J Child Fam Stud (2014) 23:10501061

DOI 10.1007/s10826-013-9762-x

ORIGINAL PAPER

Parenting and Prematurity: Understanding Parent Experience

and Preferences for Support
Koa Whittingham Roslyn N. Boyd
Matthew R. Sanders Paul Colditz

Published online: 24 May 2013

 Springer Science+Business Media New York 2013

Abstract Infants born very preterm are at risk of developmental and behavioural problems and their parents are at
risk of psychological distress and compromised parenting.
This study has two key aims: (1) to identify, from the parents own perspective, the unique aspects of parenting an
infant born very preterm and (2) to assess parent preferences
for support including opinions of a new, tailored parenting
intervention, Prem Baby Positive Parenting Program (Triple
P). A qualitative approach was taken with focus groups of 18
parents of infants born preterm and a thematic analysis
conducted. Parents identified several unique aspects of
parenting an infant born preterm including: difficulty coping
with the stress of hospitalisation; institutionalisation to the
hospital environment; a lack of preparation for the transition
to parenthood; grief; isolation; getting into bad parenting
habits of overnurturance and a lack of certainty about
developmental expectations. Parents preferred parenting
support that is tailored to parents of infants born preterm, has
flexible delivery, enhances coping skills and the spousal
relationship and is sensitive to the emotional context of
parenting an infant born preterm. Understanding the experiences and the preferences of parents of infants born
K. Whittingham (&)
R. N. Boyd
Queensland Cerebral Palsy and Rehabilitation Research Centre,
The School of Medicine, Faculty of Health Sciences,
The University of Queensland, Brisbane, Australia
e-mail: koawhittingham@uq.edu.au
M. R. Sanders
Parenting and Family Support Centre, School of Psychology,
Faculty of Social and Behavioural Sciences, The University
of Queensland, Brisbane, Australia
P. Colditz
Centre for Clinical Research, The University of Queensland,
Brisbane, Australia

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preterm is an important step in tailoring parenting interventions to fit their needs.

Keywords Parenting intervention
Early intervention

Prematurity
Preterm
Infant

Introduction
Infants born at\37 weeks gestation are considered preterm
and infants born at \32 weeks gestation (approximately
2 % of infants) are considered very preterm. Infants born
very preterm are at risk for a range of developmental and
behavioural problems later in life including attentional
problems, hyperactivity, educational difficulties, externalising behavioural problems and adjustment difficulties
(Bhutta 1993; Johnson et al. 2010; Saigal 1991; Stanley
et al. 2000). Approximately 10 % of very preterm infants
develop major disabilities such as cerebral palsy and 50 %
develop intellectual, educational and/or behavioural problems (Stanley et al. 2000). The mean general intelligence
quotient (IQ) score of children born very preterm is
approximately 2/3 SD below their full-term peers (Bhutta
1993).
Children born very preterm are not only at risk of
developmental and behavioural difficulties, they are also at
risk of compromised parenting. Parents of infants born
preterm experience a challenging transition to the parental
role and this is reflected in increased depression, anxiety
and stress (Davis et al. 2003; Greco et al. 2005; McGettigan et al. 1994). Further, preterm infants may be more
irritable, vocalise less, demonstrate less positive affect and
give cues that are more difficult for parents to interpret
(Bozzette 2007; Miller and Holditch-Davis 1992) making
the establishment of a positive parent-infant relationship

J Child Fam Stud (2014) 23:10501061

and parental responsiveness challenging (Amankwaa et al.

2007; Feldman and Eidelman 2007). Yet, quality parenting
plays a key protective role in childrens development. It is
well understood that parenting practices have a major and
wide reaching impact on childrens development (Collins
et al. 2000) including language and social development
(Landry et al. 2006), executive processing skills (Landry
et al. 2002) and academic achievement (Cowan et al.
2005). Further, this has been confirmed in infants born
preterm (Landry et al. 2006; Treyvaud et al. 2009). A costeffective solution to supporting the development of children born very preterm is needed and harnessing the protective effects of quality parenting may provide a solution.
How we can best support parents of infants born very
preterm in their transition to parenting?
Early interventions for preterm infants, commencing in
the Newborn Intensive Care Unit (NICU), have included
interventions incorporating parental involvement with
benefits to developmental outcomes at up to 36 months
corrected age (Vanderveen et al. 2009). This includes
diverse interventions such as the Newborn Individualized
Developmental Care and Assessment Program (NIDCAP),
Kangaroo care and supportive educational interventions.
However, despite existing evidence for including parents in
early intervention there is a paucity of research on parenting interventions, interventions that focus on improvements in generalisable parenting skills, for parents of
infants born very preterm.
A randomised, controlled trial (RCT) with 260 families
of infants born preterm (\34 weeks gestation) demonstrated the effectiveness of an educational program delivered via audiotapes and written materials in decreasing
parental stress and improving parent-infant interaction
(Melnyk et al. 2006). In addition, the mother-infant transaction programme has recently been found to improve
maternal responsivity, mother-infant interactions and infant
regulation in a cohort of 68 families of preterm infants
(Newnham et al. 2009). Also of note is a cluster-randomised controlled trial of the Parent Baby Interaction Programme, an intervention that incorporated principles of
developmental care and focussed on increasing parental
sensitivity to infant cues through observation, discussion of
development, and specific activities such as stroking and
greeting the infant (Glazebrook et al. 2007; Johnson et al.
2009). In a trial with 233 infants all\32 weeks gestation at
birth, the Parent Baby Interaction Programme was shown
to have no effects on infant cognitive or motor development at 24 months corrected age or maternal responsivity
and mother-infant interaction at 3 months corrected age
with the authors themselves concluding that the intervention itself may simply be ineffective.
Behavioural parenting interventions, based in social
learning theory and behavioural analysis, have a wide

