Introduction
Stressful for parents of premature babies in the NICU. Parents and newborns benefit from family-integrated care (FICare), which incorporates them into the healthcare team and creates a setting that encourages parental presence and participation in neonatal care.
A newborn’s time in the hospital and subsequent growth benefit greatly from the involvement of both the father and mother. Paternal presence in early life has been linked to enhanced survival and improved social and emotional skills in offspring later in life when studied in animal models Human fathers often feel left out of their newborn’s care and decision-making during the NICU stay. Even though they are supposed to be there for their mothers and help with the care of their infant, fathers who have given birth prematurely may suffer from postpartum depression, anxiety, and other mental health issues. In the NICU, they may find it difficult to maintain a long-term presence while keeping other duties at home and at work. Not being active in the care of their newborns can lead to emotions of powerlessness and uncertainty in fathers. FICare appears to reduce stress in moms, but how it does so is still a mystery. Dads’ perinatal experiences in cases of preterm and, in particular, studies of the association between neonatal care settings and fathers’ engagement in newborn care and outcomes of paternal mental health are seldom researched.
To better understand the effects of the FICare model in single family rooms with thorough couplet-care for the mother and baby dyad on fathers’ mental health (stress, anxiety, depression, decreased father-newborn bonding, self-efficacy and satisfaction). We also wanted to see if the FICare model had any effect on fathers’ mental health and if parental involvement acted as a moderator.
Methods
Research Plan
The data for this study came from a prospective observational cohort study that compared FICare to SNC in open-bay units (eAppendix 1 in the Supplement). The most significant consequence is the neurodevelopment of premature infants at the corrected age of two years. The mental health of parents is also assessed during the course of the study. This study adheres to the TREND reporting requirements and the A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies for nonrandomized studies (AGReMA-SF). This experiment was approved by the United Nieuwegein Research Ethics Committee in the Netherlands.
There were no exclusion criteria for neonates delivered or transferred to level-2 neonatal wards participating in the trial in the Netherlands. After providing written informed consent, parents of preterm neonates (gestational age 37 weeks) who spent more than seven days in the hospital were allowed to participate in the study. We focused on the fathers of the households in our study. To acknowledge and respect the fact that there are persons bearing children who do not identify as either a father or a mother, we included same-sex couples. In order to make things clearer, we refer to the dads of newborns as those who are in a paternal relationship with the baby’s mother. A parent’s active mental illness (i.e., psychosis) or being under the care of child services were both exclusion criteria, as were the parent’s lack of fluency in either Dutch or English or the presence of any newborn congenital abnormalities that could affect the baby’s neurodevelopment or the death of a newborn (see eAppendix 1 in the Supplement). Figure 1 depicts the study’s enrolling process.
Exposedness (FICare Model)
One of Amsterdam’s largest teaching hospitals has implemented the FICare model to provide a whole mother-newborn couplet care system in single family rooms with rooming-in possibilities, as well as a concomitant involvement programme for parents and recurrent education for hospital staff.
To ensure that mothers were never separated from their newborns while they were receiving neonatal and/or maternity care in this setting, the services were integrated for all newborns and their families (couplet-care). During obstetric, maternity, and neonatal care, fathers might be present with their families at all times. In addition, nurses encouraged, coached, and counselled parents in their role as the primary caregivers for their newborns. Rooming-in facilities were available for parents who wished to attend but were not required to stay for the whole 8 hours per day.
All areas of infant care, including but not limited to, delivering feedings through nasogastric tube, breast, or bottle; skin-to-skin care; and controlling temperature regulation, were advocated by the researchers. To better involve parents in their children’s care, the practise of family-centered rounds was adopted, which allowed parents to take an active role in daily medical rounds and decision-making. Parents were also given group education sessions on all aspects of (preterm) baby and family health in addition to the individual lessons they got.
Observational Crew (SNC)
Both the Amsterdam and Alkmaar teaching hospitals in the Netherlands, which have level-2 newborn units, served as the study’s control hospitals. They had distinct maternity and newborn care units within each of these facilities. Transferred to the neonatal unit were sick or premature neonates born fewer than 35 weeks gestation, weighing less than 2000 g, or in an unstable condition. The neonatal ward and the maternity ward were kept separate. Open bay units were used in the neonatal wards (eFigure 4 in the Supplement). Curtains and chairs for parents were provided in each incubator. Whenever feasible, nurses try to involve parents in the care of their children. The paediatrician offered parents the option of receiving weekly updates from their child’s doctor. The paediatrician and nursing staff conducted daily rounds without the presence of the patient’s relatives. Daily rounds were a time for nurses to inform parents of any changes to treatment plans that had been made. There were no accommodations for parents to stay in the hospital with their infant while the baby was being cared for.
