[Note: This article is being published in draft form for use in an active research study. Its contents may be adjusted as we receive feedback from collaborating health care professionals.]
Bonding refers to the parent’s feelings, thoughts, and behaviors towards their child, while attachment refers to the relationship infants build with their caregivers.1 Some ways to improve parent-infant bonding include skin-to-skin contact, breastfeeding, cuddling, talking, singing, and spending quality time with the infant. Parents can also bond during pregnancy, referred to as maternal-fetal bonding or prenatal attachment.
Early bonding has been linked to a number of health benefits for both parents (e.g., reduced postpartum depression, improved mental and emotional health, improved interpersonal relationships)2,3 and infants (e.g., improved responsiveness of parents to infant’s needs, improved brain development, engendering secure attachment, improved mental, emotional, and social health).4
Benefit for Children
Although the literature overwhelmingly agrees that parental bonding is important in cognitive development of infants, empirical evidence and longitudinal cohort studies are lacking. The evidence available does show a correlation between stronger parental bonding and improved social and emotional skills and mental health outcomes for children as well as improved emotional and mental health for parents.5-7
While evidence is lacking to support the benefits of bonding for infants, there have been studies evaluating the adverse health outcomes of neglect. A 2012 retrospective cohort study (n=74) compared Romanian children who endured neglect due to institutionalization to children raised in a typical, non-institutional environment.8 The institutional rearing experienced by these children had low caregiver investment, low ratio of caregivers-to-children, and psychological and physical neglect. Using structural magnetic resonance imaging (MRI), the researchers found that children who were reared in an institutional setting demonstrated inhibited brain growth and had significantly smaller total cortical gray matter volume (-33.98, p=0.01) than children who were never institutionalized. While this is an extreme example, it illustrates that a lack of emotional support and care at a young age affects the brain development of children.
Benefit for Parents
A 2023 study compared a cohort of 227 mother-infant pairs with a lower mean bonding score determined using the Pre- and Postnatal Bonding Scale (PPBS, scored 0-15 with higher scores indicating more positive bonding) to a cohort of 566 mother-infant pairs (mean prenatal bonding 11.24 vs 12.77, mean postnatal bonding 12.83 vs 14.03).9 Among the cohort with better bonding, the mean score for depressive symptoms assessed using the Edinburgh Postnatal Depression Scales (EPDS, scored 0-30 with higher scores indicating more depressive symptoms) was lower (5.76 vs 4.47), and scores for partner support assessed using a subscale of the Tilburg Pregnancy Distress Scale (TPD, scored 0-20 with higher scores indicating more support) were higher (9.81 vs 10.66 for prenatal support, 15.50 vs 16.51 for postnatal support). Social-emotional development was only measured in the cohort of 227, but statistical analyses found that stronger maternal-infant bonding in the postpartum period was associated with better social-emotional capacities in early childhood.
A 2014 cohort study in China (n=1,267 mother-child pairs) examined the link between bonding on child behavioral outcomes at six years of age, with bonding predominantly defined as breastfeeding and speaking to the baby.10 Bonding was evaluated through a retrospective survey about communication while feeding. The behavior of the child was measured using the Child Behavior Checklist (CBCL), which measures behavior on a scale of 1.5 to 5, with higher scores indicating greater behavior problems. All the behavior measures were also summed into an overall score out of 20. Children who were exclusively breastfed and spoken to had the lowest scores when compared to both children who were exclusively breastfed but not spoken to and children who were not exclusively breastfed and not spoken to. Scores were significantly different for anxiety/depression (3.11 vs 3.30 and 3.71, p=0.04), somatic complaints (2.56 vs 3.27, p=0.023), being withdrawn (1.87 vs 2.73, p<0.001), and the overall behavior score (10.01 vs 12.79, p=0.001). Children who were actively bonded with also had lower scores than children who were also exclusively breastfed but not actively bonded with (anxiety depression 3.11 vs 3.30, somatic complaints 2.56 vs 2.70, withdrawn 1.87 vs 2.40, overall score 10.01 vs 11.12).
Bonding has also been shown to be beneficial to the non-birthing parent. A 2013 qualitative study conducted in Denmark found that fathers who practiced skin-to-skin contact with their pre-term infants in the neonatal intensive care unit (NICU) felt more confident and that it helped them step into their roles as parents.11 Another similar 2012 qualitative study conducted in Sweden had similar findings: fathers who practices skin-to-skin contact felt that it helped them feel close to their infants. They additionally found that this improved bonding improved their relationships with their partners.12
A 2015 study of 28 pre-term infants and their parents found that skin-to-skin contact increased parental oxytocin levels, decreased cortisol levels, and decreased anxiety.13 Maternal oxytocin levels significantly increased from 50.49 to 57.95 pg/mL while holding their infants, and paternal oxytocin levels increased from 41.25 to 49.78 pg/mL (p<0.05). Maternal cortisol significantly decreased from 0.15 to 0.12 μg/mL, and paternal cortisol levels decreased from 0.30 to 0.24 μg/mL (p<0.05). Maternal anxiety levels assessed using an 8-item visual analog scale (higher scores indicating higher anxiety) decreased from 24.31 to 5.85, and paternal anxiety levels decreased from 19.98 to 5.80.
