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. Author manuscript; available in PMC: 2026 May 5.
Published before final editing as: J Reprod Infant Psychol. 2026 Mar 3:1–17. doi: 10.1080/02646838.2026.2631181

Labor and Delivery Characteristics, Maternal Birth Satisfaction, and Early Relational Health Among COVID-19 Pandemic-Born Children

Jennifer M Warmingham 1, Andréane Lavallée 1, Marissa Lanoff 1, Jenna Russo 2, Ginger Atwood 1, Jill Owen 1, Charlee Manigat 1, Cristina R Fernández 1,3, Paul Curtin 1, Judy Austin 4, Ashley N Battarbee 5, Ann Bruno 6, Fatimah S Dawood 7, Sharon Ettinger 8, Kimberley Gani 1, Cynthia Gyamfi-Bannerman 9, Maha Hussain 1, Margaret Kyle 1, Seonjoo Lee 10,11,12, Panagiotis Maniatis 7, Rachel Marsh 10,12, Tyler Morrill 14, Mirella Mourad 3,13, Gabriella Newes-Adeyi 14, Lawrence Reichle 14, Tyler C Morrill 14, Vera Semenova 7, Wendy Silver 1,3, Alan T Tita 5, Michael Varner 6, Kristina Wielgosz 7, Melissa S Stockwell 1,3, Catherine Monk 10,13, Dani Dumitriu 1,3,10
PMCID: PMC13137259  NIHMSID: NIHMS2149630  PMID: 41777123

Abstract

Aims/Background:

Medical events during birth and self-reported birth experience may influence early relational health (ERH) in the postpartum period. Limited longitudinal work has been conducted in this area, particularly among women who gave birth during the COVID-19 pandemic. The goal of this study was to assess labor and delivery characteristics and maternal birth satisfaction as predictors of ERH domains of mother-reported bonding and observed emotional connection in the first year of life among women who gave birth during the COVID-19 pandemic.

Design/Methods:

Participants included mothers (n=384) with and without SARS-CoV-2 infection during pregnancy who gave birth at three U.S.-based academic medical centers who were enrolled in the Epidemiology of Severe Acute Respiratory Syndrome Coronavirus-2 in Pregnancy and Infancy COVID-19 Mother Baby Outcomes (ESPI COMBO) Study. Labor and delivery information was abstracted from medical records. Mothers completed surveys assessing birth satisfaction (2 months) and bonding (4 months postpartum). A remote (Zoom) video visit was conducted at 4-6 months postpartum and observed mother-infant emotional connection was coded using the Welch Emotional Connection Screen. We evaluated study aims using structural equation models.

Results:

Maternal and infant medical risk (e.g., maternal complications, unplanned cesarean deliveries, care escalation) were associated with lower maternal birth satisfaction, which in turn predicted lower mother-reported bonding and observed emotional connection in infancy.

Conclusion:

Results provide insight into perinatal determinants of early relational health among infants born during the COVID-19 pandemic and inform transdisciplinary clinical care approaches to support families and children in the transition to motherhood.

Keywords: early relational health, bonding, birth satisfaction, labor and delivery, COVID-19

Introduction

Women who gave birth during the COVID-19 pandemic experienced unique stressors. Infection prevention efforts altered hospital policies and intrapartum practices, which caused increased uncertainty and stress(Birnie & Baram, 2025). Rates of pregnancy-related medical complications also rose in the first year of the pandemic(Arora et al., 2020; Firestein et al., 2022; Janevic et al., 2021; Molina et al., 2022; Preis et al., 2022). Maternal satisfaction with the birth experience was also affected during the pandemic(Preis et al., 2022). Objective events that occurred during birth (e.g., medical interventions, pandemic-related changes to labor and delivery) and self-reported birth experience may each have an influence on downstream mother-infant early relational health (ERH), or the quality of the caregiver-infant relationship, in the first year of life(Adesanya et al., 2022; Babu et al., 2022; Döblin et al., 2023). Despite the intergenerational health implications of pandemic-related changes to the transition to motherhood, there are limited longitudinal studies investigating these processes within a pandemic cohort(Döblin et al., 2023; Mayopoulos et al., 2021).

