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Prevalence of anxiety, depression, and stress among parents of neonates admitted to neonatal intensive care unit: a systematic review and meta-analysis
-
Asha P. Shetty, M.Phil, PhD1
, Kurvatteppa Halemani, M.Phil, PhD2, Alwin Issac, MSc, M.Phil1, Latha Thimmappa, MSc, PhD3, Sanjay Dhiraaj, MD4, Radha K, M.Phil, PhD5, Prabhaker Mishra, PhD6, Vijai Datta Upadhyaya, MS, MCh7
- Corresponding author: Kurvatteppa Halemani, M.Phil, PhD. College of Nursing, All India Institute of Medical Science, Raeberali, Uttar Pradesh, India Email: kurru.hali@gmail.cpm
- Received March 25, 2023 Revised August 9, 2023 Accepted August 10, 2023
- Abstract
-
- Background
- Background
- Neonatal intensive care unit (NICU) admission causes significant distress that can hinder the successful transition into parenthood, child-parent relations, and child development.
- Purpose
- Purpose
- This systematic review and meta-analysis aimed to understand parental psychological phenomena. Here we assessed the emotional response of parents of newborns during NICU admission.
- Methods
- Methods
- Two authors independently searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Clinical Key, and Google Scholar databases for studies published between January 01, 2004, and December 31, 2021. The review followed Cochrane collaboration guidelines and the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement. The quality of the included studies was assessed using the modified Newcastle-Ottawa Scale. Stata software (version 16) was used to compute the results.
- Results
- Results
- This review comprised 6,822 parents (5,083 mothers, 1,788 fathers; age range, 18–37 years) of NICU patients. The gestational ages and neonatal weights were 25.5–42 weeks and 750–2,920 g, respectively. The pooled prevalence of anxiety was higher among mothers (effect size [ES], 0.51; 95% confidence interval [CI], 0.41–0.61; and heterogeneity [I2]=97.1%; P<0.001) than among fathers (ES, 0.26; 95% CI, 0.11–0.42; I2=96.6%; P<0.001). Further, the pooled prevalence of depression was higher among mothers (ES, 0.31; 95% CI, 0.24–0.38; I2=91.5%; P<0.001) than among fathers (ES, 0.12; 95% CI, 0.03–0.22; I2=85.6%; P<0.001). Similarly, the pooled prevalence of stress was higher among mothers (ES, 0.41; 95% CI, 0.31–0.51; I2= 93.9%; P<0.001) than among fathers (ES, 0.22; 95% CI, 0.09–0.34; I2=85.2%; P<0.001).
- Conclusion
- Conclusion
- NICU admission is more stressful for mothers than fathers and can affect mental health and quality of life. Mothers reported a higher pooled prevalence of stress, anxiety, and depression than fathers, possibly attributable to their feelings about birthing a sick child.
- Introduction
- Introduction
The diagnosis of an illness in a child causes significant distress to parents. The grief is further aggravated when an infant is admitted to a neonatal intensive care unit (NICU). The NICU provides specialized and integrated care to infant who require close supervision and life support equipment to ensure normal body function. Parents fear the diagnosis and prognosis of illness, the associated medical risks, being separated from their child, the unfamiliar hospital environment, and hindrances accessing information and communicating with healthcare professionals. Although resilience varies among parents, distress can negatively impact the successful transition into parenthood, child- parent relationship, and child development [1,2].Earlier studies reported mental health problems among parents of NICU infants, while recent studies reported the prevalence of anxiety and posttraumatic stress among parents of NICU babies [1,2]. Healthcare centers tend to ignore the mental health of primary caregivers of hospitalized patients. However, sick newborns require immediate intervention to reduce complications. Most infants admitted to the NICU require long-term care. Therefore, parental involvement and effective communication during NICU admission may increase their satisfaction and lead to continued care after discharge.To the best of our knowledge, this is the first systematic review and meta-analysis of recent studies published worldwide. In contrast to previous studies, this review focused on mental health problems among parents of neonates admitted to the NICU. However, understanding parental reactions to hospitalization is essential to healthcare providers offering appropriate interventions. Furthermore, we recognized the importance of separately examining anxiety, depression, and stress levels in mothers and fathers. This systematic review and meta- analysis aimed to understand the psychological phenomena experienced by parents of newborns during NICU admission.
