Experiences of New Mothers with Premature Babies in Neonatal Care Units: A Qualitative Study

Background: Although mother-newborn attachment is very important for infant development babies in need of neonatal intensive care have to be separated from their mothers. A mother might experience distress in bonding with her vulnerable newborn because of admission to the neonatal care unit (NICU). Purpose: The purpose of the study was to describe the new mothers’ experiences of having a premature baby at the NICU. Methods: This study was patterned with a descriptive qualitative design. Data were collected through in-depth interviews with 25 new mothers using semi-structured questions. Participant’s each word has been recorded. Records were transcribed and content analysis was made. Results: Four main themes and sub-themes were emerged regarding the experiences of mothers; 1) The barriers of having a premature newborn; feeling of separation from their baby, feeling of isolation towards NICU setting, feeling of emotional distress, 2) Lack of self-confidence for motherhood, 3) Maternal-newborn interaction, 4) Maternal-health staff interaction; insufficient communication and psychosocial support. Mothers stated that they felt themselves incompetent in terms of post-NICU care due to anxiety, inadequate support and self-confidence. They needed effective information about the hospital practices and post-NICU care. Conclusion: Mothers presented many feelings with some positive and negative experiences such as sadness, alienation, fear and anxiety, depression, guilty, losing their self-confidence about maternity skills, and insufficient bonding with their babies. Mothers also expressed their needs and expectations as emotional support and empathic approach from staff. It is extremely important for mothers to get psychological support in order to cope with the infants staying in NICU.

plement this approach for newborns and preterm babies. To address this gap, evaluation of experiences faced by parents about parent-infant separation during neonatal care is an important need in order to better understanding of their challenges and also women's expressions can help us explore the best way to prepare for the child care period.

Purpose
The aim of the present study was to investigate new mothers' experiences in order to better understanding of their experiences during their premature infant's hospitalization at the NICU.

Methodology Research design, sampling and setting
This qualitative study was performed between Jan and May 2016 in a tertiary hospital in Ankara, Turkey. Participants consisted of mothers whose babies were hospitalized at NICU. The mothers were selected by convenience sampling. A total of 25 mothers volunteered and consented to participate. The study hospital NICU has 29 beds (17 fully equipped, 2 isolation, 10 open incubators). Family-centered care policy has been adopted and implemented in the unit. As the inclusion criteria: 1) Mothers who gave birth before the 37 th gestational week (singly), 2) Whose babies were hospitalized in NICU for at least 3 days, and 3) Who could speak Turkish were preferred. Exclusion criteria were as follows: 1) Mothers whose children have died, 2) Mothers whose child had severe disability, and 3) Mothers who have spent < 3 days at the hospital (the hospitalization period of > 3 days was accepted as sufficient time for mothers to create "beneficial" experiences of NICU to share with us).

Data collection
The questions asked to the participants were directed using questionnaire form and also in-depth interviews were conducted using semi-structured questionnaires by the researcher. These interviews were held in a private room in the hospital's mother hotel. During the interviews; open-ended questions were used to identify the support elements received by healthcare professionals, and to explore mothers' feelings of having a preterm baby, and having to be hospitalized in the NICU. The open-ended questions included: How NICU staff/ relatives approached your needs as the mother of a preterm baby. What more support would you like to receive in addition to these?
These interviews lasted between 30-40 minutes. During the interviews, the researchers not interrupted talking of the participants, and the talks continued until the participants repeat the same statements, and there was nothing different to say. The interviews were recorded and transcribed with a tape recorder within the knowledge of the participants.

Data analysis
Qualitative content analysis was used to classify concerning mothers' descriptions and feelings of their experiences using general thematic cods. The interviews listened repeatedly to gain a sense of the content by two researchers and also an independent women health nursing department's academician not involved in the study to comply with the impartiality and openness principle. Then transcribed categorically to capture the similar mothers' statements regarding their child's companion at the NICU.

Ethical considerations
Rules specified in the Helsinki Declaration were observed in the data collection phase. The study protocol was approved by the Ethics Committee of University hospital. Before the interviews, it was highlighted to the mothers that this study was a scientific study and would not directly benefit them today, but this information would be useful for mothers who had the same problem in the future. Mothers voluntarily provided written informed consent was obtained before study.