1051

evidence-base (Eyberg 1998; Patterson 2005; Sanders

1999; Webster-Stratton 1998) and have been adapted for
high risk groups such as parents of children with developmental disabilities (Roberts et al. 2006; Sanders et al.
2004; Whittingham et al. 2009). The adaptation of such a
parenting intervention for parents of infants born preterm
may prove to be more effective in producing sustained
effects than existing early interventions. The efficacy of
behavioural parenting intervention has recently been
demonstrated in families of young children (mean
age = 38.1 months, SD = 13.4) born premature (Bagner
et al. 2010). In an RCT of 28 families the parenting
intervention was associated with improved parenting
practices and decreases in child behavioural and attentional
problems. This demonstrates the relevance of the behavioural parenting intervention paradigm to parenting a child
born very preterm but also raises the question of whether
this intervention paradigm could be successfully applied in
infancy. Is there good fit between the support that a
behavioural parenting intervention, applied in infancy,
could provide and the unique challenges of parenting an
infant born very preterm? Further, what are the preferences
of parents of infants born very preterm for such an
intervention?
The current study has two key aims: (1) to identify, from
parents own perspective, the unique aspects of parenting
an infant born very preterm and (2) to assess parent preferences for parenting support including parental opinions
on a new behavioural parenting intervention in development, Prem Baby Triple P. The collection of preference
data directly from parents is an important step in the successful adaptation of an evidence-based behavioural parenting intervention to their needs.

Method
Design
This is a qualitative study with data collection through
focus groups. The analytic methodology used is thematic
analysis, a descriptive qualitative methodology that is not
theoretically bounded (Braun and Clarke 2006). Thematic
analysis is widely used within psychological research. A
qualitative approach was chosen to facilitate the gathering
of a rich data set.
Participants
A total of eighteen parents of children born very preterm
(B32 weeks gestation) participated in this study. The
majority of participants were recruited through the Preterm
Infants Parents Association (PIPA). In addition, all

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parents of an infant born very preterm (\32 weeks gestation) who had presented at a community health centre in
the Royal Childrens Hospital and Health Service District
within the past 6 months were invited to participate. No
incentives to participate were offered. Participant characteristics are reported in Table 1.
Prem Baby Triple P Triple P (Positive Parenting Program) is a behavioural parenting intervention that promotes
positive, caring and consistent parenting practices at a
population level (Sanders 1999; Sanders et al. 2002). The
results of three independent meta-analyses using 55 evaluation studies confirm that Triple P has significant positive
effects on child behaviour (de Graaf et al. 2008; Nowak
and Heinrichs 2008; Thomas and Zimmer-Gembeck 2007)
and parenting style (Nowak and Heinrichs 2008; Thomas
and Zimmer-Gembeck 2007) with small to moderate effect
sizes when universal and low intensity treatments are
included (d = 0.35) (Nowak and Heinrichs 2008) and large
effect sizes for higher intensity interventions (d = 0.88)
(de Graaf et al. 2008). Triple P has recently been extended
to infancy with the development of Baby Triple P (Spry
et al. 2008). The adaptation of Baby Triple P to parents of
infants born very preterm has produced Prem Baby Triple
P. Prem Baby Triple P, like Baby Triple P, contains four
sections: (1) positive parenting focuses on positive parenting principles, developing a positive relationship with
baby, exploring influences on babys development and
creating a safe environment, (2) responding to baby focuses
on settling, teaching new skills, crying and sleeping patterns, establishing limits and encouraging contentment (3)
survival skills focuses on exploring parenting traps, common experiences and expectations, acceptance, exploring
emotions and coping skills and (4) partner support focuses
on communication skills, maintaining relationship happiness and planning for the management of chores. Thus,
Prem Baby Triple P targets parenting skills, parental
adjustment and the spousal relationship in order to impact
on infant development and behaviour. Prem Baby Triple P
is designed to be disseminated in four hospital-based group
sessions along with four telephone consultations delivered
after discharge.
Procedure
This study was approved by the Royal Childrens Hospital
and Health Service District Ethics Committee (2008/114)
and the University of Queensland Medical Research Ethics
Committee (2008002268) and informed consent was
obtained from all participants. Four focus groups were
conducted with the participants broken into small groups to
allow for more comfortable discussion. Each focus group
lasted 2 h in total. The focus groups were all moderated by
the first author with assistance from the second author. The

