Maternal Experience of Neonatal Intensive Care Unit Hospitalization: Trauma Exposure and Psychosocial Responses

  • Pamela A. GellerEmail author
  • Alexa Bonacquisti
  • Chavis A. Patterson
Part of the Integrating Psychiatry and Primary Care book series (IPPC)


For mothers in the postpartum period, admission of their newborn to a neonatal intensive care unit (NICU) is often an unanticipated experience that can be shocking and traumatic, and can elevate maternal risk for psychiatric symptoms, including posttraumatic stress. In this chapter, the NICU experience, psychosocial implications, mental health consequences, and screening tools that have been used to identify maternal psychiatric symptoms in this setting will be reviewed. Psychosocial interventions and programs addressing the stress and psychological reactions of mothers with an infant in a NICU will be introduced, as will recently developed interdisciplinary recommendations for the support of NICU families and a nurse training program to promote optimal communication between NICU nurses and parents. The chapter concludes with future clinical and research directions to continue improving maternal adjustment and mental health during a child’s NICU hospitalization.


NICU Hospitalization Neonatal Intensive Care Unit (NICU) NICU Experience NICU Nurses Nurse Training Program 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Alcorn KL, O’Donovan A, Patrick JC, Creedy D, Devilly GJ (2010) A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychol Med 40(11):1849–1859CrossRefPubMedGoogle Scholar
  2. Alkozei A, McMahon E, Lahav A (2014) Stress levels and depressive symptoms in NICU mothers in the early postpartum period. J Mater Fetal Neonatal Med 27(17):1738–1743. doi: 10.3109/14767058.2014.942626 CrossRefGoogle Scholar
  3. Barr P (2011) Posttraumatic growth in parents of infants hospitalized in a neonatal intensive care unit. J Loss Trauma Int Perspect Stress Coping 16(2):117–134. doi: 10.1080/15325024.2010.519265 Google Scholar
  4. Beck CT (2003) Recognizing and screening for postpartum depression in mothers of NICU infants. Adv Neonatal Care 3(1):37–46CrossRefPubMedGoogle Scholar
  5. Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, Rubens C, Menon R, Van Look PF (2010) The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Organ 88(1):31–38. doi: 10.2471/BLT.08.062554 CrossRefPubMedGoogle Scholar
  6. Beck CT, Driscoll JW, Watson S (2013) Traumatic childbirth. Routledge, New YorkGoogle Scholar
  7. Bonacquisti, A, Geller, PA (2016) Psychological responses and treatment among mothers in the neonatal intensive care unit: the impact of attachment, attitudes, social support, and health behaviors. Unpublished doctoral dissertation, Drexel University, PhiladelphiaGoogle Scholar
  8. Callahan JL, Borja SE, Hynan MT (2006) Modification of the perinatal PTSD questionnaire to enhance clinical utility. J Perinatol 26(9):533–539CrossRefPubMedGoogle Scholar
  9. Carter JD, Mulder RT, Darlow BA (2007) Parental stress in the NICU: the influence of personality, psychological, pregnancy and family factors. Personal Ment Health 1(1):40–50CrossRefGoogle Scholar
  10. Cherry AS, Blucker RT, Thornberry TS, Hetherington C, McCafferee MA, Gillaspy SR (2016) Postpartum depression screening in the neonatal intensive care unit: program development, implementation, and lessons learned. J Multidiscip Healthc 18(9):59–67. doi: 10.2147/JMDH.S91559 CrossRefGoogle Scholar
  11. Chertok IR, McCrone S, Parker D, Leslie N (2014) Review of interventions to reduce stress among mothers of infants in the NICU. Adv Neonatal Care 14(1):30–37CrossRefPubMedGoogle Scholar
