This study is constrained in its scope of generalizability given certain limitations. First, this study captured a convenience sample of mothers from three NICUs in the Philadelphia-area; while the sociodemographics of the current sample appear to be largely consistent with available data on NICU admissions nationwide, it is possible that these findings may not represent the broader population of mothers with infants in the NICU. Of note, the three NICUs in which data collection took place exhibited differences and variability in terms of size, patient population, severity of infant condition, and sociodemographic status of patients, which may limit our ability to draw conclusions about maternal psychological responses and treatment in NICUs not represented within this study.
Another limitation is the study’s reliance on self-report measures. Participants completed the initial assessment independently, which affords potential advantages and disadvantages regarding the current research. Independent self-report measures may have encouraged more honest responses from participants than might have been obtained in an interview format, suggesting that the data collection approach was beneficial in achieving accurate and representative responses. However, the self-report nature of the responses may have been subject to participant bias and might have been enhanced by the collecting
data from multiple methods, such as collateral information or direct behavioral observations of maternal-infant interactions.
Finally, as previous discussed, the study produced a follow-up response rate of slightly less than 60%, resulting in a significant proportion of participants who were lost to follow up. This is noteworthy in that it is unclear why participants were lost to follow up and how their follow-up data would have impacted the current results. For example, nearly half (46%) of participants with an EPDS score > 10 were lost to follow up,
suggesting that the participants lost to follow up were potentially experiencing high levels of depressive symptoms that are not reflected in the current data as they did not complete the study. Differential symptoms among participants who dropped out versus those who completed the study could have impacted the results in a significant way, particularly if the majority of participants who were lost to follow up were experiencing increased psychiatric symptoms compared to the entire sample. Moreover, there was a proportion of women who declined to participate in the study (n = 38; 21.5%), leaving the
experience of these mothers to remain unknown, particularly as it relates to psychiatric symptoms and NICU adjustment. It is possible that mothers who declined to participate in the study may have been experiencing the most distress and therefore chose not to participate, thereby preventing their experiences from being reflected in the current study. The current study was underpowered to detect an effect for Hypotheses 4, 5, and 6; data collection remains ongoing to achieve the full sample required to fully power those analyses.
5.7 Conclusions
The current study found that NICU mothers experience generally high levels of depression, anxiety, and stress while their infant is in the NICU, with these symptoms emerging as positively correlated to one another. In addition, higher levels of depressive, anxiety, and stress symptoms among NICU mothers were associated with poorer
functioning in multiple domains, such as maternal-infant attachment, maternal attitudes and adjustment, social support, and overall health. It appears that maternal psychological responses are exacerbated in the NICU environment, suggesting that NICU admission may heighten maternal risk for mental health symptoms, particularly among mothers with preexisting vulnerabilities and prior reproductive traumas. While depression and anxiety symptoms were shown to significantly decrease over time, stress symptoms remained consistent during NICU admission and several months later, indicating that stress may be an important component in understanding mothers’ postpartum experiences. Moreover, depressive symptoms during NICU admission were found to predict depressive
symptoms 2-3 months later, underscoring the importance of screening for depression during the NICU admission when mothers are engaged in the healthcare system and may be able to more readily utilize mental health referrals (Hynan et al., 2015). In addition, barriers to psychological treatment and attitudes towards treatment were negatively correlated, such that as favorable attitudes towards psychological treatment increased, perceived barriers to treatment decreased. The barriers that were endorsed most frequently were structural barriers related to time, childcare, and financial aspects of pursuing mental health treatment. This study emphasizes the theoretical framework of a cumulative stress model and provides important information regarding future clinical and
research directions in this arena. The inclusion of psychologists embedded within the NICU environment is clearly warranted to address the burgeoning mental health needs of this population, given the numerous opportunities for clinical intervention that exist in the hospital setting. In addition, this study demonstrates the importance of conducting
additional research on the psychosocial aspects of NICU admission for parents, particularly regarding the development of more comprehensive predictive models that can enhance follow-up and engagement with mental health care for a population in great need.
