Journal of Reproductive and Infant Psychology

Vol. 29, No. 4, September 2011, 364373

Premature birth: subjective and psychological experiences in the

rst weeks following childbirth, a mixed-methods study
Nelly Goutaudiera, Amliane Lopeza, Natalne Sjourna, Anne Denisb and Henri
Chabrol*a
a
Universit Toulouse II, Octogone Centre dtudes et de recherches en psychopathologie,
Toulouse, France; bLaboratoire Inter-universitaire de Psychologie, Universit de Savoie,
Chambry, France
(Received 10 October 2010; nal version received 10 September 2011)

Objective: The aim of the study was to explore the experience of premature
infants mothers, the way they are taken care of, how they cope with this traumatic
experience as well as the psychopathological and psychosocial consequences post
delivery. Method: A qualitative and quantitative study was carried out on 27
women from the south of France area who delivered preterm infants still
hospitalised in a neonatal intensive care unit. Two questionnaires were completed,
the IES-R and the EPDS, assessing posttraumatic stress and postpartum depressive
symptoms. A semi-structured interview was also conducted. Results: Trauma of
premature birth and caesarean, feelings of guilt, anxiety, ambivalence towards the
infant, the medical staff and the infants hospital discharge, were all part of their
perception. Furthermore, difculties for mothers to dene themselves as such and
the importance of sharing with women who have been through the same experience
were evidenced. Postpartum depression and posttraumatic stress disorder were also
highlighted. Conclusion: Our ndings highlight that premature birth can be
traumatic and lead to the development of psychopathological symptoms. Moreover,
this study suggests the need to develop a specic support focusing on the sharing of
experience and prevention in order to prevent disorders from developing.
Keywords: prematurity; mothers experience; support; way to cope with; posttrau-
matic stress disorder; postpartum depression; psychopathological consequences

Introduction
The rate of prematurity has steadily increased in France since 1997 (Blondel,
Supernant, Du Mazaubrun, & Brart, 2005). In 2004, around 8% of all infants born
in France were preterm (dened as births occurring at less than 37 weeks gestation;
Blondel et al., 2005). Prematurity has become an important issue, not only in France
but also in many other countries. Indeed, the preterm birth rate has also risen in most
of the industrialised countries, with the USA rate increasing from 9.5% in 1981 to
12.7% in 2005 (Goldenberg, Culhane, Iams, & Romero, 2008). The UK has the high-
est rate of premature birth in Europe with 5 infants born prematurely every hour
(Karatzias, Chouliara, Maxton, Freer, & Power, 2007).
Many studies have emphasized that the future of premature infants mostly
depends on mothers experiences and rst motherinfant interactions (Carel, 1977;

*Corresponding author. Email: chabrol@univ-tlse2.fr

ISSN 0264-6838 print/ISSN 1469-672X online

2011 Society for Reproductive and Infant Psychology
http://dx.doi.org/10.1080/02646838.2011.623227
http://www.tandfonline.com
 Journal of Reproductive and Infant Psychology 365

