EXPERIENCES OF MOTHERS WITH A PREMATURE BABY ADMITTED

TO THE NEONATAL INTENSIVE CARE UNIT (NICU) AT HOSPITALS IN

WINDHOEK, NAMIBIA

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE

REQUIREMENTS FOR THE DEGREE OF MASTER IN NURSING SCIENCE

OF THE

INTERNATIONAL UNIVERSITY OF MANAGEMENT

BY

DHLAMINI YVONNE

150014724

JANUARY 2023

SUPERVISOR: DR A.R.E. KLOPPERS

ABSTRACT
Around the world, 15 million premature babies are born every year. Sixty per cent (60.0%)
of the premature babies are born in Africa and South Asia due to a lack of medical
interventions. Mothers have strong emotional experiences when their babies are in the
intensive care unit (ICU), and these emotions have an influence on their thoughts, feelings
and relationships and this leads to possible family disruptions. The problem that the study
examined is that there is a disruption of normal mother-baby physical contact and the care
provided by the mothers to premature babies. However, there is a lack of written evidence
on the experiences of mothers with premature babies admitted in Windhoek hospitals in
Namibia.
The purpose of the study was to explore and describe the experiences of mothers with
premature babies admitted to the NICU in hospitals A & B in Windhoek, Namibia. The
objectives of the study were to: explore the experiences of mothers with a baby that is
admitted to the NICU in state hospitals A & B in Windhoek, Namibia; describe the
experiences of mothers with a baby that is admitted to the NICU in state hospitals A & B in
Windhoek, Namibia; and factors that influence the presence of mothers at bedside of
premature babies admitted to the NICU at hospitals in Windhoek, Namibia.
The significance of the study is that it is beneficial to the IUM, MOHSS, NICU nursing
personnel and to the researcher as a Registered Nurse. It is beneficial to the IUM research
in providing knowledge to the research fraternity and can be used as reference, MOHSS
will give insight of the problems and issues to be considered when making policies and
gives ideas of issues to be dealt with concerning mothers and nursing staff, NICU nursing
personnel and the researcher as a Registered Nurse benefit for they all will understand the
support needed in the in the unit particularly when mothers are going through the
emotional frustration and provide quality individualized care.
The research design was qualitative, exploratory, descriptive and contextual. The target
population was mothers with premature babies admitted to the NICU at the state hospital
and a total number of ten (20) mothers from hospitals A& B were interviewed. An interview
guide, an audio recorder and field notes were used as the data collection instruments. The
researcher used the face-to-face interview technique of collecting data, while using a non-
probability purposive sampling method. The research philosophy followed was

ii
constructivism, and the humanistic theory was employed for the study. Pilot testing was
done and those who took part in the pilot study did not form part of the main study and the
data from the pilot study were not used in the final research report.
Data were collected through in-depth interviews with mothers of babies admitted to the
NICU. The main question asked was: How did you feel when your baby was admitted to
the NICU? This was followed by probing until data saturation was attained. An audio
recorder was used and notes were taken. During data analysis, the verbatim data were
transcribed. Teschers’ open colour coding was used to categorise concepts with similar
meanings into key themes and sub-themes.
 Key theme 1: Participants expressed different emotions. The sub-themes were:
mothers had fear of touching the baby in the incubator; mothers felt very scared
when the baby was fed with different feeding methods such as nasogastric tubes;
mothers felt anxious about the well-being and survival of the baby; mothers needed
emotional support through family and counseling; mothers felt disheartened
because of financial struggles; the absence of accommodation facilities was
stressful; mothers felt very happy with the baby’s condition when there was a
positive outcome of the treatment; and mothers’ spirituality was positively changed
through prayer.
 Key theme 2: The nursing care given to babies. The sub-themes were: mothers
were grateful to nurses because they helped to take good care of the babies; and
nurses were stressed, rude, and failed to give good care in that they neglected the
babies.
 Key theme 3: Communication between the mother and the healthcare members.
The sub-themes were: healthcare personnel lacked in giving information regarding
the progress of the baby's health condition; and nurses were communicating with
mothers regarding the care of their babies.
Trustworthiness was ensured through credibility, transferability, dependability and
confirmability. Ethical principles such as written informed consent, confidentiality,
right to privacy, autonomy, beneficence, non-maleficence and the principle of justice
were observed throughout the research process.

iii
Mothers expressed different emotions, felt scared to touch the baby; grateful about
the care to babies by Nurses; and how the healthcare members failed in giving
information regarding the progress of the baby’s health condition.
The conclusion was mothers had both negative and positive experiences during
their stay in NICU, as expressed by fear and anxious about baby survival and how
nurses failed to care for their premature babies and that they were rude and failed
to communicate about baby well being. It was concluded that, some nurses took
good care of the babies. The study recommended that health professionals working
in NICU should be mindful in offering support groups, the Ministry of health should
adopt policies that allow permanent presence of mothers in the hospital, employ
more social workers and that nurse educators be mindful in teaching student nurses
about respectful care and give support to mothers to promote their mental health.
Limitations of the study were only state Hospitals in Windhoek were interviewed and
cannot be generalized to the other private sectors ad hospitals outside Windhoek.

iv
KEYWORDS

Premature babies

Mothers

Neonatal Intensive Care Unit (NICU)

Mother-baby relationship

v
ACKNOWLEDGMENTS

Firstly, I would like to thank the Lord for granting me an opportunity to study and to reach
this far and also the wisdom to pursue this journey. It was not an easy journey of balancing
work, motherhood, social life and studies. His grace has taken me this far.

I would like to appreciate and honour the following people who walked the journey with me
until the completion of my study:

 Dr A.R.E. Kloppers for her unending support and encouragement right up to the
final product of this thesis;

 Prof. A.S. van Dyk for her support during this study;

 The Ministry of Health and Social Services for allowing me to use their facilities;

 Mothers with babies admitted in the NICU for participating in the study;

 The International University of Management, nursing staff for the support and

 Family and friends for their encouragement.

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DEDICATION

I DEDICATE THIS THESIS TO:

 God for his love and faithfulness and for bringing his purpose into fruition:

Philippians 4 vs 13 - I can do all things through Christ who gives me strength;

 My mother (Mouritious Dhlamini), for her initiative to pay for my registration fees

and her unending support and prayers;

 My late father who believed in me and instilled in me perseverance and courage;

 My children (Tanatsirwanashe, Tinayeishe & Katty-Tendai) for being a great support

system and for prayers every day;

 My siblings (Priscila,Pelma & Simba), who encouraged me to continue with my

studies; and

 My uncle A. Toga Nxele for playing an important part and being a great support with

my thesis.

vii
DECLARATION

I, Yvonne Dhlamini, hereby declare that the study is a true reflection of my own work and
that this work or any part of it has not been submitted for a degree in any other institution.

I declare that, no part of this thesis may be reproduced, stored or transmitted in any form,
or by means of electronic, photocopying, recording or otherwise without prior permission
from me or of The International University of Management.

Further, I grant the International University of Management the right to reproduce this
thesis in whole or in part, in any matter of format which the International University of
Management may deem fit for any person or institution requiring it for research and study
purposes.

…………………………. …………………………..

Signature Date

viii
Table of Contents
ABSTRACT.........................................................................................................................................ii
KEYWORDS.......................................................................................................................................v
ACKNOWLEDGMENTS...................................................................................................................vi
DEDICATION....................................................................................................................................vii
DECLARATION...............................................................................................................................viii
ABBREVIATIONS.............................................................................................................................xi
LIST OF ANNEXURES....................................................................................................................xii
LIST OF TABLES.............................................................................................................................xiii
CHAPTER ONE...................................................................................................................................1
INTRODUCTION AND BACKGROUND OF THE STUDY............................................................1
1.1 INTRODUCTION......................................................................................................................1
1.2. BACKGROUND OF THE STUDY..............................................................................................3
1.3. PROBLEM STATEMENT.........................................................................................................6
1.4 PURPOSE OF THE STUDY......................................................................................................6
1.5 OBJECTIVES OF THE STUDY................................................................................................6
1.6 RESEARCH QUESTION...........................................................................................................7
1.7 SIGNIFICANCE OF THE STUDY............................................................................................7
1.8 DEFINITION OF KEY CONCEPTS.........................................................................................7
1.8 ETHICAL CONSIDERATIONS................................................................................................8
1.9 CHAPTER SUMMARY...............................................................................................................11
2.1. INTRODUCTION.......................................................................................................................12
2.2. RESEARCH DESIGN.................................................................................................................12
2.2.1 QUALITATIVE APPROACH...................................................................................................12
2.2.2 EXPLORATIVE APPROACH..............................................................................................13
2.2.3. DESCRIPTIVE APPROACH...............................................................................................13
2.2.4. CONTEXTUAL APPROACH..............................................................................................13
2.3. RESEARCH METHOD..........................................................................................................13
2.3.1. TARGET POPULATION.........................................................................................................14
2.3.2 SAMPLING METHOD.........................................................................................................14
2.3.3 SAMPLE SIZE......................................................................................................................14
2.4 RESEARCH PHILOSOPHY.......................................................................................................15
2.5 THEORETICAL FRAMEWORK................................................................................................15
2.6 PILOT TESTING.........................................................................................................................15
2.7. DATA COLLECTION METHOD...............................................................................................16
2.8. DATA ANALYSIS METHOD.....................................................................................................16

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2.9. TRUSTWORTHINESS / MEASURES.......................................................................................16
Table 2.9.1 CRITERIA AND THEIR APPLICATIONS FOR TRUSTWORTHINESS....................17
2.10. CHAPTER SUMMARY...........................................................................................................19
3.1 INTRODUCTION........................................................................................................................20
3.2 DATA ANALYSIS AND LITERATURE CONTROL.................................................................21
TABLE 3.2.1...................................................................................................................................21
3.3.1 KEY THEME ONE: PARTICIPANTS EXPRESSED DIFFERENT EMOTIONS..................22
3.3.3. KEY THEME TWO: NURSING CARE GIVEN TO BABY..............................................36
3.3.4. KEY THEME THREE: COMMUNICATION BETWEEN MOTHERS AND THE
HEALTHCARE MEMBERS..........................................................................................................40
3.4. CHAPTER SUMMARY..........................................................................................................44
........................................................................................................................................................46
4.1. INTRODUCTION.......................................................................................................................46
4.1.1 CONCLUSION WITH REGARDS TO THE OBJECTIVES OF THE STUDY..................47
........................................................................................................................................................47
4.2 RECOMMENDATIONS..............................................................................................................54
RECOMMENDATIONS FOR NURSE EDUCATION............................................................55
4.3. LIMITATIONS............................................................................................................................56
4.4 CHAPTER SUMMARY..............................................................................................................56
REFERENCES...................................................................................................................................57
ANNEXURE A.........................................................................................................................64
ANNEXURE B........................................................................................................................66
ANNEXURE C.........................................................................................................................67
ANNEXURE D.........................................................................................................................68
ANNEXURE E.........................................................................................................................69
ANNEXURE F.........................................................................................................................70

x
ABBREVIATIONS

MOHSS - Ministry of Health and Social Welfare

NICU - Neonatal Intensive Care Unit

WCH - Windhoek Central Hospital

IHK - Intermediate Hospital Katutura

NCRST - National Commission on Research Scheme & Technology

xi
LIST OF ANNEXURES

ANNEXURE A: VERBAL CONSENT FORM

ANNEXURE B: PERMISSION LETTER FROM NATIONAL COMMISSION ON

RESEARCH SCHEME & TECHNOLOGY

ANNEXURE C: PERMISSION LETTER TO THE MINISTRY OF HEALTH AND

SOCIAL SERVICES – INTERMEDIATE HOSPITAL KATUTURA

ANNEXURE D: PERMISSION LETTER FROM THE MINISTRY OF HEALTH AND

SOCIAL SERVICES – WINDHOEK CENTRAL HOSPITAL

ANNEXURE E: PERMISSION LETTER FROM THE MINISTRY OF HEALTH AND

SOCIAL SERVICES – HEAD OFFICE

ANNEXURE F: INTERVIEW TRANSCRIPTS

xii
LIST OF TABLES

2.9.1 Criteria of trustworthiness Strategies…………………………………...17

3.1.1 Key-themes and Sub-themes……………………………………………21

xiii
 CHAPTER ONE

INTRODUCTION AND BACKGROUND OF THE STUDY

1.1 INTRODUCTION

Prematurity is the gestational age as an indicator of physical and neurological maturity

of premature babies (Valizadeh, Zamanzadeh, Akbarbegloo, & Sayadi, 2012).
Prematurity refers to birth before 37 weeks of gestation and it is a common problem
among infants in most countries (Valizadeh,et al.,2012). Premature babies are more
vulnerable to morbidity and mortality and they require special care and hospitalisation in
the Neonatal Intensive Care Unit (NICU). Worldwide, the incidence of babies born
prematurely is estimated to be around 15 million each year. In Ghana, about 140,000
babies are born annually, and 8,400 of these babies are premature, who die before 30
days of life (Amadu, Twumasiwaa, & Fuseini, 2021).
In Namibia, because of the risk factors associated with survival of prematurity, it was
found that 26 babies died before reaching the age of one. However, intensive care
hospitalization causes a multitude of losses for the mothers, including the loss of the
idealized baby and the impossibility of being with the baby at home. Mothers who are
only spectators to the baby's care feel grief-stricken of their maternal role, unable to
recognize themselves as mothers, and frequently reluctant to accept and acknowledge
their baby because a team has taken over the care that, by default, she should be
delivering. Mothers frequently experience feelings of worthlessness, failure, and
inferiority. Any chance of connecting with the premature baby can be hampered due to
the sensitive time mothers and families are going through, which will disrupt the mother-
baby relationship. So, promoting the proximity of mothers to their premature babies
encourages the development of emotional attachments and, as a result, empowers
mothers to care for their babies. It is well established that a positive working relationship
between mothers and the nursing staff is necessary to promote attachment and the
mothers' continued presence in the NICU during the premature baby hospitalization

1
Veronez, Borghesan, Corrêa, & Higarashi, (2017).
Mothers have induced fear and an uncertain motherhood feeling towards the feeling of
being a real mother of her premature baby (Kashele, 2020). There is an increasingly
interest in mothers’ experiences when having premature baby admitted in NICU and
thus challenges nurses to not only focus on the developmental care of the premature
baby but enable mothers to go through the uncertain feelings. In general, the admission
of the premature baby in the NICU, poses more challenges in how the mothers have to
be separate from their babies and other babies at home, which causes strains on
mother baby relationship. Therefore, continuous support, information on meeting the
premature baby needs and positive reinforcement about their parenting is imperative
from the nursing staff to mothers (Shiweda, 2018).

A study conducted in South Africa identified a number of risk factors for premature birth
that also make it more difficult to provide for premature infants. They include the high
burden of disease, resource limitations on many different fronts, as well as societal
disparities pertaining to social determinants of health. Everyone agrees that having a
premature baby is difficult and stressful for the mother. Premature babies are
susceptible to a number of physical, neurological, and developmental issues that could
affect their current and future feeding abilities as well as the mother's experience.

Premature babies frequently exhibit neuro behavioral dysfunction as a result of their

neurological, sensory, and metabolic immaturity, which delays or disrupts the
development of skills necessary for efficient oral feeding (Van Schalkwyk, & Gerber,
2021). These abilities could include rhythmic sucking, planning a suck-swallow-breath
routine, and motor organization. When caring for their premature baby mothers have a
unique early parenting experience that could potentially change how the mother and
baby interact in the first few months of life. Low socioeconomic level mothers of
premature babies encounter additional difficulties that put them at risk and may have a
detrimental impact on how they care for their preterm infant (Van Schalkwyk, & Gerber,
2021). Risks arise from both the general difficulties of being a preterm mother and the
particular financial difficulties associated with each situation.

2
Poor mother-baby bonding and attachment, poor maternal mental health, and possibly
subpar feeding and communication development are all examples of this Van
Schalkwyk, & Gerber, 2021).

1.2. BACKGROUND OF THE STUDY

Every baby is born with an inherent ability to respond to the environment which
naturally dictates the interaction between mother and baby. When this natural
attachment is interrupted, for instance when the baby is born as a premature, then the
baby's emotional development is negatively influenced such that when the baby
requires care in a neonatal intensive care unit (NICU), it becomes difficult to establish
contacts between the mother and the premature baby. Separation between the mother
and the premature baby is found to be the most difficult occurrence for mothers when
their new-born baby is admitted in a NICU.

Admission at birth for a premature baby to the Neonatal Intensive Care Unit (NICU) is a
deviation from the norm of having a healthy pregnancy and childbirth. This admission to
the NICU gives rise to trauma, psychological distress, altered parenting roles, and
emotional and practical challenges for mothers since it alters mother-baby interaction as
the babies will be in the incubator (Valizadeh et al., 2012). Because of suckling
inabilities, the babies have to be fed through nasogastric tubes instead of breast milk.

In Namibia, Hospital A admitted 1124 babies between the period of April 2014 and
March 2015, and 60% of these numbers were premature babies, meaning that these
babies were delivered before nine months with less than 2.5 kg (Shiweda, 2018). In the
United States of America, nearly half a million premature babies are born each year and
the delivery has significant psychological implications for mothers due to a longer stay in
the NICU (Kerthu & Maano, 2019).

Premature birth is an unexpected event or a medical complication that is experienced by

mothers, interrupting the pregnancy and resulting in an emergency, and mothers are
normally not braced for it. These babies are born with low weight and physiological

3
immaturity that requires NICU admission for vital signs monitoring and nutrition control.
Therefore, hospitalisation in the NICU is for a significantly longer period, and premature
babies that have complications and are critically ill require intensive nursing care, and
professional people are required to take care of them (Nazari, Moradi, Rezaie, Akbari,
Qolizadeh, & Sabzi, 2020). Some babies admitted are sick and cannot take breast milk
or take a bottle yet, hence tube feeding is used to supplement their nutrition or by
formula, and the tubes are often changed. These activities may include or exclude
mothers in the care of their babies and this may induce a sense of being unhelpful
(Manning, 2012).

This experience of babies being in the incubator breeds fear in mothers whereby they
may fear touching their premature babies in the incubator for different reasons which
include lack of control, limited knowledge of the incubator’s functionalities and fear of
making mistakes. Unfamiliar instruments and machinery connecting to the premature
baby can pose many emotions to the mother. A feeling of exclusion then takes over as
the mother may feel a lack of interaction and a sense of not belonging to the NICU or
the care of their premature baby (Steyn, Myburgh, & Poggenpoel, 2017). This has a
negative effect on her maternal feelings as compared to the contrary when a feeling of
participation dominates and a continuous dialogue exists. When the mother is supported
by an individualised approach to care and appropriate communication is used,
attachment can be facilitated (Nazari, et al., 2020). The mother is cared for as a unique
person with unique needs and this supports her maternal feelings in a positive manner.
Nursing care practice limits maternal stress by creating opportunities for mothers'
involvement in tube feeding, and thereby ensuring that positive effects are attained for
their well-being. The care of premature babies by professional nurses plays a key role
in ensuring the start of positive mother-baby interactions (Russell, Sawyer,Rabe, Abbott,
Gyte, Duley, & Ayers, 2014).
The implication for nurses and other health professionals is that it is important to
decrease mothers’ experience of exclusion and to increase their feeling of participation
when their premature baby is cared for in the NICU. A return visit to the responsible
nurse to go through the treatment and experiences should be offered to all mothers

4
whose premature baby has been cared for in the NICU and the provision of adequate
information by nurses to mothers during this time is imperative. Nursing staff can further
dispel the mothers’ fretting by urging them to participate in the care of their premature
babies (Amadu et al., 2021). By continuous communication and motivating the mothers
to develop a relationship with their premature baby, their stress and anxiety are
dispelled. Research shows that active parent participation in the care of the premature
baby promotes the bonding of the parent with the premature baby. The mother with a
baby in the NICU develops from being an outsider to being an engaged parent and her
stress and anxiety for the premature baby can be reduced. Parental participation in the
care of the premature baby can include social activities such as talking to the premature
baby, as well as holding, touching, bathing and feeding the premature baby in the NICU
(Medina, Granelo – Molina, Fernandez-Sola, Hernandez-Padilla, Avilla, & Rodriguez,
2018).
In some settings, mothers with preterm babies are not accommodated in the hospital
facility but are permitted to see their babies for a given period of time though the time is
limited. In some instances, mothers live far away from the hospital and they may need a
support system to be able to cope with an unexpected event. It is imperative to
understand the mother's experience when in this unique environment and thus be able
to recognise their needs and address them effectively (Kohan, Borhani, Abbaszadeh,
Sultan Ahmadi, & Khajehpoor, 2020). When the mothers are discharged from the
maternity care unit, practical problems emerge as there are no beds or space in the
NICU for the mothers who have a premature babies admitted in the NICU. When a
premature baby requires care in the NICU, it is not always possible for the mother to be
there in the hospital during the whole period. The parents are encouraged to be with
their premature babies and participate in their care whenever possible though with
limited restrictions and time allocations given for visitation.