TABLE 1
Participant Sociodemographic Characteristics. N = 127 n %
Ethnic-racial background* African-American/Black Asian/Pacific Islander Caucasian Latina/Hispanic Multiracial Not reported 38 4 66 14 4 1 29.9 3.1 52.0 11.0 3.1 0.8 Current relationship status
Single, not currently in a relationship Unmarried, living separately from partner Unmarried, living together with partner Married Not reported 11 11 35 69 1 8.7 8.7 27.6 54.3 0.8 Educational attainment
Some high school High school diploma Some college
2-year college or associate’s degree 4-year college or bachelor’s degree Some graduate education
Master’s degree PhD/MD/JD 5 32 28 15 21 3 21 2 3.9 25.2 22.0 11.8 16.5 2.4 16.5 1.6 Employment status Unemployed Employed part-time Employed full-time
Employed, but not working (e.g., maternity leave, FMLA) 40 8 25 54 31.5 6.3 19.7 42.5 Estimated annual combined household income
Under $15,000 $15,000-29,999 $30,000-59,999 $60,000-99,999 $100,000-149,999 $150,000-250,000 Over $250,000 Not reported 21 19 28 26 19 8 3 3 16.5 15.0 22.0 20.5 15.0 6.3 2.4 2.4 M SD / Range
Age (in years) 29.63 5.23 / 18-41
*Participants were instructed to select all options that applied to their ethnic-racial background.
TABLE 2
Participant Reproductive History. N = 127 n %
Number of children 1 2 3 4 5 6 52 47 11 10 5 2 40.9 37.0 8.7 7.9 3.9 1.6 Number of children admitted to a NICU*
1 2 3 4 101 20 4 2 79.5 15.7 3.1 1.6 History of pregnancy loss
Yes No 52 75 40.9 59.1 If yes, number of pregnancy losses experienced (n = 52)
1 2 3 4 5 32 13 3 3 1 61.5 25.0 5.8 5.8 1.9 History of fertility treatments
Yes No Not reported 15 111 1 11.8 87.4 0.8 If yes, NICU infant conceived via fertility treatments (n =
15)
Yes No
11
4 73.3 26.7 Twin birth in NICU
Yes No 10 117 7.9 92.1
*This number reflects participants with twins in the current NICU admission (i.e., a mother with twins in the NICU with no prior NICU admissions in other children would have selected 2).
FIGURE 3
Participant Recruitment and Enrollment Flow Sheet
*Participants were deemed ineligible post-enrollment due to being non-biological mothers of NICU infants (i.e., one adoptive mother and two mothers who were same-sex partners of the biological mother).
LIST OF REFERENCES
Aagaard, H., & Hall, E. O. (2008). Mothers' experiences of having a preterm infant in the neonatal care unit: a meta-synthesis. Journal of Pediatric Nursing, 23(3), e26-e36. Abramowitz, J.S., Meltzer-Brody, S., Leserman, J. Killenberg, S., Rinaldi, K. Mahaffey,
B.L., & Pedersen, C. (2010). Obsessional thoughts and compulsive behaviors in a sample of women with postpartum mood symptoms. Archives of Women's Mental Health, 13(6), 523-530. doi: 10.1007/s00737-010-0172-4.
Aiken, L.S. & West, S.G. (1991). Multiple regression: testing and interpreting interactions. Newbury Park: Sage.
Ainsworth, M. D. S. (1969). Object relations, dependency, and attachment: A theoretical review of the infant-mother relationship. Child Development, 969-1025.
Alkozei, A., McMahon, E., & Lahav, A. (2014). Stress levels and depressive symptoms in NICU mothers in the early postpartum period. Journal of Maternal Fetal Neonatal Medicine, 27(17), 1738-1743. doi: 10.3109/14767058.2014.942626 Andresen, P. A., & Telleen, S. L. (1992). The relationship between social support and
maternal behaviors and attitudes: A meta-analytic review. American Journal of Community Psychology, 20(6), 753-774.
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176.
Austin, M.P., Hadzi-Pavlovic, D., Priest, S.R., Reilly, N., Wilhelm, K., Saint, K. & Parker, G. (2010). Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection? Archives of Women's Mental Health, 13(5), 395-401. doi: 10.1007/s00737-010-0153-7.
Ballabh, P., Kumari, J., AlKouatly, H. B., Yih, M., Arevalo, R., Rosenwaks, Z., & Krauss, A. N. (2003). Neonatal outcome of triplet versus twin and singleton pregnancies: a matched case control study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 107(1), 28-36.
