Towards a Social Model of Prematurity: Understanding the Social Impact of Prematurity and the Role of Inclusive Parenting Practices in Neonatal Intensive Care Units

1. Summary

We sincerely thank you for your time and effort in reviewing our manuscript. We greatly appreciate your encouraging feedback and insightful critique of our work and have addressed all the points raised, as detailed below.

The page numbers, text lines, and paragraphs given in our response correspond to the revised manuscript with marked-up corrections (additions in the text and in the tables are marked in red font). Here, in our responses, all additions in the text are marked in italics.

2. Response to Comments and Suggestions for Authors

Comments 1:

To enhance clarity and support theoretical understanding, it is recommended that this entry include visual representations (Conceptual diagrams or framework models) of the medical and social models as they relate to prematurity and parental inclusion in the NICU 

Response 1:

Thank you for pointing this out. Therefore, we have included a figure that illustrates inclusive practices, though medically applied, are fundamentally rooted in social principles.

Lines (between) 324 to 326:

Figure 1: Characteristics of the social and the medical models of prematurity. Their intersection highlights the practices and approaches shared by both models.

Comments 2:

The manuscript primarily reflects findings and practices from high-income, Western healthcare contexts. The applicability of parental inclusion strategies in NICUs across diverse cultural and socioeconomic settings is not addressed.

Response 2:

We thank the reviewer for this important recommendation we acknowledged the Western/high-income context bias and added paragraphs in all main sections of the manuscript discussing barriers in low- and middle-income countries.

Consequently, we modified all sections as follows:

(Social Impact of Prematurity)

Lines 139 to 147: In contrast with high – income countries (HICs), in lower – and middle -income countries (LMICs), which account for over 60% of preterm births, inadequate medical infrastructure significantly impacts survival and health of preterm infants [37]. Poor access to antenatal care, delayed identification of complications, inadequate medical support, lack of skilled birth attendants, and insufficient resources for managing preterm babies, highlights the profound inequities in access to adequate care [37,38]. By addressing the challenges associated with prematurity, parental inclusion in the NICU might be equally important as NICU practices, and even more, as it fosters a strong dyadic relationship between the parent and child.

(Parental Inclusion in the NICU)

Lines 202 to 211: Another key focus on parental inclusion practices, is that research originates mainly from high-income, Western contexts. There is limited research in LMICs, where inadequate staffing, limited space, cultural beliefs and lack of parental leave can hinder inclusive practices [34,37]. Moreover, even within Western systems, socioeconomic status, educational level, minority ethnic groups and cultural expectations can shape how parents are perceived and included in NICU care [35,37]. Addressing these inequities is critical to ensure that inclusive care is not a privilege for a few but accessible to all, considering diversity and adapting practices accordingly [37]. These inequities and the challenges faced by preterm infants and their families, highlight the limitations of purely medical approaches and the need to move beyond medical explanations.

(Social and Medical Model of Disability)

Lines 239 to 247: Medical and social models though they are the predominant models for defining disability worldwide, have limitations [58]. Both were conceptualized in high-income Western nations. Shaped by robust welfare systems, democratic institutions, strong disability rights movements and disability activism [58] often disregarding the realities of low- and middle-income nations [61,62].

Comment 3: The focus is predominantly on mothers, with limited attention to fathers, or other primary caregivers.

Response 3:

We thank the reviewer for this valuable comment. We expanded the discussion to include the role of fathers and non-birthing caregivers, supported by recent literature.

(Parental Inclusion in the NICU)

Lines 185 to 201: Parents are encouraged to be present in many NICUs, but their physical presence does not always mean participation. Parental participation levels and inclusion practices may vary significantly depending on unit culture, staff attitudes and institutional policies [48]. It seems that there is not enough emphasis on parental needs for guidance and psychological support to foster a balanced parenting style. Stegmann-Woessner, G., et.al., (2025), cite from an adult born preterm: “Well, there is a guide for dog training and there is no guide for premature baby training” [24]. Research on parental inclusion in NICUs mainly focusing on the mother’s experiences and needs. Although, over the last decade fathers’ experiences have received more attention, fathers and non-birthing caregivers are often overlooked or underrepresented in both research and practice [49,50,51]. Even in NICUs that routinely invite parents to medical rounds - and report higher rates of fathers' presence - attendance does not necessarily mean participation [52]. While policies like paternity leave and social benefits are important, they alone are not sufficient to ensure fathers' engagement in neonatal care. Fathers often feel excluded and not fully responsible for their infant care. They often tend to prioritize mother's needs over their own, potentially ignoring their own emotional well-being. [53]. ​A supportive care culture within the unit plays a crucial role in encouraging fathers' participation [52].

