Decolonizing study-abroad programs in nursing in low- and middle-income countries.

Study abroad programs expose scholars, including nursing faculty and students, to different settings and cultures. However, the world of global health is rooted in colonial practices that have the potential to cause harm to communities. In this reflection, we provide lessons we have learned through study abroad that guide strategies for decolonizing our practice while working toward cultural safety and humility. We utilized a qualitative case study method. Authors discussed and reviewed study abroad programs through a series of virtual discussions. Discussions showed that study abroad programs present opportunities for students and faculty to grow and learn. However, unacknowledged privileges among visiting students and faculty, and lack of understanding of the impacts of colonialism, may lead to harm in communities and inequitable relationships with local providers. Understanding the privileges that we hold is important in advancing positive and equitable experiences in study abroad programs.

Experiences of recruitment and retention in academia: A collaborative autoethnography of early-career faculty members of color.

BACKGROUND: Recruitment and retention of diverse faculty in schools of nursing continues to be an important challenge but little has been written from the perspectives of early-career faculty of color on their decision to join academia and their retention. PURPOSE: We aim to understand the perspectives of a cluster hire of early-career faculty of color on their recruitment, mentorship and support received, and resources needed for long-term retention. METHODS: Five faculty members conducted a joint autoethnography of their perspectives through recruitment, hiring, and first year as faculty. Two group discussions were analyzed for emergent themes using thematic analysis, maintaining reflexivity. DISCUSSION: Four themes were identified: Intentionality to diversity faculty, Plan for professional development, Clear antiracism diversity equity and inclusion standards, and Retention enablers and barriers. CONCLUSION: We provide strategies (e.g., targeted resources, diverse cluster hires, building community) to inform recruitment and retention of early-career faculty of color.

Psychosocial experiences of cancer survivors and their caregivers in sub-Saharan Africa: A synthesis of qualitative studies.

OBJECTIVE: To synthesize and examine current literature on survivorship experiences and psychosocial oncologic care programs of individuals affected by cancer in sub-Saharan Africa (SSA). METHODS: This was a systematic review guided by the PRISMA 2020 guidelines. We searched 6 databases for articles published from inception to 21 October 2021. Articles were appraised using the Johanna Briggs Institute's Checklist for Qualitative Research. For data synthesis, we used the World Health Organization (WHO) quality of life framework [WHOQOL] to organize experiences into 6 domains/themes. RESULTS: Twenty-five qualitative studies were included in the synthesis. Studies focused on psychosocial care of adults (>18 years) affected by cancer in SSA. The common WHOQOL domains were social relations, spirituality/religion/personal beliefs, and psychological. CONCLUSION: Findings echo need for individuals with cancer and their caregivers. Healthcare professionals are an essential resource for information and support services that can be tailored to individuals need. This synthesis highlighted caregiver stress and stressors from the community that could impact care of individuals with cancer. A holistic approach is needed that incorporates professional and social aspects of care.

Scoping Review of Early Toxic Stress and Epigenetic Alterations in the Neonatal Intensive Care Unit.

BACKGROUND: Preterm infants are uniquely vulnerable to early toxic stress exposure while in the neonatal intensive care unit (NICU) and also being at risk for suboptimal neurodevelopmental outcomes. However, the complex biological mechanisms responsible for variations in preterm infants' neurodevelopmental outcomes because of early toxic stress exposure in the NICU remain unknown. Innovative preterm behavioral epigenetics research offers a possible mechanism and describes how early toxic stress exposure may lead to epigenetic alterations, potentially affecting short- and long-term outcomes. OBJECTIVE: The aim of this study was to review the relationships between early toxic stress exposures in the NICU and epigenetic alterations in preterm infants. The measurement of early toxic stress exposure in the NICU and effect of epigenetic alterations on neurodevelopmental outcomes in preterm infants were also examined. METHODS: We conducted a scoping review of the literature published between January 2011 and December 2021 using databases PubMed, CINAHL, Cochrance Library, PsycINFO, and Web of Science. Primary data-based research that examined epigenetics, stress, and preterm infants or NICU were included. RESULTS: A total of 13 articles from nine studies were included. DNA methylations of six specific genes were studied in relation to early toxic stress exposure in the NICU: SLC6A4, SLC6A3, OPRMI, NR3C1, HSD11B2, and PLAGL1. These genes are responsible for regulating serotonin, dopamine, and cortisol. Poorer neurodevelopmental outcomes were associated with alterations in DNA methylation of SLC6A4, NR3C1, and HSD11B2. Measurements of early toxic stress exposure in the NICU were inconsistent among the studies. DISCUSSION: Epigenetic alterations secondary to early toxic stress exposures in the NICU may be associated with future neurodevelopmental outcomes in preterm infants. Common data elements of toxic stress exposure in preterm infants are needed. Identification of the epigenome and mechanisms by which early toxic stress exposure leads to epigenetic alterations in this vulnerable population will provide evidence to design and test individualized intervention.

