ABSTRACT OBJECTIVE To describe factors associated with quality of couple relationships among parents of infants cared for in neonatal intensive care units (NICUs) 1 year after birth and

examine the trajectory of the relationship quality compared to parents from maternity units (MUs). STUDY DESIGN Longitudinally comparative cohort design. Parents answered surveys during the

first year after discharge about the couple relationship, social support, and depressive symptoms. RESULTS Better social support and a hospital stay of 7–14 days were positively associated

with the couple relationship in NICU mothers, whereas not having slept together with the partner and infant during hospitalization were negatively associated. Depressive symptoms were

OTHERS CLINICIAN–FAMILY RELATIONSHIPS MAY IMPACT NEONATAL INTENSIVE CARE: CLINICIANS’ PERSPECTIVES Article 05 June 2021 FATHERS’ EXPERIENCES OF SUPPORTING THEIR PARTNERS DURING THEIR PRETERM

INFANT’S STAY IN THE NEONATAL INTENSIVE CARE UNIT: A MULTI-METHOD STUDY Article 01 September 2021 FAMILY INTEGRATED CARE REDUCES STRESS IN TRANSFERRED PARENTS OF PRETERM INFANTS, BUT NOT

ACROSS ALL FAMILIES: A STEPPED-WEDGE CLUSTER-RANDOMIZED TRIAL Article 20 May 2025 INTRODUCTION For most parents, becoming a parent brings joy, completeness in becoming a family, and

increased tenderness [1, 2]. However, the transition to parenthood can be challenging [3] and stressful [4] and may have a negative impact on the couple relationship, e.g., reduced marital

quality and satisfaction [5, 6], increased marital strain, decreased sexual contentment [1], and increased risk of depression [7]. Factors positively associated with relationship

satisfaction are female sex, younger age, higher education, better income, and social support [8, 9]. Support from the partner during times of distress is linked to greater intimacy and

trust [10], has a buffering effect on the relationship [8, 11], and enhances self-rated health in mothers [12]. Meier et al. [13] concluded that it is not only important how well partners

support each other during times of stress but also that their engagement in parenthood is equal. Inequality in household tasks has also been associated with poorer health in both parents

[14, 15]. Parents of neonatally cared infants often face distressing situations in a new and unfamiliar environment [16]. Experiencing symptoms of psychological trauma or depression is

common for parents in neonatal intensive care units (NICUs) [17, 18]. Thus, NICU parents have increased risks of strain in couple relationships. However, few studies have investigated the

couple relationship during and after NICU hospitalization. Some studies suggest that parents’ psychological distress and increased symptoms of depression related to NICU hospitalization may

lead to long-term negative effects on the couple relationship [19, 20], and that the quality of the couple relationship decreases from NICU admission to discharge [21, 22]. Stefana et al.

[23] suggest that the NICU experience might strengthen the couple relationship if the parents share their emotional states with each other. Results show preterm birth can influence the

couple relationship positively and negatively [22,23,24,25,26,27]. In this sense the parents can be important sources of support for each other but also vital sources of increasing concern

and stress [24]. Although knowledge about factors associated with the quality of the NICU parents couple relationship is important for improving neonatal care and families’ long-term

well-being, few studies have explored this issue. Therefore, the aim of this study was to describe factors associated with NICU parents’ quality of the couple relationship 1 year after

birth. Further, we aimed to describe the trajectory in the quality of the couple relationship the first year after birth compared to parents of term and healthy infants. We hypothesized that

parents of preterm/ill infants experienced significantly more strain in the couple relationship compared to parents of term/healthy infants. METHODS DESIGN This is the second paper from an

ongoing longitudinal comparative cohort study (PANC—Parenthood After Neonatal Care) over 3 years [25]. An advisory group of parents whose infants had been cared for in NICUs was involved in

developing the study aim, design, and recruitment strategies. They also tested different validated instruments and the questionnaires and helped to interpret the study’s findings. The

parents had experiences from different NICUs in Sweden. The parents’ infants were born extremely preterm, very preterm, or preterm. Ethical approval was obtained from the Swedish Ethical

Review Authority (dnr: 2019-04367). SETTING Families from six NICUs and four maternal units (MUs) in the middle and south of Sweden participated in the study. The NICUs varied in level of

care from level II (infants born from gestation week (gw) 32 and infants having milder breathing problems) to level III (infants born from gw 22 and infants having severe breathing problems

requiring a ventilator). The families participating in the study were recruited during the COVID-19 pandemic when different visiting restrictions were in place at NICUs and MUs. At all six