- Methods
- Methods
- 1. Protocol and registration
- 1. Protocol and registration
- 2. Search strategy and study selection
- 2. Search strategy and study selection
The search strategy was developed using a combination of MeSH (medical subject heading) terms and keywords (mother OR father OR parents OR maternal OR NICU mother OR NICU father OR lactation mother OR newborn mother OR NICU parents OR preterm mother) AND (anxiety OR fear OR nervousness OR depression OR hopelessness OR sleep problem OR afraid OR sttabress OR uneasiness) AND (NICU unit OR hospitalization OR NICU OR neonatal unit). The first 2 authors independently searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Clinical Key, and Google Scholar databases for studies published between January 01, 2004, and December 31, 2021. The reference lists of all relevant studies that fulfilled the inclusion criteria as well as related systematic reviews, meta-analyses, and review articles were manually searched. Duplicate records were excluded by title and abstract screening. The remaining original full-text articles were screened against the inclusion criteria.Articles that fulfilled the following criteria were included in the review: observational studies whose participants were parents of children undergoing NICU treatment; studies that adopted standardized measurement tools; and studies that reported cutoff scores for anxiety, depression and stress among NICU parents. Studies that evaluated the efficacy of various interventions for stress, anxiety, and depression among parents of NICU patients were excluded. Any disagreements between the first 2 authors (AS and KH) regarding the data extracted from the articles were referred to the third author (AI), and dissimilarities were resolved in discussion with the third reviewer. The data extraction form included the first author’s name, year of study, country in which the study was conducted, sample size, parental age and educational level, infant’s gestational age and birth weight, instruments used during data collection with cutoff scores, and study outcomes.- 3. Search outcome
- 3. Search outcome
The search identified 6,518 studies from online databases and 6 from printed materials. A total of 1,541 duplicate records were removed before the first screening. Further, 4,812 were rejected for not meeting the inclusion criteria. The full-text review eliminated 131 articles. The reasons for exclusion included a lack of sample size, time of data collection (when the neonate was admitted to/discharged from the NICU), participant characteristics, measurement tools, cutoff scores, and study outcomes. Finally, 41 articles were included in this meta-analysis. A summary of the study selection process is shown in Fig. 1.- 4. Quality assessment of included studies
- 4. Quality assessment of included studies
The quality of the includefigd studies was assessed using the modified Newcastle-Ottawa Scale [5]. Each included study was appraised for selection, comparability, and outcomes. The scores on the assessment tool were 0–5. Studies that achieved a score of ≥3 were considered to have a low risk of bias. The appraisals of the included studies are presented in Table 1.- 5. Parental anxiety, depression, and stress
- 5. Parental anxiety, depression, and stress
Parents of NICU patients often experience mental distress due to being away from their newborns, financial obligations, and family responsibilities. Anxiety, depression, and stress were the primary outcomes of the included studies. The authors of the primary studies employed various scales to evaluate parental anxiety, including the State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Beck’s Anxiety Inventory, Hamilton Anxiety Rating, and Self-Rating Anxiety Scale.Similarly, depression and stress were assessed using the Edinburgh Postnatal Depression Scale; Beck’s Depression Inventory; Center for Epidemiologic Study Depression, Anxiety and Stress Scale; Parental Stress Scale; Posttraumatic Stress Disorder Questionnaires; Stanford Acute Stress Reaction Questionnaires; and Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, respectively.- 6. Statistical analysis
- 6. Statistical analysis
The first 2 authors (AS and KH) manually calculated the pooled prevalence across studies using Microsoft Excel. We then computed the pooled estimated prevalence using a random-effects model with 95% confidence interval (CI). Categorical or dichotomous variables are reported as percentages with values of P<0.05 considered significant. Study heterogeneity was evaluated using I2 values: high, >75; medium, 50–75; and low, <50.3) Furthermore, a subgroup analysis was performed across the included studies. All analyses were performed using Poisson distribution under the Metaprop function of Stata 16 (Stata Corp LP, College Station, TX, USA).
