Close Collaboration with Parents-Implementation and effectiveness.

AIM: There has been a need to develop programs to facilitate family-centered care. This paper describes the content of a program called Close Collaboration with Parents, its implementation, and research on its effectiveness. METHODS: The program is a systematic training with a focus on staff communication and observation skills and skills to support parenting. The primary implementation strategy is mentoring. Staff engage in bedside practices and reflections with mentors covering all four phases of the program. The effects of this unit-wide program have been evaluated using a pre-post study design, a qualitative study design, and a register-based study design. RESULTS: The program has been successfully implemented in 26 units so far. Our research has shown that the training benefits infants, parents, staff, and healthcare organisations. Specifically, family-centered care practices improved after the program, the parents' presence and parent-infant skin-to-skin contact increased, infant growth improved and the length of hospital stays shortened. The mothers' depressive symptoms decreased in the long term. CONCLUSION: We have described an educational program for the multidisciplinary staff of a neonatal intensive care unit, Close Collaboration with Parents. The program has changed hospital care cultures for the benefit of infants, parents, staff, and even the healthcare organisation.

Close Collaboration with Parents Affects the Length of Stay and Growth in Preterm Infants: A Register-Based Study in Finland.

INTRODUCTION: This study aimed to evaluate how Close Collaboration with Parents (CC), a neonatal intensive care unit (NICU)-wide educational model for healthcare staff to improve their family-centred care practices, affects the length of stay (LOS), growth, and later hospital visits and rehospitalizations of preterm infants. METHODS: This register-based study included all preterm infants born below 35 weeks of gestation in Finland from 2006 to 2020. Eligible infants were classified into the Full Close Collaboration (Full-CC) group (n = 2,104) if the NICUs of both the delivery and discharge hospitals had implemented the intervention; into the Partial-CC group (n = 515) if only one of the NICUs had implemented the intervention; and into the control group (n = 11,621) if neither had implemented the intervention. RESULTS: The adjusted LOS, the primary outcome, was 1.8 days or 6% shorter in the Full-CC group than in the control group (geometric mean ratio 0.94, 95% confidence interval [95% CI] 0.89-1.00). Growth was better in the Full-CC group compared to the control group: adjusted group difference 11.7 g/week (95% CI, 1.4-22.0) for weight, 1.3 mm/week (95% CI, 0.6-2.0) for length. The Full-CC group infants had lower odds of having any unscheduled outpatient visits compared to the control group (adjusted odds ratio 0.81; 95% CI, 0.67-0.98). No significant differences were found in any other comparisons. DISCUSSION/CONCLUSION: The unit-wide intervention improving family-centred care practices in NICUs may lead to more efficient use of hospital resources by shortening the LOS, improving growth, and decreasing hospital visits of preterm infants.

Skin-to-Skin Contact at Birth for Very Preterm Infants and Mother-Infant Interaction Quality at 4 Months: A Secondary Analysis of the IPISTOSS Randomized Clinical Trial.