Tarabulsy, Larose, Pederson, & Moran, 2000). Nevertheless, the sometimes sudden
and unexpected aspect of the situation or the motherinfant separation can have a
negative impact on this relationship and may lead women to experience several
negative affects and difculties such as: sense of unreality (Pavoine, Azmar, Rajon,
& Raynaud, 2004), thoughts of death (Ferrari, 2000), feeling of not being a good
mother as well as feelings of guilt (Garel, Bahuaud, & Blondel, 2004;
Vollenweider, Nicastro, Sabeh, Lambiel, & Pala, 2004). In this particular context,
the mother can be under the impression of not having delivered and has difculties
recognising the infant as her own (Garel & Blondel, 2003).
The infants hospitalisation is a very difcult and stressful period for parents
(Carter, Mulder, Bartram, & Darlow 2005; Garel & Blondel, 2003; Singer,
Davillier, Bruening, Hawkins, & Yamashita, 1996) and may have some psychoso-
cial and psychopathological consequences. Indeed, after such an experience, the
relationship between both mother and father can be disturbed; arguments and/or
separation can occur (Ferrari, 2000). According to Gamba Szijarto et al. (2009),
parents of preterm babies would be more likely to develop posttraumatic stress
disorder (PTSD) symptoms than parents of full-term infants.
According to Miles, Holditch-Davis, Todd, Schwartz and Scher (2007), during
hospitalisation, 63% of mothers had scores indicating a risk of depression. Even
though there is a lack of relevant research in this area, posttraumatic stress would
be common for parents of premature infants and such symptomatology could be
long-term (Karatzias et al., 2007). The infant, the couple, as well as siblings, can
all be affected by these psychological disturbances (Garel & Blondel, 2003). As
several authors highlighted, psychopathological consequences do not seem to be
proportional to the infant physical reality, but rather to the mothers degree of
involvement in her maternity (Pavoine et al., 2004).
The infants hospital discharge is a transition period (Pavoine et al., 2004) more
or less well experienced (Garel et al., 2004) which could be the root cause of
ambivalent feelings. Indeed, considering mothers fear of not being able to take care
of their baby and/or not being a good mother, women can be torn between the wish
to bring the baby back home and the desire to let it be hospitalised (Ferrari, 2000).
As a consequence, supporting mothers is then very important considering it can
have an impact on the way the situation is experienced.
Even though prematurity does not necessarily lead to repercussions regarding
the infants physical or psychological condition and does not automatically lead
mothers to develop postpartum depression and/or PTSD, the increase of preterm
deliveries (and their impact on the motherinfant relationship) emphasises the need
to provide an in-depth examination of all preterm birth issues. The current study
thus focuses on the infants hospitalisation, highlighted in an exploratory study con-
ducted by our research team (Goutaudier, Laurent, Sjourn, Denis, & Chabrol, in
press) as one of the most traumatic periods. The aim of the current study was to
assess mothers experience of preterm delivery and infants hospitalisation as well
as psychopathological consequences after childbirth.

Method
Participants
Twenty-seven women over the age of 18, speaking French uently, who delivered a
preterm infant still hospitalised in a neonatal intensive care unit were included in
366 N. Goutaudier et al.

the current study. Among the 27 women (range 1936; M = 29; SD = 2.7), 15
(56%) had a caesarean section and 12 (44%) delivered vaginally. The gestational
age of the newborn infants ranged from 27 to 37 weeks (M = 30.6; SD = 2.7). Six
infants (22.2%) were born at 3237 weeks gestation, 13 (48.1%) were born at 28
31 weeks gestation and 8 (29.7%) were born at less than 28 weeks gestation. The
length of the infant stay in the NICU ranged from 2 to 9 weeks (M = 3.3, SD =
1.5).

Procedure
Several meetings were organised in order to select the most appropriate research
design to use for the current study. A mixed method was selected to increase the
quality of nal results and to provide a more comprehensive understanding of both
experience of preterm birth and potential psychopathological consequences. Indeed,
qualitative measures were used to explore mothers experience, and quantitative
measures were also added in order to collect more specic data about possible psy-
chopathological consequences (e.g. PTSD) which would have been difcult to
assess only with a qualitative design.
The study followed the ethical guidelines of the Helsinki declaration and was
approved by an ethics committee. Women were approached on a postnatal ward
and through Internet forums dedicated to prematurity. Messages were posted on two
Internet forums in November 2009. Nine women were approached on the ward and
agreed to participate and eight responded to the Internet advertisement. These
women gave their agreement to participate between December 2009 and May 2010.
Considering that the entire population was small, and that the desired sample char-
acteristic was rare, the snowball method was also used between January and May
2010. The 17 mothers who consented to participate were asked to pass on details of
the study to other mothers meeting the inclusion criteria. This resulted in 11 more
women expressing interest in the study, all of whom agreed to participate.
The study was briey explained to them as well as the fact that interviews
would be recorded and transcribed. Moreover, they were told that no compensation
was offered to participate in the study and that they could receive a brief report of
the results. Among the 28 women who agreed to participate, one could not be con-
tacted. The remaining 27 mothers agreed to be included in the study.
Women were all met by the two researchers in charge of conducting the study,
either in the postnatal ward or in their own accommodation and completed a con-
sent form. Questionnaires were completed before the interview before starting the
often painful process of remembering. Interviews were recorded and transcribed in
their entirety.

