Iran Journal of Nursing

Background & Aims: Proper intervals between births have been emphasized as a factor to guarantee the health of the mother and infant. Therefore, reproductive health programs are essential to achieving this important goal. Birth intervals are an effort to maintain a certain interval between births, which is explicitly defined relative to the newborn. Closely birth intervals are referred to as rapid repeated pregnancy in the public health and medical literature and increase the risk of various disorders in the mother and infant. The current literature in this regard indicates that more than 54 million women suffer from health problems during pregnancy and delivery each year, and approximately 1.5 million die, 99% of which occur in developing countries. Since the time and interval of subsequent births are the main determinants of fertility, fertility researchers have widely investigated these factors. In addition, evidence suggests that short intervals between births cause numerous adverse consequences in childhood and adulthood. The present study aimed to investigate the birth intervals and its determinants in the rural women of Fars province, Iran. In general, we sought to identify the vulnerable groups of women that need special attention in health and reproductive health programs, so that the general health of mothers and infants would be promoted in the community.
Materials & Methods: This cross-sectional, analytical study was conducted using a researcher-made questionnaire on 882 married women aged 15-49 years with two or more children living in the rural areas of Fars province. The survey was performed using cluster sampling in October 2015. The independent variables included age, age of the spouse, year of marriage, ethnicity, religion, education level, and occupation status. In addition, the birth year of each child was recorded by asking the women, and birth interval was the dependent variable. Based on the fertility level of the women, the intervals between the first and second births, as well as the second and third births, were also considered and emphasized. Data analysis was performed in SPSS version 16 using frequency tables and multiple regression analysis at the significance level of 0.05.
Results: The mean age of the participants was 35.29±6.25 years, and the mean age of the spouses was 40.31±6.89 years. The mean age of the women in the first marriage was 19.56±3.95 years. The majority of the respondents were Persians and Shiites, and the majority of the women (53.6%) had two children. Furthermore, 4% of the rural women had academic education or higher educational degrees than diploma, and this rate was estimated at 5.6% for men. The findings also indicated that the largest proportion of the rural women and their spouses had secondary education or lower. In terms of occupation status, 3.3% of the rural women and 94.9% of the spouses were employed. In addition, approximately 83.6% of the rural households earned less than 10 million Rials, and 0.9% earned more than 25,000,000 million Rials per month. According to the results, 31.8% of the women with two children gave birth to their second child less than three years after the birth of the first child. This rate was estimated at 52%, 65.7%, and 80% for the women with three, four, and five children, respectively. The interval between the second and third birth for 25.3%, 50.5%, and 78.8% of the women with three, four, and five children was less than three years, respectively. On the other hand, all the women with four children gave birth to their fourth child less than three years after their last child. The multivariate analysis of the data indicated that ethnicity (P=0.023) and religion (P=0.002) had a significant effect on the birth interval between the first and second births, and the average birth interval in the Persian and Shiite women was higher than the women of other ethnicities and Sunni women. Notably, ethnicity (P=0.001) and religion (P=0.027) were the only significant variables to affect the interval between the birth of the second and third children of the rural women in Fars province.
Conclusion: According to the results, demographic and socioeconomic characteristics had relatively similar effects on the birth interval between the first and third children, while the explanatory power of these factors increased relatively with the interval between the second and third births. In other words, the interval between the first and third childbirths in the rural women was relatively the same, and no significant differences were observed in terms of the socioeconomic characteristics of the women. Ethnicity and religion also had significant effects on the birth interval, which could be associated with the socioeconomic status of the rural women. It seems that the employed women had to increase their birth intervals due to the combination of childbirth and occupation. Nevertheless, no significant correlation was denoted between the occupation status of the women and birth intervals, while our findings indicated that the employed women were more likely to give birth to their second child within an increased interval from the first birth compared to the unemployed women, while it was the opposite in the case of the interval between the second and third births. Previous studies have indicated that the education level of women is a significant influential factor in birth intervals, while no such significant correlation was observed in this study. Furthermore, it could be inferred that the Sunni and non-Persian women needed more attention as a vulnerable population, and they should be properly trained on the importance of adequate birth intervals. These women also need more attention to raise their awareness regarding adequate birth intervals. By adopting and implementing the necessary training courses in vulnerable women, the issues associated with birth intervals could reduce, which in turn promotes the general health of these women and their infants.

