Arch Womens Ment Health (2015) 18:187–195 DOI 10.1007/s00737-014-0445-4

ORIGINAL ARTICLE

Postpartum bonding: the role of perinatal depression, anxiety and maternal–fetal bonding during pregnancy S. Dubber & C. Reck & M. Müller & S. Gawlik

Received: 13 February 2014 / Accepted: 20 July 2014 / Published online: 5 August 2014 # Springer-Verlag Wien 2014

Abstract Adverse effects of perinatal depression on the mother–child interaction are well documented; however, the influence of maternal–fetal bonding during pregnancy on postpartum bonding has not been clearly identified. The subject of this study was to investigate prospectively the influence of maternal–fetal bonding and perinatal symptoms of anxiety and depression on postpartum mother–infant bonding. Data from 80 women were analyzed for associations of symptoms of depression and anxiety as well as maternal bonding during pregnancy to maternal bonding in the postpartum period using the Edinburgh Postnatal Depression Scale (EPDS), the State– Trait Anxiety Inventory (STAI), the Pregnancy Related Anxiety Questionnaire (PRAQ-R), the Maternal–Fetal Attachment Scale (MFAS) and the Postpartum Bonding Questionnaire (PBQ-16). Maternal education, MFAS, PRAQ-R, EPDS and STAI-T significantly correlated with the PBQ-16. In the final regression model, MFAS and EPDS postpartum remained significant predictors of postpartum bonding and explained 20.8 % of the variance. The results support the hypothesized negative relationship between maternal–fetal bonding and postpartum maternal bonding impairment as well as the role of postpartum depressive symptoms. Early identification of bonding impairment during pregnancy and postpartum depression in mothers plays an important role

S. Dubber (*) Center for Psychosocial Medicine, Heidelberg University Hospital, Vossstr. 2, 69115 Heidelberg, Germany e-mail: [email protected] C. Reck : M. Müller Department of Psychology, Ludwig-Maximilians-Universität München, Leopoldstr. 13, 80802 Munich, Germany S. Gawlik Department of Obstetrics and Gynecology, Heidelberg University Hospital, INF 440, 69120 Heidelberg, Germany

for the prevention of potential bonding impairment in the early postpartum period. Keywords Postpartum depression . Anxiety . Pregnancy . Maternal–fetal attachment . Postpartum bonding

Introduction Anxiety and depression in women during pregnancy and the postpartum period have been matters of great scientific interest (Bennett et al. 2004; Figueiredo and Costa 2009; Matthey et al. 2003; Tronick and Reck 2009). Pregnancy and puerperium are times of particular vulnerability, therefore many women exhibit symptoms of emotional distress during this period. While maternal prenatal and postnatal depression and its effects on both the mother’s health and her child’s development is a well-recognized health issue (Grigoriadis et al. 2013), there are limited studies on the prospective value of anxiety and depressive symptoms and their link to the emotional involvement with the fetus during pregnancy (Figueiredo and Costa 2009). According to a systematic literature review, antenatal depression affects approximately 12 % of women with the highest prevalence in the second and third trimesters of pregnancy (Bennett et al. 2004). There is an overwhelming amount of data suggesting an association between untreated depression or anxiety during pregnancy and unfavorable outcomes for both mother and fetus such as lower birth weight, preterm birth as well as behavioral problems of the child postpartum (Bonari et al. 2004; Grigoriadis et al. 2013; Grote et al. 2010; Marcus 2009). Postpartum Depression, according to DSM-IV criteria, is reported to be prevalent in 6.1 % of women in Germany (Reck et al. 2008) and can negatively influence mother–child interactions (Moehler et al. 2007; Reck et al. 2004).

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Regarding anxiety, empirical studies have reported a high prevalence of anxiety symptoms in more than 25 % of pregnant women (Britton 2011; Ross and McLean 2006). Anxiety levels seemed to be higher during pregnancy when compared to the postpartum period (Andersson et al. 2006; Buist et al. 2003; Figueiredo and Costa 2009). Reck et al. (2008) reported a prevalence rate of 11.1 % for postpartum anxiety disorders which is higher than the rate of 6.1 % found for postpartum depressive disorders. Maternal bonding1 was described by Cranley (1981) as a qualitative change in the relationship of a mother to her infant, which already emerges during pregnancy. This change takes place due to the physically developing fetus and psychological adjustments accompanying the upcoming mothership. Cranley (1981) defined maternal–fetal bonding as “the extent to which women engage in behaviors that represent an affiliation and interaction with their unborn child,” and developed the Maternal–Fetal Attachment Scale (MFAS) to measure the construct. Brockington (2004) argues that the development of the relationship between a caregiver and an infant is the most significant process after birth. Biologically, maternal bonding has the function of securing the nurturing and protection, and thus, the survival of the child (Carter and Keverne 2002). The development of maternal–fetal bonding is crucial because it can positively influence maternal health practices during pregnancy and thus, neonatal outcome (Alhusen et al. 2012). Furthermore, women with higher maternal–fetal bonding are reported to show more secure postpartum attachment styles and their children showed better early development compared to women with lower maternal–fetal bonding and less secure attachment styles (Alhusen et al. 2013). Moreover, for the child, the attachment bonds developed in early childhood may constitute the foundation of the individual attachment style well into adulthood (Waters et al. 2003). Considering mental health during pregnancy Alhusen (2008) reports in her review that both depression and anxiety, as well as substance abuse during pregnancy have a negative association with maternal–fetal bonding. In the postpartum, Reck et al. (2004) states in an overview that it is well known that affective disorders like depression can negatively influence mother–infant interactions. Depressed mothers are often described as being passive, withdrawn, unresponsive or intrusive (Field 1998; Field 2010). They also express more negative feelings towards their children than non-depressed mothers (Reck et al. 2004). Current literature suggests that children of mothers with mental disorders are at risk of later As “attachment” and “bonding” are often used synonymously we find it necessary to distinguish these terms. In this study, the term bonding refers to the feelings the mother has towards her fetus/infant, whereas the term attachment stands for the relationship a child has developed to its mother.

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psychopathology and poor functioning in a range of developmental domains (Goodman and Gotlib 1999; Moehler et al. 2007; Wan and Green 2009). Moreover, the meta-analysis conducted by Atkinson et al. (2000) showed a significant impact of maternal depression on later child attachment security. The adverse effects of anxiety on the mother’s emotional involvement with the infant are not as obvious in the literature as the impact of depression (Figueiredo and Costa 2009). Britton (2011) also documented in a non-clinical sample of 296 women 1 month after delivery that ratings of overall temperamental difficulty were independently associated with symptoms of anxiety and depression in the early postpartum period. Feldman et al. (1997) stated that increased anxiety preand postnatally seem to interfere with the mother’s ability to bond and interact sensitively with the child. However, little is known about the effects of anxiety and depression on the mother's emotional involvement with the fetus during pregnancy and its predictive value for postpartum bonding. The bond of a mother to her fetus developing during pregnancy is assumed to be an important precursor of postpartum bonding. In her work, Raphael-Leff describes that even before birth, parents begin to ascribe characteristics to their baby, partly based on discernible fetal rhythms and responses, partly based on their own fantasies and imaginations (Raphael-Leff 2001). Early identifications or unresolved conflicts with the women's own parents may surface at this time of transition from being the child of her mother to being the mother of her own child. As a result, a damaging internal image may hereby color the experience of the growing fetus as it may influence early parenthood. Raphael-Leff (2001) states that although the sex and the personality of each baby inevitably influences caregiving, antenatal conceptualization of the baby generally primes the parent's orientation. Only few quantitative studies so far have investigated this presumption. The study by Müller (1996) reported a moderate positive correlation between prenatal, assessed with the Prenatal Attachment Inventory (PAI; Müller 1993) and postnatal bonding, assessed with the Maternal Attachment Inventory (MAI; Müller 1994) in a US sample consisting of 128 women recruited from childbirth education classes. Van Bussel et al. (2010) drew the same conclusion by finding a comparable correlation in a Dutch sample with 263 participating women from a routine clinic sample who completed three different quantitative measures for mother-to-infant bonding. Van Bussel et al. (2010) used the Maternal Antenatal Attachment Scale (MAAS; Condon 1993) to measure prenatal maternal bonding; to assess postpartum maternal bonding the Maternal Postpartum Attachment Scale (MPAS) by Condon and Corkindale (1998), the Postpartum Bonding Questionnaire (PBQ; Brockington et al. 2001) and the Motherto-Infant Bonding Scale (MIBS; Taylor et al. 2005) were administered. Furthermore, Siddiqui and Hägglöf (2000) investigated

Postpartum bonding

in a sample of 100 randomly recruited women whether maternal prenatal attachment assessed with the PAI was associated with the mother–infant relationship postpartum. They revealed that maternal prenatal bonding towards the fetus functions as a strong predictor of early mother–infant relationship. However, this study did not consider potential confounders as maternal stress and anxiety pre- and postnatally. Therefore, in the current study we aimed at identifying the influence of maternal pre- and postnatal symptoms of depression and anxiety and maternal–fetal bonding during pregnancy on postpartum bonding. We hypothesized that maternal– fetal bonding during pregnancy predicts postpartum mother– infant bonding. Furthermore, we included an investigation on the influence of maternal symptoms of depression and anxiety on the postpartum mother–infant relationship.

Methods Study design and procedure Originally, 433 pregnant women were recruited at the Heidelberg University Women’s Hospital as part of the Heidelberg Peripartum Study between January 2007 and January 2010. The study is a within-group longitudinal design using a questionnaire survey at two time points. After giving their informed consent, the participants received a prenatal questionnaire set during late pregnancy (M=32 weeks of gestation) with the request to fill them out at home and return them. The questionnaires collected socio-demographic data as well as self-reported information about maternal–fetal bonding, symptoms of depression and anxiety. Three months postpartum (M=12 weeks), a second set of questionnaires was sent to the participants’ homes. The set of questionnaires collected the same information as the prenatal set just the questionnaire regarding maternal–fetal bonding was replaced by one regarding maternal postpartum bonding. For the current assessment, women younger than 18 years, bearing multiplets, with serious medical conditions as well as the ones speaking inadequate German were excluded from the study. Out of the final cohort sample of 334, two overlapping random subsamples were recruited for assessment of maternal–fetal bonding and assessment of postpartum bonding impairment due to economic reasons (see Fig. 1). In order to exclude effects of drop-outs, missing values and random subsampling on the study results, Little’s MCAR test (missing-completely-at-random-condition) was run with the final study sample (N=334) and all relevant variables. This test ensures the representativeness of subsamples for the final study sample. The Health Service’s Ethics Committee approved all components of the project.

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Sample Due to limited overlapping of the random subsamples for assessment of maternal–fetal and postpartum bonding (N= 30), Little’s MCAR test was run on the total data set (N=334) to ensure the representativeness of subsamples for the whole study sample and thereby to exclude effects of drop-outs and missing values. This test was revealed non-significant (p= 0.051) meaning that the MCAR condition is fulfilled. Regarding the fact that the critical p value is just missed, we considered confounders for our analyses (as described below) to increase the MAR plausibility (missing at random) in order to obtain consistent estimations of our subsamples. The final sample (N=80) was composed of participants having no missing values regarding the primary outcome (postpartum bonding). Women were aged between 24 and 44 years (M=32.8, SD=4.4) and by median were pregnant for the second time. Overall, 80.4 % of the participants were married, 16.1 % in a relationship and 3.5 % divorced. Almost half of the participants (47.0 %) held a university degree, 15.2 % had a university entrance qualification, 34.8 % of the women left school with a high secondary qualification and only 3.0 % had a low secondary qualification. Infants were born between the 38th and 42nd weeks of gestation (M=39.7, SD=1.2). 52.6 % of the women had an induction of labour and 59.7 % received an epidural during delivery. Birth duration was M=6.0 h (SD=5.8) on average. Half of the mothers (50.6 %) delivered spontaneously, while 17.7 % had a primary (planned) caesarean section. 24.1 % of the infants were born by secondary (unplanned) caesarean section and 7.6 % by vacuum extraction. About half (51.9 %) of the infants were female. The average birth weight was M=3,332.2 g (SD= 432.1). 84.8 % of the infants were breast fed postpartum. Descriptive statistics of study variables are demonstrated in Tables 1 and 2. Instruments Edinburgh Postnatal Depression Scale (EPDS) To assess the participants’ severity of depression, both pre- and postnatally, the German version of the Edinburgh Postpartum Depression Scale (Cox et al. 1987) by Bergant et al. (1998) was chosen. It is a ten-item self-rating scale, scored from 0 to 3, that has been validated for the detection of prenatal and postnatal depression in numerous studies (Matthey et al. 2006). A higher sum score indicates greater depression. Originally developed as a screening instrument for the postnatal period, the EPDS is a feasible questionnaire during pregnancy (Cox et al. 1996). The scale is sensitive to changes in severity of depression with a sensitivity and specificity of 91 %, respective 95 % in detecting depressive disorders in mothers (Matthey et al. 2001). In our German sample, data reveal a Cronbach’s α of 0.832

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Fig. 1 Flowchart depicting sample recruitment, screening and procedures

Enrollment

Assessed for eligibility (N = 433)

Excluded (n = 99):

Representative sample

Random PBQ-16 sample

< 37 weeks of gestation (n = 26) Fetal congenital abnormalities (n = 61) Multiple gestations (n = 12)

Final cohort sample (N = 334)

Random subsample Maternal-fetal bonding MFAS (n = 82)

Little’s MCAR-test (missingcompletely-at-random-condition) MAR-plausibility (missing at random)

Subjects with complete MFAS and PBQ-16 data (n = 30)

(prepartum) and 0.825 (postpartum). Matthey et al. (2006) recommend a cut-off of 15 or more for assessment in the prepartum and of 13 or more in the postpartum. State–Trait Anxiety Inventory Anxiety was assessed with the German version of the State– Trait Anxiety Inventory (STAI; Spielberger et al. 1970; Laux Table 1 Descriptive statistics of study variables

MFAS EPDS pre STAI-S pre STAI-T pre PRAQ-R EPDS post STAI-S post STAI-T post

Random subsample Postpartum Bonding PBQ-16 (n = 80)

N

Minimum

Maximum

Mean

SE

SD

30 54 54 55 55 77 79 77

68.00 0.00 20.00 21.00 11.00 0.00 22.00 20.00

147.00 19.00 59.00 54.00 40.00 21.00 67.00 58.00

117.72 5.15 35.57 33.93 20.60 4.36 32.72 31.90

3.76 0.59 1.23 1.12 0.87 0.44 0.88 0.88

20.60 4.37 9.07 8.30 6.44 3.86 7.80 7.74

et al. 1970). The state scale (STAI-S) evaluates feelings of apprehension, tension, nervousness and worry as anxiety of a temporary condition while the STAI trait scale (STAI-T) refers to anxiety as a personality feature. Both subscales comprise 20 items. Participants rated on a 4-point scale from 1 (almost never/not at all) to 4 (almost always/very much). Both scales are analyzed separately, and each sum score ranges between 20 and 80 points, with a higher score indicating greater anxiety. The subscales were administered during pregnancy and after giving birth. We found the STAI suitable for our study as the instrument does not contain any somatic symptoms, minimizing possible bias due to pregnancy-related symptoms. Grant et al. (2008) validated the STAI to DSM-IV criteria for the prenatal period. Several studies have demonstrated that the STAI has adequate concurrent validity and internal consistency (r=0.83). In our German sample data have an internal consistency of α=0.903 (state) and α=0.895 (trait) in the prepartum and α=0.917 (state) and α=0.900 (trait) in the postpartum. Grant et al. (2008) argues and uses a cut-off score of 40 or more.

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Table 2 Frequencies and percentages of participants below and above cut-off values Scale

Cut-off

f

%

Valid %

Cumulative %

EPDS prea

Postpartum bonding: the role of perinatal depression, anxiety and maternal-fetal bonding during pregnancy.

Adverse effects of perinatal depression on the mother-child interaction are well documented; however, the influence of maternal-fetal bonding during p...
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