Importance: Good-quality parent-infant interactions have protective effects on infant socio-emotional and behavioral development. These interactions are especially critical for very preterm infants at risk of vulnerabilities related to immaturity. Skin-to-skin contact (SSC) has been found to improve mother-preterm infant interaction behaviors, but few studies exist regarding its benefits when initiated immediately after birth. Objective: To determine the effect of immediate SSC at birth for very preterm infants on mother-infant interaction quality at 4 months of corrected age. Design, Setting, and Participants: This secondary analysis used data from the Immediate Parent-Infant Skin-to-Skin Study (IPISTOSS), a randomized clinical trial conducted between April 1, 2018, and June 30, 2021, at 3 neonatal units in Sweden and Norway. Participants included very preterm infants (28-33 gestational weeks of age) and their parents. Four-month follow-up was concluded in December 2021. Data analyses were performed on March 16 and September 18, 2023. Intervention: Infants were allocated to standard incubator care or SSC with either parent initiated at birth and continued throughout the first 6 hours after birth. Main Outcomes and Measures: The primary outcome was mother-infant interaction quality as measured with the Parent-Child Early Relational Assessment (PCERA), based on video recordings of a 5-minute free-play situation with mother-infant dyads at 4 months of corrected age. A multilevel regression analysis was performed. Results: This analysis included 71 infants (31 twins [44%]) and 56 mothers. Infants had a mean (SD) gestational age of 31 weeks 3 (1.3) days, and more than half were male (42 [59%]); mothers had a mean (SD) age of 32 (4.9) years. There were 37 infants allocated to standard care and 34 to SSC with either parent after birth. During the first 6 hours after birth, fathers provided more SSC than mothers, with a median (IQR) of 3.25 (2.25-4.5) and 0.75 (0-2.5) hours, respectively. A statistically significant difference in 1 of 5 PCERA subscales (subscale 3: infant positive affect, communicative and social skills) was observed, with higher-quality mother-infant interaction in the SSC group at 4 months (Cohen d = 0.67 [95% CI, 0.17 to 1.17]; P = .01). This effect remained significant when adjusting for primiparity, child sex, and observation setting. Conclusions and Relevance: In this study of the effect of immediate parent-infant SSC after very preterm birth, SSC was beneficial for the mother-infant relationship. These findings suggest that immediate SSC should be supported in the clinical setting. Trial Registration: ClinicalTrials.gov Identifier: NCT03521310.

Improving NICU staff decision-making with parents in medical rounds: a pilot study of reflective group dialogue intervention.

Introduction: The communication skills of healthcare professionals play a crucial role in successful shared decision-making with parents in neonatal intensive care. Improving communication skills can be achieved through practice and reflection on personal experiences after authentic interaction events with parents. The process of reflection typically involves three phases: description, reflection, and critical reflection. In this study, our aim was to explore the acceptability of the Reflective Group Dialogue intervention and its effectiveness in supporting the reflective process. Methods: This qualitative pilot study was conducted in the neonatal intensive care unit at Uppsala University Children's Hospital, Sweden. The sample consisted of nine medical rounds with seven families, five neonatologists, seven registered nurses, and five assistant nurses. Purposive sampling was used to collect the data. The intervention comprised four elements: (1) before the intervention, a recorded presentation on shared decision-making was given to the entire unit staff, (2) an observation of a normal medical round discussion with parents, (3) an interview with parents about their experience after the same round, and (4) a reflective discussion with the participating health care professionals after the round. The parent interviews and reflective discussions were audio-recorded and transcribed verbatim. They were analyzed using thematic analysis as a theoretical strategy. Results: Both parents and staff widely accepted the intervention and found it beneficial. We identified four discussions that remained in the descriptive phase of the reflection process, four that reached the reflective phase, and one that reached the critical reflection phase. The descriptive discussions were characterized by using a single perspective to reflect, often based on personal opinions. The reflective discussions included analyzing interaction sequences from both staff and parent perspectives and were primarily based on actual observations of communication during medical rounds. The critical discussion led to a new awareness of current practices concerning parental involvement in decision-making. These discussions also utilized "what-if" thinking to evaluate potential new practices and their pros and cons. Conclusions: The intervention seems promising as it was perceived as beneficial by the recipients and facilitated reflection in most cases. However, to enhance the feasibility of the intervention, some improvements are discussed.

Depressive symptoms in mothers of preterm infants before and during COVID-19 restrictions in neonatal intensive care units.