Components of ERH include but are not limited to the quality of caregiving behavior(Rodrigues et al., 2021), children’s attachment to primary caregivers(Ranson & Urichuk, 2008), caregiver feelings toward their children and dyadic interaction quality(Harrist & Waugh, 2002). Each has implications for child social, cognitive, and emotional health and development both early in life(Forrer et al., 2024; Zhang et al., 2025) and throughout the lifespan(Englund et al., 2011; Sroufe, 2005). Because of the far-reaching impact on child health, ERH is recognized across disciplines (e.g., pediatrics, psychology, nursing, obstetrics) as a critical target of intervention to promote healthy child development(Dumitriu et al., 2023; Garner et al., 2021; Le Bas et al., 2022; Madigan et al., 2013; Raby et al., 2015; Zeanah & Lieberman, 2016). ERH is composed of multiple components that can be measured via mother/father report (e.g., surveys) or observation (e.g., coded behavior). The field lacks studies evaluating whether ERH components develop in concert via shared pathways or separately with unique contributors(Maas et al., 2016; Nakić Radoš, 2021). Most research on birth-related contributors to ERH has focused on the impact of mode of delivery on postpartum bonding, without considering other components of ERH, such as dyadic interaction(Binyamin et al., 2022; Döblin et al., 2023; Forti-Buratti et al., 2017; Poojari et al., 2019; Zanardo et al., 2016). Spontaneous vaginal delivery is typically associated with more positive bonding, and unplanned cesarean delivery has been associated with lower bonding(Döblin et al., 2023; Poojari et al., 2019). Self-reported experience of birth, usually measured with mother report of “birth satisfaction”(Gärtner et al., 2015; Sawyer et al., 2013; Schaal et al., 2019; Taheri et al., 2018), is defined by internal experiences that the mother feels (e.g., feeling in control, supported, and safe) that can be influenced by external factors (e.g., obstetric interventions, interactions with medical providers)(Brand & Gartland, 2024). Greater birth satisfaction is associated with positive mother-infant bonding(Smorti et al., 2020). Outside of research with preterm infants(Bilgin & Wolke, 2015), there is limited work investigating the possible associations between birth experience and observable/dyadic ERH.

Using a sample of mothers who gave birth during the COVID-19 pandemic in the United States, we evaluated the effect of objective and self-reported birth experiences on two components of ERH: mother-reported bonding and observed emotional connection assessed in the first year of life. We assessed mother-reported birth experience (birth satisfaction) as a mediator of the effect of objective birth experience on ERH outcomes. Drawing data from a multi-site U.S.-based cohort of mothers who gave birth in 2021 and including measurement of objective and self-reported maternal birth experience and multi-method assessment of ERH, this study is poised to advance knowledge about perinatal determinants of ERH among pandemic-born children.

Methods

Participants and Study Design

This is a secondary analysis of data from the CDC-funded Epidemiology of Severe Acute Respiratory Syndrome Coronavirus-2 in Pregnancy and Infancy (ESPI) Network Columbia University-based COVID-19 Mother Baby Outcomes (COMBO) Initiative study. The ESPI study was a prospective SARS-CoV-2 infection surveillance study that enrolled pregnant women from three academic medical centers in the U.S. (Columbia University Irving Medical Center [CUIMC], University of Alabama-Birmingham, and University of Utah)(Dawood et al., 2022). Women were eligible if they were pregnant at <28 weeks gestation; aged 18–50 years; willing to self-collect and mail mid-turbinate nasal swab specimens and respond to weekly surveillance contacts; willing to have data collected from their infants’ medical records at delivery; and able to speak and read either English or Spanish. Women were ineligible if they were enrolled in a COVID-19 or influenza vaccine clinical trial or intended to enroll in a trial during the current pregnancy. Appendix 1 describes SARS-CoV-2 status classification.

The ESPI COMBO study recruited ESPI participants who completed >40% of weekly ESPI surveillance procedures. Mothers enrolled in ESPI COMBO were invited to complete additional online surveys and remote video visits (via Zoom) with their infants 4-6 months postpartum. Participants were enrolled from May 2021 to December 2021. A total of 453 dyads (out of 689 approached) enrolled in the ESPI COMBO study. Although all mothers were invited to complete all ESPI COMBO study procedures, all study procedures were voluntary and therefore some mothers completed more study activities than others. Study procedures (video visits, surveys) were conducted in English and Spanish. This study was reviewed and approved by the CUIMC Institutional Review Board (IRB), which was the central IRB for data collection sites (CUIMC, University of Utah and University of Alabama at Birmingham IRBs) (See 45 C.F.R. part 46.114; 21 C.F.R. part 56.114). Written informed consent was completed by mothers prior to engagement in both ESPI and ESPI COMBO study procedures, including medical records abstraction. The current study includes N=384 mother-infant dyads (84.8% of N=453 enrolled in ESPI COMBO study) who had data on key study outcomes (i.e., completed birth satisfaction or bonding surveys).

