Psychosocial Difficulties Experienced By Parents Of Babies Treated In A Neonatal Intensive Care Unit During The Coronavirus Pandemic

Kostenzer J.
Hoffmann J.
von Rosenstiel-Pulver C.
Walsh A.
Zimmermann L.
Mader S.

COVID-19 Zero Separation Collaborative Group
Neonatal care during the COVID-19 pandemic - A global survey of parents' experiences regarding infant and family-centred developmental care.

;

Treyvaud K.
Spittle A.
Anderson P.J.
O'Brien K.

A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant.

;

He et al., 2021

He F.B.
Axelin A.
Ahlqvist-Björkroth S.
Raiskila S.
Löyttyniemi E.
Lehtonen L.

Effectiveness of the close collaboration with parents intervention on parent-infant closeness in NICU.

;

Anwar Siani et al., 2017

Anwar Siani S.
Dol J.
Campbell-Yeo M.

Impact of parent-targeted eHealth on parent and infant health outcomes: A scoping review.

;

Garfield et al., 2021

Garfield H.
Westgate B.
Chaudhary R.
King M.
O'Curry S.
Archibald S.J.

Parental and staff experiences of restricted parental presence on a Neonatal Intensive Care Unit during COVID-19.

). Further longitudinal research is warranted because the limited interaction between parents and their babies to prevent transmission in NICUs negatively affects the cognitive, emotional, and social development of the latter in the long term (

Kostenzer J.
Hoffmann J.
von Rosenstiel-Pulver C.
Walsh A.
Zimmermann L.
Mader S.

COVID-19 Zero Separation Collaborative Group
Neonatal care during the COVID-19 pandemic - A global survey of parents' experiences regarding infant and family-centred developmental care.

;

Treyvaud K.
Spittle A.
Anderson P.J.
O'Brien K.

A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant.

). Pre-pandemic studies have shown that parent-centered care interventions catered to psychosocial needs are essential for NICU infant-parent bonding (

Anwar Siani et al., 2017

Anwar Siani S.
Dol J.
Campbell-Yeo M.

Impact of parent-targeted eHealth on parent and infant health outcomes: A scoping review.

;

He et al., 2021

He F.B.
Axelin A.
Ahlqvist-Björkroth S.
Raiskila S.
Löyttyniemi E.
Lehtonen L.

Effectiveness of the close collaboration with parents intervention on parent-infant closeness in NICU.

;

Kostenzer J.
Hoffmann J.
von Rosenstiel-Pulver C.
Walsh A.
Zimmermann L.
Mader S.

COVID-19 Zero Separation Collaborative Group
Neonatal care during the COVID-19 pandemic - A global survey of parents' experiences regarding infant and family-centred developmental care.

;

Osorio Galeano and Salazar Maya, 2021

Treyvaud K.
Spittle A.
Anderson P.J.
O'Brien K.

A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant.

). Parents experience higher stress levels when they visit their NICU babies because they are worried about transmitting COVID-19 to them (

Osorio Galeano S.P.
Salazar Maya Á.M.

Experiences of parents of preterm children hospitalized regarding restrictions to interact with their children imposed because of the COVID-19 pandemic.

). Parents of NICU babies feel extra anxiety because not only do they have to deal with the current situation but also go through the pandemic (

Darcy Mahoney et al., 2020

Darcy Mahoney A.
White R.D.
Velasquez A.
Barrett T.S.
Clark R.H.
Ahmad K.A.

Impact of restrictions on parental presence in neonatal intensive care units related to coronavirus disease 2019.

;

Virani et al., 2020

Virani A.K.
Puls H.T.
Mitsos R.
Longstaff H.
Goldman R.D.
Lantos J.D.

Benefits and risks of visitor restrictions for hospitalized children during the COVID pandemic.

;

Muniraman et al., 2020

Muniraman H.
Ali M.
Cawley P.
Hillyer J.
Heathcote A.
Ponnusamy V.
Coleman Z.
Hammonds K.
Raiyani C.
Gait-Carr E.
Myers S.
Hunt K.
Govande V.
Jain A.
Clark R.
Doherty C.
Raju V.
Clarke P.

Parental perceptions of the impact of neonatal unit visitation policies during COVID-19 pandemic.

;

Kostenzer J.
Hoffmann J.
von Rosenstiel-Pulver C.
Walsh A.
Zimmermann L.
Mader S.

COVID-19 Zero Separation Collaborative Group
Neonatal care during the COVID-19 pandemic - A global survey of parents' experiences regarding infant and family-centred developmental care.