Barnett, B., & Parker, G. (1986). Possible determinants, correlates and consequences of high levels of anxiety in primiparous mothers. Psychological Medicine, 16(01), 177-185.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173.
Barr, P. (2011). Posttraumatic growth in parents of infants hospitalized in a neonatal intensive care unit. Journal of Loss and Trauma: International Perspective on Stress and Coping, 16(2), 117-134. doi: 10.1080/15325024.2010.519265 Barrett, J. & Fleming, A.S. (2011). Annual research review: all mothers are not created
equal: neural and psychobiological perspectives on mothering and the importance of individual differences. Journal of Child Psychology and Psychiatry, 52(4), 368-397. doi: 10.1111/j.1469-7610.2010.02306.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893.
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77-100.
Beck, C. T. (2003). Recognizing and screening for postpartum depression in mothers of NICU infants. Advances in Neonatal Care, 3(1), 37-46.
Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics & Child Health, 9(8), 541.
Berle, J.O., Mykletun, A., Daltveit, A.K., Rasmussen, S. Holsten, F. & Dahl, A.A. (2005). Neonatal outcomes in offspring of women with anxiety and depression during pregnancy. A linkage study from The Nord-Trondelag Health Study (HUNT) and Medical Birth Registry of Norway. Archives of Women's Mental Health, 8(3), 181-189.
Bernard, R.S., Williams, S.E., Storfer-Isser, A., Rhine, W., McCue Horwitz, S., Koopman, C. & Shaw, R.J. (2011). Brief cognitive-behavioral intervention for maternal depression and trauma in the neonatal intensive care unit: a pilot study. Journal of Traumatic Stress, 24(2), 230-234.
Bialoskurski, M., Cox, C., & Wiggins, R. (2002). The relationship between maternal needs and priorities in a neonatal intensive care environment. Journal of Advanced Nursing, 37(1), 62-69.
Bloch, M., Schmidt, P.J., Danaceau, M., Murphy, J., Nieman, L. & Rubinow, D.R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry, 157, 924-930.
Bozetepe, H., Inci, F., & Tanhan, F. (2015). Posttraumatic growth in mothers after infant admission to neonatal intensive care unit. Paediatric Croatia, 59, 14-18. doi: 10.13112/PC.2015.3
Boyd, R. C., Le, H. N., & Somberg, R. (2005). Review of screening instruments for postpartum depression. Archives of Women’s Mental Health, 8(3), 141-153. doi: 10.1007/s00737-005-0096-6
Breitkopf, C. R., Primeau, L. A., Levine, R. E., Olson, G. L., Wu, Z. H., & Berenson, A. B. (2006). Anxiety symptoms during pregnancy and postpartum. Journal of Psychosomatic Obstetrics & Gynecology, 27(3), 157-162.
Britton, J. R. (2008). Maternal anxiety: course and antecedents during the early postpartum period. Depression and Anxiety, 25(9), 793-800.
Busse, M., Stromgren, K., Thorngate, L., & Thomas, K.A. (2013). Parents' response to stress in the neonatal intensive care unit. Critical Care in Nursing, 33(4), 52-59. Carter, J. D., Mulder, R. T., & Darlow, B. A. (2007). Parental stress in the NICU: The
influence of personality, psychological, pregnancy and family factors. Personality and Mental Health, 1(1), 40-50.
Cheng, C.-Y., Fowles, E. R., & Walker, L. O. (2006). Postpartum maternal health care in the United States: a critical review. The Journal of Perinatal Education, 15(3), 34.
Cherry, A.S., Blucker, R.T., Thornberry, T.S., Hetherington, C., McCafferee, M.A. & Gillaspy, S.R. (2016). Postpartum depression screening in the neonatal intensive care unit: program development, implementation, and lessons learned. Journal of Multidisciplinary Healthcare, 9, 59-67. doi: 10.2147/JMDH.S91559
Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155.
Committee on Fetus and Newborn. (2012). Levels of Neonatal Care. Pediatrics, 130(3), 587-597. doi: 10.1542/peds.2012-1999
Cox, J. L., Holden, J., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry, 150(6), 782-786.
Cusson, R. M. (2003). Factors influencing language development in preterm infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(3), 402-409. Cutrona, C. E. (1984). Social support and stress in the transition to parenthood. Journal
Davis, D. L., & Stein, M. T. (2004). Parenting your premature baby and child: The emotional journey: Fulcrum Publishing.
