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Around 2 in 5 (40%) parents have anxiety or post-traumatic stress when their newborn baby needs intensive care (neonatal care). Research found that levels declined over time, but a year after the birth, 1 in 4 (25%) were still suffering. These levels are much higher than those generally seen in new parents.

Post-traumatic stress can develop after a stressful or frightening event. People may have flashbacks, difficulty concentrating or other distressing symptoms. Before this study, little was known about how many parents have anxiety or post-traumatic stress when their baby needs specialist care. The information will help services plan and deliver services so that parents receive adequate support.

The research suggests these parents have significant needs for a prolonged period. The findings could prompt professionals to assess parents' mental health while their baby is receiving intensive care, and for some time afterwards. This includes staff caring for babies in hospital, doctors caring for women after birth, midwives and health visitors. The researchers hope that mental health screening and support will become a routine part of care for parents whose babies are in hospital.

More information about neonatal care is available on the NHS website.

What’s the issue?

Babies who are sick or born early (prematurely) may need specialist care in hospital neonatal units. This can be extremely distressing for parents. They are separated from their baby, and in an unfamiliar and overwhelming environment. They are likely to be worried about their baby’s health and survival.

The experience can affect parents’ mental health. Previous research has shown that 2 in 5 (40%) women develop depression when their sick or premature baby is treated in a neonatal unit. Depression can harm their relationship with their infant and impact the child’s development.

However, little is known about how many of these parents develop anxiety and post-traumatic stress. The findings from this study could inform clinical practice and policy, and help services plan and deliver suitable support to meet new parents’ mental health needs.

What’s new?

This review included 56 studies, which involved more than 6,000 parents in all. The studies were carried out across the world. Most focused on mothers but some looked at fathers or other primary carers. The researchers pooled data on anxiety and post-traumatic stress at 3 time-points after birth.

They found that:

  • up to 1 month after birth, around 2 in 5 parents had anxiety (42%) or post-traumatic stress (40%)
  • between 1 month and 1 year after birth, both conditions became less common and affected 1 in 4 parents (26% for anxiety; 25% for post-traumatic stress)
  • after 1 year, post-traumatic stress levels had not fallen (27% parents); there were not enough data to estimate how common anxiety is at this stage.

The studies assessed anxiety and post-traumatic stress in different ways. This could partly explain the different estimates of how many parents had anxiety or post-traumatic stress. For example, the researchers say anxiety 1 month after birth could be between 1 in 3 (31%) parents and more than half (53%).

The researchers also found that anxiety was more common in mothers than in fathers.

Why is this important?

This is the first study to estimate levels of anxiety and post-traumatic stress in parents of babies admitted to neonatal units.

It suggests that around 2 in 5 (40%) parents of hospitalised babies have anxiety or post-traumatic stress. Levels declined over time, but for the first year after birth, 1 in 4 (25%) parents are affected. This is considerably more than general levels among women who have just had babies (15-20% have anxiety; 4-10% have post-traumatic stress).

These findings highlight significant need in this group of parents. Anxiety and post-traumatic stress can last for a prolonged period, long after babies are discharged from hospital.

These estimates may not apply to parents whose babies had died, parents of babies with birth disorders, parents with pre-existing mental health conditions, or parents from minority ethnic backgrounds. These groups are likely to be at increased risk of anxiety and post-traumatic stress, and the conditions even more common. More inclusive studies are needed.

More research is also needed on fathers and other carers. This study found that mothers are more likely to have anxiety than fathers. This could be due to the different roles played by each parent, or due to societal pressures. However, only a small number of studies compared mothers and fathers, and the researchers say this finding should be considered with caution. More work is also needed to consider the best tool to use to measure these conditions.

What’s next?

The National Institute for Health and Care Excellence (NICE) suggests that all women have their mental health assessed in their first visit to primary care when pregnant, and soon after giving birth. Parents of babies in neonatal units may need repeated assessments over the longer-term.

Staff often focus on caring for the baby, and parents’ wellbeing can be overlooked. As a first step, neonatal staff, midwives and obstetricians could ask parents directly about their mental health. GPs and health visitors could monitor this group over the following months.

Mental health screening for all parents could be a standard part of care when a baby is admitted to hospital, and in the year after birth. A clear pathway to treatment is needed for parents with raised anxiety and post-traumatic stress. Adequate health services resources are needed to ensure early referral and appropriate interventions are offered.

You may be interested to read

This NIHR Alert is based on: Malouf R, and others. Prevalence of anxiety and post-traumatic stress (PTS) among the parents of babies admitted to neonatal units: A systematic review and meta-analysis. eClinicalMedicine 2022;43:101233

An eClinicalMedicine podcast including one of the authors of this study: In conversation with… Fiona Alderdice on anxiety and post-traumatic stress among parents of babies admitted to neonatal units.

Mental health awareness week: a blog post discussing this study from the Policy Research Unit in Maternal and Neonatal Health and Care (PRU-MNHC).

Mental wellbeing support on the neonatal intensive care unit: a patient information factsheet by NHS University Hospital Southampton NHS Foundation Trust.

The UK charity Bliss for babies born premature or sick provides information to support parents’ mental health.

Funding: This research is funded by the NIHR Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

Having a baby admitted to hospital is a traumatic and often unexpected event, and parents will be vulnerable to mental health problems. But we don’t know the extent of mental health problems in this group, which makes it difficult to plan services or to provide adequate support for parents.

We were surprised by how high anxiety and post-traumatic stress levels remained over time, demonstrating the longer term needs of these parents.

Asking parents about their mental health could be happening now. Screening in neonatal units should also be feasible, with a tool brief enough to use in clinical settings. We will need to ensure that whichever tool we use minimises the risk of missing parents who need additional support, while not overloading the system with referrals for parents who are not necessarily in need of professional support.

Fiona Alderdice, Senior Social Scientist, National Perinatal Epidemiology Unit (NPEU), and Professor in Perinatal Health and Wellbeing, Queen’s University Belfast 

Bliss 

This study provides further evidence that parents of babies born premature or sick and admitted to neonatal care are at significantly higher risk of experiencing mental health problems. It also highlights for just how long parents can be affected after their babies have been born.

Bliss has long campaigned for better psychological support for parents of babies admitted to neonatal care, and our own research has indicated how widespread the need is. Through our quality improvement accreditation programme, the Bliss Baby Charter, we work with most neonatal units across the UK to improve the psychological support they offer to families.

However, there needs to be more focus on national provision of support – both in terms of national funding for specialist neonatal psychology posts while parents are on the neonatal unit, and the improved integration of the needs of this group within perinatal mental health services in the community.

Caroline Lee-Davey, Chief Executive of Bliss 

Neonatologist 

This study highlights the mental health risks to parents of sick and preterm newborns. It is high time that we not only collate better data about such risks, but also set up appropriate screening programmes for such high-risk groups and provide them with relevant interventions and support. There is urgent need for some form of screening for parents in the immediate postnatal period and at least till about 1 year of age.

Minesh Khashu, Consultant Neonatologist and Professor of Perinatal Health, University Hospitals Dorset & Bournemouth University

Methodologist 

These results could have an impact on clinical practice, potentially via appropriate guidelines. Staff in neonatal units need to be more aware of what parents are experiencing.

This is an ambitious and well-conducted review. However, the wide range of studies included in the analysis means that the average estimates fall within a wide range. The study combined results from mothers and fathers, though differences have been reported in other reviews.

Steve Edwards, Director of Health Technology Assessment, British Medical Journal Technology Assessment Group (BMJ-TAG), BMJ 

 

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