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. Author manuscript; available in PMC: 2025 Jan 2.
Published in final edited form as: Matern Child Health J. 2024 Jan 2;28(1):11–18. doi: 10.1007/s10995-023-03873-4

The Protective Role of Maternal-Fetal Bonding for Postpartum Bonding Following a NICU Admission

Lucia Ciciolla 1, Karina M Shreffler 2, Ashley N Quigley 1, Jameca R Price 3, Karen P Gold 3
PMCID: PMC11195440  NIHMSID: NIHMS1999402  PMID: 38165585

Abstract

Introduction

Admission of a newborn to a neonatal intensive care unit (NICU) can be a highly stressful event that affects maternal psychological well-being and disrupts the early maternal-infant bonding relationship. Determining factors that promote maternal-infant bonding among those with a NICU admission is essential for the development of effective interventions.

Methods

Using a longitudinal clinic-based sample of diverse and low-income pregnant women, we examined whether maternal-fetal bonding measured during the second trimester moderated the association between NICU admission and postpartum bonding measured at six months post birth, controlling for demographic characteristics.

Results

Approximately 18% of the sample experienced a NICU admission at birth. NICU admission was associated with lower postpartum bonding (b = −8.74; p < .001, Model 1), whereas maternal-fetal bonding was associated with higher bonding reported at six months postpartum (b = 3.74, p < .001, Model 2). Results of the interaction revealed that women who reported higher maternal-fetal bonding reported higher postnatal bonding regardless of NICU admission status.

Discussion

Because maternal-fetal bonding can be enhanced through intervention, it is a promising target for reducing the risks of NICU admission for the early maternal-infant relationship.

Keywords: NICU, Neonatal, Pregnancy, Bonding, Postpartum, Attachment

Introduction

Each year, approximately 1.5 million newborns (10–15% of all babies born) are admitted to the Neonatal Intensive Care Unit (NICU) in the U.S. (Harrison & Goodman, 2015). A considerable body of research has documented negative psychological consequences for parents who have children in the NICU, including increased stress, depression, and anxiety (Alkozei et al., 2014; Bonacquisti et al., 2020; Lefkowitz et al., 2010; Wyatt et al., 2019). The potential implications of a NICU admission are therefore profound, as maternal psychological well-being promotes early mother-infant bonding (Kinsey & Hupcey, 2013) and infant attachment security (Coyl et al., 2002), which are essential for the child’s subsequent development and well-being (Zeanah, 2018). Recent evidence using a national sample points to NICU admission as a risk factor for increased odds of diagnosed attachment disorder by five years of age (Upadhyaya et al., 2020).

Fortunately, emerging evidence suggests that parent-infant relationship-based interventions designed to enhance sensitive, nurturing caregiving can reduce the risk for disruptions in bonding and disorganized attachment with moderate to large effects (Cohen’s d ranging from 0.30 to 0.84) (Bernard et al., 2012; Cicchetti et al., 2006; Steele & Steele, 2017). Moreover, many NICU programs incorporate attachment and relationship-based interventions to support parental engagement and improve infant developmental outcomes (Klawetter et al., 2019; Kim & Kim, 2022). Therefore, exploration of modifiable prenatal factors that can buffer the adverse impacts of NICU admission on the early mother-infant relationship is critical. Maternal-fetal bonding (MFB), referring to the affectionate feelings a mother develops for her baby during pregnancy (Brandon et al., 2009; Cranley, 1981; Muller & Mercer, 1993), is one such factor. MFB serves as a direct indicator for maternal sensitivity and the postpartum mother-infant relationship (Maas et al., 2016; Rossen et al., 2019) and is responsive to interventions (de Jong-Pleij et al., 2013; Ji et al., 2005; Nishikawa & Sakakibara, 2013; Sandbrook & Adamson-Macedo, 2004; Shreffler et al., 2019).