Measures

Objective Birth Experience: Labor and Delivery Characteristics

Mode of delivery (unassisted vaginal delivery, assisted vaginal delivery, planned cesarean delivery, unplanned cesarean delivery), infant delivery complications (severe and non-severe categories; see Appendix 2), maternal delivery complications (severe and non-severe categories; see Appendix 2), prematurity, primiparity, single/multiple gestation, and Neonatal Intensive Care Unit (NICU) admission (yes/no) were extracted from medical records. Mothers completed the Coronavirus Perinatal Experiences-Impact Survey (COPE)(Thomason et al., 2020) at 6 months postpartum, reporting whether they experienced eight different changes to their birth plan due to the COVID-19 pandemic. For example: “Support people (e.g., partner, family) were not permitted to attend baby’s delivery.” Response options were yes/no.

Self-Reported Birth Experience: Birth Satisfaction

The Labor and Delivery Index (LADY-X)(Gärtner et al., 2015) is a self-report survey used to assess labor and delivery satisfaction that was completed by mothers at approximately 2 months postpartum. The LADY-X consists of seven items regarding: 1) availability of healthcare professionals, 2) information given by healthcare professionals, 3) having wishes taken seriously during childbirth, 4) emotional support provided by healthcare professionals, 5) feelings of safety, 6) concerns about the child’s health, and 7) duration until first contact with child. Each item has three response options (scored 0, 1, or 2) that describe different experiences. Higher scores indicate greater satisfaction. The LADY-X survey had adequate inter-item internal consistency in the whole sample (Cronbach’s α=.80) and in the subset who completed the instrument in Spanish (α=.79).

Early Relational Health

Maternal-Infant Bonding.

The Postpartum Bonding Questionnaire (PBQ) is a 25-item survey used to measure mother-infant bonding at approximately 4 months postpartum(Brockington et al., 2001). The validated Spanish language version of the PBQ was used for Spanish-speaking participants(Garcia-Esteve et al., 2016). Sample questions include “I feel close to my baby” and “I wish the old days when I had no baby would come back.” Mothers were asked to rate how often they agreed with these statements on a 5-point Likert scale that ranges from always (0) to never (5). The PBQ was scored based on Lavallée and colleagues’ analysis of the factor structure of the PBQ in broader COMBO Initiative study sample (N=690)(Lavallée et al., 2023). Specifically, 14 of the original 25 items were used to create a mean score (PBQ-R). The 14 items were summed to yield a total score, which was then divided by 14 to yield a mean. Lower scores indicate more positive bonding. Inter-item internal consistency for the PBQ-R was good (Cronbach’s α=.87).

Emotional Connection.

The Welch Emotional Connection Screen (WECS)(Hane et al., 2019) was used to code a 3-minute face-to-face interaction between mother and infant at the 4-6 month video visit. Mother-child interaction videos were recorded via Zoom and coded by experienced WECS coders using a standard score form. Coders assigned scores on subscales relevant to dyadic interaction quality: Attraction, Vocal Communication, Facial Expressiveness, and Sensitivity/Reciprocity. Subscales were summed to yield a total score, with higher scores indicating greater emotional connection (20% of videos were double coded independently for reliability; Intraclass correlation=0.98).

Covariates and Demographic Data.

Mothers self-reported depressive symptoms (3-6 months postpartum) via the PHQ-9(Kroenke & Spitzer, 2002). Demographic data (maternal race, ethnicity) were collected via an online survey at enrollment. Additional descriptive data (insurance status, infant date of birth, infant sex, NICU stay length, maternal age at delivery) were abstracted from medical records. Maternal SARS-CoV-2 status in pregnancy was ascertained via surveillance testing in the ESPI protocol(Dawood et al., 2022) using results from polymerase chain reaction (PCR) or serology testing, as previously described(Firestein et al., 2023). Three maternal SARS-CoV-2 statuses were created: negative test result, SARS-CoV-2 detected during pregnancy, and SARS-CoV-2 detected - timing unknown/outside of pregnancy (for SARS-CoV-2 testing and status algorithm, see Appendix 1).

Data Analysis

Preliminary Data Processing

This study collected a large amount of data (survey, medical record abstraction) regarding birth experience. We leveraged two analytic strategies to reduce the dimensionality. First, subgroups of mothers with similar objective birth experiences were identified using Latent Class Analysis (LCA) in Mplus (v8.6(Muthén & Muthén, 1998–2017)). The following variables were used as categorical indicators of the LCA model: NICU admission, single/multiple gestation, primiparity, maternal complications at delivery (severe/non-severe), infant complications (severe/non-severe), pandemic-related birth plan changes (yes/no), as well as mode of delivery (vaginal unassisted/vaginal assisted/planned cesarean delivery/unplanned cesarean delivery). Maternal birth satisfaction was modeled as a latent factor using a confirmatory factor analysis (CFA) model in R v.4.3.1(Team, 2023) (lavaan package(Rosseel, 2012)) that used the seven LADY-X items as indicators. See Appendix 3 for information about model specification and fit for both preliminary data processing steps. Data are reported in accordance with STROBE criteria for cohort studies(Von Elm et al., 2014).

