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Boye 6208-6 Steel Crochet Hook 5"-Size 6/1.8mm (3Pk) Wrights 6208-6
Бренд: Wrights
~ 842 ₽ 8.73 $
Manufacturer Part Number 6208-6
Manufacturer Wrights
Item Height .2
Item Width 1
Item Length 7.5
Item Weight 0.02000
Boye 6208-6 Steel Crochet Hook 5"-Size 6/1.8mm (3Pk)
Item Description
BOYE-Steel Crochet Hook measures 5in long and feature the preferred tapered throat and smooth rounded head. Precision- crafted quality assures a fine finish and accuracy of gauge. One hook per package. Made in USA.
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May 13, 2014
China Has Strategic Confidence (So Expect Tensions to Continue)
Source: The Diplomat
Journalist Dingding Chen
President Obama just completed a four-country trip to Asia two weeks ago. Before his trip, expectations were high that he could get some major achievements and China would be the loser. For example, U.S. analyst Ely Ratner expected Obama to do three things in Japan: 1) declare that Article V of the U.S.-Japan defense treaty covers the Diaoyu/Senkaku islands; 2) single out China for engaging in provocative and destabilizing actions; and 3) voice strong support for Japanese constitutional reinterpretation on the issue of collective self-defense, though as it turned out later, Obama only did the first thing.
However, when we look closer at what Obama got out of his Asia tour, overall the U.S. didn't gain much from this trip, to the disappointment of hardliners in the U.S. and Japan. For example, even though Obama officially declared that the U.S.-Japan security treaty will cover the Diaoyu/Senkaku islands, during his joint press conference with Japanese Prime Minister Shinzo Abe Obama also quickly pointed out that it is not a new policy and that both Japan and China should restrain themselves. In Obama's words: "I emphasized with Prime Minister Abe the importance of resolving this issue peacefully — not escalating the situation, keeping the rhetoric low, not taking provocative actions, and trying to determine how both Japan and China can work cooperatively together. And I want to make that larger point. We have strong relations with China. They are a critical country not just to the region, but to the world." What is really interesting here is that Obama also wants Japan to keep the rhetoric low and not to take provocative actions. Perhaps because of such balanced remarks and other issues, some Japanese commentators are disappointed.
Please visit The Diplomat to read the full article.

subset: commoncrawl


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veganise verb to adapt a dish that contains animal-derived components so that it is vegan
So stock up on some easy-to-veganise extras in tow, bring enough for everyone to sample, and you'll hopefully wake up on Boxing Day pleasantly surprised.
[www.thedebrief.co.uk/ 19 December 2015]
food swamp noun an area with an abundance of fast food retailers but a dearth of healthy, fresh food sellers
'The food swamp or the lack of access to healthy food is a much bigger problem than the food desert,' she said.
[http://www.thestar.com/ 10 November 2015]
kukicha (tea) noun a Japanese tea made from stems and twigs of tea plants
Ever feel nauseated if you drink too much green tea?
Kukicha tea is a Japanese green tea made from the roasted twigs, stalks and stems of the green tea plant (unlike Chinese varieties made from the leaves) and has no such effect.
[http://www.dailymail.co.uk/ 02 November 2015]


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Earthen Vessel Gallery brings together a collection of handcrafted works created by independent artists from the region and across North America. Representing over 100 artisans, we offer an extensive selection of contemporary jewelry, handmade apparel, metal, art glass, and pottery. Earthen Vessel Gallery first opened in Durango as a pottery shop in 1976. Over time, we expanded our selection to include other forms of art and began "Celebrating All Things Handmade" as 99% of everything in our store is handcrafted.
Whether you are interested in adding to our own collection, looking for a gift, or want to take something back home to remember your trip to Durango, we will help you find that unique, thoughtful piece of art.
This site uses cookies for measurement, ads and optimization. By continuing to use our site you agree to our privacy policy.


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Loud'N'Nasty making a comeback and poised to release new single soon
Loud'N'Nasty making a comeback and poised to release new single soon
Loud'N'Nasty may perhaps be the original Swedish sleaze rockers having formed way back in 1997. Lead vocalist / bassist Rob Nasty and guitarist Chris Loud have joined forces once again in Loud'N'Nasty who will be releasing a new single soon.
The following message was posted on Loud'N'Nasty's Facebook page earlier today:
"#loudnnasty2019 #loudnnasty #swedishsleaze #newsingleoutsoon"
Rob Nasty was interviewed by Sleaze Roxx back in September 2015 and asked whether it was groups such as Loud'N'Nasty and Hardcore Superstar that paved the way for bands such as Crashdïet. Nasty replied: "Well… If it was us or if it was just that we were just doing our thing just before the other bands came with the same idea, I cannot say. But when David [Shepard] sent me an e-mail and told me he liked Loud'N'Nasty a lot, he sent some photos from his first photo session of Crashdïet and I was like, "Man! That's awesome cus I did not know of any other bands back then." I asked if he could send me some songs and he told me he didn't have any recordings yet. That was kind of funny and I loved that answer. Hardcore Superstar was at that time not seen as a sleaze band at all I think?"
Sleaze Roxx stated the following in its review of Loud'N'Nasty's 2004 release Teaser Teaser: "Ratt hasn't sounded this good since 1986's Dancing Undercover! But wait — this ISN'T Ratt, it is just a Swedish band named Loud'N'Nasty that delivers a convincing version of Ratt'n'Roll. Catchy choruses, venomous guitars, bad attitudes and lyrics that border on obscene equal one thing — a cool sleaze release."
Loud'N'Nasty's "Annie" video:
Loud 'N' Nasty – Annie
Sleaze Glam….album: Teaser Teaseryear: 2004Chris Loud – Guitars, VocalsRob Nasty – Lead Vocals, BassT-Bone – Drums


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Richard Walker
Richard Walker is professor emeritus of geography at the University of California, Berkeley, and former chair of the California Studies Association. He has written widely on the Bay Area and California; his books include The Atlas of California: Mapping the Challenges of a New Era (2013), The Country in the City: The Greening of the San Francisco Bay Area (2007), and The Conquest of Bread: 150 Years of Agribusiness in California (2004).
by Richard Walker
Posted on October 15, 2013
Stage Presence: Richard T. Walker
by Stella Lochman
Posted on September 06, 2012
Backstage: Richard T. Walker
by Stella Lochman
Posted on August 30, 2012


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by Harold Goldberg
On Martin Luther King Day at a small, noisy Mexican restaurant, I met with the affable Forrest Dowling. He's the co-founder of The Molasses Flood, the studio that will release the rogue-like river raft trip that is The Flame in the Flood later this month.
Forrest talked about his work with Irrational Games, the makers of the much-lauded BioShock series. With enthusiasm and candor, he told me about the motley group of former Irrational employees who came together to work on a dream game that would become The Flame in the Flood and then mounted a successful Kickstarter campaign.
We talked about the crazy vagaries of gamemaking and the painting-like creations of BioShock art director Scott Sinclair which appear throughout the game. At some point after a beer or two, we began to talk about what we could do regarding The Flame in the Flood at the New York Game Awards.
We have good news. Forrest is putting together a trailer which he himself will premiere at the New York Game Awards. I've seen a version that's not the final edit, and has a bit of everything: superb artwork and music, a few reveals, and some taut humor as well.
We can't wait for you to see it at the New York Game Awards on February 9th.
So, Forrest and The Flame in the Flood, welcome to the New York Game Awards!


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Every year, our Youth Career Services division connects Montgomery County students with local businesses to get our youth ready for life after school. We've worked with over 500 local companies, and we're always looking for new businesses to host our area's students for work experience.