In this study, we used a longitudinal sample of women recruited during pregnancy to examine the association between NICU admission and postpartum bonding six months after birth. We hypothesize that (1) NICU admission should reduce postpartum bonding; and (2) MFB should moderate the impact of NICU admission at birth for postpartum bonding. These research questions attempt to lay the groundwork for future prenatal interventions designed to enhance the early maternal-infant relationship when there is a risk for disrupted bonding.

Methods

Sample

Data for the current study came from a longitudinal, urban, clinic-based prospective study involving 177 pregnant women (ages 16–38) recruited in 2017–2018 at their first prenatal visit. The participating clinics serve a racially diverse and medically underserved patient population in which the large majority (nearly 90%) reported utilization of public insurance for their prenatal care. The sample for the current study was restricted to the 116 participants who completed the 6-month post-birth survey and responded to the question about NICU admission. Attrition was greatest between the first and second trimester; the majority of known reasons for attrition were due to pregnancy loss.

Procedure

The overall goal for the data collection was to examine causal mechanisms for the relationship between maternal stressors during pregnancy and subsequent maternal and infant well-being. Data for the current study were collected across six time points, beginning in the first trimester of pregnancy, and continuing through six months postpartum. See Fig. 1 for a flowchart of screening, eligibility, and participation across assessment. Informed consent procedures and enrollment were done in person at recruitment during the first prenatal visit. Participants were eligible for the study if they were less than 16 weeks pregnant at their first appointment and planning to give birth and retain custody of their children. Participants were ineligible if they could not read and participate in English or Spanish. Participants were compensated $50 for participation in the first assessment, and $40 for each subsequently completed survey (electronic). All recruitment and study procedures were approved by IRB. Participants were contacted via cell phone texts and emails with links to additional online surveys in each trimester of pregnancy and postpartum. Participants were compensated within 24 h of completing a survey assessment using a ClinCard (reloadable debit card).

Fig. 1.

Fig. 1

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Screening, eligibility, and participation rates of study participants

Measures

Participants provided demographic information as part of the first survey assessment, which occurred at the first prenatal appointment (average gestation age of 10 weeks). Education was measured as a continuous variable representing number of years in school, ranging from 8 to 19. Due to little variation in income among the sample, an indicator of economic hardship was used instead. Economic hardship was measured using six questions utilized in previous national studies (see Johnson et al., 2009), including the following: In the past year, did any of the following happen to you or members of your household because of a shortage of money… “Could not pay electricity, gas, or telephone bills on times?”; “Could not pay the mortgage or rent on time?”; “Pawned or sold something?”; “Went without meals?”; “Was unable to heat home?”; “Asked for financial help from friends and family?”; “Asked for help from welfare/community organizations?” Responses were coded as 0 = “no” and 1 = “yes” and were summed for a total score ranging from 0 to 6, with higher scores indicating a higher level of economic hardship. Union status was coded such that those who were married/cohabiting were coded as 1 and all others coded as 0. Maternal age in years was included as a continuous variable. Due to the potential association between pregnancy intentionality and maternal-fetal bonding (Shreffler et al., 2021), we also controlled for whether or not the pregnancy was unintended based on two survey questions (0 = pregnancy was reported to have been planned or that the participant had been trying to become pregnant; 1 = pregnancy was reported to be unplanned or that the participant was trying to avoid pregnancy).

Maternal-fetal bonding was measured at the second assessment, occurring in the second trimester of pregnancy. The Prenatal Attachment Inventory (Muller & Mercer, 1993; Siddiqui et al., 1999) is a 21-item self-report measure used to assess maternal-fetal bonding. Items are rated on a 4-point scale (1 = almost never; 4 = almost always) assessing maternal thoughts and behaviors towards the fetus (e.g., ‘I feel love for the baby’ or ‘I stroke the baby through my tummy’). Higher scores indicate higher maternal-fetal bonding, and prior studies have found the scale to be valid across diverse cultural contexts (Foley et al., 2021). Cronbach’s alpha for the scale in this sample is 0.93, indicating excellent reliability.

NICU admittance was measured approximately one month after birth in the fourth assessment as a stand-alone variable, coded yes (1) or no (0) to the question, “Did your baby/babies spend any time in the neonatal unit?”

