Social Determinants of Health and Parenting Self-Efficacy Among Mothers of Preterm Infants

Background and Purpose: Parents of infants who are hospitalized in neonatal intensive care units (NICUs) experience complex stressors that increase their risk for emotional distress and mental health conditions and may also disrupt parents’ perceptions of parenting self-efficacy (PSE), an important factor influencing parent-child attachment, parent well-being, and child health and development. Despite research suggesting the importance of PSE to parent and child outcomes, factors influencing PSE are not well understood, particularly in the NICU population known to reflect racial/ethnic and socioeconomic disparities. The aim of this study was to use a social determinants of health (SDoH) framework to explore the relationships between social and environmental factors and PSE among mothers of preterm infants hospitalized in Colorado NICUs.

Methods: This prospective cohort study enrolled mother-infant dyads whose infants were born <32 weeks gestational age and admitted to four NICUs in the Mountain West region. Mothers completed an initial survey when their infants were between 32-34 weeks gestational age, which included sociodemographic predictors and the primary outcome measure, parenting self-efficacy. Parenting self-efficacy was measured using the PMP S-E, a twenty-item assessment measuring self-reported ability at performing infant care-related tasks. The survey also collected self-reported information about the exploratory outcomes of depression and acute stress, as measured by the Edinburgh Postnatal Depression Scale and Acute Stress Disorder Scale. Mothers completed a survey six weeks after infant discharge from the NICU, which collected information about secondary outcomes, including infant health status, utilization of healthcare, new diagnoses, and supplemental oxygen use. Bivariate relationships were assessed using the Wilcoxon Rank Sum Test, Kruskal-Wallis Test, or Correlation depending on data structure. Multivariable linear regression models were used to assess the independent association between maternal and infant characteristics and PSE.

Results: Our sample included 187 mothers of NICU infants, the majority (57%) were non-Hispanic white and 67% were 25-35 years of age. The median and interquartile range (IQR) of PMP S-E score for the cohort was 68 (IQR = 58,72). Our final multiple linear regression model to predict efficacy score, which included maternal race/ethnicity, age, insurance, employment status before giving birth, gestational age, depression, and having other children, was significant (F_(12,160) = 3.17, p = .0004, adjusted R_­² = .13). Postnatal depression was associated with a decrease in PSE (β= -4.2, p < .01), while race/ethnicity other than non-Hispanic white (β= 3.3, p = .02) and having other children (β= 4.2, p < .01) were associated with a higher score.

Conclusions and Implications: Our findings suggest that using a SDoH framework in NICU research and practice may create opportunities to more holistically understand and address the ways in which social and environmental factors shape NICU parent and child health trajectories. Social workers, medical practitioners, and researchers should be mindful of how implicit biases may manifest in the assessment of parenting competence in the NICU. Additionally, targeting parenting self-efficacy in NICU-based interventions may be a promising strategy to increase parental engagement, reduce infant length of stay, and decrease urgent care and emergency department visits post-discharge.