Montgomery County covers all the wages and Workers Compensation insurance for the student workers, and we even provide job readiness training before they arrive to your work site.
If you'd like to participate, you agree to provide your work site location and training services to students in the YouthWorks program.
Fill out the form below to let us know you're interested, and you can view our program agreements. We have two agreements: one for private companies and another for public entities:
Click here for the private employer agreement
Click here for the public entity agreement
For companies already working with YouthWorks, you'll need to fill out the Work Site Survey to help us place students with your organization.
Give us a call at (937) 224-1482 if you have any questions.


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Come Together! April Challenge on Beanstack
Come Together this April in a variety of virtual ways! Join us on Beanstack for some friendly rivalry, a bookless bookclub, Earth Day activities, a new Community Dialogue and of course reading lists, all to encourage and celebrate the many ways we can come together, even while still apart. $100 Downtown Dollars to be won! https://www.stratford.library.on.ca/beanstack


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Train to be a career coach and join our team
Looking to be a career coach?
If you are interested in training as a career coach or considering joining our team, and have what it takes, then get in touch. You'll need to fulfil the criteria and pass our selection process, and in return, we provide all the necessary training and support to launch your own career as a career coach. Compared to operating independently, you'll have all the systems and support you need as well as working under the UK's leading brand with the potential to both have work given to you as well as the option to bring in your own work. You'll also be working alongside others who are highly skilled and share our values of best practice and innovation so your coaching career can really develop and flourish.
What skills do you need?
To become a Licenced Career Coach you will receive full training in career coaching on an intensive course and will also have all the support you need to coach clients. You can also bring business in and you'll earn more as a result. In time, you may also want to run your own office as a franchisee.
You'll need to have the following background, experience and qualities:
- A strong interest in career management
You will already have a strong interest in working in this area and have been involved in personal development activities either for yourself or your staff in your career to date. You must be genuinely interested in delivering coaching.
- Senior background
Our clients are typically senior managers or at board level, so it's important that you are comfortable working alongside people operating at this level and have an understanding of the issues they face.
- A passion for delivering a quality, customer-focused service
You'll have experience in delivering customer-focused products or services and a passion for ensuring customer care.
- Be prepared to learn and continually develop
We will provide intensive training and support to enable you to become a first-class coach. You must be prepared to learn and demonstrate that you take continuous personal development seriously.
- Autonomy and compliance
This is a superb opportunity with the superb support and guidance of a central team. You will need to be able to work on your own whilst always adhering to a structured system of operation.
As a Licenced Career Coach you'll benefit from:
- Comprehensive induction and training programme
- Option to work full or part-time
- Most of the administration is dealt with centrally
- Operations manuals covering relevant areas of the business
- Benefit from a group network
- Support if you are interested in bringing in your own work
- Benefit from national partnerships, relationships and brand awareness
- New clients through our website and national promotions
- Client support for information resources for their job search campaigns
As a Licenced Career Coach, you'll coach clients under a proven system and with a highly regarded brand, with all the help and support you need. You're your own boss, able to determine your hours, but not alone.
You'll have all the support and training you need to ensure you are able to grow and develop as a career coach.
To find out more about training as a Licenced Career Coach, the costs involved, and our next training dates get in touch.
For an initial discussion send your CV via the contact form below and one of our franchise team will be in touch.
Alternatively, contact the franchise team on 01753 888995.
Moving on to running your own office as a Franchisee
If you would like to do this full-time, run and grow your own business and are also happy bringing business in yourself, then take a look at our Franchisee option. We operate regional Personal Career Management Centres across the UK under franchise and there may be one available close to you. We use different selection criteria for these roles. If you are interested in potentially running a franchise, we would like to hear from you.
This is an investment opportunity. Anyone considering buying a Licence should seek professional advice before doing so and take their own steps to check the information provided here and elsewhere. Like any business, there are risks associated with buying a business.
Contact Us


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Customise your study plan according your need. Bookmark the lectures for further reference. Get some capsule classes before the exam date.
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text: our organization is engaged in manufacturing and supplying a wide range of Spun pipes, Half Round Pipes,Sensing poles, Electric poles, Cement articles. These pipes are manufactured using finest quality raw material, which is availed from the renowned vendors of the market. These pipes are well-known and acclaimed for their features such as durability, high performance and accurate dimensions.


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When backpacking you trade the luxury, comfortable hotels, transport and restaurants for shared bed hostels, long overnight bus/train journeys and cheap local food stalls. Because of this budget backpacking essentials differ from regular holiday essentials and the following are items which may be very valuable to you which you need to keep in mind!
However, items such as cameras, GoPro etc are not mentioned as these items are required for all types of travelling.
Think Ahead, don't leave it for the last minute!
1. Ear Plugs
Owning a pair of ear plugs could mean the difference between a good nights sleep and a sleepless night. Some bus/train journeys can be very noisy or some fellow dorm sharers may be very noisy and trust me you do not want a bad night when you need to wake up at the crack of dawn and continue travelling. Sleep is essential!
2. Eye Mask
If you are a light sleeper like myself an eye mask can do wonders when you need to catch up on sleep during the day whsilt making a journey. They arealso extremely handy when staying in hostels as other dorm sharers will switch lights on at any given time regardless if you are trying to get some sleep.
3. Travel Towel
A small travel towel always comes in handy, especially as many budget places will charge extra for towels and lets face it when we are trying to budget the last thing we want is to have to pay extra for towels. The best thing about them is they are super absorbant, dry very quickly and can pack small.
4. Inflatable Pillow
Long overnight bus/train/plane journeys are expected when backpacking. We occasionally travelled long distances during the night in order to save on money spent on accomodation and it meant we didn't waste our time travelling during the day. It may also be useful when you need to sit on the floor for longer than desired. Being inflatable means it doesn't take up space nor weigh when you are not using it!
5. Power Bank
Nowadays we rely a lot on electronic devices, such as smart phones, cameras, GoPros, ipads etc. Some journeys can be ridiculously long so an external charger can save the day. The last thing you want when you are trying to kill time on a 10 hour bus journey or out on a day trip is for your device to run out of charge. External hardrives with hours of charging time can be found on ebay at low prices. Keep in mind if flying into/out of China these are prohibited and will be confiscated if found.
6. Spare SD Cards
We all know the world we live in now, capturing every moment on our camera is vital nowadays and we may get snap happy! There will be times that you find it hard to locate a computer store to transfer photos from your SD card to your back up device (unless you carry a laptop with you) and even though your hostel may have a desktop you need to hope it will be available. Having spare SD cards is a smart move.
7. Dry Bag
A dry bag may be useful for two things, keeping wet things contained in order to avoid wetting the other items in your bag and secondly for keeping your valuables dry. Some aquatic tours require dry bags so if you have one yourself it's better as they may charge and it's very handy for days at the beach or during rainy weather.
8. Lock
These are useful to lock your backpacks when you leave them unattended in shared accomodation or to use on lockers as you may need to pay extra to rent a padlock. You would be surprised at what goes missing in some hostels. A combination lock is better than a normal pad lock as there is no risk of losing the key!
9. Flip Flops
Flipflops are not just for wearing at the beach. It is highly recommended that flip flops are worn in hostel bathrooms to avoid catching anything nasty! Do not go bare footed as you do not know who has stepped in those showers nor when it was last cleaned.
10. Travel Adapter
Travel adapters are essential and even though more expenisve than a single individual adapter I would recommend an international adapter so you know you will be sorted in which ever country you travel to.