Postpartum bonding was measured in the sixth survey assessment, occurring at six-months postpartum. The Postpartum Bonding Questionnaire (Brockington et al., 2006) is a 25-item scale assessing the mother’s feelings or attitudes toward her baby (e.g., “I feel close to my baby”). Items are rated on a 5-point scale (1 = always; 4 = never) and scores were recoded such that higher scores indicate higher perceived bonding. The PBQ is one of the most widely tested and validated measures of postpartum bonding, particularly in diverse samples (Mathews et al., 2019). Cronbach’s alpha for the scale in this sample is 0.88, indicating good reliability.

Hierarchical multiple regression analysis was run using Mplus 8.1 (Muthén & Muthén, 1998–2017), with full information maximum likelihood (FIML) estimation to handle missing data (Enders, 2010). The analysis included NICU admission in Model 1, maternal-fetal bonding in Model 2, demographic variables as covariates in Model 3, and the interaction term [NICU admission X maternal-fetal bonding] in Model 4. Covariates included maternal age, economic hardship, education, married/cohabiting union status, and pregnancy intentions.

Results

Descriptive statistics on study variables and demographics for the full sample are presented in Table 1, along with descriptives according to NICU hospitalization. Participants were 25.16 (SD = 5.54) years old on average and approximately 20% of the sample had more than a high school education (M = 12.99, SD = 2.17). The majority of infants were male (56.3%) and 62.1% of mothers reported being married or cohabiting. Approximately 42.1% of the sample reported identifying as White, 29.8% as Black, 17.5% as Native American, and 10.5% as Hispanic (not shown). The racial/ethnic breakdown of the sample is similar to demographics reported in the 2020 Census for the urban area where data collection occurred (NICWA, 2022).

Table 1.

Descriptive statistics and mean comparisons of key study variables according to NICU hospitalization (N = 116)

Variable Total sample NICU admission No admission Range ANOVA FNICU or Chi-Square
n = 116 n = 21 n = 91
M (SD) or %(n) M (SD) or %(n) M (SD) or %(n)
Maternal-fetal bonding 63.27 (12.51) 66.33 (10.36) 62.56 (12.9) 36–84 1.56
Postpartum bonding 121.99 (10.76) 114.74 (18.46) 123.47 (7.74) 58–129 11.37**
Education 12.99 (2.17) 13.38 (2.16) 12.89 (2.17) 8–19 0.85
Economic hardship 1.47 (1.81) 1.75 (2.2) 1.41 (1.72) 0–6 0.57
Married/Cohabiting 62.1% (72) 61.9% (13) 62.1% (59) 0–1 0.00
Age 25.7 (5.47) 27.0 (6.09) 25.4 (5.31) 16–38 1.47
Unintended pregnancy 58.3% (67) 61.9% (13) 57.4% (54) 0–1 0.14
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Note:

**

p < .01

Descriptive statistics suggest that those with a newborn admitted to the NICU at birth reported significantly lower levels of postpartum bonding at 6-months postpartum (M = 114.74 vs. M = 123.47 for those without a NICU admission). Maternal-fetal bonding rates among those who later experienced a NICU admission were somewhat higher than those who did not experience a NICU admission (M = 66.33 vs. M = 62.56, respectively), though the difference was not significant. There were no significant demographic differences between those who experienced a NICU admission and those who did not.