- Results
- Results
- 1. Study characteristics
- 1. Study characteristics
- 2. Participant characteristics
- 2. Participant characteristics
The review studies involved 6,822 participants (age range, 18–37 years), of whom 5,083 were mothers and 1,788 were fathers. The gestational age and neonatal weight ranges were 25.5–42 weeks and 750–2,920 g, respectively. Among the included studies, most participants were mothers, while one study included only fathers (Table 2) [39].Among the included studies, 22 primary studies reported anxiety in the mother, 3 studies reported both fathers and mothers as participants, and one study reported anxiety in the father [29,38]. The pooled prevalence of anxiety was higher among mothers (effect size [ES], 95% CI, and heterogeneity [I2] (ES, 0.51; 95% CI, 0.41–0.61; I2=97.1%; P<0.001) [7,9-11,14,15,18-20,24,28-31,33-35,40,41,44] than fathers (ES, 0.26; 95% CI, 0.11–0.42; I2=96.6%; P<0.001) of NICU babies [29,30,38,44]. An overall subgroup analysis revealed that approximately 47% of parents were anxious about NICU admissions (ES, 0.47; 95% CI, 0.38–0.56; I2=97.1%; P<0.001) (Fig. 2).The highest and lowest prevalence of anxiety in the included studies were reported among mothers of newborns admitted to the NICU at 13% and 93% respectively [22,31]. Similarly, the highest and lowest prevalence of anxiety among fathers of newborns admitted to the NICU were 0.09% and 46%, respectively (Fig. 2) [29,30].- 3. Depression
- 3. Depression
Fathers typically experienced fewer depressive symptoms (ES, 0.12; 95% CI, 0.03–0.22; I2=85.6%; P<0.00) than mothers (ES, 0.31; 95% CI, 0.24–0.38; I2=91.5%; P<0.001) whose newborns were in the NICU [6,8,14,17-19,35,37,39-41,43]. An overall subgroup analysis revealed that 28% of parents were depressed about NICU admissions (ES, 0.28; 95% CI, 0.21–0.35; I2=94.6%; P<0.001) (Fig. 3).- 4. Stress
- 4. Stress
Mothers of newborns admitted to the NICU are more likely to experience stress (ES, 0.41; 95% CI, 0.31–0.51; I2= 93.9%; P<0.001) than fathers (ES, 0.22; 95% CI, 0.09–0.34; I2=85.2%; P<0.001 [8,12,13,16,17,21-28,32,34,36,42]. Overall, these findings demonstrate that parents experienced stress during the hospitalization of their newborns in the NICU (ES, 0.37; 95% CI, 0.27–0.47; I2=94.1%; P<0.001) (Fig. 4).- 5. Measurement tools with cutoff scores
- 5. Measurement tools with cutoff scores
Among the 22 studies that assessed the prevalence of anxiety among parents of newborns admitted to the NICU, 13 used the State-Trait Anxiety Inventory scale (ES, 0.53; 95% CI, 0.39–0.60; I2=95.3%; P<0.001) [9,11,15,20,24,31,33,34,38,40,41]. Three studies used the Hospital Anxiety and Depression Scale (ES, 0.45; 95% CI, 0.11–0.80; I2=98.6%; P<0.001) [28- 30,44]. Two studies used Beck’s Anxiety Inventory scale (ES, 0.60; 95% CI, 0.04–1.25; I2=98.9%; P<0.001) [10,19]. Two studies used the Hamilton Anxiety Rating scale (ES, 0.42; 95% CI, 0.26-0.58; I2=90.7%; P<0.001 [14,35]. One study used the Self- Rating Anxiety Scale (Fig. 5) [7].Among the 11 studies that assessed the prevalence of depression among parents of newborns in the NICU, 4 used the Edinburgh Postnatal Depression Scale (ES, 0.35; 95% CI, 0.18–0.52; I2=93.2%; P<0.001) [6,8,37,39], 3 used the Beck’s Depression Inventory scale (ES, 0.35; 95% CI, 0.18–0.52; I2=93.8%; P<0.001) [14,19,35], 2 used the Centre for Epidemiologic Study Depression Scale (ES, 0.40; 95% CI, 0.28–0.52; I2=72.6%; P<0.001) [17,40], and 2 used the Depression, Anxiety and Strs Scale (ES, 0.19; 95% CI, 0.14– 0.25; I2=0.03%; P<0.001 (Fig. 6) [18,43].Among the 18 studies that assessed the prevalence of stress among parents of newborns in the NICU, 6 used the Parental Stress Scale (ES, 0.57; 95% CI, 0.46–0.69; I2=92.2%; P<0.001) [8,12,13,16,17,34], 6 used the Perinatal Posttraumatic Stress Disorder Questionnaires (ES, 0.37; 95% CI, 0.31–0.42; I2=46.1%; P<0.001) [22-24,28,36,42], 3 used the Stanford Acute Strs Reaction Questionnaires (ES, 0.32; 95% CI, 0.25–0.39; P<0.001) [24,30,31], and 2 used the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (ES, 0.19; 95% CI, -0.09 to 0.48; I2=95.7%; P<0.001) [25,32] (Fig. 7).The pooled prevalence of the participants was calculated as 95% CI. The participants were divided into 2 age groups: <30 years (n=2,941) (ES, 0.51; 95% CI, 0.50 to -0.52) and >30 years (n=3,364) (ES, 0.48; 95% CI, 0.47–0.49). Similarly, the majority of participants were mothers (n=5,102) (ES, 0.73; 95% CI, 0.72–0.74) than fathers of newborns (n=1,803) (ES, 0.26; 95% CI, 0.25–0.27). Further, most of the babies were born after 30 weeks’ gestation (n=5,358) (ES, 0.83; 95% CI, 0.82–0.84) and weighed more than 1.5 kg (n=4,633) (ES, 0.77; 95% CI, 0.76–0.78). The existing original studies adopted a cohort (n=4,542) (ES, 0.6; 95% CI, 0.64–0.66) and cross-sectional research design (n=2,363) (ES, 0.34; 95% CI, 0.33–0.35). Twenty-two studies were conducted in South and North America (n=2,644) (ES, 0.38; 95% CI, 0.37–0.39), 11 in Asia (n=1,635) (ES, 0.23; 95% CI, 0.22–0.24), 4 in Europe (n=1,314) (ES, 0.19; 95% CI, 0.18–0.20), and 4 in Australia (n=1,312) (ES, 0.19; 95% CI, 018–0.20). The pooled prevalence of anxiety, depression, stress, and measurement tools is summarized in Table 3.