Experiences of gender-based violence among Somali refugee women: a socio-ecological model approach.

Gender-based violence (GBV) is an all-encompassing term that speaks to acts or threats that may lead to physical, sexual or emotional harm to an individual based on their gender. This paper provides a scoping review of research on gender-based violence among Somali refugee women in different parts of the world. Using the socio-ecological model as a framework, we reviewed 30 empirical studies focusing on some form of GBV among Somali refugee women. We identified societal, community and individual factors contributing to the experience of GBV. We also discuss how these factors influence women's willingness to access care, especially healthcare and social services. The review reveals that oftentimes, institutions that work closely with this population have a limited understanding of how closely culture affects the willingness and ability to seek help about GBV. Based on our analysis, we suggest ways in which social institutions and healthcare providers can provide culturally-safe support to Somali refugee women who have experienced some form of GBV.

Feasibility of Stress Research in Premature Infant-Maternal Dyads During and After Neonatal Intensive Care Unit Hospitalization.

BACKGROUND: Stress from preterm infant admission to the neonatal intensive care unit (NICU) is associated with infant and maternal physiologic changes, including endocrine and epigenetic alterations. Little is known about the mechanisms connecting NICU stress to biologic changes, and whether preterm infant and maternal stress are reciprocal. As a preliminary step, feasibility and acceptability of measuring indicators of stress are required. PURPOSE: This study evaluated the feasibility and acceptability of research examining perceptions and biologic markers of stress in premature infant-maternal dyads during and after NICU hospitalization. METHODS: We evaluated study feasibility using a longitudinal descriptive design. Acceptability was measured via a maternal questionnaire. Exploratory data regarding hospitalization, perceptions of stress, social support and social determinants of health, and biologic markers of stress were collected during the first week of life and again 3 months after NICU. RESULTS: Forty-eight mothers were eligible for the study, 36 mothers were approached, 20 mothers consented to participate, and 14 mothers completed data collection. Mothers reported high levels of study acceptability despite also voicing concern about the sharing of genetic data. Exploration of DNA methylation of SLC6A4 in preterm infants was significant for a strong correlation with perception of total chronic stress. IMPLICATIONS FOR PRACTICE AND RESEARCH: Clinical practice at the bedside in the NICU should include standardized screening for and early interventions to minimize stress. Complex research of stress is feasible and acceptable. Future research should focus on linking early life stress with epigenetic alterations and evaluation of the dyad for reciprocity.

The impact of the COVID-19 pandemic on help-seeking behaviours of Indigenous and Black women experiencing intimate partner violence in the United States.

AIMS: This article discusses possible barriers to help-seeking that Indigenous and Black women encountered when seeking help related to experiences of intimate partner violence during the COVID-19 pandemic. DESIGN: This article is focused on understanding the impact of the COVID-19 pandemic on populations at highest risk for intimate partner violence in its most severe forms. DATA SOURCES: Literature sources range from 2010 to 2022. The article is also informed by the experiences of scholars and advocates working with Indigenous and Black women experiencing intimate partner violence in Wisconsin. In our write-up, we draw on Indigenous feminism and Black feminist thought. IMPLICATIONS FOR NURSING: Help seeking is contextual. The context in which help seeking occurs or does not occur for Indigenous and Black women, due to the barriers we discuss is vital for nurses to understand in order to provide efficient and meaningful nursing care. CONCLUSION: Our goal is to center the nursing profession in a leadership position in addressing the complex and unique needs of Indigenous and Black women who experience the highest rates of intimate partner violence and also experience the greatest barriers to care and support. IMPACT: We seek to contribute theory-driven knowledge that informs the work of nurses who are often the first to encounter survivors of intimate partner violence within the clinical setting. Help-seeking is often hindered by factors such as geographic and jurisdictional, economic, and structural response barriers. This knowledge will enhance nurses' ability to lead and advocate for clinical practice and policies that minimize the barriers women experience following intimate partner violence, especially during pandemics, disasters, and other extraordinary circumstances. PUBLIC CONTRIBUTIONS: This article is based on the collaboration of community advocates, nurse scientists, and public health scholars, who work closely with Indigenous and Black survivors of violence and seek to meet their needs and offer them meaningful support.

