تاثیر حمایت زود هنگام بر استرس مادران نوزاد نارس در بخش مراقبت‌های ویژه نوزادان، یک مطالعه نیمه تجربی

زمینه و هدف: زایمان زودرس برای مادران یک تجربه فوق العاده استرس‌زا است. در این مطالعه برآنیم که تاثیر اجرایی شدن مداخلات حمایتگرانه زود هنگام مبتنی بر شواهد را بر استرس مادران نوزادان نارس در nicu ارزیابی نماییم.روش بررسی: این مطالعه نیمه تجربی در بخش‌های نوزادان بیمارستان‌های شهید اکبرآبادی و مهدیه شهر تهران، از 25 بهمن 1394 تا 25 اردیبهشت 1395 که به طور تصادفی به سایت‌های مداخله و کنترل اختصاص داده شدند، انجام شد. بر اساس معیارهای ورود/ خروج، 68 نوزاد و مادر در بیمارستان شهید اکبرآبادی (کنترل) و 75 نوزاد و مادر در بیمارستان مهدیه (مداخله) وارد مطالعه شدند. در زمان ترخیص، استرس مادر توسط ابزار استرس والدین: واحد مراقبت ویژه نوزادان (pssnicu: parental stressor scale: neonatal intensive care unit ) اندازه گیری شد. در گروه مداخله، در حمایت اطلاعاتی، معنوی، تکریمی و عاطفی از مادران در nicu، مداخلات مختلفی پیش بینی شده بود که به تدریج از ابتدای ورود نوزاد به nicu، شروع و در سراسر اقامت در واحد نوزادان ادامه یافت و تا سه ماه از زمان تولد نوزاد پی‌گیری شد. گروه کنترل تحت مراقبت معمول قرار گرفتند. داده‌ها با استفاده از نسخه 13 نرم افزار stata و با استفاده از آزمون‌های تی، مجذور کای و وزن دهی درمانی احتمالی معکوس inverse probability treatment weights (iptw) تحلیل شدند. یافته‌ها: پس از تعدیل متغیرهای قبل از درمان توسط iptw، اختلاف میانگین تعدیل شده در نمره استرس نسبت به محیط nicu، 0.55( 0.89 تا 0.2) با (0.001> p) و نسبت به تغییر در نقش مادری، 0.37 (0.68 تا0.06) با (0.02= p)، نسبت به ظاهر و رفتار و درمان نوزاد، 0.29 (0.43 تا0.37) با (0.89= p) و نمره استرس کل 0.25 (0.58 تا 0.07) با (0.13= p) بود که نمره استرس نسبت به محیط nicu و تغییر نقش مادری، در گروه مداخله، نسبت به کنترل به شکل معنی‌داری کمتر بود.نتیجه‌گیری کلی: با توجه به اجرای موفقیت آمیز مداخلات در خصوص برخی زمینه‌های استرس مادری، پیشنهاد می‌شود سیاست گذاران نسبت به اجرایی نمودن این مداخلات مبتنی بر شواهد، در قالب مدل‌هایی خانواده محور، حمایت‌گر و خوشامدگو در nicu اهتمام ورزند.

Effect of Early Support on the Stress of Mothers with Preterm Infants in Neonatal Intensive Care Units: A Quasi-experimental Study

