Parents of preterm infants two months after discharge from the hospital: are they still at (parental) risk?
Abstract: It is well-known and documented that the premature birth of an infant and its subsequent hospitalization in the Neonatal Intensive Care Unit (NICU) is a source of considerable stress for parents. However, little is known about the parents' emotional state and functioning during the months following the infant's discharge from the NICU. The present study compares parental stress and perceptions of parental competence among mothers and fathers of preterm infants two months after discharge from the NICU in Israel with those of parents of full-term infants. The findings show that even at this point in time parents of preterm infants still show higher levels of parental stress and lower perceptions of parental competence than do parents of full-term infants. The importance of the findings for the design of intervention and treatment programs is discussed.

KEY WORDS: Israel; NICU; parental stress; preterm infants; social work
Article Type: Report
Subject: Infants (Premature) (Family)
Parenthood (Social aspects)
Parenthood (Psychological aspects)
Stress (Psychology) (Social aspects)
Authors: Olshtain-Mann, Orly
Auslander, Gail K.
Pub Date: 11/01/2008
Publication: Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2008 National Association of Social Workers ISSN: 0360-7283
Issue: Date: Nov, 2008 Source Volume: 33 Source Issue: 4
Topic: Event Code: 290 Public affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 190051939
Full Text: The birth of a healthy baby and the parenting roles that ensue are considered normative life transitions that require numerous physical and emotional adjustments. These changes may place heavy demands on parents' time, energy, and resources. These in turn may result in stress--a feeling that arises when a situation makes demands on the individual that are appraised as exceeding available resources and upsetting the sense of well-being (Lazarus & Folkman, 1984).

Premature birth and subsequent hospitalization of an infant in the Newborn (or Neonatal) Intensive Care Unit (NICU) are particularly stressful. Major stressors include concern for the survival of the newborn and potential effects on his or her development (Hack, Taylor, Klein, & Mercuri-Minich, 2000; Hughes, McCollum, & Sheftel, 1994; Partridge et al., 2005); difficulties in carrying out the parental role, including the separation from the baby and the somewhat limited opportunity to foster attachment (Franklin, 2006; Miles, Funk, & Kasper, 1992; Preyde, Ardal, & Bracht, 2001); the physical environment of the NICU; and the interaction with the professional staff (Miles et al., 1992).

Minuchin (1974) claimed that parenthood is one of life's most difficult tasks and that parents never feel they are doing the job to their full satisfaction. Most parents have doubts and lack confidence regarding fulfillment of their parental role. Researchers from LeMasters (1957) through McCubbin and Blum-Dahl (1985) and more recent studies (Ferketich & Mercer, 1995; Hudson, Eleck, & Fleck, 2001) have claimed that parents in modern society feel a lack of confidence that is mainly due to the huge responsibility that comes with the parental role and the high and sometimes unrealistic expectations society holds about being a "good parent."

When a baby is born prematurely, parents may be even less certain of their competence. This uncertainty may stem from their feelings of lack of control over their child's health and survival. Parents of preterm infants report that it is difficult to develop feelings of parental competence when confronted by the highly technological environment in which the baby is treated and where any contact with the baby, even feeding and holding, takes place under the direction and supervision of the medical staff. Parents of preterm infants tend to see themselves as secondary caregivers to the infant, whereas the nurses in the NICU are seen as the primary caregivers (Miles et al., 1992; Preyde et al., 2001).

Parental stress and competence have long-term implications for the child and the parent as well. The stressful experiences of parents of preterm infants may seriously delay the attainment of the parental role (Easterbrooks, 1988; Harrison, 1990) and may have a long-term effect on parent-infant interactions and child development (Nadeau, Boivin, Tessier, Lefebvre, & Robaey, 2001; Saigal, Hoult, Streiner, Stoskopf, & Rosenbaum, 2000). For example, Benzies, Harrison, and Magill-Evans (2004) found that parenting stress regarding the preterm infant during the first year of life predicted the frequency of childhood behavior problems at age 7. Muller-Nix and colleagues (2004) found that during play interaction at age 6 months, mothers of preterm infants who had experienced traumatic stress in the perinatal period were less sensitive and more controlling than were mothers of full-term infants. At 18 months of age, the interactional behavior of preterm infants was different from that of full-term infants and was correlated with maternal traumatic stress. The researchers asserted that these results underline the importance of maternal traumatic experience related to premature birth and its potential long-lasting influence on mother-child interactional behavior.