Davis, L., Edwards, H., Mohay, H., & Wollin, J. (2003). The impact of very premature birth on the psychological health of mothers. Early Human Development, 73(1), 61-70.
DeMier, R. L., Hynan, M. T., Harris, H. B., & Manniello, R. L. (1995). Perinatal
stressors as predictors of symptoms of posttraumatic stress in mothers of infants at high risk. Journal of Perinatology, 16(4), 276-280.
Diffin, J., Shields, M.D., Cruise, S., and Johnston, L. (2013). Parents' experience of caring for their infant following surgery in the neonatal period: a literature review. Journal of Neonatal Nursing, 19(5), 271-289.
Doering, L. V., Moser, D. K., & Dracup, K. (2000). Correlates of anxiety, hostility, depression, and psychosocial adjustment in parents of NICU infants. Neonatal Network: The Journal of Neonatal Nursing, 19(5), 15-23.
Farr, S.L., Dietz, P.M., O'Hara, M.W., Burley, K., & Ko, J.Y. (2014). Postpartum anxiety and comorbid depression in a population-based sample of women. Journal of Women's Health, 23(2), 120-128. doi: 10.1089/jwh.2013.4438
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191.
Fegran, L., Helseth, S., & Fagermoen, M. S. (2008). A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. Journal of Clinical Nursing, 17(6), 810-816.
Feldman, R., Weller, A., Leckman, J. F., Kuint, J., & Eidelman, A. I. (1999). The nature of the mother's tie to her infant: Maternal bonding under conditions of proximity, separation, and potential loss. Journal of Child Psychology and Psychiatry, 40(6), 929-939.
Field, A. (2005). Discovering Statistics Using SPSS. Thousand Oaks, California: Sage. Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychologial
help: A shortened form and considerations for research. Journal of College Student Development, 36(4), 368-373.
Fischer, E. H., & Turner, J. I. (1970). Orientations to seeking professional help:
development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35(1p1), 79.
Friedman, S.H., Kessler, A., Yang, S.N., Parsons, S., Friedman, H. & Martin, R.J. (2013). Delivering perinatal psychiatric services in a neonatal intensive care unit. Acta Paediatrica, 102(9), e392-e397. doi: 10.1111/apa.12323
Gale, S. & Harlow, B.L. (2003). Postpartum mood disorders: a review of clinical and epidemiological factors. Journal of Psychosomatic Obstetrics and Gynecology, 24(4), 257-266.
Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: a systematic review of prevalence and incidence. Obstetrics & Gynecology, 106(5, Part 1), 1071-1083.
Gaynes, B. N., Gavin, N., Meltzer-Brody, S., Lohr, K. N., Swinson, T., Gartlehner, G., . . . Miller, W. C. (2005). Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes: Summary. AHRQ Evidence Report Summary, Rockville, MD.
Geller, P.A. (2004). Pregnancy as a stressful life event. CNS Spectrums, 9(3), 188-197. doi: 10.1017/S109285290008981.
Geller, P. A., Nelson, A. R., & Eichenbaum, E. (2013). Agency in childbearing:
Psychological issues surrounding the paths towards parenthood. In M. V. Spiers, P. A. Geller & J. D. Kloss (Eds.). Women’s Health Psychology. New York: John Wiley & Sons, Inc.
Geller P, Woodland M, Daetwyler C. (2015). Psychological and Medical Aspects of Pregnancy Loss. MedEdPORTAL Publications. Available from:
https://www.mededportal.org/publication/10240. doi: 10.15766/mep_2374- 8265.10240
Gjerdingen, D. K., & Center, B. A. (2003). First-time parents’ prenatal to postpartum changes in health, and the relation of postpartum health to work and partner characteristics. The Journal of the American Board of Family Practice, 16(4), 304-311.
Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum depression screening: importance, methods, barriers, and recommendations for practice. The Journal of the
American Board of Family Medicine, 20(3), 280-288.
Glover, V. (2011). Annual research review: prenatal stress and the origins of
psychopathology: an evolutionary perspective. Journal of Child Psychology and Psychiatry, 52(4), 356-367. doi: 10.111/j.1469-7610.2011.02371.x
Gottlieb, B. R. (2006). The role of social networks and support in postpartum women's depression: a multiethnic urban sample. Maternal and Child Health Journal, 10(4), 375-383.
