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        "titulo" => "Ser m&#227;e de m&#250;ltiplos prematuros no contexto de desvantagem socioecon&#244;mica&#58; estresse percebido e sintomas psicol&#243;gicos"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Maternal perceived stress and psychological problems&#58; means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviations for the multiple births <span class="elsevierStyleItalic">vs</span>&#46; socioeconomic disadvantage&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Every year&#44; an estimated 15 million babies are born preterm worldwide &#40;&#60;37 gestational weeks&#41; and this number is rising&#46; In Portugal&#44; where this study was conducted&#44; approximately 7&#46;7&#37; of children were born prior to term in 2014&#44; while in 2001 it was about 5&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Such significant increase constitutes an important public health issue&#46; Indeed&#44; younger and more fragile infants are surviving their neonatal intensive care unit &#40;NICU&#41; stays&#44; with many of them exhibiting high rates of special needs as they grow older&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Several mental health problems have also been reported for parents&#46; Evidence has revealed that mothers of preterm infants often show elevated stress levels and psychological difficulties&#44; which&#44; in turn&#44; seem to compromise their parenting abilities and&#44; consequently&#44; child development&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> Therefore&#44; more research focused on the impact of medical and social risk factors on parental adjustment is crucial in the field of prematurity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Research conducted during the last decades has provided a growing body of evidence on the adverse effects of child health risks for parents&#8217; psychological functioning&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Recently&#44; researchers have been particularly interested in the putative aggravating role of being a mother of multiples&#46; Adding to the stresses of being a parent of a preterm &#40;more fragile&#41; infant&#44; families of preterm multiples are often exposed to additional health and emotional demands&#44; including prolonged hospitalization&#44; child cerebral palsy&#44; hemorrhage&#44; and developmental delays&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#44;6</span></a> Moreover&#44; mothers with multiple gestation pregnancies and their partners have to care for and relate to more than one baby&#44; to whom they may have been separated during their first days after delivery&#46; Such parents often experience more financial pressures&#44; fatigue&#44; social isolation&#44; and practical difficulties that emerge from the need of looking after for more than one infant at once&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> Not surprisingly&#44; researchers have recently revealed that mothers of preterm multiples are more likely to be depressed&#44; to present elevated anxiety&#44; and to experience more parenting stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#8211;11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the importance of the findings described above&#44; the research in this field is still characterized by a lack of studies focused on the identification of environmental factors that may buffer the negative effects of multiple births on the psychological well-being of mothers of preterm infants&#46; This gap in the literature is notable&#44; given years of research highlighting the negative impact of family psychosocial adversities on women&#39;s psychological functioning&#46; For instance&#44; Goyal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> showed that first time mothers exposed to low socioeconomic status were 11 times more likely than mothers with no socioeconomic risk factors to have clinically elevated depression scores&#46; Although not focused on the role of multiple births&#44; also of note is the work of Wormald et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> These investigators analyzed the levels of stress of parents of very low birth weight &#40;VLBW&#41; infants&#44; finding that the mothers of VLBW infants who exhibited significantly higher stress levels were the ones who were exposed&#44; not only to medical complications&#44; but also to more socioeconomic adversities &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; lower education&#44; unemployment&#41;&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">The current study</span><p id="par0020" class="elsevierStylePara elsevierViewall">Taken together&#44; these findings clearly suggest that it is worthwhile to further examine the links between family socioeconomic risks and the adjustment of mothers of preterm multiples&#46; Therefore&#44; this study aimed to investigate the differences between mothers of preterm multiples and mothers of preterm singletons regarding maternal perceived stress and psychological symptoms&#44; and to explore the adverse amplified effect of socioeconomic disadvantage&#44; while controlling for the putative effect of child medical risks&#46; It was hypothesized that mothers of preterm multiples would be at increased risk for higher stress levels and psychological symptoms&#44; in comparison to mothers of preterm singletons&#44; especially &#40;or even exclusively&#41; when living in a context of socioeconomic disadvantage&#46; In other words&#44; the authors expected that the impact of multiple births on the psychological well-being of mothers of preterm infants would be amplified by the adverse effects of socioeconomic disadvantage&#46;</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Participants and procedure</span><p id="par0025" class="elsevierStylePara elsevierViewall">Ninety-five mothers of 1-year-old preterm infants participated in this cross-sectional study&#46; Data collection was carried out in two public hospitals from Northern Portugal&#46; This research