Data Gathering
In the study, fathers were asked to complete questionnaires on stress (Parental Stress Scale: NICU [PSS-NICU] with a maximum score of 130; higher scores indicate more stress), anxiety and depression (Hospital Anxiety and Depression Scale with a maximum score of 42; higher scores indicate more depression symptoms), and self-efficacy as a parent (Perceived [Maternal] Parenting Self-efficacy Scale with a maximum score of 42; (Post-partum Bonding Questionnaire; maximum score, 125, with higher scores indicating more impaired parent-newborn bonding). Hospital discharge surveys were completed by dads to measure their satisfaction with care received and their engagement and collaboration with health care personnel in neonatal care using CO-PARTNER and EMPOWERMENT of PArents in THe Intensive Care–Neonatology questionnaires. Participants answered a questionnaire regarding their educational history, present job and the cultural background with which they identify most (determined by the participant), smoking, drinking, and recreational drug usage.. Lastly. In an effort to boost response rates, fathers were reminded up to twice (7 and 14 days after initial questionnaires were sent).
Analytical Methods
Mann-Whitney U tests and independent t tests were used for nonnormally distributed data. 2 tests were employed to examine binary outcomes for differences. Two-sided testing was used in all tests. We used the Fisher exact test to determine differences in predicted cell counts of 5 or fewer.
A comparison of the pre-discharge characteristics of dads with and without discharge outcome variables was made. The data were believed to be missing at random. Missing data at the item level was handled by using the proposed guidance as detailed in Sterne’s paper and the multivariate imputation by chained equations (mice) technique with parcel summary scores. We used the imputation model to include all variables, including auxiliary variables related to the likelihood of missing data or the variables themselves that had missing data. The imputation model did not include any variables that were multicollinear with other variables included in the model. In order to produce imputed data sets, we did 20 imputations and 50 iterations on all data sets (see eAppendix 1 in the Supplement). With the aid of convergence plots, it was possible to monitor the progress of the experiment. The imputed data sets were used for all analyses, and the results were combined according to Rubins guidelines.
Multivariate linear or logistic regressions were used to examine the relationship between the FICare model and the outcomes of dads. We first conducted a (natural) logarithmic or square root transformation to normalise non-normally distributed outcome data, or if failed, dichotomized outcomes, in order to create a normal distribution. Statistical methods were used to identify and evaluate potential literature-based confounders and modifiers (see eAppendix 1 in the Supplement).
We ran mediation analyses on the imputed data set to see whether parental involvement is a potential mediator of the observed link between the FICare model and mental health (i.e. the c-path). Two linear regression models were also built in addition to the overall association model. Total parental involvement was considered a potential mediator for varied mental health outcomes in fathers in single-mediator models (Figure 2). The mediator’s connection to the FICare model was estimated in the first regression model (a-path). FICare’s direct effect size (c’path) and its relationship with outcomes (b-path) were calculated in the second regression model. Both simple mediation studies and more complex ones were conducted. Confounders were included in all models for the re-analyzed data. We used the a and b coefficients to compute the indirect effect size. The bootstrap CIs of 95% were computed using 1000 bootstrap resamples around the indirect impact size ranges.
To perform multiple imputation35 and calculate bootstrap 95 percent CIs, we utilised R statistical software version 3.6.1 (R Project for Statistical Computing). P 0.05 was considered significant in all tests. From January to April of 2021, data was analysed.
Involvement in Medical Treatment
In the FICare model, fathers were more active in their newborns’ care than they were in the SNC model. It was found that dads were more likely to be present and had higher overall engagement scores when using the FICare model (adjusted odds ratio 3.424; 95 percent confidence interval, 0.860-5.988; P =.009). When compared to dads in the SNC, CO-PARTNER tool domain 3: less information seeking, fewer participation in medical care (domain 2: tube feeding, monitoring the infant, restriction of visitation to the newborn, and participation in daily rounds) (domain 3: less information searching, less participation in medical care). As a result, they pledged to do more to protect their child in the future. No differences were seen in the way people cared for a newborn.
Analyzing the influence of parental involvement on educational outcomes
We could tell the difference between the FICare model’s direct effect (by the c’ path) and its indirect effect (via higher parental participation) using mediation studies (the ab path). There were two possible outcomes to the mediation analysis (Table 3).
Positive Effects of the FICare Model Explained by Parental Involvement
Adjusted indirect impact, 0.051; 95 percent CI, 0.133 to 0.003) and lower impaired parent-newborn bonding scores (ab path) were related with increased total participation in the FICare model (ab path). Fathers’ depressed symptoms and parent-newborn bonding were not linked to the FICare model’s positive outcomes (c’ route).