Measures
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) was assessed using the French version of the
Impact of Event Scale-Revised (IES-R) (Brunet, St-Hilaire, Jehel, & King, 2003;
Weiss & Marmar, 1997), a 22-item self-report questionnaire. The items are grouped
into three subscales: intrusion, avoidance and hyper arousal. The answers are
rated on a 4-point scale (from 0 = not at all to 4 = extremely). A global score, from
0 to 88, can be calculated by adding the scores for each of the three subscales. The
cut-off score of 36 suggested by the French validation study (Brunet et al., 2003)
 Journal of Reproductive and Infant Psychology 367

was used in the current study as an indicator of specic symptoms of PTSD. The
IES-R is the most frequently used scale for the evaluation of PTSD symptoms
(Bouvard & Cottraux, 2002). Moreover, this scale assesses most DSM-IV-TR diag-
nostic criteria for PTSD.

Postnatal depression
Depressive symptomatology was assessed using the French version of the Edin-
burgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987; Gude-
ney & Fermanian, 1998), a 10-item self-report questionnaire. The answers are rated
on a 4-point scale from 0 to 3, depending on the severity of symptoms. A global
score, from 0 to 30, can be calculated by adding the scores for each of the 10
items. The cut-off score of 12 suggested by the French study of Teissdre and
Chabrol (2004) was used in the current study as an indication of possible postpar-
tum depression. The EPDS is widely used to assess postpartum depression symp-
toms (Dayan, 2008) and is very rapid to complete.

Mothers experiences
A semi-structured interview was carried out on individual basis in order to explore
mothers experience. A guide, divided into two parts (childbirth and infant hospital-
isation), based on literature data and on the exploratory study previously conducted
by our research team, was designed. Thirty-four questions focusing on both delivery
(11 items) and infants hospitalisation (23 items) were included in the guide. Thus,
womens experience of delivery and infants hospitalisation (e.g. Could you talk to
me about childbirth?), feelings and fears associated to preterm birth (e.g. What
was the most difcult moment?), mother role (e.g. What about your mother role?
Did you have difculties investing in it?), social support perceived (e.g. Could
you talk to me about your relationship with your infant/medical staff/your partner/
your relatives?), womens perception of the environment/their infant (e.g. Have
you been surprised by your infants physical appearance?), as well as their future
plans, were explored. In order not to generate anxiety regarding the infants health,
we chose not to use a sickness score and did not ask how sick the babies were,
either to mothers or to medical staff. However, women could talk about it if they
wanted to. In order to identify potential biases, the guide was pilot tested.

Data analysis
Standard deviation and mean scores on the EPDS (M = 14.9; SD = 6.2) and on the
IES-R (M = 41.4; SD = 16.2) were calculated.
Concerning thematic analyses, data were collected by two researchers. Both
were graduate female students in psychopathology and were experienced in con-
ducting research interviews. Themes were not identied in advance and were
derived from the data which had been coded independently by two data coders
under the supervision of a professor of clinical psychology and a PhD (HC & NS).
Because these raters were part of the same research team that developed the content
categories, themes were discussed by 10 researchers during a meeting organised at
the laboratory, providing an additional opportunity to check on the reliability of
content coding. Six themes were highlighted: experience of childbirth, experience
368 N. Goutaudier et al.

of infants hospitalisation, motherinfant relationship, perceived social support,

adaptive strategies and psychopathological and psychosocial consequences. The
mean length of interviews was 61 min (SD = 15). Quotations are identied in the
result section (e.g. I.2 = interview number 2).

Results
Scores on the EPDS and the IES-R
Twenty-one women had a higher or equal score to 12 on the EPDS, indicating a
potential postnatal depression (M = 17.38; SD = 4.39). Likewise, 21 mothers had a
higher or equal score to 36 on the IES-R, indicating a possible PTSD (M = 43.96;
SD = 11.23). Data are presented in Table 1.