;

Van Veenendaal et al., 2021

Treyvaud K.
Spittle A.
Anderson P.J.
O'Brien K.

A multilayered approach is needed in the NICU to support parents after the preterm birth of their infant.

;

He et al., 2021

He F.B.
Axelin A.
Ahlqvist-Björkroth S.
Raiskila S.
Löyttyniemi E.
Lehtonen L.

Effectiveness of the close collaboration with parents intervention on parent-infant closeness in NICU.

). Therefore, such parents need psychosocial support more than ever.

Materials and Methods

This study adopted phenomenology, which is a qualitative research design. The study population consisted of all parents of babies treated for at least two weeks in the NICU of a City Hospital in Turkey between July and August 2021. The sample consisted of 20 parents (ten fathers and ten mothers). Participation was voluntary.

The NICU in question consists of three blocks, each of which beds 40 babies. Due to the pandemic, parents can only see their babies at birth and once a week on tablets (FaceTime) provided by the hospital. On weekdays, doctors give parents detailed information about their babies. On weekends, nurses inform them about the general conditions of their babies. Parents cannot meet with their babies face-to-face to reduce the risk of transmission. However, they FaceTime with them once a week. Parents of babies with poor general conditions are encouraged to see them. The study was approved by the Clinical Research Ethics Committee of the City Hospital (No: E2-21-740). Verbal and written consent was obtained from parents who agreed to participate and have the interviews recorded. All participants were briefed about the research purpose, procedure, and confidentiality. The interviews were held in the NICU training room, which was quiet and comfortable. During the interviews, preventive measures (mask, hygiene, social distance, etc.) were followed. Parents were called to get appointments for the interviews. They were called the days they would show up at the hospital to FaceTime with their babies or drop off milk for them. Each interview lasted 30–45 minutes. The interviews were conducted by a clinical nurse with a master's degree in psychiatric nursing and seven years of NICU experience. The inclusion criteria were (1) having a baby treated in the NICU for at least two weeks and (2) speaking and understanding Turkish. The data were collected using a sociodemographic characteristics questionnaire and a semi-structured qualitative interview form. The interview form consisted of the following questions:

-
What kind of family relationships did you have during pregnancy, and what are your feelings and thoughts about pregnancy?
-
What are the pregnancy and isolation precautions during the COVID 19 pandemic?
-
How did you feel, and what did you think when your baby was placed in the NICU?
-
Has any of your children been placed in a NICU before?
-
What are your feelings and thoughts about the “no visitors” policy at the NICU?
-
What are your feelings and thoughts about FaceTiming with your babies once a week?
-
What has been your source of support since the COVID-19 pandemic?

All interviews were recorded and transcribed. Afterward, participants' responses were coded. Two experts were consulted about the codes to ensure consistency.

Results

Demographic results

Participants had a mean age of 32.2 + 36.1 years and at least middle school degrees. Their babies were admitted to the NICU for congenital anomalies (n = 3) or preterm birth (n = 7). The mean NICU admission duration was 18 days. The analysis revealed five themes: long-distance parenting, sources of stress, sources of support, coping mechanisms, and expectations.

Themes

Long-distance parenting

Since March 2020, the NICU has had a “no visitors” policy to reduce the risk of COVID-19 transmission. Parents can visit their babies only once after birth and FaceTime with them once a week. On weekdays, doctors give parents detailed information about their babies. On weekends, nurses inform them about the general conditions of their babies. All participants expressed what it made them feel not to be able to see and touch their babies during the COVID-19 pandemic. All participants stated that they experienced anxiety, helplessness, and symptoms of depression (sadness, hopelessness, crying, feeling empty, worthlessness, guilt, self-blame, and problems concentrating and making decisions). They also had difficulty thinking, speaking, and moving.

Participant (1-F): “I was feeling bad, I forced myself to go and see my baby, but I couldn’t touch her or hug her.”

Participant (5-M): “Being a mother of a baby placed in a NICU…I feel like it’s my baby…but I also feel like it’s not…I feel like it’s theirs. I can’t touch him, see him, or hug him. I’d lost a baby in another hospital. I used to take her on my lap. I used to show up every day and give her kangaroo care. I even tried to breastfeed her. But now, it’s not the case.” (Both mother and father started crying. Therefore, we had a break.)

Participant (6-F): “They used to let us see our other baby. We could touch him and talk to him. But this time, I saw my baby only during birth. We've parted since then. I see her when I FaceTime with her, I feel like I can touch her, but I just can’t.”