Understanding mothers' experiences allows and assists clinicians to identify disparities

in care. This can aid with future work and increase care accessibility for mothers with
babies when admitted to the NICU. Literature has shown a deficit in examining the
relationship between the distress of mothers and the NICU hospitalisation of non-

5
mothers (Medina et al., 2018). Thus this study aimed to explore the experiences of
mothers with a baby admitted to the NICU, to inform clinical practice and future
research.

1.3. PROBLEM STATEMENT

The birth of a premature baby can disrupt normal mother-baby physical contact and the
care provided by the mother. Caring for premature babies in the NICU may bring
challenges on a practical and emotional level and this may be demanding in terms of
the time and financial support for the mother. Premature babies are separated from their
mothers during the period of care in the NICU and mothers may have emotional
burdens due to the separation from their babies. Premature babies are often given
expressed breast milk, and depending on where mothers live, some have to come to the
NICU every day to express breast milk or they may be kept as lodgers in the hospital.
This may complicate the mother-baby early interaction and there might be lessened
parental satisfaction due to a lack of active participation and mothers spending less time
with their babies. There is also a lack of an effective approach to the mothers’
associated needs because of their babies' survival and growth and the different
experiences they gather when babies are being admitted to the NICU. A more
personalised and supportive NICU environment for mothers needs to be researched to
benefit mothers and their experiences whilst their babies are in the NICU (Russell et al.,
2014). Not much-written evidence on the experiences of mothers with a premature baby
that is admitted to NICU in hospitals in Windhoek, Namibia, is available, hence this
research sought to fill in this gap.

1.4 PURPOSE OF THE STUDY

The purpose of the study was to explore and describe the experiences of mothers with
premature babies admitted to the NICU in selected hospitals in Windhoek, Namibia.

6
1.5 OBJECTIVES OF THE STUDY

The objectives of the study were to:

 Explore the experiences of mothers with a premature baby admitted to the NICU in
selected hospitals in Windhoek, Namibia;
 Describe the experiences of mothers with a premature baby that is admitted to the
NICU in hospitals in Windhoek, Namibia; and
 Factors that influence the presence of mothers at bedside of premature babies
admitted to the NICU at hospitals in Windhoek, Namibia.

1.6 RESEARCH QUESTION

The study consisted of the main question followed by probing questions.

Main question:
“How did you feel when your baby was admitted to the NICU”?

1.7 SIGNIFICANCE OF THE STUDY

The findings of this study can benefit the IUM Research Committee by contributing to
the body of scientific knowledge. The study may provide guidelines and serve as the
basis for decision-making for both the NICU nursing team in Hospitals A & B and the
Ministry of Health and Social Services (MOHSS), Namibia. In addition, the findings
might serve as an educative and awareness tool regarding care and treatment for
mothers and baby care for the NICU nursing personnel. The researcher, as a registered
nurse, will benefit from the results of this study by gaining increased knowledge and
better health advocacy for the future.

1.8 DEFINITION OF KEY CONCEPTS

Experiences

7
Experience is something personally encountered, undergone, or lived through (Brink &
van Rensburg, 2016). An experience is an “event” or occurrence which leaves an
impression on someone (Mish, 2004). For this study, the experience is defined as an
impression left on the mothers when babies are admitted to the NICU.

Prematurity
Prematurity is when a baby is born before 37 weeks of pregnancy (Mish, 2004).
Premature birth is a birth that takes place more than three weeks before the baby's
estimated due date (Mish, 2004). For this study, the definition for prematurity is babies
born before 37 weeks of pregnancy.

Neonatal Intensive Care Unit (NICU)

The Neonatal Intensive Care Unit is a specialised area of a hospital solely for the
treatment of ill or premature new-borns (Mish, 2004). The Neonatal Intensive Care Unit
is a specialised area of the hospital where babies who need intensive medical care are
admitted (Mish, 2004). In this study, it is defined as a place where new-borns born
prematurely are admitted.

Mother
A mother is a female of a child, who performs the role of bearing some relation to their
children (Mish, 2004). A mother is a woman to her child (Mish, 2004). For this study,
mothers are defined as the ones taking care of the baby.

1.9 ETHICAL CONSIDERATIONS

An approval letter to conduct the research and collect data was granted by the
International University of Management (IUM), Ministry of Health and Social Service
(MOHSS), National Commission on Research Scheme & Technology (NCRST), and
Hospitals A & B. These authorities gave an approval letter for the research to be
conducted.

APPROVAL LETTERS

8
The approval letters were from the IUM Research Committee, Ministry of Health and
Social Services, and the Matron’s Office of State Hospitals A and B in Windhoek,
Namibia. The authority to carry out the study, the topic of study, the place of study, and
the research framework were sanctioned by the MOHSS.

WRITTEN INFORMED CONSENT

Written informed consent is an ethical principle of research ethics that prospect
participants to participate voluntarily in a study with full information as to what it means
for them to take part in the study (Brink, van der walt, & van Rensburg, 2016).
Participants were verbally informed about the study and participants were allowed to
ask questions regarding the study and they were given a written informed consent form
to sign before data collection.

CONFIDENTIALITY
Confidentiality represents an agreement that is formed between the researcher and
participant, via the informed consent process, that ensures the participant's identity,
personal information, responses (Barnhill, & Barnhill, 2014). Participants were assured
that the information they shared was protected by the use of a password to the audio
recordings and would never go beyond other people not related to this research and
that the participants’ information was to be kept confidential from other participants at all
times. The researcher used security updates, firewalls, antivirus software, and strong
passwords for the computer to decrease the chance of disclosing the data to
unauthorized individuals. Whenever a computer is infected with malware, all data on the
hard drive is captured. In the event that the device is lost or stolen, the researcher
deployed deactivation techniques using a mobile device( Halvorsen, Harvey, de Ruiter,
& Jerpseth, 2021).

RIGHT TO PRIVACY
It is the participants’ right to control the amount of information they want to reveal about
themselves (Brink et al., 2016). Data were collected one on one in a closed room. Data
recorded were kept safe and never shared with other people that were not part of the

9
research, but only with the authorised persons and the IUM research committee.
The records and audio recordings were kept secure through the use of a password to
the protected files.

ANONYMITY
Anonymity is the researcher's responsibility to prevent all data gathered during the study
from being linked to individuals or participants (Brink et al., 2016). Anonymity also refers
to the idea that information collected from the participants will remain confidential and
nameless (Halvorsen, Harvey, de Ruiter, & Jerpseth, 2021). Participants' identities
were kept secret and no link between participants and data collected was done. This
means that research data was collected and the researcher did not record any personal,
numbers, names or identifying information.

AUTONOMY
Autonomy is the recognition of participants’ rights and the respect for individual informed
decision about whether to participate in the research or not (Polit & Beck, 2009).This led
to the emphasis on autonomy as a fundamental value to safeguard people's freedom to
make their own decisions. The autonomy principle thus refers to individual autonomy
and the right to be free from outside intervention. Respect for competent participants'
autonomy is seen as a universal and unbreakable moral standard in the field of health
ethics (Halvorsen, Harvey, de Ruiter, & Jerpseth, 2021). Participants had the
information and understanding necessary to make an autonomous choice, and they
were also aware that their participation in the study had to be voluntary and
uncompelled (Barnhill, & Barnhill, 2014). The researcher informed the participants about
the study and they in turn decided to participate and they were aware that they could
withdraw from the study at any time without any penalty.

BENEFICENCE
Beneficence is the right to protect people from discomfort (Polit & Beck, 2009). The
moral duty to act in others' best interests and reduce danger during the research
process is reflected in beneficence (Halvorsen, Harvey, de Ruiter, & Jerpseth,

10
2021).The benefit has to outweigh any present or future hazards to participants.
Interviews were conducted in an environment where a closed door was available, with
good ventilation and a comfortable chair to sit (Barnhill, & Barnhill, 2014).

NON-MALEFICENCE
Non-maleficence is the principle of dictating that harm should not come to individuals as
a result of their participation in a research project (Brink et al., 2016). Avoiding harm to
research participants' personal safety is referred to as non-maleficence (Barnhill, &
Barnhill, 2014). Participants were monitored for any signs of distress and debriefing was
done to allay anxiety. In this study, participants were notified during granting of the
written informed consent that if they felt uncomfortable in answering any of the
questions, they may leave at any stage of the interview.

PRINCIPLE OF JUSTICE
The principle of justice refers to the participants' right to fair selection and treatment
(Brink et al., 2016). And finally, conducting health research must adhere to the moral
requirement of justice. The foundations of justice can be found in prehistoric philosophy
(Barnhill, & Barnhill, 2014). The theory is still relevant and extremely applicable on a
global scale, nevertheless. The researcher ensured that fair selection occurred and that
all who wished to participate in the study were welcome to do so without any
manipulation. Participants' selection was directly related to the problem and data
saturation. No promise or reward was given to participants.

1.9 CHAPTER SUMMARY

This chapter focused on the introduction and the background of the study, the problem
related to the study and its objectives, the purpose of the study, the significance of the
study, definition of key concepts, research question and the ethical principles of
research. The next chapter focusses on the research methodology.

11
 CHAPTER TWO
RESEARCH METHODOLOGY

2.1. INTRODUCTION

The previous chapter discussed the introduction and the background of the study, the
problem related to the study and its objectives, the purpose of the study, the significance
of the study, a definition of key concepts, the main research question and the ethical
principles of the research. The present chapter focusses on the research design,
population, sampling methods and sampling size, pilot testing, the data analysis
method, trustworthiness, research philosophy and theoretical framework. The research
methodology is an overarching plan of action and a principle for a research project. The
studying of the methods used in the field as well as the theories and the principles
behind the methodology process helps to develop a formula that matches the study
objectives. The researcher used the methodology as a specific procedure or technique
to identify, select, process, and analyse the information about the experiences of
mothers with premature babies admitted to the NICU.

2.2. RESEARCH DESIGN

A research design is a strategic framework for action that serves as a bridge between
theory and the implementation of research (Brink et al., 2016). The research design is
an overall strategy integrating different components in a coherent and logical way to
ensure the effective addressing of the research problem (Polit & Beck, 2009).
Qualitative exploratory, descriptive, and contextual approach was used for this study.
By utilising this approach, the researcher was able to comprehend and explain the
meaning of what participants experience during their daily lives, namely the experiences
of mothers with premature babies admitted in the NICU in this context.

12
2.2.1 QUALITATIVE APPROACH

A qualitative research design is concerned with establishing answers to the ‘whys’ and
‘hows’ of the universal essences of a phenomenon in a research study. The relevance of
a qualitative approach in this study lies in that it describes habits in a manner that gives
ideas as to what could be contributing to certain behaviours or habits (Thomas &
Hodges, 2010; Polit & Beck, 2009). The qualitative research approach seeks to
understand and describe the experiences of mothers with premature babies admitted to
the NICU.

2.2.2 EXPLORATIVE APPROACH

An explorative approach is a methodological approach that explores research questions
that have not previously been studied in depth (Thomas & Hodges, 2010; Sih et al.,
2019). The explorative approach was found to be suitable for this study because it could
help to explore the experiences of mothers after their premature babies were admitted
to the NICU as a way to develop new knowledge.

2.2.3. DESCRIPTIVE APPROACH

The descriptive approach is used to describe the characteristics of a population (Polit &
Beck, 2009). In a qualitative study, a descriptive approach aims to have a
comprehensive summary of events and it allows the researcher to be immersed in data
and not just the surface of words and events. Qualitative descriptive designs are
typically a reasonable combination of sampling, data collection, analysis, and
representation techniques (Kloppers, 2008). This approach was used in the present
study because the researcher sought to describe the phenomenon of the experiences of
mothers with premature babies admitted to the NICU.

2.2.4. CONTEXTUAL APPROACH

A contextual approach considers the relationship between individuals and their physical,
cognitive, and social worlds (Springer, 2009). In this design, we used a contextual
constructivist approach to describe the context, mechanisms, and outcomes in exploring
mothers' experiences whilst their premature babies are admitted in the NICU
(Stellwagen, van Kempen, Westmaas, Vet, & Scheele, 2021).

13
2.3. RESEARCH METHOD

The research method refers to the strategies, processes or techniques utilised in the
collection of data or evidence for analysis in order to uncover new information or create
a better understanding of a topic (Brink et al., 2016). Research methods consist of a
target population, sampling method and sample size. In this study in-depth interviews
face to face were done and researcher’s aim was to understand respondent's point of
view, experiences, feelings, and perspectives. Interviews were done with mothers with
premature babies admitted in NICU of Katutura Intermediate and Windhoek Central
Hospitals respectively.

2.3.1. TARGET POPULATION

A population refers to the collective set of individuals which are of relevance to the
research and it is the source of answers during the research process (Polit & Beck,
2009). The population was mothers with premature babies admitted to the NICU of state
hospitals A and B in Windhoek, Namibia. State hospitals A & B had admitted 668
premature babies from January to June 2022 before the commencement of the data
collection.

2.3.2 SAMPLING METHOD

Sampling is a process in which a researcher chooses a sample (Thomas& Hodges,

2010). A non-probability, purposive, convenience sampling was used based on the
availability and willingness of the participants to take part in the interviews. A sample
was drawn from mothers of babies that were admitted to the NICU in hospitals A & B of
Windhoek, Namibia, from the period of February to June 2022. For this study, sampling
was based entirely on the researcher’s judgment. Participants who were able to speak
English and willing to participate in the study were interviewed.

2.3.3 SAMPLE SIZE

A sample is a subset or infinite part of a statistical population whose properties are

studied to gain information about the whole population (Polit & Beck, 2009). The sample
size was twenty (20) participants. The sample size was determined by saturation of data

14
about the dense description of the experience of mothers. Saturation of data means that
respondents provide no new information or that there is redundancy of previously
collected data (Burns & Grove, 2007).

15
2.4 RESEARCH PHILOSOPHY

The philosophy of qualitative research is interpretive, humanistic and naturalistic

(Creswell & Tashakkori, 2007). Constructivism is a theory of learning based on the idea
that knowledge is constructed by the knower based on their mental activities (Polit &
Beck, 2009). This philosophy was incorporated in the present study because it is
relevant and the truth is relatively constructed by individuals. In this study,
constructivism emphasises mothers' understanding and knowledge of the world through
their experiences and reflection during the nursing care whilst their premature babies
are admitted in the NICU. It has a reality that is perceived to be subjective and a
construct of the human mind (Polit & Beck, 2009).

2.5 THEORETICAL FRAMEWORK

A theoretical framework is the use of theories in a study that simultaneously conveys the
deepest values of the researcher(s) and provides an articulated signpost or lens for how
the study will process new knowledge (Deeney, Lohan, Spence,& Parkers, 2012). The
theoretical framework used was the Humanistic theory which stresses that human
beings are inherently good. Humanistic basic needs are vital to human behaviours and
they have an important place in human beings, their meaning, and action in research
(Polit & Beck, 2009). In this study, the researcher provided respect for human beings
and sought to improve the state of humankind. In this study, mothers’ feelings, paying
attention to their individuality and respecting their rights were an important concern. The

essence of humanistic care in this study was the thinking of people-oriented

existence, value, freedom and development and the complex emotions that were

brought by baby admitted in NICU.

2.6 PILOT TESTING

Pilot study is a small-scale of a proposed study that is conducted before the actual
experiment that is designed to test and refine procedures (Fraser Fahlman, Arscott, &
Guillot, 2018). A pilot test of the interview guide was done for clarity, meaning, and

16
ambiguity to ensure that questions are clear and that participants understand what is
meant by the research question (Brink et al., 2016). The pilot test was done on four
mothers of premature babies that were admitted to the NICU with two mothers from
hospital A and two mothers from hospital B before the actual research and the results
from the pilot study were not included in the final data analysis. During the pilot study
the researcher noted that participants did not understand the probing question which the
question was then designed to be specific to how they felt.

2.7. DATA COLLECTION METHOD

Data collection is the methodological process of gathering information about a specific
subject (Brink et al., 2016). An in-depth face-to-face interview was used to collect the
data relating to the research questions. Interviews were conducted every Tuesday and
Thursday three times in a month in state hospital A and B. Participants were found
sitting in the waiting area expressing breast milk and waiting for visiting hours in the
NICU. The interviews were done in a closed room where one on one interviews were
held for privacy and confidentiality. The interview room had a chair for the researcher in
one corner and a bed on the side where mothers had to sit. The researcher introduced
herself to the participants and they were informed about the study and that their
participation was voluntary. Those who decided to participate in the study were told that
their participation was free and that there was no payment or favour that would be given
to them for participating in the study. Informed consent was explained to participants,
that they could withdraw at any time if they would feel uncomfortable to continue with
the study and that they could do this without judgement. Permission was asked for the
researcher to use an audio recorder to record all verbal communication and note taking
was done for all non-verbal communication. The main question that was asked was:
“How did you feel when your baby was admitted to the NICU”? This was followed by
probing until data saturation.

2.8. DATA ANALYSIS METHOD

Data analysis is an interpretive process that focuses on the subject to explore the
similarities and differences of experience (Polit & Beck, 2009). The researcher listened

17
to the audio recordings and read through the notes. Then the data were transcribed
verbatim (word-for word). Tesch's open colour coding was used to categorise concepts
that have the same meaning into key themes and sub-themes.
Techs’s Steps used:
 Step 1: The researcher attentively read through each recording to gain a
thorough comprehension of it before taking notes as they occurred.
Step 2: The most intriguing data document in the stack was read more for its
context than its actual substance. The researcher writes down the ideas in the
document's margin once more.
Step 3: Upon the completion of all interview materials, a list of all notions was
created, and comparable concepts were grouped together. Three separate
columns were created to reorganize these ideas.
Step 4: The researcher went over the information again, coded the concepts, and
added the codes next to the relevant passages of text. To explore if any new
categories might be discovered, the researcher tested out this prototype data
organization method.
 Step 5: The researcher attempted to categorize the concepts using the most
evocative language possible. The number of categories was decreased by
combining similar topics. By creating lines between the categories, the
researcher continued to capture interrelationships.
Step 6: Data was managed by coding and categorizing occurred as soon as data
collection began.
Step 7: Grouping the data to produce themes and development of themes was
facilitated manually.
 Step 8: The coded data was placed into large groups and synthesized to show
how the topics produced interrelated. (Creswell, 2006).

2.9. TRUSTWORTHINESS / MEASURES

Trustworthiness is a process that establishes the validity and reliability of qualitative
research. Kloppers (2008) suggest that quality research is trustworthy when the
experiences of the study participants are presented accurately. The feelings, ideas, and

18
opinions of participants can be described qualitatively. Thomas and Hodges (2010)
describe the four general criteria which are namely: truth value, applicability,
consistency, and neutrality, and the strategies of credibility, transferability, dependability,
and confirmability were incorporated in this study.