- Discussion
- Discussion
This is the first systematic review and meta-analysis to report the pooled prevalence of anxiety, depression, and stress among parents of neonates in the NICU. Our findings showed that 49% of mothers and 23% of fathers felt anxious when their newborns were admitted to the NICU. Previous studies found similar results: 40% of mothers and 20% of fathers experienced anxiety symptoms during their newborns’ NICU hospitalization.43,46) However, proper counseling and parental involvement during hospitalization improved parental satisfaction [45].Depression is another major issue among parents of NICU patients. Our meta-analysis revealed that 31% of mothers and 12% of fathers experienced depressive symptoms. Although postpartum depression is common among new mothers, parents reported reduced depression symptoms (from 33.3% to 11.7%) by the fourth week of the NICU admission [47].Similarly, many NICU parents often report high levels of stress from being physically separated from their newborn and the financial burden compared to parents of healthy babies. Our meta-analysis revealed that 41% of mothers and 21% of fathers experienced psychological stress. The NICU intervention modality and parent- centered care significantly reduced parental stress [48]. Newborns are admitted to the NICU for various reasons, including premature birth, low birth weight, infection, and congenital anomalies [49]. Faced with medical challenges, parents struggle to embrace parenthood [50]. This could be attributed to the mother’s feelings about birthing a sick child and being more concerned about their child’s future growth and development [51]. In addition to being away from family, hospitalization significantly increases the clinical symptoms of stress, anxiety, and depression among the parents of neonates in the NICU [10,12,15,16,43].However, there was no significant correlation between neonatal sex and the psychological symptoms experienced by the parents of neonates admitted to the NICU [16]. Social support, family income, and parental education level were significantly negatively correlated with anxiety and depression among mothers of neonates in the NICU [19].A similar systematic review and meta-analysis evaluated parent-centered communication regarding parental satisfaction during newborn NICU admission. They concluded that good communication and parental support boosted parental satisfaction. Furthermore, our study results urge healthcare workers to provide timely and effective parent-centered counseling for parents of neonates in the NICU. However, identifying the negative factors that reduce the psychological problems experienced by parents of NICU patients remains challenging for healthcare workers. Family-centered instructional interventions can reduce distress symptoms among mothers and fathers of preterm infants to a similar magnitude. Timely counseling of parents may help them better adjust to the hospital environment and enhance their mental wellbeing [39].The main strength of our review is that it assessed the pooled prevalence of stress, anxiety, and depression and included a subgroup analysis of the pooled prevalence of stress, anxiety, and depression in NICU mothers and fathers.Our review has some limitations. The majority of neonates were discharged before 1 month of age. Therefore, the prevalence of psychological symptoms among parents was examined between only the first and fourth weeks of hospitalization. Second, most of the studies were conducted in high-income countries. Therefore, we could not perform a subgroup analysis of the variations in the prevalence of stress, anxiety, and depression between low- and high- income countries.In conclusion, NICU admission can affect parents’ psychological health, which could have a detrimental effect on the parent–child interaction. Parents of neonates in the NICU require counseling, empathy about the neonate’s condition, and encouragement to visit their child in the NICU. More qualitative studies with longitudinal follow-up are needed to address this issue.
- Footnotes
-
Conflicts of interest No potential conflict of interest relevant to this article was reported.
Funding This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Author contribution Conceptualization: KH, APS; Data curation:AI, LT; Formal analysis: PM; Methodology: KH, APS, LT; Project administration: VDU, SD; Visualization: VDU, SD, PM; Writing-original draft: APS, KH, AI; Writing-review & editing: SD, RKM, LT
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Fig. 1.
PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) flow diagram of study selection process.
Fig. 2.
Prevalence of anxiety among parents of newborns in neonatal intensive care unit. CI, confidence interval; REML, restricted maximum likelihood.
Fig. 3.
Prevalence of depression among parents of newborns in neonatal intensive care unit. CI, confidence interval; REML, restricted maximum likelihood.
Fig. 4.
Prevalence of stress among parents of newborns in the neonatal intensive care unit. CI, confidence interval; REML, restricted maximum likelihood.
Fig. 5.
Subgroup analysis of anxiety scales used by studies included in the meta-analysis. CI, confidence interval; REML, restricted maximum likelihood.
Fig. 6.
Subgroup analysis of depression scales used by studies included in the meta-analysis. CI, confidence interval; REML, restricted maximum likelihood.
Fig. 7.
Subgroup analysis of stress scales used by studies included in the meta-analysis. CI, confidence interval; REML, restricted maximum likelihood.
Table 1.
Quality appraisal of the included studies using the modified Newcastle-Ottawa Scale
| Study | Country | Representativeness of samples >70% response (1) | Sample size >200 (2) | Response rate >80% (3) | Validated tool with cutoff (4) | Detail statistical information, not required further calculations (5) | Total Scores | Study quality |
|---|---|---|---|---|---|---|---|---|
| Carter et al. [44] (2007) | NZ | * | * | * | * | * | 5/5 | Low risk |
| Yurdakul et al. [6] (2009) | Turkey | * | - | * | - | * | 3/5 | Low risk |
| Vanderbilt et al. [22] (2009) | USA | * | - | * | - | * | 3/5 | Low risk |
| Holditch-Davis et al. [23] (2009) | USA | * | * | * | * | * | 5/5 | Low risk |
| Holditch-Davis et al. [24] (2015) | USA | * | - | * | * | * | 4/5 | Low risk |
| Lefkowitz et al. [25] (2010) | USA | * | - | * | - | * | 3/5 | Low risk |
| Barr [26] (2010) | Australia | * | - | * | * | * | 4/5 | Low risk |
| Dantas et al. [52] (2012) | Brazil | * | - | * | * | * | 4/5 | Low risk |
| Jubinville et al. [27] (2012) | Canada | * | - | * | * | * | 4/5 | Low risk |
| Kong et al. [7] (2013) | China | * | * | * | - | * | 4/5 | Low risk |
| Alkozei et al. [8] (2014) | USA | * | - | * | - | * | 3/5 | Low risk |
| Eutrope et al. [28] (2014) | France | * | - | * | - | * | 3/5 | Low risk |
| Mulder et al. [29] (2014) | NZ | * | - | * | - | * | 3/5 | Low risk |
| Margaret et al. [9] (2014) | India | * | - | * | * | * | 4/5 | Low risk |
| Segre et al. [10] (2014) | USA | * | * | * | - | * | 4/5 | Low risk |
| Garfield et al. [11] (2015) | USA | * | - | * | * | * | 4/5 | Low risk |
| Umasankar et al. [12] (2016) | Sri Lanka | * | - | * | - | * | 3/5 | Low risk |
| Pace et al. [30] (2016) | Australia | * | * | * | - | * | 4/5 | Low risk |
| Lim et al. [13] (2017) | Malaysia | * | * | * | - | * | 4/5 | Low risk |
| Harris et al. [31] (2018) | USA | * | - | * | * | * | 4/5 | Low risk |
| Salah et al. [14] (2018) | Palestine | * | - | * | * | * | 4/5 | Low risk |
| Vinall et al. [32] (2018) | Canada | * | - | * | - | * | 3/5 | Low risk |
| Trumello et al. [33] (2018) | Italy | * | - | * | * | * | 4/5 | Low risk |
| Valizadeh et al. [15] (2019) | Iran | * | - | * | * | * | 4/5 | Low risk |
| Ong et al. [34] (2019) | Malaysia | * | - | * | * | * | 4/5 | Low risk |
| González-Hernández et al. [35] (2019) | Mexico | * | * | * | - | * | 4/5 | Low risk |
| Toly et al. [36] (2019) | USA | * | - | * | * | * | 4/5 | Low risk |
| Ganguly et al. [16] (2020) | India | * | - | * | - | * | 3/5 | Low risk |
| Bonacquisti et al. [43] (2020) | USA | * | - | * | - | * | 3/5 | Low risk |
| Soghier et al. [17] (2020) | USA | * | - | * | * | * | 4/5 | Low risk |
| Axelin et al. [37] (2021) | Finland | * | - | * | * | * | 4/5 | Low risk |
| Cajiao-Nieto et al. [38] (2021) | Spain | * | - | * | - | * | 3/5 | Low risk |
| Das et al. [18] (2021) | USA | - | - | * | * | * | 3/5 | Low risk |
| Garfield et al. [39] (2021) | USA | * | - | * | * | * | 4/5 | Low risk |
| Souza et al. [19] (2021) | Brazil | * | - | * | * | * | 4/5 | Low risk |
| Greene et al. [40] (2015) | USA | - | - | * | * | * | 3/5 | Low risk |
| Rogers et al. [41] (2013) | USA | * | - | * | * | * | 4/5 | Low risk |
| Surmeli Onay et al. [20] (2021) | Turkey | * | - | * | * | * | 4/5 | Low risk |
| Naeem et al. et al. [42] (2019) | Iran | * | - | * | * | - | 3/5 | Low risk |
Table 2.