Comment 4: The entry tends to generalize parental emotional responses and experiences, without distinguishing variations due to individual, cultural, or contextual factors, which can lead to oversimplification.

Response 4:

We appreciate this observation and acknowledge that parental emotional responses and experiences are diverse and influenced by individual, cultural, and contextual factors. In revising the entry, we have emphasized that dominant frameworks, including the medical model, are not neutral but culturally specific, rooted in Western societal norms and hierarchies. By recognizing the cultural underpinnings of these frameworks, we aim to avoid oversimplification and provide a more nuanced, intercultural, and strengths-based perspective on parental experiences. We did not elaborate with examples or extensive references, as this is not the primary focus of the entry. However, as you pointed out, it was important to highlight it.

(Parental Inclusion in the NICU)

Lines 203 to 207: There is limited research in LMICs, where inadequate staffing, limited space, cultural beliefs and lack of parental leave can hinder inclusive practices [34,37]. Moreover, even within Western systems, socioeconomic status, educational level, minority ethnic groups and cultural expectations can shape how parents are perceived and included in NICU care [35,37].

(Social and Medical Model of Disability)

Lines 239 to 247: Medical and social models though they are the predominant models for defining disability worldwide, have limitations [58]. Both were conceptualized in high-income Western nations. Shaped by robust welfare systems, democratic institutions, strong disability rights movements and disability activism [58] often disregarding the realities of low- and middle-income nations [61,62]. In these contexts, inadequate healthcare infrastructure, limited accessibility, and high mortality rates make both models insufficient. Violation of human rights, poverty and political instability positioning access and survival as more urgent than accessibility and inclusion [62]. Additionally, the status of research in disability is still limited and faces significant challenges [61].

Lines 248 to 252: Moreover, Shakespeare critiques the rigid dichotomy between medical and social models of disability (e.g., impairment vs. disability, medical vs. social models). He argues that such binary oppositions oversimplify the realities of disabled people’s lives and disability identity. He advocates for a relational approach that recognizes both embodied experiences [58, 63].

Lines 256 to 262: Therefore, disability, cannot be fully explained by political exclusion alone; it arises from the dynamic interplay between individual impairments and social environments [59]. This critique, combined with persistent inequalities and systemic barriers, even in countries where these models have been established, underscores the necessity of a context-sensitive, intersectional framework. Such a framework would integrate structural, cultural, and embodied dimensions, to foster a more globally inclusive disability discourse [63].

(Social and Medical Model of Prematurity)

Lines 295 to 298: Braveman and colleagues research findings showed that African-born immigrant women had lower PTB rates than U.S. - born Black women. The authors suggested that these most favorable outcomes, may reflect African-born women’s comparatively less exposure to racism during sensitive life periods [70].

1. Summary

We sincerely thank you for your time and effort in reviewing our manuscript. We greatly appreciate your encouraging feedback and insightful critique of our work and have addressed all the points raised, as detailed below.

The page numbers, text lines, and paragraphs given in our response correspond to the revised manuscript with marked-up corrections (additions in the text and in the tables are marked in red font). Here, in our responses, all additions in the text are marked in italics.

Comments 1:

The subject is relevant and timely, and the inclusion of interdisciplinary perspectives and historical context adds useful background. However, the discussion remains broad and introductory, lacking the depth and analytical rigor expected at a more advanced level. Rather than offering a critical perspective or engaging deeply with the literature, the entry primarily summarizes existing ideas. As such, it functions more as a starting point for further exploration than a fully developed analysis. A more critical analysis of the topic could be added [….] There are frequent repetitions of the same concepts throughout the text, which could likely be consolidated.