AIM: Little is known about the specific restriction measures used in intensive care units (NICUs) during the COVID-19 pandemic and their impact on parental well-being. Hence, this study aimed to assess the association between restriction measures and mothers' post-partum depressive symptoms. METHODS: This comparative cohort study included mothers who gave birth before 35 weeks of gestation in Estonia. The outcome measure was mothers' post-partum depressive symptoms at the time of infant discharge, evaluated using the Edinburgh Postnatal Depression Scale (EPDS). In addition to the pandemic itself, the number of restriction measures in the NICUs was analysed as a potential explanatory factor for depressive symptoms. RESULTS: The study included 55 mothers before the pandemic in 2018-2019 and 54 mothers during the COVID-19 pandemic in 2021. No significant difference was found in the median EPDS scores between the cohorts: 7.0 [interquartile range (IQR): 4.0-12.0] and 8.0 (IQR: 5.0-12.8) respectively. The number of restriction measures was not associated with mothers' EPDS scores in either unadjusted or adjusted models. CONCLUSION: The COVID-19 pandemic or the number of restriction measures used in Estonian NICUs did not associate with mothers' post = partum depressive symptoms.

Effects of the Close Collaboration With Parents Intervention on the Quality of Family-Centered Care in NICUs.

BACKGROUND: Systematic training for the neonatal staff to support parents' active involvement is lacking. There is little information about the effectiveness of educational interventions. PURPOSE: To evaluate the effects of an educational intervention to neonatal staff on the quality of family-centered care from the perspectives of parents and nurses. METHODS: A quasi-experimental before and after study was carried out in 5 Finnish neonatal units in 2014-2018. Data were collected using the DigiFCC-tools with a 7-point Likert scale. Thirty-one fathers and 53 mothers were recruited before the intervention and 21 fathers and 61 mothers after the intervention. They answered 1 question every evening until their infants' discharge. Each nurse answered 1 corresponding question after every shift, during the same period before and after the intervention. Before the intervention 3239 responses and after the intervention 3092 responses were received from nurses. RESULTS: The fathers' total score and the score indicating "Shared decision making" were higher after the intervention than before the intervention. The mothers' total score did not differ between the 2 time periods. The nurses' total score was higher after the intervention than before the intervention. Of the individual items, higher scores were found for "Active listening," "Parents' trust in the nurse," and "Emotional support." IMPLICATIONS FOR PRACTICE: Developing the staff's negotiating and active listening skills facilitates better support for parents during infants' intensive care. IMPLICATIONS FOR RESEARCH: Family-centered care interventions such as Close Collaboration with Parents should be studied in randomized controlled trials, also including child outcomes.

Fewer maternal depression symptoms after the Close Collaboration with Parents intervention: Two-year follow-up.

AIM: To test whether the implementation of the Close Collaboration with Parents intervention at a neonatal intensive care unit (NICU) decreases depression symptoms of mothers up to two years after the delivery of preterm infants. METHODS: We used a non-equivalent two-group design, comparing mothers of very low birthweight infants in the same NICU before (2001-2006) and after (2011-215) the intervention. The unit carried out the educational intervention (2009-2012) that was targeted at its healthcare team and aimed to improve their skills to collaborate with parents. Maternal depression symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) six months and two years after the expected birth date of the infant. RESULTS: We found a median difference of 2.56 (95% CI from 1.64 to 3.48) in EPDS at the two-year follow-up between the pre-intervention and post-intervention groups, p < 0.001. Furthermore, we found no interaction between measurement time-points and group, implying that the intervention effect on maternal depression symptoms was similar at the six-month and two-year time-points. CONCLUSION: The intervention seems to have long-term preventive effects on maternal depressive symptoms. This effect is of clinical significance as prolonged maternal depression associates with adverse child outcomes.

The Paternal Brain in Action: A Review of Human Fathers' fMRI Brain Responses to Child-Related Stimuli.