Early Contact and Breastfeeding
An important factor in successful bonding between parent and child is skin-to-skin contact within one hour of birth.14 The World Health Organization (WHO) recommends immediate and uninterrupted skin-to-skin contact and breastfeeding within the first hour after birth. Breastfeeding promotes feelings of closeness and bonding between mother and baby, which can enhance maternal well-being, promote feelings of security, and reduce the risk of postpartum depression.
A 2017 randomized-control trial (n=71) found that implementing bonding education including encouraging breastfeeding can increase mother-infant attachment.15 The intervention group received three sessions of supportive group education sessions around bonding with their baby and the role of breastfeeding. The Muller Maternal Attachment Inventory (MMAI, scored 26-104 with higher scores suggesting stronger attachment) was utilized to assess the level of attachment. In the intervention group, all mothers breastfed for at least one year compared to 86% of controls. MMAI scores were 16.22 points higher among the intervention group compared to controls (90.74 vs 74.52, p=0.001) within 3-7 days of childbirth. The intervention group continued to have 10.35-point higher scores through 12 months after childbirth (97.71 vs 87.36, p<0.001). Additionally, each one-point increase in MMAI scores was associated with a one-point decrease in depression scores as assessed using the General Health Questionnaire (GHQ, subtests scored 0-21 with scores ≥6 indicating the presence of psychiatric symptoms).
A 2012 prospective study (n=137) found that breastfeeding was associated with lower rates of postpartum depression as assessed by the Mini International Neuropsychiatric Interview (MINI) and Edinburgh Postnatal Depression Scale (EPDS; scored 0-30 with scores over 10 indicating possible depression).16 Four months postpartum, 26.3% of those who didn’t breastfeed had depression compared to 3.3% of those who did breastfeed (p=0.0025). Those who didn’t breastfeed had higher EPDS scores, with a mean score of 8.1 vs 4.5 for those who did breastfeed.
References
- Ettenberger M, Bieleninik Ł, Epstein S, Elefant C. Defining Attachment and Bonding: Overlaps, Differences and Implications for Music Therapy Clinical Practice and Research in the Neonatal Intensive Care Unit (NICU). Int J Environ Res Public Health. 2021;18(4).
- O'Dea GA, Youssef GJ, Hagg LJ, et al. Associations between maternal psychological distress and mother-infant bonding: a systematic review and meta-analysis. Arch Womens Ment Health. 2023;26(4):441-452.
- Pazzagli C, Buratta L, Coletti E, Mazzeschi C. Mother-to-infant bonding mediates the effects of depressive and anxious postpartum symptoms on parenting stress. J Psychosom Obstet Gynaecol. 2023;44(1):2264487.
- Ainsworth MD. Infant--mother attachment. Am Psychol. 1979;34(10):932-937.
- Joas J, Möhler E. Maternal Bonding in Early Infancy Predicts Childrens' Social Competences in Preschool Age. Frontiers in Psychiatry. 2021;12.
- Parfitt Y, Ayers S, Pike A, Jessop D, Ford E. A prospective study of the parent-baby bond in men and women 15 months after birth. Journal of Reproductive and Infant Psychology. 2014;32(5):441-456.
- Le Bas G, Youssef G, Macdonald JA, et al. The Role of Antenatal and Postnatal Maternal Bonding in Infant Development. J Am Acad Child Adolesc Psychiatry. 2022;61(6):820-829.e821.
- Sheridan MA, Fox NA, Zeanah CH, McLaughlin KA, Nelson CA. Variation in neural development as a result of exposure to institutionalization early in childhood. Proceedings of the National Academy of Sciences. 2012;109(32):12927-12932.
- de Waal N, Boekhorst M, Nyklíček I, Pop VJM. Maternal-infant bonding and partner support during pregnancy and postpartum: Associations with early child social-emotional development. Infant Behav Dev. 2023;72:101871.
- Liu J, Leung P, Yang A. Breastfeeding and Active Bonding Protects against Children’s Internalizing Behavior Problems. Nutrients. 2014;6(1):76-89.
- Helth TD, Jarden M. Fathers' experiences with the skin-to-skin method in NICU: Competent parenthood and redefined gender roles. Journal of Neonatal Nursing. 2013;19(3):114-121.
- Blomqvist YT, Rubertsson C, Kylberg E, Jöreskog K, Nyqvist KH. Kangaroo Mother Care helps fathers of preterm infants gain confidence in the paternal role. J Adv Nurs. 2012;68(9):1988-1996.
- Cong X, Ludington-Hoe SM, Hussain N, et al. Parental oxytocin responses during skin-to-skin contact in pre-term infants. Early Hum Dev. 2015;91(7):401-406.
- Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative. In. Geneva: World Health Organization & United Nations Children's Fund (UNICEF); 2018.
- Shariat M, Abedinia N. The Effect of Psychological Intervention on Mother-Infant Bonding and Breastfeeding. 2017.
- Hamdan A, Tamim H. The relationship between postpartum depression and breastfeeding. Int J Psychiatry Med. 2012;43(3):243-259.
