Perinatal anxiety in mothers of neonatal intensive care unit-admitted neonates: A case–control study on prevalence and associated factors

INTRODUCTION

Perinatal anxiety refers to the onset of clinically significant anxiety symptoms in mothers during the immediate period following childbirth, often within the first few days to weeks postpartum. It is marked by excessive worry, restlessness, irritability, difficulty sleeping, and intrusive thoughts, frequently focused on the newborn’s health and safety.^[1,2] Although it may occur alongside postpartum depression, postpartum anxiety is a distinct condition with unique clinical features that can impair maternal functioning and early mother-neonate bonding.^[3]

The Neonatal Intensive Care Unit (NICU) admission of babies creates multiple stressors that impact mothers emotionally, physically, and socially.^[4,5] Uncertainties about the baby’s prognosis combined with the unfamiliar and technologically demanding environment of the NICU exacerbate feelings of fear and anxiety. The emotional turmoil caused by disrupted postpartum bonding and feelings of powerlessness leads to or intensifies anxiety symptoms.^[6,7]

The NICU environment is a potent source of stress. Elevated maternal stress levels can be caused by the continuous sound of alarms, the sight of complex medical equipment, and the experience of sporadic, frequently limited parental contact with the baby. In many instances, mothers report feeling alienated from the caregiving process, which not only intensifies anxiety but also hampers the creation of a strong bond with their baby.^[7,8]

As the literature suggests, early identification of distress in NICU mothers can facilitate timely interventions that improve not only maternal well-being but also promote more positive outcomes for the neonate. A more thorough investigation of the ways in which stress, depression, and anxiety interact and affect maternal functioning as well as neonate development will be made possible by the integration of several methodological approaches.^[6,7]

Research on stress evaluation and anxiety in NICU-admitted newborn mothers remains crucial because of its significant clinical and developmental and policy implications. By synthesizing findings from a wide array of published studies, this study endeavors to clarify the prevalence and determinants of maternal distress in the NICU, while also evaluating the tools and interventions currently available to support affected mothers. This research will generate enhanced knowledge about maternal mental health within NICUs which will guide future intervention strategies to improve maternal and neonate outcomes.^[4,5]

MATERIAL AND METHODS

This hospital-based, cross-sectional case–control study was conducted from May 2024 to April 2025 in the NICU and obstetrics wards of a tertiary care hospital in Punjab, India. Ethics approval was obtained from the institutional review board, and all participating mothers provided written informed consent. The case group included 160 consecutive mothers (aged 18–45 years) of preterm (<37-week gestation) or low-birth-weight (<2.5 kg) neonates admitted to the NICU. The control group comprised 160 mothers of healthy full-term neonates (≥37 weeks and ≥2.5 kg) in the obstetric ward. All mothers were interviewed between 3 and 7 days postpartum while still admitted (inpatient department) in the obstetric ward (controls) or NICU (cases). Cases and controls matched on maternal age (±2 years) and socioeconomic status (assessed by occupation and income level). Exclusion criteria for both groups included a history of major psychiatric illness, significant obstetric complications, or refusal to participate. Mothers in both groups were majority married homemakers from similar demographic backgrounds. Mothers were allowed limited NICU access (two visits per day of 30 min each) under strict infection control measures including hand hygiene, gowning, and masking.

RESULTS

Anxiety prevalence in NICU mothers versus controls

Mothers of NICU-admitted neonates had markedly elevated anxiety levels relative to mothers of healthy newborns. On the PASS, the mean total anxiety score in the NICU group was 38.9 (SD ≈ 7), compared to 30.1 (SD ≈ 8) in the control group – a substantial and significant difference (P < 0.001 by Mann–Whitney U-test; data not shown in tables). Using the threshold score of 21 to define “significant anxiety,” 148 out of 160 NICU mothers (92.5%) screened positive for clinically significant anxiety, in contrast to 113 out of 160 control mothers (70.6%). This difference was highly significant (χ² test, P < 0.0001). In other words, nearly all mothers in the NICU group exhibited at least moderate anxiety symptoms, whereas about 30% of control mothers did not show elevated anxiety [Table 2 and Figure 1].

Table 2: The comparison of the prevalence of anxiety between the cases and controls.

Anxiety	Cases	Control	Chi-square test value	P-value
Present	148	113	24.02	9.52x10-7
Absent	12	47		Significant

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Figure 1:

Graphical comparison of anxiety prevalence in cases and controls.

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It is notable that even among control mothers of healthy neonates, the anxiety prevalence was not negligible at around 70%. This likely reflects that the immediate postpartum period can be anxiety-provoking in general (with concerns about newborn care, recovery from childbirth, etc.). However, the NICU mothers’ anxiety rates were significantly higher still. A majority of NICU mothers described feeling “extremely” or “very” anxious on multiple PASS items, particularly those related to acute worries about their baby’s health and feelings of panic or tension in the NICU setting.