Hall, S.L., & Hynan, M.T. (2015). Interdisciplinary recommendations for the psychosocial support of NICU parents. Journal of Perinatology, 35(S1).
Harrison, W., & Goodman, D. (2015). Epidemiologic trends in neonatal intensive care, 2007-2012. JAMA Pediatrics, 169(9), 855-862. doi:
10.1001/jamapediatrics.2015.1305
Hayes, S.C, Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd edition). New York, NY: The Guilford Press.
Heermann, J. A., Wilson, M. E., & Wilhelm, P. A. (2005). Mothers in the NICU: outsider to partner. Pediatric Nursing, 31(3), 176-200.
Helle, N., Barkmann, C., Ehrhardt, S., von der Wense, A., Nestoriuc, Y., & Bindt, C. (2016). Postpartum anxiety and adjustment disorders in parents of infants with very low birth weight: cross-sectional results from a controlled multicentre cohort study. Journal of Affective Disorders, 194, 128-134. doi:
10.1016/j.jad.2016.01.016 h
Hummel, P. (2003). Parenting the high-risk infant. Newborn and Infant Nursing Reviews, 3(3), 88-92.
Hynan, M.T., Mounts, K.O, & Vanderbilt, D.L. (2013). Screening parents of high-risk infants for emotional distress: rationale and recommendations. Journal of Perinatology, 33, 748-753. doi: 10.1038/jp.2013.72
Hynan, M.T., Steinberg, Z., Baker, L., Cicco, R., Geller, P.A., Lassen, S., Milford, C., Mounts, K.O., Patterson, C., Saxton, S., Segre, L., & Stuebe, A. (2015). Recommendations for mental health professionals in the NICU. Journal of Perinatology, 35, s14-s19.
Kara, S., Tan, S., Aldemir, S., Yilmaz, A.E., Tatli, M.M. & Dilmen, U. (2013). Investigation of perceived social support in mothers of infants hospitalized in neonatal intensive care unit. Hippokratia, 17(2), 130-135.
Kearvell, H., & Grant, J. (2010). Getting connected: How nurses can support mother/infant attachment in the neonatal intensive care unit. The Australian Journal of Advanced Nursing, 27(3), 75.
Kohn, I., & Moffitt, P.-L. (2000). A Silent Sorrow: Pregnancy Loss--Guidance and Support for You and Your Family: Psychology Press.
Korja, R., Savonlahti, E., Ahlqvist-Björkroth, S., Stolt, S., Haataja, L., Lapinleimu, H., . . . Lehtonen, L. (2008). Maternal depression is associated with mother–infant interaction in preterm infants. Acta Paediatrica, 97(6), 724-730.
Kulbok, P. A., Carter, K. F., Baldwin, J. H., Gilmartin, M. J., & Kirkwood, B. (1999). The multidimensional health behavior inventory. Journal of Nursing
Measurement, 7(2), 177-195.
Kumar, R., Robson, K., & Smith, A. (1984). Development of a self-administered questionnaire to measure material adjustment and material attitudes during pregnancy and after delivery. Journal of Psychosomatic Research, 28(1), 43-51. Lancaster, C.A., Gold, K.J., Flynn, H.A., Yoo, H., Marcus, S.M., Davis, M.M. (2010).
Risk factors for depressive symptoms during pregnancy: a systematic review. American Journal of Obstetrics and Gynecology, 202(1), 5-14. doi:
10.1016/j.ajog.2009.09.007.
Lee, H. C., Green, C., Hintz, S. R., Tyson, J. E., Parikh, N. A., Langer, J., & Gould, J. B. (2010). Prediction of Death for Extremely Premature Infants in a Population- Based Cohort. Pediatrics, 126(3), e644-e650. doi: 10.1542/peds.2010-0097 Lefkowitz, D. S., Baxt, C., & Evans, J. R. (2010). Prevalence and correlates of
posttraumatic stress and postpartum depression in parents of infants in the
Neonatal Intensive Care Unit (NICU). Journal of Clinical Psychology in Medical Settings, 17(3), 230-237.