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J Child Fam Stud (2014) 23:10501061

Table 1 Participant characteristics of parents within the focus groups
(N = 18)
Variables

Participant characteristics

Parent age in years Mean (SD)

36.89 (5.30)

Parent sex
Male
Female

2
16

Parent marital status

Single
Married
Defacto

1
15
2

Parent level of education

\10 years

12 years

Vocational education/college
certificate

Trade/apprenticeship
University degree

2
10

Parent employment
Full time

Part time

Home duties
Type of household in which
the child is living
Original family

16

Step-family

Sole parent family

Number of children in the

household

1.89 (0.83)

Gestational age of preterm infant

at birth (weeks)

26.33 (2.66; range 24.0032.57)

Current age of preterm infant

(months; uncorrected)

22.28 (10.10; range 10.5048.00)

Preterm infant sex

Male
Female

8
10

Previous participation in a parenting intervention

No

15

Ellen Baron centre for sleep

issues as infant

Boundaries with kids

Professional assistance sought for

preterm child for social, emotional
or behavioural problems (e.g. from
psychologist, psychiatrist,
counsellor, social worker)
No
Psychologist

10
3

Paediatrician

Counsellor

Child health nurse

Occupational therapist

School counsellor

J Child Fam Stud (2014) 23:10501061

focus groups began with a briefing on the planned content

and delivery of Prem Baby Triple P and the opportunity to
view draft copies of Prem Baby Triple P parent workbooks
(30 min). This was done first to ensure that parents had
sufficient time to become familiar with the proposed
intervention. A facilitated discussion was conducted
focusing on the unique challenges of parenting an infant
born very preterm and on parent preferences for parenting
support, including the appropriateness of planned Prem
Baby Triple P content and delivery (90 min) (see
Appendix for a list of questions). The focus groups were
recorded and transcribed verbatim by the first author along
with research assistants. Sections of the recordings were
transcribed by two transcribers to ensure that the transcription process was accurate.
Materials
Participants were given draft copies of the Prem Baby
Triple P workbooks to peruse before and during the focus
group discussion. Participants completed a demographic
questionnaire and an acceptability questionnaire both
designed for the purposes of this study. The acceptability
questionnaire involved parents rating the acceptability of
the proposed content and delivery of Prem Baby Triple P as
well as assessing perceived barriers and facilitators to
parent participation in Prem Baby Triple P.
Data Analysis
The data were analysed qualitatively using descriptive
thematic analysis. During thematic analysis patterns within
the data (themes) are identified and reported so that the
data set is organized in an understandable manner that
maintains the rich detail of the data set (Braun and Clarke
2006). The transcripts were analysed line by line, broken
into discrete parts and grouped together by similarity of
content and/or meaning. Analysis was continued until
saturation was reached. During analysis the themes were
organized to reflect the two key aims of this study: (1) to
identify unique aspects of parenting an infant born very
preterm and (2) to assess parent preferences for parenting
supporting including parental opinions on Prem Baby
Triple P. Qualitative analysis was conducted by the first
author with confirmation of the analysis performed by two
research assistants who coded sections of the transcript.
Additional quantitative data was collected via a demographics and acceptability questionnaires to support the
qualitative findings. All quantitative data were collated
using SPSS 17.00 to identify descriptive statistics and to
conduct a pair-wise t test to identify which of the four
sections of Prem Baby Triple P parents found particularly
relevant to parenting an infant born preterm.

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Results
Analysis was organised according to the two study aims, to
identify unique aspects of parenting an infant born very
preterm (leading to seven themes) and to assess parent
preferences for parenting support including parental opinions of Prem Baby Triple P (leading to four themes). The
themes are summarised in Table 2 and are discussed in
detail below.
Identifying the Unique Aspects of Parenting an Infant
Born Very Preterm
The Stress of Hospitalisation
All of the parents emphasised that their babys hospitalisation was stressful and traumatic. Parents described that
time of their lives as being in a state of limbo where
survival is the priority. Parents further explained that
they had minimal control at this time and hence any perceived loss of control or loss of an opportunity for contact
with their child was experienced as intensely stressful.
Parents agreed that the best response to parental stress from
health professionals is to normalise this experience,
acknowledge the parents feelings and support parents in
their own unique coping. Parents would have liked extra
support in hospital from a social worker or psychologist
who was approachable and present on the ward.
Its a tragedy in lots of ways. It really is a tragedy.
You dealt with a major tragedy.
Were so protectiveI had an exact similar instance
with a nurse. Its there, I come every day, I didnt get
there in time, and the babys already been fed. You
just lose it. And as I said, and when you think about
it, I lost it because I didnt get to hold the tube.
Institutionalised
Some parents reported that taking their baby home had been a
positive experience that they had felt well prepared for. Others
reported feeling daunted by the prospect of taking their baby
home. Parents found that when they took their baby home
theyd become institutionalised with some parents continuing
to record their babys temperature and activities as was done in
hospital. Some parents also found that their babys behaviour
in terms of feeding, sleeping or crying changed when they took
their baby home due to the difference in the environment,
particularly changes in stimulation. Other parents found that
their baby kept the same routines that had been established in
hospital and that they needed to fit in with already established
sleeping and eating patterns.