Table 2.9.1 CRITERIA AND THEIR APPLICATIONS FOR TRUSTWORTHINESS

Strategy Criteria Applications
Credibility Prolonged engagement The researcher spent
sufficient time with the
preparation of field work
and data collection until
saturation was reached

Member checking Research data was

Transferability Purposive sampling
Dense description
Dependability Dependability audit
Coding
Confirmability Reflective analysis
constantly checked with
respondents to confirm that
the responses are those of
participants
A sample of mothers with
premature babies was
purposively selected owing
to it being suitable for the
aim of the study
A broad description of data
collection methods was
given. Findings and
literature control were
provided for clarity.
Verbatim quotes were
provided as part of the
description of findings
Data were recorded and
can be retrieved when
needed and data findings
were controlled with related
literature
Themes and categories
identified were agreed on
by the researcher and the
research supervisor
Field notes and audio

19
 recorder are available upon
enquiry

CREDIBILITY
Credibility is the confidence that can be placed in the truth of the research findings. The
researcher has to ask if the findings are representing plausible information drawn from
the people being studied (Polit & Beck, 2009).This concept is analogous to internal
validity in quantitative research (Connely, 2016). The researcher spent sufficient time
with the preparation of field work and data collection until saturation was reached. Field
notes were taken and data was constantly checked with respondents to confirm that the
responses are those of the participants. A reader can inquire, "Was the study carried out
using conventional procedures normally utilized in the stated qualitative approach, or
was an appropriate rationale offered for variations?" Thus, a grounded theory study
should be carried out similarly to other grounded theory investigations (Connely,
2016);Dikobe, Moagi, & Sehularo, (2022).

TRANSFERABILITY
Brink et al. (2016) state that external validity is the degree to which the results can be
generalised to other settings. The nature of transferability, the extent to which findings
are useful to persons in other settings, is different from other aspects of research in that
readers actually determine how applicable the findings are to their situations (Connely,
2016). The researcher can apply the findings in other contexts or to other participants.
The researcher ensured the provision of a thick description of the research design,
findings and literature control to ensure clarity (Connely, 2016). Verbatim quotes were
provided as part of the description of findings. A qualitative study's transferability may be
difficult. This study is grounded on a theoretical framework, as recommended by Dikobe,
et al., (2022), to promote transferability. Another procedure known as transferability
enables other researchers to use the study's findings in their own context.

20
DEPENDABILITY
Dependability is the provision of evidence such that if it were to be repeated with the
same or similar participants in the same or similar contexts, its findings would be similar
(Brink et al., 2016). Connely, (2016), also refers dependability to the stability of the data
over time and over the conditions of the study. The enquiry auditor, generally a peer,
verifies the processes and procedures used by the researcher in the study and
determines whether they are acceptable and dependable (Makhene, 2019). Related
literature was used to control data findings. A comprehensive description of data
collection methods, coding, themes and sub-themes identified were agreed on by the
researcher and research supervisors.

CONFIRMABILITY
According to Brink et al. (2016), confirmability is the process that guarantees that what
the researcher has found and given as a conclusion and has made as a
recommendation can be supported by her data and that there is a link and agreement
between the investigation and what was initially found. Connely, (2016), refers to
confirmability as the neutrality or the degree findings are consistent and could be
repeated. This is analogous to objectivity in quantitative research. There is an ability for
potential congruency if the conclusion can be transferred to other contexts of data in
terms of accuracy, relevance or meaning. Qualitative researchers keep detailed notes of
all their decisions and their analysis as it progresses. In some studies, these notes are
reviewed by a colleague; in other studies, they may be discussed in peer-debriefing
sessions with a respected qualitative researcher. These discussions prevent biases
from only one person’s perspective on the research Connely, (2016). It means that data
were recorded, written, and analysed into key themes and sub-themes (Makhene,
2019).

2.10. CHAPTER SUMMARY

This chapter focused on the research methodology and the research design, that is, the
qualitative, explorative, descriptive, and contextual approach which was applied to the

21
study. Research methods, the target population, sampling method and sampling size,
research philosophy, theoretical framework, pilot testing, data collection and methods
and analysis of data and trustworthiness were discussed. The next chapter focuses on
data analysis and literature control.

22
 CHAPTER THREE

DATA ANALYSIS AND LITERATURE CONTROL

3.1 INTRODUCTION
The previous chapter focused on the research methodology, research design:
qualitative approach, explorative, descriptive, contextual approach, research methods,
target population, sampling method and sample size, research philosophy, theoretical
framework, pilot testing, data collection methods and analysis of data and
trustworthiness, as were applied to this study.

The present chapter discusses the analysis of data and literature control. Qualitative
study results are presented in a narrative format using participants’ direct quotations and
supported by existing literature. The concepts with the same meaning in the data are
categorised with key themes and sub themes.

The key themes and sub-themes are:

 Key themes 1: Participants expressed different emotions. Sub-themes: mothers
had fear of touching the baby in the incubator; mothers felt very scared when the
baby was fed with different feeding methods, such as nasogastric tubes; Mothers
felt anxious about the well-being and survival of the baby; mothers needed
emotional support through family and counselling; mothers felt disheartened
because of financial struggle; absence of accommodation facilities was stressful;
mothers felt very happy with the baby’s condition when there was a positive
outcomes of the treatment; mothers’ spirituality was positively changed through
prayer.
 Key theme 2: Nursing care given to babies. Sub-themes: mothers were grateful
to nurses because they helped take good care of the babies; nurses were

23
 stressed, rude, and failed to provide good care in that they neglected the babies
and were not willing to answer to questions.
 Key theme 3: Communication between the mother and the healthcare members.
Sub-themes: Healthcare personnel lacked in giving information regarding the
progress of the baby's health condition; nurses were communicating with mothers
regarding the care of their babies.

3.2 DATA ANALYSIS AND LITERATURE CONTROL

PRESENTATION OF THE FINDINGS

During the data analysis, three (3) major themes and twelve (12) related sub-themes
were identified. They reflected the lived experiences of mothers with premature babies
admitted to the NICU. These themes and sub themes are outlined in table 3.2.1:

TABLE 3.2.1

THEMES SUB-THEMES

1. Participants expressed There were different kinds of emotions expressed

different emotions
by the participants:
 Mothers had fear of touching the baby in
the incubator
 Mothers felt very scared when the baby
was fed with different feeding methods
such as nasogastric tubes
 Mothers felt anxious about the well-being
and survival of the baby
 Mothers needed emotional support
through family and counseling
 Mothers felt disheartened because of
financial struggles
 Absence of accommodation facilities was

24
 stressful
 Mothers felt very happy with the baby’s
condition when there was a positive
outcomes of the treatment
 Mothers’ spirituality was positively changed
through prayer

2. Nursing care given to baby  Mothers were grateful to nurses because

they helped take good care of the babies
 Nurses were rude and failed to give good
care in that they neglected the babies

3. Communication between mothers  Healthcare personnel (medical and

and the healthcare members were nursing) failed to give information
mentioned regarding the progress of the baby's health
condition
 Nurses were communicating with mothers
regarding the care of their babies

3.3.1 KEY THEME ONE: PARTICIPANTS EXPRESSED DIFFERENT EMOTIONS

Emotions are defined as strong feelings deriving from one's circumstances, mood, or
relationships with others (Mish, 2004). Furthermore, emotions are derived from stress
as a stimulus such as pain or out-of-control circumstances that can lead to an emotional
imbalance (Amadu et al., 2021). In this study, emotions are described as the unpleasant
feelings mothers experience when a premature baby is being cared for in the NICU.

The current research revealed and demonstrated that the premature birth of a baby and
the baby's consequent care in a NICU environment elicit powerful emotions and
thoughts in mothers. It also showed that there is a need for nurses to recognise
mothers’ unfulfilled needs because those needs induce stress and may intensify into

25
worse situations that may impact mothers even after discharge. These experiences of
emotions may have long-lasting effects on the mothers and how the mothers will relate
with their babies.

The research results also show that upon admission of babies in the NICU, mothers’
response to the event becomes stressing, thereby affecting their emotions, thoughts,
feelings, and their relationships with their premature babies and those around them.
This study results demonstrates that having a premature baby delivered and then being
admitted to the NICU is an emotionally taxing time filled with difficulties. Mothers'
experiences while being admitted to the NICU influenced how they saw their baby
surviving. These findings are crucial in identifying the particular difficulties mothers of
premature babies admitted in NICU experience (Namusoke, F., Sekikubo, Namiiro, &
Nakigudde, 2021).

Sub-themes that were generated from mothers’ emotional experiences were as follows:
Mothers felt very scared when the baby was fed with different feeding methods such as
nasogastric tubes; mothers felt anxious about the well-being and survival of the baby;
mothers needed emotional support through family and counselling; mothers felt
disheartened because of financial struggles; the absence of accommodation facilities
was stressful; mothers felt very happy with the baby’s condition when there was a
positive outcome of the treatment; and mothers’ spirituality was positively changed
through prayer.

SUB -THEME ONE: MOTHERS HAD FEAR OF TOUCHING THE BABY IN THE
INCUBATOR

Participants experienced fear of touching their babies whilst their premature babies
were in the incubator. It is a possibility from the research that at this stage, the
premature babies are very tiny and sometimes in a bad state and that did not help in
terms of mothers fearing to touch them.

The experiences of the participants were discussed as follows:

26
“The moment I saw her in those oxygen pipes in the incubator I was scared to touch her
and I cried, I was emotional”.

“I was scared to touch her whilst in the incubator.”

The premature baby's fragility and the demanding NICU environment can be the main
contributing factors. The results of this study show that the majority of mothers found the
NICU atmosphere to be difficult. It followed other experiments in which the main
stressors were tubes and the, use of the incubator on the premature baby – lying in
there and some of which produced distinct sounds to warn the staff on the physiological
happenings of the baby. Mothers have reportedly been impacted by the NICU
environment, particularly mothers who take on the duty of caregiving (Abeasi, & Emelife,
2020). Thus, the physical environment can be crucial in reducing motherly stress and
fostering contentment, which is consistent with a study by (Williams, et al., 2018). Some
researchers have emphasized the significance of early challenge identification and
implementation of essential remedies. If this is feasible in the long run, it would lessen
the difficulties these mothers encounter upon their premature babies being admitted
(Abeasi, & Emelife, 2020).

According to studies by Abeasi and Emelife, (2020), the NICU environment is still
stressful for mothers. The separation of mother and baby during this time is a concern
particularly when they fear to touch their babies because that will result in reduced
baby-mother attachment or bonding and interaction. This means that there is a
possibility that they may not be care givers but mere bystanders who feel deprived of
their role as mothers. Furthermore, their fears are elevated and issues of withdrawal
and emotional breakdown come into play. In these daunting experiences, it becomes
important that mothers are urged and encouraged deliberately to exercise bonding
through touching their babies (Kohan et al., 2020).

The research found that it is common for most mothers to fear touching their babies
whilst they are in the incubator when admitted to the NICU. These experiences result in
harbouring feelings of worthlessness and non-achievement as mothers when they fear
touching the baby in the incubator. All these delicate issues faced by mothers

27
compromise the possibility of bonding with the baby and they cause disorders in the
mother and baby relationship (Lomotey, Bam, Diji, Asante, Asante, & Osei, 2020).
Therefore, mothers need to be encouraged to hold, touch, feed or perform any small
caring activities that involve touching their babies. From a professional point of view, it is
crucial to understand the situations, feelings, and experiences mothers go through when
dealing with trauma and challenges related to the events that arise during a baby's stay
in the NICU ( Shoghi, Peyrovi, & Alinejad-Naeini, 2021).

Previous studies on this subject has shown that mothers' reactions to a baby's
premature birth, as well as the care that follows in an intensive care unit (ICU), are
strong. Mothers' encounters left a lasting impression on them and every relationship
they had. Lomotey, et al. (2020) demonstrated that mothers are frequently unprepared
for the exposure of their babies and themselves when babies are admitted to the NICU.
According to our findings, which are in line with earlier research, mothers develop fears
and uncertainties about their premature baby's survival as a result of their daily
interactions with them. They may also wonder whether nurses are truly caring for the
premature baby in the same way that they would as mothers. Sometimes, mothers'
expectations of themselves, their children, and the nursing staff are unrealisable and
unmet Gutiérrez, Garca, Prellezo, Paul, Del Castillo, & Sánchez (2020); (Horwood, et
al., 2019).

In a study done in Ghana, participants had fear of touching the babies because they
thought that something would go wrong. It was also owing to the fact that the equipment
was unfamiliar and strange. The study findings are in agreement with the current study
findings that routine care was provided in the incubator and yet it was noted that the
incubator alarm is anxiety-provoking and elevates mothers’ stress levels. The mothers
were also scared of touching their babies and they were not sure how to operate the
incubator, hence orientating them is imperative (Parsa, Karimi, Basiri, & Roshanaei,
2018).

Other studies mentioned the constant alarms and noise of the incubator whilst babies
were sleeping added to the participants’ fear to touch their premature babies as they

28
had no idea as to what was happening. This caused them to miss the baby’s growth and
small milestones. This is reason enough to emphasise the need for mothers to be well-
versed with the equipment, because equipment might be strange to the mothers and the
NICU environment might be overwhelming (Amadu et al., 2021). According to Buys &
Gerber (2021), women had typically uncomfortable hospital visits, noting that seeing
their premature babies in incubators surrounded by loud monitors and tubes made them
feel worried out and made them associate the medical procedures with their babies
medical susceptibility. Mothers of preterm infants seem to be generally in agreement
with these findings (Garti, et al., 2021; Steyn et al. 2017).

On the contrary, some mothers had to find ways to overcome their fears and be in touch
with their babies whilst in the incubator. This is in agreement with some studies that
reveal a different outlook that some mothers would insist on touching their babies (Steyn
et al., 2017). In addition, some participants grew out of their fear and that effort helped
them to remain besides their premature babies, learn how to operate the incubator and
thus increase their chances of attachment. In consistent with other researchers, it was
found that participants in a study conducted in Australia expressed fear to touch their
premature babies. And yet staying close, touching, and bonding with premature babies
had tremendous benefits for mothers in that they could find coping strategies (Adcock,
Cram, Edmonds, & Lawton, 2021). Not only did they find coping strategies but they
were able to touch their babies whilst they were in the incubator and by so doing they
experienced joy and happiness, thus alleviating their stress levels owing to fear. In
addition, these experiences showed that the attachment and involvement of mothers in
touching their babies led to the maturation and improvement of babies and increased
the emotional well-being of mothers as well (Sih, Bimerew, & Modeste, 2019).

Several studies have shown how the neonatal unit's technology environment can be
overwhelming for mothers and how it may have an impact on the attachment process,
especially when the premature baby is in the incubator. The sight of so many premature
babies hooked up to various monitors and strange gadgets shocked the mothers. In a
four-interview phenomenological study including seven mothers of preterm children, it
was discovered that mothers did not report having been negatively impacted by the

29
extremely ill newborns being cared for in the incubator in the NICU. While they wanted
to help with their babies' care, some mothers were unable to handle the circumstance.
The mother's perception of her own well-being and the well-being of her children may
be impacted by attachment processes that are delayed or difficult (Adcock, et al., 2021);
Garti, et al., 2021).

Premature mothers in Ghana nursed their premature babies in incubators to provide

warmth and were first given intravenous hydration treatment and oxygen to help them
feel better. At first, mothers were wary of the apparatus and unable to make personal
contact with their preterm infants through touch. In this study, mothers' initial interaction
with their premature babies was impeded by these environmental conditions as well as
other previously associated worries. Additional studies revealed how the technologically
advanced atmosphere of the neonatal unit impacts physical touch between the mother
and the baby and puts their interaction in danger. According to other studies, mothers
typically feel responsible for the growth and development of their premature babies
(Amadu, et al., 2021),(Abeasi, & Emelife, 2020).

SUB-THEME TWO: MOTHERS FELT VERY SCARED WHEN THE BABY WAS FED
WITH DIFFERENT INSTRUMENTS SUCH AS THE NASOGASTRIC TUBE

Usually, premature babies are born without the ability to respond to maternal alerts like
suckling reflexes amongst other issues and this deprives them from responding to
breastfeeding, thus nasogastric tube feeding becomes the only viable option. In this
study, because mothers’ participation through breastfeeding was different, they had no
such option, hence negative emotions such as being scared became common in these
situations. Mothers felt that their roles were altered and feeding the baby with a
nasogastric tube became obviously strange and not easy because it was new to them,
thus causing a lot of uncertainty.

A lot of thoughts surrounded the issue of tube feeding. An example of fear of feeding
with the nasogastric was described by one participant as follows:

30
“I was very scared to touch the baby because she was very small, but there is just one
more step to finish continuous feeding on the tube.”

Mothers have a special struggle when a premature baby is born, one for which she is
unprepared. Premature babies face unique challenges that call for more vigilance,
enduring commitment, ongoing education, and tremendous support from one's family
and wider network. Incubator care and tube feeding present difficulties for mothers. In
another study done in South Africa, they mentioned how mothers go through periods of
fear, worry, anxiety, depression, and loneliness. Mothers described feeling frightened,
anxious, and worried (Steyn, et al., 2017). Nearly all of the mothers spoke of feeling
helpless and anxious about the future. They talked about feeling scared every day and
worrying that they would lose their infants with tube feeding errors. In an effort to
counteract disparaging remarks about their premature babies, mothers felt the need to
distance themselves from family and friends (Garti, Donkor, Musah, Appiah, Gyekye,
Akuoko, & Menlah, 2021). When mothers lack knowledge and are unable to
discriminate between their premature babies' immediate requirements and ongoing
needs, they are more likely to engage in unproductive coping mechanisms. Although
there are many issues with in-hospital care that affect survival rates, in hospital tube
feeding care and training to mothers of premature babies becomes crucial.

Mothering a premature baby is universally acknowledged as a complex and stressful

experience. This is so because a premature baby is at risk of variable medical,
neurological and developmental challenges that may influence present and future
feeding skills (Adkins & Doheny, 2017).

It is consistent with Buys, & Gerber's (2021), findings that mothers' experiences with
tube feeding were generally unfavourable, whereas their experiences with cup feeding
were mixed. The assumption that a premature baby receiving tube feeding is a "sick"
baby led some mothers to describe tube feeding as a bad experience. Seeing their
infants struggle with the discomfort of the tube was tough for the mothers to witness.
Some mothers found it challenging because they were worried that their premature
babies weren't getting enough milk, while other mothers saw cup feeding as a sign of

31
excellent development. It was their dream and hope that their premature babies would
be transferred for a cup feeding.

Mothers seldom ever discussed bottle or breastfeeding, which suggests that their
struggles with tube feeding often outweighed their feeding experiences. Feeding
anxieties and stressful feeding situations were experienced. Also, it is clear that, nurses
address any related concerns and involve the mother in the feeding process when
appropriate because tube feeding proved to be a significant source of stress for mothers
of premature baby (something that is strongly advocated in NICUs worldwide) (Craig et
al. 2015). This might help lessen the stress and unfavourable opinions surrounding tube
feeding.

The current study findings are in line with Amadu et al. (2021), who reported that
participants articulated strong thoughts of fear whilst their premature babies were being
fed using the nasogastric tube. Their emotions and feelings inclined one another and
they felt scared to feed due to issues of not being prepared to use the nasogastric tube
feeding. Therefore, fear was induced when babies were surrounded by technological
instruments. They feel confident in their ability to provide for their premature baby in a
setting that is supportive of the growth of attachment ties and they have realistic
expectations. The family is the setting in which an intimate connection is created
between mothers and children, but when mothers are in the neonatal unit, the
technology needed to treat a premature baby prevents them from meeting their baby for
the first time. The equipment in the facility, such as the feeding tubes, alarmed mothers.
Mothers claimed that they were intimidated by the equipment and that it took them a
while before they felt comfortable helping with their baby's feeding. Due to
overwhelming fear of tube feeding, mothers were hesitant to feed their premature
babies (Amadu, et al., 2021).