Background & Aims: During pregnancy, women have expectations of their future baby, and preterm delivery may negatively affect such expectations. On the other hand, postpartum maternal stress is a well-established issue, which intensifies with the birth of a premature infant. Preterm birth is an unexpected experience and a multifaceted incident that leads to two main consequences, which are the medical and neurophysiological complications of the infant (especially in very-low-birth-weight infants weighing less than 1,500 grams and aged less than 32 weeks) and the adverse effects on the mother-infant relationship due to the prolonged admission of the infant to the neonatal intensive care unit (NICU). If the infant is not discharged, the mother will be unable to fully assume their maternal role. Therefore, proper intervention protocols help reduce maternal stress and empower mothers to cope with the complex and technological environment of the NICU. The present study aimed to evaluate the impact of evidence-based early supportive interventions on the maternal stress caused by preterm birth.
Materials & Methods: This quasi-experimental study was performed at the NICUs of Mahdieh Hospital and Shahid Akbarabadi Hospital in Tehran, Iran. Sampling started on February 14, 2016 and continued until May 14, 2016. Both centers were teaching, referral hospitals with three levels of NICUs. NICU level one is designed for generally ill and low-birth-weight infants who do not require intensive care (minimal care and basic care following delivery), NICU level two is considered for the infants who need other intensive care than ventilator support and surgical care, and NICU level three is designed for the critically ill infants who require life-sustaining therapies, particularly auxiliary ventilation and optimally tailored neonatal intensive care. In this study, the hospitals were considered as random allocation units, with Mahdieh Hospital assigned to the intervention site and Shahid Akbarabadi Hospital assigned to the control site. The sample population included mothers with premature infants. Preterm infants and their mothers were selected within three months based on the inclusion and exclusion criteria of the study. The inclusion criteria were having an infant with the gestational age of less than 37 weeks, birth weight less than 2,500 grams, and high probability of survival, maternal consent for enrollment, Iranian nationality, and the ability to communicate verbally. The exclusion criteria were infants with abnormalities or severe debilitative conditions (e.g., grade III or IV intraventricular hemorrhage). During the study period, 75 mothers and infants were classified as the intervention group, and 68 mothers and infants were assigned to the control group. The intervention was designed based on the model of the support system of mothers with premature infants. In this model, parents and infants are at the center of the support model and should be supported during critical transitional periods, including pre-fertilization, before delivery, NICU admission, discharge, and at home. Based on the model, various interventions were provided to the mothers at the NICUs, which gradually started upon the admission of the premature infant to the NICU, continued throughout the admission, followed-up the subjects until three months since the birth of the infant. In the intervention group, the mothers were provided with continuous informational support (emphasis on the continuous provision of information to the mothers about the infants' illness, treatment, growth and care, infants' emotional and behavioral needs and responses, and maternal rights and responsibilities during admission). Furthermore, we provided spiritual support (in an illness crisis, spirituality may be essential to coping and have a positive impact on the response of individuals since reliance upon a higher power could become a source of hope for a positive outcome. Fostering spiritual values protects individuals' integrity and gains spiritual perseverance to encounter hardships), appraisal support (strengthening and supporting the maternal role and encouraging mothers to strengthen their relationship with their infants and actively partake in their care since doing their best in the care of the infant makes them feel better. In fact, encouraging mothers to participate in care of preterm infants allows them to conceive their maternal role), and emotional support (addressing the feelings and concerns of the mothers and showing concern for their health and the health of the newborn so that they could adopt to the infant's illness and the other affected aspects of their lives). The control group received routine care. Upon discharge, maternal stress was measured using the parental stressor scale: neonatal intensive care unit (PSS-NICU). The main sources of maternal stress included the NICU environment, infant's appearance, special behaviors of treatment of the infant, mother-infant relationship, and maternal role. Data analysis was performed in the STATA software version 13 using t-test, Chi-square, and inverse probability of treatment weighting (IPTW).
Results: After adjusting the pre-treatment variables by the IPTW, the mean difference in the adjusted stress score regarding the NICU environment was estimated at 0.55 (range: 0.89-0.2) (P<0.001), while it was 0.37 (range: 0.68-0.06) regarding the changes in the maternal role (P=0.02), and 0.29 (-0.43-0.37) regarding the infant's appearance and behavior and treatment of the infant (P=0.89). In addition, the total stress score was estimated at 0.25 (range: 0.58-0.07) regarding the NICU environment (P=0.13), and the stress score of the intervention group was significantly lower compared to the control group regarding the changes in the maternal role.
Conclusion: For the successful implementation of interventions designed based on scientific evidence and facilities, it is suggested that policy-makers implement these evidence-based interventions to improve the quality of care of premature infants and reduce maternal stress in the form of family-centered support models in NICUs. Furthermore, it is recommended that similar investigations be performed on fathers. Although the results of this study confirmed the effects of the intervention on reducing maternal stress regarding the technological NICU environment and changes in the maternal role, it may not lead to the significant reduction of total stress and stress about infants' appearance, behavior, and treatment in mothers. As such, detailed studies should be conceived based on effective interventions in this regard.