Study characteristics
| Study | Country | Study design | Sample size |
Characteristics parents |
Characteristics of newborn |
Measurement tool |
Outcome of individual studies | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Participants | Mean age in years range b/w | Mean education above HS | Mean GA range b/w (wk) | Mean weight range b/w (kg) | Name of scale | Cutoff score | Point of data collection | |||||
| Carter et al. [44] (2007) | NZ | Cohort | 447 | Parents | M-30.1 | * | 35.1 | 2.47 | HADS | >12 | <3 Weeks | After 9 months of hospitalization parents were not reported anxiety or depression symptoms. |
| M-242 | F-33.1 | |||||||||||
| F-205 | ||||||||||||
| Yurdakul et al. [6] (2009) | Turkey | CS | 88 | NICU | 30 | 60 | 32.6 | 1.95 | EPDS | >13 | <4 Weeks | Depression and anxiety correlated each other among NICU mothers. |
| Mother | ||||||||||||
| Vanderbilt et al. [22] (2009) | USA | Cohort | 59 | Mother | 29 | 39 | 34 | 2.35 | PPQ | >6 | <7 days | Early intervention was reduced the posttraumatic stress. |
| Holditch-Davis et al. [23] (2009) | USA | Cohort | 177 | Mother | 25.8 | * | 28.3 | 1.10 | PPQ | >6 | During admis | GA, away from home and hospitalization were trigger factors heighten the mental stress in NICU mother. |
| Holditch-Davis et al. [24] (2015) | USA | Cohort | 232 | Mother | 27 | 31 | 27.2 | 1.06 | STAI | >47 | During admis | Neonate mother indicating different kind of psychological distress to NICU units. |
| PPQ | >6 | |||||||||||
| Lefkowitz et al. [25] (2010) | USA | Cohort | 128 | Parents | M-29 | M-21 | <30 | * | ASD | >1 symptom | <7 days | Parents were reported depression and anxiety during hospitalization of their newborn infants. |
| M-87 | F-33 | F-9 | ||||||||||
| F-41 | ||||||||||||
| Dantas et al. [52] (2012) | Brazil | CS | 60 | Mother | 26.5 | 11 | 31.5 | 1.49 | STAI | >40 | During admission | Mother reported high prevalence of anxiety during admission of their newborn baby in NICU unit. |
| Jubinville et al. [27] (2012) | Canada | Cohort | 40 | Mother | 29.2 | 24 | 29 | 1.37 | SASRQ | >38 | <7 days | Safe hospital environment may reduce the psychological distress among NICU parents. |
| Alkozei et al. [8] (2014) | USA | CS | 85 | Mother | 31.9 | 51 | 30.1 | 1.37 | EPDS | >10 | <7 days | NICU mother already psychological disturbed, addition stressor factors including away from home further increases the anxiety & depression. |
| PSS (NICU) | >3 | |||||||||||
| Eutrope et al. [28] (2014) | France | Cohort | 100 | Mother | 29.8 | 79 | <32 | 1.32 | PPQ | >19 | <7 days | Known history of trauma & present birth weight significantly increased anxiety & depression in NICU mother. |
| HADS | >8 | |||||||||||
| Mulder et al. [29] (2014) | NZ | Cohort | 447 | Parents | M-30.1 | M-126 | 35 | 2.47 | HADS | >11 | During admission | There was no long-term mental distress among mother of NICU babies. |
| M-242 | F-33.1 | F-* | ||||||||||
| F-205 | ||||||||||||
| Margaret et al. [9] (2014) | India | CS | 20 | Mother | 20-35 | 12 | 30-34 | 0.75-3.5 | STAI | >40 | <7 days | Mothers exhibit anxiet y towards hospitalization. |
| Segre et al. [10] (2014) | USA | CS | 200 | Mother | 28.1 | 14 | 34 | 0.37-3.7 | BAI | >16 | 2 Weeks | The risk factors like premature, infant illness were prime reason for anxiety and depression in NICU mother. |
| Garfield et al. [11] (2015) | USA | CS | 113 | Mother | 24.7 | 49 | <37 | 1.07 | STAI | * | <4 Weeks | Low income & poor family support demonstrated higher psychological problems in NICU mother. |
| PSS | >6 | |||||||||||
| Umasankar et al. [12] (2016) | Sri Lanka | CS | 75 | Mother | 30 Manually | * | 30-36 | 1.5 | PSS (NICU) | >3 | <7 days | Alteration in parenteral role & hospitalization heighten the stress among NICU mother. |
