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Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 127-131

Factors associated with postnatally maternal-infant attachment in taif, Saudi Arabia

1 College of Medicine, Taif University, Taif, Saudi Arabia
2 Department of Pediatrics, Pediatric Resident, Alhada Military Hospital, Taif; Demonstrator, College of Medicine, Albaha University, Albaha, Saudi Arabia
3 Consultant of Child Mental Health, Former Assistant Pediatric Professor, College of Medicine, Taif University, Taif, Saudi Arabia

Date of Web Publication1-Oct-2018

Correspondence Address:
Dr. Abdulrahman Ahmad Alzahrani
College of Medicine, Taif University, Taif
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_50_18

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Background: The attachment is an important aspect of the relationship between mother and infant. However, besides mother, the other influential factors, including social and cultural environments, play a key role in the level of attachment to their infants. Therefore, the regional studies are needed to assess the impact of factors affecting attachment postpartum period. In this study, we investigated the effect of factors on mother–infant attachments in Taif city, Saudi Arabia. Methodology: The survey was carried out among 200 women 1–2 months postnatal, who were attending healthcare center in the middle of the city and were living in Taif city, Saudi Arabia. It was held during the period from January to March 2018. The survey was used to acquire sociodemographic data, reproductive history, and mother–infant attachment scale. Results: Out of 200 women, 172 (86%), 20 (10%), and 8 (4%) mothers showed positive, negative, and unclear attachments, respectively. Positive attachment was high among educated (90.6%) and employed (85.2%) mothers (P = 0.001). Furthermore, high gravidity and parity promote positive attachments. The positive attachment was more inclined toward girl child (95.7%), while the other factors including social support, being a full-term baby, breastfeeding, pregnancy planning, and history of abortion showed no significant effect on attachment. Conclusion: The psychological status of the mother is one of the governing factors which affect bonding during pregnancy and postpartum. Extensive care should be provided to pregnant women with high number of pregnancies especially if they are of lower level of education to help them avoid negative attachment with their infants.

Keywords: Gravidity, maternal-infant attachment, parity, positive attachment, Saudi Arabia

How to cite this article:
Abbas SI, Turkistani MH, Al-Gamdi AA, Alzahrani SA, Alzahrani AA, Helmy FF. Factors associated with postnatally maternal-infant attachment in taif, Saudi Arabia. Saudi J Health Sci 2018;7:127-31

How to cite this URL:
Abbas SI, Turkistani MH, Al-Gamdi AA, Alzahrani SA, Alzahrani AA, Helmy FF. Factors associated with postnatally maternal-infant attachment in taif, Saudi Arabia. Saudi J Health Sci [serial online] 2018 [cited 2022 Aug 19];7:127-31. Available from: https://www.saudijhealthsci.org/text.asp?2018/7/2/127/242504

  Introduction Top

Maternal emotional feelings and loving attitude toward their infant lead to the establishment of an effective attachment system. This important psychological process was named “bonding.”[1] Kitamura et al. performed path analysis to elucidate the causal relationships between maternal bonding and abusive parenting and indicated that bonding failure in the postpartum period predicted abusive parenting.[2] In addition, it has been suggested that postpartum maternal bonding can be predictable through that during pregnancy.

In a longitudinal study, women with more feelings of closeness and tenderness toward their fetuses in pregnancy reported more feelings of pleasure and affiliation in the relationship with their infants.[3] Women have ability to approach her pregnancy in a sensitive way. Therefore, they can build up very strong and good relationship. For the last three decades, disorders of the mother–infant relationship, including emotional rejection, have increasingly attracted the attention of clinicians and researchers in perinatal mental health.[4]

Previous studies reported that maternal depressive mood associated with bonding disturbances.[5] A meta-analysis by Beck suggested that maternal depression often coexists with bonding failure.[6] Therefore, there has been focus on the association between maternal depression and bonding disturbance.[7],[8] Maternal depression may lead to the occurrence of bonding failure, and conversely, bonding failure may lead to maternal depression.

