Perception of the development of the mother-child relationship
Physicians and nurses referred to the difficulty mothers of babies cared for in an intermediate NICU had to develop the mother-child relationship within this environment. They observed that for most mothers it was a difficult experience to be separated from her baby immediately after giving birth. At the intermediate NICU mother’s initially seemed insecure and waited for permission from the healthcare team to be close, touch or care for her baby even when they had received authorization to do so. They attributed the mothers’ difficulty to the fragile appearance of the premature baby, the limited contact often imposed by the routine of the unit and their lack of participation in the decisions regarding the care given to her baby.
“…there’s the mother who at the beginning doesn’t even go up to the incubator or the crib, if the baby is in a crib…but it’s not because she doesn’t like the baby or for any lack of love, it’s nothing like that, it’s actually fear, insecurity (nurse technician)
According to physicians and nurses, during first contacts with the baby in the intermediate NICU, many women expressed feelings of guilt for having had a baby that was not well and needed hospitalization. They said that these women questioned themselves whether they had done something during pregnancy that could have harmed the baby or if their body was not good enough to gestate a healthy baby.
“So I think that to greater or lesser extent these mothers feel that something was lacking in them, that they are not as good for their baby as other mothers” (physician)
Most of the HCPs, independently of their functions, reported having observed that, when the mothers initiated contact with their babies in the intermediate NICU environment most of them were very concerned with the baby’s situation and some frightened to approach them. They felt a great need to touch and hold her baby and when they were able to do so they became calmer. These HCPs also perceived that as time went by and mothers spend more time with her baby, most of them began to identify themselves as the mother of her baby, became more confident with her ability to care for her baby and started to take the initiative to interact with her baby.
“…they gradually feel more at ease, become more participative…You can see how they gain confidence as each day goes by…I think even when they can touch the baby, even if they can’t pick it up…just by touching it, they feel in contact with the baby and it calms them…They feel that the baby is real, they touch its hand, they actually allow themselves to believe that the baby is theirs, the child is theirs, not just a baby undergoing treatment…” (physician)
All the participants reported that the majority of the mothers were very affectionate with their newborn bay. Tried to stay as long as possible with her child, even when still recovering from delivery or when the baby needed treatment or interventions that limited direct contact. The mothers talked to their babies, caressed them and some sang to them. Some mothers, when unable to be present, maintained telephone contact.
“…most of the time, they try to give as much of themselves as they can to their babies, irrespective of how they themselves are, because many are still recovering from delivery…and a bit unsteady…in pain…sometimes still weak…and they go to a great effort to be present…most of the mothers…are very affectionate, they want to touch their baby…Some even rock the baby in the incubator with their hands, moving it, you know, by rocking its bottom to calm it in the incubator…” (nurse)
Concern with the baby’s needs
The majority of the HCPs referred to the importance of contact between the mother and her baby, to the baby’s need to be close to the mother and to receive her care. They believed that the feelings, the closeness and the presence of the mother contributed to the baby’s well-being and recovery and the production of breast milk. Because of these convictions, whenever they noticed that a mother was not present, they tried to find out why and to identify ways of helping and encouraging her to be present.
“So I think we always expect the mother to bond, to help her develop a good relationship…in this case we were worried…all right, so the father was doing everything right….but we weren’t happy; we wanted the mother to be here, and then she came and we were happy, she was able to take care of her baby and to take it home…” (physician)
“It seems to go round in a circle, right? I visit my baby more often, I pick it up and my bond with it grows, I have more milk, so when the time comes for the baby to feed from my breast, it’ll be easier. It seems that … this relationship develops better and it even contributes to allowing the baby to leave hospital faster” (nurse)
Nurses reported that their priority was the well-being of the babies in the intermediate NICU and that they made efforts to identify any possible problems or discomfort they may have, paying attention to all the details of the care provided. Furthermore, some nurses considered that this focus on the baby’s well-being sometimes led them to forget about the mother’s needs and to limit possibilities of care, proximity and direct contact of the mother with her baby.
“First the well-being of the baby….Sometimes it’s restless because something is wrong; sometimes it’s just the way the baby is, you have to know that … You need to know what is going on, what is going on with the baby …but you need to see it from the mother’s point of view too. She’s tired…because sometimes they tell her that she has to breastfeed, she has to breastfeed…So sometimes we…we are very focused on the baby and demanding things of her…” (nurse)
Most of the interviewed physicians expressed concerns with the mother’s ability to care for her premature baby, since these babies behave differently from a full-term infant; they are sleepier and less responsive. They believed that mothers would find it difficult to understand and identify the needs of premature babies and that they needed to receive professional and specialized guidance.
“They think…that since they are mothers they will know what the baby needs, you know?…that it will be instinctive and she’ll know when she’s home what she has to do to ensure that the baby is all right…most of the time, with babies born at term, that’s fine, but with premature babies it’s not. The behavior of premature babies is not like that of the other children…” (physician)
Some HCPs, particularly the nurse technicians, reported that concern with the needs of the premature baby ended up with them assuming the responsibility for certain tasks that should have been performed by the mothers. They also recognized that sometimes it is difficult for the mother to hold her baby or to perform some tasks of caring that could facilitate the mother child relationship because the HCPs of the NICU believe that those attitudes could hamper the routine care provided to the baby.
“What often happens is that we’ve just finished taking care of the baby, got it all settled down, so we make decisions such as: no, you’re not going to pick the baby up now that it’s sleeping, we need to let a premature baby sleep … we’re afraid, we have our doubts, it’s a concern of ours… letting this mother take charge of this baby…” (nurse technician)
The role of the healthcare team in mother-child bonding
The majority of the participants reported that, in general, the HCPs tried to help women bond with their child by giving support and encouragement. Many said that good communication with the mothers was important, supported and helped them in the process of bonding with their babies. Gestures and words had to be used with care to ensure that their own knowledge was not imposed upon the mothers, since that would interfere negatively in the bonding process.
