Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13024 Factors associated with maternal stress while caring for premature infants at home Rinik Eko Kapti,1 Yuni Sufyanti Arief,2 Nurona Azizah,1 Sholihatul Amaliya,1 Lilik Supriati,1 Ari Damayanti Wahyuningrum3 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, East Java; 2Faculty of Nursing, Universitas Airlangga, Surabaya, East Java; 3Nursing Science of Widyagama Husada Health Science College, Malang, East Java, Indonesia Abstract The occurrence of stress in mothers with premature infants is known to have a negative impact on both mothers and their infants. To overcome the condition, nurses must understand its influential factors to provide effective assistance. Therefore, this study aims to identify factors associated with stress in mothers with premature infants. The study procedures were carried out using a cross-sectional design with a purposive sampling tech- nique comprising 188 mothers with premature infants. In addition, the instruments used were questionnaires for assessing the PSS (Parent Stress Scale), knowledge about the benefits of caring for infants, and support. Data analysis was then carried out using uni- variate analysis, chi-square, and binary logistic regression. The majority of mothers had a moderate level of stress, accounting for 46.3% of the total population. In addition, the results showed that factors associated with moderate levels of stress in mothers with premature infants were younger age, low level of education, SC delivery method, living in rural areas, low knowledge of care, very low infant weight, and low partner support. Based on the results, maternal factors and unfavorable infant conditions could increase stress in mothers with premature infants. Introduction According to the World Health Organization (WHO), the inci- dence rate of premature births was 11.1% of all live births global- ly, and in 2015, approximately 15 million cases were recorded annually.1,2 Several studies have shown that 60% of these cases typically occur in low and middle-income countries in Africa and South Asia.2 In addition, premature birth is widely known as the leading cause of death in children under 5 years, and its incidence rate has shown an increasing annual trend.3 The high risk of mor- tality and morbidity associated with the condition necessitates specialized care in the hospital neonates unit and at home. This is to ensure the continuity of appropriate care after discharge as well as the well-being and adequate health of premature infants.1 In line with previous studies, mothers typically serve as the main caregivers for their infants at home. However, caring for pre- mature infants is a challenging process, requiring mothers’ accep- tance and understanding of the differences compared to full-term babies.4 Previous reports have shown that the caregiving process is characterized by various requirements, such as adequate feed- ing, close monitoring, and comprehension of behavior. These requirements often lead to a range of emotional conditions, such as fear of harming their babies, loneliness, and feeling of being left alone to bear the burden, leading to an increased risk of mental health disorders. A previous study showed that mothers experi- enced fatigue and stress, further exacerbating symptoms of depression.1,2,5 Several studies have shown that maternal distress and psycho- logical problems often persist and increase after hospital discharge due to the severe stress of hospitalization and the severity of infants’ condition at home.6 The transition from hospital to home often presents several stressors to mothers, including the appear- ance of premature infants, changes in maternal roles, and the chal- lenges associated with daily child care.6 A recent report showed that mothers with premature infants had higher stress compared to others with full-term infants.7,8 This result was inconsistent with other studies that stress of caregivers who cared for their infants at home on average was normal daily stress.9 Stressful conditions have been reported to have a negative impact on mothers and their infants. Maternal stress can present obstacles in achieving optimal maternal behavior and fulfilling