Impact of perceived rearing and social support on bonding failure and depression among mothers: A longitudinal study of pregnant women
Introduction
Some mothers fail to establish an emotional bond with their newborns; this is termed bonding failure. Bonding failure is a major perinatal mental health concern that leads to a lack of maternal affection, increased irritability, aggressive impulses, or rejection of the infant (Brockington, 2011).
Between 4% and 12.2% of women in the general population have been reported to have poor bonding scores in the postpartum period (Taylor et al., 2005; Reck et al., 2006; Figueiredo et al., 2007; Bienfait et al., 2011). Bonding failure often starts during pregnancy and can persist beyond the first weeks or month of the postpartum period (O'Higgins et al., 2013; Ohara et al., 2017b). When bonding failure is severe, mothers may try to escape or seek permanent transfer of infant care within or outside of the family (Brockington, 2004). In addition, bonding failure may lead to abusive parenting (Alhusen et al., 2012; Ohashi et al., 2016), insecure interactions between the mother and infant (Hornstein et al., 2006), and disturbance of early childhood development (Edhborg et al., 2011). Therefore, from the standpoint of the perinatal care, it is important to identify risk and protective factors for bonding failure and to intervene at an early stage.
Maternal depression is one of the major factors associated with bonding failure. In longitudinal studies, significant positive relationships have been found between bonding failure and postnatal depression (Nagata et al., 2003; Moehler et al., 2006; Dubber et al., 2015; Nonnenmacher et al., 2016; Matsunaga et al., 2017). In addition, in a previous report, we performed path analysis to examine the causal relationship between bonding failure and depression during pregnancy and the postpartum period and reported that bonding failure predicted depressive mood in both (Ohara et al., 2017b).
Past investigations, however, may not have been free from flaws. Although many researchers have suggested that these two issues might be confounded by other variables (Yoshida et al., 2012; Alhusen et al., 2013; Dubber et al., 2015; Kitamura et al., 2015), confounding factors between bonding failure and depression have not been fully considered, so it remains unclear whether bonding failure leads to maternal depression or vice versa, or if these two issues are confounded by other variables. Based on the above, we also previously examined the associations between bonding failure, depression, and social support among mothers (Ohara et al., 2017a). We entered social support among mothers into structural equation modeling (SEM) as a confounding factor between bonding failure and depression, and found that social support during pregnancy had a great influence on bonding failure and depression in the postpartum period. However, we further speculate that another possible confounding factor in addition to social support may exert differential influences on bonding failure and depression. To this end, longitudinal follow-up studies incorporating causal path models are still required. The first research question of the present study therefore concerns the possible causative links between perinatal bonding failure and depression, as well as search for potential confounding factors.
Perceived rearing (one's own memories of being raised) has been examined as the key to understanding psychological adjustment or maladjustment. A number of studies have been conducted on the link between perceived rearing and depression in adulthood (Handa et al., 2009; Kitamura and Tanaka, 2012). In previous studies, perceived rearing has been measured using the Parental Bonding Instrument (PBI) (Parker et al., 1979). The PBI has two factors: Care and Overprotection. Using the PBI, a series of studies by Parker et al. reported that PBI results could be related to some psychiatric conditions; for example, neurotic depression was found to be characterized by low Care and high Overprotection scores (Parker, 1981, 1983; Plantes et al., 1988). Inadequate parental rearing style characterized by low Care or high Overprotection was shown to be related to depression among women in the perinatal period (Kitamura et al., 1999; McMahon et al., 2005). Recently, one longitudinal study reported a significant correlation between low Care and postpartum depression (Hayakawa et al., 2012).
Bonding failure may be linked to perceived rearing; however, few studies have investigated this issue, and reported that the recollection of a negative child-rearing history was associated with maternal bonding problems towards the infant in the postpartum period. Choi et al. (2010) reported that low maternal care during parents' own childhoods was associated with greater bonding difficulties with their own infants. Similarly, Williams et al. reported that the effects of recalled parenting experiences during childhood on the current bonding towards an infant were mediated by metacognition (Williams et al., 2016). However, these studies were cross-sectional; therefore, causality has not been determined.