Lifetime stressor exposure, systemic inflammation during pregnancy, and preterm birth among Black American women.

Although Black American mothers and infants are at higher risk for morbidity and mortality than their White counterparts, the biological mechanisms underlying these phenomena remain largely unknown. To investigate the role that lifetime stressor exposure, perceived stressor severity, and systemic inflammatory markers might play, we studied how these factors were interrelated in 92 pregnant Black American women. We also compared inflammatory marker levels for women who did versus did not go on to give birth preterm. During the early third trimester, women completed the Stress and Adversity Inventory for Adults to assess the stressors they experienced over their lifetime. Women also provided blood samples for plasma interleukin (IL)-6, IL-8, IL-1ß, and tumor necrosis factor (TNF)-α quantification. Preterm births were identified by medical record review. Controlling for relevant covariates, there were significant positive associations between average levels of both overall and acute perceived stressor severity and plasma IL-1ß levels. Controlling for perceived stress at assessment and exposure to racial discrimination did not affect these results. Mediation models revealed that exposure to more chronic stressors was related to higher plasma IL-1ß levels, as mediated by higher average levels of overall perceived stressor severity. Exposure to fewer acute stressors was related to higher plasma IL-1ß levels, as mediated by higher average levels of acute perceived stressor severity. Finally, women who went on to give birth preterm had higher levels of plasma IL-6. These data thus highlight the potential importance of assessing and addressing lifetime stressor exposure among mothers before and during maternal-infant care.

A qualitative assessment of gender roles in child nutrition in Central Malawi.

BACKGROUND: Child malnutrition persists globally with men and women playing distinct roles to support children's nutrition. Women frequently carry the bulk of the workload related to food, care, and health, all of which are critical factors in child nutrition. For this reason, development efforts have emphasised women ignoring the potential role of men in supporting children's nutrition. This study sought to understand the different roles that Malawian men and women play in children's nutrition. METHODS: This qualitative was conducted in rural Central Malawi as part of a baseline study in 2017 for the CARE Southern Africa Nutrition Initiative. Seventy-six participants were interviewed, including 19 men and 57 women, using focus group discussions and in-depth interviews. We sought to understand the gender distribution of men's and women's roles and how these roles influence child nutrition. RESULTS: We found that both men and women were involved in productive, reproductive, and community work. However, consistent with the literature, women carried a disproportionate workload in supporting child nutrition compared to men. Women's heavier workloads often prevented them from being able to meet children's food needs. Nevertheless, shifts in gender roles were observed in some of the sampled communities, with men taking up responsibilities that have been typically associated with women. These changes in gender roles, however, did not necessarily increase women's power within the household. CONCLUSIONS: Traditional gender roles remain prevalent in the sampled communities. Women continue to be primarily responsible for the food, care, and health of the household. Women's heavy workloads prevent them from providing optimal care and nutrition for children. While efforts to advance gender equality by encouraging men to participate in child care and other household responsibilities appear to have had marginal success, the extent to which these efforts have successfully encouraged men to share power remains unclear. Improving gender equality and child nutrition will require efforts to redistribute gendered work and encourage men to move towards shared power with women over household decision-making and control over income.

Predicting Risk for Early Breastfeeding Cessation in Israel.