  12. Chow S, Chow R, Popovic M, Lam M, Popovic M, Merrick J, Margalit RNS, Lam H, Milakovic M, Chow E, Popovic J (2015) A selected review of the mortality rates of neonatal intensive care units. Front Public Health 3:225. doi: 10.3389/fpubh.2015.00225 PubMedPubMedCentralGoogle Scholar
  13. Committee on Fetus and Newborn (2012) Levels of neonatal care. Pediatrics 130(3):587–597. doi: 10.1542/peds.2012-1999 CrossRefGoogle Scholar
  14. Davidson JR, Book SW, Colket JT, Tupler LA, Roth S, David D, Hertzberg M, Mellman T, Beckham JC, Smith RD, Davison RM, Katz R, Feldman ME (1997) Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med 27(1):153–160CrossRefPubMedGoogle Scholar
  15. Davis DL, Stein MT (2004) Parenting your premature baby and child: the emotional journey. Fulcrum Publishing, GoldenGoogle Scholar
  16. Davis L, Edwards H, Mohay H, Wollin J (2003) The impact of very premature birth on the psychological health of mothers. Early Hum Dev 73(1):61–70CrossRefPubMedGoogle Scholar
  17. Doering LV, Moser DK, Dracup K (2000) Correlates of anxiety, hostility, depression, and psychosocial adjustment in parents of NICU infants. Neonatal Netw 19(5):15–23CrossRefPubMedGoogle Scholar
  18. Fairbrother N, Janssen P, Antony MM, Tucker E, Young AH (2016) Perinatal anxiety disorder prevalence and incidence. J Affect Disord 200:148–155. doi: 10.1016/j.jad.2015.12.082 CrossRefPubMedGoogle Scholar
  19. Feeley N, Zelkowitz P, Cormier C, Charbonneau L, Lacroix A, Papageorgiou A (2011) Posttraumatic stress among mothers of very low birthweight infants at 6 months after discharge from the neonatal intensive care unit. Appl Nurs Res 24(2):114–117. doi: 10.1016/j.apnr.2009.04.004 CrossRefPubMedGoogle Scholar
  20. Fegran L, Helseth S, Fagermoen MS (2008) A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. J Clin Nurs 17(6):810–816CrossRefPubMedGoogle Scholar
  21. Feldman R (2009) The development of regulatory functions from birth to 5 years: insights from premature infants. Child Dev 80(2):544–561CrossRefPubMedGoogle Scholar
  22. Feldman R, Weller A, Leckman JF, Kuint J, Eidelman AI (1999) The nature of the mother’s tie to her infant: maternal bonding under conditions of proximity, separation, and potential loss. J Child Psychol Psychiatry 40(6):929–939CrossRefPubMedGoogle Scholar
  23. Field T (2010) Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev 33(1):1–6CrossRefPubMedGoogle Scholar
  24. Forray A, Mayes LC, Magriples U, Epperson CN (2009) Prevalence of post-traumatic stress disorder in pregnant women with prior pregnancy complications. J Matern Fetal Neonatal Med 22(6):522–527CrossRefPubMedPubMedCentralGoogle Scholar
  25. Grekin R, O'Hara MW (2014) Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev 34(5):389–401CrossRefPubMedGoogle Scholar
  26. Hall SL, Hynan MT (2015) Interdisciplinary recommendations for the psychosocial support of NICU parents. J Perinatol 35:S1CrossRefPubMedPubMedCentralGoogle Scholar
  27. Hall SL, Cross J, Selix NW, Patterson C, Segre L, Chuffo-Siewert R, Geller PA, Martin ML (2015) Recommendations for enhancing psychosocial support of NICU parents through staff education and support. J Perinatol 335:s29–s36CrossRefGoogle Scholar
  28. Harrison W, Goodman D (2015) Epidemiologic trends in neonatal intensive care, 2007–2012. JAMA Pediatr 169(9):855–862. doi: 10.1001/jamapediatrics.2015.1305 CrossRefPubMedGoogle Scholar
  29. Helle N, Barkmann C, Ehrhardt S, von der Wense A, Nestoriuc Y, Bindt C (2016) Postpartum anxiety and adjustment disorders in parents of infants with very low birth weight: cross-sectional results from a controlled multicentre cohort study. J Affect Disord 194:128–134. doi: 10.1016/j.jad.2016.01.016 h CrossRefPubMedGoogle Scholar