Results
The average age of the mothers was 27. (20-42), the average age of gestational age was 26 weeks (24-28), and the average of hospitalization time was 2 weeks (1-4). The largest proportion of women had unemployed (78%), had medium economic level (71%), and had completed high school (73%). All of mothers had health insurance.
The findings demonstrate that four main themes and their subthemes were identified: The emotional and psychological difficulties of having a premature newborn Feeling of separation-alienation from their baby: Mothers felt some challenges due to clinically unstable and the impairment of their premature child. Mothers described the preterm birth as a traumatic event that could increase stress and negative feelings such as sadness, separation, fear, anger, insecurity, anxiety, and depression. Among the interviewees who mentioned these feelings, the following stand out:

Lack of self-confidence
Mothers have stated concerns about their maternity role and having premature babies. They didn't have a chance to complete their baby's routine preparations before the baby's birth, which made it difficult for them to experience the feeling of motherhood after the baby's sudden birth. The following stand out:

Maternal-newborn interaction
It was determined that the more positive feelings the mothers had towards their babies, the less their initial worries. Mothers wanted to be close to the infant and hold him/ her as soon as possible after the birth. Among the interviewees who mentioned these feelings, the following stand out: Feelings isolation towards the NICU setting: In the early period after the baby's admission to the unit, mother felt some difficulties; the attention of the mother focused on the NICU environment, and the baby remained in the second plan until they perceive the environment. Among the interviewees who mentioned these feelings, the following stand out:

Discussion
In the present study, mothers listed problems as a barrier such as not being able to breastfeed the baby, not being able to establish intimacy with their baby, and not being able to sufficient communicate with healthcare professionals. Mothers stated that they have difficulties in meeting vital needs such as facilitating the early mother-infant relationship, solving their strain and concern in early stages following the birth of their baby. Beyond that, they explained the inadequacy of socio-psychological support as "later problems", although so quickly. Initially, I did not feel like a mother after my birth because I was not prepared yet. I need to spent time with him. I hope day by day I will be reinforced for care of my baby". "I felt concern how I become a mom to my baby at the beginning. It was very stressful in connection with a preterm birth. I try to keep this unexpected situation under control because I should be strong".
"I was so shocked when I first visit the NICU. She was so tiny. She looked not very well in the incubator; she has many drips with feeding tube and many other things on their chest. I felt failed myself in motherhood and scared deeply then I started the cried."

Maternal-health provider's interaction and expectations
Effective communication: The mothers were expressed their expectations from health professionals as encouraging to take care of their babies. Mothers wanted to get to know their babies by seeing, caring, holding, grasping, touching, and talking them as without interrupt as possible in the NICU. They also desired adequate information on their own nutrition, mental and physical recovery, breastfeeding, and motherhood, and encouragement to cope with their baby's care problems from NICU staff. Unfulfilled expectations made mothers feel both disappointment and sadness. These findings emerged in the following statement from mothers: "I desired that involving in feeding my baby, changing nappies or playing with my babies to raise my maternal confidence". As I spent time at NICU, my distress gradually subsided and I adapted better to my baby care routines. I need someone to support me".
"My first encounter with my baby was much more difficult than I thought. We could not spend all time at the hospital. I did not leave my baby in there. But there was nothing I could do. Then I tried to focus more realistic balance with the support of staff".
"I was sometimes even depressed but health providers in the NICU who provide constantly informed about our baby' condition and all procedures care for the baby, they assisted how should I hold my baby. I always trust them because they stay very close to our baby thereby this guidance is very crucial for me".
"It is very difficult to communicate with the healthcare team. I had trouble getting used to the situation because of their attitude. Not everyone is the same, of course, but I have that mothers with poor economic status, poor family communication, unmarried, and seriously premature babies (low birth weight, premature, anomaly) have low self-confidence [27,28].
Quality togetherness of mother and baby is important for a healthy mother-infant attachment [11]. It has been stated in previous studies that babies develop mentally and physically faster as mothers have more opportunities to be with and care for their babies [20,22,26]. In this study, mothers; it was revealed that they could not touch their babies enough, could not hold them, talk to them, spend time together and this situation strained the mother. According to the studies, the NICU environment has created a barrier to mother-infant interaction and it was also explained that health professionals play a facilitating role in mother-infant interaction [12,29,30].
Expectations of mothers in this study; care for this particular baby is disclosure of his condition and information and attention to intimacy. Some mothers found the support of healthcare professionals very positive. NICU services in Turkey have been deployed in the overall teaching and research hospital. The complexity of these units and the workload of the nurses may not allow these professionals to adequately interact with the mother. In another study where the two groups were compared, nurses provided education and social support for mothers' babies remaining in NICU. It was observed that some mothers suffered from nurses' indifference, some mothers got stronger by receiving staff support [29]. Furthermore, another study reported that nurses and doctors do not fulfill their educational roles and are even perceived as irresponsible. Mothers expected heath providers to be more directive and friendly [23].
The findings of this study revealed that the emotional states of mothers in NICU processes are generally sensitive. Mothers have high concerns on many issues, especially the insufficient maternal involvement and fear of losing their baby. In this study, "communication" could be a lifeline for them to deal with their problems. In this study, mothers mostly stated that their expectations about communication were not met. A few of them participated in the care through nurses and this experience reduced the anxiety of the mothers. The mother hotel was considered as a very good opportunity as it allows mothers to stay and get closer to the baby. This opportunity was found positive in the study. Mothers also reported that a psychologist should take care of them for mental support and a social worker for their social needs. Similarly, previous studies reported that mothers were unable to deal with doctors at all, and they complained that communicating with health staff was very difficult and they used negative communication methods, which pushed a mother to loneliness. Although communication skills differ from person to person, it is thought that the communication of healthcare professionals with mothers, even at a basic level, will ensure the adaptation of mothers to NICU and reduce the workload of these professionals [5,11,23,24,29,30].