Thematic analysis of interviews

Experience of childbirth
Eighteen women reported negative experiences of childbirth: It was awful from
beginning to end, and still, it is an understatement! (I.4); It was an absolute hor-
ror (I.21). Most described anxiety, stress, helplessness and anguish notably due to
the unexpected aspect of the situation: I was panic-stricken, it was so unexpected
(I.13); Theres nothing to do except wait it out (I.19).
Seven women mentioned a more positive experience of the situation resulting
from the evocation of the risk of preterm delivery or an earlier experience of moth-
erhood: I knew that prematurity was a risk, so I had time to prepare myself! (I.5).
The majority of mothers who delivered by caesarean section were traumatised
by this type of delivery: I felt like a butchered piece of meat (I.12). In addition,
half considered that a better preparation to this type of delivery would have been
benecial: I read about pregnancy (...) there was nothing about the caesarean, its a
pity (I.2), and considered caesarean as traumatic as preterm delivery.
Even though the medical cause had been identied for only 4 of them, 20 moth-
ers considered themselves as the only ones responsible for preterm delivery: Its
my fault, so yes I feel guilty, I felt like the worst mother in the world! (I.13); Im
the only one responsible for all that (I.25).

Experience of infants hospitalisation

The infants hospitalisation generated anxiety, helplessness and fear for the future of
the baby for a large majority of mothers: I was afraid all the time and I could not
do anything, its very frustrating (I.24). In addition, this period was reported very
negatively by more than two-thirds of them describing the atmosphere as cold,

Table 1. Posttraumatic stress disorder and postnatal depression scores in our sample on the
IES-R and on the EPDS.
Impact of Event Scale* N = 27 100%
Yes (> 36) n = 21 77.8%
No (< 36) n=6 22.2%
Edinburgh Postnatal Depression Scale** N = 27 100%
Yes (> 12) n = 21 77.8%
No (< 12) n=6 22.2%
*Impact of Event Scale: scale assessing PTSD symptoms.
**Edinburgh Postnatal Depression Scale: scale assessing postnatal depression symptoms.
 Journal of Reproductive and Infant Psychology 369

austere and scary. Some were also overwhelmed by fears of death: I was afraid
my baby would die; I was completely obsessed with it (I.22). The separation was
also reported negatively by the majority of women: Being separated from ones
son is the worst thing that can happen to a mother! (I.6).
A further ambivalent vision of the infants hospitalisation was highlighted for 7
women, torn between anxiety and relief of the immediate care of the infant: It
was one more step! Having my son in neonatology was already something huge
(I.5). Moreover, a minority of women also reported a more ambivalent experience
concerning the separation, between deprivation of their mother role and expectation
of an improvement of the situation.
Nine mothers showed a lot of apprehension regarding the infants hospital dis-
charge. Most considered not being ready and reported being afraid of not being a
good mother or not being able to cope with a possible problem without medical
staffs help: Ive never been alone with my daughter, so what if I dont know what
to do? What if I do something wrong? (I.1); If something goes wrong, I dont
know what I would do . . . (I.4). On the other hand, 10 women were more positive
and explained expecting the infants hospital discharge with impatience. Others
reported a more ambivalent vision, between happiness to nally invest their mother
role, fears of death, anxiety and dread of possible consequences: Im so-so; I
dont really know . . . I cant wait, but Im also afraid (I.19).

The motherinfant relationship

At birth, 16 mothers had no contact with their infant, which resulted in intense feel-
ings of frustration, feelings of emptiness or anger towards the medical staff for 10
of them: I am so mad at them; Its a bitter pill to swallow! (I.17).
All the women who had no contact with the baby after delivery were shocked
by the infants physical appearance at the rst meeting: My son . . . He didnt look
like a baby (I.3); He looked like an alien (I.20), and 9 had difculties recognising
their baby as their own: I told my husband: are you sure thats him? I thought he
had made a mistake (I.10).
Regarding the mother role, 10 women had no difculty in taking up this role: I
was not only a woman but a mother (I.23); As soon as I saw him, it was crystal
clear, I was a Mum (I.21). On the other hand, 16 took more time, even until the
fears of death had disappeared: I told myself: do not get too close to your baby
because if something horrible happens . . . (I.9).
Concerning the motherinfant relationship, 10 women said they were able to
establish a strong bond with their infant: I felt like she was talking to me, her eyes
were telling me so many things! (I.14); We have a very special bond, you have
no idea! (I.7). Nevertheless, 13 women considered this bond was affected by pre-
maturity: A bond . . . yes, but I dont think it is as strong as the others (I.3); My
baby is premature, so of course our bond is not that strong (I.24).