Travel Tip: If multiple devices need to be charged at the same time take a small extension cord which can be attached to the international adapter allowing you access to several of your home countries sockets!
11. Sleeping Liner
A light sleeping liner can come in handy when you are not convinced about the dirty looking sheets in some hostels and some hostels may even make you pay extra for bedding. Generally, the overnight buses and trains we took were clean but on the train from Yangon to Bagan (Myanmar) I was a bit itchy and wished I would have had one with me.Besides they're light and can be rolled to a small size.
12. Ipad or Laptop
Depending on your preference, an ipad or small laptop is very useful to have. One thing we realised once we had started travelling was that as we chose to take our ipad we were unable to use it to transfer media from the SD card to our External Hardrive so we were forced to always go in search for a desktop. An External Hardrive can be considered an essential device for some travellers in order to back up your media files. However, if you decide to take a laptop it can be stored in the laptop.
13. Sarong
For the ladies, a sarong is always a good idea. Not only can it be used to wrap yourself at the beach but it can also be used as a beach towel, to cover yourself up when visiting sacred temples (you may be be asked to pay if you are not appropriately covered up) or to simply use as a blanket when making journeys.
Extra Tips: It is always handy to have a torch on you and an alarm. I have not mentioned it above as these are accessible on smart phones, avoiding extra items. Additionally, a Swiss Army Knife is useful but these will not be let on the plane as carry-on. Regarding ear plugs and eye mask, most long haul flights hand them out so if you forget to purchase them just hope you will be given one!
#travelessentials #earplugs #eyemask #travel #adapter #powerbank #advice #blog


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Pain & Injury Center
Wrist, Hand & Finger Injuries
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune disease causing inflammation and damage to the joints. It is often a progressive condition that starts in the hands and feet, mostly usually in the wrist and knuckles, before spreading to other joints in the body.
Shop Rheumatoid Arthritis Braces & Supports
A joint is formed at the junction of two articulating bones. The end of each bone is covered with cartilage, a smooth, slippery coating that protects the bones as they slide across each other. Around the joint is a strong membrane that encloses the joint parts in a capsule. The capsule has a thin, membranous lining, the synovium, which secretes synovial fluid to lubricate and provide nutrients to the cartilage. Outside the capsule are ligaments and tendons that keep the bones in their proper alignment.
In the case of rheumatoid arthritis (RA), the bodys immune system reacts inappropriately to an external trigger. Substances that irritate the synovium are secreted, causing it to become thicker with resultant swelling, redness and pain. This disease can eventually destroy bone and cartilage in the joint. It can also stretch the tendons and ligaments so that the joint becomes misaligned and deformed.
There is thought to be a hereditary aspect to rheumatoid arthritis. Having a family member who suffers from this condition does not mean that another member will automatically develop it. However, it is believed that an individual can have a genetic predisposition making that person vulnerable to certain viruses or bacteria that may trigger the onset of the disease.
Therefore, if there is a family history of RA, you are at increased risk. If you are female you are up to three times more likely to develop it, and if you smoke you are even more vulnerable. Although RA can develop at any stage of life, it tends to affect people between the ages of 40-60.
Symptoms can come and go and have varying degrees of severity. Times when the disease is active are known as flare-ups. They can often be interspersed with periods of remission when symptoms are much reduced or non-existent. When symptoms appear, they tend to be symmetrical, that is, present in the same places on both hands.
Typical symptoms include:
Aching pain in the joint.
Warmth and swelling around the joint.
Redness and puffiness of the hand.
Stiffness and loss of range of motion, especially in the morning, and lasting longer than one hour after getting up.
Firm bumps under the skin on the fingers or elbow (rheumatic nodules).
Soft lump on the back of the hand that moves as the fingers straighten.
Tiredness, low fever, appetite or weight loss.
Fingers start to angle away from the thumb.
Sudden inability to bend or straighten a finger due to tendon rupture.
The middle joint of the finger is bent upwards.
The middle joint is bent downwards and the joint nearest the nail bent upwards.
Wrist bones standing out.
Numbness or tingling in the hand.
Squeakiness when the joint is moved.
Snapping or locking of the joint.
Your doctor will take your medical history, which will include questions about any family history of rheumatoid arthritis, your symptoms and whether your daily activities are being affected.
Your hands will be assessed, with attention paid to any redness, swelling, loss of range of motion, joint deformity or nodules under the skin.
There is not one definitive test to confirm the existence of RA, but laboratory tests can point to a positive diagnosis. Blood, urine and synovial fluid can be analysed for particular antibodies and proteins that indicate the presence of the disease. X-rays are often used to view the condition of the joint, and sometimes an MRI scan is performed to provide particular detail.
Unfortunately there is no cure, but treatment can relieve symptoms and help to improve function of the hands.
There are many different medications available, and your doctor will work with you to find the best combination. Some that might be considered are:
NSAIDs (non-steroidal anti-inflammatory drugs) can be taken orally, or as creams or gels to be applied topically.
DMARDs (disease-modifying anti-rheumatic drugs) slow or stop the immune system attacking.
Biologics are often used in conjunction with DMARDs. They target specific proteins that are involved in an immune response.
Corticosteroids can be used to reduce inflammation and suppress the immune system.
Immunosuppressants calm an immune response.
TNF-alpha inhibitors suppress an inflammatory substance.
A hand therapist will assist you by finding devices to help with daily activities such as picking up objects or opening jars. Sometimes a splint to be worn during the day or at night might be recommended. Exercises can be taught to maintain and increase mobility in the hands.
Some alternative therapies that you may find helpful are:
Acupuncture for pain relief.
TENS (transcutaneous electrical nerve stimulation). This treatment interferes with pain signals being sent to the brain.
Counter-irritants such as menthol or capsaicin in ointment can also interrupt pain signals.
The medicinal herbs thunder god vine, evening primrose, borage and blackcurrant have been found to ease symptoms, as have fish oils, but always check with your doctor first. If taken with certain prescribed medicines there can be dangerous interactions.
Sometimes your doctor might feel that surgery would be the best option for you. A ruptured tendon can be repaired, the synovium removed, or a joint fused, any of which will relieve the symptoms associated with rheumatoid arthritis.
Self-help options:
Exercise can increase range of motion and flexibility of the joints. Tai chi, swimming and water aerobics are recommended. Hand exercises such as those listed below should be done on a daily basis, provided they do not cause new pain.
Soaking the hand in warm water for 4 minutes, then in cool water for 1 minute, repeated for half an hour and ending with a warm soak, has been found to ease pain.
These are to be done with the approval of your doctor, and should not cause you pain. They are designed to increase flexibility and mobility, not strength.
Bending fingers:
Relax your hand. With the fingers together and straight, and without moving the wrist and knuckles, bend the fingers at the end and middle joints. Slowly return the fingers to the starting position. Repeat with the other hand. Do this several times.
Start with your fingers spread out straight, then slowly form a loose fist and place your thumb around the outside the fingers. Dont squeeze hard. Slowly return to the starting position. Repeat with the other hand. Do this several times.
Wide hand:
Gently spread your fingers as far apart as you can, without forcing them. Relax the fingers and slowly bring them together before spreading them out wide again. Repeat with the other hand. Gradually increase the number of times you do this exercise.
Tip touch:
With your fingers and thumb straight, touch the thumb to the pad on your palm, just below your little finger, or as far across your palm as you can. Return your thumb to the starting position, then touch the tip of each finger, in turn, to the thumb, forming an O shape. Straighten each finger after touching the thumb. Repeat with the other hand.
Finger walk:
With the palm down on a table and the fingers slightly spread out, and keeping the wrist and thumb still, lift and move the index finger toward the thumb. Repeat with each finger in turn. Repeat with the other hand. Do this exercise several times.
