Characteristics of the studies

Of the 11 studies included in this systematic review, eight are descriptive qualitative studies, two are phenomenological studies, and one is a comprehensive study. Regarding the characteristics of the publications, the majority were published in 2020 (n = 3; 27.3 %) and in Brazil (n = 6; 54.5 %). No publications were found in Spanish, only in Portuguese and English.

Regarding the data collection location, seven studies were carried out in the hospital context, three in the home context and one study in the community. Nine articles presented structured or semi-structured interviews as a data collection method, while one used a focus group discussion that was carried out with mothers of low birth weight babies and another was carried out through maternal diary records.

Regarding the content of the articles, it was possible to identify five main categories: maternal feelings, care needs and challenges, breastfeeding, mother-baby bond and social support.

Figura 2 3 describes the publications selected for the study containing the article reference, objective, method and main results related to the topic covered in this review.

Table 2: Description of the qualitative studies included in the review regarding maternal perception of care for low birth weight newborns. Bahia, Brazil, 2023 

Source: Own elaboration.

Maternal feelings

The hospitalization process is characterized as a stressful, traumatic and worrying experience, leading to family disruption, especially the separation between mother and child, whose contact is essential for the development of the maternal role. ¹¹ The studies analyzed here showed that mothers had difficulties trying to construct this role with their babies hospitalized immediately after birth and with limited access to them.

The literature shows that the entire process considered normal for experiencing pregnancy suffers a breakdown in expectations upon the arrival of a premature or low birth weight baby. Upon learning that there is a possibility of the newborns’ hospitalization, mothers feel frustrated, undoing their representations of the imagined baby. ^(10,12

Therefore, feelings such as anxiety and stress arise, since even knowing that intensive care is necessary due to the severity, the fear of the unknown becomes a threat to coping with situations, significantly influencing the performance of maternal competence. ^13,21

Furthermore, the mothers’ reports showed that the disorder experienced in the hospital environment has other justifications based on social circumstances, such as not being able to take their child home immediately, concern for the other children who remained at home, with household chores and the marital relationship. ^(12,21

Some mothers, faced with the fear resulting from hospitalization, turn to spirituality as a way of comforting their insecurities. ¹⁴⁾ Thus, a feeling of impotence is seen as a factor of emotional imbalance and increases anxiety levels, as the health of the newborn may also be compromised. ^11,15

Although hospital discharge should be considered something positive, as it is a moment awaited by mothers and families, there is still a feeling of restlessness, they feel unable to promote care without the supervision of health professionals, there is still the conception that premature babies need double care, even with the guidance of professionals.⁽¹⁵

Care needs and challenges

There are needs that express the baby’s survival and full development, such as physical needs, security and regulation. One of the difficulties in caring for NBWB is the lack of experience related to the insufficient stock of knowledge about the common complications they present, such as crying or colic.¹⁵⁾ These problems present themselves as conditions that are not favorable to sustaining physical and physiological integrity.

The studies analyzed deal with the lack of practice in this daily care, for example, bathing, feeding or preventing infections. Thus, concerns about feeding include fear of causing the baby to choke, due to the risk of aspiration which could lead to respiratory infections. ¹⁴⁾ The feeling of apprehension resulting from fragility and the probability of the baby acquiring illnesses implies care, which is understood as physical protection and safety, which are met through the promotion and maintenance of bodily integrity, in addition to the prevention of damage and illness. ^14,15

On the other hand, maternal competence and autonomy are reinforced and facilitated when the particularities of the RNBP are recognized and assistance directed to their needs is established. Learn to understand and monitor your behaviors taking into account your uniqueness. ¹¹⁾

Experiences are diverse in relation to each care activity, some mothers understand that providing breast milk is the best option to support their hospitalized babies, but the feeling of expressing does not make them feel confident and determined. ¹³⁾

Then, even the first bath constitutes a challenge for mothers, a daily care that arouses apprehension and insecurity about the correct way to latch, the movements to be made, the babies’ possible reactions and the presence of the umbilical stump.¹¹⁾