Several factors have been found to be related to parental stress and competence among parents of preterm infants, including socioeconomic status (Cronin, Shapiro, Casiro, & Cheang, 1995; Siefert, Thompson, Ten Bensel, & Hunt, 1983), parental age and education (Auslander, Netzer, & Arad, 2003a; Zahr, 1993), and religiosity (Hughes et al., 1994). This last factor is particularly important in Israel, where religiosity both denotes one's level of religious observance and also defines one's sociocultural affiliation. For example, being ultra-orthodox indicates strict observance and literal interpretation of Jewish law as well as membership in a collectivist culture in which members' lives are strictly governed by group norms and beliefs. Distinct standards of dress and language and self-segregated neighborhoods, schools, and other institutions serve to perpetuate a system of values and norms (Shor, 1998). Earlier studies in Israel found ultra-orthodox and religious mothers to be less anxious following the birth of a preterm infant as compared with mothers who defined themselves as secular or traditional (Auslander et al., 2003a), whereas ultra-orthodox fathers had significantly lower expectations of the NICU staff (Auslander et al., 2003b).

The literature on parents of preterm infants suffers from several limitations, including the timing of studies, the samples selected, and the lack of control groups, detailed as follows: Most studies involving parents of preterm infants can be divided into two main groups--those that focus on the hospitalization period and those that focus on the long-term effects of prematurity, that is, after several years.

Studies in the first group included examinations of parental stress, competence, expectations, satisfaction, and coping in the NICU (Auslander et al., 2003b, Nottage, 2005; Preyde et al., 2001) as well as interventions to improve these outcomes. Most included mothers only. Browne and Talmi (2005) described a short-term high-risk mother-infant dyad group intervention in the NICU and its enhancement of mother's knowledge and sensitivity. Jotzo and Poets (2005) described how mothers in the NICU who were included, after giving birth, in an intervention program combining early crisis intervention and intense support at critical times reported reduced symptoms of traumatization relating to premature birth. Preyde and Ardal (2003) described the effectiveness of a parent "buddy" program for mothers in the NICU. This parent-to-parent peer support paired mothers with trained mothers who previously had a preterm infant, who provided principally telephone support in reducing stress among mothers.

The second group of studies examined the long-term effect of prematurity on parents and children and the relationship between them. Most of these studies took place 18 months to several years after birth and point to the need for preventive interventions to mediate the risks of later adverse outcomes (Benzies et al., 2004; Halpern, Brand, & Malone, 2001; Muller-Nix et al., 2004; Swartz, 2005; Taylor, Klien, Minich, & Hack, 2001). Very few studies focus on the period between hospital discharge and the first 18 months of the infants' life. This creates a void in our knowledge and understanding of parents' needs during this period. Major child-development theorists, including Freud, Erickson, Bowlby, and Ainsworth have stressed the importance of the parent-infant relationship during the first months of life for the infant's future emotional development.

This study focuses on the period of two months after discharge from the NICU. By this time, initial survival issues have been resolved and parents are caring for their baby on their own, without medical supervision. It would be expected that once the main stressors of premature birth and hospitalization have been eliminated, parents' stress levels and perceived competence would be similar to those of parents of full-term babies at the same point in time. To assess this, the current study included a comparison group of parents of full-term infants.

The few studies that focus on this time period used very limited samples. For example, Thomas, Renaud, and Depaul (2004) examined parenting stress among mothers of preterm infants six to 10 weeks after discharge. Findings show that mothers of preterm infants experienced stress that is largely attributed to the particular characteristics of low-birthweight infants. As opposed to the present study, this study included mothers only. Also, researchers reported a high rate of missing items. Only 16 of the 29 mothers' scores were complete.

Another study by Jackson, Ternestedt, and Schollin (2003) included interviews of seven sets of parents of preterm infants at two weeks and at two, six, and 18 months of age. Findings were analyzed by using a phenomenological method. Similarities in how mothers and fathers described their parental roles involved concern for the child, insecurity, adjustment, and relationship with the child. However, mothers had more responsibility and control of the care and a need to be confirmed as a mother, whereas fathers were confident in leaving the care to others and sought to find a balance between work and family life. Building upon these small studies, the current study used a fairly large sample of both mothers and fathers of preterm infants.

