Maternal birth-related stress and school-age emotional and behavioural outcomes of children with hypoxic-ischemic encephalopathy

Chapter One introduces the researcher's background, research context and theoretical paradigm. Against the background of an emerging evidence base, Chapter Two of this thesis outlines a systematic literature review of the existing evidence which investigates the association between birth-related post-traumatic stress (PTS) and parent-child relationship quality in the first two years of life. 

A comprehensive, systematic search identified 24 quantitative studies that examined parental birth-related PTS in relation to indicators of parent-child relationship quality. Sample sizes ranged from 19 to 2802 parents and studies utilised a range of measures and designs. The 24 studies included both general population samples and high-risk birth populations, such as parents of pre- term infants. 

Several domains of parent-child relationship quality were investigated including: bonding, maternal behaviours and child behaviours. Some evidence suggested that parental birth-related PTS is associated with less optimal parent-child relationship quality, such as less maternal warmth and greater maternal anxiety towards the infant. 

However findings were inconsistent across all domains of parent-child relationship quality. The inconclusive findings and the heterogeneity of the reviewed papers as a whole limits the conclusions that can be drawn. Further and more rigorous research is needed to advance our current understanding of how parental birth-related PTS may influence the parent-child relationship. Further study is also needed to advance our current understanding of partner's birth-related PTS on the parent-child relationship, as current evidence is scarce.

The empirical paper (Chapter Three) assessed maternal birth-related stress and school- age emotional and behavioural outcomes in children with neonatal hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) compared with typically developing peers aged six to eight years (mean age 6.94) participated. 

Mothers completed measures of birth-related stress. Children's emotional and behavioural difficulties were completed by parents (n = 45 for the HIE group, n = 28 for the control group) and teachers (n = 28 for the HIE group, n = 21 for the control group). Mothers of children with HIE reported significantly greater levels of birth-related PTS (p>.001). 
Parental and teacher reports of children's emotional and behavioural difficulties found that children displayed significantly greater internalising and externalising difficulties at home but not at school. Maternal birth-related distress fully mediated the association between HIE and parental reported internalising difficulties, but not externalising difficulties. 

Our findings indicate that HIE is associated with increased risk of birth-related distress in mothers, and increased risk of emotional and behavioural difficulties in children. Implications for Educational Psychologists (EPs) and key stakeholders are discussed.