Parental involvement alone cannot explain the positive outcomes associated with the FICare model.
Compared to fathers in SNC, fathers in FICare were less stressed at discharge. Neither parental involvement nor the 95 percent confidence interval (CI) indicated that it was a mediating factor in this association. It was found that the FICare model had no influence on fathers’ self-efficacy at discharge (adjusted indirect effect of 0.457; 95 percent CI, 0.119 to 1.357) or on satisfaction with care (adjusted indirect effect of 0.018; 95 percent CI 0.022 to 0.075) while they were involved in neonatal care.
Discussion
When the FICare model was implemented in single family rooms with total couplet care for the mother-newborn dyad in the Netherlands, we found that fathers reaped the benefits. FICare’s NICU-related stress in dads was significantly lower than that seen in earlier studies, and we offer probable explanations for this through mediation analyses. FICare in moms and single family rooms have been linked to lower stress in fathers. FICare’s mental health outcomes for fathers are better than those of the control group despite differences in gestational age at the start of the study.
In our research, we found that the setup of the unit, with single family rooms and comprehensive couplet-care, is particularly supportive of dads in lowering stress. Unexpectedly, the lower stress levels could not be attributed to more active involvement in caring.
During a newborn’s hospital stay, fathers must provide emotional support to the mother, manage the household, and possibly return to work immediately. They are sensitive to the fact that the well-being of both the mother and the infant is on their minds at all times. In addition, interpersonal factors, such as fatherhood attitudes, the support of health care providers, or parent-clinician contact, could potentially moderate the link between fathers’ involvement in care and stress. For this reason, it is possible that dads’ education and support needs differ from those of mothers’, but qualitative study should be conducted in order to fully examine this possibility.
We discovered positive correlations between the FICare model and depression and parent-newborn attachment among fathers. This study adds to the growing body of evidence demonstrating that fathers of preterm babies have better mental health as a result of their involvement in the care of their children.
A multicomponent care model, the FICare model in this study, tackles parent-newborn separation and promotes parent participation through several features, such as the architectural design, integration of neonatal and maternity care, and a concomitant parental participation programme. Parents’ and newborns’ mental health cannot be improved only by altering the building’s layout. Furthermore, even without further FICare, patients can take part in routine medical procedures. The CO-PARTNER tool was used to examine the connections between various dimensions of parental participation (as assessed by the CO-PARTNER tool) and the mental health outcomes of fathers. Even in open-bay newborn facilities, stimulating and encouraging parent participation can be enhanced. This is vital for present care settings that are unable to move to separate family rooms or couplet-care. Even though we were unable to study the relationship between the father and the newborn in this study, we believe that increased interaction in care and improved father-newborn bonding will also lead to a stronger reciprocal (emotional) relationship over time between father and newborn, which will be beneficial to the newborn.
According to our findings, fathers in the FICare model reported lower levels of stress than those in the SNC model. Biomarker measurements (e.g. cortisol in hair or saliva) could be included in future study to better characterise stress trajectories during and after neonatal hospitalisation. Prenatal screening of all expectant fathers and families for mental health disorders (such as anxiety, depression, and the risk of disrupted bonding) should also be standard practise.
There are both advantages and disadvantages to each.
Among the study’s strengths are the vast number of fathers who participated. We used advanced statistical approaches and a newly constructed parent participation scale that was validated in fathers to find and explain the hypothesised association of increasing parental involvement in the FICare model with outcomes in fathers. The level of consent and response from fathers was particularly high.
This study also has many flaws, however. In the absence of father-specific scales, we relied on women and mothers for the majority of the validation in this study. Future research should focus on designing and validating measures for fathers because they too may be unhappy or nervous and struggle to cope with the arrival of a sick or preterm infant. As a result, we can evaluate interventions across trials and tailor support to the specific requirements of individual fathers.
We can’t prove a link between participation and results because the study was conducted in a hospital without randomization. It’s possible that our findings point to a two-way relationship between participation and outcomes. For example, fathers who were under a lot of stress participated more than those who were less stressed. There is a need for future research to add randomization in order to evaluate hospital-based therapies (ie, stepped-wedge cluster randomization). 52 A difficult task, given the trend toward single-family rooms and the nuances of NICU care culture.
Conclusions
A new FICare model with complete couplet-care for the mother and baby dyad in single family rooms was related with fewer fathers’ felt stress in a study of level-2 neonatal facilities in the Netherlands. There are fewer depression symptoms and improved parent-newborn bonding in this FICare model because men can engage more. No matter how a neonatal intensive care unit is built, the culture of care should be geared toward the requirements of dads and their ability to actively engage in their child’s care.