Every day, mothers were able to engage by feeding their baby, which lessened the
psychological distress of being separated from them. The literature study demonstrated
how mothers' participation in their premature babies' tube feedings, reduced their

32
suffering and aided in the development of a bond between mother and  baby (Amadu, et
al., 2021).

It is therefore in cases like these that it becomes important to orientate mothers on how
to feed their babies in the given environment. An orientation of the environment and
instruments by nurses could encourage mothers to learn how to feed their premature
babies and be competent until babies move from the tube feeding stage to the next.
Nurses can alleviate the stress in mothers by teaching tube feeding which allows
mothers to be part and parcel of the care process (Akkoyun & Tas Arslan, 2019).

SUB- THEME THREE: MOTHERS FELT ANXIOUS ABOUT THE WELL-BEING AND
SURVIVAL OF THE BABY

This research also gathered that mothers feared losing their premature babies through
death and this brought about thoughts of sadness especially in times where there is
poor improvements with the baby’s health. Additionally, they felt helpless in a situation
where they could not do much given the baby’s different threatening conditions, thereby
making their experience worse. The death of other premature babies in the NICU
worsened the situation for the mothers as they wondered if their babies would survive.

Some mothers accentuated:

“I thought that he was not going to make it but a few days, they removed the oxygen,
they put off the tubes and drips”.

“When you come from there, you are just feeling bad, and you wonder if the baby will
survive ……….'.(mother crying)”.

“I was just crying thinking my baby was not going to make it and I spoke to someone
who said, ‘look all these babies were small and they just made it.’”

“He was struggling very much with his breathing, then I broke down into tears, I thought
he was not going to make it, now they found an infection…”.

33
Mothers experience anxiety, uncertainty, and concern about their child's future in the
neonatal unit since it is a frightening and foreign environment. Mothers require
tremendous emotional support in order to help them deal with the birth of their
premature. It is crucial to educate health professionals on the emotional impact of
neonatal care based on an understanding of the parent experience in line with a family-
centered approach to neonatal education. The NICU is a frightening and unsettling
place for some babies are seriously ill. Technology has a terrifying and dehumanizing
effect. Nobody can predict the outcome for mothers with any degree of precision. Other,
healthier babies are all hooked to devices, have feeding tubes, and are kept in
incubators. Families are at a loss for words. Many medical professionals weigh in, and
each one offers a somewhat different message. These neonatal characteristics
frequently cause psychological harm. While many of NICU mothers experience post-
traumatic stress disorder, anxiety, sadness, and protracted bereavement, others grow
resilient and learn to cope with terrible events in healthy ways (Haward, Lantos, Janvier
& POST GROUP, 2020).
Many mothers were shocked and in disbelief when they saw how small their premature
babies were, and they worried about their health. Similar accounts of challenging
situations and feelings of incredulity were found in a review of comparable studies,
indicating that mothers of premature babies generally share these experiences (Buys &
Gerber 2021); (Garti, et al., 2021). These results highlight the psychological effects of
premature birth on the mother, emphasizing the importance of hospital staff supporting
these new mothers at this time. The majority of mothers expressed concern for their
premature babies' wellbeing and a perception that they were extremely fragile.

The mother's thoughts or attitude regarding her baby's susceptibility to disease or

damage are reflected in the parent's assessment of the baby's  vulnerability. The
present study found that the baby's tiny size, poor health, and the hospital's medical
environment all had a significant impact on mothers. The small size of their babies at
birth caused shock or disbelief in all mothers, which proved to be a source of stress for
the mothers. Mothers seemed to link the baby's diminutive stature to care giving
challenges in various care settings. The premature baby's small stature makes it difficult

34
for other people in the mother's life to provide the baby with the best care (Buys, &
Gerber 2021).

Many mothers who participated in the study stated that they were reluctant to talk to
their premature babies because they were worried about losing the baby. These results
were in line with research that claimed mothers put off talking to their babies when their
health was poor and the prognosis was uncertain. Mothers utilize this coping
mechanism to lessen their pain after their premature babies pass away. Grief prediction
refers to this phenomena. Grief prediction discourages mothers of NICU patients from
expressing their emotions until they are certain that their baby will live. Support is
required from the nurses who look after the mothers of newborns admitted to the NICU
(Heydarpour, Keshavarz, & Bakhtiari, 2017). In order for the mothers of newborns who
are admitted to the NICU to make a smoother transition to motherhood, the nurses who
care for them must offer them assistance. Nurses must actively urge women to take on
the role of mother in order to achieve this goal. The study findings were similar with
those of several women who said that speaking with other mothers was a supportive
experience when the baby’s survival was not clear.
According to the primary affective bond theory, which is preferred, the interaction
between a mother and her premature baby is a process that begins before birth and
comes to a head at the end of the first year of life, and it is subject to the influences and
effects of psychological and environmental factors. When faced with the unexpected
path to this experience, mothers frequently feel helpless to protect or care for their baby,
which impacts how they interact with them (Ued, Silva, da Cunha, Ruiz, Amaral, &
Contim, 2019). It is harder for some NICU mothers than for others.

When a baby is admitted to the NICU, mothers' experiences urge the professionals to
further support them. Because the mothers are distressed by the separation after birth,
it is challenging to form a bond with a premature baby in the NICU. As a result, NICU
treatments including feeding tubes, newborn monitoring, and incubator placement have
an adverse influence on the appearance of the premature baby and hinder bonding. The

35
parenting experience is different from what mothers anticipated or what feels normal as
a result of all of these events (Haward, Lantos, Janvier, & POST Group. 2020).

Strong stress feelings were reported by mothers in reports by Yang et al. (2017),
possibly as a result of a mismatch between the perceived demands of motherhood and
the support that was available from family and the nursing staff. Similarly, our research
revealed that mothers' experiences with changes related to their premature babies
caused them to be extremely sensitive and disturbed, which left them in an aroused
state. With the fear that their child's condition may deteriorate, worsen, or worsen,
mothers experienced tremendous feelings of anxiety and rage (Horwood, et al., 2019).

The lives of their premature babies make mothers feel frail and vulnerable. A loss of
connection may result from parents having fewer opportunities to communicate
affectionately with their infants and to communicate affectionately with their infants and
from being afraid to touch or feed them. Mothers are negatively affected by the
interruption of the mother-premature baby attachment, which can be made worse by the
newborn's clinical stateJiménez-Palomares, Fernández-Rejano, Garrido-Ardila,
Montanero-Fernández, Oliva-Ruiz, & Rodríguez-Mansilla, (2021).

The findings in another study, which revealed that 86.8% of mothers of premature

infants in NICU felt anxious about the survival of their premature babies and that half of
them thought that the development of their parental role was delayed, echoed these
anxieties. This is consistent with other descriptive studies that have comparable
features ( Jiménez-Palomares, et al., 2021). Since a mother's  actions in child-
upbringing situations are directly influenced by parental competence, it is well-
recognized that parental competence protects mothers from stress.

Mothers have varied coping mechanisms for their emotional pain and sense of
inadequacy. Some people develop into highly logical information gatherers who study
machines and numbers, look for certainty in uncertainty, or try to exert control over the
uncontrollable. They have little time or space to reflect on what parenthood means

36
because they are struggling to control their intense emotions. Survival of premature
babies and the deteriorating conditions of the babies, made mothers to struggle with
those intense emotions. However it resulted in some mothers stopping to visit their
premature babies in the NICU because they find the emotional strain of trying to be
there too much, and others become emotionally numb while they are there.

These experiences made mothers to be anxious and this increased their fear and
insecurity pertaining to the well-being of their premature babies. Care providers became
important in this situation where participants wanted to give up on their babies’ situation.
Nurses encouraged mothers and assured them that their premature babies’ situations
would improve. Results of the current study align with the findings of the study by
Horwood, Haskins, Luthuli & McKerrow (2019). Adama et al. (2018)’s findings also
showed that changes concerned with the premature babies make mothers to be highly
sensitive and traumatised because the conditions of sick babies result in overwhelming
emotions of anxiety and anger because they anticipate the deterioration of baby's
condition or the baby’s death.

At the national referral hospital, many mothers with premature babies were concerned
and unsure about the condition for their premature babies. The mothers would worry
continually about the premature baby's weight and that the baby wouldn't survive
because of its small stature. Mothers reported feeling nervous about caring for their
infants; they faced feeding difficulties and said they could overcome all the other
difficulties if they were certain their babies would live. Their concern was for the well
being of their babies, the survival of their premature babies while their premature baby
was in the NICU and their observation of how other babies were dying ( Petty, Jarvis, &
Thomas, 2019).This is consistent with previous studies, which indicated that mothers of
hospitalised infants are worried about their survival ( Namukose, et al., 2021).

Different studies concur with the fact that participants fail to accept their situation in the
face of the complex premature baby’s health conditions. The changing health conditions
of premature babies made mothers to be in a state of confusion which made them to

37
lose their determination to care for their babies. In a study done in Ghana, it was found
that feelings of anger are secondary emotions which basically can arise from
experiences of loss, disappointment, anxiety, and worry (Amadu et al., 2021). Similar to
this study, participants had feelings of uncertainty in terms of the baby's survival as well
as their role in their babies’ well-being (Maureen, Lonia, Patricia, Margaret, & Ellen,
2019). These emotions were found to be true because mothers often want to see their
babies thriving.

Continuous support from professionals, therefore, was found to be necessary as this

provided mothers with a platform to air their fears which in turn helped nurses to identify
ways to allay participants’ anxiety. In addition, Hall, Cross, Selix, Patterson, Segre,
Chuffo-Siewert, & Martin, (2015) agree that mothers felt troubled and uneasy and they
had numerous other feelings of guilt, fear, sadness, and anger due to the continuous
change in the babies' condition. Moreover, Adama et al., (2018) state that the
experiences of mothers are not always easy because they are always anxious about the
continuous changes in the baby's condition, and they have to go through those
challenging emotions in hoping for their baby’s survival. Kertu and Maano (2019) also
share that nurses should establish a caring relationship to alleviate stress in mothers
about their premature babies’ well-being and survival. Paying attention to their
psychological and physical well-being, as well as sharing knowledge with mothers about
the different conditions that premature babies go through as a means of empowering
them in the care of their babies.

On the contrary, as seen in a few cases in some research, Hall et al. (2015) gathered
that mothers were left with less to no choice but to accept the situation despite their
anxiety. Research brought out the fact that the more mothers accepted their babies’
situation, the more they had increased positive coping mechanisms that allowed them to
feel so much better emotionally, physically, and mentally. The experiences by
participants taught them perseverance in that even if they were troubled, they had to
stay positive.

38
SUB-THEME FOUR: MOTHERS NEEDED EMOTIONAL SUPPORT THROUGH
FAMILY AND COUNSELLING

This research found that the focus in the NICU is mainly on the preterm babies and as a
result, the clinical depression symptoms of participants are often missed during their
babies’ stay in the NICU, thus their emotional state is often not considered. Pre-existing
family dynamics are contributory to the emotional distress of participants and this results
in participants giving less attention to their babies. The study noted that participants’
emotional distress is sometimes not identified and even if noticed, there is no access to
support.

Some mothers recounted their experiences as:

“They must even do counseling. It is needed because it is not easy, some are not even
having family around”.

“They must employ counsellors that are based in the unit so that they can see that this
person is worried, then they can call you in their office and talk to you”.

“Sometimes as a parent, you need counseling, not every day but sometimes when you
are sitting in this room, it is not every mother that is happy”.

Given the expectation of raising a healthy baby, the mother's first visit to the premature
baby hospitalized in a neonatal unit is regarded as a frustrating and disturbing
experience. The reality of having a baby with medical issues who needs hospitalization
and care makes the mother feel helpless, guilty, insecure, and afraid (Ued, et al.,2019).
When mother transfers the care of the premature baby to the medical staff and has no
influence over the baby's health, the concept of maternal autonomy is put to the test. It
becomes a difficult routine to spend a lot of time in the hospital or travelling there and
back and those who have further children must abandon them. Another worry is that
mothers who have additional children must entrust their care to family members. The
growth and development of the newborn might be impacted by the parenting style of the
parents (Ued, Silva, da Cunha, Ruiz, Amaral, & Contim, 2019).

39
In this study, it was discovered that during the NICU admission, mothers were forced by
situations to find coping strategies. Mothers tried to find peace, patience and solace
from other people given their situation. This research noted that during their stay in the
NICU department, most of the time mothers were in the waiting room, and they never
received counselling sessions, prayer sessions, discussion groups or even talk sessions
with any health professional. Turner, Chur- Hansen, & Winefield, (2015) also emphasise
the need to concentrate on mothers' emotional and psychological states during the
hospitalisation of premature babies until the time of discharge. It has been proven that
failure to do so results in less attachment for mothers and their premature babies which
may add to the vulnerability of both. In other sources, researchers described the NICU
as an extremely stressful experience that has a positive linear association between
high-stress perception, severe depressive symptoms and poor sleep quality in mothers
(Manning, 2012), thus adding to the need for emotional support through counselling.

Lack of understanding was one of the main obstacles faced by mothers who had never
previously given birth to a premature child. The majority of mothers lacked the
knowledge necessary to properly care for a child who had been admitted to the NICU. In
an anthropological study, mothers of premature newborns admitted to the NICU ranked
knowledge of parenting as one of their top priorities  (Heydarpour, Keshavarz, &
Bakhtiari 2017). Consequently, when confronted with a premature baby in the NICU in
this situation, the mother is perplexed. When a mother delivers a premature baby, the
reaction of her family is unfavourable, which adds to her stress or causes the premature
baby to be rejected by the family.

Such behavior is cultural, raises mothers' concerns, and emphasizes the value of
education for people, families, and society (Heidari et al. 2012). Emphasis was placed
on supplying the primary family members with knowledge to aid the mother and her
family in boosting their self-esteem and self-efficacy for caring for premature babies. In
a study by Heydarpour et al. (2017), mothers who took part said that receiving criticism
and unfavourable assessments from others prevented them from becoming competent
mothers.

40
Mothers identified bias and social support as social factors influencing adaptation to the
parental role. Also noted as a factor influencing maternal competence was social
support. Support from a variety of sources, including practical assistance from the
mother's emotional support, particularly from the family, and knowledge-based
assistance from midwives or other healthcare professionals, was crucial for a healthy
adjustment to motherhood. Other studies corroborated these results (Abeasi, & Emelife
2020). Support from partners, relatives, and nurses can make the mothers feel more
confident and can help her conceal her negative emotions. Mothers requested that
nurses give them emotional support by informing them about the care that their child is
receiving and letting parents know what to expect once their premature baby is brought
into the NICU.

 Mothers' favourable experiences were greatly influenced by the care giving,

information, and emotional support they received from others. Literature demonstrates
that this occurs frequently (Leahy-Warren et al. 2020). Mothers  who received more
assistance appeared to have gone from an initially unpleasant experience to a more
positive one all around. Nursing staff and other mothers of premature babies who are
going through the same thing and have two sources of support in the hospital setting.
While mothers received many sources of support when the premature baby was still in
the hospital, according to a study by Buys & Gerber, (2021), it was the support in the
home setting that had the biggest impact on the improvement in the mothers' overall
experience. Family members frequently provided such important help. Both family
members and healthcare professionals frequently provided this kind of appreciated
support. The study emphasizes the beneficial effects of social networks, healthcare
personnel, and support facilities (such prayer rooms) on maternal experiences. Hence,
healthcare professionals like doctors and nurses should be aware of mother's individual
perceptions and work to deliver individualized, culturally sensitive care (Garti, et al.,
2021).

41
Other studies also identified that the accumulation of events saddens the participants
and as such, some thoughts, fears and feelings of failure overshadow them (Yang, He,
Lee, Holroyd, Shorey, & Koh, 2017). Offering mothers support groups or other forms of
emotional support was therefore important to help them to vent their frustrations. These
groups were found to lessen their distressing experiences and the anxiety of hospital
admission and discharge (Turner, 2013). In the absence of support groups, nurses
rendering care to premature babies need to consider the mothers' needs and being a
great support system and ensuring holistic service delivery to the mothers (Williams,
Patels, Stausmire, Bridges, Mathis, & Barkine, 2018).

It is well known that mothers who receive official, structured support from medical
professionals and their families  experience fewer depression and anxious symptoms.
The mothers in this study, mentioned getting  support but was inadequate.
As a measure, support groups was established in countries like Ghana to promote a
positive re-conception of premature babies. Community support organizations in Ghana
can use cultural brokering to improve cross-cultural understanding, peer support, and
effective communication among mothers, healthcare professionals, and the larger social
network. In a research conducted in Ghana, mothers were encouraged to move forward
despite some of their unpleasant experiences (Garthi, et al.,2021).
 The poor assistance provided by families was another theme that arose from the study
in Ghana. Contrary to the findings of this study, other investigations have indicated that
some family members and fathers offered mothers of babies admitted to the NICU
support, the majority of which was emotional. According to previous research, it is
plausible that mothers and their families in the current study were coping with their own
anxiety and depression in addition to the demands of numerous responsibilities, which
may have been too much for them to handle. It might possibly be because men are
expected to handle stressful situations without expressing themselves due to cultural
differences among populations. Mothers have been found to have significant levels of
anxiety and depressed symptoms have been reported in mothers and the family of
premature babies(Abeasi, & Emelife, 2020).

42
In order to improve their own health and protect their capacity to care for their infants,
mothers may benefit from the assistance of family members and medical professionals
in practising self-care. Skin-to-skin contact in particular, as well as feeding and holding
their premature babies in the NICU, resulted in significant happiness and bonding for
mothers and their premature baby. Lewis, et al., (2019), this sense of bonding played a
major role that is why mothers chose to hold and nurse the premature babies. Unlike in
some previous research done by Adama et al., (2019), mothers did not specifically
mention feeling alienated, bonding difficulties, or difficulties related to becoming a
mother. In spite of their initial worries, several mothers in this study actively sought
opportunities to feed and touch their newborns in order to form bonds with them. All this
was possible due to the support given to them by family members. The fact that these
infants were healthy enough to be held safely and that nurses felt more at ease allowing
mothers to participate in this activity may be a contributing factor to this difference
(Lewis, et al., 2019).

The current study also gathered that not receiving family support brings sadness.
Therefore, the recognition of positive family relations as contributors to the well-being
and positivism of participants is needful. Family support comes in handy in such
situations and encounters, and these supporting relationships hype up hope and zeal to
care for the premature babies (Petty, Jarvis, & Thomas, 2019). Family support coupled
with healthy professional support then becomes imperative in bringing relief in and from
the stressful situations. The significance of family and nursing support has been
demonstrated by this study, necessitating continuous family support. The necessity of
mothers being self-aware and able to sustain their hope for their children is emphasized
by (Adama et al.,2018). According to Yang et al., (2017), although relationships do
contribute to a mother's ability to remain optimistic and maintain her optimism for her
premature baby, not all of them do. Mothers were well aware of the relationships that
helped them do so. The quality of the interactions mothers have with their families, their
caregivers, and other mothers is especially crucial since these ties provide them with
support and information about how to care for their premature babies ( Hall, et
al., 2015).

43
Mothers were observed to be spending more time in the NICU and less time with their
relatives and social networks  (Fowler, et al., 2019). Mothers' interactions with
premaature babies admitted to NICU were greatly influenced by their interactions with
their families, infants, and the nursing staff. This seems to add that some mothers did
not struggle to communicate their needs and feelings to their families, as well as to
express them to themselves and their infants. Mothers' ties with themselves, their
families, and their hope for their offspring played a crucial part in their development as
self-aware individuals( Kohan 2020); Horwood, et al., 2019).

