Cortisol patterns of depressed mothers and their infants are related to maternal–infant interactive behaviours

Background: Postpartum depression (PPD) reduces maternal–infant interaction quality, stresses infants and mothers, and is linked to adverse child social–emotional and cognitive developmental outcomes. Objectives: A hypothesised mechanism for these observed relationships is the stress-related over-activation of the hypothalamic–pituitary–adrenal (HPA) axis and resultant altered cortisol patterns. While cortisol levels of mothers and infants are strongly correlated, environmental, maternal, infant and maternal–infant interactive factors may also contribute to altered cortisol patterns. Thus, the objective of this study is to use Barnard’s Child Health Assessment Model to explore the influences on maternal and infant diurnal cortisol patterns for matched pairs of mothers and infants affected by postpartum depression. Method: Secondary analyses were conducted on data collected from mothers and their infants affected by symptoms of PPD (n = 53). Multiple regression models were undertaken to study mothers’ and infants’ diurnal cortisol patterns using area under the curve analysis. Results: Having a preterm child predicted both an increase in overall cortisol levels (p = .01) and a reduction in the daily decline (p = .02) in cortisol patterns for mothers. Difficult life circumstances (p = .04) also predicted a reduction in mothers’ expected daily decline in cortisol. For infants, maternal–infant interaction qualities including cognitive growth-fostering (p = .03) and socioemotional growth fostering (p = .02) reduced overall cortisol levels and increased the daily decline in cortisol, respectively. Conclusion: For mothers, preterm birth was the most robust predictor of elevated cortisol levels. For infants, more optimal maternal–infant interactions predicted lower levels of infant cortisol. Future research should examine interactions among infant temperament, maternal responsiveness and infant cortisol patterns.     

State of the science of maternal–infant bonding: A principle-based concept analysis

Objectiveto provide a principle-based analysis of the concept of maternal–infant bonding.Designprinciple-based method of concept analysis for which the data set included 44 articles published in the last decade from Pubmed, CINAHL, and PyschINFO/PsychARTICLES.Settingliterature inclusion criteria were English language, articles published in the last decade, peer-reviewed journal articles and commentary on published work, and human populations.Measurement and findingsafter a brief review of the history of maternal–infant bonding, a principle-based concept analysis was completed to examine the state of the science with regard to this concept. The concept was critically examined according to the clarity of definition (epistemological principle), applicability of the concept (pragmatic principle), consistency in use and meaning (linguistic principle), and differentiation of the concept from related concepts (logical principle). Analysis of the concept revealed: (1) Maternal–infant bonding describes maternal feelings and emotions towards her infant. Evidence that the concept encompasses behavioural or biological components was limited. (2) The concept is clearly operationalised in the affective domain. (3) Maternal–infant bonding is linguistically confused with attachment, although the boundaries between the concepts are clearly delineated.Key conclusiondespite widespread use of the concept, maternal–infant bonding is at times superficially developed and subject to confusion with related concepts. Concept clarification is warranted. A theoretical definition of the concept of maternal–infant bonding was developed to aid in the clarification, but more research is necessary to further clarify and advance the concept.Implications for practicenurse midwives and other practitioners should use the theoretical definition of maternal–infant bonding as a preliminary guide to identification and understanding of the concept in clinical practice.     

Maternal–foetal attachment independently predicts the quality of maternal–infant bonding and post-partum psychopathology

Purpose: The aim of this study was to evaluate the association of maternal antenatal attachment and post-partum psychopathology, maternal–infant bonding, while checking for antenatal psychopathology, for lifetime psychiatric diagnosis and for the known risk factors for peripartum depression.

Methods: One hundred and six women recruited at the first month of pregnancy (T0) were evaluated with the structured interview for DSM-IV TR (SCID-I) to assess the presence of lifetime psychiatric diagnosis and with the Perinatal Depression Predictor Inventory-Revised (PDPI-R), the Edinburgh Postnatal Depression Scale (EPDS), and the State–Trait Anxiety Inventory (STAI). At the sixth month of pregnancy (T1) and at the first month post-partum (T2), all patients were evaluated with the PDPI-R, the EPDS, the STAI, at T1, with the Maternal Antenatal Attachment Scale (MAAS), and at T2 with the Maternal Postnatal Attachment Scale (MPAS).