| Pace et al. [30] (2016) | Australia | Cohort | 214 | Parents | M-32.7 | 92 | 27.7 | 1.02 | HADS | >8 | Before D/C | The anxiety and depression elevated in beginning of NICU and it became declines over period of times. |
| M-113 | F-34.7 | |||||||||||
| F-101 | ||||||||||||
| Lim et al. [13] (2017) | Malaysia | CS | 104 | Parents | 30.1 | 49 | * | * | PSS (NICU) | >3 | <7 days | Considerably more stress reported in NICU mother than father of newborn admitted in NICU. |
| M-62 | ||||||||||||
| F-42 | ||||||||||||
| Harris et al. [31] (2018) | USA | Cohort | 37 | Mother | 29.7 | * | 32 | 1.10 | STAI | >33 | <7 days | There was no psychological difference between termed and preterm babies of NICU mother. |
| Salah et al. [14] (2018) | Palestine | CS | 195 | Mother | 28.2 | 90 | * | 2.76 | BDI | >10 | Social factors increase the psychological distress in NICU mother. | |
| HAM-A | >17 | |||||||||||
| Vinall et al. [32] (2018) | Canada | Cohort | 36 | Mother | 31 | * | <37 | * | PCL | >33 | Before/C | Traumatic procedure in neonatal unit increased the maternal stress among NICU mother. |
| Trumello et al. [33] (2018) | Italy | Cohort | 62 | Mother | 34 | 20 | <32-37 | 1.68 | STAI | >39 | <7 days | Newborn admission was negatively impact and increases emotional distress. |
| Valizadeh et al. [15] (2019) | Iran | CS | 100 | Mother | ±31 | 56 | 34 | 1.85 | STAI | >40 | <7 days | Mother with higher education and prematurity babies demonstrated state anxiety during hospitalization. |
| Ong et al. [34] (2019) | Malaysia | Cohort | 180 | Mother | 29.3 | 104 | 31.1 | 1.46 | STAI | >40 | After first week | Mothers exhibit high anxiety symptoms during NICU admission of their babies. |
| PSS (NICU) | * | |||||||||||
| González-Hernández et al. [35] (2019) | Mexico | Cohort | 188 | Mother | 24.7 | 9 | * | * | HAM-A | >18 | <2 Weeks | Age and occupation were significance with anxiety and depression of NICU mother. |
| BDI | >10 | |||||||||||
| Toly et al. [36] (2019) | USA | Cohort | 19 | Mother | 25.6 | 11 | 29.7 | 1.54 | PPQ | >19 | During admission | Signif icance dif ference bet ween depression and stress among mother of premature babies admitted in NICU unit. |
| Ganguly et al. [16] (2020) | India | CS | 100 | Parents | F-27 | 36 | * | 1.5 | PSS (NICU) | * | After 24 hr of admission | Stress was not significance between mother and father but length of hospitalization significances to stress among NICU parents. |
| M-30 | ||||||||||||
| Bonacquisti et al. [43] (2020) | USA | Cohort | 127 | Mother | 29.6 | 26% | * | * | DASS | .>21 | During admission | Mother and newborn separation increases the psychological symptoms among NICU mothers. |
| Ganguly et al. [16] (2020) | India | CS | 100 | Parents | F-27 | 36 | * | 1.5 | PSS (NICU) | * | After 24 hr of admission | Stress was not significance between mother and father but length of hospitalization significances to stress among NICU parents. |
| M-30 | ||||||||||||
| Bonacquisti et al. [43] (2020) | USA | Cohort | 127 | Mother | 29.6 | 26% | * | * | DASS | .>21 | During admission | Mother and newborn separation increases the psychological symptoms among NICU mothers. |
| Soghier et al. [17] (2020) | USA | CS | 300 | Parents | 30 | 225 | 28-37 | 1-2.5 | CESD-10 | >10 | Before D/C | Even term infant parents demonstrated high depression. Social support inversely proportional to depression. |
| M-267 | PSS | >3 | ||||||||||
| F-33 | ||||||||||||
| Axelin et al. [37] (2021) | Finland | Cohort | 1101 | Parents | M-31 | M-337 | 31.8 | 1.58 | EPDS | >13 | During D/C | Provision of family center care may improve mental wellbeing of parents of newborn admitted in NICU unit. |