In a study done in Ghana, it was found that the absence of support and visitation from
family causes mothers to struggle in carrying out their roles because they are too
stressed to care (Amadu et al., 2021). Furthermore, Yu, Zhang, & Yuan, (2020)
expressed the need for counseling, care, and support from families towards the mothers
whilst they care for their premature babies. Therefore, nurses were regarded as a
source of support to participants through giving counseling. In addition, Granero-Molina,
, Fernandez- Sola, Hernandez – Padilla, Lasserrotte, & Rodriguez, (2019); Medina
(2019), identified that participants had some circumstances where they felt lonely,
desperate and not happy because they felt that they needed family support. Different
types of support to care for mothers is imperative in allaying anxiety. The amount of time
spent in the NICU and families’ reactions to the happenings in the NICU made mothers
to feel alone and isolated, therefore, the researchers felt that there is an increased need
for counseling (Yang et al., 2017).

In another study done in the United Kingdom, the report indicated that depression and
anxiety symptoms are prevalent amongst mothers of hospitalised premature babies in
the NICU. Therefore, one of the UK's standard care includes maternal depression
screening and referrals to mental health professionals with no follow-up. The strategy in
place brings mothers to a point where they can vent and express their emotions through
counseling (Leahy-Warren, Coleman, Bradley, & Mulcahy, 2020). It is consistent with
other researchers who expressed significant clinical depression symptoms seen in
mothers and the need for emotional support in mothers who are often busy visiting their
infants and have limited time to seek care. This in turn deprives most mothers from

44
receiving treatment even if there is a significant need for counseling. Researchers
realised the importance of nurses in encouraging the mobilisation of social and
professional support which is counseling and early intervention in addressing mothers'
emotional well-being (Williams et al., 2018).

Several reasons were gathered which emphasised on the need for mothers to have
access to counselling. This is because mothers’ daily lives get emotionally interrupted
due to the accumulation of minor daily hassles which include a lack of family support
and financial difficulties. Furthermore, the absence of family support sometimes evolves
on pre-existing family dynamics (Russell et al., 2014). In a study done in Australia,
women expressed having family support as an important element to cope with
hospitalisation and the emotion of having to deal with unexpected baby conditions
(Woodhart, Goldstone, & Hartz, 2018).

It is critical to keep in mind that every NICU mother is unique. Not all NICU mothers
experience depression, and among those who do, it doesn't always happen in an
uniform manner. Each mother has her own unique definition of motherhood, takes the
trip at her own pace, and has her own opinion of what it means to be a good or horrible
mother. Contrary to prior views or experiences of the early stages of motherhood, the
circumstance, the setting, the people, and the interactions that women have with
physicians and their premature baby are not as they appear to be (Van Schalkwyk, &
Gerber, 2021).

Family-centered care is a philosophy that aims to improve communication with families.

Some of its potential advantages include increased parental comfort and competence in
post-discharge care, increased parental comfort and success with breastfeeding,
shortened hospital stays, decreased post-discharge re-admissions, and increased staff
satisfaction. An approach to medical care known as "family engagement and support" is
based on the idea that patients' families can contribute significantly to their emotional,
social, and developmental well-being. Family-centered care is a philosophy that aims to
improve communication with families (Van Schalkwyk, & Gerber, 2021).

45
SUB-THEME FIVE: MOTHERS FELT DISHEARTENED BECAUSE OF FINANCIAL
STRUGGLES

Participants in this research showed that neonatal admission came with unexpected
costs ranging from buying babies’ needs, mothers’ needs and transport to and from the
hospital among other provisions. Mothers, therefore, experienced challenges in trying to
balance their finances which to a larger extent also affected their relationships and thus
influenced their experiences in a negative way.

Some of the mothers had this to say:

“It's not easy because every day you are spending money and there are days you don't
have taxi money".

“I did not feel happy, like for me going home and coming here is difficult, I cannot
manage taxi money, it’s a problem every time.”

Within the first year after delivery, mothers of preterm babies run the risk of experiencing
mental health issues. Researchers discovered that women generally are sleep deprived,
anxious about money, and burned out, all of which might exacerbate depressive
symptoms. The mother needs support to maintain her physical fitness and avoid
becoming unduly worn out so she can play her role in an enjoyable experience. To avoid
predisposing the mother to post-traumatic stress disorder (PTSD), which can impair her
general quality of life, hypervigilance can be put to better advantage. Mothers in a
Ghanaian research reported receiving financial and social assistance from their
partners, families, and friends. Some mothers reported getting both financial and
emotional support from their friends and family in the form of of money and gifts. They
aided the mothers with making purchases and covering out-of-pocket costs for the
newborns' medical care (Garti, et al., 2021). Their financial load was somewhat
lessened.

In this study, a possibility was that the admission had a direct financial responsibility that
was placed on families and it was unlikely substantial and this exacerbated their

46
financial situation because of the long stay and long term medical follow-ups. The
findings of this study are consistent with other studies that found that the long stay of
admitted babies in the NICU made it difficult for participants to have an effective
financial plan and cost management. Unfortunately, in most research findings, there are
no systems in place that are there to assist participants who have long term admission
periods and long term medical follow up costs (King, Mowitz, & Zupancic, 2021).

The findings noted issues of transport to and from the hospital on a daily basis as a
cause for concern in relation to their financial difficulties. Other difficulties mentioned by
mothers in the current study included the high expense of transportation to and from the
hospital. The study mentioned above agrees with other studies. According to a previous
study, preterm accounts for about 10% of all medical expenses for infants and 35% of
all daily transportation costs (Abeasi, & Emelife, 2020); (Garti, et al., 2021).

Mothers frequently named structural obstacles and their financial repercussions as key
factors influencing their experiences. Studies that have hitherto been done on structural
barriers mainly focus on supply-side hurdles like substandard facilities or poor
communication among clinical staff. Without a consistent source of income, mothers
reported finding it difficult to sustain their families (Lewis, et al., 2019). When mothers
(especially those with hourly employment) wanted to spend time in the neonatal
intensive care unit, they occasionally couldn't work as many hours, which put further
pressure on the family's income (Buys, & Gerber, 2021). Several mothers were forced to
decide between being present in the hospital to care for their premature babies and
paying monthly payments, which resulted in difficult decisions and additional stress .
The main issue of insufficient parental leave highlights many of the other practical
difficulties young mothers encounter (Lewis, et al.,  2019).

Since mothers aren't allowed to feel what they're feeling or act as they're acting, they
might wonder how they can be mothers. Every mother's experience is unique, and many
of them are marked by emotions of disorientation, financial difficulties and exclusion.
It is important for medical professionals to remember that NICU mothers can be just as
delicate as they are powerful (Buys, & Gerber, 2021). Mothers may suffer silently and

47
severely as a result of even a little, accidental remark made by a professional, or
financial demands and some remarks may even leave permanent scars besides the
scarcity of babies need. Reminding NICU mothers that it is common to experience a
rapid shift between opposing feelings, such as excitement upon meeting our baby, terror
at being in the NICU, and grief at the prospect of losing their wonderful baby, can help
them to normalize it for and be reassured (Haward, Lantos, Janvier, & POST Group.
2020).

SUB-THEME SIX: ABSENCE OF ACCOMMODATION FACILITIES WAS

STRESSFUL

This research found that preterm babies were admitted in units separate from where
their mothers. Additionally, some of the mothers came from far away cities from the
admission hospitals. As such, mothers were either accommodated in a different unit or
they made visits from home or from an accommodation that they had arranged
themselves. This created issues of despair in mothers when they could not be in the
same place as their premature babies to witness and participate in their being cared for
by the nurses. Additionally, a financial burden was placed on the participants as they
had to pay for their own accommodation as well as expenses for commuting daily to
visit their premature babies whilst in admission. Mothers expressed the need for
accommodation at the facilities together with their babies.

Mothers accentuated the following:

“My husband was here, from Walvis Bay, so he decided to stay a week here in front of
the hospital…..(crying).”

“For me, I would like in terms of transport to move even during the night, but sometimes
no transport money, so if they have beds and enough wards that can accommodate
mothers that could make a difference."

48
“I was discharged because there was no space in Central, there is only for those that
are coming from Otjiwarongo.”

‘‘Maybe, they should give us rooms here to stay with our babies and just feed them all
the time they want.”

According to Abeasi and Emelife (2020), mothers in that study reported having restricted
access to their premature babies due to the need to visit during specific hours of the
day, due to lack of accommodations. A major requirement of the mothers has been
highlighted in previous research, which is contrary with the current study, as interaction
with the premature baby to encourage bonding is imperative. Mothers in this study are
given time schedules to follow when visiting their babies. Many repercussions result
from mothers' restricted access to their premature baby. Several studies have
demonstrated how the mother-child connection was impacted by the limited interaction.

Visiting hours scheduled in NICU of different studies done, explained how that was
regarded by most mothers and restricted access. So, the mother's inability to have
frequent access to the premature baby is likely to generate negative feelings that will
increase stress levels, which will then cause less engagement with the baby. According
to earlier studies, it would be beneficial if mothers of premature babies are given the
opportunity to bond with their babies by taking on the role of parents. It is crucial to
recognize issues early on and provide the required remedies. If this is feasible in the
long run, it would lessen the difficulties these mothers face upon when their babies are
being admitted (Abeasi, & Emelife, 2020)

This frustration expressed by mothers about the lack of accommodation that is close to
their premature babies is also evident in other research studies where researchers
expressed concerns in this regard and emphasised the need for Ministry of Health to
ensure the provision of permanent accommodation in health facilities. The findings
suggest that this would enable mothers to be closer to their premature babies where
they will be part of the caring journey, thus allowing them to better understand the
transitions and changes of their babies' condition. A United States research expressed

49
the same challenge about the absence of adequate and affordable accommodation near
the NICU where some mothers had to find transport from home to the hospital,
although, there were available free rooms for parents adjacent to the NICU, rooms
available were not enough for most participants to stay in (Neu, Klawetter, Greenfield,
Roybal, Scott, & Hwang, 2020). In another research, mothers expressed that the
availability of accommodation or parent rooms facilitated their visitation to their
premature babies and relieved them on the financial burden because of multiple visits
(Lewis, Andrews, Shenberger, Betancourt, Fink, Pereira, & McConnell, 2019).

Furthermore, this research gathered that some mothers avoided frequent hospital visits
as they sought to suppress their emotions. It is consistent with this study that, Kerthu
and Maano (2019), discovered that the absence of accommodation in the hospital
premises became an issue that broke or hurt mothers because their wish is to be with
their premature babies all the time and at least know what is happening, hence this was
limited and constricted. In other cases, some medical facilities had scheduled intervals
during the day to cater for those who stayed far from the hospital by affording them an
opportunity of spending extended amounts of time during the day with their babies. Still,
the provision of accommodation would be a plausible solution to remedy these
challenges (Yang et al., 2017).

Our findings further emphasize the significance of accommodation facilities during a

premature baby's stay in the NICU, particularly in light of the NICU experience's overall
financial needs. The emotional toll of not having direct access to their premature baby
was noticed by mothers who were unable to remain in or close to the NICU. Similar
research shown that having continuous access to the NICU, day or night, in person,
alleviated this strain. When mothers had access to the hospital's few overnight rooms in
or close to the NICU, they felt the most at peace on an emotional and economical level.
Transportation was another expense connected with getting to the hospital, according to
Lewis et al (2019).Mothers would frequently have to juggle a job, other children, and a
strenuous schedule of breast pumping as they travelled a distance to the hospital from
their different locations. For mothers, especially those who were healing from physical
stress from childbirth, organizing these activities was challenging and time-consuming.

50
SUB-THEME SEVEN: MOTHERS FELT VERY HAPPY WHEN THERE WAS A
POSITIVE OUTCOME OF THE TREATMENT

In this research, the joy and happiness of mothers was evident when progress and
improvements were seen in their premature babies. Different milestones meant a lot to
the mothers as they were relieved from a lot of pressure and distress. These milestones
included premature babies getting to a stage where they were able to breastfeed,
thereby providing the long needed yearning and opportunity for bonding and normalcy.

Some mothers shared their experiences as follows:

“I have so much hope. She is better now compared to the beginning, now I have this
urge of waking up every morning to go to my baby”.

“She is growing very quickly, which means she was getting love from the nurses”.

This research gathered that these changes and milestones changed the mothers’
relationship with the health professionals, especially the neonatal nurses. The trust
levels and confidence in the nurses therefore increased. This change in the relationship
is also noted in other studies where mothers had better relationships with nurses when
there was change in the baby’s condition. Mothers trusted nurses more and they felt
more secure with their babies’ treatment (Horwood et al., 2019). Mothers were happy
about their babies' progress, treatment, and well-being, and this made their trust to
increase and they expressed the belief that their babies were well-taken care of by the
medical staff. The positive outcome from the treatment and subsequently the well-being
of the premature babies made the whole experience of the mothers to be bearable
when their fears were alleviated (Malakouti et al., 2013).

This research also found that positive treatment outcomes allowed mothers to display
maternal-responsive behaviours like cuddling, talking, smiling, playing, and watching the
premature babies' responses and actions. The observations are consistent with other
research outcomes such as the findings of Shiweda (2018).

51
SUB-THEME EIGHT: MOTHERS' SPIRITUALITY WAS CHANGED POSITIVELY
THROUGH PRAYER

Spirituality and the belief in a higher power is the pivot on which many people’s lives
rotate. Spirituality is an undeniable part of the human race which is often ignored or
undervalued when all things are good (Edraki, Noeezad, Bahrami, Pourahmad, &
Shirazi, (2019). Depending on a religious belief or creed, people turn to a power outside
themselves for hope, relief and courage. This research gathered that many of the
participants, together with their families, turned to God for mercy and help when they
found themselves in a space of frustration and uncertainty. Some of them attributed the
possible birth of their preterm babies to the providence of God in his mercy and
goodwill. Their spirituality was further tested as they went through the challenging
journey to their baby’ recovery. All of this pushed them to find solace, hope and courage
in God throughout their NICU journey.

Some of the mothers expressed how their spirituality was tested as follows:

“It took us a lot of praying for him to get where he is today.”

“My family had a WhatsApp group in which we prayed every time and shared
information about the progress and support.”

“That day, I spent the whole day praying.”

“I was discouraged, but my friend told me to pray and said, ‘don't be down, pray’”

“That week babies were dying and my mother said, ‘God gave you that child to be alive,
pray’”.

“I am so grateful to God. He got discharged and today we are going home”.

Religion was found to be crucial in the mothers' interpretation of the premature delivery
and in demonstrating emotional support, in addition to personal assistance. The
availability of religious services and amenities during these mothers' hospital stays was
a significant plus. In a study by Arzani, et al., (2015), that looked at maternal coping

52
mechanisms for handling premature babies, religious elements of maternal thinking
were also discovered. This research underlines the significance of understanding a
person's ideas and values as well as the possible impact they may have on their
behaviour and perceptions.

Several mothers felt that their experiences were significantly influenced by their religious
convictions and sense of faith. The results of this study were in line with those of the
study by Heydarpour, et al. (2017), which found that spiritual support gives people a
sense of optimism and tranquility and makes them believe that God is watching out for
them and guarding them from stress. According to a study by Heydarpour, et al. (2017),
most Iranian women feel that everything that happens it is God's will, and they should
comply. This belief helps them accept the challenging circumstances and better adjust
to their roles as mothers.

Some researches testify to the same fact that as mothers experience challenges every
day with their babies' health and the fact that they were not prepared for the situation,
they naturally became spiritually aware and that awareness intensified owing to the
circumstances. To find meaning in the experiences and challenges, mothers had
constant prayers and this allowed them to make some connection with God. Mothers
reported boosting their faith, thus resulting in a change of attitude regarding their
circumstances. As much as the approaches to spirituality differed because of cultural
diversity, mothers’ feelings and perceptions or religious beliefs, enhancing spiritual care
was imperative for positive mothering, where the lack of it only worsened the mothers’
trauma (Büssing, Wabermann, Hvidt, Langler, & Thiel, 2018).

In another study done by Maureen et al. (2019), mothers also expressed how their
experiences touched their lives and brought about a broader impact to their spiritual life.
Their spirituality was put to test and their relationship with God helped them to have the
courage and hope they needed in the situation. Mothers reported that admission to the
NICU gives no time to prepare for arising challenges and this forces one to seek for God
and this search for God’s experience led to personal growth and the needed strength
(Medina et al., 2018).

53
This research also found that family support and contribution through prayers for the
premature babies and their mothers gave participants the needed encouragement. An
experience of praying together as a family uplifted and allowed mothers to handle their
fears and doubts. The spiritual relationships of mothers positively changed as they
became more closer to their families and to God ( Bussing, et al., 2018). Their mental,
physical and spiritual well-being became evident as they hoped for the healing of their
premature babies and a positive future for them. Mothers sought God for the strength to
enable them to face an unknown tomorrow in relation to their premature babies’ life and
meaning. Fowler, Green, Elliot, Petty, & Whiting, (2019) confirm that when mothers find
meaning in events and experiences, it improves their mental health.

These events encouraged them to hold on to their faith in God as they believed that
their babies would get better. These mixed emotions contributed to the mothers’ journey
and emotional experiences. The study results could be used to find ways to reduce
stress and improve coping among parents with regards to these stressful situations (Sih
et al., 2019).

According to the study, one of the coping techniques for facing challenges is faith in a
supernatural God. Mothers prayed to thank God for providing them with a baby and to
ask for grace and strength to help them through their premature babies' seemingly
hopeless situations. This is in line with research conducted by Sih et al., (2019), who
discovered that prayer was the most effective coping mechanism utilized by mothers of
premature babies. Mothers prayed to God to intervene and ensure their preterm babies'
health.

The religious backgrounds of the mothers revealed that the majority of these mothers
relied on God's mercy; as a result, it was discovered that people's reliance on prayer
increases while they are dealing with a stressful incident. Mothers in this study had faith
in prayer because they believed it brought them assurance, certainty, and hope, which
lessened the sadness, shock, mixed emotions, fear, and dishonesty they experienced
as a result of their baby's illness. This is consistent with a study by Sih et al. (2019),
which discovered that religious involvement has a significant emotional or mental impact

54
on distress. Mothers practised prayer by calling on God's name constantly and by
expressing their faith in God's ability to help them keep their baby alive. The mothers in
this study also showed faith in God's ability to provide them more energy to take care of
their babies and to handle the stress associated with premature delivery.

Mothers' spiritual connections are directly correlated with their hopes for their babies,
the future, and meaning in life, all of which are connected to their experiences and
mental health. Mothers' mental health is improved when they find significance in their
experiences, according to research by (Fowler, et al., 2019).

A second key theme discussion follows below.

3.3.3. KEY THEME TWO: NURSING CARE GIVEN TO BABY

Neonates are a specialised cohort of patients requiring an individualised approach in

nursing care. The sensitivity of the situation makes it difficult for mothers to easily trust
the health professionals in their absence, thus affecting their emotional well-being and
health. This can only be remedied when there is certainty that their babies are well
taken care of. However, studies have shown that in events of discontentment from poor
care, increased future abortions, increased poor psychological adjustment and
preference for a caesarean section are a certain result. Failure to provide quality care
subjects the patients to risks of adverse outcomes and therefore, nurses or health
professionals should be highly skilled in this department for them to be able to deal with
mothers and their sick babies (Treyvaud, Spittle, Anderson, & Obrien, 2019).

Nursing care is ascertained by the way nurses use their knowledge and skills to
recognise the individuality of the person cared for. Caring is always specific and
relational such as that found in a nurse-patient relationship (Treyvaud et al., 2019).

This section of the research discusses the sub-themes regarding nursing care given to
babies. Mothers were grateful to the nurses because they helped them in taking good
care of the babies; and, some nurses were rude, and failed to give good care to the
babies and they neglected the babies.

