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Six-week postnatal depression predictsparenting stress profiles in mothers ofpreterm childrenMargo A. Pritchard a , Paul B. Colditz b , David Cartwright c , PeterH. Gray d , David Tudehope e & Elaine Beller fa Women’s and Newborn Services, Royal Brisbane Wome’s Hospitaland The University of Queensland Centre for Clinical Research ,Herston , Australiab The University of Queensland Centre for Clinical Research ,Herston , Australiac Women’s and Newborn Services, Royal Brisbane Women’sHospital , Herston , Australiad Newborn Services, Mater Mothers’ Hospital , South Brisbane ,Australiae Division of Neonatology, Mater Mothers’ Hospital , SouthBrisbane , Australiaf Centre for Research in Evidenc-Based Practice, Bond University ,Robina , AustraliaPublished online: 28 Aug 2012.

To cite this article: Margo A. Pritchard , Paul B. Colditz , David Cartwright , Peter H. Gray , DavidTudehope & Elaine Beller (2012) Six-week postnatal depression predicts parenting stress profiles inmothers of preterm children, Journal of Reproductive and Infant Psychology, 30:3, 303-311, DOI:10.1080/02646838.2012.710832

To link to this article: http://dx.doi.org/10.1080/02646838.2012.710832

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Six-week postnatal depression predicts parenting stress profiles inmothers of preterm children

Margo A. Pritcharda*, Paul B. Colditzb, David Cartwrightc, Peter H. Grayd, DavidTudehopee and Elaine Bellerf

aWomen’s and Newborn Services, Royal Brisbane Women’s Hospital and The University ofQueensland Centre for Clinical Research, Herston, Australia; bThe University of

Queensland Centre for Clinical Research, Herston, Australia; cWomen’s and NewbornServices, Royal Brisbane Women’s Hospital, Herston, Australia; dNewborn Services, MaterMothers’ Hospital, South Brisbane, Australia; eDivision of Neonatology, Mater Mothers’

Hospital, South Brisbane, Australia; fCentre for Research in Evidenc-Based Practice, BondUniversity, Robina, Australia

(Received 29 August 2011; final version received 7 July 2012)

Objective: This study examined the relationship between maternal postnataldepression (PND) at 6 weeks and first-year parenting stress for mothers of verypreterm (gestation < 32 weeks) singleton children. Background: PND isreported as a strong predictor of parenting stress, but few studies examine theeffectiveness of parenting interventions according to PND status. In the pretermpopulation, the differential benefit mothers with PND experience from parentinginterventions is also unclear. Methods: Validated questionnaires were used tocollect information on both PND at 6 weeks and first-year parenting stress from123 mothers of very preterm singleton children. Results: After adjusting forbaseline birth and social risks, mothers who had PND at 6 weeks were morelikely to experience parenting stress (OR 3.6, 95%CI 1.2, 12, p = 0.03) andhave higher parental distress (OR 5.5, 95%CI 1.6, 18.0, p < 0.01) during thefirst postpartum year. Conclusion: When assessing the benefits of parentinginterventions in reducing parenting stress, the effects of early PND in mothersof preterm infants should not be underestimated.

Keywords: postnatal depression; parenting stress; preterm infant; social risk

Background

It is well recognised that parenting a child born very preterm has immediate andoften prolonged effects on maternal psychological health, adversely affecting mater-nal�infant interactive behaviour, infant social–emotional development, and latermental health (Tough et al., 2008; Treyvaud et al., 2009, 2010). While the mecha-nisms for adverse maternal�child outcomes are not fully understood (Aarnoudse-Moens, Weisglas-Kuperus, van Goudoever, & Oosterlaan, 2009; Bhutta, Cleves,Casey, Cradock, & Anand, 2002; Treyvaud et al., 2010), research highlights thatthe preterm-born child is vulnerable to maternal psychological distress and parent-ing experience (De Ocampo, Macias, Saylor, & Katikaneni, 2003; Feldman, 2007;

*Corresponding author. Email: m.pritchard@uq.edu.au

Journal of Reproductive and Infant PsychologyVol. 30, No. 3, July 2012, 303–311

ISSN 0264-6838 print/ISSN 1469-672X online� 2012 Society for Reproductive and Infant Psychologyhttp://dx.doi.org/10.1080/02646838.2012.710832http://www.tandfonline.com

