Premature Birth Studies

Effects of Prematurity on Development - part 3

By Michele Bell

A substantial body of descriptive literature suggests that there are three aspects of the parenting experience that are unique to prematurity. These include the interruption of a normal pregnancy, the prolonged hospital experience, and the behavioural patterns peculiar to the premature infant (Minde, 2000; Goldberg & Di Vitto, 2002). This section considers each of these aspects and how they may affect the premature infant, their parents and later childhood development.

Mothers undergo a developmental process during pregnancy associated with the physical movements of their infant in the womb that is an important aspect in the process of prenatal maternal preoccupations and attachment of the mother to her infant (Winnicott, 1956). When this process is suddenly interrupted, the birth changes from a prepared event to an unanticipated emergency associated with anxiety and fear for the infant's very survival. Given that the mother was unprepared for her infant's birth suggests that we have premature parents as well as premature infants (Eckerman & Oehler, 1992). Indeed, the crisis aspect of the premature birth and its associated psychological impact has long been recognised (Pederson, Bento, Chance Evans & Fox, 1987; Minde, 2000; Goldberg & Di Vitto, 2002). In addition, parents soon must come to terms with the fact that they cannot care for their infants, possibly causing anxiety, which may be reinforced by the overwhelming technical environment in which their infants are placed (Field, 1990). That is, instead of looking forward to bringing their newborn home, parents anticipate a prolonged hospital stay, and the possibility of life-threatening complications.

Given the precarious nature of the premature infant to maintain homeostasis, the primary agenda of the New Born Intensive Care Unit (NICU) is to maintain the physical well being by means of respiratory machines and incubators (Goldberg & Di Vitto, 2002). As previously mentioned, parents are exposed to a highly technical space that, in its very nature, fails to foster normal parent-infant bonding. For example, infants are fed at particular intervals even if they have to be aroused from a deep sleep and are often subjected to invasive procedures all of which may be contrary to the expected mother-mediated protection from environmental perturbations (Field, 1990; Minde, 2000; Goldberg & DiVitto, 2002). Consequently, to the extent that the premature infant experiences human contact, it is primarily for medical procedures. Medical procedures alone have been estimated to account for the majority of social and physical contact a premature infant endures whereas, mothers' account for a mere 14 percent (Goldberg & Divitto, 2002). In addition, parent's social interactions with their infants in NICU proceed under very different constraints than those for parents of full-term infants. Observational research suggests that parents become acquainted with their infants for relatively brief periods largely separated in time, and in periods not necessarily related to feeding (Eckerman & Oehler, 1992). Not surprisingly, parents often believe that the medical professionals know better how to care for their infant. That is, others feed their infant, clean their infant and instruct mothers when and how to contact their infant, and decide what is and isn't an emergency (Goldberg & Di Vitto, 2002). Indeed research suggests that, mothers of premature infants often feel alienated from their infants, during their NICU stay (Eckerman & Oehler, 1992). However lower levels of maternal engagement also appear to persist after the infant has reached full recovery and returned home (Minde, 2000).

To determine which factors might contribute to these lower levels of maternal engagement Minde, Whitelaw, Brown and Fitzhardinge (1983) tested variables pertaining to the length of neonatal course and the medical complications of premature infants. The authors compared 20 premature infants with few complications and 20 infants with serious complications during their neonatal course. After controlling for birth weight, gestational age and socioeconomic status, the authors report a clear association between length of stay and mother-infant interaction. That is, in the dyad with the baby who was sicker, the baby's level of alertness and physical activity and the mother's level of maternal engagement were consistently lower, both in NICU and three months following discharge. In a subsequent study, (Minde, 2000) that compared premature infants who had been hospitalized for more than 35 days with premature infants who were discharged within 17 days, the authors again found significant differences in infant and parental behaviours. For the infant who was discharged within 17 days, social behaviours of the infant and mother's responsiveness rebounded immediately following discharge. However, for the infant who spent a significant time in hospital due to immaturity rather than illness, the recovery of maternal behaviour lagged behind the infant's recovery and could still be documented some three months following discharge.

One interpretation of these results is that prolonged separation due to extreme prematurity acts negatively upon maternal behaviour. This interpretation can be understood from Winnicott's (1956) psychoanalytical view of the mother's mental life during the immediate post-birth period. As mentioned previously, Winnicott asserts that in order for a mother to develop a selective and enduring bond with her infant she must be in a temporary state of 'primary maternal preoccupations'. This condition refers to the mother's exclusive and obsessive like involvement with thoughts and concerns for her newborn. Winnicott contends that a state of heightened anxiety coupled with an exclusive mental focus on the new baby is not only normal but crucial to the formation of maternal attachment and subsequent maternal responsiveness.
Interestingly, these clinical data have recently been supplemented by a study examining the effects of maternal bonding under conditions of proximity, separation and potential loss (Feldman, Weller, Leckman, Kuint & Eidelman, 1999). Concerning the maternal aspect of bonding, characterized by mental representations of the infant, an increase-decrease pattern in response to initial and prolonged separation was found in mothers of term and premature infants. Whereas mothers of term infants experienced medium to high levels of thoughts and concerns for their infants, initial separation increased these preoccupations. However, with prolonged separation these maternal preoccupations significantly decreased. The authors suggest that at a certain point on a continuum from proximity to separation, the highly anxious state of maternal preoccupations appears to turn into disengagement and diminished reactivity which is characteristic of maternal depression.

A large body of research indicating greater anxiety and depression among mothers of premature infants when compared to mothers of term infants supports these data. For example longitudinal studies investigating mother's emotional life following a premature birth report that premature mothers are more likely to experience a heightened state of anxiety one week after the birth. However, premature mothers tend to indicate the most negativity some 4-5 weeks after their infant has reached full recovery and returned home (Gennaro, 1988). In two other descriptive studies, mothers of premature infants reported two periods of emotional difficulty. The first being immediately after birth and the second being after the baby returned home (Bidder, Crowe & Gray, 1974; O'Brian, Heron Asay, McCluskey-Fawcett, 1999).

Even mild disruptions in responsiveness due to subclinical depressive symptoms have been shown to increase the risk for compromised attachment patterns in premature dyads and later adverse internalizing, externalizing and poor social functioning of children (Poehlmann & Fiese, 2001). Further, these mild depressive symptoms show positive associations with neo-natal indices pertaining to the duration of their infant's hospitalization. Taken together, these findings suggest two outcomes. Firstly, that a highly anxious state in premature mothers may be an important predictor of depressive mood following the discharge of an infant. Further, that premature infants who are separated from their mothers for prolonged periods and whose mothers experience depression or mild feelings of apathy, may be at the greatest risk for the development of internalizing, externalizing and poor social functioning.

Having established the difficulties of maternal bonding for parents of infants born premature who are separated for extended periods, it should also be noted that following discharge these infants place enormous demands on their parents. Studies that have followed premature dyads shortly after discharge are numerous, and have noted substantial differences in the premature infant as a social partner regardless of mother's emotionality. For example, where behavioural and social differences between premature and term infants are reported, premature infants are found to be less responsive, to show less positive affect (Field, 1979), and to be less initiating and more irritable (Goldberg & DiVitto, 2002; Cox, Hopkins & Hans, 2000). These findings lead Field (1979) and others (Mangelsdorf, Plukett, Dedrick, Berlin, Meisels, McHale, & Dichtellmiller, 1996) to conceptualize the premature infant as having a relatively high threshold to social stimulation coupled with a low tolerance for behavioural stimulation. That is, premature infants are less socially responsive and harder to soothe.

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