. 2019 Apr 29;15:1745506519844044. doi: 10.1177/1745506519844044

Table 15.

Characteristics of the studies included in the evaluation of bonding/attachment between mother and infant.

First author’s name	Sociodemographic data: 1. Country 2. Maternal mean age 3. Gender of newborn	Sample size	Design: 1. Study design 2. Time of follow-up 3. Number of groups 4. Description of groups	Tool used to assess PPD	Prevalence of PPD	Outcomes	Type of consequences
Mother-to-infant bonding
Dubber²⁹	Germany Mean age: 32.8 ± 4.4 years Female babies: 51.9%	80	Cohort study 21 weeks Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 13)	Not given Mean EPDS: 4.36 ± 3.86	Postpartum bonding	Maternal education, MFAS, PRAQ-R, EPDS, and STAI-T were significantly correlated with the PBQ-16. The final regression mode revealed that maternal–fetal bonding (B = −0.076, SE = 0.026, p < 0.01) and postpartum depressive symptoms (B = 0.529, SE = 0.183, p = 0.01) remained significant for explaining postpartum bonding. The results support the hypothesized negative relationship between maternal–fetal bonding and postpartum maternal bonding impairment as well as the role of postpartum depressive symptoms.
Edhborg⁴⁷	Bangladesh Mean age: 24.6 ± 6.1 years Female babies: 50.8%	671	Cohort study 3 months Four groups: - Depressive symptoms - Anxiety symptoms - Both depressive and anxiety symptoms - Neither depressive nor anxiety symptoms	EPDS (Depressed = EPDS ⩾ 10)	Depressive symptoms: 11%; anxiety symptoms: 35%; both depressive and anxiety symptoms: 3.4%; neither depressive nor anxiety symptoms: 51%	Maternal emotional bonding to the infant	In the adjusted model, maternal depressive symptoms showed a direct association with the mother’s emotional bonding to the infant, indicating a negative impact on maternal bonding to the infant if the mother shows depressive symptoms 2–3 months postpartum.
Figueiredo⁸²	Portugal Mean age: 26.6 years Female babies: 47.6%	315	Cross-sectional study Three groups: - Positive bonding - Negative bonding - Unclear bonding	EPDS (Depressed = EPDS ⩾ 13)	EPDS > 9: 15.7% EPDS > 13: 5.9%	Emotional involvement; bonding	Lower emotional involvement with the newborn was observed when the mother was unemployed, unmarried, had less than a grade-9 education, had previous obstetrical/psychological problems, or was depressed, and when the infant was female, had neonatal problems, or was admitted to the intensive care unit. Lower total bonding results were significantly predicted when the mother was depressed and had a lower educational level; being depressed, unemployed, and single predicted more negative emotions toward the infant as well.
Korja⁵⁶	Finland Mean age: 28.8 ± 5.05 years Female babies: 43.0% NB: mothers of preterm infants	30	Cohort study 6 months Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 13)	12.6%	Mother–infant interaction	PCERA scores on the maternal positive affective involvement scale (p = 0.03) and maternal positive communication scale (p = 0.009) were lower in mothers with depressive symptoms compared to mothers who did not have symptoms of depression. The number of depressive features did not affect any of the infant scales. In dyadic variables, mothers with depressive symptoms had slightly, but not statistically significantly, lower scores on dyadic mutuality scales (p = 0.09) and dyadic flatness scales (p = 0.06).
Korja⁵⁴	Finland Mean age (years): Preterm infants: 28.3 ± 5.1 Full-term infants: 28.2 ± 4.8 Female babies (%): Preterm infants: 45 Full-term infants: 49 NB: mothers of preterm and full-term infants	83	Cohort study 1 year Two groups: - Preterm infants - Full-term infants	EPDS (cut-off value not given)	Not given	Maternal attachment representations (balanced, disengaged, and distorted)	The relationship between the EPDS score and the main three representation categories (balanced, disengaged, and distorted) showed that the mean score on the EPDS was higher for the mothers in the distorted category (M = 8.69, SD = 6.42) than for the mothers in the disengaged (M = 5.50, SD = 3.00) and balanced (M = 5.27, SD = 3.9) categories (χ² = 6.62, p = 0.037).
Lanzi⁵²	USA Mean age: 19.8 years Female babies: 53.5%	660	Cohort study 11 months Four groups: - No depression - Mild-to-moderate depression - Moderate-to-severe depression - Severe depression	BDI	23.7% of mild-to-moderate depression; 7.5% of moderate-to-severe depression; 2.7% of severe depression	Contingent responsiveness and general verbalness; maternal warmth and sensitivity	For each grouping of mothers, the data suggested that as depression increased, both the mothers and the babies scored less favorably on warmth and sensitivity.