Working splints and resting splints are available to reduce swelling, ease pain and prevent joint deformity. Although studies have not found conclusive evidence that they are effective, patients prefer wearing them to not wearing them, so there is some apparent benefit. Padded resting splints were found to be more comfortable than unpadded.
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Employee Spotlight:Debbie Burkhardt
CHI St. Joseph Health
Debbie Burkhardt, Nurse Manager for Trauma Services at Madisonville Hospital, always goes above and beyond for her patients. When one of her patients was concerned about going home due to his living conditions, Debbie stepped up. To prevent the wound on the patients foot from becoming infected, she worked with our Resource Center to contact a team to go in and clean his home (with the patient's permission). When Debbie found out the patient had no running water due to a broken pipe, she contacted a plumber to repair the issue. She has a giving heart, and this is not the first example of her helping a patient in need. We are very proud to have her as part of our team!


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Lamar Odom strains the vocabulary of hoops criticism. To understand how, begin with the question of positional taxonomy. Every Lakers box score, depth chart and official game program will tell you that Lamar is a power forward, and indeed he is. He plays on the front line alongside either Andrew Bynum or Pau Gasol, and on defense he guards opposing fours. But he doesn't fit neatly into any of the power-forward substrata recognized by the analytical vernacular. Although he can shoot three-pointers with some competence, he's not a classic "stretch four" in the mold of Dirk Nowitzki. And although he has a potent scoring touch around the rim, he doesn't have the back-to-the-basket post game of a Carlos Boozer or Zach Randolph. He's probably closest to the "point forward" archetype that we associate with Scottie Pippen, but even that label seems a bit misapplied, as Lamar doesn't handle the ball or initiate his team's offense quite as often as Pippen did his. Lamar spends time in each of these categories but never lingers long in any of them.
Likewise, attempts to describe the value of his play suffer from clumsiness of diction. Often, when writers or fans are looking to praise Lamar, they say he's "underrated." This adjective fails in its intended purpose both because it's not inherently complimentary - one could be pretty bad and still be underrated - and because its frequent deployment is self-sabotaging. We can call a player underrated only so many times before it becomes obvious that the player in question, by general consensus, is perfectly well thought of. "Versatile" is another one that we reach for in discussing Lamar, and at least this descriptor has the advantage of being true, if not of being especially vivid.
The most common expression of disparagement about Odom's game is that it's "inconsistent." In fact, I'm not sure he's any less consistent than a typical NBA player. Everyone has good games and bad. From night to night, it's difficult to predict whether Kobe Bryant or Pau Gasol, to take as examples two of Lamar's more esteemed teammates, will be in peak form or something substantially less than that. I'm not aware of any rigorous evidence proving that Lamar's production is susceptible to greater variance than that of his teammates. Lamar's inconsistency, I'd argue, simply looks different.
When Kobe has a poor game, it's almost always because he shoots badly. (Well, lately it's also because he plays bad defense, but that doesn't get much recognized or talked about.) Fortunately for Laker fans, it's been a while since Kobe has a hit a rough shooting patch, but a series of games in late November illustrates the phenomenon. On November 28th, Kobe shot 14-for-33 in a home loss to Indiana. Two nights later, he shot 9-for-25 in a loss at Memphis. The night after that, he shot 10-for-24 in a loss at Houston. When Kobe stumbles, he does so visibly -- ostentatiously, even. His shortcomings lend themselves to easy diagnosis: Kobe "shot too much" or showed "bad shot selection" or "broke the Triangle." These are failures of commission, and whether or not one agrees with the particular criticism, the terms of the conversation are understood by all.
When Lamar disappoints, he does so along a different dimension. You'll never see Lamar Odom shoot 9-for-25, because when he can't find the basket he stops attempting to find it. Instead, for better or worse, he ratchets down his role. A bad game for Lamar is 3-for-7 from the field with five rebounds. When Lamar plays poorly, he recedes from view. As some might put it, he "disappears," and in this he short-circuits our expectations for professional athletes.
The popular imagination conceives of NBA players as having a greater-than-usual command over their bodies, and we're quicker to excuse failure when it's attributable to physical limitations. In the eyes of many Laker fans, Derek Fisher can get away with being an atrocious defender because we look at him and see instantly that he's 6-foot-1 and in his mid-'30s. We readily grasp how those two characteristics do not easily put one in the running for Defensive Player of the Year. But when someone like Lamar Odom comes up short -- someone who's 6-foot-10 and blessed with speed, strength and fast-twitch musculature that most of us can only dream of - we attach to it a greater degree of culpability. It registers as a failure of temperament, or even character.
This strikes me as misguided. People are not imbued at birth with identical supplies of aggressiveness, "intensity" or any of the other abstract nouns you might hear during an NBA telecast. There's reason to believe that Lamar Odom can no more will himself to be a dervish of activity every second he's on the court than Derek Fisher can remove years of wear and tear off his legs. Human limitations take both tangible and intangible forms, and the latter are no less real than the former.
Moreover, Lamar's occasional recessiveness isn't always the liability it's made out to be. When someone doesn't have their shot working, we don't want them to keep shooting. The instinct that makes Lamar defer to his teammates in those situations is, sometimes, a good one. Not always, of course: there are plenty of occasions when Odom's offensive creativity is needed to provide a spark, or when he's not working quite hard enough on the glass. But even if we could, say, inject Lamar with a vial of Kobe's hyper-competitive psychosis, we'd want to think hard and long before doing so, because it might well take away a big part of what makes Lamar such an effective teammate.
All this is kicking around in my mind these days because the man, at age 31, is enjoying what is pretty clearly his best season as a pro. He's contributing 34 minutes a night of very efficient scoring, productive work on the glass and ball-handling and distribution that few men of his size can rival. On a Lakers team that has sometimes struggled at the defensive end, his work against opposing power forwards has been stellar. He also doesn't get enough credit for his durability: Lamar played all 82 games last season and has played all 45 games this season, while shifting effortlessly between the starting lineup and reserve unit depending on the availability of Gasol and Bynum. There's talk that Odom could make the All-Star Game next month. It probably won't happen because the forward position in the West is such a logjam, but given Lamar's superb performance this season, my hope is that the ongoing conversation about his virtues as a player will evolve beyond the "underrated"/"inconsistent" crudities that have bogged it down.
What's nice is that when Lamar retires 10 years from now, he'll leave behind a shorthand for talking about a very specific kind of basketball player. Somewhere, an 11-year-old is in the midst of a huge growth spurt and just learning how to handle the ball on the break, hit a seven-foot bank shot and attack the offensive glass at just the right angle. Maybe he won't play hard all the time, but he'll play hard often enough, and at his best he'll be able to do literally anything his team needs. And when he finally gets to the Association, we won't have to struggle to cram him into categories that don't really describe what his game's all about. Instead we'll be able to say, "he's just like Lamar Odom."
Follow Dex on Twitter @dexterfishmore.


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On-line version ISSN 2223-6279
Print version ISSN 0379-8577
Curationis vol.39 n.1 Pretoria 2016
A life uncertain - My baby's vulnerability: Mothers' lived experience of connection with their preterm infants in a Botswana neonatal intensive care unit
Rosinah K. NcubeI, II; Hilary BarlowIII; Pat M. MayersI
IDivision of Nursing and Midwifery, University of Cape Town, South Africa
IIMidwifery at Bamalete Lutheran School of Nursing, Oodi, Botswana
IIISchool of Child and Adolescent Health, University of Cape Town, South Africa
BACKGROUND: Preterm and low-birth weight infants are often separated from their mothers when admitted to neonatal units for stabilisation of body temperature and technological support.