caregiving roles.10-13 Stress due to premature birth typically causes poor mother-infant interactions, thereby affecting their physical and mental health.14 Prolonged levels can also lead to psycholog- ical disorders in mothers, such as postpartum depression or infants blues.15 Maternal stress is often influenced by several factors, namely age, education level, occupation, and infants weight during stay at the NICU.16 Previous studies also showed that personality, mental health, and family contributed to its type and levels. In addition, other influential factors include the function of the family, socioe- conomic status, and parent’s perception of premature infants.17 Although various reports have explored the incidence of maternal stress during NICU stay,18-23 there are limited studies on its occur- rence at home.9 This shows that nurses need to understand stress and associated influential factors to provide effective intervention Significance for public health This study is the first study to critically examine factors related to stress in mothers when caring for premature infants at home. The results of this study encourage health workers at the community level to be able to pay attention to maternal psychology and provide appropriate interventions so that mothers can care for their premature infants at home reasonably and adequately. Mothers with low stress will help premature infants become healthy in growth and development. [page 90] [Healthcare in Low-resource Settings 2024;12(s1):13024] Non -co mmerc ial us e o nly to mothers.24,25 Therefore, this study aims to assess factors associ- ated with maternal stress when caring for premature infants at home. Based on findings, this is the first study conducted in Indonesia within this context. Materials and Methods Design This study was carried out using a cross-sectional design with an observational approach. Sample Data collection was carried out from July to November 2022, and the sample population comprised mothers who cared for pre- mature infants at home in the Malang area (Malang City, Malang Regency, and Batu City). In addition, the inclusion criteria were mothers who cared for premature infants at home for 1 day to 3 months, mothers and premature infants were in good health, and premature infants had no congenital diseases. The number of par- ticipants in this study was 188 individuals who were selected using the purposive sampling method. Ethical considerations The study procedures were granted ethical clearance under number 2605-KEPK by the Institutional Review Board (IRB) Faculty of Nursing, Universitas Airlangga, Indonesia. Data collection and procedure The procedures began with licensing and obtaining ethical clearance. Detailed informed consent was provided to each respon- dent without any coercion to participate in the study, followed by offline data collection using a paper-based questionnaire. The par- ticipants filled out the questionnaires according to their conditions, and analysis was performed using SPSS. The data input process began with editing, which referred to checking the completeness of the data in the questionnaire. In addition, coding facilitated the scoring and interpretation of the range value. The missing and error data were also assessed and analyzed using univariate and bivariate analyses. An instrument for data collection Stress questionnaire used the parental stress scale (PSS), con- sisting of 18 questions with a minimum score of 18 and a maxi- mum of 90 with 5 statement items (1=Strongly disagree, 5=Strongly disagree). The questionnaire on knowledge of the ben- efits of caring for premature infants at home was modified from a previous questionnaire.26 In addition, it had a Likert scale possess- ing 6 statement items, with maximum and minimum scores of 24 and 4, respectively. The questionnaire of spousal support, and health worker support, was assessed using a variant compiled from the postpartum social support screening tool, consisting of 5 ques- tions and 4 questions.27 The instruments used in this study had been tested for reliability and validity. Stress questionnaire was declared valid with a value range of r 0.538-0.861, while, it had a reliability value of 0.860. The knowledge