Results: Multivariate regression analyses showed that maternal–foetal attachment was the variable most significantly associated with postnatal symptoms of depression and anxiety and with quality of maternal-infant attachment. The logistic regression analyses showed that antenatal attachment may predict postnatal depressive and anxiety symptoms (respectively, OR: 0.83 – IC [0.74???0.95], p?=?.005, OR: 0.88 – IC [0.79???0.98], p?=?.02), and the quality of maternal postnatal attachment (OR: 1.17 – IC [1.08???1.27], p?Conclusion: The quality of maternal–foetal bonding may independently predict the quality of maternal–infant attachment and post-partum depressive and anxiety symptoms. A comprehensive assessment of maternal risk factors for perinatal psychopathology during pregnancy should include the evaluation of antenatal attachment that could be modifiable by specific interventions promoting the quality of maternal bonding.     

Psychometric properties of the Postpartum Bonding Questionnaire and correlates of mother–infant bonding impairment in Italian new mothers

Objectiveimpaired maternal bonding is a risk factor for problems with infant well-being and development. The investigation of perinatal variables related to disorders of the mother–infant relationship as well as the administration of reliable and valid screening tools to new mothers in the postpartum can help identify early signs of a disturbed mother–child relationship. The Postpartum Bonding Questionnaire (PBQ) has been shown to be a valid screening instrument, but its dimensional structure is still controversial. An analysis of the literature demonstrated the need for research into the perinatal correlates of the quality of mother-newborn bonding as measured by the PBQ, and for information about the reliability and validity of the Italian version of the questionnaire.Aimto (a) carry out preliminary analysis of the psychometric properties of an Italian version of the PBQ and (b) explore how mother–infant disturbances are related to relevant perinatal psychological variables.Designthe research design consisted of a prenatal and a postnatal phase.Settingprenatal education classes delivered in public and private institutions.Participants123 pregnant Italian women were recruited from prenatal education classes.Measurementsin the prenatal period participants completed a questionnaire measuring maternal-fetal attachment; at the postnatal assessment (3 months postpartum) participants completed the Italian PBQ together with measures of mother–infant attachment, the couple's adjustment and maternal psychological well-being. Exploratory factor analysis was used to investigate the factor structure of the PBQ. Internal consistencies were evaluated using Cronbach's alpha. Nomological validity was assessed via Pearson correlations.Findingsa three-factor model provided the most meaningful representation of the PBQ data, with one factor reflecting annoyance and anger towards the infant, another reflecting detachment and rejection and the third reflecting anxiety about infant care. Internal consistencies were good. Impaired mother-infant bonding was negatively correlated with prenatal and postnatal mother–infant attachment and couple adjustment, as well as being positively correlated with maternal depressive symptoms.Key conclusions and implications for practicethe Italian PBQ is a reliable, valid screening instrument and can be used for research, including transcultural comparisons in perinatal psychiatry. It can also be used clinically to detect signs of a disordered mother–child relationship. Knowledge of the variables generally associated with mother-infant bonding problems combined with data from postpartum administration of the PBQ could be used in midwifery to develop preventive programmes based on the specific needs of new mothers.     

Birth-related,psychosocial, and emotional correlates of positive maternal–infant bonding in a cohort of first-time mothers

Objective

to describe the development of a shortened 10-item version of the Postpartum Bonding Questionnaire (S-PBQ) and examine the relationship between birth-related, psychosocial, and emotional factors and maternal–infant bonding.

Design

cross-sectional interview study.

Setting

women having their first baby in Pennsylvania, USA.

Participants

we interviewed 3005 women in their third trimester and at one month post partum who were enroled in the First Baby Study.

Measurements and findings

for the S-PBQ, we completed factor analysis and examined instrument properties. We examined the relationship between birth-related, psychosocial, and emotional factors and maternal–infant bonding using adjusted linear regression models. The S-PBQ demonstrated acceptable internal reliability (Cronbach?s α=0.67). Analysis revealed a socio-economic bias such that women who were older, more educated, not living in poverty, and married reported lower bonding scores. Maternal–infant bonding was significantly negatively correlated with maternal stress, maternal pain, and post partum depression, and positively correlated with partner support with the infant, and social support.