The postpartum bonding questionnaire has been standardized for the postpartum period.[4] Kumar reported that some mothers showed a delay in the development of maternal bonding, resulting in infant neglect or impulses to harm the infant.[9] In addition, a longitudinal study also showed that bonding impairment in the postpartum period was related to insecure parenting behaviors.[10] However, little has been reported on the relationship between maternal-infant attachment postnatally.

Maternal-infant attachment is an extremely important issue that begins in early infancy and continuous throughout the life of the baby. It is important to detect factors that will affect the maternal-infant attachment include maternal factors and sociocultural environment.

  Methodology Top

The participants were 200 women from 1 to 2 months postnatal attending healthcare center. Women, who have infant more than 2 months, were excluded from the study.

A cross-sectional study was applied, using a structured questionnaire [Table 1]. It was designed to obtain the necessary information from a convenient sample of 200 women 1–2 months postnatal who attending healthcare center in the middle of Taif city, Saudi Arabia. It was held during the period from January to March 2018.
Table 1: The summary of mother-infant attachment questionnaire responses

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The trained data collectors, those were medical students at Taif University, collected the data from women who came to the healthcare center every Sunday and Monday of each week.

Participants were seated in a waiting room to answer the questionnaire. Primarily, they informed that their participation is voluntary and will be restricted for scientific purposes. Then, the informed consent was obtained. The participants were first surveyed about their sociodemographic data and reproductive history including two parts describing maternal as well as infant variables. Maternal variables included sociodemographic characteristics and reproductive history of postnatal women such as age, occupation, education level, residence, number of pregnancy, number of abortion, number of children, and family income. Whereas fetal variables include the following: general characteristic of the infant such as gender, age, and maturity. Then, the mother–infant attachment questionnaire was applied on the women. It consists of 15 statements, each item varied from not at all which have scoring 0, to very much which have scoring 2. Then, finally categorized as follows: positive attachment, unclear attachment, and negative attachment.

Data were entered and analyzed to Statistical Package for the Social Sciences program (SPSS), version 21.0, IBM, Armonk, NY, United States of America. The frequencies, mean, standard deviation, Chi-square test, and Student's t-test were applied. P < 0.05 was considered as statistically significant.

  Results Top

A total of 200 women participated in our survey regarding mother–infant attachments; the mean age of the mothers was 30.4 years (standard deviation [SD] ±6.6). Further, 64% of women had university education, 23% had high school only, 8% had an elementary education, 4% had primary education, and 1% had no education at all. About 66% of them were homemakers, 27% were employees, and 7% were students.

The participants had a number of pregnancies ranging from 1 to 9 times, 27% of them had only one pregnancy, 18% had pregnancy twice, and 24% had pregnancy thrice, while more than three times pregnancy were lesser in frequencies. The number of children ranged from 1 to 8, with decreasing frequencies as the number increases. The orders of children ranged from 1 to 8, 33% of them were first order, 20% were second order, and 23% were third order.

About 75% of participants never had an abortion, 16% had once, while 6% had twice, and 3% had three times. About 69% of participants considered their family income as moderate, and 28% considered it high whereas only 3% considered their family income low. About 46% of the studied infants were girls, and 54% were boys, out of which 70% of them were at the age of 2 months. About 67% of the infants were normally delivered, 87% are full term, and 66% of them were breastfed. In addition, 86% of the infants received the routine care, 14% had additional medical care, and 30% of the infants were through planned pregnancy. The score of the attachment ranged from 0 to 22, with a mean score of 5.4 (SD ± 4.6). About 4% of the participants (eight cases) had a score of over 20 and were negatively attached to their infants. 10% of the cases were of unclear attachment, and 86% were positively attached to their infants [Figure 1].
Figure 1: The degree of attachment frequencies

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The effect of various factors on the degree of attachment was compared, and statistical significance was evaluated at P < 0.001, which was higher in the educated women [Table 2]. The percentage of negative attachment was higher between uneducated and only primary educated mothers. The status of employment is a significant factor which affects the level of attachments among mothers. It established that homemakers were more negatively attached as compared to employed women. The attachment level in mothers who were students was not well established after this study, and it was ambiguous. The other critical factor to affect the degree of attachment was the gender of an infant (P = 0.001). The girl child attracts higher positive attachment; whereas in the case of the boy infant, the degree of attachments was either unclear or negative.
Table 2: The association of the degree of attachment with sociodemographic data

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Other factors, including the family income, the type of delivery, the type of feeding (breast or bottle-fed), the maturity of the baby (full term or premature), the care received by the baby (whether routine care or specific medical care), and whether the pregnancy is planned or not, had no statistically significant effect (P > 0.05) on degree of attachments [Table 2].