questionnaire was valid with an R- value range of 0.449-0.920, and its reliability was 0.980. The total score was 5-25 for partner support, and 4-20 for health worker support. The support questionnaire was valid with an R-value range of 0.601-0.991 and a reliability value of 0.988. Data analysis Data was screened for missing items. Total scale scores were computed for measures of maternal stress, knowledge, spousal support, and health worker support. The score of each variable is categorized as follows: ≤55%, moderate: 56-≤75%, and high: 76- 100%. Descriptive statistics (frequency and percentage) were com- puted to describe the experience, mothers’ age, education level, employment, birth methods, economic status, residence, infants’ birth weight, prematurity, benefits of care, spousal support, and health worker support. Univariate analysis, chi-square tests, and binary logistic regression were performed with a final report of odds ratios (OR) and 95% confidence intervals (CI). All the anal- yses used SPSS version 25. Results and Discussion As shown in Table 1, this study shows that among 188 partic- ipants, the majority had no experience with premature infants, were in late adolescence age of 17 - ≤25 years, the last education was high school, were not used, the method of delivery was by Sectio Caesarea, had low economic status, and living in rural areas. In addition, most of the participants had Very Low Birth Weight (1000-<1500 grams), prematurity in the category of moderate pre- mature infants (31-36 weeks), knowledge of caring infants benefits in the low category, getting spousal support and health workers in the high category, and stress in the mild category. Based on the results of the analysis with crosstab, the participants with mild stress mostly did not have experience with premature infants, were of the age of early adult mothers aged 26 - ≤35 years, high school education, not used, method of delivery by cesarean section, low economic status (≤ regional minimum wage), residing in rural areas, and infants condition with very low birth weight (1000- <1500 grams). The analysis results with chi-square showed that the p-value on the variables of residence, birth weight, benefits of care, spouse support, and health worker support was lower than 0.05. This showed that there was a significant relationship between res- idence, birth weight, care benefits, spouse support, and health worker support with stress, as shown in Table 2. Table 3 showed that mothers in their late adolescence aged 17 - ≤25 years were at risk of experiencing moderate stress 11.059 times higher compared to those in their late adulthood aged 36 - 45 years. In addition, education with an odds ratio value of 7.901 showed that mothers who had an elementary school education were 7.901 more at risk of moderate stress compared to others with college education. Mothers who gave birth by cesarean section had a moderate risk of stress, which was 15.301 higher compared to those who gave birth normally with an odds ratio of 15.301. Participants who lived in rural areas had a moderate risk of stress 6.665 higher than others living in urban areas with an odds ratio of 6.665. The results also showed that the category of Very Low Birth Weight had a moderate stress risk of 0.033 times higher than Low- Birth-Weight. The low category in knowledge with an odds ratio value of 14.851 showed that moderate category care knowledge had a moderate risk of experiencing moderate stress 14.851 times higher compared to others with high category care knowledge. Spousal support in the moderate category had an odds ratio value of 75.809, showing that moderate category spousal support had a risk of experiencing moderate stress 75.809 times higher than oth- ers in low category spousal support. A stressor was a situation that exceeded the ability of the mind 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13024] [page 91] Non -co mmerc ial us e o nly or body when dealing with stress source. When the event or situa- tion provided stimulation, individuals typically performed an assessment and cope, leading to the progression of stress to a high- er or lower stage.28 According to Lazarus and Folkman’s transac- tional theory of stress