanish speaking families. Previous workhas found that children of US-born Latinas with depression have poorer developmental outcomes than foreignborn Latinas [40]. Social capital has been found to improve maternal health of foreign-born Latina women[41]. Moreover, there is evidence of Latina paradox insome situations, where babies born to US-born Latinawomen face similar outcomes to Whites while babies offoreign-born Latinas have better outcomes in terms ofprematurity and birthweight [42]. Similarly, it has beenshown that among families with limited English proficiency, there were higher incidence rates of completionof influenza vaccines and preventive visits [43]. This hasbeen attributed to concepts like “simpatia (politeness toavoid conflict)” or “respeto (respect)” as well as “marianismo” or female gender role in Hispanic culture. Moreover, it has been demonstrated that poverty, toxic stressand preterm birth can also impact developmental outcomes [44]. Also, while not appropriately powered, weidentified that Black race was associated with worseFig. 2 Adjusted association of parents with positive post-traumatic stress and depression screening and child developmental outcomes (n 89)
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48Page 7 of 10Table 2 Adjusted association of maternal mental health measure scores and medical outcomes (re-hospitalization or emergencyroom visit)OR (95%CI)Positive Perinatal Post-traumatic Stress Disorder Questionnaire 1.29 (0.5,(PPQ) screen3.29)Pvalue0.6Positive Patient Health Questionnaire2 ScreenOR (95%CI)Pvalue1.06 17 (0.34,3.98)Ref0.81.16 (0.34,3.96)0.461.44 (0.52,3.96)0.82Maternal Education High SchoolReferenceSome college1.46 (0.53,3.98)Ref0.48Primary languageEnglishReferenceNon-English0.64 (0.21,1.99)0.440.61 (0.2,1.88)Ref0.39Less than 20,0001.6 (0.54,4.71)0.521.57 (0.52,4.68)0.56 20,001– 40,000Reference 40,001– 60,0001.67 (0.23,12)0.661.72 (0.24,12.31)0.64More than 60,0000.8 (0.09,6.96)0.620.81 (0.09,7.04)0.62Infant chronologic age (month)1.11 (1.04,1.9)0.0031.12 (1.04,1.20)0.003Medical equipmenta3.47 (1.24,9.76)0.023.48 (1.24,9.74)0.02Annual household incomeRefAdjusted odds ratios with 95% confidence intervals are shown vs. reference categories unless otherwise noted. Model adjusted for race/ethnicity, maternaleducation, language, annual household income, birth weight, use of medical equipment, and enrollment in early interventionaUse of medical equipment includes: oxygen, tracheostomy, wheelchair, adaptive stroller, feeding tubeFig. 3 Quality of life scores and positive post-traumatic stress anddepression screeningneurodevelopmental outcomes independent of parentalstress or depression. A recent publication by the EuniceKennedy Shriver National Institute of Child Health andHuman Development Neonatal Research Network foundthat neurodevelopmental impairment has increasedacross all ethnic groups and not just minorities (increasefrom 2006 to 2014: black infants, 70%; Hispanic infants,123%; white infants, 130%) [45]. Studies have demonstrated that concepts like structural racism and discrimination are associated with maternal health outcomes[46–49] and future work should be conducted to demonstrate how they might impact our findings.We did find a significant association between screening positive for post-traumatic stress and depressionsymptoms and lower quality of life scores. Previous studies have established how the act of caring for a preterminfant negatively affects family dynamics and maternalquality of life [5] but may improve over time [50]. In thisstudy we used one of the same scales previously used toassess quality of life the Multicultural Quality of Life
Gateau et al. BMC Pregnancy and Childbirth(2021) 21:48Index (MQLI) which assessed a mothers’ overall healthand well being including physical well being and socialemotional support. Showing how maternal posttraumatic stress and depression symptoms affect qualityof life establishes an important potential modifiable riskfactor. We also conducted a sensitivity analysis with ourE-value analysis and found that that a moderate confounder may affect our results. For example, for participants who screened positive for post-traumatic stress(PPQ), the associated E-value (95% CI) was 2.27 (1.03)and for the PHQ-2 screen was 2.21 (1.62). Constructslike social support, living situation, nutrition and previous mental health disease and coping may also contribute to findings. Further evaluation is thus warranted onthe possible protective effects increased social supportand improved quality of life have on minimizing poorpostpartum mental health and child health outcomes inpreterm infants. This study reinforces the need to universally screen NICU mothers for PTSD and depression.LimitationsThis was a cross-sectional study; thus directionality ofneither association nor causality is able to be determined. The tools used to assess post-traumatic stressand depression were screening tools and not diagnosticones. Additionally, despite the strong association between Black race and worse outcomes on cognitive,motor and adaptive developmental screens seen in theadjusted logistic regression models, the sample size ofBlack mothers in the study was very small and was notpowered to evaluate the association of race with developmental and adaptive behavioral