  30. Holditch-Davis D, Bartlett TR, Blickman AL, Miles MS (2003) Posttraumatic stress symptoms in mothers of premature infants. J Obstet Gynecol Neonatal Nurs 32(2):161–171. doi: 10.1177/0884217503252035 CrossRefPubMedGoogle Scholar
  31. Holditch-Davis D, Santos H, Levy J, White-Traut R, O’Shea TM, Geraldo V, David R (2015) Patterns of psychological distress in mothers of preterm infants. Infant Behav Dev 41:154–163CrossRefPubMedPubMedCentralGoogle Scholar
  32. Hummel P (2003) Parenting the high-risk infant. Newborn Infant Nurs Rev 3(3):88–92CrossRefGoogle Scholar
  33. Hynan MT, Steinberg Z, Baker L, Cicco R, Geller PA, Lassen S, Milford C, Mounts KO, Patterson C, Saxton S, Segre L, Stuebe A (2015) Recommendations for mental health professionals in the NICU. J Perinatol 35:S14–S18CrossRefPubMedPubMedCentralGoogle Scholar
  34. Kazak AE (2006) Pediatric psychosocial preventative health model (PPPHM): research, practice, and collaboration in pediatric family systems medicine. Fam Syst Health 24(4):381–395CrossRefGoogle Scholar
  35. Kenner C, Press J, Ryan D (2015) Recommendations for palliative and bereavement care in the NICU: a family-centered integrative approach. J Perinatol 35:S19–S23. doi: 10.1038/jp2015.145 CrossRefPubMedPubMedCentralGoogle Scholar
  36. Lee HC, Green C, Hintz SR, Tyson JE, Parikh NA, Langer J, Gould JB (2010) Prediction of death for extremely premature infants in a population-based cohort. Pediatrics 126(3):e644–e650. doi: 10.1542/peds.2010-0097 CrossRefPubMedGoogle Scholar
  37. Lefkowitz DS, Baxt C, Evans JR (2010) Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU). J Clin Psychol Med Settings 17(3):230–237CrossRefPubMedGoogle Scholar
  38. March of Dimes Perinatal Data Center (2011) Special care nursery admissions. National Perinatal Information System/Quality Analytic Services. White Plains, NYGoogle Scholar
  39. Matricardi S, Agostino R, Fedeli C, Montirosso R (2013) Mothers are not fathers: differences between parents in reduction of stress levels after a parental intervention in a NICU. Acta Pediatr 102(1):8–14CrossRefGoogle Scholar
  40. Melnyk BM, Feinstein NF, Moldenhouer Z, Small L (2000) Coping in parents of children who are chronically ill: strategies for assessment and intervention. Pediatr Nurs 27(6):548–558Google Scholar
  41. Melnyk BM, Feinstein NF, Alpert-Gillis L et al (2006) Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the creating opportunities for parent empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics 118(5):e1414–e1427CrossRefPubMedGoogle Scholar
  42. Meyer EC, Zeanah CH, Boukydis CFZ, Lester BM (1993) A clinical interview for parents of high-risk infants: concept and applications. Infant Ment Health J 14(3):192–207. doi: 10.1002/1097-0355(199323)14:3<192::AID-IMHJ2280140305>3.0.CO;2-R CrossRefGoogle Scholar
  43. Meyer EC, Coll CTG, Lester BM, Boukydis CFZ, McDonough SM, Oh W (1994) Family-based intervention improves maternal psychological well-being and feeding interaction of preterm infants. Pediatrics 93(2):241–246PubMedGoogle Scholar
  44. Meyer EC, Coll CTG, Seifer R, Ramos A, Kilis E, Oh W (1995) Psychological distress in mothers of preterm infants. J Dev Behav Pediatr 16(6):412–417.Google Scholar
  45. Meyer EC, Brodsky D, Hansen AR, Lamiani G, Sellers DE, Browning DM (2011) An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol 31:212–219. doi: 10.1038/jp.2010.109 CrossRefPubMedGoogle Scholar