| M-635 | F-33 | F-231 | ||||||||||
| F-466 | ||||||||||||
| Cajiao-Nieto et al. [38] (2021) | Spain | Cohort | 51 | Father | 20-45 | 39 | <37 | * | STAI | * | 3rd day | Father repor ted anxiet y towards parenthood and NICU unit during hospitalization. |
| Das et al. [18] (2021) | USA | CS | 96 | Mother | 28.4 | * | 35.2 | 2.33 | DASS | .>21 | Before 44 weeks | Early screening may reduce the psychological symptoms among NICU mothers. |
| PHQ | >9 | |||||||||||
| Garfield et al. [39] (2021) | USA | Cohort | 431 | Parents | M-33 | M-175 | 31.5 | 1.87 | EPDS | >13 | <7 days | Parents were demonstrated depression symptoms during NICU admission of their babies. |
| M-230 | F-35.1 | F-149 | ||||||||||
| F-201 | ||||||||||||
| Souza et al. [19] (2021) | Brazil | CS | 91 | Mother | >18 | 48 | 37 | 2.69 | BAI | >1 | Before D/C | Social factors heighten the psychological discomfort among NICU parents. |
| BDI | >10 | |||||||||||
| Greene et al. [40] (2015) | USA | Long | 69 | Moher | 27 | 52 | 27.5 | 0.95± 0.24 | STAI | >40 | Before 2nd Weeks | Psychological problems often reported in primipara mothers than multipara. Therefore, distractive intervention targeting these populations. |
| Cohort | CES-D | >16.6 | ||||||||||
| >19 | ||||||||||||
| Rogers et al. [41] (2013) | USA | Long | 73 | Mother | 27.2 | 39 | 25.5 | * | STAI | >40 | At time of D/C | Factors related to family, marital status, parental role and newborn characteristic increased the psychological problems among NICU mothers. Therefore, planned intervention may reduce these problems. |
| Cohort | * | * | ||||||||||
| Surmeli Onay et al. [20] (2021) | Turkey | CS | 93 | Mother | 30.6 | 28 | 28 | 2.5 | STAI | >40 | <7 days | Tendency of psychological symptoms of NICU mothers were not affect the EBF in preterm infants. |
| Naeem et al. et al. [42] (2019) | Iran | Cohort | 80 | Parents | * | M-47 | 34-36 | * | PPQ | >19 | 3-5 Days after birth | GA was major reason for psychological symptoms NICU parents. Onset psychological symptom earlier in mothers than fathers. fathers indicated delayed onset of PTSD symptoms. |
| F-33 | ||||||||||||
b/w, between; M, mother; F, father; HS, higher secondary; GA, gestational age; NZ, New Zealand; CS, cross-sectional study; NICU, neonatal intensive care unit; HADS, Hospital Anxiety and Depression Scale; EPDS, Edinburgh Postnatal Depression Scale; PPQ, perinatal posttraumatic stress disorder; STAI, State-Trait Anxiety Inventory; ASD, acute stress disorder; SASRQ, Stanford Acute Stress Reaction Questionnaire; SAS, Self-Rating Anxiety Scale; PSS, Parental Stressor Scale; BAI, Beck’s Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies Depression Scale; HAM-A, Hamilton Anxiety Rating Scale; PCL, posttraumatic checklists; DASS, Depression Anxiety and Stress Scale; CESD-10, Center for Epidemiological Studies Depression Scale; PHQ, Patient Health Questionnaire.
Table 3.
Pooled prevalence of participant variables among included studies
CI, confidence interval; STAI, State-Trait Anxiety Inventory; HADS, Hospital Anxiety and Depression Scale; HAM-A, Hamilton Anxiety Rating Scale; BAI, Beck’s Anxiety Inventory; SAS, Self-Rating Anxiety Scale; BDI, Beck Depression Inventory; EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; DASS, Depression Anxiety and Stress Scale; CESD-10, Center for Epidemiological Studies Depression Scale; PPQ, perinatal posttraumatic stress disorder; PSS, Parental Stressor Scale; SASRQ, Stanford Acute Stress Reaction Questionnaire; PCL, posttraumatic checklists; ASD, acute stress disorder; NICU, neonatal intensive care unit.
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