Primary Analysis Plan

We used chi-squared difference tests and 1-way ANOVAS to evaluate differences in descriptive data across study sites and labor and delivery classes. Spearman’s rank correlation was used to evaluate the association between bonding and emotional connection. For the PBQ-R and LADY-X surveys, inter-item internal consistency was evaluated using Cronbach’s alpha(Bonett & Wright, 2015).

Longitudinal Associations: Labor and Delivery, Birth Satisfaction, and ERH.

We used a set of Structural Equation Models (SEMs) to test longitudinal associations between labor and delivery classes, birth satisfaction, and indices of ERH. In all models, missing data were handled via listwise deletion. Bonding and emotional connection were outcomes in separate models due to the discrepancy in sample size (fewer people completing video visit in which emotional connection was coded).

First, we evaluated the effect of labor and delivery class (objective birth experience) on ERH outcomes. Second, we evaluated the effect of birth satisfaction (self-reported birth experience) on ERH outcomes. Finally, we tested birth satisfaction as a mediator of the effect of labor and delivery classes on ERH outcomes. In all SEMs, covariates included study site (Utah/Alabama/New York), language of assessment (English/Spanish), and infant age at assessment. Maternal pregnancy SARS-CoV-2 status was entered as a predictor of birth satisfaction. For ERH outcomes, covariates included infant sex, maternal depressive scores, and WECS coder (for emotional connection). SEM global fit was evaluated for all models(Hu & Bentler, 1999; Kline, 2015). Goodness of model fit was determined by nonsignificant values of the χ2 statistic, values of the CFI greater than .95, SRMR values less than .08, and RMSEA values smaller than .05.(Hu & Bentler, 1999; Kline, 2015) RMediation(Tofighi & MacKinnon, 2011) was used to estimate asymmetric 95% confidence intervals (CIs) for indirect effects from labor and delivery class to ERH via birth satisfaction. Confidence intervals that did not include zero were interpreted as significant indirect effects.

Results

Participants

Mothers included (n=384) gave birth from 01/2021 – 09/2021. Based on ESPI surveillance testing (PCR, serology), 17.7% of mothers had SARS-CoV-2 detected in pregnancy, 15.9% had SARS-CoV-2 detected pre-pregnancy or timing unknown, and 66.4% did not have SARS-CoV-2 detected. See Table 1 for demographic and descriptive statistics overall and by study site. All mothers were offered participation in video visits, however only a subset opted into video visits and have usable data to code emotional connection (n=249). A smaller proportion of the New York site participants participated in video visits (48.6% for NY vs 72.2% Alabama and 68.6% Utah; p<.001).

Table 1.

Study sample characteristics across study sites.