OBJECTIVES: This study aimed to 1) Examine factors associated with cessation of exclusive breastfeeding in Israel and 2) Develop predictive models to identify women at risk for early exclusive breastfeeding cessation. METHODS: The study used data from longitudinal national representative infant nutrition survey in Israel (n = 2119 participants). Logistic regression was used to identify risk factors and build predictive models. RESULTS: The rate of exclusive breastfeeding cessation increased from 45.4% at 2 months to 85.7% at 6 months. Five factors were significantly associated with higher odds of exclusive breastfeeding cessation at 2 months: being a primapara, low educational level, lack of previous breastfeeding experience, negative attitude towards birth, and lack of intention to breastfeed. Six factors were significantly associated with higher odds of exclusive breastfeeding cessation at 6 months: younger age, being in a relationship with a partner, lower religiosity level, cesarean delivery, not taking folic acid during pregnancy, and negative attitude towards birth. Both 2 and 6-months models had good predictive performance (C-statistic of .72 and .68, accordingly). CONCLUSIONS FOR PRACTICE: This nationwide study successfully identified several predictors of exclusive breastfeeding cessation and created breastfeeding cessation prediction tools for two time periods (2 and 6 months). The resulting tools can be applied to identify women at risk for stopping exclusive breastfeeding in hospitals or at community clinics. Further studies should examine practical aspects of applying these tools in practice and explore whether applying those tools can lead to higher exclusive breastfeeding rates.

Experiences of Malawian Mothers During Their Infants' Hospitalization.

BACKGROUND: Hospitalization of a newborn infant is stressful for all mothers. Hospitals in Malawi have limited nursing staff and support, so mothers are the primary care providers for their hospitalized infants. Few studies have explored the experience of these mothers as both care providers and mothers. PURPOSE: The purpose of this study was to explore the experiences of mothers during the hospitalization of the infant. The goal was to increase knowledge of their primary concerns about the hospital stay. METHODS: This was a descriptive qualitative study conducted at Queen Elizabeth Central Hospital in Malawi. Mothers were interviewed prior to their infant's discharge. We used the directed content analysis approach to analyze our data. RESULTS: Twenty mothers of preterm or full-term infants were interviewed. The primary concerns were perinatal experiences, the infant's condition and care including breastfeeding, support from family members, and support and care from healthcare providers. Additionally, mothers of preterm infants were concerned about the burdens of kangaroo mother care. IMPLICATION FOR PRACTICE: In hospitals that provide limited nursing support to mothers and their infants, it is important to identify a support system for the mother and provide mothers with information on infant care. IMPLICATIONS FOR RESEARCH: Future research should identify specific supports and resources in the community and hospital settings that are associated with positive hospital experiences.

The Role of Family Members in Providing Support For Malawian Women With Preterm Infants During Infant Hospitalization.

Purpose: Family support is essential for women with preterm infants during hospitalization. In low-income countries, the additional burden of infant care due to shortages in nursing staff necessitates that family members (guardians) be physically present to care for woman and the infant. The purpose of this study was to explore the types of support that Malawian women of preterm infants need during hospitalization. Methods: This descriptive qualitative study was conducted at a tertiary level hospital in southern Malawi. We recruited 15 women with preterm infants during hospitalization and conducted in-depth interviews. Data was audio-recorded, transcribed, and analyzed using NVivo. Results: The postpartum women participating this study preferred females and members of the maternal side of their family for guardians. Participants' support needs included physical, financial, emotional, and spiritual support. Barriers such as financial constraints and the lack of accommodations for guardians had left the participants without support persons physically present to help them.

Racial Discrimination and Stress Across the Life Course: Associations With Prenatal Inflammation, Perceived Stress, and Depressive Symptoms.

