Does Mindfulness Reduce Maternal Stress and Promote Mother-Infant Bonding in NICU?

Purpose Having an infant in the neonatal intensive care unit(NICU) is highly stressful and it implicated in mother infant bonding. This study investigated the relationship between mothers’ dispositional mindfulness and level of stress and quality of bonding. Methods Self-report measures of Dispositional Mindfulness, Parental Stressor Scale, and the Postpartum Bonding Questionnaire were administered to 120 mothers with newborns admitted in the NICUs in three hospitals in Qom city in Iran. The data analysis was carried out by using a hierarchical multiple regression. Results Mean score of stress, bonding and mindfulness were 114.29±27.33, 67.77±5.38, and 126.27±22.39 respectively. There was a significant inverse relationship between total mindfulness score and mother’s parental stress. Also, high scores of stress were associated with greater impairment in bonding. Observing and acting with awareness led to better mother to infant bonding. Conclusions Improvements in mindfulness could help mothers to reduce stress and better bonding whit their infants.


Introduction
It is well proven that having an infant in the neonatal intensive care unit(NICU) is highly stressful and exposes parents at risk to trauma symptoms (1)(2)(3). Parenting stress in NICU is defined as an imbalance between expectations, perceived resources and demands of caregiving(4) and originates not only from uncertainty regarding neonate's baseline condition and prognosis but also from medical problems, because these babies are at greater risk of infection and nutritional problems(5) (6).
Infants in the NICU are usually less accessible to the mother because of the monitor leads, tubes for feeding and breathing and NICU itself experienced as the stressful, noisy and cold environment. In addition, mothers in the NICU are in the postpartum period that is accompanied by hormonal changes, family role changes, new responsibilities, fatigue and sleep problems (6). Previous studies showed that high level stress experienced by mothers in the NICU is associated whit depression, anxiety (7), symptoms of acute stress disorder and posttraumatic stress disorder in them (1)(2)(3) 3 These symptoms usually persist until after the baby is discharged from the hospital(8) and can negatively affect the mother-infant dyad and can cause subsequent problems such as sleep and feeding disorders (7).
Another reason to pay attention to mothers stress in the NICU is that, it interferes whit mother infant bonding (4). Bonding refers to the primary relationship between mother and infant that is characterized by an emotional response to the infant, especially in the first year after childbirth (9).It denotes the development of parental feelings toward the baby and occurs within the first hours after birth and is reinforced by bodily contact (10).
The quality of the bonding between mother and infant impacts directly on the child's mental health and development. So this communication should be intimate, warm, steady and kindly and providing comfort and pleasure for baby also mum (11).
In the absence of a good attachment to the initial caregiver, babies are not only emotionally cut off from others, but also will preserve the inability to bond with other people around them and this circumstance put the basis at risk of future emotional and behavioral problems(12) (13).
When the infant spends the first few weeks or months in the NICU, the complexities of the ward, the specific clinical care and the individual circumstances and appearance of the infant negatively affects the formation of bonding. In addition, problems caused by parental stress impede parents' adaptation to the neonatal intensive care unit environment and have a long-term impact on the parent-child relationship and reduce their ability to care for the child (14).
According to above mentioned, reducing the levels of mother stress is important not only for improving mother psychological health but also to improve mother-infant bonding and mental and developmental health of baby(4).
One of the psychological features that is nowadays highly interested is mindfulness. Mindfulness is defined as a dispositional (trait) property and as a provisional status of mind that can growth by mindfulness exercises (15). It is "the awareness that become by focusing on the goal in the present moment, and by being non-judgmental to the experience happening moment by moment" (16).
Mindfulness leads to a lasting sense of well-being by simply accepting what is happening and knowing that this experience is also passing and then will have been replaced by new experience (16).

Mindfulness techniques are increasingly incorporated into clinical and therapeutic interventions based
on stress reduction (i.e. eating disorders ,obsessive-compulsive disorder, and generalized anxiety) (17) and its usefulness in daily activities as well as the more unusual conditions of stressors or serious illnesses even in pregnancy have been proven (18) (19).
But the answer to this question is still unclear, whether in the mother in the NICU; under the most difficult conditions after childbirth, hormonal changes, pain and fatigue, insomnia, exposure to new parental role and changing family responsibilities, the stressful condition of the baby, and the complexity of NICU environment, is mindfulness still helpful for mother to reduce her stress and make a better bonding with her infant?