Response 1:

We thank the reviewer for this valuable comment. Though this manuscript serves as an initial entry, we appreciate this observation and have revised several sections – particularly the Parental Inclusion section and both Social and Medical Models parts - to include a more critical perspective. In the process we also merged and identified potential overlaps in concept to make text more cohesive. These additions and revisions aim to strengthen the theoretical and analytical depth of the entry:

A)    The limitations of the medical model in addressing broader social determinants.

(Social and Medical Model of Disability)

Lines 239 to 252: Medical and social models though they are the predominant models for defining disability worldwide, have limitations [58]. Both were conceptualized in high-income Western nations. Shaped by robust welfare systems, democratic institutions, strong disability rights movements and disability activism [58] often disregarding the realities of low- and middle-income nations [61,62]. In these contexts, inadequate healthcare infrastructure, limited accessibility, and high mortality rates make both models insufficient. Violation of human rights, poverty and political instability positioning access and survival as more urgent than accessibility and inclusion [62]. Additionally, the status of research in disability is still limited and faces significant challenges [61]. Moreover, Shakespeare critiques the rigid dichotomy between medical and social models of disability (e.g., impairment vs. disability, medical vs. social models). He argues that such binary oppositions oversimplify the realities of disabled people’s lives and disability identity. He advocates for a relational approach that recognizes both embodied experiences [58, 63].

Lines 256 to 262: Therefore, disability, cannot be fully explained by political exclusion alone; it arises from the dynamic interplay between individual impairments and social environments [59]. This critique, combined with persistent inequalities and systemic barriers, even in countries where these models have been established, underscores the necessity of a context-sensitive, intersectional framework. Such a framework would integrate structural, cultural, and embodied dimensions, to foster a more globally inclusive disability discourse [63].

(Social and Medical Model of Prematurity)

Lines 305 to 311: Presenting prematurity within the medical and social model of disability, we may highlight aspects of care and support that transcend the simple medical – social dichotomy. Medical support for prematurity cannot be understood as separate from the social context but deeply embedded within it. Brazelton’s approach offers a critical insight in this regard as he emphasized both the individuality and inherently social nature of newborns, demonstrating their need for interaction and relational closeness from the very beginning of life [10,73].

Lines 312 to 324: Parental inclusive practices [27,28,47,48], as kangaroo care and skin-to-skin contact, have been shown to be effective not only in improving biological outcomes – such as weight gain and stabilization of physiological parameters – but also fostering social interaction and emotional closeness between the neonate and the caregiver. In Kangaroo care, placing the infant directly on the caregiver’s body, is created physical contact which is deeply social. What is often interpreted solely as a biological o physiological functioning is also profoundly interpersonal (Figure 1). Is not only the physical contact that promote growth and physiological stability but also the social intimacy. That demonstrates that biological development is, at its core, socially mediated. The implementation of these practices within the NICUs further underscore that medical care for prematurity is not neutral or external to society; it is inherently a social issue. This means that the social dimension of medicine is not an “ad-on”. On the contrary this may mean that medical treatment itself is intrinsically connected to the social model.

Lines 330 to 339: Drawing from the social model, we finally argue that prematurity is also social constructed, much like the socially constructed disability. Based on the narratives of adults born preterm [74], prematurity may can be understood as a distinct form of identity that persists across the life course, shaping experiences, and social relationships. However, this identity is not neutral; it is produced and mediated through intersections with other social identities – such as race – which influence both the risk of preterm birth and the ways in which neonatal care is accessed and experienced. Also, the very fact of increased PTB rates among racial minority groups illustrates that prematurity is also social produced. The notion of an identity of prematurity highlights that prematurity is shaped not only by biological factors, but also by social recognition and access to care.

We have also included a diagram to support these between lines 324 and 326.

Figure 1: Characteristics of the social and the medical models of prematurity. Their intersection highlights the

practices and approaches shared by both models.

B)     The systemic and institutional inequalities that influence preterm birth outcomes and care practices.