STUDY GOALS AND HYPOTHESES

The aim of the current study was to gain further understanding of the emotional state and functioning of parents of preterm infants after an initial period of adjustment following discharge from the NICU. Do these parents still suffer from higher parental stress and lower parental competence than do parents of full-term infants, as has been reported during the hospitalization period? On the one hand, common sense might lead us to think that by this time, once the main stressors of premature birth and hospitalization have been eliminated, parents' stress levels and perceived competence would be similar to those of parents of full-term infants. On the other hand, the very few empirical studies examining parents of preterm infants at this point in time had sample limitations. Therefore, the earlier-mentioned question was explored in this study with no specific a priori hypotheses.

In addition, we examined several characteristics of the parents (age, education, religiosity, and parity) and the baby (birth week, birthweight, breathing difficulties in the NICU, complications in nervous system, length of hospitalization) that were related to parental stress and competence in previous studies. This examination enabled us to identify parents at higher risk who might benefit from outreach and early intervention efforts.

METHOD

Study Population and Sample

The target population of this study was Hebrew-speaking couples (mothers and fathers) whose preterm baby was hospitalized in the NICU of any of three hospitals in Jerusalem during the period of 2000 through 2001 .The premature babies weighed 1,750 grams (3.85 pounds) or less, were born in the 36th week of pregnancy or earlier, and were treated in the NICU for at least one week. Parents of infants who were not expected to survive or who had severe congenital anomalies, as determined by the attending physician, were excluded. Both parents were interviewed. A nonmatched comparison group of Hebrew-speaking parents of full-term infants born in the same hospitals was also recruited. In both groups, only singleton babies were included.

Data Collection

Parents of full-term infants were approached by the principal investigator, together with a nurse in the maternity ward, before the mother's discharge. The parents were informed of the purpose of the study and asked to give their written consent to participate, before the data collection, in accordance with the hospitals' Institutional Review Board. Those who consented provided contact details. The principal investigator contacted them two months later and arranged to interview both parents at their home.

Parents of preterm infants were approached by the NICU social worker. In Israeli hospitals, parents of NICU patients routinely meet with a social worker who prepares them for their first visit in the NICU, accompanies them, and offers support and referrals as needed. In this project, the social worker informed the parents of the study and those who agreed to participate were told that the researcher would contact them after discharge. A few days before discharge, the social worker reminded them to expect the researcher's call two months later.

Refusals. Among parents of preterm infants, only two couples refused. Both stated that they did not want to commit to an interview two months away.

Attrition. Among parents of full-term infants, attrition was much higher and occurred at three points in time: (1) At the initial invitation stage, 29 mothers refused. Fourteen were ultra-orthodox Jewish women who stated that their belief system does not allow them to participate. According to them, either their beliefs would not permit them to share intimate family details with strangers or they observed the restriction against men conversing with strange women or being alone with them in a room. The remaining 15 women were not willing to commit so long in advance to an interview at a period they knew would be busy for them. (2) At the phone call stage, 14 couples dropped out. The reasons were as follows: They changed their minds or they moved away and had problems in finding the time to meet with the interviewer. (3) After the interview was scheduled, 16 fathers were not present and could not be interviewed: Six of the fathers were ultra-orthodox men who were not aware of the need to meet with a woman interviewer and refused to participate once she arrived.

Interviews. All interviews were conducted by social workers trained by the principal investigator following a set protocol. The protocol specified what to tell parents and how to instruct them to complete the questionnaires. The interview included answers to parental stress and parental competence questionnaires. Both mother and father filled out the questionnaires in private, without consulting or sharing the answers with each other.

Sample. The study relied on a consecutive nonprobability sample, in which all parents who met the inclusion criteria were invited to participate until a sample of 80 pairs of parents of preterm babies and 80 pairs of parents of full-term babies were interviewed.

Measures

Two dependent variables, parental stress and parental competence, were measured.