Study Site
Overall
N(%) or M(SD)		 New York
N=105
N(%)		 Utah
N=207
N(%)		 Alabama
N=72
N(%)		 χ2 or F-stat p-value
Maternal Characteristics
 SARS-CoV-2 Status a 13.7 .008
  Detected during pregnancy 68 (17.7%) 21 (20.0%) 42 (20.3%) 5 (6.9%)
  Detected - timing unknown/pre-pregnancy 61 (15.9%) 17 (16.2%) 38 (18.4%) 6 (8.3%)
  Not detected (negative test results) 255 (66.4%) 67 (63.8%) 127 (61.4%) 61 (84.7%)
 Race 216.0 <.001
  Black or African American 43 (11.2%) 23 (21.9%) 1 (0.5%) 19 (26.4%)
  Native American or Alaska Native 1 (0.3%) 0 (0.0%) 1 (0.5%) 0 (0.0%)
  Native Hawaiian or Other Pacific Islander 2 (0.5%) 2 (1.9%) 0 (0.0%) 0 (0.0%)
  Asian or Asian American 8 (2.1%) 1 (1.0%) 6 (2.9%) 1 (1.4 %)
  White 249 (64.8%) 21 (20.0%) 181 (87.4%) 47 (65.3%)
  More than one race 19 (4.9%) 4 (3.8%) 12 (5.8%) 3 (4.2%)
  Other 25 (6.5%) 23 (21.9%) 1 (0.5%) 1 (1.4%)
  Declined or unknown 37 (9.6%) 31 (29.5%) 5 (2.4%) 1 (1.4%)
 Ethnicity
  Not Hispanic or Latina 278 (72.4%) 19 (18.1%) 190 (91.8%) 69 (95.8%)
  Hispanic or Latina 97 (25.3%) 80 (76.2%) 15 (7.2%) 2 (2.8%)
  Declined or unknown 9 (2.3%) 6 (5.7%) 2 (1.0%) 1 (1.4%)
 Insurance 35.9 <.001
  Medicaid (public) 101 (26.3%) 37 (35.2%) 63 (30.4%) 1 (1.4%)
  Private 275 (71.6%) 66 (62.9%) 139 (67.1%) 70 (97.2%)
  Other 7 (1.9%) 2 (1.9%) 5 (2.4%) 0 (0%)
  None 1 (.2%) 0 (0%) 0 (0%) 1 (1.4%)
Infant Characteristics
 Date of birth 1/2021 – 09/2021 1/2021 – 08/2021 1/2021 – 09/2021 1/2021 – 07/2021 - -
 Sex 3.6 .16
  Male 196 (51.1%) 51 (48.6%) 114 (55.1%) 31 (43.1%)
  Female 187 (48.8%) 54 (51.4%) 92 (44.4%) 41 (56.9%)
Delivery and Birth Characteristics
 Mode of delivery 70.5 <.001
  Vaginal Unassisted Delivery 241 (63.4%) 55 (52.9%) 143 (69.1%) 43 (62.3%)
  Vaginal Assisted Delivery 12 (3.2%) 3 (2.9%) 8 (3.9%) 1 (1.4%)
  Planned Cesarean Delivery 75 (19.7%) 46 (44.2%) 22 (10.6%) 7 (10.1%)
  Unplanned Cesarean Delivery 52 (13.7%) 0 (0.0%) 34 (16.4%) 18 (26.1%)
 Gestational Age (weeks) 38.80 (1.50)
Range: 28.86-41.14 weeks		 38.60 (1.60) 38.90 (1.48) 38.80 (1.39) 1.3 .26
  Extremely Preterm (<28 weeks) 0 (0%)
  Very Preterm (28 to less than 32 weeks) 2 (.52%) 0 (0%) 1 (.48%) 1(1.4%) 5.3 0.3
  Moderate to Late Preterm (32 to less than 37 weeks) 23 (6.0%) 10 (9.5%) 11 (5.3%) 2 (2.8%)
  Term (37 weeks or later) 358 (93.2%) 95 (90.5%) 194 (93.7%) 69 (95.8%)
 NICUb admission 50 (13.0%) 14 (13.3%) 28 (13.5%) 8 (11.1%) 0.3 0.9
  NICU admission length (days)c 11.0 (20.4) 10.5 (11.8) 12.0 (25.3) 8.3 (11.7) 0.1 0.9
 Maternal complications at delivery-severe 77 (20.1%) 10 (9.5%) 48 (23.2%) 19 (26.4%) 10.3 0.01
 Maternal complications at delivery-nonsevere 70 (18.2%) 18 (17.1%) 33 (15.9%) 19 (26.4%) 4.0 0.1
 Infant complications at delivery - severe 70 (18.2%) 6 (5.7%) 52 (25.1%) 12 (16.7%) 17.7 <0.001
 Infant complications at delivery - nonsevere 113 (29.4%) 5 (4.8%) 73 (35.3%) 35 (48.6%) 46.9 <0.001
 Multiparous delivery 9 (2.3%) 3 (2.9%) 5 (2.4%) 1 (1.4%) 0.4 0.8
 Birth plan changes due to COVID-19 162 (42.2%) 30 (28.6%) 106 (51.2%) 26 (36.1%) 16.0 <0.001
 SARS-CoV-2 detected at delivery (mother) 8 (2.1%) 2 (1.9%) 3 (1.6%) 3 (5.6%) 2.9 0.2
 Maternal age at delivery (years) 32.1 (5.1) 32.8 (5.5) 31.7 (5.2) 32.2 (4.0) 1.8 0.2
 Primiparity 163 (42.4%) 40 (38.1%) 95 (45.9%) 28 (38.9%) 2.2 0.3
Birth satisfaction (LADY-Xd total score) n=381 11.8 (2.5)
Range: 0–14		 11.6 (3.0) 11.8 (2.2) 12.2 (2.2) 1.9 0.15
Early Relational Health
 Postpartum Bonding (PBQ-R e ) n=374 1.8 (2.1)
Range: 0-2.1		 .98 (1.5) 2.1 (2.2) 1.8 (2.1) 10.8 <.001
 Emotional Connection (WECS f ) n=249 6.4 (1.7)
Range: 4-11.5		 6.3 (1.9) 6.5 (1.7) 6.2 (1.6) 0.98 0.7
Maternal Depression (PHQ-9 g ) n=371 3.8 (3.9)
Range: 0-22		 2.9 (3.8) 4.3 (3.9) 3.7 (3.9) 3.9 0.02
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a