NICUs, the parents had access to their infants 24 h a day without any restrictions (unless they had COVID-19 symptoms). In five of the NICUs, both parents could stay at the unit day and

night, but relatives, friends, and siblings could not visit the unit as they could before the pandemic. At some MUs, there were restrictions for the fathers/partners, such as not staying at

the unit with the mother and infant during certain months. All MUs had visiting restrictions for siblings, relatives, and friends. The provision of services from hospital social workers and

follow-up care of the infants functioned as usual. RECRUITMENT All parents at the participating NICUs and MUs were informed about the study during their hospital stay. The information was

available in four languages (Swedish, English, Arabic, and Somali) and comprised brochures, posters, and a study website containing written information and video clips. Both the birthing and

non-birthing parent were invited to participate if they met the following criteria: at least 18 years of age, could speak one of the four languages, had been discharged from the unit to

home (and not to another health care facility), their infant did not need palliative care, and social services were not involved in taking care of the infant. From March 2020 to March 2021,

1 month after discharge, the parents were sent information about the study, a link to the study website, the study consent form, and the first questionnaire. Parents willing to participate

filled in the consent form and returned it with the first questionnaire in a prepaid envelope. In total, 923 parents answered the first questionnaire 1 month after discharge and were

included in the study: 439 parents from NICUs and 484 from MUs (22% and 20% response rates, respectively). The second questionnaire was administered 6 months after discharge and was answered

by 783 parents (85%): 365 parents from NICUs and 418 from MUs. The third questionnaire was implemented when the infant was 1 year of age and was answered by 687 parents (74%): 323 parents

from NICUs and 364 from MUs (Flowchart, Fig. 1). In this project we chose not to use the term “partners” for fathers and non-birthing mothers as they are parents and not only partners. For

simplicity, we hereafter refer to the birthing parents as mothers and non-birthing parents as fathers. MEASURES The first questionnaire contained questions on parents’ sociodemographic

background (gender age, education, occupation, civil status), experiences during pregnancy, birth, the NICU stay, and their health before and after birth. Questions were also asked about

infant characteristics (length of hospital stay, gestational age, birth weight) and the infant’s health and care needs during the hospital stay and 1 month after discharge. The second and

third questionnaires also included sociodemographic questions about civil status, occupation, health, household tasks, economy, and how long the parent had been home with the infant. We used

the Quality of the Dyadic Relationship (QDR36) [26] to assess the quality of the couple relationship. The QDR36 is a modified and validated version of the Dyadic Adjustment Scale (DAS)

[27]. It contains 36 questions divided into five dimensions: consensus (11 items), cohesion (4 items), satisfaction (11 items), sensuality (5 items), and sexuality (5 items). Each item is

scored between 1 (Never) and 6 (Always). Each dimension’s mean score ranges from 1.00 to 6.00 and the total index is the sum of the dimension’s mean scores, (5.00–30.00), with higher scores

indicating better quality in the dyadic relationship. The QDR36 and DAS had been validated in Swedish and English contexts [26, 27]. The Edinburgh Postnatal Depression Scale (EPDS) [28] was

used to assess depressive symptoms. The EPDS includes 10 questions about the participant’s past 7 days. Each question has four statements as answers. The statements are scored on a

four-point scale (0–3) with a total sum ranging from 0 to 30, where higher scores indicate more depressive symptoms [28]. There are conflicting guidelines and usage of the cut-off values

regarding purpose, population, sensitivity, and specificity [29,30,31]. We used the recommended cut-off values ≥10 for fathers [31] and ≥13 for mothers [32] in our analyses. The EPDS was

available in the four study languages. All but the Somali version had been previously validated for women [29], and the English version had also been validated for men [31]. To assess

parents’ social support, we used the Social Support Survey (MOS-SSS) [33]. The MOS-SSS consists of 19 items. Each item is scored on a five-point scale from 1 to 5, with answers ranging from

“None of the time” to “All of the time”. The index is the total sum of all item scores, ranging between 19 and 95, divided into the number of items. The index total score can be between 1.00

and 5.00. The MOS-SSS was available and validated in two of the four study languages, English [33] and Arabic [34]. All the questions and instruments not available in the target language

were translated forward to the target languages by professional translators, then translated back into the source language by other translators, inspired by the ISPOR procedure [35]. The

original and translated versions were discussed with NICU staff and senior university lecturers who fluently spoke Swedish and the target languages until consensus was reached. STATISTICAL