To establish the correlation between score achieved and factors, Spearman's correlation test was performed. High score represents more negative attachments whereas low score demonstrates positive attachments. The correlation between mother's age and score was weak correlation with correlation score of 0.24. A significant correlation between score and other factors including number of pregnancies (P = 0.019, correlation coefficient = 0.17), children (P = 0.002, correlation coefficient = 0.22), and order of the baby (P = 0.002, correlation coefficient = 0.22) was established; no significant impact of number of abortions was majored on the score (P = 0.9). There is also a significant correlation between the number of pregnancies, children, and order of the baby (which are all interconnected variables) and the score, with the P values 0.019, 0.002, and 0.002, respectively, with the correlation coefficient = 0.17, 0.22, 0.22, respectively, which means that there is a weak correlation between the number of pregnancies, children, and order of the child and the score achieved. The number of abortions is also tested; however, there is no statistically significant correlation with the score (P = 0.9) [Table 3].
Table 3: The correlation coefficient and significance of various factors with the total of score

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  Discussion Top

Mother–infant attachment or bonding is critical to social, emotional, and cognitive development of the child and failure of bonding in the postpartum period leads to abusive parenting. Kumar RC concluded that women who reported the absence of affection; felt sometime feeling of rejection, hate, neglect, or impulse to harm at least one of their infants/children.[9] These feelings initiated immediately after the birth and were children specific. These characteristics are commonly termed as “maternal bonding disorder.”

In this study, 4% of the participants (eight cases) scored more than 20 and were negatively attached to their infants. However, 86% of mothers were positively attached to their infants; whereas, the remaining 10% of the cases were unclear about attachments. Sahar A. Rizk also reported similar results from the region of Alexandria in Egypt. Where she found that about half (47.3%) of the mothers had positive attachment to their infants 1 month postnatally. Moreover, the negative attachment was recorded by 32% of mothers, while only one-fifth (20.7%) of them had unclear attachment.[11]

Rizk also concluded from her study that positive maternal-infant attachment was significantly higher among educated (50.8%), employed (52.7%), socially supported (61.1%), primigravidous (60.7%) and primiparous (58%) mothers having urban residency (53%), full-term (54.2%) breastfed (61.3%) boy (63.5%), planned pregnancy (58.4%), and no history of abortion (52.7%).[11] These observations are similar to the results our report regarding mother's education, occupation, gravidity, and parity.

In addition, the positive attachment in her study was more inclined toward boys; our study demonstrated higher inclination toward girls. This might be attributed to the effect of social and cultural differences. However, some factors, including social support, being a full-term baby, breastfeeding, pregnancy planning, and history of abortion, showed no significant effect on attachment, compared to Rizk study; however, these factors critically impacted mother's attachments.[11]

In a study carried out by Orün et al.,the median scores of Mother-to-Infant Bonding Scale were not changed with respect to few social determinants such as maternal age, education level, occupation, family structure (nuclear or extended), marital adjustment, and planned pregnancy.[12] In another study, Chen et al. explored perinatal attachment in naturally and infertility-treated pregnant women in Taiwan and reported that women, who became pregnant after fertility treatment, had higher maternal-fetus and maternal-infant attachment scores.[13] Therefore, it seems that pregnancy mode and level of education are the main factors which exert a significant impact on maternal-fetus attachment.