As fathers are increasingly involved in childcare, understanding the neurological underpinnings of fathering has become a key research issue in developmental psychobiology research. This systematic review specifically focused on (1) highlighting methodological issues of paternal brain research using functional magnetic resonance imaging (fMRI) and (2) summarizing findings related to paternal brain responses to auditory and visual infant stimuli. Sixteen papers were included from 157 retrieved records. Sample characteristics (e.g., fathers' and infant's age, number of kids, and time spent caregiving), neuroimaging information (e.g., technique, task, stimuli, and processing), and main findings were synthesized by two independent authors. Most of the reviewed works used different stimuli and tasks to test fathers' responses to child visual and/or auditory stimuli. Pre-processing and first-level analyses were performed with standard pipelines. Greater heterogeneity emerged in second-level analyses. Three main cortical networks (mentalization, embodied simulation, and emotion regulation) and a subcortical network emerged linked with fathers' responses to infants' stimuli, but additional areas (e.g., frontal gyrus, posterior cingulate cortex) were also responsive to infants' visual or auditory stimuli. This review suggests that a distributed and complex brain network may be involved in facilitating fathers' sensitivity and responses to infant-related stimuli. Nonetheless, specific methodological caveats, the exploratory nature of large parts of the literature to date, and the presence of heterogeneous tasks and measures also demonstrate that systematic improvements in study designs are needed to further advance the field.

The validity of the Language Environment Analysis system in two neonatal intensive care units.

AIM: To evaluate the validity of the Language Environment Analysis (LENA) system's automatic measures in two neonatal intensive care units supporting parent-infant closeness, and in two Finno-Ugric languages: Finnish and Estonian. METHODS: The sound environment of 70 very preterm infants was recorded for 16 h in the neonatal intensive care units with the LENA system roughly at the gestational age of 32 (+2) weeks. Of these, the recordings of 14 infants (20%, two 5-min samples with a high percentage of speech, totally 140 min) were analysed in detail and in two different ways. Parental closeness diaries were used to document the presence of the parents. Agreements between LENA system and human coder estimates were analysed. RESULTS: Findings showed a high variation in agreements. The highest agreements were found in female and adult word counts (r = 0.91 and 0.95). The agreements for child vocalisation count, conversational turns and silence were modest or low (r = -0.03 to 0.64). CONCLUSION: Our study provides novel information on the validity of the LENA system in the neonatal intensive care unit. Findings show that the LENA system provides valid information on adult words, but LENA estimates for child vocalisations were less valid at this early age.

Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU.

BACKGROUND: Parent-infant closeness during hospital care of newborns has many benefits for both infants and parents. We developed an educational intervention for neonatal staff, Close Collaboration with Parents, to increase parent-infant closeness during hospital care. The aim of this study was to evaluate the effectiveness of the intervention on parent-infant closeness in nine hospitals in Finland. METHODS: Parents of hospitalized infants were recruited in the hospitals during 3-month periods before and after the Close Collaboration with Parents intervention. The data were collected using daily Closeness diaries. Mothers and fathers separately filled in the time they spent in the hospital and the time of skin-to-skin contact with their infant during each hospital care day until discharge. Statistical analyses were done using a linear model with covariates. RESULTS: Diaries were kept before and after the intervention by a total of 170 and 129 mothers and 126 and 84 fathers, respectively. Either parent was present on average 453 min per day before the intervention and 620 min after the intervention in the neonatal unit. In the adjusted model, the increase was 99 min per day (p = 0.0007). The infants were in skin-to-skin contact on average 76 min per day before the intervention and 114 min after the intervention. In the adjusted model, skin-to-skin contact increased by 24 min per day (p = 0.0405). CONCLUSION: The Close Collaboration with Parents intervention increased parents' presence and skin-to-skin contact in nine hospitals. This study suggests that parent-infant closeness may be one mediating factor explaining benefits of parenting interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04635150 . Retrospectively registered.

Fathers' prenatal attachment representations and the quality of father-child interaction in infancy and toddlerhood.