SARS-CoV-2 Status determination procedure: After enrollment (during pregnancy), participants self-collected and submitted weekly mid-turbinate nasal swabs for SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing, completed weekly questionnaires about illness symptoms, and submitted additional mid-turbinate swabs with COVID-19-like symptoms. Participants also had serum collected at enrollment, at the end of the second trimester and at end of pregnancy for testing for SARS-CoV-2 antibodies.

b

NICU:Neonatal Intensive Care Unit

c

NICU admission length (days) computed only for those with NICU Admission documented in medical record (n=47).

d

LADY-X: Labor and Delivery Experiences; higher scores indicate more positive experience

e

PBQ-R: Postpartum Bonding Questionnaire - Revised (see Lavallee et al., preprinted 2022). Lower scores indicate better bonding.

f

WECS: Welch Emotional Connection Scale. Higher scores indicate greater emotional connection.

g

PHQ-9: Patient Health Questionnaire - 9 items. Higher scores indicate greater depressive symptoms.

Labor and Delivery Characteristics

Three classes of labor and delivery characteristics were identified by the latent class analysis model (N=384; See Appendix 3). Figure 1 shows item response probabilities in the 3-class solution (vs. sample mean). Classes are described below.

Figure 1. Labor and Delivery Characteristics: 3 Class Solution.

Figure 1.

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Item response probabilities (plotted; from 0-1.0) indicate the proportion with each labor and delivery characteristic within class.

NICU=Neonatal Intensive Care Unit; Vaginal Asst.= vaginal assisted delivery; Vaginal Unasst = vaginal unassisted delivery; Mat. Severe Comp. = Severe Maternal Complications; Mat. Non-Severe Comp.= Non-Severe Maternal Complicat ions; Inf. Severe Comp. = Severe Infant Complications; Inf. Non-Severe Comp. = Non-Severe Infant Complications

  1. Low Risk Delivery Class. The majority of the sample (72.1%) fell in this class, which was characterized by high rates of vaginal unassisted delivery (80.0%), low rates of NICU admission (0.04%), and low levels of maternal (6.1-13.0%) and infant complications (9.9-23%), as compared to the full sample. In this class, 2% of infants were born preterm, 36.0% of mothers were primiparous, and 40.0% of this class reported pandemic-related birth plan changes.

  2. Maternal High Risk Delivery Class (13.5%). Rates of maternal severe (54.0%) and non-severe complications (56.0%) were elevated in this class and the majority (76.0%) delivered via unplanned cesarean. Additionally, 77.0% of mothers were delivering their first child. Rates of NICU admission (6.8%) and preterm birth (6.2%) and infant complications (1.0% severe, 32.0% non-severe) were higher than the Low Risk Delivery Class, but not when compared to the overall sample rates.

  3. Infant High Risk Delivery Class (14.3%). The majority of infants in this class (76.0%) were admitted to the NICU, with 70.0% experiencing one or more severe infant complications and 55.0% experiencing non-severe infant complications. Maternal complications occurred at elevated rates (25.0% severe, 42.0% non-severe). Within this class, 8.6% were multiparous deliveries, 28.0% were born premature, 40.0% vaginal unassisted deliveries, 32.0% planned cesarean delivery, 21.0% unplanned cesarean delivery.

Birth Satisfaction

We estimated a confirmatory factor analysis (n=381; n=3 lost to follow up) using the seven items of the LADY-X survey as ordered categorical (levels: 0, 1, 2) indicators. Standardized factor loadings (λ) were all significant (ps<0.001) and ranged from 0.53-0.88, indicating good local fit. See Appendix 3 for more information about CFA estimation.

Primary Study Results

Appendix 3 presents demographic and key study variables across labor and delivery classes. There were no differences in the distribution of labor and delivery class across study site or maternal racial identity. A higher proportion of the Maternal High Risk Delivery Class identified as non-Hispanic/Latina (90.4%) as compared to the other labor and delivery groups (Infant High Risk Class: 70.91%; Maternal Low Risk Delivery Class: 69.31%, p=0.01). Those who participated in video visits did not differ from those who did not in labor and delivery class distribution or birth satisfaction total score.

ERH Components.

In the n=245 subjects with both bonding and emotional connection data, emotional connection and bonding were not correlated (r=0.048, p=0.45).

Objective Birth Experience and ERH.

