NEONATOLOGY ON THE WEB

Historical Review and Recent Advances
in Neonatal and Perinatal Medicine

Edited by George F. Smith, MD and Dharmapuri Vidyasagar, MD
Published by Mead Johnson Nutritional Division, 1980
Not Copyrighted By Publisher

Chapter 9

Maternal Bonding: An Overview

Roberto Sosa, M. D.

Over the centuries, the attachment between a mother and her newborn infant has been considered a natural process and it is expected of the mother to care for and nurture her infant. However, the process by which a mother and her baby develop a close relationship is not clearly understood. It is known that maternal behavior is influenced by multiple factors that include the mother's own upbringing, socioeconomic conditions, her cultural beliefs and background, her relationship with her father, as well as her experiences with present and past pregnancies. In contrast to lower animal species, the human infant is not able to care for himself and requires extensive support and care from the mother in order to survive. It appears that shortly after birth the baby, as well as the mother, are in a state of readiness that allows them to interact with each other. It is well known that the neonate has the ability to interact socially. Moreover, recent studies suggest that the newborn baby has a far greater range of capabilities than was previously recognized. Saigal,^[1] et al., in minute-by-minute observations described the behavioral state of 36 term infants during the first hour of life. The infants spent approximately 60% of the first hour in the quiet-alert state and only 10% of the time in the irritable-crying state. Studies by Brazelton^[2] have demonstrated that during the quiet-alert period, the infant is in a receptive state.

The human infant has some degree of visual acuity. The infant can focus and will show preferences for patterns that simulate human faces.^[3-6] Robson^[7] has suggested that eye-to-eye contact may be an important factor in enhancing maternal behavior (see Figure 1). The newborn infant will also respond preferentially to his mother's voice.^[8] Between 6 and 10 days of age, the neonate displays some olfactory capabilities by turning his head toward his mother's breast. These capabilities in the newborn infant can be attractive to the mother and, therefore, stimulate interaction between them.^[9]

CROSS CULTURAL BELIEFS

The relationship between a mother and her newborn infant is also influenced by cultural beliefs and traditions of different societies. In most cultures, the birth of a child is considered a joyful event and part of ordinary life. The history of human infant care reveals that in most preindustrial societies infants and their mothers remained in close contact through infancy and early childhood.

As described by Lozoff^[10] during the existence of men as hunters and gatherers, babies were toted on the mother's back or side throughout the day. This enabled the mother to perform her daily chores with little interruption and at the same time provide the baby with nutrition, warmth and protection. Among contemporary hunters and gatherers this manner of child care continues. Babies are carried on the mother's back and breast feeding is universal.

In Santa Maria Cauque,^[11] a village located in the highlands of Guatemala, preparation for motherhood starts early in childhood. The birthing process, breast feeding and rearing of children are part of everyday life. No formal preparation is carried out and knowledge is obtained through experience and from frequent advice from adults. Infants, children and young adolescents are constantly exposed to all different aspects of child rearing and participate eagerly in this task (see Figures 2-3). Maternal-infant interaction starts immediately after birth, breast feeding is universal and, as with the hunters and gatherers, infants are carried on the mother's back (see Figure 4).

CHANGING PATTERNS

According to Chaney,^[12] in the Colonial days in Plymouth, the birth of a baby was a cultural and social event. When the wife started labor, the husband would summon the local midwife and close family friends. The friends would provide companionship for the mother and would take care of the house and children. After delivery of the placenta, the baby would be dried off and put immediately to the mother's breast. According to the Plymouth Colony records, most families had children born 2 years apart and it is believed that breast feeding was the only contraceptive method employed.

This was very much the way of life until the late 1800's when, in order to meet better standards of care, the setting for birth was moved from the home to the hospital. Initially mothers and infants were cared for in the same maternity wards; however, the elevated mortality and morbidity from infectious disease led to strict isolation techniques and exclusion of visitors (see Figure 5). In 1940, isolation practices led to the formation of separate wards for mothers and babies which remained the predominant mode of care until recently.

STUDIES ON SEPARATION

In the last 15 years there has been increased interest in the possible effects of attachment and separation between the mother and her newborn infant. Several studies have focused on the importance of early contact and improved motherhood (see Table 1). Although, to date, more than 13 separate studies have demonstrated a relationship between early contact and improved maternal attachment, important questions still need to be answered. Klaus and Kennell^[13-14] have pioneered many of the initial studies on separation.