OBJECTIVES: The aim of the study was to explore and describe the lived experiences of mothers regarding care of their hospitalised preterm infants in a neonatal unit in a public hospital in Gaborone, Botswana.
METHOD: This study utilised a qualitative exploratory and descriptive phenomenological study design. Mothers of hospitalised preterm infants were purposefully selected, with whom there was extensive engagement. Two in-depth interviews were conducted with each participant (P
RESULTS: Mothers were shocked by the sudden birth of a preterm infant and found the neonatal environment intimidating. This increased their fear and anxiety and delayed development of a relationship with their infants. Support from staff, other mothers in the neonatal unit and family members enabled the mothers to overcome their fear and to develop an emotional connection with their infants.
CONCLUSION: On-going supportive communication with the mothers by healthcare professionals promotes their confidence and competence in caring for their preterm infants, which in turn promotes mother-infant attachment.
Introduction and background
Internationally, neonatal deaths (an infant under 28 days of age) (US National Library of Medicine 2013) account for nearly 41% of all deaths among children under the age of 5 years. The majority of these deaths are in developing countries, and in particular in the African region (Oestergaard et al. 2011). In Botswana, the neonatal mortality rate in 2012 was 29 per 1000 live births (Countdown to 2015. Maternal, Newborn & Child Survival 2015). The global prevalence of low-birth weight (LBW) infants is 15.5%, and this contributes to 60-80% of all neonatal deaths (WHO 2016). LBW has been defined as weight less than 2500 g (WHO 2011a:1). A preterm or premature infant is one born at less than 259 days of gestation (Valero de Bernabe et al. 2004).
Africa and South Asia are the regions where the least progress in reducing neonatal deaths has been achieved over the period 2001-2011 (WHO 2011b). HIV in pregnancy contributes to LBW among neonates, with an associated high incidence of neonatal deaths (Chen et al. 2012; Creek et al. 2010). This is a complicating factor in Botswana, with its high prevalence of HIV among pregnant women (27.7% in 2010) (Unite for Children, Botswana 2012).
Specialised care is required for neonates in neonatal intensive care units (NICUs); the requirements for effective treatment of such neonates could overwhelm the healthcare system, especially in developing countries where there is a lack of equipment and shortage of adequately qualified healthcare personnel (Ruiz-Peláez, Charpak & Cuervo 2004).
LBW and preterm infants are unable to regulate their body temperature and are vulnerable to numerous complications, including respiratory problems, neonatal jaundice, feeding problems and neonatal infections (Eichenwald & Stark 2008; Lau & Morse 2003). Such infants require technological intervention and support, are nursed in NICUs (Cinar & Filiz 2006) and are separated from their mothers (Tilokskulchai et al. 2002).
A mother, unprepared for the birth of a preterm infant (Aagaard & Hall 2008), might experience difficulty in bonding with her vulnerable infant if separated from him or her because of admission to the NICU (Tilokskulchai et al. 2002). Mothers of LBW and preterm infants experience a higher incidence of psychological distress during the neonatal period (Holditch-Davis et al. 2003; Malakouti et al. 2013; Tilokskulchai et al. 2002). Maternal behaviour noted in these studies included fear of touching or harming their infants, emotional ambivalence and lack of confidence in their role as parents of a small and vulnerable infant, which is mitigated by the involvement of mothers in the care of their infants while in the NICU (Erlandsson & Fagerberg 2005). Maternal psychological distress has been reported to increase the child's risk of developmental problems (Kingston 2011). Globally, initiatives aimed at minimising separation of mother and infant, promoting infant well-being and maternal coping skills include kangaroo mother care (Nyqvist et al. 2010), the Baby-Friendly Hospital Initiative (Nyqvist et al. 2013; Nyqvist & Kylberg 2008) and the Humane Neonatal Care Initiative (Charpak, Ruiz & Calume 2000).
Problem statement
Despite increasing evidence that minimising separation from mother and infant soon after birth is beneficial for both, there remains some reluctance to implement this practice with neonates and preterm infants in developing countries (Charpak & Ruiz-Peláez 2006). Family-centred care in NICUs has not been optimally promoted (Obeidat, Bond & Clark 2009). Reasons for this may include health professionals' lack of knowledge and expertise, as well as human and structural resource constraints (Hurst 2006; Irlam & Bruce 2002).
In Botswana, preterm infants are admitted to the health facility's NICUs and the mothers are admitted to the postnatal ward. In the Setswana culture, the mother is the primary caregiver for an infant and no other relative is allowed access to the NICU (Datta 2007; Sedimo, Mbongwe & Kote 2010). Mothers have regulated and structured access to their infants in order to feed and interact with them. The Botswana Ministry of Health (MoH 2011) reported that none of the 34 hospitals assessed in Botswana in 2010 met the criteria to be declared as 'baby-friendly' based on global and national criteria. The criteria for a hospital's baby-friendly accreditation include a written breastfeeding policy, appropriate training of healthcare staff for promotion of breastfeeding, rooming-in and support of breastfeeding mothers (UNICEF 1991).
Aim of the study
The aim of the study was to explore and describe the lived experience of mothers with regard to the care of their preterm infants, within a hospital NICU environment in which mothers had restricted interaction with their preterm infants.
Research method and design
The study was qualitative, explorative and contextual in nature, using Husserl's descriptive phenomenology as the philosophical underpinning for the study (Lopez & Willis 2004). Descriptive phenomenology requires careful description of the individual's experience and meaning attributed to the experience and that the phenomenon is explored 'through direct interaction between the researcher and the objects of study' (Kumar 2012:793). The phenomenon was the experience of mothers with preterm infants in the NICU.
The study setting was a high-care infant unit/NICU in a referral hospital in Gaborone, Botswana, one of two referral hospitals in the country and the largest neonatal setting in the southern part of the country. This 40-bed unit, with intensive care beds for critically ill infants, admits preterm infants from the city as well from clinics and district hospitals in the south. There are approximately 1400 neonatal admissions per year (Mudzikati & Dramowski 2015).
Study population and sample
Women whose preterm infants had been admitted to the hospital NICU immediately post-delivery were purposively sampled. Women who met the following inclusion criteria were invited to participate in the study: a woman who had delivered a singleton infant before 37 weeks of gestation (definition of preterm infant described previously and the assumption that the mother's experience would be different for multiple preterm infants), whose infant had been hospitalised for more than 5 days (assuming that the mother had sufficient 'experience' of the NICU to enable her to reflect on her experiences), stable or improved health of infant and able to communicate in Setswana or English. Women who had delivered a preterm infant who was acutely ill at the time of data collection or whose infant had a congenital abnormality were excluded from the study.
Data collection
The study was conducted over the period December 2010 to January 2011. Eight mothers participated in the study. Participants' ages ranged from 23 to 30 years. All eight infants had been admitted to the NICU for prematurity and its associated complications. One participant's infant (P8) was transferred to the premature infants' section after stabilisation, and one participant's infant died from respiratory complications (P3); however, she requested to remain in the study. All preterm infants were nursed in incubators or radiant warmers (Ogunlesi 2009) in the premature infant section while receiving intravenous and oxygen therapy, until their condition had stabilised or they weighed 1300 g. Thereafter, they were nursed in cribs within the NICU until they had gained sufficient weight and were feeding satisfactorily. Infants are routinely discharged at 1800 g weight, if well and feeding has been established.