Despite the strong evidence that fathers have a crucial role in child well-being, very little is known about the development of the father-child relationship from prenatal to postnatal period. In this longitudinal study, the fathers' prenatal attachment representations (n = 129), between 29 and 32 gestational weeks, were assessed with the Working Model of Child Interview, and the father-child interaction was analyzed with the Parent-Child Early Relational Assessment at 4 and 18 months after the birth. The results showed that fathers' prenatal balanced attachment representations were associated with more positive paternal behaviors compared to fathers with disengaged attachment representations when the child was 4 months old, but not when the child was 18 months old. In addition, positive changes occurred in the interaction quality between 4 and 18 months in all three groups of representation categories (balanced, disengaged, distorted), which offers an optimistic view of the evolving nature of the father-child relationship. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Close Collaboration with Parents intervention improves family-centered care in different neonatal unit contexts: a pre-post study.

BACKGROUND: The quality of family-centered care and parental participation in care in neonatal units differ widely across the world. Appropriate education might be an effective way to support medical staff in neonatal units to collaborate with parents and implement family-centered care. The aim of this study was to evaluate the effects of the educational intervention on the quality of family-centered care in eight Finnish neonatal intensive care units from both the staff and parent perspectives. METHODS: A mixed-method pre-post intervention study was conducted in eight neonatal intensive care units in Finland. Data were collected from staff and parents using the Bliss Baby Charter audit tool and semi-structured interviews. RESULTS: The quality of family-centered care, as assessed by staff and parents, increased significantly after the intervention in all eight units. The intervention was able to help staff define and apply elements of family-centered care, such as shared decision making and collaboration between parents and staff. In interviews, staff described that they learned to support and trust the parents' ability to take care of their infant. CONCLUSIONS: The educational intervention increased the quality of family-centered care and enabled mutual partnership between parents and staff. IMPACT: This study shows that the educational intervention for the whole multi-professional staff of the neonatal unit improved the quality of family-centered care. The Close Collaboration with Parents intervention enabled mutual partnership between parents and staff. It also provides evidence that during The Close Collaboration with Parents intervention staff learned to trust the parents' ability to take care of their infant.

Experiences of interactive ultrasound examination among women at risk of preterm birth: a qualitative study.

BACKGROUND: Pregnant women who are at risk of preterm birth are often stressed, anxious and depressed because of worries and fears related to the health of the unborn baby, their own health and uncertainty about the future. Only a few studies have assessed the types of psychological support that would relieve these stress symptoms among women with high-risk pregnancies. The aim of this study was to describe 1) how women at risk of preterm birth experienced an interactive 3/4-dimensional (3/4D) ultrasound examination, and 2) their need for psychological support during the antenatal period. METHODS: This qualitative study was conducted at one university hospital in Finland in 2017. Women with a singleton pregnancy of 26-32 gestational weeks (gwks) were included in the study. The interactive 3/4D ultrasound included a joint observation of the baby, based on the mother's wishes, with an obstetrician and psychologist. After the examination, the experiences were explored with a semi-structured interview. The data was analyzed using inductive thematic analysis. RESULTS: The women enjoyed the fact that the staff were focused on her fetus and genuinely present during the session and also enabled the women to actively participate. Watching the baby and her/his activities made the baby more concrete and relieved their concerns. The need for additional psychological support varied individually. CONCLUSIONS: Interactive ultrasound examination is an interesting way to awaken mental images, increase attachment, and reduce stress. The results imply that an interactive way of jointly looking at the fetus supports pregnant women at risk of preterm birth and may be useful in clinical practice.

Key factors supporting implementation of a training program for neonatal family- centered care - a qualitative study.

BACKGROUND: Traditionally, the care of infants in neonatal care units has been professionally centered, paying less attention to family support. In recent years, many interventions have been developed to improve family-centered care and thereby parent and infant outcomes. Understanding the key factors of implementation of these interventions would help improve clinical practice. The aim of this study was to describe the staff's perceptions of the implementation of the Close Collaboration with Parents Training Program and to identify the barriers and facilitators of the implementation. METHODS: A descriptive qualitative interview study was conducted in eight neonatal intensive care units in Finland. Nineteen unit managers and 32 nurses were interviewed after their unit had finished the 1.5-year training program. Data were analyzed using thematic content analysis. RESULTS: Key factors facilitating the implementation of the training program were multidisciplinary commitment and the staff's motivation to change their professional role to work as the parents' facilitator. Observable benefits promoted the implementation, as well as experiential learning as a facilitation method. The role of mentor was remarkable as a facilitator. In addition, contextual elements such as support from leadership and proper timing were important. CONCLUSIONS: Implementation of family-centered care is facilitated by staff who is prepared to accept parents as partners and adopt a new professional role. Enough time for preparation, readiness for the change, solid support from the leadership, and a multidisciplinary approach are needed as well. Mentoring was found to be one of the key factors facilitating the change.