In 1972, their study of 28 low income primiparous women disclosed that mothers who received early and extended contact, (one hour of extra contact with their infants within 3 hours after birth, and five hours of extra contact daily for 3 days), had significantly higher attachment behavior scores when compared with a similar group of women who followed hospital routines. It is interesting to note that this difference was still evident at a one year followup. In a standardized free play situation when the infants were 2 years old, there was a significant difference in the mothers' speech patterns to their infants.^[15] Mothers in the extra contact group used fewer imperatives and more conversational language in communicating with their children.

DeChateau,^[17-^18] in Sweden, studied maternal behavior during the first hour after delivery, in a group of 62 middle income mothers. The 22 primiparous mothers received their infants 15 minutes after birth. The infants were unclothed and were encouraged to suckle. In the two other groups of 20 primiparous and 20 multiparous mothers, the infants were received 30 minutes after birth, clothed and in a crib. In the 3 groups, the infants stayed with their mothers and fathers in the delivery room for a period of 2 hours. After this period of time all groups received care according to hospital routine. During the first 3 days, the mothers were allowed contact with their infants for feedings only. During the second part of the hospitalization, the mothers were allowed to participate in the daily care of their babies. Observations were made 36 hours after delivery.

Primiparous mothers with extra contact behaved similarly to multiparous mothers. However, when compared with primiparous mothers on routine care, the mothers in the extra contact group behaved with significant difference. They held their infants more often and their babies cried less. The difference was more pronounced in the mothers of male infants. At a 3 month followup visit, the difference in maternal behavior persisted. The male infants in the extra contact group smiled more and cried less frequently.

Contrary to these findings, Svejda,^[26] in a study of 30 lower middle class primiparous mothers, did not find any difference in maternal behavior when a group of extra contact mothers were compared with a control group. The extra contact group mothers received their infants skin to skin for approximately 15 minutes on the delivery table and an additional 45 minutes of contact in private. Mothers in the control group were able to see their infants in a crib and were given their clothed infants to hold for a period of approximately 5 minutes. At 36 hours after delivery both groups of mothers and infants were videotaped during a 10 minute interaction and a 15 minute breast feeding period. Some differences were obtained when the role of sex was investigated. Mothers of female infants who had early contact showed more affectionate behavior.

O'Connor,^[24] in the United States, in a study of 301 mothers, noted that by increasing the time of contact between the mother and baby after birth, the number of mothering behavior disorders was less, compared with a control group of mothers who followed hospital routines. However, Siegel^[25] and associates, in a study of 202 low income families, failed to demonstrate the influence of early and extended contact on child abuse.

THE EFFECTS OF EARLY CONTACT ON BREAST FEEDING

Several studies have explored the influence of early maternal contact and a successful and prolonged lactation (see Table 2). Observations of Winters^[27] in Seattle and Souza^[28] in Brazil have shown that early and extra contact between the mother and her newborn infant can increase the incidence and duration of breast feeding. Sosa^[29] reported in a study of more than 100 primiparous women in Guatemala that the mothers who had received early and extra contact had a higher incidence and duration of breast feeding, when compared with a control group of mothers. Mothers in the control group were given their infants at 12 hours of age and then every 4 hours for feedings. Mothers in the experimental group received their infants shortly after birth, on the delivery table, and then spent 45 minutes of skin to skin contact in a private room. After this intervention, both groups of mothers followed hospital routines.

The infants in the extra contact group had a higher incidence of breast feeding and were weaned at a later age. In DeChateau's^[18] studies on early contact and maternal behavior, he reported that at a 3 month followup visit, 58% of the mothers in the extra contact group were still breast feeding, as compared with only 25% of the mothers in the control group.

SPECULATIONS

The human maternal infant bond starts early in pregnancy, has a tendency to strengthen as the child grows older and is affected by numerous factors (see Figure 6). At the present time, data to support the existence of a sensitive period in the human species are inconclusive. Although a majority of mothers feel a sense of belonging to their infants immediately after birth, in some mothers this sense of intimacy commences at a later time. McFarland^[30] has pointed out that normal women become attached to their infants at different intervals of time: 41% during pregnancy, 24% at birth, 27% during the first week of life, and the remaining 8% after the first week of life.

