Bonding: Recent Observations That Alter Perinatal Care

For almost three decades, there has been special interest in the bond between parents and their infants in the hope that better understanding of this relationship could result in improved perinatal care routines and a reduced incidence of parenting disorders such as child abuse, neglect,failure to thrive, and abandonment. Recent research findings provide a compelling rationale for major changes in some birth practices related to the bonding process.The term bonding refers to the emotional tie from parent to infant; attachment generally is used for the tie from infant to parent. A bond can be defined as the unique relationship between two people that is specific and endures through time. Parenteral bonds to their child can persist during long separations of time and distance, even though visible signs of their existence may not be apparent.Abandonment in this article refers to the caretaker, usually the mother, relinquishing all responsibility and care for an infant, usually in the first hours after delivery, by leaving the baby in the hospital and disappearing. A doula is a caring woman experienced in childbirth who provides continuous physical and emotional support to the mother during and for a short time immediately after childbirth.Researchers have questioned whether a period of time for parent-infant contact in the first minutes, hours, or days of life may alter the parents’ later behavior with that infant. In biologic fields,these moments have been called sensitive periods. As an example, a mother received analgesic medication 1 hour before she delivered her baby, and she was asleep when the baby was born. When she awoke, she thought her baby was a boy, so she was upset when the nurse brought an infant girl. It took 12 days for her to appreciate that she had a girl. This confusion probably could have been avoided if she had received no medication and was given her baby immediately. At a recent visit to her pediatrician, she said jokingly,“I still wonder if she is my baby.”A critical period in biology refers to a circumscribed time during which an embryologic feature (eg, the effect of thalidomide) or a behavior develops. If this period passes without a certain event occurring, such as contact of a mother animal with her newborn, the usual parent-infant bonding will not occur and generally cannot be recaptured at a later time. (This is not appropriate terminology for human parent-to-infant bonding; early separation does not prevent formation of a close, intimate bond.)As vital as the first hours may be for the interaction of mother and infant, they should not be expected to produce instant feelings of love for the infant by the mother and the father. When MacFarlane asked 97 mothers, “When did you first feel love for your baby?”, 41% said during the pregnancy and 24% said at birth, but 27% said that it was during the first week and 8%said after the first week. In a randomized controlled trial of doula support in South Africa, the women in the continuously supported group took 2.9 days to feel the baby was their own compared with 9.8 days for mothers who labored without doula support. The mother’s feeling of love for her baby is not instantaneous, but the first hour appears to be an especially valuable time in the bonding process.The attachment or bonding of a parent to an infant begins during pregnancy and increases shortly after birth. The bonds from the caretaker(s),usually the mother and father, to the infant are crucial for the baby’s survival and development. The power of this attachment is so great that it enables the mother and father to make the many sacrifices necessary for the care of their infant attending to the infant’s crying, protecting the baby from danger, and providing feedings in the middle of the night, despite their own desperate need for sleep.An understanding of bonding, as well as research on this topic, has been hampered by the lack of any simple measurement of its strength. The presence of mother-to-infant bonding has been assessed by measuring some aspect of maternal care or behavior.The wise pediatrician will keep in mind that the mother’s behavior with her infant is influenced by many factors. An example of a cultural factor is the concern of some Southeast Asian mothers that the“evil eye” will harm their babies if they show admiration and love, so they do not look “en face” and keep the baby at the foot of their beds in old disheveled clothes. The powerful effect of a mother’s own early experiences is demonstrated by George Engel’s long-term study of Monica, 1who had esophageal atresia and required gastrostomy feedings during her first year. She fed her dolls and then her four daughters in the same way she had been fed, lying horizontally on her lap(Fig. 1 ).The practices of a mother’s culture, her relationship with the father,the amount of support he provides, and the mother’s emotional state (eg,positive self-esteem or depression) may influence the mother’s behavior with her new infant. As an example, mothers who had continuous support by a doula during labor and delivery showed more affectionate interaction with their infants after leaving the delivery room than mothers who did not have a doula. They were less willing to leave their babies alone, and they reported picking up their babies more frequently when they cried. A higher percentage of supported mothers not only considered their babies beautiful, clever,healthy, and easy to manage, but believed that