Parental Stress. This variable was measured on a scale developed by Pearlin and Schooler (1978).This instrument consists of nine items, each beginning with the phrase, "When I think about my experiences as a parent, I feel ..." and ends with one of the following feelings: frustrated, tense, worried, satisfied, troubled, unhappy, emotionally drained, successful, unsure of myself. Responses range from 1 = very much to 4 = not at all, with several items reverse-coded. Scores are summed and range from nine (low stress) to 36 (high stress). Construct validity and reliability were assessed by Pearlin and Schooler. The instrument was translated to Hebrew and used in an earlier study done in Israel (Shmueli-Polak, 1992), with a reliability score of [alpha] = .89. In the present study [alpha] = .87.

Parental Competence. This variable was measured by the 22-item Self-Perception of the Parental Role (MacPhee, Fritz, & Miller-Heyl, 1996) instrument. For this study, we used the six-item Parental Competence subscale. Each item includes two opposing statements such as the following: "Some parents often worry about their functioning as parents while other parents feel confident about their parenting abilities." The parent is asked to choose one of the two statements and then to add whether it is "very true" or "more or less true." Scores are summed and range from six (low competence) to 30 (high competence). MacPhee et al. (1996) reported internal consistency of [alpha] = .78 to .87 and test-retest reliability of .80 to .88. They also found both construct and criterion validity. The present study was the first to use this instrument in Israel. It was translated into Hebrew, back-translated, and pretested with internal consistency of [alpha] = .68. The internal reliability in the present sample was [alpha] = .69.

Independent Variables. These variables were obtained through a self-report form and included the following parental background variables that were found to be relevant in earlier studies: parity, level of education, and degree of religiosity, which was initially coded as an ordinal variable (1 = secular, 2 = traditional, 3 = religious, 4 = ultra-orthodox). For the purpose of this study, degree of religiosity was recoded into a different variable (1 = not religious, including secular and traditional; 2 = religious; 3 = ultra-orthodox). Parents' age and gender were included, as is routinely done in most health-related research.

Data regarding the infant's medical condition were obtained by the NICU social worker and included infant's gender, birthweight, gestational age at birth, required breathing assistance, central nervous system (CNS) complications, and length of hospitalization.

Data Analyses

The first set of data analyses was carried out on the entire sample (preterm and full-term). It included a comparison of parental stress and perceived parental competence between parents of preterm and parents of full-term infants, for mothers and fathers separately, through the use of t tests.

The second set of analyses included the preterm sample only. We carried out multivariate analyses to identify factors related to parental stress and competence among parents of preterm infants, for mothers and fathers separately, using linear multiple regression. Preliminary bivariate analyses were carried out to identify variables related to the dependent variables, stress and parental competence (data not shown). On the basis of those analyses, the following variables were included in the multivariate analyses: parental background variables (age, level of education, religiosity) and medical and infant status variables (gender, birthweight, gestational age at birth, required breathing assistance, CNS complications, length of hospitalization, and birth order).All of the variables were entered simultaneously.

RESULTS

Of the entire sample (N = 320), mothers' average age was 30 years (SD = 5.14) and fathers' was 33 years (SD = 5.75). The level of education of both mothers and fathers was fairly high, with mothers having an average of 14 years of education (SD = 2.48) and fathers having an average of 15 years of education (SD = 4.67). More than 50 percent of couples were secular and traditional (56.2 percent), 25.3 percent were religious, and 18.5 percent were ultra-orthodox. Of 160 infants, 76 were girls (47.5 percent) and 84 were boys (52.5 percent). The preterm infants' average birthweight was 1,326 grams (2.92 pounds) (SD = 327.12 grams), and average birth week was 30 (SD = 2.83). On average, hospitalization lasted 60 days (SD = 33); 71.3 percent of the preterm infants received help breathing and 12.5 percent had CNS complications.

Stress and Parental Competence among Parents of Full-Term and Preterm Infants

Levels of parental stress and parental competence were compared separately for mothers and fathers between parents of full-term and preterm babies. At two months after discharge, mothers of preterm babies showed significantly higher levels of parental stress (M = 16.33, SD = 3.6) than did mothers of full-term babies (M = 14.82, SD = 3.55; t(79) = 2.69, p < .01). Similarly, mothers of preterm babies had significantly lower levels of parental competence (M = 22.53, SD = 4.02) than did mothers of full-term babies (M = 24.57, SD = 3.24; t(79) =3.57, p < .01). Fathers of preterm babies showed significantly higher levels of parental stress (M =15.22, SD = 4.70) compared with fathers of full-term babies (M = 13.13, SD = 3.51; t(79) = 3.04, p < .01). There were no significant differences in parental competence between fathers of preterm (M = 24.64, SD = 3.09) and fathers of full-term babies (M = 24.46, SD = 3.74; t(79) = -0.33, ns).