was previously approved by the Portuguese National Commission for Data Protection&#44; and by the ethical boards of the participating hospitals and of the university involved in the coordination of the study&#46; Mothers were asked to complete two questionnaires to assess maternal psychological symptoms and perceived stress&#44; and reported on socioeconomic factors&#44; child medical risks&#44; and whether or not they had delivered multiples&#46; Mothers signed a written informed consent&#44; permitting their own participation in the study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Measures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Maternal perceived stress</span><p id="par0030" class="elsevierStylePara elsevierViewall">Mothers completed the Portuguese version of the Daily Hassles Questionnaire&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14&#44;15</span></a> This measure includes 43 items&#44; rated on a 5-point scale &#40;0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no hassle to 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>big hassle&#41;&#44; assessing stressors related to daily life and to the activities of parenthood&#46; Items were summed to obtain a final score&#46; In the present study&#44; the internal consistency score for the scale was <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Maternal psychological problems</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mothers completed the Brief Symptom Inventory &#40;BSI&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">16&#44;17</span></a> The BSI includes 53 items rated on a 5-point scale &#40;0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>not at all to 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>extremely&#41;&#44; measuring the presence of various symptoms experienced by the mother in the past week&#46; The questionnaire assesses nine psychopathological dimensions and three global scores&#46; The Positive Symptoms Distress Index&#44; one of the global scores&#44; was used in the study&#44; as a measure of symptom intensity corrected for the number of symptoms&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Family socioeconomic disadvantage</span><p id="par0040" class="elsevierStylePara elsevierViewall">Mothers reported on three socioeconomic risks&#44; namely&#58; &#40;i&#41; family living in poverty &#40;family monthly income&#44; adjusted for family size&#44; below national income levels&#41;&#44; &#40;ii&#41; parental unemployment &#40;<span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; one of the parents was unemployed at the time of the study&#41;&#44; and &#40;iii&#41; low parental educational level &#40;<span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; one of the parents had under nine years of education&#41;&#46; Each risk factor was scored as absent &#40;0&#41; or present &#40;1&#41;&#46; Then&#44; the sample was split into two groups of socioeconomic disadvantage&#58; &#40;1&#41; families exposed &#40;to one or more risks&#44; 58&#46;8&#37;&#41;&#44; and &#40;2&#41; families not exposed &#40;no risks&#44; 43&#46;2&#37;&#41; to socioeconomic adversities &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> for descriptive statistics on family risks&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Covariate</span><p id="par0045" class="elsevierStylePara elsevierViewall">A child medical risk index was calculated to serve as covariate&#44; consisting of the mean of standardized scores of child gestational weeks &#40;reversed&#41;&#44; birth weight &#40;reversed&#41;&#44; and number of days in the NICU&#46; A higher score is indicative of greater medical risk&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Data analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Data were analyzed using the Statistical Package for Social Sciences software &#40;SPSS&#41; &#40;IBM Corp&#46;&#44; Released 2013&#44; IBM SPSS Statistics for Windows&#44; version 22&#46;0k&#44; NY&#44; USA&#41;&#46; Descriptive statistics for maternal perceived stress and psychological symptoms were first examined for the total sample&#46; Then&#44; independent <span class="elsevierStyleItalic">t</span>-tests and chi-squared tests were used to determine whether mothers of preterm multiples and mothers of preterm singletons were different with respect to maternal age&#44; child medical risks&#44; and family socioeconomic disadvantage&#46; Differences between mothers exposed and mothers not exposed to socioeconomic disadvantage were also examined with respect to maternal age and child medical risks&#46; Further analyses were conducted using two-way multivariate analysis of variance &#40;MANOVA&#41; to test group differences in maternal perceived stress and psychological symptoms&#44; while controlling for child medical risks&#46; Interaction effects were also explored&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Sample characteristics are presented in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; At time of assessment&#44; mothers were aged 19&#8211;48 years &#40;34&#46;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;20&#41;&#46; Seventy-two were primiparous and 17 were mothers of multiples &#40;all twins&#44; except one mother of triplets&#41;&#46; In the majority of cases&#44; the pregnancy was planned &#40;82&#46;1&#37;&#41;&#44; medically monitored &#40;96&#46;8&#37;&#41;&#44; and infants were delivered vaginally &#40;50&#46;5&#37;&#41;&#46; The majority of mothers were married &#40;91&#46;6&#37;&#41;&#46; The remaining were single &#40;6&#46;3&#37;&#41; or divorced &#40;2&#46;1&#37;&#41;&#46; Regarding maternal education&#44; three mothers had four years of formal education&#44; 25 had five to nine years&#44; 30 had ten to 12 years&#44; and the remaining had a college degree&#46; Seventy-three mothers had a job&#44; 21 were unemployed&#44; and one mother was retired&#46; Moreover&#44; 31 &#40;32&#46;6&#37;&#41; families were living with incomes below the national poverty line&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">For the total