Key conclusions and implications for practice

For researchers who wish to measure maternal–infant bonding but are in need of a relatively short scale, the 10 item S-PBQ may be a useful alternative to the original version. However, it is important that researchers measuring maternal–infant bonding also investigate socio-economic bias in their studies and adjust for this effect as needed. Our results also indicate that clinicians should be aware of life stressors that may impact the maternal–infant relationship, in order that intervention may be provided to improved health outcomes for mothers, infants, and families.     

Breastfeeding intention and practice in an urban minority population: relationship to maternal depressive symptoms and mother–infant closeness

Current literature shows that predictors of breastfeeding practice vary depending on women's ethnic background. This study examines predictors of planning to breastfeeding and of successful breastfeeding initiation and persistence, including the relationship to maternal depressive symptoms, social support, and mothers' perception of closeness to their infants, in a sample of low‐income African American and Hispanic women in the urban Northeast. Detailed interviews were conducted in the early third trimester, at 2 weeks following delivery, and 3 months postpartum. Rates of intention to breastfeed were similar for Hispanic and African American women. Among Hispanics, greater identification with Hispanic culture was associated with increases in the likelihood of planning to breastfeed. A smaller proportion of Hispanic women persisted, especially among those women who supplemented with formula. For all women, we found no relationship between breastfeeding practice and either social support or depressive symptoms. Mothers' perception of closeness to their infants was greater among breastfeeders compared to bottlefeeders.     

Maternal attachment feelings mediate between maternal reports of depression,infant social–emotional development,and parenting stress

Objective: The current study examined whether having a positive maternal postpartum depression screening was associated with maternal report of poorer infant social–emotional development and more negative maternal report of parent–child interaction, and whether scores on a measure of maternal feelings of attachment influenced this relationship. Methods: Two hundred and thirty-two first-time mothers and their infants were assessed using self-reporting questionnaires when infants were 2 and 6 months of age. At 2 months, mothers were screened for postpartum depression and their feelings of attachment to their infants were also measured. At 6 months, mothers reported on infant social–emotional development and the parent–child interaction. Results: Findings revealed an association between having a positive screening for maternal depression at 2 months, and reports of both at-risk infant social–emotional development and parent–child dysfunctional interaction at 6 months. Further analyses indicated that maternal feelings of attachment mediated rather than moderated these relationships. Conclusions: These results suggest that the association of maternal postpartum depression with later child outcomes may be the result of the negative effects of maternal depression on maternal feelings of attachment to her infant.     

An exploratory study of the relationship between mother–infant interaction and maternal cognitive function in mothers with mental illness

There is evidence for a deleterious effect of maternal mental illness on mother–infant interaction. Presence of mental illness and lowered maternal cognitive function independently predict quality of interaction, but their combined effect on interaction is unclear. A pilot study was conducted to explore the relationship between maternal serious mental illness (SMI), cognitive function, and mother–infant interaction. Six mothers with SMI (two with schizophrenia and four with depression) and 12 mothers with no psychiatric history were recruited, together with their infants (all aged between 5 and 18 weeks). Mother–infant interaction was assessed using the Crittenden Care Index. The Cognitive Drug Research computerised assessment battery provided measures of memory and attention. In support of previous literature, mothers with SMI were significantly less sensitive during interactions with their infants. They also demonstrated impairment relative to controls on an index of speed of memory processing. A hierarchical regression model revealed that presence of maternal mental illness was a significant predictor of maternal sensitivity, but when speed of memory processing was accounted for, the strength of this relationship was reduced, suggesting that the relationship between maternal mental illness and mother–infant interaction may be partially mediated by level of cognitive function. Further study is warranted.     

Relationship between neurobehaviours of Chinese neonates and early mother–infant interaction

This study examined the relations between newborn neurobehavioural profiles, and the characteristics of early mother–infant interaction, in Chengdu, China. The Brazelton Neonatal Behavioural Assessment Scale (NBAS) was administered to healthy, full‐term newborns at a mean age of 3 days, and the Nursing Child Assessment Teaching Scale (NCATS) was used at 1 month to characterize mother–infant interaction. The NBAS peak of excitement item was correlated with the NCATS caregiver subscale score, and the NBAS autonomic startles item was correlated with the NCATS child subscale scores. NBAS peak of excitement and startles accounted for 34% of the variance of the NCATS caregiver score, and the NBAS autonomic stability items (tremulousness, startles, and lability of skin colour) predicted 42% of the variance in the NCATS child score. Maternal age, education, family income, and perceived stress were not associated with NCATS caregiver, child and total scores. Maternal nurturing behaviours did not differ between one‐child families with boys or girls in this urban Chinese sample. Results suggest that in this Chinese sample, indicators of newborns' autonomic stability and intensity of response to stimulation were predictive of early mother–infant interaction. Implications of the lack of association between infant and maternal demographic factors and mother–child interaction are discussed.     

