Background: Mother-child bonding is rooted in the affective relationship between mother and child that is shaped during pregnancy and leads to the mental growth of infants. Objectives: This study was conducted to determine the relationship between mother-child bonding and maternal mental health in Ilam. Methods: In this descriptive-analytical study, 300 mothers in Ilam were selected using a two-stage cluster sampling method. The demographic characteristics questionnaire, the mother-infant bonding scale, Spielberger anxiety inventory, and edinburgh postnatal depression scale constituted the data collection instruments in this study, which were completed in the eighth to tenth postnatal week. Data were analyzed in SPSS via descriptive statistics (means and standard deviations) and inferential tests (t tests and ANOVA). Results: The results of this study revealed that the mean and standard deviation of the obtained mother-child bonding scores were 38.48Â±12.86. Weakened mother-child bonding and risk of child abuse comprised the highest and lowest frequencies, respectively. Mother-child bonding had a statistically significant association with mothers' state anxiety, trait anxiety, and depression, and these variables affected mother-child bonding (P < 0.05). Conclusions: Considering the relationship between mother-child bonding and maternal mental health, proper screening is required to pursue secondary prevention in pregnant mothers. In addition, it is essential to perform necessary interventions to improve maternal mental health to facilitate better mother-child bonding. Â© 2018, Journal of Comprehensive Pediatrics

Borji, M.

Nariman, S.

Otaghi, M.

Safari, S.

Shahbazi, F.

