Fundamentals of Midwifery: A Textbook for Students (35 page)

., Wadephul, F., Jomeen, J. (2013) Maternal–fetal relationships and psychological health: emerg- ing research directions.
Journal of Reproductive and Infant Psychology
31(5), pp. 490–499.Laxton-Kane and Slade (2002) also note that attachment and bonding differ in that (postna- tal) bonding is reciprocal – the infant will relate directly with the mother. However, it is impor- tant for neonatal/infant physical sensory and cognitive development that this reciprocal relationship is acknowledged by the mother to enable a secure attachment from the infant (Canadian Paediatric Society Position Statement 2004).
The importance of bonding
Bonding increases through the course of pregnancy (Della Vedova et al. 2008; Cannella 2005) and is positively related to early fetal movements (Hjelmstedt et al. 2006). Antenatal bonding has been linked to postnatal parent–infant relationships, infant development and maternal and child psychological health (Figueiredo and Costa 2009; Della Vedova et al., 2008), as well as improving health behaviours in pregnancy and formation of maternal identity (Della Vedova et al. 2008). However, it has also been proposed that reduced bonding during pregnancy can act as a protective mechanism against loss (Clement 1998).Early research on bonding by Kennell et al. (1974) focused on the post-birth context and described mothers who were given immediate contact post-birth, and extended contact there- after and found these women displayed significant differences in ‘attentiveness and responsive- ness’ towards their infants from birth to one year.Critiques have been made about the concept of bonding both postnatal (Eyer 1994) and antenatal (Mitchell 2001). Eyer (1994) suggested that bonding was misappropriated and turned into a ‘rigid doctrine’ which necessitated bonding in the first hour at a woman’s peril, with the onus placed on women to ensure that their infants emerged psychologically sound. Mitchell (2001) reinforces this argument suggesting that bonding with the fetus is a cultural construct related to the impact of a woman’s behaviour on the baby’s development.Whilst this is an important consideration in terms of maternal consequences, evidence indi- cates a ‘sensitive’ period does indeed exist post-birth (Bystrova et al. 2009), which is enhanced by immediate skin to skin, breastfeeding and rooming in. But bonding is more than proximity; bonding utilises all the senses, including the smell, taste, touch and sound of the baby.
The importance of attachment
Bowlby (1988) defined different forms of attachment, notably secure and insecure attachment and found that infants displaying secure attachments with their caretakers were more
Box 4.3 Secure attachment behaviour

Self-reliant

Self-confident
80
_•
High self-esteem

Resilience

Flexible

Curious and exploring

Able to regulate behaviour

Able to form relationships

Persistence

Socially competent

Empathic

Socially assuredself-reliant. Secure attachments (see Box 4.3) require maternal psychological availability to relate to the infant. Sroufe (2005) noted that for infants with a secure maternal attachment, in later life they demonstrated more flexibility, resilience, curiosity and exploratory behaviours, could moderate their behaviour, were more self-assured, socially competent and could develop healthy adult romantic relationships. Conversely, the insecure (disorganised) attached individu- als displayed dissociative behaviours and self-harm.The US National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth behaviour (2006) noted the quality of the maternal–infant interactions were ‘
the most important and consistent predictors of child cognitive and social development
’ and that better outcomes were noted when the mother was ‘
sensitive, responsive, attentive, and cognitively stimulating
’. A meta-analysis into disorganised attachment and later behaviour prob- lems found that attachment insecurity was associated with behavioural problems which were more prevalent in boys (Fearon et al. 2010). While it is important to note the impact of secure and insecure attachment on the social, emotional and cognitive development of the infant, it is equally important to examine factors which can impact on attachment and how women who are not bonding with their infants can be recognised and supported.
Potential factors influencing attachment and bonding
Ultrasound scans and bonding
Early suggestions that ultrasound could enhance bonding have been embraced by many authors Campbell (2006). However, empirical evidence overall is scant, though many women and their partners report that the baby feels more real and like a member of the family after a scan (Molan- der et al. 2010). Roberts (2012) reports the duality of the scan experience: the sonographer’s task to view and measure the fetus from a clinical perspective; and the parents, who perceive the scan as an opportunity to ‘see the baby’. She reports that behavioural, personality and physical char- acteristics are projected onto the fetus with imaginative interpretations of the features of the scan to create a fetal identity. However, the quality of the scan’s bonding experience is dependent on the sonographer’s sensitivity and feedback (Roberts 2012). There is some evidence that having seen the fetus on a scan can make loss more difficult for some women (Black 1992). More recently the commercial introduction of non-diagnostic 3D and 4D scans to promote bonding has encour- aged parents to‘meet’ with and engage with the fetus pre-birth. Early speculation regarding the
potential psychological effects of 3/4D scans was based on emotional reactions to these scans (Campbell 2002). Some studies have reported a positive bonding impact (Roberts 2012; de Jong- Pleij et al. 2013), whilst others have shown no effect (Lapaire et al. 2007). The evidence to support the psychological benefits of scanning and bonding remains tenuous; the scan is here to stay and it is important that sonographers approach their description of the fetus thoughtfully andthat the midwife appreciates the importance of the scan in terms of its impact on the mother,
⁸¹
whether negative, positive or ambivalent.
Maternal psychosocial status
Factors within the family, for example, maternal depression, low income, domestic violence or lack of social support can impact on the bonding process. When the mother feels insecure in her social setting this insecurity may result in an insecure attachment for the infant. Furthermore where a disjunct exists between the antenatal representation of the infant by the mother, which may emerge in part from the scan and the ‘real’ infant, there is potential for discordant bonding (Huth-Bocks et al. 2011). Whilst the promotion and support of bonding is important, bonding is not always instantaneous and practitioners should be mindful not to create standards for women which are both unrealistic and unattainable, within the context of their lives and the continuum of motherhood transition.Neuroscience research has revealed interesting developments in the physiological impact on bonding and attachment. Studies have found that particular areas of the brain and discrete hormones are stimulated during the maternal–infant interaction. However, maternal depression and substance abuse can inhibit these activities and hence bonding (Swain et al. 2007; Strath- earn 2011).
Summary
The relationship between the mother and the baby is the foundation for all future relationships. It is essential for survival of the infant who will instinctively attach to its caregiver and is a powerful, instinctive, emotional and biological activity in women which occurs in the antenatal and postna- tal period. Donald Winnicott coined the term‘
goodenough
’mother whom he defined as the ordi- nary devoted mother, arguably a mother who had bonded with her child (Winnicott 1953). Bonding and attachment theory are clearly defined and discussed in the literature and the mid- wife’s role is to navigate through pregnancy and the postnatal period with the woman, promoting every opportunity for the mother to develop a deep, meaningful relationship with her infant. This may require an interprofessional approach and referral to additional services, to ensure mothers have the support they need to determine a secure base for themselves and their infant.
Key points

The perinatal period is a period of physical and social change and is therefore inevitably char-
acterised by emotional lability.