BACKGROUND: Among Black Americans, interpersonal racial discrimination is common. Stress, including following discrimination, contributes to pregnancy complications. In this secondary analysis, we provide data on associations among discrimination, stress, and their interaction across the life course and inflammation, perceived stress, and depressive symptoms during pregnancy. METHODS: During the early third trimester, Black American women (n = 93) completed the Experiences of Discrimination Scale, the Stress and Adversity Inventory, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Inventory. Plasma interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α), and IL-ß levels were quantified. Associations were examined by linear regression, controlling for demographic, behavioral, and clinical covariates. RESULTS: Associations among racial discrimination and plasma IL-8, TNF-α, and IL-ß levels depended upon average ratings of life course stress. When stress was low, discrimination in the mid tertile was associated with the highest levels of IL-8, TNF-α, and IL-ß. Subscale analyses suggested that findings related to IL-8 were driven by chronic stress whereas findings related to TNF-α and IL-ß were driven by acute stress. When examined together, greater discrimination but not greater life course stress was associated with higher prenatal perceived stress. In subscale analyses, the association between discrimination and prenatal perceived stress depended upon average ratings of life course acute stress. When acute stress was low, discrimination in the midtertile was associated with the highest levels of prenatal perceived stress. When acute stress was high, discrimination in the high tertile was associated with the highest levels of prenatal perceived stress. There were also direct associations among greater life course chronic stress, prenatal perceived stress, and prenatal depressive symptoms. Associations were attenuated when discrimination was included as a covariate. CONCLUSIONS: The current analyses suggest that, among Black Americans, prenatal inflammation, perceived stress, and depressive symptoms may be shaped by racial discrimination and stress across the life course. In many cases, associations among discrimination and prenatal parameters depended upon how stressful exposures to life course stressors had been rated. The data suggest the potential for adaptive plasticity under some stress and highlight the deleterious nature of compounding stress.

A Systematic Review on Outcomes of Preterm Small for Gestational Infants Born to Women With Hypertensive Disorders in Pregnancy.

There is a lack of knowledge on the intersection between prematurity, small for gestational age, and hypertensive disorders of pregnancy (HDP). Therefore, the aim of this systematic review was to examine the outcomes of preterm infants who were small for gestational age born to women with HDP. Searches were conducted with no date restriction through the final search date of May 13, 2020, in the following databases: PubMed, Web of Science Core Collection, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text (EBSCOhost), and Embase (Elsevier). A total of 6 studies were eligible for this review. The adjusted odds of mortality and necrotizing enterocolitis were significantly lower in the pregnancy-induced hypertension (PIH)/HDP group than in the non-PIH/HDP group. There was no significant difference in the odds of respiratory distress syndrome, bronchopulmonary dysplasia, and intraventricular hemorrhage between PIH/HDP and non-PIH/HDP groups. There was no significant difference between PIH/HDP and non-PIH/HDP groups in cystic periventricular leukomalacia, retinopathy of prematurity, late-onset sepsis, patent ductus arteriosus, length of hospital stays, duration of supplemental oxygen use, duration of mechanical ventilation, and continuous airway pressure. The studies included in this systematic review demonstrated that PIH/HDP is associated with lower infant mortality and necrotizing enterocolitis.

Spatial analysis of factors associated with HIV infection in Malawi: indicators for effective prevention.

BACKGROUND: The objective of this study was to model the predictors of HIV prevalence in Malawi through a complex sample logistic regression and spatial mapping approach using the national Demographic and Health Survey datasets. METHODS: We conducted a secondary data analysis using the 2015-2016 Malawi Demographic and Health Survey and AIDS Indicator Survey. The analysis was performed in three stages while incorporating population survey sampling weights to: i) interpolate HIV data, ii) identify the spatial clusters with the high prevalence of HIV infection, and iii) perform a multivariate complex sample logistic regression. RESULTS: In all, 14,779 participants were included in the analysis with an overall HIV prevalence of 9% (7.0% in males and 10.8% in females). The highest prevalence was found in the southern region of Malawi (13.2%), and the spatial interpolation revealed that the HIV epidemic is worse at the south-eastern part of Malawi. The districts in the high HIV prevalent zone of Malawi are Thyolo, Zomba, Mulanje, Phalombe and Blantyre. In central and northern region, the district HIV prevalence map identified Lilongwe in the central region and Karonga in the northern region as districts that equally deserve attention. People residing in urban areas had a 2.2 times greater risk of being HIV-positive compared to their counterparts in the rural areas (AOR = 2.16; 95%CI = 1.57-2.97). Other independent predictors of HIV prevalence were gender, age, marital status, number of lifetime sexual partners, extramarital partners, the region of residence, condom use, history of STI in the last 12 months, and household wealth index. Disaggregated analysis showed in-depth sociodemographic regional variations in HIV prevalence. CONCLUSION: These findings identify high-risk populations and regions to be targeted for Pre-Exposure Prophylaxis (PrEP) campaigns, HIV testing, treatment and education to decrease incidence, morbidity, and mortality related to HIV infection in Malawi.