Lilja⁴⁴	Sweden Mean age: 27.8 years Gender of newborn: not given	419	Cohort study 1 year Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 10)	22.2%	Women’s mood over the first year postpartum; women’s relationship with their infant; women’s relationship with their partner	The mothers who scored high on the EPDS 10 days postpartum rated their relationship less positive on the infant relationship scale throughout the entire first year (at 6 months and 1 year) compared with the mothers who scored low on the EPDS 10 days postpartum. Mothers who scored high on the EPDS on day 3 scored significantly lower on the infant relationship scale on day 3 (t = −4.269, p < 0.001) and day 10 than mothers with low EPDS scores on day 3 postpartum (t = −4.074, p < 0.001). This relationship was not found at 6 and 12 months postpartum. In addition, women with depressive symptoms showed less closeness and warmth and experienced more difficulties in their relationship with their child during the first year.
McMahon⁶⁴	Australia Mean age: 31.4 ± 4.2 years Female babies: 47.0%	111	Cohort study 11 months Three groups: - Never depressed - Brief depression - Chronic depression	CIDI	68.8%: 33.9% of brief depressed and 34.8% of chronic depressed	Insecure state of mind regarding attachment	Mothers diagnosed as depressed were more likely to have an insecure state of mind regarding attachment. Logistic regression analyses (secure vs insecure) revealed a significant main effect for depression group (Wald χ²(2) = 6.47, p < 0.05). Chronically depressed mothers were significantly more likely than never depressed mothers to be classified as having an insecure state of mind regarding attachment (Wald χ²(1) =5.44, p < 0.025, OR = 4.03), with a similar but nonsignificant trend (after Bonferroni correction) emerging when briefly depressed mothers were compared with never depressed mothers (Wald χ²(1) = 4.01, p < 0.05, OR = 3.01).
Moehler⁶¹	Germany Mean age: 33.3 years Female babies: 45.0%	101	Cohort study 14 months Two groups: - PPD - No PPD	EPDS; SCL-90-R	Not given	Maternal bonding to the infant and child	Maternal depressive symptoms at 2 weeks, 6 weeks, and 4 months postnatally, but not at 14 months, were found to be strongly associated with lower quality of maternal bonding to the infant and child from 2 weeks to 14 months postnatal age. EPDS scores at 4 months were correlated with bonding at 2 weeks (r = 0.28), 6 weeks (r = 0.39), 4 months (r = 0.35), and 14 months (r = 0.28). Mothers with postnatal depressive symptoms at 4 months postnatal age had more negative bonding patterns starting before 2 weeks postnatally and lasting at least until 14 months postnatally. Even mild and unrecognized maternal depressive symptoms had a significant impact on maternal bonding if they occurred during the first four months of life.
Muzik⁴³	USA Mean age (years): Event+: 29.26 ± 5.93 Event–: 28.3 ± 5.15 Gender of newborn: not given	150	Cohort study 5 months Two groups: - PPD - No PPD	PDSS	Not given	Mother–infant bonding	All women, independent of risk status, showed increased bonding with their infant over the first 6 months postpartum; however, women with postpartum psychopathology (depression and PTSD) showed consistently greater bonding impairment scores at all time points.
O’Higgins³⁴	UK Mean age: 33.5 years Female babies: 45.5%	79	Cohort study 1 year Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 13)	63.3%	Mother-to-infant bonding	A comparison of the bonding scores for the depressed and the nondepressed groups (defined by the EPDS score at 4 weeks) showed differences between them in the early weeks (1–4 weeks: p < 0.001), at 9 weeks (p = 0.001), at 16 weeks (p < 0.5), and at 1 year postnatal (p < 0.05). Women who scored ⩾13 on the EPDS at week 4 were 5.13 times more likely to experience poor bonding (MIBQ ⩾ 2) at the same time (p < 0.01). Both EPDS at 4 weeks and bonding in the early weeks were associated with bonding at 1 year. However, when both factors were entered simultaneously into a logistic regression, only the early bonding scores predicted bonding at 1 year (p < 0.01).
Orün³¹	Turkey Mean age: 25.1 ± 5.2 years Female babies: 54%	189	Cohort study 2 months Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 12) BSI	16.9%	Mother-to-infant bonding	The PBQ score was significantly correlated with depression (r = 0.225, p = 0.002). Significant correlations were found between the MIBS and EPDS scores (r = 0.377, p < 0.001) and between the PBQ and EPDS scores (r = 0.449, p < 0.001). The MIBS score was correlated with the depression subscales of the BSI (r = 0.150, p = 0.041). Mother–infant bonding and later interaction were associated with maternal psychopathologies, especially PPD.
Vliegen³⁷	Belgium Mean age (years): T1: 29.39 ± 4.40 T2: 32.95 ± 4.51 Gender of newborn: not given	41	Cohort study 3.5 years Two groups: - PPD - No PPD	BDI-II (Depressed = BDI ⩾ 13)	39%	Maternal depression; treatment after hospitalization; life events; relationships	Regarding emotional availability, a significantly lower level of mutual attunement was observed, but no differences were found in the other indices of emotional availability.