sample&#44; mothers&#8217; mean perceived stress was 32&#46;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;12&#44; while the mean of psychological symptoms was 1&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;37 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Analyses showed that mothers of preterm multiples and mothers of preterm singletons were not significantly different in any of the following demographic and study variables&#58; maternal age&#44; <span class="elsevierStyleItalic">t</span>&#40;93&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;1&#46;18&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;24&#59; child medical risks&#44; <span class="elsevierStyleItalic">t</span>&#40;93&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;45&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;66&#59; or family socioeconomic disadvantage&#44; <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;91&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#46; Likewise&#44; mothers exposed and mothers not exposed to socioeconomic disadvantage did not differ in terms of child medical risks&#44; <span class="elsevierStyleItalic">t</span>&#40;93&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;90&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#59; however&#44; mothers living in a context of socioeconomic disadvantage were significantly older&#44; <span class="elsevierStyleItalic">t</span>&#40;93&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;35&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Effects of multiple births and socioeconomic disadvantage</span><p id="par0065" class="elsevierStylePara elsevierViewall">Then&#44; two-way MANOVA was performed&#46; Multiple births and family socioeconomic disadvantage were included in the analysis as factors&#44; while child medical risk was entered as a covariate&#46; Data entered into the MANOVA satisfied the requirements for homogeneity of covariance matrices &#40;Box&#39;s test&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;12&#41; and equality of variances for each dependent variable &#40;Levene&#39;s tests&#58; for perceived stress&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#59; for psychological problems&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;93&#41;&#46; The main results revealed a statistically significant principle effect of multiple births on the combined dependent variable&#44; <span class="elsevierStyleItalic">F</span>&#40;1&#44;95&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;25&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#44; Wilks&#8217; &#923;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;89&#46; Further examination of this result indicated that mothers of preterm multiples reported higher levels of stress than mothers of preterm singletons&#44; <span class="elsevierStyleItalic">F</span>&#40;1&#44;95&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;70&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#44; Eta<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#46; No significant differences were observed between mothers exposed and unexposed to socioeconomic disadvantage &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; However&#44; there was a marginally significant multiple births <span class="elsevierStyleItalic">vs</span>&#46; socioeconomic status effect on the combined dependent variables&#44; <span class="elsevierStyleItalic">F</span>&#40;1&#44;95&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;75&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#44; Wilks&#8217; &#923;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#46; Given this tendency&#44; between-subjects effects were then examined&#46; Results indicated that the impact of multiple births on maternal psychological problems &#40;but not levels of stress&#41; differ whether mothers were exposed &#40;<span class="elsevierStyleItalic">vs&#46;</span> unexposed&#41; to socioeconomic adversities&#44; <span class="elsevierStyleItalic">F</span>&#40;1&#44;95&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;25&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#44; Eta<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;055&#46; More specifically&#44; simple effects analysis revealed that&#44; in the context of socioeconomic disadvantage&#44; mothers of preterm multiples significantly reported more psychological symptoms &#40;1&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#41; than mothers of preterm singletons &#40;1&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#41;&#46; However&#44; in the absence of socioeconomic adversities&#44; mothers of preterm multiples &#40;1&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#41; and mothers of singletons &#40;1&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;42&#41; reported similar levels of psychological problems &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The present study aimed to examine the differences between mothers of preterm multiples and mothers of preterm singletons with respect to perceived stress and maternal psychological symptoms&#44; while controlling for the effect of child medical risks&#46; As expected&#44; the results revealed that mothers of preterm multiples experienced significantly higher stress levels than mothers of preterm singletons months after delivery&#44; when their children were 12 months of corrected age&#46; It is important to highlight that this result is in line with previous studies&#44; which have also shown&#44; consistently&#44; that mothers of multiples are significantly more likely than mothers of singletons to report severe parenting stress&#44; not only days after delivery&#44; but also months after giving birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;18</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Surprisingly&#44; no significant differences emerged between groups with respect to maternal psychological symptoms in the present study&#46; This data is consistent with other studies that have also failed to document differences