Perceived social support

Ten mothers reported a positive representation of caregivers, reporting they were
supported daily: I know they are here, they are great! (I.1); They consider us as
human beings, its so nice! (I.27). However, ve women reported a negative repre-
sentation of the medical staff and considered that they received no support: What
370 N. Goutaudier et al.

is wrong with these people? Do they have hearts under these white coats? (I.17);
If I was the one in charge, I would re all of them! (I.16). Other mothers reported
a more ambivalent image of caregivers, admitting their competence, but felt
deprived of motherhood: It hurts a little bit, sometimes Im afraid that she could
become closer to them than me . . . (I.11); Im the one who is supposed to take
care of them before and after birth (I.8). Concerning the psychological care offered
at the hospital, 12 mothers considered having received no support and regretted it:
I think if I had met someone I would have been comfortable with, I might feel bet-
ter right now! (I.17), and some, in order to protect themselves, did not agree to
meet a psychologist: Im not ready yet, it is not time (I.21).
Concerning close relatives, the father was present during labour for 17 mothers
and 10 described his presence as reassuring; I would not have held out without him,
I would have become hysterical (I.15); Im so glad he was there! (I.26). Of the 17
women, 14 considered their husband an important element of support: My husband?
He is like Superman [laughs] he keeps my head above water! (I.27), He was wonder-
ful (I.1). First degree relatives also proved to be an important source of support.

Adaptive strategies
Adaptive strategies were different for individual women. However, 15 women went
to discussion groups in order to meet mothers who had been through a similar situ-
ation and considered this experience as therapeutic. Twelve women looked for
information in order to be able to cope with any eventuality: Its my own way to
ght (I.18); It helps me to handle things (I.25). A third of the women spent a lot
of time with their infant in order to repair things and/or to ght fears of death, I
gured, if my baby dies I have to be there! (I.1), Its the least I can do! (I.18).
On the other hand, 10 mothers had to move away from the hospital in order to start
afresh: Sometimes I feel like my head is going to blow up, it allows me to take a
break (I.13); I need to go home at night (I.24).

Psychopathological and psychosocial consequences

Half of the women reported that premature delivery had a negative impact on their
marital relationship. They reported severe tension and/or considered that their relation-
ship was in danger: We argue all the time; I think we are going to split up, we cant
go through it (I.25). Four mothers were separated from their husband and considered
themselves as still undergoing the trauma of abandonment that they attributed to pre-
mature delivery: The father left me (...) it is a lot, its hard to handle everything . . .
(I.1); I cant stop thinking about the fact that hes gone, its not fair! (I.19).
At the time of the interview, most women still considered themselves as affected
by the trauma of premature birth and more than half declared suffering from psy-
chological disorders resulting from premature birth, such as: sleeping disorders,
anxiety, eating disorders, self-esteem issues, and/or resumption of tobacco use and
violent behaviour towards themselves.

Discussion
Even though our sample may not be representative of all mothers who gave birth
prematurely in France and this study is limited by the nature of the design which
 Journal of Reproductive and Infant Psychology 371

