Mother-Child Bonding at 1 Year Associations With Symptoms of Postnatal Depression and Bonding in The First Few Weeks
Mother-Child Bonding at 1 Year Associations With Symptoms of Postnatal Depression and Bonding in The First Few Weeks
Mother-Child Bonding at 1 Year Associations With Symptoms of Postnatal Depression and Bonding in The First Few Weeks
DOI 10.1007/s00737-013-0354-y
ORIGINAL ARTICLE
Received: 19 October 2012 / Accepted: 6 April 2013 / Published online: 21 April 2013
# Springer-Verlag Wien 2013
M. OHiggins
Krembil Neuroscience Centre, Toronto Western
Hospital, 399 Bathurst Street,
Toronto, ON, Canada M5T 2S8
I. S. J. Roberts
Thomas Coram Research Unit Institute of Education,
University of London, 27/28 Woburn Square,
London WC1H 0AA, UK
V. Glover : A. Taylor
Institute of Reproductive and Developmental Biology,
Faculty of Medicine, Imperial College,
Hammersmith Campus, Du Cane Road,
London W12 0NN, UK
A. Taylor (*)
School of Biomedical Sciences, Kings College,
London, Stamford Street,
London SE1 9NH, UK
e-mail: alyx.taylor@kcl.ac.uk
Introduction
A mothers thoughts about her baby stimulate affection
and protective feelings, which facilitate the beginning of
the motherinfant relationship (Ainsworth and Bell 1974).
These feelings (Kumar 1997) usually begin during the
pregnancy. The mothers feelings about her baby, described as bonding, normally continue and increase when
the baby is born, and underpin the development of her
relationship with her child. Robson and Kumar (1980)
showed that up to 40 % primiparae and 25 % of
multiparae mothers were indifferent to their babies on first
holding them, although most developed affection within
the first week.
The mothers feelings toward her unborn infant have also
been described as maternal attachment (Cranley 1981) or
prenatal attachment (Muller 1993). Attachment was first
used to describe a two-way relationship in which both
parties are active (Bowlby 1969). Cranleys MaternalFetal
Attachment Scale includes a subscale called Interaction in
which the mother can record physical actions by the unborn
child that she perceives to be the response to her own
actions. In contrast, motherinfant bonding describes the
382
M. OHiggins et al.
Methods
Participants and procedure
This work was designed as a prospective cohort study.
Hammersmith Hospital NHS Ethics Committee granted
ethics approval. Women were recruited on the postnatal
ward of Queen Charlottes and Chelsea Hospital, London
(Fig. 1). Participants were given verbal and written
descriptions of the study and written consent was obtained.
Only those mothers with healthy, full term (over 36 weeks)
babies were approached. Women were also excluded from
the study if they had a recorded history of a psychotic
disorder, were under 17 years of age, did not speak sufficient English or were receiving support from social workers
for housing or social problems. Those who were willing to
take part were screened for depressive symptoms at 4 weeks
postnatal, sent to them by post. Of the 2048 women who
returned their questionnaires, 285 women (13.9 %) met
screening criteria for high risk of depression (EPDS
13). They were invited to take part in the study group,
and 89 women agreed to participate, of whom 50 completed the study. This group is presented here as the
depressed group. Of the women whose screening scores
indicated they were not depressed, 1,376 (67.2 %) scored
EPDS 8, 95 were selected at random and invited to take
part in the study. This group is described as the nondepressed group. Forty five of these women agreed to
participate and 29 completed the study. Women who
scored from 9 to 12 on the EPDS at screening were
not invited to take part in the study, to clearly delineate
the depressed and non-depressed. All the women were
asked to complete the depressive symptoms questionnaire
and motherinfant bonding questionnaire at 9 weeks,
16 weeks and 1 year postnatal. At 9 weeks postnatal,
the women were given two versions of the bonding
questionnaire, the first asked the women to describe her
feelings in the early weeks (14 weeks postnatal) and
the second asked for her current feelings.
As part of a larger study, the depressed group were
randomly assigned either to a support group or to a
baby massage group for 6 weeks between week 9 and
16 postnatal, as described by OHiggins et al. (2008).
The intervention study was designed to investigate
possible effects of attending a baby massage group in
the early postnatal period compared with attending a
general support group, on maternal mood, motherinfant interaction and infant behaviour. There were no
differences in bonding scores at any time point
382
M. OHiggins et al.
Methods
Participants and procedure
This work was designed as a prospective cohort study.
Hammersmith Hospital NHS Ethics Committee granted
ethics approval. Women were recruited on the postnatal
ward of Queen Charlottes and Chelsea Hospital, London
(Fig. 1). Participants were given verbal and written
descriptions of the study and written consent was obtained.