and coping, individuals constantly assessed stimuli from their environment.29 In addition, stress was a relation- ship between individuals and the environment, which was assessed as an inability to deal with a dangerous or threatening situation. The results of this study showed that stress of mothers who cared for premature infants at home was mostly (53.7%) in the low category, with 46.3% being in the moderate category. These results were consistent with previous reports conducted where more than 50% of mothers were under moderate stress.18,21,22,30 In this study, none of the participants had a high category of stress compared to a previous report, where approximately 20-30% experienced high stress.22,31,32 This condition could be because those 3 studies mea- sured mothers’ stress in the hospital. Meanwhile, premature infants who were already at home and cared for by their mothers were assessed in this study. The sample population comprised mothers who cared for premature infants at home from 1 day to 3 months. A study conducted by De Castro Pereira et al. in 2019 on mothers of premature infants who were already at home showed that the average stress was at a total score of 42, showing normal levels. These stress levels did not require referral to a specialist, but close monitoring by the health team, both from the outpatient clinic and the health center.9 Stress of mothers who cared for premature infants at home was correlated to babies’ birth weight, residence, knowledge of caring, spouse support, and health worker support. Maternal age in the 17- 25 years category had a higher risk of experiencing stress com- pared to others in late adulthood aged 36 - 45 years. The results were inconsistent with previous studies, where there was no differ- ence in stress levels between mothers aged <25 years and those aged ≥25 years, although the mean score was slightly higher in mothers aged ≥25 years.15 A significant association was found between parental age and general stress when faced with the appearance of infants in the NICU with the older age group report- ing higher levels of stress (K = 13.6, p = 0.004).16 Younger age was associated with emotional instability33 and in this study, most mothers lacked experience in caring for premature infants. Mothers with lower education levels had stress risk higher than those with higher education. The results obtained were inconsistent with a study conducted in the NICU setting. Previous reports showed that education level had no effect (p>0.05) on parental 4th International Nursing and Health Sciences Symposium Table 1. Maternal and infant characteristics. Variables Category Frequency Percent Experience with premature infants None 164 87.2 Experienced 24 12.8 Mother’s age Late adolescence (17 – ≤25 years) 75 39.9 Early adulthood (26 – ≤35 years) 73 38.8 Late adulthood (36 – 45 years) 40 21.3 Education level Primary school 24 12.8 Secondary school 54 28.7 High school 76 40.4 Diploma 12 6.4 Bachelor’s degree 22 11.7 Employment Not used 136 72.3 Used 52 27.7 Birth methods Sectio Caesarea 144 76.6 Normal 44 23.4 Economic status Low (≤ regional minimum wage) 127 67.6 High (> regional minimum wage) 61 32.4 Residence Rural 99 52.7 Urban 89 47.3 Infant’s birth weight Extreme low birth weight (<1000 grams) 20 10.6 Very low birth weight (1000-<1500 grams) 137 72.9 Low birth weight (1500-<2500 grams) 31 16.5 Prematurity Very premature (24-30 weeks) 20 10.6 Moderately premature (31-36 weeks) 164 87.2 Borderline premature (37-38 weeks) 4 2.1 Benefits of care Low 82 43.6 Medium 28 14.9 Large 78 41.5 Spousal support Low 8 4.3 Medium 47 25.0 Large 133 70.7 Health worker support Low 2 1.1 Medium 38 20.2 Large 148 78.7 Stress Mild stress 101 53.7 Moderate stress 87 46.3 [page 92] [Healthcare in Low-resource Settings 2024;12(s1):13024] Non -co mmerc ial us e o nly 4th International Nursing and Health Sciences Symposium Table 2. Correlation between stress and respondent characteristics. Variables Category Stress p Mild Moderate Experience with premature infants None 87 (86.1) 77 (88.5) 0.628 Experienced 14 (13.9) 10 (11.5) Mother’s age Late adolescence (17 – ≤25 years) 33 (32.7) 42 (48.3) 0.070 Early adulthood (26 – ≤35 years) 42 (41.6) 31 (35.6) Late adulthood (36 – 45 years) 26 (25.7) 14 (16.1) Education level Primary school 16 (15.8) 8 (9.2) 0.107 Secondary school 22 (21.8) 32 (36.8) High school 45 (44.6) 31 (35.6) Diploma 8 (7.9) 4 (4.6) Bachelor’s degree 10 (9.9) 12 (13.8) Employment Not used 69 (68.3) 67 (77.0) 0.184 Used 32 (31.7) 20 (23.0) Birth methods Sectio Caesarea 73 (72.3) 71 (81.6) 0.132 Normal 28 (27.7) 16 (18.4) Economic status Low (≤ regional minimum wage) 70 (69.3) 57 (65.5) 0.580 High (> regional minimum wage) 14 (30.7) 10 (34.5) Residence Rural 69 (68.3) 30 (34.5) 0.000 Urban 32 (31.7) 57 (65.5) Infant’s birth weight Extreme low birth weight (<1000 grams) 4 (4.0) 16 (18.4) 0.003 Very low birth weight (1000-<1500 grams) 82 (81.2) 55 (63.2) Low birth weight (1500-<2500 grams) 15 (14.9) 16 (18.4) Prematurity Very premature (24-30 weeks) 10 (9.9) 10 (11.5) 0.926 Moderately premature (31-36 weeks) 89 (88.1) 75 (86.2) Borderline premature (37-38 weeks) 2 (2.0) 2 (2.3) Benefits of care Low 35 (34.7) 47 (54.0) 0.002 Medium 12 (11.9) 16 (18.4) High 54 (53.5) 24 (27.6) Spousal support Low 0 (0.0) 8 (9.2) 0.000 Medium 6 (5.9) 41 (47.1) High 95 (94.1) 38 (43.7) Health worker support Low 0 (0.0) 2 (2.3) 0.037 Medium 15 (14.9) 23 (26.4) High 86 (85.1) 62 (71.3) [Healthcare in Low-resource Settings 2024;12(s1):13024] [page 93] Table 3. Multivariate analysis factors associated with stress in mother with premature infant. Variables Category OR 95% Confidence interval Mild Mild Moderate Experience with premature infants Experienced .264 .067 1.034 Mother’s age Late adolescence (17 – ≤25 years) 11.059* 2.181 56.068 Early adulthood (26 – ≤35 years) 1.985 0.444 8.882 Education level Primary school 7.901* 1.010 61.833 Secondary school 1.177 0.164 8.443 High school 10.989 0.768 157.301 Diploma 5.502 0.542 55.877 Birth methods Sectio Caesarea 15.301*** 3.352 69.847 Residence Rural 6.665*** 2.392 18.569 Infant’s birth weight Extreme low birth weight (<1000 grams) 3.452 0.456 26.135 Very low birth weight (1000-<1500 grams) 0.254* 0.072 0.893 Benefits of care Low 3.611* 1.285 10.146 Medium 14.851** 2.765 79.763 Spousal support Low 3664621118.106 0.000 . Medium 75.809*** 15.920 360.981 * p-value < 0.05. ** p-value < 0.01. *** p-value < 0.001. Non -co mmerc ial us e o nly stress during the care of premature infants in the NICU.34,35 Although not very significant, low education level was a predictor of PTSD (Post Traumatic Stress Disorder) in mothers who were caring for infants at home.36 Low levels of maternal education could affect mothers’ knowledge and skills in caring for infants.33 Mothers who gave birth using the SC method had a higher level of stress than the vaginal method. A related study found that the incidence of moderate stress after SC delivery was 36.7%, which was higher than the incidence of stress post-vaginal delivery of 6.7%.37 Another study also showed that most mothers experi- enced moderate anxiety (86.7%),38 caused stress, postpartum blues, and psychosis.38 The results showed that mothers of premature infants in the Very Low Birth Weight category were at higher risk of stress com- pared to others in the Low-Birth-Weight category. These results were consistent with previous reports, where low birth weight was associated with maternal stress.39 The severity of premature condi- tion was found to correlate with stress score because mothers saw the appearance and behavior of premature infants that were differ- ent from infants born normally.40 The appearance and behavior were the highest stressors in causing maternal stress, where low infants’ weight at birth also affected health and development in the future.16 Another variable related to stress in this current study was where mothers lived. The risk of mental health problems was found to be higher in individuals who were in rural areas41 due to limited resources and support, leading to a stressful life.42 In addi- tion, preterm birth rates were higher in rural areas, along with inad- equate access to specialist health services and support.43 Limited resources, support, access, and health services caused stress when mothers cared for premature infants at home and lived in rural areas. The results showed that mothers with moderate levels of knowledge were 14,851 times