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Miceli et al., 2000; Saylor, Boyce, & Price, 2003; Treyvaud et al., 2009; Vanderbilt& Gleason, 2010). Emerging behavioural and neuroimaging studies support the cen-tral role that responsive parenting has in influencing brain development and behav-iour through adolescence in preterm-born children (Als et al., 2004; Feldman, 2009;Frye, Malmberg, Swank, Smith, & Landry, 2010; Milgrom et al., 2010). However,the effectiveness of early parenting interventions remains unclear in the pretermpopulation (Spittle, Orton, Doyle, & Boyd, 2007; Vanderveen, Bassler, Roberterson,& Kirpalani, 2009).

Commonly, parenting interventions are targeted at mothers under the stress ofboth neonatal intensive care experience and their preterm infant’s behaviour. Theseinterventions predominately focus on supporting maternal mental health and reduc-ing parenting stress by assisting mothers to develop responsive parenting behavioursthat optimise childhood neurodevelopment. While issues of dosage, timing, servicesreceived, and support continuity are likely to influence effectiveness of these inter-ventions, the differential benefits related to specific maternal risk factors are oftenunderstated (Ramey, Ramey, & Lanzi, 2006).

Maternal postnatal depression (PND), including depressive symptoms (Tronick& Reck, 2009), is a high-prevalence maternal risk affecting up to 40% of mothers(Vigod, Villegas, Dennis, & Ross, 2010). A meta-analysis of parenting pro-grammes in mothers of term children has shown positive short-term, but not long-term benefits for depression (Barlow, Coren, & Stewart-Brown, 2002). Parentingprogrammes for mothers of children born preterm for depression show mixedresults (Deater-Deckard & Bulkley, 2000) with likely short-term benefits (Melnyket al., 2006) but with longer-term benefits remaining unclear (Spittle et al., 2010).However, in the preterm population, it is unclear what differential benefit motherswith early PND experience from parenting interventions. Maternal PND isreported as a strong predictor of parenting stress (Leigh & Milgrom, 2008), trajec-tories (Brummelte, Grunau, Synnes, Whitfield, & Petrie-Thomas, 2011; Holditch-Davis et al., 2009), and child developmental and behavioural outcomes (Feldman& Eidelman, 2009; Huhtala et al., 2011; Korja et al., 2008). Even given thesepredictors, few studies examine the effectiveness of parenting interventions byearly PND status.

Therefore, the aim of this study was to examine the relationship between PNDat 6 weeks (and other risk factors) with parenting stress during the first postnatalyear and to identify associated parenting stress profiles.

Methods

Participants

Study participants were recruited from Queensland tertiary neonatal units and tookpart in a randomised controlled trial (RCT) of developmental screening surveillancefor infants born at < 32 weeks gestation. This has been reported previously(Pritchard et al., 2008). In the RCT 423 infants were born during the 13-monthrecruitment period, 76 did not meet eligibility criteria (would not return for followup; no primary health clinician), 18 refused participation and 127 were back-transferred to their regional hospital before consent was obtained. A total of 202infants were randomised and the study group is representative of very pretermchildren born in high-income countries. In the current study, we longitudinally

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studied 127 mothers with singleton deliveries from the child’s birth to 12 monthscorrected age for prematurity. We collected social and health-risk information fromparents, perinatal information from medical records, and used maternal self-reportthrough validated questionnaires for parenting stress and depression status. All chil-dren received a multi-disciplinary neurodevelopmental assessment to determine adisability status at 12 months corrected age. Participating hospital human ethicscommittees approved the study.