Exploring physical and sensory abilities, observing the responses to the environment and the rhythm of each child and each mother, increases the possibility of care. In such a way, being a mother of a NBW means making the best choices with dedication, of being with the baby, thus, both concern and occupation help to achieve general well-being.¹⁵

In fact, a study that analyzed the reception of mothers of premature babies hospitalized in a Baby-Friendly Hospital showed that mothers in almost all reports show an interest in being present and monitoring their child’s progress, feeling like they are participating in the process of adaptation to these needs, with the support of the professional team. ¹⁶⁾

Another need is associated with adaptation to individual differences, in this case, mother and child, in an interaction process in which one influences the other. One can then see the relevance of the first physical contact between them, the construction of this bond of affection capable of reducing the anxiety and fears present there. ^11,16

The ability to provide the necessary care, and above all, having the ability to understand the signals given by the child, in these periods of greater dependence, is essential to constitute the competence of the maternal role. ¹⁵ Those who experience the Kangaroo Method highlight in practice the opportunity to feel their child’s changes in breathing, temperature, sleep nuances, among other particularities of the child, and thus begin to build a bonding relationship. ^14,16

On the other hand, stress together with maternal age and socioeconomic conditions can interfere with the development of this competence. The distance from older children and other factors, consequently, causes anxiety and difficulty in breastfeeding, for example, altering the care of the baby and the ideal weight gain for its development. ¹⁴

The nurse has autonomy and the ability to act in this process defined as: path of appropriation of the maternal role. ¹¹⁾ Bearing in mind that, in addition to the experience gained in practice, they need to be guided in relation to the particularities of this category, to avoid risks and exposures. ⁽¹⁴⁾

The detailed guidance and follow-up are capable of conferring skill and undoing the negative impression about the execution of routine activities, making them an active subject of the educational process. A study carried out with four mothers found that a good relationship with the team and the mother’s adaptation to hospital routines facilitate the demystification of the perception of a very fragile baby. ^10,11)

Breastfeeding

Studies show that mothers recognize the value of breast milk for the immune system, prevention against infections, organ formation and the bond formed, being seen as fulfilling their role as mother. ^17,22) The possibility of breastfeeding a hospitalized child is so important that it is seen as a scenario for improvement and indicates that hospital discharge is near. Because of this, it is important to highlight that mothers encounter barriers to starting early breastfeeding, such as: the baby’s physical problems, mother-baby separation, among others.^11,13,17)

Despite this recognition, hospitalization generates anguish, anxiety and concern, making it impossible to maintain breastfeeding, as was verified in Chinese neonatal units, the initial separation is a focal impediment to the beginning and continuation of this process.^13,17)

The long period of mother-child separation after birth can affect milk production, causing a late start to breastfeeding, which is detrimental to the weight gain of babies born with low birth weight. Added to this is the fact that there is fear and insecurity about how to feed the child, as another study shows that mothers’ concern about their child’s health is so great that it weakens the establishment of breastfeeding. It is therefore necessary to encourage mothers to express milk, especially after birth during the first few hours. ^12,13,17)

If this mother does not receive prior guidance, the responsibility of breastfeeding becomes a burden and a possible aggravating factor for early weaning, capable of resulting in a worsening of the child’s development. In fact, a qualitative study with mothers of low birth weight babies in an urban hospital in Tanzania reinforces that interventions by health professionals tend to effectively encourage mothers to achieve exclusive breastfeeding. ¹²⁾

Mother-baby bond

In the context of care and healthy development, there is a need to promote ongoing nurturing relationships. According to recent studies, neural synapses are activated through the stimulation that children receive, from the prenatal period to the first years of life, which arise from interactions responsible for emotionally and intellectually developing the baby’s brain circuit. ²³ In other words, he depends on another human being to satisfy his basic needs, however, this care goes beyond the dimension of mere survival and involves an irrational and affectionate process. In this case, a continuous nurturing relationship is defined as a safe, empathetic, emotionally motivating and interesting interaction, established in a balanced way over time, between the caregiver and the child. ¹⁰⁾