ANALYSES The required sample size was calculated based on the hypothesis that NICU parents would be more likely to experience distress and problems in parental relationships 6 months after

discharge, as indicated by lower scores on the QDR36 compared to parents of term and healthy infants. With alpha set at 0.025 (two-tailed) and power at 0.80, we needed to include parents of

393 infants per group (NICU and MU) to detect a small effect size (_d_ = 0.2). Descriptive statistics are given as frequencies and percentages. A missing completely at random (MCAR) test was

performed to evaluate whether missing data were completely random for the outcome variable QDR36 and the variables chosen to be analyzed as predicted associated factors. The QDR36 showed

the highest missing percentage (3.1%). The missing data were assumed to be random (_p_ = 0.141); thus, no multiple imputation was performed [36]. The predicted factors chosen to be analyzed

included NICU-specific factors and factors previously shown to influence the quality of couple relationships. A generalized linear model was used to analyze what factors were associated with

the couple’s relationship (dependent variable). The results are presented with the change of mean at QDR36 (B), 95% confidence interval (95% CI) and _p_ value for each factor. A Linear

mixed-effect model was used to analyze the trajectory of the QDR36 Index and its five dimensions at three time points (1 month, 6 months, 1 year) for four groups (NICU mothers, NICU fathers,

MU mothers, MU fathers) and compare the groups (NICU mothers versus MU mothers and NICU fathers versus MU fathers). The model was adjusted for having older children living at home, multiple

births, and having been treated for psychological symptoms during pregnancy. The results are presented with estimated marginal means and 95% CIs for each factor at each time point in the

four groups, as well as _p_ values for comparing the groups. Only participants who answered the 1-year questionnaire were included in the analyses. Missing cases were 9%. The level of

significance was set at _p_ ≤ 0.05 (two-tailed). IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp, Armonk, NY, USA) was used in all analyses apart from the linear mixed-effect model

analysis, where we employed R 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria). The datasets generated and analyzed during the current study are not publicly available due to

an ongoing long-term project but are available from the corresponding author upon reasonable request. RESULTS CHARACTERISTICS OF PARTICIPATING NICU PARENTS See Table 1 for detailed

characteristics of the participating parents. The parents’ infants stayed in hospital between 1 and 150 days, and most of the infants (54%) were born at term (gw ≥37). Among parents of term

infants, 96% of infants stayed in hospital for 1–14 days. Only 7–8% of the parents had very or extremely preterm infants (born between gw 23 + 0 and 31 + 6). All parents’ infants born

between gw 23–27 had a longer hospital stay than 60 days, and among parents of infants born in gw 28–31, 89% of the infants had a longer hospital stay than 30 days. During the time in the

NICUs, 63% of the mothers and 69% of the fathers reported staying at the unit for the whole or part of the time with their partner AND their infant. NICU parents were significantly more

likely to be first-time parents (_p_ = 0.009), have multiple births, a lower gestational week at birth, longer hospital stays, and have more infants with illness or impairment compared to MU

parents (_p_ < 0.001) (not presented in table). FACTORS ASSOCIATED WITH NICU PARENTS’ QUALITY OF THE COUPLE RELATIONSHIP 1 YEAR AFTER BIRTH For mothers, the following factors were

significantly associated with a more positive couple relationship (higher mean QDR36 index) 1 year after birth: being younger (_p_ = 0.003), born outside Sweden (_p_ = 0.02), having better

social support (_p_ = 0.01), and a hospital stay of 7–14 days at a NICU compared to 1–6 days (_p_ = 0.04). Risk factors for having a lower mean QDR36 index included not sleeping together

with the infant and father for the whole or part of the hospital stay (_p_ = 0.04), and experiencing performing most of the household tasks (_p_ = <0.001). For fathers, being younger was

associated with a more positive dyadic relationship (_p_ = 0.007). Risk factors for having a lower mean QDR36 index included an EPDS score of ≥10 (_p_ = <0.001) and multiple births (_p_ =