Two in-depth interviews with each participant were conducted in a quiet room in the postnatal ward of the study facility. The primary question asked of each participant was: 'Tell me about your experience of having your baby cared for in the neonatal unit'. The first interview was conducted 5 days after admission of the preterm infant, and the second interview just prior to discharge of the infant. All interviews were conducted in Setswana and audio-recorded. In order to facilitate engagement with the participants, the first author, a nurse-midwife and Setswana speaker, spent time each day with the participants during the study data collection phase, especially when the mother was feeding her infant. Field notes were kept and used to inform the data analysis and facilitate the rich description of the lived experience. Data saturation was achieved after these participants had been interviewed, at which point no new information emerged and no further recruitment was done.
The primary research question 'Tell me about your experience of having your infant cared for in the neonatal intensive care unit', was followed, when necessary with prompt questions and reflections:
Can you describe your feelings when you first saw your son/daughter?
Since you first held him/her, how have your feelings changed?
Describe anything in the neonatal intensive care unit that strongly affected you, for example: made you feel happy or sad, frightened or reassured?
Tell me about your interaction with the medical/nursing staff in the neonatal intensive care unit.
If there was anything that could have made this time easier for you and your family, what is it ?
Data management and analysis
Interviews were transcribed verbatim in Setswana and then translated into English and checked for accuracy by a colleague fluent in both languages (Davidson 2009). Field notes were used to capture the pauses, laughter, tears, distractions and non-verbal communication during an interview (Bailey 2008; Hycner 1985). The transcripts were analysed using the approaches of Colaizzi (1978) and Hycner (1985). The transcripts were read and reread while listening to the audio-recordings. For each transcript, significant statements were extracted, initial meanings were formulated and the transcript reread to ensure fidelity to the participant's words. This was repeated for each transcript. Meanings were then organised into clusters and checked against the data to validate the emerging patterns. Each cluster of themes was then examined. Five central themes emerged.
Ethical considerations
Ethical approval was obtained from Human Research Ethics Committee, Faculty of Health Sciences of the University of Cape Town (HREC REF: 332/2010), the Ministry of Health of Botswana Health Research and Development Unit and the hospital Institutional Research and Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki (World Medical Association 2008).
Permission for the study was obtained from the Hospital Superintendent, the Principal Nursing Officer and Head Nurse of the NICU. Mediated access to potential participants was negotiated through the duty nurse who informed the mothers in the unit about the study. Interested potential participants were provided with information about the study. Once participation was agreed to, formal written informed consent was obtained.
Participants were informed about the study purpose, confidentiality and the right to withdraw from the study without any penalty or risk to the care of their infants (Morse 2007). They were also informed that the study would not benefit them directly but that the information obtained through the study may influence nursing practice, therefore benefiting mothers and preterm infants in future. All transcripts were coded to protect identity and data safely stored.
Arrangements were made with hospital social workers for psychosocial support should any of the participants experience any emotional distress as a result of their participation. A particular ethical concern arose for the researchers, as a mother, who had agreed to participate, lost her infant shortly after the first interview. This participant was offered the opportunity to withdraw from the study; however, she requested to be allowed to reflect on the loss of her infant and her interview data were therefore included in the analysis. This highlights the importance of facilitating a trusting relationship with study participants so that their choice is respected, even in situations of emotional distress.
The principles for ensuring trustworthiness were adhered to in the study. Prolonged engagement in the setting, accurate descriptions of the context, methodology, careful transcriptions of interviews and rich description of the participants' lived experience all contribute to the credibility of qualitative research and have been applied in this study.
Five themes emerged which reflect the experience of mothers whose preterm infants were admitted to the NICU:
A life uncertain - my baby's vulnerability
An unfamiliar and intimidating environment
Interacting with health professionals
From fear to emotional connections
An enabling support network.
A life uncertain - my baby's vulnerability
The unexpected birth of a preterm infant was traumatic. Denied the psychological preparation for the birth during the third trimester, mothers experienced uncertainty, emotional and psychological stress and feared for the survival of their newborn infant. For this mother, her concern when realising her infant's different appearance and vulnerability was evident:
'After delivery … after delivering him … I did not expect that he will be so small. I was scared because I was even feeling cold and took off the clothes that I was wearing' (P7).
It was difficult for the participants to take on their anticipated maternal caring roles. They yearned to handle their infants but felt incapable and afraid of doing so, fearing that handling could damage the baby. 'Aah I was afraid of him; he was too small. I didn't know how to handle him though I ended up handling him and changing his nappy' (P1). The presumed vulnerability of the infant initially affected the interaction of the mother with the baby:
'At first I was scared, seeing him … wondering how … am I going to handle such a very small baby? I also thought that … he was … very small and soft, handling him might hurt him since his hands are not yet proper.' (P1)
It was difficult to believe that this tiny, frail and vulnerable infant would survive, and this made it even more difficult to invest in the new relationship:
'The baby was too small … you could not believe that he will survive for a longer time. I used to see babies but I never saw a baby born that small. I was wondering … whether he will survive or not.' (P2)
Fear and anxiety was at its greatest when an unexpected complication was observed, such as cessation of respiration: 'I was frightened because he was not breathing. I was wondering whether he was dead or what was happening to him' (P4). This participant described her immense fear when she found her infant with secretions from mouth and nostrils, as she thought he was not breathing: 'He had a lot of foam from his mouth and yellow stuff from his nostrils … that frightened me as I was wondering … I thought he is not breathing well, you see…' (P7).
Any perceived abnormality increased participants' concern about their infants' well-being and they needed explanations: 'Last time I asked the nurse about the fact that my baby experienced eye discharges every time the light was put on and whether that does not affect him' (P7).
The limited, although regular, 3-hourly contact with their infants was stressful, particularly as mothers became aware that each nurse cared for more than one infant. They wanted to be allowed to stay in the NICU to ensure the infant's safety:
'Some babies lose their lives because they were not identified or seen. So when you are there … going to the neonatal unit more often, I think it is safe …this would even assist nurses because I think some things happen when they are not aware….' (P7)
An unfamiliar and intimidating environment
The unfamiliar, intimidating environment of the neonatal unit exacerbated mothers' anxieties. The equipment impeded easy contact, which was compounded by their awareness of many other sick infants:
'You might have seen your baby but seeing so many of them is scary because some of them have many drips with so many other things on their chest and nostrils.' (P7)
Participants wanted to be informed about the equipment and its function, and incubator alarms added to the anxiety:
'You know where those babies are … when you get there, you do not know the equipment … the first thing that frightens you is the machine that the baby will be kept in, as it alarms since you will be wondering what is happening, you see.' (P5)
The lack of adequate orientation to the NICU environment seemed to increase the mothers' anxiety and fear of coping:
'We could have been told that the people in the neonatal unit are different from those outside the unit. Do not be surprised by what you will see, because they do not breathe on their own, they are assisted to breathe.' (P7)
This participant expressed her concern about the effect on the mothers who observed infants who did not appear to be breathing and might even be dead:
'Other things which were frightening are babies who were dying. You will find a baby who has long died kept for a long time. It is you who will tell yourself that the baby is dead … isn't it that the baby has to breathe.' (P7)
The initial loss of weight (not uncommon in preterm infants) was a source of great fear for the mothers:
'…is weight dropped, dropped and dropped… I wondered if he would end up weighing 500 g as his weight dropped … I heard that some babies were weighing 650 g and these are the babies who were going [dying] … I also wondered if my baby is also going.' (P7)
Participants began to realise that, despite the care, not all infants survived, and every visit to the unit created increased anxiety:
'What is frightening is that we are sleeping with other mothers who also have babies in the same room as mine. Sometimes when we come, maybe coming for a three o'clock feed or any other time, you will find that baby dead. That is what frightened me thinking that maybe one day, when I come here, I will be told that my baby is no longer alive.' (P8)
Cleanliness became an important concern for mothers, as this was deemed to be a measure of the quality of care: 'It's … where the babies are, is very clean. It seems as if they clean every time we leave. I have never seen that place dirty.' (P8)
Relationships with health professionals
Positive interactions with the healthcare providers, particularly nurse-midwives, created a sense of partnership and facilitated communication. Participants felt reassured when the staff members answered their questions and provided adequate explanations:
'There is good interaction this time. I am considering the fact that you will be asking the nurses about the condition of the baby, she will be patient enough to explain.' (P8)
Although it was difficult to wait for assistance, participants appreciated that staff informed them when they could assist immediately: 'There is good communication between the mothers and the nurses. It is only that sometimes it is very difficult to accept some situations as they come.' (P8)
It was important for the participants to be clearly informed of procedures and tests and what these meant:
'They did the chest X-ray and the head X-ray… Then they told me that the X-ray revealed bleeding from the lungs. The way they told me the disadvantages of bleeding from the lungs … I ended up accepting the situation .…' (P3)
Being listened to was important, especially by the doctors, whom the mothers felt were more willing to listen than the nurses. Participants felt that the doctors listened to them and respected their concerns:
'Sometimes when I tell them that my baby is on and off, they listen to me. Last time they wanted to discharge the baby but I told them that the baby has changed. I did not want the nurse to do that on my behalf and they listened to me.' (P4)
The support from the health professionals was important to help them cope with caring for their tiny infants: 'I was afraid of him … not knowing how I am going to handle him…. There is a nurse who told me not to be afraid of him because it is me who is going to take care of him while they show us how to take care of them' (P1). For this participant, the birth of a preterm infant had been especially stressful, as she had lost a child born prematurely the previous year. This had reawakened her memories of the loss and raised fears that this infant too would die.
