Paternal experiences of premature babies, music therapy and the kangaroo position: content analysis
Luzia Borges Leal1, Carolina Mathiolli1, Milena Torres Guilhem Lago1, Adrinana Valongo Zani1
1 State University of Londrina, PR, Brazil
ABSTRACT
Objective: To understand the experiences and perceptions of fathers of premature babies regarding the realization of the kangaroo position with or without music. Method: Qualitative study with the Family-Centered Care theoretical framework. The sample consisted of parents aged between 19 and 39 years old, who had hospitalized premature newborns and who had the opportunity to perform a kangaroo position with or without music therapy. The collection took place from April to June 2020. The Content Analysis methodological framework was used. Results: The speeches allowed the identification of five categories: Feelings provided by the first kangaroo position; Skin-to-skin contact and the awakening of fatherhood; Re-signifying the kangaroo care method through music; Music and its meanings; Paternal feelings regarding music and COVID-19. Conclusion: Music therapy associated with the kangaroo position for the father was considered a moment which strengthened the father-child bond, as well as reducing sadness and anxiety.
Descriptors: Music therapy; Kangaroo method; Premature newborn; Father.
INTRODUCTION
The technological evolution in neonatology services, especially in neonatal intensive care units (NICUs),has decreased the mortality rates of preterm newborns (PTNB), and associated with this achievement is the inclusion of parents in the care of this specific and complex population. Thus, there is a need for interventions in NICUs that facilitate the creation of affective bonds between fathers and premature newborns. Thus, developing trust and valuing the potential of these fathers(1).
In the hospitalization process of the PTNB, most studies emphasize only maternal vulnerability and feelings, excluding the father from this moment, considered difficult and painful, perhaps due to the cultural and historical force of social division of roles between men and women(1-2). However, the most intense presence of the father figure is observed in the NICU. And in this scenario, it is necessary to value and empower the father by including him in the care of his child.
Early-established positive interactions between father and child have shown a reduction in cognitive deficit. On the other hand, studies show that these parents feel stressed, oppressed and isolated(3). In this context, integrative therapies have been implemented in neonatology services in order to help reduce stressful factors and strengthen family affective bonds. Among them is music therapy.
Music in nursing practice has been highlighted as a complementary therapeutic resource that has helped in the physiological and emotional recovery of both the patient, including the stability of PTNBs, as well as the family. In addition, it is an easy-to-use therapeutic tool, accessible, with minimal side effects and that can be used in various contexts and for various diseases(4,5,6).
Another model of qualified and humanized care is the Kangaroo Care Method (KCM) with skin-to-skin contact being part of this method, which begins early and evolves to the Kangaroo Position (KP), which consists of keeping the NB in skin to skin contact, only in diapers, in the vertical position next to the parents' chest, which also provides several benefits to parents and newborns (7).
Throughout the stages of KCM, the participation and presence of the father is highlighted by the Brazilian ministerial norms, as, like the mother, it is necessary to introduce him to neonatal care. Thus, the experience of the father performing KCM aims to help understand the effectiveness of his participation and empowerment with his preterm baby. In these circumstances, the father is considered a being-in-situation in which the body meets the other body, which is evidenced by skin-to-skin contact(8).
Therefore, in this context, there is a need to associate these two interventions, i.e., music therapy and KCM, in order to provide humanized care. And in this context, it is aimed to insert the father figure, since the father has demonstrated the desire and need to be seen in other roles within the family context, no longer being a supporting actor and becoming a lead actor along with his companion, seeking to strengthen the preterm father-mother-child bonds. Thus, the following question emerged: How does the father experience and perceive the behavior of the preterm child when performing the KCM associated or not with music? Therefore, the aim of this study was to understand the experiences and paternal perceptions in relation to the performance of KCM with or without the use of music.
METHODOLOGY
The present study is part of a broad research entitled "Music therapy as a strategy in the care of newborns, children, pregnant women, puerperal women and their families". This is a descriptive, exploratory study with a qualitative approach. The "Family Centered Care" (FCC) theoretical framework was adopted, which can be considered an approach which recognizes the family as a fundamental part of care and aims to stimulate the family's bond with the patient, in addition to ensuring their participation in the planning of health actions and inserting them in decisions and conducts(9,10).