Caregivers’ understanding of these interactions is the foundation for safe development, with the formation of attachment and the maternal-infant bond being its basis. Thus, attitudes such as talking, touching, looking, smiling and playing are seen by mothers as positive interactions in relation to creating rapport, even if the babies are sleeping or when they are breastfeeding, for example. ¹⁸⁾ This conception is constituted gradually and takes time, little by little, the feeling of belonging is awakened in her through reciprocal responses, when she caresses him, she sees that he calms down; When speaking, the baby looks at her, until there is full recognition. ^10,14)

The Kangaroo Method, according to mothers in relation to child care, is one of the bonding providers, as it offers autonomy, financial savings and promotes the well-being of both. Despite the favorable aspects expressed during this process of rapprochement, it is important to highlight the obstacles and adversities that oppose the formation of attachment and possibilities for interaction right after birth. ^18,19

Adding to the above, a study carried out with 11 Chinese mothers states that premature babies often suffer a prolonged period of separation from their mothers, and they are exposed to stress, depression and other negative emotions. ¹³⁾ This distance prevents both mother-baby attachment and the establishment of breast milk supply.

Another study compared the experience of mothers of full-term and pre-term babies, the result confirmed that the majority of mothers of pre-term babies reported not having been separated from their babies after birth, on the other hand, all mothers of preterm babies had the opposite experience. ²⁰⁾

It is worth highlighting that admission to the Neonatal Intensive Care Unit causes a feeling of loss and physical and emotional separation, interfering with interpersonal relationships, preventing skin-to-skin contact, removing the right to exercise the maternal role. ^8,13,14 Furthermore, according to the majority of participants in a phenomenological study carried out in an Academic Hospital in Johannesburg, there was a feeling of fear related to the child’s fragility, which prevented them from freely touching the baby during hospitalization in the Nursing Unit. Neonatal Intensive Care. ¹⁸⁾

Such exposure of the child to adverse and stressful situations or lack of stimulation has a direct impact on their overall development, which may seriously aggravate or cause long-term delays, given that this initial period is characterized by a high degree of plasticity in brain organization and the damage can reach irreversible dimensions.^3,21)

Social support

Social support is based on the concept of structure that is defined as: stable, supportive and culturally continuous communities. Therefore, the effective participation of all components that make up this network must be able to meet the needs of the child and provide support for families, thus contributing to the full development of children. ²¹

In many countries, parental participation, for example, is encouraged during hospitalization, a crucial aspect for the formation of a mother-baby bond and, post-discharge, this subject becomes substantial support for the care of the newborn at home.^11,13) When mothers feel supported, they can not only offer self-preservation care, but also decode the baby’s peculiarities and desires, attributing new meanings to the newborns’ emotions. ¹⁰

In addition to the father, the community group that accompanies this mother has the power to influence her attitudes and choices. Those who are part of a pro-breastfeeding community are less likely to choose formula for their child, since behavioral examples and opinions tend to affect decisions about breastfeeding.¹³⁾

The family can equally act as a strengthener or weakener of needs, due to the fact that low birth weight babies are, for the most part, very small, it causes a strange visual impression on family members, generating a feeling of impotence and distance in the context of the NICU. ^11,18) On the other hand, factors such as experiences transmitted from other generations to the mother, the help of daily care for the baby serve as incentives for self-confidence, a feeling of greater security and enhanced care. ¹⁵⁾

When these mothers arrive at home, they do not always find an environment suited to their needs and those of their baby. This requires family participation in collaboration, encouragement and division of tasks, preventing the mother from becoming overwhelmed. Regarding this family support, a qualitative field study carried out with 13 mothers of premature babies showed that the majority of participants relied on family members, on the other hand, the article with two focus group discussions carried out in Malawi stated that few participants acknowledged having social support or encouragement, the majority reported not having any type of help, ^14,19) which can directly affect maternal health, due to the overload of domestic responsibilities, and consequently the care that this child will receive from the mother.