Journal of health research in community

Introduction
The birth of a preterm infant and subsequent admission to a neonatal intensive care unit (NICU) can be challenging and stressful for mothers, potentially affecting their physical and psychological well-being and their ability to provide care. The NICU environment, ongoing concerns about the infant’s condition, disruption of usual mother–infant interactions, and changes to daily routines may increase caregiving burden. Previous studies have documented substantial parental stress and difficulties coping with an infant’s hospitalization in the NICU [3, 4]. Sleep disturbances and fatigue are also common among parents of preterm infants and may limit mothers’ physical and psychological capacity to participate effectively in infant care [14]. Therefore, this study aimed to determine the relationship between caregiver burden, fatigue, and sleep quality, and to identify predictors of caregiver burden among mothers of preterm infants hospitalized in the NICU.

Methods
This descriptive, correlational, cross-sectional study was conducted in 2023 in the NICUs of Tehran University of Medical Sciences. A total of 123 mothers were recruited using convenience sampling. Data were collected using a demographic and clinical characteristics checklist and standardized questionnaires assessing sleep quality, fatigue, and caregiver burden. 
Sleep quality was assessed using the Pittsburgh sleep quality index (PSQI), maternal fatigue using the Piper Fatigue scale (PFS), and caregiving burden using the Elmesta Caregiver burden questionnaire [14, 24, 29].
Data were analyzed using SPSS 22. Correlation analyses were performed to examine relationships among the study variables. Independent-samples t-tests and one-way analysis of variance were used to compare mean scores. Binary logistic regression analysis was also performed to identify predictors of caregiver burden while controlling for demographic and clinical characteristics. 

Results
The mean sleep quality score was 10.63 (SD=3.18), the mean caregiver burden score was 57.19 (SD=13.44), and the mean fatigue score was 39.25 (SD=11.41). The majority of mothers (92.7%) experienced poor sleep quality. Regarding caregiver burden, most mothers (59.8%) experienced a moderate level of burden, while approximately one-quarter (23.0%) experienced a severe level. In terms of fatigue severity, 69.9% of mothers reported severe fatigue, 23.6% reported moderate fatigue, and 6.5% reported mild fatigue. These findings indicate that a substantial proportion of mothers experienced sleep disturbances, fatigue, and considerable caregiver burden simultaneously.
Binary logistic regression analysis, controlling for demographic and clinical variables—including maternal age, infant age, maternal education, maternal occupation, paternal occupation, monthly income, infant sex, mode of delivery, and the presence of comorbidities—showed that fatigue, inadequate sleep, infant age, and maternal age were significant predictors of caregiver burden. 
Fatigue was the strongest predictor of caregiver burden. Mothers experiencing fatigue had 13.7 times the odds of experiencing caregiver burden as mothers without fatigue (OR=13.7, P=0.018). Sleep problems were also significantly associated with caregiver burden; mothers with sleep problems had 8.6 times the odds of experiencing caregiver burden as those without sleep problems (OR=8.6, P=0.012). 
In contrast, infant age and maternal age were identified as protective factors. For each one-day increase in infant age, the odds of caregiver burden decreased by approximately 27% (OR=0.73, P=0.013). Similarly, each one-year increase in maternal age was associated with an approximately 12% reduction in the odds of caregiver burden problems (OR=0.88, P=0.023). 

Conclusion
Mothers of preterm infants hospitalized in the NICU simultaneously experienced substantial sleep disturbance, fatigue, and caregiver burden. The high prevalence of sleep problems observed in this study is consistent with evidence of sleep disturbances among parents of preterm infants, as NICU hospitalization and persistent concerns regarding the infant’s health may disrupt mothers’ normal sleep patterns [14, 29]. Furthermore, high caregiver burden may involve considerable physical and psychological demands, and the resulting fatigue may impair mothers’ ability to adapt to and effectively fulfill their caregiving role. The particularly high odds ratios observed for fatigue and sleep problems as predictors of caregiver burden underscore the importance of addressing maternal well-being alongside the infant’s clinical needs. 

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Tehran University of Medical Sciences (Code: IR.TUMS.FNM.REC.1401.059). The study objectives were explained to all participants, and written informed consent was obtained from them.

Funding
This study was funded by Tehran University of Medical Sciences (Grant No.: 3-1401-62475-100).

Authors contributions
Investigation and validation: Fariba Heydarzadeh; initial draft preparation: Nagmeh Razaghi and Akram-Sadat Sadat-Hoseini; editing & review, supervision, project administration: Akram-Sadat Sadat-Hoseini; methodology: Fariba Heydarzadeh and Akram-Sadat Sadat-Hoseini; analysis: All authors; resources: Fariba Heydarzadeh and Nagmeh Razaghi. All authors have read and approved the final version of the manuscript.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors would like to thank Tehran University of Medical Sciences for financial support, and the staff of selected hospitals and all mothers who participated in this study for their time and cooperation.
 

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