Conclusion and Recommendations
The feelings and needs of mothers with preterm baby in they are very important. The findings of previous studies are similar to our results, also mothers described hospitalization and discharge procedures and social security as an additional barrier issues [10,17,18].
In a study performed by Jackson, et al. [19] mothers have felt in control during pregnancy. For them, the baby was the happiness element of life after birth. Suddenly handing over this source of happiness to other hands, due to a health problem, drove them away from their babies. In this study, the emotions that make mothers feel alienated from their babies; the delicate and fragile nature of babies, difficulty in touching, difficulty in breastfeeding or expressing milk in difficult conditions for her, and not being able to participate in the care of the baby as a mother. They were concerned that the preterm infant would be affected for survival. Furthermore, mothers consider the experience of having their baby admitted to a NICU as distressing and traumatic, and life altering. Similar results have been demonstrated in other studies [10,13,20,21].
Both "bonding" and "attachment" relationship develops better with the continuous union of mother and baby. However, normal bonding process is hindered by illness, NICU hospitalization after premature births may cause psychological and social problems in mothers. Therefore, understanding NICU mothers' psychosocial needs is important also to contribute to the best possible long-term outcome for the infant and family [22]. The rapid alienation of this mother from her baby supports this view and reveals the difference between the other mothers and this mother withdrawing from their babies [23]. In the present study, mothers explained that they were afraid of the complex environment in which these advanced techniques were used and that they were surprised by the specialization of the doctors and nurses. On the other hand, they were worried about the disruption of the treatment of their babies among such complex procedures. Studies have shown that the technical equipment and the medical language spoken in NICUs all over the world cause stress in mothers and they feel very lonely here [5,8,[11][12][13]. In different studies, it was revealed that mothers experienced emotional distress; some blame themselves, some feel so tense, and some want to eliminate the factors that prevent her from reaching her with a very high anxiety for her baby [7,19,24]. In a meta-analytic study, mothers stated that they are highly affected by all kinds of stressors during their hospital stay, this situation differs according to the severity of the baby's health problem and the mother's previous psychological problems, especially the first week of the postpartum period is the period with the highest stress. In the same study, mothers cannot cope with baby's care, depressive, and not being able to control her emotions [25].
In the present study, mothers basically stated that they felt inadequate about baby care. These shortcomings; the thought of proving oneself as a good mother to others, anxiety of not being able to cope with difficulties and running away, anxiety about leaving the baby or the environment, and not being able to notice possible problems with the baby due to inexperience have been expressed. The sudden introduction of a baby to intensive care after birth causes mothers to decrease their self-efficacy [26]. Studies have shown the NICU were varies from mothers to mothers in this study. Mothers especially needed to be enhancing their maternal role. According to the mothers, health providers in the NICU was essential role for accomplish early maternal-newborn bonding. In this regard, mothers must be given adequate support by health staff in order to solve their emotional problems and ensure early bonding with their babies. Further and larger comprehensive studies are needed to explore mothers' feelings and to implement family-centered interventions in order to enhance mother-newborn interactions in the NICU.

Limitation
This study was performed in the NICE of tertiary hospital. For this reasons, the findings may not represent of all hospitals in general.