The study site was the Neonatal Unit of a tertiary teaching hospital that is a high complex reference for the Unified Health System (SUS) in the northern region of Paraná. The neonatal unit has 10 neonatal intensive care beds, 10 neonatal intermediate care beds and four neonatal kangaroo intermediate care beds.
Six parents aged between 19 and 39 years with children hospitalized in the NICU and/or the Neonatal Intermediate Care Unit (NICU) participated in this study. These parents were invited to participate in the study by the main researcher and were informed about the research objectives, data collection procedures, confidentiality in the treatment of information and the possibility of interrupting their participation at any time, without causing issues to the care of their child or family. The inclusion criteria adopted were parents who had children hospitalized in the NICU with gestational age of birth of less than 37 weeks, born between March and June 2020 and who had the opportunity to perform KCM. Parents of newborns with malformations, fathers who did not assume paternity, and unstable newborns that did not allow the performance of KCM were excluded. Data were collected from April to June 2020.
Regarding data collection, it was necessary for the father to perform KCM twice. The first was performed for a period of one hour, according to the unit's routine. The second was performed again for an hour, but this time music was played for the newborn.
The music was made available to the baby through a headset, which was disinfected before and after use, and subsequently connected to a DVD player with recorded music, maintained at a maximum volume of 35 dB. This song was a lullaby that in the background had the sound of the mother's womb, which was validated by a music therapist for such an intervention. The headphones were placed close to the baby's ear region without touching it, so that no discomfort was generated by this device.
Right after the two moments of KCM, on the same day, an interview was performed with the father using an instrument that contained two parts: the first referring to the characterization of the father and his son and the second referring to the objectives of the study. The questions that guided this study were: 1) Tell me about the first time you performed the kangaroo position with your child? 2) Tell me what it is like for you to perform the kangaroo position with your child? 3) Tell me what you felt or noticed in your child's behavior when you performed the kangaroo position without music and when you did it with the use of music. 4) Tell me what it was like to experience the application of music to your child while performing the kangaroo position? 5) Does music have any meaning to you, in your life, in your daily life?
The collected information was recorded through a digital recorder, with an average duration of 30 minutes and later transcribed by the responsible researcher. A field diary was also used for this researcher to write down perceptions during the interview and evaluation of paternal behavior in both moments of KCM.
Regarding data analysis, the statements were submitted to the methodological framework "Content Analysis" which involves: floating reading and subsequent immersion in detailed readings of the participants' speeches, and which, throughout this stage, generate generic components and inferences, allowing codification and subsequent interpretations; and with that, the development of thematic categories that group the results in the form of similar messages(11).
In this study, parents were identified by the letter “P” followed by the participation number as a way to avoid identifying the research participants. This research began after approval by the Research Ethics Committee, by means of a Certificate of Presentation for Ethical Appreciation (CAAE) nº 34061520.7.0000.5231, as per opinion n.4.152.325, and obtaining the informed consent form, duly informed and signed by the participants of the study.
RESULTS
There were 56 admissions of PTNB eligible for the study between March and June 2020. Among these, six died and 16 were transferred to another inpatient unit or hospital service, 26 parents did not remain during the hospitalization of their children for more than one hour to perform KCM and two newborns were discharged before their parents could perform KCM at both times (with and without music). Therefore, six parents participated in this study.
It should be noted that this number of parents who did not remain long enough in the unit for interventions to occur was due to the COVID -19 pandemic, and that due to the uncertainties of infections, the study setting restricted the permanence of the parents, prioritizing the presence of breastfeeding mothers, which made it impossible for the father to remain for prolonged periods to perform the interventions.
The ages of the fathers ranged from 19 to 39 years, three had completed high school, one had not completed high school, one had not completed elementary education and one had completed higher education, all had a stable union with the mother of the NB for at least one year, three had other children and three were experiencing fatherhood for the first time, four had family income equivalent of one to five minimum wages and two with an income of below the minimum wage, only one pregnancy was planned.
Regarding the NBs, four had Gestational Birth Age (GA) of less than 28 weeks, two with GAs greater than 31 weeks and length of hospital stay ranging from three to seventy-three days, none were under sedation at during music therapy or KCM.
Regarding the parents' statements, five categories emerged: 1) Feelings regarding the first kangaroo moment; 2) Skin-to-skin contact and the awakening of fatherhood, 3) Resignifying kangaroo care through music; 4) Music and its meanings, 5) Fathers feelings related to music and COVID-19.