their babies cried less than other babies. In fact, more of the supported mothers believed that their babies were “better” when compared with a “standard baby.”In contrast, the nonsupported mothers perceived their babies as“almost as good as” or “not quite as good as” a standard baby. In addition, seven randomized trials revealed that women who received continuous support in labor with a doula had a 25% reduction in the length of labor, greater than 50% reduction in cesarean deliveries, and required significantly less oxytocin, medication, and operative vaginal deliveries.Although it has been helpful to examine a mother’s or father’s behavior with a baby, this may be misleading. In a hospital study in the United States that tested criteria for potentially abusive mothers, 30%of the new mothers were identified as potentially abusive, but follow-up of the women and their newborns disclosed no evidence of a parenting disorder. When observed, a drug-abusing mother may appear to have great love for her newborn, but the next minute she may leave the infant on the table unattended. No reliable and simple test is available to distinguish parents who will abuse.A special area of bonding studies has focused on increasing mother-infant time together through simple, low-cost intervention in the first hours and days following birth.One of the most significant findings in this early period is related to breastfeeding. Six of nine studies revealed that when a mother wants to breastfeed, is permitted to have early contact with her infant with an opportunity for suckling in the first hour of life, and is rooming-in with her infant, she is more successful than mothers who do not have these experiences. She succeeds in initiating breastfeeding and is able to breastfeed for a longer period than mothers who do not have early contact and rooming-in with their babies (Fig. 2).In addition, studies of Brazelton and others have shown that if nurses spend as little as 10 minutes helping mothers discover some of their newborn infants’ abilities, such as turning to the mother’s voice and following the mother’s face or imitation and assisting mothers with suggestions about ways to quiet their infants, the mothers became more appropriately interactive with their infants face to face and during feedings at 3 and 4 months of age.O’Connor and colleagues carried out a randomized trial with 277 mothers in a hospital that had a high incidence of parenting disorders. One group of mothers had their infants with them for 6 additional hours on the first and second day, but no early contact. The routine care group began to see their babies at the same age but only for 20-minute feedings every 4 hours,which was the custom throughout the United States at that time. In follow-up studies, 10 children in the routine care group experienced parenting disorders,including child abuse, failure to thrive, abandonment, and neglect during the first 17 months of life compared with two cases in the experimental group, who had 12 additional hours of mother-infant contact. A similar study in North Carolina that included 202 mothers during the first year of life did not find a statistically significant difference in the frequency of parenting disorders; 10 infants failed to thrive or were neglected or abused in the control group compared with seven in the group that had extended contact. When the results of these two studies are combined in a meta-analysis, it appears that simple techniques, such as adding additional early time for each mother and infant to be together and closing the newborn nursery, may lead to a significant reduction in child abuse. However, a much larger study will be necessary to confirm and validate these relatively small studies.Publication of these studies stimulated a lively debate in the early 1980s about the significance of the findings. Michael Lamb, the major critic, published somewhat similar objections almost simultaneously in Pediatrics and The Journal of Pediatrics. He expressed concern about failure to replicate findings and methodologic problems and suggested that “ although early contact may have modest but beneficial short-term effects in some circumstances, no positive long-term effects have been demonstrated.” The multiple inaccuracies in his review have resulted in some confusion and misunderstanding among those not well-acquainted with the field as well as an inability to reconcile completely differences in the evaluation and interpretation of each study. Diane Eyer,author of Mother-Infant Bonding—A Scientific Fiction, and Lamb were particularly critical of the practice of aiding the study of parental attachment in humans with observations in animal mothers. As noted previously in this article, this was not designed to explain human behavior, but to provide a view of humans within the context of evolutionary development. The approach was used cautiously, quoting Schneirla, “While …. analogy has an important place in scientific theory, its usefulness must be considered introductory to a comparative study in which differences may well be discovered that require a reinterpretation of the similarities first noted.”For further discussion of this controversy, see the two reviews of Lamb and two short rebuttals by Anisfeld and associates and Klaus and Kennell (see Suggested Reading).In the 14 years since the conclusion of the controversy, and studies of mothers and infants have new and critical mother and infant a of to their early moments the most example is the of if on the