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J Child Fam Stud (2014) 23:10501061

Table 2 Summary of the themes emerging from the focus group with parents of infants born preterm
Theme

Summary of the theme content

Research question one: identifying the unique aspects of parenting an infant born very preterm
The stress of hospitalization

Parents described the time of hospitalization as stressful and traumatic with a focus on medical crises and
loss of control as parents

Institutionalised

Parents were mixed in whether they felt prepared to take their baby home. Most parents reported that they
had been institutionalised and relied upon hospital routines and habits when they took their baby home
Parents stated that they felt unprepared for parenthood, had not experienced the normal transitions to the
parental role and did not receive the same support from friends and family that other parents do

Unprepared for parenthood

Grief

Parents described a significant grieving process with grief about the loss of pregnancy, grief about the loss of
expected parenting experiences and grief for the potential loss of the baby

Getting into bad parenting habits

Parents explained that there is a tendency to get into bad parenting habits of overnurturing their preterm
child. Parents felt these habits were negative as they did not encourage independence and appropriate
behaviour

Isolation

Parents reported isolation in their babys first year related to minimization of infection risk (leading to
decrease in socializing) and a lack of understanding from friends and family

Developmental expectations

Parents reported uncertainty around developmental expectation. They stated that it was difficult to judge
whether a specific issue was a result of the prematurity, a sign of a disorder or a part of normal
development

Research question two: parental opinions of Prem Baby Triple P

There is a need for Prem Triple P

Parents emphasized that there is a need for Prem Baby Triple P. They stated that there is currently a gap in
the delivery of parenting information specific to parents of infants born preterm and that Prem Triple P
could prevent bad parenting habits later on

The content of Prem Triple P is

appropriate

Parents found the content appropriate. In particular, focusing on self-care, partner support, developing a
positive relationship with your baby and developmental information (adjusted for corrected age)

The importance of a tailored

program

Parents emphasized the importance of Prem Triple P being a tailored intervention and being clearly
presented as such. Parents were positive about tailoring and made further suggestions

Remember parental stress

Parents discussed the importance of remembering that parents of infants born preterm are highly stressed
while their baby is in hospital. Parents felt that Prem Triple P could be an important means to support
parents at this time. They suggested considering flexible delivery options

A lot of prem parents feel institutionalized. I know

myself, when they started talking about discharge I
was just in shock. What am I going to do? Where is
my safety net? And when I got home I didnt feel
comfortable until I drew up my own little chart
Its sort of like, basically, almost cutting that bit of an
apron string with the hospital I remember taking
[my baby] home, sort of sitting there going well,
where is everybody? because for so long youve had
that 24 hour a day person behind you. Even going
through special care its still there. Theres always
someone to askIts just that sort of, You can go
home, bye, see ya and youre going ohwhat you
want me to go? Are you sure? We can stay you
form that attachment to the hospital and you relate to
the theyll be ok while theyre in the hospital and
then you take them home and its like well, Im in
charge oh god, whose idea was this?
Unprepared for Parenthood
Parents described themselves as unprepared for parenthood, arriving without the normal progression such as baby

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showers and reading parenting books. They also stated that

their family and friends were unsure of how to respond to
their preterm childs birth so they didnt feel that they
received the same congratulations and support that most
parents do.
It is called the crash course.
I remember when I was young and stupid and I said
well, Im going to get pregnant and have a baby in
40 weeks and, you know, never in my wildest dreams
did I think that at 24 weeks I was going to have that
tiny little skin rabbit up there going this is your
baby.
Grief
Parents discussed the grieving process and the trauma of
having a baby born very preterm. Parents grieved for the
loss of the pregnancy, for the loss of expected parenting
experiences (e.g. being the first to hold the baby) and for
the loss of the baby (while there was still doubt about the
babys survival). Some parents stated that they had been
reluctant to bond in the beginning because they were afraid

J Child Fam Stud (2014) 23:10501061

of their child dying. Related to the grief there was a sense

of guilt, particularly on behalf of the mother. Parents
agreed that it is important for the grief to be acknowledged
and normalised by health professionals. Further, they stated
that it is important for parents themselves to acknowledge
their grief so that they can focus on parenting later on.
These particular emotions of guilt, of anger, of grief,
of loss that you feel, even though your baby is alive,
which is fabulous, because in the initial bit youre
not really sure how long thats going to last. But
the fact that, you know, the grief of what I didnt
get to you dont get to hold the baby.
Well, I in the beginning, I withheld a lot of my
wanting to bond because I was afraid that we were
going to get that call.