more at risk of stress than others with high levels of knowledge. According to Aldirawi, 42.6% of participants had a low level of knowledge to care for premature infants at home after treatment in the NICU.44 Another study showed that the majority of mothers (53%) had a low level of knowledge regarding premature infants care.45 Ong stated that stress correlated with the level of knowledge and ability of moth- ers. This showed that the higher stress, the lower the level of knowledge and ability of mothers in caring for premature infants.35 Premji also recorded that maternal knowledge indicators affected maternal stress (p<0.00).46 Some knowledge indicators of caring for premature infants, such as nutrition (54.2%), temperature reg- ulation (50%), and umbilical cord care (46%) were also still low compared to infection prevention (73.3%), vaccination (60.2%), and jaundice (67.1%).44 Lack of partner support could trigger stress 75,809 times high- er compared to mothers with great partner support. The results of this study were in line with Abdeyazdan and Racine that adequate partner support could help relieve maternal stress in caring for infants in the NICU (p<0.01) and at home (p<0.001) (47,48). Family support, specifically spouses, was the support that mothers needed during the first 6 weeks after giving birth to premature infants.49 Conclusions In conclusion, most of stress experienced by mothers when caring for premature infants at home was in the moderate category. This study showed several factors that could influence mothers’ stress while caring for premature infants. In addition, support from health workers was very essential to optimize the participants’ abil- ity to cope and reduce stress levels. Health workers also needed to provide psychological interventions, which have not been optimal- ly given to individuals with premature infants in Indonesia. References 1. Osorio Galeano SP, Ochoa Marín SC, Semenic S. Preparing for post-discharge care of premature infants: Experiences of parents. Investig y Educ en Enferm 2017;35:100–6. 2. Davis-Strauss SL, Johnson E, Lubbe W. Information and Support Needs of Parents With Premature Infants: An Integrative Review. J Early Interv 2021;43:199–220. 3. Ye M, Tao J. Parents’ experience of having premature baby: A literature review. In 2018. Available from: https://api.semantic 4th International Nursing and Health Sciences Symposium [page 94] [Healthcare in Low-resource Settings 2024;12(s1):13024] Correspondence:Rinik Eko Kapti, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia 65151. Tel.: +62341569117 - Fax: +62341564755, E-mail: rinik.eko@ub.ac.id Key words: caring; mother; premature; stress Contributions: REK, and YSA contributed substantially to the concept and work design. SA and NA collected data. LS and ADW conducted data analysis, data interpretation, and drafting of the manuscript. REK revised it critically for the important intellectual content and final approval of the version to be published. Conflict of interest: the author declares no potential conflict of interest. Funding: this study was funded by the Research Institutes and Community Service (BPPM), Faculty of Health Science, Universitas Brawijaya. Clinical trials: not applicable. Ethics approval: the study procedures were granted ethical clearance under number 2605-KEPK by the Institutional Review Board (IRB) Faculty of Nursing, Universitas Airlangga, Indonesia. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgements: the authors are grateful to the participants, contrib- utors, and the Research Institutes and Community Service (BPPM), Faculty of Health Science, Universitas Brawijaya, for the financial assis- tance. Received: 3 November 2023. Accepted: 28 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13057 doi:10.4081/hls.2024.13057 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- Non -co mmerc ial us e o nly scholar.org/CorpusID:208490994. 4. Breivold K, Hjaelmhult E, Sjöström-Strand A, Hallström IK. Mothers’ experiences after coming home from the hospital with a moderately to late preterm infant – a qualitative study. Scand J Caring Sci 2019;33:632–40. 