 0.05) (Table 2). THE TRAJECTORY OF THE COUPLE RELATIONSHIP DURING THE FIRST YEAR AFTER BIRTH NICU parents’ QDR36 index slightly decreased from 1 month after hospital discharge until the

infants were aged 1 year. The decrease in the QDR36 index was 0.8 for NICU mothers and 0.7 for NICU fathers (Table 3). For the comparison group of parents from MUs, the QDR36 index decreased

by 0.9 points for both mothers and fathers. For all parents (NICU mothers and fathers, MU mothers and fathers), cohesion and sensuality decreased the most. Mothers rated sexuality

significantly higher than fathers in both groups, and MU mothers rated consensus significantly lower than MU fathers. However, there were no significant differences between the NICU and MU

parents in the trajectory of the quality of the couple relationship during the infants’ first year (Table 3). Thus, our hypothesis was not supported, as parents of preterm/ill infants did

not experience significantly more strain in the couple relationship than parents of term/healthy infants. DISCUSSION This study is unique in that it focuses on couple relationships after

having a preterm or ill infant discharged from a NICU, specifically, but also compared to parents of healthy and term infants. Our study shows no significant differences in the quality of

the couple relationship up to 1 year after birth between parents of preterm/ill infants and parents of term/healthy infants. Both groups of parents rated the quality of their relationship as

high, and their rating only decreased slightly during the first year of the infant’s life. The present results are discussed in light of previous research and the Bowen Family Systems

Theory (BFST) [37]. In the center of the theory is the individual and the nuclear family (one-generation parents and their children). Surrounding the nuclear family is the extended family

(closest family members and friends) [37, 38]. Emotional processes govern relationships within couples, families, and the extended family. The theory emphasizes that the interplay between

individuality and togetherness is important within relationships. It affects stability, cohesiveness, and cooperation. When the relationship is balanced, individuals put equal amount of life

energy into the relationship, which increases togetherness [37]. Everyone in the system affects each other, and those in the nuclear family affect each other most [37, 38]. Our findings

show that better social support from significant others (family and friends) was associated with a better couple relationship among mothers when the infant was 1 year of age. Previous

studies have shown that family and friends are important sources of support for parents in the NICU [39]. Even so, there are often restrictions on who can visit, how many visitors, and how

long they can stay [40, 41]. NICUs often lack guidelines or routines for how family and friends can be involved, despite the importance of the support family and friends can provide [42]. In

line with the BFST the extended family can be _“a significant stabilizing force”_ for the nuclear family ([37], p. 267), which highlights the importance of receiving support from

significant others [37]. Hence, including family and friends in the NICU could be important in promoting better social support and strengthening the long-term relationship between couples. A

hospital stay between 7 and 14 days compared to 1 to 6 days was associated with a better couple relationship 1 year after birth in mothers. In a Swedish study, mothers whose infants had

longer hospital stays showed significantly lower risks of postpartum depression symptoms 4 months after discharge [43]. According to the BFST, people manage reactions and anxiety primarily

through relationships [37]. Hence, parents with longer hospital stays may have more time to process the birth of their infant together, receive support and counseling from staff, and support

each other before coming home to other household duties and work. Further, findings from the present study show that mothers who did not sleep together with their partner and infant during

the whole or parts of their hospital stay, rated the couple relationship lower than the mothers who did sleep with their partner and infant. We do not know why some parents slept with their

partner and infant and some did not. One explanation might be that they had other children at home that needed care. There is also a possibility that parents who already had a good

relationship also had a higher preference for sleeping and staying together than parents who struggled in their relationship. However, sharing experiences and understanding what the partner

goes through might increase intimacy, trust, and the opportunity to support each other. Kerr and Bowen state that the interplay between individuality and togetherness leads to emotionally

significant relationships [37]. Thus, it must be seen important to begin the parental journey in togetherness to share the experience of becoming parents. If both parents could stay in the

unit together, they have a better chance of investing equal energy into the relationship and giving each other emotional and practical support, previously shown to be associated with a

better couple relationship [8, 11, 13, 37]. In Sweden, parents have good possibilities of staying together at NICUs because they both receive temporary parental leave during hospitalization.

In our study, nearly 70% of NICU fathers stayed at the NICUs together with their partner AND infant for all or part of the hospitalization period. In our study the number of parents with

symptoms of depression was small, regardless of gender. Accordingly, the results must be interpreted cautiously. Fathers’ depression symptoms were associated with lower quality of their

couple relationship, an association confirmed in previous studies [4, 7]. Also, according to the BFST, a family member’s physical or psychological symptoms affect the other family members.