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been cautious of receiving guests. In addition, this was due

to a lack of understanding from their friends and family
about the traumatic nature of their experiences and the fact
that their baby was still Prem after discharge from
hospital.
We didnt go out for three months. We came home
and we didnt go out. We came home at the beginning of winter and stayed home and every single
doctor and nurse said it, stay home.
They just cant wrap their head around it. Like some
of our friends were watching a video [of the baby]
because she was still in Special Care and theyre like
oh, shes pretty big, shes pretty big. Then my hand
comes in and blocks her out completely. Oh, no shes
not. Thats just the start of it, the rest of it; they cant
wrap their heads around it.

Getting into Bad Parenting Habits

Developmental Expectations
Parents felt that the trauma, grief and genuine medical
issues in their babys earliest months had encouraged them
to develop parenting habits that were functional at the time
of hospitalisation but negative in the long term. In particular, parents discussed a tendency to be overprotective and
to put a lot of energy into parenting their preterm child.
Parents stated that this was to optimise their childs
development and that it was also partly connected to the
guilt that mothers experienced about not being able to carry
their child to term. Parents reported that as their baby grew
into toddlerhood they had difficulty judging appropriate
developmental expectations. As a result, they were concerned that they had not sufficiently encouraged independence and appropriate behaviour.
I thinkwith behaviouryou tend to let them go
because they are a bit more special Its like theres
a whole different behavioural pattern that you let
them get with [them] because they can.
And I think the guilt kind of stays with you. Every
minute Im doing the washing or cooking dinner Im
thinking I should be doing something with him but
probably I shouldnt? I dont think I know what a
normal parent does and the guilt just stayed with me.
Isolation
Parents reported feeling isolated particularly in their babys
first year. Partly, this was due to the demanding daily
routine during their babys hospitalisation followed by a
need to protect the baby from infection after discharge.
Parents explained that, in order to protect their baby from
infection, they had isolated themselves in their home and

Parents explained that they were uncertain about the

appropriate developmental expectations for their child.
They found it difficult to judge whether a specific issue was
a result of the prematurity, a sign of a disorder or a part of
normal development. In addition, they explained that their
babys earliest months gave them a heightened awareness
of medical and developmental issues and as a result they
were constantly looking for signs of developmental disorders or medical illness in their child. Parents explained that
this was motivated by knowledge that if their child did
have a disability then early intervention would be
important.
Youre always looking. Is that normal behaviour or is
that premmie behaviour?
My community nurse at the community health clinic
told me I should be starting her on solids at her six
months real age and then I rang special care and they
said probably, we normally go corrected age but
whatever the baby wants so I gave up and just went
with whatever she told me. But when I went back to
the community nurse a couple of months later she
was into me because this baby should be on mashed
and dah, dah, dah, and you should fast track this baby
through all of this and I just went you know, how am
I supposed to know what Im supposed to do?
Parental preferences for parenting support
Parents expressed that they would have liked to receive
parenting support themselves. On average parents gave
Prem Baby Triple P a rating of 9 (range 710, SD = 0.71)

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on a scale of 110 for how enthusiastic they would have

been about participating in the program. Most parents felt
that once they were approaching discharge they would be
hungry for parenting information. Parents liked the use
of a workbook and felt that the workbook contained
practical information. In addition, they liked the fact that
parents would receive phone consultations after discharge
from the hospital. The group sessions in the NICU were
rated 6.44 (range 110, SD = 2.28) and the telephone
consultations after discharge were rated 7.00 (range 410,
SD = 2.00) on a Likert Scale of 110 for utility as a
delivery modality. Barriers to participation and advantages
to the delivery modality are presented in Table 3 for group
sessions and Table 4 for telephone consultations.

J Child Fam Stud (2014) 23:10501061

Table 3 Barriers and advantages to delivery of Prem Triple P in
group sessions during hospitalisation
Number of parents
identifying this as a
barrier or advantage

N (%)

Barriers to own participation in group sessions of Prem Triple P

It takes too much
time

8 (44.44)

4.12 (1.96)

Competing work
commitments

4 (22.22)

5.00 (0.82)

10 (55.55)

5.2 (2.04)

Would not feel

comfortable
accessing Prem
Triple P

2 (11.11)

5.00 (2.83)

Family members
would not be
supportive

1 (5.55)