55
SUB-THEME ONE: MOTHERS WERE GRATEFUL TO NURSES BECAUSE THEY
HELPED IN TAKING GOOD CARE OF THE BABIES

Mothers expressed gratitude for the good job that the nurses did in the way they cared
for their babies. Nurses were reported to show compassion for the babies even in the
absence of their mothers and additionally encouraged mothers to keep their hope in the
healing of their babies.

A positive response to the good care rendered by nurses to the babies was indicated as
follows:

“The nurses were feeding her after I had failed, now she is grown and I can breastfeed.”

“The nurses were so good and also nurses from the Kangaroo”.

“Nurses are doing a great job, the care they give the baby, nobody does that for
someone”.

“I was happy because they were treating the baby very nicely, bathing them.”

“I never got my baby sleeping in vomit or dirty linen saver, I am very happy.”

Taking good care of babies includes involving their mothers in the process as evidenced
from the mothers’ expressions above. In a study done in South Africa, the focus was
more on increasing the nursing team's efforts in making sure that there was a mother-
centred NICU care (Treyvaud et al., 2019). This study observed that participants’
sadness came when they were excluded from the care processes of their babies. As a
result of the exclusion, participants would be seen to have obscure behaviours resulting
from stress and the uncertainty in not knowing the treatment plan for their baby. In
addition, emotional distress in mothers following the hospitalised premature baby is
common. In another study done by Davila & Segre, (2018), it was found that about 33%
of mothers during the admission of their premature babies are stressed and they
develop suicidal thoughts compared to the general perinatal population with 14%.

56
Therefore, the study recommended that nurses should foster good care to premature
babies and lessen depression through screening and referrals to relevant health
professional help. Mothers’ participation and involvement in the care of their babies was
therefore seen as an important way of improving the babies’ condition because they
became part and parcel of the treatment plan (Steyn et al., 2017).

In a study conducted in Iran, nurses cared for the babies and established caring
relationships involving mothers in supporting them physically and emotionally. Nurses
were so much involved in the care of babies such that mothers, particularly first-time
mothers, believed that they were happy and had confidence in them to take good care
of their babies (Parsa et al., 2018). In some instances, however, mothers had a strong
belief that as much as nurses would take care of the babies so well, they could never fill
the place of the mother (Fowler et al., 2019). In other studies, nurses were reported to
be giving much attention to only those mothers with no experience (Negarandeh,
Hassankhani, Jabraelli, Abbaszadeh, & Best, 2021).

Similarly, in a study that was done in South Africa, most participants expressed gratitude
and felt secure whilst their premature babies were taken care of by the nurses as they
could see improvements in the baby's condition (Steyn et al., 2017).

SUB-THEME TWO: NURSES WERE RUDE AND FAILED TO PROVIDE GOOD CARE
IN THAT THEY NEGLECTED THE BABIES

In the same study, some mothers found difficulties in expressing their emotions and
thoughts. Mothers expressed feelings of anger when the nursing staff were not giving
good care to the babies. When mothers are admitted in the NICU, they get in with
expectations of good care for their babies from the nurses. Their expectations were
unfortunately not met as the nurses failed to interact positively with them.

The following are some of the responses gathered from the mothers in light of their
experiences with the nurses:

57
“Nurses were being rude, that if you tell them the baby has hiccups they will tell you,
what are we supposed to do with the baby’s hiccups?”

“Sometimes they were rude when you ask them when you see something not in order
and they say yeah at least you are here, you can fix it.”

A lot of issues surround mothers' behaviours and their responses to stress. Perceived
demands by mothers on how their babies should be treated during hospitalisation stirs
confusion between mothers and nurses. A report by Yang et al. (2017) expresses that
there were strong stress emotions by mothers potentially as a result of the mismatch
between the perceived demands of motherhood and the care available from the nursing
staff. This may influence mothers’ satisfaction of care. Therefore, and the available
research indicates how mothers can be discouraged from trusting the nurses in relation
to how they care for the premature babies (Turner, Winefield & Chur-Hansen, 2013).

It is imperative, therefore, that nurses give good care to the premature babies and that
they consider treating them as individuals by giving them personalised care rather than
generalising their care in order to make them happy (Amadu et al., 2021). According to
Lake, Staiger, Cramer, Hatfield, Smith, Kalisch & Rogowski, (2020), there were events
where nurses failed to care for the premature babies in their care. This naturally added
more worry and stress to the mothers of these premature babies. The study found that
nurses’ attitudes and interpersonal skills are a vital element that affects mothers'
experiences and relationships in the NICU. Research considered the care provided by
the nurses not solely on their skills but also on the number of NICU nurses available on
the shift, the shortage of nurses and the high number of premature babies admitted to
the NICU as some of the possible causes that result in poor care (Akkoyun & Tas
Arsian, 2019).

3.3.4. KEY THEME THREE: COMMUNICATION BETWEEN MOTHERS AND THE

HEALTHCARE MEMBERS
Communication can be described as the reciprocal and effective process in which
messages are sent and received between two or more people (Slatore, Slatore,
Hansen, Ganzini, Press, Osborne, Chesnutt, & Mularski 2012). Throughout the process

58
of communication with mothers’ of premature babies’ admission to the NICU, there is
interaction with various healthcare professionals, including neonatal physicians,
neonatal nurses, social workers, physical therapists, speech therapists, and providers
from other medical disciplines. These professionals not only provide care to premature
babies, but can also help mothers with information to better understand their infants’
medical status, and to make the transition to becoming independent caregivers at home.
Throughout this process, communication is pivotal (Slatore et al., 2012).

In another study done by de Salaberry, Hait, Thornton, Bolton, Abrams, Shivananda, &
Osiovich, (2019), nurses took care of participants and premature babies as well
timeously giving information to allay participants’ anxiety. They realised that it is evident
that conversations with the preterm mothers is a good strategy to create a favourable
experience for the participants. This strategy is actually proven in instances where the
health professionals shared part of their lives and exchanged life experiences with
participants with the belief that participants would find comfort and confidence in them
providing care to their infant. Nurses were able to relate at a deeper level with the
participants and they were able to provide care according to the needs of the
participants and the families (Gathara, Serem, Murphy, Obengo, Tallam, Jackson, &
English, 2020).

Another study by Stelwagen et al. (2021) found that mothers requested for information
about their premature baby’s health on a continuous basis by visiting and phoning the
neonatal unit throughout the day and as some nurses responded positively to the
mothers request, a bond between the nurses and the participants started to develop.
Mothers had the privilege to be informed about everything that could possibly be
relevant to their babie’s condition such as the causes, progress, outcomes, treatment,
procedures and their infant’s behaviour, and all that happened while they were not
present.

In this research, sub-themes were discussed according to the information gathered

under the main theme: Communication between mothers and health care personnel
was mentioned, together with the sub-theme, health care personnel (medical and

59
nursing) failed to give information regarding the progress of the babies’ health
conditions.

SUB-THEME ONE: SOME HEALTHCARE PERSONNEL FAILED TO GIVE

INFORMATION REGARDING THE PROGRESS OF THE BABIES’ HEALTH
CONDITION

The research found that while mothers were separated from their babies, when they
seek for information on what had been taking place with their babies, some nurses were
not cooperative, meaning that they were not willing to provide answers. This naturally
stressed the mothers and as a result, they lost trust in the nurses who were taking care
of their babies.

Mothers expressed their thoughts as below, which were both negative and positive:

“Even if you ask a question to say, how is the baby? they will not tell you nicely and say
no this is what happened, NO!”.

“They did not even explain it, you only see Doctors and nurses coming to your bed and
then they start talking ……".

"They did not tell me that the baby must take five days without eating”.

“They draw the blood or check the baby, they will not come to you and tell you, like the
findings, No”!

“Nurses were telling us about the baby, about your future and family planning”.

“Nurses were telling me how to express and feed her".

Communication between the mothers and the health care personnel in dire situations is
critical, therefore, communication is imperative. The NICU communication is considered
to be ideally directed towards fostering mothers’ participation in infant care in an equal
partnership with providers as a way to achieve the best possible outcomes of care –

60
both during admission and following discharge. The relationship appears to be built and
maintained notably throughout admission time. Therefore, effective information
exchanged about infants’ medical situation is considered fundamental (Amadu et al.,
2021; Slatore et al., 2012). Health professionals should therefore be supportive by
giving patient-centred care as a critical component of the shared decision-making and
therapeutic alliance domain (Slatore et al., 2012). According to Kerthu and Maano
(2010), the NICU interaction of physicians and nurses with mothers can greatly
influence their perceptions long after their babies are discharged.

Although mothers in the current study reported getting some information from the health
professionals  they felt it was insufficient. Mothers wished the professionals to provide
them with more information. This is also in line with a study that found inadequate
communication with medical professionals in terms of quantity and quality. According to
one study, mothers preferred and relied more on face-to-face interactions with the
medical staff than online contact. If mothers are really not given enough information, it
makes them more anxious and forces them to look up information on their own using
various web search engines. According to a study by Abeasi and Emelife, (2020), some
mothers read online owing to failure. Some mothers read online since they weren't
given enough information; yet, they would have wanted to get it from the staff, especially
the nurses. Information is widely disseminated thanks in large part to nurses. But, in a
research, more people (56%), compared to 49% who preferred nurses, preferred to get
their knowledge from neonatologists. Mothers are admitted into the NICU in four stages:
prenatal, acute, convalescent, and discharge. As they move through the stages, their
informational needs may change. While providing information, it's critical to determine
the best moment to do so and the mothers' informational needs in order to get the best
results (Abeasi & Emelife 2020).

Mothers who participated in this study said there was no effective communication
between them and the staff personnel. Some mothers believed that communication
between them and the medical staff was lacking. Several relevant research demonstrate
how ineffective interactions between staff and mothers of preterm infants impact staff
interactions with mothers. According to the survey, mothers generally felt that

61
communication with doctors and nurses was poor, despite some mothers reporting that
nurses interacted with them as they should have expected (Amadu, et al., 2021).

Some mothers complained that the medical and nursing staff did not communicate well
with them and that their interactions with them were not positive. Another study
mentioned that, some mothers said it would be beneficial if the physicians and nurses
tried to communicate with the mothers. These results demonstrate the necessity of
conversation as a key tactic in building rapport with the mothers. Although being able to
meet the requirements of the mother and the family, nurses were unable to engage with
mothers on a deeper level in some instances. While introducing themselves, nurses
neglected to explain the unit's routine to the mothers in order to establish a channel of
contact. In those instances mothers, in turn, felt comfortable sharing their worries, which
aided them in taking an active role in taking care of the premature baby (Slatore et al.,
2012).

While mothers of premature babies are being admitted to the neonatal unit, NICU
nurses should work to establish positive relationships with them in order to foster
dialogue. They also showed the value of effective communication between nurses and
mothers of premature newborns in another trial done in Ghana. This is crucial when a
premature baby is hospitalized because the nurse helps the mother to bond with the
baby by communicating with her (Amadu, et al., 2021). The guidance and strengthening
of mothers' reactions to their babies can be facilitated by nurses who are sensitive to the
needs of mothers. Nurses and practitioners in other health care disciplines play an
important role to providing mothers with information regarding their premature babies,
and continuous updates on premature babies' condition, thus reducing the impact of
mothers fear and stress levels (Shiweda, 2018). These interpersonal communication
skills become handy when mothers are informed by nurses on the procedures done on
the premature babies.

In Ghana, a method was implemented to improve communication between the nurses

and the mothers. In order to establish a connection with the mothers in the unit and
learn what the mothers want from them, all health workers adopted the "talk" method.

62
This might improve the growth of positive ties between the premature babies, unit's staff
and the mothers (Slatore et al., 2012). Nurses lacked in helping mothers feel confident
hence their self-esteem was unaffected. Information giving  helps mothers build,
maintain, and improve their self-esteem and confidence. The necessity of giving
mothers assistance with anything related to the preterm infant's care and the
significance of educating them on how to care for a preterm baby have both been
emphasized in various studies (Amadu, et al., 2021). Therefore it is crucial to be
observed.

The development of caregiving skills in mothers by means of facilitative acts is crucial.

Giving the mother reliable, empowering information about how to care for her baby is
one of the facilitative activities. Another is assisting in reducing the amount of time the
mother and baby spend apart while in the hospital. Providing the mother information
increases her self-assurance as she cares for the premature baby. This helps in
alleviating thoughts of fear and uncertainty, thus making the mothers’ situation bearable
as well as encouraging them to provide the needed emotional support to their premature
babies (Hall et al., 2015).

The mother's ability to care for her premature baby will depend on her confidence in her
ability to do so, which can have an impact on the mother-infant connection. Nurses need
to be aware that they are the ones who can promote mother-infant attachment positively
or adversely. The majority of mothers expressed concern over the nursing staff's lack of
communication with them regarding the premature babies' conditions and medical
treatments. When the condition of their premature babies, the procedures performed on
the baby, and the baby's care were not communicated to mothers,  they appeared to
feel more anxious (Gathara, et al., 2020). Conversely, it was clear that when there was
no explanation, their concern tended to grow. The truth was also clear, as their worry
seemed to grow whenever information regarding the baby's condition and care was
withheld. Several studies show how providing mothers with information about their
premature babies' care and health status aids in reducing mothers' anxiety and fosters
interaction between the mothers and their premature babies (Deeney, et al., 2012).

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In a phenomenological study conducted by Hall, et al.,(2015), it was discovered that
mothers felt their anxiety levels were heightened by the lack of information regarding
their babies' conditions, medical procedures, and treatment. The other's expressed
feeling nervous as they sought proper information about the babies' illnesses and were
constantly curious about the baby's progress while receiving therapy (Hall, et al., 2015).
In addition, the mothers said that they were curious about what was happening when
their infant was ill and taken to the intensive care unit.

They wanted to comprehend what was occurring and believed it was crucial for them to
be fully aware of their baby's situation (Kynoe, Fuggelseth, & Hanssen, 2020). Mothers
felt a part of the team when the doctors and nurses explained what was happening.
Family-centered premature baby care should be built on open and honest discussion
about medical and ethical matters between mothers, the visiting relatives, and
specialists. For both mothers and medical staff, communication in the NICU has been
proven to be frustrating (Maureen, et al., 2019).

Mothers complained that they weren't always fully informed about the effects of
illnesses, the need for special care, and moral and ethical debates surrounding the care
of their infants. This may have been an effort to keep mothers in the dark about
ambiguities or squabbles around the care of their NICU premature babies. Mothers of
premature babies have a fundamental need for information that is accurate, timely, and
compassionate. Mothers find it more stressful when information is suppressed, despite
the fact that such knowledge is overwhelming (Kynoe, et al., 2020). According to
research, mothers in their study wanted to know anything that might be related to their
premature baby's illness, including causes, progress, results, therapies, and their
infant's behaviour. Knowledge has the power to empower mothers and is considered as
a human right. When given information on their infants, mothers said they enjoyed the
nurses and were pleased with the care since they were curious about how their babies
were doing.

Consistent with the findings of this research, researchers found that effective
communication between the mothers and the health care personnel ensures that

64
mothers feel more involved in the care of their premature baby and on the contrary, poor
communication leads to withdrawal from the NICU and its nursing personnel staff, thus
hampering parent-infant attachment. Lack of information from nurses to mothers about
the general well-being and progress of their premature babies breeds conflict between
the nurses and mothers (Kynoe, Fuggelseth, & Hanssen, 2020). Several other studies
have shown that adequate communication between healthcare professionals and
participants in the NICU contribute towards mothers’ satisfaction.

Lack of communication as evidenced from other studies causes a lot of dissatisfaction,

anxiety and helplessness to the mothers as they felt further detached from the event
surrounding their premature babies. Consistent with other research studies, constant
poor communication with mothers leads to feelings of anxiety where mothers felt
excluded from their premature babies' care (Slatore et al., 2012). Lomotey et al. (2020),
adds that the lack of communication and misunderstanding between mothers and the
health care professionals is a stressor that might lead to serious mismanagement of
babies where proper care may be withheld, thereby resulting in babies suffering many
risks.

Other researchers indicated another method of communication which is through the use
of different communication methods in the NICU where information is given by gestures,
whispering, using simple words and repeating the same message many times as a form
of dispensing information. However, mothers found difficulties with this method of using
different forms of communication because the boards had limited explanations and the
context is needful in neonatal care (Kynoe et al., 2020).

It is therefore important to note from the study that communication from nurses to
mothers is pivotal, as it allows mothers to feel more involved in their premature babies’
care. The bonding between the mothers and nurses also made the care management
easy for both professionals and mothers. Some researchers have suggested that it
would be necessary to have a communication plan and strategy from the initial and
critical stage of hospitalisation so that mothers can receive the needful communication

65
experience from the start. This would also aid in promoting maternal autonomy and
home adaptation even after discharge (Manning, 2012).

Orientation and communication on how to use the machined environment is also

important because deprived orientation to the environment and its machines contributed
to the fear in mothers in that they were not sure about how to use the machines. There
is proof that communication helps mothers who are raising a premature baby in the
NICU to talk about their feelings and can help mothers feel like they are an important
part of their baby's existence. Encouraging participation in the baby's care can also help
mothers deal with the unpredictability of the baby's health (Haward, Lantos, Janvier, &
POST Group. 2020).

Mothers whose premature babies are admitted to a NICU mostly depend on the nurses
to give them information and support about the condition and care concerning their
babies. Effective communication between nurses and mothers is a crucial supportive
care, yet in a new and busy environment, this might be inadequate. The manner in
which the nurses informed the mothers about the care of their premature babies is an
important factor that helps the parents to bond with their babies, thus relieving stress.
Good communication between nurses and mothers assists with the early bonding
between premature babies and mothers according to this study and many other sundry
studies (Gathara, 2020). Improvement is however needed as some mothers indicated
that they were not receiving the needed communication and support from the nursing
staff.

3.4. CHAPTER SUMMARY

This chapter discussed on the different key themes and their sub themes as expressed
by mothers. It is evident from the research findings that mothers go through different
emotions whilst caring for their premature babies, each of the mixed emotions
contributed to the mothers’ journey and experience. Effective communication between
nurses and mothers was regarded as a crucial supportive care in that the manner in
which nurses informed the mothers about the care of their neonates was an important
factor that helped mothers to bond with their premature babies, thus relieving stress.

66
According to this study and many other sundry studies good communication between
nurses and mothers assist early bonding between mothers and neonates. It is also
evident from this study that nursing care given to babies by nurses becomes imperative
for allaying mother’s anxiety whilst not present. However, some nurses were seen to be
taking good care of the babies hence, some nurses failed to give care to babies and
neglected them. It is however evident from the study findings that healthcare personnel
failed to give information and communicate with mothers.
The next chapter focuses on the conclusion according to the objectives of the study, the
recommendations and the limitations.

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 CHAPTER FOUR
CONCLUSION, RECOMMENDATIONS AND LIMITATIONS

4.1. INTRODUCTION
The previous chapter discussed the key themes and sub-themes that emerged from
interviews done and supporting literature was provided, pertaining to the experiences of
mothers with premature babies admitted to the NICU. This chapter focuses on
concluding comments according to the objectives of the study as well as
recommendations and limitations to the study.

The purpose of the study was to explore and describe the experiences of mothers with a
premature baby admitted to the NICU in state hospitals in Windhoek, Namibia. The
main research question was: How did you feel when your baby was admitted to the
NICU?
The objectives of the study were to:
 Explore the experiences of mothers with a premature baby that is admitted to the
NICU in state hospitals in Windhoek, Namibia;
 Describe the experiences of mothers with a premature baby that is admitted to
the NICU in state hospitals in Windhoek, Namibia; and
 Factors that influence the presence of mothers at bedside of premature babies
admitted to the NICU at hospitals in Windhoek, Namibia.

The conclusions were drawn for the themes and sub-themes that were considered to be
important in the study.