Participant (9-M): “I hear it from others, and I read about it. Mothers could do kangaroo care in the past; I wish we had that now. Being separated and not being able to touch him, it's so hard. He's four months old now, and I haven't even breastfed him.”

Participant (12-M): “I just imagine how she smells.” (The mother started crying, and her husband consoled her.)

Participant (15-M): “I take a picture of him on the tablet. I pump my milk looking at him.”

Sources of stress

The greatest sources of stress for participants were the thought of “not being able to see their babies again” and “infecting them with the virus.” Two in five participants were out of breastmilk, while one in five participants reported reduced breastmilk levels.

Participant (5-M): “I had another baby. They called me and told me she was dead. I’d answered that phone. When they called me, I was like, ‘Are they gonna tell me she’s dead. Has something bad happened to her?’ That’s all I could think of. So, I can’t answer the phone when they call from the hospital.” (The mother was leaning forward and avoiding making eye contact. She cried many times throughout the interview. She was afraid that she might lose her baby because she had lost another baby treated in a NICU.)

Participant (6-F): "I saw my baby only during birth. But we've never pressed them to let us see her. We don't visit her, although we're sometimes allowed to because we don't wanna infect her. Maybe, we can take some tests and then see her."

Participant (10-F): “I’m afraid of infecting my baby with the virus.”

Participant (13-M): “My home is too busy, so I’m always on edge, like what if I get infected with the virus. I drop off milk at the NICU, and I'm like, what if my milk has the virus.”

Participant (14-M): “I don’t have enough breastmilk. I’m like, what if it’s not enough for my baby. All I can do is drop off milk at the hospital. I’m like, what if I can’t even do that.”

Participant (18-M): “I FaceTimed with my baby. She had a hard time breathing. I can’t get it out of my head. And now, I’m out of breastmilk.”

Participant (20-M): “I’m OK not touching my baby, as long as she’s fine. What if I can never see my baby. What if I can’t touch her or hug her. I don’t even know how she smells.”

Sources of support

Participants reported that their spouses were the greatest source of support that helped them get through tough times. They also got support from their families and friends.

Participant (10-F): “My husband and family have always been there for me.”

Participant (12-M): “My husband has been a tremendous source of support. We feel like we’re on our own. I don't wanna see and talk to anyone. Our families and friends are also there for us, but I don’t wanna talk to them.”

Participant (14-M): “I sometimes feel lonely. I know that everybody is there for me, but I can't help but feel that way.”

Participant (17-F): “I wish I could leave the hospital with my baby on my lap. But it just didn’t work out. We get back home empty-handed every week. My wife cries a lot. We support each other. There’s nothing we can do about it.”

Coping mechanisms

Participants stated that they cried and prayed a lot. They added that FaceTiming with their babies, receiving support from their spouses, and talking to friends and relatives made them feel good. They were also happy when they had enough breastmilk.

Participant (7-M): “All I can do for my baby is pray and pump milk.”

Participant (11-F): “We need to be strong, so we wiped our tears and showed up hoping that we’re gonna see our baby. We always pray.”

Participant (15-M): “My husband and I have argued a lot during this period. But he's the one who understands me the most. I feel good when I talk to him.”

Participant (16-M): There is nothing else I can do but pray. I cry, and I pray, I cry, and I pray. What else can I do?

Participant (19-F): “I feel good when I talk to my mom and my sister.”

Expectations

Participants noted that they needed much psychosocial support during this period. They stated that they expected healthcare professionals to provide them with more information and allow them to visit their babies more often.

Participant (8-F): “Talking to you and pouring out my heart made me feel so good. So, it turns out that even talking to a complete stranger makes one feel good. Bless your heart!”

Participant (16-M): “I wish healthcare professionals let us know more.”

Participant (20-M): “We’re so happy that we got to talk to someone who works here and knows our baby.”

Discussion

This study investigated the psychosocial problems experienced by parents of babies placed in a NICU during the COVID-19 pandemic. The study also focused on parents’ coping mechanisms and expectations.

Being a parent of a baby in a NICU can be a very stressful experience, which is exacerbated by the COVID-19 pandemic (

Bua et al., 2021

Bua J.
Mariani I.
Girardelli M.
Tomadin M.
Tripani A.
Travan L.
Lazzerini M.

Parental stress, depression, and participation in care before and during the COVID-19 pandemic: A prospective observational study in an Italian neonatal intensive care unit.

;

McCulloch et al., 2021

McCulloch H.
Campbell-Yeo M.
Richardson B.
Dol J.
Hundert A.
Dorling J.
Whitehead L.
MacRae G.
Bishop T.
Afifi J.
Earle R.
Rose A.E.
Foye S.
Inglis D.
Kim T.
Leighton C.
Melanson A.
Simpson D.C.
Smit M.