Infant-to-mother bonding
Korja⁵⁶	Finland Mean age: 28.8 ± 5.05 years Female babies: 43.0% NB: mothers of preterm infants	30	Cohort study 6 months Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 13)	12.6%	Mother–infant interaction at 6 and 12 months corrected age	PCERA scores on the maternal positive affective involvement scale (p = 0.03) and the maternal positive communication scale (p = 0.009) were lower in mothers with depressive symptoms. The number of depressive features did not affect any of the infant scales (evaluated as expressed positive and negative affect and characteristic mood, behavior/adaptive abilities, activity level, and communication skills). In dyadic variables, mothers with depressive symptoms had slightly but not statistically significantly lower scores on the dyadic mutuality scales (p = 0.09) and the dyadic flatness scales (p = 0.06).
Lanzi⁵²	USA Mean age: 19.8 years Female babies: 53.5%	660	Cohort study 11 months Four groups: - No depression - Mild-to-moderate depression - Moderate-to-severe depression - Severe depression	BDI	23.7% of mild-to-moderate depression; 7.5% of moderate-to-severe depression; 2.7% of severe depression	Babies’ warmth-seeking (toward their mothers); babies’ attention and arousal	For each grouping of mothers, data suggested that as depression increased, both the mothers and the babies scored less favorably on each significant domain. For the total sample of mothers, analyses indicated that depression explained a significant portion of the unique variance in the children’s warmth-seeking (B = −13, p < 0.01).
McMahon⁶⁴	Australia Mean age: 31.4 ± 4.2 years Female babies: 47.0%	112	Cohort study 11 months Three groups: - Never depressed - Brief depression - Chronic depression	CIDI	68.8%: 33.9% of brief depressed and 34.8% of chronic depressed	Insecure child attachment; disorganized child attachment	Infants of chronically depressed mothers were significantly more likely than infants of mothers who had never experienced depression to be classified as insecure (p < 0.025, OR = 3.31), while infants of briefly depressed mothers did not differ from infants of mothers who had never been depressed. 17% of the infants of never-depressed mothers were classified as disorganized or unstable-resistant, compared to 18% of the infants of briefly depressed mothers and 40% of the infants of mothers in the chronically depressed group. Neither the logistic regression analysis nor the planned comparisons results were significant.
O’Higgins³⁴	UK Mean age: 33.5 years Female babies: 45.5%	79	Cohort study 1 year Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 13)	63.3%	Mother–infant bonding	A comparison of the bonding scores between the depressed and the nondepressed groups showed a difference in the early weeks (1–4 weeks, p < 0.001), at 9 weeks (p = 0.001), at 16 weeks (p < 0.5), and 1 year postnatal (p < 0.05). Women who scored ⩾13 on the EPDS at week 4 were 5.13 times more likely to experience poor bonding (MIBQ ⩾ 2) at the same time (p < 0.01).
Orün³¹	Turkey Mean age: 25.1 ± 5.2 years Female babies: 54%	189	Cohort study 2 months Two groups: - PPD - No PPD	EPDS (Depressed = EPDS ⩾ 12) BSI	16.9%	Mother-to-infant bonding	The PBQ score was significantly correlated to depression (r = 0.225, p = 0.002). The MIBS score was correlated with the depression subscales of the BSI (r = 0.150, p = 0.041). Significant correlations were also found between the MIBS and EPDS scores (r = 0.377, p < 0.001) and between the PBQ and EPDS scores (r = 0.449, p < 0.001).
Tharner¹⁰⁶	The Netherlands Age: ±32 years Female babies: 49.9%	627	Cohort study 1 year Two groups: - PPD - No PPD	EPDS (Depressed = EPDS > 12)	8.5%	Infant attachment (attachment insecurity and disorganization)	Postnatal depressive symptoms were not related to attachment insecurity or disorganization at 14 months.
Tomlinson¹²⁷	South Africa Age (years): <20: 15.3% 20–24: 26.5% 25–29: 32.7% 30–39: 25.5% Female babies: 44.9%	147	Cohort study 16 months Two groups: - PPD - No PPD	SCID	34.7% at 2 months 12.4% at 18 months	Infant attachment	Postpartum depression at 2 months and indices of poor parenting at both 2 and 18 months were associated with insecure infant attachment. The critical 2-month predictor variables for insecure infant attachment were maternal intrusiveness and remoteness, and early maternal depression. When concurrent maternal sensitivity was considered, the quality of the early mother–infant relationship remained important, but maternal depression was no longer predictive.

PPD: postpartum depression; EPDS: Edinburgh Postnatal Depression Scale; BDI: Beck Depression Inventory; CIDI: Composite International Diagnostic Interview; SCL-90-R: Symptom Checklist-90—Revised; PDSS: Postpartum Depression Screening Scale; BSI: Brief Symptom Inventory; SCID: Structured Clinical Interview for DSM-IV; MFAS: Maternal–Fetal Attachment Scale; PRAQ-R: Pregnancy Related Anxiety Questionnaire—Revised; STAI-T: State-Trait Anxiety Inventory—Trait version; PBQ-16: Postpartum Bonding Questionnaire-16; PCERA: Parent–Child Early Relational Assessment; OR: odds ratio; SD: standard deviation; PTSD: posttraumatic stress disorder; MIBQ: Mother–Infant Bonding Questionnaire; MIBS: Mother-to-Infant Bonding Scale.