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4.1.1 CONCLUSION WITH REGARDS TO THE OBJECTIVES OF THE STUDY

OBJECTIVE ONE: EXPLORE THE EXPERIENCES OF MOTHERS WITH

PREMATURE BABIES ADMITTED TO THE NICU IN STATE HOSPITALS IN
WINDHOEK, NAMIBIA

This study aimed to explore the experiences of participants with a premature baby that
is admitted to the NICU in state hospitals in Windhoek, Namibia. The study findings
were discussed according to the objectives of the study, which were achieved through
the use of in-depth face-to-face interviews conducted on participants with premature
babies admitted in the NICU as indicated in Chapter two. During the indirect face to
face interviews, an audio recorder was used, and note taking was done as well as data
transcription to find specific ideas that describe the experiences of the mothers.

Mothers picture a healthy baby throughout pregnancy who returns home after birth, it is
believed that the mothers' emotions and experiences on the first visit to the hospitalized
child differ from the expected reality in comparison to the experienced reality. The plans
are changed when a NICU admission is necessary, and mothers experience shock,
denial, anger, frustration, guilt, depression, hopelessness, helplessness, loss,
loneliness, confusion, worry, stress, fear, and sadness (Ued, Silva, da Cunha, Ruiz,
Amaral, & Contim, 2019). The primary affective bond theory is therefore given
preference, as it states that the interaction between a mother and her baby is a process
that starts before birth and culminates at the end of the first year of life, and that it is
susceptible to the influences and effects of psychological and environmental factors.
Mothers frequently feel helpless to protect or care for their baby when faced with the
unexpected path to this experience, which affects how they connect with their babies.

The majority of mothers in this study described their experiences in the NICU as being
their first. In light of this, the nursing team may be in charge of greeting mothers at the
first visit and offering advice on medical care. This team must develop new behaviors for
greeting mothers and work to comprehend this particular moment. In order to soften the
experience of this phase and reduce the emotional and psychological aftereffects that
typically characterize it, it is necessary to reflect on attitudes that value the mothers'

69
expressed feelings (Ued, Silva, da Cunha, Ruiz, Amaral, & Contim, 2019), according to
a study.According to a study by Ued, Silva, da Cunha, Ruiz, Amaral, and Contim (2019),
it is crucial that medical staff members are available to interact with and chat to mothers.
They believe that by asking questions, they would interfere with the delivery of care,
look foolish, which heightens their worry and anxiety. They are made to feel welcome
and supported by actions such as providing clear and understandable information
regarding the clinical state and operations that will be performed on their
premature babies, emotional support through groups, and involvement in baby care.
The papers make it clear that mothers received assistance from the nursing staff when
they arrived at the NICU. The support provided helped them deal with the circumstance
even though they were terrified and anxious. Supporting mothers emotionally and with
information improves their relationship with their premature baby, medical experts, and
other people in their lives. In other studies, mothers expressed anxiety about planning
and informational help (Abeasi, & Emelife, 2020).

It was also found that mothers were concerned and worried about the baby's survival,
discouraged by financial difficulties, scared to feed the infant using tubes, and afraid to
touch the baby while it was in the incubator. With their premature babies, they formed a
bond. Mothers' feelings of love after holding their premature baby helped them form an
emotional bond with them. Research have been done that show that in order for the
mother to bond with her premature baby, she must grow to love and feel good about
her. The need for and maintenance of proximity elicits emotions of affection, security,
and delight. For one to reach higher stages of connection, they must experience the
pleasant sentiments of intimacy in their interaction with the infant (Trumello, Candelori,
Cofini, Cimino, Cerniglia, Paciello, & Babore, 2018).
Lewis, et al., (2019), mentioned that an emotionally supportive environment for
attachment is created by having feelings of fondness for this particular premature baby
and satisfaction from mastering this new parenting skill. Mothers can establish an
emotional connection with their babies when they are in close proximity to them
because they can read their indications. They added that early and prolonged contact
enables mothers to get to know their premature babies' feeding, embracing, rocking,
maintaining sustained eye contact, and actively seeking these opportunities for

70
interaction all support the formation of an emotional. Mothers The  in the current study
provided frequent contact, feeding, and stroking with their premature babies, which
allowed them to bond with them and maintain the bond even though they did not form a
relationship with them within the initial few days of engagement ( Lewis, et al, 2019).

Although fostering the possibility of the newborn's recovery, the environment of the
neonatal unit also fosters pain and the likelihood of death. The initial visit is impacted by
the complex technology, the sound of equipment alarms, and the intense lighting.
Informational assistance and encouragement to participate in caregiving are crucial in
this coping process (Ued, Silva, da Cunha, Ruiz, Amaral, & Contim, 2019). The
technology in neonatal intensive care is regarded alarming; mothers are unsure of how
to act and what they can and cannot do, and many are reluctant to touch their infant
because of the machines attached to it. The sense and experience of impotence are
represented by this circumstance. Even if it is a distressing sight to observe the baby in
the entire technological setup, because they are weak and frail, every little thing
becomes significant. The mothers recalled the attitude and positioning from the initial
visit as being significant recollections. When mothers go to meet the baby, they expect
to be able to pick them up and breastfeed them, which causes them to feel disappointed
and expectant (Ued, et al., 2019)

Our findings imply that mothers experience significant changes in their daily routines,
roles (especially parental roles), and professions such as work and daily living activities
(such as feeding, sleeping, and personal care) during a hospital stay.Mothers
experience significant changes in their daily routines, roles (especially parental roles),
and professions such as work and daily living activities (such as feeding, sleeping, and
personal care). Understanding the effect on the mothers' family life is crucial for
providing family care because it helps us identify the mothers' needs and provide them
with appropriate care. The anguish, worry, and separation stress experienced by
mothers as a result of having to hospitalize a premature newborn are referred to as the
emotional effect. Garrido-Ardila, Montanero-Fernández, Oliva-Ruiz, & Rodrguez-
Mansilla, Jiménez-Palomares, Fernández-Rejano, Garrido, & Rodrguez (2021).

71
It is clear that mothers experienced all of these feelings without receiving much support.
So, it was determined that most mothers did not receive the emotional support they had
anticipated from the nurses and their relatives. Nonetheless, several mothers reported
that their relatives and the nurses gave them the emotional support they needed to
overcome their worries. The researcher was able to determine during the data analysis
that there are little to no interventions or hospital support plans available for.
Nonetheless, several mothers reported that their relatives and the nurses gave them the
emotional support they needed to overcome their worries.
The researcher was able to determine from the data analysis that mothers with
premature babies in the NICU have little to no access to interventions or hospital
support plans. Treyvaud, et al. (2019), acknowledge the scarcity of strapping evidence
on emotional support for mothers or any specific programs or interventions to support
them throughout their stay in NICU, researchers share the same attitude to this
assertion. Also, it is advised that mothers receive multi-layered assistance while their
child is in the NICU, such as emotional support, peer-to-peer support, or mother-
centered care. Nurses should use social support services like social workers and refer
patients to clinical psychologists to improve the nurse-patient interaction and boost the
mothers' health. It has been determined that the health sector does not completely
utilize these services. The basic conclusion, though, may be that because mothers
struggled to control their emotions, their reliance on God for assistance grew. As a result
of their prayers to God, they were able to find hope, and another delight came from the
baby's improved condition. The emotional assistance that mothers received in this study
is consistent with another study that found that mothers responded favourably to the
nurses' support (Shiweda, 2018). Adkins, and Doheny (2017), echoed this sentiment
when they said that mothers needed to turn to God for strength.
According to the findings, mothers experienced emotional and financial difficulties
because they had to spend more money on transportation costs every day, despite the
fact that they received support. This was due to the fact that there were not enough
hospital accommodations for all the mothers, and some of them were forced to stay in
different places. According to a study conducted in South Africa, mothers who are also

72
caring for their infants often face financial challenges. They had to pay more for
transportation to the hospital so they could see their babies (Steyn, et al., 2017). Parallel
to this, it is established that Adcock et al. (2021) noticed concerns with mothers feeling
stressed out due to a lack of hospital accommodations because they must pay extra for
transportation when visiting their newborns. So, it may be said that Woodhart et al.
(2018) underlined the need for permanent hospital stays for mothers when their children
are admitted to the NICU.

In this study, mothers discovered that attachment to their babies was facilitated by
mother-baby relationships, regular contact with their babies, and the presence of signs
of life, developmental progress, and a lack of remorse. Every mother has a different
level of attachment to her baby. When a premature baby is admitted to a neonatal care
unit, mother-baby bonding is typically disrupted, and this separation might impact the
mother's attachment to the baby (Ncube, Barlow & Mayers 2016). Because of their
anxiety and dread, some mothers would like to avoid their premature babies, while
others would rather hold and care for them while they are being treated by medical
specialists.Mothers in this study placed a high value on attachment, as evidenced by
their preference to stay by their premature babies Sih, D. A., Bimerew, M., & Modeste,
R. R. (2019).
As a result, mothers who are caring for premature newborns outside of the hospital
endure a lot of stress. As a result, they have little interaction with those who are
remaining within the hospital. That differs from western nations where mothers can stay
close to their premature newborns in NICU wards and maintain relationships with staff
and their babies. They believed that patience and self-assurance were key components
in the process of adjusting to the role of mother. The adjustment to parenthood was
simpler for mothers who were more self-assured, and their overall health was less at
risk ( Heydarpour, et al., 2017).

Our findings further emphasize the value of cheap accommodation for babies while they
are receiving care in the NICU, particularly in light of the high cost of hotels in urban
areas and the general financial demands of this experience. Some of these mothers

73
coming from outside windhoek, hence their financial burden was more on looking after
the baby in NIU,hoping that the premature baby will be fine. The emotional toll of not
having direct access to their infants was noticed by mothers who were unable to stay in
or close to the NICU. A comparable study shown that having continuous access to the
NICU, day or night, in person or by phone, eased this strain.

OBJECTIVE TWO: DESCRIBE THE EXPERIENCES OF MOTHERS WITH A

PREMATURE BABY THAT IS ADMITTED IN THE NICU IN STATE HOSPITALS, IN
WINDHOEK, NAMIBIA
The experiences were described by transcribing data, generating codes, and analysing
key themes and sub-themes according to Tesch's steps of data analysis as fully
described in Chapter two.

It was concluded that participants were scared and anxious about the baby's survival,
were disheartened by financial struggles, were anxious about the baby's survival
chances, felt scared to feed the baby with nasogastric tubes, and had fear to touch the
baby whilst the baby is in the incubator.
Mother's emotional distress, self-efficacy, interaction, and estrangement are examples
of individual elements. Prejudice and support are examples of social factors. The
majority of women cited emotional anguish as a key aspect in their ability to adapt to
their roles as mothers. Additional research has revealed that mothers of premature
newborns in the NICU frequently experience emotions including dread, worry,
loneliness, exhaustion, grief, and alienation, which prevents them from adopting their
maternal role (Heydarpour, Keshavarz, & Bakhtiari, 2017). Negative feelings cause
mothers to become bystanders rather than participants in the process of caring for their
infants. Neonatal care is the main focus of neonatal intensive care unit services in Iran.
Moreover, the NICU pays little attention to the stress levels of mothers as they drop.
Supporting mothers may therefore assist to lessen the worry that preterm newborn
mothers suffer. The majority of people express their sorrow by crying. The loss of
pregnancy nevertheless saddens mothers of premature infants even when they have
not yet lost their children. Participants in this study also reported crying and feeling

74
depressed. This result was in line with the research by Heidari et al (2012). Instead of
being angry, mothers in this study replied by placing the blame on themselves and felt
like failures. This result was in line with other studies' findings (Heidari et al. 2012).
Anxiety and guilt grow when a person places the blame for the pregnancy's outcome on
themselves and doesn't express their unpleasant emotions. The mothers who took part
in this study expressed anxiety for the babies' survival and physical wellbeing. In light of
this, it is appropriate to interact with mothers and offer them social support when they
most need it. In their research, Heydarpour et al (2017). The obstacles to mother-child
connection were dread and worry for the infant's survival and its evolutionary
repercussions. Mothers in this this study had to deal with two different kinds of
uncertainty: one concerned the baby's life and future development, and the other
concerned the baby's care. The mothers of premature babies who were being cared for
in the NICU expressed uncertainty about their role as mothers. Uncertainness needs to
be reduced to make it easier for the mother to participate in her mothering duties make
it easier for the mother to participate in her mothering duties, uncertainty needs to be
reduced. Healthcare is evolving to become more individualized, patient-centered, and
family-centered, yet most NICUs do not fully embrace this attitude. Mothers of
premature infants were separated from their baby during hospitalization in Iranian
hospitals by medical staff.
It can be concluded that participants felt all these emotions with not so much support
being given. Most mothers did not receive emotional support from the nurses and their
families as anticipated by them. The lack of emotional support experienced by mothers
in this study corresponds to a study that also revealed that there was a negative
reaction in mothers with nurses failing to give enough support. However, some mothers
were happy with the support given by the nurses (Shiweda, 2018).

Through touching, kissing, playing with, and cuddling their babies,mothers in this study
developed attachment to their infants. A study that found that attachment of mother to
baby leads to well-being of the mother as well as better growth and development in the
preterm baby (Valizadeh, et al., 2012) confirms that these participants felt joy and
happiness, which helped to reduce their fear and prevent rejection of their preterm

75
babies. Mothers were excited to see, touch, and attempt to tube-feed their infants when
it came to seeing the baby. They gain encouragement from the  fact that their babies
were showing only the beginnings of life and were receiving enough care from the
nurses who were in charge of taking care of them (Rossen, Hutchinson, Wilson, Burns,
Olsson, & Allsop, 2016).

Another participant alluded that mothers admitted to the NICU unit be offered
counseling sessions. It might also be a result of the mothers' extreme loneliness as a
result of their families' lack of support, their depression over the baby's health at the
hospital, and their lack of opportunities for close communication. As a result, some
mothers asked that hospital discussion groups be offered (Sih, D. A., Bimerew, M., &
Modeste, R. R. 2019). Because there were no discussion groups or counseling
services available to help hospitalized mothers decompress at stressful times, this
mother chose to isolate herself from her premature baby without realizing what this
would do to both her baby and herself. In a study Smith, Steelfisher, Salhi, & Shen,
(2012), discovered that mothers of preterm babies reported that they were able to deal
better when they avoided the NICU and the hospital setting where the baby had been
admitted. According to a study by Rossen, Hutchinson, Wilson, Burns, Olsson, Allsop,
(2016), mother-infant connection is essential for both the growth of the baby and the
health of the mother.
One of the greatest fear-inspiring reactions in the relationship between mothers and
their premature babies is one of our fundamental requirements for communication.
Mothers struggled to touch the premature babies because of their intense fear of the
incubator and the prematurity of the baby. They were able to get over their
apprehension and confidently handle their premature baby thanks to the nurses'
support. Building a link between mother and baby might be delayed by the challenges
premature mothers have before they can make contact with their babies. The
attachment between a mother and her baby may be established with the help of the
staff Mothers said they wanted to cuddle and touch their babies in the incubator but
were initially hesitant of harming the baby and environmental barriers (Adu-Bonsaffoh,
Tamma, Nwameme, Mocking, Osman, & Browne, 2022).

76
There is an increasingly interest in mothers’ experiences when having premature baby
and thus challenges nurses to not only focus on the developmental care of the
premature baby but enable mothers to go through the uncertain feelings. In general, the
admission of the premature baby in the NICU, poses more challenges in how the
mothers have to be separate from their babies and other babies at home, which causes
strains on mother baby relationship. Results that showed positive significant
relationships with stress were marital status and distance from home and other children
left at home.
With relation to NICUs, numerous previous studies on mother stress have been carried
out (Heidari, Hasanpour, & Fooladi, 2014). However the mothers' levels of maternal
stress and the signs of psychological trauma have remained high, ranging from 30% to
70%. These frequently lead mothers to hide their emotions and worries, which could
worsen their stress and worry. Every individuals experience stress and anxiety
differently. Maternal stress was positively and significantly correlated with premature
baby characteristics, gestational age, length of stay, extreme preterm, and newborn
medical problems (Ong, Abdullah, Danaee, Soh, Soh, & Japar, 2019). Therefore,
continuous support, information on meeting the newborn needs and positive
reinforcement about their parenting is imperative from the nursing staff to mothers
(Shiweda, 2018).
Long-term effects of a premature birth affect the mother as well as the entire family.
Several elements that can strengthen or diminish a parent's capacity for coping have
been identified through studies. Mothers' personalities, families' dynamics, staff
dynamics, the premature babies health state, the mothers' compassion for the baby and
the loss of a typical motherhood are all influencing variables. This is consistent with
(Manning 2012). Another issue is that mothers worry more about other babies who are
left at home and are not well cared for; they are unsure of how those babies are coping,
who is specifically caring for them, and whether the care is adequate.

77
OBJECTIVE THREE: FACTORS THAT INFLUENCE THE PRESENCE OF MOTHERS
AT BEDSIDE OF PREMATURE BABIES ADMITTED TO THE NICU AT HOSPITALS IN
WINDHOEK, NAMIBIA.

Based on the identification of factors that had the most influence on the adaptation of
the role of mothers, factors were derived from the themes and sub-themes that came
from the responses of participants. Themes and sub-themes were fully discussed in
Chapter three. Positive and negative factors were expressed by participants during this
study.

 Positive responses of the participants

Based on the findings, participants expressed joy when nurses were providing good
care to their babies. However, there were incidences of nurses neglecting their babies. It
can be concluded that it is important for nurses to provide good care and it is their
responsibility to monitor babies and help mothers to develop skills in caring for their
premature babies. In addition, it can be concluded that as a result of a good nurse-
patient relationship, mothers can eliminate any negativity they have on the health
professionals. The above statement supports the views by Veronez, Borghesan, Correa,
and Higarashi, (2017), that good nursing care by nurses reduces the anguish that s
have and allows mothers to have a sense of gratitude and a sense of trust. Similarly,
Fowler et al. (2019), also concluded that the provision of care to mothers by nurses for
their sick babies creates a trusting relationship. The findings of the study further
indicated that the nurses in the hospital were good in taking care of the babies.
However, it is against this background that Veronez et al. (2017) agree with the
provision of good nursing care to babies as a way to promote maternal autonomy even
after discharge.

It is concluded that good nursing care is one of the components that aid mother and
baby attachment and mothers’ participation in the care of their premature babies.
Moreover, nurses need to strive in giving better nursing care to mothers because failure
to give such can cause an emotional crisis and negative feelings in mothers (Medina et
al., 2018). Steyn et al. (2017), also emphasise the need to concentrate on mothers’

78
emotional and psychological states during hospitalisation and at the time of discharge.
Therefore, nurses should ensure effective mother involvement in decision-making
regarding the premature baby's health and a need to acknowledge mothers’ challenges
and the provision of adequate information. This includes the identification of positive
experiences, explaining babies’ conditions, and giving care and emotional support to
mothers which is vital (Veronez et al., 2017).

Namibian researchers concurred that mothers require information or communication

support, as well as adequate physical and technical care, to deal with having their baby
in the hospital. The study pointed out that it is the nurse's duty to help mothers when
they care for their premature babies and to be enthusiastic about their work. To achieve
the required understanding, good mother engagement, nurses, and other healthcare
team members should be taken into consideration with cultural sensitivity. It is essential
that mothers participate in decisions regarding the health of their infants. They raised
concerns about it in this study and said that the Ministry of Health must seriously
consider adopting measures to make mothers' participation in NICUs permanent
(Shiwedha, 2018).