The impact of restrictive family presence policies in response to COVID-19 on family integrated care in the NICU: A qualitative study.

).

“Long-distance parenting” was the most prominent theme participants addressed during the interviews. They often cried as they talked about their feelings and thoughts. The “no visitors” policy in NICUs during the COVID-19 pandemic causes a great deal of stress and anxiety. Many neonatal clinics around the world have introduced restrictive policies to prevent the spread of the coronavirus, causing parents to experience a great deal of stress, anxiety, and depression (

Bembich et al., 2021

Bembich S.
Tripani A.
Mastromarino S.
Di Risio G.
Castelpietra E.
Risso F.M.

Parents experiencing NICU visit restrictions due to COVID-19 pandemic.

;

Bua et al., 2021

Bua J.
Mariani I.
Girardelli M.
Tomadin M.
Tripani A.
Travan L.
Lazzerini M.

Parental stress, depression, and participation in care before and during the COVID-19 pandemic: A prospective observational study in an Italian neonatal intensive care unit.

;

Cameron et al., 2020

Cameron E.E.
Joyce K.M.
Delaquis C.P.
Reynolds K.
Protudjer J.
Roos L.E.

Maternal psychological distress & mental health service use during the COVID-19 pandemic.

;

Giuseppe et al., 2021

Giuseppe B.
Giuseppina N.
Desiree S.
Angela S.
Maurizio G.
Perrone S.

Improving care in neonatal intensive units during the COVID-19 pandemic: A survey on electronic health communication.

;

Manuela et al., 2021

Manuela F.
Barcos-Munoz F.
Monaci M.G.
Lordier L.
Camejo M.P.
De Almeida J.S.
Grandjean D.
Hüppi P.S.
Borradori-Tolsa C.

Maternal stress, depression, and attachment in the neonatal intensive care unit before and during the COVID pandemic: An exploratory study.

;

McCulloch et al., 2021

McCulloch H.
Campbell-Yeo M.
Richardson B.
Dol J.
Hundert A.
Dorling J.
Whitehead L.
MacRae G.
Bishop T.
Afifi J.
Earle R.
Rose A.E.
Foye S.
Inglis D.
Kim T.
Leighton C.
Melanson A.
Simpson D.C.
Smit M.

The impact of restrictive family presence policies in response to COVID-19 on family integrated care in the NICU: A qualitative study.

;

Van Veenendaal N.R.
Deierl A.
Bacchini F.
O’Brien K.
Franck L.S.

International Steering Committee for Family Integrated Care
Supporting parents as essential care partners in neonatal units during the SARS-CoV-2 pandemic.

). Our participants also reported sadness, unhappiness, and loneliness. NICU healthcare professionals used to provide family-centered care before the pandemic. For example, they used to encourage parents to participate in care and promote breastfeeding and skin-to-skin contact. However, they have stopped involving parents in care since the onset of the pandemic, which is likely to put parents in a stressful position (

Giuseppe et al., 2021

Giuseppe B.
Giuseppina N.
Desiree S.
Angela S.
Maurizio G.
Perrone S.

Improving care in neonatal intensive units during the COVID-19 pandemic: A survey on electronic health communication.

;

Konukbay and Arslan, 2011

Konukbay D.
Arslan F.

Yenidoğan yoğunbakım ünitesinde yatan yenidoğan ailelerinin yaşadıkları güçlüklerin belirlenmesi.

Google Scholar

;

Küçükoğlu et al., 2015

Küçükoğlu S.
Aytekin A.
Gülhaş N.F.

Yenidoğan yoğun bakım ünitesinde bebeği yatan annelerin gereksinimlerinin belirlenmesi.

Google Scholar

;

Mannering et al., 2021

Mannering H.
Yan C.
Gong Y.
Alrifai M.W.
France D.
Chen Y.

Assessing neonatal intensive care unit structures and outcomes before and during the COVID-19 pandemic: Network analysis study.

;

Verderber et al., 2021

Verderber S.
Gray S.
Suresh-Kumar S.
Kercz D.
Parshuram C.

Intensive care unit built environments: A comprehensive literature review (2005–2020).

). More research is warranted to better understand the impact of restrictive policies on parent-baby attachment.