mother’s after birth, to up to her find the and to If the mother has received no medication during labor and birth and the infant is on her with the of her and a and not from her for the next baby usually begins a that with the mother’s For the first minutes, the newborn and up at the At to minutes, and and the infant begins to The baby then begins to to the from to the the the not the The of the appears to the newborn to the When the is baby to the group of mothers who did not medication and babies were not during the first hours of life for a or of of babies were to make this on their own and to to and other observations have of infants to the immediately after birth. This discovered that the newborn, after from the of birth, begins suckling and is to at a more appropriate when he or she is have shown that the infant, when and on the mother’s and then with a his or her as well as when that usually the mother and baby are The same that when the infants are with their mothers for the first minutes after birth, they at all compared with infants who were in a in a (Fig. It that each of these of the infant, the when to the mother, and the of the mother’s and more than years to the infant’s the infant from the is a of in the mother and the infant, and which of the baby’s and mother’s and the area and the of with each The for this are on the mother’s and the of the infant’s (Fig. were for survival of years when of were more before the of and the of new research findings explain some of the and provide additional support for the of two of the that the United is as of its to early mother-infant with an opportunity for the baby to in the first hour and mother-infant rooming-in throughout the hospital the of the in in throughout the an was In in a hospital a of babies are by their of rooming-in and early contact with suckling significantly reduced the frequency of from to a year. observations have been in the and when early contact and rooming-in were further that in the first hours and days after birth have special and they are additional evidence that the first hours and days of life are a sensitive period for the human This may be in to the special interest that mothers have shortly after birth in their infant will look at them and the behavior of the infant in the first hour of life during the period of the quiet there is a at this early time of the mother’s interest in the infant’s and the baby’s to and to look to understanding is in the first minutes and hours from who noted that if the of the infant the mother’s in the first hour of life, a mother will to keep her baby minutes longer in her room every during her hospital than mother who does not have contact of the during birth within the on appears to be important for the of maternal behavior and for the of bonding between mother and baby. In there is a for oxytocin, and only small the the However, multiple in the are by from the of result in a and feelings of love for the infant. It appears that during of are with women who a high are the most of in women who had their babies on their immediately after birth showed significant compared with the and a to at For the of a significant and was about minutes after of the mothers had of up to 1 hour after The after delivery and with breastfeeding not only may the to prevent but may bonding of the mother to her infant. findings may explain an in in the when many mothers were up their babies. mothers who for at days their that a of between the mother and baby during this early them together and further of The in maternal behavior with the of the infant’s on the mother’s the reduction in with early and and the maternal shortly after birth in with and all to the attachment of the parent to the debate on the interpretation and of the many research studies the effects of early and extended contact for mothers and on bonding with infants, all that all parents should be such contact time with their and in their recent critical review of and the following a sensitive have been to find any evidence that the of early mother-infant which has been such a feature of the care of women birth in has any beneficial the the available evidence that any effects that these have are The the that women of may be particularly to the effects of may be thought that of interaction in the period may some women on the to failure and behavior their and others have this This does for in hospital routines which lead to separation of mothers from their babies. In the of the evidence that such may do should be intervention that appears has been reported by who a incidence of attachment behavior at 1 year in a most of the mothers infants in infant throughout the first year. In most babies are carried on the mother’s through the and with the mother at night, there is much less infant on the that physical contact greater maternal to the of the infant Anisfeld and associates a randomized study in which group of babies was carried on the mother’s in a baby and group was in infant that less contact. When the infants were assessed in the at 3 months by the mothers the baby were more appropriately interactive and to their When all the infants months of the test was of the babies carried in the were compared with of the infants from the group that used the infant significant effects of the first hours and days are in by observations noted by who reported a special state of the mother in the perinatal period that a and the of her baby. He that this state of maternal the of pregnancy and for a after the