between mothers of multiples and mothers of singletons in psychological functioning&#46; For instance&#44; Glazebrook et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> found that mothers of multiples did not have poorer mental health than mothers of singletons&#44; one year postpartum&#46; Nevertheless&#44; the present results differ from other research that&#44; on the contrary&#44; indicated the presence of elevated psychological difficulties among mothers of preterm multiples&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#44;10</span></a> Such divergent results across studies may be attributable to methodological issues&#46; More precisely&#44; in the present investigation&#44; as well as in the work of Glazebrook et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> maternal mental health was assessed using global reports of psychological functioning&#44; while in other studies researchers have relied on measures aimed to specifically assess maternal levels of anxiety or depression&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> In addition to this possibility&#44; it may also be the case that maternal psychological difficulties may be more salient in the very first days or months after giving birth&#44; during a period when the mother is still adapting to the role of being a parent of two or more fragile children&#46; Accordingly&#44; Van den Akker et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> in a meta-analysis&#44; concluded that maternal depression was more common before the end of one year postpartum&#46; On the contrary&#44; in the present study assessments occurred one year after delivery&#46; However&#44; it is unclear whether any of these explanations is responsible for the results reported herein&#46; Future studies&#44; longitudinal in design&#44; are clearly needed&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Adding to the above research aims&#44; this report also sought to innovate and extend the current literature by exploring the putative amplifying adverse effect of socioeconomic disadvantage on the relation between multiple preterm births and maternal adjustment&#46; Data showed that mothers of preterm multiples significantly reported more psychological symptoms than mothers of singletons&#44; but only when exposed to socioeconomic adversities&#46; This result clearly points to the relevance of parental socioeconomic background for women&#39;s adjustment&#44; as previously suggested by other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#44;13</span></a> However&#44; and most importantly&#44; these results may help to clarify the inconsistencies found in the literature about the emergence of psychological symptoms among mothers of preterm multiples&#44; as discussed in the preceding paragraph&#46; More precisely&#44; this study expands previous literature by suggesting that the birth of multiples does not necessary adversely impacts women&#39;s mental health&#46; Instead&#44; it may be the case that the negative impact of multiple births on the psychological functioning of women occurs when mothers are&#44; simultaneously&#44; exposed to a context of social disadvantage&#46; Such adversity will prevent families from obtaining the resources and support needed to adequately care for and relate to more than one small&#44; fragile infant at once&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Importantly&#44; these findings also revealed that the elevated susceptibility of mothers of preterm multiples to show adjustment problems&#44; more than one year postpartum&#44; seems to occur even after controlling for the putative effect of child medical risks&#46; In fact&#44; it is worth bearing in mind that no significant associations emerged&#44; in the current report&#44; between child risks at birth and maternal perceived stress and psychological problems&#46; This lack of a significant effect is not in line with other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> However&#44; this does not necessarily mean that child medical adversities have no implications on the well-being and maternal psychological functioning&#46; Perhaps other child factors may be more prominent one year postpartum&#44; such as the presence of neurological dysfunctions&#44; as already evidenced by Walter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> On this subject&#44; more studies are needed&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Implications for policy and practice</span><p id="par0090" class="elsevierStylePara elsevierViewall">Taken together&#44; these results are notable and have important implications for practice&#46; As already mentioned&#44; in recent years&#44; there has been a rise in the number of premature births&#44; but also in the number of multiple pregnancies in many developed countries&#44; mostly due to advances in assisted reproductive technology and to older maternal age at childbirth&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> For instance&#44; data collected for the years 2004 and 2010&#44; in 29 European countries as part of the Euro-Peristat project&#44; revealed that the twinning rate increased on average by 1&#46;7&#37; units &#40;<span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; more than 12&#46;5&#37;&#41; over that six-year period&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> The present data&#44; together with the results of other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9-11</span></a> suggest that mothers of preterm multiples may be at-risk for severe adjustment problems&#44; particularly when exposed to socioeconomic disadvantage&#46; Healthcare programs should incorporate comprehensive psychological assessments of mothers of children born preterm&#44; specifically for mothers of multiples&#44; not only immediately after birth&#44; but also in the months and years to come&#46; They should also incorporate supportive services and effective&#44; more individualized psychosocial interventions for such mothers &#40;and their partners&#41; in the postnatal period&#46; Policy