Babies, ‘bonding’ and ideas about parental ‘attachment’

What goes on between parents and babies during pregnancy is important and what goes on in delivery rooms and the early days at home is important too. From a psychological point of view, the antenatal period and the early days and months with a new baby are all about adjustment, changing identity, and then parents getting to know their baby as an individual and building relationships together (Brazelton & Nugent, 2011).

‘Bonding’ is not ‘attachment’ and attachment is not an instantaneous process. ‘Bonding’ and ‘attachment’ are terms that are often used interchangeably and increasingly so over the last two decades or so among health professionals and parents themselves. New parents who have been separated from their baby, even for a short time, or who have not experienced the kind of birth they were anticipating, often worry about establishing their new relationship and a lack of ‘bonding’ at this time. This is despite a dearth of evidence to support the idea, based originally on animal research and observation, of an early ‘sensitive’ or ‘critical’ period after birth during which close physical, preferably skin-to-skin contact between mothers and babies should occur and without which later relationships and development may be affected (Eyer, 1994). In a study of the research carried out in this area, Eyer argued quite powerfully that enabling early contact, although poorly supported by research evidence, ‘became a part of hospital policy because it was politically useful in the struggle between advocates of natural childbirth and managers of the medical model of birth’ and that ‘it was uncritically accepted because it was consistent with a longstanding ideology of motherhood’ (Eyer, 1994). Thus bonding studies appear to have been a catalyst for family-oriented policies in maternity care, encouraging early contact in hospital and encouraging rooming in, bringing mothers together with their babies and confirming the importance of mothers as primary caregivers (Klaus & Kennell, 1982). There is no doubt that early contact can be very enjoyable for both parents, especially as many babies for several hours after birth have a prolonged period of alertness when face-to-face interaction is possible. Skin-to-skin contact at this time has been found to facilitate initiation and continued breastfeeding, although in terms of long-term relationship benefits the evidence is less than substantial.

‘Attachment’ traditionally has had a particular meaning as a specific aspect of the relationship that forms between infant and parent after birth which functions to make the infant, and later child, feel and be safe, secure and protected (Bowlby, 1982). Attachment theory is empirically grounded and relates to parenting, addressing the quality of the parent–child relationship as shown in interactions where the child is stressed by the presence of a stranger and the temporary absence of the caregiver, most often the mother (Ainsworth & Bell, 1970). The recognised method of assessing infant–parent attachment is the Strange Situation procedure resulting in categorisation of four major types of infant–parent attachment: that is, secure, insecure–avoidant, insecure–resistant and insecure–disorganised. It can only be assessed towards the end of the first year. The antecedents and longer-term consequences of these four types of infant–parent attachment have been well documented. Insecure–disorganised attachment is associated with significant emotional and behavioural problems, and poor social and emotional outcomes in high-risk groups (Benoit, 2004).

The antenatal ‘attachment’ that is referred to as developing during pregnancy between the mother and the growing foetus is a different phenomenon, although the same terminology is commonly used. While it is appreciated that ‘attachment’ can be used in this way, the process of the later attachment is quite clearly based on a bi-directional social psychological interaction of an infant with primary caregivers who it is anticipated can provide a secure, safe base from which to explore. In contrast, the relationship that develops during pregnancy is uni-directional, embodying maternal or paternal cognitions and emotional responses to the pregnancy and the growing foetus.

‘Maternal–fetal attachment’ is likely to be tapping into maternal attitudes and projections rather than being a similar process to that undertaken postnatally, and well beyond the newborn period into the second half of the first year, involving development of models of the ‘self’ and ‘other’ (Bowlby, 1982). Nevertheless, having some measure before birth and in the early days of becoming a new parent of how mothers and fathers and fathers conceptualise their infant and their own identity as parents is likely to be helpful in characterising adjustment to parenthood and possibly predicting later parental behaviour and attitudes. Maternal representations of their own attachment style as measured antenatally are also of interest here, as links have been found with their infants’ attachment classification at one year of age (Fonagy, Steele, & Steele, 1991).

Increasingly, this area of research has become of interest, encouraged for example by the change the use of ultrasound to visualise the foetus, and there has been acceptance of the use of the term ‘attachment’ in a way that those with a more developmental approach might still dispute. A review by Laxton-Kane and Slade (2002) in this journal focused on antenatal attachment, suggesting that an important area of emerging research involved investigating the implications of low levels of prenatal maternal attachment and risk to the foetus and maternal health-related behaviours. It was also concluded that the conceptual framework of the majority of prenatal attachment studies focused on measuring levels rather than addressing the type of attachment and suggested greater integration with, for example, the development of maternal representations of caregiving. A later review by Van den Bergh and Simons (2009) also in the journal targeted the different scales used antenatally in research on the maternal–foetal relationship: the Maternal Foetal Attachment Scale (MFAS), Maternal Antenatal Attachment Scale (MAAS) and the Prenatal Attachment Inventory (PAI). However, the ability to predict later maternal attachment from such measures was questioned, with an emphasis on the need for further research.

Over time, Condon and colleagues in Australia have developed a number of measures of antenatal and postnatal attachment for mothers and fathers (Condon & Corkindale, 1998; Condon, Corkindale, & Boyce, 2008). A more recent study (Condon, Corkindale, Boyce, & Gamble, 2013) involved collecting data from fathers at two points antenatally and also postnatally. The findings highlight a strong continuity of attachment style over the different time periods, but also the influence of the quality of the partner relationship and the partner’s mental health status. It seems intuitively likely that the feelings parents have during pregnancy about their baby are likely to be associated with later parental and infant behaviour. However, these may also be influenced by a wide range of demographic and individual factors that may also impact directly and indirectly on the child.

In conclusion, a need for careful use of terminology and clear definitions is critical if terms from one area of clinical, developmental or health psychology are adopted elsewhere, thus perhaps ‘antenatal maternal attachment’ or ‘postnatal maternal attachment’ might be distinguished from the more conventional use of the term ‘attachment’ as applied to infants. Care also needs to be taken in relation to the term ‘bonding’ which, although it may be a convenient and popular construct, has, we believe, little to offer and which is responsible for considerable parental anxiety at a time when mothers and their partners are getting to know their baby both during pregnancy and when meeting face-to-face for the first time.

The articles in this edition of the journal are as usual diverse, reflecting a wide range of areas relating to reproduction, pregnancy, childbirth and early parenthood. Although none directly have given rise to the discussion in this editorial, for many the concept of attachment will be understood as a necessary part of the context and a key element in the theories with which we try to investigate and understand many of the issues associated with reproduction and infant development.