birth of the baby. A mother support and a to and this This special and the of the mother to her baby are in the bonding that if a mother is in the way can she feel her infant’s and so the infant’s In the state of maternal the mother is better able to and provide her new infant has which is her If she the and to them in a sensitive and mother and infant will a of and It is that as the mother-infant this after day, the infant more frequently will a with the to be by and the to and the when are In a the child an than a The of a at 1 year of usually persist through and many changes have been in the perinatal the 10 it is that further changes are the of early contact and extended maternal with rooming-in for all mothers. In research is to discover of mother and infant in the early days of life, and if early to a mother who is and sensitive to the unique and of her own baby. It appears that this of maternal behavior during the first year of life will lead more frequently to a and appropriately child who a of in the are expected to be during labor and delivery in United States and a that of mothers have the father In mothers a that it is important for the father to be during labor and delivery, and a to be This that most are available for early contact with has shown that and affectionate interaction with the baby is in the first 3 months if the father has with his baby, and “en face” in the first 3 hours of the intimate of the birth of the baby and interaction a feeling of to their are for the with their parenting with the mother and infant, and that if of children to mothers and during labor and delivery, they are significantly more to have or more with their child in the first years of their United States out for its lack of or support for mothers and babies during the In contrast, it is the practice in of for the mother and the baby to be fed, and during at the first 6 in many and 6 months to 1 year in with the parents about the need for support to the birth of the baby can the mother’s bonding with her infant by and who birth to a or newborn generally have two and to the to the baby and an a in which they on the care by the and and before the infant. must reconcile their of the expected baby with the and infant. It is for them to appreciate that this baby will a and colleagues have a sensitive to the special of this an care can be for each infant, the infant is to as or This of evaluation and of a is about a week. infant’s for and special care can have a significant on his or her and In three randomized trials that have used this the experimental infants required less time on a and less and were their more The parents from the of assisting with the observations and helping in the of the care studies in have shown that infants can be with an in a care are well by the of the mother’s or father’s when the baby a and is by a The baby’s are higher when the baby is with the parent for of up to to 3 hours a the mothers feel more in the and their at contact is helpful for are not to small infants the mothers of infants in a room the or with their infant. This the mother to care for the baby more her to produce the time required by the and the mother the of with a group of mothers in similar who can provide support. of the has been with mothers in from shortly after the birth of the baby but there has been with mothers in and caring for their babies for 3 days to This mothers and their In these the mother should be considered the with the nurse as a after a or a who can their about the and to the and of the may be providing that could be greater than the other they usually the and other are in a state of emotional their are and the of the baby the of This opportunity may not be after a or a the may to the of the by not or the baby or about the This than the and the feelings with the may in some following the birth of a infant. from the is but in the early of and will require with of their and the usual of life for the first 3 to 6 the many parents still of the baby every day, but it is not such an a perinatal and are with at the or other of the In addition, or parents may these feelings as frequently are by such as the baby or the baby as they look at a parents are at the emotional with a and its long and are about their of self-esteem and their of after a that the parents’ bond to the infant is to birth. who do not to see or a infant may when they are that this in the and that the opportunity to have contact with the baby will not be available after or 3 days or after all when they are given the is 1 or hours and the baby’s is on the The parents should be to and their infant as they many are for the The parents should be about the long-term of of hospital and as of the baby, but they should be or any of these The of each is to the parents’ and emotional and to in the by the parent. A major of the pediatrician is to the parents with their children in many to for a not so by the to support the children and provide to their mother who up her baby for will have that require similar and to her and and observations the years have research group to the of that may the parents’ attachment to their infant. The of the for each and from and research than years a group of in the of at the of began the continuous study of an on and The study of Monica, an infant who was with esophageal atresia and who was fed through a she was years is a in the In 3 hours of compelling at George a of this unique and her and the first years of life are available for by For more George of of