Regression results suggest a similar pattern, with NICU admission predicting significantly lower postpartum bonding (b = −8.74, p < .001). Higher levels of maternal-fetal bonding, however, were associated with higher levels of postpartum bonding (b = 3.74. p < .001). These associations were unchanged when controlling for education, economic hardship, union status, maternal age, and pregnancy intentions. An interaction between NICU admission and maternal-fetal bonding was statistically significant (b = 10.62, p < .001). The coefficient of the interaction term reflects the difference in slope between the NICU admission group and the group with no NICU admission (i.e., 0.55-0.21 =0.34). When NICU = 0, a one unit increase in MFB is, on average, associated with 0.21 units increase in PBQ. When NICU = 1, a one unit increase in MFB is, on average, associated with 0.55 units increase in PBQ. A probe of the interaction showed that a NICU admission was particularly detrimental to postpartum bonding for mothers who reported low levels of maternal-fetal bonding during pregnancy. At high levels of maternal-fetal bonding, however, postpartum bonding among mothers with hospitalized infants did not differ from postpartum bonding levels among mothers whose infants did not require NICU hospitalization. See Table 2 for the regression results and Fig. 2 for the interaction depicted visually.

Table 2.

Hierarchical multiple regression model estimating postpartum bonding (N = 116)

Model 1
 Model 2
 Model 3
 Model 4
b SE ß b SE ß b SE ß b SE ß
Constant 123.47** 1.06 - 123.78** 1.0 - 127.04** 7.84 - 129.93** 7.6 -
NICU Admission −8.74** 2.57 −0.35 −9.51** 2.42 − 0.34 − 9.09** 2.38 − 0.33 −10.08** 2.26 − 0.36
Maternal-Fetal Bonding 3.74** 0.96 0.33 3.53** 0.95 0.32 2.31* 0.95 0.21
Education 0.07 0.55 0.02 − 0.11 0.54 − 0.02
Economic Hardship − 0.92* 0.53 − 0.16 − 0.82 0.50 − 0.14
Married/Cohabiting −1.81* 1.93 − 0.08 −1.75 1.81 − 0.08
Age − 0.12 0.19 − 0.06 − 0.15 0.18 − 0.08
Unintended pregnancy 2.08 2.0 0.10 2.31 1.89 0.11
[NICU X MFB] Interaction 10.62** 2.8 0.34
R squared = 0.10 R squared = 0.20* R squared = 0.26** R squared = 0.35**
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Note: NICU Admission (1 = yes; 0 = no). MFB = Maternal Fetal Bonding. Married/Cohabiting (1 = yes; 0 = no). Unintended pregnancy (1 = yes; 0 = no)

*

p < .05;

**

p < .001

Fig. 2.

Fig. 2

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Interaction effect of maternal-fetal bonding and NICU admission status on postpartum bonding scores

Discussion

Numerous studies have documented the adverse psychological consequences of a NICU admission for maternal well-being and the development of the early mother-infant bonding relationship. This study builds upon extant literature and examines longer-term outcomes (e.g., bonding at six months postpartum) and the potential protective role of maternal-fetal bonding.

As highlighted above, our results indicate that compared to those with no NICU admission, postpartum bonding at six months post birth is lower among those who experienced a NICU admission, and the association persists after controlling for demographic characteristics including socioeconomic status. Further, results indicate that maternal-fetal bonding is protective for postpartum bonding, mitigating potentially adverse effects associated with a NICU admission. Specifically, women who reported feeling more bonded to their baby during their second trimester of pregnancy also had higher levels of postpartum bonding at six months postpartum, regardless of NICU admission status. This finding is important because it points to a protective factor that has been shown to be responsive to interventions designed to rapidly increase feelings of maternal-fetal bonding, which previously have incorporated ultrasounds, fetal kick counting, listening to the fetal heartbeat, and attachment/mindfulness-based exercises (de Jong-Pleij et al., 2013; Ji et al., 2005; Nishikawa & Sakakibara, 2013; Sedgmen et al., 2006; Shreffler et al., 2019).

The findings are aligned with previous research suggesting long-term impairment in maternal-infant relationships and well-being following NICU hospitalization (Grunberg et al., 2019; Lean et al., 2018). However, previous research has been methodologically limited. For example, most studies on outcomes associated with a NICU admission have been conducted in the hospital setting shortly after birth, or they do not include prenatal data because participants are generally not recruited until they have experienced a NICU admission (Wyatt et al., 2019). Moreover, studies examining longer-term outcomes typically do not include a comparison group of non-NICU admission families (e.g., Grunberg et al., 2019; Lean et al., 2018). Thus, the current findings expand on previous research and overcome these limitations by utilizing a prospective, longitudinal sample that includes those who experienced a NICU admission as well as those who did not.