Perceptions of risk to HIV infection among adolescents in Uganda: are they related to sexual behaviour?

Uganda has been hailed as a success story in the fight against HIV that has seen a reversal in prevalence from a peak of 15% in 1991 to about 6.5% currently Since 1992, the largest and most consistent declines in HIV have occurred among the 15-19-year-olds. While many studies have examined how key behavior changes (Abstinence, Be faithful and Condom use) have contributed to the decline in HIV prevalence, few have studied the relationship between sexual behaviors and risk perception. Using data from the 2004 National Survey of Adolescents, multivariate logistic regression models were fitted to examine the strength of the association between risky sexual behavior and perceived risk among 12-19-year-old adolescents in Uganda. After controlling for other correlates of sexual behavior such as age, education, residence, region and marital status, the findings indicate highly significant positive association between perceived risk and risky sexual behavior among males but not females. The findings reveal that, regardless of their current sexual behavior, most female adolescents in Uganda feel at great risk of HIV infection. The findings also show that adolescents with broken marriages are much more vulnerable to high risk sexual behaviors than other categories of adolescents. These results further emphasize the need for a holistic approach in addressing the social, economic and contextual factors that continue to put many adolescents at risk of HIV infection.     

Early mother–infant interaction: associations with the close relationships and mental health of the mother

The present study examined the association between a woman's close relationships and mental health and the quality of her maternal behaviour in early mother–infant interaction. A total of 131 mothers and their infants participated in the study. The quality of the mother's childhood relationship with her own mother and her marital relationship were investigated in a semi‐structured interview and, as a part of the interview, the Structured Clinical Interview for DSM‐IV (SCID) was used to assess her mental health. Mother–infant interaction was videotaped at 8–11 weeks of the infant's age, and scored using the Global Rating Scale for Mother–Infant Interaction. The mother's childhood relationship with her mother was significantly related to her own interactive and affective behaviour with her infant. A poor, disengaged marital relationship was also associated with poorer interactive behaviour but only among mothers with mental health problems. Thus the mother's close relationships had an effect on maternal behaviour; however, maternal perinatal psychopathology per se was not related to maternal behaviour at 2 months of the infant's age.     

Effective counselling of pre-natal diagnosis of serious heart disease--an aid to maternal bonding?

The pre-natal diagnosis of a serious anomaly in the fetus precipitates a crisis for the parents. Effective counselling may help during this difficult phase. We postulated that if parents opted to continue with the pregnancy, then they are better prepared to care for the newborn infant having already experienced the grieving process. OBJECTIVES: This paper reviews our early experience, focusing on the parental perception of the counselling. METHODS AND SUBJECTS: Questionnaires were developed and forwarded to patients previously seen in a private obstetric ultrasound practice, diagnosed with or specifically referred because of the diagnosis of a complex cardiac abnormality in the fetus. The diagnosis was subsequently confirmed by a further scan in the presence of a paediatric cardiologist, who initiated explanation of the anomaly with the obstetrician ultrasonologist asking and seeking explanations in lay terms on behalf of the parents, concerning the nature of the anomaly, its possible consequences, the need for intervention, the short- and long-term risks, concentrating on quality of life issues. RESULTS: Over a 3-year period a cohort of 40 such patients were reviewed of whom a third opted for termination. The anomalies were complex and many life-threatening, most requiring surgical intervention in the newborn period or subsequently. Of the 27 that proceeded to term, responses were obtained from 21. Most described the shock at learning the diagnosis and of being very distressed at the time. Most commented that the information provided was 'just right'. The majority felt that the previous contact with the obstetrician and cardiologist was very helpful in their subsequent care of their newborn infant. Three parents noted that they continued to experience anxiety about their baby, while 3 others indicated that the previous counselling had 'no effect' on the handling of their baby. Anecdotal observations made of the parents especially of the mother's handling of the newborn infant seemed to support the parents' perception that they were helped by their prior knowledge of the diagnosis. CONCLUSION: With increasing pre-natal diagnosis of major anomalies, it is important that parents so affected have the opportunity to understand the nature of the abnormality, its significance and effects on the infant's and child's functioning and survival, and the need for intervention. Such information together with working through the grieving process during the latter part of the pregnancy may help with the handling of the infant once born and further improve their bonding with their baby, despite the need for, at times, life-threatening intervention. Further objective studies are required to confirm these preliminary observations.     