Study Aim
This study investigated the relationship between mothers' dispositional mindfulness and the level of parental stress of mothers with newborns admitted in the NICU and the relationship between mothers' dispositional mindfulness and mother-infant bonding.

Design and participants
A cross-sectional study design was used with anonymous questionnaires that were completed between April 9, 2019 and September 11, 2019. The participants of the study were mothers of the neonates admitted in the NICUs in three governmental, academic hospitals in Qom city in IRAN.
Purposeful and sequential sampling was performed until the sample size was completed. Mothers of all infants who met inclusion criteria (birth gestational age < 35 weeks, expected length of stay in NICU at least 10 days, mother Persian-speaking and have not specific illnesses and were not admitted to another ward, having at least one baby meeting in the NICU), and confirmed the informed consent were offered the opportunity to participate.
Ethical approval for this study was obtained from Ethical Committee of Qom University of Medical Sciences, Qom. Iran (IR.MUQ.REC.1398.006).
To obtain data, the researcher (who had no previous contact) approached the mothers at a time when they were visiting but not holding their baby, and when not involved with other NICU person and provided the qquestionnaires and was available for any explanation.

Instruments General Demographic and infant clinical data Form:
A researcher created infant clinical data collection form (birth gestational age, birth weight, delivery type, apgar scores, diagnoses, length of stay) and parental demographic data form (age, educational level, job, insurance, presence of other children, history of depression/anxiety, perception of support) completed by mother.  (20). The validity and reliability of the instrument have been previously confirmed in a study by Hosseini et al in Iran (22) In the present study, the Cronbach's alpha for 30 mothers was reported to be 88%. (15) is a 39-item self-report measure based on a factor analytic study of five independently developed mindfulness questionnaires. Analysis of these five mindfulness questionnaires yielded five factors that capture core aspects of mindfulness: (1) observing, (2) describing, (3) acting with awareness, (4) nonjudging of inner experience, and (5) non-reacting to inner experience. Items were rated on a 5-point Likert scale ranging from 1 (never or very rarely true) to 5 (very often or always true). The scales may be combined for an overall level of dispositional Mindfulness with a sum score ranging from 39 to 195.

Five Facets of Mindfulness Questionnaire(FFMQ): Five Facets of Mindfulness Questionnaire
Prior work has established that the subscales demonstrate good internal consistency ranging from .75 to .91 (15). The Cronbach's alpha for the full scale for this study was 0.84.
Participants rated how often they agreed with these statements on a 6-point Likert scale ranging from always (score=0) to never (score=5) When the statement reflects a negative emotion or attitude, the scoring is reversed, so low scores denoting good bonding. The PBQ has four subscales which reflect impaired bonding (Scale 1) (12 items, ranging from 0 to 60), rejection and anger (Scale 2) (7 items,

Data Analyses
Multivariate regression model was used to examine the relationships between variables by moderating the effect of independent variables, Multi collinearity analysis of variance inflation factor was used, all cases had a VIF <2. Residual plots versus predicted values were used to evaluate the regression models. The above analyzes were performed in R 3.6.1 at 95% confidence level. Based on the regression results, variables of maternal age, maternal education, and length of stay in the NICU were estimated as demographic factors related to the graft variable, in order to modify their effect, the relationship between the other variables with the linkage variable was examined further by modifying the effect of these three variables.