“Fear of hurting” was another theme that emerged from the interviews. Our participants stated that although they wanted to see, touch, and hug their babies, they were afraid that they might infect them with the coronavirus, causing extra stress and anxiety. Three participants were worried that their breast milk might contain the coronavirus. Those participants were informed that current evidence suggested that breast milk was not likely to spread the virus to babies (

Baldoni et al., 2021

Baldoni F.
Ancora G.
Latour J.M.

Being the father of a preterm-born child: Contemporary research and recommendations for NICU staff.

;

Cavicchiolo M.E.
Lolli E.
Trevisanuto D.
Baraldi E.

Managing a tertiary-level NICU in the time of COVID-19: Lessons learned from a high-risk zone.

;

Campbell-Yeo et al., 2021

Cavicchiolo M.E.
Trevisanuto D.
Lolli E.
Mardegan V.
Saieva A.M.
Franchin E.
Plebani M.
Donato D.
Baraldi E.

Universal screening of high-risk neonates, parents, and staff at a neonatal intensive care unit during the SARS-CoV-2 pandemic.

;

Manuela et al., 2021

Manuela F.
Barcos-Munoz F.
Monaci M.G.
Lordier L.
Camejo M.P.
De Almeida J.S.
Grandjean D.
Hüppi P.S.
Borradori-Tolsa C.

Maternal stress, depression, and attachment in the neonatal intensive care unit before and during the COVID pandemic: An exploratory study.

;

Waddington et al., 2021

Waddington C.
van Veenendaal N.R.
O'Brien K.
Patel N.

International Steering Committee for Family Integrated Care
Family integrated care: Supporting parents as primary caregivers in the neonatal intensive care unit.

).

“Sources of stress” was the third theme that emerged from the interviews. Participants noted that the greatest source of stress was “not being able to see their babies again” (

Bua et al., 2021

Bua J.
Mariani I.
Girardelli M.
Tomadin M.
Tripani A.
Travan L.
Lazzerini M.

Parental stress, depression, and participation in care before and during the COVID-19 pandemic: A prospective observational study in an Italian neonatal intensive care unit.

;

Campbell-Yeo M.
Dol J.
Richardson B.
McCulloch H.
Hundert A.
Foye S.
Dorling J.
Afifi J.
Bishop T.
Earle R.
Elliott Rose A.
Inglis D.
Kim T.
Leighton C.
MacRae G.
Melanson A.
Simpson D.C.
Smit M.
Whitehead L.

A co-design of clinical virtual care pathways to engage and support families requiring neonatal intensive care in response to the COVID-19 pandemic (COVES study).

;

Cavicchiolo M.E.
Lolli E.
Trevisanuto D.
Baraldi E.

Managing a tertiary-level NICU in the time of COVID-19: Lessons learned from a high-risk zone.

;

Cavicchiolo M.E.
Trevisanuto D.
Lolli E.
Mardegan V.
Saieva A.M.
Franchin E.
Plebani M.
Donato D.
Baraldi E.

Universal screening of high-risk neonates, parents, and staff at a neonatal intensive care unit during the SARS-CoV-2 pandemic.

;

Griffin et al., 2020

Griffin I.
Benarba F.
Peters C.
Oyelese Y.
Murphy T.
Contreras D.
Gagliardo C.
Nwaobasi-Iwuh E.
DiPentima M.C.
Schenkman A.

The impact of COVID-19 infection on labor and delivery, newborn nursery, and neonatal intensive care unit: Prospective observational data from a single hospital system.

;

Mannering et al., 2021

Mannering H.
Yan C.
Gong Y.
Alrifai M.W.
France D.
Chen Y.

Assessing neonatal intensive care unit structures and outcomes before and during the COVID-19 pandemic: Network analysis study.

;

Verma et al., 2020

Verma S.
Lumba R.
Lighter J.L.
Bailey S.M.
Wachtel E.V.
Kunjumon B.
Alessi S.
Mally P.V.

Neonatal intensive care unit preparedness for the novel coronavirus disease-2019 pandemic: A New York City hospital perspective.

). Participants were also worried that they might infect their babies with the virus and not produce enough breast milk. Participants wanted to see, touch, and hug their babies but were worried that they might infect them with the virus, causing them to experience stress and anxiety. Three participants had gaps in their knowledge of transmission through breast milk. They were provided with examples from current studies and clinical experiences to reduce their fear (

Baldoni et al., 2021

Baldoni F.
Ancora G.
Latour J.M.

Being the father of a preterm-born child: Contemporary research and recommendations for NICU staff.

;

Cavicchiolo M.E.
Lolli E.
Trevisanuto D.
Baraldi E.

Managing a tertiary-level NICU in the time of COVID-19: Lessons learned from a high-risk zone.

;