In adjusted SEMs, labor and delivery classes did not significantly predict bonding (Maternal High Risk Delivery Class: β=0.029, p=0.51; Infant High Risk Delivery Class: β=−0.016, p=0.72; vs Maternal Low Risk Delivery Class) or emotional connection (Maternal High Risk Delivery Class: β=0.077, p=0.22; Infant High Risk Delivery Class: β=0.034, p=0.59; vs Low Risk Delivery Class).

Self-reported Birth Experience and ERH.

In adjusted SEMs, greater birth satisfaction predicted greater bonding (β=−0.15, p=0.002) and greater emotional connection (β=0.20, p=0.012).

Objective and Self-reported Birth Experience and ERH.

In the mediation model predicting bonding (N=368), membership in the Maternal High Risk Delivery Class (β=−0.20, p=0.001) and membership in the Infant High Risk Delivery Class (β=−0.23, p<.001) were each associated with lower birth satisfaction, as compared to the Low Risk Delivery Class. Lower birth satisfaction was associated with lower bonding (β=−0.16, p=0.001). Labor and delivery class was not associated with bonding (ps=0.28-0.83). The indirect effect from Maternal High Risk Delivery Class to bonding via birth satisfaction was significant (M=0.038, SE=0.016, 95% CI: 0.01 to 0.074). The indirect effect from Infant High Risk Delivery Class to bonding via birth satisfaction was also significant (M=0.042, SE=0.018, 95% CI: 0.012 to 0.082). Together, predictors accounted for a total of 33.3% variance in bonding (R2=.333). Model fit for this model was excellent (χ2(69)=82.30, p=0.13, CFI=0.99, TLI=0.99, RMSEA=0.02, SRMR=0.03)

In the mediation model SEM predicting emotional connection (N=245), membership in the Maternal High Risk Delivery Class (β=−0.24, p=0.001) and the Infant High Risk Delivery Class (β=−0.22, p=0.009) was associated with lower birth satisfaction when compared to the Low Risk Delivery Class. Lower birth satisfaction predicted lower observed emotional connection (β=.22, p=.008). The indirect effect from the Maternal High Risk Delivery Class to emotional connection via birth satisfaction was significant (M=−0.26, SE=0.13, 95% CI: −0.56 to −0.05), and the indirect effect from the Infant High Risk Delivery Class to observed emotional connection via birth satisfaction was also significant (M=−0.23, SE=0.13, 95% CI: −0.53 to −0.028). All predictors accounted for a total of 12.2% variance in emotional connection (R2=.122). Model fit for this model was excellent (χ2(99)=121.29, p=0.064, CFI=0.98, TLI=0.99, RMSEA=0.03, SRMR=0.05). See Figure 2 and Appendix 4 for all SEM results.

Figure 2. SEM Results.

Figure 2.

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Solid lines indicate ps<.05; dashed lines indicate p>=.05; standardized parameter estimates are presented.

Note: LADY-X: Labor and Delivery Experiences Questionnaire; PBQ-R: Postpartum Bonding Questionnaire (Revised); WECS: Welch Emotional Connection Screen; ref = reference group (dummy coded predictor); Maternal COVID Status: 1=detected ever, 0=not detected. Listwise deletion was used in SEMs. Cases were omitted from analysis if they were missing either predictor or outcome variables. See text and Table 1 for Ns (out of N=384) for each key variable

Discussion

This study evaluated the impact of maternal objective and self-reported birth experience on observed and maternal-reported indices of ERH in infancy among COVID-19 pandemic-born children and their mothers in the United States. Given the significant uncertainty faced by mothers who gave birth during the COVID-19 pandemic(Eri et al., 2022; Janevic et al., 2021), identifying factors that influence ERH will help clarify determinants of social and emotional development among those born during the COVID-19 pandemic. Results from this multi-site, longitudinal study show that labor and delivery patterns characterized by either maternal or infant medical risk were associated with lower maternal birth satisfaction, as compared with deliveries with low medical risk. We found that lower birth satisfaction, rather than objective birth characteristics, was associated with both lower mother-reported bonding and lower observed emotional connection in the first year of life. Birth satisfaction, a potentially modifiable factor related to earned provider trust, experience of control and of feeling respected, has implications for two-generation health through ERH outcomes.

Results highlight the independence of bonding and emotional connection, suggesting that these processes, although both influenced by birth satisfaction, are related but non-interchangeable components of ERH. This finding is consistent with the growing literature that frames ERH as an umbrella construct that includes multiple components, including parental feeling toward their children and dyadic processes(Dumitriu et al., 2023; Garner et al., 2021; Zhang et al., 2025). Consistent with our findings, existing studies that include multiple measures of ERH typically find that some measures of ERH are more correlated than others(Feldman & Eidelman, 2007). Because some components of ERH may develop or influence children differentially, studies that include multiple indices of ERH are needed to clarify the perinatal determinants of multiple aspects of ERH so that we can map the pathways of influence via ERH components to child health outcomes(National Academies of Sciences, 2025).