How they are affected depends on their individuality [37]. Screening both parents for symptoms of postnatal depression after discharge might lead to better-tailored support, which can be

beneficial for individuals with mental health issues, as well as the couple relationship and the whole family in the long term. STRENGTHS AND LIMITATIONS This study has several strengths. In

this study an advisory group of NICU parents was involved in developing the aim, design, recruitment strategies, testing questionnaires, and interpreting the results. Thus, the advisory

group contributed with new and important perspectives, increasing the study’s relevance, credibility, validity, and findings. Over 920 parents consented to participate in the study and

answered the first questionnaire. In addition, 85% answered the second questionnaire and 74% answered the third, which are acceptable follow-up rates. The demographics of the parents were

similar in the NICU and MU groups. Parents who did not speak Swedish were also included because all information and the questionnaires were available in four languages. Our results, in which

the quality of the couple relationship was measured at 6 months, correspond well with those of Hansson and Ahlborg [6], who also used the QDR36 but in a general population of first-time

parents. The mean index scores in their and our study were between 23 and 24 points 6 months after delivery. The study also has limitations. The participation rate in the first questionnaire

was low, 20–22% of eligible parents consented to participate. A national survey for similar populations in Sweden has corresponding response rates (23%) despite being much shorter [44]. The

low participation rate concerns the representativeness and, consequently, the generalizability of the results. Our study lacks data on nonparticipating parents. Therefore, we do not know

the extent of bias in our sample. However, there is a high risk that participating parents in our study had a higher education level than the general population, which might benefit couple

relationships [8]. Regardless, the education levels were similar between NICU parents and MU parents, so higher education should have influenced the results equally in both groups. Moreover,

infants born extremely or very preterm correspond with the rates in Sweden in general [44]. The fact that the families were admitted to the hospital during the first year of the COVID-19

pandemic might have influenced their concerns and health negatively. Due to the MU’s visiting restrictions, the NICU parents had better options to be together during hospitalization. Parents

had the possibility to stay at NICU together, both during the Covid-19 pandemic and in general, which can be seen as a limitation regarding the generalization to other countries with less

beneficial social support systems. CONCLUSION No differences were seen in the quality of couple relationships during the first year after discharge between parents of preterm/ill infants and

parents of term/healthy infants. Several factors were associated with the long-term quality of couple relationships in parents of NICU-cared infants, including support from family and

friends, hospitalization for 7 to 14 days, staying together at the NICU, and depressive symptoms. Hence, it must be seen important improving family and friends’ support, facilitating time

and space for support, and enabling togetherness during hospitalization, because it may strengthen the couple-relationship long-term. Long-term studies on families’ relationships, support

needs, and parenting are warranted after discharge from NICU settings, where both parents can be together 24/7 with their infant. DATA AVAILABILITY The datasets used and analyzed during the

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ACKNOWLEDGEMENTS We want to thank the parents on the Parent Advisory Board, the statistician at the Centre of Clinical Research Dalarna (CKF), all staff at the units who took part in

providing information to parents, and a special thanks to all parents from the NICUs and MUs who participated in the study. FUNDING The study was funded through the Center for Clinical

Research Dalarna (CKF), the Healthcare Regional Research Council, the Lilla Barnets Fond, the Swedish Nurse Association, and the Paediatric Nurse Association. Open access funding provided by

Dalarna University. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * School of Health and Welfare, Dalarna University, Falun, Sweden Christine Persson, Jenny Ericson & Renée Flacking *

Centre for Clinical Research Dalarna, Uppsala University, Uppsala, Sweden Christine Persson & Jenny Ericson * Faculty of Medicine and Health, School of Health Sciences, Örebro

University, Örebro, Sweden Mats Eriksson * Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany Raziye Salari * Child

Health and Parenting (CHAP), Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden Raziye Salari Authors * Christine Persson View author publications You can

also search for this author inPubMed Google Scholar * Jenny Ericson View author publications You can also search for this author inPubMed Google Scholar * Mats Eriksson View author

publications You can also search for this author inPubMed Google Scholar * Raziye Salari View author publications You can also search for this author inPubMed Google Scholar * Renée Flacking

View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS CP, RF, ME, and RS designed the study. CP collected the data. CP and RF processed the data

and CP and JE performed the analyses. CP wrote the original draft. All authors revised, reviewed, and approved the final manuscript. CORRESPONDING AUTHOR Correspondence to Christine

Persson. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no competing interests. ETHICS APPROVAL AND CONSENT TO PARTICIPATE Informed consent was obtained from all participants.

Ethical approval was obtained from the Swedish Ethical Review Authority, dnr: 2019-04367. The study was performed in accordance with the Declaration of Helsinki. ADDITIONAL INFORMATION

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copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Persson, C., Ericson, J., Eriksson, M. _et al._ Quality

of couple relationship and associated factors in parents of NICU-cared infants during the first year after birth. _J Perinatol_ 44, 1738–1745 (2024).

https://doi.org/10.1038/s41372-024-02076-1 Download citation * Received: 22 December 2023 * Revised: 17 July 2024 * Accepted: 23 July 2024 * Published: 03 August 2024 * Issue Date: December

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