Use of selective serotonin reuptake inhibitors during pregnancy and disorganised infant–mother attachment

Objective: To examine the quality of infant–mother attachment in a prospective case series of infants whose mothers took selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Background: SSRIs are prescribed to 2–6% of pregnant women. Recent articles on the use of SSRIs during pregnancy note the increased risk for problematic infant–mother relationships among mothers with untreated postpartum depression. However, little is known about the quality of infant–mother relationships among mothers who took SSRIs during pregnancy. Methods: Five mothers who took SSRIs during pregnancy were recruited from a community study of infant development. Mothers completed ratings of postpartum depression symptoms (Beck Depression Inventory) 4–6 times between 1 month and 1 year following the infant’s birth. At 1 year postpartum, quality of infant–mother attachment was assessed using the strange situation procedure. Results: Four of the five infant–mother dyads (80%) were classified as disorganised, a rate considerably higher than in postpartum depression samples. Conclusion: These results are used to raise questions about the clinical implications of research on in utero exposure to SSRIs, perinatal depression, and disorganised attachment. Specifically, this case series raises questions about using research on the link between postpartum depression and infant–mother attachment as a rationale for the use of SSRIs during pregnancy. Current research indicates use of SSRIs during pregnancy may: (1) increase risk for disorganised attachment, (2) decrease risk for disorganised attachment, or (3) have no effect on disorganised attachment.     

Building infant–mother attachment: the relationship between attachment style,socio‐emotional well‐being and maternal representations

The pilot study explored differences in maternal representations between primiparous pregnant woman with different attachment styles and different levels of socio‐emotional well‐being. The sample included 55 pregnant women between the ages of 18 and 38, between 4 and 7 months pregnant. Representations were assessed using the ‘R’ Interview, attachment styles using the CaMir, and socio‐emotional well‐being using the OQ‐45.2. According to the results, prenatal representation of own mother‐as‐mother may be significantly related with pregnant women’s attachment experiences, but this representation may not be significantly related to the woman’s prenatal socio‐emotional well‐being. On the other hand, representation of the child and self‐as‐mother may not be significantly related to attachment experiences, but rather with prenatal socio‐emotional well‐being. This implies that the prenatal socio‐emotional context plays a great role as a protective factor with respect to the representations of the child and self‐as‐mother and, therefore, has strong implications for the future mother–infant attachment and child development, which is very relevant in terms of prevention of attachment difficulties.     

Development and preliminary evaluation of a group intervention targeting maternal mental health and mother–infant interactions: a combined qualitative and case series report

Objective and Background: The purpose of this study was to investigate the outcomes of an Emotional Wellbeing Group intervention developed to treat maternal depression and anxiety while concurrently supporting positive development of the mother–infant relationship.

Method: Five women diagnosed with depressive and/or anxiety disorders and their infants completed the Emotional Wellbeing Group. The participants completed pre- and post- intervention assessments which included self-report measures of mood and the motherhood experience, and a video-taped, unstructured play session between mothers and their infants.

Results: Four of the participants reported a clinically significant decrease in their symptoms of anxiety. All mothers reported more positive perceptions of their infants and their experience of motherhood, and showed enhanced maternal sensitivity and responsiveness towards their infants. Depression levels were not shown to improve consistently.

Conclusion: This study provides initial positive evidence to support future research directions and clinical efforts to develop interventions that target both the treatment of perinatal depression and anxiety and the quality of mother–infant interactions. Clinical insights for mental health professionals working with mothers and infants are presented.     