5. Cheung RYM, Cheng WY, Li JB, et al. Mothers' and fathers' stress and severity of depressive symptoms during the COVID- 19 pandemic: actor-partner effects with parental negative emo- tions as a moderator. BMC Psychol 2022;10:294. 6. Holditch-Davis D, Santos H, Levy J, et al. Patterns of psycho- logical distress in mothers of preterm infants. Infant Behav Dev 2015;41:154-63. 7. Tabrizi FM, Alizadeh S, Radfar M. Barriers of parenting in mothers with a very low- birth- weight preterm infant, and their coping strategies: A qualitative study. Int J Pediatr 2017;5:5597–608. 8. Zelkowitz P, Bardin C, Papageorgiou A. Anxiety affects the relationship between parents and their very low birth weight infants. Infant Ment Health J 2007;28:296–313. 9. de Castro Pereira F, Aparecida Baggio M, Silveira Viera C, et al. Premature Newborn Post-Discharge Maternal Stress. J Nurs UFPE / Rev Enferm UFPE 2019;13:74–80. 10. Garti I, Donkor E, Musah N, et al. Mothers’ experiences of car- ing for preterm babies at home: qualitative insights from an urban setting in a middle-income country. BMC Pregnancy Childbirth 2021;21:1–9. 11. Adama EA, Bayes S, Sundin D. Parents’ experiences of caring for preterm infants after discharge from Neonatal Intensive Care Unit: A meta-synthesis of the literature. J Neonatal Nurs 2016;22:27–51. 12. Pristya TYR, Novitasari A, Hutami MS. Prevention And Control Of Lbw In Indonesia: Systematic Review. Indonesian J Health Develop 2020;2:175–82. 13. Rossman B, Greene MM, Kratovil AL, Meier PP. Resilience in Mothers of Very-Low-Birth-Weight Infants Hospitalized in the NICU. JOGNN - J Obstet Gynecol Neonatal Nurs 2017;46:434–45. 14. Karbandi S, Momenizadeh A, Heidarzadeh M, et al. Effects of empowering mothers of premature infants on their stress cop- ing strategies. Iran J Psychiatry Behav Sci 2018;12(2). 15. Syamsu AF, Dwi Bahagia Febriani A, Alasiry E, et al. Maternal stressful experience in giving birth to premature baby in neonatal intensive care unit ward. Open Access Maced J Med Sci 2021;9:106–11. 16. Musabirema P, Brysiewicz P, Chipps J. Parents perceptions of stress in a neonatal intensive care unit in Rwanda. Curationis 2015;38:1499. 17. Busse M, Nurse S, Cooperative GH, et al. Parent Responses to Stress: PROMIS in the NICU. Crit Care Nurse 2015;33:52–60. 18. Gurgani S, Jogi S. A study to estimate the level of stress and coping strategies among mothers whose neonates are admitted in neonatal intensive care unit ( NICU ) at Lalla Ded Hospital , Srinagar , Kashmir. Int J Midwifery Nurs 2018;1:1–44. 19. Patil S. Level of stress and coping strategies seen among par- ents of neonates admitted in NICU. Int J Sci Res 2014;3:579– 85. 20. Paul P, Pais M, Kamath S, et al. Perceived maternal parenting self-efficacy and parent coping among mothers of preterm infants–a cross-sectional survey. E-journal Manipal Educ 2018;3:24–7. 21. Rajalakshmi S, Kalavathi S. A study to assess the level of stress and coping strategies among mothers of preterm infants admitted in Neonatal Intensive Care Unit at selected hospital, Puducherry. Int J Adv Nurs Manag 2017;5:45. 22. Sharma A. A Study to assess the level of stress and coping strategies adopted by parents of the neonates admitted in NICU in selected hospitals, Bangalore Mr. J Nurs Res Educ Manag 2019;1:12–6. 23. Tajalli S, Kouhnavard M, Jeshvaghanee SS, et al. Spiritual well-being, parental stress, and coping strategies: a cross-sec- tional study of Iranian mothers with preterm neonates. Iran J Neonatol 2022;13:98–105. 24. Doupnik S, Hill D, Palakshappa D, et al. Parent coping support interventions during acute pediatric hosptializations. Pediatrics 2017;140:1–16. 25. Kaliampos A, Roussi P. Religious beliefs, coping, and psycho- logical well-being among Greek cancer patients. J Health Psychol 2017;22:754–64. 26. Abbasi-Shavazi M, Safari Hajataghaiee S, Sadeghian H, et al. Perceived benefits and barriers of mothers with premature infant to kangaroo mother care. Int J Pediatr 2018;7:9237–48. 27. The Artemis Center For Guidance. The Postpartum Social Support Screening Tool | Artemis [Internet]. 2013 [cited 2023 Aug 2]. Available from: https://artemisguidance.com/pssst/. 28. Baqutayan SMS. Stress and Coping Mechanisms: A Historical Overview. MediterrJ Soc Sci 2015;6:479. 