Background Aims: During pregnancy, women have expectations of their future baby, and preterm delivery may negatively affect such expectations. On the other hand, postpartum maternal stress is a wellestablished issue, which intensifies with the birth of a premature infant. Preterm birth is an unexpected experience and a multifaceted incident that leads to two main consequences, which are the medical and neurophysiological complications of the infant (especially in verylowbirthweight infants weighing less than 1,500 grams and aged less than 32 weeks) and the adverse effects on the motherinfant relationship due to the prolonged admission of the infant to the neonatal intensive care unit (NICU). If the infant is not discharged, the mother will be unable to fully assume their maternal role. Therefore, proper intervention protocols help reduce maternal stress and empower mothers to cope with the complex and technological environment of the NICU. The present study aimed to evaluate the impact of evidencebased early supportive interventions on the maternal stress caused by preterm birth.Materials Methods: This quasiexperimental study was performed at the NICUs of Mahdieh Hospital and Shahid Akbarabadi Hospital in Tehran, Iran. Sampling started on February 14, 2016 and continued until May 14, 2016. Both centers were teaching, referral hospitals with three levels of NICUs. NICU level one is designed for generally ill and lowbirthweight infants who do not require intensive care (minimal care and basic care following delivery), NICU level two is considered for the infants who need other intensive care than ventilator support and surgical care, and NICU level three is designed for the critically ill infants who require lifesustaining therapies, particularly auxiliary ventilation and optimally tailored neonatal intensive care. In this study, the hospitals were considered as random allocation units, with Mahdieh Hospital assigned to the intervention site and Shahid Akbarabadi Hospital assigned to the control site. The sample population included mothers with premature infants. Preterm infants and their mothers were selected within three months based on the inclusion and exclusion criteria of the study. The inclusion criteria were having an infant with the gestational age of less than 37 weeks, birth weight less than 2,500 grams, and high probability of survival, maternal consent for enrollment, Iranian nationality, and the ability to communicate verbally. The exclusion criteria were infants with abnormalities or severe debilitative conditions (e.g., grade III or IV intraventricular hemorrhage). During the study period, 75 mothers and infants were classified as the intervention group, and 68 mothers and infants were assigned to the control group. The intervention was designed based on the model of the support system of mothers with premature infants. In this model, parents and infants are at the center of the support model and should be supported during critical transitional periods, including prefertilization, before delivery, NICU admission, discharge, and at home. Based on the model, various interventions were provided to the mothers at the NICUs, which gradually started upon the admission of the premature infant to the NICU, continued throughout the admission, followedup the subjects until three months since the birth of the infant. In the intervention group, the mothers were provided with continuous informational support (emphasis on the continuous provision of information to the mothers about the infants #39; illness, treatment, growth and care, infants #39; emotional and behavioral needs and responses, and maternal rights and responsibilities during admission). Furthermore, we provided spiritual support (in an illness crisis, spirituality may be essential to coping and have a positive impact on the response of individuals since reliance upon a higher power could become a source of hope for a positive outcome. Fostering spiritual values protects individuals #39; integrity and gains spiritual perseverance to encounter hardships), appraisal support (strengthening and supporting the maternal role and encouraging mothers to strengthen their relationship with their infants and actively partake in their care since doing their best in the care of the infant makes them feel better. In fact, encouraging mothers to participate in care of preterm infants allows them to conceive their maternal role), and emotional support (addressing the feelings and concerns of the mothers and showing concern for their health and the health of the newborn so that they could adopt to the infant #39;s illness and the other affected aspects of their lives). The control group received routine care. Upon discharge, maternal stress was measured using the parental stressor scale: neonatal intensive care unit (PSSNICU). The main sources of maternal stress included the NICU environment, infant #39;s appearance, special behaviors of treatment of the infant, motherinfant relationship, and maternal role. Data analysis was performed in the STATA software version 13 using ttest, Chisquare, and inverse probability of treatment weighting (IPTW).Results: After adjusting the pretreatment variables by the IPTW, the mean difference in the adjusted stress score regarding the NICU environment was estimated at 0.55 (range: 0.890.2) (P<0.001), while it was 0.37 (range: 0.680.06) regarding the changes in the maternal role (P=0.02), and 0.29 (0.430.37) regarding the infant #39;s appearance and behavior and treatment of the infant (P=0.89). In addition, the total stress score was estimated at 0.25 (range: 0.580.07) regarding the NICU environment (P=0.13), and the stress score of the intervention group was significantly lower compared to the control group regarding the changes in the maternal role.Conclusion: For the successful implementation of interventions designed based on scientific evidence and facilities, it is suggested that policymakers implement these evidencebased interventions to improve the quality of care of premature infants and reduce maternal stress in the form of familycentered support models in NICUs. Furthermore, it is recommended that similar investigations be performed on fathers. Although the results of this study confirmed the effects of the intervention on reducing maternal stress regarding the technological NICU environment and changes in the maternal role, it may not lead to the significant reduction of total stress and stress about infants #39; appearance, behavior, and treatment in mothers. As such, detailed studies should be conceived based on effective interventions in this regard.