An educational intervention for NICU staff decreased maternal postpartum depression.

BACKGROUND: Mothers of preterm infants are at increased risk for postpartum depression, which may disturb parenting and child development. Strategies for prevention are needed. Therefore, we evaluated how an educational intervention for neonatal staff affected depression symptoms among mothers of preterm infants. METHODS: The Close Collaboration with Parents intervention was implemented in the NICU at Turku University Hospital in Finland. Maternal depression was compared between the pre-intervention and post-intervention cohorts using the Edinburgh Postnatal Depression Scale. The eligible infants were born ≤1500 g without major anomalies and survived. Data were available from 145 and 93 mothers in the pre-intervention and post-intervention cohorts, respectively, at 4 and/or 6 months of corrected age. RESULTS: The depression scores were significantly lower in the post-intervention cohort than in the pre-intervention cohort; the estimated difference was 2.54 points (95% CI, 1.24-3.83), p < 0.001. A total of 10.3% of the mothers in the pre-intervention cohort and 2.1% in the post-intervention cohort exceeded the threshold for depression, p = 0.066. CONCLUSION: The Close Collaboration with Parents intervention decreased depression symptoms among the mothers of very preterm infants. Systematic educational intervention targeted to the whole NICU staff can potentially prevent postnatal depression among mothers of preterm infants.

Close Collaboration with Parents™ intervention to improve parents' psychological well-being and child development: Description of the intervention and study protocol.

Parents of preterm infants commonly experience separation from their infant or exclusion from their role as primary caregivers during the hospital care of their infant, which may impair parent-infant bonding and parents' psychological well-being. Therefore, we developed the Close Collaboration with Parents™ intervention to improve staff skills in communicating and collaborating with parents in neonatal intensive care units (NICU), to increase parents' presence and participation into infant care, and to improve parent-infant bonding and, thereby, parents' psychological well-being and later child development. The Close Collaboration with Parents™ intervention was developed and carried out at Turku University Hospital. The intervention was based on developmental theories about early parenthood and parent-infant attachment. The training was targeted at both doctors and nurses. The goals of the training included understanding individual behaviors and responses of infants and the uniqueness of families, using receptive listening skills in communication with parents and making decisions collaboratively with them. By increasing the sensitivity of the staff to the individual needs of infants and parents and by increasing staff-parent collaboration in daily care, the intervention supported parents' presence and parents' participation in the care of their infant. The effectiveness of the intervention is being evaluated in a prospective study comparing the post-intervention cohort (n=113) to the baseline cohort (n=232). The outcomes include bonding, long-term psychological well-being of both mothers and fathers and child development up to 5 years of age. The Close Collaboration with Parents™ intervention potentially offers a preventive and salutogenic model to integrate parents and parenting in neonatal hospital care.

MOTHERS' AND FATHERS' PRENATAL REPRESENTATIONS IN RELATION TO MARITAL DISTRESS AND DEPRESSIVE SYMPTOMS.