Variables Related to Parental Stress and Competence among Parents of Preterm Infants

No parental background variables were related to the stress of mothers or fathers of preterm infants. Only the infant's birth week was related to mother's stress. The earlier the baby was born, the higher the mother's stress (r = .258, p < .05).

Similarly, no parental background variables and only one infant-related variable were related to father's stress. Fathers of preterm infants with CNS complications reported higher levels of parental stress (M = 20.7, SD = 3.9) compared with fathers whose infants did not have such complications [M = 14.4, SD = 6.1; t(10.1) = -3.18,p < .01].

The relationship between the independent variables and the mothers' perceived parental competence are shown in Table 1. None of the infant variables were related to maternal competence. On the other hand, all three parental background variables were related to maternal competence--mothers' age, religiosity, and education. Older mothers reported higher competence than did younger mothers as did both religious and ultra-orthodox mothers. However, the more educated the mother, the less competent she felt.

The relationship between the independent variables and the fathers' perceived parental competence are shown in Table 2. Fathers' age, education, and religiosity were related to perceived parental competence, as was the baby's gender. As with mothers, older fathers reported higher perceived parental competence than did younger ones as did the ultra-orthodox fathers. On the other hand, the more educated the father was, the less competent he felt. Fathers of boys also reported higher levels of competence.

DISCUSSION AND IMPLICATIONS FOR SOCIAL WORK

The parents in this study were asked to answer questions regarding the stress and competence they felt at the time of the interview (and not in retrospect to the hospitalization), regarding their role as a parent of a new baby. Interviews took place two months after the baby's discharge from the hospital. Parents of full-term infants had two-month-old babies, whereas the parents of preterm infants had different aged babies (according to the length of the hospitalization in the NICU). They were the primary caregivers for the infants and were not receiving special assistance. The parents of preterm infants were still in contact with the NICU and were invited for medical follow-up at the hospital several times during the first year.

Although the study overcame key methodological limitations of previous

studies, several limitations of the study need to be addressed. First, the sample in this study was nonrandom, and the two groups of infants were not matched on their characteristics. Also, interviews were conducted in Hebrew, thereby excluding non-Hebrew speaking parents, particularly Arabic speakers, new immigrants, and foreign workers, further limiting the study's generalizability. The study included only singleton births despite the fact that a high percentage of preterm infants born in Israel are twins or triplets. Inclusion of multiple births would have confounded the relationship between prematurity and the outcome variables, as it would have been difficult to find a sufficient number of full-term multiple births, making it impossible to control for differences in the two groups. Finally, the decision as to the timing of the interviews (two months after discharge) was made in consultation with a senior neonatologist. However, it may be that parents of preterm and full-term infants were dealing with different stress and competence issues related to these stages.

The findings point to significant differences in the parental stress of both mothers and fathers of preterm infants compared with those of full-term infants. These parents showed higher levels of parental stress even two months after discharge. Mothers of preterm babies also showed lower levels of perceived parental competence.

It seems that although most of the stressors noted earlier (concern for the survival of the newborn, separation from the baby and limited opportunity to foster attachment, the physical environment of the NICU, and the interaction with the professional staff) are no longer present in the parents' life, they still report high levels of parental stress. It may be that the uncertainty as to the long-term effects of prematurity on the infants' development described in former studies (Cronin et al., 1995; Hack et al., 2000) still concerns these parents and contributes to their stress. Also, the fact that the medical team, with its knowledge, experience, and equipment, no longer participates in caring for the infant may leave the parents feeling helpless and worried about their ability to care for the baby on their own.

In addition to the higher levels of parental stress shared by both mothers and fathers of preterm infants, the mothers also showed significantly lower levels of parental competence than did the mothers in the comparison group. Previous studies found lower maternal competence during hospitalization. This was attributed to the mothers' viewing themselves as secondary caregivers, whereas the nurses were primary; feelings of helplessness; and lack of control and fears of not being able to care for the baby properly on their own (Preyde et al., 2001). It seems that even after two months of caring for the infant on their own at home, these mothers still feel unsure about their parental ability and functioning.

