Arch Womens Ment Health DOI 10.1007/s00737-015-0522-3
ORIGINAL ARTICLE
Association between parental depressive symptoms and impaired bonding with the infant Birgitta Kerstis 1,2 & Clara Aarts 2 & Carin Tillman 3 & Hanna Persson 4 & Gabriella Engström 5 & Birgitta Edlund 2 & John Öhrvik 1,6 & Sara Sylvén 4 & Alkistis Skalkidou 4
Received: 1 October 2014 / Accepted: 17 March 2015 # Springer-Verlag Wien 2015
Abstract Impaired bonding with the infant is associated with maternal postpartum depression but has not been investigated extensively in fathers. The primary study aim was to evaluate associations between maternal and paternal depressive symptoms and impaired bonding with their infant. A secondary aim was to determine the associations between parents’ marital problems and impaired bonding with the infant. The study is part of a population-based cohort project (UPPSAT) in Uppsala, Sweden. The Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks and 6 months postpartum and the Postpartum Bonding Questionnaire at 6 months postpartum were completed by 727 couples. The prevalence of impaired bonding was highest among couples in which both spouses had depressive symptoms. Impaired bonding was associated with higher EPDS scores in both mothers and fathers, as well as with experiencing a deteriorated marital relationship. The association between maternal and paternal impaired bonding and the mothers’ and fathers’ EPDS scores remained significant even after adjustment for relevant confounding factors. Depressive symptoms at 6 weeks postpartum are associated * Birgitta Kerstis
[email protected] 1
Centre for Clinical Research, Uppsala University, Västmanland County Hospital, S-721 89 Västerås, Sweden
2
Departments of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
3
Department of Psychology, Uppsala University, Uppsala, Sweden
4
Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
5
Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
6
Department of Medicine, Karolinska Institute, Stockholm, Sweden
with impaired bonding with the infant at 6 months postpartum for both mothers and fathers. It is critical to screen for and prevent depressive symptoms in both parents during early parenthood.
Keywords Bonding . Depressive symptoms . Fathers . Infant . Mothers . Relationship
Introduction Worldwide, depressive symptoms are common following childbirth. The prevalence of postpartum depression (PPD) is reported to be 4.5–20 % in mothers (Bennett et al. 2004; O’Hara and McCabe 2013; Wickberg and Hwang 1997) and 3–10 % in fathers (Kerstis et al. 2012; Massoudi et al. 2013; Paulson and Bazemore 2010). However, studies of paternal PPD are scarce compared with those investigating depressive symptoms in new mothers (Bradley and Slade 2011; Edward et al. 2014). For mothers, the highest rates of depressive symptoms occur early after childbirth whilst fathers more often develop symptoms when the child is 3 to 6 months old (Paulson and Bazemore 2010). There is a moderate positive association between maternal and paternal depression (Paulson and Bazemore 2010). Maternal PPD risk factors include a history of depression, anxiety and depression during pregnancy, postpartum blues, stressful life events, experiencing a poor marital relationship and difficult infant temperament (O’Hara and McCabe 2013; Patel et al. 2012). Risk factors for fathers are a history of depression and depression in their spouse (Ramchandani et al. 2008). Bonding reflects a process originating from the parent and directed towards the infant (Crouch and Manderson 1995); this should not be confused with attachment, which is reciprocal with the infant’s proximity seeking (Kaplan and Sadock
B. Kerstis et al.
1995). A lack of bonding can lead to rejection of the infant and in the most severe cases may cause feelings of wanting to harm the infant (Kumar 1997). Mothers with PPD sometimes fail to bond with their infant (Moehler et al. 2006; O’Higgins et al. 2013), and PPD can also affect their ability to cope and to engage positively with the infant (Murray et al. 2003). During the last decades, there has been a change in the perception of the father, from being less bonded than the mother to their child, to having a caregiving role and being bonded to their infant (Ainsworth 1989; Johansson 2011). However, few studies have examined paternal bonding. A Swedish study found an association between depressive symptoms and impaired bonding in both mothers and fathers, and that impaired bonding was related to depressive symptoms in the spouse (Edhborg et al. 2005). Disturbed father–infant interaction can cause poor psychological and physiological health as well as educational difficulties (Ramchandani et al. 2013). Therefore, it is important to include both mothers and fathers in studies. There are several gender-based differences between mothers and fathers including relationship roles, access to resources, activities and constraints that they face relatively to each other (World Health Organization 2002). Both women and men actively construct and reconstruct the norms of femininity and masculinity (Courtenay 2000), which can create conflicts and problems during early parenthood. There is an association between having a negative marital relationship and maternal and paternal depression postpartum (Ramchandani et al. 2011). Further, higher potential of marital separation is associated with both maternal and paternal depressive symptoms (Kerstis et al. 2014). Preoccupation with their marital conflict also appears to impair both parents’ child-rearing practices (Krishnakumar and Buehler 2000). Greater closeness between the father and child predicts a lower likelihood for marital separation (Schindler and Coley 2012). However, most depressive symptom and bonding studies assess only the mothers’ experiences. Against this background, our primary aim was to determine whether there is an association between depressive symptoms and both parents’ impaired bonding with their infant. A secondary aim was to determine whether marital relationship problems are associated with impaired maternal and paternal bonding with the infant.
for women from nearby counties with high-risk pregnancies. The study was approved by the Ethics Board in Uppsala (Dnr: 2006/150). Population The current analyses included 727 couples from the UPPSAT project. As part of the UPPSAT project, all women and their partners delivering from May 2006 to June 2007 at the Uppsala University Hospital were asked to participate in a study of postpartum depression. In total, 2318 new mothers were included in the UPPSAT project, representing 60 % of those eligible. Exclusion criteria were not being able to communicate adequately in Swedish, an unwillingness to share their personal data and intra-uterine demise or if the infant was admitted immediately to the neonatal intensive care unit. Participating couples in present study completed the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks and 6 months postpartum, and the Postpartum Bonding Questionnaire (PBQ) factor 1 at 6 months (n=727). Data collection and procedure At 6 weeks postpartum, questionnaires including EPDS were mailed to the mothers and fathers. Mothers also answered socio-demographic questions. At 6 months postpartum, the couples received the EPDS and the PBQ as well as items about their relationship and sick-leave. No reminders were sent. Edinburgh Postnatal Depression Scale (EPDS) The EPDS is a screening instrument used primarily in health care facilities to identify postpartum depressive symptoms in women (Cox et al. 1987). The scale has been translated into several languages, including Swedish (Lundh and Gyllang 1993) and validated internationally on mothers (Hanlon et al. 2008; Massoudi et al. 2013) and fathers (Massoudi et al. 2013; Matthey et al. 2001). A self-rating of 0–3 is given for each of 10 scaled items, giving a total maximum score of 30. A higher score indicates more severe depressive symptoms. When used for screening purposes, the EPDS has various cut-offs. In the current study, the EPDS score was used as both a continuous and dichotomous variable (