Feelings regarding the first kangaroo care moment
The father felt the first kangaroo care moment as positive and related to love and affection.
I have two children already, a 21-year-old son and a 15-year-old daughter from my first marriage. I'll tell you, it was the best thing I've ever been through in my life (P2).
It was the first time I ever held the baby in the kangaroo position. In Haiti I never did, didn't even know. When my wife told me, I wanted to do it too. I'm happy to hold my child in the kangaroo position. I felt a lot of love for my son
(P6).
I can´t explain the moment I held him in the kangaroo position. It was really good. First time feeling skin to skin. It was a lot of love, a lot of love (P1).
Skin-to-skin contact and the awakening of fatherhood
The meaning given for fatherhood is revealed in skin-to-skin contact, since it aroused feelings of protection in the feeling, they felt like real parents.
The kangaroo helps to have more contact. A closer contact between the child with the father, I felt more like a father (P5).
He calmed down when he was on my chest skin, a feeling of protection, at this point I felt like a real father (P4).
I want to hold him, to feel, to want to pass my heat to her, to protect her, to be a father (P1).
It was amazing, I thought to myself: let me hold him to see if it is true, if it is my son, I became a father (P2).
Resignifying the kangaroo care method through music
When the father performed a kangaroo associated with music, he presented a new meaning, experienced a moment of greater relaxation both for himself and for the child, referring that the music provided moments of greater tranquility for the baby.
He slept faster and more deeply when music was placed during the kangaroo care moment (P3).
He slept a little, every time he opened his eye, did not cry so much when he heard the music (P5).
From what I noticed, doing the kangaroo position with music is very good, it is very calm, it is very quiet, he didn´t even move (P2).
When she put on the song, she grumbled less, she was sleeping much quieter, she rarely grumbled (P1).
Doing the kangaroo position with music was very relaxing for me. It was relaxing for him also because I almost didn't feel him, you know? He was so comfortable, he didn't even move, he stayed like this the whole time. There was only one time when he grumbled, but I realized that the music calms him a lot (P2).
Music and its meanings
Music was highlighted as a tool capable of evoking various feelings and meanings. For some, music is already part of their daily life, however, they represented music as sensations and demonstration of care.
My wife is a music teacher, she always put music on when she was pregnant and for us music represents love, care (P4).
Ever since I was a kid, I've listened to music. My father was a musician and knows how to play everything, guitar, guitar, drums, flute ... and to be able to see my son so small listening to music and realize that it was good for him is wonderful (P1).
There was always seminaries (religious meetings) in my house, my mother was catholic... we lived that way, you know? Listening to music all the time, so music is important in our life (P2).
Music shows what the person is feeling, joy, sadness. It causes a lot of feelings (P1).
It would be more of a distraction, a way for you to be relaxed too. And I recommend it to all parents to do that. It's a really nice experience (P4).
Fathers feelings regarding music and COVID-19
The pandemic caused by COVID-19 had a considerable impact on everyone, including the in-hospital environment, in addition to dealing with their child's hospitalization, parents had to become resilient in relation to this moment. Thus, music is cited as a strategy, an element of pleasure to ease the stress caused during this period.
There is not much interaction with the father and mother, because of the current situation (COVID-19 pandemic), so we always have to enjoy these moments together, at this time of so many fears and doubts, doing the kangaroo position with music was very important so that my son did not feel the moments of stress and fear of the father (P3).
I do it at home. Every day I put 'Youtube' on the tv, rain music. And so my other son,´ixi´,sleeps all night. So I think being able to stay with my son here in the unit doing kangaroo care and watching him listening to music reduces my anxiety, which is very good, because this pandemic has caused a lot of uncertainty and fear, especially since we as parents are having restricted schedules. So the music makes me forget about it even if for a little while, and hope that soon my son will come home well and be safe (P2).
DISCUSSION
The fathers narratives presented show that the current scenario has been undergoing changes and the father has participated more effectively in the NICU. For a long time, fatherhood meant being a father away from childcare, where the role to them depended primarily on financial support. However, nowadays, the concerns and involvement of these fathers from the beginning is remarkable, and the presence and participation of the father in taking care of the NB has been valued, giving rise to the need to know what their perception is, what they understand about the use of innovative methods for the benefit of their child(2,12).