Results
The average of Parental Stressor score, FFM score and PB score were estimated 114. 29±27

Discussion
This study adds to our understanding about mother's stress and mother-to-infant bonding in the NICU and the role of the mindfulness in this field. According to the findings of this study the mean score of mothers' stress was 114.95 ± 27.33, that as expected, indicates high level of perceived stress in mothers with hospitalized infants in the NICU, also findings showed the mindfulness can protect mothers against parental stress in the NICU environment and can facilitate maternal-neonatal bonding, i.e. higher total scores of mindfulness were significantly associated with lower scores in parental stress and higher scores of observing and acting with awareness were significantly associated with lower total scores of bonding dysfunction. Interestingly the effect of acting with awareness still remained after adjusting the impact of influential demographic variables.
In confirmation of our findings Hicks& et al (2018) showed that more levels of dispositional mindfulness were associated with lesser depression symptoms and better prenatal bonding in the sample of expectant parents (26). Yamamoto & et al(2017) also proved in their study that mothers' mindfulness was correlated with their state and trait anxiety negatively (27).
It seems mindfulness features such as acting with awareness which is the tendency to act with the full presence at any moment that is in conflict with action automatically (27), might help mothers to avoid attentional and interpretative processing biases, that can explain why more mindful mothers reported less stress in this study. furthermore, the mindfulness can increase one's ability to withstand negative and difficult emotional states that cause more stress (28). This cognitive-behavioral approach may reduce the stress of exposure to different parenting needs and may therefore allow mothers to be more relaxed during parenting (27).
Linehan MM(1993) mentioned that mindfulness practices may facilitate mothers' capacity to tolerate chronic and acute stressors and promote awareness while reducing stress related emotions and physiologic responses(29). Other studies showed dispositional mindfulness is related to better emotion regulation ability (30) and greater adult attachment security (31) In the present study a significant negative relationship between the domains of observing and acting whit awareness and bonding remained after adjusting the effects of mother age, mother education level and length of stay in NICU.
In explaining this finding, observing as a feature of the mindfulness that tends to view the situation of herself and the infant objectively, helps the mother to better communicate with the baby in the present experience of motherhood, free of distracting thoughts about interpreting ambiguous and unknown circumstances of her baby; in addition acting with awareness that means paying attention to one's ongoing behavior tends to diminish automatic behaviors rather than using the information currently available for adaptive self-regulation (28) in fact, when observing and awareness increase, mother's ability to stand back and view conditions without drowning in them improved, as a result, she gets rid of automatic behavior patterns so she is not stressed, but rather be free from these emotions(32) so she creates better bonding whit her baby.
In the present study, the total score of mindfulness showed an inverse relationship with total score of bonding, but this relationship was not statistically significant. In explaining this finding, it should be noted that in the present study mindfulness traits were examined rather than using mindfulness exercises. It seems that under stressful conditions in the NICU, mindfulness exercises such as deep conscious breathing, body scan and ... may need to be implemented until the mother take more advantage of the benefits of the mindfulness.
Also, given that the findings indicate a significant inverse relationship between stress from infant behavior and appearance and bonding, it seems that mindfulness helps the mother to build a better relationship and better bonding with her baby by observing the baby's appearance rather than judging its appearance that led to she doesn't be engaging in negative and disturbing thoughts.
In a study by Beddoe(2007) it has been emphasized that integrating mindfulness meditation and yoga into the daily life of pregnant women can improve prenatal attachment by permitting mothers to be 9 more present in the moment and be more attentive to bodily sensations such as the fetus movements (17) Study limitations: First Since in the environment of this study due to cultural issues, fathers could not be present in the ward of the NICUs and their communications were limited, the study was done only on mothers.
Second the cross-sectional nature of the study limits the conclusions about causal relationships between variables.

Conclusion
Because of the mindfulness is considered as a kind of innate capacity or ability of human, that though can be enhanced through practice and intervention. Improving mindfulness by related interventions could assist mothers to reduce parental stress in the NICUs and bonding better whit their infants.
The results of this study highlight the importance of the mindfulness on prenatal bonding and parental stress in the NICUs. Further studies suggested to explore longitudinal and experimental research to assess the effects of improving mindfulness on parental and neonatal outcomes.

2.
Sampling was completely voluntary and excluded if they did not wish to continue participation.

3.
All samples were informed about the study before entering the study and entered into the study when completing the informed consent form. The information was retained for confidentiality and used for study purposes only.

4.
The results of the study were made available to all participants.

5.
All scientific norms were considered for the study.

6.
The authors participated in the research as follow: