Bonding Problems Emerge Early and Persist Across the First Year of Life

By | December 16, 2019

A mother’s emotional relationship with her baby begins during her pregnancy.  After her baby is born, the mother’s feelings about her baby, described as bonding, typically grow and intensify and become the foundation of the mother’s relationship with her child.

Postpartum depression can profoundly affect how a mother interacts with her child and is a risk factor for impaired mother-infant bonding, which may include a spectrum of difficulties, including decreased maternal affective involvement, decreased attentiveness to the baby’s cues, irritability, and intrusiveness.  It is important to note, however, that not all women with postpartum depression experience impaired bonding. Furthermore, certain interventions may be helpful in mitigating the effects of maternal depression on bonding.   

A recent study evaluated the association between mother-child bonding and maternal depression in a group of mothers at high risk of postpartum depression.  This prospective cohort study was carried out in São Paulo , Brazil with 346 low-income postpartum women.  These women were considered to be at high risk for postpartum depression because they had already reported depressive symptoms during pregnancy.

The Postpartum Bonding Questionnaire (PBQ)  was used to measure the quality of mother-infant bonding, and the Patient Health Questionnaire-9 (PHQ-9) was used to assess for depression at 6-8 months and again at 12-15?months after delivery.

Bonding impairment (BI) was observed at 12-15?months in 9.9% of the mothers.  BI at this time point was associated with having an occupation outside of the home (OR?=?2.82; 95% CI 1.00-7.94, p?=?.049), unplanned pregnancy (OR?=?3.46; 95% CI 1.01-11.8, p?=?.047), and presence of BI at 6-8?months (OR= 13.0; 95% CI 3.76-45.4, p?????.001).   Maternal depression was only marginally associated with BI at 12-15?months. 

These findings are similar to an earlier study which examined the association between postpartum depression and mother–infant bonding over the first year of the child’s life. Bonding was assessed using the Mother–Infant Bonding Scale (MIBQ) at four time points: 1–4 weeks, 9 weeks, 16 weeks and 1 year.  In this study, there was a strong association between scores on the MIBQ during the early weeks after birth and bonding scores at all other time points. While there was also an association between EPDS scores at 4 weeks postpartum and the bonding scores at 1 year; the quality of early bonding, rather than early depression, was the strongest predictor of bonding at 1 year.

How Can We Intervene?

These studies raise some interesting and clinically relevant questions.

In women with postpartum depression, will simply treating the depression prevent the negative effects of maternal depression on the child?  Especially in depressed women with poor bonding during the early weeks, will the bonding difficulties persist after the depression is treated?

How exactly are depression and bonding problems related?  Does postpartum depression cause or contribute to bonding difficulties?  Or is it the other way around? Does poor bonding precipitate or exacerbate depressive symptoms? In a review by Poobalan Aucott and colleagues, the authors noted that interventions involving both the mother and her child improved the mother’s feelings about her child, whereas treatments involving only the mother were found to be effective for depression but did not have a significant effect on the mother’s feelings towards her child.

In addition to psychotherapy and pharmacologic treatment, should we also consider interventions that enhance bonding?  In a randomized control trial of 117 depressed mothers, Horowitz and colleagues demonstrated that 8 weeks of interaction coaching significantly improved mother–infant interactions.

There is also the very interesting work coming out of Tiffany Field’s group.  Interaction coaching has been developed to help mothers improve their interactions with their babies by providing video feedback and giving them second-by-second suggestions as interactions occur (see Field 2006). These interventions have been shown to be effective in reducing depressive symptoms in the mother and improving the quality of interactions between the mother and her infant. Field has also demonstrated that teaching depressed mothers to massage their infants has resulted in less irritability and fewer sleep problems in the infants and better mother-infant interactions, as well as a reduction in the mothers’ depressive symptoms (Goldstein-Ferber, 2004).

Based on these findings, we might also consider a more thorough assessment of the quality of bonding as this might be a more important predictor of bonding and attachment issues later on in the child’s life.  Because bonding is so important for fostering secure attachment and the formation of subsequent meaningful relationships, we need to be attentive to these early problems with maternal-infant bonding, whether or not they occur within the context of maternal depression.

Ruta Nonacs, MD PhD

Faisal-Cury A, Bertazzi Levy R, Kontos A, Tabb K, Matijasevich A.    Postpartum bonding at the beginning of the second year of child’s life: the role of postpartum depression and early bonding impairment.  J Psychosom Obstet Gynaecol. 2019 Aug 22:1-7. 

MGH Center for Women's Mental Health