By analyzing the assumptions of the FCC with regard to dignity and respect, it can be identified in the discourses that despite the importance of the paternal figure in the care of hospitalized premature children, fathers still seek their space in these environments, as opposed to the nursing mother, who in general, already has this space guaranteed. In addition, it is possible to notice in one study that the team does not always share the same thought about paternal presence, as some people on the team argue that the father is an important subject of care and that his presence is essential, while others still they continue to propagate the father figure as that of a visitor and observer, a vehicle of infections or an intermediary of information between the mother and the multidisciplinary health team(13).
On the other hand, the moments experienced by the father with the child, such as during KCM associated with out without music, evidenced a greater participation and empowerment of the father in this process of caring for the premature child in the hospital unit, in addition to envisioning numerous feelings, mainly related to affection. Babies who experience skin-to-skin contact have lower morbidities and mortality and experiencing this care for the premature child allows the father to care for his newborn child fully, interpreting the subtle signs of their babies and become in tune to them, since the body is an instrument of contact of the man with the other and, through KCM, the father is present in the world. When experiencing skin-to-skin contact with the child, the father uses tactile, olfactory, visual and auditory senses, promoting safety and affection for the premature child and perceiving himself as a father(14,8).
Another form of evidence-based early intervention used in the NICU involves a multisensory protocol using auditory, tactile, visual, and vestibular stimulation; this intervention resulted in babies showing positive autonomic and behavioral responses to multisensory(14). Clinically, results suggest that intensive or spaced music therapy can support child development, the general acquisition of developmental milestones driven by motor skills predicting early childhood neurodevelopment. One of the most important skills an infant must display before discharge from the NICU is self-regulation, including mature and stable cardiorespiratory function. Studies have indicated that the neurodevelopmental intervention of music therapy can be used to help babies achieve this goal (14,15).
Music, especially lullabies, provides adequate auditory stimulation, disguising the aversive noises in the NICU. One study concluded that music therapy intervention for the mother of a preterm baby contributes to the self-regulation of the baby, such as relaxation, stabilization of oxygen saturation, the presentation of new competencies and the involvement in singing. These results corroborate this study, since parents realized that performing KCM associated with music therapy for their child provided a feeling of relaxation for both, in addition to strengthening bonds and awakening fatherhood (14,16,17).
It is important to mention that the effects of music therapy in the NICU on the developmental progression of high-risk infants have not been extensively studied. However, NICU music therapy for premature infants is an evidence-based method, addressing various sensory, physical, and emotional needs of premature infants and their parents. Therefore, some studies have already shown that KCM associated with music, whether sung or recorded, had greater positive effects on the physiological and behavioral results of babies, compared to KCM alone(15,17).
Given this context of changes in attitude towards fatherhood, the emergence of COVID-19 was an event that further reshaped the role of the father since the beginning of pregnancy, which was classified by the World Health Organization (WHO)as a pandemic in the beginning of March 2020 when rigid measures were introduced worldwide, considerably altering the daily routine of citizens and health care policies, including obstetrics and neonatology(12).
At this time, the hospital field of this study restricted the father's length of stay, with the objective of reducing the number of people in the environment, which generated numerous negative feelings. However, the moments that they could be with their child and perform kangaroo care associated with music were reported by the parents as a period of relaxation, in which they could forget the whole context the world because two major concerns afflicted them: uncertainties regarding the complexity of the birth of a premature child and the uncertainties and anxieties regarding the pandemic, which was unknown to all. In view of the statements obtained in the results, in which the pandemic stands out, where the father says he does not have much interaction with the child and that the schedules in the unit were restricted, a gap is perceived between what is necessary and what is offered to the family, which negatively impacts on the engagement and collaboration of the father with the child, this being one of the assumptions of the KCM that has not been guaranteed. Although theoretical knowledge about humanized care is present in the repertoire of professionals, its practice is still scarce and several factors contribute to the non-effectiveness of humanized care in the NICU environment. A common practice that denounces this condition is restricting visits from parents and family members(18). In addition, research also shows that the greatest difficulties are related to the lack of material, infrastructure and human resources; the lack of evaluation and planning of the care offered; the difficulty of relating to family members and especially the contradictory notion of providing specialized care, but at the same time judging the ability of parents to participate in these actions. Due to these complications in relation to the not so efficient approach to the family, parents feel insecure and vulnerable because they cannot be present as they would like to or perform care that makes them feel truly parents to that newborn(18,13).