1.00

Stress

There is a Need for Parenting Support

Parents felt that there is currently a lack of parenting
information specific to parenting babies born very preterm
and that Prem Baby Triple P could effectively address this
gap. In addition, parents hoped that a parenting intervention such as Prem Baby Triple P delivered early could help
parents avoid parenting habits such as over nurturance that
parents felt were negative in the long term. It was also
discussed that the Prem Baby Triple P groups could enable
parents to establish new friendships with other parents of
infants born preterm and hence decrease isolation once the
baby has gone home.
because there seems to be limited information for
prem parents and I believe the more information
thats available for them to be better parents particularly better prem parents is extremely important.
The Content of Prem Baby Triple P is Appropriate
In particular, parents believed that the focus in Prem Baby
Triple P on parents own coping skills and on partner support is important and relevant to the preterm population.
Parents explained that while their baby was still in hospital
self-care and nurturing their spousal relationship was put
on hold while the immediate medical crisis was dealt with.
In addition, some parents felt that a focus on partner support would help fathers become more involved and cope
better to the adjustment of parenting a preterm baby. Some
parents felt that fathers in particular can have difficulty
adjusting to their new parenting role as they usually return
to work while the baby is still in hospital, may be frightened of accidentally injuring such as vulnerable and small
baby and may be reluctant to become involved if the new
mother is relishing the opportunity to complete dayday
parenting tasks themselves after discharge. As important as
many parents thought partner support was most parents

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For parents identifying

this barrier or advantage
the degree to which it
would affect their
participation in Prem
Triple P on a scale of
17
Mean (SD)

Barriers to partners participation in group sessions of Prem Triple P

It takes too much
time

6 (33.33)

5.00 (0.63)

Competing work
commitments

9 (50.00)

6.00 (1.32)

Stress

8 (44.44)

5.62 (0.92)

Would not feel

comfortable
accessing Prem
Triple P

4 (22.22)

3.5 (2.92)

Family members
1 (5.55)
would not be
supportive
Advantages of this mode of delivery

1.00

Convenience

15 (83.33)

5.60 (1.05)

Able to stay close

to baby

13 (72.22)

6.15 (0.90)

Sharing
experiences with
other parents

15 (83.33)

5.73 (1.58)

Receiving
emotional
support from the
group

15 (83.33)

5.40 (1.80)

8 (44.44)

5.12 (2.17)

Would enable
partner to
participate

reported that planning the management of chores was not

relevant to them. Regarding parenting information in particular, parents felt that the focus on building a positive
relationship with your baby and developmental information
(adjusted for corrected age) were both especially relevant.
Parental report in the focus group is supported by the

J Child Fam Stud (2014) 23:10501061

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Table 4 Barriers and advantages to delivery of Prem Triple P in

telephone consultations after discharge
Number of parents
identifying this as a
barrier or advantage

N (%)

For parents identifying

this barrier or
advantage the degree to
which it would affect
their participation in
Prem Triple P on a
scale of 17
Mean (SD)

Barriers to own participation in telephone consultations for Prem

Triple P
It takes too much
time

8 (44.44)

4.37 (2.26)

Competing work
commitments

5 (27.77)

2.40 (2.90)

Stress

6 (33.33)

5.50 (1.58)

Would not feel

comfortable
accessing Prem
Triple P

2 (11.11)

1.50 (2.12)

Family members
3 (16.66)
2.00 (2.00)
would not be
supportive
Barriers to partners participation in telephone consultations for
Prem Triple P
It takes too much
time

3 (16.66)

5.33 (0.58)

Competing work
commitments
Stress

12 (66.66)

5.08 (2.15)

3 (16.66)

4.33 (3.78)

Would not feel

comfortable
accessing Prem
Triple P

3 (16.66)

4.67 (1.15)

Family members
would not be
supportive

1 (5.55)

1.00

Advantages of this mode of delivery

Convenience

8 (44.44)

5.89 (1.05)

Able to stay close to

9 (50.00)
baby
The opportunity to
13 (72.22)
put Prem Triple P
into practice at
home

6.44 (0.73)

Receiving support
after going home

15 (83.33)

6.47 (0.64)

7 (38.88)

5.43 (1.13)

Would enable
partner to
participate

5.92 (0.74)

questionnaire data. Parental ratings of each of the four

sections of Prem Triple P are provided in Table 5. Significant differences were found between parent ratings of
the importance for parenting a preterm infant and parent
ratings of the importance for parenting in general for