The support from the nurse had helped her to cope:
'She then comforted me and told me to focus on the now and forget about the past. She said we should focus on the positive side and hope that the baby will be well. I felt better after talking to that nurse.' (P8)
Sometimes negative staff interactions were frustrating for the participants, who ascribed these to lack of interest and personal problems of the nurses. Although they appreciated that the healthcare providers had numerous other responsibilities, they were concerned that, in busy times, routine care such as nappy changing was neglected:
'What made me sad is … you will find your baby there … not taken care of … If you happen not to go to the unit because you were not feeling well, by the time you go there to check on her, you will find her in the same sheets and the nappy not changed.' (P6)
Mothers wanted to be to feel included, informed of treatment changes and be involved in decision making and about their infant's progress, especially when they were not with their infants:
'All we do is to go, do what we are supposed to do and go back. They never tell us what has changed and what has not changed and how the baby is doing … sometimes you would find blood on the sheets, not knowing whether the baby was injected or what and they would not tell you.' (P6)
Participants wanted to have more support and assistance. This mother explained how she felt when she reported that her infant's feeding tube had been dislodged:
'… the feeding tube that she used to drink with was out and when you tell the nurse that it is out. He/she would tell you to feed your baby with a cup. Sometimes when lifting the baby to change the sheets, he/she would say, "lift that baby, she is yours."' (P6)
A participant described her experience of an interaction with a busy doctor:
'… when you come to the doctor and tell him that you found him doing this on the baby in order for him/her to explain what he/she was doing, he/she would tell you to go and ask the nurse.' (P5)
Lack of emotional support or counselling by staff increased the mothers' anxiety:
'… I think I was not welcomed the first day. Even today there is no one who ever told me that you delivered a premature infant … because I thought I needed counselling, you see yet I told myself that I should be strong.' (P7)
There was a feeling that they were not respected by the staff:
'…when a person talks to you like that yet you want your baby to get well, to grow and be discharged … you can end up being hurt if you are not able to control your feelings.' (P8)
From fear to emotional connection
Emotionally unprepared, it was initially very difficult for the mother to engage with the new infant:
'I was wondering why it happened to me to give birth to such … to such a small baby, I became too emotional and left him.' (P2)
A mother who had previously delivered full-term infants found her first encounter with her tiny infant especially stressful:
'…I did not expect to deliver a preterm baby because it has never happened to me. It was such a shock to me … I cried while looking at him wondering whether … mmm … thinking that he is not a baby even if people can say what.' (P7)
Over time, the participants overcame their fear as they were able to touch and hold their infants:
'Initially, I used to go to the unit and when I arrived there, I used to just stand next to him, failing to touch him, wondering what I am going to do … now happy that I was able to hold the baby.' (P1)
As the participants' feelings became more positive towards their infants, their initial apprehensiveness abated:
'My feelings have changed … I was afraid of him at first but I have now accepted him. I manage to lift him when I get there. Even when I am in the room I miss him. I have accepted him and I love him.' (P2)
Participants became more confident as they touched and handled the infants and realised that, although tiny and preterm, their infants were just like any other infant. Touch and contact through feeding their infants made the connection with them real and tangible and facilitated the mother-infant relationships:
'So when I started feeding him, I was able to touch him by then … Hee! I gave him a lot of love.' (P3)
As the tiny infant began to respond, mothers responded in turn:
'So it was very nice, I used to just look at him … even when I touched him before, I could feel that yes he is alive but there was no … But the day I saw him open the eyes I was not scared at all.' (P7)
The fear and anxiety lessened, and mothers experienced a surge of love. This participant, whose first infant had died, was so afraid that her new preterm infant would not survive that she found it difficult to connect with him, explained how her feelings began to change:
'I started loving him. At first I gave up because I had a baby who died.' (P8)
An enabling support network
Different support systems assisted the participants to cope with their difficulties while they were involved in the care of their preterm babies. With adequate information, staff support and encouragement, mothers were able to participate in their infants' care and began to increase in confidence:
'They also encourage us and tell us that if he is like this, you do this and that. They tell us that the baby will survive and it is possible.' (P2)
Support, information and encouragement from other mothers was valued:
'Some mothers who were there are the ones that comforted me by saying, please touch him, kiss him. I started touching his legs and toes' (P7).
The participants supported and encouraged each other:
'Like now, when one mother is sad, I am able to tell her that I was in the same situation, do not be sad. It will be fine … like there is a certain mother whose baby is in a coma … this is the fourth day, but I always tell her that it will be fine.' (P7)
Visits and phone calls by family members reduced the participants' isolation and enabled them to focus on the infant's care. This participant's mother appreciated her mother's support:
'My mother phoned me more often, telling me that I should not be scared because that my baby survives just like the child of … [an acquaintance]. He was born premature and here he is working for himself.' (P7)
Religious beliefs were an important resource. Prayer provided a sense of comfort and hope:
'God is great because even when I was in labour … I normally do not pray but after hearing that the baby is not alive, I talked to God and prayed seriously. I prayed and God answered my prayers' (P3).
This study described the lived experience of mothers whose preterm infants were separated from them and nursed in the NICU. The mothers' psychological preparation for a new infant, interrupted by sudden unexpected birth, affected their readiness for motherhood. Acceptance of the pregnancy and the physical and psychological changes that are associated with pregnancy is vital in order to deal with feelings of being a mother, as the attachment process commences during pregnancy (Alhusen, Hayat & Gross 2013). The mother's emotional and physical experiences in relation to her unexpected and traumatic birth engenders fear for her infant's safety, reduced confidence in interacting with her infant and may delay the attachment process (Fegran, Helseth & Fagermoen 2008; Korja et al. 2009).