eprints Iran University of Medical Sciences

J Compr Ped. 2018 February; 9(1):e14014.Published online 2018 February 25.doi: 10.5812/compreped.14014.Research ArticleInvestigating the Relationship Between Mother-Child Bonding andMaternal Mental HealthMilad Borji,1 Fatemeh Shahbazi,2 Shahin Nariman,3 Masoume Otaghi,1 and Saeid Safari4,*1Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, IR Iran2Student Research Committee, Ilam University of Medical Sciences, Ilam, IR Iran3Department of Pediatrics and Neonatology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, IR Iran4Department of Anesthesiology, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, IR Iran*Corresponding author: Saeid Safari, Department of Anesthesiology, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9392117300,E-mail: drsafari.s@gmail.comReceived 2017 May 24; Revised 2017 December 08; Accepted 2018 February 14.AbstractBackground: Mother-child bonding is rooted in the affective relationship between mother and child that is shaped during preg-nancy and leads to the mental growth of infants.Objectives: This study was conducted to determine the relationship between mother-child bonding and maternal mental healthin Ilam.Methods: In this descriptive-analytical study, 300 mothers in Ilam were selected using a two-stage cluster sampling method. The de-mographic characteristics questionnaire, the mother-infant bonding scale, Spielberger anxiety inventory, and edinburgh postnataldepression scale constituted the data collection instruments in this study, which were completed in the eighth to tenth postnatalweek. Data were analyzed in SPSS via descriptive statistics (means and standard deviations) and inferential tests (t tests and ANOVA).Results: The results of this study revealed that the mean and standard deviation of the obtained mother-child bonding scores were38.48± 12.86. Weakened mother-child bonding and risk of child abuse comprised the highest and lowest frequencies, respectively.Mother-child bonding had a statistically significant association with mothers’ state anxiety, trait anxiety, and depression, and thesevariables affected mother-child bonding (P < 0.05).Conclusions: Considering the relationship between mother-child bonding and maternal mental health, proper screening is re-quired to pursue secondary prevention in pregnant mothers. In addition, it is essential to perform necessary interventions to im-prove maternal mental health to facilitate better mother-child bonding.Keywords: Mother-Child Bonding, Stress, Anxiety, Depression, Postpartum1. BackgroundMother-child bonding is rooted in the affective di-mension of the mother-infant relationship (1), which isshaped during pregnancy and leads to the mental growthand development of infants (2). Mother-child bondingis influenced by different factors, which are as follow:infant-related factors including delayed birth, breastfeed-ing, physical problems, and restlessness; parental factorsincluding attachment style, physical ailments, postpar-tum depression, and social support networks; and mater-nal mental health problems (3, 4).Mother-child bonding leads to a mother’s gentleness,warmth, concern, and care about her child’s health and itis characterized by maternal behavior, such as looking at,touching, smiling, and talking with the child (5). In fact,mother-child bonding facilitates children’s mental, affec-tive, and social health (6, 7). However, possible disruptionsin the formation of this bond will affect children’s develop-ment and result in the appearance of complications, suchas psychosocial disorders, avoidant personality disorder,separation anxiety disorder, failure to thrive, criminal ac-tivity, and/or borderline IQ (8, 9).In the postpartum period, mothers experience sev-eral physiological and psychological changes, which some-times lead to mental disorders. These postpartum men-tal disorders cause difficulties for the baby, the mother,and other family members. Also, postpartum depressioncan be a threat to the health and safety of the mother,the baby, and other family members (10-12). Indeed, post-partum depression is an important mood disorder that isthe cause of 12.5% of hospital admissions in women (13,14). Various factors, such as the instruments used to assessdepression, sample size, and cultural background, affectthe prevalence of postpartum depression, but the generalCopyright © 2018, Journal of Comprehensive Pediatrics. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided theoriginal work is properly citedBorji M et al.prevalence of this disorder has been reported to be highin several studies (14, 15). Anxiety is another common post-partum mood disorder, which is experienced by 20% to 15%of young mothers. If this disorder persists, it can exacer-bate the risk of postpartum depression (16-18).The results of several previous studies have shown thatmaternal postpartum depression has adverse effects onmother-child bonding and relationships (19). Previous re-search on the effect of depression in pregnant womenhas been mainly conducted in relation to mothers’ demo-graphic factors or other variables, such as unintended orintended pregnancy and gender of newborns (14), type ofdelivery (20), impact of anemia on depression (21), gesta-tional diabetes (22), diet (23), and social support (24). Thus,research on the relationship between mother-child bond-ing and mental health has become more important thanever. Only 2 studies have been performed in Iran on therelationship between mother-child bonding and mentalhealth. In one of these studies, only maternal depressionwas investigated. Galeshi et al. (2016) assessed maternaldepression in Tabriz (25) and Aflakseir and Jamali assessedmaternal depression and anxiety in Shiraz (19).2. ObjectivesGiven the importance of mother-child bonding andthe essential role of mental health in maternal health andconsidering the fact that few studies have been conductedin this field, the present study was conducted to determinethe relationship between mother-child bonding and ma-ternal mental health in Ilam in 2016.3. MethodsIn the present descriptive-analytical study, those moth-ers who were referred to the health centers in Ilam in 2016were assessed. The optimal sample size of 300 participantswas selected based on previous studies (25). A two-stagecluster sampling method was implemented in this study.Thus, each of the 10 clinics in Ilam was considered as a clus-ter, and 30 participants were enrolled in the study fromeach of the clusters. The inclusion criteria for participationin this study consisted of willingness to participate in thestudy, being at least literate, and having no history of men-tal disorder. The exclusion criteria included having a babywho died, the occurrence of an incident such as the deathor hospitalization of a family member, and the hospitaliza-tion of pregnant women due to delivery complications.In this study, the data collection instruments in-cluded the demographic characteristic