outcomes. Moreover,given this study was done as a survey requiring literacy,those with literacy challenges who may represent apopulation with even greater socioeconomic barriers differing mental health outcomes, are not adequately captured in this study. Also, the power calculation wasperformed to detect the difference in PPQ scores andthe secondary outcomes (infant and neurodevelopmentaloutcomes) were not powered.Future directionsThis study reinforces the need to universally screenNICU mothers for PTSD and depression. Additionally,dedicated evaluation on the association of race and cognitive and adaptive behavioral outcomes could helpidentifying other vulnerable populations who could potentially benefit from targeting resources and interventions. Specific parental treatment interventions havebeen shown to reduce trauma symptoms and depression[51, 52]. A recent meta-analysis has also demonstratedthat cognitive behavioral therapy (CBT) is most effectiveto reduce depressive symptoms [53]. Telehealth andinternet-based mental health services may also bePage 8 of 10promising solution for low-SES mothers and high-riskmothers (e.g., those in Neonatal Intensive Care Units) toaccess mental health services. Hynan et al. review stepsto include telehealth services in providing psychosocialsupport to families, including using telemedicine forscreening, maintaining compliance with the AmericanTelemedicine Association and American PsychologicalAssociation, and for staff to familiarize themselves withweb-based support sites [54, 55]. Several NICUs alreadyemploy web-based cameras, Skype, and FaceTime toallow parents to check on their hospitalized children.Augmenting these virtual connections might be a natural next step.ConclusionsScreening scores positive for stress and depressionsymptoms were associated with a negative change insome infant development scores and maternal quality oflife scores. Thoughtful screening programs for maternalstress and depression symptoms should be instituted.Supplementary InformationThe online version contains supplementary material available at nal file 1: Supplemental Table 1. Association of maternalmental health measure scores and neurodevelopmental scores (n 89).Supplemental Table 2. Association of maternal mental health measurescores and neurodevelopmental sco
Vineland adaptive behavior scale II (VABS II) Personal, social and communication skills were assessed using the Vineland Adaptive Behavior Scales, second edition (VABS-II) [26]. Adaptive behavior refers to an individual’s day-to-day activities needed for personal and social sustenance; these scales assess what a person does
traumatic stress and you may find this workbook helpful. This workbook aims to help you to: Recognise whether you may be experiencing symptoms of post-traumatic stress. Understand what post-traumatic stress is, what causes it and what keeps it going. Find ways to understand, manage or overcome your post-traumatic stress.
Post-Traumatic Stress Syndrome - PTSD . Post-Traumatic Stress Disorder (PTSD) can occur after someone has experienced traumatic events such as combat exposure, serious accidents, physical or sexual . This workbook includes the basic sets of points that you would need to address this particular condition. If you have any further questions .
Understanding Post-Traumatic Stress Disorder (PTSD) 4 This English version of Understanding Post-Traumatic Stress Disorder is free to share. Download copies from psychologytools.com Upsetting memories of the event intruding into your mind. Having nightmares about the event. Feeling physical reactions in your body when you are reminded of the event.
South Asia have the highest maternal mortality, contrib-uting up to 86% maternal mortality globally [1]. Tanzania is among the sub-Saharan countries with the highest maternal mortality. The maternal mortality ratio in Tanzania is as high as 556 maternal death in every 100,000 live births [2]. It has been reported that the most leading causes of
counting maternal deaths. National statistics on maternal mortality, therefore, vary consid-erably from maternal death estimates: Official government figures for 2008 showed a total of 5,670 maternal deaths in Latin America, substantially fewer than the 9,075 estimated by the United Nations Maternal Mortality
Work on maternal health services has begun with a rapid appraisal of maternal health care in each of the participating countries. Maternal health services and the improvement of maternal mortality are internationally acknowledged as priority issues for health services development. Maternal health services are also useful as a health system probe.
situation of maternal mortality is still worrying. Sixteen out of the forty-eight countries in the region have very high maternal mortality ranging between 500 to 999 maternal deaths per 100,000 live births in 2017 (WHO et al.2019). The current estimates on maternal mortality show that the maternal mortality ratio, an
1.4 importance of human resource management 1.5 stress management 1.6 what is stress? 1.7 history of stress 1.8 stressors 1.9 causes of stress 1.10 four major types of stress 1.11 symptoms of stress 1.12 coping with stress at work place 1.13 role of human resource manager with regard to stress management 1.14 stress in the garment sector