Outcome measure

The Parenting Stress Index�Short Form (PSI-SF; Abidin & Wilfong, 1989) wasused to measure parenting stress. The PSI-SF is designed to measure stress inthe parent�child system, is well-validated and used in the preterm populations.It reports a Total Stress score, with � 85th percentile classified as parentingstress and indicating the need for intervention (Abidin & Wilfong, 1989). ThePSI-SF has three subscales that reflect stresses in the areas of (1) Parental Dis-tress, experienced in the parent’s role as a function of personal factors andadjustment, (2) Parent–Child Dysfunctional Interaction, and (3) Difficult Child,which focuses on the child’s behavioural characteristics. The subscales are usedto determine the profile and source of parenting stress to assist with selectinginterventions. Mothers completed forms at the child’s term equivalent age andat 4-monthly intervals until the child was 12 months corrected age. Parentingstress was defined as at least one PSI-SF Total Stress score � 85th percentileover the 12-month study period, as parenting stress is reported to occur at vari-ous times over the first 12 months.

Independent predictor variables

The Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987)has also been validated and used in preterm populations (Eberhard-Gran, Eskild,Tambs, Opjordsmoen, & Samuelsen, 2001). The EPDS comprises 10 short questionswith a choice of 4 responses; a score > 12 (out of 24) is classified as depressed.Mothers completed the EPDS at 6 weeks postpartum, prior to the child’s discharge.

Social risk categories were derived from the Australian Bureau of Statisticsdata for Queensland. We designed a social risk score defined as one or more of:single parent structure, maternal education < grade 11, weekly gross income <$400, or family identified as indigenous, which represented those at lowest 20thpercentile in Queensland. Mothers were also asked about perceptions of theirown general health (poor/fair or good/excellent) in the context of parenting. Thisquestion was based on previous focus group research (Pritchard, Colditz, & Bel-ler, 2008)

For child disability, children attended a neurodevelopmental assessment at 12months corrected age. They were classified as disabled if <�2 standard deviations(SD) on a standardised psychometric test, using Bayley Scales of Infant Develop-ment II Mental Development Index or Griffiths Mental Development Scales, or ifdiagnosed with aided deafness, blindness, or cerebral palsy (Pritchard et al., 2008).While disability is rarely confirmed at this age, we considered that its emergencemay impact on maternal stress.

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Data analysis

A chi-squared test was used to compare the categorical predictor (depressed or non-depressed 6-week PND) against the categorical outcome (stressed or non-stressedby PSI-SF score) using SPSS for Windows (version 17.0, SPSS Inc., Chicago, IL,USA). Logistic regression analysis examined:

(1) the effects of risk factors (gestation, social risk, child disability, maternal per-ception of general health related to parenting) on the relationship betweenPND and parenting stress, and

(2) the parenting stress profile, based on PSI-SF subscales (Parental Distress,Parent�Child Dysfunctional Interaction, and Difficult Child) further analysedfor differences based on 6-week PND status.

All data were dichotomised with results reported as odds ratio (OR) with 95% con-fidence intervals (CI) and p-values.

Results

Complete data were available for 97% (123/127) of the mother�infant dyads(one child died; four had incomplete follow-up due to moving overseas, refusal,and foster care). The baseline characteristics for the depression groups and totalcohort are similar to those of the larger RCT and preterm population (Table 1).During the 12-month study period, 41.5% (51/123) of mothers had parenting stressaccording to the PSI-SF Total Stress scores with subscales stress rates of 52.8%(65/123) for Parent�Child Dysfunctional Interaction, 31.7% (39/123) for ParentalDistress, and 27.6% (34/123) for Difficult Child. The rate of PND at 6 weeks was17% (21/123). Of the 123 mothers, 45.5% had either PND at 6 weeks or parentingstress through the 12 months: 28.5% (35/123) had parenting stress alone, 4%(5/123) had PND alone, and 13% (16/123) had both. The risk profile for the totalcohort included 22% with social risk, 35% with < 28 weeks gestation, 10% dis-abled at 12 months, and 30% with maternal perceptions of poor/fair general health.

Table 1. Baseline infant and maternal characteristics of enrolled infants.

Characteristics PND No PND Combined groups

Child characteristics n = 21 n = 102 n = 123Male gender, n (%) 7 (33.3) 58 (56.9) 65 (52.8)Gestation, mean weeks (SD) 27.8 (2.1) 28.6 (2.1) 28.4 (2.1)Birthweight, mean g (SD) 1037 (327) 1184 (388) 1159 (381)Cerebral disease, n (%) 4 (19.0) 22 (21.6) 26 (21.1)

Maternal characteristicsEducation � Grade 11, n (%) 4 (19.0) 15 (14.7) 19 (15.4)Single parent, n (%) 1 (4.8) 9 (8.8) 10 (8.1)Indigenous, n (%) 1 (4.8) 5 (4.9) 6 (4.9)Gross household income < $400.00per week, n (%)

1 (4.8) 9 (8.8) 10 (8.1)

Cerebral disease = intraventricular haemorrhage grades 3–4 and chronic cerebral disease = evidence ofventricular dilation (> 3 mm anterior horn width), periventricular leucoencephalopathy (any cyst forma-tion in the periventricular white matter).

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Mothers with PND at 6 weeks were more highly represented in all risk categories,with two statistically significant: child disability and perceived poor/fair perceptionof general health related to parenting (Table 2). Table 3 shows the PSI SF Total andsubscale scores at each time interval for the cohort.

Mothers with PND at 6 weeks had significantly higher parenting stress throughthe 12-month period (OR 6.1, 95%CI 2.1. 18.1, p < 0.01) (Table 2), including at 6weeks (66.7% vs. 25.5%, OR 5.8, 95%CI 2.1, 16.0, p < 0.01), 8 months (28.6%vs. 9.9%, OR 3.6, 95%CI 1.2, 11.1, p = 0.02), but not at 12 months (23.8% vs.9.9%, OR 2.9, 95%CI 0.9, 9.1, p = 0.05) and 4 months (9.5% vs. 7.8%, OR 1.2,95%CI 0.2, 6.2, p = 0.7). Logistic regression confirmed that even after adjusting forother risk factors, PND at 6 weeks in mothers was an independent predictor ofparenting stress through the first year (OR 3.6, 95%CI 1.2, 12.0, p = 0.03).The subscale profiles differed between mothers with and without PND (Figure 1).

Table 2. Risk factors and parenting stress (total and subscale) for mothers with and withoutPND at 6 weeks.

VariablePND No PND

OR 95%CIp value

N = 21 (%) N = 102 (%) N = 123

Risk factors for parentingGestation at birth < 28 weeks 9 (42.8) 34 (33.3) 1.5 0.5, 3.9 0.40Social risk⁄ 5 (23.8) 22 (21.6) 1.1 0.3, 3.4 0.08Poor/fair perception of generalhealth related to parenting

17 (80.9) 20 (19.6) 17.2 5.2, 56.8 <0.01

Disabled child⁄⁄ 5 (23.8) 7 (6.8) 4.2 1.2, 15.0 0.01Parenting Stress Scales–Short Form(PSI-SF)PSI-SF Total Stress score �85⁄⁄⁄ 16 (76.2) 35 (34.3) 6.1 2.1, 18.1 < 0.01PD⁄⁄⁄⁄ subscale �85 16 (76.2) 23 (23.5) 10.9 3.6, 33.0 < 0.01PCDI subscale �85 14 (66.7) 51 (50.0) 2.0 0.7, 5.3 0.16DC subscale �85 8 (31.1) 26 (25.5) 1.8 0.7, 4.8 0.20

⁄Social risk meant one or more of: single parent, maternal education < grade 11, weekly gross income< $400, or family identifying as indigenous.⁄⁄Disabled if diagnosed with developmental impairment <�2 SD on a standardised psychometric test,or if with aided deafness, blindness, or cerebral palsy.⁄⁄⁄A score �85th percentile at any time during the 12 month period was classified as indicating parent-ing stress.PD, Parental Distress; PCDI, Parent�Child Dysfunctional Interaction; DC, Difficult Child.

Table 3. Parenting stress (total and subscale) for the total cohort at 6 weeks, 4, 8 and 12months.

Time interval

PSI-SFTotal Stressscore � 85

PD Stressscore � 85

PCDI Stressscore � 85

DC Stressscore � 85

N % N % N % N %

6 weeks 39 31.7 26 21.1 64 52.0 23 18.74 months 10 8.1 12 9.8 18 14.6 6 4.98 months 17 13.1 21 16.4 8 6.5 11 8.912 months 15 12.2 15 12.2 11 8.9 11 8.9

PD, Parental Distress; PCDI, Parent�Child Dysfunctional Interaction; DC, Difficult Child.Parenting stress was defined as at least one PSI-SF score � 85th percentile at the specific time interval.