Still, there are several limitations to this study. The clinical cohort sample was diverse but not representative of the broader metropolitan area; for example, the sample was predominately low-income. The sample size was also small, limiting the number of control variables that could be included in the multiple regression analysis, although the response rate is comparable to other cohort studies of low-income and diverse populations (Nicholson et al., 2015). Despite sample limitations, retention rates were fairly high, especially following childbirth, perhaps due in part to the rapid payments for participation made possible by the use of reloadable debit cards. There may be additional factors associated both with NICU admission and postpartum bonding that were not measured, such as maternal psychopathology, substance use, and maternal health problems (McNamara et al., 2019; Roque et al., 2017; Vanderbilt et al., 2018). Future studies should examine whether the findings presented here might differ based upon context, such as maternal mental health or substance use disorder. Additionally, our sample was limited by having few NICU admissions, so we could not separate out those with longer stays vs. one or two-day stays or examine differences by reason for admission. Longer NICU stays or infant health conditions that might result in the need for ongoing care following a NICU stay have the potential to impact postpartum bonding (Bieleninik et al., 2021; Medina et al., 2018) and should be assessed in future studies. Finally, all data were self-reported and may be subject to measurement error or social desirability bias; for example, parents tend to report behaviors perceived as “good parenting” over those considered “bad parenting,” regardless of their actual behaviors (Lovejoy et al., 1997; Sessa et al., 2001). Parents may not accurately remember the circumstances surrounding NICU admissions and length of time in the NICU. Future studies should include electronic health record data where possible to more fully capture NICU admission rates and reasons.

Despite these limitations, the prospective ability to examine how maternal-fetal bonding mitigates the impact of a NICU admission on postpartum bonding six months after childbirth provides important insights for the early maternal-infant relationship and clinical practice. In the future, implementing screenings for pregnant women regarding their feelings of attachment during pregnancy would allow their health care providers to give them resources or potentially intervene to increase feelings of maternal-fetal bonding. NICUs could also provide resources or interventions designed to promote the early caregiver/infant relationship and reduce long-term risks to the parent-child relationship associated with NICU hospitalization. Public health programs and community-based organizations for maternal-child health (e.g., WIC, Healthy Start, Centering Pregnancy, etc.) could include programming and educational resources designed to promote reflective parenting and the early bonding relationship. Enhancing the maternal-infant relationship as early as possible should promote maternal and child well-being.

Significance.

What is Already Known on this Topic?

The experience of a NICU admission is associated with adverse maternal psychological functioning, which in turn has been found to disrupt the early maternal-infant relationship.

What this Study Adds?

Maternal-fetal bonding is protective for postnatal bonding when there is a NICU admission. Screening for and enhancing maternal-fetal bonding might be a critical target for intervention.

Acknowledgements

An earlier version of this paper was presented at the 2021 annual conference of the Society for Research in Child Development. The authors would like to thank the HATCH Project participating clinics and participants for their support and engagement.

Funding

This research was supported in part by the National Institute of General Medical Sciences of the National Institutes of Health (P20GM109097; Jennifer Hays-Grudo, PI). K.M. Shreffler was supported by the Cyndy Ellis-Purgason Endowed Chair in Child Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsors were not involved in the study design, collection, analysis, interpretation of findings, the writing of this report, or the decision to submit the article for publication.

Footnotes

Code Availability Not applicable.

Ethical Approval This study was approved by the authors’ university Institutional Review Boards. The authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent to Participate Written informed consent or assent was obtained from all individual participants included in the study. Among participants younger than 18 at the time of enrollment, informed consent was obtained from legal guardians.

Consent for Publication Not applicable; The data are presented in the aggregate.

Conflict of Interest The authors have no conflicts of interest to disclose.

Data Availability

The data are available from the corresponding author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data are available from the corresponding author upon request.

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