In contrast to mothers, fathers of preterm infants did not show lower levels of parental competence when compared with the comparison group. One explanation is the reticence of men to reveal such difficulties to researchers. Other studies show that women tend to report higher levels of tension and emotional distress, stress, and depression than do men when asked about the same life events (Doering, Dracup, & Moser, 1999; Levy-Schiff, 1994; Tommiska, Ostberg, & Fellman, 2002).

Another possible explanation is that as opposed to mothers, whose self-perception of their parental roles may have been affected by the premature birth and who carry with them feelings of guilt over not being able to complete the pregnancy, the fathers do not necessarily feel the same. Two months after the birth they are usually back to their normal routine, working away from home like the fathers of full-term babies. Studies show that fathers tend to view and value themselves as parents mainly on the basis of their ability to support their families financially (Christiansen & Palkovitz, 2001; Feldman, Masalha, & Nadam, 2001). They also do not tend to feel guilt related to the premature birth itself. Pohlman (2005) found evidence of the primacy of work among fathers of preterm infants. They returned to work quickly after their infant's birth and approached their work with a renewed sense of fervor to provide financially for their families. They found comfort in their workplace--where they felt they were experts--as opposed to the feelings they had in the NICU.

None of the parental background variables were related to stress of parents of preterms. It seems that parenting a preterm infant is experienced as an extremely stressful event regardless of gender, education, age, or religious beliefs. On the other hand, parental stress was related to the infants' medical situation. For fathers, stress was higher among those whose infant experienced CNS complications. For mothers, stress was related to gestational age so that the earlier the birth, the higher the mothers' stress. Auslander et al. (2003a) found that the earlier the birth week, the higher the maternal anxiety among mothers of preterm infants. In the current study, these feelings persist several weeks after discharge.

Three parental background variables were found related to both mothers' and fathers' of preterm infants perceived parental competence: age, education, and religiosity. Older mothers and fathers reported higher levels of parental competence. A possible explanation is that older parents are more likely to have had children before the birth of the preterm infant, thus giving them experience and a sense of competence as parents. Also, the likelihood that older parents have had more life experiences in general and more experience in mastering other new life roles may make it easier to gain a feeling of competence in their parental role as well.

Mothers and fathers who were better educated perceived themselves as less competent parents. It may be that these parents are more aware of the potentially difficult road that lies ahead with the uncertainty of their infants' normal development. Their education may also affect the demands they place on themselves and their assessment of their performance in this important life role. These parents may have higher expectations for themselves.

On the other hand, religious parents reported higher perceived parental competence than did nonreligious parents. One explanation for this finding is that parents who had a religious Jewish upbringing in Israel tend to come from larger families and are more likely to have experienced some anticipatory socialization to the parental role. They are more likely to have helped raise younger siblings and to have learned about parental functioning through observation and modeling by the adults in their society. Also, Judaism itself views the role of parenting--having children, raising and educating them--as a commandment or critical good deed (Perez & Katz, 1991).This may influence how they view themselves as parents.

Fathers of preterm boys reported higher levels of competence than did fathers of preterm girls. A possible explanation for this relationship between the child's gender and the father's perceived competence is that fathers may perceive themselves as more competent parents for sons than for daughters because of gender-specific parenting skills. Social norms may have contributed to a belief by fathers that they are more equipped emotionally and have more experience taking care of sons than daughters.

The findings of this study have important implications for social work practice. The high levels of parental stress and low levels of parental competence indicate that two months after discharge these parents are still in need of assistance. Feelings of stress seemed to cut across all population groups, whereas parents who were younger, more educated, and not religious felt less competent. These variables can be used in targeting parents at higher risk, although the consistency of stress across groups would indicate that services should be offered to all parents of preterm infants.

The literature dealing with intervention programs with parents of preterm infants is limited. Most interventions take place during hospitalization in the NICU (Browne &Talmi, 2005; Jotzo & Poets, 2005). Some use peer counselors (Preyde & Ardal, 2003), whereas others use professionals. Most interventions are carried out with mothers only (Browne & Talmi, 2005; Jotzo & Poets, 2005) and focus on infant outcomes as opposed to parental outcomes. Although stress levels are commonly measured outcomes, few if any interventions relate to parental competence. One exception is a recent study by Kaaresen, Ronning, Ulvund, and Dalai (2006), which evaluated an intervention during and following hospitalization in the NICU. Findings showed reduced levels of stress and competence among both mothers and fathers during the infant's first year of life.