Marital distress, parental depression, and weak quality of parental representations are all known risk factors for parent-child relationships. However, the relation between marital distress, depressive symptoms, and parents' prenatal representation is uncertain, especially regarding fathers. The present study aimed to explore how mothers' and fathers' prenatal experience of marital distress and depressive symptoms affects the organization of their prenatal representations in late pregnancy. Participants were 153 pregnant couples from a Finnish follow-up study called "Steps to the Healthy Development and Well-being of Children" (H. Lagström et al., ). Marital distress (Revised Dyadic Adjustment Scale; D.M. Busby, C. Christensen, D. Crane, & J. Larson, 1995) and depressive symptoms (Edinburgh Postnatal Depression Scale) were assessed at 20 gestational weeks, and prenatal representations (Working Model of the Child Interview; D. Benoit, K.C.H. Parker, & C.H. Zeanah, 1997; C.H. Zeanah, D. Benoit, M. Barton, & L. Hirshberg, 1996) were assessed between 29 and 32 gestational weeks. The mothers' risks of distorted representations increased significantly when they had at least minor depressive symptoms. Marital distress was associated with the fathers' prenatal representations, although the association was weak; fathers within the marital distress group had less balanced representations. Coexisting marital distress and depressive symptoms were only associated with the mothers' representations; lack of marital distress and depressive symptoms increased the likelihood for mothers to have balanced representations. The results imply that marital distress and depressive symptoms are differently related to the organizations of mothers' and fathers' prenatal representations.

Mother's marital satisfaction associated with the quality of mother-father-child triadic interaction.

Low marital satisfaction has been shown to be a risk factor for early parenthood and parent-child relationship problems (Erel & Burman, ; McHale, ). The aim of this study was to assess how parental reports of marital satisfaction related to family alliance and coordination in the observed triadic interaction. The study group included 120 families. Marital satisfaction was evaluated during pregnancy, at 4 months, and at 18 months using the Revised Dyadic Adjustment Scale (RDAS; Busby, Christensen, Crane & Larsson, ) for both parents. Mother-father-child interaction was analyzed in the Lausanne Triadic Play setting and coded using the Family Alliance Assessment Scale (Favez, Lavanchy Scaiola, Tissot, Darwiche & Frascarolo, ) when the child reached 18 months of age. The mother's higher marital satisfaction at every measuring point was associated with a cooperative family alliance and/or higher family coordination at 18 months. The father's experience of marital satisfaction was not related to family interaction at any assessment point. Our study suggests that a mother's experience of lower marital satisfaction during pregnancy may be an early sign of later problems in family relationships.

Initiation and exclusivity of breastfeeding: association with mothers' and fathers' prenatal and postnatal depression and marital distress.

INTRODUCTION: This study explored the effects of mothers' and fathers' prenatal and postnatal depressive symptoms and marital distress on breastfeeding initiation and exclusive breastfeeding (EBF) duration. MATERIAL AND METHODS: This was a prospective follow-up of a cohort sample of 873 families participating to an intensive follow-up cohort of longitudinal Steps to the Healthy Development and Well-being of Children study (The STEPS study) in Southwestern Finland. The depressive symptoms were evaluated by The Edinburgh Postpartum Depression Scale and marital distress by the Revised Dyadic Adjustment Scale at 20th gestational week and at 4 months postpartum. EBF was self-reported real-time and defined as an infant receiving no food or drink other than mother's breast milk since birth, except occasionally water. RESULTS: Neither parents' prenatal depressive symptoms predicted breastfeeding initiation or EBF duration. The mothers' prenatal depressive symptoms, in turn, predicted their postnatal depressive symptoms, which were associated with shorter duration of EBF. The EBF duration was shortest amongst the mothers who had depressive symptoms both pre- and postnatally compared to mothers who had depressive symptoms only in either time point alone (M = 1.54, 2.06 and 2.04 months, respectively). Higher prenatal maternal marital distress was associated with longer EBF duration. CONCLUSIONS: The findings suggest that the continuity of maternal depressive symptoms throughout the perinatal period has adverse effect on EBF duration. Identification and treatment of mothers' depressive symptoms already during the prenatal period may improve breastfeeding practices. The finding of mothers' marital distress having positive impact on breastfeeding practices requires further investigation.