“Maybe we do interfere…with what the mother knows, and we want to impose our knowledge on her, right, but I think this has a negative effect, because she may think that what she believes to be right, isn’t right….so what is right? This might make her insecure with respect to caring for the baby”. (nurse)
The support given to the mothers by the doctors was different from that given by the nurses. The doctors gave support, mainly, by providing mothers with clinical information on the baby’s condition. Before giving them the diagnosis, they evaluated each mother’s level of knowledge about the child’s status and transmitted the information clearly and carefully, since, as they had already observed, failure to understand the diagnosis would induce feelings of guilt or uncertainty in the mothers.
“…we’re very careful when we tell them things, right, sometimes we, it’s…we might make a comment that the mother may not understand…it might frighten her, she might get worried, insecure, I think this could be bad, yes…they don’t know to what extent it was something they did that might be causing whatever is wrong with the child, right…and sometimes we might say, oh, it was that infection inside the uterus or it was the mother’s high blood pressure, so we end up blaming the mother, unintentionally”. (resident physician)
All the resident physicians reported concern with the type of contact that they established with the mothers. They questioned whether the type of care provided encouraged the mother-child bonding process or not and whether it was sufficient or if they should be doing something more to help.
“…it’s a shortcoming that I feel I need to correct. I don’t normally seek contact with the mothers, I…my contact with them is more in the sense of responding to demand, for example, the mother wants to talk to me, so the nursing staff tells me ‘that mother is here and wants to talk to you, can you talk to her?’” (resident)
The majority of the physicians reported that the nursing staff represented a link between physicians and the mothers of the hospitalized babies; were responsible for establishing more intimate communication, providing care and support. They considered that mothers felt more at ease and talked more freely with nurses, whereas with them the mothers tried to talk about what they believed the doctors wanted to hear, perhaps in the hope of anticipating the child’s discharge from hospital.
“…There are rarely any mothers who say they don’t want to breastfeed, they want to get the baby out of hospital as quickly as possible because they are tired of being in the unit…So we go, talk to them about the risks, everything we need to tell the family, right…and if they have any questions the nursing staff ends up acting as intermediaries. So I think the nursing staff has greater contact with these mothers, in the care…” (physician)
The nursing staff said that they explained to the mothers that despite its fragile appearance the premature baby could be touched and held, and tried to encourage them be close to the baby. When they perceived that the mother was having difficulty in establishing contact, they gave support for different ways of interacting with her baby within the hospital environment, emphasizing that, even if it was not possible for her to hold the baby, she could touch the baby, look at the baby and talk to the bay, and that this was good for the baby and for the mother-child bonding process. Some of these HCPs believed that the lack of privacy for the mother to interact with her child could be a problem during this initial contact and they tried to create opportunities for the mother to be alone with her baby whenever the baby’s clinical condition permitted.
“The mother might be frightened, insecure…so we have to help her overcome this and explain that she won’t hurt the baby if she touches it…that contact with her will be good for the baby, also to hear her voice… then she starts to believe that contact with her is important”. (nurse technician)
All nurse technicians reported that having informal conversations with the mothers of the babies they cared for at the NICU to understand their misgivings and difficulties in bonding with their baby. Also they explained, in a simple way in order to facilitate understanding, the information the doctors gave them on their baby’s condition.
“…you sit down with the mother and talk to her, let her say what she needs to say…if you allow her to feel at ease, she’ll talk, “Oh, I don’t want to touch it”. But why don’t you want to touch it? “It’s because I’m frightened I’ll make the baby worse”. No, you can touch it and you’ll be helping it. Then she’ll get closer to the baby”. (nurse technician)
More than half the interviewed HCPs reported difficulties in relating to the mothers. Most of the physicians expressed surprise at the difficulty many mothers had in understanding why their baby had to be in hospital, the time the baby would have to stay in hospital or in accepting that the baby’s state of health was deteriorating. They believed that this occurred because the women had received scarce information during prenatal care or because the mothers refused to accept the negative part of the child’s diagnosis. Also, the nurses attributed this lack of comprehension to too much information and to the mother’s current fragile state.
“…they come in, they talk to us….sometimes they come back and ask the same thing to another member of staff…it’s obvious that they want a positive answer…but a premature baby is always a high-risk patient and if we don’t tell them this, then the mother can turn round later and say: but you didn’t tell me that! You said that everything was fine! Because even when we tell them, they only hear what they want to hear…” (physician)
“…it’s a lot of information all at once, right? It’s the baby that isn’t going home, that’s here, but why is it here? And there’s that whole story, the childbirth that she just went through, sometimes she’s still in pain too, sometimes she’s not feeling well. So, initially she can’t deal with it all, all the information”. (nurse)
According to some participants, the women who spent more time with their baby at the hospital commented and criticized the way in which the HCPs did their job, creating discomfort in the team. According to these HCPs, the difficulty in dealing with these mothers was due to a lack of training the health team to deal with the emotional needs of the mothers of the babies they cared for, and this was considered a disrupting factor in communication.
“…it’s preparing us for this…to understand this mother. What is missing is for us to receive some guidance, for us to know how to deal with this, it’s difficult. I think that sometimes we…label the mother, this mother is a nuisance, but then you don’t ask yourself why she’s being a nuisance, what is going on with her. What’s behind it?” (nurse)