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The depressed mothers had significantly higher rates of Parental Distress (OR 10.9,95%CI 3.6, 33.0, p < 0.01) and this persisted even after adjusting for other risk(OR 5.5 95%CI 1.6, 18.0, p < 0.01).

Discussion

Mothers who experienced PND at 6 weeks were more likely to have parentingstress and maternal distress-driven parenting profiles in the first year after dischargefrom neonatal intensive care, when compared to mothers who reported no PND at 6weeks. In line with other studies (Feldman and Eidelman, 2009; Holditch-Daviset al., 2009; Poehlann, Miller Schwichtenberg, Bolt, & Dilworth-Bart, 2009), ourfindings suggest that early PND exerts considerable pressures on parenting trajecto-ries through the first year. This highlights the clinical and practical importance ofpre-discharge depression screening: most cases arise in the early postpartum period(Vigod et al., 2010) when treatment is most beneficial (Melnyk, Crean, Feinstein, &Fairbanks, 2008; Saenz et al., 2009), but where few mothers are identified, or seekand receive professional care (Vesga-Lopez et al., 2008).

Given the different parenting stress profiles, consideration should be given to whateffects parenting interventions can have for depressed mothers of preterm infants.This study’s parenting stress profiles show that mothers with early depression sustainhigher parenting stress scores driven by the parental distress subscale, suggestingsignificant delay in parental psychosocial adjustment compared to non-depressedmothers. It also implies the effect of educational�behavioural approaches favoured inmany interventions (requiring mothers to act with assertiveness and focus towards thechild, and to generalise the parenting techniques throughout childhood) is likely to beseverely limited.

Many parenting programmes adopt a general approach to addressing maternalpsychological issues in conjunction with the educational behavioural sessions(Glazebrook et al., 2007; Johnson, Ring, Anderson, & Marlow, 2005; Johnsonet al., 2009; Kaaresen, Ronning, Ulvund, & Dahl, 2006; Roth et al., 1994); this

Figure 1. Percentage of mothers with parenting stress (PSI-SF total and subscale) formothers with and without PND at 6 weeks. PD, Parental Distress; PCDI, Parent�ChildDysfunctional Interaction; DC, Difficult Child. Parenting stress was defined as at least onePSI-SF score � 85th percentile over the 12-month study period.

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may not be suitable for depressed mothers or enable sustained quality, sensitiveinteractions, and improved parenting and child outcomes (Candelaria, Teti, Douglas,& Black, 2011; Glazebrook et al., 2007; Johnson et al., 2005, 2009). Parenting pro-grammes that target early depression such as the COPE programme (Melnyk et al.,2006) and improve the parents beliefs and experiences in their parental role as afunction of personal factors, such as self esteem and mood, may enhance thedepressive mothers’ availability and engagement in sessions focused on the childand other aspects of parenting. This is important because initially negativemother�child interactions and attachments are difficult to alter in later childhoodparticularly in the presence of reduced maternal psychological resource (Berlin,Brooks-Gunn, McCarton, & McCormick, 1998).

Conclusion

The inter-correlation between parenting stress and PND is recognised and inherentin the tools used. Additionally, the secondary use of data from our RCT precludesexamining other potential factors such as prior maternal mental and biologicalhealth. While neither child disability or maternal perception of general health wereindependently related to parenting stress in this analysis, the extent of the differentrates between PND groups merits closer examination in a much larger sample.However, PND seems to matter in its association with prematurity, parenting stressand childhood outcomes. At present, parenting interventions show inconsistent find-ings in the preterm population. This study supports other findings that a focus onmaternal high prevalence risk factors, like depression, may improve effectiveness ofearly parenting programs in mothers with preterm-born children. Recognising PNDprior to discharge is essential and parenting programmes should specifically addressPND in mothers of preterm infants.

AcknowledgementsThis research was supported by Neonatal Nurses Association Queensland (NNAQ) Inc.Scholarship Grant.

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