makers should additionally be informed that by improving the emotional well-being of mothers and their partners&#44; they will also be stimulating and caring for the health and optimal development of children&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Limitations</span><p id="par0095" class="elsevierStylePara elsevierViewall">There are several limitations to this report that should be addressed in future research&#46; The sample is small&#44; and&#44; thus&#44; this study is limited in its statistical power&#46; In addition&#44; as a cross-sectional study&#44; information regarding the main study variables was available for a single point in time&#46; Thereby&#44; the correlation design of this study limits the exploration of the mechanisms putatively involved in the emergence of elevated stress levels and psychological difficulties in mothers of multiples exposed to socioeconomic disadvantage&#46; The trajectories of maternal adjustment were also not possible to examine&#46; Moreover&#44; future studies should incorporate the assessment of child neurological problems as a potential predictor of maternal lower adjustment&#44; and should consider the evaluation of fathers&#8217; adjustment as well&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Despite the dramatic increase in twin births in much of the Western world&#44; it is striking that little research has sought to examine mental health in parents of multiples&#46; Thus&#44; the present study aimed to expand the current knowledge about the adjustment of mothers of preterm multiples&#44; most notably by exploring the differences between mothers of preterm multiples and mothers of preterm singletons with respect to perceived stress and psychological symptoms&#44; one year postpartum&#46; It also sought to examine the putative negative effect of maternal exposure to socioeconomic disadvantage&#46; Data revealed that mothers of preterm multiples showed elevated stress levels&#44; in comparison to mothers of preterm singletons&#46; Regarding psychological functioning&#44; mothers of preterm multiples reported significantly more symptoms than mothers of preterm singletons&#44; but only when living in a context of socioeconomic adversity&#46; These findings not only suggest that having a preterm &#40;more fragile&#41; infant&#44; in the context of multiple births&#44; is a considerable challenge for many parents&#44; but also that the care giving and psychological demands that derive from it seem to be exacerbated by the exposure of the family to socioeconomic adversities&#46; Future work should include the development of psychosocial treatments to assist parents of preterm multiples&#44; especially those who are exposed to a context of social disadvantage&#44; and who may ultimately benefit the most from supportive interventions&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleGrantSponsor" id="gs1">Funda&#231;&#227;o para a Ci&#234;ncia e a Tecnologia</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">SFRH&#47;BPD&#47;100994&#47;2014</span>&#44; <span class="elsevierStyleGrantNumber" refid="gs1">SFRH&#47;BD&#47;86075&#47;2012</span>&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Effects of multiple births and socioeconomic disadvantage"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This study aimed to examine the differences between mothers of preterm multiples and mothers of preterm singletons regarding perceived stress and maternal psychological symptoms&#44; and to explore the putative adverse amplified effect of socioeconomic disadvantage&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ninety-five mothers of 1-year-olds born preterm participated in this cross-sectional study&#46; Data collection was carried out in two public hospitals from Northern Portugal&#46; To assess maternal perceived daily stress and psychological symptoms&#44; mothers completed two questionnaires&#46; Mothers reported on socioeconomic factors&#44; including family poverty&#44; parent unemployment&#44; and low education&#44; and two groups of family socioeconomic disadvantage were created&#46; A child medical risk index was calculated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Results indicated that mothers of preterm multiples reported higher levels of stress than mothers of preterm singletons&#46; Moreover&#44; and specifically regarding psychological functioning&#44; mothers of preterm multiples reported more symptoms than mothers of preterm singletons&#44; but only when living in a context of socioeconomic adversity&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results of the present study have important implications for practice&#46; Mothers of preterm multiples are at higher risk to present mental health difficulties&#44; in comparison to mothers of singletons&#44; especially when exposed to socioeconomic adversities&#46; The development of psychosocial intervention programs and public policies are of decisive importance in helping mothers of multiples adjust to parenthood&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Examinar as diferen&#231;as entre m&#227;es de m&#250;ltiplos prematuros e m&#227;es de filhos &#250;nicos prematuros a respeito de estresse percebido e sintomas psicol&#243;gicos maternos e explorar o efeito adverso amplificado putativo da desvantagem socioecon&#244;mica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Participaram deste estudo transversal 95 m&#227;es de crian&#231;as de um ano nascidas prematuras&#46; A coleta de dados foi feita em dois hospitais p&#250;blicos do norte de Portugal&#46; Para avaliar o estresse di&#225;rio percebido e os sintomas psicol&#243;gicos maternos&#44; as m&#227;es responderam dois question&#225;rios&#46; As m&#227;es relataram fatores socioecon&#244;micos&#44; incluindo pobreza familiar&#44; desemprego dos pais e baixo n&#237;vel de escolaridade&#44; e foram criados dois grupos de desvantagem socioecon&#244;mica familiar&#46; Foi calculado um &#237;ndice de risco m&#233;dico infantil&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os resultados