Only those mothers with healthy, full term (over 36 weeks)
babies were approached. Women were also excluded from
the study if they had a recorded history of a psychotic
disorder, were under 17 years of age, did not speak sufficient English or were receiving support from social workers
for housing or social problems. Those who were willing to
take part were screened for depressive symptoms at 4 weeks
postnatal, sent to them by post. Of the 2048 women who
returned their questionnaires, 285 women (13.9 %) met
screening criteria for high risk of depression (EPDS
13). They were invited to take part in the study group,
and 89 women agreed to participate, of whom 50 completed the study. This group is presented here as the
depressed group. Of the women whose screening scores
indicated they were not depressed, 1,376 (67.2 %) scored
EPDS 8, 95 were selected at random and invited to take
part in the study. This group is described as the nondepressed group. Forty five of these women agreed to
participate and 29 completed the study. Women who
scored from 9 to 12 on the EPDS at screening were
not invited to take part in the study, to clearly delineate
the depressed and non-depressed. All the women were
asked to complete the depressive symptoms questionnaire
and motherinfant bonding questionnaire at 9 weeks,
16 weeks and 1 year postnatal. At 9 weeks postnatal,
the women were given two versions of the bonding
questionnaire, the first asked the women to describe her
feelings in the early weeks (14 weeks postnatal) and
the second asked for her current feelings.
As part of a larger study, the depressed group were
randomly assigned either to a support group or to a
baby massage group for 6 weeks between week 9 and
16 postnatal, as described by OHiggins et al. (2008).
The intervention study was designed to investigate
possible effects of attending a baby massage group in
the early postnatal period compared with attending a
general support group, on maternal mood, motherinfant interaction and infant behaviour. There were no
differences in bonding scores at any time point
383
Mothers recruited on postnatal
ward n = 3396
EPDS 13
n = 285
(13.9%)
4 weeks
postpartum
EPDS by post
n = 2048
completed
questionnaires
EPDS 13
n = 1763
(86.1%)
Measures
Depressive symptoms
The EPDS (Cox et al. 1987) is a ten-item self-report questionnaire developed for use in the early postnatal period as a
screening tool to enable primary healthcare workers to identify women who may need services for postnatal depression.
384
M. OHiggins et al.
Statistical analyses
The EPDS data were normally distributed, but bonding data
were not and could not be normalised by transformation.
Non-parametric tests were therefore used. Spearman rank
correlation was used to compare the bonding scores at each
time point (Fig. 2). 2 was used to test the association
between psychometric rating scale data at different time
points. A score of 13 or more on the EPDS was used as
the criterion for inclusion in the depressed group (Cox et al.
1987). A score of 2 or more on the MIBQ was used to
indicate poor bonding (Bienfait et al. 2011). 2 was used to
compare the demographic data of the women in the depressed and non-depressed groups. Where the expected
number in any cell fell below 5, Fishers exact test was
used. MannWhitney U-tests were used to compare the
bonding scores for the depressed and the non-depressed
groups. Logistic regression was used to test the putative
predictors of poor bonding at 1 year.
Results
Fig. 2 Bonding data for all participants comparing scores in the early
weeks (14 weeks postnatal) with bonding at 9 weeks (a); bonding at
16 weeks (b); bonding at 1 year (c) and regression line for each,
Spearman rank correlation, Sr =0.62, p<0.001; Sr =0.59, p<0.001;
and Sr =0.50, p<0.001 (two-tailed), respectively
385
32.3 (5.3)
4.0
8.0
20.0
50.0
18.0
70.0
14.0
10.0
6.0
50.0
34.6 (4.9)