Levine, R. E., Oandasan, A. P., Primeau, L. A., & Berenson, A. B. (2003). Anxiety disorders during pregnancy and postpartum. American Journal of Perinatology, 20(05), 239-248.
Littleton, H.L., Brietkopf, C.R., & Berenson, A.B. (2007). Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta- analysis. American Journal of Obstetrics and Gynecology, 196(5), 424-432. Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states:
Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335-343.
Lovibond, S., & Lovibond, P. F. (1996). Manual for the depression anxiety stress scales: Psychology Foundation of Australia.
Madu, S. N. (2006). Depression among mothers with preterm infants and their stress- coping strategies. Social Behavior and Personality: an International Journal, 34(7), 877-890.
March of Dimes Perinatal Data Center. (2011). Special care nursery admissions. National Perinatal Information System/Quality Analytic Services.
Markowitz, J.C., & Weissman, M.M. (2004). Interpersonal psychotherapy: principles and applications. World Psychiatry, 3(3), 136-139.
Matthey, S., Barnett, B., Howie, P., & Kavanagh, D. J. (2003). Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety? Journal of Affective Disorders, 74(2), 139-147. doi: http://dx.doi.org/10.1016/S0165- 0327(02)00012-5
Matricardi, S., Agostino, R., Fedeli, C., & Montirosso, R. (2012). Mothers are not fathers: differences between parents in reduction of stress levels after a parental intervention in a NICU. Acta Pediatrica, 102(1), 8-14.
Melnyk, B. M., Feinstein, N. F., Moldenhouer, Z., & Small, L. (2000). Coping in parents of children who are chronically ill: strategies for assessment and intervention. Pediatric Nursing, 27(6), 548-558.
Meyer, E. C., Coll, C. T. G., Seifer, R., Ramos, A., Kilis, E., & Oh, W. (1995).
Psychological distress in mothers of preterm infants. Journal of Developmental & Behavioral Pediatrics, 16(6), 412-417.
Miles, M. S., Funk, S. G., & Kasper, M. A. (1991). The Neonatal Intensive Care Unit Environment: Sources of Stress for Parents. AACN Advanced Critical Care, 2(2), 346-354.
Miles, M. S., Holditch-Davis, D., Burchinal, P., & Nelson, D. (1999). Distress and growth outcomes in mothers of medically fragile infants. Nursing Research, 48(3), 129-140.
Miles, M. S., Holditch-Davis, D., Schwartz, T. A., & Scher, M. (2007). Depressive symptoms in mothers of prematurely born infants. Journal of Developmental & Behavioral Pediatrics, 28(1), 36-44.
Moses-Kolko, E.L. & Roth, E.K. (2004). Antepartum and postpartum depression: healthy mom, healthy baby. Journal of American Medical Women's Association, 59(3), 181-191.
Mounts, K. O. (2009). Screening for maternal depression in the neonatal ICU. Clinics in Perinatology, 36(1), 137-152.
Muller, M. E. (1994). A questionnaire to measure mother-to-infant attachment. Journal of Nursing Measurement, 2(2), 129-141.
Nielsen, D., Videbech, P., Hedegaard, M., Dalby, J., & Secher, N. (2000). Postpartum depression: identification of women at risk. BJOG: An International Journal of Obstetrics & Gynaecology, 107(10), 1210-1217.
Novick, D. & Flynn, H.A. (2013). Psychiatric Symptoms and Pregnancy. In M. V. Spiers, P. A. Geller & J. D. Kloss (Eds.). Women’s Health Psychology. New York: John Wiley & Sons, Inc.
Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British Medical Bulletin, 67, 219-229.
O'Hara, M. W. (2009). Postpartum depression: what we know. Journal of Clinical Psychology, 65(12), 1258-1269.
O'Hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depression-a meta- analysis. International Review of Psychiatry, 8(1), 37-54.
O'Mahen, H. A., & Flynn, H. A. (2008). Preferences and perceived barriers to treatment for depression during the perinatal period. Journal of Women's Health, 17(8), 1301-1309.
Obeidat, H. M., Bond, E. A., & Callister, L. C. (2009). The parental experience of having an infant in the newborn intensive care unit. The Journal of Perinatal Education, 18(3), 23.
Osterman, M. J. K., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011). Expanded data from the new birth certificate National Vital Statistics Reports. Hyattsville,