(Parental Inclusion in the NICU)

Lines 202 to 211: Another key focus on parental inclusion practices, is that research originates mainly from high-income, Western contexts. There is limited research in LMICs, where inadequate staffing, limited space, cultural beliefs and lack of parental leave can hinder inclusive practices [34,37]. Moreover, even within Western systems, socioeconomic status, educational level, minority ethnic groups and cultural expectations can shape how parents are perceived and included in NICU care [35,37]. Addressing these inequities is critical to ensure that inclusive care is not a privilege for a few but accessible to all, considering diversity and adapting practices accordingly [37]. These inequities and the challenges faced by preterm infants and their families, highlight the limitations of purely medical approaches and the need to move beyond medical explanations.

(Social and Medical Model of Disability)

Lines 292 to 298: Notably, these disparities persist even among higher-income Black women. These findings suggest that systemic unmeasured experiences of racism, including racism-related stress and adverse environmental exposures, contribute to the risk of premature birth [69]. Braveman and colleagues research findings showed that African-born immigrant women had lower PTB rates than U.S. - born Black women. The authors suggested that these most favorable outcomes, may reflect African-born women’s comparatively less exposure to racism during sensitive life periods [70].

C)    The barriers to implementing the social model across different sociocultural and economic settings.

(Parental Inclusion in the NICU)

Lines: 186 to 191: Parental participation levels and inclusion practices may vary significantly depending on unit culture, staff attitudes and institutional policies [48]. It seems that there is not enough emphasis on parental needs for guidance and psychological support to foster a balanced parenting style. Stegmann-Woessner, G., et.al., (2025), cite from an adult born preterm: “Well, there is a guide for dog training and there is no guide for premature baby training” [24].

(Social and Medical Model of Prematurity)

Lines 281 to 287: Research findings in late preterm babies, demonstrate that it is likely social factors to have stronger influences on developmental outcomes than gestational age [65]. This becomes particularly significant when considering that adults born preterm mention that their greatest challenges are related more to psychological and social difficulties, rather than physical health. They report “feeling of otherness”, due to trauma they associate with premature birth and emotional hyperexcitability, which often lead them to social withdrawal [66].

Comments 2: Since NICU has already been defined in the text, there’s no need to explain the abbreviation again.

Response 2:

Thank you for pointing this out! We have removed the redundant definitions and now introduce the abbreviation only once, early in the text.

Line 53 to 54: NICUs, though a life-saving context, often presents sensory and emotional stressors [6–8]

Line 106 to 108: NICUs provide specialized medical care, including respiratory support, nutrition management, and developmental care, tailored to the unique needs of preterm babies and essential for optimizing their growth and health outcomes [17,26]. And

Line 118 to 120: The social impact of prematurity extends beyond the NICU, influencing family dynamics, parental mental health, socioeconomic stability, healthcare systems, and long-term developmental outcomes for children [29–32].

4. Response to Comments on the Quality of English Language

Point 1: There are also several issues with English sentence structure that need attention. Some passages are unclear or overly complex, which affects readability [….] Simplifying sentence construction and improving clarity would greatly enhance the quality of the writing.

Response 1: Thank you for highlighting some lack of clarity in our manuscript, due to big sentences. We have, accordingly, conducted a full language edit and updated text throughout the manuscript. We simplified sentences for clarity, passive constructions were revised, and ambiguous or overly complex structures were rewritten.

Concerning your example:

“From the very beginning, infants are active and seek to form meaningful relationships with caregivers in their environment” and “including staff and parents as primary and most funda- mental agents of their socialization."

We revised to the next paragraph.

(Parental Inclusion in the NICU)

Lines 149 to 157: From the very beginning, infants are active and seek to form meaningful relationships with caregivers in their environment [39]. Their development is shaped by continuous, dynamic and reciprocal interactions with them in a bidirectional process [44]. Infants can thus be understood as “active and sophisticated partners” within the parent - infant complex social relationship [43].  Long-term follow-up studies further demonstrate that in a child's efforts to cope with a potential impairment, it is equally important for the child’s environment – especially caregivers - to facilitate this compensatory learning process [40-42]. This insight is particularly relevant in the NICU environment, where parents and staff, are the primary and most fundamental agents of their socialization [40,41].