section one positive parenting, t (13) = -3.57, p = .003

and for section three survival skills, t (16) = -4.48,
p = .000, indicating that parents found the content in these
two sections especially relevant to parenting a preterm
infant. These two sections included content on developing
a positive relationship with baby and developmental
information and coping skills. Overall, parents felt that the
content of Prem Baby Triple P would be empowering.
I think that is a big issue that would help in those
early days- is feeling empowered. Because in the first
couple of weeks its not your baby- its the nurses
baby and the doctors baby. And you dont feel
empowered to do stuff.
The Importance of a Tailored Program
Parents stressed that any parenting support needed to be
carefully tailored to parents of infants born preterm and
presented as such. Parents felt that if the parenting support
was not clearly designed for parents of infants born preterm
they would not have been keen to attend. Most parents agreed
that they would expect that the majority of the actual content
would be the same as a parenting intervention for all parents.
However, they still felt that it was essential to recognise the
important differences in parenting an infant born preterm.
Parents were positive about the adapted information in the
Prem Baby Triple P content, in particular, information on
overstimulation and the importance of encouraging a flexed,
curled posture in their baby (e.g. by wrapping). In addition,
they stated that they would have liked information on
activities to promote motor development, on avoiding
infection through a self-imposed quarantine and on
continuing to parent older siblings while their preterm baby
was still in hospital. Some parents were concerned that their
preterm infants hospitalisation had done permanent damage
to their relationship with their older children. They would
have liked strategies to prevent this and information on how
to discuss prematurity with their older children. In addition,
parents would have appreciated ideas on how to communicate with others in the community about prematurity and
their own parenting decisions.
That was one of the things a safe environment for
prems. For me that definition should include noninfection, quarantine. Because the first thing I think
about regarding [my preterm baby]s safety is dont
let her get sick.
Remember Parental Stress
Parents emphasised the importance of remembering that
parents of infants born preterm are experiencing significant

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J Child Fam Stud (2014) 23:10501061

Table 5 Parent ratings of the content areas within Prem Triple P on a scale of 110 for importance, importance to parents of infants born
preterm and the degree the content would have affected participation
Mean (SD)

Section one: positive

parenting creating a safe
environment, exploring
influences on baby
development and developing
a positive relationship with
baby

Section two: responding to

your baby settling, teaching
new skills, crying and
sleeping patterns establishing
limits and encouraging
contentment

Section three: survival skills

exploring parenting traps,
common experiences and
expectations, acceptance,
exploring emotions and
coping skills

Section four: partner

support communication
skills, maintaining
relationship happiness,
planning for the
management of chores

Importance of
the content to
parenting on a
scale of 110

9.01 (1.02)

8.75 (1.06)

7.80 (1.37)

7.62 (1.58)

Importance of
the content to
parenting an
infant born
preterm on a
scale of 110

9.35 (0.88)*

8.95 (1.09)

8.28 (1.35)*

7.77 (1.58)

Degree to which
this content
affects my
desire to
participate on a
scale of 110

8.23 (1.17)

8.29 (1.17)

7.82 (1.33)

6.83 (1.37)

* Significant differences found between parent ratings of the importance for parenting a preterm infant and parent ratings of the importance for
parenting in general for section one positive parenting, t (13) = -3.57, p = .003 and for section three survival skills, t (16) = -4.48, p = .000

stress, especially while their baby is still in hospital. In

particular, parents may be feeling overwhelmed, may be
grieving or may not yet be confident that their child will
live. Parents felt that a parenting intervention like Prem
Baby Triple P could fill a gap in current hospital services
by providing parents with much needed support and
enhancing self-care and the spousal relationship just when
it is needed most. Some parents felt that this distress made
them hungry for information and that they would have been
enthusiastic about participating in a parenting intervention.
Other parents felt that timing would be important. They
explained that if parenting support was offered too early
theyd still be in information overload and would not be
able to participate. This was parents main concern about
attending Prem Baby Triple P groups while their baby is
still in hospital. Parents agreed that parenting support
should be flexible, with parents able to begin participating
when they are ready. Some parents also suggested changing the order of Prem Baby Triple P sessions so that parents
are able to attend session three on survival skills (self care,
coping) and session four on partner support before sessions
one and two on parenting. Parents explained that sessions
three and four are directly relevant for parents during the
hospitalisation time with sessions one and two on parenting
becoming relevant immediately before discharge. This was
also reflected in the questionnaire data with ten participants
indentifying stress as a barrier to participation in the group
sessions and eight identifying lack of time (see Table 3).

123

Parents felt it would be important to be able to debrief but

they didnt think this should be done in a group setting as
this would increase parents anxiety to hear the difficulties
of others.
For me personally thinking back to how I felt emotionally I dont think that I would take it in at that
stage. Maybe at the special care or close to the end
just to be in the ICU and have that emotional
weight [parenting support] would just be an extra
[weight] added.
Discussion
Identifying the Unique Aspects of Parenting an Infant
Born Very Preterm
Parents identified the transition to a parenting role to be a
uniquely stressful one for parents of infant born very preterm. In particular, the lack of preparation for parenthood,
the stress of the hospitalisation experience itself, the grief
and the isolation all contributed to a uniquely stressful life
transition. This is consistent with previous literature demonstrating that parents of infants born very preterm are at
increased risk of experiencing psychological distress
including depressive and anxious symptoms (Davis et al.
2003; Greco et al. 2005; McGettigan et al. 1994). Further,
this underscores the importance of ensuring that parents of

J Child Fam Stud (2014) 23:10501061

infants born very preterm are well supported in their

transition to parenthood. Clinicians working with parents
of infants born very preterm should be mindful of parental
stress, support parents natural grieving process and refer
parents to additional sources of support when necessary.