Maternal experiences of support and care in the intrapartum period are of critical importance to maternity care(Mohamoud, 2023). Here, we find that maternal birth satisfaction can carry over to affect the thoughts and feelings mothers experience toward their infants, captured by maternal report of bonding, as well as the quality of mother-infant emotional exchange during a dyadic interaction. This underscores the importance of multi-method assessment strategies to study ERH(Dumitriu et al., 2023). One strength of this study is the innovative home-based video assessment of dyadic interaction. Initially due to infection prevention efforts necessary because of the COVID-19 pandemic, remote video visits are flexible, allowing for inclusion of mother-infant dyads in child development research. They also lessen participant burden, thereby creating greater possibilities for expansion of multi-method assessment of ERH(Shields et al., 2021). In this study, it allowed for inclusion of participants across geographic areas of the United States to complete video visits with the same study team, further streamlining data collection and allowing for critical information to be collected about ERH during a global pandemic.

Contrary to prior findings suggesting medical characteristics of birth can be associated with mother-infant bonding(Forti-Buratti et al., 2017), we did not find direct associations between objective birth characteristics and ERH. However, the pattern-based approach to characterize labor and delivery experiences allowed us to test the impact of co-occurring medical events on birth satisfaction and ERH. This study’s results therefore extend prior results largely focused on the impact of preterm birth/NICU admission or mode of delivery on birth satisfaction and/or ERH(Bilgin & Wolke, 2015; Döblin et al., 2023; Smorti et al., 2020).

Risk for lower birth satisfaction, and subsequent decrements in ERH, was not only present among those who experienced significant infant medical risk (e.g., NICU admission, preterm), but also among primiparous mothers who experienced maternal complications and/or unplanned cesarean delivery. Mothers of infants delivered with medical complications and/or requiring NICU admission and those without severe infant complications who experience maternal delivery complications and/or emergency cesarean delivery may benefit from increased support and communication from their interdisciplinary team (e.g., nursing, obstetrics, pediatrics, social work) throughout their hospital admission and in the postpartum period. Doula services may also provide a positive bridge to promote communication and understanding between women giving birth and medical providers(Kozhimannil et al., 2016; Ramey-Collier et al., 2023). Structured preventive support programs for new parents (e.g., Practical Resources for Effective Postpartum Parenting (Werner et al., 2016)) also hold potential to help mothers process their birth experience, promote safe parenting, and strengthen ERH in the postpartum period. Taken together, these results suggest that even in a high-stress context, such as giving birth during the COVID-19 pandemic, positive relationships, trust, and open communication in the medical setting can pave the way for mothers to build positive relationships with their infants beginning early in life.

Limitations of the current study include any medical documentation differences during labor and delivery across the three hospital systems. Aside from controlling for study site in our models, we were not able to account for these differences or variation in how the three medical systems enacted COVID-19 infection prevention measures during labor and delivery over the course of the study(Arora et al., 2020). The ESPI-COMBO cohort also may not represent the general population of pregnant women during the COVID-19 pandemic as individuals who participate in cohort studies often differ from the general population and the ESPI-COMBO study selectively recruited women who had demonstrated high adherence to ESPI cohort surveillance procedures. Although the birth experience measure used here shows good test-retest stability at 8 weeks postpartum (Gärtner et al., 2015), one limitation includes retrospective recall bias of events during birth.

Conclusion

Identifying intergenerational determinants of ERH has high potential to guide interventions and policies aimed at promoting ERH to combat child adversity and promote positive developmental outcomes(Garner et al., 2021). Results highlight the importance of considering both the medical and experiential aspects of labor and delivery on mother-infant ERH in the first year of life. Transdisciplinary collaboration between medical professionals and researchers in obstetrics, pediatrics, nursing, and psychology is essential to further identify intervention targets in the perinatal period to promote positive health outcomes for mothers and children(Dumitriu et al., 2023; Monk et al., 2022).

Supplementary Material

Supplement

Funding:

This study was funded by the US Centers for Disease Control and Prevention through Contract # 75D30120C08150 with Abt Associates, and grants from the National Institute of Mental Health R01MH126531 (DD), the National Institute of Child Health and Human Development K99HD115784 (AL), Health Resources and Services Administration Fellowship T32HP10260 (JMW), and funding from the Einhorn Collaborative Gift Funds (DD).

Disclaimer:

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

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