In Brazil, neonatal units must follow the standards established by Ordinance No. 930 of 2012 of the Ministry of Health, which "defines the guidelines and objectives for the organization of comprehensive and humanized care to the critical or potentially critical newborn within the Scope of the SUS". This ordinance not only advocates the principles of humanized care for newborns, but contributes to the realization of family-centered care(13). Therefore, the KCM considers the person and his family as the center and purpose of the care of the health team and is based on four assumptions: 1)Respect and dignity- related to the willingness to listen carefully to the family and respect their values and beliefs in the planning of health actions; 2) Sharing information in a complete, impartial and accessible language in order to enable the inclusion of family members in the care provided; 3) Participation of the family in care which presupposes the need to empower them for such activity; and 4) Collaboration, participation of the institution and health policies directed and aimed at enabling the implementation of family centered care(18).
Thus, nursing care cannot be unrelated to the needs of the family, because family interaction itself influences healing and treatment(19). In this perspective, the interaction between professionals and family members allows the recognition of the family unit with exchanges of knowledge, favoring dialogue and making it possible to identify weaknesses and potentialities of the capacities of each family for care(19). According to the National Policy of Comprehensive Care for Children's Health, the father should be stimulated and present in the insertion of care for his baby starting in the prenatal consultations, empowering him to care for his child and support of his partner. When the father participates and is included, there is health promotion, safety and the protection of maternal and child care (20).
The family should be inserted in the care and considered as a unit of constant care in the child's life so that they can participate in the planning of care actions and have space to express their problems and needs(19). However, this participation should happen gradually starting from the moment of hospitalization of the NB. Family members must become empowered by their rights as parents and have free access to their child, having an equal relationship between the health team and the family with the objective of cooperation and collaboration, which does not occur in most neonatal intensive care units throughout the country(13). It is worth mentioning that, according to the Statute of the Child and Adolescent, it is the right of the child to remain accompanied by their parents throughout the hospitalization period(21).
Faced with the challenge of meeting the demands of the family and the NB as recipients of care, the nurse is considered as the individual capable of defending and supporting the role of parents, ensuring that they are effectively inserted in the relationships of care to the NB(13). The nurse plays a fundamental role in quality care for premature babies and their families. It is important to mention that this professional is the fundamental part of the team for the realization of the kangaroo position. In addition to the inclusion of parents in care, providing them with an environment with less stress, stimulating the parent-child bond and the transmission of safety and calmness(22).
Family care requires involvement, respect, ethics, personal satisfaction and negotiation strategies of health professionals. Therefore, it is desirable to have an open posture to the interactions and experiences of each family, having sensitivity to recognize and understand the needs of each individual (19).
Thus, it is valid to reinforce the importance of perceiving the family as an extension of the care provided to newborns, using methods that can provide the strengthening of the bond to the binomial, in addition to the fact that the connection established between the team and the family can also favor development of strategies for the construction of a humanized care centered on the family(18,23).
Limitation of the study
Due to the COVID-19 pandemic, there was a reduction in the length of stay of the parents in the unit and restriction of their presence in the unit, which reduced the opportunity and duration of the kangaroo position.
CONCLUSION
The results of this study proved to be promising for music therapy interventions in neonatal units, as the father experienced and perceived positive aspects in the child's behavior with the use of music associated with KCM, as well as demonstrating that these benefits reflected in himself.
Music for some parents helped to strengthen the bond with their child, awakened the meaning of fatherhood, and brought relief to the current context related to the uncertainties caused by the Covid-19 pandemic.
It was possible to see that the association of these two care strategies made it possible to guarantee, even if not fully, the four assumptions of the KCM within the study setting. The team awakened the importance of the father's presence with the child and also the practice of using music therapy in the unit.
Given this context, aiming at the excellence of the quality of early and economical care directed at the family and the newborn, it should be noted that there is a need for more studies that allow exploring other variables involved in the effectiveness of interventions and that encompass a greater number of participants that could further enrich the size and effectiveness of the study.
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Submission: 03/24/2021
Approved: 08/04/2021