Recently, one longitudinal study reported that mothers' bonding difficulties with their newborn infants were predicted by their own child-rearing history (Hall et al., 2015). They performed path analysis to elucidate the link between perceived child-rearing history and emotional bonding in the postpartum period, suggesting that low care would predict poor bonding with their newborn infant; however, they examined perceived rearing and bonding failure simultaneously in the postpartum period. Therefore, it remains unclear whether perceived rearing during pregnancy predicts bonding failure in the postpartum period. To address this issue, it is essential to assess bonding failure and perceived rearing prospectively during pregnancy and the postpartum period.
Furthermore, Mikulincer & Florian (1998) reported that in stressful situations, individuals with positive recollections of their own child-rearing history are more inclined to seek support from significant others (such as one's own parents). This report led us to speculate that perceived rearing might be correlated with social support. The second research question of the present study concerns the potential link between perinatal bonding failure, depression, social support, and perceived rearing. We were particularly interested in whether care or overprotection of perceived rearing is important in understanding perinatal mental health and social support, and whether there are differential effects of care and overprotection on the onset of bonding failure and depression, respectively.
In summary, the present study aimed to further investigate causal relationships between the four variables of perinatal bonding failure, depression, social support, and perceived rearing in childhood. To our knowledge, this is the first study to examine prospectively the impact of two aspects of perceived rearing (care and overprotection) and social support during pregnancy on bonding failure and depression in the postpartum period. We therefore devised the three following hypotheses. The first and most important hypothesis was that bonding failure and depression in the postpartum period would be predicted by perceived rearing and social support during pregnancy. The second was that bonding failure and depression at one time point in the perinatal period would predict each other at a later time point. The third and final hypothesis was that depression would lead to bonding failure or vice versa in the perinatal period.
Section snippets
Ethics statement
The study protocol was explained to all participants both verbally and in writing, and written informed consent was obtained from each participant. This study was approved by the ethics committees of Nagoya University Graduate School of Medicine, Kaseki Hospital, Nagoya Teishin Hospital, and Royal Bell Clinic. The study was conducted in accordance with the established ethical standards of all institutions. The authors assert that all procedures contributing to this work complied with the
Demographics
The mean (±SD) age of the participants was 32.4 (±4.4) years. There were 642 (75%) primiparas and 208 multiparas (five did not specify). The mean (±SD) of their partners was 34.5 (±5.5) years and the mean number of children was 0.30 (±0.57).
Correlations of the variables used in this study
The means and SDs of all the variables used in this study and their correlations are shown in Table 1. CARE (both father and mother) was negatively correlated with both the MIBQ and the EPDS subscales over both periods, except for the correlation between
Discussion
The aim of the present study was to elucidate the causal relationships between the four variables of bonding failure, depression, social support among mothers, and perceived rearing. In a large cohort of pregnant women, we examined prospectively the impact of two aspects (perceived rearing and social support) during pregnancy on bonding failure and depression in the postpartum period.
A main finding of this study was the link between perceived rearing during pregnancy and bonding failure in the
Conclusion
The findings of the present study showed that bonding failure in the postpartum period was significantly influenced by mothers' own perceived rearing as well as social support during pregnancy. In addition, depression in the postpartum period was strongly influenced by social support during pregnancy. These results suggest that psychosocial interventions that focus on both mothers' recollections of their own upbringing and social support during pregnancy are effective for preventing bonding
Contributors
Conceived and designed the experiments: SM, SG, AK, and NO. Performed the experiments: MO, YN, TS, AY, CK, and MM. Contributed reagents/materials/analysis tools: MO, YN, TS, AY, CK, and MM. Analyzed data: MO, MN, RK, MA, and NO. Wrote the paper: MO, MN, TO, BA, and NO. All authors contributed to and have approved the final manuscript.
Disclosure statement
The authors have no conflicts of interest directly relevant to the content of this article.
Role of the funding source
Funding for this study was provided by research grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan; the Ministry of Health, Labour and Welfare, Japan; the Academic Frontier Project for Private Universities, Comparative Cognitive Science Institutes, Meijo University; the Core Research for Evolutional Science and Technology; an Intramural Research Grant (21B-2) for Neurological and Psychiatric Disorders from the National Center of Neurology and Psychiatry and
Conflicts of interest
The authors have no conflicts of interest directly relevant to the content of this article.
Acknowledgements
We would like to express our gratitude to the staff of Nagoya University Hospital, Nagoya Teishin Hospital, Kaseki Hospital, and Royal Bell Clinic for their cooperation. We are also grateful to Dr. T. Kitamura for his technical advice.
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