Assessing mother‐to‐infant attachment: the Italian adaptation of a self‐report questionnaire

This study examined the extent to which race/ethnicity is a risk factor for depressed mood in late pregnancy and the early postpartum period apart from its relationship with other demographic and infant outcome variables. Data obtained from 26,877 women with newborns in Iowa indicate that 15.7% endorsed a single depression item. Logistic regression results indicate that race/ethnicity was a significant predictor of depressed mood, controlling for age, marital status, income and educational level, and infant health outcome. Compared to White women, African‐American women were significantly more likely to report depressed mood (OR = 1.25, 95% CI = 1.03–1.52). Hispanic women were significantly less likely to report being depressed (OR = 0.74, 95% CI = 0.61–0.88). The role of social support in understanding these findings is explored.     

Endometriosis and assisted reproductive techniques independently related to mother–child morbidities: a French longitudinal national study

Research questionDoes endometriosis increase obstetric and neonatal complications, and does assisted reproductive technology (ART) cause additional risk of maternal or fetal morbidity?DesignA nationwide cohort study (2013–2018) comparing maternal and perinatal morbidities in three groups of single pregnancies: spontaneous pregnancies without endometriosis; spontaneous pregnancies with endometriosis; and ART pregnancies in women with endometriosis.ResultsMean maternal ages were 30.0 (SD = 5.3), 31.7 (SD = 4.8) and 33.1 years (SD = 4.0), for spontaneous conceptions, spontaneous conceptions with endometriosis and ART pregnancies with endometriosis groups, respectively (P < 0.0001). Comparison of spontaneous conceptions with endometriosis and spontaneous conceptions: endometriosis independently increased the risk of venous thrombosis (adjusted OR [aOR] 1.51, P < 0.001), pre-eclampsia (aOR 1.29, P < 0.001), placenta previa (aOR 2.62, P < 0.001), placental abruption (aOR 1.54, P < 0.001), premature birth (aOR 1.37, P < 0.001), small for gestational age (aOR 1.05, P < 0.001) and malformations (aOR 1.06, P = 0.049). Comparison of ART pregnancies with endometriosis and spontaneous conceptions with endometriosis: ART increased the risk of placenta previa (aOR 2.43, 95% CI 2.10 to 2.82, P < 0.001), premature birth (aOR 1.42, 95% CI 1.29 to 1.55, P < 0.001) and small for gestational age (aOR 1.18, 95% CI 1.10 to 1.27, P < 0.001), independently from the effect of endometriosis. Risk of pre-eclampsia, placental abruption or congenital malformations was not increased with ART.ConclusionEndometriosis is an independent risk factor for mother and child morbidities. Maternal morbidity and perinatal morbidity were significantly increased by ART in addition to endometriosis; however, some perinatal and maternal morbidity risks were increasingly linked to pathologies related to infertility.     

Longitudinal health outcome and wellbeing of mother–infant pairs after adolescent pregnancy in Reunion Island,Indian Ocean

Objective

To evaluate longitudinal care needs and health service access among mother–infant pairs after adolescent pregnancy.

Methods

In a case–control study, data were analyzed from primiparous adolescent and adult mother–infant pairs who delivered at Reunion Island University Hospital, France, between January 2004 and December 2006, and were followed-up from maternity discharge until December 2011. Infant outcomes were hospitalization during the first 2 years of life, hospital access for “non-medical” reasons, and neuropsychiatric care. Maternal outcomes were number of pregnancies and childbirths, rapid repeat pregnancy (RRP) rate, pregnancy morbidities, and use of health services.

Results

Data from 476 cases and 476 controls were analyzed. Adolescent and control offspring did not differ in the measured outcomes. Adolescent and control mothers had, respectively, 2.4 ± 1.3 and 1.9 ± 1.1 pregnancies; 1.9 ± 0.8 and 1.6 ± 0.7 childbirths; and RRP rates of 7.6% and 2.7% (all P < 0.001). Adolescents had less pregnancy-related pathologies at the index pregnancy and more frequently had natural deliveries (P < 0.05). Younger mothers exhibited higher rates (19.7% versus 6.9%, P = 0.001) of care for psychosocial reasons (suicide attempt, acute alcohol or drug intoxication, road accident, psychiatric problems, physical abuse).

Conclusion

Concerns arise from the long-term psychosocial risk among adolescent mothers.