The ability to communicate is needed by both the parent and child to build a relationship. Infants show attachment behaviours such as crying, smiling, grasping, reaching out and establishing visual contact to maintain proximity with their parents and communicate their needs. Preterm babies are less active and alert, less responsive to touch and less able to provide clear signals of distress (Korja et al. 2009); thus, the mother's attachment process may be interrupted. Proximity through touch is reported to be the most powerful communication tool parents utilise in interacting with the infant (Fegran et al. 2008) and fear that their actions could harm the infant may inhibit contact (Fegran et al. 2008; Tilokskulchai et al. 2002). The anxiety that emanates from separation, lack of information, lack of explanation and fear for the survival of the preterm infant points to the intensity of the early bonding relationship between mother and child, her need to feel that she is the person who not only has the responsibility but can take responsibility for the care of her newborn. The threat of loss leads to anxiety; anxious mothers tend to experience higher levels of concern and increased vigilance (Rowe, Gardner & Gardner 2005), which in turn complicates attachment (Flacking et al. 2012; Holditch-Davis et al. 2009; Korja et al. 2009).
Despite the evidence (Franklin 2006; Shin & White-Traut 2007) that the NICU environment has the potential to overwhelm mothers and affect the attachment process, this study shows that mothers want to be part of their infants' care. The balance between the need for mothers to feel that their infants have the best chance at survival and their need to feel a part of their infants' care is difficult to achieve (Jackson, Ternestedt & Schollin 2003). The family is the context within which an intimate link between parents and infant is made, but the NICU environment creates a barrier, which could inhibit interaction and bonding. It is important, in the clinical context, to decrease maternal stress and promote close mother-infant contact (Korja, Latva & Lehtonen 2012).
Physical separation of mother and infant when the infant requires care in the NICU affects maternal-infant attachment and increases anxiety. Active parent involvement in the care of their preterm infant in the NICU is thought to moderate psychological stress and promote parent-infant attachment (Franck & Spencer 2003). Efforts to reduce anxiety, barriers to touch and skin contact should be made, as well as the provision of information that facilitates understanding and co-operation with the health professionals.
Effective and supportive communication from the health professionals in the NICU is vital for the mother's well-being and the infant's progress. Mothers need regular information about the infants' progress and care (Wigert et al. 2006) but this in turn is challenging for nurses and doctors, whose focus is on the management of the vulnerable infant (Fegran et al. 2008). Nurses who are sensitive to the needs of mothers are helpful in guiding and strengthening maternal responses to their infants, thus promoting attachment (Kearvell & Grant 2010). A social interaction or 'chat' strategy, in which nurse and mother connect, not only in relation to the infant's care but also about life outside the nursery, has been found to be beneficial in developing rapport (Aagaard & Hall 2008; Fenwick, Barclay & Schmied 2001). An organisational culture which supports the formation of parent-infant relationships is recommended by Flacking et al. (2012) to empower parents and include them as partners in care.
When mothers were provided with information on how to care and were also shown how to provide the caring activities, they developed confidence in taking care of their preterm baby. Aagaard and Hall (2008) suggest that facilitative actions, which include giving empowering and consistent information, are important in helping mothers to develop care-giving actions for the infant, which in turn facilitate attachment. These actions include ensuring that mothers are well informed, the development of good parent-staff relationships, open visiting to infant, breastfeeding support, promotion of physical parent-infant contact and regular updates of the infant's progress. Appropriate, timely and sensitive provision of information is a fundamental need for parents. Regular communication with parents of preterm infants allows them to be partners in care giving and decision making, and empowers the mother to fulfil her role, increases self-confidence and engenders a sense of control and feeling of being connected to her infant (Griffin 2006). Despite the overwhelming nature of such information, parents find it more stressful when information is withheld.
In this study, the relative absence of fathers is not unusual, given the cultural context, wherein fathers do not play an active role in the initial care of a newborn infant. In other studies, however, the importance of the involvement of the father has been stressed (Fegran et al. 2008; Lindberg & Öhrling 2008).
Touch, one of our basic needs in communication, is one of the most fear-inducing responses in the connection between mothers and their preterm infants. With the encouragement of the nurses, they were able to overcome their fear and were able to hold their preterm infant with confidence. The difficulties that mothers of preterm infants face before they are able to initiate contact with their infant can delay the building of a relationship between mother and baby.
Taking care of a fragile infant in an unfamiliar environment was distressing for the participants in our study, and the staff support through provision of information, encouragement and demonstration facilitated the attachment between participants and their preterm infants Support that parents receive from staff is helpful in developing competence and attachment relationships with the baby (Mok & Leung 2006; Schenk, Kelley & Schenk 2005). Mothers who receive reassurance regarding their infant's conditions were able to interact with their infants in a positive manner throughout their hospitalisation periods (Mok & Leung 2006). Support from other mothers was also helpful, particularly the encouragement from mothers whose infants had been in the NICU for a few days, could be considered 'experienced' and could provide information and encouragement to the mothers whose infants had more recently been admitted to the NICU.
Limitations of the study
This limited study explored the lived experience of eight mothers whose preterm babies were admitted to one NICU in Botswana. The interviews were conducted in Setswana and translated into English, which might have influenced the interpretation of the lived experiences. In the Setswana culture, the father has a limited role in the early days of a newborn's life; it is necessary that the experiences and role of the father with regard to a preterm infant should be understood. As a small qualitative study, the findings are not generalisable, although may be transferable to similar settings.
The health of the mother, preterm infant and family is a critical aspect of maternal and child health care. Women should be encouraged to learn as much as possible about the birth process in order to raise awareness of the possibility of preterm birth and how this is managed in maternal care settings. Information about the possibility of preterm labour and delivery is seldom provided to pregnant women. The first-time mothers in this study had never seen a preterm infant and had no previous exposure to an incubator or the NICU. Although a number of topics are covered in the form of brochures for mothers, information on preterm birth and care of a preterm infant is not freely available. Pregnant women need to be sensitively informed about the possible complications of pregnancy, preterm delivery and the available interventions that are provided, even though most infants would not need specialised care (Herbst & Maree 2006).
Mothers should have open access to the neonatal unit so that separation is minimised, mothers' stress is minimised and mother-infant interaction is enhanced (Flacking et al. 2012; Franklin 2006). Each neonatal unit should have an orientation package for parents, stipulating what they are expected to do and informing them what they should expect while in the NICU (Herbst & Maree 2006). Mothers of newly admitted infants should be orientated to the unit and counselled regarding the infant's condition and the treatment options. Support groups are a useful resource to assist the new mothers in learning from others with similar experiences. Fathers should be involved as much as possible, although infection control protocols, may limit this involvement.
Mothers would also benefit from the provision of a comfortable space as close as possible to the NICU in which they could relax, interact with other mothers in similar situations or be supported by family members. Counselling, health literacy skills and promotion of kangaroo mother care should be included in all health professional curricula.
The findings of this study demonstrate that health professionals in neonatal settings have a dual responsibility - to the infant and to the mother. Through the supportive promotion of mothers' participation in the care of their preterm infants, the mother-infant emotional connection is facilitated, which is vital for the survival of the infant and the well-being of the mother.
The authors thank the health facility for permission to conduct the study and permitting access to the study setting.
Competing interests
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
Authors' contributions
R.N. planned and conducted the study and collected the data under supervision of H.B. and P.M.M. and commented on the drafts of the article. P.M.M. wrote the article based on the research report. H.B. provided critique on drafts and wrote the abstract. P.M.M. reviewed the drafts and completed all revisions as the corresponding author.
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Pat Mayers
Received: 01 June 2015
Accepted: 23 May 2016
Published: 30 Aug. 2016