Alhusen recorded that the factors, such as family support, greater psychological well-being, and having an ultrasound, are linked with higher levels of maternal-fetal attachments; whereas the depression, substance abuse, and higher anxiety levels are commonly associated with lower levels of maternal-fetal attachments.[14] Besides, the Rossen et al. concluded that maternal depressive symptoms in second and third trimesters and stress in the second trimester were inversely related to poor mother-infant bonding 8 weeks postnatally.[15] A limitation of this study was the usage of a self-reported questionnaire to collect data about maternal-infant attachment, which was prone to recall bias.

  Conclusion Top

The psychological status of the mother is one of the governing factors which affect bonding during pregnancy and postpartum. Extensive care should be provided to pregnant women with high number of pregnancies especially if they are of lower level of education to help them avoid negative attachment with their infants. Our systemic study demonstrated that the effect of several maternal, infant, and social factors on maternal-infant attachment in Taif city.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Robson KM, Kumar R. Delayed onset of maternal affection after childbirth. Br J Psychiatry 1980;136:347-53.  Back to cited text no. 1
Kitamura T, Takegata M, Haruna M, Yoshida Y, Yamashita H, Murakami M, et al. The mother-infant bonding scale: Factor structure and psychological correlates of parental bonding disorders in Japan. J Child Fam Stud 2015;24:393-401.  Back to cited text no. 2
Edhborg M, Nasreen HE, Kabir ZN. Impact of postpartum depressive and anxiety symptoms on mothers' emotional tie to their infants 2-3 months postpartum: A population-based study from rural Bangladesh. Arch Womens Ment Health 2011;14:307-16.  Back to cited text no. 3
Brockington I. Maternal rejection of the young child: Present status of the clinical syndrome. Psychopathology 2011;44:329-36.  Back to cited text no. 4
Kokubu M, Okano T, Sugiyama T. Postnatal depression, maternal bonding failure, and negative attitudes towards pregnancy: A longitudinal study of pregnant women in Japan. Arch Womens Ment Health 2012;15:211-6.  Back to cited text no. 5
Beck CT. The effects of postpartum depression on maternal-infant interaction: A meta-analysis. Nurs Res 1995;44:298-304.  Back to cited text no. 6
Moehler E, Brunner R, Wiebel A, Reck C, Resch F. Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother-child bonding. Arch Womens Ment Health 2006;9:273-8.  Back to cited text no. 7
Nagata M, Nagai Y, Sobajima H, Ando T, Honjo S. Depression in the mother and maternal attachment – Results from a follow-up study at 1 year postpartum. Psychopathology 2003;36:142-51.  Back to cited text no. 8
Kumar RC. “Anybody's child”: Severe disorders of mother-to-infant bonding. Br J Psychiatry 1997;171:175-81.  Back to cited text no. 9
Muzik M, Bocknek EL, Broderick A, Richardson P, Rosenblum KL, Thelen K, et al. Mother-infant bonding impairment across the first 6 months postpartum: The primacy of psychopathology in women with childhood abuse and neglect histories. Arch Womens Ment Health 2013;16:29-38.  Back to cited text no. 10
Rizk SA. Factors associated with maternal-infant attachment one month postnatally. J High Inst Public Health 2012;42:103-18.  Back to cited text no. 11
Orün E, Yalçın SS, Mutlu B. Relations of maternal psychopathologies, social-obstetrical factors and mother-infant bonding at 2-month postpartum: A sample of Turkish mothers. World J Pediatr 2013;9:350-5.  Back to cited text no. 12
Chen CJ, Chen YC, Sung HC, Kuo PC, Wang CH. Perinatal attachment in naturally pregnant and infertility-treated pregnant women in Taiwan. J Adv Nurs 2011;67:2200-8.  Back to cited text no. 13
Alhusen JL. A literature update on maternal-fetal attachment. J Obstet Gynecol Neonatal Nurs 2008;37:315-28.  Back to cited text no. 14
Rossen L, Hutchinson D, Wilson J, Burns L, A Olsson C, Allsop S, et al. Predictors of postnatal mother-infant bonding: The role of antenatal bonding, maternal substance use and mental health. Arch Womens Ment Health 2016;19:609-22.  Back to cited text no. 15


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