  46. Miles MS, Funk SG, Carlson J (1993) Parental stressor scale: neonatal intensive care unit. Nurs Res 42(3):148–152CrossRefPubMedGoogle Scholar
  47. Miles MS, Holditch-Davis D, Schwartz TA, Scher M (2007) Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr 28(1):36–44CrossRefPubMedGoogle Scholar
  48. Nearing GB, Salas AA, Granado-Villar D, Chandler BD, Soliz A (2012) Psychosocial parent support programs and short-term clinical outcomes in extremely low birth-weight infants. J Mater Fetal Neonatal Med 25(1):89–93CrossRefGoogle Scholar
  49. Niela-Vilen H, Melender HL, Axelin A, Loyttyniemi E, Salantera S (2016) Predictors of breastfeeding initiation and frequency of preterm infants in the NICU. J Obstet Gynecol Neonatal Nurs 45(3):346–358CrossRefPubMedGoogle Scholar
  50. O’Hara MW, Swain AM (1996) Rates and risk of postpartum depression – a meta-analysis. Int Rev Psychiatry 8(1):37–54CrossRefGoogle Scholar
  51. Obeidat HM, Bond EA, Callister LC (2009) The parental experience of having an infant in the newborn intensive care unit. J Perinat Educ 18(3):23CrossRefPubMedPubMedCentralGoogle Scholar
  52. O'Hara MW (2009) Postpartum depression: what we know. J Clin Psychol 65(12):1258–1269CrossRefPubMedGoogle Scholar
  53. Osterman MJK, Martin JA, Mathews TJ, Hamilton BE (2011) Expanded data from the new birth certificate national vital statistics reports. National Center for Health Statistics, HyattsvilleGoogle Scholar
  54. Pai AL, Patiño-Fernández AM, McSherry M, Beele D, Alderfer MA, Reilly AT et al (2008) The psychosocial assessment tool (PAT2. 0): psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with cancer. J Pediatr Psychol 33(1):50–62CrossRefPubMedGoogle Scholar
  55. Paul IM, Downs DS, Schaefer EW, Beiler JS, Weisman CS (2013) Postpartum anxiety and maternal-infant health outcomes. Pediatrics 131(4):e1218–e1224CrossRefPubMedGoogle Scholar
  56. Perelman A (2014) Needs, services, and barriers: staff perceptions of mental health care in the NICU. Unpublished Doctoral Dissertation. Widener University, ChesterGoogle Scholar
  57. Poehlmann J, Schwichtenberg A, Bolt D, Dilworth-Bart J (2009) Predictors of depressive symptom trajectories in mothers of preterm or low birth weight infants. J Fam Psychol 23(5):690CrossRefPubMedPubMedCentralGoogle Scholar
  58. Profit J, Sharek PJ, Amspoker AB, Kowalkowski MA, Nisbet CC, Thomas EJ, Chadwick WA, Sexton JB (2014) Burnout in the NICU setting and its relation to safety culture. BMJ Qual Saf 23(10):806–813CrossRefPubMedPubMedCentralGoogle Scholar
  59. Raposa E, Hammen C, Brennan P, Najman J (2014) The long-term effects of maternal depression: early childhood physical health as a pathway to offspring depression. J Adolesc Health 54(1):88–93CrossRefPubMedGoogle Scholar
  60. Reck C, Noe D, Gerstenlauer J, Stehle E (2012) Effects of postpartum anxiety disorders and depression on maternal self-confidence. Infant Behav Dev 35(2):264–272. doi: 10.1016/j.infbeh.2011.12.005 CrossRefPubMedGoogle Scholar
  61. Ross LE, McLean LM (2006) Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry 67(8):1285–1298CrossRefPubMedGoogle Scholar
  62. Schappin R, Wijnroks L, Tuniken VA, Johnmans MJ (2013) Rethinking stress in parents of preterm infants: a meta-analysis. PLoS One 8(2):e54992CrossRefPubMedPubMedCentralGoogle Scholar
  63. Schuit E, Hukkelhoven CWPM, Manktelow BN, Papatsonis DNM, de Kleine MJK, Draper ES et al (2012) Prognostic models for stillbirth and neonatal death in very preterm birth: a validation study. Pediatrics 129(1):e120–e127. doi: 10.1542/peds.2011-0803 CrossRefPubMedGoogle Scholar