Leiderman^[31] has postulated two different factors that affect maternal behavior: 1) Temporal determinants, including the time of initiation, the continuity, and the quality of maternal contact with her baby, and 2) structural determinants that include sex, birth order, and socioeconomic conditions.

Anisfeld and Lipper^[32] in a well controlled study, revealed some of the complexities in determining the factors that affect maternal behavior after birth. In their study, the effect of early contact was stronger in primiparous mothers. Also, mothers in low socioeconomic groups appeared to benefit more from extra contact with their newborn infants.

Observations by Sosa^[33] in Guatemala suggest that the presence of a comforting person during labor and delivery can modify the mother's behavior toward her infant after birth. Mothers with a supportive person present during labor and delivery showed more affectionate behavior toward their infants, when compared with a group of mothers who labored alone.

The relationship between breast feeding and early and extended contact seems clear. Frequent suckling will stimulate the release of oxytocin and prolactin, which will stimulate milk release and production, thereby facilitating a successful lactation in the mother. One can speculate that shortly after birth the human mother and her infant are in a state of readiness that allows them to interact with each other, triggering maternal behavior and attachment. There is evidence that during the postnatal period important benefits may be provided to the mother and her newborn infant by allowing them to be together. However, important questions need to be addressed: how can we enhance maternal attachment? Is there a similar pattern of behavior in all mothers after birth? Or, is it attributed to social changes and variations in different cultures? Is there a specific period of time after birth where maternal attachment is optimal?

These are important considerations that require extensive evaluation, as they may influence the future care of mothers and babies after birth.

	Figure 1. Eye-to-eye contact.
	Figure 2. Young girls in Santa Maria Cauque, Guatemala.
	Figure 3. Children helping in the care of younger siblings. Rural area of Guatemala.
	Figure 4. A mother with her young child. Santa Maria Cauque, Guatemala.
	Figure 5. Care of newborn infants, 1940's. Courtesy of Dr. Gustavo Castaiieda. Guatemala.
	Figure 6. Maternal attachment. Adapted from National Foundation, March of Dimes 1978, Series 1: The first six hours of life, "Early Parent Infant Relationships."

REFERENCES

1. Saigal S., Nelson N., Bennett K., et al.: Observations on the behavioral state of newborn infants during the first hours of life. Am. J. Obstet. Gynecol. 139:715, 1981.

2. Brazelton T. B., Tronick E., Adamson L., et al.: Early mother-infant reciprocity. In Parent-Infant Interaction. Ciba Foundation Symposium 33, (new series), Amsterdam: Elsevier Publishing Co., 1975, pp. 137-154.

3. Hack M., Mostow B. A., Miranda S.: Development of attention in preterm infants. Pediatrics 58:669, 1976.

4. Korner A. F., Thoman E. B.: Visual alertness in neonates as evoked by maternal care. J. Exp. Child. Psychol. 10:67, 1970.

5. Gregg C. L., Haffner M. E., Korner A. F.: The relative efficacy of vestibularproprioceptive stimulation and the upright position in enhancing visual pursuit in neonates. Child Dev. 47:309, 1976.

6. Fantz R. L., Fagan J. F., Miranda S. B.: Early visual selectivity as a function of pattern variables, previous exposure, age from birth and conception and expected cognitive defect. In Cohen, L. B., Salapatek, P. (eds.): Infant Perception: from Sensation to Cognition. New York: Academic Press, Inc., 1975.

7. Robson K. S.: The role of eye-to-eye contact in maternal-infant attachment. Child Psychol. Psychiatry, 8:13, 1967.

8. Eisenberg R. B.: Auditory behavior in the human neonate: Functional properties of sound and their ontogenic implication. Ear Nose Throat Audiol. 9:34, 1969.

9. MacFarlane A.: Olfaction in the development of social preferences in the human neonate. In Parent-Infant Interaction. Ciba Foundation Symposium 33, (new series). Amsterdam: Elsevier Publishing Co., 1975, pp. 103-117.

10. Lozoff B., Brittenham G., Trause M. K., et al.: The mother-newborn relationship: limits of adaptability. J. Pediatr. 91:1, pp. 1-12. 1977.