It seems that the actual discharge from the hospital should not be considered the end of the stressful life event for parents of preterm infants. Social work interventions in the hospitals included in this study have traditionally focused on the hospitalization period, including at least one face-to face meeting with each couple and participation of the social worker in parents-doctor meetings regarding the course of treatment for the infant. The parents are offered continued emotional support according to their needs throughout the hospitalization .The social worker is also usually present at the medical check ups at the clinic, which take place several times a year. Parents may be referred to community services, but the main option in Israel is well-baby care carried out at neighborhood clinics that do not specialize in the development of preterm infants. No routine home-visiting programs are offered.

On the basis of the findings of this study and those noted earlier, it seems important to design and assess interventions that focus on parental as well as child-based outcomes; use a broader range of outcome measures, including stress and perceived parental competence; and continue intervention after discharge. The interventions should include both mothers and fathers and address the different needs of each. As Pohlman (2005) stated, fathers' stressors often lie outside the NICU, invisible to the social worker. Content should include both emotional and informational support. This support should accompany the medical check-ups that are done regularly in most NICUs. These interventions can be based either on home visits by the NICU social worker or on group interventions with fathers and mothers outside the home.

In conclusion, it seems that these parents should receive some sort of emotional support during the first year after discharge from the NICU. Furthermore, studies regarding coping and adjustment to stressful life events should include these parents as research candidates not only during the hospitalization period, but also for several months after discharge. Additional research should be done focusing on follow-ups with these parents, aimed at identifying the time at which parents of preterm infants match parents of full-term infants in parental stress and competence measures.

Original manuscript received September 7, 2006

Final revision received January 9, 2008

Accepted January 16, 2008

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Table 1: Multiple Regression: Variables
Relating to Mothers' of Preterm
Infants Perceived Competence

Variable                                 B        SE B   [beta]

Constant                              12.27       8.74
Infant variables
  Gender (a)                           1.04        .85    .13
  Birthweight                         -.00         .00   -.28
  Gestational age at birth              .42        .24    .30
  Require breathing assistance          .56        .90    .10
  CNS complications (a)               -1.85       1.48   -.15
  Birth order (a)                     -1.13        .88   -.14
  Length of hospitalization            -.03        .02   -.25
Mothers' background
  Age                               .35 ***        .09    .49
  Education                         -.69 **        .22   -.37
  Religious (a)                     2.72 *        1.23    .25
  Ultra-orthodox (a)                2.59 **        .95    .28
Overall F(11, 68) = 3.98 ***; [R.sup.2] = .39

Note: CNS=central nervous system.

(a) Dummy variables-gender: 1 = female, 2 = male; CNS complications:
1 = yes, 0 = no; birth order: 1 = first born, 0 = other than first
born; religious: 1 = yes, 0 = no; ultra-orthodox: 1 = yes, 0 = no.

* p < .05. ** p < .01. *** p < .001.

Table 2: Multiple Regression: Variables
Relating to Fathers' of Preterm
Infants Perceived Competence

Variable                               B        SE B   [beta]

Constant                            -5.32       7.19
Infant variables
  Gender (a)                         1.47 *      .72      .24
  Birthweight                         .00        .00      .05
  Gestational age at birth            .40        .20      .36
  Require breathing assistance        .76        .76      .18
  CNS complications (a)              -.19       1.21     -.02
  Birth order (a)                     .76        .71      .12
  Length of hospitalization           .01        .02      .14
Fathers' background
  Age                                 .21 **     .06      .43
  Education                          -.38 ***    .09     -.59
  Religious (a)                       .97       1.00      .12
  Ultra-orthodox                     2.71 **     .92      .38

Overall F(11, 64) = 2.76 ***; [R.sup.2] = .32

Note: CNS = central nervous system.

(a) Dummy variables--gender: 1 = female, 2 = male; CNS
complications: 1 = yes, 0 = no; birth order: 1 = first born,
0 = other than first born; religious: 1 = yes, 0 = no;
ultraorthodox: 1 = yes, 0 = no.

* p < .05. ** p < .01. *** p < .001.
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