DISCUSSION

This study found that mothers of neonates admitted to the NICU experienced substantially higher anxiety than mothers of healthy full-term neonates. This result aligns with a growing body of research identifying NICU hospitalization as a major stressor for parents. In one study, it was noted that NICU mothers have much higher rates of postpartum mood disturbances than community samples, and our findings extend this knowledge specifically to anxiety^[10] similarly identified NICU hospitalization as a key stressor that disrupts maternal emotional well-being. Subsequent studies documented elevated stress and anxiety in NICU mothers, consistent with our results.^[11,12] Indeed, one more study conducted a systematic review showing that NICU parents have high rates of both anxiety and posttraumatic stress symptoms, reinforcing that the NICU context places parents at high risk.^[13] In short, the literature consistently portrays NICU parents as a high-risk group for psychological distress, and our data confirm that maternal anxiety is markedly elevated in this population.

The neonate’s condition can change rapidly, creating pervasive uncertainty. In addition, having a sick baby in the NICU often follows a traumatic or complicated delivery, which may include an emergency cesarean section or preterm labor. Such experiences can predispose mothers to anxiety. In our sample, younger maternal age and cesarean delivery were associated with higher anxiety levels, possibly reflecting less parenting experience and the additional physical recovery associated with surgery. These findings mirror observations in other settings that younger mothers and emergency C-sections tend to correlate with greater postpartum distress.

The observed association between having a female neonate and higher maternal anxiety is intriguing. Some research suggests parental expectations and cultural factors linked to neonate gender can influence parental stress, but evidence is limited. It is possible that mothers of female neonates in our sample perceived a different set of risks or had different expectations, but this finding should be interpreted cautiously.

Maternal anxiety in the NICU can also have important downstream effects. High anxiety may interfere with caregiving activities, such as breastfeeding or skin-to-skin contact, which rely on maternal confidence and relaxation. For example, mothers dealing with NICU stressors (like breastfeeding difficulties) had more anxiety and depressive symptoms.^[14] Prolonged maternal anxiety has been linked to adverse neurodevelopmental outcomes in preterm children.^[15] In other words, when mothers are highly anxious, this can disrupt early bonding and may contribute to less optimal neonate development.

Our results have clear clinical implications. First, they underscore the importance of routine mental health screening for NICU mothers. Simple measures like administering the PASS at admission or periodically could identify mothers at risk. Second, NICU healthcare providers should be trained to recognize and address maternal distress. Third, referral systems should be in place so that mothers who score highly on anxiety screening can access counselling or psychosocial support. Although interventions were not directly tested, evidence-based programs such as the Creating Opportunities for Parent Empowerment (COPE) and structured parental education has shown benefits and may be adapted locally.

The COPE program a structured psychological support intervention for NICU parents significantly reduced maternal anxiety and depression compared to usual care.^[16] Mothers in the COPE group reported greater knowledge about neonate behavior and felt more in control. This suggests that relatively brief, focused programs can make a meaningful difference. Based on our findings, similar programs (potentially adapted for the local cultural context) could benefit mothers in this NICU.

Our study has several strengths. We used a case–control design with well-matched comparison mothers, which allowed us to isolate the impact of the NICU experience on anxiety while controlling for confounding demographic factors. The use of a validated, perinatal-specific anxiety measure (PASS) provided a focused assessment of maternal anxiety. The sample size was relatively large for a single-center study, and all participants were assessed by trained staff with high adherence to the protocol.

However, limitations must be noted. This was a cross-sectional study measuring anxiety at a single point in time (shortly after birth), so we cannot determine causality or how anxiety levels change over time. Longitudinal follow-up would be valuable to see if and when anxiety subsides as neonates recover. The study was conducted in a single tertiary hospital in Punjab, so cultural and healthcare differences limit generalizability. For example, mothers in other regions or countries with different support systems might have different experiences.

In summary, maternal anxiety was markedly higher among NICU mothers compared to matched controls, highlighting NICU admission as a significant maternal stressor. These findings underscore the importance of incorporating family-centered mental health care into the NICU. Healthcare teams should monitor and support maternal psychological well-being alongside neonatal treatment, as improving maternal mental health is likely to benefit both mother and child in the long term. Future research should develop and test targeted interventions (such as tailored counseling or peer support programs) to reduce anxiety in NICU mothers and examine their impact on outcomes for families.

CONCLUSION

The results of our study clearly show that NICU admission places mothers under considerable emotional strain, with anxiety affecting nearly all mothers in this setting. Certain factors - being younger, undergoing a caesarean delivery, or having a female newborn appeared to further elevate this risk. These findings reinforce the need for routine mental health assessment and compassionate support for mothers in the NICU. Prioritizing maternal emotional well-being may positively influence both caregiving confidence and neonatal outcomes.