11. Mata L. J.: The children of Santa Maria Cauque: A prospective field study of health and growth. Cambridge, Mass.: MIT Press, 1978.

12. Chaney A.: Birthing in early America. J. of Nurse-Midwifery. 25:2, pp. 5-13, 1980.

13. Klaus M. H., Jerauld R., Kreger N. C., et al.: Maternal attachment: importance of the first post-partum days. N. Engl. J. Med. 286:480, 1972.

14. Kennell J. H., Jerauld R., Wolfe H., et al.: Maternal behavior one year after early and extended post-partum contact. Dev. Med. Child Neurol. 16:172, 1974.

15. Ringler N. M., Kennell J. H., Jarvella R., et al.: Mother-to-child speech at 2 years: effects of early postnatal contact. J. Pediatr. 86:141, 1975.

16. Kennell J. H., Chesler E., Wolfe H., et al.: The nesting behavior in the human mother after prolonged mother-infant separation. In Swyer, P., Stetson, J., (eds.): Current Concepts of Neonatal Intensive Care, St. Louis: Warren H. Green, Inc., 1975.

17. DeChateau P., Wiberg B.: Long-term effect on mother-infant behavior of extra contact during the first hour post-partum. 1. First observations at 36 hours. Acta Paediatr. Scand. 66:137, 1977.

18. DeChateau P., Wiberg B.: Long-term effect on mother-infant behavior of extra contact during the first hour post-partum 11. A followup at three months. Acta Paediatr. Scand. 66:145, 1977.

19. Hales D. J., Lozoff B., Sosa R., et al.: Defining the limits of the maternal sensitive period. Dev. Med. Child Neurol. 19:454, 1977.

20. Kontos D.: A study of the effects of extended mother-infant contact on maternal behavior at 1 and 3 months. Birth in the Family J. 5:133-140, 1978.

21. Campbell S. P. G., Taylor P. M.: Pending an attachment: theoretical issues. Seminars in Perinatology. 3:3-13, 1979.

22. Carlsson S. G., Fagerberg H., Horneman G., et al.: The effects of various amounts of contact with the mother and child on the mother's nursing behavior. Developmental Psychobiology, 11:143, 1978.

23. Ali Z., Lowry M.: Early maternal child contact: Effects on later behavior. Developmental Medicine and Neurology, accepted for publication.

24. O'Connor S., Vietve P. M., Sheeog K. B., et al.: Reduced incidence of parenting inadequacy following rooming-in. Pediatrics 66:176-182, 1980.

25. Siegel E., Bauman K. E., Schaefer E. S., et al.: Hospital and home support during infancy: impact on maternal attachment, child abuse and neglect, and health care utilization. Pediatrics 66:183-190, 1980.

26. Svejda M., Campos J., Emde R.: Mother-infant "bonding;" failure to generalize. Child Development 51:775, 1980.

27. Winters M.: The relationship of time of initial breast feeding to success of breast feeding. M. N. Thesis, University of Washington, Washington, D.C.

28. Souza P. L. R., Barros F. C., Gazalle R. V., et al.: Attachment and lactation, XIV Congreso Internacional de Pediatria, Buenos Aires, Argentina, 1974.

29. Sosa R., Klaus M., Kennel] J., et al.: The effect of early mother-infant contact on breastfeeding, infection and growth, in Breastfeeding and the Mother. Ciba Foundation Symposium 45 (new series), Amsterdam: Elsevier Publishing Co., 1976, pp. 179-192.

30. MacFarlane A.: In Kitzinger S., Davis J., (eds.): The Place of Birth. New York: Oxford University Press, 1978, p. 189.

31. Leiderman P. H.: Mother-infant separation: Delayed consequences. In Klaus M. H., Leger T., Trause M. A., (eds.): Maternal Attachment and Mothering Disorders. Sausalito, California: Johnson and Johnson Round Table, October 18-19, 1974.

32. Anisfeld E., Lipper E.: The effects of perinatal events on mother-infant bonding. Presented at the Biennial Meeting of the Society for Research in Child Development. April 3, 1981.

33. Sosa R., Kennell J., Klaus M., et al.: The effect of a supportive companion on perinatal problems, length of labor and mother infant interaction. N. Eng. J. Med. 303:597, 1980.