 Negative responses of the participants

The findings revealed that there were some negative responses which include the way
nurses give information to mothers, lack of accommodation, and lack of support from
nurses and the entire health care team. Based on the findings, mothers felt depressed
because of not having enough accommodation facilities in the hospital. More so, some
were staying in different locations and they experienced emotional and financial
challenges because they had to spend more money on transport costs every day
(Namukose, et al., 2021).
Our research shows that mothers generally struggled to feed their premature babies.
Due to their undeveloped digestive systems, preterm babies frequently suffer eating
issues. Due to inadequate emptying, gastroesophageal reflux, and abdominal
distension, preterm neonates usually struggle to synchronize sucking, swallowing, and
breathing. They also frequently have gastric residues. Premature  babies are fed via

79
gavage, which involves inserting a feeding tube through the nose or mouth and into the
stomach, to help them deal with these issues. This makes it simple to keep an eye on
the preterm baby's feedings. In comparison to oroenteric feeding, the use of nasal
gastric feeding tubes has been linked to greater rates of central apnoea. Feeding tubes
are given to preterm infants, but mothers worry that they would harm their helpless
babies (Petty, Jarvis, & Thomas, 2019).

A study done in South Africa revealed that mothers experienced financial difficulties in
their everyday life experiences whilst caring for their babies. They had to spend more in
paying for transport to the hospital to visit their premature babies (Steyn et al., 2017).
Similarly, Adcock et al. (2021), noted issues pertaining to there being no hospital
accommodation facility as some of the stressors to mothers as they had to pay more for
transport when visiting their babies. It can therefore be concluded that there is a need
for the availability of permanent accommodation for use by mothers within the hospital
whilst their premature babies are admitted in the NICU (Woodhart et al., 2018;
Shiwedha, 2018).

The detrimental psychological and emotional impacts of premature births and their
effects on mothers have been the subject of numerous research. In addition to the
shock of an early birth, mothers also struggle to balance their new obligations while
dealing with separation brought on by the stress of being in the neonatal intensive care
unit (NICU). Few studies have used in-depth interviewing to explore these factors, with
many concentrating on low- and middle-income country contexts where hospital
environments differ significantly in the services they provide to families to support NICU
care. These environments place a high demand on mothers' energy, time, and financial
resources (Lewis , et al., 2019).

The results support earlier literature that suggested a variety of predisposing factors
related to a mother's mental and physical health could permeate the NICU experience.
These predisposing factors included stress, a lack of preparation for the newborn,
challenges coordinating visits and feedings, and other NICU-related obligations.

80
Mothers' remarks revealed unfavorable emotions, like anger and anxiety, which have
been linked in earlier work to higher rates of psychological distress ( Petty, Jarvis, &
Thomas, 2019). Some mothers felt so strongly for their premature babies that they
wanted to be more involved in their care.

Even slight improvements in the preterm baby's overall health helped the mothers'
resolve and spirit. When in the NICU, mothers should be given frequent positive
reinforcement and encouraged to celebrate milestones. It is crucial to keep in mind that
the mother is the principal actor, assisted by her family, the medical staff, and other
outside organizations. These crucial roles can substantially aid the mothers' efforts to
improve her wellbeing (Garthi, et al., 2021). According to Abeasi and Emelife (2020),
preterm infants are typically admitted to the neonatal intensive care unit (NICU) as soon
as possible after birth since their undeveloped organs may require support. Most mother
finds this to be traumatic and upsetting, especially the mother who finds it difficult to
picture herself as a mother even if she is no longer expecting.
The need for additional support services and potential referrals to mental health
professionals can all be determined by conducting a psychosocial assessment, which is
essential for detecting hazards that may influence mothers' ability to adjust. Also, health
practitioners must anticipate the mother's informational and social requirements and
create a thorough strategy for ongoing follow-up (Garti, et al., 2021). Mothers might also
struggle with a fear of the unknown, which makes them unsure of the present and the
future. The process of becoming a parent will probably be hampered. The process of
becoming a mother will probably be hampered. As a result, the premature baby may
experience both short-term and long-term impacts from these. Researchers have been
looking into concerns related to caring for the premature baby as a result of the
aforementioned effects of having premature infants on mothers and, to a large degree,
the family (Peter et al., 2019).

Mothers' perceptions of care may be impacted by a lack of emotional support and

information. Because of the limited amount of time a single nurse or doctor can spend
with each baby and mother in a crowded NICU, the critically ill are given priority. For

81
nurses working in the NICU, the chance to evaluate each mother's unique requirements
and gaps is essential (Peter, et al., 2019). Participants in this study believed that the
medical staff did not adequately explain the baby's condition or allow them opportunity
to ask any questions about the course of therapy. Similar research findings have been
hinted at in earlier studies conducted in affluent nations, when mothers caring for
preterm infants in the NICU valued being heard and having a voice a formal exchange
of information with medical experts.
Namukose, et al., 2021, when the premature baby was in the NICU, mothers felt that
their family members were not there to support them. There has never been a study
where mothers of preterm infants concerned about what the community would think of
their premature baby.However, one of the African nations with a high fertility rate and
care for the number of premature babies is Uganda (Namukose, et al., 2021).

The mothers and the nurses appeared to be having a gap in communication. Some
women stated that the nurses would ignore them when they tried to talk to them about
taking care of their baby. The high patient load and inadequate staffing levels in the
public health environment may be the cause of the communication issue in this
situation. Missing nursing care has already been linked to the NICU nurses' increased
workload. Health professionals can empower mothers who are experiencing preterm
labor by providing them with the appropriate information. Given that they are in charge
of their babies, mothers of preterm newborns are helpless due to the lack of
communication and indifference of health staff. ( Namukose,et al., 2021).

Some mothers felt so strongly for their babies that they wanted to be more involved in
their care. Adding to the body of prior literature, Lewis, et al (2019),  results indicate that
a mother's physical recovery after childbirth has a significant impact on her experience
in the NICU, affecting both her willingness to stay in the hospital and her capacity to
participate in her premature's baby care. There weren't always areas in the NICU for
rest and relaxation, making tasks like sitting to deliver tube feeding an unpleasant
struggle. In order to continue caring for or spending time with their premature baby,

82
mothers reported forgoing meals and relaxation in favor of their own fundamental needs
(Lewis, et al, 2019).

During the analysis of data gathered, the study noted that there are little to no
interventions or hospital support plans that are available for mothers when they are with
their babies in the NICU. This statement is supported by Treyvaud et al. (2019), who
acknowledge the lack of strong evidence being available on the emotional support for
mothers and the absence of specific programmes or interventions to support mothers
during their stay in the NICU. It is also concluded that a multi-layered approach that
supports a mothers whilst the baby is in the NICU is recommended. This includes
psychological support, peer-to-peer support and mother-centred care. Health care
providers should find strategies to enhance patient-nurse-relationships and promote
their health by utilising services that offer social support such as social workers and
referring them to clinical psychologists.

Support should be tailored to improve health education needs that focus specifically on
mothers and their needs. It is concluded that these services are not fully utilised in the
sudy sites or at the sites of the current study. However, the general conclusion can be
that it is imperative that the health care professionals ensure the utilisation of resources
that are available for counselling. It is also concluded that mothers fail to grasp these
experiences, therefore, increasing the way they seek God for help. The former
statement supports Adkins and Doheny (2017), who expressed that participants had to
seek God for strength and in this way, they felt uplifted and relieved from their worries
and stress.

From the findings of the study, it can be concluded that many mothers with premature
babies admitted to the NICU in the tertiary state hospital in Windhoek, Namibia did not
receive timely information and communication from nurses and the whole health
professional team. However, some mothers praised the nurses for giving adequate
information. The study unveiled that some mothers raised concerns of not receiving
timely information on the well-being and the progress of their premature babies from
nurses working in the NICU. Based on the findings, non-communication about the

83
baby's condition can aggravate anxiety and a sense of hopelessness and doubt about
the baby’s future condition (Veronez et al., 2017).

However, there is a need for nurses to improve the timely provision of information and
this is crucial for the participants. Thus it can be concluded that the study results could
be used to improve how information is given to mothers of the premature babies.
Similarly, it was proven that health professionals need to communicate effectively with
mothers as they provide information and guidance on any potential challenges and
ways to resolve them. Supportive information reduces stress and through this, mothers
can cope with their stressful situations. The relationship between NICU doctors and
nurses can have a significant impact on mothers' perceptions even after their babies
have been released, according to Kerthu and Maano (2010). Hence, it is crucial that
nurses give mothers the best care possible so that they have positive experiences.

The nurses' ability to communicate with mothers helps them to give their children the
emotional support they require (Hall, et al., 2015). Similarly, Jiménez-Palomares, et al,
(2021), found that mothers' experiences in NICUs can be anxiety-inducing, frightening,
and traumatic; as a result, it's important to assist them in coping with these
overwhelming emotions. To help mothers vent their emotions, it's crucial to provide them
with support groups or other types of emotional support; these groups have been shown
to alleviate both their distress and the anxiety of their children (Jiménez-Palomares, et
al, 2021).

To reduce worry and make it easier for mothers to care for their babies, communication
between mothers and the medical staff should be opened up at all times while the baby
is being admitted. It is an essential part of patient-centered treatment and should
promote the domains of therapeutic partnership and shared decision-making ( Slatore,
et al., 2012).

Communication is viewed as imperative and as such, professionals must be highly

sensitive in their choice of words and they need to strive to keep participants’ positive
expectations regarding the condition of their premature babies. However, the general
conclusion can be that constant and effective communication can strengthen the bond

84
and trust with mothers regarding the baby's health condition (Dosani et al., 2016).
Moreover, this can promote mothers’ mental health and they may become self-aware,
gain self-knowledge and cognition of self-growth.

Mother's participation as the child's primary caregiver in the intervention process is

stressed in a study conducted in South Africa. This is because mothers' perceptions and
experiences of caring for their infants have a significant impact on the child's future
communication and feeding development. The communication strategies in place are
not only tactful but also take into account each individual's perceptions and experiences
(Van Schalkwyk, & Gerber, 2021).

4.2 RECOMMENDATIONS

This section provides recommendations regarding the Nursing Practice, the Ministry of
Health and Social Services, Nursing Education, and for further Nursing Research.

RECOMMENDATIONS REGARDING NURSING PRACTICE

 Offering mothers support groups or other forms of emotional support is important to

help mothers vent their frustrations.

 Nurses and other health professionals working in the NICU should be mindful to
support mothers with their mental health, referring mothers for counseling and giving
formative communication.

RECOMMENDATIONS FOR THE MINISTRY OF HEALTH AND SOCIAL SERVICES

 The Ministry of Health and Social Services should consider adopting policies to make
permanent presence of mothers in the hospital by ensuring that there is enough space
and rooms for mothers to live in during premature babies' admission.

85
 The Ministry of Health and Social Services should employ more social workers who
can specifically deal with issues that concern mothers when premature babies are
admitted in the NICU.

 Professional counsellors then should ensure that there is professional counselling

during that admission experience so that the mothers can keep up with their personal,
emotional and spiritual well-being.

RECOMMENDATIONS FOR NURSE EDUCATION

 Nurse educators have a mandatory role in teaching students about respectful care to
patients during their practical placements and whilst they are in training.

 Facilitation of student nurses in being mindful to support mothers apply as this will
promote mothers' mental health where the nurses can become mindful to render high-
quality nursing care.

RECOMMENDATIONS FOR FUTURE NURSING RESEARCH

 More research should be conducted in the context of supporting mothers' mental

health with premature babies as a way to improve their maternal well-being for infants to
have a stable emotional response to their needs.

 Further research should focus on experiences of the family including the fathers and
siblings of a premature babies for better understanding of their experiences.

4.3. LIMITATIONS

The study was limited to the two state hospitals in Windhoek, therefore the findings
cannot be generalised to the private sector and other hospitals outside of Windhoek.

4.4 CHAPTER SUMMARY

Various factors cause premature birth and it is increasingly becoming common and yet
many babies survive their premature birth. Mothers with premature babies admitted to

86
the NICU have emotional experiences that also involve their thoughts and relationships.
These experience allow self-growth to the mothers and they help with the facilitation of
their mental health, and possibly an impact may be on the mental health of the mothers,
the whole family, and the society at large. However, nurses need to make the admission
of babies to the NICU an opportunity they can use to facilitate mothers' mental health.

87
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ANNEXURE A

INFORMED CONSENT FORM

Title of the study: Experiences of mothers with a premature baby that is
admitted to the Neonatal Intensive Care Unit (NICU) in Hospitals,
Windhoek, Namibia.

The purpose of the study will be to explore and describe the experiences of mothers
with a premature baby that is admitted to NICU, in hospitals, and identify the factors that
have the most influence to the adaptation of the role of motherhood to the premature
baby that is admitted. The mothers’ experiences will be assessed and compared and
documented as a contribution to medical literature.

Researcher’s name: Dhlamini Yvonne

Researcher’s position: Registered Nurse

I understand that the interview will be audio recorded. The recorded information will not
be shared with anybody besides the supervisor of the study. In the final report of the
study, examples will be quoted from the interviews, but these will not bear the actual
names of the participants; participants will not be recognized because pseudonyms will
be used. The researcher will erase the tapes on completion of the study. I understand
that I am not forced to part in the study and can withdraw from the study or the interview
without any negative impact on me.

This is to show that I ……………………………………………………………...

I agree to participate in the study. I understand that I can withdraw fro the study at any
time and that I will not be identified in the research report

Signature of the Participant ………………………….. Date…………………

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Signature of Researcher……………………………… Date…………………

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ANNEXURE B

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ANNEXURE C

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ANNEXURE D

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ANNEXURE E

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ANNEXURE F

Hospital A- Interviews Verbatim Responses

Participant: 1

The Interviews were done on mothers with babies admitted in NICU hospitals A & B in
Windhoek. Below are the responses from the participants.

Research Question- How did you feel when your baby was admitted in NICU.
Participant 1: ummh (mumbling) this is my first baby so I did not really know anything
about Premature Unit. So as she was taken from me, she was cut out, it was actually a
C- Section. I had high blood pressure, I did not understand, so when I woke up I was
like where is my baby, because I thought I was taking her home. And then they told me
she was in Premature Unit and then I did not see her for 2 days, and I was just like oh
ok! my baby is big and she is ok, but when I came here she was a bit small and I could
not really understand so I had to talk to someone, because I was just crying thinking my
baby was not going to make it. So I spoke to some who said look at all these babies,
they were small and they just made it, babies make it.
She is ok now but at the beginning you go home and then you do not sleep and when
you come here you hope you get good news and its not always the case and sometimes
you come here and she has breathing problems and then you don’t sleep during the day
you don’t eat, so its not something easy in the beginning but as times goes on you get
the hang of it and when you come you get good news and she eating well, the stomach
is well and working and as time goes on you get used to it. Then you meet the mothers
and they tell you their experiences and they tell you that my baby was not well, and they
give you hope because when you come here you are not alone anymore and its gets
easy and then you don't stay home. Sometimes you stay home and you just like I don’t
want to see her today maybe I don’t have to think a lot when I see her, but then you
come here and, you talk to people you get to know the mother and, you talk to the
people that actually understand how you feel but then when you stay home its not really

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the same and then you come here and you see people and then the nurses here its just
gets easy as times goes on but in their beginning its not easy.
Researcher: Ok so how did you find it easy?, where did you find the help from.
Participant 1: I talked to someone the first first day because I was not taking it very
easy so, they gave me someone to talk to and she sat and then it was the nurse she
talked to me and then she calm me down and told me all the things that come with
premature babies, because I did not understand at all. As time went on I was just like ok
the nurses are just here help our babies, and do their job right, but because its babies
and mothers they are really just doing it like nurses, they are here doing their best to
help us, so coming here you are not just talking to just the nurse but to a person that
really understand and they are really not like No!, I'm just here to do my job and give
medicine, but they really talk to you and make you really understand and make us fell
like when you are gone home they will take care of our babies they are not just giving
medicine but they are really taking care of them, so they make us feel like though you
mothers are gone we make you feel like we are mothers. So it makes us ease, in the
beginning when I go home I was like, what if my baby is crying and no one is changing
the diaper. Then you come back, and they did everything and fed the babies and when
they cry they calm them and so that give you that ease that ok I can sleep now and
know that my baby is really well taken care of and not that someone is just a nurse and
that’s all. And also as Mothers when we come here together we calm each other down
when someone comes crying saying my baby is not ok, you realize you are not alone
someone comes talking to you like do not cry, you should not do this and when your
milk is gone you should do this, and for me I did not know and they were like
(yooh....facial expression) you should do this, you should drink this, you should take
this, take tea in the morning hot or coffee or fluids, giving each other device, but when
you are home nobody knows these things about anything, but when you come here the
nurses tell you, you should do this from the experiences they have already.
Researcher: Ok so now after the confusion you had and the help you got from other
people and the nurses, how do you feel now?.

Participant 1: I have been here since the 8 th of May, until now.

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Researcher: So how do you feel since you are a first time mother. How do you feel
now?
Participant 1: I feel good, I feel hope, I feel she will be better, I have so much hope
compared to the beginning, now I have so much hope and I have this urge of waking up
each morning to my baby. Usually I am just like oh its 7 and i have to go, usually which
is good because you have to go see your baby I used to be not happy to wake up so
happy and go see my baby. But now when the alarm goes out I am like out the bed
rushing to go see my baby (...laughter...) but that hope was not there. I had hope but
that hope was not so high but now I am just like my baby is going to get out of here, she
going to be ok.
Researcher: Do you have chance to touch your baby once the baby is lying in the bed
in the incubator? How did you feel with all those things surrounding your baby now?
Participant 1: ummh, at the beginning I was very scared to touch the baby she was
small, I used to ask the nurses to come and turn my baby on the side, and they used to
say No (facial expression- disappointment) do not be scared to touch your baby, but the
baby is small I am like what if I break her and make her not move. But as time went own
I used not to change the diaper I used to ask please help me change the diaper all the
time but as time went you just get the handle of it. I can turn her and I can do all the
touching. I hate the incubator thing but, because I cannot hold her or do anything but
am getting there, she is still on continuous feeding and they told me apparently I cannot
touch her yet, I can touch her but cannot hold her or take her out, but the there is just
one more step for her to finish continuous feeding on the tube, so if she is done with that
then I can hold her, i am getting there, am hoping these days.. (laughter)
Researcher: (laughter), ooh ok
Researcher: so now you also say you stay at home and you come back here, why are
you not saying here?.
Participant 1: I was staying here the first days, how many days? (looks up thinking) I
was staying from the 9th to the 15th, it was really good, because you can see your baby
throughout the day, the whole day you can go even the night you can go, but then when
you go home you can not do that. With transport for me, its good because its a few
blocks away from the hospital so during the day I can go back home, or if I need

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something at home during the day, i don’t take taxi at all I am lucky but its not really
close. The walking is not fun but its not bad either, and coming you not thinking of the
walking, I am going to see my baby, its not far and I am lucky I don’t take cab everyday.
ooh yeah that's a good part.
Researcher: Ok! is there anything that you think is not done for you to have a good
experience whilst you are here with your baby? or anything that could be done to
change your experience, as a hospital?.
Participant 1: for me I do not have really complaints but I was just thinking in terms of
transport and moving around I would like to see my baby throughout the day even
during the night, so if they had enough wards or beds that can accommodate mothers
that could really really really make a difference. It would help us see the babies, for me I
cannot come back here at night, so that means I have to take cab at night and that’s
not, so (ummh nice….). For transport I was thinking that it would be easy if they had
enough beds for mother so that they can see their babies in Premature unit, so they
don’t have to move all the time and also be able to see our babies throughout the day
and also throughout the night.
Researcher: Is there anything else that you might want to say?
Participant 1: Ooh ok I would like to thank the nurses here. the experience is like very
out of were I have ever been, I have been to hospitals in my home town but I mean like
any other town, but I have never seen the care that we get here even when I was a
patient the experiences I got was (nooding her head).. The nurses are doing their job
they are really good they are not just nurses but they are really human beings (laughter)
and the way they care for us, we would like to say thank you thank you so much no
body does that for anyone’s baby and for them they have been really been there! thank
you.
Researcher: That is good! Thank you so much for your time ……
INTERVIEW ENDED

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