29. Biggs A, Brough P, Drummond S. Lazarus and Folkman’s Psychological Stress and Coping Theory. In: Cooper CL, Quick JC, editors. The Handbook of Stress and Health [Internet]. 1st ed. Wiley; 2017 [cited 2023 Aug 2]. p. 349–64. Available from: https://onlinelibrary.wiley.com/doi/10.1002/9781118993811.c h21. 30. Abimana MC, Karangwa E, Hakizimana I, et al. Assessing fac- tors associated with poor maternal mental health among moth- ers of children born small and sick at 24–47 months in rural Rwanda. BMC Pregnancy Childbirth 2020;20:1–12. 31. Tajalli S, Ebadi A, Parvizy S, Kenner C. Maternal caring abil- ity with the preterm infant: A Rogerian concept analysis. Nurs Forum 2022;57:920-31. 32. Rajalakshmi S, Kalavathi S. A study to assess the level of stress and coping strategies among mothers of preterm infants admitted in Neonatal Intensive Care Unit at selected hospital, Puducherry. Int J Adv Nurs Manag 2017;5:45. 33. Hogue CJ, Menon R, Dunlop AL, Kramer MR. Racial dispar- ities in preterm birth rates and short inter-pregnancy interval: an overview. Acta Obstet Gynecol Scand 2011;90:1317–24. 34. Akkoyun S, Tas Arslan F. Investigation of stress and nursing support in mothers of preterm infants in neonatal intensive care units. Scand J Caring Sci 2019;33:351–8. 35. Ong SL, Abdullah KL, Danaee M, et al. The effectiveness of a structured nursing intervention program on maternal stress and ability among mothers of premature infants in a neonatal inten- sive care unit. J Clin Nurs 2019;28:641–9. 36. Kress V, von Soest T, Kopp M, et al. Differential predictors of birth-related posttraumatic stress disorder symptoms in moth- ers and fathers – A longitudinal cohort study. J Affect Disord 2021;292:121–30. 37. Amperaningsih Y, Siwi PN. Post traumatic stress in postpartum mothers with emergency caesarean section and spontaneous delivery. J Ilm Keperawatan Sai Betik 2018;14:72. 38. Fadilah WN, Megawati M, Astiriyani E. The effect of hypnosis on the level of anxiety of post-cesarean mothers. Media Inf 2018;14:148–53. 39. Schappin R, Wijnroks L, Venema MMATU, Jongmans MJ. Rethinking stress in parents of preterm infants: a meta-analy- 4th International Nursing and Health Sciences Symposium [[Healthcare in Low-resource Settings 2024;12(s1):13024] [page 95] Non -co mmerc ial us e o nly sis. PLoS One 2013;8(2). 40. Malliarou M, Karadonta A, Mitroulas S, et al. Preterm parents’ stress and coping strategies in a neonatal intensive care unit in a university hospital of central Greece. Mater Socio Medica 2021;33:244. 41. Ginja S, Jackson K, Newham JJ, et al. Rural-urban differences in the mental health of perinatal women: a UK-based cross- sectional study. BMC Pregnancy Childbirth 2020;20:1–11. 42. Miles MS, Holditch-Davis D, Thoyre S, Beeber L. Rural African-American mothers parenting prematurely born infants: an ecological systems perspective. Newborn Infant Nurs Rev 2005;5:142–8. 43. Wakely L, Rae K, Keatinge D. Fragile forgotten families: Parenting a premature infant in a rural area, where is the evi- dence? Neonatal, Paediatr Child Heal Nurs 2015;18:8–17. 44. Aldirawi A, El-Khateeb A, Mustafa AA, Abuzerr S. Mothers’ knowledge of health caring for premature infants after dis- charge from neonatal intensive care units in the Gaza Strip, Palestine. Open J Pediatr 2019;09:239–52. 45. AL-Mukhtar S, Abdulghani M. Knowledge of Mothers regard- ing Premature Baby Care in Mosul city. Mosul J Nurs 2020;8:108–18. 46. Premji SS, Pana G, Currie G, et al. Mother's level of confi- dence in caring for her late preterm infant: A mixed methods study. J Clin Nurs 2018;27:e1120-e1133. 47. Abdeyazdan Z, Shahkolahi Z, Mehrabi T, Hajiheidari M. A family support intervention to reduce stress among parents of preterm infants in neonatal intensive care unit. Iran J Nurs Midwifery Res 2014;19:349–53. 48. Racine N, Plamondon A, Hentges R, et al. Dynamic and bidi- rectional associations between maternal stress, anxiety, and social support: The critical role of partner and family support. J Affect Disord 2019;252:19–24. 49. Sarach R, Rosyidah L. Psikologi Ibu Postpartum Dengan Bayi Prematur: Scoping Review. J Midwifery Reprod 2021;5:51. 4th International Nursing and Health Sciences Symposium [page 96] [Healthcare in Low-resource Settings 2024;12(s1):13024] Non -co mmerc ial us e o nly