does not allow the results to be generalised, our ndings provide some information
about how care can be provided for women in this situation.
In our sample, 78% of female respondents had a score on the EPDS highlighting
potential signs of postpartum depression. Women suffering from such a potential
depression were more likely to participate than others, which might explain these high
percentages. Moreover, most mothers were less than 3 weeks postpartum when they
completed the EPDS, which is quite early and may have also contributed to high rates
of women scoring above the cut-off. Likewise, 78% of mothers had a score on the
IES-R suggesting a potential posttraumatic stress disorder. However, some women
completed the IES-R questionnaire on the postnatal wards, which is an early assess-
ment of PTSD and could explain the high rate of PTSD potential symptoms.
Furthermore, PTSD and postpartum depression were assessed using self-report ques-
tionnaires; adding clinical interviews to the design would have been useful to fully
assess psychopathological consequences. Finally, women were met in the rst weeks
following childbirth while they were still coping with the unexpected aspect of the sit-
uation, which could have led to an over-estimation of both postpartum depression and
PTSD symptoms.
More than half of the women also reported psychological disorders resulting
from preterm birth. In line with previous ndings (Moczygemba et al., 2010), a
negative experience of delivery was reported by the majority of mothers and, for
those who delivered by caesarean, their experience was more likely to be perceived
as traumatic. Moreover, as Ferrari (2000) and Garel and Blondel (2003) evidenced,
the infants hospitalisation proved to be a very difcult period to cope with. Feel-
ings of guilt, difculties for mothers to dene themselves as such, disappointment
about the physical appearance of the infant or difculties in recognising the babies
as their own were reported by the majority of women. As these authors have also
highlighted, the approach of the infants hospital discharge is a transition period
which generated anxiety, fears of not being a good mother or not being able to
cope with a potential problem without medical staffs help. Consistent with our pre-
liminary study (Goutaudier et al., in press), the effects of psychological care offered
at the hospital were not positively identied in the current study. Considering that
the snowball method was used, we can assume that dissatised women were more
likely to participate in order to compensate for the lack of psychological support,
which could be considered as a limitation. Moreover, some women who referred to
the discussion group as therapeutic may have agreed to participate in order to share
their experience and may have focused more on the negative aspects of the situation
than the positive ones. We can also speculate that women who were asked to pass
on details of the study to other mothers meeting the inclusion criteria did it through
discussion groups, which could explain the results obtained. Furthermore, interviews
were conducted in a maternity hospital or in womens accommodation, depending
on whether they were approached on a postnatal ward, which could also be consid-
ered as a limitation. Indeed, we can speculate that the location in which interviews
were conducted could have an impact on womens mood as well as on data.
The results showed that preterm birth might be the root cause of the signicant
psychosocial disturbance described. Regarding the different sources of support,
women who have been through the same experience proved to be very helpful to
mothers in order to compensate the lack of psychological support.
This study supports the suggestion of a need for specic support over a longer
period of time using a range of methods. Reducing the anxiety generated by the
372 N. Goutaudier et al.

approach of the infants hospital discharge, preventing secondary disorders from

developing and focusing on prevention before delivery appear of prime importance,
considering that the latter could have a positive impact on the childbirth experience
itself. Indeed, according to a pilot study conducted by Chabrol, Coroner, Rusibane,
and Sjourn (2007), informing mothers during pregnancy could reduce the inten-
sity of postpartum blues. Moreover, it also seems important to pay special attention
to mothers who may be suffering from a multifactorial trauma generated by caesar-
ian and/or psychosocial consequences due to preterm birth. It therefore appears
important to develop an appropriate preparation to this type of delivery as well as
an adapted way to take care of single women in this situation. Finally, supporting
the motherinfant relationship and encouraging communication between mothers
and medical staff appears of prime importance in preterm delivery, considering that
feelings of rivalry and deprivation of motherhood are exacerbated by such a situa-
tion. While this study raises some interesting issues that relate to the experience of
preterm birth, the ndings should be considered carefully, given the early assess-
ment of womens views and wellbeing.

Conclusion
Even though premature delivery can be experienced as a full-term one and women
do not necessarily develop postpartum depression and/or PTSD, this study under-
lines that premature birth (whatever the babies health or the gestational age of the
newborn infants) may be traumatic and could lead to the development of psycho-
pathological disorders for mothers. Among the several elements that may have a
positive impact on womens experience, support appears to be one of the most
important. The results suggest that a more specic care focused on the sharing of
experience and prevention would be needed as early as possible in order to avoid
psychopathological disorders possibly developing.
Considering the rates of prematurity in many countries, womens experience of
preterm delivery is clearly an important issue to pursue. Future research is needed to
identify the long-term psychopathological consequences of premature birth. Longitu-
dinal studies could provide in-depth examination of potential problems, leading to
identication and development of preventative strategies.

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