1059

during the hospitalisation period. Parents also suggested

that they would have benefitted from the presence of a
social worker or a psychologist being readily available on
the ward.
The Future of Prem Baby Triple P

How a Parenting Intervention may be Relevant

A parenting intervention, such as Prem Baby Triple P, may
be an effective way to better support parents of infants born
very preterm in their transition to parenthood. There is a
good fit between what a behavioural parenting intervention
can offer and the challenges that parents reported. For
example, a parenting intervention could assist in empowering parents before discharge as well as helping parents to
avoid bad parenting habits of not encouraging independence and appropriate behaviour in their child in the
long term. Parents also wanted additional information on
their childs development. They reported uncertainty
around appropriate developmental expectations for their
child and this uncertainty lasted into the future as their
preterm baby became a preterm toddler and beyond. Given
the research literature suggesting that infants born very
preterm are at increased risk of a range of developmental
and behavioural problems it is not surprising that parents
are concerned about their childs development and uncertain about what to expect (Bhutta 1993; Johnson et al.
2010; Saigal 1991; Stanley et al. 2000). The provision of
accurate information on development is appropriate; however, it may also be appropriate to empower parents in
assessing their own childs specific progress in their unique
developmental trajectory so that parents are confident in
problem solving when their child is developmentally ready
for specific tasks. Overall, there is a good fit between the
challenges of prematurity and providing parents with
additional support through a behavioural parenting
intervention.
Parental Preferences for Parenting Support
Parents agreed that there is a need a parenting intervention
specifically tailored to parents of infants born very preterm.
Parents wanted parenting support for parents of infants
born preterm to be: (1) clearly tailored to be directly relevant to parents of infants born very preterm; (2) sensitive
to the emotional context of early life as a parent of an
infant born very preterm including grief; (3) flexible to
individual parent needs and coping, and (4) inclusive of
strategies to enhance coping skills and the spousal relationship. In addition, parents expressed a desire for additional mental health support during the hospitalisation
period. A parenting intervention may be one way of
improving the mental health support given to parents

Overall parents responded positively to Prem Baby Triple

P content. Parental preferences for parenting support will
be used to further adapt Prem Baby Triple P content and to
inform intervention delivery in a future RCT. In particular,
a flexible approach to intervention delivery will be taken
with the order of intervention sessions altered so that parents may obtain sessions on coping skills and the spousal
relationship before sessions on parenting practices. The
inclusion of sessions on coping skills and improving the
spousal relationship seems to be an important feature of the
program in terms of its relevance to parents of infants born
very preterm.
Limitations and Future Research
A qualitative approach was taken in this study in order to
gather a rich data set. The limitations inherent in qualitative
research should be emphasised. It is likely that this study
sampled parents who are highly motivated; certainly the
majority of the participants were well-educated mothers.
The generalisibility of the views of this small sample of
parents to the population in general, including fathers and
parents from lower SES background, cannot be known.
Also, while this research contributes towards the development of a behavioural parenting intervention for parents of
infants born very preterm, the efficacy of Prem Baby Triple
P remains to be tested in future research. The parents in this
focus group gave their opinion of Prem Baby Triple P
content after reviewing the material for 30 min only. There
is a difference between positive feedback on program
materials and actual participation. It would be valuable to
obtain qualitative feedback from parents completing the
Prem Baby Triple P intervention in future research.

Conclusion
Parents identified several unique aspects of parenting an
infant born preterm. In particular: coping with the stress of
hospitalisation; an experience of institutionalization; a lack
of preparation for the transition to parenthood; grief; isolation; getting into bad parenting habits of overnurturance; and lack of certainty about developmental
expectations. Parents stated that there is a need for parenting support and preferred that parenting support to be:
tailored to parents of infants born very preterm; sensitive to

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J Child Fam Stud (2014) 23:10501061

the emotional context of early life as a parent of an infant

born very preterm; flexible to individual parent needs, and
to enhance coping skills and the spousal relationship. This
preference data will be used to inform an RCT of Prem
Baby Triple P in the future.
Acknowledgments We acknowledge an NHMRC postdoctoral
fellowship (KW 631712); an NHMRC Career Development Fellowship (RB 473840) and a Smart State Fellowship (RB).

Appendix: Questions Asked by Facilitators in the Focus

Groups
1.

What is your general impression of Prem Triple P?

Follow Up Questions
What are your reasons for thinking X?

2.

Which content areas do you think are most relevant for

parents of babies born preterm?
Follow Up Questions
Why is that relevant for parents of children born
preterm?

3.

Which content areas do you think are not relevant or

inappropriate for parents of babies born preterm?
Follow Up Questions
Why is that not so relevant for parents of children
born preterm?

4.
5.

What is unique about parenting a preterm baby?

What are your particular concerns as a parent of a
preterm baby that youd like to see addressed in Prem
Triple P?
Follow Up Questions
Is there anything that Prem Triple P is missing?
How could we address that in Prem Triple P?

6.
7.

Would you have wanted to participate in Prem Triple

P?
What do you think of the workbook?

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