  64. Shaw RJ, Bernard RS, Storfer-Isser A, Rhine W, Horwitz SM (2013) Parental coping in the neonatal intensive care unit. J Clin Psychol Med Settings 20(2):135–142CrossRefPubMedPubMedCentralGoogle Scholar
  65. Shelton SL, Meaney-Delman DM, Hunter M, Lee S (2014) Depressive symptoms and the relationship of stress, sleep, and well-being among NICU mothers. J Nurs Educ Pract 4(8):70Google Scholar
  66. Shen H, Magnusson C, Rai D et al (2016) Associations of parental depression with child school performance at age 16 years in Sweden. JAMA Psychiat 73(3):239–246CrossRefGoogle Scholar
  67. Shin H, White-Traut R (2007) The conceptual structure of transition to motherhood in the neonatal intensive care unit. J Adv Nurs 58(1):90–98CrossRefPubMedGoogle Scholar
  68. Sneath N (2009) Discharge teaching in the NICU: are parents prepared? An integrative review of parents’ perceptions. Neonatal Netw 28(4):237–246CrossRefPubMedGoogle Scholar
  69. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC et al (2010) Neonatal outcomes of extremely preterm infants from the NICHD neonatal research network. Pediatrics 126(3):443–456. doi: 10.1542/peds.2009-2959 CrossRefPubMedPubMedCentralGoogle Scholar
  70. Tietz A, Zietlow AL, Reck C (2014) Maternal bonding in mothers with postpartum anxiety disorder: the crucial role of subclinical depressive symptoms and maternal avoidance behavior. Arch Womens Ment Health 17(5):433–442CrossRefPubMedGoogle Scholar
  71. Treyvaud K, Lee KJ, Doyle LW, Anderson PJ (2014) Very preterm birth influences parental mental health and family outcomes seven years after birth. J Pediatr 164(3):515–521. doi: 10.1016/j.jpeds.2013.11.001 CrossRefPubMedGoogle Scholar
  72. United Nations Interagency Group for Child Mortality Estimation (2016) Mortality rate, neonatal, per 1,000 live births. Available from:
  73. van Bussel JC, Spitz B, Demyttenaere K (2009) Anxiety in pregnant and postpartum women. An exploratory study of the role of maternal orientations. J Affect Disord 114(1):232–242CrossRefPubMedGoogle Scholar
  74. Vanderbilt D, Bushley T, Young R, Frank D (2009) Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit: a preliminary study. J Dev Behav Pediatr 30(1):50–56. doi: 10.1097/DBP.0b013e31819b0de CrossRefPubMedGoogle Scholar
  75. Wenzel A, Haugen EN, Jackson LC, Brendle JR (2005) Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 19(3):295–311CrossRefPubMedGoogle Scholar
  76. Wenz-Gross M, Weinreb L, Upshurt C (2016) Screening for post-traumatic stress disorder in prenatal care: prevalence and characteristics in a low-income population. Matern Child Health J 20(10):1995–2002CrossRefPubMedGoogle Scholar
  77. Wigert H, Johansson R, Berg M, Hellström AL (2006) Mothers’ experiences of having their newborn child in a neonatal intensive care unit. Scand J Caring Sci 20(1):35–41CrossRefPubMedGoogle Scholar
  78. Yurdakul Z, Akman I, Kuşçu MK, Karabekiroglu A, Yaylalı G, Demir F, Özek E (2009) Maternal psychological problems associated with neonatal intensive care admission. Int J Pediatr 2009:591359CrossRefPubMedPubMedCentralGoogle Scholar
  79. Zelkowitz P, Papageorgiou A (2005) Maternal anxiety: an emerging prognostic factor in neonatology. Acta Paediatr 94(12):1704–1705CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Pamela A. Geller
    • 1
    Email author
  • Alexa Bonacquisti
    • 1
  • Chavis A. Patterson
    • 2
    • 3
  1. 1.Department of PsychologyDrexel UniversityPhiladelphiaUSA
  2. 2.Division of NeonatologyThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  3. 3.Department of PsychiatryPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA

Personalised recommendations