0
3.6
21.4
71.4
3.6
86.2
13.8
0
0
72.4
86.0
14.0
70.0
28.0
2.0
40.0
74.3
96.6
3.4
86.2
13.8
0
69.0
82.2
NS
NS
NS
NS
NS
NS
p=0.013
NS
386
M. OHiggins et al.
Depressed EPDS13
(N=50)
Non-depressed
(N=29)
17.0 (1322)
16.7 (2.6)
5.0 (18)
4.9 (1.9)
p<0.001
13.0 (722)
13.5 (4.0)
3.0 (010)
3.1 (2.7)
p<0.001
10.0 (026)
10.0 (5.0)
3.0 (010)
3.7 (2.4)
p<0.001
8.5 (127)
9.5 (5.7)
3.0 (016)
3.4 (3.2)
p<0.001
3.0 (019)
4.8 (4.9)
1.0 (04)
1.3 (1.3)
p<0.001
3.0 (015)
2.4 (2.9)
0 (03)
0.8 (1.1)
p<0.01
1.0 (010)
1.6 (2.5)
0 (03)
0.6 (0.9)
p<0.05
1.0 (09)
1.6 (2.0)
0 (06)
0.7 (1.3)
p<0.05
EPDS 14 weeks
median (range)
mean (SD)
EPDS 9 weeks
median (range)
mean (SD)
EPDS 16 weeks
median (range)
mean (SD)
EPDS 1 year
median (range)
mean (SD)
Bonding Scores 14 weeks
median (range)
mean (SD)
Bonding Scores 9 weeks
median (range)
mean (SD)
Bonding Scores 16 weeks
median (range)
mean (SD)
Bonding Scores 1 year
median (range)
mean (SD)
Discussion
There was a strong association between scores on the MIBQ
in the early weeks postnatal and the bonding scores at all
other time-points (Fig. 2). There was also a strong association between the EPDS scores at 4 weeks postnatal and the
bonding scores at 1 year. However, logistic regression
showed that early bonding, rather than early depression,
was the main predictor of bonding at 1 year.
The study, depressed, group in this analysis comprises
two intervention groups: baby massage classes and support
group. There were no differences in bonding scores at any
time point between the women who attended baby massage
classes and the women who attended a support group
(O'Higgins et al. 2008). A no-treatment depressed group
was not included in the study for ethical reasons. For this
study these two intervention groups were combined for
further analysis.
It might be argued that poor bonding is only one aspect of
postnatal depression and therefore current screening for
387
interesting to note that a recent study by Tharner and coworkers (2012) into maternal depression and infant mother
attachment found that maternal depressive disorder, regardless of severity or psychiatric co-morbidity, was not associated with an increased risk of infant attachment insecurity or
disorganisation.
Brockington (2008) points out that intervention methods
usually involving directed play are effective for bonding
disorder. A randomised control trial of 117 mothers showed
that 8 weeks of interaction coaching significantly improved
motherinfant interaction compared to the control group
(Horowitz et al. 2001). A review by Poobalan Aucott et al.
(2007) examined the effects of treating PND on mother
infant interaction and child development. Treatments involving mother and child were found to improve the
mothers feelings about her child, while treatments involving the mother alone were found to be effective for depression but did not have a significant effect on the mothers
feelings towards her child. This indicates that early detection
and referral to appropriate services could provide effective
treatment.
The data presented in this study show a strong association between early depressive symptoms as measured by the
EPDS (weeks 14) and poor bonding scores on the MIBQ.
This situation changed by 1 year postnatal when there was
no longer an association between depressive symptoms and
poor bonding. For some women the bonding score remained
poor while the depressive symptoms improved and for
others the reverse was true. This suggests that while these
two disorders may share common triggers they may follow
different courses of development or resolution. Research
into the underlying neuro-endocrinology of bonding
(Douglas 2010), and postnatal depression (Bloch et al.
2003), may help to explain these differences.
While it is clear that postnatal depression is associated
with a risk of poorer cognitive and behavioural development
of the child (Murray 1992; Sharp et al. 1995; Hay et al.
2001; Pawlby et al. 2008), it has not been established to
what extent poor bonding contributes to this. Earlier studies
of postnatal depression and child development did not measure mother infant bonding. Future long-term studies should
distinguish different sub-groups: women who are depressed
and experiencing poor bonding; women who are depressed
but not experiencing bonding problems and women who are
not depressed but experiencing bonding problems. It is also
important to establish the predictive value of bonding disorder for later attachment problems. This will establish the
impact of each factor on the cognitive and behavioural
development of the child born at the time mother is affected.
The study presented here is a prospective study of mother
infant bonding up to 1 year postnatal. However, there are
some limitations due to the study being part of a larger overall
project. The study group comprises mother and infant pairs
388
who were assigned randomly to two different treatment conditions, one being motherbaby massage and the other attendance of a support group (O'Higgins et al. 2008). These were
found to have no different effect on outcome which enabled
their combination for this study. Another limitation of the
current study is the discontinuous data groups created by
selecting women with particular scores on the EPDS for the
study and control groups. This restricted the choice of statistical analysis. Both limitations could be avoided in the design
of future projects. It would also have been of interest to study
the mothers own attachment style, which might in turn have
been related to impaired bonding.
In conclusion, screening for postnatal depression, by administration of the self-report EPDS scale (Cox et al. 1987) or
questions presented verbally by primary healthcare workers
(NICE 2007), has become part of normal practice in developed countries, and widely reviewed (Delatte et al. 2009;
Hewitt and Gilbody 2009; Mitchell and Coyne 2009). The
results presented in this paper suggest that a specific screening
for risk of poor bonding may also be important although more
research will be needed to evaluate potential benefit versus
harm. In the future, appropriate referral services may play a
role in preventing child rejection or harm.
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