A mother’s emotional relationship with her baby begins during her pregnancy. The mother’s feelings about her baby, described as bonding, typically grow and intensify after the baby’s birth and become the foundation of the mother’s relationship with her child.

Some studies have noted an association between postpartum depression and poor bonding. Kumar (1997) showed that women with postpartum depression had prolonged difficulties with bonding compared to women who were not depressed.  However, it must be recognized that poor bonding is not universal among women with postpartum depression and that women who are not depressed may also experience bonding difficulties.

A recent study has examined the association between postpartum depression and mother–infant bonding and bonding over the first year of the child’s life. Bonding was assessed using the Mother–Infant Bonding Scale (MIBQ) at four time points: 1–4 weeks, 9 weeks, 16 weeks and 1 year.

There was a strong association between scores on the MIBQ during the early weeks after birth and bonding scores at all other time-points. There was also a strong association between the EPDS scores at 4 weeks postpartum and the bonding scores at 1 year. However, logistic regression showed that early bonding, rather than early depression, was a stronger predictor of bonding at 1 year.

While one might argue that poor bonding is one aspect of postpartum depression, this study suggests that maternal depression is not necessarily a precursor to bonding difficulties.  New mothers without depression may experience bonding problems early on, and these problems persist over the first year of the child’s life.

In a very interesting discussion section, the authors point out that while many studies demonstrate that postpartum depression is associated with a risk of poorer cognitive and behavioral development of the child, it is not clear to what extent poor bonding contributes to this phenomenon. In a study using video to analyze the interactions between mothers and their infants at 2 months of age, Murray and colleagues found that depressed mothers were more likely to have problems interacting with their babies. However, it was the quality of this interaction at 2 months, not the depression score that predicted the cognitive functioning of the children at 5 years of age.

These studies raise some interesting and clinically relevant questions.

In women with postpartum depression, will simply treating the depression prevent the negative effects of maternal depression on the child?  Especially in depressed women with poor bonding during the early weeks, will the bonding difficulties persist after the depression is treated?

How exactly are depression and bonding problems related?  Does postpartum depression cause or contribute to bonding difficulties?  Or is it the other way around, where poor bonding precipitates or exacerbates depressive symptoms? In a review by Poobalan Aucott and colleagues, the authors noted that interventions involving both the mother and her child improved the mother’s feelings about her child, whereas treatments involving only the mother were found effective for depression but did not have a significant effect on the mother’s feelings towards her child.

In addition to psychotherapy and pharmacologic treatment, should we also consider interventions that enhance bonding?  In a randomized control trial of 117 depressed mothers, Horowitz and colleagues demonstrated that 8 weeks of interaction coaching significantly improved mother–infant interactions.

There is also the very interesting work coming out of Tiffany Field’s group.  Interaction coaching has been developed to help mothers improve their interactions with their babies by providing video feedback and giving them second-by-second suggestions as interactions occur (see Field 2006). These interventions have been shown to be effective in reducing depressive symptoms in the mother and improving the quality of interactions between the mother and her infant. Field has also demonstrated that teaching depressed mothers to massage their infants has resulted in less irritability and fewer sleep problems in the infants and better mother-infant interactions, as well as a reduction in the mothers’ depressive symptoms (Goldstein-Ferber, 2004).

The authors conclude that future studies will have to delineate different subgroups of women.  New mothers who are depressed and experience poor bonding may have different needs and may respond to different interventions than women who are not depressed but are nonetheless having difficulties with bonding.  Because bonding is so important for fostering secure attachment and the formation of subsequent meaningful relationships, we need to be attentive to these early problems with maternal-infant bonding, whether or not they occur within the context of maternal depression.

Ruta Nonacs, MD PhD

Goldstein-Ferber S. Massage Therapy sleep-wake rhythms in the neonate. In: Field T, editor. Touch and Massage in Early Child Development. New Jersey: Johnson & Johnson Pediatric Institute; 2004. pp. 183–189.

O’Higgins M, Roberts IS, Glover V, Taylor A.  Mother-child bonding at 1 year; associations with symptoms of postnatal depression and bonding in the first few weeks. Arch Womens Ment Health. 2013 Oct;16(5):381-9.

Poobalan AS, Aucott LS et al (2007) Effects of treating postnatal depression on mother infant interaction and child development: systematic review. Br J Psychiatry.  2007; 191(5):378–386.