questionnaire, themother-infant bonding scale (19), the Spielberger anxietyinventory (26), and the Edinburgh postnatal depressionscale (25-27), which were completed in the eighth to tenthpostnatal week. The mother-infant bonding scale was usedfor the early diagnosis of mother-child bonding disorder;it contains 25 items with 4 factors: rejection and anger (7items), anxiety about caring for the baby (4 items), weak-ened bonding (12 items), and risk of abuse (2 items). Theitems of this scale are scored using a Likert-type scale fromnever (0) to always (5). Finally, respondents obtain a scorebetween 0 and 125, with higher scores representing prob-lematic mother-child bonding. Previous studies have con-firmed the validity and reliability of this scale (19, 25).The Spielberger anxiety inventory consists of 40 ques-tions that measure state anxiety (20 items) and trait anx-iety (20 items). The items pertaining to state anxiety arescored using a Likert-type scale from very low (1) to veryhigh (4), and the items related to trait anxiety are scoredon a Likert-type scale from never (1) to always (4). For thisassessment tool, scores between 20 and 40 suggest mildanxiety, scores from 41 to 60 represent moderate anxiety,and scores from 61 to 80 suggest severe anxiety. The re-liability of this questionnaire was confirmed in BehroozMahram et al.’s study, with a Cronbach’s alpha coefficientof 0.91 (26). The Edinburgh Depression Scale contains 10four-choice questions, with ascending scoring from low tohigh intensity for items 1, 2, and 4, and descending scor-ing from high to low intensity for items 3, 5, 6, 7, 8, 9, and10. In this scale, each item is scored from 0 to 3 and the to-tal scores range from 0 to 30. Mothers who obtain a scoreabove 12 are considered to be depressed. The reliability ofthis assessment tool was examined and verified in Galeshiet al.’s (2016) study (25, 27).Considering the ethical aspects of this study, the re-searcher embarked on conducting the research after ob-taining permission from the ethics committee of Ilam Uni-versity of Medical Sciences. Participants were free to acceptor reject participation in the research. The participants inthis study were assured that their information would re-main confidential and that they would not need to providetheir names. Data were analyzed using descriptive statis-tics (means and standard deviations) and inferential tests(independent t-tests, ANOVA) at a significance level of lessthan 0.05.4. ResultsTable 1 presents the demographic results. As shown inthe most most mothers (n = 123, 49.2%) were high schoolgraduates (2/49) and were homemakers (n = 114, 45.6%).The mean scores and standard deviations for the 4mother-child bonding factors were as follow: risk of abuse(2.16± 1.77), anxiety about caring for the baby (7.02± 3.55),2 J Compr Ped. 2018; 9(1):e14014.Borji M et al.Table 1. Demographic Profile of Pregnant MothersVariable No. (%)EducationBelow diploma 78 (31.2)High school diploma 123 (49.2)University 49 (19.6)OccupationHousewife 114 (45.6)Self-employed 42 (16.8)Employed 63 (11.2)IncomeLess than 1 million 88 (35.2)Between 1 and 2 million 89 (35.6)More than 2 million 31 (12.4)Number of pregnancies1 98 (5.2)2 103 (5.2)3 or more 49 (5.2)Number of deliveries1 57 (22.8)2 48 (19.2)3 or more 15 (6)Spousal supportLow 66 (26.4)Average 105 (42)High 79 (31.6)Support of familymembersLow 13 (5.2)Average 13 (5.2)High 13 (5.2)Age, y 27.04 (6.4)Duration ofmarriage, y 2.78 (1.3)rejection and anger (17.16± 8.68), and weakened bonding(38.48 ± 12.86). The average total score for mother-childbonding was 66.04± 13.98.Table 2 demonstrates the results for maternal anxi-ety. The results indicate that most women have some de-gree of anxiety. The mean state anxiety and covert anxi-ety scores were well above average. The findings revealeda link among mother-child bonding scores and state anxi-ety and depression, as indicated by significant correlations(0 = 0.000).Table 2. Mean Scores for Anxiety of MothersVariable Without Slight Moderate Severe M± SDAnxietyStateanxiety36 (14.4) 43 (17.2) 100(40)71 (28.4) 46.23(23.13)Covertanxiety74(29.6)55 (22) 84(33.6)37 (14.8) 37.52(23.79)5. DiscussionThe findings of this research showed that most of themothers suffered from a mother-infant bonding disorder.A weakened bond was the most prevalent type and the leastcommon disorder was related to the risk of child abuse.In Galeshi et al.’s (2016) study, which was done in Tabriz(25), the highest and lowest levels of disorder pertainedto weakened bond and anxiety about caring for the baby,respectively. In Aflakseir and Jamali’s study in Shiraz (19),weakened bond was the most prevalent disorder, which isconsistent with the results of this study.Moreover, most of the mothers in this study were de-pressed. Similar findings were found in a number of stud-ies: Zangeneh et al.’s study on women in Kermanshahshowed that 40.7% of the participants suffered from de-pression (14); in Ghojazadeh et al.’s study in Tabriz, 34.7% ofthe participants were depressed (28); Salary et al.’s study inMashhad indicated that 9.9% of the participants sufferedfrom depression (15); and 23.7% of the participants in Khor-ramirad et al.’s study in Qom were found to be depressed(13). Various factors, such as living in developing countriesand cultural issues, were involved in the high prevalence ofdepression. In this regard, culture, beliefs, and traditionscan affect the incidence of postpartum depression (29, 30).The results of this study also revealed a statisticallysignificant relationship between depression and mother-child bonding. In other words, with the increase of depres-sion in mothers, mother-child bond disorders will also in-crease. This finding is consistent with that of the studiesconducted by Galeshi et al. in Tabriz (25) and Aflakseir andJamali in Shiraz (19) in which mother-child bonding dis-orders increased with the rise of depression in mothers.Bener et al.’s study in Qatar indicated that mothers withdepression did not establish a good relationship with theirchildren after childbirth (17). It seems that postpartum de-pression caused some changes in mother-child bonding,which is consistent with the results of the present study.One limitation of this study was the employment ofself-report measures, which may have affected the accu-racy of the data. Therefore, future studies should focus onthe diagnosis and clinical examination of depression. An-J Compr Ped. 2018; 9(1):e14014. 3Borji M et al.other limitation was that father-child bonding was not as-sessed; thus, future studies should also consider this vari-able.References1. Burgess KB, Marshall PJ, Rubin KH, Fox NA. 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Investigating the relationship between mother-child bonding and maternal mental health

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Investigating the relationship between mother-child bonding and maternal mental health

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