indicaram que as m&#227;es de m&#250;ltiplos prematuros relataram maiores n&#237;veis de estresse do que as m&#227;es de filhos &#250;nicos prematuros&#46; Al&#233;m disso e especificamente com rela&#231;&#227;o ao funcionamento psicol&#243;gico&#44; as m&#227;es de m&#250;ltiplos prematuros relataram mais sintomas do que as m&#227;es de filhos &#250;nicos prematuros&#44; por&#233;m apenas quando moravam em um contexto de adversidade socioecon&#244;mica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os resultados deste estudo possuem importantes implica&#231;&#245;es para a pr&#225;tica&#46; As m&#227;es de m&#250;ltiplos prematuros apresentam maior risco de dificuldades de sa&#250;de mental&#44; em compara&#231;&#227;o a m&#227;es de filhos &#250;nicos&#44; principalmente quando expostas a adversidades socioecon&#244;micas&#46; O desenvolvimento de programas de interven&#231;&#227;o psicossocial e pol&#237;ticas p&#250;blicas &#233; de import&#226;ncia decisiva ao ajudar as m&#227;es de filhos m&#250;ltiplos a se ajustarem &#224; maternidade&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Baptista J&#44; Moutinho V&#44; Mateus V&#44; Guimar&#227;es H&#44; Clemente F&#44; Almeida S&#44; et al&#46; Being a mother of preterm multiples in the context of socioeconomic disadvantage&#58; perceived stress and psychological symptoms&#46; J Pediatr &#40;Rio J&#41;&#46; 2018&#59;94&#58;491&#8211;7&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Maternal employment &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Employed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Unemployed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Retired&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Paternal employment &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Employed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Unemployed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Retired&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Family monthly income &#40;Euros&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1509&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>880&#46;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1398&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>846&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2017&#46;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>878&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Number of household members</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Child and delivery</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Age in months &#40;corrected age&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sex &#40;&#37; of boys&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Birth weight &#40;grams&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1886&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>628&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1923&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>612&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1718&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>640&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gestational weeks</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Days in NICU</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Delivery &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Multiple births&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>C-section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In the case of multiple births&#44; one twin was randomly selected&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">NICU&#44; neonatal intensive care unit&#59; SD&#44; standard deviations&#46;</p>"
            ]
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sample characteristics&#58; means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviations&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Risk factor</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family living in poverty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parental unemployment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low parental education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Family risks</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0 risks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1 risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 or more risks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Family socioeconomic risks&#58; percentages and frequencies for total sample&#46;</p>"
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total sample&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychological problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;09&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Group differences in maternal perceived stress and psychological problems&#58; means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviations&#46;</p>"
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        "texto" => "<p id="par0115" class="elsevierStylePara elsevierViewall">The authors are very grateful to the children and parents who participated in the study&#46;</p> <p id="par0120" class="elsevierStylePara elsevierViewall">This study was conducted within the Psychology Research Center&#44; University of Minho&#44; and partially supported by the <span class="elsevierStyleGrantSponsor" id="gs2">Portuguese Foundation for Science and Technology</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">SFRH&#47;BPD&#47;100994&#47;2014</span> assigned to the first author&#59; also grant <span class="elsevierStyleGrantNumber" refid="gs2">SFRH&#47;BD&#47;86075&#47;2012</span>&#41; and by the <span class="elsevierStyleGrantSponsor" id="gs3">Portuguese Ministry of Education and Science</span> through national funds and when applicable co-financed by <span class="elsevierStyleGrantSponsor" id="gs4">European Regional Development Fund</span> &#40;ERDF&#41; under the PT2020 Partnership Agreement &#40;UID&#47;PSI&#47;01662&#47;2013&#41;&#46;</p>"
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