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi.

BACKGROUND: Mother-infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother-infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother-infant relationship in Malawi are limited and studies that observed mother-infant interactions could not be located. PURPOSE: This study explored mother-infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants. METHODS: This observational study explored maternal and infant interactive behaviors. We recruited 83 mother-infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads). FINDINGS: Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births. IMPLICATIONS FOR PRACTICE: Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants. IMPLICATIONS FOR RESEARCH: Future studies of factors that contribute to positive interactions in Malawi are needed.

Emotional distress in mothers of early-preterm infants, late-preterm infants, and full-term infants in Malawi.

BACKGROUND: Mothers of preterm infants, early or late, report more distress than mothers of full-term infants. Malawi has the highest preterm birth rate in the world, but nothing is known about the relation of preterm birth to maternal mental health. PURPOSE: To compare emotional distress among mothers of early-preterm, late-preterm, and full-term infants. METHODS: We recruited 28 mothers of early-preterm, 29 mothers of late-preterm, and 28 mothers of full-term infants. Emotional distress was assessed 24-72 hr following birth. One-way ANOVA and regression analysis were used to compare the three groups. FINDINGS: Mothers of early-preterm infants reported more distress symptoms than mothers of full-term infants, and scores of mothers of late-preterm infants fell between the other two groups. Having a support person present was associated with lower symptoms and caesarean birth was associated with more symptoms. DISCUSSION: Promoting maternal mental health is important following preterm birth and health care providers need to support mothers.

The role of sociodemographic factors in maternal psychological distress and mother-preterm infant interactions.

Preterm birth has been associated with greater psychological distress and less positive mother infant interactions than were experienced by mothers of full-term infants. Maternal and infant sociodemographic factors have also shown a strong association with psychological distress and the mother-infant relationship. However, findings on their effects over time are limited. In this longitudinal analysis, we explored the relationship of maternal and infant sociodemographic variables (maternal age, maternal education, marital status, being on social assistance, maternal race, infant birth weight, and infant gender) to maternal psychological distress (depressive, posttraumatic stress, anxiety, parenting stress symptoms, and maternal worry about child's health) through 12 months corrected age for prematurity, and on the home environment, and mother-infant interactions through 6 months corrected age for prematurity. We also explored differences related to maternal obstetrical characteristics (gestational age at birth, parity, mode of delivery, and multiple birth) and severity of infant conditions (Apgar scores, need for mechanical ventilation, and infant medical complications). Although the relationship of maternal and infant characteristics with these outcomes did not change over time, psychological distress differed based on marital status, maternal education, infant gender, and infant medical complications. Older mothers provided more a positive home environment. Mother-infant interactions differed by maternal age, being on public assistance, maternal race, infant gender, and infant medical complications. More longitudinal research is needed to better understand these effects over time in order to identify and support at-risk mothers.

Maternal Psychological Distress and Mother-Infant Relationship: Multiple-Birth Versus Singleton Preterm Infants.

PURPOSE: Multiple preterm birth is associated with more maternal psychological distress and less positive mother-infant interactions than singleton preterm birth. This study's purpose was to compare psychological distress and the relationship with their infants in mothers of multiples and mothers of singletons. DESIGN: An exploratory secondary analysis of longitudinal data. SAMPLE: 236 mothers and their preterm infants. MAIN OUTCOME VARIABLES: Maternal psychological distress (depressive symptoms, anxiety, posttraumatic stress [PTS], parenting stress), the mother-infant relationship (worry; child vulnerability; maternal positive involvement and developmental stimulation; and child developmental maturity, irritability, and social behaviors), and the home environment. RESULTS: Mothers of multiples had greater PTS symptoms at baseline, anxiety at discharge, and depressive symptoms at six months than mothers of singletons. Mothers of multiples also had more positive home environments at six months. Multiple birth was a risk factor for psychological distress but not for less positive mother-infant interactions.